June 2004 NACBHDD Newsletter
The Newsletter of the National Association of County Behavioral Health and Developmental Disability Directors
In this Issue...
NACBHD Organizational Update
The Membership Directory
NACBHD is most appreciative of your willingness to participate in the construction of a membership database, derived from the Member Directory section
of the website. While many of you have updated your contact information, quite a few of you have not yet taken the opportunity to do so. A solid
membership database increases our ability to communicate effectively and efficiently in all NACBHD operations (e.g. conference registration, dues
payments, membership services).
Dues Information
NACBHD is also most appreciative of membership responses regarding 2004 dues payments. While this effort may have been tedious, it also benefits NACBHD
future capabilities and infrastructure development. Many thanks for taking the time to update this important information.
Ninth Annual Conference:
Developing New Leaders for the Future
Ritz Carlton, Phoenix, Arizona, July 15-17
This conference will be a high point in NACBHD’s transition this year. New partnerships are being developed with other advocacy groups. We look forward to a conference that will strengthen NACBHD’s role in the Washington community and illustrate how the membership can bring knowledge and expertise to its behavioral health partners. Conference planning will be a NACBHD priority for the next few weeks, with session abstracts finalized and speakers confirmed.
Register online! Hopefully, you have received a hard copy of the preliminary conference agenda and registration form or you have visited the NACBHD website to register online. If you haven’t done so already, please take a few minutes to register now for the Conference. NACBHD members should be pleased with what they take back from this event.
Washington Update: From Executive Director Melissa Staats
Since the May Washington Update, please note the following:
Budget Resolution Likely
Chief of Staff for a House member reports that the budget resolution will pass sometime late today—May 18, 2004. However, h/she also notes that, “All
that does is set out a roadmap for how other spending decisions will be made on appropriations and tax bills, essentially setting targets for how much
we can spend. Under the terms of the budget resolution, virtually all spending programs will be held to increases that are insufficient to cover the
cost of inflation. However, it is possible -- and likely -- that the final appropriations bills will exceed those targets -- it's an election year after
all.” Advocates report that the “reconciliation instructions were dropped from the budget resolution, so there are no reconciled spending cuts for
Medicaid. However, the cuts are still assumed in the budget--but they are not mandated.” Therefore, it looks like Medicaid cuts will not be imposed.
While advocates are feeling that this is a victory—and it is—there will continue to be threats to this program.
At the time of this writing, this was accurately reported. However, a budget resolution has not been passed. The absence of the resolution does not prevent appropriations activities. In fact, both the House and the Senate have started working on appropriations.
Key Issues in House Budget Debate Center on Budget and Policy Priorities
Congress also passes legislation that deals with the budget process. Pay-as-you-go rules have been causing great debate between the House and the
Senate and have proven to be a major roadblock in securing a 2005 budget. Pay-as-you-go rules were first imposed in 1990 and specified that both
the entitlement increases and tax cuts had to be paid for. The Center on Budget and Policy Priorities report released on May 17, 2004 describes
two pieces of legislation that amend the 1990 law and their potential impacts on entitlement programs. “HR 3800 and HR 3925 would both reinstitute
pay-as-you-go for entitlement programs, but exempt tax cuts from those rules. The rules then act almost as caps (e.g. no expansion without cutting
another entitlement program) and would likely force substantial reductions in domestic discretionary programs in the years ahead.”
Both bills have good support in the House, but no Senate sponsorship. However, advocates believe that at least one of these bills could come to the House floor for a vote—in response to promises made earlier regarding agreement in the budget resolution process.
Family Opportunity Act of 2004 (FOA) Passes the Senate (S. 622)
The Senate version of the FOA 2004 passed in the Senate on May 6, 2004. NAMI writes that, “The bill provides that states may offer (state’s option—1915b
waiver required) Medicaid coverage to children (up to age 18) with severe disabilities living in families with incomes up to 250% of poverty by allowing
those families to buy into the Medicaid program (states may also offer this to families over 250%--but without FFP). The bill requires cost sharing on a
sliding scale up to the full premium cost of care with protections for lower income families.”
