Missouri operates an Administrative Agent System. In this system, mental health services are accessed through 25 service areas, with each service area serving particular counties of the state. Administrative Agents and/or Affiliates (CMHCs) are responsible for providing these services. These designated centers serve as entry/exit points in each geographic area, into and out of the state mental health delivery system, offering a continuum of comprehensive mental health services.
The Burrell Center is a non-profit organization [under section 501(c)(3) of the tax code] that was established in 1977. Until 2007, Burrell was responsible for a seven county catchment area with 500,000 people. The Center can be characterized as a semi-urban hub of a rural area. After 2007, the catchment area was extended to a ten-county area in the central region of the state. The Center has grown from a handful of employees when established to its current complement of 800 employees operating with a budget of $50 million a year.
The project director of the NAVIGATE program recruits, screens for eligibility, enrolls clients, attends the weekly team meetings, and monitors case managers including the IRT clinic staff and the family clinical staff. At Burrell she is a Community Support staff supervisor, who oversees six case workers who are employed in one of the Center's residential facilities. There were no new hires, per se, for the project. Staff positions include: one prescriber; two IRT facilitators; one family clinician; one project director; and one supported employment specialist on the ACT team [about 5% of that full-time equivalent (FTE) is RAISE-funded].
Primary referral sources for the program are hospitals, emergency rooms, inpatient units, primary care providers, school personnel, walk-ins to the 24-hour acute stabilization clinic, the 24-hour crisis line, and from the ten-bed crisis stabilization unit. Since RAISE was a good match for what the Center was already doing, it was not difficult to identify and recruit clients. They have a good working relationship with the Cox hospitals group, which is a major health and hospital provider in the region, and with the staff that provide inpatient services to people on their units. The program also recruited through the 24-hour crisis line (throughout the catchment area counties) and got some responses to the pamphlets that were distributed to primary care offices. But most of the referrals for the project were coming internally from other departments. There were a few family medical center referrals (from the family care center in a Cox hospital).
The majority of the recruiting and outreach was accomplished through word-of-mouth. Most of the recruits were in their 20s and were either on SSI or eligible to apply for it. (The high level of SSI eligibility suggests that this might be an atypical case mix at this NAVIGATE site. As discussed, above, while it is possible for young adults to qualify for SSI and still meet RAISE eligibility criteria for early psychosis, it is expected to occur rarely.) There were 25 recruits referred to NAVIGATE and 18 of them enrolled in the program, but two of them left the study later (one was mandated to a residential facility and became ineligible for the study after enrollment). The project director did most of the eligibility screening (by telephone) after people were identified or referred. Fidelity to model in terms of the clinical approach for NAVIGATE has been exemplary with relatively strong client retention. The clients consistently come to their therapy appointments and to the psychosocial/psychosocial rehabilitation offerings.
The approach to RAISE is very much in keeping with the mission of the Center (treat early, avoid larger problems, and provide needed services). The outreach work of the Center was already aggressive -- the Center worked with the mental health court, the drug court, hospital emergency rooms, responded to walk-ins and call-ins, and had good surveillance of behavioral health needs established before RAISE. An earlier grant had funded counselors in schools, and the Center stretched out that three year program to five years to study its effects.
Financing of Services
There is no federal block grant money involved in service delivery. Burrell receives an allocation from the state to serve the priority population, and they use funds as they see fit. Some mental health providers develop services that are Medicaid billable, sometimes exclusively. However, Burrell operates according to a Purchase-of-Service model in which the state has a contract with the Center for the purchase of direct human services for clients. Such contract provides more flexibility in reimbursement of services for the Center. If a service is not Medicaid billable, they use their allocated state funds to cover it. The Center actually takes a loss on many services to psychiatric clients (which include the cost of nurses and administrative support they provide to the doctors). This is part of the reason that they are working with others to attain better Medicaid reimbursement rates. Making money on some community services provides a subsidy to support workers in other less lucrative services in the Center.
About three-quarters of the funds for community mental health services come from state funds, and the majority of the remaining one-quarter comes from Medicaid and some from private insurance. Cox Health, a regional health and hospital group, provides most of the private insurance and is a big player in the state. Before the grant, CMHC services were almost solely funded by the state. Over the last years, because of initiatives started with the Center leadership and private insurance companies, there has been a notable increase in the portion of private insurance that funds services (Table 3.2). There were two study participants with private insurance initially and one is still with a private carrier. All others are on Medicaid or are eligible and have applied for Medicaid.
A reduction in state funding has had less of an impact on the Center than for other providers. The Center was able to restructure and avoid lay-offs, allowing routine job attrition and no new hiring to reduce staff in response to the reductions in budget. They try to balance revenues to stay solvent. The success was in most part due to having a visionary leadership that helped to structure the Center and funding to attain a solvent outcome. A vice president of Burrell Center is also the Chief Executive Officer of the Missouri Coalition of CMHCs and the Coalition has been very active in advocating for additional state mental health dollars.
There is one supported employment specialist on staff and that employee works with the ACT team to some extent but lack of adequate supported employment services was described by the leadership as a notable weakness in the system. There is limited funding for supported employment in the state and there is still very little attention being paid to this area. All NAVIGATE components except supported employment (which was never fully developed) are likely to be sustained after the conclusion of RAISE ETP. Burrell sees supported employment as a critical need and they are working hard to advocate for funding. More awareness about early intervention is being stirred by the grant, and much of that is occurring through word-of-mouth. In general, they expect early intervention services will be sustained and will be offered across the board and engagement will be stressed.
There is no property tax dedicated to mental health funding and there are no state or local subsidies for behavioral health care, other than the standing budget allocation from the state Department of Mental Health. There is also a Community Medical Access program in place. Because Burrell is an Administrative Agent for mental health they also treat adult substance use disorders. The drug court also has some limited resources. Burrell has its own pharmacy and helps people who cannot otherwise afford medications.
The Center believes that it is important to establish medical homes for people with severe and persistent mental illness (SPMI). The Center sees identifying high utilizers and providing customized services as a good precursor to the fiscal (and clinical) benefits that will accrue to establishing medical homes for people with SPMI, and work in that area has served as good preparation for changes that are anticipated with the ACA.
|TABLE 3.2. Burell Center, Springfield, MO: RAISE NAVIGATE Early Treatment Components and Funding Sources|
(e.g., VA, Tricare)
|Outreach and engagement||X||X|
|Alcohol and substance use treatment||X||X||X||X||X||X|
|Other outpatient visits||X||X||X||X||X||X||X|
|Inpatient care as needed||X||X||X||X||X||X|
|Planning (e.g., treatment and/or recovery plans)||X||X||X||X|
|Job coaching and other vocational supports||X||X|
|Individual resilience training||X|
|Benefits counseling (e.g., WIPA)|
|Treatment and primary care coordination||X||X||X|
|Other (e.g., occupational or psychosocial therapy, groups, etc.)||X|
|NOTE: In-house or Other means services provided by staff directly and not billed to any payer. Out-of-pocket means services were paid for either entirely out-of-pocket or some cost-sharing was required.|