Category: CO Medicaid

COACT Colorado & High Fidelity wraparound services could serve as a Model for Medicaid Adult Mental Health Services

5/12/2018

We have a HUGE challenge: bringing Medicaid Intensive Mental Health Services to scale to meet the need.

CO Medicaid to our knowledge still has not changed their regulations regarding Assertive Community Treatment (ACT), Residential Services, and Intensive Case Management as Alternative Services -- not available to all where reasonably medically necessary.

We were told by HCPF that ACT would be available where reasonably medically necessary -- but it seems to still be listed as an "Alternative Service."

That "Alternative Service" designation doesn't pass Mental Health Parity Muster as far as we're concerned.

But an option available to the State is to create an array of INTENSIVE SERVICES such as High Fidelity Wraparound to reduce the need for Residential Services and ACT.

Also, I think HIGH FIDELITY WRAPAROUND is better than Intensive Case Management --because it doesn't burnout the caseworkers as quickly and the results are likely better.

The Colorado Department of Human Services (CDHS) is already using HIGH FIDELITY WRAPAROUND for youth with serious behavioral issues -- under COACT, albeit not statewide.

COACT looks like Youth Assertive Community Treatment (ACT) with some built-in protective concepts such as:

Family Voice & Choice
Use of Natural Supports
Community-based
Culturally Competent
Individualized
Strength-Based
Persistence
Outcome-Based

Words matter -- the focus on High Fidelity Wraparound as opposed to "Assertive Community Treatment" probably has a lot of advantages -- it doesn't sound coercive and it seems more description.

I think this is pretty much what the people in the Adult Arena want as well when it comes to Assertive Community Treatment--High Fidelity Wraparound with Individual Voice and Choice.

Now one of the things that characterizes ACT is 24/7 -- 7 days a week coverage. Now not everybody probably needs that -- BUT a whole lot of people need HIGH FIDELITY WRAPAROUND.

With graduated intensive services available where reasonably medically necessary and clear screening tools, our Medicaid Intensive Mental Health Services could become much more understandable and user-friendly for everyone.

Under Medicaid Network Adequacy, we need to have an understanding of how many Coloradans need to access various levels of intensive mental health services --- and what do we need to do to plan for that.

"COACT Colorado is a system of care for children and youth with behavioral health challenges and their families.

It uses an evidence-based and effective process called high-fidelity wraparound to manage care for families with complex needs who are involved in multiple systems.

"High-fidelity wraparound implements a collaborative plan for the child and the family, as well as service providers and professionals working with the family. The process utilizes the individual strengths, needs, and culture of the family to achieve desired goals.

"High-fidelity wraparound often makes case work easier and more efficient for providers and professionals while generating positive outcomes."

https://coactcolorado.org/for-providers

1. Family Voice and Choice
Family and youth perspectives and opinions are asked for often, and prioritized during all phases of the process. Planning is built on family members’ perspectives, and the team aims to build a plan that reflects a family’s values.

2. Team-based
The wraparound team consists of individuals providing services to the family as well as the family’s natural supports.

3. Natural supports
The team actively seeks out and encourages the full participation of team members drawn from family members’ own networks of interpersonal and community relationships.

The plan reflects activities and interventions that draw on these individuals as sources of natural support.

4. Collaboration
Team members work together and share responsibility for developing, implementing, monitoring and evaluating a single high-fidelity wraparound plan. The plan is a collaboration of all team members’ ideas, opinions and resources and guides each team member toward meeting the team’s goals.

5. Community-based
The team implements a plan that offers services and supports that take place in the most inclusive, responsive and accessible settings possible; and that safely promote child and family integration into home and community life.

6. Culturally competent
The process respects and builds on the values, preferences, beliefs, culture, and identity of the family, child, and their community.

7. Individualized
The team will develop and implement a customized set of strategies, supports, and services to achieve goals laid out in its plan.

8. Strengths-based
The high-fidelity wraparound process and plan identify, build on, and enhance the capabilities, knowledge, skills, and assets of the child and family, their community, and other team members.

9. Persistence
Challenges can and will come up throughout this process. However, the team will persist in working toward the goals laid out in the plan until the team reaches an agreement that the goals have been met and the formal process is no longer needed.

10. Outcome-based
The team ties the goals and strategies of the high-fidelity wraparound plan to measurable indicators of success and monitors progress by checking in on these indicators.

If something isn’t working, the team will revise the plan.

