CCDC comments on Medicaid Mental Health Re-procurement of BHO contacts
September 7, 2012
TO: HCPF Mental Health Procurement Staff:
FROM: Julie Reiskin, LCSW, Colorado Cross-Disability Coalition
The Colorado Cross-Disability Coalition is pleased to submit these comments regarding the re-procurement of the mental health contracts. We are pleased that the Department wants to achieve a greater integration of care. The current system does not support integration of care nor does it provide high quality care. Cross-Disability means that we believe that people with different types of disabilities have more in common than not and do best working together. Therefore we work with many people with serious mental illness and a significant percentage of those individuals have other medical conditions, some as a result of iatrogenic harm.
We see the following problems with care delivery.
Clients are denied access to the right level of medical care. People with serious medical issues related to their psychiatric medications are forced to see nurses instead of doctors. There does not appear to be adequate supervision. Medical school is much longer and more intensive than nursing school for a reason. There is nothing wrong with having mid-level professionals do routine prescriptions for routine and non-complex stable cases. Even then, there should be medical supervision. We are seeing clients suffer from permanent medical consequences after being poorly advised by unsupervised staff that are not doctors. On the other hand, clients who may only need therapy are being pushed to medication. Recent examples include
Client who lost vision due to a nurse not understanding the interaction of medications with glaucoma and diabetic issues and ignoring the patient complaint of eye pain. Had there been quicker reaction and referral the client could have avoided vision loss.
Client detoxifying from prescribed drugs denied access to a doctor, medical care ignored, client forced to use internet as medical care provider.
Client needed therapy due to PTSD following a distinct trauma but was pushed to accept antidepressants. Client had medical condition that made additional medications contraindicated. Client needed but did not receive talk therapy.
Providers are overloaded and unable to provide adequate care to Medicaid patients. When a contract is signed with the state the BHO certifies that they can provide ALL medically necessary care to ALL eligible clients. There should be no excuse for the excessive wait times, for refusal to see clients as often as they need to be seen (as long as that does not exceed the limits established in regulation) or for the inability to get patients into see doctors as mentioned above. A couple recent examples of this include:
Client with history of severe SMI with depression as primary disabling factor had been doing well but experienced severe loss. Client had been able to get off of most medication and wanted to stay off as client had major health improvements as a result. Client felt symptoms could be maintained with several sessions of therapy. Client had to be aggressive in refusal of taking medications and demand therapy but the provider wanted to immediately go to medications even though the fact that she had recent loss indicated that therapy should be the first line of defense. When client finally got therapy the symptoms were able to be addressed using talk therapy and medication was indeed unnecessary.
Client got very troubling blood test results of psychiatric medication level indicating toxicity. Client has severe medical issues and history of very expensive and disabling medication reactions. Doctor did reduction in medication that caused immediate psychiatric symptoms. Client sent to specialists for possible blood disorder and numerous tests done. Once test results come back and the client desperately needs the consultation, the psychiatrist cancels several appointments and does not have time to see the patient who has now destabilized for three months
The BHO contracts had performance goals, were these met and if so how are they reported? As clients there is no outreach on how to find performance information or to even know what to expect.
There is evidence that shows peer run services as opposed to peer delivered services works. However we see very few areas inColorado where this is practiced. CHARG resource center is a shining example of how this model works and the outcomes speak for themselves. CHARG clients who need to see a doctor see one, they use nurses appropriately, and the clients can get extra therapy when going through life changes. The real proof is in the outcomes and recovery markers shown in CHARG clients, all of whom have severe mental illness. However, in most other places peer services are only peer delivered rather than peer run services. This has not been effective at anything except for creating jobs for a very small number of consumers. Peer delivered services are services that use peers (usually at very low wages) as case manager aides or adjuncts to the staff. Peer run services are where peers are in control or partnered at all levels of the organization starting at the board.
We continue to have problems with people being split apart when they have a brain injury or developmental disability. The clients get no meaningful services while the BHO say it is developmental or neurological and the DD system and medical providers say the problem is mental health. We MUST end this.
As a result of the large problems that interfere with integration we suggest the following changes be made:
1) Make the system service based not diagnosis based. The BHO contract should be about who needs psychiatrists, psychologists, therapy, at inpatient or outpatient or rehabilitative levels. The system cannot say they are about “behavioral health” then refuse to serve people with autism, Alzheimer’s, brain injury, etc., whose disabilities cause behaviors to be challenging. The diagnosis is less important then the service needs. There can and should still be medical necessity criteria placed on services. Limiting inpatient remains appropriate. Most of the evidence based clinical criteria is behavior based anyway. It is still OK to have best practices associated with certain diagnoses but that should be a guideline, not a template that must be followed.
2) Any client with comorbidities on psychiatric medication should have access to a psychiatrist. Access standards should be applied to the right level of professional. For example, it is not acceptable to say access standards are met when someone who needs a doctor is only given access to a bachelor’s level therapist.
3) There needs to be increased monitoring of iatrogenic harm from medications. When someone becomes symptomatic and develops conditions like diabetes, metabolic syndrome, medication toxicity the BHO should be required to quickly convene a multi disciplinary team. The BHO should be required to consult with the patient’s primary care physician in a matter of days. Appropriate releases should be signed before psychiatric medication is dispensed.
