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Flexible Assertive Community Treatment: Could It Help Speed Getting Colorado Out of the Mental Health Dark Ages

1/26/2018

Often when we think of a FACT Team, we're thinking of a "Forensic" Assertive Community Treatment Team working with a person who is involved with the Criminal Justice System.
Here, a FACT Team refers to "Flexible" Assertive Community Treatment that is in some ways less intense or more "flexible" in it's provision of services.
There is no question that some people may be better served by straight Assertive Community Treatment, and in fact the treatment was designed for people who need long term care to live in the Community.
Having said that, we have certainly recognized that NOT everyone needs Assertive Community Treatment, and even those who do need it and desire the provision of care, the care should still be Strength-Based, Person-Centered, and Person-Directed to the extent possible.
BUT as Flexible ACT recognizes, many people do NOT experience a constant need for intensive services and that need ebbs and flows, and may go away.
For many of the people we are aware of need Intense Case Management/Social Work Services far beyond what is available under Colorado's Intensive Case Management. Those services are desperately, desperately needed.
Of course we also have to have safe Housing to get people into. Most people don't want to live in a Drug Den whether they have mental illness or not.
So ACT or Flexible ACT is NOT going to work if we are not providing safe housing for people.
In the Netherlands, there are 35 ACT Teams and 300 Flexible ACT Teams. The Netherlands has a population of approximately 17 million, and Colorado has a population of about 5.5 million.
One of the challenges for Colorado and many states is that we have a higher percentage of people who are homeless and/or leaving incarceration than say the Netherlands or the Nordic Countries [Denmark, Finland, Iceland, Norway and Sweden].
Those higher levels of homelessness and incarceration are going to increase the need for Intensive Mental Health Services -- such as those needed by people who are homeless and/or leaving incarceration.
That's BECAUSE homelessness and incarceration amount to ABUSE and often of people who have been abused much of their lives.
We have to have SAFETY but it can be done much more humanely than what we are currently doing.
Flexible Assertive Community Treatment as well as Assertive Community Treatment where "REASONABLY MEDICALLY NECESSARY"--- might help Colorado comply with Parity and speed the process of Getting Colorado Mental Health out of the Dark Ages.

Canada.

For Dutch Mental Health Professionals

The CCAF: Certification Centre for ACT and Flexible ACT
https://ccaf.nl/international/

ACT and Flexible ACT in the Netherlands

"Both ACT and Flexible ACT teams operate in the Netherlands. The two models are outlined below. ACT for the most severely ill patients ACT provides multi-disciplinary care with shared caseloads for the 20% group of most severely ill patients with SMI.

When a patient under the care of an ACT team stabilizes, he or she proceeds to a lighter form of care such as case management, provided by ‘step-down’ teams.

There are now 35 ACT teams in the Netherlands. Flexible ACT for all SMI patients Flexible ACT provides multi-disciplinary care for the whole group (100%) of SMI patients in a particular region (50,000 inhabitants).

Continuity of care is provided for these patients. If necessary (in the event of an imminent crisis recurring psychosis, threat of readmission) a Flexible ACT team can provide full ACT care by switching to shared caseload and intensive outreach.

After the crisis a step-down procedure takes place within the same team, which ensures more continuity. Because the area covered is smaller, the team is better able to support social inclusion for these patients.

The teams collaborate extensively with social partners for that purpose. There are now about 300 Flexible ACT teams in the Netherlands.

Integration of Community & Institutional Mental Health Policy @ the Federal & State Levels with Corresponding Appropriations to Deal with Decades of Neglect

1/20/2018

I'm really glad people are taking the Opioid Crisis seriously. We're beginning to address the Crisis in Mental Health as well as the Criminal Justice System -- BUT there is a LONG, LONG WAY TO GO.
With respect to Mental Health --- it has been a pretty WILD RIDE.
I think we are primed for a more BALANCED and INTEGRATED MENTAL HEALTH POLICY than we ever have been before.
We've mentioned this before that we seem on the CUSP of a CONSENSUS when it comes to Mental Health Policy among what have historically been warring views across the Mental Health & Disability Advocacy Spectrums.
We "think" a CONSENSUS "might" look like this:

Requirements to continuously update data and analysis on the need for:
- Housing
- Appropriate Community Mental Health Treatments, Including Intensive Community Treatments such as Assertive Community Treatment;
- Institutional Care
Get rid of the Institute for Mental Disease Exclusionary Rule or IMD Rule and fully Incorporate the Institutions into the State's Olmstead Planning Process.
Allow Medicaid to Cover Housing for people needing Long Term Care

There was a BIG PUSH in 2015 to persuade Medicaid to cover Housing. Advocates and for that matter even States were rightly chanting a mantra of "Housing is Healthcare."

