A PLAN FOR C ILDR.~ MEBT/ALH LT SERVICES 'Jn ?i!~ to- eke 11Kt4 Se44iou o1 eke 11tauee State £~~ s~ ~··fm~eatt4 & ~etfflalt s~ £, "t), 1744, (1997 ?i!~, ~ KOJ 7a f:Jtan ~ s~ ~ ~ «dttt ~~eatt41teed4 Submitted December 15, 1997 by: The Department of Mental Health, Mental Retardation, Substance Abuse Services in eo:nsultation.with: the Departments of Human Services, Education, Corrections and representatives of parent groups, providers and legislators TABLE OF CONTENTS Page I. Executive Summary 1 II. Introduction History ofLD 1744 The Planning Process Who are the Children? Current Services · 1 1 1 2 5 III. Statement of the Problem Structural Problems 1. Lack of a System of Care 2. Overutilization ofHigh Cost Services 3. No Single Point of Access 4. Inequitable Distribution of Resources 5. No Clear Point of Accountability 6. Gaps in Services for Transition-Age Children 8 8 8 9 10 11 12 13 IV. What the Data Show Conclusions From The Data 14 17 V. DMHMRSAS Infrastructure Accomplishments to Date Network Service Areas 18 18 19 VI. The Proposed System of Care Values and Principles The Process of Care System Infrastructure Interagency Roles and Responsibilities Financing Medicaid Rule Review Quality Improvement Benefits ofProposed System 20 20 22 26 28 31 33 34 36 VII. Interagency Infrastructure Development in Support of a System of Care 38 VIII.State Agency Role and Responsibility Agreements 40 Administration of the Medicaid Behavioral Services Program 42 IX. Implementation Plan Capacity Study Capacity and Sizing Summary Transition Plan Infrastructure and Services/System Management Ongoing Planning Process Service Development Sequence First Year Work Plan 43 43 44 45 46 47 48 53 APPENDICES A. B. C. D. E. F. G. LD 1744 Planning Process, Legislative Resolve, and Participant List Medical Assistance Rule Review LD 1744 Child Service System Profile Local Case Review Committees GEAR Brochure Department ofCorrections/DMHMRSAS Memorandum of Agreement 1. Proposed Department ofHuman Services/DMHMRSAS Memorandum of Agreement 2. Proposed Department ofEducation!DMHMRSAS Memorandum of Agreement H. 1996 Memorandum of Agreement between DMHMRSAS/DHS I. Draft Managed Care Plan For additional information or questions, contact Robyn Boustead at 287-4251. Non-Discrimination Notice The Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) does not discriminate on the basis of disability, race, color, creed, gender, age, or national origin, in admission to, access to, or operations of its programs, services, or activities, or its hiring or employment practices. This notice is provided as required by Title II of the Americans with Disabilities Act of 1990 and in accordance with the Civil Rights Act of 1964 as amended, Section 504 of the Rehabilitation Act of 1973, as amended, the Age Discrimination Act of 1975, and the Maine Human Rights Act. Questions, concerns, complaints, or requests for additional information regarding the ADA may be forwarded to DMHMRSAS's ADA Compliance/EEO Coordinator, State House Station #40, Au.gusta, Maine 04333, 207-287-4289 (V), 207-287-2000 (TTY). Individuals who need auxiliary aids for I. EXECUTIVE SUMMARY This document, A Plan for Children's Mental Health Services, represents the final report to the 118th Maine Legislature's Joint Standing Committee on Health and Human Services, as required by LD 1744, 1997 Resolve, Chapter 80. The plan culminates six months of intensive effort on the part of Maine's child serving state agencies, parents of children with emotional and behavioral needs, legislators, providers of children's mental health services, and many other interested people from all geographic areas across the State of Maine. The Department of Mental Health, Mental Retardation and Substance Abuse Services was charged to take the lead role in designing a comprehensive, integrated system for managing the delivery of children's mental health services in the State of Maine. Accordingly, this plan does not focus solely on the mental health services funded by and provided through DMHMRSAS. Rather, all stakeholders acknowledge that the Departments of Human Services, Education and Corrections each play a meaningful part in the lives of these children and their families, and will continue to do so in the future. The Plan for Children's Mental Health Services is unprecedented in its comprehensive scope, by the commitment of its participants, and in its contents. The plan's features include: Current data, developed specifically for this report, and available to members of the Design Team, provides a foundation for planning. The data estimate that at least 42,000 Maine children have behavioral or emotional service needs serious enough to warrant treatment , and that 27,500 are challenged by serious emotional and behavioral difficulties. Information about services provided across all four child serving agencies, counting both state and federal funds, show expenditures which impact children's mental health services estimated to be as much as $151 million in Fiscal Year 1996. Of the $68 million in Medicaid funds spent on behavioral health services for Maine's children, three out of four dollars were spent in the most costly and restrictive out-of-home treatment alternatives, reducing Maine's capacity to develop community services and limiting the number of children who can be served. A values based foundation, endorsed by all participants promotes a system which is child and family centered. The strengths and needs of the child and family dictate the types of services to be provided through an individualized planning process, with families/guardians as equal and full participants. Services must be outcome based, with management and decision-making responsibility residing at the local level. Shared values require that services are delivered in the least restrictive and most clinically appropriate environment, with safety as the first priority. Stakeholders agreed that prevention and early intervention enhance the likelihood of positive outcomes and that transition to adult services, when needed, must be ensured and supported. The structural centerpiece of this plan is the development of a system of care, rather than fragmented, piecemeal responses that characterize children's mental health across the childserving agencies today. A system of care for children must have a single management authority, a single mission and a common set of values. The plan endorses an integrated system of care, led and managed by DMHMRSAS. In this system, entry may come from any point in the comm~nity and will occur when a mental health need is first identified. 1. Services will be provided through a Local Service Provider Network, part of the systems infrastructure under development by the DMHMRSAS. The management structure for this system will be through the Network Manager, an independent entity under contract to the department, that represents the single point of gatekeeping authority and accountability for the assessment of need and delivery of services in the local area. On a day to day basis, the system of care will be managed by the Child and Family Team, utilizing an individual planning process. The process envisions that whenever a child needs the services/supports of multiple systems, direct care workers from each of these systems will come together with the case manager, family and other individuals identified by the family to develop an individual service plan. The team will address issues across all domains to ensure consistency_ of approach, sanction the blending of resources across agency lines and coordinate services from multiple agencies into a unified plan of care. Multi-agency cases may also be supported through a Local Case Resolution Committee or the Regional Children's Cabinet. The plan establishes and defines Core Mental Health Service Components that are necessary to support the system of care. These service components include: prevention; crisis intervention; case management; family and child supports; clinical services; and residential treatment. The core service array is intended to provide a blueprint for developing service capacity in the seven local service areas of the state. Each of the child-serving state agencies currently provides or funds a number of these services within its own domain. The Plan addresses state agency roles and responsibilities, including new and proposed Interagency Memoranda of Understanding. Participants recognize that the mental health needs of many children, youth and families served by DHS, DOC, DOE and schools are adequately met by those systems, and responsibility for delivering those services will remain within the existing agencies. However, in the proposed system of care, closer linkages between the systems will result in DMHMRSAS playing a major role in developing, providing and monitoring mental health services within the other child-serving agencies. Financing strategies to support the development of this system include selective restructuring of Medicaid, redirection of funds from institutional settings to community-based services, expanded access to federal Title IVE dollars and flexible use of state and federal block grant funds. Mixing categorical and flexible resources in new ways will result in individualized services that meet a child's unique needs, as opposed to rigid funding that creates wasteful, "one size fits all" pro!lfam slots. Through blended funding, parts of each agency's resources can be used to fund a plan so that services and supports can be provided in a way that maximizes all revenue resources. The plan addresses implementation strategies to begin the development of a comprehensive system of care for children and their families. A multi year service development sequence outlines the types of services that will be needed to support a complete system of care. These service needs were derived from current service capacity data that show the current utilization of core mental health services, statewide. The capacity study then estimates future need for discrete services. The results indicate which services will require additional capacity and which services show excess capacity. The data show priority needs to develop crisis services, case management, in-home behavioral health and outpatient services, among others. Excess capacity is shown for acute inpatient and group homes/residential services. The plan concludes with a ~etailed First Year Implementation/Work Plan focusing on administrative, policy and regulatory priorities to be addressed through January, 1999. 11 II. INTRODUCTION HISTORY OF LD 1744 During the first session of the 118th Legislature, members ofthe Joint Standing Committee on Health & Human Services (H&HS) passed a Resolve "To Plan for Services for Children with Mental Health Needs," which became Chapter 80 ofthe laws of 1997. The impetus for the Resolve was a series of events and issues relating to children's mental health that came to the committee's attention during the course of the session. Because these issues touched all of the child-serving state agencies, the committee shaped the Resolve to address problems in the system from a comprehensive perspective. The Governor's Office and the Joint Committee demonstrated their commitment to a meaningful, permanent solution to the problems facing Maine's families by designing the Resolve as a vehicle for structural systems change. LD 1744 calls for the Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS, or the Department) to take the lead role, in consultation with the Department of Human Services (DHS), the Department of Education (DOE) and the Department of Corrections (DOC), in designing a comprehensive, integrated system for managing the delivery of children's mental health services in the State of Maine. THE PLANNING PROCESS Immediately following passage of Chapter 80, the Department created a steering committee to guide the mental health system design planning process, with membership representing all major stakeholder groups. The steering committee included policy level representatives from each of the child-serving state agencies, three members of the H&HS Committee, and representatives from the mental health service providers' organization and the statewide parent organization. The Commissioner ofDMHMRSAS served in an ex-officio capacity. The steering committee assumed responsibility for managing the overall planning process. Tasks included organizing a division oflabor, defining manageable workgroup responsibilities, establishing a workplan to address the tasks required by LD 1744, maintaining communication among stakeholders, and sanctioning changes in direction or timetables when