Bates vs. Commissioner, DHHS 

Report to the CourtIn the Matter ofBates v. Commissioner, DHHSDocket No. CV-89-88IntroductionOn May 16, 2008, the Department briefed the Court on the supplemental budgetreductions that had just been concluded. As a result of that session, on July 11, 2008, theCourt ordered the appointment of a Court Monitor. The Court Monitor was assigned theresponsibility to prepare a report that will “(1) document accurately the funding for theadult mental health system for FY 2007-2008 and thereafter: and (2) describe the impactof that funding on the defendants’ ability to achieve substantial compliance with theterms of the Consent Decree.”As Court Monitor, appointed by Justice Mills on August 21, 2008, information for myreport was obtained through a variety of sources. I received exceptional cooperation fromthe Court Master, the parties to this litigation, provider agencies, clients and theiradvocacy groups, and interested stakeholders in the communities across Maine. BetweenSeptember 14, 2008 and February 6, 2009, I conducted a number of site visits throughoutthe State: interviewed people responsible for the provision of both hospital andcommunity-based mental health services: and discussed the impact of changes in themental health system with clients, both class and non-class members, and communityofficials concerned about their well-being and recovery. I read correspondence fromconcerned professionals and family members.I reviewed an extensive number of documents related to the budget and administration ofthe mental health system. Additionally, a detailed survey was completed by twenty-sevenprovider agencies and one hundred and nine clients responded to a brief questionnaireadministered by Amistad’s Warm Line staff.My report has been well-informed by these site visits and candid discussions. In myopinion, it is beyond question that the mental health system has been deeply affected bythe budgetary changes made over the last few years and that a number of individuals,both clients and provider agency staff, have experienced uncertainty, disruption and/orthe loss of services.{W1308851.1}2There is evidence to indicate that compliance with Court Orders, including the AdultMental Health Services Plan adopted by the parties in 2006, is currently impacted by thelack of availability of sufficient appropriate housing, rental subsidies and communitysupport services (Paragraphs 31, 32.c., 93, 95, 103 and 266): the loss of flexibility in thesystem as a whole through the loss of grant funding (Paragraph 32.b.): the prohibition inNovember 2008 of any new admissions for Community Integration services inCommunity Service Networks 3 and 6 and the prohibition in December 2008 of newadmissions for Community Integration, Assertive Community Treatment and Daily LifeSkills in Community Service Networks 2 and 5 (Paragraphs 32.g.,37, 97and 274): theelimination of the three Long Term Employment Support positions and the InteragencyProgram Coordinator positions (Paragraphs 101 and 102): the reduction in the contractfor family support services (Paragraph 109): and the hiring freeze at RiverviewPsychiatric Center (Settlement Agreement, Paragraphs 174 and 202.)Furthermore, the requirements related to the implementation of the AdministrativeService Organization (ASO): the recently concluded rate standardization study: and theanticipated changes regarding crisis services and the Private Non Medical Institutions(PNMIs) have created an atmosphere of concern, considerable tension and instability.At the same time, it is my opinion that there are considerable strengths in Maine’s mentalhealth system: they need to be protected. With the re-establishment of trust and focusedattention on the needs of clients, genuinely collaborative discussions about the financialunderpinnings of the mental health system and its priorities could result in a rationalframework for future budget decisions and the concurrent actions required for fullcompliance with the Court’s Orders in this litigation.Impact on Adults with Mental IllnessAt the onset, it seems important to underscore that adults with mental illness aresubstantially more than the sum of their insurance coverage and/or their status as classmembers or not. While some information collected about clients and their needs can bedescribed as anecdotal, the underlying anxiety and concern they have expressed aboutsuch very basic supports as housing, health care, employment, counseling and in-homeservices should not be dismissed because it has not been captured through a statisticallyrelevant sample. Simply put, the conversations with clients were often painful becausethey illustrated the tremendous needs for reliable ongoing support and trustingrelationships as well as the recognition that services were at risk or actually had been lost.Important information about the needs of non-class members who are not MaineCareeligible is seriously lacking because they disappear from contact with communityprovider agencies once services are not available. One reminder of the significant level ofneed for both class and non-class members who are not MaineCare eligible can be foundin the substantial number of civil clients who are hospitalized in psychiatric hospitals,including Riverview, and who are difficult to place once ready for discharge.