Self-Directed Financing of Services
for People in Mental Health
Recovery
Judith A. Cook, PhD
Professor & Director
University of Illinois at Chicago, Department of Psychiatry
Presented at NYAPRS 7th Annual Executive Seminar on
Systems Transformation
April 27, 2011, Albany, NY
A Word of Thanks to our
Funders
• U.S. Department of Education, National
Institute on Disability & Rehabilitation
Research
• Substance Abuse & Mental Health
Services Administration, Center for
Mental Health Services
Can this System Be Reformed?
MD Higher
Ed. Comm.
UM System
Community
College
System
Dept.
Of
Veteran
Affairs
Mental Hygiene
Administration
(MHA)
MAP
S-MD
Local/State
Colleges
&
Universities
Dept
Of Human
Resources
(DHR)
MD State
Dept Of Education
(MSDE)
Blind Industries
& Services Of
Maryland
(BISM)
Medicaid
Dept. of
Social
Services
(DSS)
Core
Servic
e
Agenc
y
(CSA)
Dept of
Health &
Mental Hygiene
(DHMH)
Developmental
Disabilities
Administration
(DDA)
4
Regional
DDA
Offices
Division
Of Rehabilitation
Services
(DORS)
Community Rehab. Program
Department of Labor,
Licensing, and
Regulation
(DLLR)
Governor’s Workforce
Investment
Board
6
DORS
Regions
Local
Education
Agency
(LEA)
Consumer
Department
of
Disabilities
Local
Workforce
Investment
Boards/
One-Stops
Key Elements Missing From
Current System
• Accountability
• Choice
• Free market economy (overregulation,
lack of competition)
• Consumer sovereignty
• Personal responsibility
What is Self-Directed Care?
Funds ordinarily paid to service provider
agencies are controlled by service recipients
1. Participants develop person-centered recovery
plans
2. They then create individual budgets allocating
dollar amounts to achieve the plan’s goals
3. Staff called “brokers” are available to help people
purchase services & goods named in their plans
4. Fiscal intermediary provides financial
management services such as provider billing &
payroll taxes
How are Mental Health SDC
Programs Funded?
State general revenue (for individuals not
covered by Medicaid)
State general revenue combined with
Medicaid in some manner:
 Add-on to Medicaid: Medicaid beneficiaries receive
additional funds for SDC through 1) state MH dollars, 2)
CMS Real Choice System Change Grants, 3) CMS
Community Reinvestment Funds
 Medicaid funding pooled with other funds such as: 1)
state MH dollars, 2) MH Block Grant, 3) local funds
(http://www.cmhsrp.uic.edu/download/sdsamhsaconfsentver3.pdf)
How is SDC Cost Neutral?
• People’s individual budgets are set at
levels no higher than the system’s
current expenditures for traditional
outpatient services
• Use an average (e.g., average annual
outpatient expenditure)
• Individualized amount based on cost of
participant’s recent outpatient tx
• Provide different amounts based on
Medicaid beneficiary status
How Well Does SDC work for other
populations?
 Randomized evaluation of Cash & Counseling
programs (developmental & physical
disabilities & the elderly)
 Outcomes of SDC participants were as good or better
than regular fee-for-service (FFS)
 SDC participants received more services than their FFS
counterparts
 Budget neutrality prevailed by end of 2nd year
 Consumer satisfaction was significantly higher among
those served in SDC
 Incidences of fraudulent behavior were low
 Hiring (& firing) friends/family members not problematic
(Foster, Brown et al., Health Affairs, 2003)
Evidence for SDC in MH Populations
Single group Pre/Post Study of Florida SDC
Significant increases in # days in the community
Significant increases in global functioning
Only 16% were hospitalized (5% involuntarily
admitted)
Outcomes: 33% in paid employment, 19% job skills
training, 16% volunteer activities, 10%
postsecondary education/GED
Of direct expenditures by participants: 47%
traditional psychiatric services, 13% service
substitutions for traditional care, 29% tangible
goods, 8% uncovered medical care, & 3% on
transportation.
(Cook, Russell et al., Psychiatric Services, 2008)
Texas SDC Location & Host
Organization
NorthSTAR Region
North Texas Behavioral Health Authority
How Texas SDC Works
• Regardless of Medicaid eligibility, participants
have $4,000/year to purchase goods &
services, with up to $7,000/year available for
individuals who need high levels of service
• People must be willing to leave their current
services in order to begin SDC
• Brokers (called SDC Advisors) are available
to assist with all SDC components
• SDC is available for 2 years as a pilot
program & only for those willing to participate
in the program evaluation
Why the Dallas NorthSTAR Area?
• Managed care waiver already in place in
the 7-county NorthSTAR area
• Braided funding system in place for
Medicaid and State general revenue
funds
• ValueOptions managed care company
already administering a network of
diverse MH providers
• Local mental health authority is a conflict
of interest-free willing partner
Creating a Climate of Change
• UIC & DSHS mobilized & educated the
community – brought together people in
MH recovery, advocates, providers,
academics, family members
• Motivated & educated DSHS staff
• Created a set of multi-stakeholder
subcommittees that worked
collaboratively to design the program
• Included community providers to ensure
that their needs were addressed
TX SDC Community Advisory Board
Subcommittees
(included consumers, providers, UIC, DSHS, state VR,
managed care, NAMI, MHA, & other advocates)
Personnel
Technology
Purchasing
Provider Network
Program
Operations
Convened collaboratively via teleconference by UIC & DSHS
Use of Technology
• Program designed by community advisory
committees that met via teleconferencing &
listserv
• Participant purchases made with debit cards
• Participants communicate with each other via
a Chat Room closed to outsiders
• Support brokers travel with laptops & portable
printers, with wireless capability
Texas SDC Website
keeps participants, staff, funders, & public informed
http://www.texassdc.org/default.asp
Purchases through Debit Card
• Decreases stigma from using vouchers or
•
•
•
•
•
checks with program name on them
Increases participant familiarity with use
of debit/credit cards
Enables hiring of traditional MH providers
who want to be paid directly
Allows participant responsibility for funds
Allows program to restrict purchases (no
alcohol, guns, pornography, etc.)