S.622 also provides for treatment of inpatient psychiatric hospital services for individuals under age 21 in home or community-based services waivers (e.g. Medicaid can cover services for children in their homes) and for development and support of family to family health information centers. “Family to family health information centers will (1) assist families of children with disabilities or special health care needs to make informed choices about health care in order to promote good treatment decision, cost effectiveness, and improved health outcomes for such children, (2) provide information regarding the health care needs of and resources available for children with disabilities or special health care needs, (3) identify successful delivery models, (4) develop models of collaborations with stakeholders, (5) provide training and guidance, (6) conduct outreach activities, and (7) centers are staffed by families of children with disabilities and who have expertise in Federal and State public and private health care systems. HR 1811 is the same as S 622. Advocates and Senate staff report that the House is interested in passing their bill this year. Majority Leader Delay (R-TX) and Speaker Hastert (R-IL) have had discussions with HR 1811 main sponsor Pete Sessions (R-TX) and will work to get this passed this year. However, it is likely that the House will require a “pay as you go” amendment to the bill. Currently, there is funding in a budget reserve. But, it is unlikely the House will use this resource. If amended, the bill will go back to the Senate for vote or it will go to conference.
Costs
The CBO estimates that FOA will cost $6.58 billion dollars over five years, with states eligible to receive FFP in October 2006. Funding for the
centers is included in the legislation (already appropriated for the next three years).
Individuals with Disabilities Education (IDEA) Passes the Senate
On May 13, the Senate passed S.1248 to reauthorize IDEA, which differs significantly from the House bill passed in April 2003 (HR1350). Differences can
be found in provisions related to litigation fees and responsibility for payment, IEP development, discipline and manifest determinations, and federal
reimbursement formulas. Differences will be ironed out in conference. The Senate will not agree to a conference unless the House ensures the minority
perspective is adequately represented.
Highlights from the Senate Committee Report
The committee improves IDEA through provisions that: (1) encourage informal and speedy resolution of problems, prevent misidentification of students,
and reduce bureaucratic paperwork for teachers; (2) provide local fiscal relief through risk pools and allowing localities to use a percentage of IDEA
funds in a flexible manner; (3) shift IDEA from a compliance-driven model to a performance-driven model; (4) make schools safer by providing greater
clarity and flexibility in the law, as well as supporting approaches, including behavioral interventions, that prevent dangerous discipline problems;
(5) provide increased resources to better train teachers and parents; (6) facilitate better transitioning for students with disabilities from school
to post-secondary experiences; and (7) strengthen implementation of the law to ensure that every child with a disability receives a free appropriate
public education (FAPE).
Tennessee v. Lane and Jones
NACBHD previously reported on this case in the February newsletter. On May 17, the Supreme Court ruled 5-4 that
states can be sued for monetary damages for failure to provide people with disabilities access to courts, under Title II of the Americans with
Disabilities Act. For more information, see the Bazelon Center for Mental Health Law at
www.bazelon.org/newsroom.
Transformation: An Overview of Current Projects
Several efforts related to “transformation” in the behavioral health arena are underway, with each involving considerable work over the next several months and written reports or “action agendas” expected from each project. NACBHD has been reporting on transformation over the last year, including interviews with the Chair of the President’s Commission on Mental Health, updates on the Campaign for Mental Health Reform, and a report on SAMHSA’s role in transformation. This month, the newsletter covers both an important new initiative of the Campaign for Mental Health Reform and the work of a new Institute of Medicine committee charged with adapting its landmark report Crossing the Quality Chasm to mental health and addictive disorders. NACBHD will continue to cover all these transformation efforts as the work evolves. A brief overview of each effort:
Campaign for Mental Health Reform: Intense Effort Focusing on State and Local Transformation Underway
NACBHD spoke with Bill Emmet, project director at the National Association of State Mental Health Program Directors (NASMHPD), and project director for the Campaign, about the Campaign’s recent activities.
A State-Informed Federal Policy Initiative
The Campaign is developing a strategy that will take into account “that this is a year in which not much will move on the Hill,” says Emmet, and in which
much more is happening at the state level in terms of transformation. The strategy involves gathering information on what is happening on the state and
local level and finding out what the implications are for federal policy. The Campaign met with policy partners, including NACBHD, in late May, to
“flesh out” the plan.