necessary. Workgroups comprised ofrepresentatives of all stakeholders were organized to address three topic areas: systems/access, services and supports, and finance. Beginning in June, the three workgroups met on the average of twice a month, and maintained coordination with one another by meeting as a large group once a month. For each topic area, workgroups came to agreement on overarching principles, identification of barriers to effective services for children, and strategies to overcome the identified barriers. The intense work over the summer built a collaborative atmosphere among the state departments, providers and parents. There is a strong commitment among all the stakeholders to the creation of a mental health system for children. More detailed discussion of the planning process and a list of all participants is included in Appendix A. Almost a hundred individuals participated as members of the overall "Design Team". Section Two ofLD 1744 required that DMHMRSAS and DHS review current Medicaid rules for children's mental health services, and adopt new rules consistent with the goal of providing a comprehensive network of children's mental health services in the least restrictive and most appropriate settings. In order to implement this section of the Resolve, staff from the two Departments met a number oftimes, and with the assistance of an expert consultant, conducted a review of Medicaid rules applicable to providing care and treatment for children (see section on Medicaid Rule Review and the report as Appendix B). The planning process focused on designing a children's mental health system to assure easy, family-friendly access and a complete and comprehensive range of services and supports, financed through a creative blend of existing resources as well as reallocation and redistribution of existing dollars. The workgroups also analyzed recent utilization and cost data. The plan that follows is based on recommendations from the three workgroups. WHO ARE THE CHILDREN? Recent national epidemiological estimates from the Center for Mental Health Services project that between 14 percent and 20 percent of children and youth between the ages of 0 and 18 years of age have mental health problems serious enough to require treatment (6.8 to 9.8 million children nationally), and that 9 percent of children and youth experience serious emotional and behavioral disturbances (4.4 million children). Applying these prevalence rates to Maine, it is estimated that between 42,000 and 61,305 children experience behavioral and emotional problems, and approximately 27,500 are challenged by serious emotional and behavioral difficulties. 1 The following statistics are based on a national evaluation of 22 community-based systems of care for children and families: 1 Children Served in Community Systems of Care • • • • • • • The children served are predominantly male (63% boys, 37% girls); Most children (74%) are between the ages of6 and 15 years, with an average age of 14 years; 35% of the children have a history of physical abuse and 25% have experienced sexual abuse; A substantial percentage (42%) of the children live in single-parent homes; Over one quarter (29%) of the children have experienced one or more previous inpatient psychiatric hospitalizations; Two-thirds (67%) of families and 81% of single-parent families served are living below federal poverty level; . Two-thirds of families served are challenged by mental illness, domestic violence, and/or substance abuse. 1 Report from CMHS Strategic Planning Meeting, June 18-19, 1997, Washington, DC. The descriptive profile is based on data obtained on 11,497 children and youth involved in the Center for Mental Health Services National Evaluation of the Comprehensive Services Program for Children and Adolescents. " 2 One of the twenty-two comprehensive service demonstration sites funded by the Center for Mental Health Services is located in four counties in northeastern Maine. Called the Wings Project, it has funded and evaluated a local approach to coordinated services for children with serious emotional disturbances for the past three years. The following chart compares children and families served in the Wings Project to the national profile Comparison of Children and Families Served · Wings vs. CMHS National System of Care Profile (n=275) years (n=11 ,497) years These data show that in the four project site counties in Maine, children with serious emotional disturbance have a slightly higher incidence of physical and sexual abuse and a higher rate of mental health problems in the family than the national comparison group. Even more strikingly, children in the Maine project are hospitalized at almost twice the national rate. This finding reflects the lack of community-based services throughout the state, resulting in an over-utilization of inpatient services. A need for mental health treatment and supports may originate from any single or combination of factors which may be neurobiological, genetic, environmental, or traumatic in nature. Any of these factors can decrease a child's well being or ability to function across any or all domains of his/her life (residential, education/work, interpersonal relations, physical/psychological, safety, legal, and spiritual/cultural). Mental health services are those clinical interventions and supports which l!elp stabilize emotional and behavioral problems and teach children the self-management and social skills needed to improve their level of functioning. Clinical expertise from the mental 3 health system may be used to support children in the context of other service settings, for example, assisting the school in the reduction of the behaviors which are interfering with a child's ability to stay in school. Similarly, expertise from the school system may be invaluable for the clinician in establishing how a child learns so that behavioral plans are developed within a context that the child can understand. An integrated system of care brings each system's expertise together in order to address the needs of the "whole" child. 4 Curr\J.1t Services: Child Servir .~ Agencies in Maine .Jl I • Case Management • Home Based Services • Residential Care • Sex Offender Tx. • Substance Abuse Tx. • Transition Services • Vocational Services • Wraparound Services • Community Restitution • Detention • Electronic Monitoring • Foster care .Independent Living • • • • • • • • • • • • • • • • • • • • • • • JISS Monitoring • • Job Skills Training • Maine Youth Center • DOC Case Management Community Support Crisis Services Day Treatment Diagnostic Services Family Preservation In-home Services Parenting Classes Sex Offender Treatment Residential Care Substance Abuse Services Transition Services Transportation Vocational Services Adoption Services Child Abuse Evaluation Child Protection Services Day Care Services Forensic Interviewing Independent Living Program Foster Care Institutional Abuse Investigation Parental Capacity Evaluation Risk Assessment DHS • • • • • Day Treatment Early Intervention Homeless Services Residential Care School-Linked Mental Health • Special Education • Transition Services • Vocational Services • • • • • • • • • • • Assistive Technology Bilingual Education Even Start GOALS 2000 General Educational Services Immigrant Education Migrant Education Reading Recovery School Nutrition School to Work Student Assistance Team DOE Note: Shaded areas represent specialized services available to children with mental health needs. • • • • • • • • • • • • • • • • • • • • • • • • • • • Acute HospitalizatiL Autism Services Case Management Child & Family Advocacy Crisis Intervention Child & Family Services Consolidated Crisis Response Counseling Day Treatment Developmental Therapy Early Intervention Homebased Family Services Homeless Services In-home Treatment Infant Mental Health Services Intake & Referral Medication Management Parent/Sibling Support Group Psychological/Psychiatric Assessment Residential Care Respite School-Linked MH Services Self Help-Peer Support Sex Offender Treatment Substance Abuse Services Transition Services Vocational Services . DMHMRSAS LD 1744- MH SERVICES BY FUNDING SOURCES AND DEPARTMENT SERVICE CATEGORIES Case Management . Targeted Case Management Outpatient . . . MH Day Treatment Infant MH DMHMRSAS General Fund, Medicaid, PATH, Wings DHS General fund, Title IV-B, Family Pres. ·General Fund, Medicaid, Block Grant General Fund, Medicaid General Fund, Medicaid, Private Non-Medical Institution (PNMI) Medicaid, General Fund, Title IV-E General Fund, . Medicaid, Block Grant, OSA-Shelters General Fund, Medicaid, Title IV-E, Family Pres., Social Service Block Grant General Fund, Medicaid, Family Pres. DOC General Fund, Medicaid, Federal OJJDP, County Corr. General Fund, Federal Justice Assistance DOE General Fund, Medicaid, PartH General Fund, Medicaid General Fund, Local Educational Authority (LEA) (Educ. Cost for Res. Treat. Center) Children Outpatient Children Medication MH Adult Outpatient Interpreter Services . All Psychologists Psych Examiners . Psych RN/MSW . Hospital Outpatient Psych Hospital Outpatient . Physicians/Psychiatrists Residential . Residential Treatment Center . Group Care/ Residence . Therapeutic Foster Home . Out of State Crisis . . . Crisis Response Crisis Beds Emergency Shelters Homebased Services . . . Homebased Community Services Child/Family Community Suppt. Family Mediation Wraparound Flexible l: l Family Support Services . General Fund, Medicaid, (Wraparound) Respite Services General Fund, Fed. Wings General Fund Parent Support Groups Parent Advocacy Social/Recreation Services 6 General Fund, Medicaid LD 1744- MH SERVICES BY FUNDING SOURCES AND DEPARTMENT SERVICE CATEGORIES Early Intervention DHS General Fund Medicaid, Preventive Health Prog. Mental Health in Schools Project DMHMRSAS General Fund Birth thru School Age .School Based Services . Day Treatment School Psychologists, Counselors Substance Abuse Services . SA Outpatient General Fund Medicaid Block Grant Residential (PNMI) General Fund, Medicaid Inpatient Hospital . . Childrens Psychiatric General Hospital/Psych Hospital Out of State General Fund, Medicaid, Title IV-E, Social Services Block Grant Transportation . . 0-17 18-21 7 DOC DOE Federal PartH General Fund, Medicaid, LEA III. STATEMENT OF THE PROBLEM The following section summarize·s the major structural problems in the current service delivery system that were identified by the three workgroups. These issues, and the recommendations for the development of a system of care that follow, are in substantial agreement with recommendations made in a number of previous studies and reports, including the Maine Task Force. for Mental Health: Findings and Recommendations Regarding Services for Children (September, 1996), The Commission on Children in Need of Supervision and Treatment (March, 1989), Interdepartmental Reports per Legislative Resolves (June, 1986), Special Commission on Governmental Restructuring (December, 1991), and the Task Force on Adolescent Suicide and Self-Destructive Behaviors (May, 1996). Structural Problems 1. Lack of a System of Care. Even though Maine spends millions of dollars on behavioral health services for children, there is no unified system for the provision of mental health services for children, either at the state or local level. (X) Explanation: The statute creating the former Bureau of Children with Special Needs within the DMHMRSAS limited DMHMRSAS' involvement to children not eligible for services from any other State agency. This forced each agency to develop mental health services for the children in their respective systems. Although state and local agencies serving children and youth strive to coordinate services, there is currently no single system responsible as the lead agency in coordinating a comprehensive system for children's mental health services. This lack of a systemic approach to managing mental health resources occurs both at the state level and at the local level, where there is no effective structure for the planning or management of integrated services. Even Medicaid, the state's largest resource for financing mental health services, does not support a system of care: Because there is no designated entity responsible for coordination, capacity development and gatekeeping across complex and overlapping services, the policies governing Medicaid-reimbursed mental health services inadvertently undermine the concept of a system of care (see Medicaid Rule Review in Appendix B). The result is that a myriad of services are paid for retrospectively by Medicaid without the benefit of a network of care that was prospectively designed to serve Maine's children in the best possible way. The lack of a coordinated system of care has also resulted in conflicting definitions of the target population. Moreover, children with multiple problems (e.g., a severe emotional disturbance and mental retardation) have a particularly difficult time accessing appropriate services. 