Using Medicaid to Support Working Age Adults with Serious Mental Illnesses in the Community: A Handbook. Coverage of Community Support Components

01/24/2005

This chapter illustrates how states have employed Medicaid to cover several important components of community support. These examples are not presented as "ideal" or "model" coverages. Instead, they are intended to show the feasible range of services that can be covered through Medicaid, especially under the rehabilitative services option. The types of service capabilities/ capacities that are illustrated include:

  • Crisis services
  • Assertive Community Treatment (ACT)
  • Illness/disability management
  • Peer support/peer services
  • Supports for community living
  • Employment
  • Family education
  • Medication management
  • Services for individuals with co-occurring conditions

States routinely employ Medicaid to cover many other types of community mental health services, including individual and group psychiatric therapy, and counseling. These essential core treatment services are included in nearly every state's Medicaid program. Service coordination/case management also plays a vital role in the provision of community mental health services. As discussed in Chapter 4, states most commonly cover case management by employing the targeted case management coverage option.

In this chapter, the focus is on coverages that can promote successful community living for working age adults with serious mental illnesses. These coverages prevent or reduce hospitalization and contribute to recovery. Additional information about these and other types of services that states offer may be found in Recovery in the Community, a Bazelon Center for Mental Health publication that includes extensive information on the full range of services that states principally cover under the rehabilitative services option.2

Crisis Services

Crisis services are designed to meet the immediate needs of individuals experiencing a mental health emergency. They are flexible, mobile, and available 24 hours a day, 7 days a week. The need for crisis services may arise from a change in a person's living situation, emotional state, medication side effects, or a host of other reasons. Crisis services can range from telephone support to dispatching an on-site emergency team and following up with stabilization services.

Crisis intervention is a critical component of the Community Support System and is covered under Medicaid in some form by every state. Effective crisis intervention is vital to the well-being of individuals with serious mental illnesses, who, in its absence, potentially face dislocation, institutionalization, and even more tragic outcomes. Effective crisis intervention reduces strains on a state's other health care resources, and can prevent unnecessary confinement. There is ample evidence demonstrating that the availability of crisis services reduces costly emergency hospitalization,3 making this coverage an especially wise, cost-effective investment for states. Crisis services may be provided under either the clinic or rehabilitative services options, but, as emphasized in Chapter 4, covering them as a rehabilitative service offers greater flexibility in responding to individual needs. Given the nature of mental health crises, crisis services should be available at any time and any place, and this capability is severely constricted under the clinic option, especially with respect to follow-up crisis stabilization services.

Thirty states cover crisis management/intervention as a distinct service under the rehabilitative services option.4 In addition, crisis services are frequently included as a component of other services (e.g., Assertive Community Treatment, where the ACT team is expected to respond round-the-clock to emergencies experienced by individuals whom the team supports). Where a state offers distinct coverage of crisis intervention but also includes crisis intervention as a component of other services, only one coverage may be billed for each intervention.5 Many states also assign case managers the responsibility to arrange for crisis intervention services in their coverage of targeted case management services.

Typically, crisis services usually have three components: assessment/first response, stabilization/ follow-up, and crisis residential services. Assessment/first response is the rapid, initial response to an individual who is experiencing a crisis, both to assess the nature of the crisis and identify next steps to address the crisis. Crisis stabilization occurs after assessment and involves the development of an individual crisis treatment plan that includes short-term goals and identifies the immediate services needed to achieve those goals. These services may be offered either at a mental health clinic or furnished by a mobile treatment team. For example, under its rehabilitative services coverage, Georgia provides for both "clinic-based crisis management" and "out of clinic crisis management," depending on where the crisis can be addressed most appropriately and effectively. Finally, crisis residential services are furnished when the crisis is sufficiently acute to require round-the-clock support in order to stabilize the person. Crisis residential services are time-limited and may span a variety of interventions, depending on the needs of the individual. Crisis residential services may mean providing a bed in a small group home or a facility with significant nursing and other medical coverage.

States that elect to use the rehabilitative services option to cover crisis services can incorporate all these elements and have the freedom to deliver all components of the service through mobile teams and in a variety of settings throughout the community. Crisis teams may include a peer specialist. West Virginia (below) and Minnesota (next page) provide examples of state coverage of crisis services under the rehabilitative services option.

Assertive Community Treatment (ACT)

Assertive Community Treatment (ACT) is a mobile program of services that supports individuals who have especially intensive needs. ACT services are delivered by an interdisciplinary team that supports a limited number of individuals in any setting conducive to the individual. ACT services include monitoring, medication management, service referral, crisis intervention, short-term counseling and other interventions. ACT is provided under the rehabilitative services option.

Many states have used the rehabilitative services option to cover the provision of (P)ACT services (Program of Assertive Community Treatment). As described in Chapter 1, ACT is a mobile, holistic, interdisciplinary approach to supporting people in the community who require especially intensive services. ACT is an evidence-based practice that is an integral component of the Community Support System and has demonstrated cost-effectiveness.6 The goal of ACT is to increase community tenure and reduce the incidence of crisis and hospitalization, enabling the individual to achieve greater integration and stability. ACT programs go by different names in different states (e.g., Intensive Community Treatment) but all are characterized by mobile, 24 hour a day, 7 day a week coverage9 and feature comprehensive treatment planning/ response, continuity of staff, one-on-one services and small caseloads. ACT sometimes is described as a form of case management.10 However, ACT teams are responsible for providing a full range of coordinated services to individuals, including crisis intervention, medication management, skill building and illness management. As of 2003, 18 states furnished ACT under the rehabilitative services option. However, it is challenging to fully cover all ACT services through Medicaid, and, as a result, ACT programs usually are supplemented with state-only dollars. In general, Medicaid funds finance 40-90 percent of the costs of ACT services.11

West Virginia's Coverage of Crisis Services7
West Virginia covers both crisis intervention and stabilization. It also provides crisis support in small community residential settings to support individuals who require a structured setting. West Virginia's crisis coverage is as follows:

Crisis Services are based on a continuum of care ranging from the less restrictive setting (e.g., crisis intervention in the home/community) to a more restrictive setting (treatment in a residential facility).
  1. Crisis Intervention is an unscheduled, face-to-face intervention with a recipient in need of emergency or psychiatric interventions in order to resolve an acute crisis. Depending on the specific type of crisis, an array of treatment modalities is available. These include but are not limited to individual intervention and/or family intervention. The goal of crisis intervention is to respond immediately, assess the situation and stabilize as quickly as possible. Once the crisis is stabilized it would then be appropriate to initiate intensive in-home services or crisis stabilization services.
  2. Crisis Support is a structured program provided in community-based small residential settings. Its purpose is to provide a supportive environment designed to minimize stress and emotional instability that has resulted from family dysfunction, transient situational disturbance, physical or emotional abuse, neglect, sexual abuse, loss of family or other support systems, or the abrupt removal of a recipient from a failed placement or other current living situation. Crisis support services must be available 24 hours a day, seven days a week and consist of an array of services including individual and group therapy, counseling, intensive behavior management, clinical evaluation/assessment, treatment planning and health maintenance/monitoring.
  3. Crisis Stabilization is an organized program of services designed to ameliorate or stabilize acute or severe psychiatric signs and symptoms. This service is intended for any recipient who requires intensive crisis services without the need for a hospital setting and who, given appropriate supportive care, can be maintained in the community while resolving the crisis. Crisis stabilization services must be provided on the written order of a physician or licensed practitioner of the healing arts. Each recipient must have a psychiatric evaluation and an initial crisis stabilization plan developed within 24 hours of service initiation. These services require approval by the Office of Medical Services Utilization Review.


Minnesota's Coverage of Crisis Services8
Minnesota's coverage of crisis services addresses three phases: crisis assessment, intervention, and stabilization. A crisis treatment plan must be prepared as soon as practical. The first two phases are provided to all persons; stabilization is provided as required. In Minnesota, county mental health programs or providers contracted by counties furnish crisis response services. Crisis response team members must complete at least 30 hours of crisis response training every two years. The following is excerpted from the Minnesota Medicaid state plan:

Crisis Assessment is an immediate face-to-face appraisal by a physician, mental health professional, or a mental health practitioner under the clinical supervision of a mental health professional, following a determination that suggests the recipient may be experiencing a mental health crisis. The crisis assessment evaluates any immediate needs for which emergency services are necessary and, as time permits, the recipient's life situation, sources of stress, mental health problems and symptoms, strengths, cultural considerations, support network, vulnerabilities, and current functioning.

