March 2003 NACBHDD Newsletter
The Newsletter of the National Association of County Behavioral Health and Developmental Disability Directors
In this Issue...
Developmental Disabilities Services: Issues and Challenges
NACBHD recently joined the Consortium for Citizens with Disabilities (www.c-c-d.org) in an effort to increase our visibility in the developmental disabilities policy arena. We will partner with the Consortium on several task forces, including developmental disabilities and TANF. NACBHD's Developmental Disabilities Committee, chaired by Mike Chambers, will work to bring more of these kinds of issues to the forefront. The following article is a beginning attempt to highlight some areas of concern and challenges facing local county health authorities in the area of developmental disabilities services.
From Mike Chambers, Chair, Developmental Disabilities Committee, and Executive Director, MH/MR Administrators Association of Pennsylvania:
Pennsylvania has 67 counties with 46 county-run MR programs. Chambers described the Mental Retardation Transformation System description (available online at www.dpw.state.pa.us/general/program/asp) as a tremendous source of information about how the state has changed to a new system based on self-determination and changes in business practices and technology.
The Home and Community Services Information Systems (HCSIS) is a central computer system designed to improve quality management, delivery of services, and financial management. New technology and terminology must be learned and is challenging for counties. As Chambers said, the "business has become much more complex."
He cited coping with change and maintaining federal money as the overall challenges. The state budget situation is not good; with cuts expected. The Governor's first proposed budget is due to the legislature March 5. As Chambers described it, "There is a lot of unknown right now." There are still waiting lists. The "Prioritization of Urgency of Need for Services for Persons with Mental Retardations (PUNS), a data collection instrument that assesses the needs of individuals waiting for services, delineates the waiting list numbers as follows: emergency: 347, critical: 5,564, and planning: 16,941, out of a total state population of 11,881,640.
Pennsylvania works effectively with stakeholder groups and state leaders. The Mental Retardation Transformation System is an example of this, with the Waiting List Plan and the Every Day Lives Project developed under the auspices of the system.
Specific challenges:
From Lynn Ferrell, Executive Director, Polk County, IA, Health Services:
In Iowa, counties are primarily responsible for services for people with developmental disabilities. The lack of affordable housing and the lack of federal and state commitment to provide affordable housing are the most critical issues facing those with developmental disabilities in Ferrell's area.
Ferrell noted that the basic resources of living are not there, and he is fairly pessimistic about the commitment at the federal and state level. With the local housing authority selling off housing in the area, more resources that could be providing treatment and support are going to housing. One of the fastest growing parts of his budget is housing, with the waiting list continuing to grow. In addition, there are "nuances" that keep people with developmental disabilities from successfully attaining housing; for example, people who are unrelated can't live together in public housing.
Medicaid cost containment is an issue, as well as impending implementation of a requirement for prior authorization for targeted Medicaid management, in which the approval of the state would be needed before services would be provided. Also, Ferrell feels that the federal proposal for restructuring Medicaid is "rather frightening" and would in essence remove the entitlement nature and give states more leeway to eliminate services for people with disabilities, with the potential effect that a lot of people with disabilities will be left out of services.
At the same time, the state is limiting county services and asking for considerably more funding for state institutions. The Governor has asked for a $4 million increase for state institutions and a $4 million increase for 99 counties, with the net effect that Polk County will get $800,000 less in 2004 than in 2003. This, Ferrell said, "makes no sense in light of Olmstead," and puts counties and consumers in a bind.
While he noted that people with disabilities don't have "a loud voice" at the state and local level, an effort to get consumers and families more involved in talking with legislators about state funding issues is underway.
NACBHD recently asked Bob Gettings, Executive Director, National Association of State Directors of Developmental Disabilities Services, for his thoughts on areas of concern for county directors.