Well what Medicaid did was that it said it would fund a lot of peripheral services around Housing -- BUT NOT THE HOUSING.

Ironically what CMS did do was remind States of their responsibilities under OLMSTEAD. -- YEAH!

BUT Olmstead isn't being enforced the way it should be and States are pretty cavalierly resistant to this DISABILITY CIVIL RIGHTS LAW in no small measure because of the Housing Liability.

AND who should be caught in the middle: People with Significant Disabilities.

So the BOTTOM LINE is we don't care who pays for adequate Housing, Services, and Institutional Care -- BUT some governmental entity needs to pay for it. The State has a LEGAL DUTY to either provide all this or have a plan to do it for the Housing & Community Services and in Colorado with respect to inmates needing Competency Exams -- the State is under a Settlement Agreement.

Now because we have been neglecting this for DECADES -- we do need to JUMP START it with major appropriations. From both the Feds and the States.

MAYBE If we're NOT FIGHTING with each other and working together to get the Scale of Housing, Services, and Institutional Care we need-- we might get it.

In the meantime, I will be contacting the State to let them know they have until Thursday January 25, 2017 to get back with me on Parity and ACT to try to work something out otherwise I will be complaining to CMS REGION 8.

CMS -- Coverage of Housing-Related Activities -- June 26, 2015

Housing: A Conundrum for the States -- A Nightmare for People with Mental Illness

Assertive Community Treatment, Parity and An Opportunity

1/14/2018

As Governor Hickenlooper said there is still time left on this Administration, and if Parity got resolved that would be a HUGE Accomplishment and go a long way to soothing the Bad Feelings on Olmstead.

Under Mental Health Parity Analysis, there are 4 major classifications of benefits:

Inpatient
Outpatient
Emergency Care
Prescription Drugs

Assertive Community Treatment is considered an "Outpatient Treatment."

The Federal Parity Regulations allow although do not mandate that "Outpatient" can be subdivided into:

(A) Office visits (such as physician visits); and

(B) All other outpatient items and services (such as outpatient surgery, facility charges for day treatment centers, laboratory charges, or other medical items).

Under Page 36, of the CMS Parity Tookit, CMS likens Assertive Community Treatment to "outpatient surgery."

So a lot of the confusion with respect to Parity Analysis comes with respect to analysis not of individual benefits per se [or a least not in the first instance] but Analysis of Benefit Classifications.

The primary issue presented under Parity is not NEED BUT is the Mental Health Outpatient Classification more restrictive in some way than the Medical/Surgical Outpatient Classification.

So while the language is "Parity" it is really about not discriminating between mental health care and medical/surgical care in Quantitative Limitations and Non-Quantitative Limitations.

So what about Colorado Medicaid Alternative Mental Health Services? Those "altermative services" are "limited" by the "savings" of the Managed Care Program or at least have been and have NOT been rationally based on "medical necessity."

This is HUGELY important because one of these "alternative services" is Assertive Community Treatment and it is considered by many to be the Gold Standard in Intensive Community Mental Health Treatment -- and it's not EXPERIMENTAL -- it's been around for a long time -- further it is generally a component of US Dept. Of Justice Mental Health Olmstead Settlements.

Further, CMS in their Parity Toolkit on page 36 used Assertive Community Treatment as an example where it may be necessary to go beyond the classifications and look @ individual treatments.

In that case, CMS found a State's limitation of ACT to "reasonable medical necessity" did NOT violate PARITY since comparable medical/surgical items were so limited.

BUT what about Colorado? Colorado does NOT limit ACT by "reasonable medical necessity," we limit it on budgetary grounds we do NOT see recognized under Parity.

Further, a California Court found that a California State Parity Law did cover assertive community treatment -- otherwise, the law would be meaningless.

We need the State to address this and it would probably be helpful to include other stakeholders as well.

OK-- States Can Do Prior Authorization for ACT Under Parity BUT NOT On Cost Alone

1/5/2018

So the BIG QUESTION is not can States require prior authorization for Assertive Community Treatment -- BUT on what grounds.