2. Overutilization of High Cost Services. Current federal and some state funding rules result in the use of high cost institutional placements. As a result, Maine hospitalizes children at twice the national rate, and spends three-quarters of its child mental health dollars on the most restrictive settings. Explanation: State Medicaid criteria are complex, with multiple steps required to gain access to low cost options, while criteria for higher cost services are less restrictive. For example, "non-traditional Preventive Health Program (PHP)," the least restrictive Medicaid reimbursable service, requires prior authorization, while in-state psychiatric hospitalization has no prior authorization criteria. Guidelines concerning length of care also tend to favor hospitalization: While length of care requirements exist for four of the least restrictive Medicaid reimbursable services, psychiatric in-patient length of care decisions are controlled by the admitting hospital. Additionally, current practice has state agencies responsible for managing Medicaid seed for community-based Medicaid reimbursable services, while psychiatric hospitalization is covered 100% by the Bureau of Medical Services (BMS), an arrangement that can encourage cost shifting as a way to protect limited agency resources. 1.0 Maine's use of the optional "Medicaid Psychiatric Facility Services" (which covers free-standing psychiatric hospitals) encourages high cost out-of-state hospitalization. The availability of this option, which covers 100% of costs, encourages the use of out-of-state placements for many children with severe mental health needs. Continuity of care is more difficult to maintain for children placed out of state, as connections with families and communities deteriorate and planning for their return is hampered by lack of current knowledge about the child. Example #1: Emily has been diagnosed with a hearing impairment and significant development delays. In order to receive the specialized, in-home services she needs, Emily must first be shown to "fail" with traditional home health services, and receive prior authorization for "nontraditional PHP" from a home health provider. In contrast, if Emily's mother wanted to put her in a hospital, no prior authorization would be required. Example #2: There is a thirteen-week limit on home-based services from DMHMRSAS. This service places clinical staff in the home when a child is in extreme emotional and behavioral crisis: mental health workers help to stabilize the situation, support other family members affected by the crisis, and help the family to develop the skills necessary to handle the child's behavior. In contrast there is no limit to the total days that a child in crisis may be hospitalized, and no external UR process to review the need for continued inpatient care. 3. No Single Point of Access-- No Clear Roles or Responsibilities. There is currently no single point of access to the state's full array of mental health services, and no clear definitions of roles and · responsibilities, resulting in confusion for families about where to go for help. Explanation: Eligibility criteria vary across systems due to varying federal and state requirements and mandates. Services and resources across agencies are fragmented, and there is no coordinated mechanism for creating a clear point of entry to a full array of services. Moreover, since each child-serving agency provides some limited mental health services, there is continuing confusion about the roles of the different agencies. This situation has resulted in part from the limited mandate of the Bureau of Children with Special Needs, in part from the lack of resources and adequate specialized clinical expertise in the mental health system, and in part from the lack of capacity for the Department to deliver services on-site in the other child-serving systems. 0 Example: Wendy Kelly has agreed to provide temporary foster care services for Joe, an 18 year old boy with bipolar disorder and moderate mental retardation. Although Joe clearly requires supervision, he is currently his own guardian. Joe will continue to receive special education services until he reaches the age of21, but needs intensive in-home supports in order to remain in the community. Wendy doesn't know whether the local school district, DHS, or DMHMRSAS should be responsible. 4. Inequitable Distribution of Resources. Currently, the ability to access resources for mental health care depends to a large extent on where the child lives, as well as on parental custody arrangements. Explanation: Federal funding resources which are tied to specific populations of children create barriers to equal access. In addition, because of the fragmentation of the system, children in the custody ofDHS have access to a larger pool of resources than children residing in intact families. Many families face relinquishment of their custodial responsibility to DHS so that their children may receive services. There is also an inequitable distribution of resources geographically. A review of service utilization by geographic area reflects large disparities in use of various service components across the state. For example, children residing in the Northeast, Kennebec-Somerset, and Western service areas are more likely to receive services in inpatient hospital and residential treatment settings than children residing in other areas of the state. Without further review of the data, it is not possible to cite specific reasons for this disparity. Example: Ronnie is a 9 year old whose impulsive and often aggressive behavior places both of his two younger sisters and often his mother, in danger. His diagnosis of ADHD adds a very short attention span to his behavioral issues. The local education authority is able to educate the boy with 1:1 aides and a very structured, individualized program. At home and in the community, however, even with in-home supports, respite care, and a short crisis stabilization placement, his behavior is unmanageable. The mother is worn out, fears for the safety of her two younger girls, and has exhausted what have proven to be ineffective community-based services. Her child requires a residential treatment placement. The local PET feels, appropriately, they are able to educate him in the local school. There is no correctional involvement. The DMHMRSAS has provided numerous community-based resources, including a crisis placement, but is unable to provide the long-term residential treatment necessary as there are no funds for room and board. In desperation, the mother seeks DHS custody as the only method available to her to fund the necessary residential program. 5. No Clear Point of Accountability. Accountability for effective management of care, and for good client outcomes is divided between several agencies. Explanation: Although DMHMRSAS, DHS, and DOE have mechanisms in place for limited gatekeeping of the services within their systems, there is no coordinated gatekeeping procedure for the vast majority of Maine's mental health resources. Approximately 53% of children placed out of state have no documentation in the case record of an assigned case manager from any state agency .1 Lacking a single point of accountability, many Maine children are inappropriately placed in institutional settings, with no agency or individual clearly responsible for monitoring their treatment or assuring a timely and coordinated return to their community. Fragmented accountability has also resulted in the state's inability to collect basic data regarding number of children served, how resources are utilized and whether the interventions provided are effective. Each agency maintains separate information systems and collects different information, making it difficult to make effective policy and program decisions. Example: A DMHMRSAS mental health coordinator receives a call from Mrs. Jones. Her daughter, Jeanine is 16 years old and has been at Charter Brookside Psychiatric Hospital in Nashua, NH for 18 months. Charter Brookside wants to discharge Jeanine. Mrs. Jones is concerned that Jeanine is showing little improvement and there has been no discharge planning to put supports in place in Jeanine's home. This is Jeanine's 8th hospitalization. She has never received services from any state agency. N Report from BMS- DHS Medicaid Surveillance and Utilization Review/Quality Assurance, August 2, 1997. 1 6. Gaps in Services for Transition-Age Children. Children often "fall through the cracks" between the children and adult service systems. Explanation: Inconsistent, age specific agency mandates and funding mechanisms create problems as children whose mental health needs have been met through special education or DHS custody "age out" and transition to DMHMRSAS, creating waiting lists for adult services and disruption in continuity of care. Transition issues are exacerbated by out-of-state placements, which sever linkages between the child and his or her family and community, and by failure to begin interagency transition planning in a timely manner. Example: Sean is a 17 year old boy in DHS custody who has been at Lakeview Neuro-Rehabilitation in New Hampshire for four years.* He has a history of abuse, fire-setting and severe behavioral problems which made it impossible for him to remain either at home or with foster parents. On October 1st, DMHMRSAS receives a phone call announcing that Sean is turning 18, and will be returning to Maine. The DMHMRSAS worker, who has a responsibility for participating in planning for children as they reach 18, has had no prior contact with or knowledge about Sean, now has one week to find an appropriate residential placement. w *Lakeview serves primarily children with neurological conditions, autism, developmental delays, mental retardation, neuro-head traumas and/or traumatic brain injury. IV. WHAT THE DATA SHOW In order to assess trends in behavioral health service use and expenditures in the current child and adolescent service system, a series of analyses were conducted using FY 1996 Medicaid claims data. The current analyses focused on Medicaid service use, since Medicaid funding represents the single largest funding source for child and adolescent services, accounting for between 60 percent to 70 percent of all service use. These analyses examined service use and expenditures across the following core service areas: inpatient hospital services, residential/group services, and community-based services. They also looked at the distribution of service use across designated geographic_ service areas. An assessment ofFY 1996 Medicaid expenditures shows that $68.7 million dollars were expended on behavioral health related service to children and adolescents in Maine. The following chart shows the distribution of expenditures across three major service areas. Percent of Total Medicaid Expenditures for Children in Out of Home and Community Care Settings Total: $68,664,247 Inpatient Hospital 30,513,883 44.4% Community Care 17,298,082 25.2% 1 ~ Seventy-five percent or $51.4 Million dollars of the total Medicaid expenditures go toward serving children and youth in the most costly and restrictive out-of-home treatment alternatives including inpatient psychiatric hospitals and residential treatment centers in and out-of-state. Child Admissions to Inpatient Psychiatric Hospitals and Residential Treatment Facilities by local Service Network Inpatient Psychiatric Hospitals 60~----------, ResidentiaVGroup Treatment so~--------~ Use of Community Outpatient and Case Management Services by local Service Network Community Outpatient Services Case Management Services 120 r - - - - - - - - - - , 16 Children residing in the Northeast, Kennebec/Somerset and Western local service network areas are more likely to receive services in inpatient psychiatric hospital and residential treatment settings. Children residing in Cumbefland and York local service network areas tend to use community-based services, such as outpatient and case management services less frequently than children residing in other areas ofthe state. FACTS ABOUT MENTAL HEALTH SERVICES FOR CHILDREN IN MAINE 1. It is estimated that between 14 percent and 20 percent (42,000 - 61 ,305) of children 0 to 18 years of age in Maine have mental health challenges serious enough to require treatment and 9 percent (27, 500) have serious behavioral or emotional challenges. 