CO Medicaid's Challenge to "Uncover" & Meet the True Need for Assertive Community Treatment Under Parity -- NOW

3/12/2018

So what is the "Cover-Up" we're railing against now?
We're focused on the Insufficiency & Lack of Parity within Medicaid Mental Health Services generally and in Colorado specifically [although a lot of the criticisms could apply to other states as well].
First of all -- WE ALL WANT TO LOOK GOOD -- the State wants to look good, I want to look good, everybody I know wants to look good.
When people, or organizations, or governmental sub-divisions -- start not exactly telling the truth about something -- well, it's pretty easy to get into CROSS EXAMINATION MODE (especially in our society) -- to ferret out, uncover, reveal THE TRUTH.
IDEALLY, we make it safe enough that people can tell the TRUTH.
This becomes exceedingly problematic where safety is concerned.
AND Safety gets implicated A LOT where the Criminal Justice System is concerned -- whether its judges, prosecutors, defense attorneys, individuals, service providers, State actors responsible for ensuring adequate:

bed space
housing;
and services, often intensive services.

So Orchid Advocacy is pretty much focused on the State actors but of course they are inter-connected to all the other players, actors, individuals. What we want the State Actors to do in bringing:

Bed Space;
Housing
Services, often intensive services

TO SCALE or to have A COMPREHENSIVE, EFFECTIVELY WORKING PLAN TO BRING THE ABOVE TO SCALE to meet the needs of people with disabilities, often invisible disabilities, who are homeless, incarcerated or otherwise institutionalized is required by the LAW but it is also REALLY DIFFICULT -- that's why we're not doing it.
We do CRINGE when there is a significantly less than transparent and honest discussion and acknowledgement of the past and current difficulties to bring ACT to SCALE in Colorado.

Let's talk about Assertive Community Treatment in Colorado & Nationally:

Prior to "Federal Parity Legislation," the US Department of Justice relied on the Americans with Disabilities Act and the 1999 Olmstead Decision to FORCE States to provide more Assertive Community Treatment to people with disabilities who were institutionalized or at great risk of institutionalization.
In a New Hampshire Olmstead case, DOJ required the State of New Hampshire which is 1/3 the population of Colorado -- to provide significantly more Assertive Community Treatment as Colorado was providing at the time.
Colorado has historically considered ACT a "alternative service" under Medicaid in which there was no entitlement to the Service.
Further, a significant percentage of the ACT that Colorado does provide is not through Medicaid but through the Office of Behavioral Health. Well, why is that important -- Medicaid is an ENTITLEMENT [unless of course its an "alternative service in which case it's not an entitlement] so a lot of the rights that attach to most Medicaid Services have historically NOT attached to the provision of ACT in Colorado.
Additionally, the State of Colorado through the Dept. of Health Care Policy & Financing refused to respond to or answer a question we posed 2 & 1/2 years ago as to whether the state had an objection to a WAITLIST for ACT.
Currently, it appears --although we need to double-check-- that Colorado maybe now facially complying with Parity-- saying well, providers can seek reimbursement for ACT under the general "reasonable medical necessity" standard of Medicaid.
Why wouldn't that be enough? Well, the answer to that brings in not only:

*The Administrative & Economic Realities of ACT
*The HUGE historical resistance by Colorado State Gov't to provide full funding of this service--- we can't ignore HISTORICAL DISCRIMINATION.
*AND just the HUGE NEED to PLAN for what may be thousands of additional people with mental illness:
----who are in the Criminal Justice System
----nursing homes
----homeless
----in the Mental Health Institutes

Most States that have really been serious about this have included specific eligibility by Statute and/or regulation so that everyone is on the same page, and people who should be included aren't inadvertently left out due to vagueness.

Specifically such eligibility criteria often include along with a "mental Illness":

Criminal Justice Involvement
History of Hospitalization or Institutionalization; and
Homelessness

Colorado is moving in the right direction -- It needs to move much more to make ACT a SUBSTANTIVE REALITY FOR THE POTENTIALLY THOUSANDS OF ADDITIONAL PEOPLE WHO MAY MEET REASONABLE MEDICAL NECESSITY CRITERIA.

Examples of DOJ (US Department of Justice) Settlement Agreements that included ACT

DOJ Settlement Agreements that include ACT
U.S. v. New York – 13-cv-4165 – (E.D.N.Y. 2013)

Community-Based Mental Health Services

The Agreement will ensure that individuals with serious mental illness receive the array of services they need to successfully transition to, and remain in, community-based settings.

These services include ACT, mental health clinic services, personal care services, home health services, care coordination, and crisis services.

See Fact Sheet on the Agreement
http://www.ada.gov/olmstead/olmstead_cases_list2.htm#ny

U.S. v. North Carolina – No. 5:12-cv-557 – (E.D.N.C. 2012)
Following a nationally recognized fidelity model, the number of ACT teams throughout the State will expand to 50 ACT teams with the capacity to serve 5,000 individuals by July 1, 2019.