{W1308851.1}3Fortunately, because of the data collection required by the Consent Decree, there is moresystematically documented information about the needs of class members. Yet, there wasacross the board agreement from all parties that the collection of “unmet needs” data hasbeen flawed and mostly likely under represents the resource gaps in the mental healthsystem. For example:”…problems with data collection/processing issues…continue toaffect the intensity of the unmet needs data…It will be difficult toformulate reliable conclusions from the unmet needs data.” (See DHHS/OAMHS Unmet Needs Report, January 2009.)The data that has been most recently collected, in the Quarter 2, 2009 Report, indicates atotal of 2840 unmet needs for 1249 persons, both class and non-class members, withIndividual Support Plans (ISPs).The breakdown by Community Service Network (CSN) is as follows:CSN 1 60 needs/22 clientsCSN 2 577 needs/259 clientsCSN 3 352 needs/145 clientsCSN 4 184 needs/90 clientsCSN 5 896 needs/341 clientsCSN 6 666 needs/343 clientsCSN 7 85 needs/42 clientsThe number of individuals with unmet needs has increased from 4.3 percent to 22.1percent.It will be important to consider how this data can be supplemented in order to achieve themost accurate picture of the system as a whole. For example, the use of the “Need forChange Self-Rating Scale,” which Maine Medical Center used with clients to indicatetheir interest in vocational services/ employment, shows a much higher need forsupported employment resources throughout the State than the data collected through theDepartment’s existing process.Additional information about recent changes in the outcomes for class members isavailable in the Department’s report referenced above and in the Annual Class MemberSurvey for 2008. These statistics document that:• There has been an increase in the number of class members who experiencedhomelessness over a twelve month period (10.3% in 2008 v. 6.6% in 2007)• There has been an increase in class members with unmet housing resources(26.9% in FY09 Q2 v. 12.2% in FY09 Q1 v. 1.6% in FY 06 Q4){W1308851.1}4• According to class members’ reports, there has been a decline in the availabilityof crisis services when needed (75.6% in 2008 v. 83.3% in 2004). These numbersare from the performance indicators as reported. (Defendants have commentedthat “percentages for this standard were recalculated by the OQI for those whoused, emphasis added, crisis services and corrected within the Class MemberReport, though not within the performance and quality improvement standardsthemselves.” The recalculated numbers show an increase in availability ofservices (92.5% in 2008 v. 88.4% in 2007). However, it should be noted, if therecalculation is on the basis of reports from those who used crisis services, whenthe question is whether or not crisis services were available, the recalculation begsthe question.)• There has been an increase in class members with unmet vocational/employmentsupport needs (9.9% in FY09 Q2 v. 1.3% in FY 06 Q4.) The availability ofvocational supports has declined (62.4% in 2006 vs. 59.7% in 2008). It is knownalso that the waiting time for vocational services from the Department ofVocational Rehabilitation is increasing. A federal monitoring report for FiscalYear 2008 cites significant delays as a challenge for this agency.• The number of class members in competitive employment has decreased to 7.6%(FY 09 Q2) from 10.5% (FY 09 Q1). The number of class members who reportwanting to work is reported as 25.5% with nearly 34% of those individuals statingthat they would like help or assistance in finding work.The annual report documenting 211 calls lists 1416 calls about mental health services: thethird highest category of calls recorded. (See July 2007-June 2008 report.)During the information gathering stage for this report, there were repeated references tothe increasing incarceration of adults with serious mental illness in county jails. Theseobservations were made by service providers, sheriffs and jail administrators.The recent report by a task force convened by the former Attorney General states:There is presently a growing challenge to existing inpatientand outpatient resources for treatment of people with mentalillness. Public safety crises involving people with mentalillness have increased both in frequency and seriousness intheir threat to all parties involved. (See Report of the AttorneyGeneral’s Ad Hoc Task Force on the Use of Deadly Force byLaw Enforcement Officers against Individuals Suffering fromMental Illness, December 4, 2008, page 2.)A preliminary