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CMHS Performance Partnership Block Grant, 8/29/03
STATE OF IOWA
CMHS PERFORMANCE PARTNERSHIP BLOCK GRANT APPLICATION
FY 2004 (STATE FY 2005)
Kevin Concannon, Director Iowa Department of Human Services Hoover State Office Building Des Moines, Iowa 50319-0114
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August 25, 2003
Lou Ellen Rice Center for Mental Health Services Substance Abuse and Mental Health Services Administration US Department of Health & Human Services 5600 Fishers Lane Rockville, MD 20857
Subject: Resubmission of CMHS Performance Partnership Block Grant, FFY 2004 (State Fiscal Year 2005)
Dear Ms. Rice:
Please accept the following document as a draft of Iowa’s CMHS Performance Partnership Block Grant application for FFY 2004. This document was reviewed in draft form, by the Mental Health Planning and Advisory Council in a meeting on August 4, 2003. As in the initial application, Iowa is submitting a one-year plan using the five (5) consolidated criteria. If approved, funds available under this grant shall be used to implement the proposed activities during the State Fiscal Year 2005.
Questions regarding this submission can be addressed to:
Ms. Lila P.M. Starr, Adult Mental Health Specialist Iowa Department of Human Services, Division of BDPS Hoover State Office Bldg., 5th Floor N.E. Des Moines, Iowa 50319-0114 Tel: 515/ 281-7270 Fax: 515/281-4597 E-Mail: [email protected]
Sincerely,
Kevin Concannon, Director
2 CMHS Performance Partnership Block Grant, 8/29/03
Table of Contents
Page Application cover page 1 Governor’s letter of designation 1a Face sheet 1b Letter of submission 2 Table of contents 3 - 5 Planning Council Chair letter 5a-c Mental Health Planning Council recommendations Executive Summary 6 - 7 Section I – Funding Agreements and Certifications and Assurances 8 Community Mental Health Services Block Grant Agreement 8a-e Certification regarding debarment and suspension 8f Certification regarding drug-free workplace requirements 8f Certification regarding lobbying 8g Certification regarding Program Fraud Civil Remedies Act (PFCRA) 8g Certification regarding environmental tobacco smoke 8h Disclosure of lobbying activities 8I Assurances – non-construction programs 8j-k Maintenance of Effort Children and adults 9 Adults only 10 Children's set aside 11 Iowa Mental Health Planning Council 12 Charge 12 Mission 12 Guiding principles 12 – 13 Table 1: Membership list 14 – 16 Table 1A: Planning Council composition by type of membership 17 Table 1B: Planning Council composition: state employees and providers vs. 17 others Table 1C: Planning Council members by type of membership 18 Planning Council membership and categorization notes 19 Planning Council bylaws 20 – 26 FY 2002 block grant activities 27 – 35 Section II–State Plan Context 34 Iowa general information and demographics 37 – 38 Key elements of the Iowa mental health system 39 – 41 A. The state public mental health service system as it is envisioned for the 41 – 44 future
B. Areas identified by the State in the previous plan as needing particular 44
93 attention C. New developments and issues that affect mental health service delivery in 45 the state D. Legislative initiatives and changes 45 - 46 E. Description of regional /sub-state mental health programs 46 F. State mental health agency leadership in coordinating mental health services 48 - 49 G. Role of the State Mental Health Planning Council in improving mental 49 – 50 health H. Description of critical gaps in services and unmet needs 50 – 51 Section III: State Plan (cover page) 52 Adults with a Serious Mental Illness 53 Criterion 1: Comprehensive community based mental health system Introduction and overview Definition of adults with a serious mental illness 52 Organizational structure of the comprehensive system of care 53 Health and mental health services 53 Covered services for mental health conditions in the Iowa Plan 54 Required services in the Iowa Plan 54 County management plans 55 Mental health institutes 56 Specialized psychiatric units in general hospitals 56 Community mental health centers and other community mental 56 health providers Mental health professionals statewide 56 Residential care facilities for persons with a mental illness 57 Intermediate care facilities for persons with a mental illness 57 Medical and dental services 57 Private practitioners and clinicians 57 Rehabilitation services 58 - 60 Employment services 60 Housing services 60 – 61 Educational services 61 Substance abuse services 62 Case management services 62 – 63 Other support services to assist individuals to function outside of 64 residential settings Activities to reduce the rate of hospitalization 64 Moving towards evidence-based practices 65 – 66 Criterion 1: Goals, objectives and indicators 63 – 69 Criterion 2: Mental health data and epidemiology 70 – 71 Criterion 4: Targeted services to homeless and rural populations 71 – 77 Criterion 5: Management systems 78 – 80 Table: SFY03 Block Grant Funds 81
Children and Adolescents with a Serious Emotional Disturbance 82 Criterion 1: Comprehensive community based mental health system Introduction and overview
4 Definition of children with serious emotional disturbance 82 Organizational structure of the comprehensive system of care 82 Health and medical services 82 Child Health Specialty Clinics 82 State children’s health insurance program 82 Mental health services introduction 83 Iowa Plan – services for children 83 Child welfare services 84 Child Welfare Redesign 85 Educational services 86 – 89 Substance abuse services 89 Services for adolescents with co-occurring disorders 89 Education and Support services 90 Case management services 91 Dental services 91 Employment services 91 Housing services 91 Other social services 93 Activities leading to reduction of hospitalization for children 93 – 94 Criterion 1: Comprehensive community-based mental health system 95 Criterion 2: Mental health system data epidemiology 96 – 98 Criterion 3: Children’s services 99 – 100 Criterion 4: Targeted services to homeless and rural populations 101 – 102 Criterion 5: Management systems 103 – 104
Appendices Appendix 1: MHDD Commission Annual Report for submission to the Governor 1-3 and General Assembly, February 11, 2003 Appendix 2: Senate File 529, addressing MHDD Redesign 1-3
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Executive Summary
It has been an exciting and dynamic year for Iowa’s mental health community. The state’s mental health and developmental disabilities (MHDD) system is clearly in the midst of a transition. The combination of ongoing fiscal pressures (increasing costs and state budget deficits), legal mandates and civil rights issues (Olmstead) and evolving mental health policy on the national level (e.g., New Freedom Commission, increased flexibility in CMS) have fueled the recognition that business as usual simply will not suffice.
We have new leadership in critical positions. Kevin Concannon is now the director of the Department of Human Services (DHS), bringing many years of experience with his leadership of systems in Maine and Oregon. We have a new Medicaid director (Eugene Gessow) who has a reputation for crafting creative ways to maximize dollars in order to deliver services to more people in need. We continue to enjoy active support from our executive branch, with substantial hands-on involvement by Lt. Governor Sally Pedersen, who has been an ardent advocate of disabilities services throughout her career. And we have a newly configured and empowered MHDD commission, which is coordinating a legislatively mandated effort to redesign Iowa’s MHDD system from the ground up.
The MHDD redesign process has involved more than 150 individuals, representing all stakeholder groups, who have met regularly in 5 working groups over the past year. Each work group has recently submitted its recommendations to the MHDD commission, who will integrate and prioritize them, leading to recommendations to the Governor and legislature by December 2003 for the adult system, and by the following year for the children’s system. We have been closely following the work of the President’s New Freedom Commission, and were gratified to see the degree of consistency in terms of key themes and recommendations that emerged between our state’s process and that at the national level. These include the centrality of person- centered planning and a recovery-oriented approach, the importance of evidence-based practices, the need to expand access to rural and otherwise underserved areas, and the necessity for having a comprehensive state mental health plan.
There has also been a lot of activity around Olmstead-related issues, which have been closely integrated with the MHDD redesign process. Led by a consumer-task force, and supported by a “Real Choices Systems Change” grant, Olmstead has sparked a level of interest and a sense of urgency for disability issues in the broader community that would otherwise be very unlikely in light of current fiscal pressures. This was demonstrated in February of this year, when Governor Vilsack issued Executive Order 27, mandating the directors of twenty state agencies to work with DHS and to formally review their policies and programs so as minimize barriers to community integration for individuals with disabilities in Iowa. As a result, each state agency now has a designated Olmstead coordinator, and each has submitted initial plans to the Governor, describing their approaches to fulfilling this mandate. The cross-agency discussions and interactions around disabilities issues that have emerged from this process are unprecedented, and in a relatively small state like Iowa, are key to fostering meaningful systems change.
6 Interactions and linkages between those agencies more directly involved in mental health issues are also growing. Linkages between DHS and the Department of Corrections continue to develop and expand, with a growing awareness of the mental health burden that has been shifted to the criminal justice system. Indeed the mental health/criminal justice interface was identified by the Mental Health Planning Council this year as its top priority, and block grant monies continue to support community re-entry programs for mentally ill offenders that are dramatically decreasing reincarceration rates. The Department of Public Health, which has administrative responsibility for substance-abuse services in Iowa, took the lead in organizing and submitting an ambitious grant (in response to SAMHSA’s “COSIG” grant mechanism) which would provide for key infra-structural linkages between the two agencies so as to better serve those with co-occurring disorder. Relationships between DHS and the Department of Elder Affairs are also deepening, as are those with the Department of Education and Area Education Agencies. In short, while it would be an overstatement to imply that the silos are crumbling, there is no question that collaborative efforts are being encouraged and embraced.
Finally, there is a growing commitment to ensuring that the resources that are available for mental health services are used to support those practices that are most effective in yielding outcomes that are meaningful to consumers and families. As detailed in this plan, multiple efforts are being made to enhance the dissemination and implementation of evidence-based practices and to develop strategies by which outcomes continue to guide our practices and policies.
There are still many gaps in Iowa’s mental health system, and there are no easy answers or magic bullets. However, what we can report, and what is hopefully reflected in this document, is a new and very tangible sense of energy, optimism and consensus that has been absent from our system for quite some time.
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Section I
Funding Agreements and Certifications
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Section I Maintenance of Effort
Gross expenditures for mental health services for children and adults by funding source: FY2001, 2002, 2003, 2004 State and County Gross SFY 2001 SFY 2002 SFY2003 SFY2004 Expenditures for Mental Actual Actual Estimated Projected Health Services County Expenditures for Services to Adults with 20,225,995 24,114,949 25,000,000 25,000,000 Mental Illness* County Expenditures for Services to Adults with 68,660,021 64,920,227 64,000,000 63,000,000 Chronic Mental Illness* State Funded Mental Illness Housing 121,200 121,200 0 0 Services**** State Share of Medicaid Managed Behavioral Health Services** (The 25,285,157 29,292,026 30,900,509 31,000,000 Iowa Plan) State Share of Medicaid Managed Behavioral Health Care (The Iowa 11,865,202 14,630,038 15,434,442 16,669,197 Plan) (children)***** State Payment Program for Mental Health Services 7,610,000 10,918,602 10,959,055 11,346,533 (Adults only)***
TOTAL 121,902,373 129,367,004 131,859,564 130,346,533
Source: *County Management and Information Systems (COMIS) data, maintained by DHS; county expenditures include 50% state dollars and 50% county dollars. **DHS Medicaid Staff/MBC of Iowa ***DHS Financial Services/Ron Flug ****State Funded Mental Illness “special” housing fund is no longer available as of SFY2003. The legislature did not appropriate funds to DHS after SFY2002 *****Numbers shown represent the children’s portion of the total state share of Managed Behavioral Health Services. It is a subset of the information presented on the line above.
9 Maintenance of Effort—Adult SFY2003 State Allocation for SFY 2001 SFY 2002 SFY2003 SFY2004 Mental Health Services Actual Actual Estimated Projected 6,67 Community Services 9,000 18,688,920 17,727,890 17,727,890 Allocation*
Property Tax Relief*** 29,380,988 88,399,999 88,399,999 88,399,999
Allowable Growth*** 7,272,973 8,554,053 13,681,000 13,681,000
State Share of Medicaid Behavioral Health Services** (The Iowa 13,419,955 14,661,988 15,466,067 15,500,000 Plan) (Adults)
State Payment Program 7,610,000 10,918,602 10,959,055 11,346,533
Mental Health Housing 121,200 121,200 0 0 Fund 64,484,115 141,344,762 TOTAL 146,234,011 146,655,422
Source: *County Management and Information Systems (COMIS) data, maintained by DHS; *MHDD Community Services Fund (subject to withholding). This appropriation was created as an integral part of the MHDD initiative to increase state financial participation in MH/MR/DD services, combine funding streams to create greater flexibility, provide incentive for the development and delivery of contemporary services and encourage local governments to pool fiscal and planning resources to increase efficiencies. The majority of this fund ($17,727,890) is allocated to the counties to provide MHDD discretionary services which meet criteria consistent with the initiative objectives. **DHS Medicaid Staff/MBC of Iowa ***DHS Financial Services/Ron Flug
Children’s Set Aside, SFY2003
10 Calculated SFY 2002 State expenditures only SFY 2001 SFY 2003 SFY1994 actual Actual estimated Mental Health Block 700,000* 1,134,261 1,719,765 1,710,575 Grant 10% of FFY ’93 grant 204,710 10% of FFY ’94 Grant 204,719 State Share of Medicaid Behavioral Health 9,716,354 14,630,038 Services for Children 11,865,202 15,434,442 (The Iowa Plan)**
TOTALS 10,825,793 12,999,463 16,349,803 17,145,017
Sources of data: * The total for 1994 represents 50% of the block grant, the total for 2002 and 2003 represents the total block grant funds spent on services for children’s mental health services. The block grant is divided approximately in half between children and adult services. ** Division of Medical Services, DHS
11 Iowa Mental Health Planning Council
The Iowa Mental Health Planning Council was established in 1987 by the State Mental Health and Developmental Disabilities Commission, a policy-making body established pursuant to Section 225.C of the Iowa Code. Initially, the Council was established as a sub-committee of the MHDD Commission with members appointed for two-year terms. In August 1995, the Council acquired a distinct status to meet the intent of the federal requirements of Section 1914 (b) of Public Law 102-321. The Council currently meets no less than four times per year. It represents a cross-section of constituencies and interest groups. At least 50% of its members must be consumers, family members, advocates, and others who are not state employees or providers.
Planning Council Charge According to Attachment A, Section 1914 of the "Community Mental Health Services Block Grant Agreements," signed by Iowa Governor Thomas Vilsack, the State will establish and maintain a State Mental Health Planning Council. The duties of the council are: 1. To review plans provided to the Council pursuant to section 1915(a) by the State involved and to submit to the State any recommendations of the Council for modifications to the plans; 2. To serve as an advocate for adults with a serious mental illness, children with a serious emotional disorder. 3. To monitor, review, and evaluate, not less than once a year, the allocation and adequacy of mental health services within the State
Planning Council Mission The Council's mission, adopted in November 1995, reads:
To identify and recommend to all stakeholders a plan of core services to be developed and provided statewide on an equitable basis for adults with a serious mental illness and children and adolescents with a serious emotional disorder.
The Council adopted revised by-laws on August 4, 2003 and revised its membership structure in accordance with the federal guidelines contained in Section 1914-0 of Public Law 102-321. The next annual election of officers is scheduled for fall 2003. The Iowa Mental Health Planning Council is a member of the National Association of Mental Health Planning and Advisory Councils.
Planning Council Guiding Principles The Mental Health Planning Council, the Division of BDPS, consumers, families, advocates, and service providers share a common set of beliefs that define the values of the system. These principles form the basis on which this plan was developed and from which future policies, programs and strategies will be developed and evaluated. These principles are:
1. Individuals with serious mental illness have the same inalienable fundamental rights as any other person. These rights include the right to vote, freedom of speech, freedom of religion, freedom of sexual expression, protection from denial of life, liberty, and property, and the pursuit of happiness, and freedom from discrimination because of illness or disability.
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2. Individual and family strengths and needs should be the basis for service delivery. The individual’s abilities, needs and preferences shall determine the type and intensity of services. Individuals shall have access to an appeals process and shall maintain the right to refuse services and supports.
3. Individuals with serious mental illness and their families shall have the right to participate in identifying service needs and planning to meet those needs. Planning shall include utilization of the natural support systems to promote recovery, self-determination, and independence in the community.
4. Individuals with serious mental illness shall be served in a manner that encourages the development of each person's unique competencies.
5. Individuals with serious mental illness shall be provided the opportunity to live, work and recreate in a manner that is as close as possible to the manner in which other people live. Individuals shall be provided services in a manner that minimizes intrusion into and disruption of the individual’s life style while providing the supports and supervision needed.
6. Services shall promote individualization and opportunities for personal choice.
7. Services and supports shall be geographically and financially accessible to all persons. Individuals and families shall be served in a manner that enhances family and peer supports.
8. Development and availability of financial support for services should be based on individual strengths and needs rather than determined by program definitions or service settings.
9. A sufficient number of appropriately trained persons shall be available to provide needed services and supports. Necessary resources shall be available for use by these persons.
10. Persons with mental illness and their family members shall play an active role in service and support system planning, implementation, and evaluation.
11. Individuals with serious mental illness and their family members have insights into the service system and the provision of services. Their expertise shall be utilized whenever possible in the planning, implementation, provision, and evaluation of these services and supports.
12. Individuals with serious emotional disorders should receive services without regard to race, religion, national origin, sex, physical disability or other characteristics, and services should be sensitive and responsive to cultural differences and special needs.
Table 1: State Mental Health Planning Council membership list Name/e-mail address Type of Agency or Term Address/phone/fax
13 membership organization expires James Overland Principal State Agency, Dept. of Human 2003 Hoover Bldg, 5th Flr [email protected] Mental Health Services Des Moines, IA 50319 Ph: 515-281-8908 Fax: 515-242-6036 Micheleen Maher Principal State Agency, Dept. Of 2003 Jesse Parker Bldg Micheleen.maher@dvrs .sta Vocational Education, 510 E. 12th St te.ia.us Rehabilitation Vocational Rehab. Des Moines, IA 50319 Ph: 515-281-4146 Fax: Robert Eppler Principal State Agency, Dept. of Human 2003 701 Church St Reppler@dhs .state.ia.us Social Services Services, Iowa Toledo, IA 52342 Juvenile Home/ Ph: 641-484-2560 Girls State Fax: Training School Rose McKie Wazny Principal State Agency, Dept. of Economic 2003 200 East Grand Rose.wazny@ided .state.ia.u Housing Development Des Moines, IA 50309 s Ph: 515-242-4822 Fax: Sally Nadolsky Principal State Agency, Dept. of Human 2003 Hoover Bldg, 5th Flr Snadols@dhs .state.ia.us Medical Services, Medical Des Moines, IA 50319 Services Ph: 515-281-5796 Fax: 515-281-8512 Suana Wessendorf Principal State Agency, Dept. of Education 2005 Grimes Bldg, 3rd Flr [email protected]@ed.st Education Des Moines, IA 50319 ate. ia.us Ph: 515-281-5447 [email protected] Fax: Richard Moore Principal State Agency, Dept. of Human 2003 Lucas Bldg [email protected]. Juvenile Corrections Rights, Criminal Des Moines, IA 50319 us Juvenile Justice Ph: 515-242-5823 Planning Fax: Lowell Brandt Principal State Agency, Department of 2005 Iowa Medical and [email protected] Adult Corrections Corrections Classification Center .us Box A. Oakdale, IA 52319 Ph: 319-626-4247 Fax: 319-626-4242 Barry Buchanan Adult Consumer DBSA of SW Iowa 2005 803 Palm Street [email protected] Atlantic, IA 50022 Ph: 712-243-4650 Fax: Mary Hughes Adult Consumer MHDD 2005 P.O. Box 317 Mchughes@kctc .net Commission Kalona, IA 52247 Ph: 319-656-2356 Fax: Bill Broich Adult Consumer 2005 508 Ashworth Road [email protected] West Des Moines, IA 50255 Ph: 515-205-8062 Fax: none
14 Table 1: (continued) State Mental Health Planning Council membership list Name/e-mail address Type of Agency or Term Address/phone/fax membership organization expires Don Hruby Adult Consumer 2005 736 39th St. [email protected] Des Moines, IA 50312 Ph: 515-279-4949 Fax: Patrick O'Brien Adult Consumer NAMI Iowa, 2003 4925 Franklin #10-C [email protected] Olmstead Real Des Moines, IA 50310 Choices Consumer Ph: Taskforce Fax: Alice Holdiman Adult Consumer Olmstead Real 2005 405 E. Water Street [email protected] Choices Consumer Decorah, IA 52101 Taskforce, NAMI, Ph: 563-382-3600 Recovery Groups Fax: 563-382-3600 of Iowa Margaret Stout Family Member of an NAMI National, 2005 5911 Meredith Dr. #E [email protected] Adult with SMI, NAMI Iowa Des Moines, IA 50322 Advocacy Organization Ph: 515-254-0417 Fax: Brenda Hollingsworth Family Member of an NAMI Iowa, 2003 736 14th Ave Brenda- Adult with SMI, Iowa Consortium Coralville, IA 52241 [email protected] State Employee for Mental Health Ph: 319-353-5436 Fax: 319-353-5439 Alice Book Family Member of NAMI Iowa 2005 617 34th St [email protected] Adult with SMI W. Des Moines, IA 50265 Ph: Fax: Claudine Harris Family Member of an NAMI Iowa 2003 701 Oaknoll Dr [email protected] Adult with SMI Iowa City, IA 52246 Ph: Fax: 319-351-6772 Lori Reynolds Family Members of IA Federation of 2004 PO Box 362 [email protected] Child with SED Families, Anamosa, IA 52001 MHDD Ph: 319-462-2187 Commission Fax: Terri Zirkelbach Family Members of IA Federation of 2003 15595 130th Ave [email protected] Child with SED Families Scotch Grove, IA 52310 Ph: Fax: Cindy Laughead Family Members of AEA Parent 2004 1420 Howard Ave [email protected] Child with SED Educator, Muscatine, IA 52761 CHADD of Iowa Ph: 563-264-0309 Fax: Pat Crosley Family Members of NAMI Iowa, 2004 675 40th [email protected] Child with SED Magellan Des Moines, IA 50312 Behavioral Care of Ph: 515-273-5086 Iowa Fax: Pam Billmeier Family Member a Child 2005 1017 Harriet Ave. [email protected] with SED Carroll, IA 51401 Ph: 712-792-3738 Fax: 712-792-6813
15 Table 1: (continued) State Mental Health Planning Council membership list Name/e-mail address Type of Agency or Term Address/phone/fax membership organization expires Tammy Riley Family Member a Child Creston 2005 1106 Pear Ave. [email protected] with SED Community Prescott, IA 50859 Schools Ph: 641-322-5435 (h) Ph: 641-782-2116 (w) Fax: 641-782-9502 Mary Dubert (Vice-Chair) Public/Private Entity ISAC designee, 2005 428 Western Ave Mdubert@scottcountyiowa . County Mental Health Scott County Davenport, IA 52801 com Funder Comm. Services Ph: 563-326-8723 Provider Fax: 563-326-8730 Donna Meck Public/Private Entity, Judicial Advocate 2004 1347 127th Ave [email protected] Judicial Advocate designee Dundee, IA 52038 Ph: 319-291-2400 Fax: 319-291-2406 Dave Parr Public/Private Entity, IA Protection & 2003 950 Office Park Road [email protected] Advocacy Organization Advocacy designee West Des Moines, IA 50265 Ph: 515-278-2502 Fax: 515-278-0539 Craig Syata Public/Private Entity, Iowa Association 2004 7025 Hickman Road, Suite 5 [email protected] Provider of Community Urbandale, IA 50322 Providers designee Ph: 515-270-9495 Fax: 515-270-1039 Carl Smith Public/Private Entity, Drake University 2003 Drake University [email protected] University Resource Center 2507 University for Spec. Des Moines, IA 50311 Education Ph: 515-271-3936 Fax: 515-271-4185 Scott Shafer (Chair) Public/Private Entity, Orchard Place 2004 1206 Pleasant [email protected] Provider Child Guidance Des Moines, IA 50309 Center Ph: 515-244-2267 Fax: 515-244-1922 Ann Michalski Other, Child Advocate Mental Health 2003 1504 Iowa St [email protected] Assoc./Dubuque Dubuque, IA 52001 County Ph: Fax: Connie Fanselow Other, Child Advocate The Legal Center 2005 317 E. 6th [email protected] for Special Des Moines, IA 50309 Education Ph: 515-309-0033 Fax: Karen Schurke Other, Provider West. IA. Comm. 2003 2020 1st Ave [email protected] MHC Denison, IA 51442 Ph: Fax: Rep. Ro Foege Other, Legislator, Child Advocate, 2003 412 4th Ave S [email protected] Child Advocate Legislator Box 128 Mt. Vernon, IA 52314 Ph: 319-895-6043 Fax: Staff Lila P. M. Starr Staff Dept. of Human Ongoing Hoover Bldg, 5th Flr [email protected] Non-Member Services, Adult from 2000 Des Moines, IA 50319 MH Specialist Ph: 515-281-7270 Fax: 515-242-6036 Mary Mohrhauser Staff Dept. of Human Ongoing Hoover Bldg, 5th Flr [email protected] Non-Member Services, Ch. & from 2003 Des Moines, IA 50319 Adol. MH Ph: 515-242-6845 Specialist Fax: 515-242-6036
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Table 1A: Planning Council composition by type of membership Type of Membership Number Primary consumers 6 Family members of children with SED 6 Other representatives 4 Family members of Adults with SMI 4 State employees 9 Public and private entities 6 Total members 34* *One member is both a state employee and a family member of an adult with SMI and as a result is counted in two categories.
