Notes on the Washtenaw County CMH Board Meeting of 3/25/19

When I report on meetings, it is usually from the perspective of people with developmental disabilities and their families, so I may leave out details that would stand out more to people with other disabilities or mental illness. The CMH packet of materials that is available with the agenda before each Board meeting has much more information than what I cover and is a good resource for keeping up with current issues in the CMH system. 

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The Washtenaw County Community Mental Health (WCCMH) Board of Directors met at the administration building at 555 Towner St. in Ypsilanti, MI, rather than its usual meeting place at the Learning Resource Center at 4135 Washtenaw Ave, Ann Arbor, MI.

Minutes for the last meeting of the board can be found with the agenda and packet of meeting materials.

A detailed financial report, Attachment #2, is available. There was a discussion of methodology to determine the state Medicaid rate reimbursement for services provided by CMH. The problem with the formula used is that it apparently does not take into account all the variables that cause expenses to be higher in some places than others. Washtenaw County, for example, has a higher cost of living than other areas, but that is not accounted for in the rate of reimbursement. Also, the caseload of people served by WCCMH continues to rise while it has been falling in the state overall. 

There is continuing concern about the inability of PIHPs (regional administrative agencies that pass on Medicaid funds to local CMH agencies) to save a sufficient amount of funding in reserve to provide financial stability to the CMH system.

Trish Cortes, the Executive Director of the WCCMH, said in her report to the Board, that local agencies have been getting some traction with the Michigan Department of Health and Human Services and that the state is acknowledging the problem of insufficient revenues. A midyear adjustment is being considered.

Department of Health and Human Services (DHHS) budget hearings on Behavioral Health [Community Mental Health services including services for DD] were scheduled for March 21, 2019 before the Senate Committee on Health/Human Services. Jeff Irwin is a state Senator from Ann Arbor who is on this committee.

House Health and Human Services Committee budget hearings will be held April 11, 2019 at 1:30pm or after session, in the House Approps Rm, 3rd floor Capitol.

It is important for legislators to hear from provider agencies, consumers, and families about the impact of insufficient mental health funding. If there is no relief, it is possible that WCCMH and other CMH agencies will be in the position of being unable to provide mandated services to consumers. 

This is from an email from Alan Bolter, Associate Director of the Community Mental Health Association of Michigan (CMHAM) on DHHS Budget Hearings: 
 
“Over the past few weeks, Bob [Sheehan] and I have had several encouraging meetings with the administration and legislators and believe there may be an opportunity to make some progress on our funding challenges. We believe the DHHS budget hearings would be a perfect opportunity for our members to back up the message lawmakers are hearing from CMHAM. With that said, we strongly encourage you to participate in either or both of the upcoming hearings, especially if you have a member from your community on the committees.”

The following is the message from CMHAM to legislators on budget issues:

1. Medicaid rates set to match demand and costs: Set the Medicaid rates to the state’s public mental health system (the process that provides over 90% of the funding for this system) to reflect the actual and projected growth in demand for and the real costs of providing the services associated with Michigan’s Medicaid mental health benefit.

2. Medicaid rates to include contribution to risk reserve: Include, in the Medicaid rates to the state’s public mental health system the federally required contribution to risk reserves at a level sufficient to allow for the fiscal soundness of the public mental health system,

3. Allow the public mental health system to hold sufficient risk reserves: Allow the state’s public Medicaid mental health/specialty health plans (the Prepaid Inpatient Health Plans; PIHPs) to hold risk reserves of the size that would be held by any risk-bearing organization. With the earmarking of the risk reserve contribution in the rates (see 2 above), allow the CMHs to retain and reinvest any Medicaid savings that they generate through efficiencies and effective clinical practices.

4. Free up local dollars to meet unmet non-Medicaid needs, by halting the inappropriate drain of local dollars to fulfill state Medicaid obligations: eliminate the Local Match Draw Down requirement (section 928); assume the appropriate state role in ensuring the soundness of the state’s Medicaid mental health system by halting the demand that counties close the Medicaid gap caused by the systemic underfunding of Michigan’s public mental health system. 

5. Restore General Fund dollars to the public mental health system: Restore the lion’s share of the State General Fund dollars cut from the CMH budget to ensure that persons, not covered by Medicaid, have access to needed mental health services.