4) Performance measures should be published quarterly in understandable format. At the same place where these measures are published information about the client and family advisory committee should be provided. HCPF should have a form on the internet where clients could report issues related to performance measures or access standards. For example there should be a form on the HCPF web site where a client can report directly when they have not been seen within the appropriate amount of time, or if the access standard is an outpatient visit within seven days of a discharge the client can report when that did not happen. There should be a link to the Ombudsman office at this place so clients who want assistance can get it, but those who just want someone to know can also access this assistance.
5) Requirement that peer delivered services be turned into peer run services within a specified period of time. The state should outline what peer run services look like and after a reasonable transition period should not fund services that do not have peer run elements, including a majority or at least equal number of consumers at the board level. The transition period should be used to provide intensive training to people using services so there is a cadre of clients able to take over peer run services. At this time there are not sufficient numbers of qualified peers to run and deliver these services properly.
6) We would like to see prioritization on getting people with mental illness diagnoses out of institutions and support the comments made by theLegalCenteron this matter. We believe that many clients are needlessly institutionalized because of poor quality in both mental health care and long term care. Home health and personal care agencies are not trained nor regulated in a manner to appropriately serve this population.
7) ALL mental health services, both state plan and LTSS waiver, should be voluntary and NON punitive. HCPF should prevent all forms of punishment, including kicking people out of services for missed appointments and retaliation.
8) There remain an insufficient number of qualified clients to serve as leaders on statewide boards and committees representing people with mental illness. It is important to include people from various perspectives. Clients should receive training on how to be on boards from someone outside the mental health provider system and from an independent advocacy perspective. Moreover, client members must have access to accurate and up to date data about BHO and clinic goals and performance, both clinical and financial. Until the client representatives get the same information as the managers there will never be true representation and solutions will not be forthcoming.
In response to the specific questions outlined by the Department:
- How can the Department improve alignment of mental health and substance use disorder services? CCDC does not have the expertise to comment on this. It is important to be clear that many people who have psychiatric conditions do NOT have substance abuse disorders. There are distinct differences between addiction and mental illness and the two should be automatically co-mingled. It is true that many with mental illness self medicate but they usually stop when they receive appropriate treatment (including a doctor who listens to patient about side effects of medication).
- How can the Department achieve greater integration of services at the point of care? The issue is not about getting greater integration at the point of care, it is about coordination of care. However one great step would be a NO WRONG DOOR approach. Wherever the client presents, whether that be mental health or medical system the evaluation and assessment MUST BE DONE and a service plan MUST BE set up for the client. The mental health professionals would be able to set up plan using medical providers and vise versa but stopping the merry go round for the clients with the greatest needs would be very beneficial.
- How can the Department streamline care of individuals with complex needs who are receiving care from multiple systems? Most people with long term psychiatric conditions who use medications long term have medical problems so there should be assumption that this population does receive care from multiple systems. Each client should be able to designate who will be the primary care coordinator but each client should have one. For some that will be an outside care coordination entity like the Colorado Alliance for Health and Independence(www.coahi.org). For others it might be the primary care physician if the PCP has care coordination capabilities. Others might join a plan or RCCO that provides this service. Care coordination is a distinct service that is separate from but connected to medical and mental health care. The department should work to remove the false line between acute and long term care especially for clients in HCBS waivers, particularly the mental health waiver. Those care managers should be the primary point of contact with not only the psychiatrist but the PCP and the long term care providers. ANY case manager or care coordinator who is to coordinate care for people with SMI and multiple and/or complex health conditions should have NO MORE than 50 patients and it should only be that high if at least half of the patients are relatively stable. The department needs to define care coordination across settings and perhaps create tiers of care coordination that would be consistent across settings. These tiers or definitions should lead to appropriate case load and reimbursement. Care coordination should not be where we skimp on services. We are particularly concerned about long term care. Efforts to kick people with mental illness off of the EBD waiver are concerning, as are reports we hear where people who are clearly eligible for LTSS are denied at the SEP level in rural communities, only to end up in emergency rooms and SNFs where they then qualify for a higher level of care. The HCBS programs must be reformed to provide appropriate care for this community. Because all mental health related care is considered "unskilled" the direct care workers are low wage and often struggle with issues similar to clients', such as disorganization, lability of moods, etc. When they cannot provide the stability and appropriate assistance with organization, problem solving, and assistance with managing social situations they do not help the client and chaos ensues. The agencies, who are not really regulated, wait until a crisis is in full swing then discharge the client saying that the agency cannot meet the needs of the client. Eventually clients in rural areas go through every agency in town. Until the personal care provided for people with serious mental illness is provided by people with a much higher level of skill these problems will continue. We also believe that CMS needs to clarify for HCPF LTSS waiver managers the intent of HCBS and the need for people with functional limitations that require LTSS to receive high quality support, even if they do not have a physical disability. The LTSS services should not be clinical in nature but should be supportive.
In summary, a very significant amount of money is spent on these programs, and they could be restructured to make a positive difference in the lives of people. This can happen when there is true client involvement to the extent that clients are running services and taking legitimate leadership roles in mental health policy. Outcomes can be measured when there is transparency and when data is made available and promised evaluations are made public. The real outcomes should be reduced use of institutions, reduced suicides, and increased employment (including part time, volunteer, and self employment) and community engagement becomes the norm, rather than exception for our low income citizens who live with serious mental illness. Not only will this reduce stigma, improve quality of life dramatically but will save the state money.