2. A total of $68,664,247 in Medicaid dollars is spent on behavioral health related services to children annually. 3. Seventy-five percent or $51,366,165 of the total annual Medicaid expenditures go toward serving children in the most costly and restrictive out-of-home treatment alternatives including inpatient psychiatric hospitals and residential treatment centers. 4. In FY96 539 children and youth between the ages of 0 and 17 years are placed in instate psychiatric hospitals on an annual basis at a per child cost of $25,565 and 74 children and youth are placed in out-of-state inpatient psychiatric hospitals at a per child cost of $81,516. 5. The average length of stay in out-of-state psychiatric inpatient facility is more than 3 times longer than inpatient stays in Maine (i.e., 133 days out-of-state versus 32 days instate). 6. Children residing in the Northeast, Kennebec-Somerset, and Western local service areas are more likely to receive services in inpatient hospital and residential treatment settings than children residing in other areas of the state. 7. Children residing in Cumberland County tend to use community-based services such as outpatient clinical, case management, outpatient emergency services, in-home family services, and substance abuse services less frequently than children in other areas of the state. Note: See Appendix C for child system profile data report CONCLUSIONS FROM THE DATA Analysis of Medicaid behavioral health expenditures suggests that there is currently a substantial pool of resources supporting mental health services for children in Maine, and that an extensive array of Medicaid-reimbursable service categories has been developed. However, resources are spread across several agencies, and financial management is not well aligned with policy making authority. In addition, a large majority of all resources are spent on high-cost services, restricting the state's capacity to develop community services, and limiting the total number of individuals who can be served. This pattern of expenditures, which has resulted in part from attempts to maximize federal revenue, is in direct contrast to nationally recognized systems of care, where the majority of resources are directed to lower-cost community services. 17 V. DMHMRSAS INFRASTRUCTURE ACCOMPLISHMENTS TO DATE Over the past two years, DMHMRSAS has undergone a series of reforms which create an effective infrastructure on which to implement a coordinated system of care for children. In 1995, as part of the Productivity Realization Task Force, the Department reorganized its operations, creating three integrated Regional Offices. The Regional Offices serve as an identifiable point of linkage to other service systems at the local level. Team Leaders with specialized clinical expertise in each of the population areas served by the Department (mental health, mental retardation, children and substance abuse) work under a single Regional Director, making it easy to access specialized services, even if the individual in need doesn't fall neatly within one category or another. This structure also improves coordination between the children's and adult service systems. The full integration of the Office of Substance Abuse into the Department's operational structure will make it possible for substance abuse problems to be addressed as an integral part of all of the Department's clinical interventions and prevention activities. Early in 1996, the Legislature enacted Public Law, Chapter 691, which created seven local service areas and mandated the creation of "Quality Improvement Councils" to ensure stakeholder participation in the planning and monitoring of local service systems. These service areas provide, for the first time, a geographic structure for purposes of planning and systems development, allowing DMHMRSAS to analyze resource allocation and service utilization patterns geographically (see map on next page). The development of local service network areas has also allowed DMHMRSAS to begin program development in a systemic rather than piecemeal manner. For example, the establishment of seven "Consolidated Crisis Response Systems" in 1997 has created a single, integrated crisis capacity in each local area, greatly improving access and coordination of services. DMHMRSAS has also established a template for the essential ("core") services that need to be in place in each local provider network. Efforts have begun to build core service capacity throughout the state. For example, respite care is now available for families in all seven geographic areas. Ensuring that each geographic area has adequate capacity of all core services is the first step in ensuring equality of access to services. In the past two years, DMHMRSAS has also substantially strengthened its clinical capacity and quality assurance/management information resources. Statewide and Regional Medical Directors will ensure that DMHMRSAS can provide timely clinical consultation concerning mental health issues, and a new Quality Improvement/Quality Assurance Division will support systems improvements through ongoing outcome evaluation and through regular participation of consumers and family members in service monitoring. 18 Network ..... ~rvice Areas ~ Aroostook Service Network Northeast Service Network Hancock Washington Penobscot Piscataquis Ken-Sam Service Network Kennebec Somerset Shoreline Service Network Knox Lincoln Sagadahoc Waldo Tri-County Service Network Androscoggin Franklin Oxford, Cumberland Service Network York Service Network Aroostook VI. THE PROPOSED SYSTEM OF CARE VALUES & PRINCIPLES A system of care for children must have a single management authority, a single mission, and a common set ofvalues if it is to be effective in serving children and families. The mission and values must be shared by all stakeholders within the system, including the executive, legislative and judicial branches of government; agency staff; parents; providers; communities and payors. Developing and maintaining a common mission and set of values has historically been impeded by fragmentation of the service system. Like the proverbial blind men and the elephant, each child-serving agency has focused on one aspect of reality. For DHS, child safety is the overriding mission; for DOE, it is child learning and development; for DOC, what matters most is that the child obeys society's laws; and for DMHMRSAS, the primary goal is to improve the child's level of functioning. In the current system, separation of the different child-serving agencies leads to consideration of each legitimate -- and important -- goal in relative isolation. In addition, each system may hold oversimplified assumptions about the others, believing, for example, that DMHMRSAS serves only children with intact families, or that DHS Child Protective Services harms families by acting too quickly to remove children. Direct care workers, responding to the pressures and responsibilities of their jobs, concerned about the consequences of failing to adequately fulfill their obligations, and operating within different structures and with different professional languages, have often found themselves in conflict. In contrast, the proposed integrated system of care will support a unified mission and values by providing the opportunity for ongoing dialogue between different service components, and by creating a process for integrating different perspectives into a more complex and holistic picture. Discussions that occurred during LD 1744 workgroup sessions suggest that conflicts of this nature can be resolved when people have an opportunity to see the situation from the other's point of view. The following principles of practice are based on the vision established in December of 1995 by · the Governor's Children's Cabinet, which specified that children's needs are best met within the context ofrelationships at the family and community levels.' These principles will guide the dev"elopment, implementation and evaluation of the proposed children's mental health system. 'Statement of Vision, Mission and Goals of the Children's Cabinet, July 15, 1997 20 Guiding Principles for a Children's Mental Health System 1. Child and Family Centered. The system of care is child and family centered, with the specific strengths and needs of the child and family dictating the types and mix of services to be provided through an individualized planning process which addresses all domains of a child's life with families/guardians as equal full participants. 2. Outcome-Based Services provided to a child and family must pursue long-term outcome objectives from a whole life perspective. 3. Community Based. The system of care is community-based, with the locus of services as well as management and decision-making responsibility residing at the local level. 4. Least Restrictive and Most Clinically Appropriate Environment/Safety First. The system provides access to a comprehensive array of services that address the child's physical, emotional, social and educational needs within the least restrictive, most normative environment, with safety always the first priority. 5. Functional Integration of Supports and Services/Easy Access. The system provides services that are integrated, with linkages across all agencies and programs and mechanisms for planning, developing and coordinating services. There are clear roles and responsibilities for different child-serving agencies and a single mechanism (carousel) of access for mental health services so that no matter where a child enters into the system, he/she receives consistent access to the full range of services. 6. Single Point of Accountability for Clinical Services and Supports Management. A case management system ensures that multiple services are delivered in a coordinated and therapeutic manner, and that children can move through the system of services in accordance with their changing needs. At the management level, a single agency has clear accountability for ensuring the adequate delivery of children's mental health services. 7. Prevention and Early Intervention. The system of care, in order to enhance the likelihood of positive outcomes, promotes prevention, early identification and early intervention for children with, or "at risk of', emotional problems in order to enhance the likelihood of positive outcomes. 8. Transition to Adulthood. The system ensures smooth transitions to the community or adult service systems, if needed, as children reach maturity. 9. Rights Protection and Cultural Sensitivity. The system protects the rights of children receiving services without regard to race, religion, ·national origin, sex, physical disability, sexual orientation or other characteristics. Services are sensitive and responsive to cultural differences and special needs. THE PROCESS OF CARE Overview. In the proposed system, entry into an integrated mental health system of care may come from any point in the community, and will occur when a mental health need is first identified. Services and supports will be determined by the family in conjunction with the case manager through an individualized planning process and provided in coordination with other agencies. Access is through a single mechanism so that wherever a child enters the system, the full array of services is available. Parents will be put in contact, upon admission if desired, with another parent who has experience with the system of care through Gaining Empowerment Allows Results (GEAR) (see Appendix E). Services are provided in or near a child's community, through a local provider network. There is a single gatekeeping mechanism (case management) to assure that children receive the appropriate level of care. Management of the system and resources by the network manager occurs to decrease dependence on high cost services, and resources are redirected into building the capacity to serve children in local community-based alternatives. Mechanisms are in place to track outcome measures, do service management, and provide quality improvement to assure system effectiveness and responsiveness (see chart and detailed explanation on next two pages). Interagency Individual Planning Process: The Child and Family Team. Whenever a child needs the services/supports of multiple systems, direct care workers from each of these systems will come together with the case manager, family and other individuals identified by the family to develop an individual service plan (ISP). In situations involving multiple state agencies, the lead case manager will be selected by the family when not in conflict with statute or court order. This plan, building on the strengths of the child, family and community, will address needs in all relevant life domains, including a place to live, family, school or vocational, social, medical, psychological, legal and safety needs. With the creation of an interagency Child and Family Team, issues across all domains can be addressed in a way that ensures consistency of approach throughout all areas of a child's life. It will also allow use of creative blending of resources across agency lines, the use of natural supports when possible, and coordination of services from multiple agencies into a unified plan of care. The Child and Family Team will work to coordinate across agency boundaries, but will not take the place of any mandated plans which may address one domain within the service plan, e.g., the PET process mandated by special education. Children's Mental Health Service Array. A full array of services and supports is a key component of the system of care. Six core mental health service components have been identified: prevention; crisis intervention; case management; family and child supports; clinical services; and residential treatment (see matrix on core services). Each core service is available in varying degrees of intensity, depending on the level of need. This service array will be available in all service networks. In addition to the core services, flexible resources will be available to provide for those individual needs identified through the planning process which cannot be addressed through categorical services. The core service array is intended to provide a blueprint for developing service capacity in each geographic area of the state. As the system of care for children matures, retooling of the core service array may occur. For example, the development of specific "safety net" programs may strengthen or expand one or more core service areas. 