The By-Laws were amended in 2003 to reflect 34 as the current membership total. The Council agreed to add a representative from the Department of Corrections as suggested by CMHS and the technical assistance provided increasing the membership from 33 to 34.
Table 1B: Planning council composition: State employees and providers vs. others Number Percent
Individuals who are not state employees 22 65% and/or providers of mental health services
Individuals who are state employees and/or 12 35% providers of mental health services
Total 34 100%
17 Table 1C: Planning Council members by type of membership Adult Consumers: State Employees: 1) Don Hruby 1) Jim Overland, DHS* 2) Mary Hughes 2) Michaleen Maher, DVRS 3) Barry Buchanan 3) Robert Eppler, DHS 4) Patrick O’Brien 4) Rose Wazny, IDED 5) Alice Holdiman 5) Sally Nadolsky, DHS 6) Bill Broich 6) Suana Wessendorf, DOE 7) Richard Moore, CJJP 8) Lowell Brandt, DOC Family Members of Children with SED: Family Members of Adults with SMI: 1) Lori Reynolds* 1) Brenda Hollingsworth, Vice Chair, 2) Pat Crosley state employee* 3) Terry Zirkelbach* 2) Claudine Harris 4) Cindy Laughead 3) Alice Book 5) Pam Billmeier 4) Margaret Stout* 6) Tammy Riley Other: Public and Private Entities: 1) Ro Foege, Child advocate, Legislator 1) Carl Smith, Drake University 2) Ann Michalski 2) Scott Shafer, Chair, Provider* 3) Connie Fanselow 3) Donna Meck, Judicial Advocate 4) Karen Schurke, Provider* 4) Mary Dubert, Provider 5) Dave Parr, IA Protection & Advocacy 6) Craig Syata, IA Assn. of Community Providers, Provider* Vacancies: 0 *= Organization/individual receives CMHS Block Grant funding, eight current members in this category
18 Planning Council Membership and Categorization Issues were raised concerning the composition of the Mental Health Planning and Advisory Council at the Peer Review meeting in September of 2002. The reviewers expressed concern regarding the following: 1) Possible member conflicts of interest 1) Appropriate numbers of members within each of the membership categories 2) Identifying which members receive funding through the Block Grant and determining whether they should vote in matters relating to expenditures 1) Identifying which members are counted as state employees
We have attempted, in the tables provided within this section, to clarify the composition of the current membership and appropriate categories for each of the members. CMHS has provided technical assistance in clarifying the categories of membership and how members should be counted. The assistance provided by CMHS has been very helpful in identifying several issues that the Council has since made concerted efforts to address: 1) Pursuant to our agreement with CMHS, the MHPC agreed to add a member representing the Department of Corrections to provide input on the mental health needs of adult offenders. Lowell Brandt of the Department of Corrections joined the Council in the fall of 2002, shortly after the Peer Review.
2) The Council further agreed to develop and provide a written policy to address conflict of interest by the time of next year’s submission. The Council has made efforts to address this issue within the revision of the By-Laws, a copy of which is attached. Guidance is requested regarding the sufficiency of this response.
3) The Council has requested guidance from the Iowa Attorney General’s office regarding each of the issues listed above. A member of the Attorney General’s staff met regularly with the By-Laws Committee of the Mental Health Planning Council and provided useful legal advice and feedback during the revision process. A member of the Attorney’s General staff has also been in regular attendance during Mental Health Planning Council meetings at the request of DHS and the Council. The AG’s office has provided ongoing information about compliance with Iowa’s Open Meetings and Public Records laws and valuable feedback about procedural matters, including recording official votes, issues relating to quorum, and other issues as requested.
4) The FY2003 plan stated that the Council intended to request Technical Assistance from NAMHPAC and others, as recommended by the Peer Review and CMHS, to assist in addressing all of the issues identified as areas of concern. The Council received training in January 2003 on Evidence Based Practices and their use in Iowa, from Dr. Michael Flaum of the Iowa Consortium for Mental Health. This information has aided the Council in considering its priorities for the coming year, and the Council decided to support an increased focus on the use of the block grant funds to develop Evidence Based and Best Practices in Iowa. The Council has not yet identified, however, exactly what form of Technical Assistance to request from NAMHPAC, CMHS or other organizations.
Iowa Mental Health Planning and Advisory Council Bylaws
19 ARTICLE I – NAME
The name of this organization shall be the Iowa Mental Health Planning and Advisory Council.
ARTICLE II – DUTIES AND ACTIVITIES
The purposes of the Iowa Mental Health Planning and Advisory Council (the Council) shall be as set forth in federal law (42 USC 300x-3, Pub. Law 102-321, July 10, 1992, ADAMHA Reorganization Amendments, Public Health Service Act, 106 State. 382.).
Section 1. Duties
A. To review mental health plans provided to the Council pursuant to 42 USC 300X-4 (a) for Iowa and to submit to the state of Iowa any recommendations of the Council for modifications to the plans;
B. To serve as an advocate for adults with serious mental illness, children with a serious emotional disturbance, and other individuals with mental illnesses or emotional problems;
C. To monitor, review, and evaluate, not less than once each year, the allocation and adequacy of mental health services within Iowa; and
D. To affiliate, join, and collaborate with groups, organizations, and professional associations that the Council may designate or choose to advance its stated purposes under these bylaws and federal law; and, specifically, to join the National Association of Mental Health Planning and Advisory Councils.
Section 2. Activities
A. To organize as an effective council;
B. To participate in the development of the state’s Center for Mental Health Services (CMHS) Performance Partnership Block Grant application;
C. To provide recommendations on state goals according to criteria of the CMHS Block Grant;
D. To advise on the allocation of monies received by the Mental Health Authority under CMHS Performance Partnership Block Grant funding;
E. To review the State Medicaid (Title XIX) Plan and make recommendations to the Mental Health Authority;
F. To advise the Mental Health Authority on matters that may affect the stated purposes of this Council;
20 G. To report to the director of the Center for Mental Health Services;
H. To report to the governor of the state of Iowa; and
I. To perform other duties as required by federal regulations.
ARTICLE III – MEMBERSHIP Section 1. General
To the extent feasible, the membership of the Council shall represent the diverse population of the state of Iowa.
In each category specified in this Article III, Section 3, Subsections A-E, the listed entities shall be allowed ongoing representation. The individuals appointed by the principal state agencies (subsection A) and the public and private entities (subsection B) must be confirmed by the Council.
Section 2. Requirements
The Mental Health Planning and Advisory Council shall abide by the following federal requirements:
A. The ratio of parents of children with a serious emotional disturbance to other members of the Council shall be sufficient to provide adequate representation of such children in the deliberations of the Council; and
B Not less than 50 percent of the members of the Council shall be individuals who are not state employees or providers of mental health services. (1) A provider is someone who receives money, from any source, to provide direct services.
(2) Advocacy, education, and training organizations and their employees shall not be considered providers of mental health services under these bylaws.
(3) Volunteers and advisory and other members of governing board shall not be considered as providers solely because of such status. They must meet the definition of "provider" in B (1).
(4) Volunteers and advisory board members shall not be considered as providers solely because of their status as board members.
Section 3. Membership Categories
Membership shall be the following:
21 A. The principal state agencies with respect to Mental Health, Education, Vocational Rehabilitation, Criminal Justice, Housing, Social Services, and Medical Services (Title XIX); Eight (8) members: Mental Health Education Vocational Rehabilitation Criminal Justice Juvenile Justice Housing Social Services Medical Services —Title XIX
The Council must confirm individuals appointed by the above organizations.
B. Public and private entities concerned with the need, planning, operation, funding, and use of mental health services and related support services; Six (6) members, including at least: Iowa State Association of Counties Iowa Association of Community Providers Judicial Advocates Iowa Protection and Advocacy
The Council must confirm individuals appointed by the above organizations.
C. Adults with serious mental illnesses who are receiving (or have received) mental health services; Six (6) members.
D. The families of such adults or families of children with emotional disturbance; Ten (10) members – (Four (4) representing Adults; Six (6) representing Children): Adult representatives: NAMI Iowa Children representatives: NAMI Iowa Iowa Federation of Families for Children’s Mental Health
E. Other individuals or organizations determined by the Council: Four (4) members.
22 ARTICLE IV – MEETINGS Section 1 . General
A. Regular and special meetings of the Council shall be called by either:
(1) the chairperson; or
(2) eight (8) or more members
A. The Council shall meet no less than four (4) times a year.
B. Meetings shall be conducted according to “Roberts Rules of Order (Revised)” and comply with Iowa Code ch. 21 (Open Meetings) and Iowa Code ch.22 (Open Records).
C. Members shall be given at least two weeks advance notice of regular meetings. Special meetings may be called and noticed if necessary. Meeting notices must include place, date, and hour. Agendas shall be posted as required by law.
D. The Council’s annual meeting shall take place at the next regular meeting following the annual federal review of the Iowa State plan.
Section 2 . Voting Rights
A. Each Council member in attendance shall hold one vote.
B. Members may attend by telephone, if technically possible at the meeting location and pre-arranged with staff.
C. Under general ethical principles regarding conflict of interest in Iowa Code ch 68B (Conflicts of Interest), members of the Council shall recuse themselves when they have or anticipate having a direct financial stake in the outcome of a Council decision, independent of their status as providers of mental health services.
Section 3 . Quorum
No less than two-thirds of the members eligible to vote (34) constitute a quorum. If during a meeting the number of members present is reduced below a quorum, the meeting may continue but no vote may be taken. A majority of the quorum is needed to accept any matter put to a vote.
Section 4. Vacancies
A. Individual Council membership ends when:
(1) A member resigns or dies; or
23 (2) A member is deemed inactive by the Council upon the relevant facts having been presented; or
(3) A member’s term ends, and the member is replaced by the sponsoring organization and confirmed by the Council; or
(4) A majority of the Council terminates the member for just cause, as defined by that majority.
A. After three consecutive absences, the member shall be notified that his/her position will be declared vacant. Failure to notify shall not constitute a waiver of the attendance requirements. The Council shall determine final action.
B. Providing for telephone attendance fulfills the attendance requirements of these bylaws.
C. An individual’s termination of membership does not terminate a designated organization’s representation on the Council as provided for in Article III, Section 1.
Section 5. Terms of Office
The term of office shall be three years. All terms shall be staggered to ensure that not more than one-third of the Council members are new members.
ARTICLE V – OFFICERS AND COMMITTEES
Section 1. Officers
The officers of the Council shall be a chairperson, vice-chairperson, and secretary.
Section 2. Nomination and Election
Officers shall be nominated by the nominating committee and elected annually during the annual meeting. A quorum of Council members shall elect them by majority vote.
Section 3. Term of Office
Officers shall be elected for a one-year term. There shall be no limit to the number of terms elected to office.
Section 4. Duties
Duties of the officers are as follows:
A. The chairperson shall:
24 (1) Report to the federal government, Iowa governor, and designated persons/organizations;
(2) Notify members of meetings;
(3) Preside at Council meetings;
(4) Serve as liaison between the Council and other groups and organizations;
(5) Communicate with and regularly report to the Council;
(6) submit an annual operating budget to the Mental Health Authority; and
(7) Perform other miscellaneous functions, as developed or designated by the Council.
B. The vice-chairperson shall:
(1) Assume the chairperson’s duties if the chairperson is unable to do so;
(2) In the case of permanent inability of the chairperson, act temporarily as chairperson until the Council selects and elects a new chairperson; and
(3) In the absence of the secretary in a meeting, serve as secretary.
C. The secretary shall:
(1) Take minutes of any and all meetings of the Council, maintain accurate votes of Council business and motions, and perform other duties, as designated by the Council; and
(2) Ensure that all minutes of meetings and records of the Council’s business shall be compiled and preserved in perpetuity by the Mental Health Authority.
Section 5. Standing Committees
A. Nominating Committee
(1) The nominating committee shall consist of 3 or 5 Council members elected by the Council.
(2) The nominating committee shall nominate persons for chairperson, vice- chairperson, and secretary for consideration by the entire Council.
(3) The nominating committee shall be responsible for receiving, soliciting, and reviewing applications for Council membership, including from sponsoring organizations when appropriate, and making recommendations to the Council.
(4) Election or confirmation of an individual member or of a slate nominated by the committee will normally take place at the annual meeting, but may be called at
25 another date at the discretion of the chairperson, if the annual meeting date is unduly distant.
Section 6. Ad Hoc Committees
The Council shall create and appoint ad hoc committees to carry out any necessary Council business or activities that are not expressly provided for in these bylaws.
ARTICLE VI – CONFLICT OF INTEREST
Members of the Council shall disclose any known conflict of interest prior to participating in discussions and shall recuse themselves when they have or anticipate having a direct financial stake in the outcome of a Council decision, independent of their status as providers of mental health services.
Members may partake in discussions so long as that discussion does not convey the members’ position on the matter.
ARTICLE VII – BYLAWS
The bylaws of the Iowa Mental Health Planning and Advisory Council may be revised as follows:
A. A majority vote of all Council members can alter, amend, or repeal these bylaws, or adopt new ones after two separate readings and consideration of any proposed alterations, amendments, or repeal.
These bylaws may be altered, amended or repealed at a regular or special meeting of the Council, provided that the proposed amendments have been given a first reading at a prior meeting or that the amendments were submitted to the membership in writing at least two weeks in advance of the meeting where the vote will take place.
B. An ad hoc bylaws committee shall be created by the chairperson when necessary for the consideration and development of amendments proposed by Council members or by the officers. ***********
By-laws revision accepted by vote on August 4, 2003.
Chairperson signature and date______8/4/03______
First reading: 06/23/03 Second reading: 08/04/03
Report on FY2003 Block Grant Activities
Services for Adults with Serious Mental Illness
26 An amount of $900,000 was utilized to contract with forty-one Community Mental Health Centers and other accredited mental health providers to provide services for adult with serious mental illness. Some of these programs provided treatment, rehabilitation and support services to adults with a serious mental illness who do not meet the eligibility criteria for existing funding sources such as Medicaid and County Management Plans. Others have developed new and previously unavailable programming to serve this population through their block grant contracts such as elderly outreach, medication management programs, indigent medication programs, and/or others. Others have used the funds to provide emergency services, which are required of accredited mental health centers to provide, but where funding is not available in the local community. For the most part, services are individualized, needs and abilities-focused and organized according to the following components which are to be provided by organizational staff directly or through linkages with other community resources: 1) outreach to appropriate support or treatment services; 2) assistance or referral in meeting basic human needs; 3) assistance in housing and living arrangements; 4) mental health treatment; 5) crisis intervention and assistance; 6) social and vocational assistance; 7) transportation; 8) medication management; 9) peer support and education; 10) protection and advocacy; and 11) service coordination and development of natural support systems aimed at improved functioning level of the consumer and families. These monies supported the provision of mental health services to an average of 1189 adults with SMI per quarter during SFY03, see table below.
Services for Children with Serious Emotional Disturbance An amount of $900,000 was utilized to fund a variety of services for an average of 858 children with SED per quarter under the children’s allocation of the Performance Partnership Block Grant funds. These funds were allocated to (41) Community Mental Health Centers and other mental health care providers across the state. Services include outreach, education and support for families of children with a SED, education and training for school personnel and local providers, increasing the availability of 24-hour crisis intervention for children with SED, coordination with local school districts, mental health evaluation, and treatment.
Individuals served with Block Grant funds SFY2003* 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Total adults served 2422 2590 2388 2477 Adults with SMI 1163 1187 1184 1222
Total children served 3012 3907 3413 2656 Children with SED 750 869 924 887
*Source: Quarterly provider reports from 41 providers who receive a portion of the population based formula for Community Mental Health Centers and other mental health providers. A new method of gathering this data began in SFY2003, but will be fully implemented in SFY2004. Presently, the numbers served are unduplicated in each quarter, to the best of the provider’s ability, but are not unduplicated across the quarters. Therefore, we are unable to report an accurate yearly total.
Consumer Resource and Outreach Project The Consumer Resource and Outreach Project (CROP) began operation on April 1, 1995. CROP, which also functions as Iowa’s Office of Consumer Affairs, is housed within the
27 Department of Human Services, Division of Behavioral, Developmental and Protective Services. The mission of CROP is as follows:
To promote the hiring of consumers, survivors, and ex-patients as administrators and senior managers within the public mental health system. To provide peer support, networking, and professional development opportunities for consumers, survivors, and ex-patients in management positions within the public mental health system. To ensure consumer, survivor, and ex-patient participation in policy-making at the state and local levels. To educate mental health officials and professionals about the roles that consumers, survivors, and ex-patients can play within the mental health system management. To serve as the State Mental Health Authority's "Office of Consumer Affairs"
CROP receives $100,000 in block grant funding for these purposes and has received funding at that level since 1995. Additional funding has been provided for staffing related to the Core Indicators Project and for stipends, which CROP provides to mental health consumers to be able to attend the Annual Mental Health Conference (October of each year) and the Annual Consumer Conference (July of each year).
CROP Core Indicators Project The National Association of State Directors of Developmental Disabilities Services (NASDDDS) and the Human Services Research Institute (HSRI) developed the Core Indicators Project (CIP). The purpose of the project is to identify and measure core indicators of performance within state developmental disabilities service systems by collecting information directly from individuals with developmental disabilities and their families or advocates.
Iowa joined the project during the project’s third year. This project included the participation of 17 states. In 2001, Ruth Schanke of DHS directed Iowa's participation with assistance from the DD Council, the University of Iowa Center for Disabilities and Development, provider staff, parents of individuals with developmental disabilities, and Magellan Behavioral Care. The project used provider staff and parents of individuals with disabilities to assist in accreditation reviews. The committee developed a curriculum for use in training. The DD Council paid a stipend to parents of persons with disabilities, and persons with mental illness to assist in the project. DHS paid training costs, meals, and transportation costs. All partners helped in the actual training. A consumer survey was given to over 400 adults with disabilities to measure 27 different indicators. The results provided Iowa a baseline to look at areas where we did especially well and other areas where there was a need for improvement. A steering committee of all partners analyzed the results and established priorities for improvement.
One of the issues identified was that of insufficient staffing for completion of the interviews. A suggestion was made that the use of individuals with mental illness as interviewers might provide a means of developing the workforce needed to perform the work while also providing valuable employment opportunities for a group of individuals with disabilities. A partnership with CROP was developed wherein CROP recruited people with mental illness to become trained in the interview process. A contract was developed and CROP took over the important functions of training the staff, scheduling the completion of the work, and supervising the
28 interviewers. The individuals with mental illness who completed the training and became interviewers experienced an increase in their sense of self-worth while earning income, and learning to become self-advocates.
Nancy Tue of CROP was funded to devote 75 percent of her time on this project and devote the remaining time to outreach work for CROP. Nancy attended the National Core Indicator Project meeting in Washington DC as Iowa's representative. Nancy recruited individuals with mental illness, organized and carried out training, and set up the interviews, as well as meetings with community mental health providers, Central Point of Coordination Administrators (CPC's), and Case Management staff. Many consumers with mental illness were recruited and became active participants through this outreach.
CROP was involved in the project for SFY2002 and through May of 2003 when the project ended. The results of the last round of interviews has been sent to the Human Services Research Institute for comparison with the other 21 participating states.
These reports are available on the web at www.hsri.org/cip/core.html
The Iowa Consortium for Mental Health The Iowa Consortium for Mental Health is a joint initiative involving the University of Iowa College of Medicine Department of Psychiatry, NAMI Iowa, University of Northern Iowa, Iowa State University, Iowa Department of Human Services and other organizations and individuals involved with the mental health system across Iowa. This program received $150,000 to provide technical assistance to the State Mental Health Authority (SMHA) (Iowa DHS), promote collaboration among mental health consumers and other stakeholders, enhance the research base of mental health services, and assist the state, local governments, providers and consumers in the formulation and development of information-based policy and clinical response for mental health services in the state. Of this grant, $50,000 was used to fund the First Responders Training Program. In 2003, an evaluation of the Multi-year First Responders Training Program was completed. SFY2003 was the final year of funding for the First Responders Training Program. In SFY 2004, the Consortium will receive $100,000 in block grant funding.
The Consortium has been funded by the block grant since 1994. The mission of the Iowa Consortium for Mental Health is to identify and advance projects that enhance collaboration among community based mental health service providers, consumers, policymakers, and researchers. The goal of all collaborative efforts is to promote effective community based mental health services and service delivery systems for adults with serious mental illness and children with serious emotional disorders who live in Iowa and who receive mental health services in the public sector.
NAMI Iowa The National Alliance for the Mentally Ill of Iowa (NAMI) has received $100,000 per year from the block grant since approximately 1994 to build a network of family education, peer support, and advocacy services for mental health consumers (children and adults) and their families in the state.
29 NAMI Iowa’s mission is to achieve equitable services and treatment for Iowans living with severe mental illnesses and their families. Volunteer members of NAMI Iowa affiliates provide education and support, combat stigma, support increased funding for research, and advocate for adequate health insurance, housing, rehabilitation, and jobs for people with mental illnesses and their families.
Local affiliates and state organizations identify and work on issues most important to their community and state. Individual membership and the extraordinary work of hundreds of thousands of volunteer leaders is the lifeblood of NAMI's local affiliates and state organizations. The national office, under the direction of an elected Board of Directors, provides strategic direction to the entire organization, support to NAMI's state and affiliate members, governs the NAMI organization, and engages in advocacy, education and leadership development nationally.
