<i><b>networks</b></i>, Spring 1996 Issue

"networks" is published quarterly by the National Technical Assistance Center (NTAC) for State Mental Health Planning. The following are reprinted articles from the Spring 1996 issue. To be added to the networks mailing list - contact Christine Diaz at 703/739-9333, ext. 30, or e-mail Christine at: christine.diaz@nasmhpd.org. [Please include your name and return email address and/or telephone number in the body of your message so we may respond to your inquiry].

Managed Care and the Public Mental Health Sector

Editor's Note: Managed care presents state mental health agencies (SMHAs) with fundamental questions regarding their roles as service provider, purchaser, regulator and advocate. In this interview, we explore some of the challenges facing SMHAs with Colette Croze, M.S.W., NASMHPD's Health Care Reform Specialist in Alexandria, VA and John O'Brien, Senior Program Manager for the Technical Assistance Collaborative in Boston, MA.

Let's start at the beginning: What is managed care?

O'Brien: Managed care is designed to be a system of services where the most appropriate clinical care is provided in a cost efficient manner. Treatment is individualized to meet client need; the level of care and course of treatment are authorized and monitored to meet changing client needs; and clinical outcomes provide valuable direction for future service planning and cost efficiency. Managed care is not focused solely on cost containment, nor is it simply restricted access to services or providers.

Is managed care here to stay?

O'Brien: The administrative and provider changes that managed care technology have generated will be with us for a long time. State Mental Health Agencies (SMHAs) are more focused on becoming a "value purchaser," knowing what they want to buy and doing it in a smart way. SMHAs and providers need to be more accountable for both costs and outcomes; that is, who is served and what services are provided. Consumers are becoming better educated about how to choose and evaluate available options.

Croze: While it's probably true that the only thing that's going to significantly increase service access is more money, services can be more efficiently delivered within management structures that make the money currently in the system go further. Access then becomes more even and predictable. Right now, some individuals are intensively served while others simply receive crisis contact. Modified private sector methods for utilization management and informed consumer choice could lead to more predictable service access.

Some say that managed care will squeeze available profits out of the public mental health system and then disappear, leaving the public system with less money to serve just as many consumers as it did before.

Croze: Two key things are happening simultaneously that need to be considered separately. Managed care technology moving into the public mental health system is not necessarily the same as for-profit providers moving in. The first can happen without the second. With the entry of for-profit providers and behavioral health care organizations into the system, the public payer enjoys a whole new sense of competition. Even if some public mental health systems adopt a policy of doing business only with non-profits, I'm hopeful that they will see that they don't have to be as dependent as they have been in the past on providers who may or may not provide efficient and effective services.

O'Brien: The concern is based on previous experience with the contractual relationships and the results of early managed care initiatives. We're seeing a number of states and local mental health agencies explore ways to reduce or eliminate the potential for grandiose profit-making and reinvest some of those resources in the community to expand access and equity among services.

So there is a growing appreciation of the ways states can redirect resources through the contracting process?

O'Brien: Absolutely. Whoever was contracting with managed care organizations drove the process, and that wasn't necessarily the state mental health agency. With Medicaid agencies, cost containment was first and foremost and reinvestment wasn't necessarily a priority. Mental health authorities are becoming increasingly more savvy about managing care for the dollars they control, developing managed care plans for services purchased through general revenue dollars. They want to become very aggressive in managing other payers' funds, specifically Medicaid and now Medicare.

How successful have state mental authorities been in getting a seat at the table where these kinds of changes are being discussed?

O'Brien: It's a mixed bag. In the past, Medicaid agencies have forged ahead with some SMHAs at the table and some not at the table. Now, SMHAs are beginning to develop managed care approaches for mental health dollars. SMHAs need to produce an effective managed care plan. At the least, they need to ensure that others who are at the table don't cost shift to SMHAs when they aren't as directly involved in the process as they'd like to be.

Croze: SMHAs have to earn a seat at the table. Their role as the public mental health authority does not automatically give them credibility and authority to be the principle public behavioral health care purchaser. They need to show they have something to offer in administering a public mental health benefit.