Crisis Intervention is a face-to-face, short-term intensive service provided during a mental health crisis to help a recipient cope with immediate stressors, identify and utilize available resources and strengths, and begin to return to the recipient's baseline level of functioning. Crisis intervention must be available 24 hours a day, 7 days a week.
  • Crisis intervention is provided after the crisis assessment.
  • Crisis intervention includes development of a crisis treatment plan, which must include recommendations for any needed crisis stabilization services. It must be developed no later than 24 hours after the first face-to-face intervention. The plan must address the needs and problems noted in the crisis assessment and include measurable short-term goals, cultural considerations, and frequency and type of services to be provided. The plan must be updated as needed to reflect current goals and services. The crisis intervention team must document which short-term goals were met, and when no further crisis intervention services are required.
  • The crisis intervention team comprises at least two mental health professionals, or a combination of at least one mental health professional and one mental health practitioner with the required crisis training and under the clinical supervision of a mental health professional on the team. The team must have at least two members, with at least one member providing on-site crisis intervention services when needed.
  • If possible, at least two members must confer in person or by telephone about the assessment, crisis treatment plan, and necessary actions taken.
  • If a recipient's crisis is stabilized, but the recipient needs a referral to other services, the team must provide referrals to these services.

Crisis Stabilization is an individualized mental health service designed to restore a recipient to the recipient's prior functional level.

  • Crisis stabilization cannot be provided without first providing crisis intervention.
  • Crisis stabilization is provided by a mental health professional, or a mental health practitioner who is under the clinical supervision of a mental health professional, or a mental health rehabilitation worker who works under the direction of a mental health professional or a mental health practitioner.
  • Crisis stabilization may be provided in the recipient's home, another community setting, or a short-term supervised, licensed residential program that is not an IMD. If provided in a short-term supervised, licensed residential program, the program must have 24-hour-a-day residential staffing, and the staff must have 24-hour-a-day immediate access to a qualified mental health professional or qualified mental health practitioner.
  • A crisis stabilization treatment plan must be developed, and services must be delivered according to the plan. A plan must be completed within 24 hours of beginning services and developed by a mental health professional or a mental health practitioner under the clinical supervision of a mental health professional. At a minimum, the plan must contain:
    1. A list of problems identified in the assessment;
    2. A list of the recipient's strengths and resources;
    3. Concrete, measurable short-term goals and tasks to be achieved, including time frames for achievement;
    4. Specific objectives directed toward the achievement of each one of the goals;
    5. Documentation of the participants involved in the service planning. The recipient, if possible, must participate;
    6. Planned frequency and type of services initiated;
    7. The crisis response action plan if a crisis should occur; and
    8. Clear progress notes on the outcome of goals.

ACT is a high-end, intensive service that states reserve (via services eligibility and medical necessity criteria) for individuals with serious mental illnesses. It was originally developed specifically for individuals with schizophrenia or other psychotic disorders who exhibit a particularly high degree of functional impairment (e.g., inability to perform necessary tasks of daily living and/or incapacity to maintain a safe environment or avoid dangerous situations). ACT also is targeted to individuals who have a history of admissions to crisis residential, inpatient psychiatric, or other acute settings, and for whom less intensive mental health services have proven ineffective. ACT can also help to facilitate the transition of individuals from inpatient and other institutional settings to the community. Frequently, individuals who receive ACT have co-occurring disorders (mental illness and substance abuse) and thereby benefit from the integrated mental health/ substance abuse services.

ACT teams maintain frequent, consistent contact with the individuals they support, varying the frequency and duration of services based on the person's progress and needs.12 The composition of an ACT team includes a clinical/administrative team leader, a psychiatrist, registered nurses, a consumer/peer counselor, a qualified mental health professional (e.g., clinical social worker, licensed professional counselor), vocational specialist, and other qualified staff. This multi-disciplinary composition enables the team to address the full range of an individual's needs. ACT teams operate with a staff to consumer ratio in the range of 1:10 to 1:12. Extensive materials concerning (P)ACT are available from the National Alliance for the Mentally Ill.13

The mobile nature of ACT means that, if a state intends to offer ACT in its Medicaid program, the rehabilitative services coverage must be employed. Since ACT teams furnish the full-range of services required by each individual, other mental health services usually are not provided concurrently. Also, the provision of ACT is usually subject to prior authorization and reauthorization.

ACT has been covered under Medicaid by some states for several years. Examples of states with extensive ACT team provider networks include Wisconsin and Michigan. In 1999, HCFA (now CMS) issued a letter to state Medicaid directors (included in Appendix A) explicitly recommending that states seriously consider including ACT as a part of their community-based mental health services based on solid research concerning its efficacy. The letter urged that

"States should consider this recommendation in their plans for comprehensive approaches to community-based mental health services. Programs based on ACT principles can be supported under existing Medicaid policies, and a number of States currently include ACT services as a component of their mental health service package. Consumer participation in program design and the development of operational policies is especially key in the successful implementation of ACT programs."14

While several states now cover ACT in their Medicaid programs, many others have ACT teams that are not covered under the state's rehabilitative services option. In total, 28 states offer ACT in at least part of their state, regardless of funding source.15

Because ACT is interdisciplinary and teams furnish a wide range of services, payment for ACT services is sometimes misunderstood to require the billing of each specific service furnished by the team (e.g., separately billing for nursing services or skill build-ing). However, states are not required to un-bundle ACT services for billing purposes. Instead, ACT services may be billed by time unit (e.g., 15 minute units), provided that the services furnished by a team member are documented as falling under the scope of the state's ACT coverage.

Because ACT teams are operated by provider organizations, it is also not necessary that the billing be submitted by individual team members. The District of Columbia provides an example of a state that covers ACT. An in-depth profile of the operational features of Georgia's ACT coverage are provided in attachment A to this chapter.

ACT Coverage Example: District of Columbia
The District specifically spells out the amount and scope of ACT services directly in its state plan, providing that "The consumer's ACT Team shall complete a comprehensive or supplemental assessment and develop a self care-oriented Individualized Service Specific Plan (ISSP) (if a current and effective one does not already exist). Services offered by the ACT team shall include:
  1. mental health-related medication prescription, administration and monitoring;
  2. crisis assessment and intervention;
  3. symptom assessment, management and individual supportive therapy;
  4. substance abuse treatment for consumers with a co-occurring addictive disorder;
  5. psychosocial rehabilitation and skill development;
  6. interpersonal social and interpersonal skill training;
  7. education, support and consultation to consumers' families and/or their support system."16

Intensive Case Management

Some states cover a somewhat less exhaustive team-delivered service than ACT that is sometimes called "intensive case management" (ICM) (which should not be confused with targeted case management). ICM programs are structured similarly to ACT but are of a lower intensity, although there are similarities in the profiles of individuals served and the use of a team-based approach to service delivery. Making both ACT and ICM available can be a useful strategy for accommodating the diversity of the seriously mentally ill population as well as the changing needs of a given individual over time. Maine is an example of a state that offers both ICM and ACT under its rehabilitative services coverage. In Maine, ICM teams furnish "intensive interventions and supports to clients who otherwise might not be engaged in more traditional mental health services." ICM is also covered by some states that do not offer a standalone ACT program under Medicaid.

ICM (which can also go by other names such as mobile treatment teams) usually furnish services similar to ACT but often with higher consumer to staff ratios and more limited service availability (i.e., they may not be available around the clock). Services and supports are available wherever they are needed within the community. As is the case with ACT, ICM providers are expected to furnish a full range of services.

Missouri's Coverage of Intensive Case Management
Missouri's "Intensive Community Psychiatric Rehabilitation" provides an example of Intensive Case Management (ICM). There are many similarities between Missouri's ICM coverage and ACT; however, the ICM program is time-limited and does not have the same staffing ratio and requirements of ACT.17 Missouri's coverage is as follows:
Intensive community psychiatric rehabilitation is a level of support designed to help recipients who are experiencing an acute psychiatric condition to be served in the community, thereby alleviating or eliminating the need to admit them into a psychiatric hospital or residential setting. It is a comprehensive, time limited, community-based service delivered to recipients who are exhibiting symptoms that interfere with individual or family life in a highly disabling manner.

