September 2002 NACBHDD Newsletter

The Newsletter of the National Association of County Behavioral Health and Developmental Disability Directors

In this Issue...

• Evidence-Based Practice: A Look at a Multi-State Project and Local Perspectives on Implementation
  • Local Perspectives
• From the Hill
• Medicaid Financing of State and County Psychiatric Hospitals
• 2003 NACBHD Membership Campaign Underway
• NACBHD Annual Conference: A Great Success
• Mark Your Calendar for 2003 Conferences!
• New State Association Column
• Upcoming SAMSHA Conference to Focus on Key Medicaid and Mental Health Issues
• National Depression Screening Day Announces Revised Screening Form
• Comments or Questions About the Articles You Have Read Here?

Evidence-Based Practice: A Look at a Multi-State Project and Local Perspectives on Implementation

Research has shown that routine mental health programs do not provide evidence-based practices (those practices for which there is scientific evidence of consistent improvement in client outcomes) to the majority of clients with severe mental illness. In "Evidence Based Practice: The County Behavioral Health Authority Perspective," a session at the Annual Conference, Dr. William MacFarlane, Chief, Maine Medical Center, and Steve Baron, Director, Baltimore Mental Health Systems, discussed their experiences with the adoption and implementation of evidence based-practices (EBP). (Dr. MacFarlane discussed his model for treating schizophrenia within a family systems framework and Mr. Baron talked about the challenges in adapting an EBP model to a local system.) Our interview with Dr. Howard Goldman, Professor of Psychiatry at the University of Maryland School of Medicine and a member of the Executive Committee of the Implementing Evidence-Based Practices Project for Adults with Severe Mental Illness, as well as our conversations with NACBHD members who are involved in this issue, expands the discussion of this important, ongoing endeavor.

The Implementing Evidence-Based Practices Project for Adults with Severe Mental Illness
Dr. Goldman explained the project and county authorities' role in implementation in a phone interview. In noting the importance of EBP, he pointed out that the subject was the designated focus of the journal Psychiatric Services for 2001. The project aims "to develop standardized and training materials in the form of toolkits, and to demonstrate that the toolkits can be used to facilitate the faithful implementation of evidence-based practices and improve client outcomes in routine mental health service settings." (Psychiatric Services, 52, 179, 2001). It is sponsored by the Robert Wood Johnson Foundation, CMHS, the West Family Foundation, NIMH, NAMI, the MacArthur Foundation, several mental health research centers, state mental health authorities, and local mental health programs in eight states.

The project has three phases:

1. development of implementation support materials targeting mental health authorities, consumer, and training institutes;
2. field tests of materials (July 2002 - 2003). This is the implementation stage at the county level; and
3. a national demonstration program.

Six practices (in adults) in eight states (New York, New Hampshire, Vermont, Indiana, Maryland, Ohio, Oregon, and Kansas) are involved:

• medication prescribed within specific parameters
• training in illness self-management and recovery
• assertive community treatment (ACT)
• family psychoeducation
• supported employment
• integrated treatment for co-occurring severe mental illness and substance use disorders.

Knowledge about the design of the implementation toolkit materials was drawn from literature on changing practice in health care; discussions with provider organizations in New Hampshire, Maryland, and Ohio; focus group findings from clinicians who serve people with severe mental illness in New Hampshire and Baltimore; NAMI's advocacy experiences; from consumers themselves and from the observations of services researchers who have implemented mental health services in demonstration programs. The implementation materials will include integrated written material, Web-based resources, training experiences, and consultation opportunities. Implementation packages will also include feedback materials to help stakeholders maintain EBP, such as fidelity scales, outcome measures to track effects of practice, follow-up training, and a recommended review and revision process to adapt to site-specific needs.

Dr. Goldman's previous research had highlighted the important role county authorities play in mental health services implementation. His recent visits to project sites further underscored the importance of their roles, particularly in home-rule states and in states that have experienced devolution and decentralization of their mental health authorities.

He also noted the importance of counties in choosing to embrace EBPs as part of their quality improvement program, based on various forces including: what consumers want, what families want, what other parts of the system want, and questions related to Medicaid reimbursement.

Local Perspectives

New York
Gary Weiskopf, Executive Director, New York State Conference of Local Mental Hygiene Directors, and Melissa Staats, Deputy Director for Technical Assistance, emphasized that county government is committed to improving outcomes for individuals who utilize the public mental health system, and discussed some of the factors that may affect implementing EBP in New York.