paper published from the University of New England in January 2008reports:Following policy decisions and the implementation of budget{W1308851.1}5cuts from the state budget, which took effect on July 1, 2007,the cuts in mental health services correspond to an increase inlaw enforcement contacts with people who have mentalillness. (See McLaughlin, “Changes in the Mental Health System:What We Know So Far,” page 8.)Police Departments across the state have seen a 26 percent increasein the number of mental health-related calls for service in theFirst Quarter of the fiscal year 2008. (See ibid. page 2.)Statistics from the Penobscot County Jail have been kept consistently since at least July2007. In the period from July to September 2008, 30 percent of all inmates were onpsychotropic medication. There has been an increase in contacts with local mental healthclinicians for assistance (859 contacts in July to September 2007: 1149 contacts for thesame period in 2008.) The number of inmates on suicide watch has nearly doubled overthe last year (323 in July to September 2007: 603 in 2008.)The Utilization Review Reports of Admissions to Community Hospitals indicate anincrease in the admission of both class and non class members. The number ofadmissions rose from fifty-four in the first Quarter of 2008 to sixty-eight admissions inthe second Quarter of 2009.The Maine ASO Dashboard Report for Adult Mental Health in September 2008documents that individuals who are discharged from psychiatric inpatient units who arethen readmitted within thirty days has remained fairly constant (July, 2008-19%: August2008-14%: September 2008-17%).Maine residents in rural areas are affected by the lack of financial and other incentives torecruit psychiatrists and clinical professional. As agencies have cut back on services,transportation constraints have been magnified and waiting times have increased.In order to obtain a snapshot of the changes being experienced by callers to its WarmLine, between December 20, 2008 and January 27, 2009, Amistad staff asked forvoluntary responses to a brief questionnaire.One hundred and nine unduplicated callers, both class and non-class members, living intwelve counties responded to the questions. Forty-two individuals (38 percent) stated thatthey had either lost or were required to change mental health services.Twelve of these individuals were class members: twenty-six were not. (The status of fourpeople is unknown.) Thirty-six adults had MaineCare or other insurance: four wereuninsured and the coverage of the remaining two people is not documented.The changes in the availability of supports included: disruptions in case management asstaff were reassigned or laid off: decrease in case management hours: loss of casemanagement: limitations on counseling visits: transfer to a different provider agency: loss{W1308851.1}6of in-home supports: loss of outpatient services: cutbacks in personal care services:reduction in day services: loss of dual recovery programs: loss of transportation: changesin medication management and changes in assigned therapists.One of the most established principles in the field of mental health is continuity of care.The responses from the Amistad survey indicate that this important principle has beennegatively affected for at least some clients of the mental health system.Impact on Provider AgenciesThe potentially harmful impact of budget reductions, and the concurrent realignment ofmental health programs, on the system’s clients has been tempered by the commitment ofprovider agencies to preserve services and supportive clinical relationships to the greatestextent possible. Throughout my site visits and discussions, I found repeated evidence ofthe actions taken by agencies to absorb the financial consequences of the loss of grantfunds and the reductions in reimbursement rates. In fact, the efforts by agencies to reduceadministrative costs has resulted in the closing of offices and program sites: the reductionof staff positions: the reduction or freezing of wages: decreased training for staff:increased supervisory caseloads and increases in the required number of billable hours.The lack of meaningful provider and client representative involvement in budgetdiscussions is problematic. (The Department’s request for input in late August 2008 wasdescribed consistently as rushed and superficial. Despite requests for inclusion, providerparticipation in a task force regarding crisis service consolidation was limited to a writtensurvey. Reportedly, the work of the task force on system redesign has not been utilized indecision-making.) Many of the consequences described in this report would have beenknown earlier if there had been discussions about the impact of budget decisions.Furthermore, the sense of partnership would have been strengthened throughout themental health system.At my request, twenty-seven provider agencies responded to a detailed survey focused onthe impact of budget