Adult Mental Health Reform 2020 ARMHS Workgroup MEETING NOTES MEETING DETAILS

DATE: January 30, 2013

START/END TIME: 1:00 p.m. – 3:00 p.m.

LOCATION: Room 5134, 444 Lafayette Road, St. Paul

Remote ITV sites: Crookston, Duluth, Willmar, White Earth

Co-conveners: Ruth Moser, DHS; Julie Pearson, DHS; Melinda Shamp, DHS

Facilitator: Charlie Petersen, MMB

Notes: Beth Bibus, MMB

Members in attendance:

Jeff Alberts, Family Support Services, Inc.; Shawn Anderson, Lake Country Associates (P); Ron Brand, Minnesota Association of Community Mental Health Programs (SC); Michael Clevette, Accend Services, Inc. (ITV); Rosella Collins-Puoch, Hope Village; Claire Courtney, DEED (SC); Muriel Deegan, Bois Forte (ITV); Ed Eide, Mental Health Association of MN (SC); Jon Everett, Community Involvement Programs; Denise Gudvangen, Northwestern Mental Health Center (ITV); Kimberly Holm, Woodland Centers (ITV);; Mary Jarvis, Goodwill/EasterSeals Mental Health Services; Martha Lantz, Touchstone Mental Health; Don Lavin, Strengths@Work; Rick Lee, Woodland Centers (ITV); Katy Liapis, Leech Lake (ITV); Martin Marty, Hennepin County ; Jamie Marxhausen, UCare; Byllie Jean Meade, White Earth (ITV) ; Richard Oni, Progressive Individual Resources; Kathy Preive, Vail Place; Brian Sammon, Options Family & Behavior Services; Patricia Siebert, MN Disability Law Center (SC); April Sjulstad, Courage Center; Lura Solie, MHP/CPSS; Nan Stubenvoll, DHS (SC); Ahsley Trepp, Tasks Unlimited; Connie Vendergon, South Metro Human Services; John Zakelj, DHS

(SC – Steering Committee; ITV – attended via ITV; P – attended by phone)

AGENDA ITEM AND DISCUSSION 1. Welcome, agenda review, and introductions

Workgroup members introduced themselves and their role.

Today is the fourth and final meeting of the workgroup. The main purpose of today’s meeting is to develop recommendations to be presented at the February 27, 2013 meeting of the Adult Mental Health Reform 2020 Steering Committee. The Steering Committee, in turn, will present recommendations to DHS for consideration.

Workgroup members reviewed the notes from the last meeting and did not identify any necessary changes.

2. Review workgroup progress

Julie Pearson reviewed the workgroup’s purpose and progress:

• The group has reviewed covered services under ARMHS and identified gaps in service areas, including services required in ARMHS but not funded and services that would be good enhancements to ARMHS. • At the last meeting, there was an in-depth presentation on 1915(i), which could be a source of funding for these services. • Workgroup members have reviewed information about possible Medicaid codes that would cover these services. • The workgroup is charged with developing recommendations for additional services for ARMHS, but the workgroup is not expected to make a recommendation on the funding mechanism that would be best (for example, whether the state should pursue 1915(i) funding). In other words, this workgroup was asked to develop recommendations about what should be covered under ARMHS, not how to cover these services. Additional research is needed before making those decisions. Julie invited workgroup members to share recommendations on funding mechanisms either today or in the future.
3. Development of work group recommendations

Prior to the meeting, DHS staff surveyed workgroup members to solicit opinions regarding priorities for funding non-covered services; over 40% of members responded. DHS staff also reviewed information from previous meetings and developed possible recommendations.


The group reviewed the draft recommendations and the survey results. Discussion included:

