Iowa Mental Health and Disability Services System Redesign Interim ...

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Workgroup Discussion and Recommendations: The Workgroup discussed Olmstead principles in several meetings and agrees that people should be served in the least restrictive, most integrated settings possible. By investing in services consistent with Olmstead principles, the system will be working to ensure that the civil rights of individuals with disabilities are protected, will have a greater return on its investments, and enable the State to rebalance or reallocate funds to fill gaps in services. This includes the recognition of serving people in smaller, non-congregate care settings and leveraging Medicaid to the extent possible. Examples of smaller settings include independent apartments and small shared living residences. This process will take time, and, ultimately, financial incentives should be built into rates or contracts to support this transition. Within the continuum of inpatient care, the Workgroup discussed the role of the Mental Health Institutes, local inpatient treatment at acute care hospitals and non-inpatient, sub-acute settings. The Workgroup recommends that the legislature direct DHS to continually evaluate the inpatient continuum of services as the community system develops. The Workgroup agreed that there is a need for additional forensic inpatient capacity within the Mental Health Institutes and that as the need for long-term, civil commitment inpatient beds decreases as the community system strengthens, some beds can be re-purposed for individuals with mental illness and forensic circumstances. The Workgroup decided that the current construct of a forensic psychiatric hospital being located within the prison system should be transitioned to one that is located within the control of the mental health system. The group agreed that, when needed, inpatient care should be delivered in local, acute care settings to the extent possible and that the Mental Health Institutes are more appropriate for patients who require longer term treatment. Local, acute care inpatient units are largely non-existent in Iowa for several reasons, mostly due to geographic and reimbursement issues for acute care hospitals. The Workgroup suggests that the legislature direct DHS to explore the expansion of local acute care, inpatient capacity, including a call for beds through a Certificate of Need process and suitable reimbursement for beds. The current number of operational beds at the Mental Health Institutes is needed and should not be decreased further without a corresponding increase in the number of psychiatric inpatient beds within local, acute care hospitals. It was suggested that more beds are not necessarily needed in the system, but rather existing beds be used more efficiently. However, most members agreed there is a shortage of acute psychiatric inpatient beds and that consideration should be given to expanding beds now to meet immediate demand, even if on a transitional basis. This does not necessarily mean that new beds become permanent, and the system should be flexible enough to reallocate resources as the system evolves. As community-based alternatives become operational and demand for acute inpatient decreases, beds can be closed and funds reallocated to community services. 62
The Workgroup also recommends that DHS continue to evaluate the need for sub-acute services consistent with the recommendations in this report and the previous Acute Care Task Force Report. Within this discussion, there was discussion about the role of Residential Care Facilities (RCF) in the state. There is a wide variation in RCFs, including numbers served and services provided. Most RCFs are large (i.e. over 16 beds) and do not receive any Medicaid funding for services. The Workgroup recommends that DHS engage the Department of Inspections and Appeals and other stakeholders on defining the role of RCFs in the system and modifying licensing and inspection standards accordingly. The use of substance abuse residential services should also be considered for use as sub-acute care. G. Supporting and Maintaining a Competent and Committed Workforce The challenge of having a sufficient workforce is not unique to Iowa. Insufficient numbers of staff combined with existing staff whose knowledge and experience are inadequate to meet the needs of service recipients has created a national workforce crisis in behavioral health. For most mental health positions, there are severe workforce shortages, and nearly all of Iowa’s counties are designated as shortage areas in Mental Health Care Health Professional Shortage Areas (HPSA) 32 . Iowa consistently ranks toward the bottom in terms of the availability of psychiatrists and psychologists. In 2000, Iowa ranked 47 th among states in the number of psychiatrists per 100,000 people and 46 th among states in the number of psychologists per 100,000 people 33 . The workforce crisis is especially profound in rural areas 34 , and with children, youth and older adults, and on issues pertaining to co-occurring disorders, trauma-informed care, and cultural competence. The frequency of turnover in the workforce, often due low salaries and burnout, negatively impacts continuity and quality of care, and results in an added cost burden to providers who continually need to train new employees. The Workgroup reviewed the Annapolis Coalition (2008) report, Iowa Mental Health and Disability Services Workforce Review 35 , and the Department of Public Health’s report (2006), Iowa’s Mental Health Workforce, that addressed Iowa’s workforce challenges. The reports highlight the need to develop recruitment and retention strategies (e.g. loan repayment programs, career ladders), work with higher 32 Center for Health Workforce Planning, Bureau of Health Care Access, Iowa Department of Public Health 2006 Report, Iowa’s Mental Health Workforce. 33 U.S. Department of Health and Human Services Bureau of Health Professions, 2000. The Iowa Health Workforce: Highlights from the Health Workforce Profile. Available at URL http://bhpr.hrsa.gov/healthworkforce/reports/statesummaries/iowa.htm. 34 More than 85% of the 1,669 federally designated mental health professional shortage areas are rural (Bird, Dempsey, & Hartley, 2001), and they typically lack even a single professional working in the mental health disciplines. 35 Annapolis Coalition on the Behavioral Workforce and the Western Interstate Commission for Higher Education. (2008). Iowa Mental Health and Disability Services Workforce Review. 63