cuts and the elimination/reduction of program services. Theseresponses will be available for review by the parties at their request.In summary, in addition to the administrative actions described above, providersdocumented that they were obligated to:1. Reduce services and serve fewer clients. All seven Community Service Networks,the entire mental health system in Maine, documented service reductions. Thesereductions included outpatient counseling, Community Integration services,residential services, psychiatry, and Assertive Community Treatment.2. Eliminate services. Services were reported as eliminated in Community ServiceNetworks (CSN) 2,3,4,5, and 6. These services included one on one staffing,group treatment for dually eligible clients, Community Integration services, Daily{W1308851.1}7Living Support Services, sites for community-based psychiatry, counseling inrural areas, and loss of trauma recovery work.3. Stop accepting referrals and lessen the amount of outreach performed by staff.Throughout the mental health system, non-class members without MaineCarecoverage were affected by the lack of grant resources. This disparity is the subjectof a recommendation by the Court Master and is under discussion by the parties.Examples of other actions were documented by agencies in CSNs 3, 4 and 5. Inparticular, clients with both Medicare and MaineCare were affected due to thelower Medicare rates and the policy regarding reimbursement. The availability offree care for services was ended by one agency. One agency reported that it hashad to deny services to high risk adults because of a lack of grant funding. Inanother CSN, one thousand fewer clients were seen in FY 2008. An agency inCSN 3 reduced its outreach to people who are homeless. Another agency in thatCSN decided to sustain its outreach through its own private resources.4. Discharge clients to other providers. It was reported that seventy-five clients withnon-categorical coverage were discharged by one agency in CSN 6: three otherclients were discharged in CSN 2. Another agency in CSN 2 discharged seventyfiveclients without MaineCare coverage. Last year, an agency in CSN 6discharged one hundred and fifty-nine clients. In CSN 7, clients were dischargedto primary care physicians and private therapists. In addition, clients weretransferred to other levels of service when the Intensive Community Integrationwas ended. Some of these clients reportedly were placed in higher levels of carethan required because of the availability of General Funds for those services.Although this solves the individual problem, it limits and redirects the resourcesavailable for others in need.5. Decrease programmatic materials, supplies and activities. Concerns about theability to sustain quality care/treatment were documented in every geographicalarea of the State. Positions were eliminated in residential services in CSNs 2 and3. There were fewer opportunities for community outings, health and exerciseprograms, staff training and individualized attention to clients.6. Increase clinical caseloads and decrease clinical consultations and supervision.Agencies in CSN 2 documented increased caseloads and decreased clinicalconsultations and supervision. Caseload changes were discussed in my meetingswith clinical staff in CSN 6. The increase in staff turnover and stress levels wascited repeatedly in my site visits and highlighted in one survey response fromCSN 4.7. Transport clients longer distances to available services/sites. The closing of officelocations necessitated longer transportation distances in CSNs 3 and 5. An agencyin CSN 4 reported that less transportation was available overall to its clients.Routinely, transportation has been cited as a serious concern in the rural areas ofthe State.{W1308851.1}88. Reduce the amount of time for direct interaction between the client and clinician.Although this issue was referenced repeatedly though out the system indiscussions about the impact of the ASO, agencies in CSN 2 and 6 stated that theyhad limited the time spent directly with clients.9. Maintain longer waiting lists. Agencies in six CSNs (2,3,4,5,6 and7) reported thatthe waiting time for their services was longer. Access to certain services, such aspsychiatry, was described as difficult.There were some examples of innovative approaches to the reduction of costs includingthe implementation of an electronic record system and the introduction of energyefficiencies.Importantly, although this report does not include a review of mental health services forchildren and adolescents, there were repeated references throughout my discussions ineach area of the State about the lack of services for this group of clients and theirfamilies. The failure to address adequately the needs of young people was cited as aproblem of serious magnitude for the future. In particular, the funding of crisis servicesfor children/adolescents was identified as an area of considerable concern.And, additionally, successful