Feasibility of Expanding Self-Directed Services to People with Serious Mental Illness. 1. Introduction


Self-directed care (SDC) is an innovative program model for persons with disabilities, in which participants control an individual budget and are empowered to customize their own service plans in accordance with their preferences.1, 2 The SDC model is particularly well designed to promote consumer and family driven mental health care, one of the six goals of the President's New Freedom Commission (PNFC) on Mental Health.3 In its 2003 final report, the PNFC envisioned a larger role for consumers and families in managing the funding for their services, treatments, and supports, a change that was expected to enhance their choices and increase service system accountability. The SDC approach is now being considered by some states for larger-scale implementation in Medicaid-financed public mental health programs, suggesting there is a need to examine issues that may arise when adapting the SDC approach on a large-scale for programs serving persons with serious mental illness (SMI).

Although active consumer involvement in services planning and clinical decision-making are now fairly well accepted principles, mental health systems have not consistently implemented changes needed to ensure that consumers are involved in directing their own care. By contrast, the SDC model puts consumers "in the driver's seat"2 in that they are imbued with the authority to select goods and services they decide will best meet their needs, even when those goods and services have not traditionally been reimbursed by payers. SDC program participants control how some portion of public financing is spent, choose their own providers, and have final decision-making authority over many or most aspects of service provision.4 As a result of this flexibility, SDC has the potential to overcome mental health program inertia, which might be impeding the adoption of new policies to encourage consumer involvement in decision-making and a more uniform recovery orientation among providers and programs.

During the past decade, a movement to implement SDC as a standard component of public mental health systems and offer it to persons with a SMI has attracted considerable support. The 2003 final report of the PNFC on Mental Health3 highlighted the success of the Cash and Counseling program, a SDC model for persons with physical and developmental disabilities, and endorsed it as a promising model for adaptation to mental health systems. Several federal agencies, including the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Medicare and Medicaid Services (CMS) and the Institute of Medicine, are now encouraging adoption of SDC in states' public mental health systems. In addition, recent changes in federal regulations, which give states new options for obtaining federal Medicaid matching funds for home and community-based services (HCBS), have made SDC programs for persons with SMI more financially viable within Medicaid.

However, the prospect of a larger-scale implementation of SDC programs for persons with SMI raises critical implementation considerations about which there is currently little information available. Greater consumer decision-making authority over spending and greater flexibility in paying for non-traditional goods and services, two core features of the SDC approach, could result in various challenges for consumers, providers, SDC programs, and public mental health agencies. Additional discussion and examination of these features of mental health SDC programs, especially in the context of programs serving large numbers of consumers within a Medicaid plan, may help clarify critical issues for large-scale implementation of mental health SDC in Medicaid.

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