If you as a family member are testifying before a legislative committee or sending in written comments, you may have other concerns or want to express some of the same concerns in your own words. Advice from CMHAM: If you plan on attending, you should plan on bringing around 20 copies of your testimony and arrive at least 10 minutes early to fill out a card...

These are members of the house and senate committees considering appropriations for the Health and Human service budget: 

State House Health & Human Services Committee -- Whiteford (C), Green (MVC), Inman, Allor, Yaroch, Glenn, Huizenga, VanWoerkom, Hammoud (MVC), Hoadley, Love, Brixie, Cherry. 

State Senate Committee on Community Health/Human Services -- Sen. MacGregor (Chair), Sen. Bizon (Vice Chair), Sen. Schmidt, Sen. LaSata, Sen. MacDonald, Sen. Barrett, Sen. Hertel (Minority Vice Chair), Sen. Irwin, Sen. Santana

Community Mental Health Partnership of Southeastern Michigan (CMHPSM) Regional Update

[The WCCMH belongs to the Community Mental Health Partnership of Southeast Michigan (CMHPSM) along with CMH agencies from Livingston, Lenawee, and Monroe Counties. The CMHPSM is one of ten PIHPs (Prepaid Inpatient Health Plans) in Michigan. PIHPs are regional administrative agencies that pass Medicaid funds from the state to local CMH agencies.]

The CMHPS recently commissioned an evaluation of their Chief Executive Officer Jane Terwilliger. The results were not good. She has been CEO of the PIHP for four years and before that was the Executive Director of the Monroe County Community Mental Health Authority. There were many complaints about her job performance. The agency staff were especially upset that she has discontinued holding staff meetings. Directors on the Board from the four counties were the most critical of her performance.

Jane Terwilliger’s contract was extended for six months, but the CMHSP board has put conditions on her employment for immediate improvement with time requirements for changes. If these do not occur, her contract may be terminated. 

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Well, folks, that’s about all the excitement I can take from one more WCCMH Board meeting. The next meeting is April 19, 2019 4135 Washtenaw Ave, Ann Arbor LRC Room Michigan 9:30-11:30am .

Washtenaw Coalition for Community Choice Meeting - 4/9/2019

Join us for a meeting to get started on creating a housing community in Washtenaw County for Adults with I/DD including ASD based around a working farm, but still in Ann Arbor/Saline area. 

Tuesday, April 9, 2019 

6:30 – 8 PM 

2144 S. State St. 

Ann Arbor, MI 

Keller-Williams offices top floor 


Show Map

 

Hosted by the Washtenaw Coalition for Community Choice (WCCC)

Increasing Options and Decreasing Barriers to Housing Choices for those with Intellectual and Developmental Disabilities (I/DD) in Washtenaw County 

This will be a parent/caregiver lead group. Email Kerry at kerrykafafian@gmail.com with questions .

Michigan: Medicaid eligibility is not the only way to qualify for services for people with DD and other disabilities

A letter of clarification from the Michigan Department of Health and Human Services, dated 12/14/2018, was sent to Executive Directors of Prepaid Inpatient Health Plans (PIHPs) and Community Mental Health Services Programs (CMHSPs) concerning misinformation about eligibility for mental health services, including services for people with intellectual and developmental disabilities. The letter is from Jeffery L. Wieferich, the Director of the Michigan Bureau of Community Based Services. [PIHPs are the regional administrative agencies that pass on Medicaid funding to local Community Mental Health agencies (the CMHSPs).] 

The body of the letter clarifies access and eligibility for Community Mental Health (CMH) services and corrects inaccurate information being provided to the public. Some CMH agencies and PIHPs have been misinforming the public that their agencies will serve only people eligible for Medicaid. This is not correct.

For one thing, many people do not apply for Medicaid until they are in need of services. There is some funding to serve people not eligible for Medicaid, and they are placed on a waiting list, if funds are not available. Services must be provided to all Medicaid eligible individuals. Everyone who contacts a CMH agency is entitled to an evaluation to determine his or her level of need. 

