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


Mental health SDC programs for persons with SMI have been formed in at least eight states: Florida, Iowa, Maryland, Michigan, New Hampshire, Oregon, Pennsylvania, and Texas. Most of these programs were designed as innovative pilot programs or as experimental programs in randomized evaluations of the SDC approach. However, some programs have continued to operate beyond their initial demonstration phase. This Appendix provides a summary of these SDC programs.


Florida SDC is the earliest SDC program implemented specifically for mental health care consumers with SMI.b The Florida SDC program was established in January 2000 and is administered through the Florida Department of Children and Families.58 Florida SDC has two administratively separate program sites; one serves the Jacksonville area and another serves the Fort Myers area. The Jacksonville program (http://www.floridasdc4.com) began enrolling participants in 2002 and at any given time has 150-250 participants. The Fort Myers program (http://flsdc.org) began enrolling participants in 2005 and has approximately 90 participants. Both Florida SDC sites receive state general revenues and both utilize Medicaid, Medicare, Veterans Health Administration (VHA), and private insurance plans for coverage of mental health care services.33

Alakeson reported that in 2007 insured participants in the Jacksonville program received an annual budget of $1,672, with insurance picking up the remaining costs of care; uninsured participants received an annual budget of $3,192 and were required to spend 48 percent of this amount on clinical services.33 The program has five professional recovery coaches who are employed as independent contractors. Providers of clinical, dental and optical services must be registered in the SDC program's provider network in order to receive payment for services provided to participants. Although this arrangement implies that participants cannot see other (unapproved) providers of these services, approved providers can bill the fiscal intermediary directly for services provided.

In 2007, participants in the Fort Myers program received $1,924 if they were Medicaid or VHA eligible and $2,811 if they were Medicare eligible. Uninsured participants received $3,700 but and were required to spend 48 percent of this amount on clinical services.33 The Fort Myers program is run by a local chapter of the National Alliance on Mental Illness (NAMI). Recovery (or "life") coaches are trained peer-providersand are employed directly by NAMI. In contrast to the Jacksonville program, Fort Myers SDC participants may choose any qualified clinical, optical or dental care provider.


Iowa implemented the SDC approach on a pilot basis within an Intensive Psychiatric Rehabilitation program.2 The SDC program operated between 2006 and 2008 and was developed in partnership with Magellan Health Services, the managed care organization that manages Iowa's Medicaid plan for behavioral health.69 Under its contract with the State of Iowa, Magellan is required to set aside 2.5 percent of its capitation fee as community reinvestment funds. These funds were used to support the program administration and to pay for individualized budgets for program participants. The Iowa SDC program served 36 participants who were receiving intensive psychiatric rehabilitation services. Each participant chose one rehabilitation goal relating to housing, education, employment or relationships and could use a budget of up to $2,000 in support of achieving this goal. Magellan operated as the fiscal intermediary for the program.


The SDC program in Washington County, Maryland was started in 2007 and continues to operate with funding from the Maryland Mental Hygiene Administration. The program is modeled after the Florida SDC program, and is managed by a consumer-run organization, the Office of Consumer Advocates. The Washington County Mental Health Authority, a local "core service agency" that receives funding from the Mental Hygiene Administration, serves as the fiscal intermediary. By the end of 2009, approximately 165 consumers had enrolled in the program.

The program administration and individual budgets are supported with state general funds. Additional costs for training, program evaluation and other related technical assistance were funded by a Mental Health Transformation State Incentive Grant. Each participant could, on average, receive a budget of approximately $3,000 per year. However, there is no cap on the amount allotted to each individual and many consumers use less than the full $3,000. Instead, budgets vary from consumer to consumer based on the services that the consumer identifies as necessary to support his or her ongoing progress in recovery.

The program employs one full-time and two part-time peer-advocates (two full-time equivalents). Peers help consumers finding community resources within natural support networks wherever possible. Once the services that need to be purchased to support a consumer's recovery have been identified, participants submit purchase requests to the core services agency. Approved items are paid by check or by direct reimbursement to the participant.