Gettings suspects that the biggest issue facing those involved in providing DD services is the "precarious situation many states find themselves in with the economic downturn and state budget shortfalls." Some states are more affected than others. For example, Rocky Mountain area states that are energy-producing, such as Wyoming and New Mexico, are faring relatively well; but other states are not faring so well because of revenue shortfalls since 9/11 and the subsequent stagnation of the economy. Governors have proposed budgets with sizable cuts. Developmental disability programs have held their own, but there are states where the upcoming budget will make things even tighter. For example, Gettings says California faces a $35 billion shortfall, and New York a $10-12 billion shortfall. Thus far, these shortfalls have been absorbed largely in terms of administrative overhead issues, such as job freezes and travel restrictions, with direct services affected in some states.
There is a range of issues states face. Public resources have never been sufficient to provide services to everyone who qualifies, resulting in sizable waiting lists in many places. While existing services may be maintained, the likelihood of addressing the backlog is not likely. There are now 22 states with class action lawsuits for not providing services for people on waiting lists.
Compensation for direct support personnel in the community has been inadequate and has caused a lot of turnover. Some states have tried to address this, but whether they will be able to continue workforce improvement initiatives is questionable.
In terms of housing, Gettings said the issue is "how to find and support appropriate living arrangements for people that meets their need for social support." The waiting list problem is related to residential services and the many associated issues.
As far as Olmstead implementation (see article below) is concerned, many states have initiated efforts on the DD side to shift from institutional to home and community-based settings. Gettings described one issue as "how to accelerate change in an environment that is hostile to change." Some states will soon announce downsizing of state institutions that would have not happened in a more favorable climate. "Money Follows the Individual" may help, depending on far it reaches and how big it is. Other smaller plans, such as those under the New Freedom Initiative, will not overcome all the issues, but will help.
Gettings explained that there are structural issues around state revenues that affect the state revenue picture. For example, many state tax systems are based on a manufacturing economy, while we are now in a service and information economy, and often service and information items may not be taxed by the state, causing state taxes to tumble. Restructuring of the tax code in some states is already underway, but it will be a while before there is a reliable tax base.
Overall, Gettings feels it is a "tough time for all public and quasi-public entities trying to provide services but there are lots of grassroots local supports for services."
NACBHD spoke with Ann O'Hara, Technical Assistance Collaborative, Inc. (TAC). A national organization, TAC works on behalf of people with developmental disabilities and other special needs to provide information, capacity building, and technical expertise to organizations and policymakers in mental health, substance abuse, human services, and affordable housing.
O'Hara reported that affordable housing for people receiving SSI benefits is a challenge for every state and county. A study over the last six years of the rent to income ratio compared SSI income to the cost of modest rental housing for the each state based on "fair market rent" - what should be the cost of modest one bedroom, two bedroom, or three bedroom units. The study found that in 2000, people had to pay 98% of their monthly SSI check for a modest one-bedroom unit across the country. This is the biggest problem around housing for the developmentally disabled - and why people may be still residing with aging parents or in-group homes. (Study results are available at www.tacinc.org for 1998 and 2000; and the results for 2002 will be released soon.)
Further, O'Hara said that people on SSI are the poorest group in the United States, and that HUD reports show that 1.4 million people on SSI with disabilities (this includes all disabilities) have "worst case" housing needs. The only way these individuals can live in housing is with assistance, and that the issue facing counties is how to get people assistance. "Every dollar spent on housing is a dollar you don't spend on services." Since this is a decidedly bad trade-off, the only option is to look at programs that provide housing assistance to other low-income people and get people with developmental disabilities into these programs. O'Hara said that a part-time job will not raise enough income. (She cited a study by the National Low Income Housing Commission that showed that if people on SSI quit SSI and earn minimum wage, they will not be able to afford housing.) "The problem with housing for the developmentally disabled is not their developmental disability but their poverty."
While the affordability problem can be addressed with government housing assistance, O'Hara cited two challenges: 1) It is not an entitlement. Fewer than half who qualify ever receive it; there is not enough to go around. 2) What counties are doing and need to do is develop and implement strategies to get more government housing assistance for the developmentally disabled. The thrust for counties is that those who work with the developmentally disabled need to work more closely with local authorities that provide housing. She suggests visiting the TAC web site (www.tacinc.org) and clicking on "Opening Doors." Topics are organized programmatically.