NAMI Iowa has three educational programs designed to address the needs of mental health consumers, children and their families. The programs utilize some block grant funds as well as other funding sources. These programs are: Visions for Tomorrow (Children), 2nd year. A program designed for primary, direct caregivers of children/adolescents with neurobiological disorders of the brain as well as those who exhibit behavior that strongly suggests such a diagnosis. Family-to-Family Education, 3rd year. A program that provides basic education and skill training for family members and support persons and significant others who are faced with coping with the mental illness of a child, spouse, relative or friend. Peer-to-Peer Education, 1st year. This nine-week course is for individuals with serious or chronic mental illness. Each two-hour session is taught by a team of three trained "mentors" who are personally experienced at living well with mental illness.
Iowa Federation of Families for Children's Mental Health The Iowa Federation of Families for Children's Mental Health was awarded $100,000 to initiate education, support, and advocacy services for families of children with a serious emotional and/or behavioral disorders. The Federation has been supported with block grant funds since 1998. They received an award of $50,000 for two years and the allocation was increased to $100,000 in 2000. Despite the fact that they are required by their contract to represent the needs of families of children with SED on a statewide basis, they continue to struggle in their effort to expand across the state of Iowa. They have renewed their commitment to focus on expansion to all areas of the state in the coming year.
The Mission of the Federation of Families for Children’s Mental Health is to protect the rights and provide services to families who have children with emotional or behavior difficulties. This mission can be accomplished by dissemination of information, mentoring, advocacy training and working with those involved in systems change.
The following projects were funded based upon RFP’s in SFY2002 for Children’s Programming. Community Based Mental Health Services within the Educational Setting SFY2002 $63,462 was awarded to ResCare, in Fairfield, Iowa. This project had its second and final
30 year (SFY03) of funding and attempted to address the following issues in the rural schools systems of Henry County: Provision of individual therapy Provisions for family counseling/home visits to address issues Partnership with the school nurse to address physical/emotional needs Process of outside referrals to address unmet needs Tutoring component to address self esteem concerns
This project served children who live in any of the six counties surrounding Henry County and who attend Henry County schools. The population served includes at-risk and SED children in classes K-12 and their families. There are currently 3,765 children enrolled in the school system(s) served by the program. Children with serious emotional disorders and their families will be given priority to receive immediate direct services at the school site such as child and family therapy and parenting classes. In-home services are also provided as needed.
Community Based Mental Health Services within the Educational Setting In SFY2002 $79,260 was awarded to the Federation of Families for Children’s Mental Health for the second and final year. The program attempted to address the following: 1) Increase the proportion of children with SED’s, dual diagnoses, and related needs who receive appropriate psychiatric care and support services. 2) Enhance the ability of families and professionals to collaboratively respond to children’s mental health needs. 3) Build supportive partnerships between and among parents, youth, and professionals in addressing mental health needs in the local community. The program was funded at the same level in SFY2003, but has been discontinued for SFY2004.
Community Based Mental Health Services to Children and Adolescents with Challenging Behaviors. In 2002, $34,648 was awarded to the Gannon Center for CMH in Clinton to provide one on one counseling to children ages 5-18 within six rural school districts. Components of this program include psychiatric services to youth through the visiting nurses association utilizing an ARNP and a psychiatrist, collaboration and coordination with substance abuse services for those with co-occurring disorders, and provision of in-home family counseling and crisis intervention on a 24 hour on-call basis. Funding was renewed for SFY2003 and has been discontinued in SFY2004.
Mental Health/Substance Abuse Services to Dually Diagnosed Youth An award of $80,103 of the block grant funds was made to Northeast Iowa Mental Health Center in Decorah to provide training and support for families of teenagers with high risk factors for mental health and substance abuse problems in a program called Families in Action. The program offers a weekly after school group meeting called Reconnecting Youth. This program is for high-risk youth that are disconnected from their school and community or who have low grades, suspensions, previous dropouts, juvenile delinquency or a history of out of home placement.
Mental Health Services to Juveniles at Risk of Committing Delinquent Act(s).
31 An award of $50,080 was made from block grant funds to Polk County Juvenile Court Services and the Des Moines Child and Adolescent Guidance Center for prevention and transition programming to youth that have committed or are at high risk for committing delinquent acts. In this third year of funding the Early Services Project (ESP) plans to work toward its goal of obtaining full support for future funding through the Polk County Juvenile Court Office, United Way, and other identified funding sources. In State FY2002, the project was confident that two years of block grant funding support would be sufficient to enable the project to move its expanded operation to funding sources previously identified. However, due to the draconian cuts to state and county budgets in State FY2002, the short-term future became less clear and a third year extension of funding was requested and awarded for a final year in SFY2003. This ambitious project includes two full-time staff to provide day-to-day case management, service facilitation, and tracking. The total project point in time caseload is 25-45 children per staff under age 11, referred by police to Polk County Juvenile Court Office for the commission of a delinquent act. The project hopes to serve 100-150 children during the project year. The Des Moines Child and Adolescent Guidance Center provides clinical oversight of staff and is the employer of record, although the staff is housed at the Juvenile Court Office.
School Based Services to Minority Youth with SED An award of $79,809 from the block grant funds was made in SFY2003 to Mid-Iowa Family Therapy Clinic of Perry and Tanager Place of Cedar Rapids for an intensive case planning and assessment program called Short Term Alternative Youth School Program. Following an assessment, a case manager facilitates a team decision-making meeting using a protocol similar to the Family Unity Model. The purpose of the meeting is to define the youth’s strengths, needs, and desired outcomes relative to an identified serious emotional disturbance in order to address stability within the home and school environments. Program components include case management, therapy services, psychological evaluations, intensive skill building groups and education.
Education and Training to Enhance Service Delivery for Children with SED’s who are involved in the Juvenile Justice System An award of $89,000 was made to a self-employed mental health provider, Richard Davenport for the provision of training of a minimum of 200 persons including staffs of Youth Shelters, Juvenile Detention facilities, providers of service to children and families, and families themselves. The program was meant to be a short term, one time only project, funded from June 2002 – September 30, 2002.
32 The following projects were funded as a result of RFP’s in SFY2002-SFY2003 for Adult Programming. Education and Training to Enhance Service Delivery for Adult Correctional Consumers with Mental Illness An award of $100,000 was made to the Iowa Consortium for Mental Health to provide a much needed and extremely well received training series. The series was titled From Streets to Cells and Back Again, and was sponsored by the Iowa Consortium for Mental Health in partnership with the: Department of Corrections Iowa State Association of Counties Sixth Judicial District Department of Correctional Services
This series included six, one-day statewide workshops on from prison to community transition issues facing the mentally ill correctional consumer. In addition to the one-day workshops, six training sessions were delivered through the Iowa Communications Network (ICN) and were offered between August 22 - September 26, 2002. These trainings addressed the following issues: Psychotic disorders Mood and anxiety disorders Borderline personality disorder Substance abuse/mental illness co-morbidity Antisocial personality disorder Assertive community treatment
The requirements of the RFP were that the program attempt to train at least 200 persons from the mental health, corrections, provider, and consumer communities. The six one-day trainings had an average of 70 participants each and the ICN series turned out to be the largest training ever undertaken by the University of Iowa telecommunications staff, with 63 sites and over 900 registrants. CEUs were offered for physicians, nurses, social workers, health professionals, and a variety of service provider disciplines. The trainings were timely and well attended because of the important subject matter and excellent content, but also in part because of shrinking training budgets within all of the major state agencies and many private agencies and organizations. The evaluation results from this series indicate that it was extremely well received and identified by participants as very helpful in their efforts to understand and meet the needs of correctional inmates and consumers with mental illness. This project was funded for only a part of SFY2002, from April to September.
Education and Training to Enhance Service Delivery for Older Persons with Mental Illness An award for another short-term training project was made to the University of Iowa Department of Psychiatry. This award was in the amount of $100,000. The primary organizer was an ARNP with extensive background and experience in the provision of mental health services to elderly persons. The expectations set forth in this RFP also required the training of a minimum of 200 persons statewide and the use of the ICN to disseminate the training to the broadest possible audience. This series involved four, one-day, face to face workshops and an ICN series utilizing resources at Iowa’s community colleges throughout the state. The training far exceeded the goal
33 in terms of numbers of participants and was very well received by participants across the state. This project was also funded for only a portion of SFY2002, from April to September.
Transitional Services to Correctional Consumers with Mental Illness Three programs have been funded to provide these transitional services, designed to facilitate more successful return to the community for inmates of Iowa prisons with serious mental illness. Each program received approximately $80,000 per year in SFY2002 and 2003: First Judicial District Department of Corrections, Waterloo, IA - is entering its third year of funding Sixth Judicial District Department of Corrections, Cedar Rapids, IA - is entering its fourth year of funding Black Hawk-Grundy Mental Health Center, Waterloo, IA - is also entering its fourth year of funding
When inmates enter the Iowa Medical and Classification Center at Oakdale, Iowa, they are screened for mental health issues. Those identified as having serious mental health issues and that have a discharge plan to any of the communities served by these programs, are documented and the information is provided to the staff at one of the programs. The inmates and their counselors are then made aware of the enhanced services offered through these programs and are offered an opportunity to meet with staff from the appropriate program as their discharge date approaches. Those who choose to participate can often receive an earlier discharge than might have otherwise been available because the Board of Parole is familiar with the services, case management, and level of supervision that is available to consumers who participate in these programs. Each of the programs are utilizing Community Accountability Boards made up of community volunteers who assist in the support and oversight of discharge planning and service coordination for participants. The two programs in Waterloo share the resources of one Community Accountability Board. These programs have been well received by the consumers served, the corrections staff involved, the communities where they exist, and have been extremely successful in improving outcomes for participants. An oversight committee has been meeting quarterly for over two years to develop protocols, address issues, coordinate, and learn from these demonstration projects. The committee is made up of staff from all three programs, the adult planner from DHS, Department of Corrections, and the Iowa Consortium for Mental Health.
An evaluation component was added to these three innovative and exciting programs in SFY2003. The Sixth Judicial District Department of Corrections sub-contracted with a third party, the Institute of Social and Economic Development (ISED), in Coralville, IA, to evaluate the three programs. Each program provided one third of the $25,000 needed for the evaluation sub-contract. The evaluation didn’t get underway until part way into the fiscal year, but was able to begin to gather uniform data about the programs. ISED evaluator, Dennis Affholter, began to attend and participate regularly in the oversight committee meetings.
These programs have been the subject of presentations at the local, state and national level on several occasions throughout the past year. The Department of Corrections is working hard to see that the programs not only become sustainable, but can be replicated and perhaps become statewide in the future. Earlier this year, Gary Hinzman and Dan Craig, the Directors of the
34 Sixth and First Judicial District Departments of Corrections, coordinated a visit to Senator Grassley's Office with Michael Thompson of the Council of State Governments. Senator De Wine of Ohio is sponsoring a bill to provide more funding for mental health issues which Senator Grassley is a co-sponsor to. They also met with Senator De Wine's staff on this bill. Since their visit in Washington, several more members of the House & Senate have signed on and there has been Congressional testimony on the topic as the Bill providing $100M moves along. While in DC, they also met with SAMSHA officials about emerging corrections related mental health issues and legislation. These programs were highlighted as examples of innovation during each of their meetings. The programs have also received strong support from the Iowa Parole Board. An article featuring these programs appeared in the August 2003 edition of “Corrections Today, entitled, “Iowa Implements Mental Health Re-Entry Program.”
Funding for all three of the above programs was renewed for SFY2004, but at a reduced rate of $58,000 each, which includes $8000 to continue to provide support for another year of evaluation by ISED. In order to receive the funding again in SFY2004, each program had to agree to provide the same level of service for the reduced dollar amount and to continue efforts to seek funding at the local, state, and national level to support the continuation of these programs. A presentation was made to the Mental Health Planning Council regarding these programs in 2003 and the Council strongly endorsed the continuation of the programs, and made Transition Services to Correctional Consumers one of their top priorities for adults with SMI in the coming year. The Council and DHS have never tried reducing block grant funding in an incremental way in an effort to help programs become sustainable before, but this approach was also strongly endorsed by the Council. The Council and DHS alike will watch carefully to see if the idea of reduced funding with a requirement to seek funding and continue services can or will be a successful means of creating sustainable programming.
A table illustrating the breakdown of allocations for the SFY03 block grant funds can be found at the end of Adult Criterion 5, Management Systems, page 81.
35
Section II
Context
36
Section II: Context
Overview
1. Population: Iowa has an estimated population of 2,923,179 residents, making Iowa 30th in population and 23rd in land area. Iowa's metropolitan areas consist of 10 cities with populations ranging from approximately 46,000 to 198,000 residents.
Map of the State of Iowa and Counties Population: 2,923,179 (2001 Census)
Lyon Osceola Dickenson Emmet Kossuth Winnebago Worth Mitchell Howard Winneshiek Allamakee
O'Brien Clay Palo Alto Hancock Sioux Cerro Gordo Floyd Chickasaw
Fayette Clayton
Plymouth Cherokee Buena Vista Pocahontas Humboldt Wright Franklin Butler Bremer
Webster Black Hawk Buchanan Delaware Dubuque Woodbury Ida Sac Calhoun Hamilton Hardin Grundy
Tama Benton Linn Jones Jackson Monona Crawford Carroll Greene Boone Story Marshall
Clinton Cedar
Harrison Shelby Audubon Guthrie Dallas Polk Jasper Poweshiek Iowa Johnson Scott
Muscatine
Pottawattamie Cass Adair Madison Warren Marion Mahaska Keokuk Washington
Louisa
Mills Montgomery Adams Union Clarke Lucas Monroe Wapello Jefferson Henry Des Moines
Fremont Page Taylor Ringgold Decatur Wayne Appanoose Davis Van Buren Lee
Iowa has seven Metropolitan Statistical Areas (MSA). The MSAs are located in the following counties or clusters of counties: Total Population • Woodbury County 103,877 • Pottawattamie County 87,704 • Dallas, Polk, and Warren Counties 40,750—374,601—40,671 • Black Hawk and Bremer Counties 128,021--23,325 • Linn and Johnson Counties 191,701--111,006 • Dubuque County 89,143 • Scott County 158,668
Source: www.silo.lib.ia.us/datacenter/state/htm, 2000 census, as reported in 2002
37 2. Demographics: Urban population for MSA's equals 1,349,179, which is 46% of the approximate 3 million total state population. Total population of persons under age 18 is (25.1%). Iowa receives a small share of our immigrant population from Bosnia, Sudan, the Middle East, Latin America, and Southeast Asia. Population distribution by race is shown below. Percent Distribution of Population by Race (2000 estimated)
White 93.9% African American 2.1% American Indian, Eskimo, Aleut 0.3% Asian/Pacific Islander 1.3% Hispanic (of any race) 2.8% All Persons 100.00%
Source: (www.quickfacts.census.gov)
3. Business and Industry: Iowans rely heavily on manufacturing, insurance, communications, retail/wholesale trade and government as their source for personal income. Agriculture is a leading industry in the state with more than 90,000 family and commercial farms. Within the United States, Iowa ranks first in pork and corn production and second in soybean production.
State of Iowa Personal Income Earned by Industry Source FY 2001 Industry Source Percent Percent Change Services 23.0 5.7 Manufacturing 20.5 -1.8 Government 15.9 5.3 Retail trade 9.3 1.9 Agriculture 2.2 8.7 Wholesale trade 7.3 -6.8 Finance, insurance, real estate 7.9 13.9 Construction 6.4 7.0 Other 7.5 4.2 (Source: www.iowaworkforce.org/trends/income.html)
4. Education: Iowa has 3 state universities (University of Iowa, Iowa State University, and University of Northern Iowa), 62 public and private colleges and 28 community colleges. Its public K – 12 education system is typically rated as within the top five nationally in terms of a variety of parameters including standardized test scores.
Key Elements of the Iowa Mental Health System
38 The Iowa system of community-based services for adults with a mental illness is uniquely decentralized and remains largely under the control of county governments. This decentralization has both strengths and weaknesses. Since the submission of the last application this has not changed. The task of the Mental Health Authority in this system is to utilize a collaborative process that involves consumers, family members, advocates, principal public and private agencies, the provider community, county governments, key legislators, and the public so that the service system is fully responsive to the needs of consumers and other constituents.
While the provision of mental health services for children and adolescents remains fragmented, funding of some of these services is managed through state and federal revenues. Planning, funding, regulation and administration of children’s services are becoming a statewide concern. These responsibilities are diffused in a number of state agencies including the state mental health authority and the state child welfare authority (the Division of Behavioral, Developmental and Protective Services for Families, Adults and Children of the Iowa Department of Human Services), the Division of Field Services of the Department of Human Services which oversees the regional and local offices of DHS, the Juvenile Court System, the Department of Education, the Department of Public Health, the Department of Human Rights, the Department of Inspections and Appeals, Child Health Specialty Clinics, Area Education Agencies, the Governor’s Developmental Disabilities Council, county governments, public and private school districts, child welfare, empowerment and decategorization boards. These are some of the entities involved in the planning, funding, administering, and regulating of children’s services in Iowa. Furthermore, these responsibilities are vested in several divisions, bureaus, departments, commissions, mandates, and initiatives often sharing overlapping responsibilities. On February 1, 2000 the Division of Behavioral, Developmental and Protective Services filled a full time position of Child and Adolescent Mental Health Specialist under a PEO contract. The position was specifically responsible for the design and implementation of a children’s mental health initiative, authoring the annual Community Mental Health Block Grant, oversight of services and activities provided to Community Mental Health Centers and other organizations through block grant funding, and serving as primary staff to the Mental Health Planning Council. Denise Lange, the child and adolescent mental health specialist, terminated her employment as a contractor with the state of Iowa in September of 2002. The Planning Council raised concerns about the vulnerability of the position as it had never been approved as an FTE with the State of Iowa. The Division did seek to obtain permission to convert the position to that of a state employee and approval was eventually given. Mary Mohrhauser joined the Division of BDPS as the new child and adolescent mental health specialist in January of 2003 via inter-agency transfer.
The Iowa Mental Health Authority is only one player in this pluralistic environment. The Division provides for $1.8 million of the federal CMHS Block Grant funds for expenditure through the DHS accredited community mental health centers to provide coordinated programs of mental health services to children with SED and their families and adults with serious or chronic mental illness. A number of child mental health programs in Iowa are operating under the licensure, accreditation or approval of other entities. A key difference in working to develop a coordinated system of services for children and adolescents with a serious emotional disturbance is that, rather than joining extensively with county governments as is the case with adults, the groups to enjoin are other state departments and divisions that fund, provide and
39 regulate these services and service providers, families and advocacy groups. The intended outcome of this collaboration is to coordinate services for children and adolescents at the state and local level so that the current configuration of funding streams, regulatory authority, and service initiatives begin to resemble a coordinated system of care.
The Iowa Plan for Behavioral Health (The Iowa Plan) continues to be jointly supported by the Department of Human Services and Department of Public Health. This plan continues to oversee mental health and substance abuse services by combining two previously separate managed care programs, the Mental Health Access Plan (MHAP) and Iowa Managed Substance Abuse Care Plan (IMSACP) to enhance the opportunity for Iowans to obtain appropriate services to live, recreate, and work in the community with minimum disruption in their lives. The Iowa Plan is designed to focus services toward an ideal system of care by offering: Easy and prompt access to needed services and supports Improved outcomes for consumers which span multiple programs and funding streams A seamless service delivery system which spans health, mental health, substance abuse, education and special education Strong consumer and community investment in the local service delivery system contoured to community strengths and needs Interagency planning and coordination of services Prevention and early intervention with those at risk Communication in the primary language of the consumer and family Freedom to purchase service elements based on consumer choice and needs
The Iowa Plan continues to represent procurement of an integrated managed care program to implement both mental health and substance abuse services through a single contractor. The contractor is at full risk for all Medicaid-funded services and provides specified administrative support for the Department of Public Health-funded delivery system. The contractor is also required to manage services to persons with a mental health diagnosis who fail to establish legal settlement in the county and are enrolled in the State Payment Program. The contractor is required to: Implement a quality assurance process to monitor consistency of access and quality of care Focus on best practices within and across the systems Support local planning and decision-making through existing decategorization boards and county Central Point of Coordination, and provider consortia Allow flexible and cost-effective use of resources by blending various funding streams Individualize services by requiring the consideration of environmental factors in the authorization of services and supports Promote an on-going dialogue between the state agencies, consumers, and providers through roundtables for a variety of constituencies Eliminate duplication and gaps through a coordinated, consumer-centered treatment planning and administration of services Improve consistency through centralized utilization management, quality assurance, provider profiling, statistical reporting, and analysis
40 The Iowa Plan covers both categorically and medically needy individuals eligible under the Iowa Medicaid program. Enrollment in the Iowa Plan is mandatory and automatic for Medicaid beneficiaries (approximately 240,000 average number of enrollees per month) except for the following excluded categories: Persons age 65 and older Persons who are eligible for Medicaid as a result of spending down excess income Persons living in the two Glenwood and Woodward Resource Centers Those whose Medicaid benefit package is limited, such as Qualified Medicaid Beneficiaries (QMB), illegal aliens, and others not entitled to the full range of mental health and substance abuse treatment included in the Iowa Medicaid fee-for-service program.
A. The state public mental health service system as it is envisioned for the future. There has been a tremendous amount of effort directed at envisioning the future of the MHDD system in Iowa over the past two years, and in translating that vision into practical strategies. The “vision” task was initially taken up by the Mental Health and Developmental Disabilities Commission in 2001. At that point, 7 long-term goals were established: 1. Funding mechanisms in which the funding follows the individual 2. Consumer-directed services – individualize services to meet the needs of the individual instead of having to choose from a “menu of services” that fit people into available services. 3. Appropriate service delivery in the most integrated setting – (in accordance with the Olmstead decision) 4. Safe, affordable and accessible housing that provides choice and integration in the community 5. Safe and affordable transportation that is responsive to individual needs 6. Equal opportunities and choices in employment without disqualification in services and benefits. 7. Increased system flexibility which supports growth and development of peer support and peer counseling networks
In 2002, strategies and actions necessary to begin moving towards these goals were then delineated in the following 14 areas: 1. Restructuring of the legal mental health authority: Develop and empower a meaningful mental health authority for the state, with both the responsibility and authority to establish and implement a coordinated system of care for children and adults with mental illness, brain injury and developmental disabilities. The commission has had longstanding concerns that the MHDD system as a whole is fragmented, and that there has not been an adequately empowered single point of authority and accountability for the system. This concern predated the infra-structural changes that occurred in November 2001 for DHS, including the elimination of the MHDD division administrator position and drastically reducing staffing in what had been the Division of MHDD. With these changes, the concern became even more pressing and urgent. The commission feels that without the creation of such a central point of authority and responsibility, it will be impossible to move forward with any of the recommendations contained herein.
41 2. Core Services: The current institution-based mandates should be replaced by a defined set of core community services that must be provided to children and adults with serious mental illness and developmental disabilities.
3. Eligibility: Uniform eligibility criteria for core services should be created and standardized on a statewide basis. This includes both clinical criteria as well as financial eligibility criteria.
4. Legal settlement: The MHDD commission recognizes that this is a very complex issue with many implications. However, the commission feels strongly that the current legal settlement policy is wrong and needs to be eliminated. The commission supports the replacement of legal settlement with a policy in which funding follows the individual rather than legal settlement. This will likely require an increase in the state’s contribution to funding for core community services.
5. Restructuring of oversight bodies: The role of citizen oversight commissions should be strengthened and retained. The MHDD commission and the State County Management Committee should be combined in an effort to minimize redundancy and help to create a clear point of accountability at a state level. This body should have oversight over the mental health authority described in the point above.