We think it pretty clear that States can require prior authorization based on:

reasonable medical necessity (See CMS Parity Toolkit);
a viable less expensive alternative treatment that is just as effective (we would note there is research showing that intensive case management is NOT as effective as assertive community treatment in appropriate cases)

So that brings us to the CRUX of the MATTER -- Can States Deny ACT Based on Cost Alone Where:

Reasonable Medical Necessity is Satisfied, and
There is NO Viable Less Expensive Alternative that is Just As Effective

Our Answer is NO the State Cannot Deny ACT Under Those Circumstances. Otherwise, what is the Point of Parity.

And that was really the ANSWER of the California Court in addressing the issue under the California State Parity Law as well.

Washington State Parity Analysis

In order to rectify the discrepancy between the outpatient BH and M/S benefits, the state will remove the language in BHO contracts that requires initial authorization for all outpatient services.

The contract language will allow authorization of some of the highest intensity services, such as the Program for Assertive Community Treatment (PACT).

Allowing the BHOs to require prior authorization for some, but not all, of their outpatient benefit brings that system in alignment with the outpatient
M/S benefit.

The state will incorporate these changes into the January 2018 BHO contracts. This allows time for contract negotiation, execution, and submission to CMS. In the coming weeks, the state will meet with BHOs to better define which high-intensity outpatient services may require additional authorization (e.g. PACT) and to identify data and operational changes.

Eligible Recipients for ACT in Minnesota -- Colorado NEEDS to Catch Up With the Law & Stop Harming Its Citizens

1/4/2018

Below from the Minnesota Dept. of Human Services website:

Eligible Recipients

Recipients eligible to receive ACT [Assertive Community Treatment] services must meet the following criteria as assessed by an ACT team:

18 years old or older (Individuals ages 16 and 17 may be eligible upon approval by the commissioner)
Have a primary diagnosis of schizophrenia, schizoaffective disorder, major depressive disorder with psychotic features, other psychotic disorders or bipolar disorder
Have a significant functional impairment demonstrated by at least one of the following:
No indication that other available community-based services would be equally or more effective as evidenced by consistent and extensive efforts to treat the individual; or a
Written opinion of a licensed mental health professional that the recipient has the need for mental health services that cannot be met with other available community based services, or is likely to experience a mental health crisis or require more restrictive setting if assertive community treatment is not provided.

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=ID_058151

We know that ACT has also been used with people experiencing substance issues. We haven't thoroughly researched that; although the principles would appear to be the same.

It certainly seems pretty clear to us that under Parity Colorado Medicaid should be covering Assertive Community Treatment for people with mental illness where there is:

No indication that other available community-based services would be equally or more effective as evidenced by consistent and extensive efforts to treat the individual; or a
Written opinion of a licensed mental health professional that the recipient has the need for mental health services that cannot be met with other available community based services, or is likely to experience a mental health crisis or require more restrictive setting if assertive community treatment is not provided

Assertive Community Treatment, Parity & Addressing Recidivism

12/31/2017

  For decades really we have been trying to provide viable alternatives to prison.
It seems to us incredibly important not to under-estimate the challenges people are facing. When we do under-estimate the challenges -- it does lead to recidivism.
The prisons are full of people with mental illness and substance use issues.
Back about 3 or 4 years ago, the Denver Post reported that there were 5700 people with mental illness in Colorado Department of Corrections Custody.
One of the reasons we are such big fans of ACT (assertive community treatment) is that it requires small caseloads and there is a team approach to deal with all the complicated systems.
Further, there are studies very much in line with the video to the right in which some people view their ACT caseworkers as a family member -- a mom, an aunt, etc.
Now some people might think that's crossing all kinds of boundaries -- we actually think that can be positive and it really depends on the situation.

Colorado
  Colorado recognizes the importance of ACT. We have often said this needs to be available outside the criminal justice system for people leaving mental institutes, nursing homes, etc.Colorado has sort of recognized the importance of Assertive Community Treatment (ACT).
Under Medicaid Managed Care, it treats ACT as an "optional service" that is paid for from savings from the Managed Care Program -- meaning there is NO Entitlement to ACT if it is reasonably medically necessary.

Well, it is policies like that --that put people with the most serious mental health needs at the back of the line.

That absolutely discriminates and violates Parity and it is having horrific/"insane consequences" in our society.

There are a lot of things that need to be fleshed out with ACT in an inclusive manner:

Medical Necessity;
Civil Rights Protections

Some states have developed Centers of Excellence around ACT and Colorado should as well.

Colorado Springs Independent

By Patience Kabwasa

Recidivism continues to contribute to overcrowding Colorado prisons

The State has refused to answer whether they have an objection to a waitlist for ACT for over 2 years in our efforts to bring Colorado in compliance with Olmstead.

