Mhdd system redesign report



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MHDD SYSTEM REDESIGN REPORT




TO GOVERNOR THOMAS J. VILSACK

AND THE 80th IOWA GENERAL ASSEMBLY


Prepared by the




Iowa Mental Health and Developmental Disabilities Commission


JANUARY, 2004



TABLE OF CONTENTS

Page


MHDD Commission Membership ………………………………………………………1

Executive Summary…………………………………………………………………..…...2

Introduction ……………………………………………………………………………….4

Vision for the Redesigned System……………………………………………………….. 6



MHDD Commission Recommendations………………………………………………….8

A. Access…………………………………………………………………………8

B. Financial Eligibility……………………………………………………………8

C. Functional/Diagnostic Eligibility...……………………………………………8

D. Residency...……………………………………………………………………9

E. Core Services…………………………………………………………………10

F. Individuals Served By The System………………………………………. ….11

G. Service Coordination………………………………………………………... 11 H. Management Entities……………………………………………………….. 12 I. State Entity……………………………………………………………….…. 13

J. State Institutions……………………………………………………………...14

K. Disability Services Funding………………………………………………….16

L. Phase-In Strategy…………………………………………………………… 18

Conclusion……………………………………………………………………………… 20

Contact Information……………………………………………………………………...21

Appendix A: Definitions……………………………………………………………...A-22

Appendix B: House File 529………………………………………………………….B-31

Appendix C: Cost Estimates ...……………………………………………………….C-35

Appendix D: Phase-In Chart...………………………………………………………. D-40

MEMBERS OF THE COMMISSION


Michael Bergan, Chair; Winneshiek County Supervisor, accountant with Home Town Projects Corp., board member of the Northeast Iowa Mental Health Center, Decorah

Jane Halliburton, Story County Supervisor, Chair of Story County Board of Health, Ames

Lannie Miller, Palo Alto County Supervisor, West Bend

Patricia Penning, Department of Human Services Nominee, Sioux City Area Manager, LeMars

Kittie Weston-Knauer, Department of Human Services Nominee, Principal, Scavo Campus, Des Moines

Ronald Walls, Board Member of the Mental Health Center of North Iowa, Administrator at Liberty Square Care Center, Clear Lake

Jacqueline Kibbie-Williams, Iowa Association of Community Providers Nominee, CEO of Village Northwest Unlimited and family member of an individual with a disability, Sheldon

William Gorman, Provider of Developmental Disability Services to Children, Executive Director of Systems Unlimited, Solon

Lynn Ferrell, Central Point of Coordination (CPC), Executive Director of Polk County Health Services, Urbandale

Julie Jetter, Central Point of Coordination (CPC), Buchanan County Community Services Director, Independence

Brian Ridler, AFSCME Nominee, Resident Treatment Worker at Woodward State Resource Center, Woodward

Russell Finken, Family Member of an Individual Living at a State Resource Center, Principal of Glenwood Middle School, Glenwood

Mary Hughes, Service Consumer, Executive Director of the Fullness of Living Center, Kalona


Lori Reynolds, Parent of an Individual with a Disability, Executive Director of Iowa Federation of Families for Children’s Mental Health, Anamosa

Linda Kellen, Vice Chair; Family Member of an Individual with Brain Injury, Chief Operating Office of Opportunities Unlimited, Sioux City

Jon Grate, Advocate, National Alliance for the Mentally Ill Nominee, Davenport
LEGISLATIVE MEMBERS OF THE COMMISSION
Senator Kenneth Veenstra, Orange City (Lyon, Plymouth, Sioux)

Insurance Agent; Assistant Majority Leader; Chair of Senate Human Resources Committee; Health and Human Services Appropriations Subcommittee.



Senator Amanda Ragan, Mason City (Cerro Gordo, Floyd, Howard, Mitchell)

Executive Director Community Kitchen of North Iowa/Executive Director, Meals on Wheels; Ranking Member of Senate Human Resources Committee



Representative Danny Carroll, Grinnell (Mahaska, Poweshiek)

Member of House Human Resources Committee



Representative Mark Smith, Marshalltown (Marshall)

Licensed Independent Social Worker; Ranking Member on House Human Resources Committee; Health and Human Services Appropriations Subcommittee



EXECUTIVE SUMMARY
The Mental Health and Developmental Disabilities (MHDD) Commission recommends that several aspects of the current system for delivering adult disability services be changed to provide better access to services, to fund core services to more people statewide, to equalize county funding obligations, and to distribute funds on a more equitable basis.

The recommendations will assure universal access to information and outreach, to initial service coordination, and to crisis services. The system will link individuals with disabilities to basic supports such as housing subsidies, utility subsidies, food assistance, transportation subsidies, medical and dental care. Funds will be available where each individual resides and will not be determined on an archaic calculation of “legal settlement.” While this does not assure that each core service will be available in every locality, it does assure equal access to services. Adults with mental illness, chronic mental illness, mental retardation, developmental disabilities other than mental retardation, or disability due to brain injury will be eligible if they meet standardized functional assessment criteria and either qualify for Medicaid funding or have an income below 150% of the federal poverty level.

