October 29, 2008 Patients Rights Advocate Training Presenter: Hank Hallowell, Sonoma County Patients’ Rights Advocate A Brief Overview of County Mental Health Services

1991 Bronzan – McQorkuodale Act CA Welfare & Institution Code 5600 AKA Realignment  Passed in response to continuing mental health budget uncertainties  Reorganized the funding and focus of public mental health servicer

Funding Provisions  Created a dedicated Revenue stream outside of the general budget process that was funded by an increase in state sales tax and vehicle license fees  Trust funds set up for mental health, public health and social services in each county  Expectation was that economic growth would help revenue keep up with inflation. Established a formula for determining how revenue growth would be divided up.

Funding Provisions (Continued) Provided more flexibility for counties in how money could be spent as well as provisions that encouraged longer term planning (no “use it or lose it”) Allowed local Board of Supervisors to O.K. the reallocation of no more than 10% among the 3 trust funds Required a “maintenance of effort” for county contribution

Performance Contract with DMH (WIC 5650) Replaced the Annual County Short Doyle Plan with a contract that specified, among other assurances, that;  The county would provide services to persons receiving involuntary treatment  The county shall comply with all provisions and requirements in law pertaining to patients’ rights  The county comply with other state and federal laws, report specific data, meet all the various requirements and rules necessary for MediCal, reimbursement etc.

Performance Contract with DMH (Continued)  The local Mental Health Board has reviewed and approved procedures ensuring citizen and professional participation at all stages of the planning process

Program Reform Mandated the provision of client centered and culturally competent services in an integrated system of care targeted to seriously and persistently mentally ill children, adults, and older adults Created “performance outcome measures” to gauge the effectiveness of such services.

Program Reform (Continued) Implemented in statute the California State Master Plan (AB 904) Services were to be provided “to the extent resources are available.”

Target Population - Adults with serious and persistent mental disorders “Persons with the existence of a mental disorder which is severe in degree and persistent in duration which may cause behavioral functions which interferes substantially with the primary activities of daily living, and which may result in an inability to maintain stable adjustment and independent functions without treatment, support, and rehabilitation for a long or indefinite period of time”

Target Population (Continued) The person shall Have a DSM identifiable diagnosis - - other than substance abuse disorder or developmental disorder or an acquired traumatic brain injury.. And, as a result of the mental disorder has substantial functional impairments or symptoms, or a psychiatric history demonstrating that without treatment there is an immanent risk of decomposition to having substantial impairment or symptoms

Target Population (Continued) And – As a result of a functional impairment and circumstances the person likely to become so disabled as to require public assistance, services or entitlements

Target Population – Seriously Emotionally Disturbed Children or Adolescents A minor under 18 with psychiatric diagnosis, other than primary substance abuse disorder or developmental disorder, which results in behavior inappropriate to the child’s age according to expected developmental norms. Members of this target population shall meet one or more of the following criteria;

Target Population – Seriously Emotionally Disturbed Children or Adolescents (Continued) 1) As a result of the mental disorder has substantial impairment in at least two of the following areas  Self Care  School functions  Family relationships  Ability to function in the community

Target Population – Seriously Emotionally Disturbed Children or Adolescents (Continued) And either of the following;  A) the child is at risk of removal from home or has already been removed from the home  B) The mental disorder and impairments have been present for more than six months or are likely to continue for more than a year without treatment

Target Population – Seriously Emotionally Disturbed Children or Adolescents (Continued) 2) The child displays one of the following:  Psychotic features  Risk of suicide  Risk of violence due to mental disorder 3) The Child meets special education eligibility requirement as specified

Consolidation of Medi-Cal Fee-for-Service Combined Medi-Cal Fee-for Service System and the county Short-Doyle Medi-Cal System Counties given their portion of the state match for the Federal Financial Participation (FFP) Counties offered right of first refusal to become the local Mental Health Plan Agreed to met the mandated guidelines for participation

Consolidation of Medi-Cal Fee-for-Service (Continued) The local MHP became providers of both psychiatric inpatient services as well as for specialty mental health services. Specialty Mental Health Services are services for people with mental illness or emotional problems that a regular doctor cannot treat. 1) Title 9 CCR, et seq

Local Mental Health Plans are responsible for Informing and educating Medi-Cal recipients about the availability and methods of accessing specialty mental health services Providing written information and forms in various languages, as well as services in language of choice, and that interpreter services are available at no charge to the recipient. Screening and assessing Medi-Cal recipients to determine if meet “Medical Necessity” for receiving services

Local Mental Plans are Responsible for (Continued) Maintain an appeal and a grievance process that meets regulatory requirements

Medical Necessity for Non-hospital Speciality Mental Health Services: Medi-Cal beneficiary must meet all the following criteria: 1) Must have a covered diagnosis

Medical Necessity for Non-Hospital Specialty Mental Health Services (Continued) 2) Must have at least one of the following impairments as a result of the qualified diagnosis (es)  A significant impairment in an important area of life functioning  A probability of significant deterioration in an important area of life functioning  Children also qualify if there is a probability the child will not progress developmentally as developmentally appropriate (child is a person under 21 years old).