• Several group members noted that there is a difference between expanding services and increasing the rate. There is also a difference between covering services that are required but not funded and providing enhanced services. There are components in ARMHS that are necessary but not covered and there are components that need to be expanded. The group agreed on changes to Recommendation A to capture these distinctions. The group also agreed to add language to the funding priorities to emphasize which services are required but not reimbursed. • Governor Dayton’s budget proposal includes increased funding for ARMHS (see next section of these notes); this workgroup’s recommendations will help support this proposal and will help guide DHS on implementing legislatively approved funding increases. • This group identified early on that provider reimbursement runs at least 20% short, the increases that could come from the governor’s budget would likely fill this gap. • One way to think about the list of priorities in Recommendation A is to see items 1-3 as strengthening what ARMHS currently does, and the remaining priorities as expanding the range of ARMHS. • ARHMS is different than other services because it requires that we provide services in the home or in community setting of choice—this is why transportation is such a necessary part of ARMHS. Providers have been filling in the blanks on this, especially in Greater Minnesota. • A caution: there are different regulations for transportation providers under Medicaid, and the rate is very different than an ARMHS worker’s rate—we need to avoid unintended consequences with the recommendation on transportation. We should focus on getting an adequate reimbursement rate. • The group agreed to add language to the recommendation to reflect the two types of transportation at issue: staff travel to provide services to a client and transportation of a client to get the client to services. • A workgroup member noted that there is another workgroup in DHS that is working on how transportation costs are reimbursed—this is a good time to be looking at this problem. • No-shows are not reimbursable under Medicaid—no client means no payment. Even so, the state could decide to address that issue in the rate or by other methods with state dollars. • Care coordination is expected and required under Medicaid, but there’s not a way to get reimbursement under ARMHS currently. • The group discussed several options for the language in the recommendation regarding care coordination (included in text below). • Several workgroup members noted that there is not much emphasis on employment in the recommendations. The listing of IPS in the recommendation regarding evidence-based practices hints at this, but there was a lot of discussion in workgroup meetings about the need for employment services, and that is not reflected in the recommendation. Providing more information about the evidence based practices (minimally, spelling them out instead of using acronyms) may help with this somewhat. • Other group members said that the inclusion of (and reimbursement for) evidence based practices is critical, not just employment-related services. • The group agreed to keep the recommendation regarding evidence based practices as the fourth priority. • The group also agreed to include family & natural supports psycho-education among the listed evidence based practices, rather than as a stand-alone priority. • The group discussed the outreach priority and agreed that there should be a separate recommendation regarding outreach (Recommendation B, below). There are two aspects to outreach: the therapeutic outreach that can be connected to a client, and community outreach to expand access to ARMHS generally. Both of these activities are necessary, and costs are currently absorbed by providers. • When we are considering outreach to underserved communities, it is important to not only focus on immigrant communities—there are many communities that lack information about and access to ARMHS (such as African American communities). If our focus is on decreasing disparities, we need to acknowledge and address differences in access and services. • For MedEd services, the focus should be on the diseases prevalent in this population: cardiovascular, pulmonary disease, diabetes—these are the biggest killers, and they should be listed. • In response to a question from a member, Melinda Schamp noted that a code modifier can be used to enable a provider to receive reimbursement for 2 providers during the same time period (for example, one person providing services and the other person taking notes and guiding the client). • The group discussed whether “med ed” should be expanded to “medical education” rather than “medication education,” but this may have unintended consequences. • Providers have increased their use of services that are not face-to-face, but DHS policy and reimbursement coverage haven’t kept up with these changes, which is why a recommendation on this issue is important. • We need to make sure that teleservice expansion doesn’t have unintended consequences—like outsourcing a call center. DHS will need to establish guidance for providers and ensure that these services are connected with the treatment plan.
Consensus recommendations

After discussion, the group agreed on the following recommendations. The group also agreed that a sub-group of volunteers from the workgroup should examine and revise the text of the recommendations for clarity, and that the final versions of the recommendations would be emailed to the group for review and comment.

Recommendation A

Expand the range of services offered under ARMHS and adjust provider reimbursement for currently covered and unfunded but necessary services. Services should be funded in the order of priority/importance listed:

1. Clinical Direction & Oversight: This is a non-reimbursable service component, but essential to the delivery of services. Often, the MHP Clinical Supervisor is providing oversight and direction in the development and approval of the functional assessment, LOCUS, interpretive summary, and treatment plan. In addition, the MHP Clinical Supervisor is engaged in staff development & training which has increased in response to the implementation of EBPs, cultural considerations regarding staff & services. Also, there is an expectation regarding an evaluation of services at minimum every six months. Program organizations cover this cost for clinical supervision. This is a required but not covered service. 2. Transportation: Providers serve people in multiple counties. Workgroup members have indicated a need for 1) adequate reimbursement to cover the costs of transportation for the provider to provide services to the client, 2) coverage of staff travel & client transportation costs for clients to needed services, and 3) no shows means no payment, even though the provider has driven to the client’s home or scheduled meeting place in their community. This is a required but not covered service. 3. Coordination of Care: Reimbursement for pulling together key documentation and [giving information from and getting information to//sharing information with//collaborating with] physicians and others to support the treatment and rehabilitation plan. These are required parts of treatment, but not reimbursed for this. 4. Evidence-based Practices, including IDDT, IPS, IMR, and Family & Natural Supports Psycho-education: components that do not currently fit under the ARMHS platform. Costs to deliver all components of these practices are not covered. Training & intensive additional supervision are necessary to implement. Employment-related Services was identified early on as being beneficial in attaining employment for Adults with SMI. Family & Natural Supports Psycho-education is beneficial where support network is unfamiliar with mental health services and models of treatment. 5. Outreach to Diverse Communities About ARMHS: Often, there is a process of outreach which is focused on education regarding the nature or science of mental illnesses involving describing, discussing with key family and community members as to the nature of ARMHS, and how there can be benefits in restoring functioning. This is relevant to establishing a therapeutic engagement within the person’s diverse community which is resistant, reluctant, or unsupportive of techniques for management of symptoms associated with a mental illness. Did find approved MA codes. 6. Med Ed Service Category Expansion: Additional health/wellness services which can influence mental health. As adults, many people are experiencing the on-set of metabolic syndrome, central nervous system disorders, sleep apnea, etc., often in conjunction with a serious mental illness. 7. Parenting/Family Services: Rehab interventions with Adults with SMI in the role of parent & where children are present during sessions.
Recommendation B