NOW our argument is PARITY -- Colorado doesn't make this essential service available to all where reasonable medically necessary (like Minnesota does with Adult & Youth ACT as a rehabilitation Service).

US Dept. of Justice – Civil Rights Division

Examples and Resources to Support Criminal Justice Entities in Compliance with Title II of the Americans with Disabilities Act

C. Collaboration with Other Entities

States, counties, and cities, which often administer both criminal justice and disability service systems, have obligations under the ADA to ensure people with mental health disabilities or I/DD receive services in the most integrated setting appropriate to their needs.

Services such as scattered-site supported housing, Assertive Community Treatment (ACT), crisis services, intensive case management, respite, personal care services, behavior support, nursing care, peer support, and supported employment services can support a jurisdiction’s efforts to divert people with these disabilities from the criminal justice system and serve them in their communities.

https://www.ada.gov/cjta.html

Parity, ACT & What the Community Really Wants -- Soteria, Open Dialogue, Peer Run Services, & the Hearing Voices Network

11/16/2017

Medicaid gives a lot of latitude to get waivers of various requirements for states to experiment with the idea of improving services and quite frankly some other other objectives.
Assertive Community Treatment (ACT) has been around since the 1970s and it is largely not available to youth and adults where reasonably medically necessary because of flat out discrimination -- it costs a lot for this community mental health treatment.
We really don't care how the State makes ACT available to all where reasonably medically necessary just that they do it.
Which brings us to an inconvenient fact: for the the most part what the Community is really clamoring for is:

Soteria
Open Dialogue
Peer Run Services, and
The Hearing Voices Network

ACT probably has a big role to play -- BUT so do these other alternatives that people are desperate for.

Soteria Approach to Psychiatric Services

Open Dialogue

Peer Run Services

Hearing Voices Network

More -- A LOT MORE -- Money in Housing & Intensive Mental Health Treatment is Needed in Colorado for People with Mental Illness -- It Could Be Along The Lines of A Billion Dollars

9/20/2017

A lot of people in the general disability community were pretty envious of the Mental Health Community -- an investment of $40 Million in mental health this year in the Legislative Session.

But that was before the Sh**
Hit the Fan on CMHIP (CO Mental Health Institute @ Pueblo) and the "immediate jeopardy" designation, persistent staffing problems, ad nauseam.

BUT -- WHAT IS IT GOING TO TAKE TO HOUSE and TREAT THOUSANDS OF PEOPLE WITH MENTAL ILLNESS IN CO JAILS & PRISONS --

WHEN WE CURRENTLY DON'T HAVE THE HOUSING & ASSERTIVE COMMUNITY TREATMENT (ACT) IS OFTEN NOT AVAILABILE.

ACT is NOT AVAILABLE to ALL WHERE REASONABLY MEDICALLY NECESSARY UNDER CO MEDICAID -- THAT'S DISCRIMINATION.

BTW -- ADULT & YOUTH ACT are available in Minnesota where reasonably medically necessary.

https://www.usgovernmentspending.com/colorado_state_spending_pie_chart

Colorado's gross domestic product is $334.7 billion.

As a lot of States, we have chosen to ignore the SCALE of the housing needs of people with disabilities regardless of Olmstead for years.

The cost shifting of people with intensive mental health needs to the Criminal Justice System and to the Homeless Shelter and the Streets is being called out and recognized in a way it hasn't been in the past.

The Chickens are coming home to roost -- AND WE WANT:

Inclusion
A Comprehensvely, Effectively Working Olmstead Plan with Measurable Goals that Bring Housing & Services to Scale to Meet the Need, and
Facilities for People with Disabilities that are ADEQUATELY FUNDED & STAFFED and NOT RIFE with ABUSE or BREEDING GROUNDS FOR SUICIDE.

Parity, Assertive Community Treatment, and Discrimination

8/13/2017

To the right and below are several resources from the Centers for Medicare and Medicaid Services (CMS) on implementation of the Mental Health Parity and Addiction Equity Act.

One of our complaints has been that the Colorado Medicaid Mental Health Program is Discriminatory because it fails to offer the evidence-based treatment Assertive Community Treatment to all where reasonably medically necessary.

Minnesota offers Adult Assertive Community Treatment as a Medicaid Rehabilitation Service. Minnesota also offers Youth ACT.