See Fact Sheet on the Agreement
http://www.ada.gov/olmstead/olmstead_cases_list2.htm#NC

Amanda D., et al. v. Hassan, et al.; United States v. New Hampshire, No. 1:12-CV-53 (SM)
-          Over the first three years of the Agreement, the State will expand ACT team service capacity so as to be able to serve at least 1,500 people in the target population {Of course, New Hampshire is only 1/3 the population of CO]; this expansion will provide ACT team services to hundreds of additional people in need.

-          The State will develop effective regional and statewide plans going forward to provide sufficient ACT services to ensure reasonable access by additional eligible individuals.

See Agreement Fact Sheet
http://www.ada.gov/olmstead/olmstead_cases_list2.htm#wood

CO Medicaid Mental Health Quality & Network Adequacy, Olmstead, & Contracting: Known Knowns, Known Unknowns, and Unknown Unknowns

2/13/2018

I think sometimes why Olmstead is so resisted by States is that it provides a dictate -- BUT it doesn't provide a lot in HOW.
The U.S. Supreme Court's decision was really designed to give the States flexibility. It has taken awhile since the original 1999 Olmstead Case to work some of this out.
The Minnesota Federal Olmstead Planning Case, the Georgia/DOJ MI/DD Comprehensive Settlement Agreement, the Delaware/DOJ Findings Letter re: NO Fundamental Alteration where bringing Housing & Services to Scale, DOJ Guidance on Olmstead-- at the end of the day there was a lot to be gleaned from those.
Then States like Colorado promptly ignored all that stuff -- also, known as LAW.
So it's a little bit, maybe a lot Pollyannish to say, "If the States just had the right tools, they would do the right thing."
BUT the States are doing some right things in Colorado and around the country -- they've even got some good things in their provider contracts -- although, not NEAR ENOUGH.
States spend A LOT MORE TIME on contracting with providers than they do with Olmstead Planning.

With Olmstead Planning -- often States just don't do Olmstead Planning at all or there are no MEASURABLE GOALS, etc. even though its pretty much common knowledge that the States have NOT brought Housing & Services to Scale to prevent unnecessary institutionalization of people with disabilities, including the great risk of institutionalization in homelessness.

BUT the Code of Federal Regulations & CMS have some "requirements" -- some softer than others -- regarding:

Managed Care Quality Assessment &
Improvement

One of the challenges to one's sanity is that we already have some pretty important known values::

Thousands of people with mental illness in Colorado Jails.
Thousands of people with mental illness in Colorado Prisons.
Thousands of People with mental illness who are Homeless.
Thousands of People with mental illness who are in nursing homes.
Federal Legal Duties on States to provide Housing & Services for People with Disabilities to avoid unnecessary institutionalization, or the great risk of institutionalization inherent in homelessness OR Provide a Comprehensive, Effectively Working Plan to do so with Measurable Goals, Etc..
Federal Legal Duties on States to Provide Mental Health Parity, including modifying CAPITATION RATE SETTING where necessary.
It is Medicaid Mental Health Managed Care that needs to have "NETWORK ADEQUACY" to provide for the people listed above in the Community. NEWS FLASH: COLORADO MEDICAID DOES NOT HAVE "NETWORK ADEQUACY" FOR THIS.
The State has made some improvements, BUT what it is doing is WAY NOT ENOUGH to comply with the LAW and even more importantly save Coloradans with mental illness from the Horrors of Abuse or Neglect or the Daily rights violations that have been and are occurring.

42 CFR § 438.330 Quality assessment and performance improvement program.

(a) General rules.

(1) The State must require, through its contracts, that each MCO, PIHP, and PAHP establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees that includes the elements identified in paragraph (b) of this section.

(2) After consulting with States and other stakeholders and providing public notice and opportunity to comment, CMS may specify performance measures and PIPs, which must be included in the standard measures identified and PIPs required by the State in accordance with paragraphs (c) and (d) of this section. A State may request an exemption from including the performance measures or PIPs established under paragraph (a)(2) of this section, by submitting a written request to CMS explaining the basis for such request.

(3) The State must require, through its contracts, that each PCCM entity described in § 438.310(c)(2) establish and implement an ongoing comprehensive quality assessment and performance improvement program for the services it furnishes to its enrollees which incorporates, at a minimum, paragraphs (b)(2) and (3) of this section and the performance measures identified by the State per paragraph (c) of this section.

(b) Basic elements of quality assessment and performance improvement programs. The comprehensive quality assessment and performance improvement program described in paragraph (a) of this section must include at least the following elements:

(1) Performance improvement projects in accordance with paragraph (d) of this section.

(2) Collection and submission of performance measurement data in accordance with paragraph (c) of this section.

(3) Mechanisms to detect both underutilization and overutilization of services.

(4) Mechanisms to assess the quality and appropriateness of care furnished to enrollees with special health care needs, as defined by the State in the quality strategy under § 438.340.