6. Children’s MH and DD services: The commission is very concerned that Iowa’s children’s mental health and disability service system is particularly fragmented and dysfunctional. This situation is worsening in the context of increased restrictions on reimbursement for mental health services for children with emotional and behavioral disorders. A major effort will be necessary in order to achieve the goal of creating a coordinated system of mental health services for children that is easy to access and links children, parents, schools and health care providers.
7. Relationship between DHS and the Department of Corrections (DOC): The commission is concerned that more and more individuals with mental illness appear to be winding up in correctional settings. The commission recommends closer coordination and communication between DHS and DOC, specifically to: a) improve transition between correctional settings and community-based settings for offenders with mental illness and developmental disability; b) increase funding for, and improve treatment of offenders with mental illness and developmental disabilities while in correctional settings, and c) decrease the number of individuals with mental illness in correctional settings.
8. Compliance with Olmstead: The commission urges full support and funding for the implementation of the Iowa Plan for Community Development in an effort to fully comply with the Olmstead decision.
9. Unserved individuals: Individuals with brain injury as well as those with developmental disabilities without cognitive impairment, often “fall through the cracks” of the current system. Equitable access to services for such individuals is critical and must be addressed with both changes in legislation/code as well as additional allocation of resources.
42 10. Enhance support and training for direct-care workers: Recruitment to these positions is an ongoing problem, and turnover is extremely high. These types of positions are vital to an effective service delivery system and require additional support. Training requirements should be increased and implemented and salaries, benefits, and incentives should be increased.
11. Personal Assistance Services: Funding should be made available for consumer- controlled personal assistance services for all Iowans with disabilities. The state must be a contributor to this funding, and should also pursue federal funding.
12. Develop a statewide system of peer support: Fund and expand a consumer-driven network covering the entire state to provide peer support and counseling, and opportunities for self-advocacy for Iowans with all types of disabilities .
13. State funding share to counties: Community services and allowable growth must be restored to the original appropriation for FY 2002. Not doing so will result in decreased access to and quality of services.
14. Parity: For more than twenty years the legislature and the two sitting governors have discussed various parity proposals. To date, nothing has been passed into law. This is a critical policy that must be enacted for the well being of all Iowans. The MHDD commission strongly urges the signing of parity legislation into law that covers persons with mental illness and substance abuse illness. These recommendations paved the way for the “MHDD Redesign” process (to be described further below in section E), which was begun by legislation in the 2002 session, and furthered by legislation in this year’s session. This process involved five workgroups, including one on “roles and responsibilities” and another on “support design”, who together were charged with further delineating the core tenants and philosophical underpinnings of the future system. The most recent iteration (Aug 2003 draft) of those principles are as follows: 1. The system begins with the person 2. A plan of supports is developed based on the needs and wants of the person. 3. Supports are developed based on the plan, which is based on the person. 4. Outcome-based quality assurance standards for service/support providers are used to allow the development of the supports needed, which are based on the plan, which is based on the person. 5. Outcome-based standards are based on outcomes in the person’s life. 6. Assume people can live in the community given the appropriate supports. 7. Person Centered Model with an individual budget (includes the Recovery Model for people with mental illness). 8. The plan belongs to the person, not to service providers. It crosses systems and funding streams. 9. Services do not come in packages. 10. Services are accessible across the state (and in urban/rural area). 11. Services are identified flexibly to allow creativity and development of new services/service providers. 12. Training is ongoing for all system participants including consumers, support staff, funders, and the public.
43 13. The system must assure a level of health and safety while balancing rights of choice. (Alive and miserable is unacceptable, happy and dead is incompatible.) 14. Consumer/Family responsibilities should be included and encouraged. 15. Adults should have access to life long learning opportunities. 16. People have the potential for growth 17. People should not be forced into or to stay in poverty to receive supports
Taken together, these goals, strategies and principles reflect a vision for Iowa’s public mental health system for which there is broad consensus.
B. Areas identified by the State in the previous State plan as needing particular attention, including the significant achievements in the previous fiscal year. In last year’s plan, 2 areas needing particular attention were identified:
1. Meeting the needs of indigent patients who do not qualify for county-funded services and who are not eligible for Medicaid.
An early outcome of the MHDD Redesign effort is the Commission’s commitment to eliminate Legal Settlement. Legal settlement is Iowa’s rather archaic method of establishing which County will be responsible for the funding of services for a given individual in need of disability related services. There has been a broad consensus for years that this process is cumbersome, outdated and often a barrier to an individual’s ability to obtain services in the community of the consumer’s choice. The idea of eliminating legal settlement and moving toward a residency based methodology is expected to greatly reduce one of the major barriers for people previously ineligible for county-funded services.
2. Access to mental health professionals (psychiatrists) in the rural parts of the state.
There has been a major effort to link psychiatrists to the rural parts of the state through the 15 Child Health Specialty Clinics (CHSCs) located across the state. All fifteen CHSCs in the State are now linked directly to the University of Iowa Hospitals and Clinics through the use of the Iowa Communications Network (ICN). Magellan Behavioral Health Care (MBC of Iowa) provided a grant, utilizing it’s Community Reinvestment Fund, to purchase the technology to link all of the CHSCs to this innovative telemedicine system. The Department of Psychiatry at the University of Iowa provides the psychiatric services through this system. CHSCs are located in the following communities and serve multiple counties, in some cases, so that their services are available statewide: Burlington, Carroll, Council Bluffs, Creston, Davenport, Des Moines, Dubuque, Fort Dodge, Iowa City, Mason City, Ottumwa, Sioux City, Spencer, and Waterloo.
C. New Developments and issues that affect mental health service delivery in the state. Kevin Concannon began his employment as the new DHS Director in the spring of 2003. His arrival was met with great optimism and enthusiasm within the mental health community, as Iowa DHS had never had a Director with primary background in mental health. The Director has arrived at a time of enormous financial stress within State government, and in the midst of legislative mandates to redesign the state’s mental health and developmental disabilities system as well as to redesign the child welfare system. The Director has identified one of his primary goals for the agency will be to make the best possible use of federal resources. The Director has attended many public forums where he has been well received by
44 mental health consumers and family members, advocates, providers, and others. He is a regular participant at MHDD Commission meetings where the MHDD system is being redesigned. Director Concannon is acting as the identified State Mental Health Authority at present and it is unclear whether he intends to designate those responsibilities to someone else in the future.
DHS also has a new Medicaid Director as of June 2003. Gene Gessow has joined the agency after an over one year void where the medical division had no director. Prior to that time, Cathy Anderson, former Deputy Director and Chief of staff served as acting Medicaid Director while also functioning as the State Mental Health Authority. Cathy left her employment with DHS in December of 2002. Mr. Gessow’s arrival has also met with much enthusiasm within the mental health and disability communities. He is faced with the task of trying to reign in the Medicaid budget, where skyrocketing pharmaceutical costs threaten to bankrupt the Medicaid budget.
DHS is the lead agency in the State’s effort to respond to the U.S. Supreme Court’s landmark decision in Olmstead. The Iowa Plan for Community Development, written in 2000, became the basis for a successful application to the Centers for Medicaid and Medicare Services (CMS) for the Real Choices Systems Change grant, awarded in 2001. Iowa received $1.3 million, which has been subcontracted to the Center for Disabilities and Development (CDD) at the University of Iowa, Iowa’s Center on Excellence in Disabilities. Some of the many pieces of the work plan to address Olmstead implementation intersect with other efforts underway at DHS, including; Personal Attendant Services work group, the Medicaid Infrastructure Grant effort, MHDD redesign, and several major initiatives related to Olmstead. The Governor’s Executive Order #27, issued February 4, 2003 directed twenty state agencies to collaborate with each other and the Olmstead Real Choices Consumer Taskforce in the identification of barriers to community living for people with disabilities and steps toward removal of those barriers. The Lieutenant Governor launched a huge initiative to develop 1000 new housing opportunities for people with disabilities within the next three years as an Olmstead related initiative, in February. The staff for the project, at the Center for Disabilities in Iowa City and at the Employment Policy Group, an arm of the CDD, in Des Moines, is providing research, support and coordination to all of the efforts mentioned above and have become an active partner with DHS in trying to coordinate and move forward on these many intersecting activities. Lila P.M. Starr, the adult mental health specialist and planner is also the statewide Olmstead Coordinator and works collaboratively with the Olmstead Real Choices Consumer Taskforce, the staff at CDD, the many state agencies involved, the Governor’s office, and many other stakeholders, to facilitate Iowa’s progress in making our Olmstead goals and plans a reality for Iowans with disabilities. The Olmstead decision and Iowa’s implementation effort have done a great deal to put wind in the sails of many of the efforts mentioned above.
D. Legislative Initiatives and Changes The Mental Health and Developmental Disabilities (MHDD) Commission is the state’s policy-making body for the provision of services to persons with mental illness, mental retardation or other developmental disabilities, or brain injury (Iowa Code 225C.5). The web site for the MHDD Commission is www.dhs.state.ia.us/MHDD. In 2002, legislation combined the duties of the MH/DD Commission with the State County Management Committee and created a new MHDD Commission and reshaped the membership. The reconstituted MHDD Commission began to redesign the mental health, developmental disability, and brain injury service delivery system in November 1, 2002 pursuant to the new legislative mandate. In spring of 2003, additional legislation (see Appendix, “House File 529, An Act Directing the MHDD Commission to Make Recommendations for Redesigning the Mental Health and Developmental Disabilities Services System For Adults”) established these parameters for the redesign effort:
1. Deliver recommendations for a redesigned adult MHDD system to the legislature by December 1, 2003
45 2. Include in those recommendations assurance that individuals with mental illness, mental retardation, developmental disabilities, or brain injury have access to services, regardless of where they live assurance that funding will follow the covered individual statewide clinical and financial eligibility standards: a minimum set of core services that will be funded for those populations through the MHDD system a new funding process that equalizes distribution of MHDD funds
The MHDD Commission formed workgroups composed of individuals with disabilities, their family members, advocates, service providers, county personnel, and various state agency personnel. To date, over 150 people have served on one or more workgroups. In March 2003, the MHDD Commission established their vision and mission for the redesign effort (see appendix “Vision and Mission for MHDD Redesign). The workgroups have proposed, and the Commission adopted, a redesign strategy based on self-directed and person-centered planning and service coordination. The workgroups are formulating additional recommendations to be considered by the Commission in formulating its report to the Governor and the Legislature. The Commission will share their recommendations with the legislature, continue to work on finalizing and implementing any legislative action, and monitor the implementation of the recommendations over the next several years.
The Commission anticipates working on redesign of a system for addressing children’s mental health and developmental disabilities next year, culminating in a report to the legislature in December 2004 and implementation of those recommendations in subsequent years.
The redesign initiative has the support and interest of Lt. Governor Sally J. Pedersen, DHS Director Kevin Concannon, and several key legislators.
E. A brief description of regional/sub-state programs, community mental health centers, and resources of counties and cities, to the provision of mental health services within the State. As noted above, Iowa’s mental health delivery system is highly decentralized, with substantial county control. Each county is legislatively mandated to prepare management plans for mental health services that must meet the minimum legislative standards and must be approved by the Iowa Department of Human Services. Recent changes have eliminated the requirement that County plans be submitted annually, although they must still be approved and updated as the range of services or other issues change within each County. Administrative rules for county management plans must include: (a) Enrollment and eligibility process (b) Scope of services covered (c) The method of plan administration (d) The process of managing utilization and access to services (e) Quality assurance
The other major subsystem is the Iowa Plan, which is also detailed in Section B as well as in other areas within this plan.
The "central point of coordination" (CPC) has become a critical position within the overall mental health system in Iowa. As previously stated, the individual counties play a large role in overall mental health funding and service delivery system. Legislation in the mid 1990's, clarified roles and responsibilities of state and county authorities for mental health funding and services, and created the position of the CPC. Each county was mandated to designate a CPC. That person's job is to manage the county-funded mental health budget.
46
Most of the time, the role of CPC is a full time job, but it ranges from a part time job of one person in some of the smaller counties, to up to 3 full time positions in some of the larger counties (e.g. Polk). Most counties have their own CPC, but some counties share a CPC.
The CPC is to control the dollars the county has to provide services to the people who need them. The CPC makes funding decisions, not clinical. The majority of CPC’s have a social work degree, a few are Business finance, with a smattering of other 4-year degrees.
Prior to the advent of the CPC, funding decisions were often being made by County Boards of Supervisors, in the context of their routine meetings. Typically, the mental health center director, one of the therapists or the local Department of Human Services Director would come to the board meeting, request a closed session (to discuss client information), tell the board about the needs of the individual, then ask for specific help for that individual. Most of the time the request for special needs was addressed as soon as the board went back into open session. The problem with this scenario is that the individuals who could make the best arguments were funded.
There are many advantages to the CPC system. Assigning responsibility for mental health funding at the county level to a single administrative entity goes a long way in decreasing system fragmentation. This entity oversees and negotiates the reported mental health needs and costs of its county's residents. It is in their interest to have services as highly coordinated as possible, and this is usually in the patient's best interest as well. In working with case managers, an involved and creative CPC can help to facilitate housing, vocational, psychiatric, rehabilitative and other services. In some of the smaller counties, this person typically gets to know many of the individuals receiving mental health services fairly well, and they often become an important member of the overall health care team.
CPC's are also allowed some flexibility in how to manage the county mental health budget. The discretion and flexibility of CPC’s has led to some of the most innovative and potentially important mental health programming throughout the state. One county CPC in Southwest Iowa is working with the sheriff’s department, the local mental health provider, the local substance abuse provider and the county attorney to help divert those individuals who have a dual diagnosis of substance abuse and serious mental illness. These individuals are causing overcrowding in the jails because there is not a program nearby to address their dual issues. The providers and CPC have produced a protocol for the sheriff’s department to use to help identify dual diagnosis individuals. These individuals are then diverted into the local program to help deal with their substance abuse issues and their mental health issues. This program is just getting off the ground, but similar programs in other states have proven to be successful, and it is hoped, this one will be also.
As the role of the CPC becomes increasingly important, and with it the need for high quality and stable staff, a variety of needs and issues will emerge. Ongoing educational efforts for all individuals who work with in this system are needed.
F. Description of how the State mental health authority (SMHA) provides leadership in coordinating mental health services within the broader system. Kevin Concannon began came to Iowa from Maine, to be the new DHS Director, in 2003. He is the acting State Mental Health Commissioner and the administrative role of SMHA is within the Division of Behavioral, Developmental, and Protective Services for Families, Children, and Adults of the Iowa Dept. of Human Services. The adult mental health system in Iowa is a county based system managed at the local level in all 99 counties by individuals vested with authority by the County Boards of supervisors to develop County Management Plans, identify and direct services, and
47 manage the budget for mental health and developmental disability services. These individuals are called Central Point of Coordination Administrators (CPCs). There is additional information about the CPCs and their role elsewhere in the Plan.
The State Mental Health Authority (Division of BDPS) is faced with a considerable task regarding the evolution of a collaborative process involving consumers, family members, advocates, public and private agencies, providers and county officials. The role of the SMHA is to encourage and create partnerships between stakeholders at the state, local, regional, and federal level in order to establish and implement an organized community-based system of care. The State must facilitate sharing of the diverse financial, technical and human resources, define shared goals and objectives, identify consumer-based outcomes and performance measures and move toward the creation of a common data base for monitoring outcomes and performance measures. The State must also provide meaningful technical assistance to counties for local system development to meet the needs of adults with a serious mental illness, and children and adolescents with an emotional disorder and their families.
The process for the development of County Management Plans requires meaningful involvement of various stakeholders, including consumers, family members, county officials, and providers. The process used to involve these stakeholders must be documented in the county plans, including how comments received on the plan were considered in the development of the final plan. The county now has the option of using the Mental Health and Developmental Disabilities Regional Planning Councils established under Iowa Code 225C. 18 to develop the local plans. The plans must also contain a list of the persons designated by the county to develop the plan and their affiliations. SMHA also requires the support and involvement of consumers and family members in the development and implementation of Work Programs for all contracts with DHS for any portion of the block grant funds.
The Department of Human Services was and is the lead agency in the development and implementation of Iowa’s response to the U.S. Supreme Court’s Olmstead decision. Within it’s role as the driving force behind all efforts related to Olmstead, many new partnerships have been forged and new opportunities created. Additional information can be found in section C.
The Iowa General Assembly mandated a redesign of Iowa’s mental health and developmental disabilities services system in 2002. MHDD redesign is underway and involves stakeholders from all over the State. DHS is the lead agency for this effort and the SMHA is providing the staffing and support to the MHDD Commission and its five workgroups. Research and support is also being provided by the Center for Disabilities and Development of the University of Iowa as the result of their contract with DHS to implement the Iowa Plan for Community Development (Iowa’s response to the Olmstead decision). For additional information, see section D. The SMHA is forging partnerships with many stakeholders from the mental health community, but also with the broader disability community, to enhance and strengthen its efforts to improve mental health service delivery in the State.
G. The role of the State Mental Health Planning Council in improving mental health services within the state The duties of the Council are to advise the Division of Behavioral, Developmental and Protective Services (SMHA) and the MHDD Commission on the administration of the overall state plan.
48 Since the implementation of the Mental Health Planning Act (PL 99-660) and its "successors", the Council has been a key element in the review of Iowa's State Plan for Mental Health Services.
This has been a dynamic year of change for the Mental Health Planning Council. The many changes and the new sense of urgency to become organized and focused have developed for a variety of reasons. The failure of our Block Grant Application & State Plan to be approved at the Peer Review in South Dakota in October of 2002 and the questions raised by peer reviewers and CMHS as a result had a huge impact upon our Council and its process. It caused the members to become aware that they knew very little about the application process and the role of the council in that process as envisioned by CMHS. The learning curve for Council members since that time has been formidable. There have been many changes in the membership, an increase in membership to add a representative from adult corrections, the By-laws have been re- written, a representative of the Attorney General’s office has been invited to attend all of the Council’s regular meetings and several committee meetings, the Council has become committed to the idea of functioning in accordance with Iowa’s Open Meetings and Public Records laws, and perhaps most importantly, Council members have begun to ask the kinds of questions that will enhance their knowledge of all areas involved in the implementation of the block grant. Following the Peer Review, when the Plan was being re-written, the Iowa Consortium for Mental Health and at least four Council members played an active role in the development of the response, the re-write and the editing of the Plan. Since that time, the Council has increased its meeting schedule from every other month to monthly for most of the year in order to gain momentum and increase its’ understanding of its’ work and the improvement of the group’s process.
Other significant ways in which the Council has shown leadership include the effort to see that the Council was well represented within the State’s MHDD Redesign process, which is addressed in detail elsewhere in this Plan. Two members of the MHPC are also members of the sixteen-member MHDD Commission since it was restructured in November of 2002. Many Council members participate in the work groups of the Commission and make efforts to see that the Commission receives input based upon the State Plan and activities of the Council. Brenda Hollingsworth, Vice Chair of the MHPC will make a presentation to the MHDD Commission on the State Plan and the concerns of the Council during one of the Commissions upcoming meetings. This is expected to take place in September or October. The Council has developed an ad-hoc Monitoring and Oversight Committee to help meet its goal to have a more active role in understanding and providing input to the SMHA about the projects funded with the block grant, technical assistance, support to the SMHA, and perhaps quality improvement issues. This ad-hoc committee has met only once to date and has scheduled to meet monthly for six months beginning in October of 2003. The ad-hoc committee may then determine to meet on a less frequent basis. The Council has also been linking its work to Iowa’s efforts to address the U.S. Supreme Court ruling in Olmstead. Two Council members also serve on the Olmstead Real Choices Consumer Taskforce, which is the monitoring the advisory body to DHS, which is the lead agency for Olmstead. The Council’s linkages with these and many other important initiatives have strengthened its role and its potential impact across a wide variety of arenas affecting people with mental illness. The Council is using its resources to expand the knowledge base of its members, legislators, state and county officials, policy makers, consumers and family
49 members to invest in the mental health system consistent with the values and vision of the Council.
Each year, the MHPC identifies priority areas of focus for the upcoming State fiscal year.
For SFY 2004, the identified priorities for the Adult Mental Health System include:
Transition programming and support to correctional consumers with mental illness Assertive Community Treatment Illness (Wellness) Management and Recovery Dual diagnosis
For SFY 2003, the identified priorities for the Children’s Mental Health System include
Alternatives to the Child in Need of Assistance (CINA) adjudication (as a means to obtain needed mental health services for children) Wraparound Services (Mental Health) School Based Mental Health programs Mental Health needs in detention, shelter, and other out-of-home placements Early intervention and diagnosis and early childhood services
H. Description of critical gaps in services and unmet needs projected for the duration of the plan being submitted There are a variety of gaps and unmet needs in Iowa’s public mental health system. Among those that are seen as a priority by the MHPC:
1. Inadequacy of information systems capacity, with a particular focus on outcomes: While the county management information system (COMIS) allows for quantification of some aspects of access to specific services, we do not have an adequate means of quantifying quality of care across the state. There is a need to a) identify a meaningful set of outcome measures that can be practically gathered across delivery sites, b) train and incent providers in their use, and c) develop methods to aggregate and feedback these data to providers, payers, consumers and other stakeholders. There is consensus that the service delivery system should be driven by outcomes that are meaningful to consumers and families, so the ability to track these outcomes in a reliable, consistent and valid manner is critical.
2. Under-resourced and under-empowered state mental health authority: Iowa’s system of local (county) control of MHDD services combined with ongoing budget cuts at the state level has left an already limited mental health authority significantly under-resourced. This is felt on multiple levels, including lack of adequate staff for oversight, quality assurance and credentialing. There is growing consensus for the need for a comprehensive, central and organizing state mental health plan, and for the requisite resources needed for its oversight. Even the most ardent supporters of local control seem to be recognizing the need for a central and consistent vision for the mental health system in Iowa.
50 3. Under-utilization of evidence-based practices: As described further below, several mental health practices with the strongest evidence-base are not being widely implemented in the state. For example, there are significant administrative barriers involved in delivering integrated substance abuse and mental health services to individuals with co-occurring disorders, limiting that practice. Substantially more employment resources are directed towards sheltered workshops than towards supportive employment, despite the much more compelling evidence for the latter. Lack of reimbursement limits the use of family psycho-education. Assertive community treatment is available only in 3 cities, and unavailable in any of the rural areas. Efforts to enhance the dissemination and implementation of evidence-based practices are a priority.
4. Inadequate access to community-based mental health services for children, leading to an over-reliance and inappropriate use of child welfare services and /or congregate care settings. Many communities lack the resources necessary to maintain children with serious emotional disturbances in their homes and schools. While Olmstead guides us towards community integration, the reality of this situation leads to many children finding their way into congregate settings such as PMIC’s (Psychiatric medical institutions for Children) to access services not available in their communities. Similarly, the child-welfare system is often used as a substitute for mental health services.
5. Rigorous residency requirements often lead to long administrative delays in accessing services. Iowa’s system of establishing legal settlement poses a barrier to accessing mental health services for many Iowans.
6. Inequities in access to and quality of mental health services across the state: There is a lot of variability from county to county in terms of eligibility for, and availability of high quality mental health services.
7. Limitations in educational opportunities for front-line mental health staff. Ultimately the quality of a system depends upon the quality and abilities of the line staff. More must be done to ensure adequate educational and developmental opportunities for mental health staff at all levels.