SMHAs earn a seat at the table by doing a lot of hard work inside their agency and with stakeholders throughout the system. They develop plans to confront issues that haven't been confronted before, like the role of the state hospital or provider relationships that have been seen by other key players, including state Medicaid agencies, as overly protective.

What impact have consumers had on developments in managed care?

Croze: Increasingly, consumers and their families are letting SMHAs know what they like about the current system so those components can be preserved. They're also telling SMHAs much more clearly what needs improvement.

An important vehicle that consumers have developed to exchange knowledge and share information on managed care is the Consumer Managed Care Network. This group recently completed work on a "Platform for Action" that reflects the key aspects of a quality managed care system that's responsive to consumer needs and concerns, including: recovery-oriented values, protection of consumer rights, and consumer involvement in all aspects of the managed care system.

What about the concern that services offered under a community support model for persons with serious mental illness are not typically offered by managed care organizations?

O'Brien: People look at what's traditionally been contracted for through Medicaid agencies, which have not typically included those services. As SMHAs have begun to develop their own managed care plans, those services and supports have become important. Since they're measurable, utilization and cost can be monitored and they can be included in plans and purchased.

Croze: When you shift into an insurance mode of thinking, you have to be sure to administer a mental health plan that can afford the covered services for all beneficiaries when those services are deemed to be medically or clinically necessary.

The public mental health system has many small pockets of discretionary funding - for housing and supports, for vocational development, for psychosocial support services - but we use them in a way that doesn't make the full range of services available to all persons in need. Making a relatively small amount of money available for a small group of consumers doesn't fit with an insurance notion of coverage. The benefit package must be available to all beneficiaries in a behavioral health plan.

So what do we do to develop more inclusive benefit packages?

Croze: A managed care company does what the payer says. They'll try to negotiate a contract that's in their interest, but once the contract's signed, they are responsible to the entity providing the money. In analyzing the effect of policies on the public behavioral health system, we should realize that it's as much the choices that the payer has made as it is the attitudes or practices of the managed care partner.

John mentioned earlier that SMHAs want to be the primary public mental health payer, managing Medicaid and Medicare's money along with their own. To provide coverage for recipients of public services, we have to acknowledge the wide array of people who are dependent on public services. It isn't just persons with serious mental illness or people who are uninsured, it's also people who are underinsured, who in some parts of the country can consume 30-40% of a community mental health center's service capacity. If the SMHA wants to be the public policy expert on mental health, it has to address the needs of all populations now dependent on the public mental health system while maintaining a focus on people with the most serious disabilities.

O'Brien: This clearly goes back to the issue of benefit packages and eligibility. When they begin to think about developing a plan and looking at the costs of that plan, states are in the position of making some very difficult decisions about who's going to be eligible to enroll in that plan. They may have to make the decision that uninsured and underinsured individuals cannot be a priority.

What can states expect in the next few years with regard to their role in managed care?

Croze: Under managed care, states have to decide if they're going to make or buy a product or service. Some tough soul searching must occur that may mean the state has to stop doing some things it can't do as well as the private sector, in favor of those things that it does as well or better. The state also has a responsibility to protect the public interest which cannot be delegated.

O'Brien: And along with the "make or buy" decision, the decision has to be made regarding those things that are done within the state mental health agency and those things that are accomplished elsewhere within state-operated services, but perhaps not within the SMHA. Decisions to make or buy information services, to develop provider networks and to provide inpatient services, for example, have serious personnel implications if they are more efficiently and effectively delivered by the private sector. The whole privatization issue has to be on the states' radar screens over the next couple of years.

How can states prepare to take the next steps toward managed care?

O'Brien: States have to be clear about what needs to be managed better. They may say they want to move into managed care but some aren't yet sure what they hope to accomplish and whether managed care technology is the appropriate vehicle.

Can states be helped to frame the problems and questions they want to address and then determine how managed care technology can be helpful?

Croze: Absolutely. We have to increase technology transfer across state and regional lines so that states can collectively address issues rather than always solving problems on their own. Any last ideas that you'd like to share?

