Disability and Behavioral Health Services

Introduction

The Division of Disability and Behavioral Health Services (DBHS) is comprised of:  Addiction and Prevention Services, Mental Health Services, Community Supports and Services and the state’s mental health and mental retardation hospitals.  The mission of DBHS is: “To support Kansans in living self-determined, meaningful lives, we ensure access to quality person-centered mental health, addictions and disability services.”  To fulfill its mission, DBHS sets policy and oversees grants and contracts for programs that deliver a variety of services to Kansans eligible for these services.  DBHS also manages the Sexual Predator Treatment Program. 

Addiction and Prevention Services (AAPS)

Problem Gambling Readiness Activities .  The 2007 Kansas Legislature passed Senate Bill 66 which created and appropriated funds for the Problem Gambling and Addiction Grant Fund to address problem gambling and other addictions.  SRS is responsible for the administration of this new fund.   In collaboration with stakeholders and consultation with other states who receive problem gambling funds, SRS has taken steps to ensure that Kansas will have a comprehensive system in place to address problem gambling in Kansas.  This system of prevention, treatment and public awareness programs will effectively target: (1) problem gamblers and their families who need services now and in the future, (2) those at risk for developing problems with gambling, and (3) those with co-occurring, problem gambling and other addictions as provided by the bill.

Pre-paid Inpatient Health Plan (PIHP).   Effective July 1, 2007, the Substance Abuse PIHP was launched in Kansas.  SRS contracted with ValueOptions-Kansas (VO).  VO is responsible for managing substance abuse services provided to Kansans which are funded by either Medicaid or federal substance abuse block grant dollars.  This program is designed to meet the substance abuse needs of Kansans in ways that address CMS requirements, enhance accountability and efficiency in the public substance abuse service system, and expand our capacity to serve Kansans in need of substance abuse treatment.
SRS and VO provided multiple forums and other activities to hear from and be responsive to providers and members during the preparation for and implementation of this program.  Over 850 people, representing agencies across the state, participated in these web based forums to receive updates and answer questions during the implementation process. 
ValueOptions and SRS continue to respond to provider questions and concerns by increasing payment frequency, increasing block grant payment rates for key services, delivering additional provider training and conducting intensive individualized provider outreach.  Trainings have occurred on medical necessity, claim submission, billing improvements and Third Party Liability management.  Each provider is assigned a provider relations regional representative to assist in hands-on problem solving of any issue or concern that arises. 
For members, unprecedented outreach has occurred with VO engaging in over 135 focused activities to reach those who are eligible for and in need of substance abuse services.  Highlights of the impact of the PIHP on the system include an increase of over 50% in access to adult reintegration, a reduction in the number of days needed in intermediate services, and an increase in the use of outpatient treatment and in the number of outpatient treatment providers.  For many members, these changes mean they are able to access needed services more quickly and closer to home.

Adolescent treatment utilization has decreased significantly, and we are working with stakeholders and the Juvenile Justice Authority (JJA) to determine the cause of this decrease.  We believe this is not necessarily caused by the implementation of managed care but may be a combination of this and the implementation of the Psychiatric Residential Treatment Facilities that I will discuss shortly.  SRS and VO continue to actively collaborate with providers and advocacy group members to enhance the public substance abuse system.  Currently there are jointly staffed work groups focusing on unique issues of adolescent treatment and fiscal year 2009 block grant funding strategies.

New Standards for Substance Abuse Providers .  New licensing standards for the 237 licensed/certified providers in the state became effective January 1, 2007.  The standards by which alcohol and drug treatment facilities are licensed were substantially revised and adopted by regulation on January 1, 2007.  The prior standards had been in place for nearly 30 years.  To ensure that the new standards reflected current practice while minimizing fiscal impact, SRS sought extensive stakeholder input.  AAPS worked with all providers during calendar year 2007 to prepare them for the implementation of the new standards as of January 1, 2008.   Numerous regional Standards Training sessions were held across the State in 2007, as well as webinars for providers on approved policy and procedure.  Providers who did not attend the trainings were contacted and offered technical assistance.  Each SRS regional consultant has been asked to evaluate their region for continued training in 2008 and have started reviews under the new standards.