(5) For MCOs, PIHPs, or PAHPs providing long-term services and supports:

(i) Mechanisms to assess the quality and appropriateness of care furnished to enrollees using long-term services and supports, including assessment of care between care settings and a comparison of services and supports received with those set forth in the enrollee's treatment/service plan, if applicable; and

(ii) Participate in efforts by the State to prevent, detect, and remediate critical incidents (consistent with assuring beneficiary health and welfare per §§ 441.302 and 441.730(a) of this chapter) that are based, at a minimum, on the requirements on the State for home and community-based waiver programs per § 441.302(h) of this chapter.

(c) Performance measurement. The State must -
(1)

(i) Identify standard performance measures, including those performance measures that may be specified by CMS under paragraph (a)(2) of this section, relating to the performance of MCOs, PIHPs, and PAHPs; and

(ii) In addition to the measures specified in paragraph (c)(1)(i) of this section, in the case of an MCO,PIHP, or PAHP providing long-term services and supports, identify standard performance measures relating to quality of life, rebalancing, and community integration activities for individuals receiving long-term services and supports.

(2) Require that each MCO, PIHP, and PAHP annually -
(i) Measure and report to the State on its performance, using the standard measures required by theState in paragraph (c)(1) of this section;

(ii) Submit to the State data, specified by the State, which enables the State to calculate the MCO's,PIHP's, or PAHP's performance using the standard measures identified by the State under paragraph (c)(1) of this section; or

(iii) Perform a combination of the activities described in paragraphs (c)(2)(i) and (ii) of this section.

(d)Performance improvement projects.

(1) The State must require that MCOs, PIHPs, and PAHPs conduct performance improvement projects, including any performance improvement projects required by CMS in accordance with paragraph (a)(2) of this section, that focus on both clinical and nonclinical areas.

(2) Each performance improvement project must be designed to achieve significant improvement, sustained over time, in health outcomes and enrollee satisfaction, and must include the following elements:

(i) Measurement of performance using objective quality indicators.

(ii) Implementation of interventions to achieve improvement in the access to and quality of care.

(iii) Evaluation of the effectiveness of the interventions based on the performance measures inparagraph (d)(2)(i) of this section.

(iv) Planning and initiation of activities for increasing or sustaining improvement.

(3) The State must require each MCO, PIHP, and PAHP to report the status and results of each project conducted per paragraph (d)(1) of this section to the State as requested, but not less than once per year.

(4) The State may permit an MCO, PIHP, or PAHP exclusively serving dual eligibles to substitute an MA Organization quality improvement project conducted under § 422.152(d) of this chapter for one or more of the performance improvement projects otherwise required under this section.

(e) Program review by the State.

(1) The State must review, at least annually, the impact and effectiveness of the quality assessment and performance improvement program of each MCO, PIHP, PAHP, and PCCM entity described in § 438.310(c)(2). The review must include -

(i) The MCO's, PIHP's, PAHP's, and PCCM entity's performance on the measures on which it is required to report.

(ii) The outcomes and trended results of each MCO's, PIHP's, and PAHP's performance improvement projects.

(iii) The results of any efforts by the MCO, PIHP, or PAHP to support community integration for enrolleesusing long-term services and supports.

(2) The State may require that an MCO, PIHP, PAHP, or PCCM entity described in § 438.310(c)(2) develop a process to evaluate the impact and effectiveness of its own quality assessment and performance improvement program.

CO Medicaid Managed Care, Capitation, & Parity: It's Time To Get REAL

2/11/2018

So the HUGE problem under Medicaid Managed Care is that it has in some instances provided incentives for Mental Health Centers to concentrate on the least needy patients at the expense of the most needy patients.
Now we're NOT the only ones that think this -- in fact, the opinion runs across the Mental Health Advocacy spectrum from national conservative advocate D.J. Jaffee with the Mental Illness Policy Organization & Dr. Torrey with the Treatment Advocacy Center to Colorado's own liberal visionary Amy Smith with BrainStorm.
Not everybody agrees with this assessment -- like the Mental Health Centers and States-- and this does quite frankly have a lot of nuances to it.
Nonetheless, there are a lot of built in tensions with Medicaid Managed Care and large-scale financing of "expensive"/intensive community mental health treatment, and that is even though such "expensive"/intensive community mental health treatment is generally less expensive than:

Prisons
County Jails,
Nursing Homes, and
Hospital Beds

Well, why is that? The Community Mental Health Centers don't see it in their financial interests to provide large scale Assertive Community Treatment where "reasonably medically necessary." So there is some being provided and there have even been real efforts by Colorado to increase access to ACT BUT it is STILL woefully inadequate.
THIS IS NOT IN THE BEST INTERESTS OF PATIENTS. This is in the best financial interests of States and Mental Health Centers.
AND from our perspective we've got the results and the trail to prove it -- thousands of poor people with mental illness in jails, prisons, homeless, etc. and a Medicaid system that is still coming to terms with its HUGE role in the problem.
And even with that, Colorado like most States is just flat out AFRAID to address this problem openly and honestly, because there is a lot of complexity to it and there's at least on one side of the balance sheet some real costs involved.
So Colorado does NOT have:

Network Adequacy for Intensive Community Mental Health Treatments such as Assertive Community Treatment.
An Adequate Assessment or Eligibility Tool for Reasonable Medical Necessity for Assertive Community Treatment -- the latest current vagueness continues to hurt vulnerable people.
Mental Health Parity

People we can solve this, but not by pretending this problem doesn't exist.