The process, which does not have a formal name, but which Emmet refers to as a “state-informed federal policy initiative,” is supported from a grant from the MacArthur Foundation. The work will take place over the next six months, with an action plan ready by January 2005 for distribution on the Hill and to the media. The process involves:
Work is underway on the first phase of the project, with plans for the Campaign to communicate with states in June, July, and August. The groundwork will be laid to have a draft of findings by October 1, and then return the draft to those consulted for review and preparation of the final document by January.
The Campaign “is doing what it is set up to do”
“The Campaign is doing what it is set up to do,” says Emmet – bringing parties to the table to draw on the unique compositions of the partner organizations
as well as represent the collective experience of the organizations involved. And he says, “I think it’s going to be the real test for the Campaign –
to achieve consensus and speak with a common voice.”
Legislative Agenda
The work strategy over the next six months supplements, and does not supplant, the Campaign’s legislative agenda. Emmet notes that there has been
progress on the Family Opportunity Act, which was recently passed in the Senate (see Washington Update in this newsletter), and the Mentally
Ill Offender Treatment and Crime Reduction Act, for which there soon may be a hearing by the House Judiciary Committee and which has gained more sponsors
in the House.
SAMHSA reauthorization is unlikely to happen this year. In terms of the State Incentive Grants for Mental Health System Transformation, Emmet says, “We remain very supportive of those grants and see them as good things to motivate states to get involved in transformation.” These grants (for $44 million) are in the President’s Budget for FY 2005, which has not been acted upon yet. (The FY 2005 year starts October 1.)
Work with federal agencies to increase awareness of the goals and recommendations of the President’s Commission, and to address the issues of fragmentation
highlighted in the Final Report
The Campaign will continue to meet with these agencies, such as the Centers for Disease Control (CDC) and the Department of Housing and Urban Development
(HUD) to address behavioral health issues across the broader public health spectrum.
Carter Center Symposium Follow-Up
There will be an online survey of attendees, which should be out soon. Emmet says it should yield some interesting information about transformation
efforts and what issues are being addressed.
After the Election
While the Campaign wants to work with the current administration to craft their budget plans for 2006, it is possible that a new administration might
shift in a different direction, and the Campaign would like to be able to help chart that course.
For information on the Campaign, see www.mhreform.org.
IOM’s Crossing the Quality Chasm:
Adaptation to Mental Health and Addictive Disorders
The Institute of Medicine (IOM), a private, nonprofit advisory arm of the National Academies of Science, based in Washington, DC, has initiated a new project focusing on adapting the findings and recommendations of its landmark 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century to the field of mental health and addictive disorders. Ann Page, Senior Program Officer for the project, spoke with NACBHD about the project and its committee, the Committee on Crossing the Quality Chasm – Adaptation to Mental Health and Addictive Disorders, which recently began meeting.
Origin
Page notes that Crossing the Quality Chasm, which found that the U.S. health care system is “in need of fundamental change and recommended a framework
and strategies for achieving substantial improvements in the quality of health care” (www.iom.edu), has
been used by federal and private organizations to reengineer healthcare delivery. A number of organizations, including the American College of Mental
Health Administrators and SAMHSA, contacted the IOM about the need to include mental health and addictive disorders. The project is a public/private
partnership funded by SAMHSA, the Robert Wood Johnson Foundation, Cigna, the National Institute of Drug Abuse, the National Institute of Mental Health,
the Veterans’ Health Administration, and the Annie E. Casey Foundation.
Committee Charge
The charge of the Committee on Crossing the Quality Chasm – Adaptation to Mental Health and Addictive Disorders “is to explore the implications of
the Chasm report for the field of mental health and addictive disorders and to develop an agenda for change. The committee will examine both ‘environmental
factors’ such as payment, benefits coverage and regulatory issues, as well as, health care organization and delivery issues.”
(www.iom.edu.project.asp) While the developmental disabilities sector is not explicitly
mentioned in the charge, it is an area the Committee will address at its next meeting.
The Committee’s Work
Page says that the Committee will look at the six aims for improving healthcare and the ten rules to guide the redesign of healthcare outlined in
Crossing the Quality Chasm, hear testimony from stakeholders, and develop a blueprint of recommendations, which has been requested by the funding
organizations. When asked about consideration of the goals and recommendations outlined in the Final Report of the President’s Commission on Mental
Health (which is what the Campaign for Mental Health Reform is working to advance), Page says that the Committee has “a practical work plan that will
feed into the implementation of the Final Report.”