Intensive community psychiatric rehabilitation is intended for the following recipients:
  • Persons who would be hospitalized without provision of intensive community based interventions; or
  • Persons who have a history of extended or repeated hospitalizations; or
  • Persons who have crisis episodes; or
  • Persons who are at risk of being removed from their home or school to a more restrictive environment; or
  • Persons who require assistance in transitioning from a highly restrictive setting to a community-based alternative, including, specifically, persons being discharged from inpatient psychiatric settings who require assertive outreach and engagement.

Intensive community psychiatric rehabilitation is provided by treatment teams delivering services that will maintain the recipient within the family and significant support systems, and assist recipients in meeting basic living needs and age appropriate developmental needs.

A treatment team comprising individuals required to provide specific services identified on the Individualized Treatment Plan (ITP) delivers this level of service to recipients who meet the community psychiatric rehabilitation (CPR) eligibility criteria.

Illness/Disability Management

Illness management, an important evidence-based practice, involves educating the consumer to improve coping strategies, utilize medications more effectively, and reduce relapses and hospitalization.

The ability to understand and self-manage one's own mental illness is central to recovery. Illness/ disability management is a recognized evidence-based practice. Individuals can be successfully educated about their own warning signs of relapse and can develop relapse prevention plans and strategies to guard against its occurrence.18 Illness management is sometimes referred to as disability or symptom management. The main thrust of illness management is to equip individuals with skills to help them manage all aspect of their illness and its impact on their lives. Its ultimate goal is to allow individuals to progressively take greater command of their own lives and recovery. The skills imparted include day-to-day coping skills, anticipating the need for services, evaluating treatment and clinical options, symptom management skills, and others needed to manage one's illness. Illness management can be covered under the rehabilitative services option.

Twenty-four states cover illness management under Medicaid for individuals with serious mental illnesses. New Hampshire provides an example of a state that offers illness management as a core community mental health service covering many dimensions of community support (e.g., skill development and psychotherapeutic interventions) and, hence, serves more ends than strictly illness management. However, the overall thrust of the coverage is illness management and recovery.

New Hampshire's Coverage of Illness Management Services
New Hampshire stresses recovery-oriented illness management services. New Hampshire added Mental Illness Management Services (MIMS) to its Medicaid program in 1992. MIMS consists of a menu of services delivered in the community that are designed to enhance individuals' ability to manage their mental illness and live independently in the community. In 2002, over 900 adults received MIMS. The coverage spans several dimensions, including educating the person about coping mechanisms when symptoms emerge, developing skills to handle daily tasks and social/ professional/medical interactions, and assisting the person to develop stronger communication and conflict resolution skills. Individuals may receive one or several of these services depending on their needs and can receive them in either a clinic setting, the home, or work environment.19 New Hampshire's rules define MIMS as follows:20

MIMS shall be face-to-face interventions, and include the following elements and objectives:
  1. Group therapeutic intervention, which shall have as its objective the development and maintenance by a client of skills needed to successfully interact with other persons in the community, including the following skills: (a) conflict resolution; (b) personal responsibility; and (c) communications.
  2. Medication education, which shall have as its objective the development by a client of the skills necessary to comply with physician prescribed medication;
  3. Symptom management, which shall have as its objective the identification and minimization of the negative effects of psychiatric symptoms which interfere with a client's daily living, financial management, personal development, and community integration;
  4. Individual psychotherapeutic intervention, which shall have as its objective the development by a client of interpersonal and self-care skills and an understanding of his or her mental illness to enable the client to adapt to community settings in which he or she lives and functions;
  5. Supportive counseling, which shall: (a) include interactions with a client and/or persons in the client's immediate support system; and (b) have as its objective the development and/or maintenance of client growth and supports necessary for that client to manage his or her mental illness;
  6. Crisis management, which shall: (a) include client training regarding management of a psychiatric crisis; and (b) have as its objective the ability of a client to identify a psychiatric or personal crisis, implement the crisis management plan identified in the client's ISP, if appropriate, and/or seek needed support from either residential or clinical staff; and
  7. Family support provided to a client and/or family member(s), if the client and family member(s) wish to receive this service, which shall: (a) include family education and consultation; and (b) have as its objective the development and maintenance of family support systems and/or better management by the client of his or her mental illness.

New Hampshire also specifically provides that individuals who have experienced mental illness and family members can qualify as program staff based on their direct experiences. The state provides for per diem payment of MIMS when it is furnished in a licensed community residence and time/unit billing when it is not.

Peer Support

Peer support and peer-delivered services are central to the recovery movement and can cross a variety of service categories. Peer support services are delivered from consumer to consumer. Several states provide that individuals who have experienced a mental illness may qualify to furnish services such as community support and skills training.

Because peer support is a hallmark of the recovery movement and an essential element of community support, more states are incorporating peer support and peer-delivered services into community mental health services. Peer support stresses that individuals -- with the assistance of peers -- should play an active and direct role in their own recovery, thereby promoting hope and empowerment and enhancing their own ability to live successfully in the community. Moreover, enlisting trained individuals who themselves have experienced serious mental illnesses to support their peers brings the consumer perspective to the front lines of recovery. Peers may furnish clubhouse-style peer counseling to support consumers in managing their illness, telephone support to ensure consumers are ready and on-time for work, on-site crisis management, and other relevant recovery supports. This support can greatly assist individuals by increasing their ability to self-manage their symptoms, advocate for themselves, and utilize effective coping skills to avert potential crisis situations.21`

Essentially, there are two avenues for covering peer support and peer-delivered services. Peer support may be covered as a distinct rehabilitative services benefit. States can also weave peer-delivered services into other covered rehabilitative services, such as living skills training or social support, by enabling individuals who have experienced a mental illness to qualify as practitioners. As previously noted (see Box p. 78), New Hampshire's MIMS coverage provides for qualified peers to furnish some services. In the case of ACT, program standards require that a peer be a member of the ACT team.

"Studies show that consumer-run services and consumer-providers can broaden access to peer support, engage more individuals in traditional mental health services, and serve as a resource in the recovery of people with a psychiatric diagnosis. Because of their experiences, consumer-providers bring different attitudes, motivations, insights, and behavioral qualities to the treatment encounter."22

Currently, eleven states23 offer peer support services in some form, mostly by providing for peers to qualify as practitioners of rehabilitative services. Iowa provides an example of a state that enlists peers in the provision of services. At this point, only two states (Georgia and South Carolina24) have implemented a distinct Medicaid peer support coverage under the rehabilitative services option. Georgia's precedent setting coverage is described in Attachment B to this Chapter. Georgia also has incorporated peer-delivered services into many of its other rehabilitative services.

Supports for Community Living

Many working-age adults with serious mental illnesses require skills restoration training to overcome the functional limitations that accompany their illness and live in the most integrated setting possible. This training is a vital component of recovery-oriented services and promotes independence. Services such as targeted case management also can play an important role in assisting individuals to secure stable housing.

The fundamental purpose of Medicaid rehabilitative services coverage is the restoration of func tioning. Serious mental illness is accompanied by significant functional limitations in areas such as basic living and social skills. Furnishing rehabilitative services that address these limitations and equip individuals to function more independently is an essential ingredient in promoting successful community living for working age adults with serious mental illnesses. In order to qualify as a rehabilitative service, services furnished to improve living skills must have a restorative focus.

Peer Support Counselors in Iowa25
Iowa has integrated peer-delivered services into the package of services it offers under the rehabilitative services option by providing that some services may be furnished by peer support counselors. A peer support counselor is defined as "a person who has been diagnosed with a chronic mental illness, who provides counseling and support services to other adults with the same or a similar diagnosed mental illness."26 A peer support counselor must meet five requirements: (1) Successfully complete training that is supervised by an LPHA (Licensed Professional of the Healing Arts - an MD or licensed psychologist); (2) Abide by professional ethics adopted by National Board of Certified Counselors that bind licensed mental health counselors; (3) Provide qualified services that are aligned with the rehabilitative portion of an individual's treatment plan, and that are supervised by an approved professional;(4) Demonstrate competency in service delivery as determined by meeting professional standards of a national organization overseeing that particular service area; and (5) Provide services through employment or by a contract with a Medicaid-approved provider.27 Peer support is not defined as a distinct service but is woven into other rehabilitative services, including (1) community living skills training; (2) employment-related services; and (3) day program services for skills training and development.