22 EZ ?{?aPMm THE PROCESS OF CARE Carousel of Care Entry Assessment of need Provider Network lnteragency Problem Solving Network Manager Plan Approved] Reauthorized THE PROCESS OF CARE Activity Who's Responsible Access/Entry • Crisis care: Crisis response within one hour; assigned case manager with 24 hours • Urgent care: Child connected with case manager within 24 hours < ~ Network Manager • Non-urgent service need: Child connected with case manager within 7 days • Family connected to GEAR, parent-to-parent support Individualized Services Plan (ISP) Developed • Assemble team of individuals from all involved systems • Case manager, family & youth determine strengths, needs, goals • Create an Individual Service Plan which may include ---services/supports from service array ---natural supports (e.g., big brother, YMCA, parent to parent) ---services from other systems (e.g., probation, special education) ISP Child and Family Team Primary Case Manager (or lead CM) • Lead Case Manager identified through the integrated initiative CM, if applicable • Funding specific to plan includes use of all eligible federal funding streams blended with flexible funds • Plan authorized by Network Manager for 3 months maximum Plan Implemented • Provide services on ISP I ' CM • Coordination of care, linkage to resources • Crisis services, if needed ' / /~\ I' ( M/A ~/ ) :•.-:Qut_()f:.State:·_··_. . . . .. .. . .. ' ' ..... ' . . . . .. .. .: -~ •'. ::· ,:·' for Inpatient: Hospitals Community Hospitals, and Residenti Facilities 5M. ,1 51% - . . . .. .t . . Child Re·si:dentiai/G.roup Treatment Use by Local Service Netw·ork 50 c: 0 40 :;::1 as '3 Q. 0 a.. ::2 :2 0 30 0 0 0 ci ..~ 20 fA· ' .. . \ . ~· #' '*' • lliiliiiilii~ > ·~ ·~,~ ~: .. _-, '· '"· > ~· .. ' ,... .. "/'"···¥ ·•" tl"""'''"': ·c··· . --.. v, \ liliiiliilt' ~ ·s· . ·-····~ ~- .... ~ ~-··":· ' ...... ' ··-~'1 . ·e·-"·· . ...... . ....,; • .m-., . C . ·u" ·.\ ';t . . \, ~..:~ ... ;., . '' ' ~ 0 ~ '3 300 a. 0 0.. ~ .s::: 250 () 0 0 0 c5 200 ~ L.. Q) a. C/) c Q) ·a. ·o 150 Q) 0::: cQ) 100 ~ as ~ ·::1 ··-· 0 0 L.. .·.a> •. ·. ·•·.·•· .'J£ Child Clinical Service Use by local Service Network Child Case M,an:agement. Service Use by local Service Network 0 :;:::; (\'J 120 "5 a. 0 a.. "C 100 :.2 () 0 0 0 ci 80 ~ L- CD a. 60 • 1s·. erv1ce· •· u·.·se b:_ y Loca1 · . : •1. ld >. E..mergency c--·1·.tntca , s·ervtce Ch Network 50 r::: 0 :.;:::; co 3 a. 0 a.. 40 "C :.E (.) 0 0 0 30 ci T"" .... (I) a. 20 · u·,.:se bl · N·t Respa·ts ·e .,erv1ce .y ,oca r·s· : .ervrc·e : e :work•· •· c: 0 ~ 90 0 80 as :; c. D. :2 :E (,)· 0 0 0 0 ..... .... G> c. ~ c. 1/) G> 0::: C> c: "iii ::> 70 60 50 40 30 C.hild Home-ba;sed Service Use by l.ocal Service Network 25 c: 0 :;::; «J "3 c. 20 0 a.. 32 :c 0 15 0 0 o_ 0 ...... ._ 10 Child Substance Abuse Service Use by Local 60 c 0 +=I «< :; Q. 0 D.. 50 32 :E 0 0 0 0 40 0 ..... .... Q) Q. sc 30 Q) ·a. ·o Q) 0::: 20 S-ervice~ Network 3's Comparison of Children and Families Served · Wings vs. CMHS National System of Care Profile ngs (n=275) e Average years 44% 62% 14 years APPENDIX D: Local Case Resolution Committees ··.. _. ,.... _;<>::'; Caribou __ Kennebec and Somerset Children's Network, Waterville Contact: Neil Colan KVMHC 873-2136 T1Y 626-3614 -/• hI ~-~----~=~~~~1~~eT~a;~4-2017 ;()' / •··· Aroostook ~ tt l _. ' Children's Regional Coordinating Committee Auburn Contact: Larry Sexton Voice 795-4500 TTY 795-4503 ~~~~~~~;;;~!t1~}t':.·r~~::.~~:.t~f ..'~l·:~~r"' ·r~ :·~1 .;.:.1: .. <;.,: ... : .'~: }'_}·c '' . 4(, ·, . Northeast Case Resolution Committee Contact: Julie Caitling Voice 941-2988 TTY 941-2988 ~s A .... .erset.· / ,~~~:f{1~~~f.;,'.r: ~\ !!'~~j~t:J;;.~i~~~rt~ ~'1iJ~.:,:,.~~:r~~i·~lil Penobscot _,. __ , , ·' ._ ·-.-· . /tlf____ \ . . .n Bangor Interagency Case Resolution Committee Rockland Contact: Nancy Duncan Voice 594-2541 TTY 338-5846 ~jj, . ~.' ., .. ·•. : Cu~beri~nd C~untY · Case Resolution Committee Portland Contact: Susan Lieberman Voice 822-0126 TTY822-0248 :;.·~ York County ·Case Resolution Committee Sa co Contact: Susan Lieberman Voice 822-0126 TTY 822-0248 ·--.In -" Midcoast ·: - Knox ~J. ,~ 4 Sagadahoc County Case Resolution Committee ·.Contact: PollyCrowell 729-4148 No TTY Available Pooled Flexible Funding Guidelines 2/11/97 The Children's Cabinet has been meeting over the last several months to develop specific recommendations for the establishment of a case resolution system which could provide meaningful support to families for keeping children at risk in their own homes and communities. The system described below is the result of these discussions. It is designed to build on work that has been done previously, particular1y in utilizing local case review committees which have already been established. Certain principles under1ie this system. These principles are: • Individualized plans are developed by a local team, comprising the people who know the child and family best; • The plan Is needs driven rather than service driven; • The plan is family centered; • The parent is an integral part of the team and has ownership of the plan; • The plan is strengths based; • The plan is focused on normalizat ion; • Services are created to meet the unique needs of the .child and family; • Services are community based, accessing more restrictive levels of care only for brief periods of stabilization; and • Services are culturally competent•. The model proposed is not a program or a type of service. Rather, it is value based and an unconditional commitmen t to create services on a •one kid at a time• basis to support normalized and inclusive options for youth with complex needs and their families. It operates on the premise that people at the community level have the best understanding of the needs of the particular child and family, and that they are in the best position to develop solutions with that family and child. THREE KEY CONCEPTS: 1. THIS IS A NEW WAY OF THINKING ABOUT SERVICES TO CHILDREN AND FAMILIES. PARTICIPANTS IN THE PROCESS MUST-BE COMMITTED TO CHANGE AND BE ABLE TO · CHANGE THEIR WAY OF WORKING. 2. · POOLED FUNDS ARE USED AS A SUPPLEMENT TO, NOT A REPLACEMENT FOR, PROGRAMS AND SERVICES FOR WHICH CHILDREN AND FAMILIES ARE ALREADY EbiGIBLE. 3. EVERY EFFORT MUST BE MADE TO REMOVE BARRIERS AT THE LOCAL COMMITTE E LEVEL. CASES MUST ONLY BE REFERRED TO THE REGIONAL CHILDREN'S CABINET, OR SUBSEQU ENTLY TO THE CHILDREN'S CABINET, IF RESOLUTION IS BEYOND THE CAPABILIT Y OF THE COMMITTEE TO RESOLVE. c:'<.v!ndowsltemp~ulde.doc 1 02117/9710:28 AM Pooled Fle>dble Funding Guidelines • • • Identify child and family strengths and needs, based on existing infonnation (e.g., family support systems, evaluations, family and social histories, etc.) with family input at the case review meeting; Develop with the family a comprehensive plan to support the child and family; Identify strategies and resources needed to implement the plan, Including existing resources and pooled funds where appropriate; Establish timeframe for implementation; • Identify primary case manager to work with family to assure plan implementation and schedule for review (at least annually); • · Refer to Regional Children's Cabinet only if ban1ers to implementation occur, which are beyond the scope or ability of the local committee to resolve. The committee must identify the barriers which interfere with implementation; • • Manage budget assigned to the committee; • Provide required reports of expenditures to next level committee; AND Maintain data as required (e.g., #of referrals, type of referrals, services provided, barriers to plan implementation identified - both system and fiscal). • GUIDELIN ES FOR EXPENDITURE OF POOLED FUNDS: • • • • • • • • The child has been accepted for review by the committee; Existing resources, including natural support systems, existing categorical program funds, community resources (both fiscal and human), must be committed for those portions of the comprehensive plan for which they are appropriate or eligible; The local case review committee has developed a comprehensive plan; Pooled funds are used flexibly to fill in gaps identified by the family and committee as being the highest priority for successful implementation; Purchase of services is not time limited, but dependent on time frames identified in the case plan; Funding resources and the individual case plan are reviewed in accordance with a schedule developed by the local committee, but at least annually, to assure continued appropriateness of particular resources; · Local Committees may authorize payment of room and board costs for purposes of stabilization or as a part of a treatment plan for a period up to three weeks. Any such expenditures must be reported to the responsible Regional Children's Cabinet; and Plans which identify a need for longer tenn residential services for which other funding resources cannot be Identified must be referred to the responsible Regional Children's Cabinet. The Regional Children's Cabinet will collect data on these requests to be foJWarded -- to the Children's Cabinet. Pooled, flexible funding may not be used to pay for room and board costs for anything other than short term as noted above. ACCESS ING LOCAL COMMITTEE REVIEW c:1Nindows\temp'Gulde.doc 3 02/1719710:28AM Pooled Flexible Funding Avail able As of November 1996, funding is available to pool in accordance with this initiative as follows: r-------------------------------~---------- --------Lapse/C arry Status ~----------, Funds to be I allocated to the : I RCCsas I follows. RCC I I will bill I I assigned department II I $500,000 Funds Carry Region II I I I I I : Department of Human Services $420,000 Funds Carry Region Ill I I : Department of Corrections $100,000. To Be Determined Region I I I ~50,000 Funds Lapse Region I I I I Department of Mental Health, Mental Retardation, and Substance Abuse Services l Department of Education :Total Availab le as of Novemb er 1996 $1,070,000 I -------------------------------- '----------- ----------- '------ -----! An initial allocation of $200,000 will be allocated to each of the 3 Regions for immediate dissemination to the Local Case Resolution Committees within that Region. Pat O'Brien- DMHMRSAS; Barry StoodleyDepartment of Corrections 941-3130. [volcemall: 9414748] 941-3132 10 Franklin St. Bangor. 04401 Becky Hayes-BooberDepartment of H!Jman 561-4197 561-4122 396 Griffin Rd.Bangor 04401 - becky.hayes.boober@state. me.us [at central off~ee] Services; Augusta, Me 04333" nancy.andrews@state.me. us "23 State House Station Augusta, Me 04333" us "23 state House Station Nancy Andrews; -DOEEnglish Language Arts I Writing William Prlmmennan DOE - Health Education home: bhboober@aol.com work:. 287-4484 287-5927 "23 State House Station Augusta, Me 04333" Thomas Keller - DOE Science biU.priiMlerman@state.me. tom.keller@state.me.us 941-4071 941-4675 Maine State Police. 