Strategic Prevention Framework-State Incentive Grant .    SRS has awarded $8.9 million in federal Strategic Prevention Framework (SPF) Grants to fourteen Kansas community partnerships to support efforts to prevent and reduce underage drinking.  Planning grants totaling $600,000 will support a nine-month planning process to develop community-based strategies to impact underage drinking.  Additional funds of $8.3 million will be available to support implementation of approved community plans and a statewide media campaign during the next three years. The following counties received grants: Clay, Dickinson, Finney, Harper, Kingman, Linn, Nemaha, Osage, Reno, Russell, Seward, Shawnee, Sumner, and Woodson.   These grants allow the state to partner with local communities to achieve a shared goal of reducing underage drinking by implementing and sustaining effective, culturally competent prevention strategies.

MENTAL HEALTH

Disaster Relief – Mental Health Services .   SRS is coordinating the public behavioral health response for the victims of the Greensburg tornado and the southeast Kansas floods.  The magnitude of the loss caused by these disasters results in enormous grief and stress on the victims.  Many people who functioned well prior to these catastrophes experience mental health problems as a result of the stress caused by the disasters.  Most people respond well to the crisis counseling provided by the public behavioral health programs.  SRS contracts with Kansas State University (KSU) to implement the Kansas All-Hazards Behavioral Health Program (KAHBH) for immediate response to disaster areas.  KAHBH is responsible for the statewide organization and coordination of immediate behavioral health response to disasters and other all-hazards events.  The longer-term response and recovery is then passed to the Kansas Assisting Recovery Efforts (KARE) programs.
Both of these mental health response teams were used after the Greensburg tornado and the devastating flooding in southeast Kansas. 

• KAHBH responders were on the ground offering outreach services to the Greensburg citizens three days after the disaster.
• SRS was then awarded the following grants to provide ongoing behavior health and crisis counseling services in the disaster areas:
• A $204,972 FEMA Immediate Services Program (ISP) grant for the Greensburg area.
• A $683,812 FEMA and CMHS Regular Services Program (RSP) grant for the Greensburg area (KARE 1).
• A $288,464 FEMA and CMHS ISP grant for the southeast Kansas Flooding areas.
• A $1,323,970 RSP grant for the southeast Kansas Flooding area (KARE 2).

Pre-paid Ambulatory Health Plan (PAHP) .  Effective July 1, 2007, the Mental Health PAHP was launched in Kansas.  SRS contracted with Kansas Health Solutions (KHS).  KHS is responsible for managing mental health services provided to Kansans which are funded by either Medicaid or Medikan dollars.  This program is designed to meet the mental health treatment needs of

Kansans in ways that address CMS requirements, enhance accountability and efficiency in the public mental health service system, increase the network of qualified providers and expand our capacity to serve Kansans in need of mental health services.

To assist with the transition to this new system and address any funding shortfalls, the Governor amended her budget recommendation last year to add $10 million to the CMHC grants for FY 2008.  The Legislature accepted the Governor’s amendment and added another $7 million for a total addition of $17.0 million.  The Governor has recommended this increase be reduced by $7.0 million in FY 2009, back to $10.0 million.  SRS is monitoring all current SRS payments made to the CMHCs and comparing it with payments made for the same time period last fiscal year to determine the effects of all the fiscal changes on each CMHC.
A key value in the structure of the PAHP program is the increase of qualified providers to meet the mental health needs of Kansans, both to increase service access and to enhance customer choice.  During the implementation phase, KHS has made it a priority to outreach and support providers outside of the existing Community Mental Health Center (CMHC) system, with significant results.  The current provider network includes these providers – in addition to the 1,180 mental health professionals directly connected to the CMHCs – resulting in a provider network increase of 60%.   New providers in the network (those outside of the CMHC-based array of providers) are providing over 30% of the outpatient treatment services being delivered to Medicaid/Medikan members.