In regard to Olmstead implementation (see article below), O'Hara called it a two-part equation - services and housing - and that carrying out complex services is difficult with no housing in which to live. While the solution is affordable housing programs, the growth in affordable housing programs in the last ten years has been legible.
Olmstead Implementation
NACBHD spoke with Charles Curie, SAMHSA Administrator, about Olmstead implementation, the New Freedom Initiative, and issues for county behavioral health directors.
Curie explained that, in general, Olmstead efforts are consistent with the New Freedom Initiative (the President's plan to reduce barriers to community integration for people with disabilities), which is consistent with operationalizing the ADA, and with SAMHSA's vision of "a life in the community for everyone" and its mission of "building resilience and facilitating recovery." SAMHSA's matrix outlining crosscutting principles and priority programs focuses these issues as follows:
Programs/Issues |
Crosscutting Principles |
|
Co-Occurring Disorders |
Data & Evidence based outcomes |
There will be strong collaboration with HUD on housing issues, with labor on employment, with CMS on the self-determination approach on Medicaid, and with state mental health authorities.
Curie feels that the following are the main issues for county behavioral health directors:
"In looking to the future and resources for counties, the New Freedom Initiative Action Plan, due in the spring, will be a tremendous opportunity for the field, including county directors."
NACBHD spoke with members regarding their Olmstead implementation efforts and plans.
George Braunstein, Executive Director, Chesterfield Community Services Board (VA) explained the implementation plan in Virginia and issues and challenges facing his community.
The state of Virginia started to look at Olmstead implementation relative to a legislative initiative that came forward from the 2002 legislative session. Work groups were assigned from steering committees tasked with developing Olmstead in Virginia. "The work groups are going on as we speak," reports Braunstein. The work groups, composed of representatives from community service boards, private sector providers, state government, and consumer and families, are performing investigative work in different topic areas, such as providers and housing issues. The work groups will produce a plan that goes to the steering committee, which will in turn create a plan to present to the Governor.
The pressure to discharge people who are identified as discharge ready from state training centers will lead to a huge influx of MR citizens into the community system. With mentally ill populations, there has been some effort to deinstitutionalize. The reinvestment plan proposed by Virginia governor Warner and under review by the legislature may address some of this. The reinvestment plan is separate from Olmstead, but addresses deinstitutionalization by transferring state provided services to community management. Braunstein cited two major challenges: not enough money and too few resources. He explained resources in more detail.
Housing
There is not enough affordable housing available in a number of communities. This is both an issue of policy and quantity, according to Braunstein; how to support people in housing and where they will live. Availability and quality are scarce: "What we have seen in Richmond, is that it might be a rooming house with very poor quality, but that may be all there is."
Transportation
"Chesterfield has really struggled to provide transportation." Braunstein reports that the Chesterfield Community Services Board, next to the county school system, is the largest transportation provider in the county, with essentially no available public transportation system. An experiment with a regional transportation board in Richmond has not worked well with consumers.
Personnel
Planning would include adding positions where appropriate, but there may not be enough personnel for some services, such as experienced psychiatric nurses.
Braunstein noted that he had just touched on the "resources for how people live," and he believes Olmstead planning and implementation will emphasize the need for further funding. "There are lots of discharge ready in Virginia, if we can highlight that need it will help."
Rob Schladale, Assistant Secretary, California Health and Human Services Agency, submitted the California Health and Human Services Agency Olmstead Plan Development Process (below) as an update on California's Olmstead efforts.