106 Hogan Rd. Bangor "Valerie SeabergDepartment of Education; Education Team Leader/Policy Director for Personnel, Quality Assurar~ee & Regl~l Education Services" 287-5806 287-5900 Department of Education.23 State House Station. Augusta 04333 valerie.aeaberg@state.me. us Rhama Schofield 287-4223 287-4268 DMHMRSAS. State House Station 40 rhama.schofield@state.me. us U. Darrell OUellette [CID Ill] - Department of Public Safety Also: 2 APPENDIX E: GEAR Brochure ::o ~ rnm::011111 GEAR rt....,resentatives are parents of children with developmental or mental health special needs. 0. 0 c."' :;·OJ 10::=-'il a. f., Par ent -x (j) ~ -g(j)-= s:.::.., / they ... listen understand n share iriformatio 1 support an d 1encourage share experiences i \ I m ... \ ' ~ ~ \ \ ! I ,.... t ~ ~ •, llr 1; i ' ' Netw ork \ Gai~in~ . . ,.· . E~po~erme~i Allows ........ . Results i.1. ! ' . ', ·. \ ··· Parents workin~ to~ether to help each other and their children with special needs ' \ c ' I . GEAR (00 q '11 f ("· 1.-L ' \· . ; l ! GEAR was started by parents who\.. ·· 1-800-264-9224 recognized the need for help and support for parents coping with the demands of caring for children with special·needs. Toll free Number provided by United Families for Children's Mental Health, Inc. :j '. \. GEAR offers ... • encouragement through support ~roup meetings and by phone • workshops on topics of interest • local conferences • social opportunities :; . A pro~ram of Crisis and Counselin~ Centers ll / . Sponsored by: Department of Mental Health, Mental Retardation & Substance Abuse Services { I"' You are not alone GEAR parent representatives have the experience of loving and caring for a child with demanding special needs. They know the importance of having someone to talk to who understands what life can be like coping with issues at home, in the community, and at school.· Parents are not judged or blamed for their child's behavior or other issues. • • Parents can find help through problem solving and the shared experiences of other parents in the GEAR network. • Throu~h sharing information, parents learn about services for children, how to access them and what has worked for others. GEAR emphasizes the strengths of children & families and builds on them. • ~ ~ ~ Contact ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ GEAR statewide by calling 1-800-264-9224 to find out more about support groups and other GEAR sponsored adlvltles In your area. Toll free Number provided by United Families for Children's Mental Health, Inc. Your local GEAR representative is: GEAR Phone Numbers Parent-to-parent encouragement h~ppens when two or more parents support each other. Call Services to Children with Speciai Needs to get 800 numbers for crisis, community support and Respite in your area. • by phone, • at local GEAR support group meetings • at training workshops • at social events All sponsored by GEAR to bring parents together. GEAR exists to facilitate contact between parents to prevent isolation and share knowledge gained by experiences with our children's disabilities and contact with the system of care. One parent's view... "This support group for parents of children with special needs has given me a greater understanding of myself, an acceptance of my human lmperfedlons, even as I continue to strive for a greater quality of life. I feel It Is so Important to be able to relate with others who have 'been there'; who go through the same trials I do, without casting judgment upon me. I The caring Is genuine and heartfelt. experience frustration and uncertainty In a crisis, but I know that I am not alone. I am free to share my feelings amongst those who are sincere and supportive of my efforts, and where I feel safe to express my pain. I am encouraged to continue trying and reinforced by those who have tried methods and had positive results. One step at a time, to a greater understanding of myself and the needs of my 'special' chlld.N Regional offices of Dept. of Mental Health, Mental Retardation & Substance Abuse ServicesServices for Children with Special Needs Region 1 - Cumberland & York counties 1-800-492-0846 Region 2 - Kennebec, Somerset, Kno~, Waldo, Lincoln and Sagadahoc counties 1-800-866-1814 -Androscoggin, Franklin, Oxford counties 1-800-866-1803 Region 1 - Penobscot, Piscataquis, Hancock & Washington counties 1-800-227-7706 - Aroostook County 1-800-767-9857 r-··-~~--~~~~;~--~:~·~:;·;~-~---············································1 I Community support: I Agency for Respite: I· I ~-------·--········----------·········-·············-·····--·····---------··························-1 APPENDIX F: Department of Memorandum of A greement MEMORAND UM OF AGREEMENT BETWEEN DEPARTMEN T OF MENTAL HEALTH, MENTAL RETARDATIO N AND SUBSTANCE ABUSE SERVICES AND DEPARTMEN T OF CORRECTIONS PURPOSE The Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) is the lead executive agency responsible for the children's mental health services system. This responsibility includes: system design and implementation, creation and management of local provider networks that provide a full range of services, establishment of a single gatekeeping authority, establishment of uniform standards and procedures, care coordination, monitoring and evaluation. The Department of Corrections (DOC) is responsible for diverting from the correctional system, juveniles referred by law enforcement officers supervising youth on probation, providing care and supervision to youths detained or committed in Maine's juvenile correctional facilities, and supervising youth on aftercare from those facilities. The Departments jointly recognize that many youth in the correctional system have mental health treatment needs, and agree to work together to formalize new roles and responsibilities for each agency in addressing the mental health needs of children in a unified system of care. The following activities will be undertaken during the period 12/15/97-3/1/98, and will culminate in a signed Memorandum of Agreement Implementation Plan by March 1, 1998. 1. The DMHMRSAS/DO C will jointly develop a clinical team to review treatment needs and to develop a plan for the provision of treatment for children committed to the Maine Youth Center, including staffing levels and a budget. 2. The DMHMRSAS/DO C will jointly develop a protocol for intensive case management (ICM) staff positions-in each of the three DMHMRSAS regional offices. ICMs will be assigned to work with regional DOC juvenile caseworkers in assessment and treatment planning for children under supervision of DOC. Relevant clinical information will be shared between the two departments. 3. The DMHMRSAS/DO C will jointly work to develop a secure facility for adjudicated youth who, due to severe mental health disorders, mental retardation or substance abuse issues, would otherwise be inappropriately placed at the Maine Youth Center. 4. The DMHMRSAS will expand its 24-hour crisis response capacity, including the development of additional beds, to assure ability to respond to juveniles under supervision ofDOC. 5. The DMHMRSAS/DOC will jointly develop and implement appropriate cross-training curricula for staff of the two Departments. 6. The DOC will provide the DMHMRSAS clinical team access to adjudicated youth and all appropriate records for the purpose of assessing treatment needs and developing appropriate plans of care for children at the Maine Youth Center. 7. The DMHMRSAS/DOC will work jointly to develop necessary financial and administrative structures and mechanisms to support the above activities and other components of a unified system of care. tJ./11/11 7 Date Date tv)~~ !JaJ; Commissioner, Department of Corrections ~~()~ Commissioner, Depal1ff(ent ofMental Health, Mental Retardation and Substance Abuse Services APPENDIX I Proposed Department of Human Memorandum of A greement DRAFT MEMORANDUM OF AGREEMENT BETWEEN DEPARTMENT OF MENTAL HEALTH, MENTAL RETARDATION AND SUBSTANCE ABUSE SERVICES AND DEPARTMENT OF HUMAN SERVICES The Department of Mental Health, Mental Retardation and Substance Abuse Services and Department of Human Services joint agree to undertake the following activities during the period of 12/15/97-3/1/98, and will culminate in a signed Memorandum of Agreement Implementation Plan by March 1, 1998: 1. The DMHMRSAS will expand the availability of 24-hour crisis services, including crisis beds, for children in foster care and those who come into custody suddenly. 2. The DMHMRSAS/DHS will work jointly to assess the treatment and support needs of mentally ill parents, and to develop appropriate services to strengthen the family and ensure the safety of the child. 3. The DMHMRSAS will establish formal mechanisms to work with the Bureau of Child and Family Services to assure the development of state-of-the-art treatment programs for abused children and for those with severe behavioral problems who need out of home placements. Priority attention will be paid to those children with specific severe behavior disorders who have been or are at risk of being sent out of state. 4. The DMHMRSAS/DHS will work jointly to develop a no reject policy between the state and its providers. 5. The DepartmentswilFwork together to develop and implement cross-training to include, but not be limited to, trauma, abuse, philosophy and legal mandates (federal and state). 6. The Departments will work jointly to develop necessary financial and administrative structures and mechanisms to support the above activities and other components of a unified system of care. Date Commissioner, Department of Human Services Date Commissioner, Department of Mental Health, Mental Retardation and Substance Abuse Services APPENDIX 2: Proposed Department of Memorandum of A greement DRAFT MEMORANDU M OF AGREEMENT BETWEEN DEPARTMEN T OF MENTAL HEALTH, MENTAL RETARDATIO N AND SUBSTANCE ABUSE SERVICES AND DEPARTMEN T OF EDUCATION The Department of Mental Health, Mental Retardation and Substance Abuse Services and the Department ofEducation agree to the following framework for discussion and negotiation of respective responsibilities which will occur during the period of 12/15/97-3/1/98, and will culminate in a signed Memorandum of Agreement Implementation Plan by March 1, 1998. The two Departments agree to: 1. Discuss ways of increasing school staff knowledge regarding access to mental health services, and mental health staff knowledge about the educational system. 2. Define roles and participation of mental health staff on SAT and PET Teams 3. Define mechanisms for access to and utilization of mental health services in addressing mental health needs of children in schools, as identified through the school-based mental health initiative. 4. Work with Child Development Services (CDS) to revise the MOA of 1994 to reflect new federal law and the new DMHMRSASrtation, professional services, recreatio supp orte d employment, supp orte d living, trans and· vou cher . SUBSTANCE ABUSE alcohol and coordinates and evaluates all of the Stat e's nts, leme imp , lops deve s, plan ram prog This activities. othe r drug abuse prevention and trea tme nt OFF ICE OF ADV OCA CY The s and ·grievances of clients of the Department. The Office of Adv ocac y investigates claim and ns, laws, administrativ~ rules and regulatio Office also advo cate s for compliance with all a rights and dignity of these clients, and act as institutional and othe r policies relating to the gnated desi ts. In addition, the Office of Advocacy is monito"r of restrictive and intrusive treatmen Act (22 the mandate of the Adu lt Prot ectiv e Services inve stiga tor ·agent of the Dep artm ent und er · 1-f.R.S.A., Sect ion 347 0 et seq.). 