KHS has provided a member handbook to all Medicaid and Medikan eligible members which describes what services are available to them and how to access those services.  In addition, all members have received a directory of network providers.  Over 270,000 of those member mailings have occurred.

Timely service access is another important goal for the PAHP.  During the first six months of the PAHP program, the KHS provider network has met or exceeded the target for timely service access established in the SRS/KHS contract, and improved overall service access from last year.

Psychiatric Residential Treatment Facilities (PRTF) .  In FY 2006, the Centers for Medicare and Medicaid Services (CMS) informed SRS and JJA that the State Medicaid Plan covering Level V and VI facilities had to be changed if Kansas wanted to continue claiming federal Medicaid funds for these facilities.  In response, SRS and JJA began efforts, in cooperation with the Kansas Health Policy Authority (KHPA), providers and key stakeholders to establish a new State Medicaid Plan Amendment for Psychiatric Residential Treatment Facilities to replace what had been known as Level V and VI facilities.   These PRTFs operate on standards based on federal CMS requirements, utilize a screening and continued stay process to ensure youth meet criteria for that level of care and are reimbursed using a methodology that ensures adequate funding for the facilities to operate, including the additional costs of meeting the higher federal standards.  Youth who do not need the more intensive services of a PRTF may be referred to Youth Residential Centers (YRCs) which are not covered under Medicaid but funded with State General Funds and IV-E funding. 

As of January 31, 2008, there were 195 children and youth in the custody of the Secretary placed in a PRTF with an average length stay of 70 days.  The estimated FY 2008 cost of these PRTFs is $29 million.  This includes all Medicaid eligible youth served in these facilities, except for those in JJA custody.  As of January 31, 2008, there were 73 children and youth in the custody of the Secretary placed in a YRC II. 

PRTF Demonstration Grant .  The U.S. Department of Health and Human Services (HHS) has awarded SRS a grant to provide services to youth who are at risk of being admitted to a psychiatric residential treatment facility (PRTF) or transitioning from a PRTF.  The grant funds are to be matched, managed, paid, and reported in the same manner as Medicaid funds; however, they are not technically Medicaid funds.  HHS has targeted these funds to serve youth with a serious emotional disturbance (SED) who may not technically qualify for the Home and Community Based Services Waiver for youth with a SED (SED Waiver).  To qualify for the SED Waiver the youth must have a SED and be at risk of placement in a mental health hospital.  While most youth who are referred to PRTFs meet these criteria, a few may not.  This grant will help ensure none of these youth are turned away from community based service.    Youth targeted for services through this grant have a SED, are 4-18 years of age (up to age 22 if needed) and have been found eligible for PRTF admission or are being discharged from a PRTF.

The grant will be managed in the same way as the SED Waiver, through the mental health managed care organization, Kansas Health Solutions (KHS).  The CMHCs and their affiliates will be the primary providers of PRTF Community Based Alternative services.  CMHCs will have the responsibility to serve or arrange to serve these youth.  KHS will be paid a capitated monthly amount for each recipient that will be reconciled for cost at the end of the year.  KHS will review and authorize plans of care for each person accessing these services.  KHS will pay the providers on a fee for service basis.  The grant is scheduled to start April 1, 2008 and the total amount of the grant for five years is:

Federal Share  $17,406,672 
State Share      $12,316,619
Total                $29,723,291

Increased Demand on Hospital Census.

Short Term Solutions – KVC STAR and Via Christi.   In FY 2007 Osawatomie State Hospital (OSH) and Rainbow Mental Health Facility (RMHF) once again experienced an increase in adult admissions resulting in a census exceeding capacity on a regular basis.  The 2006 Joint Legislative Budget Committee recommended providing funds to allow SRS to contract with a private inpatient psychiatric provider to help reduce the demand for state mental health hospital services.  In response to this recommendation, the 2007 Legislature appropriated $1.9 million in state funds to provide private inpatient services for youth who would otherwise be served at RMHF.  The majority of these funds, ($1.1 million) was used to replace federal Medicaid funds lost when RMHF discontinued serving Medicaid eligible youth.  Approximately $450,000 will be used to fund a private provider to serve youth who would have otherwise been referred to RMHF, and approximately $350,000 will be used to cover any additional loss of Medicaid funding at RMHF or additional expenses associated with the utilization of the private provider.  As a result of this action, RMHF can now serve an additional 20 adults per day. 