51 Section III
State Plan
FY 2003 (STATE FY 2004)
52 Section III Adults with a Serious Mental Illness
CRITERION 1: Comprehensive Community Based Mental Health System
Definition of Adults with a Serious Mental Illness Pursuant to Section 1912 of the Public Health Services Act, as amended by Public Law 102-321, adults with a serious mental illness are persons:
Age 18 and over Who currently or any time during the past year Have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-IV That has resulted in functional impairment that substantially interferes with or limits one or more major life activities.
These disorders include any mental disorders (including those of biological etiology) listed in DSM-IV or their ICD-9-CM equivalent (and subsequent revisions), with the exception of DSM- IV "V" codes, substance use disorders which are excluded, unless they co-occur with another diagnosable serious mental illness. All of these disorders have episodic, recurrent, or persistent features; however, they vary in terms of severity and disabling effects.
Functional impairment is defined as difficulties that substantially interfere with or limit role functioning in one or more major life activities including basic daily living skills (e.g. eating, bathing, dressing); instrumental living skills (e.g. maintaining a household, managing money, getting around the community, taking prescribed medication); and functioning in social, family, and vocational/educational contexts. Adults who would have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are considered to have serious mental illness. (Federal Register, Vol. 58, No. 96, May 20, 1993)
Organizational Structure of the Comprehensive System of Care Iowa's public mental health system has been described in detail in the Context section. It consists of at least two distinct components: (1) The Iowa Plan for Behavioral Health and (2) County Management Plans. Described below are the components that form the basis of Iowa’s comprehensive system of care for adults with a serious mental illness.
Health and Mental Health Services Through a managed care contract the Iowa Plan for Behavioral Health (The Iowa Plan) covers approximately 240,000 eligible enrollees (children and adults) under the Iowa Medicaid program. The original contract was implemented January 1, 1999 and continued through June 30, 2001, with three optional extension periods of up to one year each. The contract is now in its third year under the optional extension period, which will end on June 30, 2004, when the contract expires. DHS is currently in the process of writing the request for proposals (RFP) for the future of managed behavioral health care for Iowa’s Medicaid population.
Unless specifically excluded, all categories of beneficiaries are covered by the Iowa plan. Only the State has the discretion to exercise the extension options. Under established capitation rates, the
53 contractor is at full risk for providing all Medicaid funded mental health and substance abuse services to enrollees, regardless of pre-existing conditions. As stated earlier, the Iowa Plan for Behavioral Health combines two previously separate managed care programs, the Mental Health Access Plan (MHAP) and Iowa Managed Substance Abuse Care Plan (IMSACP). The Contractor also manages services to persons with a mental health diagnosis who are enrolled in the State Payment Program (SPP).
The managed care contractor is required to support local system planning through existing planning entities including the County Central Points of Coordination, County Management Plans, Decategorization Boards and Empowerment Boards, and also hold roundtables involving consumers and providers to seek input for planning and implementing services.
The Iowa Medicaid Program covers both categorically and medically needy persons. All categories of Medicaid eligible beneficiaries are covered by the Iowa Plan unless specifically excluded. The average monthly enrollment during the first year of the managed care contract in 1999 was 175,967. Enrollment for SFY 2002 was 240,000 and it projected to be 240,000 during SFY2003. In a typical month, the number of unduplicated enrollees who received one or more services is 13,616 persons. Approximately 62% of the persons receiving services are children.
Covered Services for Mental Health Conditions in the Iowa Plan Covered services are those which are included in the Iowa Medicaid Program and are reimbursed for all non-Iowa Plan beneficiaries through the state's Medicaid fiscal agent (DHS medical division). The Contractor will develop a network of appropriately credentialed mental health service providers to assure availability of the following services to meet the mental health needs of eligible enrollees:
• Emergency services for psychiatric conditions available on a 24 hour basis • Ambulance services for psychiatric conditions • Inpatient hospital care for psychiatric conditions • Outpatient hospital care including intensive outpatient services, individual and group therapy, occupational therapy, medication administration, activity therapy, family counseling, partial hospitalization, and day treatment • Psychiatric physician services including consultation for other medical conditions • Psychological services for diagnosis, evaluation, and treatment of mental illness at state schools and Mental Health Institutes for enrollees under age 21 • Services provided through a Community Mental Health Center, including the services of a psychiatrist, psychologist, social worker, or psychiatric nurse, and day treatment • Targeted case management services to persons with a chronic mental illness • Medication management, excluding medications • Psychiatric nursing services by a home health agency • Psychiatric or psychological screening prior to nursing home admission • Mental health services subsequent to EPSDT screening
Additional Required Services in the Iowa Plan Although not covered in the fee-for-service Iowa Medicaid Program, the following services are required of the Contractor as appropriate ways to address the mental health needs of enrollees. The Contractor must expand availability of all required services assuring system capacity to meet the needs of Iowa Plan enrollees. These additional required services are:
54 • Services for persons with dual diagnoses (substance abuse and mental illness) • Case consultation by a psychiatrist to a non-psychiatrist physician • Services of a licensed social worker • Mobile crisis services • Mobile counseling services • Integrated mental health services and supports to assist enrollees remain in or return to the community and limit the need for out-of-home placement, similar to wraparound services available in the child welfare and juvenile justice system • Psychiatric rehabilitation services • Focused care management • Peer support services • Supported community living services • Assessment of the functioning level of a child with serious emotional disorder or adult with a serious mental illness; the scale to be repeated by intervals specified by the regimen • Assertive Community Treatment • Specified services to persons admitted at the State Mental Health Institutes (MHI’s) • Specified inpatient evaluations for mental health conditions • Prevention and early intervention services
County Management Plans A county-based system provides services to persons not eligible for Medicaid through County Management Plans. The counties also pay for certain non-Medicaid services to persons eligible for Medicaid as outlined within the individual county plans. This county based system was initially created in 1996 by Senate File 69 and House File 2430 which established the creation of local planning councils and defined the responsibility of those councils to develop plans for support services and housing to meet the needs of person with mental illness.
Gross county expenditures for mental health services in SFY2002 were $89 million. The State furnished $116 million as its share of property tax relief, annual growth allowance, and the MHDD Community Services payment to counties to cover some of the cost of disability services managed by counties. Each county has created the office of Central Point of Coordination (CPC) for administration of mental health services. County Management Plans define how the local service system will assist individuals, families and children to access mental health services and needed supports, such as income support, education, emergency relief, housing, and medical care. It is the responsibility of the CPCs to develop and administer the County Management Plan for the mental health and developmental disabilities services in each county.
Funding of services for persons with a mental illness has historically been county-based. This reliance on county-based funding is steadily diminishing as the State increases assistance to counties in property tax relief ($88,399,999) and annual growth payment ($8,554,053) distributed on a formula basis. Property tax relief and growth payments ($96.9 million in FY 2002) are combined with property tax levies raised by the counties to fund all disability services. Due to political and fiscal realities, counties will continue to be financial partners in the provision of mental health and other disability services in the state. Even though the legislation places the responsibility for development and implementation of County Management Plans
55 squarely on Iowa’s counties, each county controls their service system infrastructure that is not funded by Medicaid. Through local control each county prioritizes needs, develops plans, establishes system goals and indicators, identifies consumer outcomes, and allocates resources.
Whether federal Medicaid, State, county, or other funding streams are used to pay for mental health services, those services are provided to eligible Iowans by a system that incorporates a variety of elements. A brief description follows:
Mental Health Institutes (MHl) The Iowa Department of Human Services operates four specialty psychiatric hospitals known as Mental Health Institutes. All four are licensed as hospitals and provide inpatient psychiatric services to adults. One has a program to provide long term geropsychiatry; one provides substance abuse treatment and two of the MHI’s serve children and adolescents.
Specialized Psychiatric Units in General Hospitals Twenty-five general hospitals in Iowa have licensed psychiatric units with a total capacity of 995 beds. While more concentrated in metropolitan and urban areas, psychiatric hospital services are available in most parts of the state.
Community Mental Health Centers and other Community Mental Health Providers Community Mental Health Centers each serve a defined catchment area ranging from one to nine counties. Other mental health providers generally serve a specific, and generally smaller, geographical area. These agencies may be accredited to provide any of the following services: partial hospitalization, day treatment, intensive outpatient, psychiatric rehabilitation, supported community living, outpatient treatment, emergency services, and evaluation.
Mental Health Professionals Statewide There are approximately 230 psychiatrists in the State of Iowa. The majority of the psychiatrists practice in metropolitan or urban counties. A secondary concentration is found in or near those counties with a psychiatric institution, an MHI or a VA Hospital. In 2002 there were a reported 434 psychologists, 4678 social workers, 500 individual mental health counselors and 174 marital and family therapists.
Residential Care Facilities for Persons with a Mental Illness The Iowa Department of Inspections and Appeals licenses "Residential Care Facilities for Persons with Mental Illness" that provide accommodations, board, personal assistance and other essential needs of daily living to three or more individuals for a period exceeding 24 hours. Clients must be able to sufficiently or properly care for themselves, but do not require the services of a registered or licensed practical nurse. Fifteen programs with 371 beds are currently licensed. These programs provide care in residential facilities to persons with severe psychiatric disabilities who require specialized psychiatric care. While scattered around the state, these programs are not available in every community.
Intermediate Care Facilities for Persons with a Mental Illness The Iowa Department of Inspections and Appeals also licenses "Intermediate Care Facilities for Persons with Mental Illness," which are institutions, places, buildings, or agencies whose
56 primary purpose is to provide accommodations, board and nursing care for a period exceeding 24 consecutive hours to three or more individuals who have mental illness. Currently, only one program with twenty-five beds holds this licensure in Iowa.
Medical and Dental Services The Iowa Foundation for Medical Care (IFMC) is the State's Quality Improvement Organization. IFMC works with physicians and health care professionals to promote high quality medical care for Medicare beneficiaries in both inpatient and outpatient settings. Medicare's quality improvement efforts, better known as the Health Care Quality Improvement Program (HCQIP), are designed to: Assist health care providers with their quality improvement efforts Improve the processes and outcomes of medical care for Medicare beneficiaries Conduct case review to determine if services provided are medically necessary, appropriate and meet professionally recognized standards of care Educate Medicare beneficiaries regarding their hospital rights and responsibilities and the importance of preventive health care Respond to Medicare beneficiaries concerns about the quality of care they have received.
IFMC serves as a primary resource for Medicare beneficiaries in Iowa. IFMC beneficiary education and community outreach activities are designed to provide Medicare consumers with the information they need to make informed decisions about their health and the health care services they receive. An important part of the HCQIP program is educating Medicare beneficiaries about their rights and responsibilities and the importance of utilizing preventive health care services provided for by Medicare. IFMC offers a speakers bureau to provide education about hospital rights, adult immunizations and the importance of mammography screening. In addition to making group presentations, IFMC staff participate in health fairs and other events in an effort to reach out to Medicare beneficiaries and their advocates. IFMC distributes a newsletter, Medicare Today, to beneficiaries throughout the state and provides a Medicare Consumer HelpLine. Knowledgeable HelpLine representatives answer questions about the quality of health care Medicare beneficiaries receive. Services are funded by Medicare and are provided at no charge to the consumers.
Private Practitioners and Clinicians The Iowa Department of Public Health Board of Medical Examiners is responsible for regulating medical and osteopathic doctors. Mental health professionals such as social workers, mental health counselors, and psychologists are licensed by the Bureau of Professional Licensure.
Rehabilitation Services Intensive Psychiatric Rehabilitation (IPR) In 1998, the State of Iowa initiated a statewide implementation of Intensive Psychiatric Rehabilitation, a program that is unique because it incorporates recovery-oriented principles as part of a public sector managed care plan. Magellan Behavioral Care of Iowa, an affiliate of Magellan Behavioral Health, administers the program and is responsible for its implementation and adoption statewide. IPR is guided by the values of consumer involvement, empowerment,
57 and self-determination. Its mission is to provide enhanced role functioning through strategies for readiness, skill, and support development. Presently, the outcomes of this program are being studied by the Center for Psychiatric Rehabilitation at Boston University.
IPR provides services to adults with a serious and persistent mental illness who are interested in making a community ‘role recovery’ within the next six months to two years. The concept of role recovery is to engage or re-engage individuals in personally meaningful community roles. The purpose of intensive psychiatric rehabilitation services is to assist the person to choose, obtain and keep valued roles and environments. The four specific environments and roles in which psychiatric rehabilitation will assist the individual are living, working, learning, and social interpersonal relationships.
Consumers enrolled in the Intensive Psychiatric Rehabilitation Services are involved in all aspects of the recovery process. Role recovery goals are established with the full input of each individual. There are four phases of the psychiatric rehabilitation process: Readiness Development, Goal Setting, Goal Achieving and Goal Keeping. Psychiatric Rehabilitation Practitioners meet with consumers as often as needed and as determined by the consumer and the practitioner.
Consumer Efforts to Promote Recovery/Wellness in Iowa The following information provided by Alice Holdiman, consumer advocate, Mental Health Planning Council member, and Chair of the Olmstead Real Choices Consumer Taskforce, regarding consumer run and recovery related programs. Alice gathered the information from a number of consumer advocates around the state, including other MHPC members.
Grass roots efforts in Iowa are very much aligned with the President’s New Freedom Commission on Mental Health in promoting recovery, cure, and prevention. In addition to activities being conducted by major consumer-activist groups, there are several ongoing efforts by other consumers to advance wellness, recovery and mental health in Iowa. Northeast Iowa Mental Health Center has taken the lead in Recovery Education. They teach the Wellness Recovery Action Plan (WRAP), based on the model of Mary Ellen Copeland. WRAP is a consumer-driven program which educates consumers to manage illness and become active partners in their recovery. As an outgrowth, many consumers who have taken the WRAP class have gone on to form and sustain support groups to assist each other with the formation and maintenance of wellness plans.
At least four Iowa consumers have earned certificates to facilitate this wellness-training for other consumers. One is also a trainer of trainers and is currently part of a project which will share WRAP with three more Community Mental Health Centers. Overall, they hope to train 100 persons, both providers and consumers, to teach the program and promote consumers’ responsibility in their own recovery. The Iowa Consortium for Mental Health, in conjunction with Magellan Behavioral Care of Iowa, is developing Technical Assistance Centers for recovery oriented approaches, including WRAP (Wellness Recovery Action Plans) and ACT (Assertive Community Treatment). Consumers will serve on the advisory boards and participate in evaluation and assistance.
58 A holistic recovery/discovery model entitled The Holistic Approach to the Fullness of Living, which has been created and developed by Iowa consumer Mary C. Hughes, complements Mary Ellen Copeland’s work. Trainings have been made available by the efforts of a consumer-run business, the Fullness of Living Center. Mary Hughes is a Planning Council member and a member of the MHDD Commission.
A program called Recovery Group is based on the early work in cognitive therapy by Dr. Abraham Lowe, M.D. Group participants are trained to spot symptoms and eliminate or control them by applying tools which convert insecure thoughts to secure ones. Recovery Groups are run entirely by consumers using the model which Dr. Lowe devised. Several groups exist in Iowa. Recovery Groups of Iowa, Inc. (RGI), a group founded and governed by consumers, is available to train group leaders to educate others to support and teach one another to control symptoms and prevent relapse and hospitalization. RGI has founded two local groups for consumers as well as a new group that trains family members and friends to deal with difficult situations that may arise when living with persons with mental illness.
Consumer-run, staff supported consumer-run, and recovery-orientated drop-in centers are springing up in many locations throughout Iowa. Besides other empowering activities, many of these drop-in centers are successfully providing peer support services. We are hoping to set up statewide training and credentialing for peer support workers as is done in the state of Georgia. Presently only three locations pay their peer support workers, and the rest are volunteer workers. More peer support workers need to be paid for their invaluable contribution to the recovery of individuals. Peer Support Programs such as North Iowa Mental Health Center (Mason City), ResCare (Des Moines) and Hope Haven (Rock Valley). There are also volunteer Peer Support Programs at Club 520 (Abbe in Cedar Rapids) and Mid-East Iowa CMHC (Iowa City). Drop-in Centers such as The Friendship Center in Fort Dodge and the Club 520 in Cedar Rapids are completely run by peers. The North Iowa Mental Health Center has drop-ins that are partially staffed by peers.
The Iowa P.E.E.R.S. Network (People Educating & Encouraging Recovery & Support) is a new statewide consumer group that is providing peer support training, Wellness Recovery Action Plan training, and Hearing Distressing Voices training for providers, as well as encouraging local support group development. The Annual Empower Mental Health Consumer Conference is planned by mental health consumers (all currently members of P.E.E.R.S. ) with at least 75% of the workshops presented by consumers, for consumers.
The Depression & Bipolar Support Alliance (DBSW), which has several locations across Iowa, is a grass roots volunteer organization that works to improve the lives of people living with mood disorders. They provide information through educational videos, literature and speakers. By sharing resources with those who have concerns about mental health, they offer support to consumers, families, and friends of persons with mood disorders and ADHD.
59 Employment Services Bridge to Employment. Iowa is the only state in the nation to be awarded both the Social Security Administration (SSA) and the Rehabilitation Services Administration (RSA) grants. The Department of Human Services partnered with Workforce Development for the SSA grant and was one of the partners with the Department of Education, Division of Vocational Rehabilitation for the RSA grant. Given the similarity between the purposes, there is a significant effort to insure that activities are coordinated and there is a high level of communication. The overall purpose is to assist Iowa in developing the infrastructure to enable coordination of service delivery systems which increase the rates of employment and self-sufficiency of Iowans with disabilities.
The Social Security Administration approved twelve states for cooperative agreements to conduct demonstration projects. The purpose was to develop integrated service delivery systems which increase employment of individuals with disabilities who receive Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). At the same time the Rehabilitation Services Administration approved grants to five states with the purpose of assisting persons with disabilities who receive Family Investment Program (FIP) benefits to obtain employment. Both grants are 5-year projects, which end September 30, 2003.
Housing Services Many adults with serious mental illness utilize the “HUD Section 8 Rental Voucher Program”. This program increases affordable housing choices for very low-income households by allowing families to choose privately owned rental housing. The public housing authority (PHA) generally pays the landlord the difference between 30 percent of household income and the PHA- determined payment standard, about 80 to 100 percent of the fair market rent (FMR). The rent must be reasonable. The household may choose a unit with a higher rent than the FMR and pay the landlord the difference or choose a lower cost unit and keep the difference.
Several assistance programs exist under Section 8. Together, the voucher and certificate programs help more than 1.4 million households in the United States. The administering PHA or governmental agency inspects the housing units to make sure they comply with HUD quality standards. The voucher program is similar to the Section 8 certificate program but gives households more choices, especially in high-demand markets where landlords may be reluctant to accept HUD's FMR level.
Through the Section 8 Rental Voucher Program, the administering housing authority issues a voucher to an income-qualified household, which then finds a unit to rent. If the unit meets the Section 8 quality standards, the PHA then pays the landlord the amount equal to the difference between 30 percent of the tenant's adjusted income (or 10 percent of the gross income or the portion of welfare assistance designated for housing) and the PHA-determined payment standard for the area. The rent must be reasonable compared with similar unassisted units.
Home and Community Based Services Waiver Rent Subsidy Program
60 Rental subsidies have been available to various disability populations in the state since 1996 through the home and community-based waiver programs (including. Ill and Handicapped; Elderly; AIDS/HIV; MR; Brain Injury and, Physical Disabilities Waivers). Consistent with the spirit of Olmstead, the overall purpose of this program is to encourage and assist persons who currently reside in a medical institution to move to and live in community housing. Unfortunately, Iowa like most other states does not have a waiver specifically targeted to individuals with mental illness and so it is difficult if not impossible for individuals with mental illness to take advantage of this potentially important opportunity. This is an issue we continue to review in the context of implementing our Olmstead plan.
Educational Services NAMI Family-to-Family Education Program. This 12-week course for family caregivers of individuals with mental illnesses is offered statewide by NAMI-Iowa. The course is taught by trained volunteer family members. All instruction and course materials are free for class participants. The Family-to-Family curriculum focuses on schizophrenia, bipolar disorder (manic depression), clinical depression, panic disorder and obsessive-compulsive disorder (OCD). The course discusses the clinical treatment of these illnesses and teaches the knowledge and skills that family members need to cope more effectively. In Our Own Voice: Living with Mental Illness This program recently became available in Iowa. It is an informational outreach program on recovery presented by trained consumers to other consumers, families, students, professionals, and others seeking to learn about mental illness. The program is designed to offer insight into how people with serious mental illnesses cope with the realities of their disorders while recovering and reclaiming productive lives with meaning and dignity. It is an opportunity for consumers to gain self-confidence, self-esteem, and income while serving as role models for the community. A goal of the program is to show that mental illness is nothing to be ashamed of and that recovery is an ongoing reality. NAMI Peer-to-Peer Program NAMI Iowa's Peer-to-Peer Recovery Education Course has been taught by sixteen trained consumer mentors in the cities of Des Moines, Cedar Rapids, Atlantic, Carroll, Iowa City, and Davenport. This relatively new nine week Signature Education program of NAMI has graduated ninety consumers in its first year. The program of recovery education is currently expanding to five new locations around Iowa that may include the cities of Council Bluffs, Spencer, Fort Dodge, Dubuque and Mt. Pleasant in the southeastern section of Iowa. Response has been positive to this unique class that is a beginning for many, to the tools needed for recovery.
The annual Mental Health Consumer Conference, Empower 2003, was held this year in Fort Dodge, on July 14-16, 2003. This conference, which was first held in 1999, provides an opportunity for mental health consumers to join with each other and share ideas, talents, and experiences. Information is designed to enhance consumers’ skills and to assist them in their path toward recovery. The conference includes state and nationally recognized keynote speakers, entertainment, peer support, social functions and more. In 2003, the mental health
61 block grant provided approximately $20,000 in stipends to support the attendance of consumers who might otherwise be unable to attend.
Substance Abuse Services Substance abuse treatment in Iowa is provided in all 99 counties. Services are available regardless of a client's ability to pay. The public service delivery system combines Medicaid, State, and federal substance abuse block grant treatment funds under a single statewide contract jointly administered by the Department of Human Services and the Iowa Department of Public Health. As previously mentioned, the contract for substance abuse treatment has been combined with contracted managed mental health services since 1999 through the Iowa Plan. The substance abuse portion of the contract is approximately $15.0 million. Each Department distinctly funds and has specific service requirements for its population. For Medicaid services, the Iowa Managed Substance Abuse Care Plan contract is a capitated, at-risk plan to provide managed substance abuse treatment under a federal Medicaid Section 1915(b) waiver for enrolled Medicaid beneficiaries.
The Bureau of Substance Abuse licenses and monitors approximately 110 substance abuse treatment programs. It provides technical assistance to programs and is responsible for investigation of complaints against licensees. This Bureau also develops, submits and administers the federal Substance Abuse Block Grant, administers the Methamphetamine Target Capacity Expansion (TCE) grant treatment program, and coordinates collaborative efforts and services with the Department of Corrections and criminal justice system. In addition, the Bureau coordinates services, and approves evaluations and treatment completion results for OWI (operating a vehicle while intoxicated) offenders.
Case Management Services Targeted Case Management. Targeted Case Management is a service that assists recipients in gaining access to appropriate living environments, needed medical services, and interrelated social, vocational, and educational services. In Iowa, case management services are used to link consumers to service agencies and support systems responsible for providing the necessary direct service activities, and to coordinate and monitor those services. Case managers are not responsible for providing direct care. Each county ensures that targeted case management is available for eligible persons with a chronic mental illness, mental retardation, or developmental disability. These agencies are accredited by the Division of BDPS and may be private agencies, county-run programs or DHS programs, and provide coordination services to their clients. Targeted case management for persons with a chronic mental illness is reimbursable through the Iowa Plan for Behavioral Care program. Within an accredited case management program, the average caseload is not more than 45 consumers per worker.