O'Brien: Communication is critical in this work, not just in letting people know what you're doing, but also being able to effectively "sell" your ideas throughout the system: from Governor's Offices, to legislatures, budget offices, Medicaid agencies, providers and absolutely, consumers and families.

And, if it weren't already tough enough, timing of that communication is critical. Done too soon, or waiting too long, can doom the State's ability to pull off any movement into managed care. This is part of the real challenge that states now face. We have our work cut out for us.

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CMHS FUNDS NEW TA CENTER

The Center for Mental Health Services (CMHS) and the National Association of State Mental Health Program Directors (NASMHPD) have entered into a cooperative agreement to create a new National Technical Assistance Center (NTAC) for State Mental Health Planning. The award covers a three-year period from October 1, 1995 through September 30, 1998.

NTAC's mission is to help bring about long-term improvements in public mental health service systems, in partnership with State Mental Health Agencies (SMHAs), consumers, family members and State Planning Councils. Technical assistance, training and consultation are being offered to all 55 states and territories to:

Facilitate networking and communication.
Serve as a clearinghouse for best practices and model programs.
Collect and disseminate information on state activities in managed care, performance-based outcome measures, and practice standards.
Convene NTAC constituents, in-person and electronically, to examine and create practical solutions to current problems.

NTAC will offer on-site training and technical assistance as well as maintain a database of expert consultants, publications, and reports on topics of special interest. NTAC will work to deliver flexible, speedy and cutting-edge technical assistance; promote service and system integration at state and local levels; support consumer choice and independence; encourage accountability; develop data-sensitive decision-making capabilities; and, respond to constantly changing environmental needs.

NTAC's work is guided by a Steering Committee with representatives from State Mental Health Agencies, CMHS, consumer and family member organizations, the academic community and others. NTAC staff are available to help constituents with their training and technical assistance needs across the full range of management and clinical areas faced by today's public mental health system.

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STEERING COMMITTEE

Richard Bast
Public Health Advisor
Division of State & Community Systems Development
Center for Mental Health Services
Rockville, MD

Paolo Delvecchio
Consumer Affairs Specialist
Center for Mental Health Services
Rockville, MD

Don Gilbert
Commissioner
Department of Mental Health & Mental Retardation
Austin, TX

David Granger
Manager of Evaluation & Quality Outcome Monitoring
Cuyahoga County Community Mental Health Board
Cleveland, OH
(American Assoc. of People of Color MH Consumers)

Carrol Hernandez, Ph.D.
Director
Mental Health Division
Department of Social & Health Services
Olympia, WA

Ronald Manderscheid, Ph.D.
Chief
Survey and Analysis Branch
Center for Mental Health Services
Rockville, MD

Pamela Marshall, J.D.
Private Consultant
Little Rock, AR

Sinikka McCabe
Director
Office of Mental Health
Dept. of Health and Social Services
Madison, WI

A. Kathryn Power
Director
Department of Mental Health, Mental Retardation and Hospitals
Cranston, RI

Teri J. Sanders
Statewide Family Advocate
MIKID
Flaggstaff, AZ

David Shern, Ph.D.
Dean
Florida Mental Health Institute
University of South Florida
Tampa, FL

Garrett Smith
Director of Consumer Advocacy
Mental Health & Developmental Disabilities Division
Department of Human Resources
Salem, OR

NASMHPD Staff:

Bruce D. Emery, MSW
Director
National Technical Assistance Center
for State Mental Health Planning
National Association of State Mental Health
Program Directors (NASMHPD)
66 Canal Center Plaza, Suite 302
Alexandria, VA 22314
PH: (703) 739-9333, x 28
FAX: (703) 548-9517
E-MAIL: bruce.emery@nasmhpd.org

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Message from NTAC's Director

What's in a name? When it comes to the name of this newsletter, quite a bit. The word "networks" captures the essence of the National Technical Assistance Center's (NTAC) mission as envisioned by the funders and planners of this new project. We’ll work to bring together key players in the mental health community--consumers, family members, state planning councils and state mental health agencies--to target critical problems and issues; to identify potential solutions; and to determine what works best for you in the context of the unique circumstances you face.