So what are the missing pieces of information that are preventing "actuarial soundness" in Colorado Medicaid Mental Health Capitation Rate Setting?

ACTUARIAL STANDARDS BOARD: MEDICAID MANAGED CARE

42 CFR 438.6(c)
Actuaries are specifically directed to this section:

(c) Delivery system and provider payment initiatives under MCO, PIHP, or PAHP contracts—(1) General rule. Except as specified in this paragraph (c), in paragraph (d) of this section, in a specific provision of Title XIX, or in another regulation implementing a Title XIX provision related to payments to providers, that is applicable to managed care programs, the State may not direct the MCO's, PIHP's or PAHP's expenditures under the contract.

From the Dept. of Health Care Policy & Financing's Contract with the RCCOs (Regional Care Collaborative Organizations)

7. PAYMENTS TO CONTRACTOR A. Maximum Amount Payments to Contractor are limited to the unpaid, obligated balance of the Contract Funds.

The State shall not pay Contractor any amount under this Contract that exceeds the Contract Maximum.

The State shall not pay Contractor any amount under this Contract that exceeds the PMPM [Per Member Per Month] amount for that month submitted to the State as specified in Exhibit B.

p. 6
https://www.colorado.gov/pacific/sites/default/files/Rocky%20Mountain%20RCCO%20FY%2017-18.pdf

Washington State Study Showing Medicaid Managed Care Led To Incarceration Of People with Mental Illness

Colorado Medicaid Regulations on Capitation Rate Setting from the Secretary of State's website (emphasis added)

42 CFR §438.6 --- Special contract provisions related to payment

<<<<< Well, it sounds good, but if quality measures are NOT enforced this can become a nightmare & in fact it has become a nightmare in Colorado & across the Country.

Mental Health Parity: Finding the Line Between Prohibited "Fail First" Medicaid Provisions and Reasonable Medical Necessity

2/5/2018

The Mental Health Parity & Equity Addiction Act of 2008 prohibits so called "Fail First" provisions.
What does that mean? It means that people can't be required to "FAIL" @ a less expensive treatment, before receiving a more expensive, likely more intensive treatment.
Well, okay --- but not everyone needs the most expensive, intensive treatment.
How are we going to determine who needs which treatments?
Well, we can't do it the old crazy way that has been rife within Colorado Medicaid for years and probably many other State Medicaid Programs:
Colorado Medicaid historically only covered intensive treatments such as Assertive Community Treatment as long as the money didn't run out from the Savings of the Medicaid Managed Care Program.
Well it is these kinds of HORRIFIC policies that Mental Health Parity is designed to get rid of.
That still doesn't mean that everyone needs Assertive Community Treatment --- What we do need are coherent criteria for "reasonable medical necessity" and eligibility for various treatments across the spectrum for example Flexible ACT, etc.

The State has invited me to speak about these issues to the Regional Accountable Entities -- which I very much appreciate.

Ultimately, it's the
State's responsibility to comply with Mental Health Parity Law. Colorado isn't doing that right now.

The State indicates it will have some requirements for "network adequacy" --- Sounds good, but we don't know what it actually means.

Further it does strike us that the State is trying to side-step responsibility for Parity and put it on the Regional Accountable Entities.

The invitation from the State to speak to Regional Accountable Entities is great ---- but it is not sufficient.

We need "reasonable medical necessity" criteria for ACT or a process to get it by the end of this week, or I'm going to CMS Region 8.

The State of Colorado Could Give Lucy A Run for Her Money in Parity Bait & Switch Routines

At Bottom It's Work: Reasonable Medical Necessity "Tools" for Assertive Community Treatment AND Could Someone Please Give the State of Colorado Some More BANDWIDTH

1/28/2018

There is so, so much work to be done in Medicaid Mental Health. It is NOT likely to get done and it's NOT being done if it is left to the Medicaid Directors to get it done.
There have to be sufficient staff with sufficient knowledge to whom Medicaid Directors can delegate the vast majority of this Mountain of Work.
Maybe a grant for Mental Health Transformation for Parity and Olmstead Compliance, and that could be broader than just Mental Health.
The Advocacy Community can do a lot research for the State [which the State is probably going to want to double-check and conduct their own research --- of course, that takes time].
BUT at some point the State has to do a fair amount of work, not just summarily declaring themselves in compliance with Olmstead and Parity -- which they are NOT.
I think we pretty much get that the big issue is money when it comes to complying with Disability Civil Rights Laws, even if ultimately they would save money -- where do you get the money in the first place?
There are a lot of ideas that we have already bandied about BUT the State has to have the BANDWIDTH to pursue them.