The letter makes these clarifications:

• Staff from a CMHSP may not state that the CMHSP only serves Medicaid beneficiaries. For those individuals that do not have Medicaid coverage, the Mental Health Code…is clear that a CMHSP must serve anyone in an emergent (crisis) situation…Following that, an assessment is required to be completed so that level of need is determined. If an individual’s level of need is not as severe as other individuals, then the CMHSP may determine that it does not have sufficient general funds to provide services and the individual is to be placed on a waiting list for CMHSP services (non-Medicaid only) and the CMHSP should maintain the list.
• CMHSP Access Center staff must screen anyone that calls for a crisis and then assure that applicants are offered appointments for assessments with mental health professionals of their choice within the…contract-required standard timeframes. For those individuals without Medicaid coverage, the Mental Health Code also states that a waiting list must be maintained for anyone that is determined not as severe as other individuals…
• When an individual with mental health needs [including people with intellectual and developmental disabilities] is denied community mental health services, for whatever reason, he/she is notified of the right under the [Mental Health Code] to request a second opinion and the local dispute resolution process…
• CMHSP websites should not be conveying only Medicaid eligible beneficiaries are served.
• When an individual has private insurance, this is not solely a reason to deny CMHSP services. The CMHSP is required to complete an assessment of the individual’s needs and then prioritize based on the [Mental Health Code]. The CMHSP shall not deny an eligible individual a service because of individual/family/income or third party payer source…

Another source of funding for children under the age of 18 is the Michigan Children's Waiver Program (CWP).

From the CWP Website: "To be eligible for the CWP, the child must have a documented developmental disability and need medical or behavioral supports and services at home. In addition, the child must have behavioral or medical and habilitative needs at home on a consistent daily basis that meet requirements for the level of care for an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)."

The CWP waives the requirement that the family qualify for Medicaid and allows the child to be considered for services regardless of the family's income. There are a limited number of children's medicaid waivers, but it is worth getting on the needs-based waitlist.

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See the letter of clarification for references to the Michigan Mental Health Code.

See also Michigan Protection and Advocacy Service on eligibility for services.

Group Living in Ann Arbor: OK for Young Professionals and Students, but not for Adults with Disabilities???

This is about an article in the Ann Arbor News, “Group-living townhouses with co-working space will target young professionals in Ann Arbor” by Ryan Stanton, 2/23/19. 

You may detect a note of sarcasm on my part, when I describe what is being proposed here in Ann Arbor to much acclaim. If this were proposed by families of adults with intellectual and developmental disabilities, as a housing and service solution for their family members, some advocacy groups would denounce the effort as an attempt to re-institutionalize people with IDD and segregate them from society by providing services where they live targeted to their specific needs. 

Because this project is designed for young professionals, with the idea of helping them save money and share services with other like-minded adults, we are unlikely to hear cries of righteous indignation and accusations that it is just a scheme to oppress and infantilize young professionals. This is a complaint you would inevitably hear if this was built for people with disabilities. I think it would be a fine idea to have an option like this for people with disabilities who prefer group living and can benefit from it.

To be clear, housing people with disabilities was not an issue in this article, and I don't mean to imply that there was any hint of discrimination by the city or developer against any particular group of people. This is just me, struck by the contrast in how we think about non-disabled people just living their lives, and people with disabilities being caught up in controversies over other people wanting to decide for them how they should live.

The Housing Project for Young Professionals:

A developer will build 11 six-bedroom units, that city officials initially assumed was for students used to dorm-like living: 

“This is emphatically not a student housing project,” said developer Heidi Mitchell of Prentice Partners of Ann Arbor.

“It is actually a co-living, co-working space with (shared) vehicles targeted toward young professionals.” 

Here is what is planned:

“The apartments are conceived as three-story walkups, with the first floor being a common area with kitchen/dining and living/gathering spaces, four bedrooms, each with a bathroom, on the second floor, and two bedrooms with a shared bathroom on the third floor.

“‘Each townhome is designed to be a standalone unit, sharing only the exterior areas as collective commons space,’ the plans state, noting there will be a row of five units and a row of six units, with a ‘mews’ design that allows for communal access and gathering between."
...

“Bedrooms will be about 150 square feet, giving each tenant what Mitchell calls their own ‘cocoon suite.’

“Each townhouse will have its own front door access, as well as a second access from the communal area.”

The project is designed to allow people to live without owning their own car and to share workspaces so they can work from home if they want.