A substantial majority of states cover the restoration of basic or daily living skills as a rehabilitative service. These services assist individuals to live more independently by enabling them to do more for themselves. Such services can include "training, guiding, supervising, cueing or reminding, or techniques to teach how to overcome barriers by changing how the person interacts with his/her environment."28 The span of basic or daily living skills addressed through these services can be quite wide-ranging, including IADLs such as food preparation, money management, grocery shopping, personal hygiene, medication self-administration and housekeeping. As discussed in Chapter 4, the actual performance of daily activities (e.g., meal preparation) for a person requires alternate coverage under the personal care/ assistance category. Iowa (below) and Minnesota (following page) provide examples of the coverage of basic living skills.

In a similar vein, the restoration of social and interpersonal skills focuses on developing interpersonal relationships, solving problems and resolving conflicts. Most states cover the restoration of these skills as a rehabilitative service.

Keeping in mind the broad goal of achieving maximum community integration, functioning, and recovery, sixteen states offer elements of social and recreational supports under the rehabilitative services option. States may provide certain services that facilitate the development of social networks, increase environmental adaptability, and ultimately strengthen an individual's ability to live independently. These services are aimed at employing recreational activities that focus on reducing isolation and withdrawal and that support goals identified in an individual's treatment plan. For example, Missouri's psychosocial rehabilitation coverage includes "participation in informal and organized group activities to help reduce stress and improve coping, which are normative to the community, such as exercise, self-education, sports, hobbies, supportive social networks, etc."29 However, social/recreational activities not aimed at recovery-related or therapeutic objectives may not be covered under Medicaid.

Some states have distinct coverages of services for the restoration of basic living skills, social, interpersonal and other skills; elsewhere, states combine these services with others.

Supporting Individuals in Community Living Arrangements

Promoting successful community living for working age adults with serious mental illnesses involves not only meeting their service needs but also aiding them to secure housing. Having a stable living arrangement is extremely important. There is a strong correlation between homelessness and mental illness -- 46 percent of U.S. adults who experience homelessness at least once in a given year have also had a mental health problem during that year.30 The importance of stable housing was underscored by the President's New Freedom Commission on Mental Health, which asserted that "The lack of decent, safe, affordable, and integrated housing is one of the most significant barriers to full participation in community life for people with serious mental illnesses."31

Medicaid and especially rehabilitative services can contribute significantly to successful community living by underwriting services and supports in a person's living arrangement. But, other resources must be tapped in order to secure housing for individuals who cannot afford it. Except in the case of Medicaid-funded institutional services (e.g., nursing facilities), Medicaid dollars cannot be used to pay for housing or other living expenses ("room and board") of Medicaid beneficiaries. This policy encompasses all types of Medicaid community services for people with disabilities. As in the case of some other services (e.g., employment) that contribute to recovery, successful community living strategies cannot rely solely on Medicaid funding. Tapping federal, state, local and private housing resources -- along with a person's own resources -- is critical to help individuals maintain stable housing. Medicaid funding can then be employed to bring services and supports into their living arrangements.

Iowa's Coverage of Services for Restoration of Basic Living Skills
Iowa offers a good example of a typical state's coverage, offering "services [that] are age-appropriate skills training or supportive interventions that focus on the improvement of communication skills, appropriate interpersonal behaviors, and other skills necessary for independent living or, when age-appropriate, for functioning effectively with family, peers, and teachers. Training for independent living may include, but is not limited to, skills related to personal hygiene, household tasks, transportation use, money management, the development of natural supports, access to needed services in the community (e.g., medical care, dental care, legal services), living accommodations, and social skills (e.g., communicating one's needs and making appropriate choices for the use of leisure time)."32


Minnesota's Coverage of Services for `Living and Social Skills33
Minnesota ties together training in living and social skills in its "Mental Health Basic Living and Social Skills" coverage:

ARMHS [Adult Rehabilitative Mental Health Services] Basic Living and Social Skills are activities that restore a client's skills essential for managing his or her illness, treatment, and the requirements of everyday independent living. These skills need to be restored if recipients are to be able to leave inpatient or residential programs and live independently in the community. If these abilities are not developed clients may require inpatient or other intensive services. [Services are furnished to] Instruct, assist, and support a recipient in areas such as:
  • Interpersonal communication skills
  • Transportation skills
  • Community resource utilization and integration skills
  • Mental illness symptom management skills
  • Crisis assistance
  • Medication monitoring
  • Relapse prevention skills
  • Household management skills
  • Health care directives
  • Employment-related skills
  • Budgeting and shopping skills
  • Transition to community living
  • Cooking and nutrition skills

Community living is best exemplified through a supportive housing model, which assists individuals to live in community-integrated living arrangements. Supportive housing programs adhere to four basic tenets: permanence and affordability, safety and comfort, accessibility and stability, and empowerment and independence.35 Supportive housing for persons with serious mental illnesses includes several fundamental components -- assistance to tenants to help them understand and meet the requirements of tenancy, comprehensive assessment, coordination of psychiatric services, medication management, crisis services, connections to other community resources, and staff training.36 Several of these components (e.g., basic living/social skills training, assessment services/targeted case management, medication management, and crisis intervention) can be covered under Medicaid. It is estimated that Medicaid can underwrite anywhere from 25 to 80 percent of the services that fall under the "supportive housing" umbrella.37 The rehabilitative services option provides a means to fund many services that are integral to supportive housing. Assisting individuals to access housing support programs and/or locate affordable housing is Medicaid reimbursable through targeted case management. More information on the role that Medicaid can play in supportive housing is found at the Corporation for Supportive Housing web site.38

Impact of Community Housing
A 2003 survey by the Tennessee Department of Mental Health and Developmental Disabilities (TDMHDD) found that individuals with mental illnesses who were provided a community residential placement experienced a sharp reduction in their admissions to psychiatric hospitals. In the two years after relocating into homes, a sample of 105 individuals experienced a total of 10 hospital admissions, compared to 154 before placement. The state's Creating Homes Initiative, a targeted, grassroots, local community, multi-agency collaborative operated by the TDMHDD Office of Housing Planning and Development has spearheaded the department's efforts to develop and expand permanent housing options (including group homes, apartments, and home ownership) and services for people with mental illness and co-occurring disorders.34

The rehabilitative services option permits states to furnish therapeutic support services in the person's living arrangement. Such living arrangements can include the person's own home, his or her family's home if that is where the individual lives, and other living arrangements (e.g., supervised apartments, group homes, and other congregate arrangements) operated by mental health service providers. With respect to the latter, Medicaid services furnished at such sites are reimbursable as long as the living arrangement does not run afoul of the IMD exclusion (i.e., do not have more than 16 beds), and the services furnished have a rehabilitative purpose. The types of services and supports furnished at a person's living arrangement cover a wide array of typical rehabilitation services, including basic living skills training, medication management, illness management, and other therapeutic interventions.

State approaches to the provision of services and supports to people in their living arrangement vary. In some instances, states simply provide that rehabilitative services may be delivered in any community location, including a person's private residence. Some states explicitly cover rehabilitative services in licensed community residences as "residential services" or distinctly provide for their delivery in a variety of living arrangements. Often, the use of licensed community residences is reserved for individuals who require some level of continuous oversight and a more structured setting. Nebraska's residential services coverage provides an example of how a state can employ supervised community residences as a bridge to more independent living arrangements. Maine's coverage of "in-home support" (following page) illustrates another approach by furnishing services not only in licensed community settings but also a person's own home.

While Medicaid funding is not available to pay for housing and other everyday living expenses, the rehabilitative services option can be employed to bring critical services into a wide variety of community living arrangements. As pointed out by the President's Commission, the aim should be to create "flexible, mobile, and individualized support services…to support and sustain consumers in their housing."39

Employment-Related Services

Employment-related services that support entry into or maintenance of employment may be furnished under Medicaid. They can include onsite crisis supports, symptom management and others. Job searching services and job training and coaching are not eligible for Medicaid reimbursement.