The redesigned system will provide funding for core services including coordination and monitoring services, community services and supports, inpatient services, and residential services. See page 10 “Core Services” for more information about core services.
Funds for the adult disability system will come from county property taxes, state appropriations, federal funds, and other sources. Counties will contribute at an equalized property tax rate threshold. State and federal funds will be distributed to counties or coalitions of counties using case rates based on functional assessments of eligible individuals. This assures that individuals will have access to available funding based on their individual needs.
The Commission anticipates that system changes will occur over the course of the next six to eight years. Section L details the phase-in strategy. In Phase 1, the Legislature would authorize the changes and the system would develop fiscal data and tools. In Phase 2, the equalized property tax rate and the new method for distributing MH/DD funds would be implemented. In Phase 3, all affected populations would be assured funding for core services statewide. Finally, in Phase 4, each county or consortium of counties (in this report called “management entity”) would relinquish funding obligations for individuals that have “legal settlement” in the county. Instead, they would fund individuals who reside in the management entity. Appendix D provides more details.

It is likely that the new system will require additional revenue. First, a $200,000 appropriation is needed to fund collection of fiscal data, development of functional assessment tools, and development of case rates. Revenue to fund statewide delivery of core services may come from additional appropriations, proposed property tax restructuring, or other sources. See Appendix C for an explanation of costs of redesigning the system.

State legislation passed in 2002 expanding the duties of the MHDD Commission, and House File 529, found in Appendix B, provided impetus for the redesign effort and this report. The Olmstead Decision (Olmstead V. L. C. [98-536] 527 U.S. 581) handed down by the US Supreme Court provided additional impetus. This report does not make recommendations regarding redesign of an MHDD system for children. The MHDD Commission intends to make recommendations regarding the children’s MHDD system in a report to the legislature in December 2004.
The report is a product of the MHDD Commission and the work of 150 Iowans that voluntarily served on workgroups meeting regularly for more than a year. The volunteers included individuals with disabilities and their families, representatives of county and state government, advocates, educators, and service providers. A copy of the full report and its appendices can by obtained from DHS staff at 515-281-4593, bflores1@dhs.state.ia.us, or on the Iowa Department of Human Services website at http://www.dhs.state.ia.us/publication.asp.

INTRODUCTION

This report sets out recommendations from the Iowa Mental Health and Developmental Disabilities Commission (MHDD Commission) for redesigning Iowa’s system of support for adults with mental health needs, developmental disabilities, or brain injuries. In this report, this system will be identified as the MHDDBI system. See definitions for key terms in Appendix A.

The Commission also has a statutory duty to set out similar system redesign recommendations for children. The Commission anticipates collecting and analyzing information about the children’s MHDDBI system in 2004, and issuing recommendations for system improvement in December 2004.

The Commission had several reasons to study and recommend changes in the adult MHDDBI system this year. On February 1, 2001, President George W. Bush announced the New Freedom Initiative. Founded upon the spirit of the Americans with Disabilities Act and the Olmstead Supreme Court decision, the New Freedom Initiative represents a comprehensive set of proposals designed to ensure that Americans with disabilities have the opportunity to learn and develop skills, engage in productive work, make choices about their daily lives, and participate fully in their communities.
Nationally there is considerable momentum in the mental health community to focus services, supports, and funding on individuals needs. The President’s New Freedom Commission, spearheaded by President George W. Bush, focuses attention on the centrality of person-centered planning and a recovery-oriented approach, the importance of evidence-based practices, the need to expand service access to rural and otherwise underserved areas, and the necessity of having a comprehensive state-wide mental health plan.
Iowa Governor Tom Vilsack issued Executive Order 27 in February 2003 to call on state agencies to “move purposefully to swiftly implement the Olmstead Decision.” The order directed the heads of 20 state agencies to undertake steps to identify and address barriers to community living for individuals with disabilities and long term illnesses in Iowa.

In Iowa we are taking a second look at how best to serve individuals that have high intensity needs or combinations of needs. Some of these individuals currently live in state Resource Centers, state Mental Health Institutions, or Intermediate Care Facilities for Persons with Mental Illness or Mental Retardation but would prefer to be in their own homes or communities. The Olmstead/Real Choices Consumer Task Force and others are seeking ways to provide opportunities for those individuals to live, learn, work, recreate and otherwise contribute in their chosen communities. The Commission is partnering with the task force, the Governor’s Developmental Disabilities Council, and others to assure that our system best serves the needs of these individuals.