“The site is within walking and bicycling distance of downtown, the UM campus, a grocery store, CVS, and other destinations, including a bowling alley and UM athletic facilities, with nearby access to public transit.”

“'Obviously we’re not allowed to say you can’t rent if you’re a student, but I can promise you all of our marketing efforts will be directed toward people who are in the workforce,' she said, calling housing for young professionals 'definitely an area of need in the city.'

“'..all of our marketing efforts will be directed toward people who are in the workforce,' says the developer and not at students. "

Do I detect a whiff of discrimination here, not to mention segregation? Definitely not! This is for normal people choosing to live together who also lead their own lives and find it easier and less expensive when so many of their needs can be met in one place.

But six bedrooms in one townhome??? That sounds suspiciously like a group home, congregate living, an intolerable predicament if the people who were living there were disabled. And there is no doubt about it, 11 town homes in close proximity to each other with six people living together in each unit definitely makes it an institution. 

Oh, the horror! Bring on the Young Professional Self-Advocates who know exactly how every young professional should live and will work tirelessly to stop this project in its tracks! 

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See also, "Saline, Michigan: Families take the initiative in creating new housing for people with DD", The DD News Blog, 2/13/18 

"...Dohn Hoyle thinks the Saline project falls short. Hoyle is the public policy director for the ARC Michigan. Because the condos will have 24-hour care and house only residents with disabilities, Hoyle sees less independence than what’s being marketed…'It will be their own place in the sense of their own condo, but remember what you’ve done is you’ve set up a group-living situation [by] having everybody who lives there have a disability,’ Hoyle said.”

Words Matter: The Language of Disability

The article below is from the November 9, 2018 VOR Weekly News Update by VOR’s Executive Director Hugo Dwyer. VOR, a “Voice Of Reason”, represents families and friends of people with severe and profound intellectual and developmental disabilities (IDD), including people with complex behaviors that put them at risk for seriously harming themselves or others. 

Most of the disabled individuals represented by VOR families and friends require an institutional level of care, whether the care is provided in an actual institution for those with the highest needs or in a community setting often funded by Home and Community-Based Services (HCBS) Medicaid Waivers. 

VOR supports choice from a full array of high quality options based on individual need. Many influential advocacy organizations, such as the ARC, promote “Community for All” and the elimination of institutional and other congregate settings, despite evidence of systemic problems and underfunding of community care. The results of poor quality community care lead to abuse, neglect, exploitation, and isolation, the very characteristics that have arbitrarily been assigned to institutions, regardless of the quality of care and the appropriateness of the setting to meet individual needs. 

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On Language: The "R" Word, the "I" Word, and the Subtext of Discrimination

by Hugo Dwyer

11/9/18

While attending the meeting of the President’s Committee for People with Intellectual Disabilities (PCPID) in Washington D. C. last month, I heard a number of participants mention their strong dislike of the “R” word. The general consensus was that the "R" word is hurtful, that it had been used to insult and marginalize people with intellectual disabilities. One speaker compared using the "R" word to using the "N" word.

We can all agree that the "N" word has always been a term associated with ignorance, racism, and hate. We can all pretty much agree that the "R" word has deviated from its original clinical usage to describe an intellectual condition, mental retardation, to become a derogatory, insulting, and disenfranchising term. As a result, we have stopped using the "R" word.

What struck me was the fact that most of the participants freely used the "I" word, Institution, as a demeaning term, without ever seeing the irony of their using this term in a manner that is hurtful, and disenfranchising to those who believe that Intermediate Care Facilities (ICFs) are the best solutions for a minority of individuals with intellectual and developmental disabilities, complex medical problems, and behavioral disorders.

ICFs are a legitimate, valuable component of our full continuum of care. They deliver a higher level of service for people with higher levels of need. ICFs are certified by CMS, and are thereby held to a much more stringent set of guidelines than HCBS waiver settings.

When members of the I/DD community derogatorily refer to ICFs as "institutions", their intent is often to invoke memories of the past, where people with I/DD were cruelly warehoused without treatment in places like New York's infamous Willowbrook State School or Pennsylvania’s Pennhurst State School and Asylum. Modern day ICF's bear no resemblance to those institutions. The use of the "I" word is just as hurtful, just as demeaning and marginalizing to our families as the use of the "R" word might be to theirs.