The CHHSA Olmstead planning process began in August 2002 with an invitation to interested community organizations to host Olmstead Forums. The Agency's Long Term Care Council created a Tool Kit that included all of the instructions and documents an organization would need to host a forum. Also provided were several reporting forms, with which forum sponsors as well as individual attendees could provide input to the Agency. Subsequently, during the months of September through November, more than 30 forums were held around California. A substantial amount of data was created and forwarded to CHHSA for use in preparing an Olmstead Plan. In October 2002, the Agency convened the first in a series of Olmstead Work Group meetings in Sacramento. Work Group participation has been open to all individuals who wish to attend. More than 100 consumers and stakeholders attended the first meeting, which was used principally to agree upon a process for subsequent Work Group Activities. In November, December, and January 2003, Work Group meetings were held in San Diego, Fresno, Los Angeles and Oakland. Each meeting focused on one of four global issue areas, including Assessment of individuals for community services, Transition and Diversion services, Community Service Capacity issues, and Quality Assurance. On January 29, 2003, a draft Olmstead Plan outline was distributed to Work Group members and posted on the Agency's Olmstead web page. This page may be accessed at www.chhs.ca.gov/olmstead.html. The outline, and stakeholder comments, will be discussed at a Work Group meeting scheduled for February 13, 2003, in Sacramento. The Agency will consider all comments to its draft plan outline and will respond to each. While California clearly faces serious fiscal constraints, the Agency intends to identify a broad array of desirable Olmstead activities, even if their implementation must be identified as subject to the availability of additional resources. Once all consumer comments have been received, the Agency will complete preparation of its plan. The plan is due to the Legislature by April 1, 2003.
Call for Nominations
NACBHD's 2003 Robert C. Egnew Excellence in Policy Award
We welcome nominations from NACBHD members of those in their states and communities who have demonstrated noteworthy accomplishments in federal and/or state advocacy and policy development. This is a wonderful opportunity to recognize an individual who has contributed to advancement of the county behavioral health authority policy agenda. Get eligibility requirements and complete the application form online at www.nacbhd.org/egnew_award.html. Submit the application by April 15th. The award will be made during the Awards Luncheon at NACBHD's Annual Conference in July in Milwaukee.
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From the Hill
Robert Egnew, Public Policy Director, NACBHD
The recent announcement by the Bush Administration that it was proposing dramatically changing the Medicaid program has a number of people in and around Washington DC asking questions. The Administration has not made any formal proposal as of yet and, in fact, no one outside of the Administration has seen anything in writing. The key components of the Administration's Medicaid Reform proposal would include the following elements:
NACBHD Legislative Conference: A Great Success
NACBHD's 2003 Legislative Conference held Feb. 26 - 28th in Washington, DC proved to be useful, informative and important for NACBHD's visibility and its continuing alliances with its policy partners in mental health, developmental disabilities and substance abuse. To summarize the highlights - the conference began with a beautiful and courageous presentation by William Cope Moyers, who moved the audience with his story of his own addiction and recovery. He stressed the need to overcome stigma and advocate at the federal, state and local levels for the reforming of our alcohol and drug abuse treatment system so they provide adequate, quality services to all who need them. Working now on behalf of the Hazelden Foundation, Moyers made an impassioned plea for education, advocacy and compassion, recognizing the importance of the recovery movement in these efforts.
Several excellent panels examined mental health, developmental disabilities, substance abuse and children's behavioral health policy issues and provided clarity and direction for NACBHD'S advocacy efforts. Our work to strengthen alliances with our policy partners in all three disciplines is certainly paying off.
Once again, Glenn Stanton, Deputy Director, Elderly & Disabled Health Programs, Medicaid Branch, CMS joined us and presented CMS' position on Medicaid reform. NACBHD will be meeting with CMS for discussions to bring the concerns of county authorities to greater attention.
We welcomed Kim Love, Deputy Legislative Assistant to Sen. Debbie Stabenow (D-MI) who explained the Sen.'s efforts on Medicare prescription drug benefits and other initiatives with which the Senator is involved.
The Federal Update included presentations by directors of CMS, CSAT and CSAP. Gail Hutchings, Acting Director, CMHS, spoke on behalf of Charlie Curie who could not attend the conference, providing the SAMHSA overview.
With a record attendance from across the country, this was truly the strongest legislative conference NACBHD has held. Many participants went to Capitol Hill to talk with members of Congress. The increased visibility and credibility we have experienced over the years, was evident in the quality and scope of this important conference.
Mark Your Calendar
NACBHD's 2003 Annual Conference
Innovations in Cost Savings for Results
JULY 10 - 12TH
Hyatt Regency Milwaukee
Milwaukee, WI
Look for the Registration Brochure, Sponsorship and Display Area information in early April. All information available online at www.nacbhd.org.