NTAC will accomplish its mission in a number of ways: by convening individual state and regional meetings, national conferences and workshops; by coordinating teleconferences and forums on the internet; and by supporting visits by constituents in neighboring states to share ideas and learn what works well in other places.

NTAC will continuously assess mental health service management and delivery trends so that we can respond with technical assistance that helps you meet those challenges. And, respond in a way that maintains and advocates public service values. We are also developing a comprehensive resource materials library--when you want to find out how other sates have responded to the challenges you are facing--NTAC will serve as a clearinghouse for concrete, practical solutions developed by your colleagues and peers.

Each quarterly issue of networks will be organized around a theme of importance to you and will include articles and other contributions actively solicited from leaders in the field-- people with cutting-edge ideas and technology. Your comments, advice or suggestions about this or future issues of networks are welcomed.

Our premier issue focuses on managed care. The feature article, "Managed Care and the Public Mental Health Sector," is a conversation with two highly respected providers of technical assistance on managed care. "NTAC Project Highlights" also described a number of current managed care-related technical assistance projects designed to support sates and other constituents at varying levels of managed care development.

NTAC's role of providing training and technical assistance to help states improve their mental health services, planning, delivery and evaluation is important to us and want to offer you the support you need - let us know what you think.

-Bruce D. Emery, M.S.W.

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NTAC Project Highlights

The provision of technical assistance (TA) to state mental health authorities to improve the delivery of mental health services is the core mission of the National Technical Assistance Center (NTAC) for State Mental Health Planning. One critical aspect of this mission is facilitating effective partnerships among consumers, family members, state planning councils and state mental health agencies. During the past several months, NTAC staff have engaged in a number of TA activities focused on meeting its mission. Here are a few highlights of those projects:

Requests for Applications. In early April, NTAC staff, guided by members of its Steering Committee, disseminated a Request for Applications (RFA) containing guidelines, application requirements and selection criteria for obtaining technical assistance through NTAC. The RFA was sent to over 1,500 key stakeholders in state mental health organizations, including mental health commissioners in each state and territory, state consumer affairs liaisons, state chapters of the National Alliance for the Mentally Ill, state planning council members, and others. NTAC has received requests for technical assistance from a number of states and is in the process of reviewing and responding to these requests. Applications for technical assistance are accepted on an ongoing basis and will be reviewed quarterly.

Performance Partnership Grants. NTAC has supported four meetings with the U.S. Department of Health and Human Services (HHS) related to Performance Partnership Grants (PPG s). These meetings were regionally-based (Portland, OR, San Francisco, Chicago, and Philadelphia) drawing several hundred representatives from the fields of health, mental health, infectious diseases, substance abuse and chronic diseases. The goal of these regional meetings has been to develop information that will enhance the process of decision-making in public health programs and eventually to develop objectives to guide states in negotiating Performance Partnership Grants.

Given that PPG s in some form are likely to replace the current Community Mental Health Services Block Grants, the ideas and recommendations generated during these meetings are critical to identifying measurable goals for the mental health field that will improve the quality of life for adults with psychiatric disabilities and children with serious emotional disturbance. NTAC sponsored a national PPG meeting on May 17 to convene a small working group of state mental health directors, consumers, federal representatives, and NASMHPD staff who were involved in the regional PPG meetings. This meeting focused on identifying lessons learned during the regional meetigs and on developing a series of practical recommendations to the National Academy of Sciences as it presents performance measures to HHS this fall.

Identifying Best Practices in Housing. On January 24-25, 1996, NTAC co-sponsored the "Housing Experts Workshop: Best Practices in a Changing Environment," with the Homeless Programs Branch of the Center for Mental Health Services (CMHS) and the National Resource Center on Homelessness and Mental Illness. Thirty national experts in housing development and finance were convened, including representatives from CMHS, the U.S. Department of Housing and Urban Development, state mental health directors, consumers, family members, advocates, service providers and technical assistance centers to identify best practices in providing housing to persons with psychiatric disabilities.