The families of people with severe and profound disabilities support the goals of inclusion and competitive employment for those who have the ability to participate in these environments. But we cannot help but feel marginalized and discriminated against by others in our own community, when we hear the word "institutions" used in a demeaning manner, when we are told that equivalent services are available in "the community",. Families who support these choices are often told that we are uninformed, afraid of risk, or that we just don't care enough for our loved ones to put them into waiver settings. That is hurtful. That is demeaning. That marginalizes us.

It's time for us all to acknowledge the breadth of the disability community, and work to support one another in our individual goals of making better lives. Please don't allow others to use the "I" word to demean and marginalize those who make this choice.

Washtenaw County: Citizens for Mental Health & Public Safety

Glenn Nelson, Co-Chair of Citizens for Mental Health & Public Safety (CMHPS), informed the WCCMH Board at the 2/15/19 meeting of his organization's new Website. According to the Website, CMHPS "...is a group of concerned citizens advocating that the money allocated to the City of Ann Arbor from the November 2017 Mental Health and Public Safety Millage be used for public safety and mental health services for the residents of Ann Arbor." [The millage funding is specifically directed to benefit people with mental illness and local communities and not people with developmental disabilities, most of whom are covered by Medicaid-funded mental health services.]

That sounds pretty straightforward. That was the purpose of a 2017 millage (property tax) initiative that passed with overwhelming approval: "...to improve the treatment to people with mental health needs, provide increased financial support for mental health crisis, stabilization and prevention, and for continued law enforcement services provided by the Washtenaw County Sheriff’s Office, and for local governments which have their own police force..."

There is some controversy over how Ann Arbor is choosing to spend millage funds:

In July 2017 the Ann Arbor City Council passed a resolution to spend its revenue of $20 million over 8 years as follows:

• 40% for affordable housing, which we support so long as this includes supportive services.
• 20% for bicycle and pedestrian safety, which we recognize is an important component of public safety.
• 40% for climate change actions, which we oppose because these are not related to mental health or public safety.

I am all for initiatives that address climate change, but this looks like a highjacking of funds meant to improve mental health services by a project that is not directly related to mental health issues. Addressing climate change funding in competition with funding for mental health services is not a good precedent.

[Update: After learning more about the millage and agreements reached in order to get it passed, I have come to realize that some of the millage funds are to reimburse cities and townships who do not contract with the county sheriff's office for policing and have their own police departments. Much of the millage funding goes to the Washtenaw County Sheriff's office to improve public safety, but towns and cities that do not have a contract with the Sheriff's  department get a reimbursement from the millage to spend as they see fit. Ann Arbor is not obligated to spend funds on mental health services and it is up to the the local government to decide how they will spend the reimbursement.]

Get the facts and follow the controversy on the CMHPS Website. Look for updates and new information.

Washtenaw County: Notes on Community Mental Health Board Meetings

I often attend Washtenaw County Community Mental Health  (WCCMH) board meetings. My interest in CMH is primarily to follow policies and changes in services for people with intellectual and developmental disabilities (IDD). People with mental illness are by far the majority of people served by the agency and the subjects covered at the board meetings reflect that. I will attempt to cover topics of interest to the whole population served by WCCMH, but it is best to review the agenda and minutes for Board meetings to get a broad idea of topics discussed. 

For those interested in funding for mental health services, there are detailed financial reports tracking revenues and expenditures included in the agenda for each meeting.

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Introduction: The Washtenaw County Community Mental Heath agency provides services to adults with a severe and persistent mental illness, children with a severe emotional disturbance, and individuals with a developmental disability, residing in the county. The WCCMH is a department of the Washtenaw County Board of Commissioners . 

The WCCMH Board of Directors meets on the third Friday of the month. Agenda and minutes are available on-line before each meeting at the Washtenaw County LRC (Learning Resource Center) at 4135 Washtenaw Ave., Ann Arbor, MI 48108. The location for meetings is sometimes changed because of scheduling conflicts or for other reasons. Check the agenda before the meeting for changes.

WCCMH Board meetings are usually scheduled from 9:30 to 11:30 a.m. with a time set aside at the beginning of each meeting for comments from the public.