The DHS Case Management Unit implements targeted Case Management in 30 of Iowa's 99 counties. The other 69 counties are responsible for procuring this service either through purchase of service contracts with providers or hiring their own case managers. Accreditation for this service is the responsibility of the Division of BDPS of the Iowa Department of Human Services. The managed care contractor for the Iowa Plan has approximately 50% of fiscal responsibility
62 for this service. The state and county share fiscal responsibility for non-Iowa Plan eligible Medicaid recipients.
Performance benchmarks for case management dictate that consumers are able to live and work as independently as possible in a community setting through skills enhancement services that are coordinated and monitored. Performance indicators for Case Management Services are: • Consumers receive case management from qualified case managers. • Consumers are part of a team composed of a case manager and the organizations and natural supports providing direct services. The team establishes the service plan that guides and coordinates the delivery of services. Goals are to be based upon consumer needs derived from social history, and current assessment.
Consumers are linked with appropriate resources to receive direct services and supports. Consumers participate in developing an individualized plan. Consumers are encouraged to exercise choice, make decisions, and take risks that are a typical part of life, and to fully participate as members of the community. Family members and significant others are involved in the planning and provision of services as appropriate and as desired by the consumer.
63 Other support services to assist individuals to function outside of residential settings. Supported Community Living Programs. Supported Community Living Programs (SCL) are accredited by the Division of BDPS of the Department of Human Services to provide supervised supported living to persons with disabilities. Approximately 90 of these programs currently provide services to persons with a mental illness. While many of these programs began as residential with on-site supervision, many have evolved to supported living programs that provide in-home services and supports to persons with a disabling mental illness. Supported Community Living programs operate in most of the Iowa counties.
Activities Leading to Reduction of Hospitalization In addition to those activities covered in previous sections, several initiatives have been undertaken recently by various state agencies to enhance the opportunities for Iowans with disabilities to live and work in the community of their choice. While these initiatives were not undertaken in response to the U.S. Supreme Court Decision in Olmstead, they do reflect the State of Iowa’s activities to implement the values and principles that underpin our system of services and, thus, are in concert with Olmstead.
Case Management Program for the Frail Elderly The Case Management program for the Frail Elderly is designed to assist persons who are frail elders to gain access to a variety of services through the assistance of a case manager. A comprehensive assessment of the individual’s medical, social, emotional, and personal needs is completed. A team of professionals works with the individual to develop a plan of care that will allow the client to live safely and independently in his or her own home.
Senior Living Trust Fund The Senior Living Trust Fund will generate funds for the development of alternative services for persons who are elderly and/or have disabilities who are either residing in nursing homes or are at risk of such placement. Iowa will be using these funds to develop a comprehensive long-term care system offering a full continuum of services that promote independence and offer choices for the elderly and persons with disabilities. A portion of the Trust Fund is allocated to develop affordable long-term care alternatives such as day programs, respite care, home health services, transportation services, and assisted living programs.
Adult Rehabilitation Option for Persons with Chronic Mental Illness The Department of Human Services medical services unit has worked with county representatives to design and submit a state Medicaid plan amendment to add the rehabilitation option for persons with chronic mental illness. This greatly expands the community service options for persons with mental illness and ensures that these services are available statewide. Community support services included are symptom management and support services, community living skills training, and employment-related services. Day program services include both skills training and skills maintenance services. The plan amendment was effective January 1, 2001.
Moving Towards Evidence-Based Practices (EBP’s)
64 There has been significant activity to move towards greater implementation of evidence-based practices (EBP’s). This activity has been spearheaded by the Iowa Consortium for Mental Health (ICMH), through direct support from the block grant. As detailed in last year’s application, the ICMH conducted a statewide review of the utilization of EBP’s in Iowa (through a block-grant RFP), which demonstrated the under-utilization of several of the mental health practices that have the strongest evidence-base. For example, there are only 3 Assertive Community Treatment (ACT) programs statewide. This effort was detailed in last year’s block grant application, and the results are summarized in the table below.
Mandated or Use Clarity of Evidence- Use in Model recommende in Barriers in Iowa construct Based U.S. d Iowa Assertive Shortage and misdistribution of Community + + + + + + + + ++ + + + + + MH professionals, funding, Treatment (ACT) training of staff, awareness, rurality Funding, oversight, family and Supported + + + + + + + + + + ? patient concerns about loss of Employment benefits School-based Funding, decentralized distributed Clinical Mental ++ + + + + + + ++ + governance, community buy-in Health Services Family Psycho- Labor intensive, attitudinal, + + + + + + + + + + + + education reimbursement Funding, training issues, shortage Elder Outreach + + + + + + + + + + and misdistribution of MH Programs professionals Medication Lack of centralized mental health Treatment + + + + + + authority, education, enforcement, Algorithms funding Early Childhood + + + + + + Reimbursement, parental attitudes Interventions Integrated substance + + + + + + + + Reimbursement, credentialing abuse & MH services Judicial resistance to specialty courts, lack of large population Mental Health Courts + + + + + + centers within jurisdictions, funding KEY: + = minimal; ++ = moderate; +++ = strong; ++++ = very strong / very widespread
Partly in response to this review, last year’s block grant application focused on expanding the capacity for ACT as its primary goal and objective in the 1st criterion of the adult section. Progress in this area is detailed in the current application, under criterion 1. The MHA, in collaboration with the ICMH and other stakeholders also submitted applications for the joint SAMHSA/NIMH “Science to Service” initiative last fall, as well as SAMHSA’s EBP mechanism in the spring of ’03. One of the goals of these applications was to establish a statewide technical assistance center for EBP’s. While the SAMHSA/NIMH grant was not funded, and the SAMHSA grant is still pending, the process of writing these grants and getting the requisite letters of support resulted in increasing awareness and enthusiasm for furthering this effort. In May of ’03, MBC of Iowa awarded a grant from its “Community Reinvestment Fund” to the ICMH to carry out some of the goals delineated in the two prior federal applications. This has allowed for the creation of a statewide Technical Assistance Center for Evidence-Based Practices (TAC). The TAC is focusing on 2 of the EBP’s that have been supported by SAMHSA: Assertive Community Treatment and Illness Management and Recovery.
65 MHA and the MHPC are committed to furthering this EBP effort. The intent is to use increasing proportions of block grant funds over the next several years as incentives for providers to enhance their capacity to provide those service that have a greater evidence-base. This will be a gradual process, involving staff training and development, methods to evaluate model fidelity, methods to evaluate appropriateness for these services and methods to evaluate outcomes. The goal, objectives and indicators below are consistent with this intent.
66 Criterion 1: Comprehensive Community Based Mental Health Service System
Goal: To enhance the quality and effectiveness of community-based mental health services to adults with serious mental illness in Iowa by promoting the implementation of evidence-based mental health practices.
Objective: To expand the capacity to provide Assertive Community Treatment Services to persons with serious mental illness in Iowa
Population: Adults with a Serious Mental Illness
Criterion: Comprehensive Community Based Mental Health Service System
Brief Name: ACT services
Indicator 1: Number of individuals receiving ACT services annually
Measure: Number of (unduplicated) individuals receiving ACT services annually in Iowa
Performance Indicator Data Table 1 Fiscal Year: 2003 Population: SMI Adult Criterion: Comprehensive Community Based Mental Health Service System
Performance Indicator FY 2002* FY 2003* FY 2004** (Actual) (Actual) (Projected) N receiving ACT services 143 162 228
*Numbers reflect sum of the average daily census annually for the 3 existing ACT teams ** Includes projected increases in census of the existing teams plus 30 patients for 1 additional new team.
Source of Information: There are currently 3 ACT programs in Iowa: 1) IMPACT Program at University of Iowa: 2) Abbe Center for Community Mental Health in Cedar Rapids; and 3) Golden Circle / Eyerly Ball Community Mental Health Center in Des Moines. ACT census data come from each program. A program at the North Central Iowa Mental Health Center in Ft. Dodge is in the planning stage, and projected census numbers come from that center based on its plans.
Indicator 2: Number of active ACT programs statewide
Measure: Number of ACT programs statewide
67 Performance Indicator Data Table 2 Fiscal Year: 2003 Population: SMI Adult Criterion: Comprehensive Community Based Mental Health Service System
Performance Indicator FY 2002 FY 2003 FY 2004 (Actual) (Actual) (Projected) Number of ACT programs 3 3 4 statewide
Indicator 3: Submission of statewide ACT accreditation standards for consideration for incorporation into Iowa Code
Measures: a) (yes/no) completion of statewide ACT accreditation document; b) (Yes/no) submission of this document through appropriate channels for incorporation into Iowa Code.
Significance: Assertive Community Treatment (ACT) is a model of intensive community outreach which has a strong evidence base in the treatment of severely and persistently mentally ill individuals. The penetration of ACT is highly variable across the nation, ranging from states in which ACT is mandated in every county, to others where there are no programs. Iowa currently has 3 ACT programs and has not added any new programs over the past several years. Furthermore, none of the 3 existing programs have achieved full fidelity to the ACT model. At a time when the Olmstead Decision and the President’s New Freedom Initiative are dominating the mental health landscape, the need for effective and intensive community based services for people who previously had been considered too ill to live outside of residential settings, has a new urgency. If Iowa is really going to be able to keep very sick patients out of institutional settings, services with the intensity, accountability and comprehensiveness of ACT will be required. As such, the planning council voted to include ACT as one of its priorities for the adult system this year.
Narrative: In last year’s block grant, we initiated the goal of expanding the use of evidence- based practices in general, with the specific objective of enhancing the capacity for Assertive Community Treatment. Substantial progress has been achieved towards these aims. Specifically, MBC of Iowa funded the Iowa Consortium for Mental Health to begin a Technical Assistance Center for Evidence-based practices. The TAC focuses on two evidence-based practices: 1) Assertive community treatment and 2) illness management and recovery. For each of these practices, we have established statewide advisory boards to help guide the further development, dissmentation and implementation of these practices.
For ACT we are on establishing of a review process guided towards optimizing fidelity to the ACT model, utlizing structured fidelity measures. We are also in the process of developing and disseminating a common set of outcome measures to be used by each of the ACT programs.
The technical assistance center is also working with several mental health centers across the state to assess their interest in, and readiness level for the establishment of new ACT programs. This
68 process is futherest along at the North Central Iowa Mental Health Center in Ft. Dodge. Plans are now underway to begin an ACT program at that center within the next several months, with a goal of having 30 patients by July 1, 04.
A critical issue for ACT is the need to ensure and hopefully expand its reimbursement so that it remains financially viable for providers. The majority of ACT services in Iowa have been reimbursed by MBC of Iowa, through the Iowa Plan. However, it is important to recognize that as of this time, ACT is not a direct Medicaid-reimbursable service in Iowa, and MBC of Iowa has been financing through a “special fund”. The contract with MBC of Iowa expires on June 30, 2004, and while they will likely bid for it again, the outcome remains unclear. As such, a high priority for this year is to pursue the process by which ACT can become a Medicaid- reimbursable service for the state’s medicaid plan. In order for this to happen, ACT needs to be offered more broadly around the state, and there needs to be clear accreditation standards within state code.
69 Criterion 2: Mental Health Data and Epidemiology
Goal: To track treatment penetration rates of seriously mentally ill adults in Iowa.
Objective: To provide ongoing estimates of the ratio of estimated prevalence of seriously mentally ill adults relative to those receiving treatment
Population: Adults with a Serious Mental Illness
Criterion: Mental Health Data and Epidemiology
Brief Name: Treated Prevalence of Mental Illness
Indicator: Number of adults who have a serious mental illness and received mental health services during the fiscal year
Measure: Numerator: Number of adults with a serious mental illness who received mental health services Denominator: Estimated number of adults with a serious mental illness in the state
Sources of Information: 1) MBC of Iowa quarterly reports for those who were funded by the Iowa Plan; 2) The CoMIS data base for those funded by counties; 3) Quarterly reports from CMHC’s receiving block grant funding, to DHS.
Special Issues: 1) We do not have the capacity to ensure that the numbers from the three sources above are unduplicated. (Capacity will improve through the Data Infrastructure Grant) 2) Numerator values only indicate those who are receiving publicly funded services. We cannot report on number of persons who received mental health services through private practitioners and the VA system. 3) Denominator values are taken from Kessler et al, 1996, which estimates a national prevalence of SMI as 5.3%.
Significance: Valid estimates of prevalence and penetration rates of treatment are inherently central and core indicators of the system needs and performance.
Indicator Table: State Fiscal Year
70 Performance Measures FY2001 FY2002 FY2003 FY2004 Actual Actual Estimated Projected Numerator: Served by Iowa Plan* 12,518 13,616 13,616 13,616
Served by County 31,720 35,019 33,000 33,000 Served by CMHS Block Grant** 3,000 5,504 1,189 1,200
Denominator 114,000 116,041 116,041 116,041 *Iowa Plan data are available on a monthly basis, i.e., for the month of June 02, 17,295 people were receiving mental health services through the Iowa Plan. We are presenting this as an estimate of the number of people receiving services in that fiscal year. ** Individuals served by the CMHS block grant is taken from quarterly reports by the 41 providers in 2003 who received a portion of the $1.8 million, which is contracted to community mental health providers. The number presented for 2003 is a quarterly average of adults with SMI served in 2003. Prior years figures include all adults served over all four quarters and are unlikely to be unduplicated.
Criterion 3: Not applicable
71 CMHS Performance Partnership Block Grant, 8/29/03
Criterion 4: Targeted Services to Homeless and Rural Populations
Goal 4(a) Increase access to housing services among homeless adults with serious mental illness.
Objective: Maintain or increase the number of seriously mentally ill adults served by PATH (Projects for Assistance in Transition from Homelessness) across the state relative to the previous fiscal year
Population: Adults with a Serious Mental Illness
Criterion 4: Targeted Services to Homeless and Rural Populations
Brief name: Services to Homeless Persons with a Serious Mental Illness
Measure: Numerator: Number of enrolled adults with serious mental illness provided services annually by the PATH program in Iowa. Denominator: Estimated number of homeless mentally ill in Iowa
Indicator Table: State Fiscal Year FY 2001 FY 2002 FY 2003 FY 2004 (actual) Actual Estimated Projected Numerator: Number of 827 847 855 860 adults enrolled in PATH* Denominator: Estimate of number of homeless 3,000 3,000 3,000 3,000 adults with SMI *Source: PATH Annual Reports for Fiscal Years 2001, 2220, 2003 www.pathprogram.com/state_contacts/state_summary **Denominator: see below for sources of estimates
Narrative Information In 1999, (the most recent year for which an accurate estimate can be found) an estimated 18,592 homeless people and 7,306 near-homeless people lived in the state of Iowa. 1 Of these, approximately 75% may be estimated to be adults (consistent with the split in Iowa’s general population between adults and children). It is widely recognized that a substantial proportion of homeless individuals suffer from serious mental illnesses. Estimates vary by study and location, and a reasonable estimate is ~ 25%. Thus in Iowa, we can estimate the homeless mentally ill adult population in Iowa to be in ~ 3000.
1 Department of Public Health, Vital Statistics of Iowa for years 1975-1999.
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Each year, the state utilizes funds for federal Projects for Assistance in Transition from Homelessness (PATH) to provide mental health and community support services, including, outreach, mental health evaluation and treatment, consultation and education services to more than 700 homeless mentally ill adults. As the table above indicates, there was a 2.4 % increase (827 to 847) in the number of individuals served by the PATH program between FY 2001 and 2002. The data from FY 2003 will be reported by the end of December 2003. We are estimating/projecting a slight increase this year relative to last, and hope to maintain or increase access to PATH over the next fiscal year.
A statewide Interagency Task Force on Homelessness meets once every other month to plan and coordinate expanded housing options for the state's homeless population. The Adult Mental Health Specialist and Planner, Lila P.M. Starr, began participating in this Interagency Taskforce on Homelessness in September of 2002. Her participation is important to her role as the PATH Coordinator for the state, which she took on in November of 2001 when the Division of BDPS was restructured. Participation in the Taskforce will provide valuable linkages to other agencies and homeless activities across the state, which can and will be beneficial to her role as Adult Mental Health Specialist and Planner for the CMHS Block Grant. At the December 2002 quarterly meeting of the PATH program providers throughout the state, a consensus was reached that all PATH programs in the state will begin having representatives participate in the statewide Interagency Taskforce on Homeless meetings, which are broadcast throughout the state via the ICN tele-communications system. The PATH program requires that the PATH program intended use plans be open to public comment and efforts are being made to solicit more public input to the annual PATH application process. As a step toward increasing awareness, the annual PATH application was shared with the Mental Health Planning Council for feedback as well as to the Interagency Task Force on Homelessness.
73 Criterion 4: Targeted Services to Homeless and Rural Populations
Goal 4 (b): Expand outreach and access to mental health services for rural populations in the state
Narrative Mental Health Services for Iowa’s Rural Population Iowa is a highly rural state. Half of its 2,923,179 residents reside in the 89 of Iowa’s 99 counties that have been designated as rural for Medicare reimbursement purposes and by the U. S. Census Bureau. “Rural” in Iowa is thought to be synonymous with “agricultural,” but that is not necessarily the case. Only about 300,000 individuals reside on Iowa’s 90,000 farms. Nearly an equal number of Iowa residents live in homes in the countryside that once belonged to active farmers and the remainder of Iowa’s rural population (i.e. almost 900,000 people) reside in Iowa’s many small towns (towns with less than 10,000 residents).
Iowa’s rural population is quite diverse and this is an important factor to take into account in the delivery of mental health services to Iowa’s rural population. The number of Amish and Mennonite farmers and Hassidic Jewish farmers is increasing in Iowa. They currently comprise approximately 23,000 persons. Ownership of farmland by these cultural groups is increasing by approximately 5% annually. Significant immigrant groups of Bosnian and Sudanese refugees have come to live in Iowa, mostly working in Iowa’s food processing and farm equipment manufacturing industries. A surprising portion of these immigrants live in rural towns and travel on a daily basis to their work sites. Iowa has only a few thousand migrant farm workers of Hispanic origin; the vast majority of Hispanic or Latino residents in Iowa live in its towns and villages where they find employment in the meat packing and food processing industries, manufacturing, construction and service (e.g., motel and hotel housekeeping and food preparation) trades (U. S. Census Bureau, 2002).
Historically, Iowa has contributed considerably more income to the federal budget than it has received in reimbursement from federal origins. The U. S. Bureau of the Census (2002) estimated that 46,641 families (i.e., 6% of Iowa families) and 258,008 persons (i.e., 9.1% of all Iowans) lived in poverty in 1999. While many of Iowa’s families and individuals living below the poverty line qualify for Medicaid or Medicare health insurance coverage, a growing segment of Iowa’s rural individuals and families cannot afford health insurance. In 2001, 8.6% of Iowa residents lacked health insurance coverage of any type (National Priorities Project Database, 2002). The Iowa Insurance Commission Office estimates that the number of Iowans who live in rural areas who do not have health insurance (i.e., 11% of rural residents) exceeds those in urban areas (i.e., 7% of urban residents). While only about 7% of Iowa’s farmers and their families lack health insurance, significantly greater numbers of non-farming persons who live on farmsteads or in small towns and migrant farm workers and recent immigrants to rural areas lack health insurance. Usually, lack of health insurance accompanies economic stress. As Hoyt, O’Donnell and Mack (1995) concluded, economic stress is most likely to occur among families that live in older farm rental houses and small rural towns. They commented that the economic condition and psychological distress of these persons were not significantly different from persons living in urban ghettos. Mines, Gabard and Steirman (1997) noted that other specific groups of the U. S. rural population, such as Hispanic migrant farm workers and recent
74 immigrants, nearly always lack health insurance, and there is no reason to believe that Iowa’s rural population differs significantly from the U. S. rural population in this regard.
Iowa’s farm families also have difficulty accessing mental health care because of other health insurance complications. Roy (2001) surveyed 717 northwest Iowa farm families and found that 5% of the families reported lacking health insurance coverage for one month or longer during the previous year. Nine percent of the respondents indicated that they did not fill a drug prescription during the previous year because of financial difficulties. The average annual health care costs (health insurance premiums plus out-of-pocket expenses) were $5,709 for the 663 families that answered this question. These health care costs constituted 12.6% of their total household income (farm plus non-farm). Most farm families who lack health insurance coverage do not qualify for Medicaid because they possess too many assets (e.g., farm machinery and livestock) but they cannot afford the high cost of individually owned health insurance policies. In order to keep health insurance costs down, many families have reduced mental health and substance abuse coverage. Yet, financially distressed farmers are often those in most need of mental health assistance.
Farm and rural residents are less likely to seek treatment for mental illness than urban residents because of negative stigma associated with mental health services. There is need for rural service delivery models that are sensitive to the culture of farm families and the many specialized cultural groups (e.g., Amish, Mennonite and Hassidic Jewish groups) with clusters in parts of Iowa. Twenty percent of Iowa’s counties lack a professional mental health service provider currently. All of these are rural counties. Within Iowa most rural mental health services are provided by its 36 community mental health centers which serve multiple counties, private provider groups such as Lutheran Services and Catholic Charities, and by itinerant professionals who travel to counties which lack their own indigenous provider and have a fee for service arrangement with a nearby mental health clinic or private providers.
Lack of practicing psychiatrists in rural Iowa is a serious concern. Over 50% of Iowa’s psychiatrists practice in just 4 of the state’s 99 counties. The number of practicing psychologists, social workers, psychiatric nurses and marriage and family therapists per 100,000 residents in rural areas of Iowa is less than half the number of these trained mental health professionals in metropolitan counties of the state (Substance Abuse and Mental Health Services Administration, 1996). Lack of funds for effective rural mental health service delivery is particularly critical. State budget cutbacks, combined with heavy local tax burdens bode poorly for effective state implementation of rural mental health services. As the Iowa Public Health Plan, Healthy Iowans 2010, indicates, “The rural population continues to be under heavy pressure. The ‘farm crisis’ which began in the 1990’s threatens to eclipse the one that was so disastrous in the 1980’s. The plight of the rural population has tremendous mental health implications. Today, the ability to deal with these issues is probably even less than it was in the 1980’s, given the erosion of county funding for mental health services. Additionally, the delivery of all health care services in rural areas is heavily impacted by the serious difficulty of recruiting needed health care professionals. This is particularly true of mental health professionals, especially psychiatrists.” (Iowa Department of Public Health, 2000).
75 Although there are no data to verify this impression, there is reason to believe that there are few significant differences in the prevalence of mental illness and substance abuse in Iowa’s rural population, compared to its urban population (Hartley, Bird and Dempsey; 1999; Wagenfeld, Murray, Mohatt and DeBruyn, 1994). Notably, however, suicide is much more common in rural areas of Iowa, especially in the farm population (Gunderson, Donner, Nashold, Salkowicz, Sperry and Wittman, 1993; Rosmann, 1999). Substance misuse, especially alcohol abuse and domestic violence are considerably more prevalent among specific rural groups such as rural adult Hispanic males (Castro and Gutierres, 1997), Native Americans (Donnermeyer, 1992) and farm youth (Conger and Rueter, 1996). In Iowa, economic distress, such as insufficient farm income and low wages, are significantly associated with increased risk for mental disorders, especially depression in farming areas (Rosmann, 2002). Residents of small towns who are heavily dependent upon the farm economy in Iowa are also negatively impacted and have greater risk for depression and other mental health disorders (Rosmann and Delworth, 1990). Among specific recommendations stemming from the above are:
Specialized training is needed in behavioral health for providers who serve the rural population; in many cases, primary care providers also need to develop an understanding of the culture of farmers, migrant farm workers, recent immigrants to Iowa, and specialized cultural groups (e.g., Amish, Mennonite and Hassidic Jewish groups) so as to better serve these residents, since primary care providers often are the first health care professionals that consumers approach in many areas. Service programs are needed that utilize indigenous residents, such as farmers and residents of the many specific cultural groups in Iowa, who understand the local culture, to conduct outreach activities. Programs are needed that support the faith-based community in their work with residents and to integrate them with professional behavioral health care providers in their rural areas.