For individuals with serious mental illnesses, securing employment is an important step in their recovery and their living successfully in the community. Many adults with serious mental illnesses strongly desire to work, yet very few are in fact working. According to the President's New Freedom Commission, there is a 90 percent unemployment rate among this population.40 Anecdotal evidence of the importance of employment as a consumer service abounds. Each year, the Georgia Mental Health Consumer Network asks individuals about their top priorities, and the answer consistently is "wanting jobs … better jobs."42

Nebraska's Residential Services Coverage
The Psychiatric Residential Rehabilitation Program is designed to
  1. Increase the client's capabilities, resources, and functioning so that she or he can eventually live successfully in the residential setting of his or her choice;
  2. Decrease the frequency and duration of hospitalization.

The Psychiatric Residential Rehabilitation program provides skill building in community living skills, daily living skills, medication management, and other related psychiatric rehabilitation services as needed to meet individual client needs. Psychiatric Residential Rehabilitation is a facility-based, non-hospital or non-nursing facility program for persons disabled by severe and persistent mental illness, who are unable to reside in a less restrictive residential setting. These facilities are integrated into the community, and every effort is made for these residences to approximate other homes in their neighborhoods.

Program Components: The program provides

  1. Community living skills and daily living skills development.
  2. Client skills development for self-administration of medication, as well as control of symptoms and recognition of signs of relapse.
  3. Skill building in the usage of public transportation and/or assistance in accessing suitable local transportation to and from the Psychiatric Residential Rehabilitation program.

Licensure Requirements: The program shall be licensed as a Residential Care Facility, Domiciliary, or Mental Health Center by the Nebraska Department of Health.

Staffing Requirements: The program must have appropriate staff coverage to provide services for clients needing to remain in the residence during the day.

Bed Limitation: The maximum capacity for this facility shall not exceed eight beds. Waivers for a maximum of ten beds may be granted when it is determined to be in the best interests of clients.

Supportive Services: The program provides the following supportive services for all active clients: referrals, problem identification/solution, and coordination of the Residential Rehabilitation program with other services.41


Maine's Coverage of In-Home Support
In Maine, community support rehabilitative services are furnished to individuals who have a "severe and disabling mental illness." In-home support is furnished to individuals who require some measure of personal supervision in addition to therapeutic supports services. The following description of in-home support is excerpted from the Maine Medical Assistance Manual:

In-home support is personal supervision and therapeutic support services provided to an adult with major mental illness in his or her home or temporary living situation pursuant to an individual support plan (ISP). These services are provided in order to allow a person to maintain the highest level of independence possible. To the degree possible, persons using this service will participate in the hiring and training of the support worker. In-home support has two levels of service as indicated in A and B below.

  1. Transitional Living Skills Services are those services that focus on assisting a consumer on a short-term basis (up to one year)to learn or further develop those skills deemed necessary or desirable to maintain and enhance community tenure and achieve the consumer's goals as identified in his or her ISP. Related to the ISP, a transitional living skills service plan must be developed specifying ISP goal area(s); a beginning and ending date for the provision of the services; and a specific number of hours and the times that the living skills services will be provided. Transitional Living Skills Services are billed at an hourly rate, and may be provided up to 24 hours per day (recipient sleep time is not Medicaid reimbursable). The transitional living skills service plan must be reviewed quarterly as part of the ISP in the required ninety calendar day review cycle to determine on-going medically necessary needs.
  2. Intensive Living Skills Services are those services which focus on assisting an individual either living in his or her own home or in a shared housing situation (i.e., state licensed supervised apartment, group home, state licensed congregate living program) to learn or maintain skills necessary for independent community living. These services may be required for an indefinite period of time but may change over time to respond to the changing medically necessary needs of the individual. Related to the ISP, a long- term living skills plan will be developed stating specific goals and objectives. Service goals might include providing personal supervision for the tasks related to personal skill development, assistance in daily living skills activities, community integration and monitoring of medication. Intensive Living Skills Services are billed on a per diem basis. The intensive living skills plan must be reviewed quarterly as part of the ISP in the required ninety calendar day review cycle to determine ongoing medically necessary needs and level and type of services required.
    In addition to in-home support, Maine also provides under its community support coverage of day treatment/ rehabilitation services, home support services that "are those therapeutic and skill development/maintenance services provided in a person's own environment."

Chapter 3 outlined the options available to states that permit individuals with disabilities to maintain Medicaid eligibility after they are successfully employed. State adoption of the Medicaid "buy-in" option is an important step in overcoming an important barrier to employment -- namely, the loss of Medicaid eligibility due to excess earnings. Many working-age adults with serious mental illnesses need supports in order to secure and maintain employment. Supported employment is a recognized evidence-based practice. Furnishing supports to individuals that lead to their employment can result in reductions in their utilization of mental health services and promotion of their self-esteem and recovery. In order to secure and maintain employment, individuals may need basic or daily skill development services along with other relevant skill training to function successfully in the work place (sometimes called social and interpersonal skills.) Illness management services can also help an individual to maintain employment. Additionally, peer supports can also be very helpful in aiding and encouraging individuals to work. Targeted case management services also can be useful in connecting individuals to employment services, including vocational rehabilitation.

Another dimension of employment is job-specific training. Federal Medicaid policy, however, prohibits the use of Medicaid funds to pay for "vocational" services (including sheltered workshops), except under limited circumstances.43 As a consequence, it is not possible to employ the rehabilitative services option to underwrite the costs of job-specific training (e.g., job coaches) in order to craft full-featured supported employment services. Consequently, when it is a state's aim to promote employment, it is necessary to complement the supports that fit under the rehabilitative services option by tapping other resources to secure job-specific training services for individuals. Those resources can include vocational rehabilitation services or funding, jobs programs, or other non-Medicaid state and local funds. Depending on the funding source, it can be especially important to coordinate mental health and vocational services.

Irrespective of funding source, at least 43 states provide some type of supported employment service to consumers with mental illness. In the context of the rehabilitative services option, however, about 30 states include employment-related services in their programs. Some states break these services out separately while others include them in other skills-related service coverages. Texas and Kansas provide examples of states that have specifically broken out employment-related services under the rehabilitative services option. Iowa's coverage qualifies supported employment providers to furnish these services in addition to mental health agencies.

Using Personal Care Services In the Work Place

As noted in Chapter 4, Utah (as well as other states) recently added the coverage of "employment-related personal care/assistance services. This coverage is available to support individuals with serious mental illnesses who are returning to work. Utah is working with a major mental health agency to employ personal care to support individuals in the Salt Lake City area, illustrating that supporting people with serious mental illness in their return to work need not necessarily be confined to the use of the rehabilitative services option. This effort is described on the following page.

Family Education

Family psychosocial education and therapy services include educating the family about the nature of a person's mental illness and training family members how to support the person and to problem solve.

Educating family members and significant others about the nature of an individual's mental illness and enlisting their active participation as members of the treatment team in support of the individual is an essential component of the Community Support System and a recognized evidence-based practice. According to SAMHSA, individuals whose families actively participate in a psychoeducation program show a significant decline in relapse rates and re-hospitalizations. In some cases, these rates can decrease by as much as 50 percent over the course of a year.44 As noted in Chapter 2, a substantial percentage of working-age adults with serious mental illnesses live with their families. Medicaid can play an important role in underwriting family-education. So long as these services focus on addressing the needs of the Medicaid beneficiary, they are eligible for Medicaid funding. For example, Ohio stipulates that these services must be "directed exclusively to the well-being and benefit of the person served and are assistive to maintaining independent living in the community."45 A wide range of family education activities meet this test.

Thirty-one states offer some type of family education services. In general, family support/ education includes educating the family about the nature of the individual's illness, resolving confusion about the family member's treatment plan and its goals, equipping the family with skills to help the person in managing his or her illness (e.g., symptom and medication management) and dealing with crises, and problem-solving. Family education services are only furnished when the individual agrees that the family member or significant other may participate.