National Association for the Dually Diagnosed (NADD) Offers Spring Teleconference Series
NADD is offering a series of teleconferences this Spring, which will feature experts in mental health and developmental disabilities. Individuals may participate from their offices and may have additional people around the phone. Each 60-minute session will include a presentation and a question and answer session with the presenters. Presentations are geared to beginner, intermediate, and advanced levels, depending on participant experience in the subject area. Conference subjects, times, and registration information are available at www.thenadd.org; click on the teleconference link. Or, contact NADD at (800) 331-5362.
Online Directory of Physicians Credentialed to Prescribe Buprenorphine Available through SAMHSA
SAMHSA recently issued a press release (January 23, 2003, www.samhsa.gov) regarding the availability of an online directory of physicians credentialed to prescribe buprenorphine, the new medication prescribed to treat addiction to prescription pain relievers or heroin. Physicians credentialed by SAMHSA can treat their patients with buprenorphine. The online directory will be updated daily and is available at www.buprenorphine.samhsa.gov.
"New Paths to Recovery," a series of educational forums, will be held by SAMHSA in various metropolitan locations to inform physicians and the public about buprenorphine in the treatment of opiate abuse. Information on the forums and on physician training can be accessed at www.samhsa.gov. Physicians seeking information on training and credentialing may call 1-866-287-2728.
Living with Grief: Coping with Public Tragedy
Hospice Foundation of America's
Tenth Annual Bereavement Teleconference
Wednesday, April 30, 2003
1:30 p.m. to 4:00 p.m. EDT
Moderated by Cokie Roberts, this live-via-satellite broadcast will discuss factors that define a public tragedy, and offer
insight and advice to healthcare organizations and mental health professionals as they support their communities and assist
those coping with loss. Contact hours for psychologists, counselors, social workers, physicians and other professionals are
available at most local sites.
To find a teleconference site in your community, please visit HFA's web site at www.hospicefoundation.org/teleconference and click on the "Locate a Site" prompt, or call HFA at 1-800-854-3402.
NACBHD Welcomes Additional New 2003 Members
In addition, we extend a warm welcome to our new colleagues and members in Utah:
The CalWORKs Project is pleased to make available for download two new documents from its longitudinal research in two California counties. The first document presents study findings regarding child well-being and parental mental health, alcohol and other drugs and domestic violence issues. Either the full report (69 pages) or a separate executive summary (15 pages) may be downloaded. Chandler, D., Meisel, J., & Jordan, P. (2003). TANF Families in which there are Alcohol or Other Drug, Mental Health, or Domestic Violence Issues: Child Well-Being One Year After Welfare Reform. California Institute for Mental Health 2030 J Street, Sacramento, CA 95814. Available at www.cimh.org/calworks. The report is of most interest to researchers in that it explores the differential effects of a variety of measures and methods of analysis. Policy-makers and advocates may instead prefer to download Policy and Practice Brief Number Three: Chandler, D., Meisel, J., & Jordan, P. (2002). Multiple Risks Threaten Children of TANF Recipients with Alcohol and Other Drug, Mental Health or Domestic Violence Issue. California Institute for Mental Health. Available: www.cimh.org/calworks. The second new document is a working paper on domestic violence-the first study report to focus on the third round of interviews conducted in Fall of 2001 and early 2002. Meisel, J., Chandler, D., & Rienzi, B. (2003). Domestic Violence Prevalence and Effects on Employment in Two California TANF Populations. It is also available at: www.cimh.org/calworks.
The NACBHD Bulletin is published electronically six times a year by the National Association of County Behavioral Health Directors, 1555 Connecticut Avenue, NW, Suite 200, Washington, DC 20036. Articles of interest to county/local behavioral health professionals are welcome by the 15th of the month prior to publication. Please submit copy to Nancy Sydnor-Greenberg at nesydnor@erols.com. Editor-in-Chief - Dr. Sandra Naylor Goodwin, sgoodwin@cimh.org. NACBHD is an affiliate of the National Association of Counties.