Objective: Maintain or increase the access to and treatment of mental illness in rural areas of the state.
Population: Adults with a Serious Mental Illness
Criterion 4: Targeted Services to Homeless and Rural Populations
Brief Name: Services to Rural Populations
Indicator: Adults with mental illness who live in rural areas and receive mental health services and supports.
Measure: Numerator: Prevalence of treated illness among adults with a mental illness who live in communities that are defined as rural. Denominator: Percent of state population living in rural areas applied to Kessler, et. al., national prevalence estimates for Iowa.
State Fiscal Year Performance Measures FY 2001 FY 2002 FY2003 FY2004
76 (actual) (actual) (estimated) (projected) Numerator: Served by Iowa Plan* 12,518 13,616 13,616 13,616
Served by County 31,720 35,019 33,000 33,000 Served by CMHS Block Grant** 3,000 5,504 1,189 1,200
Denominator*** 83,406 83,406 83,406 83,406 *Iowa Plan data are available on a monthly basis, reflecting people who were receiving mental health services through the Iowa plan in the selected month. We are presenting this as an estimate of the number of people statewide receiving services in that fiscal year. ** Individuals served by the CMHS block grant is taken from quarterly reports by the 41 providers in 2003 who received a portion of the $1.8 million, which is contracted to community mental health providers. The number presented is a quarterly average of adults with SMI served in 2003. Prior years figures include all adults served over all four quarters and are unlikely to be unduplicated. ***The ratio of 53% rural population is applied to Kessler's prevalence estimates for adults with SMI in Iowa. Despite the agricultural profile of the state, Iowa has seven Metropolitan Statistical Areas (MSA's). Urban population in these MSA's is 1,349,467, which are roughly 46% of the total state population.
Availability and Access in Rural Areas under County Management Plans County Management Plans provide access to the service system through the office of Central Point of Coordination Administrator established in each county in the state. Access points may also include providers, public or private institutions, advocacy organizations, legal representatives, educational institutions, churches, Sheriffs offices and police departments. The County Management Plan must assure access to needed emergency basis on a 24-hour basis.
Transportation to obtain goods and services, for reduction of isolation or to otherwise promote independent living is featured in individual county plans.
77 Criterion 5: Management Systems
Goal: Maintain or increase public expenditures for community-based mental health services for adults with a serious mental illness for during State FY2003.
Population: Adults with a Serious Mental Illness
Criterion: Management Systems
Brief Name: Expenditures for Community-Based Services
Indicator: Allocation of financial resources necessary to implement the plan
Measure: Numerator: Total State Expenditures for community-based services Denominator: Total State Expenditures for Mental Health Services
Special Issues: County expenditure reports are being refined to include significant data elements to report expenditures on specific services for adults with SMI
Significance: While financial resources shall not increase significantly during the subsequent years, coordination of services through flexible funding mechanisms is necessary to enhance the impact of service dollars. CQI measures are necessary to ensure improved and cost effective services
78 Funded Programs by State Fiscal Year Numerator FY 2001 FY 2002 FY 2003 (actual) (estimated) (projected) County expenditures 88.9M 90M 90M on mental health services Of the county 39,329,393 40M 40M expenditures above, total for community MH related services Of the county MH 34,417,392 35M 35M expenditures, total for community residential (non-institutional) State allocation to 17.5M 19.5M 15.5M counties for all disability services (property tax relief and growth payment) Total capitation payments 67.8M 78.9M 78.9M to managed care contractor (includes state share of Medicaid and federal dollars) Total 174.2M 188.4M 184.4M
Sources of information: County Management Plan Expenditures Reports, counties report their data on 12/1/02 for SFY2002, therefore data is not yet available for SFY2002. We will project similar expenditures for 2002 and 2003 as in 2001. Capitation Payments to Managed Care Contractor
Narrative Description of the role of the CMHBG in the state, including new innovative services funded by the grant and the manner in which block grant funding is expected to be expended in FY03.
Typically, approximately half of the block grant ($1.8 million) is distributed across CMHC’s and other community mental health providers. The size of the allocation is based on a formula which is largely driven by local population. The allocations last year ranged from $21,000 to $94,000 across CMHC’s. Approximately half of all funds are directly targeted to children’s programming. There are separate allocations to each CMHC for children and adult programming (note: the numbers above reflect total funds received).
The CMHC’s are encouraged to use these monies for innovative programming and for programming that strives to keep individuals in community-based rather than institutional settings. These funds are also used to ensure services to individuals who do not meet the established eligibility criteria of other payment systems. This funding stream of “last resort” has
79 become an increasingly vital source of funding for many CMHCs, which find it increasingly difficult to operate in the current fiscal environment.
Recipients of block grant funds are required to generate and submit work plans that describe the services and programming that they intend to provide with the funds, as well as the unmet needs that these are designed to address. The work plans typically include a projected estimate of the number of individuals to be served by these funds.
80 The following chart describes the breakdown of allocations for the block grant in SFY 2003:
CMHS Block Grant SFY2003
Utilization of block grant funds SFY2003 SFY2003 Children Adults Services Community mental health centers and other MH providers, based on population formula 900,000 900,000 Projects funded by Requests for Proposals 430,575 438,000 Youth and Shelter Services, Transition Program for Children/Youth with SED 200,000 Advocacy / Support / Training / Research
NAMI (70% adult 30% children) 30,000 70,000 Iowa Consortium for Mental Health 50,000 100,000 Consumer Resource and Outreach Project (CROP) Office of Consumer Affairs 100,000
Federation of Families for Children’s Mental Health 100,000 Stipends for Consumer Participation in Annual MH Conference, October 2002 8,923 Barb Ettleson, Outcomes Unlimited, Presentation Fee for 12/02-03/02, MHDD Commission 1,500 1,500
Annual consumer conference (100% adult) 10,000 Annual mental health conference (50% Adult and Children, support for DHS staff) 750 750 Other Core Indicators Project, contract amendment for CROP, three part-time staff for project ($33,658) ($14,150) 47,808 Administration Administrative (5% of Block Grant Award) (50% adults and 50% children) 91,728 91,728 Sub Totals 1,804,553 1,767,709 Total Contracted amount SFY2003 3,572,262 Total CMHS award for FFY 2003 3,669,110
Children and Adolescents with a Serious Emotional Disturbance
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Criterion 1: Comprehensive Community Based Mental Health Service Systems
Definition of Children and Adolescents with a Serious Emotional Disorder Pursuant to Section 1912 of the Public Health Services Act, as amended by Public Law 102-32- 1, "children with a serious emotional disturbance are persons:
• From birth to age 21, • Who currently, or any time, during the past year • Have had a diagnosable, mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-IV • That resulted in a function impairment which substantially interferes with or limits the child's role or functioning in family, school, or community activities."
These disorders include any mental disorder (including those of biological etiology) listed in DSM-IV or their ICD-9-CM equivalent (and subsequent revisions), with the exception of DSM-III-R "V codes, substance use, and developmental disorders, which are excluded, unless they co-occur with another diagnosable serious emotional disturbance. All of these disorders have episodic, recurrent, or persistent features and they vary in terms of severity and disabling effects.
Functional impairment is defined as difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative or adaptive skills. Functional impairments of episodic, recurrent, and continuous duration are included unless they are temporary and expected responses to stressful events in the environment. Children who have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are included in this definition.
Organizational Structure of the Comprehensive System of Care for Children with SED Health and Medical The Iowa Department of Public Health, Division of Family & Community Health, Bureau of Family Health promotes the health of Iowa families by providing resources for health care services through public and private collaborative efforts. Specific programs offered by the Department of Public Health to serve children with SED are varied and cross the array of needs. Following are some of the highlighted programs that are available through the Iowa Department of Public Health.
Child Health Specialty Clinics There are 16 community based child health centers covering all 99 Iowa counties. These clinics are charged with developing health programs and designing services that are responsive to the needs of the community through contracts with the Iowa Department of Public Health. The clinics are working with managed care organizations to build partnerships to improve care coordination services, informing families about services available in the community including Medicaid and Hawk-I (CHIP), and working with the dental community to improve dental care access.
State Children’s Health Insurance Program (SCHIP)
82 The State Children's Health Insurance Program (SCHIP) was created by the new Title XXI of the Social Security Act. Title XXI enables states to provide health care coverage to uninsured, targeted low-income children. House File 2517 was enacted in 1998 to initiate the program in Iowa. Medicaid expansion has been approved to assist in the dissemination of the program. Mental health and substance abuse treatment is covered under SCHIP. Targeted low-income children are those who are under 19 years of age, who reside in families with income below 200% of the federal poverty level, are not eligible for Medicaid or covered under a group health plan or other health insurance. Iowa's (SCHIP) program provides Medicaid coverage for children below 133% of the federal poverty level (Medicaid Expansion program) and non- Medicaid coverage for children below 200% of the federal poverty level. The non-Medicaid program is known as the Healthy and Well Kids in Iowa (HAWK-I) program. The HAWK-I program covers mental health and substance abuse but limits may apply.
Mental Health The Children’s Mental Health System consists of at least two distinct components within the Department of Human Services: (1) the Iowa Plan and (2) the Child Welfare System. In addition, the Department of Education, the Department of Public Health, and county-based mental health centers provide some mental health services to children.
Iowa Plan for Behavioral Health (Iowa Plan) Iowa’s Mental Health Medicaid program is called the Iowa Plan and is administered through a managed care contract with MBC of Iowa, an affiliate of Magellan Behavioral Health. Unless specifically excluded, all categories of Medicaid-eligible beneficiaries are covered by the plan. Under established capitation rates, the contractor is at full risk for providing all Medicaid funded mental health and substance abuse services to enrollees, regardless of pre-existing conditions. The contractor interfaces with the child welfare and juvenile justice system to coordinate mental health and substance abuse needs of children and families in these systems. The contractor provides administrative services for the Iowa Department of Public Health funded substance abuse delivery system.
The managed care contractor supports local system planning through existing planning entities including the County Central Point of Coordination, County Management Plans, Decategorization Boards, Empowerment Boards, and holds roundtables involving consumers and the provider community to seek input for planning and implementation of services.
The Iowa Medicaid Program covers both categorically and medically needy persons. The average monthly enrollment during the first year of the managed care contract in 1999 was 175,967. Current monthly enrollment average for FY 2002 is 224,013. In a typical month, unduplicated enrollees who received one or more services are approximately 17,250 persons. Approximately 55% of the persons receiving services are children.
Although not covered in the fee-for-service Iowa Medicaid Program, the following services are required of the Contractor as appropriate ways to address the mental health needs of enrollees:
• Services for persons with dual diagnoses (substance abuse and mental illness) • Case consultation by a psychiatrist to a non-psychiatrist physician
83 • Services of a licensed social worker • Mobile crisis services • Mobile counseling services • Integrated mental health services and supports to assist enrollees remain or return to the community and limit the need for out-of-home placement similar to wraparound services available in the child welfare and juvenile justice system • Psychiatric rehabilitation services • Focused care management • Peer support services • Supported community living services • Assessment of functioning level of a child with serious emotional disorder or adult with a serious mental illness; the scale to be repeated by intervals specified by the regimen • Assertive Community Treatment • Specified services to persons admitted at the state Mental Health Institutes (MHI) • Specified inpatient evaluations for mental health conditions Prevention and early intervention services
Child Welfare The Division of Behavioral, Developmental, and Protective Services for Families, Adults and Children of the Iowa Department of Human Services is responsible for a family-focused, community-based Child Welfare system. Within the Child Welfare system is the second component of the children’s mental health system: Rehabilitative Treatment Services (RTS) and Psychiatric Medical Institutions for Children (PMIC’s). The Iowa Foundation for Medical Care is the authorizing agent for RTS services 1. Rehabilitation Treatment Services (RTS) are designed to restore a function or skill that a child lost or never gained as a result of interference in the normal maturation learning process due to individual or parental dysfunction. RTS programs serve children, and in special circumstances, persons up to the age of 21. The goal of RTS services is to maintain the child at home or as close to home and community as possible in the most normalizing and age appropriate setting in order to avoid unnecessarily restrictive or otherwise inappropriate placements. Categories of RTS services include:
Family-Centered Services: Interventions designed to provide treatment services to child and family when the identified child has been determined to have rehabilitative treatment need and is are most often provided within the child’s home. The Rehabilitative Treatment Services components include therapy and counseling, restorative living, family and social skill development, and psychosocial evaluation. Family Centered Services focus on preventing out-of-home placement for children identified being at such a risk for various reasons including but not limited to individual child dysfunction, family dysfunction and child protective issues. Family Preservation: An intensive, time-limited intervention to prevent out-of-home placement of children and stabilize the family. Family Preservation Services consist of therapy and counseling, skill development, psychosocial evaluation, supervision, transportation, family resource building and any other supportive services deemed necessary to stabilize the family. This program is the only program within Iowa which is delivered as a "bundle" of services and has a limited flexible spending
84 component to meet needs of a child and family for which there is no other funding source. Family Foster Care: Provides care for children who are unable to live in their own parental or family homes. Placement goals for children include family reunification unless or until such a goal is no longer deemed appropriate at which time the goal is to seek permanency for the child. Therapeutic foster care may be offered to children with a high degree of service and supervision needs, and is often the level of care needed for children with SED’s. Therapeutic foster care includes the availability of a professional with expertise to provide support and assistance to the foster families and the children in therapeutic foster care. Group Care: Provides highly structured 24-hour treatment services and supervision to children in a licensed group care facility. Children placed in group care cannot be otherwise served in less intensive settings due to the severity of their emotional or behavioral problems. Services are also provided to biological families with the primary goal of reuniting the child with the family.
2. Psychiatric Medical Institutions for Children (PMIC’s): These facilities have become a primary placement option for adolescents with SED’s who have behaviors and treatment needs that exceed those that can be provided in the parental home and/or are being provided to children with SED’s who require placement for other issues related to family dysfunction or abuse. There are twelve providers that deliver these services to children in Iowa. Services include diagnostic, psychiatric, nursing care, behavioral health, and services to families, including family therapy and other services aimed toward reunification or aftercare. Children served are those with psychiatric disorders that need 24-hour services and supervision. Diagnoses of attention deficit, oppositional defiant, conduct, adjustment, and other behavioral disorders make up 50% of the admissions. Major depression, bi-polar, and other mood disorders make up another 33% while post traumatic stress, psychotic, reactive attachment, developmental and anxiety make up 17% of the diagnoses upon admission.
Child Welfare Redesign The 2003 Iowa General Assembly enacted a provision of state law calling for: The Department of Human Services [to] initiate a process for improving the outcomes for families in this state who become involved with the state system for child welfare and juvenile delinquency by implementing a system redesign to transition to an outcome-based system for children. (Senate File #453 – signed by the Governor)
With the adjournment of the 2003 Legislative session, the Iowa Department of Human Services, along with Juvenile Court Services, launched a system design and implementation project, entitled Better Results for Kids in the 21st Century.
An extensive “listening phase” has been completed through town meetings, focus groups, and individual interviews involving over 1000 Iowans and covering the broad spectrum of stakeholders for this system. This information gathering process included youth who are currently in the system, biological, adoptive, and foster parents, grandparents, private providers,
85 DHS staff, juvenile court officers, attorneys, medical professionals, educators, judges, and community members. In addition, the Project Team conducted its own research on systems in other states and contacted national child welfare experts.
Iowa’s redesign effort is building on this work and on Iowa’s recent (May 2003) Child and Family Service Review; and specifies in detail the parameters that are to guide the design step in this project. A final design will be submitted to the Project Steering Committee for its consideration. The Steering Committee will submit its recommendation(s) to the Director of DHS. Once the Director accepts the final design, an implementation phase will begin.
The proposed system must be outcome-based and include performance-based purchasing; it must specify the interactions and partnerships among the major participants in the system, for example: the public child welfare agency, the public juvenile justice agency, private child welfare agencies, and the public education system. The design will recognize that the system must operate on an allocation of state resources for FY2004 that has decreased by $10M from FY2003. Yet this does not assume that total resources invested in the system must decrease. The proposed system must provide for the involvement of children and families in planning and in decisions about their lives.
Educational Services Success4 is an important initiative in Iowa’s school improvement process designed to address the multitude of challenges for today’s youth. The basic principles of the program are: 1. Social, emotional, intellectual and behavioral skills are essential to success in school and throughout life. 2. All children and youth can be successful socially, emotionally, intellectually, and behaviorally. 3. Families, schools, and the community must work together in partnership to ensure the social, emotional, intellectual, and behavioral well being of children and youth. 4. Changing the family-school-community relationship is necessary in order to create an environment, which nurtures social, emotional, intellectual and behavioral development for all children and youth.
The Iowa Department of Education is currently undertaking a broad-based effort to redesign its five-year-old Success4 initiative - originally an outgrowth of the Iowa Behavioral Initiative. Facilitators for this process include researchers, Dr. Howard Adelman and Dr. Linda Taylor from the School Mental Health Project *at UCLA. They will conduct a series of meetings for stakeholders to help the Success4 Design Team create a comprehensive system of learning supports that aligns with the Iowa Collaboration by Youth Development results framework and can be embedded into Iowa's school improvement process. Stakeholder groups include all Iowa state agencies and organizations that serve youth as well as professional educational associations, parent groups, and national experts in the field of positive youth development. (*The School Mental Health Project is supported in part for the U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Adolescent Health.)
86 Success4 will be redesigned in the fall of 2003 and implemented in 2004. This redesign will address problem issues that currently exist, build upon lessons learned from the previous initiatives, and infuse the work of promoting healthy social, emotional, intellectual, and behavioral developments into the overall school improvement efforts in Iowa through the development of statewide, regional, and local systems of learning supports.
The Parent Training and Information Center of Iowa, in collaboration with other existing services and programs, provides information and training to families of children with special needs throughout the State of Iowa to ensure that children with disabilities have access to free and appropriate educational services as required by the Individuals with Disabilities Education Act. About 60% of the requests for services received by PTI involve mental health or behavioral issues. PTI focuses particularly on under-served families and parents of children who may be inappropriately identified for special education or inappropriately excluded from special education. PTI assists parents to better understand their child’s disability, provides information to training on the Individuals with Disabilities Education Act and other disability rights, promotes the development of skills to enable parents to effectively participate in the IEP process and in school reform activities, provides family support information, assists in the development of IEPs, provides one-on-one parent and family support, and offers workshops and technical assistance across the State of Iowa. For the year ending September 30, 2002, the Parent Training and Information Center of Iowa reported the following: 7600 contacts were made to PTI by parents and professionals, through one-on-one problem-solving by telephone, in-person consultations, trainings, meetings, letters, and individualized information packets. 1560 of the individuals served by PTI Iowa were from culturally and racially diverse families. 2286 parents attended training sessions and other presentations offered by PTI Iowa. 1524 professionals serving children with disabilities attended training sessions and other presentations offered by PTI Iowa. 6800 people received the PTI Press newsletter published by PTI Iowa. 71,177 hits were counted on the PTI Iowa web site.
A follow-up telephone survey of parents served by PTI Iowa found: 96% of the parents surveyed reported that the individual assistance they received from PTI Iowa helped them obtain services they felt their child needed. 87% of the parents surveyed reported they felt more confident about working with school personnel after speaking to PTI Iowa. 80% of the parents surveyed who had attended PTI workshops reported they believed their child received more appropriate services because the parent used the information from the workshop. 88% of the parents surveyed who received one-on-one assistance felt they could not have received this service had PTI Iowa not been available.
The Parent Training and Information Center of Iowa is one of the founding members of the ASK Family Resource Center, a cooperative of family-friendly organizations that offer a broad range of information and services focused on benefiting children with disabilities and promoting “Access for Special Kids.”
87 The Legal Center for Special Education (TLC) is a non-profit corporation created to provide effective, low-cost, and readily available legal and advocacy services for parents of children with disabilities across the State of Iowa. TLC’s focus is on issues concerning the educational rights of children with disabilities, and on issues involving services and supports related to educational development, including residential treatment, medical supports, and psychological services. TLC offers four levels of advocacy services: Consultation and Self-Advocacy Training Representation in Pre-Appeal conferences or other alternative methods of conflict resolution Representation in Due Process Proceedings or similar administrative actions Representation in court actions to enforce legal rights
In the course of serving families throughout the State of Iowa, TLC is frequently called upon to advocate for students with SED in matters related to their ability to attend school, to benefit from their education, and to access appropriate residential, mental health treatment, and behavioral services.
The Legal Center provides technical assistance and legal back-up to the Parent Training and Information Center of Iowa which supports the PTI in serving over 7500 families a year and helps assure that they can offer legally sound training on the rights and responsibilities mandated by the IDEA, Section 504 of the Rehabilitation Act, and related statutes and regulations.
For the year ending March 31, 2003, The Legal Center reported the following:
The Legal Center provided direct representation to 191 children with disabilities and their families. The Legal Center for Special Education represented children and parents in approximately 90 percent of all pre-appeals, mediations, and hearings on special education issues in the State of Iowa. Of the parents who have contacted our office and requested services for their child, about 81 percent have followed through with our recommendations and “got what they needed” for their child. Of the parents who entered into formal attorney-client agreements with The Legal Center, about 97 percent “got what they needed” for their child. The Legal Center’s overall record of successfully resolving disputes between families and schools is about 90 percent. In about 98 percent of all cases, The Legal Center has been able to successfully resolve disputes between families and schools through conflict resolution efforts without resort to due process hearings. The Legal Center is also one of the founding members of the ASK Family Resource Center.
Iowa Behavioral Alliance The Department of Education awarded this five-year, $2.3 million grant in November 2002. It has three key elements: 1) development and implementation of multi-system school-based services for students with significant and complex mental/behavioral problems; 2) Drop-out
88 Prevention; and 3) Positive Behavioral Supports. Furtherance of the goals established in the Children’s Mental Health Initiative was one of the stated objectives in the RFP released by the Department of Education for this grant. The grant was awarded to Drake University and Iowa State University. Some important components of the project will include partnering with the Child Health Specialty Clinics, the use of telemedicine, the use of person-centered planning, wraparound services, and the development of systems change philosophy for whole school environments.
Early ACCESS is a partnership between families with young children, birth to age three, and providers from the Departments of Education, Human Services, and Public Health, the Child Health Specialty Clinics and Iowa’s Area Education Agencies. The program is federally funded under IDEA Part C funds. The purpose of the program is for families and staff to work together to identify, coordinate, and provide needed services and resources that will help the family assist their toddler to grow and develop. All services to the child are provided in the child’s natural environment including the home and other community settings where children of the same age without disabilities participate. Service coordination and a host of other services are provided including psychology, screenings, evaluations, assessments, social work, health and medical evaluations. Eligibility requirements, other than age, include that the child has a condition or disability that is known to have a high probability of later delays if early intervention services are not provided or the child is already experiencing a 25% delay in one or more areas of growth or development.