The state should make funding available for providers to engage in outreach activities to inform communities, particularly underserved and diverse communities, about ARMHS services.

Recommendation C

Review what other states are doing to cover the services which Minnesota does not cover.

Recommendation D

DHS continue to work with CMS consultant in further exploration of developing a 1915i state plan amendment to address service gaps.

Recommendation E

DHS will further explore the cost of covering each identified service gap.

Recommendation F

Explore payment for non-face-to-face delivery of service through telecommunications; Phone, email, texting with the Person, Family, and Service Providers (ex: Phone Coaching). Phone contacts are necessary, but not always covered.

Recommendation G

Look beyond ARMHS more broadly, especially in some areas like employability. There are unique issues, interfacing with several agencies and requires collaboration with VR. Explore financial models that can get people to work.

4. Presentation: Governor’s budget proposal

John Zakelj from DHS provided the group with information about Governor Dayton’s budget proposal as it relates to ARMHS. For the first time in many years, there’s a possibility for increasing funding for ARMHS. This workgroup’s discussions informed the proposal, and the final recommendations will be helpful. There is a long way to go before this proposal becomes a reality, including many committee hearings and debates; it is very important for workgroup members to stay informed and involved in the next months.

John recommended that workgroup members review information on DHS’s website:

• DHS’s 2013 legislative session fact sheets, which include information on a variety of proposals. • DHS’s fact sheet on the proposal to adjust Adult Rehabilitative Mental Health Services payment rate and services.

In addition to the proposal to adjust ARMHS directly, ARMHS will be affected by the expansion of MA coverage to people who are below 138% of federal poverty level without regard to assets—this will mean more people will be eligible for ARMHS.

Additionally, ARMHS is among the services that will be affected by the proposed 5% rate increase for fee-for-service providers.

In developing the proposal, DHS had to make some assumptions, which included:

• A combination of rate increases and changes in covered services will equate to a 30% increase in ARMHS payments per person. • More people will be served because providers are paid better for services: 5% growth projected in the first year and another 5% growth in the second year. • After the legislation is passed, it will take about 1 ½ years (to January 1, 2015) to get everything into place. Factors leading to this length of time include:
o Getting changes through the federal process, which allows several 90 day periods for back-and-forth exchanges of questions and responses o Changes to the state’s information systems to add codes and change rates

Because of funding constraints, DHS had to pull the funding for ARMHS expansion from other parts of the DHS budget. In the proposal here, the money is coming from the mental health grants. There are several reasons why this source was selected:

• The mental health grants are state money only—with ARMHS expansion, we get federal money (and so more people served for the same amount of state money). • It is likely that many of the people who receive services through the counties with mental health grant dollars will be picked up either by the expansion of MA to those below 138% of poverty levels or by expanding ARMHS services. • By reducing the mental health grant money by 11%, we get a more than 40% increase in ARMHS.

Additional workgroup discussion included:

• DHS has not determined whether the reduction in mental health grants will be equal across all counties. • The 5% rate increase for providers will likely happen far sooner than the 2015 date for ARMHS service expansion, but the date has not been set. • The 5% rate increase proposal will have many advocates, including physicians, hospitals, etc. • There could be negative consequences to the plan to reduce mental health grants, including that counties would stop providing needed services. It’s possible that the money is better spent at the local level than through ARMHS. • DHS does not have specific information on how many people will be pulled in under the MA expansion—once a person is determined to have more income or assets than would be allowed for MA, counties don’t track how much more they have.
6. Next steps

DHS will contact the identified volunteers to work on final language for the recommendations, and that language will be emailed to the workgroup.

Workgroup members were thanked for their participation in this important work.

People can find additional information at the Adult Mental Health Division’s website.

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