NTAC staff are now working on a "Housing Tool Kit" which will provide practical tools and recommendations to help state mental health authorities and state housing authorities increase access to affordable and decent housing for persons with psychiatric disabilities.

Performance Measures and Managed Care. The July meeting of state mental health commissioners convened by NASMHPD will include a pre-meeting institute, co-sponsored by NTAC and the NASMHPD Research Institute, focused on performance measures and managed care. The pre-meeting institute will assess the experiences of state and county mental health authorities with managed care to date to help identify the variety of performance measures now used within the managed care environment.

State and County Managed Care. Mental health commissioners from several states have requested that NTAC convene a focus group of representatives from states with county-based mental health systems to examine their unique issues and concerns as they consider entering into managed care arrangements. As a first step, NTAC will host a focus group via teleconference to identify key issues and to present these issues to the full NASMHPD commissioners meeting in July.

Disaster/Crisis Counseling. On June 6-7, 1996, NTAC hosted a meeting with CMHS to examine states recent experiences with presidentially-declared disasters and to make recommendations for improving the provision of assistance to states following disasters. Examples of recent disasters examined include floods in the mid-west, the civil unrest in Los Angeles, and the bombing in Oklahoma City. The work of more than 25 national experts participating in the meeting will be guided by a report assessing states disaster relief efforts and a survey of key informants conducted by NTAC.

Click here to see a copy of NTAC s RFA for Technical Assistance. For information on how to obtain support for technical assistance, call Bruce Emery at 703/739-9333, ext. 28, or e-mail Bruce at: bruce.emery@nasmhpd.org.

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YOU WANTED TO KNOW...

As director of child and youth services for a state office of mental health, I coordinate transition services for adolescents with serious emotional disturbances. How can I locate a consultant who can help to ensure that all the stakeholders are as involved and as invested as they need to be?

NTAC maintains a consultant database of nationally recognized experts representing a broad range of disciplines from such diverse groups as federal, state and local governments, public and private service providers, researchers and academics, as well as consumers, families and advocates.

NTAC can provide the names of consultants who can assist you in identifying and responding to core systems-level and service-level issues in providing transition services to adolescents with serious emotional disturbance. This information, in turn, can be used in a variety of ways based on your individual needs. For example, to facilitate a meeting of key stakeholders or to develop program guidelines.

I am the consumer affairs liaison for a state mental health agency. What technical assistance can NTAC provide in addressing issues related to services for persons with co-occurring mental health and substance use disorders in my state?

On an ad hoc basis, NTAC can help you locate key reference literature and experts knowledgeable about co-occurring mental health and substance use disorders. NTAC can also provide you with more formal technical assistance around issues that support state mental health agency system improvements in planning, delivering and/or evaluating services.

Several key requirements for obtaining NTAC support for on-site technical assistance include:

approval of the state commissioner of mental health;
broad-based participation of key stakeholders; and
funding requests limited to a maximum of $5,000.

Click here to view NTAC's Request for Applications (RFA) and learn the requirements and selection criteria to qualify for assistance. For more information regarding the consultant database and/or NTAC technical assistance, call Bruce Emery at 703/739-9333, ext. 28, or e-mail Bruce at bruce.emery@nasmhpd.org.

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NRI Compiles Managed Care Data

The NASMHPD Research Institute (NRI), under contract to CMHS, is currently compiling Fiscal Year 1995 data for the second cycle of the State Mental Health Agency (SMHA) Profiling System. The SMHA Profiling System provides a centrally maintained, computer-based compilation of descriptive information about the organization, funding, operation, services, policies, statutes, and clientele of state mental health agencies.

The first cycle of the SMHA Profiling System tracked the SMHAs involvement in managed care activities, including selected privatization of their systems. In the second cycle of the Profiles, an entire section of the policy component has been dedicated to compiling information on managed care. This section includes questions on Medicaid waivers, mental health carve outs, types of services covered, the SMHA s role in the process, and more.