• Staffing, both in terms of the number of staff, and in terms of skills and availability of supervision. They noted concerns about changing practices at a time when there is a staff shortage for existing caseloads. Providers might suffer financial repercussions if staff are not available to provide services. Sending staff out for training may mean that fewer resources are devoted to the general population and raises the question of the impact on other clients, whose needs may not be addressed by EBP. (The EBP supported by the NYS Office of Mental Health and the Drake initiative addresses the needs of individuals with schizophrenia. Counties provide services to individuals with many diagnoses and many other human services needs beyond mental health treatment.)
  
  
• Financial/reimbursement issues. In regard to reimbursement, there is not a Medicaid identified payment for family psychoeducation, and ACT teams are in the process of being identified for this payment. However, ACT is an urban model, which as designed, is difficult to support in more rural settings. The regulatory change process is lengthy, with limitations on new Medicaid mental health funding at the local level in New York. In addition, travel for training time may not be reimbursed. (Ms. Staats cited a recent study by Dr. MacFarlane (see above) that noted that the most important factors in willingness to implement EBPs were financial and caseload issues.)
  
  
• Discussion about what kind of services will be provided and who is involved in decision-making.
  
  

In New York, adult services are supported largely through clinic operations, but psychotherapy - the predominate service - is not incorporated in those EBPs articulated by the state agency. Psychopharmacology is often the purview of individual psychiatrists. That makes it most difficult to change behavior and prescribing practices. Other practical issues were cited, such as the availability of training and resource materials. Toolkits as currently drafted are quite lengthy.

Both felt that a dialogue about what implementation really means, particularly in regard to specific issues such as resource support (e.g., training, reimbursement), would be helpful. An NIMH RFP, which involves a one-year planning grant for implementing EBP, is a resource for working out the implementation on a pilot basis and for building consensus. While Weiskopf characterized EBP as "the right thing to do," he also emphasized: "the key thing is that the system drives what happens," and changes must be made "at the system level."

California
Neal Adams, Medical Director, Adult Services, California Department of Mental Health, commented on EBP implementation in California. Noting that state systems are configured differently, he felt that a dialogue between state mental health authorities and counties is essential in terms of states helping counties address potential barriers to implementation such as laws, regulations, and payment methods. Adams is concerned about the difficulty in addressing quality management when systems are extremely diverse and noted equity in quality is a major challenge: "We talk about parity at a national level, but we need to talk about equity at a local level."

From the Hill

By Robert Egnew, Director, Governmental Affairs

With Congress on its August recess, elections looming, the increased politicizations of issues, and the projected increasing federal budget deficit, legislation has ground to a near halt. Congress will return in September with what appears to be a very full agenda that will include passing all the appropriation bills, dealing with the issue of drug benefits for the elderly and the creation of the Department of Home Land Security. Congress will reconvene in September and will be in session for that month before adjourning again in October to return to their districts to campaign for election.

Many substantive issues important to the developmental disabilities, substance abuse treatment and mental health fields continue to be held in abeyance. The Mental Health Parity Legislation, which at last count had 247 co-authors or more than half of the total members in the House of Representatives, is yet to have a hearing in which it is voted upon. Without Presidential intervention, the bill is unlikely to come to the floor of the House for a vote because of the position taken by the Republican leadership. Some political wags believe that if the President is going to intervene, it will be done during the final budget negotiations. Those political pundits who don't believe the Administration is serious about parity predict that the President will not intervene and the parity bill will die in the House before coming to the floor.

The Temporary Assistance to Needy Families (TANF) Re-Authorization bill may also not be heard in the remaining session because of the press of business. If it is heard, most insiders believe it will be a very quick debate that will be time-limited and with only a few amendments considered. NACBHD continues to work as part of the Disability Coalition to push for expanding the time a TANF recipient can spend in treatment and have it count toward the TANF work requirement. If the TANF-Re-Authorization does not go to the floor, a continuing resolution will probably be passed to keep the existing program in place until the 2003 Congressional Session.

The Federal Medical Assistance Percentage (FMAP) amendment is an important piece of federal legislation that local behavioral health authorities should track. The FMAP amendment (Senators Rockefeller (D-WV), Collins (R-ME) and Nelson (D-NE) was attached to the generic drug bill which passed out of the Senate on a 78-21 vote. The House is considering their version of the bill and it will likely end up in conference committee. If adopted, this amendment will provide billions of dollars over the next few years in an increase in the percentage federal financial participation in the Medicaid program and could provide substantial fiscal relief to states.