Background: the framework of Crossing the Quality Chasm
The Quality Chasm’s framework consists of six aims for improving healthcare and ten rules to guide the redesign of healthcare. The six aims for improving healthcare are making healthcare more safe, effective, patient-centered, timely, efficient, and equitable. The ten rules to guide the redesign of healthcare are:
- Care based on continuous healing relationships
- Customization based on patient needs and values.
- The patient as the source of control.
- Shared knowledge and the free-flow of information.
- Evidence-based decision-making.
- Safety as a system property.
- The need for transparency.
- Anticipation of needs.
- Continuous decrease in waste.
- Cooperation among clinicians.
Committee Members and Committee Meetings
Membership
The 21 member committee has expertise from both the public and private sector, and from mental health and substance abuse services. Mary Jane England,
MD, chairs the committee. She is a child psychiatrist, currently the president of Regis College in Massachusetts, and formerly president of the
Washington Business Group on Health, among other positions she has held in mental health and healthcare. Page says many committee members also wear
“multiple hats” with the following areas represented: children and adolescents, consumers, informatics, systems engineering, primary care, economics,
legal and ethical issues, as well as state Medicaid agency representation and a secretary of a state department of public welfare.
Meetings
The Committee’s first meeting was in late April, with plans to meet four to five more times between now and February. The next meeting is July 13, in
Washington, DC, and NACBHD’s Executive Director, Melissa Staats will speak during the open mike session. (See below for an agenda for the July 13
meeting.) A November meeting is planned for California. Testimony is by invitation, and meetings are open to the public while the Committee is hearing
testimony; deliberations are closed. (Consumers and families provided testimony at the first meeting in April, with representatives from NAMI, the
National Mental Health Association, and the National Alliance of Multiethnic Behavioral Health Organizations, among others, present. Other stakeholders
will provide testimony at future meetings, including individual providers.
July 13 meeting
The July meeting will address the first three areas of Crossing the Quality Chasm, with invited testimony focusing on:
- The extent to which mental health and substance abuse services are patient-centered as defined in Crossing the Quality Chasm.
- Testimony on the effectiveness and quality of mental health and substance abuse services from the point of view of adults, children, and veterans.
- Safety issues in mental health and substance abuse services, such as the use of seclusion and restraints.
The Final Report
Once the Committee has completed its report, the report goes through a blinded review process by other experts with expertise similar to that of the
committee to determine if the recommendations are supported by the evidence. After the Committee responds, the report proceeds to an IOM appointed
monitor for an external review. The sponsors do not receive the report until it is final. The final report will be publicized and the committee
chair and members will deliver presentations. Publication is projected for Fall 2005; interested parties will be able to download the report free
of charge in PDF format from the National Academies Press.
For more information on the Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders, or for more information about the report Crossing the Quality Chasm: A New Health System for the 21st Century, see www.iom.edu. To inquire about testimony or open mike sessions for committee meetings, contact rbenson@nas.edu.
SAMHSA’s NREP Expanding to Include Mental Health Treatment and Prevention Programs
NACBHD recently spoke with Kevin Hennessy, Ph.D., SAMHSA’s Science to Service Coordinator. Hennessy is in charge of SAMHSA’s National Registry of Effective Programs(NREP) and will speak at the NACBHD Annual Conference, July 15-17, about the agency’s expansion of NREP, how county authorities can be involved in NREP, and SAMHSA’s science to service agenda.
NREP was started by SAMHSA’s Center for Substance Abuse Prevention in 1998 as a national registry of model substance abuse programs, and is expanding to encompass all SAMHSA domains, including substance abuse treatment and mental health treatment and prevention programs. Expansion is beginning this year and will be put into place over the next few years, with a primary goal of greater inclusion of programs and stakeholders.
Hennessy describes SAMHSA’s vision for NREP as becoming “the leading national resource for practical, contemporary, reliable information on scientific treatment and prevention services for substance abuse and mental health disorders.” Programs designated as model programs by SAMHSA have been reviewed by NREP and “tested in communities, schools, social service organizations, and workplaces across America, and have provided evidence that they have prevented or reduced substance abuse and other related high-risk behaviors.” (www.modelprograms.samhsa.gov) Within the context of SAMHSA’s science to service agenda, an expanded NREP would include:
NREP expansion plans include the creation of Stakeholder Review Boards composed of consumers, providers, and purchasers, who will determine, based on relevant criteria, which effective mental health treatment and prevention programs become model programs.