2 DEVELOP.MENT AL DISABILITIES OFFICE The Developmental Disabilities Office provides staff support to Maine State Planning and ng and Advisory Council on Developmental Disabilities. The Office assists the Council in improvi in ages all of persons e.nhancing the network of services available to developmentally disabled Maine. AUGUS TA 1vfENTAL HEALT H INSTIT UTE The August a Mental Health Institute is mandated to treat adults who require intensive 24-hour ec, psychiatric services from the following counties, Androscoggin,. Cumberland, Franklin, Kenneb d Knox, Lincoln, Oxford, Sagadahoc, Somerset, Waldo and York. All services are provide , or without regard to race, creed, color, sex national origin, ancestry, age, physical handicap ability to pay. BANGO R 1vfENTAL HEALT H INSTIT UTE t, The Bangor Mental Health Institute provides patient-centered multidisciplinary treatmen . habilitation and rehabilitation to adults with psychiatric illness severe enough to require psychiatric hospital services and for whom no alternative treatment is available. The Bangor Mental Health Institute serves northern and eastern Maine. AROOS TOOK RESIDE NTIAL CENTE R The Aroosto ok Residential Center operates on a 24-hour per day/seven days per week basis. The Residen ts must be 18 years or older and experiences behavioral adjustment difficulties. aimed at primary purpose of the Center is to provides residential services and behavioral training · These increasing functional dependence to help the adult client live in the mainstream of society. ess, services include teaching basic skills, such as, personal hygiene, daily household cleanlin tion. individual and group social and recreational skills and overall community socializa ELIZA BETH LEVIN SON CENTE R mental The Elizabe th Levinson Center serves mentally fragile children with severe and profound . The program retardat ion, ages birth through twenty, and is a combined·residential and medical children are accepted to the facility through the Interdisciplinary Team {IDT) process and approve d by the Medica id criteria. 3 DESC RIPT ION OF DMHMRSAS AD.MINISTRATIVE UNIT AND ALLOCATION BASES S Commissioner's Office progranuning and administration The Commissioner's Office has the overall responsibility for the e systems. This unit is of the mental health, mental retardation and substance abuse servic on total dollars expended allocated to all program areas and state operated facilities based (Meth od A). Division of Svstems Operations ve Structure that integrates all This Division creates, for the first time, a regional administrati a single point of authority for all disability groups. Regional Directors will provide leadership and tal and community services work behavioral health and developmental services, ensure that hospi ee the development of Local to compliment rather than to compete with each other, and overs program areas and state operated Service Netw orks. The cost for this Division is allocated to all B). The sub-units· of this Division facilities on the basis of the distribution of employees (Method are the three regional offices and Facility Operations. Remo n I. II and ill t Costs are allocated based upon a time study (Method C) excep ution of for the Regional Direc tor which is allocated based on the distrib · , employees (Meth od B). Facility Operations ution Costs are allocated· to state operated facilities on the basis of distrib . of employees (Meth od B). Division of Administration line operations while ensuring This Division will focus on integrating funding sources to stream performance-based mechanisms maintenance of effort for various disability grou.ps, developing The introduction oftechniques and redistributing resources to the most cost-effective programs. ion. The cost for this Division is to bette r manage care will also be the responsibility of this Divis basis of the distribution of allocated to all program areas and state operated facilities on the n Resources, Management employees (Method B). The sub-units for this Division are Huma Care and Consent Decree/Legal Infor matio n Systems, Accounting, Reimbursement, Managed Services. 4 Human Resources Human Resources is responsible for employee relations, benefits management and other personnel related activities for all personnel reimbursed under the DNfHJvfRSAS budget. In addition, Human Resources is responsible for all payroll activities related to D.MHNfRSAS Central Office personnel. The cost for this unit is allocated to all program areas and state operated facilities on the basis ofthe distribution of employees (Method B). The payroll supervisor renders payroll services exclusively to Central Office personnel. The cost of the payroll supervisor is based on employee distribution within Central Office (Method B). Manageme nt Infonnation Systems This Unit exists to design, implement and support information technology throughou t the Department. Encompassed in the mission of this Unit is the selection, installation and on-going support of hardware, networks, desktop productivity software and decision support mechanisms. Because of the ~ distribution of activities within the 1v.ITS unit, the costs are allocated based upon a time study (Method C). Accounting The Accountin g unit reviews and analyzes monthly accounts for all program areas and institutions and monitors the state account for contributing matching funds for Medicaid programs: mental retardation, mental health and children's services. This unit also implements budgeting, monitoring and control and financial manageme nt activities. Maintains accounting and budget control for the state Medicaid "seed" funds for D:MHNIRSAS pro grains eligible for federal match. Because of the distribu~on of activities of the Accounting unit, the costs are allocated based upon a time study (Method C). Reimburse ment This office supports revenue activity related to billing and collections from all payors including third parties for services rendered directly by DMHMRSAS · programs or facilities. Because of the potential distribution of activity across several program areas, the costs for this unit are allocated based upori a time study · (Method C). Managed Care The Managed Care unit is comprised of key staff with financial and program experience. The unit is responsible for coordinating input from stakeholders representing children, adulrmenta l health, mental retardation and substance abuse 5 services to develop a strategy and design for implementation of manag ed care elements in the Depart ment's service structure. Specific functions include staffing the managed care steering committee and subcommittees; researching current program and funding practices and producing reports as needed; drafting design ate proposals for review by senior administration and steering corrunittee; coordin m managed care implementation with DRS staff; work with regional and progra staff to implement design components, etc. Because this unit will design and implement a comprehensive managed care system, the costs are allocat ed to all program areas and state operated fadlities based on total dollars expend ed (Method A). Consent Decree/Legal Services The Office of Consen t Decree/Legal Services is responsible for monito ring the implementation of the Depart ment's three consent decrees; overseeing the public the guardianship progra m and analyzing statutory and regulatory issues involving ement manag Department. The guardianship program, utilizing the statewide case · system, provides services to individuals with ment~l retardation who are or incapacitated, in need qf protective services and who have no family members friend willing or able to serve as guardian. As the guardianship progra m is solely for mental retardation, costs will be directly allocated to the mental retarda tion progra m (Method D). Distribution of activities for the other compo nents of the Office, will be allocated based upon a time study (Method C). Division ofPror ntms g and evaluation, This Division Will strengthen the capacity of the system to do data-based plannin improvement(CQI). to convey a program vision and to implement principles of continuous quality rs in all aspects of CQi efforts will mclude increased involvement.ofconsuiners and family membe m and budget policy making and operations, the use of normative data to trigger intensive progra of clinical and reviews and a variety of trairung and technical assistance activities to bolster levels d B). The technical expertise. Costs are allocated based on distribution of employees (Metho nce and sub-units of this Division are Quality Assurance and Training, Technical Assista ation and Children Consultation, Advocacy and Consumer Affairs, Mental Health, Mental Retard Progra m Systems and Sub.stance Abuse. Oualitv Assurance and Training The Quality Assurance portion of this unit is responsible for coordi nting the progra m monitoring and review activities of the Department. The unit will work l with the Quality Improvement Councils, Program Evaluation Teams and regiona and t shmen offices in perform,ing quality improvement activities, including establi monitoring of client outcomes for services, program evalution and conununity d evalut"ation. Particular emphasis in these activities is given to inform ation provide 6 directly by consm;ners relating to their experiences of the Departmen t's contract servtces. The training portion of this unit will focus on the provision of appropriate in-service training, workshops , consultation in order provide cutting edge information and skill building in the fields of mental retardation, mental health children's services and substance abuse. This effort is aimed at the Departmen t's staff but will also include contractor agency staff and consumers. As part of this· effort, the Departmen t will work in conjunction with the Muskie Institute's Center for Public Sector Innovation to create a Center for Learning. This effort will be in concert with the Departmen t's visions and mission of an integrated and responsive system that listens and responds to the voices of consumers and continues the work of8ystem reorganiza tion. Costs are allocated to all program areas and state operated facilities based on total dollars expended (Method A). Technical Assistance and Consultation The Technical Assistance and Consultation unit is the nucleus for information, training, technical assistance and consultation around specific areas of services that cut across all disability groups including trauma, client-directed service approaches, multicultural issues, deafhess, women's issues and HIV Aids. The team is available for consultation and resource deployment for particular individuals and agencies for the regional offices and local service networks, and across all disciplines including mental health, mental retardation, substan~e abuse, for children, adolescent s and adults. The tea..rll is responsible, when appropriate, for needs assessments, program development and policy direction. Costs are allo:cated to all program areas and state operated facilities based on total dollars expended (Method A). Office of Advocacv and Consumer Affairs Advocacy is responsible for providing case advocacy for the clients in the Departme nnhrough 13.5 positions assigned. The Office provides case study and assessment, case supervision and management for all clients including Medicaid eligible clients, and provides ·direct care consultation to state agencies and courts. Costs are allocate based upon a time study (Nfethod C). Consumer Affairs is responsible for assisting consumers in deve1oping a variety of skills which will help them to become aware of themselves as having lives beyond the limitations imposed by illness and the systems, to raise their level of satisfaction with their own lives by sponsoring programs which allow them to use, improve, or gain recognition .of their gifts and talents. As there are three Consumer Advocates , one for each program, costs will be directly charged to the appropriate ,program · (Method D). 7 Mental Retardation Program Svstems The Mental Retardation Program Systems unit is responsible for the coordination of mental retardation programs and for the planning, promotion, operation and policy development ofthe complete and integrated statewide community programs for persons with mental retardation and autism. The Mental Retardation Program Manager is responsible for the development of clear and effective policies governing the operation of all programs and for providing support to Regional Directors and Regional Mental Retardation Team Leaders in the operation of all programs for persons with mental retardation or autism. Activities performed by the unit include monitoring· services and expenditures under the Home and Community-Base Program waiver and managing case management services. The costs for this unit are directly charged to the mental retardation program (Method D). Mental Health Program Systems The Mental Health Program Systems unit is responsible for planning mentaL.health programming across the State, expanding community mental health programs, encouraging the participation of community residents in these programs, gaining increased understanding of community mental health programs, encouraging the participation ·or community residents in these programs, gaining increased understanding of community mental health needs and securing state and local financial support. The costs for this unit are directly charged to the mental health · program (Method D). Children Program Systems The Children Program Systems unit is responsible for serving "children in need of treatment" with particular reference to children aged 0 to 5 years who are developmentally disabled or who demonstrate developmental delays, and to children aged 6 to 20 years who have treatment needs related to mental illness, mental retardation, developmental disabilities or emotional and behavioral needs that are not under current statutory authority of existing state agencies. Activities includ·e managing case management services. The. costs of this unit are dire~tly charged to the children's services program (Method D). Substance Abuse The Substance Abuse unit develops comprehensive plans for combating alcohol and drug abuse and established operating and treatment standards. It provides training, consultation, technical assistance and service delivery strategies to help schools and communities reduce the problems attributable to tobacco, alcohol and other drugs, DEEP provides or oversees education, evaluation and/or treatment for all Oill offenders in the State of Maine in order to lessen the incidences of 8 injury and fatalities which result from drinking and driving. The costs for this unit are directly charged to the substance abuse program (Method D). State Forensic The Forensic Evaluation Office evaluates the mental health of persons who have committed crimes and the court req~ires a judgment as to whether an individual is competent to stand trial. Because of the potential distribution of activity across several program areas, the costs for this unit are allocated based on a time study (Method C). 