Money Follows the (Whole) Person Relocating Nursing Home Residents with Serious Mental Illness to the Community Helen Eisert, LCSW University of Texas Health Science Center at San Antonio Dena Stoner, Senior Policy Advisor Texas Department of State Health Services Kim Arambula, RN United Healthcare

Topics Context and Overview of the Money Follows the Person-Behavioral Health Pilot (MFP-BH). Assessing the potential for an adult with mental illness to live in the community. Utilizing Cognitive Adaptation Training and substance use services to increase independent functioning.

The Big Picture People with severe mental illness live 25 years less than other Americans and have more health problems earlier in life. 1 National data indicates that large numbers of nursing facility residents have a primary diagnosis of mental illness, with a disproportionate number being under the age of In 2007, over 7,000 Texas nursing facility residents were former clients of the public mental health system. The public mental health system in Texas serves only a fraction of people with severe mental illness. 3

Unmet Needs in Texas Texas Population (18+): 19,207,256 Estimated number with serious and persistent mental illness: 499,389 Number served in DSHS-funded Community Mental Health Services: 156,642 (31% need met)

The Challenge Since 2001, over 36,000 Texans have returned home under the State’s MFP program and the Texas MFP Demonstration. Despite this impressive achievement, many people with mental health and substance use disorders remained in nursing facilities. Nursing facilities are generally not optimal environments for people to recover from mental illness.

Texas MFP History 1999 – Supreme Court Olmstead decision. Governor’s order – State legislation passes. Texas’ MFP program begins – National MFP Demonstration authorized by Congress – State awarded federal grant. TX MFP Demonstration begins, including the Behavioral Health (BH) Pilot (AKA “the BH Pilot”) – BH Pilot expands from the San Antonio area to Austin and additional counties.

Sam’s Story

Sam 65 year old male with a behavioral health diagnosis of Bipolar Disorder and Dementia. Transferred to the nursing facility a year ago after suffering a traumatic brain injury due to a suicide attempt. He utilizes a wheelchair and can sometimes transfer. Some NF staff feel he can do more. NF social worker did not feel Sam could leave the facility. He has always lived in group homes or with family. His only family now is a brother in Oregon. He has never managed his money. Although he is verbally aggressive at times, he seems to establish strong relationships with staff at the nursing facility. He is not sure he will be successful moving out, but “really wants to try.”

Discussion What concerns might you have about Sam moving into an apartment by himself? What type of information would be important for you to share with any worker assisting him in relocation back into the community? What individual strengths might help Sam be successful in his own apartment?

Video #1

Behavioral Health Pilot

MFP BH Pilot Goals Transition adults with severe mental illness and/or substance abuse disorders from nursing facilities to the community. Successfully support individuals in the community by integrating mental health and substance abuse services with long term care services and supports. Result in positive, long-term changes to the Medicaid system.

BH Pilot Scope Includes adults with mental health or substance use conditions and functional limitations who have resided in a nursing facility for 3+ months. Partnership of Medicaid, Mental Health and Long Term Care systems is key.

Getting Stuck! Housing Income Documents Behavioral Health/Substance Use Issues Transportation

BH Pilot Services Pre-Transition Services – Participants can receive up to six months of services while they are still in the nursing home. Transition Services – Participants can receive up to one year of services in their home once they have moved out.

Basic MFP Services Service Coordination Relocation Assistance Health and Long Term Services

MFP Services with BH Pilot Service Coordination Relocation Assistance Health and Long Term Services BH Services – Cognitive Adaptation Training – Substance Use Services

Participant Characteristics Age range from 27-89, with an average age of Complex needs (mental, physical, social). High level of medical vulnerability. Sense of self and problem-solving skills compromised by institutionalization.

Participant Characteristics (con’t.) Common mental health issues – Depression – Anxiety – Bipolar – Schizophrenia Many participants have two or more mental health/SUD diagnosis.

Rehabilitative/Recovery Services

Cognitive Adaptation Training (CAT) Evidence-based psycho-social intervention. Uses a motivational strengths perspective to facilitate person’s initiative and independence. Provides environmental modifications (e.g., calendars, clocks, signs, organizers) to help people bypass cognitive challenges and organize their environment and function independently.

Compensating, Not “Curing” The techniques and strategies that persons learn through Cognitive Adaptation Training (CAT) enable them to mitigate issues with executive function, attention, memory, and psychomotor speed. CAT helps persons increase their performance of ADLs, social function, and occupational function. CAT does not cure cognitive issues; it helps the person function better with them (similar to how glasses can help a person see better, even though they do not “cure” the eyes’ condition).