How can county behavioral health authorities be involved in NREP?
Hennessy encourages county behavioral health authorities to be involved in NREP:
While program developers are encouraged to submit data and materials for review at any point, the technical assistance and the role of NREP Stakeholder Review Boards will take at least another year to implement.
Hennessy encourages submissions from NACBHD member organizations
For more information about NREP and model programs, see www.modelprograms.samhsa.gov.
View the NREP section for detailed evaluation criteria and background information on the review process. If you would like to discuss the viability of
your program as a candidate for review, contact NREP at 866-43NREPP or NREPP@intercom.com.
The science to service agenda and the grant process
SAMHSA has reengineered the discretionary grant process in the last year to create four standard grant mechanisms. Hennessy reports that there is a
concerted effort in SAMHSA to have most of the funding fall under one of these discretionary grant mechanisms: 1) Services Grants; 2) Infrastructure
Grants; 3) Best Practices Planning and Implementation Grants; 4) Service to Science Grants. For more information, see
www.samhsa.gov. Click on “Grant Opportunities,” and then click on “Useful Information for
Applicants.” Information about the four standard grant mechanisms will be under “Standard Grant Announcements.”
Look forward to a discussion of SAMHSA's science to service agenda at the Annual Conference
At the Annual Conference July 15-17 in Phoenix, NACBHD members will have an opportunity to meet Hennessy and discuss NREP and SAMHSA’s broader science
to service agenda. SAMHSA has a systematic agency-wide effort to fully implement effective evidence-based practices and to strengthen feedback from the
field to influence services research programs. This effort influences SAMHSA’s work with NIMH, NIDA, and NIMH. SAMHSA works collaboratively within and
across those agencies to maximize interventions of the highest possible quality. Ultimately, Hennessy says, NREP is really about quality improvement
and reducing the time lag between the development and adoption of effective treatments.
Developmental Disabilities Survey:
A Report from Committee Chair Lynn Ferrell
Lynn Ferrell, Chair of NACBHD’s Developmental Disabilities Committee and Executive Director, Polk County Health Services, Des Moines, Iowa, submitted the following report on the recent survey of NACBHD Board members: The County Role in Delivering Services for Persons with Developmental Disabilities. The survey illustrates the county role in delivering or funding of services for persons with developmental disabilities and identifies key federal issues faced by county programs.
Survey Respondents
Of the 18 states with local members in NACBHD, 11 responded to the survey. Of the seven states which did not respond, three are believed to have a
county-based DD system. The 11 states represent 40% of the nation’s population.
Delivery and Administration of Services
In ten of the 11 states responding, services for persons with developmental disabilities are county-sponsored. In two, the state mandate is only to
serve persons with mental retardation, rather than the broader definition of developmental disabilities. In one state, counties are required to put
up some local match money, but have no organizational responsibility for delivering services. In one state, counties plan services for persons with
developmental disabilities, but the state contracts with the provider network which actually delivers the services. In one state there is local
administration of DD services, but it is through a network of regional non-profit centers and there is no connection with county government.
When the county has responsibility for sponsoring DD services, the county typically chooses to designate administration under a larger organizational umbrella—usually a mental health/substance abuse authority or a broader social services department. In only one state did a respondent report that locally administered DD services are placed in a separate department of county government. In one other state, the local administrative entity is a part of the state agency, even though there is a local county match requirement.
Funding of Services and Related Issues
The reliance on Medicaid funding, and especially Home and Community Based Waivers, for the DD system is evidenced by the fact that nine of the ten
respondents with county-based DD systems identified Medicaid as the most pressing issue at the federal level. Respondents cited the waivers, optional
services, and Medicaid reform as critical. One respondent added that CMS’ reinterpretation of existing policies is also a key issue for their state.
Other federal issues noted by the respondents include the reauthorization of the Temporary Assistance to Needy Families (TANF) program as it pertains
to parents on TANF who have disabled children, reauthorization of the IDEA special education law, waiting lists for services, and low Medicaid
reimbursement rates.