Flexible ACT

Minnesota Eligibility for ACT

Eligible Recipients Recipients eligible to receive ACT services must meet the following criteria as assessed by an ACT team:

• 18 years old or older (Individuals ages 16 and 17 may be eligible upon approval by the commissioner)
• Have a primary diagnosis of schizophrenia, schizoaffective disorder, major depressive disorder with psychotic features, other psychotic disorders or bipolar disorder
• Have a significant functional impairment demonstrated by at least one of the following:
• No indication that other available community-based services would be equally or more effective as evidenced by consistent and extensive efforts to treat the individual [or]
• Written opinion of a licensed mental health professional that the recipient has the need for mental health services that cannot be met with other available community based services, or is likely to experience a mental health crisis or require more restrictive setting if assertive community treatment is not provided

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_058151

Minnesota Eligibility for Youth ACT

Eligible Recipients To be eligible for Youth Act, MHCP recipients must be 16 – 20 years old and have:
• Diagnosis of serious mental illness or co-occurring mental illness and substance abuse addiction
• CASII level of care determination of level 4 or above
• Functional impairment and a history of difficulty in functioning safely and successfully in the community, school, home, or job
• Probable need for services from the adult mental health system within the next two years
• Have a current diagnostic assessment indicating the need for intensive nonresidential rehabilitative mental health services
http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=DHS16_181612#er

Pennsylvania ACT Standards and Guidelines

Consumer Eligibility: Following are the eligibility requirements for Assertive Community Treatment Services: Adults, 18 years of age or older, who have serious and persistent mental illness.

A person shall be considered to have a serious and persistent mental illness when all of the following criteria for diagnosis, treatment history, and functioning level are met.

A. Diagnosis: Primary diagnosis of schizophrenia or other psychotic disorders such as schizoaffective disorder, or bipolar disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-R or any subsequent revisions thereafter). Individuals with a primary diagnosis of a substance use disorder, mental retardation, or brain injury are not the intended consumer group; AND

B. Functioning level: Global Assessment of Functioning Scale (as specified in DSM IV-R or revisions thereafter) ratings of 40 or below; AND C. Consumers who meet at least two of the following criteria:

10 a. At least two psychiatric hospitalizations in the past 12 months or lengths of stay totaling over 30 days in the past 12 months that can include admissions to the psychiatric emergency services;

b. Intractable (i.e., persistent or very recurrent) severe major symptoms (e.g., affective, psychotic, suicidal);

c. Co-occurring mental illness and substance use disorders with more than six months duration at the time of contact;

d. High risk or recent history of criminal justice involvement which may include frequent contact with law enforcement personnel, incarcerations, parole or probation;

e. Literally homeless, imminent risk of being homeless, or residing in unsafe housing; f. Residing in an inpatient or supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not available; AND

D. Difficulty effectively utilizing traditional case management or office-based outpatient services, or evidence that they require a more assertive and frequent non-office based service to meet their clinical needs [This may be problematic from a Parity Standpoint in that it may require "FAIL FIRST," which is prohibited by the Mental Health Parity and Addiction Equity Act of 2008]

An individual who needs to receive ACT services, but who does not meet the requirements identified above may be eligible for ACT services upon written prior approval by the Behavioral Health Managed Care Organization or the County MH/MR Office, as applicable. In order to meet the DACTS fidelity standard related to admission criteria, at least 90% of the consumers admitted to the program shall meet the eligibility criteria outlined in the bulletin.