Mental Health Parity and Addiction Equity Act (MHPAEA)

The Mental Health Parity and Addiction Equity Act (MHPAEA, Pub.L. 110-343) makes it easier for Americans with mental health and substance use disorders to get the care they need by prohibiting certain discriminatory practices that limit insurance coverage for behavioral health treatment and services. MHPAEA requires coverage for mental health and substance use disorders to be no more restrictive than the coverage that generally is available for medical/surgical conditions. This requirement applies to:

Copays, coinsurance, and out-of-pocket maximums
Limitations on services utilization, such as limits on the number of inpatient days or outpatient visits that are covered
The use of care management tools
Criteria for medical necessity determinations

Federal statutes require Medicaid and CHIP programs to comply with mental health and substance use disorder parity requirements.

On March 29, 2016 CMS put on display at the Federal Register a final rule applying these requirements to Medicaid non-managed care benchmark and benchmark-equivalent plans as described in section 1937 of the Social Security Act (referred to in this rule as Alternative Benefit Plans, or ABPs), the Children’s Health Insurance Programs (CHIP) under title XXI of the Act, and Medicaid managed care organizations (MCOs) as described in section 1903(m) of the Act.

Final Rule: Application of Mental Health and Substance Abuse Disorder Parity Requirements to Medicaid Managed Care, CHIP, and Benchmark Coverage (CMS-2333-F)
Fact Sheet on the Final Rule (PDF 75.99 KB)
Frequently Asked Questions (FAQs) (PDF 90.11 KB)
CMS Press Release
Slide presentation on the final rule (PDF 163.9 KB)

Below are resources that may assist Medicaid Directors to understand MHPAEA’s application to the Medicaid program.

The Parity Compliance Toolkit (PDF 456.99 KB) provides detailed technical guidance and tools to help states understand and perform the parity analysis for each of the requirements of the final parity rules.

The Parity Implementation Roadmap (PDF 295.57 KB) gives policymakers recommendations for how to approach parity implementation and compliance from a planning and operational perspective.

Webinar slides (PDF 927.37 KB) presented on February 9, 2017 provided an overview of the content and use of the Parity Compliance Toolkit and Implementation Roadmap.

Webinar slides (PDF 2.48 MB) presented on February 23, 2017 provided information on the Application of Mental Health and Substance Use Disorder Parity Requirements to Medicaid and Children’s Health Insurance Program.

Webinar slides (PDF 1.89 MB) presented on March 9, 2017 provided information on the Application of Mental Health and Substance Use Disorder Parity Requirements to Medicaid and Children’s Health Insurance Program

https://www.medicaid.gov/medicaid/benefits/bhs/index.html

Trying to Meet a Very Large Need: ACT & Housing

8/2/2017

When considering ACT [Assertive Community Treatment] and Housing, the State and Stakeholders need to consider separate legislative fixes.
For Adult and Youth ACT: authorization to seek Medicaid funding of ACT as a Rehabilitative Service for those where reasonably medically necessary as is done in Minnesota.
   We need a statute directing the State to develop a Housing/Supportive Housing Plan for People with Disabilities who are institutionalized (including incarceration) or at great risk of institutionalization in Colorado with Measurable Goals that would bring Housing & Supportive Housing to Scale to Meet the Need in a 5 to 10 year Time Frame.
   The State should be empowered to use Housing Trusts, Social Impact Bonds, Etc. to accomplish that Goal.
   If we start dealing with the BIG ROCKS of an Olmstead Plan with Measurable Goals and far greater access to Intensive Mental Health Services than what we've got now -- the Comprehensive Plan will be much easier.

2009: National Disability Rights Network -- A Decade of Little Progress Implement Olmstead

These conversations with the State re: Olmstead get so conflated into: "We're Doing Good Things."

AND the truth is the State is doing good things, very good things, but they are not complying with Olmstead.

"But if we're doin' good things, what does it matter?" Well, it is the law.

   But beyond that the problem of sufficient housing and community services for people with disabilities who are institutionalized or at great risk of institutionalization is incredibly difficult and complicated.both practically and politically.

     We NEED that Comprehensive, Effectively Working Olmstead Plan with Measurable Goals.

   The Olmstead decision was in 1999. In no state have housing and community services been brought to scale to meet the needs of substantially all people with disabilities in a State who are institutionalized or at great risk of institutionalization.

   In fact, the numbers are quite stunning with thousands of people with mental illness in Colorado incarcerated, in nursing homes, and homeless.

     It is right and proper to celebrate our successes. BUT it is also right and proper to be HONEST. AND to do that we need the most up to date data, construct measurable goals based on that data, and a plan to bring HOUSING & COMMUNITY SERVICES to SCALE to meet a very large need.

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