Representative Patrick Kennedy (D-RI) continues to provide significant leadership on mental health issues in the House with the introduction of H.R. 5078," The Child Mental Health Service Expansion Act" and H.R. 5077, " The Positive Aging Act of 2002". Both piece of legislation assist the mental health field in terms of the availability of child trained mental health professionals and provide funds for demonstration mental health programs for seniors. NACBHD is meeting with Representative Kennedy's office to focus on how we might be able to work with our congressional representatives to develop support for these two bills.

Medicaid Financing of State and County Psychiatric Hospitals

Debra Draper, Ph.D., of Mathematica Policy Research, Inc. heads a SAMSHA-funded project examining Medicaid financing of state and county psychiatric hospitals and how policy changes may affect these institutions. She discussed the project at July's Annual Conference; and in a recent phone conversation, reviewed the highlights of this complex issue.

The one-year project seeks to gain a better understanding of several key areas: 1) the forces and issues affecting Medicaid financing of public psychiatric hospitals; 2) changes in Medicaid payment policy for services in these hospitals over the past 10 years; and 3) current arrangements through which these institutions receive Medicaid funds, and the potential impact of Medicaid policy changes on state and county psychiatric hospitals.

Project Overview
A literature review of relevant issues was the initial phase of the project. Subsequently, an expert panel was convened in January 2002 to better understand the issues that would be directly examined in selected states. The panel consisted of representatives from state mental health authorities, state Medicaid agencies, mental health policy researchers, representatives from NACBHD, NASMHPD, NAPH, and government representatives. Intensive case studies were conducted in five states (Iowa, California, Maryland, Arkansas, and New Jersey) each of which varied in size, geographic location, and experience with Medicaid financing of their public psychiatric hospitals. Site visits ran from March - June 2002, with Mathematica staff discussing the key issues with a range of stakeholders including: state and county mental health authorities, state Medicaid agencies, state budget office representatives, staff from the states' governors' offices, administrative staff of state and county psychiatric hospitals, and at least one advocacy group in each state.

Importance to County Mntal Health Authorities
Dr. Draper reviewed specific reasons for understanding Medicaid financing of public psychiatric hospitals issues' impact on county mental health authorities:

• Such changes may affect county authorities' costs and capacities.
• Treatment options may change for people in need of care.
• Counties may encounter changes in their relationships with the other entities with which they work.

Historical Perspective
In examining Medicaid funding, Dr. Draper notes that, significantly, "You can't really think about Medicaid funding as a snapshot," without considering the historical issues behind it. These historical factors include:

• The shift from institutional care to community-based care beginning in earnest during the 1960s.
  
  
• Since the beginning of the Medicaid program in 1965, Medicaid has been customized by states with tremendous variation, including how public mental health systems are structured. In California, for example, the state "carves out" public mental health services to the individual counties. In Iowa, the state uses an external vendor to help administer and manage it's Medicaid managed care behavioral health carve-out program.
  
  
• The Institutions for Mental Diseases (IMD) exclusion, which precludes Medicaid funding of treatment for those ages 21-64 in state and county psychiatric hospitals, means that for many facilities, this exclusion applies to the bulk of the populations they treat. The underlying policy premise of the IMD exclusion is that those suffering from long-term mental illness are the responsibility of the state, and it encourages the use of community-based treatment settings instead of psychiatric hospitals.
  
  
• The advent of psychotropic drugs in the 1960s has allowed those suffering from mental illness to be maintained in the community.
  
  
• The growing patients' rights movement has also contributed to deinstitutionalization.
  
  

In terms of the numbers of individuals affected by these historical factors, Dr. Draper explained that between 1970 and 1998, the number of public psychiatric hospital beds decreased 85%, from 400,000 beds in 1970 to 63,000 beds in 1998. There was only some increase in private and general psychiatric beds during that same period of time (+50,000).

Current Pressures
Shifting to the present, Dr. Draper explained some of the current pressures facing public hospitals, and noted that county mental health authorities are involved in treating and placing individuals potentially affected by these challenges.

• The managed care movement has created pressure for less restrictive venues of care, using inpatient psychiatric services when other alternatives have been exhausted or are inappropriate.
  
  
• Medicaid managed care has proliferated in the last 10 years, with 21 million Medicaid managed care beneficiaries now enrolled - more than half of all Medicaid beneficiaries. While Medicaid beneficiaries have access to mental health services provided by their respective states, they may be affected by the IMD exclusion.
  