9 ALLO CATI ON BASE S AND PROC EDU RES Meth ods ntage of total costs. A. Alloc ation of costs based upon each unit/p rogra m perce distributed acros s Depa rtmen t B. Alloc ation -of costs based upon the perce ntage of perso nnel sub-units. selected days in each quarter, C. Alloc ation of costs based upon a time study of 10 randomly ent progr am areas. based upon the time spent of available work ed hours on differ ties relate exclusively to that D. Charg ed directly to a partic ular progr am because all activi partic ular program. 10 APPENDIX I: Draft Managed Care Plan DRAFT: DECEMBER 5, 1997 DEPARTMENT OF MENTAL HEALTH, MENTAL RETARDATION AND SUBSTANCE ABUSE SERVICES REPORT ON MANAGED CARE PLAN TO THE HEALTH AND HUMAN SERVICES COMMITTEE BACKGROUND The Department of Mental Health, Mental Retardation and Substance Abuse Services (the Department) has explored the potential for funding and administering services through a managed care plan over the past two years. This is consistent with the Department's recognition that better organized systems for the delivery and financing of ser\rices will lead to reduced gaps in services, less reliance on the most restrictive of service options and more opportunity for higher quality and more individualized care. The creation oflocal service networks in seven regions of the state (c. 691, PL 1995) was the first step in this process. Since then the Department, in partnership with the Department of Human Services (DHS), has further explored the potential for managing benefits (services) covered by the state Medicaid plan for persons who are eligible for Medicaid. At present the two departments are preparing a Waiver proposed to enroll select Medicaid recipients in a program which will allow for prior authorization, to access all necessary behavioral health services 1 within the capitated benefit package. The Department is proposing the necessary changes in -its delivery system and infrastructure to manage all behavioral health services for persons who are enrolled in Medicaid. This process will require changes in policy, financing and programs over the next several years. Managing the behavioral health benefit for persons who are Medicaid recipients is an initial step towards implementing a managed care strategy for many of the Committee in Department's recipients. The Department created a statewide Steering . 1996 to advise on the development and implementation of this initiative. This Committee is made up of consumers, family members, representatives ofDHS, the Department of Education, DMHMRSAS and other statewide provider and advocacy organizations and providers. . The Current System · The current Medicaid behavioral health system is comprised of general hospitals and other inpatient facilities; clinics; individual practitioners; community mental health centers; and substance abuse agencies. Services provided by these agencies include: 1behavioral health is a term used to describe mental health and substance abuse services behavioral health services while other states are requiring local or regional management of behavioral health services. This approach is different than the private sector models used in Iowa, Massachusetts, New Mexico, Tennessee and as used by Maine's DHS for primary healthcare. The primary difference between the public and private sector managed care systems is the utilization of the existing public system. Public sector managed care systems often re-invest savings into the service system rather than paying large profits to for- profit vendors. Public sector managed care systems also have a stronger, oversight and leadership role of the state mental health/ substance abuse authority. The major difference between the DHS model and the DMHMRSAS model is reflected in this distinctiol'!. In Maine, DMHMRSAS has basic responsibilities for persons who are not Medicaid eligible who also need their care managed through this system and has responsibility for expenditures of non-Medicaid funds for services not reimbursable by Medicaid for persons who are eligible. DMHMRSAS also has significant legal responsibilities for behavioral health services for those who are Medicaid eligible thus making the public sector model more desirable and warranted. DHS does not have the same responsibilities or system to manage. The Department's Basic System Design Below is a description of the Department's proposed Medicaid managed care program. Included is a description of eligible populations, enrollment requirements, covered services, access and gatekeeping requirements, appeals, the financing model, and the responsibilities ofDMHMRSAS, the statewide Administrative Services Organization and Network Managers. In addition, the selection process for Network Managers and the Administrative Services Organization is described below. Eligible populations The Department is proposing to assume the responsibilities for managing the behavioral health benefits currently administered by the Department of Human Services for select Medicaid recipients. The targeted Medicaid recipients who would be included in the proposed initiatives would include: • • • • • • • Aid to Families with Dependent Children-(AFDC). AFDC-related. Supplemental Security Income (excluding individuals over the age of 65). SSI-related (excluding individuals over the age of65). SOBRA eligible children and pregnant women. Transitional Medicaid eligibles. Children eligible for Medicaid who are under protective custody • • • • • communication and physical accommodation; choice of providers where available; access to on call services during non business hours; culturally competent services; and reimbursement for out of pocket expenses to get to service locations. Care Coordination includes the gatekeeping responsibility, care coordination for all enrollees including intensive care management for individuals at high risk, referral and discharge planning and arrangements for high cost care. Gatekeeping includes determining the appropriate level and type of care for each person needing service, assignment to the agreed upon service ad provider for specifically agreed upon times, and planning for follow-up care. Arrangements will be made for case management. The enrollee's functional level, risk, history and diagnosis will determine the type and amount of case management and other services provided. Appeals Enrollees may appeal any service-related decision including admission, continued stay, termination and level of care. For example, if the appeal is concerning a decision made about emergency services, the appeal must be reviewed and a decision made within one hour. For urgent services, the decisions must be made within twenty-four hours. For routine services, the decision must be made within one week. Financing Model The Department will be fully capitated for a carve out of behavioral benefits. The Department will be responsible for meeting the federal and state capitation requirements. The Department will enter into a performance contract with Network Managers as described below and Network Managers will be responsible for contracting for a full array of services for Medicaid enrollees living in the designated geographic area. Those contracts will be fee for service contracts. In addition, the Department will enter into a contract with a qualified vendor who will assist the Department in meeting risk requirements and providing infrastructure support as described below. ), The capitated amount the Department receives will be based on funds spent for approved services (benefits) in a base year to be determined by DHS and the Department and approved by HCFA. The amount will be carved out of the DHS capitation for its mandatory Medicaid managed care program and transferred to the Department. For example, if the amount spent for behavioral health benefits in FY 1996 was $168 million and FY 1996 was determined to be the base year, then that amount would be the amount capitated to the Department. As part of a Waiver agreement with HCFA, the state would determine what amount of that capitation was to be saved. Generally, states are asked to save 5%, which is taken offthe top by HCFA. At the same time, HCFA will approve an • • agreements, uniform discharge planning, assignment of case managers and use of uniform intake and assessment tools and standardizing treatment planning. This also includes assuring low incidence and specialty services will be made available and arranging for out-of-network services. Procurement and Contracting for Services - Network Managers will contract for services with eligible providers. Network Managers will assure that providers will comply with performance requirements. They will credential providers, reimburse providers and assure flow of information to assure services can be properly authorized and verified. Appeals- Network Managers will be responsible for responding to all appeals by providers and recipients regarding service decisions within the timeframes established by the Department. If the provider or recipient is not satisfied with the result of the appeal the Department will be responsible for resolving such appeals. Administrative Services Organization The Department is proposing that these benefits be managed separately from the general health benefits administered by DHS through health maintenance organizations. The initiative will be managed statewide through a contract between the Department and one qualified administrative services organization (ASO). The Department will enter into a risk-comprehensive contract with the administrative services organization. The administrative services organization will be responsible for the following functions: • Utilization management service authorization - The ASO will be responsible for performing service authorization functions for all behavioral health benefits. Specifically, the vendor will be responsible for pre-authorizing all requests for mental health and substance abuse admissions to inpatient hospitals and authorizing requests for services for all outpatient and community services identified above. • Payment Authorization/ Claims processing - The ASO will be responsible for developing and administering the claims submission process for all credentialed providers. In addition, the ASO will be responsible for adjudicating claims against services authorized and be responsible for reimbursing providers. The ASO will also establish and negotiate rates for services in the benefit package. the Department and DHS will provide the necessary guidance and oversight on the rate setting process developed by the ASO. In addition, the ASO will comply with the necessary state and federal guidelines for processing claims. The ASO will also be responsible for verification of Medicaid eligibility with the Department of Human Services. • Developing Management Reports - The Department will need to monitor the activities of its vendor and the behavioral health system. It is proposed that frequent management reports will be necessary to assure proper oversight and monitoring. At a minimum the Department will request the following reports from its ASO: • Utilization and expenditure reports