Money Follows the (Whole) Person The MFP Behavioral Health Pilot Dena Stoner, Senior Policy Advisor Texas Department of State Health Services 25th Annual HCBS Conference, Denver, CO

Long Term Care: Traditional View 2

A Dose of Reality People with severe mental illness live 25 years less, on average, than other Americans and experience health problems earlier in life. 1 Over 7000 people in Texas nursing facilities in 2007 were former mental health or substance abuse clients. In San Antonio, over 640 NF residents were former clients. 2 Over 350 people (most under age 65) were discharged from Texas State Hospitals to nursing facilities in Former MH and SA clients represent a subset of the people with mental health and substance abuse disorders in nursing facilities. 3

In Other Words… “The future ain’t what it used to be.” -Yogi Berra 4

Behavioral Health Pilot Pilot Site: San Antonio (Bexar County) Goals: —Transition adults with mental health and / or substance abuse disorders from nursing facilities to the community. —Successfully maintain individuals in the community. —Improve systems of care for long term care clients who also have these disorders. —If the pilot is successful, Texas will consider amending its adult nursing facility waivers to include the demonstration services.

Fitting It All Together Health and Human Services Commission (State Medicaid) through 1915(b)(c) waiver —Acute and long term care (HMOs) —Service coordination (HMOs) Department of Aging and Disability Services —Eligibility verification (local staff) —Relocation assistance (center for independent living) Department of State Health Services (MHSA Authority) —Demonstration MH and SA services (local contracts) 6

Pilot Scope Up to 50 participants per year can be included in the Pilot. In addition to existing HCBS, acute care services and care coordination, Pilot demonstration services include: —Substance abuse services —Cognitive Adaptation Training (CAT) Pilot services are provided through a contract with the local mental health authority (Center for Health Care Services). Technical assistance regarding CAT is provided by the UT Health Science Center in San Antonio. 7

Participants Adult in nursing facility. Has resided in Medicaid nursing facility for six months or more. Consents to MFP Demonstration and meets criteria for it. Desires to reside in the community (Bexar County). Meets mental health/substance abuse adult population criteria: —GAF score =<50; and at a behavioral diagnosis, OR: —DSM IV – R substance abuse disorder, OR —Diagnosis of severe mental illness (schizophrenia, bipolar or major depressive disorder).* *A diagnosis on file in the state MHSA system or a diagnosis by an MD. 8

Demonstration Period Federal demonstration match available for: 180 days while participant resides in NF (pre-transition services), and 365 days after participant leaves the Nursing Facility (intervention period). 9

Substance Abuse Services Individual and group counseling. Pharmacotherapy – opiate addiction. Maintenance/aftercare. Linkage to community resources. 10

Cognitive Adaptation Training Evidence-based service. Provides assistance and environmental modifications to help people establish daily routines, organize their environment, and function independently. Uses motivational interviewing to facilitate the person’s initiative and independence. Coordinated with HCBS services. 11

CAT Interventions: Dressing ApathyDisinhibition Mixed 12

CAT Interventions: Organization Did I take my medication today? 13

Timeline Operations Phase: April 2008 – September 2012 —Service delivery. —Create and adjust. —Sustainability analysis. —Sustainability plan. Phase-out: September 2012 – September 2013 —Cease intake. —Phase-out activities. —Final evaluation completed. 14

Challenges Relocation: outreach, housing. Coordinating enrollment, IT and services across multiple organizations. Complex needs. 15

“Care” vs. Recovery Behavioral health conditions are cyclic and require intermittent or on-going support throughout life. Current HCBS waiver eligibility rules contradict the goals of recovery (require an institutional level of care). Recovery requires rethinking the relationship between long term care, mental health, employment, housing and other supports. Individuals in recovery may need a continuum of residential options over time to become independent. 16

Progress 72 people referred to Pilot. 24 people are in service currently. —20 returned to the community:  20 receive CAT.  10 also receive substance abuse. —4 receive services in the nursing home (substance abuse and CAT). 20 awaiting enrollment. 17

A New Perspective 18

Brenda Brenda has several mental illnesses and abused alcohol. She was admitted to a nursing facility after being hospitalized for the consequences of substance abuse (cirrhosis, Hepatitis C, anemia). Alcohol induced dementia, made it hard for her to care for herself. The relocation specialist found her an apartment and obtained furniture and household supplies. Her HMO service coordinator requested CAT and substance abuse services. The CAT therapist worked with Brenda and her personal attendant on daily tasks such as taking her medications, managing money, and keeping medical appointments. 19

Brenda (con’t.) Her physical health has improved significantly. She now receives individual substance abuse counseling. She is maintaining her health, takes pride in her independence, and will begin taking a computer class in the community. She is engaging in more leisure activities and looks forward to obtaining a paid job. 20

Ernest Ernest was admitted to a nursing facility due to severe respiratory problems resulting from a history of abusing street drugs. Ernest wanted to leave the nursing facility, move into the community, and join a program to help him cope with his long history of substance abuse. The HMO Service Coordinator requested MFP Behavioral Health Pilot services (CAT and Substance Abuse). The HMO, relocation contractor, and Behavioral Health team met with Ernest in the nursing facility to discuss the program and his transition to independence. 21

Ernest (con’t.) After securing an apartment, he began receiving CAT services. He now has independence over his decisions and living situation. He has been paying his bills on time, and recently established a savings account. The CAT therapist helped him learn to attend medical appointments, schedule transportation, and register for school. Ernest began volunteering at the nursing home where he used to live. The HMO provided him with personal and nursing care. He remains sober and will be starting school in the summer to become a nursing facility Activity Director. 22

Lessons Learned Mental health and substance abuse services can be integrated into long term care systems. Service coordination and communication are key. Mental health and substance abuse services should begin before discharge from the nursing facility. Substance abuse is a significant issue in long term care. Life goals are important to maintaining health. More housing access/options are needed. 23

For Further Information Project Director: Project Manager: