Michigan: Washtenaw County's Mental Health Mess

The Ann Arbor News featured a long article about the decrease in funding for Community Mental Heatlh (CMH) services in Washtenaw County: "Analysis: Where has all the money gone? Washtenaw County's mental health mess" by Ben Freed, 11/15/15.

Kudos to Ben Freed for figuring this out and analyzing  a mess similar to the results of Humpty Dumpty falling off the wall in the nursery rhyme.  Freed has unscrambled the egg and now I am trying to understand and translate his analysis, so that us ordinary people dealing with the mental health system can at least have a clue as to what happened.

The CMH system provides services primarily to people with developmental disabilities, mental illness, and drug abuse problems. For individuals who are eligible for Medicaid and are developmentally disabled, Washtenaw County CMH still has a responsibility to provide them with all services that are deemed medically-necessary through a person-centered planning process that results in an Individual Plan of Services (IPOS). Most people with developmental disabilities fall under this category. This has not changed, but many other people who were previously covered by CMH who do not fit that category, have found themselves with greatly reduced services or none at all. This is bound to affect the entire system.

What Happened?

Washtenaw County's mental health services budget was $80 million in fiscal year 2012 and has fallen to $66.7 million in Fiscal Year 2016. 

Where has the $14.3 million gone? Freed breaks it down into several categories to account for the lost funds.

$3.86 Million: The WCHO deficit

The Washtenaw Community Health Organization was formed in 2000 in partnership with the University of Michigan and was designated the Prepaid Inpatient Health Plan (PIHP) for a four county area as well as the CMHSP (or what had previously been called the CMH ) for the County. The PIHP is a regional administrative agency that distributes Medicaid funding to the counties belonging to its affiliation and the CMHSP provides the services. 

Within the WCHO, Medicaid funding and the number of people served would fluctuate over the course of a year and deficits in one county, usually Washtenaw, would be plugged by surpluses in other counties. This practice was not hidden and it was the accepted way of balancing the budget.  Sometimes infusions of state funding would also fill the gaps. 

By 2014, it became clear that the gap had reached unmanageable proportions and a Washtenaw County Behavioral Task Force recommended dissolution of the WCHO and a takeover by Washtenaw County government to provide better oversight and monitoring of CMH. There were also changes in state funding and the PIHPs that eventually led to substantial changes:

“A new organization, the Community Mental Health Partnership of Southeast Michigan, was formed to take over PIHP duties from the Washtenaw Community Health Organization, which was eventually phased out as an entity in 2015. Its county functions were absorbed by the CSTS [Community Supports and Treatment Services], which took on the name Washtenaw County Community Mental Health.”

Cuts in services to offset the deficit have been the source of controversy and have led to devastating results for some County residents.

$8.5 million: Medicaid and carry over

Medicaid funding accounts for 80% of the Washtenaw CMH budget. Medicaid funds can only be used for certain services for Medicaid-eligible individuals and cannot be used for other services or for those who do not qualify.

Here is where you have to watch the bouncing ball to understand what is going on with Medicaid:

If the economy improves, as it has in the last couple of years, fewer people qualify for Medicaid and funding to CMH goes down:

“As of June 2015, there were 3,333 fewer total Washtenaw County residents on Medicaid than the previous June—that number includes all Medicaid enrollees, not just mental health patients. In FY 2015, Washtenaw County received about $1.4 million less than was budgeted for that year and in the coming year the county's Medicaid payout will be down by $2.5 million.”

In previous years, any Medicaid money that was not used up could be rolled over into the next year’s budget: 

In 2012, the WCHO had $8milliion to carry over to its next fiscal year. “By FY 2014 the carry forward had shrunk to $6 million and four months into the following fiscal year, it was gone. This year there is no carry forward money to help supplement the Medicaid dollars. At the same time, community living support costs grew from $10.4 million in FY 2010 to more than $22 million by FY 2014. Core provider costs had grown from $25.8 million to nearly $30 million over the same time period.”

Also, “Three of the four counties in Washtenaw County's PIHP region did not receive enough Medicaid dollars to fully fund their programs in FY 2014 and the $1 million surplus from Lenawee was distributed to help the other three support their deficits.”

$2.2 Million: The State of Michigan

Although the State Budget Office tells us that the state's total mental health budget - including the Healthy Michigan Plan (Medicaid expansion) - grew by 9 percent to a total of $2.8 billion in 2015, local CMH agencies are struggling with financial problems not addressed by the state or exacerbated by state funding decisions.

Michigan introduced its Healthy Michigan Plan (Medicaid expansion), in 2014, and more than 600,000 people signed up who had previously not had Medicaid coverage:

“Because enrollment was higher than expected, the state had less money to pay per patient than they had previously estimated. Approximately 15,000 people enrolled in the program in Washtenaw County, but the per-patient rate was adjusted down by $10 per month mid-year by the state.” This resulted in $1million less revenue than expected for Healthy Michigan Plan CMH consumers that will carry over into 2016.

Then, “with the new federal funding coming into mental health services, the state also took the opportunity to cut general fund allocations to county mental health agencies across the state.” Because this money had been used to fill in gaps for County residents who did not qualify for Medicaid or were on the borderline of qualifying, services that were once provided with general fund money, are the most adversely affected by the state’s decision.

As a result, “’You're starting to see those people in the ER, you're going to start seeing them in the justice system, people who had been under our care,’ Cortes said. ‘These are people we've been serving for more than a decade.’”

“…Washtenaw County's general fund allocation for FY 2012 was $8.36 million. In FY 2016 it is $2.8 million, but the state is also taking on about $1.9 million payments to state hospitals that previously came from the general fund allocations.”

What happens next?

There are state-level discussions going on to request an increase in general fund dollars for county CMH agencies. Washtenaw County Board of Commissioners has stepped up to continue funding of the county’s vocational training program. The County has also added a “structural $400,000 allocation to mental health from its general fund that will be paid for through the anticipated increases in taxable value in the county.”

“…St. Joseph Mercy Hospital and University of Michigan Health System have each pledged more than $100,000 to Community Mental Health and the Washtenaw County Health Plan is adding an additional $150,000. Those funds will all go toward direct services for people not covered by Medicaid.”

In addition, “The county is also in negotiations with the unions about maintaining staffing and pay levels for county employees”.

The article also covers the programs that are likely to be most affected by the changes in Washtenaw County and the services that will likely be dropped. 

Read the full article here...

Another article, "What the mental health funding cuts mean for one woman's struggles" by Ben Freed, 11/15/15, follows the day-to-day changes in the life of a woman with severe mental illness whose services have been reduced or eliminated.

Washtenaw ACA on rate reductions for self-determination direct care workers

On July 1, 2015, Kathy Homan, President and CEO of Washtenaw Association for Community Advocacy, commented to the Washtenaw County Board of Commissioners regarding the decision by the Washtenaw Community Health Organization (WCHO) to reduce the hourly rate of pay for direct care workers under self-determination living arrangements:


“In May of this year, CSTS reduced the hourly rate of pay for Self-Determination budgets and removed all additional line item allowances from all [Medicaid] waiver recipients using self-determination. This reduction has decreased, if not ceased, the ability for people with developmental disabilities to be included in their community. The rate reduction was done with no input from the community and in violation of The Centers for Medicare and Medicaid (CMS) Budget Authority Process in the Habilitation Supports Waiver application, as stated in the letter from Michigan Department of Health and Human Services that was sent to the WCHO on June 4, 2015. I spoke with CMS after receiving a copy of this letter and confirmed that the violation to the Authority Process also included all other Home and Community-Based Service Waivers. This same letter stated that 'As a result, we are requesting that the WCHO reverse this decision immediately and retroactively to May 15, 2015 for all SD and choice voucher arrangements effected by this action.'

"The WCHO’s response to MDHHS, dated June 15, 2015 states '1. In coordination with the Washtenaw CSTS Clinical Team, we are collaborating with the individual and/or guardian to review the Individual Plan of Service (IPOS) and the Self-Determination budget. Upon review with all parties, the IPOS will be reviewed and signed off on by the individual and/or guardian and the CMHSP.' '2. Through the completion and signature on the updated IPOS, each individual and/or guardian will be provided Adequate Notice of Rights.' It also states that the WCHO will attempt to negotiation a solution locally. Should a solution become unattainable, WCHO will ensure individuals are provided assistance with filing a Medicaid Fair Hearing. We believe the WCHO response does not comply with the letter from MDHHS and is considered by some families as a bullying tactic.

"Self-determination is a policy through the public mental health system that is to be made available to any person receiving services through PIHPs and CMHSPs. The five principles of self-determination are Freedom. . . to plan a real life, Authority. . . over your resources, Support. . . . for building a life in your community, Responsibility. . . to the wise use of funds, and Confirmation…of the important roles that individuals must play in a designing systems.
 
"In October of this year, the Washtenaw County Board of Commissioners will have more oversight for CSTS. We ask that you include people with developmental disabilities and their families on the Community Mental Health Board so nothing again is ever decided about them without them." [emphasis added]

[The MDHHS is the Michigan Department of Health and Human Services, a new department that merges the old Department of Community Health and the Department of Human Services.]

2nd Town Hall Meeting on Washtenaw County DD Services - 5/7/15

This was a 2nd meeting to answer questions about services for people with developmental disabilities provided by the Washtenaw County Community Mental Health (CMH) agency.  The subject of the meeting was the review of Community Living Services provided by CMH and pay rates for people using Self-Determination. The meeting was attended by about 50 people at St. Luke Lutheran Church in Ann Arbor on 5/7/15. 

Handouts included:
 
The Washtenaw County Behavioral Health Task Force Report Frequently Asked Questions
 
Community Living supports Frequently Asked Questions

Self-Determination: Frequently Asked Questions on pay rates

[The Washtenaw Community Health Organization (WCHO) is currently the name of the CMH agency for Washtenaw County. This will be changing in October 2015 when the agency is reorganized and becomes a CMH agency controlled by county government.]

For further clarification on how changes may affect you or your family member, contact your supports coordinator or other members of the team assisting you with CMH services.

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This was mostly a question and answer session, with a lot of questions about the budget for the WCHO that has a $3.8 million deficit out of a total of over $80 million. 

The WCHO has given assurances that the amount, duration, and scope of services to individuals will not be cut. However, from the last meeting it was clear that the Individual Plans of Service (IPOS) will be reviewed to assure that Medical necessity criteria are being applied. Services can be reduced if the WCHO can justify it on the basis that they do not meet criteria for medical necessity. [This has always been true for Medicaid services. One question to ask is what has changed, if you are being told that a service no longer meets the medical necessity criteria?]

Question: If this is a budget problem, where is the budget being cut? Answer: There have been staff changes and many positions will be left open. Presumably, costs may be cut by finding services that are determined to not be medically necessary. The WCHO advises people to work with their clinical team and their fiscal intermediaries to handle changes. 

Self-Determination direct care providers will receive lower rates set by the PIHP (Prepaid Inpatient Health Plan) [PIHPs are regional administrative agencies that pass on Medicaid funds to local CMH agencies] - the CMH Partnership of Southeastern Michigan. Previously,  administrative fees, workers compensation, and other charges were supplemented with other funds, but this will no longer be the case.

Question: Is the Message that Self-Determination is being eliminated? WCHO: No, the agency is still offering this as an option. [The main concern, however, is that a reduced pay rate could make it more difficult to hire and retain workers] Individuals may choose to go back to a more traditional way of providing services through the CMH with less individual control of how or by whom services are provided. 

Medicaid Funding:
 
Ironically, the improving economy leads to less federal funding for medicaid because federal Medicaid matching funds decrease. CMH has done better when the economy is poor.  

There are 33,000 Medicaid enrollees in Washtenaw County. Capitation is the part of funding available that is conditioned on a set amount per person.

Healthy Michigan is Michigan’s version of Medicaid expansion under the Affordable Care Act. It covers people with incomes at or below 133% of the federal poverty level ($16,000 for a single person or $33,000 for a family of four). this means that there are a lot more people covered by Medicaid, many of whom have needs for mental health services, but the rate paid is lower under Healthy Michigan than that paid for people already qualifying for regular Medicaid. This results overall in less funding for people needing mental health services, but more people needing these services.

Comment: If we spend less now, less funding will be available in the future to the extent that it is based on current spending. WCHO: The IPOS process will not change.

Comment and Question: Are Cuts expected in future years? Are we going toward a system that gives a given sum of money to families ($20,000/year?) to spend as they choose?

Question: When rate changes for Self-Determination were contemplated, why wasn’t the community brought in? Answer: Decisions were made in public meetings of the PIHP with time allowed for public comment. No special announcements were made. 

Complaint: The rate change is a done deal, that we are being informed of, but we were not included initially in making the decision.

Question: Who is the leadership for the WCHO and why were we not being well-represented when decision to lower rates was decided? [The higher cost of living in Washtenaw County should be taken into account.] Are the people making the decision elected?  Answer: The WCHO was represented by the Executive Director and others hired by the WCHO board. The Board is not elected. [It does include people with disabilities and family members of people with disabilities.]

Question on “Goods and Services” for Self-Determination: Can unused Goods and Services money be used to fill in the gaps? Answer: WCHO is not sure. 

[FYI: “The purpose of Goods and Services is to promote individual control over, and flexible use of, the individual budget by the HSW beneficiary using arrangements that support self-determination and facilitate creative use of funds to accomplish the goals identified in the individual plan of services (IPOS) through achieving better value or an improved outcome. …A Goods and services item must be identified using a person-centered planning process, meet medical necessity criteria, and be documented in the IPOS [Individual Plan of Service]” This is from the Michigan Medicaid Provider Manual, page 979 of the PDF file that is available on-line. I have been told never to click on print when looking at this document. It is 1,840 pages long.]

Question on the Children’s Waiver: This is a state-run, fee-for-service waiver, with the funding coming from the state. So why is the rate for those worker’s being reduced? Answer: The WCHO uses General Fund dollars [these are state funds that are not designated for a specific purpose such as education, transportation, corrections, etc.] to supplement the rate if it is different than what the state allocates. General Fund dollars now available for the WCHO is less that $1million, a very small amount compared to what is needed to maintain services to people relying on general fund dollars.
 
WCHO Board and Committee Meetings for 2015

CMH Partnership of Southeastern Michigan meeting information

Corrections and comments welcome!

Washtenaw County, MI : 2nd Town Hall Meeting on Community Living Services and Self-Determination, 5/7/15

Second Washtenaw CMH Town Hall Meeting Scheduled

Recent Updates on Community Living Supports (CLS) and Self-Determination

Thursday, May 7, 2015
5:30 to 7:00 P.M.
St. Luke Lutheran Church

4205 Washtenaw Ave
(near the intersection of US 23 and Washtenaw Ave.)

Ann Arbor, MI 48108

Click here to download a printable flyer

In response to the Town Hall Meeting held on April 14, 2015, the following items are posted on the WCHO Website:

Washtenaw County Customer Service e-mail

Washtenaw County Behavioral Health Task Force FAQ on the future of the WCHO (Washtenaw Community Health Organization)

CLS PowerPoint Presentation from the 4/14/15 meeting (open from this page on the WCHO Website ; click on Townhall/CLS Announcement)

CLS FAQ

Washtenaw County Legislators

Summary of 4/14/15 meeting on community living services in Washtenaw County, MI

The 4/14/15 meeting in Ann Arbor was sponsored by the Washtenaw Community Health Organization (WCHO) and Community Supports and Treatment Services (CSTS) to discuss the future of community living support services. These local Community Mental Health (CMH) agencies provide Medicaid-funded services to people with disabilities, including people who are developmentally disabled and mentally ill and their families. 

The meeting was attended by about 100 [make that 180!] people eager to hear whether the WCHO [facing a budget deficit of $3.8 million] and CSTS had plans to cut services that allow individuals and their families to survive and thrive in community settings.

The meeting began with a PowerPoint presentation on “Utilization Management”, a fancy term for assuring that public funds are spent for the purposes intended by law and policy. The full presentation can be linked to here on the WCHO Website. [Click on “Town Hall Announcement” and then “CLS PowerPoint Presentation”] . The emphasis was on “medically necessary” services and a plan to review and evaluate Individual Plans of Service (IPOS’s), looking at those plans with the highest utilization rate first. These reviews may or may not result in cuts to services for individuals. 

There was nothing new as far as CMH agencies' obligation to be fiscally responsible and to provide Medicaid services that are "medically necessary".  Here is a blog post from The DD News Blog with the definition of medical necessity. The definition does not limit recipients of services to what would ordinarily be considered strictly medical services. It includes services to maintain or improve functioning and allow a person to live in the community.

As is usually the case, the most interesting part of a public meeting is the public and the questions and observations of people who went out of their way to attend the meeting. Here are some of the issues that were raised by the crowd:

The letter that went out to recipients of services under “Self-determiniation” arrangements announcing a decrease in the pay rate for direct service providers: 

• This was not the main topic of the 4/14 meeting, but the explanation for decreasing the pay was that Washtenaw County wants pay rates to conform to rates in the other counties in the 4-county affiliation of the Community Mental Health Partnership of Southeast Michigan. 
• Someone pointed out that there is no requirement that pay rates for every county be the same and that Washtenaw has the highest cost of living in the four-county region.  
• It is ironic that pay rates for direct service providers under self-determination living arrangements are being cut, while the Federal government through its rule on Home and Community-Based service settings encourages these kinds of living arrangements over congregate care and is applying pressure on states to move in this direction. Cutting pay rates is a sure way of making it harder for individuals to hire direct care staff who are competent and reliable.

The CSTS PowerPoint emphasizes the success of the WCHO and CSTS in cutting hospitalization times for people with mental illness. An audience member spoke of talking to family members of people with severe mental illness who say that hospital stays are way too short and do not allow people to adjust to new medications and to transition back to the community.

There were also complaints that families were already being threatened with service cuts, including people needing care and supervision 24 hours a day. Some were told there was no appeal of service cuts, even though there is both a local and state appeals process required by law. For more information see Recipient Rights and page 24 and 25 of the Guide to Services.

More meetings:

Check the announcements page of the WCHO Website for more information on a meeting scheduled for May 7, 2015 at St. Luke Lutheran Church in Ann Arbor.

The WCHO Board of Directors meets on the third Tuessday of every month.

The new pay rates for direct care workers for Self-determination go into effect on May 15, 2015, but there will be a meeting before that date to discuss concerns of consumers.

Washtenaw County, MI : CMH to announce rate decrease for Community Living Services

Update 4/16/15: About 100 people attended the WCHO/CSTS meeting on Tuesday, April 14, 2015 to discuss Community Living Services and potential cuts in services when they are found on further evaluation to not meet "medical necessity" criteria. The above letter was for people who hire providers through "Self-determination" arrangements. Although this was not the main subject of the meeting, it did come up. There will be future meetings on the "Self-determination" decision and on other Community Living Services. Stay tuned.

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The Washtenaw Community Health Organization and Community Supports and Treatment Services are holding a meeting tonight to discuss plans affecting Community Living Supports for people with disabilities. These include staffing for people in their own homes.

According to a letter sent to consumers (individuals with disabilities and their families who receive services), the rate of pay for these direct care workers will be reduced to $13.88 per hour, which includes worker’s compensation, transportation, community participation, taxes, and training. The letter says that “While this is not a reduction in your current level of services, it may reduce the amount you can pay staff.” WCHO also encourages consumers to meet with their clinical teams and consider options, “including the option to use one of our contracted providers for CLS services”.

The change will go into effect on May 15, 2015.

People whose services are funded through Medicaid Waivers, especially those with exceptionally high needs, find themselves extremely limited by the allowable amount of funding available to pay service providers. The higher the needs, the more skilled and reliable direct care workers need to be to fulfill those needs. Reducing the hourly wage of workers who, if they do their jobs well, take on tremendous responsibility to do difficult work leads to diminishing returns: a high turnover rate, poorer care, and sometimes no care at all.

The change in rate is justified as “necessary to ensure that Washtenaw County’s rate is the same as our regional partners and to ensure that we are being fiscally responsible.” Another way of looking at it is that both these things might be accomplished by raising the rate of our regional partners and ensuring a more stable and reliable workforce all the way around.

What you need to know about Michigan Due Process and Services for DD

Spring at last

I attended two presentations in the last 6 weeks by Stacy Coleman sponsored by NAMI (National Alliance on Mental Illness) of Washtenaw County, Michigan, and the Washtenaw Community Health Organization (WCHO). Stacy works for the WCHO and is a Medicaid Hearing Officer. She is an expert on Medicaid law as it pertains to people served by the Community Mental Health system. Her presentations on due process rights and mental health services for people with mental illness and developmental disabilities are always informative.

This was a refresher course for me (see the Friends of DD Newsletter from November 2010) and a reminder that many families of people with DD are not well-informed about their family member's rights, the availability of services, or the remedies afforded to Medicaid recipients who disagree with decisions made by their local CMH. It is not only a lack of information that is the problem, but the reality that many families are sometimes misinformed and misled by people within the CMH system.

Here are a few bits of information from Stacy's presentation that you need to know:

IN MICHIGAN, THERE ARE NO WAITING LISTS FOR SERVICES

Because of agreements Michigan made with the Federal agency that regulates Medicaid (CMS) that allows the state to have a managed care system for Medicaid-funded mental health services, there can be no waiting lists for services.

MEDICAL NECESSITY

Mental Health Services for people with DD must be"Medically Necessary". The same criteria apply to people with mental illness.

According to the Michigan Medicaid Provider Manual, individuals with developmental disabilities who are eligible for Medicaid are entitled to "medically necessary" supports, services, and treatment that are:

• Necessary for screening and assessing the presence of a developmental disability
• Required to identify and evaluate a developmental disability
• Intended to treat, ameliorate, diminish, or stabilize the symptoms of developmental disability
• Are expected to arrest or delay the progression of a developmental disability
• Are designed to assist the individual to attain or maintain a sufficient level of functioning in order to achieve his goals of community inclusion and participation, independence, recovery, or productivity.

The determination of medical necessity must be based on information provided by the person with a DD, the person’s family and/or others who know the individual, and clinical information from health care professionals. The determination must be based on a person-centered plan and made by appropriately trained developmental disabilities professionals within federal and state standards of timeliness. It must be "sufficient in amount scope, and duration of the services" and documented in the Individual Plan of Service.

Services "sufficient in amount, scope, and duration" need to be specified in the IPOS with as much detail as is necessary to meet the needs of the person.

Services may not be denied based solely on present limits of the cost, amount, scope, and duration of services. Determination of the needs for services shall be conducted on an individual basis.

WRITTEN NOTICE FOR ADVERSE ACTIONS

When you ask for a service (do this in writing to make sure you have documentation of the request), the CMH agency must give you a written notice if the agency decides:

• to deny or limit the service
• reduces, terminates or suspends the service, denies payment for a service in whole or in part, or fails to authorize a service

In most cases the CMH agency must give you advance notice of an "adverse" action 12 calendar days before the action takes effect, or they must give you notice at the time the Individual Plan of Service is completed.

MEDICAID HEARINGS 

You may ask for a state Medicaid hearing through the Michigan Department of Community Health if you do not agree with the decision of the PIHP (the WCHO in Washtenaw County). Go to the Michigan Department of Community Health website for more information and a "Request for Hearing" form.

Services must continue while a hearing decision is pending if you have asked for the hearing in a timely manner. See the WCHO website on hearings and appeals for more information.

Here is more on the WCHO regional Due Process and Appeal Committee with links to related documents including the Medicaid Provider Manual.

Michigan's Plan for Dual Eligibles: Comments on PIHPs and State-wide Assessments

PIHPs (Pre-Paid Inpatient Health Plans) 
 
PIHPs distribute Medicaid funds to local Community Mental Health agencies in the state and provide other administrative services and management. [The Washtenaw Community Health Organization (WCHO), serves as the PIHP for a four-county area of southeastern Michigan while also serving as the Community Mental Health (CMH) agency for Washtenaw County.]

The state has decided to preserve the PIHP structure for the management and financing of local CMHs, but the number of PIHPs will be greatly reduced with each one serving a much larger geographic area than it does now. The plan does not give much detail about what the PIHPs will look like or how accessible they will be to the people they serve. The decision to preserve the PIHP structure does not assure that there won’t be major changes in how PIHPs operate.

Screening and State-wide Standardized Assessments

According to the plan, (page 2) “Upon enrollment, all beneficiaries will be initially screened to determine basic needs, followed by a more in-depth standardized assessment to determine the possible array of services. The need for specialty services through the separately contracted PIHPs will also be determined at this time…”

Does this mean that a person with a developmental disability could be assigned to an Integrated Care Organization (ICO) (this would likely be something like a Medicaid managed health plan) rather than a PIHP, even though PIHPs under current law are responsible for managing and financing mental health services to people with DD? If a person with DD chooses to be in an ICO, would they still have access to all the mental health services they need?

Also according to the plan, (page 14) once a person is determined to fall under the PIHP part of the system, the PIHP “will conduct a more extensive person-centered assessment” The core assessment instrument can trigger the use of multiple sub-sections that “span the full ranges of needs and, individually, allow for gathering in-depth information in specific areas…” Over time other subs-sections “…may be triggered, leading to identification and linkage to new services”.

Under this plan, the state will develop a standardized assessment instrument covering physical and mental health care for 200,000 people that will determine the needs of individuals and presumably the services they will be eligible for, before the individuals themselves, their families, and others who know them well, have had a chance to participate in the Person-Centered Planning process where these decisions should be made.

Why bother having a Person-Centered Plan if a state assessment has already made the determination of needs and the identification of services? 
 
Is there an “instrument” that currently exists that can identify all the medical and social supports for 200,000 people with needs as diverse as the population of people who are eligible for both Medicaid and Medicare? If not, how much will it cost to devise such an “instrument” with its expanding multiple subsections and linkages?
 
Rather than assisting a PCP team (that includes the individual being served) in determining needs and services, the standardized state-wide assessment proposed by this plan, appears to have reduced the PCP to a rubber-stamp of the state’s determination of needs and services.

A user's guide to Community Mental Health, Washtenaw County

"I go to meetings so you don't have to."

It has been almost two years since I began attending meetings of the Washtenaw Community Health Organization (Washtenaw County's Mental Health agency) and its various committees. Very often I am the only "outsider" there when important decisions affecting people with disabilities and their families are made. Fortunately, there are consumers of mental health services represented on the Board, but it still tends to operate on the abstract level of policy and funding and does not necessarily take into consideration factors you might feel are important.

There are many ways to make your voice heard. Every WCHO Board and committee meeting begins with an opportunity for public participation where you can say (almost) anything you want - it does not have to be on the agenda or otherwise under consideration by the Board. The meetings are formally run and as much as I may want to insert myself into the conversation during the meeting, that is not how things work. I have to stifle that impulse and plan to come back to raise issues that I think are important. Of course, discussions with staff and Board members before and after the meetings are always possible, and attending meetings regularly is a good way to find out who does what and who to talk to when specific questions arise.

The Executive Director of the WCHO, Patrick Barrie, is a former Deputy Director for the Michigan Department of Community Health. He knows a great deal about state policy, funding, and the politics of mental health services. His reports to the WCHO Board are informative and interesting, especially if you have a geeky need to know how the mental health system works.

The WCHO Board meets on the third Tuesday of each month at the Learning Resources Center at 4135 Washtenaw Avenue, Ann Arbor, near the intersection of Washtenaw Avenue and Hogback Road. Some of the items discussed at recent meetings include the restructuring of the WCHO organization to fix problems with the decentralizing and fragmentation of services and functions of the organization in recent years. For instance, Community Supports and Treatment Services (CSTS) had become an independent publicly-funded provider agency, but now it is coming more under the direct control of the WCHO to improve efficiency and control over services. Another issue is that after years of encouraging a greater choice in service providers for consumers, there are now too many providers for the WCHO to monitor effectively and there are questions about the efficiency of contracting with so many small providers.

Committee meetings that might be of interest to consumers include the Program Committee that meets monthly and the Quality Management Committee that meets quarterly. One of the issues facing the WCHO is getting a handle on whether the programs offered are of value to consumers and of sufficient quality to meet their needs. Part of the reorganization of the WCHO will provide the committees with information they will need to make this determination. In addition, the Finance Committee approves and oversees contracts with the WCHO and focuses on funding issues.

The Affiliation Committee is one of the most interesting to me, as it involves Board members and staff from Washtenaw County plus the three other counties (Lenawee, Livingston, and Monroe) in the Community Mental Health Partnership of Southeastern Michigan. State issues concerning mental health funding and policy come up frequently for discussion. The state organization representing Community Mental Health Boards, the MACMHB, comes in for some criticism with many CMH Boards feeling that the MACMHB does not do enough advocacy on behalf of local CMH's and has become instead a mouthpiece for the Michigan Department of Community Health. The Affiliation is evaluating its role in the MACMHB and will be offering recommendations for improvement of the organization. The Affiliation Committee also approves policy changes for the recipient rights office and assesses the overall fiscal health of the four mental health boards.

The Recipient Rights Advisory Committee meets quarterly to go over reports that analyze incidents of abuse, neglect, and exploitation of mental health consumers. The committee takes into consideration special areas that need scrutiny such as the under-reporting of incidents by service provider staff and incidents in supported living (unlicensed) settings. This committee also serves as an appeals committee to hear appeals brought by or on behalf of WCHO recipients regarding Rights investigations. The recipient rights committee members tend to touch on basic issues that we are all concerned about - the safety and well-being of our family members wherever they are receiving services.

For information about the WCHO Board and committee meetings, check the Washtenaw County Calendar of Events. The calendar includes meetings for all county government boards and committees.

To receive information on Board and committee meetings prior to the day of the meeting, e-mail Suzanne Gondeck at gondeks@ewashtenaw.org .

WCHO Town Hall Meeting: June 29th, 2010

Join the Washtenaw Community Health Organization (WCHO) and Community Supports and Treatment Services (CSTS) in a fun and informative evening.

Share your thoughts and ideas on the Community Mental Health System in Washtenaw County and hear what others have to say.

2010 Town Hall Meeting
Tuesday, June 29, 2010
5:00 pm – 8:00 pm
Washtenaw County Human Services
555 Towner, Ypsilanti MI 48197
In the Large Conference Room

Spaghetti Dinner provided by Full Circle Drop In Center and Dessert provided by Fresh Start Clubhouse

All are Welcome! No reservations necessary!

For more information, contact Customer Service at (734) 544-3050 or (877) 779-9707

March 2010: News from the WCHO and the Recipient Rights Advisory Committee

I have been attending Washtenaw Community Health Organization (WCHO) Board meetings for most of the last year in an attempt to understand and follow changes in the agency during the current economic crisis. Very few outsiders attend these meetings—most of the participants and attendees are either Board members or staff from the WCHO or CSTS (Community Supports and Treatment Services). The Board deals with complex issues concerning money and policy that affect the people they serve but, in my opinion, their decisions are not always anchored in the realities of life that we and our family members face each day. The Board does best when we keep them informed and connected to how their actions affect our family members.

For example, at the end of last summer, there were plans afoot to contract out all the vocational and skill-building programs that were operated by CSTS, a public agency. This was part of the County Board of Commissioners move to close a huge budget deficit. Families went to the WCHO and the Board of Commissioners with heartfelt arguments for why the CSTS programs should not be eliminated or changed. Eventually the CSTS employees' union made concessions to the County Board, their employer, that preserved most of their jobs. Then, the WCHO decided to continue contracting with CSTS for vocational and skill-building programs without interruption. Another outside agency that provides supported employment and skill-building programs for other WCHO consumers, was going to be dropped by the WCHO, which would have caused disruption to the people served by that agency. The outside agency felt that the WCHO had made the decision with inaccurate information. The WCHO then decided to continue the contract without interruption. Not all policy and funding decisions work out as well as this one did, but it would never have happened if no one had spoken up.

WCHO Board funding outlook

During a Board discussion on WCHO funding, the Executive Director Patrick Barrie said that continued federal stimulus funding and Medicaid funds would help the agency (and the state) make it through the next six months. If the health care reform legislation makes it through Congress, there will be many opportunities to expand Medicaid funding and to take advantage of demonstration projects. This could avoid cuts that are under consideration by the Michigan Senate. If health care reform fails, there are other possibilities to consider, (passing out Prozac was suggested) but no one is very optimistic about any of these. [Health care reform did pass, so hold the Prozac for now.]

Recipient Rights Advisory Committee Report

The Recipient Rights Advisory Committee for the WCHO has worked on decreasing the number of complaints having to do with "Failure to Report". (If an employee of a WCHO programs fails to report a possible rights violation, that is in itself a violation of rights.) Through training of people who work in group homes, supported living situations, and in other programs funded by the WCHO, the Recipient Rights Office has emphasized the responsibility of employees to report rights violations that they see in their work with people served by the WCHO. There has been a dramatic increase in the number of rights violations reported, perhaps due in part to this emphasis.

There is concern by the Recipient Rights Committee in the large number of substantiated complaints in unlicensed supported living sites for people with developmental disabilities. There were 71 reported for the last fiscal year. Rights complaints in licensed group homes for people with developmental disabilities came in a distant second, with 26 complaints. Substantiated rights complaints increased 50% overall during the last fiscal year.

The Recipient Rights Advisory Committee believes that there should be further investigation of this problem. Some of the causes of the problem may be outside the scope of the Recipient Rights Office, however. For instance, when there are complaints that services are not suitable to the individual’s needs, it may be that Person-Centered Plans are not adequately addressing the needs of the people served. The cause of the problem may lie with staff training, lack of accurate information to families, misunderstanding of PCP requirements, etc.

The WCHO Board is interested in supporting the idea of further investigation into these problems, but asked that the committee come up with a more specific proposal.

The WCHO, the Governor's budget, and DD services

The Washtenaw Community Health Organization (WCHO) board met last night. The Executive Director Patrick Barrie summarized the Governor's proposed budget for the Department of Community Health for fiscal year 2011. It shows an increase in Medicaid funding for MDCH of about 3% and a small decrease in General Fund allocations. This sounds much better than the dire predictions of up to 20% cuts in DCH programs, but the proposals are based on some shaky assumptions:

• that the tax system will be restructured to lower the sales tax and imposes a tax on services;
• that large numbers of teachers and state employees will retire and be replaced with new hires at a lower pay rate and decreased benefits;
• that physicians and hospitals will be taxed to generate more federal funds that will go back to physicians and hospitals;
• and that federal Medicaid stimulus funds will be extended for another six months.

The largest reductions proposed are in funds for people with substance abuse problems. These are often the same people who end up in emergency rooms and hospitals at greater cost to the health care system and the community than if they had received treatment before they reached a crisis situation. There has been much discussion at the WCHO board and committee meetings of plans to provide better access to services for people with mental illness and substance abuse problems. Early access saves money in the long run and generally improves the quality of life for these consumers.

So far in this budget crisis, there has been almost no discussion by the WCHO board of services for people with developmental disabilities other than to say that most people with developmental disabilities qualify for Medicaid and are therefore entitled to services. It helps that Medicaid funding is available and will probably increase.

We know, however, that the Michigan Department of Community Health is targeting for elimination programs for people with the most severe disabilties - group homes, sheltered workshops, and day programs. One might logically think that the state is motivated by a desire not only to save money, but to shift more of the responsibility from serving people with severe and complex disabilities from the state to local mental health agencies. But the state claims to have a higher moral purpose: specialized programs that serve only people with disabilities discriminate against them by isolating and segregating them from people who are not disabled. By eliminating these programs the state serves the noble purpose of rescuing people with disabilities from discrimination.

The mental health system fully supports people with mental illness and substance abuse problems in joining together in clubhouse programs and recovery and support groups. Other parts of the system encourage a full array of options for senior citizens, including group living in independent and assisted living facilities. But when it comes to people with severe developmental disabilities, the state is set on saving them from the horrible fate of having to associate with people like themselves. Now that's discrimination!

Washtenaw County: CHS Vocational Services Contract Reinstated

This is an update to another blog entry from 11/19/09.

At the December 2009 WCHO Board meeting, the Board voted to rescind an earlier decision to discontinue a contract with CHS, an agency that provides supported employment and other vocational services to people in Washtenaw County. The initial decision to discontinue the contract was based on a misunderstanding regarding CHS's financial status. After CHS reported to the Board about its financial stability, the contract was reinstated.

CHS will continue to serve the same client base and provide the same skill building/supported employment services as they have been doing.

The MDCH vision of the future

Lansing is a place I do not pretend to understand. Emanations from the Michigan Department of Community Health (MDCH) about its "vision" for people with developmental disabilities seem especially murky and at times far removed from reality.

On December 16, 2009, Michael Head, a Deputy Director at MDCH, met with the directors of the state's Prepaid Inpatient Health Plans (PIHPs). PIHPs are regional affiliations of Community Mental Health agencies. (Our PIHP is the CMH Partnership of Southeastern Michigan that includes the CMH agencies from Washtenaw, Lenawee, Livingston, and Monroe Counties.)

According the PowerPoint presentation of Mr. Head's talk, Michigan's "vision" for adults with developmental disabilities is for them to have the supports and services necessary to be healthy and safe and to successfully:

• contribute to their communities
• earn an income in a non-segregated community setting
• live in their own homes
• have full community inclusion with meaningful participation and membership
• have friendships and relationships
• have fulfilling lives

According to the MDCH, people who do not conform to the state's vision of success (people who live in group homes or are unable to earn an income in non-segregated settings, for example) are now being deprived of a new-found right, "the right to live in the world".

The state's vision dovetails nicely with the MDCH proposals to deal with the state's economic crisis: eliminate the bad old "legacy" programs such as day programs, sheltered workshops, group homes, and other programs in settings designed especially for people with the most severe and complex disabilities. A principle underlying the planning process for the future is that consumers need to get used to making do with less than adequate services, but rest assured: the state is more than willing to give them ample opportunity to participate in the fight over what to do with the remaining resources.

There are many well-defined rights for people with disabilities, including the right to treatment and services suitable to the person's condition and the right to participate in determining those services through the Person-Centered planning process. State and local mental health agencies have the obligation to assure that rights are protected and services available to meet the needs of a diverse population. There is nothing wrong or illegal with the existence of programs such as day programs, licensed group homes, and sheltered workshops that provide for the needs of many people with developmental disabilities. No one can deny a person participation in benefits that are generally available to everyone in a community, based solely on a person's disability, but neither can a person be forced to participate in a program or service they do not need or desire. And rights do not disappear in a bad economy.

"Living in the world" is not a right, but an often unpleasant reality that we all have to cope with. Everyone, unless one happens to be a hermit, lives in a community. "The" community, however, is an ill-defined abstract notion that is open to interpretation. Attempting to eliminate an infrastructure of services that many people with developmental disabilities depend on by choice and necessity does nothing to protect rights and very likely will not save money.

There is no getting around the seriousness of Michigan's economic crisis, but placing the burden of the crisis on vulnerable people and their families who have few resources with which to fight back is not a reasonable or humane approach.

Serious problems facing Community Mental Health system in Michigan

On January 13, 2010, the CMH Boards under the Community Mental Health Partnership of Southeastern Michigan met to hear very bad news about Michigan's funding of mental health agencies. Because of the state's deflationary spiral downward and drastically reduced revenues, all local Community Mental Health agencies can expect unprecedented cuts in funds from the state.

The four CMH boards from Washtenaw, Lenawee, Livingston, and Monroe Counties braced themselves for the beginning of the 2011 budget negotiations which start in February when the Governor delivers her budget proposals to the state legislature. The meeting began with a sobering state budget overview and a presentation on finance basics and the impact of the crisis on the state's General Fund and Medicaid funding.

I am no expert on state finances, but this sure sounded bad to me:

• The current recession at 22 months ("peak to trough") is the longest since the Great Depression.
• Leading indicators point to an imminent national recovery, but Michigan has been in a longer and deeper decline than other states.
• Auto sales are going up again, but the Big Three market share has dropped from around 70% of the market in the early 1990's to 35% of the market now. (Nationally, fewer people today work in manufacturing jobs than did in 1941.) Michigan Vehicle employment dropped 78% from 2000 to 2010. Overall, 1 million jobs have been lost since 2000. The forecast for 2010 is a Michigan unemployment rate of 15.3%.
• In good times, Michigan's personal income relative to the U.S. was 122%. We have fallen to 87% of the national average.
• States revenues in the General Fund for 2010 are equal to the General Fund level of 1965, when adjusted for inflation. All the rumors about how our taxes keep going up are not exactly true: Michigan taxes as a percent of personal income have declined since 2000.

After significant cuts in spending for the 2010 fiscal year, the state has told all agencies that they must submit program reduction proposals for fiscal year 2011 equal to 20% of their General Fund appropriation and the Department of Community Health also wants agencies to submit proposals for 20% reductions in Medicaid spending. (This is especially troublesome, because Medicaid pays for most of the specialty services for people with developmental disabilities.)

If the threatened cuts were to be fully implemented, Washtenaw County would have to cut $1.9 million from its General Fund authorization. Even though Medicaid-enrolled consumers are entitled to needed services, Medicaid funds would be cut by $8.8 million.

The four-county affilliation that includes Washtenaw County is developing a strategy to make sure that the CMH Partnership of Southeastern Michigan takes a leadership role in influencing how the state will respond to this crisis. They have been disappointed in the past by the lack of leadership from their state association (the MACMHB) and plan to take more direct action.

From the discussion this week, it appears likely that the short-term strategy to get us through the next 18 months will be to push for an expansion of Medicaid and tap into other sources of federal funding while developing a long-term strategy for remaking the community mental health system. If the healthcare reform legislation makes it through Congress, it will open possibilities for funding through numerous demonstration projects. The affiliation, rather than focusing solely on the money, will focus on changing the system and serving consumers.

Update on WCHO vocational programs

See update here.

Developmentally disabled consumers in vocational and skill-building programs in Washtenaw County can expect these programs to continue, although some consumers receiving supported employment services will be working through another provider.

At the November 17, 2009 meeting, the Washtenaw Community Health Organization (WCHO) Board voted to discontinue the contract with CHS, a provider of supported employment services, and reassign consumers receiving supported employment services to Workskills, another supported employment provider, and Community Supports and Treatment Services (CSTS). The CSTS skill-building programs (day programs and PACE groups) will continue as is. No consumers will lose vocational and skill-building services.

The programs provided by CSTS were threatened earlier in the year by drastic lay-offs and cuts by the Washtenaw County Board of Commissioners in order to plug a $30 million hole in the county budget. The County renegotiated labor contracts with county employee unions, saving $5.2 million over the next two years and 120 - 150 county jobs at CSTS.

The WCHO, which contracts for services from CSTS, will be able to fund the vocational and skill-building programs by consolidating some programs and using increased Medicaid funding from the federal government.

All three of the supported employment service providers (CSTS, Workskills, and CHS), had few complaints from recipient rights or customer services, but CHS is having serious financial problems. [It was noted at the meeting that there have been complaints about the choice of jobs available through supported employment programs.] The WCHO Board decided that the option of maintaining the contract with Workskills and CSTS would least disrupt consumers and still be cost-effective.

Changes are expected to be implemented by March 1st, 2010, which will allow time for adequate communication and negotiation with providers and adjusted work at CSTS.

Update on Washtenaw County programs and other budget news

Donna Sabourin, the Director of Community Supports and Treatment Services, attended the last Friends of the Developmentally Disabled meeting on September 24th, 2009 and was able to give us an update on CSTS vocational services to people with DD.

Without knowing how much the Washtenaw Community Health Organization will be getting from state general funds, the WCHO granted an extension of the contract with CSTS for 90 days. Some cuts to CSTS were made final by the Washtenaw County Board of Commissioners, but these cuts did not affect vocational and skill-building services.

According to Donna, the WCHO would like CSTS to continue providing vocational services and to take in two other programs that were contracted to other providers. A work skills program that has provided supported employment services to one group of consumers for 10 years would go to CSTS along with a program for another group of consumers that has has had three providers in 5 years. By taking in these two programs, there will be less choice in providers for employment programs, but it will give the second group of consumers more stability. CSTS has also said that the agency can provide these services without increasing staffing, saving money for the WHCO.

At the time of the Friends meeting, Donna said that a tentative agreement on concessions from the employees union had been reached. According to Annarbor.com, October 7, 2009, Washtenaw County workers union gives up raise to save jobs, the membership of AFSCME Local 2733 has indeed agreed not to take a previously agreed on 3% raise in 2010 and to forgo a salary adjustment in 2011. The agreement will save $5.2 million over the next two years and 120 - 150 county jobs. The union has also agreed to take 8 "bank days", similar to furlough days.

Bob Guenzel, Washtenaw County Adminstrator, according to Annarbor.com, had high praise for the union:

I want to give a special pat on the back to our labor partners...They really came through and, remember, they didn't have to sit down to the table with us at all. They stepped up and, in my mind, really put the county first and put services first.

The Washtenaw County Board of Commissioners also voted unanimously to restore over $442,750 in human services funding in exchange for $450,000 in capital expense reductions. It appears that the county is on the verge of having a balanced budget for the next two years.

The state is operating on a continuation budget for 30 days while the legislature continues to negotiate a balanced budget. At the September WCHO meeting, there was discussion of the likelihood of severe and unprecedented general fund cuts to the Michigan mental health budget. The state seems unwilling or unable to come up with a long term solution to deficits in mental health funding. The impact of reduced general funds for mental health will be felt more by people with mental illness than by those who are developmentally disabled.

The WCHO October meeting is scheduled for Tuesday, October 20th, 2009 from 6 - 8 p.m. at the LRC, 4135 Washtenaw Ave, Ann Arbor. For a schedule of official meetings in Washtenaw County, you can view the calendar of events here.

Washtenaw County funding cuts for DD services

The Washtenaw County Board of Commissioners (BOC) met on September 2, 2009. During public participation at the beginning of the meeting, at least five people, some with their disabled family member, made statements to the commissioners opposing proposals to reduce funding to Community Supports and Treatment Services' (CSTS) vocational and skill-building programs. The BOC was genuinely moved by the family members who talked about how much they rely on these programs for their loved ones and the distress it causes when programs are abruptly changed or terminated. The commissioners appeared not to be aware of the heartfelt opposition to these proposals.

The meeting was covered by AnnArbor.com and the Ann Arbor Chronicle .

Part of the meeting that was not covered by local on-line news, were comments and questions by Ronnie Peterson, a commissioner from Ypsilanti. He has personal experience with a disabled uncle whom his family cared for and was especially sympathetic to the concerns of families. First, he emphasized that the BOC has not taken any steps on CSTS funding. He was surprised by the opposition from families concerning cuts in funding by the county that could result in CSTS losing many programs that families rely on. He wondered what steps CSTS had taken to involve and inform families of possible funding cuts, before the BOC was notified of the impact these cuts would have on CSTS programs. He said he would not want to approve something opposed by consumers.

Donna Sabourin, the director of CSTS, spoke much later in the meeting to update the BOC on CSTS funding. She said the Washtenaw Community Health Organization (WCHO) contracts with the CSTS to provide the vocational and skill-building programs that serve a large number of people with developmental disabilities. She presented three options for the future of these programs:

1. The WCHO receives Medicaid funding for the vast majority of people participating in these programs and expects increases in Medicaid funds to help pay for services. The WCHO might increase funding to CSTS to make up for the cuts in funding from Washtenaw County and keep current programs, if funding permits.
2. The WCHO could contract with other entities to provide the same services at less cost.
3. The WCHO already uses other contractors to provide some vocational services. There has been a problem with some of these programs having to switch providers every year. The CSTS could bring these programs back to CSTS without increasing CSTS staffing, thereby saving money and maintaining their current programs with WCHO funding, including the increases in Medicaid funding.
   

The 3rd option may be the best, but it would require approval of the WCHO based on that agency’s estimate of future funding.

BOC meetings are available for viewing by webcast here. Past meetings are found in the archives. Under the viewing screen, there is a place where you can select an agenda item (such as Public Participation) and go directly to viewing that part of the meeting.

Important meetings coming up:

WCHO Board Meeting: Tuesday, September 15, 2009, 6 – 9 p.m. at the LRC building at 4135 Washtenaw Ave., Ann Arbor. Contact information: Suzanne Gondek at (734) 544-3014 or gondeks@ewashtenaw.org .

Washtenaw BOC Meeting: Wednesday, September 16, 2009, 6:30 p.m., Board Room in the Administration Building at 220 N. Main St., Ann Arbor.

Jill Barker
Friends of the Developmentally Disabled
jillrbarker@sbcglobal.net