  
• Caps have been implemented in the last few years on state DSH claims. For states that include IMDs in their DSH programs, there are caps on the amount of money these facilities can claim through the DSH program. For example, starting in 2003, states can spend no more than 33% of their DSH allocation on IMDs. An estimated one in five states will be impacted by these caps.
  
  
  • Eight states have IMD expenditure authority under Medicaid 1115 waivers - they may receive matching federal dollars for those 21-64, but there are typically 30 day per episode and 60 day annual limits.
    
    
  • States are facing major fiscal challenges, with four out of five states facing major shortfalls. Medicaid accounts for 20% of state spending. States are examining ways to address these budget crises, particularly in relation to Medicaid. Dr. Draper notes that several organizations have published papers or discussions addressing this issue, such as the Kaiser Family Foundation (www.kff.org) the National Conference of State Legislatures (www.ncsl.org), and the National Governor's Association (www.nga.org).
    
    
  • Pressure for states to be in compliance with the Olmsted Act furthers the shift to community-based treatment.
    
    
  • The configuration and roles of public psychiatric hospitals are changing and evolving, with a considerable shift toward treating a forensic population. This potentially decreases the capacity for those civilly committed and may cause capacity constraints in some situations.
    
    
  • The lack of parity puts pressure on public psychiatric hospitals.
    
    

Mathematica staff are currently writing the final report of the project's findings. The report will then be reviewed at the federal level, with a possible general release in late 2002. For questions, contact Dr. Draper at (202) 484-5265 or DDraper@Mathematica-mpr.com.

Use NACBHD's Toll Free No.: 1-800-228-6905

2003 NACBHD Membership Campaign Underway

As we approach the annual Fall Membership Campaign, we are proud of our achievements this year. We are making impressive strides in our advocacy efforts; increasing our visibility on the federal level [see "From The Hill" above]. Our communication with federal agencies has greatly improved, as Charlie Curie and agency directors recognize NACBHD as a significant player, and county authorities as key components of the public system. With an improved web site, new Membership Newsline distribution list and vital conference programs, NACBHD is better positioned than ever to provide you the services you need and the voice in Washington you deserve. No other national organization represents your interests. No other organization is dedicated to advocating for county behavioral health systems. Join us this year. Renewal notices will be out by late October. Please watch for your notice and stay current with us.

NACBHD Annual Conference: A Great Success

NACBHD's Annual Conference, July 25 - 27th in San Diego, CA combined a strong program with outstanding speakers. The keynote speaker, Monica Oss, President, Open Minds, spoke eloquently and substantively about leadership and change in the public behavioral health system. She integrated awareness of changing information technology with the need for county authority directors to blend public influence with managing the dynamics of complex work environments.

The discussion about leadership continued with presentations by Dr. Mark Tager, President, Workskills-Lifeskills, Inc. in San Diego, who emphasized the importance of balance in our lives and how that impacts leadership style. He took the group through some intriguing exercises that demonstrated the value of relationship and trust to any interaction. Dan Brown, President, Dan Brown and Associates in Toledo, OH presented his organizational performance model and suggested ways that county directors can perceive their organizations and themselves differently in order to create an environment that allows for change and ensures a more dynamic organization.

The group dialogue that followed was a natural way for participants to think about what they had heard and begin to integrate it into their own situations. The group shared the realities of their systems of care, and exchanged ideas and information on a variety of related topics.

The session on evidence-based practice presented by Dr. William MacFarlane, Chief, Maine Medical Center and Steve Baron, Director, Baltimore Mental Health Systems, brought this critical discussion home by providing both the global and local views. Dr. MacFarlane discussed his model for treating schizophrenia within a family systems framework, and defined the standards that have been developed for assessment and treatment. Mr. Baron talked about the challenges he encountered in adapting an EBP model to a local system containing a large metropolitan area with persistent addiction and mental illness problems.

The Michigan experience with the Medicaid pre-authorized formularies and supplemental rebate system was the topic of the next session. Presented by county directors and the director of the MI Association of Community Mental Health Boards, the session provided background to the initiative and defined the challenges for county authorities in the state that rely on the ability to prescribe the medications deemed necessary for the clients they serve.