In Michigan, statewide implementation of the SDC approach began in 2003 and is formally supported by the Mental Health and Substance Abuse Administration (MHSAA), the state mental health authority. The MHSAA has created a policy framework--the Choice Voucher System--for implementing SDC arrangements in programs serving adult participants in the state's public mental health system.70 The Choice Voucher System provides prototype contractual agreements, payment mechanisms and other technical assistance information for supporting the SDC approach in programs for adults who are receiving mental health and/or developmental disability services. SDC programs can operate with flexible funding from Medicaid, using the state's 1915b/c waiver authority.c SDC programs are managed by county mental health service providers and peers are employed to support SDC participants. The development of SDC programs was also promoted by state grants awarded to Kalamazoo and Oakland Counties in 2005.

New Hampshire

The State of New Hampshire developed the Dollars and Sense Individual Career Account (ICA) demonstration research project to test the impact of greater beneficiary choice and control over vocational service planning, budgeting and service/item procurement on vocational outcomes and consumer satisfaction.71, 72 Although the ICA service model did not include all SDC components, it did include person-centered planning and individualized budgeting. The project also offered a subset of individuals a "cash account" developed with project dollars and matching funds from the New Hampshire Division of Behavioral Health. A total of 181 individuals enrolled in the project over a 3-year period. All participants were Social Security Disability Insurance beneficiaries or SSI recipients at the time of enrollment, and two-thirds had a mental health disability.


Oregon has an innovative SDC program called the Empowerment Initiatives Brokerage (EIB). The EIB is a consumer-operated organization started in 2004 using funding from a Real Choice Systems Grant.68, d Unlike SDC programs in other states, EIB offers participants only a 1-year period of participation. Participants have access to an individual budget of $3,000 and are supported through a person-centered planning process. Peer service providers are employed as coaches or "resource brokers." Alakeson reports that the program's total cost is approximately $10,000 per consumer served.33

Although the Real Choice Systems Change grant ended in September 2005, EIB continues to operate under contracts with Multnomah and Clackamas Counties, where the program has operated since 2001. EIB services in Multnomah County are similar to SDC services in other states, and are funded by a mixture of Medicaid dollars and state general revenue. In Clackamas County, EIB has a specific focus of supporting transitions to independent living arrangements for individuals currently living in group homes. The housing brokerage is state funded but overseen by Clackamas County.


The Delaware County Self-Directed Care for Community Integration of Individuals with Psychiatric Disabilities is a 2-year pilot SDC program for non-elderly disabled adults with SMI who have a history of ongoing engagement in public mental health care services. The program, which began operating in 2010, is part of an ongoing collaboration between the Delaware County Office of Behavioral Health, Magellan Behavioral Health of Pennsylvania, the Mental Health Association of Southeastern Pennsylvania, and the University of Pennsylvania Collaborative for Community Integration.

The program was implemented for the purpose of conducting a randomized trial to compare mental health SDC to traditional care. Beginning in January 2010, approximately 150-160 persons, all of whom were receiving Medicaid, were randomized either to the Delaware County SDC program (75-85 persons) or to traditional managed behavioral health care (75 persons). The SDC program features individualized budgets and person-centered planning. Peer support specialists serve as recovery coaches, and they are managed by a program supervisor. Magellan serves as the program's fiscal intermediary.

The amount of money assigned to participants' individualized budgets is calibrated based on each participant's 2-year history of Medicaid expenditures for outpatient mental health care services. As a result, each participant may have been allocated a unique budget for spending on traditional and non-traditional products and services. Using this method, SDC participants with more intensive service needs in the past could be expected to spend more money during their first 2 years of SDC participation than participants with less intensive service needs.