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Iowa Mental Health and Disability S
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E. Process and Timeframes for the F
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The second source of principles is
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order to standardize approaches, re
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Children’s Disability Services Wo
Page 11 and 12: The Workgroup strived to attain a r
Page 13 and 14: Psychiatric Medical Institutions fo
Page 15 and 16: performance measures developed by t
Page 17 and 18: II. METHODOLOGY Senate File 525 cal
Page 19 and 20: III. VISION AND PRINCIPLES FOR THE
Page 21 and 22: Individual Outcomes • People make
Page 23 and 24: IV. REPORT OF THE INTELLECTUAL AND
Page 25 and 26: • Financial - Medicaid eligible
Page 27 and 28: 1. Service Coordination Service Coo
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Page 31 and 32: - in these difficult budget times -
Page 33 and 34: D. Outcome Assessment and Performan
Page 35 and 36: By using the Quality Framework, sta
Page 37 and 38: The table below illustrates how typ
Page 39 and 40: • Increased requirements by the C
Page 41 and 42: of performance data, it is importan
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Page 45 and 46: allows supervisors to track a DSP
Page 47 and 48: Furthermore, this redesign process
Page 49 and 50: C. Eligibility - Adults The Workgro
Page 51 and 52: service should be considered for co
Page 53 and 54: Any current or future state or regi
Page 55 and 56: 1. Peer Run Self-help Centers: The
Page 57 and 58: areas. ACT teams in rural areas can
Page 59 and 60: F. Olmstead and System Rebalancing
Page 61: continuum, how it should be funded,
Page 65 and 66: H. Provider Qualifications and Moni
Page 67 and 68: VI. REPORT OF THE CHILDREN’S SERV
Page 69 and 70: • PMIC bed/Residential Services -
Page 71 and 72: • Learning Supports for Students
Page 73 and 74: order to provide a strong system of
Page 75 and 76: D. Initial Recommendations Recommen
Page 77 and 78: Recommendation Two: Rollout of init
Page 79 and 80: under the Iowa Plan 50 . Services w
Page 81 and 82: • Planning for implementation can
Page 83 and 84: • The RFP will seek proposals fro
Page 85 and 86: o I am part of a community; I belon
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Page 89 and 90: Table One: Summary of the Potential
Page 91 and 92: families from among the different d
Page 93 and 94: to begin operations and transition
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Page 97 and 98: Function Yes No Comments Data colle
Page 99 and 100: Function Regional discretion within
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Page 103 and 104: o o Process to be used and resource
Page 105 and 106: Performance Domain Examples from ot
Page 107 and 108: • Maintenance of the strength of
Page 109 and 110: Service Integration and Coordinatio
Page 111 and 112: B. Regions designate a transportati
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• Inclusion of Physician Assistan
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and were resolved by the team in th
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9. Mental Health Courts and Identif
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See Appendix F for details of each
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New Core Services Prioritized new c
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IX. REPORT OF THE PSYCHIATRIC MEDIC
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X. INTEGRATION AND TRANSITION PLANN
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eligible for Medicaid after 2014, t
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XI. CONCLUSION This report presents
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Services Currently Provided to Adul
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CMS State Balancing Incentive Payme
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Appendix C Children’s Disability
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o Roles o Data o Communication o Co
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o Crisis teams o Immediate access t
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• State plan for college/universi
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Appendix D Recommended Definition o
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Appendix E Brain Injury Definitions
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Appendix F Brain Injury Workgroup R
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Corresponding # to narrative recomm
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Adult Intellectual and Developmenta
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Brain Injury Workgroup Name Agency
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Judicial-DHS Workgroup Name Agency
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PMIC Transition Workgroup Name Agen
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Regionalization Workgroup Name Agen
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