SRS entered into an agreement with KVC Behavioral Healthcare, Inc. to provide inpatient psychiatric treatment to youth who would otherwise be served by RMHF.  KVC, through a program called STAR, admits youth to its inpatient hospital setting for initial treatment and acute mental health stabilization.  Once the youth is adequately stabilized, the youth is transferred to the STAR psychiatric residential treatment facility to complete inpatient treatment.  KVC STAR has agreed to serve all youth CMHCs determine are in need of state hospital services in the eastern Kansas catchment area and to serve them until their mental health symptoms are adequately stabilized for them to live successfully in their home with community mental health services and supports.  KVC STAR has agreed to specific patient outcomes that meet or exceed what was provided by RMHF.  These include limiting the use of seclusion and restraint, monitoring the number of admissions to the program, monitoring the average length of stay for the youth, as well as seeking to reduce the number of re-admissions.  Primary payment for KVC STAR services is either private or public insurance, including Medicaid and SCHIP.  The cost to serve youth who have no insurance to cover their stay is paid by SRS with State General Funds.  From July 1 to November 3, 2007, KVC STAR served 117 youth with an average daily census of 9.4 youth.  These youth had an average length of stay of 13.4 days and 11 youth have been readmitted.

Last Spring, SRS entered into an agreement with ComCare, the Community Mental Health Center in Sedgwick County, to reimburse Via Christi Regional Medical Center for the cost of short term inpatient mental health treatment of persons involuntarily admitted to Via Christi for whom ComCare determined such treatment was needed. 
SRS is exploring various approaches that would allow this model to be replicated across the state.  Ideally Kansans would have access to more geographically dispersed inpatient psychiatric settings which would allow both youth and adults who need inpatient treatment to receive it closer to their families and communities.   Increasing access to this level of care would enhance treatment efforts, improve discharge planning and ensure continuity of needed community mental health services.

Longer Term Solutions – Hospital & Home Initiative.  In response to the growing demand for more inpatient mental health beds SRS formed a Hospital and Home Initiative Core Work Team.  This Core Work Team includes leaders from mental health, substance abuse, developmental disabilities, consumers, and advocates.  In recognition that inpatient mental health services are not provided in isolation, but are part of a complete mental health service system, the Core Team’s purpose was defined:  “To research and design a plan to implement an effective array of hospital and community services that support mental health wellness and recovery through partnerships and data driven strategies.”

The Core Team has formed sub-groups who are using research, data, and real life experience to develop recommendations and identify specific tasks to address the following areas: (1) Access to Services; (2) Screening, Assessment and Discharge; and (3) Crisis Prevention and Intervention.  In addition, each sub-group is charged with determining the role of the State Hospitals in the mental health system.

Approximately 70 key stakeholders are involved in this process.   These sub-groups are to report on their progress in March, 2008 with a final work product to be completed in the summer of 2008.  One outcome of this initiative will be the identification of specific steps that can be taken by SRS and other stakeholders which will have the most significant and immediate impact to improve the mental health service delivery system in Kansas.

Therapeutic Preschool and School Violence Prevention .  For several years the Kansas Legislature has appropriated $1 million in Children’s Initiative Funding (CIF) to SRS for Therapeutic Preschools to serve young children who have a serious emotional disturbance (SED) or who are at risk of having a SED.  This funding was sufficient to fund six pilot therapeutic preschool projects in various areas of the state.  In recent years these projects began to become more financially self-sufficient and other service models were being advocated for that could provide support for more of these youth being served in a broader array of child care options.  Therefore, in coordination with the Early Childhood Mental Health Advisory Council and Kansas Association for Infant Mental Health, SRS began shifting the use of the appropriated CIFs to an Early Childhood Mental Health Consultation model of community based intervention and prevention. 