All mental health care services that are available through the Pennsylvania's 1915(b) HealthChoices Medicaid waiver program are paid for using Medicaid funding from the 1915(b) waiver. All products and services not covered under the 1915(b) waiver (e.g., classes at a community college) are paid for using "Freedom Funds." Freedom Funds are residual savings from the prior fiscal year of the state's 1915(b) HealthChoices waiver. Expenditures are deducted on an ongoing basis from the balance of participants' individual budgets. The financial intermediary monitors budget balances to ensure that participants are not likely to over spend their budgets before the end of the plan year.

Certified peer support specialists--individuals who are in recovery themselves and who embody the message that recovery is possible--are reimbursed using 1915(b) HealthChoices waiver funding, as peer support services are Medicaid-reimbursable. By using certified peer support specialists in the role of recovery coaches, the program does not require additional funding from another (non-Medicaid) source to pay for coaching services. The rate paid for peer support specialist services also includes an administrative reimbursement to cover the costs of a program supervisor. These reimbursements cover the costs of the Delaware County SDC program supervisor, who approves participants' purchases and is responsible for various administrative tasks. During the Delaware County program's first year, some additional funding was provided by the mental health authority to cover training and operational expenses.


The SDC program in Dallas County, Texas (Texas SDC) was established in 2009 through a public-academic partnership between the Texas Department of State Health Services (DSHS) and the UIC).73 In 2005, the two organizations began planning a pilot SDC program for persons with SMI. In that year, Texas was awarded a SAMHSA Transformation State Incentive Grant, which provided funding for pilot program planning, implementation, and evaluation. The Texas SDC program is being rigorously evaluated in a randomized trial comparing Texas SDC (150 persons) to services as usual (150 persons). Those assigned to SDC are provided with tools for person-centered planning and creation of an individual budget tied to specific recovery goals.

The program planning process was designed to ensure that the resulting program would be responsive to the needs of the local community and also based on the available evidence.73 Multi-stakeholder subcommittees were formed, made up of consumers, providers, researchers, DSHS staff, family members and other mental health advocates. Subcommittees met weekly via teleconference and in-person over a 3-month period to decide on the program's policies and procedures, determine staffing and organization, create a purchasing policy, design the provider network, and discuss use of information technology to enhance program operation. Subcommittees sought research evidence as well as information from participants and state administrators at SDC programs in Florida and Oregon.

Texas has a Medicaid 1915(b) managed care waiver for Dallas County, which permits Medicaid financing to be combined with state general revenues, mental health block grant funding, and other local program funding. Participants in Texas SDC are allocated an individual budget of $4,000 per year, with up to $7,000 per year available for individuals who need high levels of service.73 This latter group includes individuals whose outpatient service expenditures in the year prior to program entry exceeded the average of $4,000 due to mental health or related life crises. Medications, crisis services, and inpatient care are not covered in the SDC budget but remain available through the current service system. The program is managed by a managed behavioral health care organization, Value Options, which also serves as the fiscal intermediary.

In relation to program organization, participants can select services and providers from the program's provider network, and participants complete a person-centered planning and budgeting process with assistance from coaches, who are called "SDC Advisors." Although participants must use care providers in the Texas SDC program network, any provider who agrees to abide by the SDC program's philosophy and policies can enroll. This implies that participants can continue seeing the same providers they were seeing before entering SDC as long as these providers are willing to enroll in the Texas SDC provider network. Persons in mental health recovery are involved in all aspects of the program, including recruiting and hiring the program's director and SDC Advisors, and serving on the community advisory board.73

Information technology is integrated into the design of the Texas SDC program. Participants' purchases are made with pre-paid debit cards (the Allow Card of America™ pre-paid MasterCard). SDC Advisors travel in the community to provide brokerage services with laptops and portable printers, using wireless technology to help participants create recovery plans and budgets. A Texas SDC program website (http://www.texassdc.org) establishes a public presence for the program and serves as a portal for communications among participants, coaches, and program administrators. Participants communicate with each other via a chat room that is closed to outsiders, which they access through a secure link from the website.

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