Community-based mental health services, as used in this report, are a range of services that are part of a system of treatment and support for people with mental health disorders that enable them to live stably in the community.55 Given our focus on services for people living in PSH, this most often means services that are included in Medicaid state plans under the rehabilitative services and targeted case management options. In addition, some states cover some of these services as optional state plan home and community-based services, which may include habilitation, psychosocial rehabilitation, case management/service coordination, housing locator services, and other services and supports for community integration.
The basic eligibility criterion for most mental health services available under Medicaid has two elements--diagnosis and functional impairment. To be eligible for mental health services, a person's mental illness must meet certain diagnostic criteria and cause functional impairment significant enough to interfere with important areas of daily living as defined by each state. The criteria may also incorporate consideration of duration--that is, the mental health disorder and functional impairment has lasted or is expected to last at least 12 months, or it could reasonably be expected to last that long if services are not provided. States vary in details, but most require several sources of evidence related to these elements before making an eligibility decision. Making the final determination is as precise a process as states can make it, but most also recognize the need for some flexibility and discretion.
Diagnosis usually comes first. To become eligible for many mental health services, most states stipulate that a person must have "a diagnosable mental, behavioral, or emotional disorder that meets the criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM)."56 State mental health agencies have some flexibility in identifying the specific diagnoses they will use to establish eligibility. Generally the list of "included diagnoses" consists of schizophrenia and other psychotic disorders, and mood disorders such as bipolar disorder or major depression. The terms "serious mental illness (SMI) and "serious (or severe) and persistent mental illness (SPMI)" are often associated with these specific diagnoses if a person also meets functional impairment and duration criteria. Some states use SMI and SPMI to designate who is eligible for particular levels of care. Some states also include specific personality disorders (e.g., borderline) or other diagnoses. To assure that their scarce mental health resources are used as effectively as possible for the population that is their primary responsibility, most state mental health agencies exclude people who have diagnoses of developmental disorders, substance-related disorders, dementia, diagnoses associated with physical conditions, and sleep disorders--unless the person has a co-occurring diagnosis of a qualifying mental disorder.
After diagnosis, the next consideration is functional impairment. To be considered eligible for most mental health services, a person's mental illness must "result in functional impairment that substantially interferes with or limits one or more major life activities." Activity areas may include feeling, mood, and affect; thinking; family relationships; interpersonal relationships/social isolation; role/work performance; socio-legal conduct; and self-care/activities of daily living. Because it is not always possible for an assessment form or procedure to include every eventuality that would affect a person's functioning, states usually build in some flexibility and assessor discretion but require adequate written justification and documentation.
States may develop specifications for how many or what combination of areas must be impaired for a person to be considered eligible for public mental health services, including services that are covered as Medicaid benefits. Specifications may include the number of functional areas affected and the severity and duration of the dysfunction. Illinois, for example, specifies that a person must have impaired functioning in three or more areas to be eligible for services covered under the rehabilitative services option in a program model that Illinois defines as "Community Support Team" services, but it also allows a person to continue to receive those services if, at reassessment, functioning has improved in some areas but is still impaired in at least two areas.
The eligibility criteria adopted by states may also incorporate consideration of duration. For example, the functional impairment must have lasted at least a year or be expected to last at least that long. Treatment history is often used as evidence of duration (and also of diagnosis or functional impairment). Usually the criteria take into consideration the type of care a person has received in the past (e.g., residential treatment, hospitalization, medications), as well as the frequency (e.g., for two or more continuous or intermittent episodes). The criteria may focus on treatment episodes within the past 12-24 months, specifically to assure that the condition is current. The longer, more frequent, or more continuous the treatment experiences, the more likely a person will qualify for higher levels of service. In considering the likely future duration of impairment, wording is often included specifying that the person's level of functional impairment is likely to continue in the absence of the treatment or intervention for which she or he is being considered.
As part of their assessment, states may require use of a rating scale such as the Global Assessment of Functioning Scale (GAF) or the Level of Care Utilization System (LOCUS) (Sowers, George, and Thompson 1999, also see text box). Some states specify specific scores on these instruments as qualifying for different levels of service interventions, but these scores are virtually always only one among other pieces of evidence that play a role in the final decisions about eligibility and approval for a particular level of care. For instance, the District of Columbia requires a global LOCUS score of 20 to qualify for Community Support Services and a score of 24 or higher to qualify for Assertive Community Treatment (ACT).
In Minnesota, the LOCUS score is converted to a level of care recommendation. Assertive Community Treatment services may be authorized for a person whose needs are at level 4, while less-intensive Adult Rehabilitative Mental Health Services can be authorized for a person whose needs are at level 3 or level 2.
5.2.1. Criteria Pertinent to People Experiencing Chronic Homelessness
In addition to the elements commonly found in rating scales and to multiple and frequent psychiatric inpatient admissions, states may direct that other risk factors be taken into consideration during assessments to determine a person's eligibility for some types of mental health services. Examples of these other factors are chronic homelessness, repeated arrests and incarcerations, lack of follow-through taking medications, failure to achieve stable housing, ongoing inappropriate public behavior, excessive use of crisis or emergency services with failed linkages, and similar indicators of functional impairments.
For example, in Illinois the service initiation criteria used to determine a person's eligibility to receive Community Support Team services (described below and often connected to PSH) include moderate to severe symptoms of mental illness, a finding that less-intensive services are inappropriate, and three or more of the following:
- Multiple and frequent psychiatric inpatient re-admissions, including long-term hospitalizations.
- Excessive use of crisis/emergency services with failed linkages.
- Chronic homelessness.
- Repeated arrest and incarceration.
- History of inadequate follow-through with elements of a treatment plan related to risk factors, including lack of follow-through taking medications, following a crisis plan, or achieving stable housing.
- High use of detoxification services (e.g., two or more episodes per year).
- Medication resistance due to intolerable side effects or illness that interferes with consistent selfmanagement of medications.
- Clinical evidence of suicidal ideation or gesture within the last three months.
- Ongoing inappropriate public behavior within the last three months, such as public intoxication, indecency, disturbing the peace, and delinquent behavior.
- Self-harm or threats of harm to others within the last three months.
- Evidence of significant complications, such as cognitive impairment, behavioral problems, or medical problems.57
These criteria and others used in defining eligibility for Medicaid-covered mental health services in Illinois incorporate some of the characteristics of the most vulnerable people experiencing chronic homelessness and help to target intensive, team-based clinical and rehabilitative services to this group of people.
5.2.2. Who Does the Assessment?
For all the specificity of state eligibility requirements, the assessment process remains a human interaction. For persons who are experiencing chronic homelessness, the process of engaging and establishing the trust needed to complete an accurate assessment can be challenging. Some states or counties allow outreach workers or teams to complete the assessment process and submit their findings to the "gatekeepers" who authorize services for consumers in the mental health system. This helps to reduce barriers that might otherwise limit access to Medicaid-reimbursed mental health services for people who are homeless but reluctant to engage in treatment.
For some types of benefits, including home and community-based services covered as optional Medicaid benefits under Section 1915(i), federal law requires that assessments to determine eligibility and develop an individualized service plan must be conducted by independent staff rather than the staff who are currently delivering supportive services. During site visits for this study, the research team heard that this can be very challenging for some people who are experiencing chronic homelessness. A typical assessment may take between one and three hours, during which the person being assessed is often on his or her best behavior, or may be reluctant to disclose information to a stranger who has not first established a trusting relationship. As a result the full extent of a person's functional limitations may not become evident to the independent assessor. Sometimes the consequence is that the assessment misses a good bit and the person gets a score outside the range needed to qualify for the level of service actually needed.58