"Dealing with Homeless, Fires and Lawsuits" -- A Modest Proposal

1/21/2018

With our Dark Humor, Colorado's situation of "Homeless, Fires, and Lawsuits," reminds us of the Plagues on ancient Egypt in the Bible.
Colorado's situation may not be as much Divine Intervention as the Chickens Coming Home To Roost -- of course, maybe it's the same thing.
In any case, we need NOT only to deal with the ROOT CAUSES of these problems --- BUT have the COURAGE & INTEGRITY to acknowledge the SCALE OF THE PROBLEMS.
On some level, Colorado is addressing the ROOT CAUSES of these problems -- BUT it hasn't really been wholly effective because STATE GOVERNMENT is afraid to acknowledge the SCALE of the Problems and their LEGAL RESPONSIBILITY to provide HOUSiNG & SERVICES for People with Disabilities or to Have a Plan to Bring Those Housing & Services to SCALE under the US Supreme Court's 1999 Olmstead Decision.
Why is that? Why are politicians afraid to do that?
I'm sure this is going to SHOCK everyone -- BUT the well recognized reason is that this isn't CHEAP -- in fact -- it's EXPENSIVE.
So when you have Governmental Entities not complying with various LAWS @ the State, County, or Municipal level --- LAWSUITS are pretty predictable.
Housing and Intensive Community Mental Health Treatment that many people who are Homeless need --- is EXPENSIVE.
There is not necessarily just one way to FUND that. One way that was pioneered by the City of Denver was the use of Social Impact Bonds.
We have said it before and we'll say it again -- one of the most SERIOUS & DANGEROUS problems Colorado State Government has is that it is woefully Under-Staffed.
As one professor said -- "You can't read 'War and Peace' while you're taking a shower."
You can't:

Make those applications for Social Impact Bonds;
Adequately Monitor Facilities
Sufficiently Engage with the Public on Innovative Ideas for a Pretty Broken Mental Health System
Etc.

If you don't have the Bandwidth to do it.

There is a HUGE NEED within the Colorado Dept. of Health Care Policy and Financing (HCPF) for MORE HUMAN RESOURCES to deal with the TRANSFORMATION that needs to take place in MEDICAID to ADDRESS the MENTAL HEALTH CRISIS that Colorado is experiencing and is seen in the rest of the Country as well.

Further, while we understand that the Office of Behavioral Health and HCPF are closely coordinating ---- we think these offices need to be fully integrated--- so that concerns relating to Institutional and Community Mental Health Care are seamlessly addressed.

Additionally, LET'S BE VERY CLEAR --- IT IS OFTEN CHEAPER FOR GOVERNMENTAL ENTITIES TO VIOLATE THE LAW AND PAY ATTORNEYS FEES FOR THE OCCASIONAL LAWSUIT THAN IT IS TO COMPLY WITH THE LAW THE WAY THE LAW IS CURRENTLY ENFORCED.

So if one's most important value is "saving taxpayer dollars" -- Colorado's got the Government for you.

BUT make no mistake about it, it comes with a lot of abuse and neglect of people with disabilities and inhumane treatment of people with mental illness on the streets and in jails and prisons.

If we work together, we can figure out a way to pay for Sufficient Housing & Services for People with Disabilities and make a Plan to bring those Housing and Services to SCALE.

Colorado Springs Gazette: Letter to the Editor

Dealing with homeless, fires, lawsuits

If you build it, more will come. We will never have enough space until the homeless get mental help to change their lifestyles.

I am referring to the hard core group (mainly singles) that refuse to obey any laws that don't suit their style of living.

I would also like to thank the ACLU for helping put fear in our community, especially legal residents of the Westside (Old Colorado City), by not allowing Colorado Springs to enforce it's laws for fear of being sued and wasting precious taxpayer dollars on legal fees.

Tom Gallivan
Colorado Springs

http://gazette.com/letters-dealing-with-the-homeless-fires-taxes-and-lawsuits/article/1619255

Colorado Abuse & Neglect Scandals Involving People with Disabilities

Integration of Community & Institutional Mental Health Policy @ the Federal & State Levels with Corresponding Appropriations to Deal with Decades of Neglect

1/20/2018

I'm really glad people are taking the Opioid Crisis seriously. We're beginning to address the Crisis in Mental Health as well as the Criminal Justice System -- BUT there is a LONG, LONG WAY TO GO.
With respect to Mental Health --- it has been a pretty WILD RIDE.
I think we are primed for a more BALANCED and INTEGRATED MENTAL HEALTH POLICY than we ever have been before.
We've mentioned this before that we seem on the CUSP of a CONSENSUS when it comes to Mental Health Policy among what have historically been warring views across the Mental Health & Disability Advocacy Spectrums.
We "think" a CONSENSUS "might" look like this:

Requirements to continuously update data and analysis on the need for:
- Housing
- Appropriate Community Mental Health Treatments, Including Intensive Community Treatments such as Assertive Community Treatment;
- Institutional Care
Get rid of the Institute for Mental Disease Exclusionary Rule or IMD Rule and fully Incorporate the Institutions into the State's Olmstead Planning Process.
Allow Medicaid to Cover Housing for people needing Long Term Care

There was a BIG PUSH in 2015 to persuade Medicaid to cover Housing. Advocates and for that matter even States were rightly chanting a mantra of "Housing is Healthcare."

Well what Medicaid did was that it said it would fund a lot of peripheral services around Housing -- BUT NOT THE HOUSING.

Ironically what CMS did do was remind States of their responsibilities under OLMSTEAD. -- YEAH!

BUT Olmstead isn't being enforced the way it should be and States are pretty cavalierly resistant to this DISABILITY CIVIL RIGHTS LAW in no small measure because of the Housing Liability.