The Children’s Cabinet reviewed the Early Childhood Consultation Model and found that the program had not demonstrated the accomplishment of performance goals nor did it fit well with the Children’s Cabinet focus on early childhood development.  As a result the Governor did not recommend continued funding for this program in FY 2009.
The School Violence Prevention Program has been funded with $228,000 from the CIF.  The Children’s Cabinet recommended that CIF funding for this program be discontinued because the program has not accomplished performance goals and does not fit the focus on early childhood development.  As a result, the Governor did not recommend continued funding for this program in FY 2009.

COMMUNITY SUPPORTS AND SERVICES

Home and Community Based Services (HCBS) Waivers .  Medicaid waivers are federally approved requests to waive certain specified Medicaid rules.  For instance, federal Medicaid rules generally allow states to draw down federal Medicaid funds for services provided in institutions for persons with severe disabilities.   Many of the community supports and services provided to persons with disabilities such as respite care, attendant care services, and oral health care, are not covered by the regular federal Medicaid program.  Home and Community Based Services (HCBS) waivers give the state federal approval to draw down federal Medicaid matching funds for community supports and services provided to persons who are eligible for institutional placement, but who choose to receive services that allow them to continue to live in the community.  CMS requires that the cost of services paid through HCBS waivers be, on the average, less than or equal to the cost of serving people in comparable institutions. 

In recent years there have been no waiting lists for the HCBS waivers with the exception of the MR/DD waiver, which serves persons with a developmental disability.  Currently there are 1,317 people on the waiting list receiving no services and another 555 people receiving some services who are waiting for additional services.  The Governor has recommended $4.5 million SGF, $11.2 million all funds, for FY 2009 to serve an additional 288 people from the waiting list.   Each year on the average, 208 people come off the waiver and these positions are filled from the waiting list, usually with crisis placements.   We have one statewide waiting list for HCBS-MR/DD services which includes both the unserved and the underserved.  A person’s position on the waiting list is determined by the request date for the service(s) for which the person is waiting.  Each fiscal year, if funding is made available, we serve people on the statewide waiting list, and the persons with the oldest request dates are at the top of the list.  Currently, the persons at the top of the list have been waiting since June 7, 2005.  
The Governor’s recommendation for FY 2009 supports continuation of a no waiting list policy for the PD waiver, the TBI waiver, the SED waiver, and the TA waiver.

 The Governor also includes a recommendation for systematic review of compensation for HCBS direct care workers and the development of a multi-year plan to expand community capacity through rate adjustments and to continue to work towards the elimination of waiting lists for services from the HCBS waivers.   As part of a multi-year plan, enhanced departmental review, with oversight and enforcement powers over rate increases is included to ensure community service providers are meeting the primary purpose of enhancement of direct care workforce needs.

Autism Waiver .  The target population for the new HCBS Autism Waiver is children with Autism Spectrum Disorders, including Autism, Aspergers Syndrome, and Other Pervasive Developmental Disorder-Not Otherwise Specified.  Children will be able to enter the program from the age of diagnosis through the age of five for a period of three years.  Children who need continued services beyond three years and who have demonstrated continued improvement, may qualify for an exception to the three year limit.  The waiver is funded to serve 25 children the first year.  On January 17, 2008, a random selection process was conducted to determine the 25 children to be served.  There were 154 applications for the 25 slots which led to the establishment of a waiting list.  

Services to be provided through the Autism Waiver include: Consultative Clinical and Therapeutic Services, Intensive Individual Supports, Respite Care, Parent Support and Training and Family Adjustment Counseling.  Assessments for this program are conducted by KVC Behavioral Healthcare, Inc. through a contract with SRS.  KVC assesses the children for level of care needs, provides information to families regarding service providers and assists with Medicaid enrollment.

Developmentally Disabled Waiver – Challenging/Difficult to Serve .  The MR/DD system is facing the issue of serving individuals who exhibit challenging behaviors that may be the result of dual diagnoses of a developmental disability and mental illness.  SRS has met with different groups of stakeholders to develop a comprehensive approach to meeting the needs of these consumers.  Serving consumers who demonstrate aggressive and violent behaviors presents challenges that include safety of other consumers, risks presented to staff, inadequate funding, and a lack of housing options.