Substance Abuse Services The Iowa Plan has data on how many children come to the attention of the child welfare system via court ordered Medicaid funded evaluations for substance abuse. In the last quarter of State FY2002, the Iowa Plan served 17 such children. Of those, 20% went to inpatient hospitalization and 80% went to various residential programs. This suggests that the vast majority of children served by Iowa’s child welfare system do not initially present through the publicly funded substance abuse evaluation. We do not know of any data available to illustrate how many children are funded by private insurance.
Services for Adolescents with Co-Occurring (Substance Abuse/Mental Health) Disorders: Two of the 12 PMIC facilities in Iowa provide services to adolescents diagnosed with co- occurring substance abuse and mental health disorders. The program located in Glenwood, Iowa has a capacity of 15 and the program in Sioux City, IA has a capacity to serve up to 41 children at any given time. Both programs serve children aged 12 to 18. In SFY20003, a total of 141 children were served in these two programs.
Education and Support Services:
NAMI Family Education Course The course consists of a series of workshops for caregivers of children with brain disorders. Caregivers may be parents, extended family, or foster parents. Visions for Tomorrow is a family member-to-family member course. Teachers of the program will be trained family members who have experienced firsthand the rewards and challenges of raising children with brain disorders. The course offers caregivers an opportunity to share
89 mutual experiences and learn valuable lessons from one another. Visions for Tomorrow covers educational material and provides the basics for day-to-day caregiving skills.
Statewide Parent Specialists and Support Networks
1) ASK (Access for Special Kids) Family Resource Center www.askresource.org This statewide resource center is a “one-stop-shop” for children and their families. Through its member organizations, the ASK Family Resource Center provides a broad range of information, advocacy, support, training, and direct services. The cross-disability, collaborative, blending of resources approach strengthens their effectiveness across the state by eliminating duplication and providing families with a clear simple and direct source of information. Parent Training and Information Center (PTI) Family Voices of Iowa (FVI) The Legal Center for Special Education (TLC) Iowa Family Support Initiative (IFSI) Child Health Specialty Clinics (CHSC) 2) Parent Coordinators have children with special educational needs and provide free peer support to other parents. There are 34 Parent Coordinators across the state that identify local needs, develop support groups, provide appropriate resource material and conduct appropriate workshops. They are paid through the Department of Education. 3). Parent Consultants have children with special health care needs and provide free peer support to other parents. There are 16 Parent Consultants across the state. They are paid through Iowa’s Title V Program and are located in the Child Health Specialty Clinics. 4). Parent Liaisons have foster and/or adoptive children and provide free peer support to other parents. There are 15 Parent Liaisons across the state who identify the needs of foster and adoptive parents, develop local support groups and communicate concerns to local DHS workers. They are contracted by the Department of Human Services.
Home & Community Based Service Waivers Families receive support services, such as respite, supported community living, and home health care, when their child qualifies for one of the Medicaid HCSB Waivers. (Mental Retardation, Ill & Handicapped, Brain Injury, AIDS, etc.)
Child Care Services: Supplement parental care by providing care and protection to children in or outside their family homes for part of the day. Services include supervision, food, transportation, comprehensive child development and care, including services to children with special needs.
Case Management Services Children receiving child welfare services to address their mental health needs receive case management from the Department of Human Services. Children within the juvenile justice system receive case management services from a juvenile court officer.
Within the redesign of child welfare/juvenile justice services currently being done, the case management services will be reviewed.
90 Dental Services The Bureau of Oral Health promotes and advances health behaviors to reduce the risk of oral diseases and improve the oral health status of all Iowans. Programs are in place targeting pregnant women, children, and youth for the prevention, early identification, referral, and treatment of oral disease. These programs have been implemented in schools, maternal and child health agencies, public dental health clinics, and other community-based settings. Children with SED access these services in the same manner as other children.
Iowa Access to Baby and Child Dentistry (ABCD) is a program to improve access to dental care for low-income children. Iowa has had four ABCD programs implemented through Title V Child Health Agencies: 1) Dubuque Visiting Nurse Association; 2) North Iowa Community Action Organization; 3) Mid-Iowa Community Action, Inc.; and 4) Washington County Public Health and Home Care. The focus of the ABCD program is to identify and ease barriers to early preventive dental care through infrastructure-building and care coordination services, allowing communities to strengthen oral health services for children and work with local dentists to provide a dental home to low-income children through age 21.
Employment Services Iowa is responding to a federal mandate to provide transition services to children in the care of the DHS when the child reaches the age of sixteen. This mandate included the provision of services related to assessment of skills, education related to work readiness, and preparing the youth to enter the world of work as an adult. A portion of the Performance Partnership Grant is used for provision of transition services to children with SED.
Services provided through the Iowa Aftercare Services Network (IASN) include: pre-exit planning (up to 3 months prior to youth “aging out”), for youth deemed to be at high risk for unsuccessful transition into adulthood; aftercare services for youth, ages 18 through 20, for youth who have “aged out” of foster care or a PMIC – services include a case management component, assisting youth with acquiring needed life skills and linking youth to appropriate community resources to assist them in their transition into self-sufficiency; a vendor payment component, of up to $1000 per youth, to assist with housing, clothing, transportation, medical needs, food, day care, etc. Services are available to youth in each of Iowa’s 99 counties.
Housing Services The Department of Human Services (MHA) does not offer any services specifically designated as housing services for children. However, on a regular basis many families with significant housing issues, including inadequate housing and homelessness, come to the attention of the child welfare and juvenile justice systems, as well as the attention of other community based programs and schools. It is quite common for families being served within these systems to have housing related needs and individualized goals within their treatment plans to address these needs. The services may take many forms, some examples include: referrals for homemaker/home health aide programs to assist with home maintenance and cleanliness issues; referrals to local Section 8 Leased Housing programs; referrals and coordination with local housing inspection departments; coordination with Community Action Programs which are in several communities across the state and provide housing services utilizing federal HUD and HOME funds; Community Development Block Grant funds and other services; referrals to
91 programs that can assist with budgeting and money management skills that are so closely tied to the ability to obtain and maintain housing; and others.
Having knowledge of this kind of array of available community services and how to facilitate families involvement with such services is expected of those who provide treatment and case management services to children and families who come to the attention of DHS and the juvenile justice systems.
When children come to the attention of the child welfare system and are determined to need Rehabilitative Treatment Services, (RTS), information is gathered about the child’s living arrangement at the time of authorization. The following table represents the living arrangements of these children across the past three state fiscal years. Fifty-eight percent of children lived with a parent while 17% lived in foster family homes and 8% lived with relatives.
The following chart identifies placement of children at the time of an RTS authorization request. Children may receive more than one authorization in a year resulting in duplication of children and their living arrangements.
RTS Living FY 2000-2001 FY 2001-2002 FY 2002-2003 Arrangement Detention 15 80 60 Foster home 4,474 4,019 3,577 Group care 2,992 3,203 2,865 Hospital 41 14 31 Other 614 461* 329 Parent home 15,245 12,256 10,701 Relative 2,196 1,881 1,940 PMIC 63 58 47 Shelter 780 611 746 Subacute 0 0 0 Total 26,420 22,583 20,296 *The FY 01-02 RTS Characteristic Report included the number of children in detention as part of the “other” category. Detention has been pulled out as a separate category for this report.
92 CMHS Performance Partnership Block Grant, 8/29/03
Social Services Protective Services These services begin when a referral of possible child abuse and/or neglect is received by DHS regarding a child and/or family.
When such a referral is received, a Child Protective Worker (CPW) will conduct a child protective assessment which includes not only information regarding the specific allegations but an assessment of child and family strengths, needs, recommended services, and necessary court action to remedy the protective concerns and promote safety for the child.
A child protective treatment worker is assigned to work with the child and family to develop an appropriate individualized treatment plan, which may include mental health services for the children or parents identified, in order to address any identified protective and family concerns.
Shelter Care Short-term placement and emergency services provide crisis intervention, daily supervision, medical and mental health care and protection.
Mental Health Issues in Detention/Shelter A workgroup to address mental health issues in detention/shelter care has been formed at the request of the Iowa Juvenile Justice Advisory Committee and is administratively housed within the Iowa Criminal and Juvenile Justice Planning Division (CJJP). This work group is focused on the issue of increased admissions of youth with mental health issues to Iowa’s detention and shelter facilities. At the work group’s recommendation, CJJP contracted with the University of Iowa Hospitals and Clinics to review the increase in admissions through facility visits and interviews and to develop a variety of informational/training products for the staff.
Supervised Community Treatment Comprehensive, multidisciplinary treatment services within a school or community setting. Youths participate in the program 4-6 hours a day, 5-6 days a week for an average of ten months. Services are targeted for youth 9 through 17 who are experiencing severe behavioral or emotional problems, and are adjudicated delinquents or who are at-risk of delinquency. These programs are frequently referred to as day treatment and have the desired outcome of providing treatment services to a child within the community while not having to transfer custody and be placed out-of-home.
Activities Leading to Reduction of Hospitalization The complete list of services described within the narrative in this section could be described as having the potential to reduce the need for hospitalization of children with SED’s.
93 Local projects in children’s mental health have begun as collaborative efforts to achieve not only a reduction is hospitalization for children with SED but to assure that children and their families receive the needed services in a timely, unduplicated manner.
The Integrated Pediatric Behavioral Health (IPBH) program at the Creston Regional Center began taking referrals the first part of 2003. The IPBH provides integrated and comprehensive mental and behavioral health services. Referrals originate from communities, schools, families, and individuals and will involve screenings at the Integrated Evaluation and Planning Clinics (IEPC’s). These clinics provide multidisciplinary evaluation and diagnostic services for children with behavioral, developmental, and medical concerns. The staff includes a pediatrician, psychologist, social worker, dietician, and nurse practitioner. Children identified by the IEPC as being in need of expanded services are referred to the IPBH where staff works closely with the families to coordinate mental health care for their child. The clinic provides greater access to mental health services through extensive care coordination, sub-specialty consults and educational in-services to assist professionals in serving children with a mental and behavioral health diagnosis. The educational component of the program will provide in-services for school and AEA staff. Tele-health services will be utilized as needed to bring appropriate additional expertise for the care of any specific child via the Iowa Communications Network (ICN). MBC of Iowa is supporting this innovative and collaborative process through the provision of technical and clinical assistance with the hope of enhancing the coordination of care and reducing and/or preventing hospitalization. This program is attempting to do evaluation of outcome achievement by comparing the services received through this program with a similar number of children identified in a demographically comparable area without such a program.
94 Criterion 1: Comprehensive Community-Based Mental Health System
Goal: Create and implement an organized community-based system of care that meets the needs of children with serious emotional disorders and their families.
Objective 1: Maintain or increase enrollment of children in public health insurance plans.
Population: Children with SED
Brief Name: Community-Based Mental Health System of Care
Indicator: Enrollment of children in public health insurance plans.
Measure: Numerator: Number of children enrolled in Hawk-I and Iowa Plan Denominator: Estimated Number of children in the state eligible for Hawk-I and Iowa Plan
State Fiscal Year Numerator SFY2002 SFY2003 SFY2004 estimated Number of children enrolled in Iowa Plan* 129,600 144,000 145,000 Number of children enrolled in Hawk-I** 13,672 15,169 18,000
Denominator*** 85,000 88,400 88,400
Sources of Information: * These figures reflect the number of children enrolled in the Iowa Plan, which is approximately 60% of the total number of enrollees. ** Based on the estimates shown on the Iowa Department of Public Health website. www.idph.state.ia.us/fch/cover/insured_map1102.pdf *** Prevalence estimate for children with a SED per NIMH Epidemiological study. This denominator has been brought forward from previous years and may be outdated.
Significance: Since July 1998, Iowa continues to provide health care coverage to uninsured, targeted low-income children less than 19 years of age. In Iowa, the Children's Health Insurance Program (SCHIP) required under Title XXI of the Social Security Act is called Hawk-I.
95 Objective 2: Increase the number of Local Education Agencies (LEA's in school districts) and Area Education Agencies (AEA's) accessing federal Medicaid funding to assist in the provision of mental health services to eligible children.
Population: Children with SED
Brief Name: Community-Based Mental Health System of Care
Indicator: Enrollment of AEA's and LEA's enrolled as Medicaid providers.
Measure: Numerator: Number of LEA's and AEA's enrolled as Medicaid providers Denominator: Number of LEA’s and AEA's eligible to become enrolled as Medicaid providers
State Fiscal Year Numerator SFY2002 SFY2003 SFY2004 (actual) (actual) (projected) Number of LEA’s 4 95 150 enrolled Number of AEA’s 15 11 12 Enrolled Denominator: Eligible AEAs 15 15 12 Eligible LEAs 370 370 370 Sources of Information: Iowa Dept. of Education, Dann Stevens, Suana Wessendorf (MHPC State agency representative)
Special Issues: AEAs are mandated by Iowa Code to participate in being enrolled as Medicaid providers. Due to legislative action in 2003, the number of AEAs has been reduced by merging AEAs from 15 to 12. While it is projected that approximately 200 LEAs will be enrolled as providers, it is projected that approximately 125-150 will actively submit claims.
Significance: Area Education Agencies (AEAs) have been able to seek Medicaid reimbursement for special education services since 1988. Local Education Agencies (LEAs) have been able to claim for their services since March 0f 2001. Criteria for Medicaid reimbursement requires the child be Medicaid enrolled and have an IEP (ages 3 to 21) or IFSP (ages birth to 2) that defines the services.
Additional information: The statistical data reflects claims paid in the State fiscal year for Behavioral, Psychological, or Social Work services that would be appropriate for a child with SED. Generally, LEAs provide behavioral services and the AEAs provide psychological and social work services, as well as all of the birth to age 2 services.
Criterion 2: Mental Health System Data Epidemiology
96
Goal: Maintain or improve the treated prevalence of mental health services to children with SED’s
Objective: Treated prevalence of serious emotional disorders among children with SED
Population: Children and Adolescents with a Serious Emotional Disorder
Brief Name: Treated prevalence of mental health services to children with SED
Indicator: Children and Adolescents with a Serious Emotional Disorder who received mental health services during the fiscal year
Measure: Numerator: Number of children with SED who received mental health services Denominator: Number of children estimated to have a serious emotional Disturbance
State Fiscal Year SFY2001 SFY2002 SFY2003 Numerator (actual) (actual) (projected) Children receiving Medicaid managed 19,580 22,216 22,216 behavioral health services*(Iowa Plan) Children with SED receiving Child NA 4,502 4,500 Welfare treatment services** Denominator*** 85,000 88,400 88,400
Sources of Information: * unduplicated children receiving services funded by MBC of Iowa per average month. ** 20% of all children receiving Rehabilitative Treatment Services through the Child Welfare system have an SED. Iowa Foundation for Medical Care, annual report, September 2002 *** NIMH Epidemiological Study. The estimate of children and adolescents between ages 0 to 18 who need mental health intervention of some sort are based on NIMH Epidemiological Studies. According to this estimate, the prevalence rate among 0-18 age group is 11.8 percent. This prevalence rate, when applied to 718,000 children and adolescents in this age group, yields 88,400 children who need mental health services in the state.
Special Issues: Due to the design of the current data collection systems, it is challenging to track unduplicated children with SED who may receive mental health services from more than one delivery system (i.e. Medicaid, SCHIP, and Child Welfare).
97 Criterion 3: Children’s Services
Goal: Improve identification of children in out-of-home placements who have need for mental health services.
Objective: Number of children in out-of-home placements receiving mental health services.
Population: Children with a Serious Emotional Disorder
Brief Name: Mental health services to children living out of home.
Indicator: Percentage of children with SED who are placed out-of-home (e.g., foster care, residential home)
Measure: Numerator: Children placed out-of-home Denominator: Children with SED
State Fiscal Year SFY2001 SFY2002 SFY2003 (actual) (actual) (projected) Out of home placements Family foster care 4474 4019 4000 Group foster care 2992 3203 3000 Relative home 2196 1881 2000 Shelter 780 611 600 PMIC 63 58 60 Detention 15 80 60 Children with SED 88,400 88,400 88,400
Sources of Information: Numerator: Iowa Foundation of Medical Care Denominator: NIMH Epidemiological Study
The numbers in the table represent places where the children who received Rehabilitative Treatment Services were residing at the point they were that discharged from RTS.
Special Issues: Approximately 35% of all children receiving RTS in state fiscal year 2003 had an SED. Approximately twelve percent of Iowa’s children receiving Rehabilitative Treatment Services (RTS) are living out-of-home. This includes children remaining in the parental home as well as those placed out-of-home. The percentage of children with SED, receiving RTS and placed out of home has not been accurately tracked to date. Narrative While the children’s mental health system in Iowa is centralized in that most funding is federal or state and most services are planned and administered at the state level, planning, regulation and administration of children's services is not vested in a single state entity. Rather, these responsibilities are diffused in a variety of agencies including the state mental health authority
98 and child welfare agency (the Iowa Division of Behavioral, Developmental, and Protective Services for Families, Adults, and Children of the Iowa Department of Human Services), the Iowa Department of Human Services regional and local offices, the juvenile justice system, the Iowa Department of Education, the Iowa Department of Public Health and the Iowa Department of Inspections and Appeals.
99 Criterion 4: Targeted Services to Homeless and Rural Populations
Goal: Improve identification of homeless school age children with an SED.
Objective: Identify number of homeless school age children
Population: Homeless Children
Brief Name: Mental health services for homeless school age children
Indicator: Percentage of homeless children with SED receiving mental health services
Measure: Numerator: Homeless school age children needing mental health services Denominator: Homeless school age children
State Fiscal Year SFY2002 SFY2003 SFY2004 (actual) (actual) (projected) Homeless school age 4709 5886 5886 children needing MH services* Homeless school age 18,111 22,639 22,639 children in Iowa** *26% of the school age children identified mental health services as their most prevalent need. ** Of Iowa’s 22,639 homeless children 80% are school age. The other 20% are preschool age.
Sources of Information: Drake University reports of Homeless Children and Families in Iowa
Special Issues: SFY 2003 reflects the children living in court-placed shelter care programs who were not included in the Drake University report the previous year.
Narrative Iowa’s Adult Mental Health Specialist and PATH Coordinator, Lila Starr, participates in the state’s Interagency Taskforce on Homelessness. This organization has been working to restructure it’s roles and responsibilities, reorganize it’s membership, increase linkages to the Governor’s office, which established the taskforce, and to clarify it’s role in housing and homelessness as well as continuum of care issues. The primary focus of the last two meetings has been around a new study on homelessness conducted by the Department of Education, in conjunction with all of the 364 school districts across the state. This study, expected to be released in December of 2002, undertook an ambitious agenda of capturing information about homelessness for children and their families, as well as data regarding the primary needs and obstacles to housing for these children and families. The primary purposes of “Iowa’s Homeless Children/Youth and Their Families,” are listed below:
1) Estimate the number of homeless children and youth in Iowa
100 2) Estimate the number of children not living with adults 3) Provide a demographic profile regarding homeless children and youth and their families 4) Identify the causes of homelessness for homeless children and youth and their families 5) Identify the educational and personal needs of homeless children and youth and programs provided to meet these needs 6) Identify barriers that interfere with the enrollment, attendance, and success of homeless children and youth in school 7) Estimate the number of homeless adults in families with children 8) Estimate the number of homeless adults not living with children
Mental health was identified as one of the greatest needs for the children and/or family members in this study. The information contained in this report will be reviewed with the Mental Health Planning Council and perhaps presented in more detail by appropriate persons from the Department of Education. We will attempt to learn how this study may be useful in targeting Block grant funds and/or addressing any of the priorities of the Council.
Psychiatric services are lacking particularly in rural areas and fewer psychiatrists are accepting Title XIX. Due to the rural nature of Iowa, it has proven to be extremely difficult to attract psychiatrists as well as other mental health service providers to the state. There are several counties that have psychiatric services for a few hours a week while other counties have none, which poses yet another barrier. Transportation has been and continues to be a huge barrier for persons who lack their own transportation.
101 Criterion 5: Management Systems
Goal: Maintain or increase public expenditures for community-based mental health services for children diagnosed with a serious emotional disturbance.
Population: Children with Serious Emotional Disturbance
Criterion: Management Systems
Brief Name: Expenditures for Community-Based Services
Indicator: Allocation of financial resources necessary to implement the plan
Measure: Numerator: Total State Expenditures for Children with Serious Emotional Disturbance (SED) Denominator: Total State Expenditures for Mental Health Services
Expenditures for Children with SED by State Fiscal Year SFY2002 SFY2003 SFY2004 (actual) (actual) (projected) Medicaid Behavioral 14,630,038 15,434,442 16,669,197 Health/Iowa Plan –(kids only)* Rehabilitative treatment 12,193,668 9,088,424 8,726,918 services** Psychiatric Medical Institutes 8,432,744 8,725,154 8,523,194 for Children (PMICS)*** MH Block Grant 1,539,765 1,530,575 1,545,880 (children’s services) Medicaid spending for Not available 78,580 78,580 children MH services Numerator 36,796,216 34,857,175 35,543,769 Denominator 129,367,004 131,859,564 130,346,533
Sources of Information: *Iowa Plan and Medicaid Spending: Iowa Dept. of Human Services, Medical Division **RTS expenditures Sources: FY02 family centered and family preservation dollars based on percentage of cases in which child's behavior was primary reason for service on April 2003 reports from child welfare data. FY03 and FY04 dollars are calculated using data from the same source for July 2003. FY 02 adoption services based on percentage of cases in which child's behavior was primary reason for service in April 03. FY03 and FY04 dollars are calculated using data from the same source for July 2003.
102 FY 02 family foster care and group care based on percentage of cases in which child's behavior was the primary reason for removal on the April 03 child welfare data report. FY03 and FY04 dollars are calculated using data from the same source for July 2003. ***PMIC Spending: Iowa Dept. of Human Services, Finance Division
Denominator: Gross expenditures for mental health for children and adults (see Maintenance of Effort, page 9)
Special Issues: The Iowa Plan has projected an 8% increase in eligible children for SFY2004 which is reflected in the increase of spending.
The total funding for PMIC's in SFY2004 is increased from FY2003, however the state funding impact is decreasing because of the enhanced federal participation rate (FFP) designated for Iowa at the federal level from April 2003 to June 30, 2003. The federal FFP rate was 62.86% from July - Sept., 2002; 63.50% from July - Sept., 2003; and 65.88% from Oct., 2003 to June 30, 2004, or a SFY state match of 33.23%.
Significance: Many children with SED are served through the child welfare system. The child welfare system experienced a budget cut of approximately $10 million in SFY2004. While the Department of Human Services is making an effort to find this money in other places, this cut may indeed impact the service level for children.
Narrative Typically, approximately half of the block grant ($1.8 million) is distributed among 40 Community Mental Health Centers (CMHCs) and other community mental health providers. The size of the allocation is based on a formula which is largely governed by local population. The allocations for SFY2003 ranged from $21,000 to $94,000 across CMHC’s. Approximately half of all funds are directly targeted to children’s programming. There are separate allocations to each CMHC for children and adult programming (the numbers shown reflect total funds). This funding stream of “last resort” has become an increasingly vital source of funding for many CMHCs.
Recipients of block grant funds are required to generate and submit work plans that describe the services and programming that they intend to provide with the funds, as well as the unmet needs that are being addressed. The work plans typically include a projected estimate of the number of individuals to be served by these funds.
A table illustrating the breakdown of allocations for the SFY03 block grant funds can be found at the end of Adult Criterion 5, Management Systems, page 81.
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