The WCCMH belongs to the Community Mental Health Partnership of Southeast Michigan (CMHPSM) along with CMH agencies from Livingston, Lenawee, and Monroe Counties. The CMHPSM is one of ten PIHPs (Prepaid Inpatient Health Plans) in Michigan. PIHPs are regional administrative agencies that pass Medicaid funds from the state to local CMH agencies. 

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Rather than giving a full account of the February 15th, 2019 WCCMH Board Meeting, I will touch on subjects that are frequently discussed in addition to topics of interest specific to this meeting.

There always seems to be a funding crisis of some kind within CMH agencies. For example, in the 2/1/19 Year-To-Date Financial Status for Washtenaw CMH, Medicaid shows a deficit (expenditures exceeding revenues) of $2.2 million and the Healthy Michigan Plan (Medicaid expansion under Obamacare) shows a deficit of $930,000. 

Before you start hyperventilating, there are some key points to understand about funding for CMH. The state requires local CMH agencies to fund medically necessary mental health services to all Medicaid-eligible individuals - waiting lists are not allowed. At the same time, budget deficits are prohibited while the state has an obligation to adequately fund local CMH agencies. When the state underfunds the CMH system, deficits grow and local agencies, along with regional PIHPs, are stuck in the middle with conflicting mandates to fund all necessary services and to budget their revenues and expenditures without deficit spending. Conflicts between the state and local agencies are common. There are occasional adjustments to funding from the state that partially alleviate these problems, but permanent fixes to the system are necessary to bring stability.

Recently, the WCCMH filed a lawsuit against the state for not providing sufficient funds for the agency to meet its obligations to the people it serves. [More on this later]. 

"Systemic Underfunding of Michigan's Mental Health System"

This is a document from the Community Mental Health Association of Michigan (CMHAM), an organization for CMH Boards of Directors. These are key points that CMHAM makes to explain the dilemma of underfunding:

• There is a growing demand for mental health services not reflected in funding to the public system such as addressing the opioid crisis and preventing suicide.
• There is insufficient Medicaid funding to meet community demand and real costs of care, including  the funding approach being based on two year old data, thus not reflecting current and emerging needs and costs. Two examples were brought up at the meeting. The Medicaid funding to pay for a mandate to expand state autism services to children and adults up to age 21 is not yet based on actual costs of the program. People with intellectual and developmental disabilities (IDD) are funded at a higher rate than those without intellectual disabilities, even though there are people with severe physical disabilities without ID who have equally high needs.
• The state’s public Medicaid mental health system was underfunded by $133 million in Fiscal Year 2017. During that period, the public system spent over 99% of the funds that it received on mental health services with 6.1% spent on administration. During that same year, the private Medicaid managed care plans took in profits of over $136 million, while spending only 89.8% on medical services with administrative costs 40% higher than the public system. 
• The public system is unable to retain savings of sufficient size to ensure fiscal stability.
• The State General Fund (non-Medicaid) support for the public mental health system and its ability to meet increasing community demand has fallen off dramatically. Due to cuts in this source of funding, $7.50 per person per year is available, to the public mental health system, to provide mental health care to the 8 million Michiganders without Medicaid coverage.

In addition, there has been a statewide and somewhat mysterious “migration” of disabled individuals covered by basic Medicaid and identified as DAB (Disabled, Aged, and Blind) to other categories including those covered by Healthy Michigan, the state’s version of Medicaid expansion under Obamacare. The reimbursement rate for people covered by Healthy Michigan is significantly lower than reimbursement for people identified as “DABs”. This "migration" has led to a statewide reduction of revenues for mental health services. 

Washtenaw County Mental Health and Public Safety Millage

In November 2017 voters passed the Washtenaw County Mental Health and Public Safety Millage by a wide margin. WCCMH continues to plan for how funds available for CMH will be spent. Citizens for Mental Health and Public Safety have a new Website with information on the millage and controversies regarding how the money will be spent. [a millage is a local property tax initiative approved by voters in a millage election]

State News

Robert Gordon will head the Michigan Department of Health and Human Services. 

There is a staffing crisis at State Hospitals that will have to be dealt with. Also, a large number of long term state employees of DHHS have left and will have to be replaced.

Confusion reigns.