Texas' Coverage of Employment-Related Services
Texas offers employment-related services that provide "age appropriate training and supports that are not job specific, and have as their focus the development of skills to reduce or overcome the symptoms of mental illness that interfere with the individual's ability to make vocational choices, attain, or retain employment. Included are activities such as skills training related to task focus, maintaining concentration, task completion, planning and managing activities to achieve outcomes, personal hygiene, grooming, communication, and skills training related to securing appropriate clothing, developing natural supports, and arranging transportation. Also included are supportive contacts in school, or on-or-off the work-site, to reduce or manage behaviors or symptoms related to the individual's mental illness that interfere with job performance, or progress toward the development of skills that would enable the individual to obtain or retain employment."46


Kansas' Coverage of Employment-Related Services
Kansas defines employment-related services as: "Assistance which shall have as its objective the development and implementation of a plan for assuring appropriate consumer community integration and the provision of both supportive counseling and problem-focused interventions in whatever setting is required to enable consumers to manage the symptoms of their illness. Services provided at the worksite must be focused on assisting the individual to manage the symptom of mental illness, and not to learn job tasks. These interventions will fall primarily in the areas of achieving the required level of concentration and task orientation, and facilitating the establishment and maintenance of effective communications with employers, supervisors and co-workers."47


Utah's Coverage of Employment-Related Personal Assistance
In 2003, Utah received CMS approval to furnish employment-related personal care services. Valley Mental Health - the behavioral health contractor for the Salt Lake City area - and the Utah Medicaid program are collaborating to employ this benefit to furnish people with mental illnesses a short-term personal care assistant to facilitate their return to work. Utilization data has shown that individuals with serious mental illnesses who do manage to secure employment often experience an immediate spike in their symptoms due to increased stress and anxiety, frequently leading to a rapid loss of employment, which thrusts them full-time back into high-intensity services. In an effort to combat this, the Utah Medicaid program is working through Valley to arrange for "frontloaded" personal assistance for individuals with serious mental illnesses to re-enter the job market. During the first 90 days of employment, consumers would receive intensive personal care services to help them ease into the new situation. As their stress level decreases and they become more accustomed to the job, personal care hours would taper off until the individual no longer requires them. The hope is that not only will the consumer be more likely to retain employment, but also that the use of crisis and other intensive services can be avoided.48

In addition to assistance with ADLs and IADLs, the Utah coverage provides for transportation to and from the workplace, case management support to access and coordinate services and supports available at the work site, and coordination of employment-related personal care with other Medicaid state plan services. These include home-based personal care and services "designed to assist an individual with a disability to perform daily activities on and off the job that the individual would typically perform if they did not have a disability." Employment-related personal care services are available through agencies or through individual personal assistants who are employed by the beneficiary. Utah requires that, for this arrangement, the beneficiary use the services of an approved intermediary to coordinate claims submittal and payments (including tax payments).

Vermont offers "collateral contact" to family members or other significant individuals, which includes "meeting, counseling, training or consultation" services. The type of services needed are left up to the discretion of the family.49 Maine, in its rehabilitative services coverage, provides for "family education and consultation, if desired by a person receiving community support services and his or her family, in order to help family members develop support systems and help the person manage his or her mental illness."50

Family education is distinguishable from the "family therapy" psychiatric therapeutic treatment modality because it envisions an active role for the family in aiding the person's recovery.

Medication Management

Medication management is a body of practice that stresses the selection of appropriate medications for individuals, along with continuing review and the provision of additional services that reinforce individuals' adherence their medication regimen.

The emergence of evidence-based practices is beginning to influence state coverages of certain types of services. For example, states frequently cover medication management and education under Medicaid. As discussed in Chapter 4, medications can play an important role in the treatment of serious mental illnesses. The typical focus of medication management is to make sure that individuals follow their medication regimen and are educated about the importance of adhering to the regimen. Medication management as an evidence-based practice, however, envisions a more intensive course of treatment that is now beginning to be reflected in some state coverages. The District of Columbia (following page) provides an example of an especially comprehensive coverage of medication management services.

Medication "algorithms" have also emerged as an important medication management practice; at least 21 states utilize some type of algorithm in part or all of their state.51 A medication algorithm is a set of best-practice clinical procedures that physicians are encouraged to follow in treating consumers. Medication algorithms focus on specific types or classes of medications (i.e., newer atypical anti-psychotics) and also include other best practice procedures such as patient and family education. One state that has developed a noteworthy Medicaid medication algorithm program is Texas. The Texas Medication Algorithm Project (TMAP) began in 1996 and focuses on the implementation of public services, as well as to promote the cost-effective provision of services. Specifically, TMAP focuses on adults with schizophrenia, bipolar disorder, and major depressive disorder, and comprises four distinct parts:

District of Columbia: Medication Management Coverage
In the District of Columbia, medication treatment and management are combined. Medication/Somatic Treatment services encompass a full range of services related to the prescription and monitoring of the effects of medications as well as medication education. In particular:

"Medication/Somatic Treatment services are medical interventions including physical examinations; prescription, supervision or administration of mental health-related medications; monitoring and interpreting results of laboratory diagnostic procedures related to mental health-related medications; and, medical interventions needed for effective mental health treatment provided as either an individual or group intervention. Medication/Somatic Treatment services include monitoring the side effects and interactions of medications and the adverse reactions a consumer may experience, and providing education and direction for symptom and medication self-management. Group Medication/Somatic Treatment shall be therapeutic, educational and interactive, with a strong emphasis on group member selection, facilitated therapeutic peer interaction and support.52"
  1. Medication treatment algorithms derived from evidence-based, scientific practice;
  2. Supporting the provider with technical assistance and clinical guidance in algorithm implementation;
  3. Patient and family education; and
  4. Documentation of treatment provided and consumer outcomes.

TMAP stresses the importance of a global approach that enlists providers, physicians, consumers, and family members in maximizing treatment effectiveness and reducing inefficiencies in the service delivery system. According to state officials, adults who participated in TMAP fared better than those who did not in areas such as symptomatology, cognition, and need for hospitalization.

Missouri is currently implementing a program that is similar to TMAP but focuses specifically on a physician education approach to medication management. The Missouri Department of Mental Health and the Division of Medical Services (the state's Medicaid agency) have joined forces to pilot a privately-funded physician education/algorithm approach to Medicaid psychiatric drug management. The goals of the Collaborative Behavioral Health Project are to: (a) improve the quality and consistency of medication prescribing practice based on national best practice guidelines; (b) improve adherence to medication plans; and, (c) lower prescribed drug outlays.

Through the project, physicians are provided reports based on Medicaid claims data that profile and compare their practices to best practice guidelines and include: (a) psychiatric medications prescribed by a physician for each Medicaid beneficiary during a given month; (b) any other Medicaid psychiatric prescriptions filled by any beneficiaries on the provider's list (i.e., medications prescribed by another physician); and (c) indicators where the physician's prescriptions were not in accordance with clinical best practices (e.g., prescribing an outdated antipsychotic medication). This feedback is purely informative -- providers are not "punished" for their prescription habits. The aim is to give physicians a complete picture of their prescribing practices and prompt changes in accordance with best practices. Since these reports are generated monthly, the state can see whether or not changes are actually occurring.

This program began in January 2003 and each month, between one-third and one-half of providers are reported to be altering their prescription practices based on information they receive. In addition, physician feedback about the program has been overwhelmingly positive. While specific figures are unavailable, Missouri estimates that the program has provided a substantial cost-savings.53

Supporting Individuals with Co-Occurring Disorders

Individuals with co-occurring disorders can pose a variety of service delivery challenges. This section provides information concerning services for individuals with co-occurring substance abuse disorders and co-occurring developmental disabilities. It describes efforts to effectively meet the needs of these individuals.

A significant number of individuals with serious mental illnesses also have a co-occurring disorder.54 Substance abuse is a frequently co-occurring disorder among working-age adults with serious mental illnesses. There are also a significant number of individuals with developmental disabilities who have a co-occurring serious mental illness. Effectively supporting individuals with co-occurring disorders poses three principal challenges:

  • Treatment/practice. One major challenge is identifying and applying integrated, effective treatment strategies that concurrently address both disorders. Parallel or sequential treatment of each disorder is frequently not effective in meeting individuals' needs.
  • Service Delivery. State service delivery systems typically are organized to serve individuals who have a single "primary" disorder. Problems often arise in bringing to bear the necessary expertise and services to serve persons whose co-occurring disorders cross system lines.
  • Finance. Disorder-specific "funding silos" can make it difficult to marshal the financial resources needed to serve persons with co-occurring disorders.

Surmounting these challenges often requires pursuing multiple strategies, including disseminating information about effective treatment strategies, cross-training provider staff, re-aligning service delivery system structures and policies, and promoting effective collaboration at the local level.