CAT Intervention Categories Hygiene Medication Management Orientation Money Management Transportation Eating/Nutrition Cooking Toileting Dressing Housekeeping Social Skills Stress Management Vocational Skills

Customized to Behavior Apathy – A person does not start necessary activities without being told or does not complete all the steps. – Prompting and cueing to complete each step in a sequenced task. Disinhibition – A person acts in a way that is not appropriate to a situation, gets easily distracted, or behaves very impulsively. – Removal of distracting stimuli and cues for inappropriate behavior. Mixed – Both prompting of steps and removal of distracting stimuli.

Customized to Executive Functioning Poor - Cues must be larger, more proximal, more numerous. Fair - Cues can be more subtle cues, less proximal.

Apathetic – Fair Executive Function

Disinhibition – Fair Executive Function

Apathy – Poor Executive Function BeforeAfter

Assessments Completed by a rater at the time of relocation and every three months after relocation up to one-year post- discharge from the BHP. These assessments are completed separately from the CAT therapist. An environmental and functioning assessment completed by the CAT therapist upon move-out.

Video #2

Substance Use Services

Substances of Choice 44% have alcohol dependence. 20% have opioid dependence. 14% have cocaine dependenc e. 10% have cannabis dependence. 7% have poly-substance dependence. 5% have amphetamine dependence. 84% use tobacco. 45% have 2 or more active SUDs.

Problems with Pain Dosage in facility often unsustainable in the community. Clients must have separate pain management. Problematic when using other substances such as marijuana or alcohol.

Stages of Change Pre-contemplation: 20% Contemplation: 39% Preparation: 16% Action: 11% Maintenance: 14%

Services Assessment Individual & Group Counseling Tobacco Cessation Counseling Peer Support 24-hour On-Call Support Motivational Interviewing Harm Reduction Person-centered care planning Interdisciplinary team approach Home-based and in facility

The Team Approach Collaboration with providers with mutual clients essential. Valuing the diversity of perspectives. Real time support in the field invaluable.

Outcomes To date, 71% of individuals in the Pilot have maintained independence in the community. Success post-discharge is being evaluated. Preliminary analysis indicates that Medicaid costs for participants are lower on average than costs prior to their discharge from the NF.

MFP-BH Outcomes MCAS Score (p less than.0001): Baseline: 56 Treatment: 60 QLS Score (p less than.001): Baseline: 53 Treatment: 57 SOFS Score (p less than.01): Baseline: 35 Treatment: 39 Results indicate a significant improvement in targeted functional outcomes post facility discharge in all clinical outcome assessments.

Assessing for Relocation Needs

Assessment for Relocation Needs

Relocation Process

Relocation Services CAT – Weekly meetings with CAT Therapist in NF. – CAT interventions as needed in NF. IDT – NF Care Plan meeting with relocation partners. – Concerns addressed with client and plan made. Move – Discharge planning meeting. – Start of Care day set.

CAT Assessment/Intervention Client must “drive” the process. Set small, achievable goals. Introduce basic CAT interventions to increase independence and client awareness (e.g. calendar, checklists). Collaboration with NF staff essential.

Role of Personal Bias in Assessment

Other Observations About Sam Very open to CAT interventions. Willing to try new things. Use of humor. Personal resilience. Personal resources.

From Institution to Art Gallery

Video #3

The Pilot Today Over 291 people have been served since Over 140 have completed a year of Pilot services. Project findings have been recognized and published in national journals. Examples of increased independence include getting a paid job at competitive wages, driving to work, volunteering, getting a GED, teaching art classes, leading substance use peer support groups, and working toward a college degree. Eight participants have achieved gainful employment, five have returned to school, and over 20 began volunteering. Fifteen participants are working towards employment.

The Future TX Medicaid mental health and substance abuse services for people with severe illness are transitioning to managed care. TX could include the Pilot services in its managed care long term services and supports system. Thousands of Texans could benefit. Texas is sharing results nationally to inform federal policy changes that support independence, recovery.

Questions?

Contact Information Dena Stoner, Senior Policy Advisor Texas Department of State Health Services (512) Helen Eisert, LCSW, Program Coordinator UT Health Science Center (512) Kim Arambula, RN, Manager United Healthcare