AND who should be caught in the middle: People with Significant Disabilities.

So the BOTTOM LINE is we don't care who pays for adequate Housing, Services, and Institutional Care -- BUT some governmental entity needs to pay for it. The State has a LEGAL DUTY to either provide all this or have a plan to do it for the Housing & Community Services and in Colorado with respect to inmates needing Competency Exams -- the State is under a Settlement Agreement.

Now because we have been neglecting this for DECADES -- we do need to JUMP START it with major appropriations. From both the Feds and the States.

MAYBE If we're NOT FIGHTING with each other and working together to get the Scale of Housing, Services, and Institutional Care we need-- we might get it.

In the meantime, I will be contacting the State to let them know they have until Thursday January 25, 2017 to get back with me on Parity and ACT to try to work something out otherwise I will be complaining to CMS REGION 8.

CMS -- Coverage of Housing-Related Activities -- June 26, 2015

Housing: A Conundrum for the States -- A Nightmare for People with Mental Illness

Medicaid Is A Mixed Bag And It Is NOT Some Innocent By-Stander in the Current Mental Health Crisis whether in Colorado or the Rest of the Country

1/17/2018

We're going to pick-apart Jaffe's summarized analysis of Medicaid's role in the current crisis and suggest why both Conservative and Liberal Mental Health Advocates have plenty to fear from Medicaid Mental Health and the States who administer the State Medicaid Programs.

With regard to "anti-psychotics," historically people and professionals including advocates thought they were going to work a lot better across the board than they did. So they were a HUGE part of de-institutionalization and the community mental health movement.
NOW -- we recognize that "genetic testing" may be really necessary to decide which medications are best. Further, a lot of these medications work on the brain globally and not on individual neural circuits and that is probably not a good thing, according to Cal-Tech neuroscientist David Anderson.
Further our whole understanding of "mental illness" is changing to something much more related to the brain, the gut and "immune system" than it was before. So the point being, we don't have a complete and comprehensive understanding of "mental illness" and and we're very slow to change incorrect old ideas.
So if you thought "anti-psychotics" were going to solve all these problems and "medication adherence" you probably didn't think you needed a lot in Community Mental Health and Medicaid Mental Health.
50 Years on or So -- SURPRISE! People with mental issues need a lot more than medication, the medication is more complicated than advertised, and "Medication Adherence" requires a competent profession and one that listens to its patients. We are lacking in both.
You just can't be a viable medical/healthcare profession and rely on outdated science like the DSM 5. Mental health professionals are NOT paid as much because they are NOT worth as much. Hopefully, the integration of physical and mental health which is so desperately needed in mental health will help both people with mental illness and the mental health profession raise its standards and its salaries.
So Medicaid is a BIG PART of that integration of physical and mental health care AND they deserve A LOT of credit for that.
BUT what happened when we realized "anti-psychotics" weren't going to be enough? We rushed right in to fund effective and expensive intensive community mental health treatments like -- Assertive Community Treatment, right?
HELL NO! We let the jails, prisons, homeless shelters and streets handle the intensive treatment needs.
This has gotten pretty nightmarish and Orwellian in Colorado where the State won't even answer a question whether it has an objection to a "waitlist" for ACT.
BUT now we're supposed to have Medicaid Parity, and the State continues to fail to fund this treatment as it would a medical/surgical treatment.
So it is this INTENSE STATE RESISTANCE to adequately fund Intensive Community Mental Health Treatments on par with medical treatments that led to:
- the Mental Health Crisis;
- Calls to get rid of the Institute for Mental Disease [IMD] Rule in Medicaid;
- AND a Call to a Return to Asylums
When State Medicaid Programs like Colorado's Resist the Large Funding Needs of People with Serious Mental Illness -- They Are Also Violating the Law & Civil Rights of Thousands of Coloradans with Mental Illness who are Homeless and Incarcerated.

From "Insane Consequences" . . .

"In spite of common lore, it is Medicaid, more than the advent of anti-psychotics and tranquilizers, or the construction of community mental health centers, that caused and continues to cause "de-institutionalization."

"The overall effect of exclusion [Medicaid's exclusion of payment for Institutes of Mental Disease] has been to create incentives or states to move patients out of state hospitals, which has contributed to homelessness and inappropriate incarceration."

See page 187 of the book.

See the Caption below for Colorado's Version of the Orwellian Nightmare

The Orwellian Nightmare is in one instance the Dominance of Irrational Political Concepts. Kind of like Colorado Medicaid's Refusal to Provide Assertive Community Treatment where "Reasonably Medically Necessary" Helps Coloradans with the most serious community mental health needs. Perhaps most distressing, the Orwellian practice of the Hickenlooper Administrations confusing politeness and cordiality with good faith and complying with the law.

Val's Blog