Federal Medicaid policies, of course, most directly bear on the question of financing services for individuals with co-occurring conditions. The following sections describe policies affecting services for persons with serious mental illnesses with co-occurring substance abuse disorders and developmental disabilities. Examples of how various states support these individuals using Medicaid dollars are provided.

Services for Individuals with Co-Occurring Substance Abuse Disorders

In 2001, an estimated 20 percent of adults with serious mental illnesses were dependent on or abused alcohol or illicit drugs.55 An estimated 3 million adults had both a serious mental illness and a substance abuse disorder.56 It also is estimated that more than one-half of all individuals with serious mental illnesses served through the public mental health system have co-occurring substance abuse disorders. There is a growing recognition that co-occurring substance abuse disorders are the "expectation, not an exception" among individuals with serious mental illnesses.57

Individuals with mental and substance abuse disorders pose major challenges for public systems. They experience high rates of homelessness, hospitalization, and criminal justice system involvement. The costs of serving these individuals are estimated to be about twice as great as persons with a single disorder. However, only about 19 percent of individuals with serious mental illnesses who have a co-occurring substance abuse disorder are treated for both disorders and many are not treated for either.58 When individuals with co-occurring disorders receive effective services, they experience substantially better outcomes, and the high costs associated with frequent hospitalization and incarceration are significantly reduced.

A consensus exists that integrated treatment, which combines mental health and substance abuse services within the same, multidisciplinary system of care, is the most effective approach to successfully serving persons with co-occurring substance abuse disorders. As noted in Chapter 1, "Integrated Dual Disorder Treatment" is a recognized body of evidence-based practice that leads to demonstrably higher rates of dual recovery and thereby reduced costs. In 2001, the majority of states were implementing this practice statewide or in some parts of their states.59

Several barriers have been identified to effectively serving individuals with co-occurring mental illnesses and substance abuse disorders. Two major barriers are:

  • Mental health and substance abuse services usually are delivered through distinct service delivery systems at the state and local levels. This can result in fragmented services and clouded lines of responsibility for serving persons with co-occurring disorders, sometimes causing individuals to bounce between systems or be denied services by one system due to the presence of the other disorder. Accompanying funding and regulatory silos frequently make it difficult to coordinate and integrate the delivery and financing of needed services.
  • The lack of clinicians and other mental health professionals who are cross-educated and trained and have expertise in serving individuals with co-occurring disorders.

Several states have taken steps to address these problems. In about one-half of the states, a single state agency (often termed a "behavioral health" authority) administers both mental health and substance abuse services; many states have carried consolidation of service delivery down to the regional or local level.60 For example, New Mexico created a behavioral health authority in 1997 and, since, has taken several additional steps aimed specifically at improving services for individuals with co-occurring disorders, including integrating such services at the regional level.61

Elsewhere, state mental health and substance abuse authorities are collaborating to strengthen services for individuals with co-occurring disorders, including implementing "no wrong door" policies. In 2003, for example, the Texas Department of Mental Health and Mental Retardation (TDMHMR) and the Texas Commission on Alcoholism and Drug Abuse concurrently issued rules specifically to ensure that individuals with co-occurring psychiatric and substance abuse disorders are not denied services in their respective systems because of a co-occurring disorder. The TDMHMR rules include standards to "ensure the effective and coordinated provision of services to individuals who require specialized support or treatment due to co-occurring psychiatric and substance abuse disorders." These standards apply to community mental health services underwritten with Medicaid and other funds. They spell out both knowledge and technical competencies that provider staff must possess, as well as standards of care.62

In a similar vein, the Missouri Department of Mental Health's Divisions of Comprehensive Psychiatric Services and Alcohol and Drug Abuse jointly developed and implemented "Core Rules for Psychiatric and Substance Abuse Programs" that identify common treatment principles, outcomes and administrative standards.63 The Divisions also have promulgated practice guidelines for the treatment of individuals with the most severe co-occurring disorders.64

States are also implementing innovative strategies for financing integrated services for individuals with co-occurring disorders, blending together state and local tax dollars, mental health and substance abuse block grant funds, and Medicaid dollars.65

Effectively supporting people with co-occurring substance abuse disorders frequently requires states to pursue strategies that fall outside the direct purview of federal Medicaid policy. In this arena, states must often invest dollars to create new system capabilities by financing services' start-up costs. Many states have used federal mental health and substance abuse block grant dollars to do so, as well as to underwrite necessary provider training.66

Federal Medicaid Policies Affecting Services for Persons with Co-Occurring Substance Abuse Disorders

States may offer substance abuse treatment services under the Medicaid clinic and/or rehabilitative services coverage categories. Federal policies concerning Medicaid coverage of substance abuse services are not different from those that apply to the coverage of mental health services. Under the rehabilitative services option, for example, states may elect to cover treatment services, counseling and other services that promote the recovery of persons who have a substance abuse disorder.

In general, states make markedly less extensive use of Medicaid to underwrite substance abuse services than mental health services.67 Only about one-half the states offer substance abuse services under the Medicaid rehabilitative services option and several of these cover only limited outpatient services. There are several states that do not cover substance abuse services for adults at all under either the clinic or rehabilitative services options. At the same time, many states have implemented more robust coverages of substance abuse services. For example, Minnesota's coverage spans a wide-array of substance abuse rehabilitation services.68

In the case of individuals who have co-occurring disorders, assorted problems have arisen in integrating Medicaid substance abuse treatment with mental health treatment. One problem stems from the practice of targeting services by "primary" disorder. For example, individuals who have "primary" mental disorders might be prevented from receiving substance abuse services when services eligibility criteria limit services to persons who have a "primary" substance abuse disorder (and vice versa). As services for individuals with co-occurring disorders have evolved, limiting services by "primary" disorder has given way to the recognition that there is no hierarchy of disorders because both exist independently. Along these lines, state policy changes, such as those made in Texas and Missouri, aid in avoiding this problem. Another problem often arises in the arena of provider qualifications. When provider qualifications that apply to substance abuse and mental health services differ significantly, it can be difficult for a provider in one system of care to employ Medicaid dollars that are tied to the other system of care that has different provider qualifications. In order to integrate services within one system or the other, states should consider strategies to cross-certify providers to furnish services. The foregoing problems, of course, parallel some of the generic challenges previously described in serving individuals with co-occurring disorders. Federal Medicaid policy does not dictate that the coverage of mental health and substance abuse services must be constructed in a silo-like fashion (i.e., the coverage of substance abuse services must be completely distinct from the coverage of mental health services). Some states have crafted interlocking rehabilitative option coverages of mental health and substance abuse services. For example, Georgia's rehabilitative services coverage (see Appendix B) spans both mental health and substance abuse services. Some of the services included in Georgia's coverage (e.g., ACT) are available for persons who have a mental illness, a substance abuse disorder, and/or co-occurring disorders. Defining services in this fashion avoids creating silos. As one would expect, some services that Georgia offers are specific to the treatment of substance abuse or mental illnesses (because not everyone who has a substance abuse disorder also has a mental illness, and vice versa.) In addition, Georgia's provider specifications require that community agencies have the capability to serve both populations, another means of avoiding silos.

Missouri's substance abuse rehabilitative services coverage (Comprehensive Substance Abuse and Rehabilitation -- CSTAR) specifically incorporates services for individuals with co-occurring disorders. Services include individual and group counseling, psychosocial education, residential support, family therapy and co-dependency counseling. CSTAR provides for the management of co-occurring disorders and mental health services.69 It builds on the previously described steps that Missouri has taken to adopt common principles for the treatment of substance abuse and mental health services. In Missouri, providers who meet applicable requirements can be cross-certified to furnish both mental health and substance abuse services.

When a state has elected not to cover substance abuse treatment services as a distinct coverage under its state plan, it may still provide for their provision as components of the rehabilitative services that it furnishes to individuals with serious mental illnesses. Many states have incorporated substance abuse/addictive services into their coverage of mental health rehabilitative services and, thereby, created a framework for furnishing integrated treatment for individuals with co-occurring disorders through a single treatment team, or a program using a single service plan.70 For example, ACT teams must have the capacity to address the needs of individuals who also have a substance abuse disorder.

State coverages of ACT services include the treatment of both disorders, employing an integrated, multidisciplinary approach. Even when a state separately covers substance abuse services, these services still may be incorporated into mental health rehabilitative services provided there is no duplicate billing for services. In addition, if a state's coverage of substance abuse services provides only for limited outpatient benefits, additional services can be incorporated into the coverage of mental health services (e.g., furnishing substance abuse counseling as part of illness management services).

