Re-Balancing the Service System for People with Mental Illness, Developmental Disabilities and Addictive Diseases (MHDDAD)

What is MHDDAD?

Department of Human Resources Division of Mental Health, Developmental Disabilities and Addictive Diseases 5 MHDDAD Regional Offices 7 State HospitalsCommunity Providers

Who we serve: Children & Adults with: serious mental illness developmental disabilities addictive diseases

Funding Sources State funds Federal Block Grant funds Medicaid funds Medicare funds Private insurance / private pay County funds Various public and private grants

Services for children & adolescents MHDDAD

MHDDAD Children & Adolescents Services Preserve families Avoid hospitalization Support participation in everyday life

Community Services - C&A Served Serious Emotional Disturbances

Community Services - C&A Served Addictive Diseases

Hospital Services - C&A Served Serious Emotional Disturbances

Services for adults with mental illness and/or addictive diseases

Adults (MH &AD) Services Best Practices Transition from institutions Assure availability of medication

Community Services - Adults Served Mental Health

Community Services - Adults Served Addictive Diseases

Hospital Services - Adults Served Mental Health

Services for people with developmental disabilities

Developmental Disabilities Services Reduce the waiting list Transition from institutions Ensure provider availability Ensure community capacity

Community Services - Adults Served Developmental Disabilities

Community Services - C&A Served Developmental Disabilities

Olmstead ‘99 Consumers with DD Served in State Hospitals Source: BHIS Dec.’06 HB Note: FY07 Data is Oct. 31, ‘06

Developmental Disabilities Waiver Planning List Persons Waiting for Waiver Services Source: MHDDAD Dec. ’06 HB Nov. ‘06

Forensic Services

Ensure timely movement from jails Ensure appropriate treatment setting

State Mental Health Administrators in the major of the states report increasing percentages of forensic patients in state hospitals. Source: State Profile Highlights: National Association of State Mental Health Program Directors Research Institute, Inc. (NRI)

Why does the system need to be re-balanced?

Isolation of people with mental illness, addictive diseases and developmental disabilities in hospitals and institutions Use of hospitals as the preferred treatment forced people and resources into “deep end” services - Example: Central State Hospital housed 13,000+ people in the 1960s. Today’s system of 7 hospitals has 2,513 beds Old Paradigm

Historical grant-in-aid funding to CSBs not driven by need, demographics or outcomes Children not considered priority customers Lack of accountability for the people most in need getting effective services

New Paradigm People served as close to home, family and community as possible Provider competition affords greater consumer choice Fee for service and utilization review ensure that the right people are getting the right services in the right amount at the right price Children get their fair share of the resources Nobody should live in a hospital (particularly children and people with developmental disabilities)

Hospitals are our Burning Platform Public behavioral health system is the “ safety net ” when private systems are exhausted Increased demand for substance abuse treatment is driving people into deep end services such as emergency rooms and state hospitals Courts are increasingly relying on state hospitals Mental illness causes more disability than any other class of medical illness in America.

Georgia’s Mental Health System… …is about 8 years behind other states in transitioning resources to community-based services …only since 2001 has Georgia been spending more resources on community services than hospital services

Burning Platform Children are hospitalized at 3X the national rate Adults are hospitalized at 3.5X the national rate Elderly are hospitalized at 24X the national rate 417 people currently in state hospitals could be discharged, but lack needed community services People are living in hospitals - 66% have been in the hospital for over 1 year; 25% for 10+ years

Hospital readmission rates are twice the national rate Currently exceeding forensic bed capacity by 35% (164 beds). Projecting a 89% capacity shortfall by 2010 (417 beds) 64% of forensic consumers have had previous MHDDAD contact = missed opportunity Resources of other systems are drained - Examples: Sheriff ’ s Offices, DFCS, DJJ, DOE, local emergency rooms Burning Platform

Revenue Maximization projected Medicaid revenue would replace $37.4M in state funds annually (did not occur) Medicare earnings were over-projected due to seriously mentally ill consumers exhausting their lifetime benefit Because public system is “ safety net ” when other resources are exhausted, most consumers come with no insurance or ability to pay Olmstead Decision accelerated community placements Escalating costs – utilities, medical treatment, staff …

Actions Taken 1)Consistent statewide set of standards for the community: Defined who will be served What basic services will be available to all Georgians Redistributed funding so every area gets their fair share

Actions Taken 2) Created a front door to service system: Established Single Point of Entry ( ) Funded Crisis Intervention Training for 20% frontline law enforcement officers to divert mentally ill from jails Created 23 hour observation units at 4 hospitals to avoid 66% of hospital admissions Established crisis stabilization services for children to avoid 60-75% of hospital admissions Increased adult crisis stabilization services by 30% since FY04

3)Increased the number of people that can be served in the community: Steady increase in number of MR/DD waivers Open competitive market place with fee-for-service to increase # of providers, consumer choice and number of people served Use of Case Expeditors to safely move consumers from hospitals to the community External utilization review of hospital and community services to ensure the right services for the right people in the right amount Actions Taken

Actions To Be Taken Reduce the cost of pharmacy operations and medications (estimated annual savings $1.2M) Operate smaller, more specialized hospitals Privatize specific services such as billing Consolidate selected hospital functions Potential federal funding of Money Follows the Person Grant Legislative proposal allowing misdemeanor defendants found incompetent to stand trial to be evaluated and treated for competency restoration in the community

Consolidation of MHDDAD and DFCS child and adolescent behavioral health systems - positioning MHDDAD to provide treatment and DFCS to provide protection Consolidation of MHDDAD and Public Health substance abuse prevention services - positioning DHR to impact health behaviors Future Initiatives

Future Initiatives Restructuring Child & Adolescent Substance Abuse Services Current System $4.9M funding inpatient beds - Length of stay 9-12 months adolescents served annually New System $2.5M funding - 32 inpatient beds - Length of stay 3-6 months children served annually $2.4M funding - Outpatient, community- based services - 1,350 adolescents served annually

Future Initiatives Sheriff ’ s Tele-medicine Pilot –technology to link Sheriff ’ s Offices and state hospitals; only transport those who must be moved Crisis Services for children –add mobile crisis services and funds to purchase additional crisis beds

Child & Adolescent Parent-to-Parent Peer Support Program: - links parents of emotionally disturbed children with other parents who have successfully navigated the service delivery system Increase Medicaid waiver service slots and expand supports to families & consumers with the new developmental disability waiver: –Individual Budgets –Supports Intensity Scale –Choice of Services –Financial Support Services Future Initiatives

Characteristics of the Reformed System  Every area of the state will have: A true single point of entry Crisis stabilization for children and adults A set of core services  Deinstitutionalization of developmentally disabled and long term mental health consumers  Individualized treatment planning and utilization management  Maximum self-sufficiency and independence for adults with appropriate supports