The annual awards luncheon was especially meaningful this year as the Wernert Award for Innovation in Community Behavioral Healthcare went to the Nathaniel Project in New York City. Dan Still, Deputy Commissioner, New York City Dept. of Health and Mental Hygiene attended to helped Joel Copperman receive the award and recognition for the department's heroic efforts in the aftermath of September 11th. The Wernert family was also on hand to congratulate the winner. NACBHD's first Robert C. Egnew Award for Excellence in Policy was awarded to Bob Egnew for his tireless effort on behalf of county behavioral health authorities in CA and throughout the country. He graciously accepted a plaque and a resolution passed in his honor by the California Mental Health Directors Association and the California Institute for Mental Health.

Participants heard a round up from California and listened to a description of a couple of model programs in several counties related to the homeless mentally ill and innovative programs addressing the needs of the dually diagnosed.

Tom Graham, Director of Operations, Public Partnerships, a subsidiary of Public Consulting LLC the intermediary service for the Massachusetts Dept. of Mental Retardation, discussed two innovative approaches to information technology that address challenges faced by county behavioral health directors. The session provided detailed information on several models, including costs and quality implications. Dr. Deborah Draper, Project Director, Mathematica Policy Research, Inc. provided excellent information on Medicaid financing in state/county psychiatric hospitals. Dr. Draper elaborated on the forces that are shaping Medicaid financing changes and engaged with participants in a good dialogue about their impact on county systems.

The conference was rich, full and contained the depth of subject matter that our members expect and deserve. Check out NACBHD's web site for the 2003 conference schedule. Information on the Legislative and Annual Conferences will be appearing in the next couple of months.

Mark Your Calendar for 2003 Conferences!

Legislative Conference
February 26 - 28th
Jurys Doyle Hotel, Washington, DC

Annual Conference
July 10 - 12th
Hyatt Regency Milwaukee
Milwaukee, WI

New State Association Column

In recognition of the efforts of our state association members, we are initiating a new State Association Column. It will include state association announcements, news, interviews and stories that are of interest to all of our members. By raising the visibility of our state associations, we believe we can increase the visibility of these organizations and share their expertise and knowledge with their state association colleagues and county director members across the country. State association directors and staff members can contact Nancy Sydnor-Greenberg, newsletter Write/Coordinator with information and/or a story for the November issue at nesydnor@erols.com.

Upcoming SAMSHA Conference to Focus on Key Medicaid and Mental Health Issues

The upcoming SAMSHA conference "Medicaid and Mental Health Services" will focus on several important Medicaid and mental health issues. The conference, scheduled for September 17 and 18 in Baltimore, is sponsored by SAMSHA and CMHS. NACBHD representatives will be among the 250 invitees, and will report on the conference in a future issue of the newsletter. Three major areas of focus are:

• The relationship between mental health agencies at the state level and Medicaid agencies
• Medicaid issues and psychotropic medication
• Immediate issues for Medicaid and how they affect mental health services

David Wiebe, Chair of NACBHD's Medicaid Committee, reports that SAMSHA has provided scholarships for 20 NACBHD members to attend the invitation-only conference. He is "very pleased that CMHS has recognized the very important role of county authorities in this issue." Because Medicaid is a major funder of local mental health services (about 50% of all revenues received by mental health authorities), Wiebe says participation at this level is extremely important at this "very significant conference."

National Depression Screening Day Announces Revised Screening Form

National Depression Screening Day's revised screening form now includes questions on generalized anxiety and post-traumatic stress disorder. The added questions solidify the event's ability to address a range of common disorders including major depression, anxiety, bipolar disorder, and suicidality. "County behavioral health authorities can now organize and promote one program to address a range of disorders. The goal is ensure consistency, excellence, and efficiency in mental health screening activities," explains Douglas G. Jacobs, MD, NDSD founder and executive director. "We now have one simple screening form that effectively screens for a range of commonly underdiagnosed disorders and reflects current medical understanding that these illnesses and symptoms are more likely than not to occur concurrently." NACHBD members can download a registration form for the October 10th National Depression Screening Day by visiting www.mentalhealthscreening.org/ndsd/nachbd or request one by calling the NDSD office at (781) 239-0071.

Comments or Questions About the Articles You Have Read Here?

Contact Nancy Sydnor-Greenberg with your comments about the content of the articles for a new Letters To The Editor Section. She can be reached at nesydnor@erols.com.

The NACBHD Bulletin is published electronically six times a year by the National Association of County Behavioral Health Directors, 1555 Connecticut Avenue, Suite 200, Washington, DC 20036; (202) 234-7543; www.nacbhd.org. Articles of interest to county behavioral health authority 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. Previous newsletter issues are available on NACBHD's web site.