In some states where Medicaid mental health services are furnished through a 1915(b) or 1115 waiver program, the program encompasses both mental health and substance abuse services. For example, as discussed in Chapter 6, Iowa elected to pull together both types of services together under a single 1915(b) waiver program rather than continue to operate each type of service under a distinct waiver program. While spanning both categories of services in a waiver program does not necessarily resolve all the problems associated with integrating services for persons with co-occurring disorders, it offers the potential for avoiding or mitigating funding silo problems.

Federal coverage policies do not preclude the integration of mental health and substance abuse services for persons with co-occurring disorders. States may craft rehabilitative services coverages that provide for such integration. More challenging for states may be creating and expanding the capacity to deliver integrated treatment services for individuals with these co-occurring disorders.

Services for Individuals with Co-Occurring Developmental Disabilities

Depending on the definition of mental illness used, there are varying estimates of the number of persons who have both a serious mental illness and a developmental disability such as mental retardation (sometimes referred to as persons with a "dual diagnosis").71 Some state administrators estimate that the rate of occurrence of major mental illness in individuals with a developmental disability is similar to the rate in the general population.72 In other words, probably between 5 to 7 percent of adults with developmental disabilities also have a major mental illness. Although in absolute terms the number of working-age adults who have a developmental disability and a major mental illness is relatively small, frequently they consume a disproportionate share of service system resources.

Serving individuals who have both a serious mental illness and a developmental disability is garnering increased attention. Such individuals frequently pose significant service delivery challenges. Problems arise in the arena of diagnosis, with mental illness sometimes misidentified as maladaptive behavior. Diagnosis is also more challenging among individuals with more severe mental retardation. Since this is a very low incidence population, and treatment can be complex, there are a limited number of providers and professional practitioners (especially psychiatrists) who have the requisite capabilities to serve these individuals.

For persons who have a both a mental illness and a developmental disability, systems issues frequently arise at both the state and local levels, stemming from lack of coordination between the mental health and developmental disabilities services sys-tems. As with substance abuse, these issues often revolve around questions concerning "primary diagnosis." In some states, a significant number of individuals with a co-occurring developmental disability have been institutionalized in state IMDs.73 In addition, these individuals frequently experience high rates of community hospitalization. Sometimes, they bounce between the mental health and developmental disabilities systems or unfortunately, fall between the cracks. These persons also experience involvement in the criminal justice system.

Several states have taken active steps to improve services for persons with serious mental illnesses and developmental disabilities. In 2002, the National Association of State Directors of Developmental Disabilities Services (NASDDDS) and the National Association of State Mental Health Program Directors (NASMHPD) surveyed state MRDD and mental health directors to identify elements important for effectively serving individuals with these co-occurring disorders. Department directors identified strategies that they regard to be important, including entering into written interagency agreements, creating interagency task forces, coordination of services and payments, cross-system provider training, and joint involvement in hospital discharge planning.74 In about one-third of the states, the administration of mental health and developmental disabilities services is located in the same state agency, a step that can potentially facilitate the delivery of services to individuals with these co-occurring conditions.

The Ohio Departments of Mental Health and the Department of Mental Retardation and Developmental Disabilities have forged an interagency agreement that spells out specific joint responsibilities as well as those for each agency. Each department is responsible for identifying individuals with co-occurring disorders within their own systems, cross-training local agencies and providers, and promoting communication across programs at the county level.75 In addition, the departments have collaborated in identifying clinical best practices in serving individuals with developmental disabilities and mental illness.76 At the local level, some county boards of mental retardation and developmental disabilities operate Program of Assertive Community Treatment (PACT) teams that serve individuals with these co-occurring disorders.

Pennsylvania's Office of Mental Retardation has promulgated a framework to be followed at the county level to assure service coordination between the mental health and mental retardation administrators. This framework includes provisions for:

  • Engaging providers who have experience and expertise in treating individuals with co-occurring mental illness and mental retardation;
  • Ensuring that a lead agency (MH or MRDD) is identified for each dually diagnosed individual that enters the system; and,
  • Implementing cross-system trainings within each system at both the administrator and provider level77

In Arizona, an agreement has been forged between the state behavioral health and developmental disabilities authorities concerning the provision of services to individuals with co-occurring disorders. This agreement provides for the deployment of expert consultation to address the needs of such individuals.

Federal Medicaid Policies Affecting Services with Co-Occurring Developmental Disabilities

As in the case of individuals with co-occurring substance abuse disorders, federal Medicaid policy principally affects the financing of services on behalf of individuals with co-occurring developmental disabilities. This topic can be confusing. As discussed in Chapter 4, federal policy differentiates between the coverage of "rehabilitative" and "habilitative" services. Habilitative services are closely identified with services for persons with developmental disabilities and federal payment for them is limited to services furnished in ICFs/MR or through an HCBS waiver program that serves as an alternative to placement in an ICF/MR. Habilitative services may not be furnished under the rehabilitative services option except in a limited number of states.78

However, this does not mean that individuals with developmental disabilities may not receive mental health treatment and related services under the clinic or rehabilitative services options. Individuals with developmental disabilities who meet the "services eligibility" criteria that apply to a state's Medicaid mental health services may be furnished such services on the same basis as other Medicaid beneficiaries. As in the case of individuals with a co-occurring substance abuse disorder, limiting services to individuals with a "primary" mental illness diagnosis sometimes leads to the disqualification of individuals with developmental disabilities from receiving necessary mental health treatments. Emerging best practice is that "phrases such as 'primary diagnosis' no longer have relevance nor should they be used in determining service delivery to persons with mental illness and developmental disabilities."79 Integrated treatment approaches are also aided when provider qualifications are established that permit the cross-certification of providers. Ohio has taken this step and, hence, cleared the way for developmental disabilities providers to implement PACT teams.

In its rehabilitative services coverage (see Appendix B), Georgia has specifically provided that individuals with a co-occurring mental illness and mental retardation or other developmental disability are among those who may receive mental health treatment services. Services that they may receive include crisis residential services and community support services, which include rehabilitative, environmental support, and targeted case management, which is considered essential to assist individuals to obtain necessary services.

They may also receive: 1) evaluations and assessments to identify barriers that impede the development of skills necessary for independent functioning in the community; 2) assistance and support in crisis situations; 3) symptom monitoring and self management of symptoms; 4) assistance to increase social support skills that ameliorate life stresses resulting from the person's disability; and 5) coordination to gain access to necessary rehabilitative and medical services; and 6) coordination of services in the Individual Service Plan.80

In developmental disabilities services, the 1915(c) HCBS waiver program has emerged as the dominant Medicaid financing vehicle for community services. Through their HCBS waiver programs, states commonly cover "behavioral services" that include the treatment of co-occurring mental disorders. Because an HCBS waiver program cannot generally cover services that are otherwise available through a state's Medicaid program, it has not been common for states to include mental health services per se in their waiver programs.81 HCBS waiver participants, of course, are eligible for the mental health services that a state offers under its Medicaid state plan.

Some states have employed the HCBS waiver program to develop especially strong capabilities for serving individuals with co-occurring conditions. One such state is Vermont which created the Crisis Intervention Network as a critical element of its successful effort to shift all individuals with developmental disabilities to the community and close its only public institution. The aim of the Network is to avoid hospitalization.

Vermont recognized that, in order to close its institution, it had to establish effective services in the community to address the needs of persons who experience psychiatric or behavioral crises. The Network furnishes consultation to community agencies to support persons experiencing a crisis, including dispatching staff to work with the person. The Network also maintains a small crisis residential capacity. This especially effective capacity was developed independent of Vermont's mental health system but has the capacity to deliver critical mental health services to individuals.82

In summary, states can use Medicaid to serve adults with serious mental illness who also have a co-occurring developmental disability. Simply put, these individuals are eligible for any Medicaid clinic and rehabilitative mental health services that a state already provides, subject to the criteria that a state spells out in its Medicaid plan. The difficulties that lie in effectively supporting this population are very real, but generally lie outside of funding/eligibility issues. While challenges continue to exist in terms of system collaboration and service delivery, states are taking significant steps to build agency relationships, train providers, and generally integrate important services across systems to support dually diagnosed adults in the community.

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