Medical Necessity for non-hospital Specialty Mental Health Services (Continued) 3) And must have each of the intervention criteria below  Focus of the proposed intervention addresses the condition identified in # 2  Expectation that proposed intervention will Significantly diminish the impairment Or Prevent significant deterioration in an important area of life functioning Or Allow a child to progress developmentally as individually appropriate

Medical Necessity for non-hospital Specialty Mental Health Services (Continued)  And the condition would not be responsive to physical healthcare-based treatment

Services “Required” Entitlement Mental Health Services:  Including mental health treatment services provided by licensed clinicians as well as rehabilitation or recovering services that assist persons with developing coping skills for daily living. May be provided in clinic or community, individuality or in a group

Services “Required” Entitlement (Continued) Medication Support Services Targeted Case Management Crisis Intervention and Crisis Stabilization Adult Residential Treatment Services Day Treatment Intensive Day Rehabilitation Psychiatric Health Facility Psychiatric Inpatient Hospital Services

Grievance System A Grievance is an expression of unhappiness about anything regarding specialty mental health services (and isn’t an issue covered by the Appeal and Fair Hearing processes.

Grievance System (Continued) Grievances: May be filed at anytime May be filed orally or in writing, if filed orally it does NOT have to be followed up in writing May authorize someone to act on his/her behalf Grievance forms and self-addressed envelopes must be available at all provider sites

Grievance System (Continued) Decision makers must be qualified to make a decision (if clinical) and not involved in any previous level of review or decision-making A written confirmation that grievance has been received shall be sent to the beneficiary. Grievance shall be entered into “Grievance Log” that is reviewed by state

Grievance System (Continued) A decision regarding the grievance must be made with in 60 days, with a possible two week extension The beneficiary is notified in writing as to the decision A Notice of Action is sent to the beneficiary if the timeline is not met

Appeal Process An appeal is a request to review a decision made by the Mental Health Plan or your provider about your specialty mental health services. Generally will be about a denial or change of service Standard Appeal  Must be written and signed  Services may continue if the appeal is within 10 days of a notice of action (if received)

Appeal Process (Continued)  Have reasonable opportunity to review records and information and present evidence in writing or in person.  May take up to 45 days to review  Receive written notice that the appeal is being reviewed, that you have a right to a State Fair Hearing following the Appeal Process, as well as the notice of the decision.

Appeal Process (Continued) Expedited Appeal  May be requested if waiting for 45 days will jeopardize life, health or ability to maintain or regain maximum function.  If does not qualify for expedited process will be notified within 2 days orally and in writing. May file a grievance  If expedited process is granted will resolve with 3 working days, though a 14-day extension is possible

Notice of Action May receive a notice of Action if:  Upon assessment, person does not qualify for specialty mental health services  MHP changes the type or frequency of services  MHP terminates specialty mental health services  MHP does not meet required timeline in the grievance or appeal process

Notice of Action (Continued) Are generally triggered by the authorization process so many clients getting services directly from the county will not receive Notice of Action. There are lots of reasons why people may not get a N.O.A.

The Client Plan – or Service plan or care plan The Annual Plan upon which all individual’s services are based Goals, objectives and interventions identified by client and staff Must be signed by the client For reimbursement all service notes must match goals and interventions Can be amended during course of year

Medi-Cal Administrative Activities Claiming for activities associated with the administrative Activities include outreach, training, planning, quality assurance, quality improvement  Reimbursements rates differ depending upon whether all Medi-Cal clients or only some  Reimbursements rates differ whether or not provider is licensed (SPMP-skilled professional medical provider)

Other Populations Receiving Services Early and Periodic Screening Diagnosis and Treatment Services - - Medi-Cal funded services for children, youth and adolescents up to 21. Includes Therapeutic Behavioral Services Cal-Works – Medi-Cal beneficiaries enrolled in the Cal-works program through (TANF) Provides services to overcome mental health barriers to work.

Other Populations Receiving Services (Continued) AB3632 – Mental Health services that enable children/youth to benefit from their public education ConRep Services – State funded program that provides treatment services and supervision to certain persons on forensic status Local Forensic Services – may provide mental health services in local jails, and detention facilities – may be funded by Mental Health or criminal justice. AB 2034 Program-services to homeless target population clients who are not “open” to the system.

Rationing Care - Strategies Clinical ____ Balance ____ Fiscal risk = Amount & type of services

Rationing Care – Strategies (Continued) Limiting access of non-target population clients and redirecting to other systems – like federally qualified health clinics (FQHCs) Limiting access to uninsured clients – though have a mechanism to get them on benefits ASAP Shift Medi-Cal recipients to physical health care system – no longer meet “medical necessity”.

Current Trends Cost of providing services increases Lack of growth in realignment MHSA funds new “full partnership” and outreach services can’t be used to supplant existing services Increase in Medi-Cal population means more core funding diverted to those services

Current Trends (Continued) Los Angeles County – $125 million in MHSA funds - $70 million short-fall in core mental health budget Santa Clara County - $19 million in MHSA funds for $17 million cut from core mental health budget Fresno County - $8.6 million in MHSA funds - $8 million cut in core Mental health budget * Budget information from LA Times “New Funds, enduring ills” by Gold & Romney 9/16/07

Approaching a Two-Tiered System “Full-partnership” services from MHSA funded programs Fewer & fewer services available to other target-population clients

Other Topics? Questions? Thank You