Allows program staff to monitor expenses
Use of Braided Funding
Medicaid
State general revenue
Mental health block grant
Local funds
The Challenge: State must be able to account for all expenditures separately
at the back-end, while remaining seamless to the consumer at the front-end.
Use of Peer Support & Services
• People in MH recovery involved in all aspects
of planning the project
• Emphasis on including consumer-operated
programs & certified peer specialists in the
provider network
• Employment of peers as program staff-50%
of SDC Advisors are peers
Research &
Evaluation
• Randomized controlled trial
study conducted by the UIC
National RTC on Psychiatric Disability
• Focus on recovery outcomes, participant
satisfaction, service use, & service costs
• Goal - to conduct research with the rigor to
inform public policy in the state, with potential to
support model’s replication in other communities
• Involving participants & other stakeholders in
the research process from start to finish
• Some Early Research
Findings
Characteristics of 1st 75 SDC Study Participants
SDC (n=44), Services as Usual (n=33)
Female
Caucasian
African American
High School/GED
Unmarried
Parents
Annual income < $10,000
Treated overnight for MH
Treated for substance use
Physical condition/impairment
Currently working
See self holding job in next year
Average age
Average household size (inclu. participant)
68%
59%
25%
67%
85%
68%
44%
61%
52%
48%
15%
60%
40 years
3
As of May 2010, Types of Traditional
Clinical Purchases Authorized
4% 2%
Individual Therapy
8%
10%
44%
Psychiatrist
Groups
Case Management
32%
Medication Mgmt
Other
As of May 2010, Types of NonTraditional Purchases Authorized
6%
1%
Health/Fitness
10%
30%
Transportation
Communications/PC
10%
Clothing/Furniture
Job/School
Allow Card
12%
16%
16%
Emerency Rent/Utility
Documents
Ratio of Traditional/Non-Trad. Purchases
(among those with approved budgets for 2+ months)
• 58% of budget allocated to traditional/42%
•
•
•
•
non-traditional purchases (with an average of
40% of total budgets allocated)
Per participant, traditional % range from 20%98%
Per participant, non-traditional % range from
2%-80%
% of participants adhering to 60/40 split = 61%
Average monthly expenditure (est.) =
$302/person (median=$290, sd=154)
Recovery Goals of One SDC
Participant
 Find a prescribing psychiatrist with whom I
feel comfortable
 Participate in supportive psychotherapy to
enhance my ability to cope
 Improve my health & physical fitness
 Better manage my feelings of depression
 Lower my stress level
 Prepare myself for a job
(Cook et al., Psychiatr Rehab J, 2010)
Purchases Made by 1 Participant Over 4 Months
Purchase
Total cost of Purchase
Individual Therapy
$910.00
Psychiatrist
$332.50
Initial MH Assessment
$90.00
Physical Fitness
$273.34
Massage Therapy
$300.00
Tuition (12 hours)
$265.00
Books for School
$250.38
Debit Card Fees
$3.95
Total Traditional Services = $1,332.50 (55%)
Total Non-Traditional Goods/Services = $1,092.67 (45%)
Grand Total Purchases = $2,425.17 (100%)
(Cook et al., Psychiatr Rehab J, 2010)
TX SDC Participant Satisfaction Survey
 42 participants with 3+ month tenure; 31 completed
the survey for a 74% response rate with no refusals
 How would you rate the SDC program?
 Poor/Fair
10%
 Good/Excellent 90%
 How do the MH services you’re buying now compare
to those you got before SDC?
 Worse
 About the same
 Better
7%
19%
74%
 Would you recommend the SDC program to a friend?
 Not sure
 Yes
3%
97%
SDC Participant Outcomes
Living in own home or apartment
84%
Working for pay
26%
In school/taking a class
19%
Psychiatric hospitalization
6%
Physical health now vs. before SDC
Worse
About the same
Better
10%
35%
55%
“Ownership of one’s life…is a physical,
mental, spiritual, and responsible
connection or reconnection to life for
an individual who seeks his or her own
destiny.”
Nancy Fudge, Florida SDC Participant
Further Information about SDC
SDC Fact Sheet
http://www.cmhsrp.uic.edu/download/SDCResearchFactSheet.pdf
Funding Options
http://www.cmhsrp.uic.edu/download/sdsamhsaconfsentver3.pdf
Planning Guide
http://www.bazelon.org/issues/mentalhealth/publications/DriversSeat.pdf
Managed Care & SDC
http://www.magellanprovider.com/MHS/MGL/about/whats_new/providerfo
cus/new/archives/fall06/clinical/article1.asp
For more information, see http://www.cmhsrp.uic.edu/nrtc/default.asp