As a result of stakeholder input, SRS is evaluating the feasibility of the following strategies: (1) Expansion of the Dual Diagnosis Treatment and Training Services Outreach Team at Parsons State Hospital, (2) Development of a short term out-of-home service which includes crisis intervention and stabilization, and (3) Establishment of a funding stream through the MR/DD waiver allowing for payment of a higher reimbursement rate for the time a consumer is in crisis.
A second group of consumers that present unique challenges are those with inappropriate sexual behaviors and those that are identified with predatory sex offending behaviors.  Currently, these consumers are being served at Parsons State Hospital and several are ready for discharge into the community.  SRS is negotiating with a CDDO to develop a home to serve these consumers. 

Changes to the Technology Assisted Children’s Waiver and the Attendant Care for Independent Living Programs.   CMS has determined that Kansas may no longer administer the Attendant Care for Independent Living (ACIL) program as it has in the past. Because the ACIL program targets and is only available to a specific group of children (medically fragile), it is not allowed through the Medicaid state plan.  SRS also administers the Technology Assisted (TA) Children’s waiver which targets medically fragile children who are not Medicaid eligible due to family income.  This waiver disregards parental income, thereby making the children Medicaid eligible based on their medical condition.  The children served through the TA waiver receive ACIL services once they are Medicaid eligible.  In response to CMS and due to the similarities of the populations, a decision has been made to merge the TA waiver and ACIL program.  With this change SRS can continue to serve the medically fragile children on the ACIL program.  SRS projects this will be a cost neutral change in that the funding from the ACIL program will transfer to the TA waiver. 

The current TA waiver will be amended to meet the needs of these children.  Changes include: increasing the age limit from 18 to 21 and adding services that are provided through the MR/DD waiver to include case management, skilled nursing services, attendant care, respite services and home modifications.  If a child is receiving services through the MR/DD waiver and receiving ACIL services, they will be offered the choice of TA waiver services or MR/DD waiver services, with the ability to choose the waiver that best meets their needs. 
During the initial and ongoing waiver amendment development process, SRS has requested consumer, family, and service provider input.  Once a draft of the amendments has been written, additional meetings will be held for stakeholder review.
In addition to these activities around the ACIL program, the 2007 Legislature directed SRS to work with the Kansas Health Policy Authority to research the impact of shifting funding as deemed appropriate from projected Medicaid inpatient caseload savings to fund rate increases for case managers and in-home nursing care providers.  A copy of the report SRS made to the Legislature in January is available for you today.

Money Follows the Person Demonstration Grant .  Money Follows the Person (MFP) is a federally funded demonstration grant designed to enhance participating states’ ability to increase the capacity of approved HCBS programs to serve individuals that are currently residing in institutional settings.   Funded over a five year period for $36,787,453 federal funds, ($48.0 million All Funds), this grant is driven by the advocacy of seniors and consumers with disabilities for all persons to have the choice of a community home over institutional care.  The benefit for Kansas is an enhanced federal participation to create additional community capacity, facilitate intermediate care facilities bed closure, train staff, and ensure individuals have the supports in their homes to be successful, reducing the risk of re-institutionalization. 
Target populations for this grant include persons currently residing in nursing facilities and intermediate care facilities for the mentally retarded.  Individuals must have resided in the facility for a minimum of six months and have been Medicaid eligible for a minimum of 30 days to be eligible to move into the community.

SRS will identify individuals that are currently residing in qualified institutional settings and assist them to move into home settings of their choice.  SRS estimates that approximately 934 individuals will make this choice. 

SRS, as the lead agency for the demonstration grant, has partnered with the Kansas Department on Aging to develop benchmarks and implementation strategy.  Additionally, KHPA is an integral partner as the state Medicaid agency.

Community and consumer stakeholders are actively involved in developing and submitting an “Operational Protocol” that will, when approved by CMS, guide the implementation of the MFP demonstration project.  It is expected that the first individual movement from an institution into the community will occur after July 1, 2008.