What Happens Next?
NACBHD’s DD Committee appreciates the contributions of survey respondents. This data is most helpful and will be used to establish the DD Committee’s
agenda (both policy and legislative). The data also begins to document the role of county governments and local authorities in the delivery of
developmental disability services. The development of an agenda and role of county governments and local authorities (based upon this data) will serve
as the basis for the DD Committee Meeting that will be scheduled during the July Conference in Phoenix.
State Budget and Medicaid Issues in Georgia
Tod Citron, Executive Director, Cobb/Douglas, Georgia, Community Services Board, spoke with NACBHD about issues his organization faces in light of state budget and Medicaid constraints.
Overview
Georgia has had a depressed economy with depressed tax revenue, and a Republican administration and state legislature (for the first time since
Reconstruction) that has emphasized that there will be no tax increases, resulting in cutting expenditures, including at the local level. For FY
2004, there was a 5% spending cut for all state departments. The Board falls under the Department of Human Services as a contracted provider, with
$800,000 out of its $21 million budget cut and a 10% cut in Medicaid rates for the Medicaid rehabilitation option -- this at a time Citron says that
they are “serving more people than we have ever served before.” Cobb and Douglas counties are located in suburban Atlanta, and have experienced
unprecedented growth over the last decade, resulting in a 10% increase in the clients served each year, from 5,600 in FY 96 to 12,800 in FY 2003.
An additional $100,000 was cut in the last quarter of 2004, targeted specifically at the child and adolescent substance abuse program. Another
$300,000 will be cut from the child and adolescent substance abuse program for FY 2005 starting July 1.
The Impact
As a social service infrastructure agency, Citron says his organization is “severely stretched,” resulting in an inability to offer the full delivery
system, which highlights the fragmentation addressed in the Final Report of the President’s Commission on Mental Health. He points to instances of the
severely mentally ill landing in jail because of the reduction in psychiatric beds, resulting in a cost-shift to taxpayers, or the increasing workload
for fewer case managers, all resulting in a phenomenon Citron describes as “the rationing of adult mental health care.” He says that there are “so
many other things I’d like to be doing in adult mental health services.” In addition, many adults are the working poor with no insurance or are
underinsured – there are many adults in the area who do not qualify for Medicaid. Ten to fifteen percent of adults may have Medicaid, while half
of children may have it. Child and adolescent mental health services can generate good revenues because of the high number of children and adolescents
on Medicaid. Medicaid is 35% of the agency’s revenue.
Outlook
Advocacy groups have had some positive influence on these issues. For example, a recent move to shut down two state hospitals was successfully fought
off, with local NAMI chapters involved. And, the developmental disabilities lobby in Georgia is very well organized and was able to turn around a
waiver issue with its “Unlock the Waiting List” campaign for those with physical or developmental disabilities on a Medicaid waiting list for home and
community based services. This has been helpful for his Board; they are at capacity and welcome clients with waivers.
Citron calls the budget situation and the resulting complications, the “most incredible challenge of my professional life.” He has been in the position for five years, and previously worked in the private sector as administrative director for Columbia HCA for all behavioral health services in the Atlanta market. He has an M.S.W. and a master’s degree in health care administration. While he is amazed at the challenges in the public sector, he remains hopeful. Word is that the economy is getting better and Georgia state revenues are increasing. Citron hopes there are no additional cuts, but it is hard to say for certain.
Housing Update
HUD SuperNOFA Is Out
The Department of Housing and Urban Development’s (HUD) Super Notice of Funding Availability for 2004 has been released. The HUD SuperNOFA is intended
to expand the availability of affordable housing for people with disabilities. For further information and to access the complete SuperNOFA, see the
Technical Assistance Collaborative website at www.tacinc.org, and click on “What’s New.” For
highlights of the SuperNOFA and homelessness, see the Federal Interagency Council on Homelessness at
www.ich.gov.
Zarrow Mental Health Symposium
The Zarrow Mental Health Symposium, scheduled for September 29 – October 1, 2004 in Tulsa, will be national in scope and address housing and community
supports for people with mental illness. The conference will focus on developing “innovative programs to assist people with mental illness in securing
safe, decent homes in the community.” For more information, see www.mhat.org/zarrow/overview.