SMHA employees and the general public will be able to access these managed care data through the Internet and the NRI bulletin board system. SMHA employees may call the Research Institute to request information and special analyses. The data are expected to be available by Fall 1996.

For more information, contact Ted Lutterman at the NASMHPD Research Institute at 703/739-9333, or click here to e-mail Ted - ted.lutterman@nasmhpd.org

Click here to reach NRI's Web Site

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Boards Look to NTAC for Decision-Making Support to States

In late March, the NASMHPD and NASMHPD Research Institute (NRI) Boards of Directors met to shape program and budget plans for FY 1996-97 and beyond. The Boards jointly reflected on program and fiscal trends faced by many state mental health agencies (SMHAs), reviewed Commissioners priorities for NASMHPD and NRI services, and approved a FY 96-97 work plan for the two organizations that included the goals of NASMHPD s new National Technical Assistance Center (NTAC) for State Mental Health Planning.

The Boards indicated that although it is unrealistic for NASMHPD and NTAC staff to provide the actual solutions to states management and fiscal dilemmas, NTAC can play a unique and vital role as a facilitator in working with senior SMHA managers to stimulate dialogue and to promote collaborative problem-solving among the states. Examples of issues that may be addressed include the closing of state hospitals, state/county relationships, outcome indicators for contract compliance, and culturally competent service delivery.

The NASMHPD Board emphasized the critical role that NTAC can and should play in convening states through both national and smaller, regional-based forums. The Boards also suggested that states consider contributing both staff and fiscal resources to form joint technical assistance enterprises to pursue specific interests where NTAC would function as conveners.

Board members agreed that NTAC is a valuable new asset to the states and to our associations.

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NTAC Calendar of Events

Summer 1996

July 17, Pre-meeting Institute, "A National Dialogue on Managed Care and Performance Measures in Public Mental Health Systems," [Targeted to state and county mental health administrators involved in development and evaluation of managed care systems or performance measures],Chicago, IL. Call Bruce Emery at (703) 739-9333, ext. 28, or e-mail Bruce at: bruce.emery@nasmhpd.org.

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NTAC's Technical Assistance/Training
Other Mental Health-Related Conferences/Events

NTAC's Technology Corner

AVAILABLE NOW...

NTAC currently posts state-related mental health information on the National Mental Health Knowledge Exchange Network (KEN) EBBS, a project of SAMHSA s Center for Mental Health Services (CMHS). Access to the EBBS service via modem is available 24-hours-per-day by dialing: 1-800-790-CMHS (2647).

You can also contact KEN's web site at:
http://www.mentalhealth.org

COMING SOON...

NTAC is now developing electronically-based communication platforms that will offer discussion forums and access to state-related mental health information.

Interested parties with Internet access will be able to browse NTAC s World Wide Web home page where they can learn of upcoming conferences and events; download information on model programs, policy statements, and legislative updates; send e-mail messages; and link to other web sites...

For more information, e-mail: ntac@nasmhpd.org [Please include your name and return mailing address, email address and/or telephone number in the body of your message so we may respond to your inquiry].

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"networks" is published quarterly by the National Technical Assistance Center (NTAC) for State Mental Health Planning, and is supported under cooperative agreement between the National Association of State Mental Health Program Directors (NASMHPD) and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (CMHS/SAMSHA).

Spring 1996 Issue -

Bruce D. Emery, M.S.W., director
Gail P. Hutchings, M.P.A., assistant director
Lynnette A. Banning, technical assistance associate / editor
Vera Hollen, research assistant
Rebecca Crocker, technical assistance support specialist / production
Christine Diaz, administrative assistant

Cited reproductions, comments, and suggestions are encouraged. You may also be added to the mailing list for networks. Contact Christine Diaz at 703/739-9333, ext. 30, or send e-mail to: christine.diaz@nasmhpd.org. [Please include your name and return mailing address, email address and/or telephone number in the body of your message so we may respond to your inquiry].

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Click here to download the entire Spring '96 Issue

NTAC Publications