In 2002, legislation combined the MHDD Commission with the State County Management Committee and reshaped the Commission’s membership. Consistent with its new legislative mandate, the reconstituted MHDD Commission began to redesign the mental health, developmental disability, and brain injury service delivery system in November 2002. In spring of 2003, House File 529 (Appendix B) required that by December 31, 2003, the Commission recommend changes that would improve the system. It asked that the Commission include in those recommendations:


  • Assurance that individuals with mental illness, mental retardation, developmental disabilities, or brain injury have access to services, regardless of where they live

  • Assurance that individuals have access to available funding, based on their individual needs

  • Statewide standards for clinical and financial eligibility

  • A minimum set of core services that will be funded for eligible individuals based on their individual unmet needs

  • A new funding process that equalizes distribution of MHDD funds

The legislation did NOT require that the system attempt to operate using reduced appropriations. Neither did it limit the Commission redesign efforts to “budget neutral” recommendations.

Each year more than 50,000 of Iowa’s adults use one or more services funded by the disability services system. The services range from short-term outpatient counseling provided to an individual with depression by a community mental health center, to intensive mental health treatments and extended institutional stays for individuals with severe mental health needs and challenging behaviors. Families may need nursing or respite care to supplement the primary care they provide for an individual with autism or brain-injury. An individual with profound mental retardation may need care in a supervised environment 24 hours a day. The special needs of individuals with disabilities range from no special needs whatsoever to needs for financial management training, medication management, assistive devices, transportation, personal care attendants, assertive community treatment or trained peer support. In other words, the needs are as individual as the individuals themselves.

Although some families can pay for the full range of services and supports their loved one needs, many cannot. Iowa allocates county tax revenue, makes state legislative appropriations, and directs federal health system dollars (primarily Medicaid) toward meeting the needs of those who cannot pay the full cost themselves.
Iowa funds and delivers services through local management by county Central Points of Coordination (CPCs), services from a network of providers, administrative oversight by the Iowa Department of Human Services, and policy oversight by the Mental Health and Developmental Disabilities (MHDD) Commission. The web site for the MHDD Commission is www.dhs.state.ia.us/MHDD.
The MHDD Commission formed workgroups composed of individuals with disabilities, their family members, advocates, service providers, county personnel, and various state agency personnel. To date, over 150 people have served on one or more workgroups. The redesign initiative has the support and interest of the legislature, Lt. Governor Sally J. Pedersen, DHS Director Kevin Concannon, and the Iowa State Association of Counties. In March 2003, the MHDD Commission established a vision, values, principles, and foundations for the redesigned system (see Vision, System Values, System Principles, and System Foundation sections of the report). The workgroups have proposed, and the Commission adopted, a redesign strategy based on self-directed and person-centered planning and service coordination. Through this report, the Commission is sharing its recommendations for system change.


VISION FOR THE REDESIGNED SYSTEM

The VISION AND MISSION OF THE MHDD COMMISSION is to build and implement a coordinated system for Iowans with mental illness, mental retardation or other developmental disabilities, or brain injury, where individuals receive necessary, high quality services and supports on an equitable, timely and convenient basis, enabling them to live, learn, work, recreate and otherwise contribute in their chosen communities.

SYSTEM VALUES
Choice: The ability of Iowans with disabilities and their families to make informed choices about the amounts and types of service and supports received.
Empowerment: The reinforcement of the fundamental rights, dignity and ability of Iowans with disabilities to provide valuable input, accept responsibility, make informed choices, and take risks.
Community: The system supports the right, dignity, and ability of all individuals with disabilities to live, learn, work, and recreate in the communities of their choice.
SYSTEM PRINCIPLES
1. Individuals with disabilities have the same fundamental rights as non-disabled persons.
2. Unique individual and family strengths, needs, choices and preferences are the basis for services and support planning and delivery.
3. Individuals and their families take the lead in identifying service and support needs and in planning to meet those needs. Service and support planning and delivery encourage the development and enhancement of natural support systems of individuals and their families. Individuals and their families have the right to appeal if the planning, access or delivery of services and supports does not meet their needs and choices.
4. Quality services are provided in a manner that encourages and supports the development of each individual’s abilities and minimizes intrusion in or disruption of the individual’s life style.
5. Housing should be affordable, safe, stable, and in settings that maximize community integration and opportunities for community inclusion.
6. Funding for service and support provision follows the individual needs and choices of individuals and their families. Services and supports are provided in a culturally competent manner, focus on outcomes and the prevention of the need for more costly services and supports.

7. Individuals and their families actively participate in service and support system planning, resource prioritization, program implementation, and evaluation of the quality and effectiveness of services and supports.

8. Services are delivered by a means that is accountable for administering a system of services in a consistent, fair, equitable, high quality, and efficient manner. There should be a single point of financial, clinical and administrative accountability.
9. There will be a comprehensive, effectively working plan for Iowa communities to ensure that individuals with disabilities receive services in the most integrated setting appropriate to their needs. This plan would implement the Olmstead Supreme Court decision which states that unnecessary institutionalization of individuals with disabilities is discrimination under the Americans with Disabilities Act.
10. Services and supports may be provided by public, private, non-government, and/or faith-based organizations and entities with established roles in the system of services and supports.



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