initiatives have been constrained and compromised bydecreases in their funding. For example, Spring Harbor Hospital’s dual diagnosisAssertive Community Treatment team, ACCESS, had a rate reduction that led to thelaying off of three staff. Caseload sizes were increased for the remaining team members.The family support programs provided by the National Association for the Mentally Ill(NAMI) were drastically curtailed as the result of a 48 percent budget cut. While theDepartment’s funding continued for NAMI’s police training program (CIT), the fundingreduction for family support programs resulted in fewer staff available for the CITprogram and the loss of reimbursement for officer replacement costs. The contract for thesupported employment program at Maine Medical Center was cut by 5.8 percent. MaineMedical Center was able to minimize the impact of this decrease only because there wasa vacant position.Each of these programs represents best practice in the field and offers replicable costeffectiveapproaches for recovery.On December 1, 2007, the impact of financial constraints was intensified by theDepartment’s implementation of its contract with an Administrative ServiceOrganization, APS Healthcare.APS authorizes services covered by MaineCare sections 17, 65 and 97: grant fundsallocated for Community Integration, Assertive Community Treatment, and Daily LivingSupport Services: and PNMI residential costs once approved by the Regional Office.{W1308851.1}9The Department made certain assumptions when the Administrative Service Organization(ASO) initiative was first presented to the Legislature: 1) Total baseline expenditures forbehavioral health services were $442 million: 2) the estimated savings from the ASOwould be 5 percent with an annualized savings estimate of $23 million once fullyimplemented in FY 09. The savings from the General Fund were estimated as $8.5million.The contract with APS Healthcare cost $8,683,750 on October 29, 2007. Of this amount,$2,170,937 was from the General Fund: $6,512,813 was funded from the Block Grant. InFiscal Year 2009, total payments to APS are expected to be approximately $5,013,572.Of this amount, approximately $1,373,902 will be in General Fund dollars.Based on an analysis of expenditures for services subject to utilization management byAPS, from FY 2007 -FY 2008, there was a total reduction of $8,080,010 in GeneralFunds. Of this amount, $3,884,603 is attributed to rate reductions. The remainder of$4,195,407 is attributed to reduced utilization of services (See Welch memo, January 27,2009).The introduction of the ASO has resulted in considerable debate, much but not all of itnegative in nature, within the provider community. The increased administrative burdenhas been well documented in the provider surveys. The denial rate is low-less than .5 ofone percent, according to the most recent information from APS. (The comparable rate inother states is 1-2%.) The low denial rate has been interpreted, with justification, toindicate the sound clinical judgments and assessments submitted for approval from theprovider agencies. (APS reports that it works closely with providers to reduce the numberof denials.)The decision to use an ASO is not the subject of this report. However, it is referencedhere because it was implemented within the same time period as major financialconstraints and changes in program service requirements. The focus of the providercommunity was diverted substantially to this new authorization process when clientservices also were demanding extraordinary attention. Limited resources were redirectedextensively from programmatic needs to administrative responsibilities, such as dataentry and billing authorization, mandated by the role of the ASO.Finally, by all reports, the stress of the administrative requirements linked to the ASOhave taken a substantial toll on clinical staff persons who have been required torestructure and reduce their interaction time with clients: increase the amount of timespent on paperwork: and divert their attention from their main substantive interest-assisting clients with their recovery from mental illness.Riverview Psychiatric CenterAccording to budget documents distributed by the Department on February 19, 2008, theFY 2007 Actual Budget for Riverview was $31,249,982: the FY 2008 Actual Budget was{W1308851.1}10$28,976,647 and the projected budget for FY 2009 is $30,640,012. As of February 16,2009, the FY 2009 expenditures to date are $18,489,231.In the current fiscal year, for the first time, funds allocated specifically for client care atthe hospital have been directed to non-hospital purposes:1) $250,000 for Community Integration costs2) $100,000 in General Funds pursuant to the curtailment order3) $144,101 for a psychiatrist position, through Spring Harbor Hospital, for16 hrs/week at the Portland Clinic and 4 hrs/week at the Health Clinic forthe Homeless in Portland.Additionally, beginning in July 2007, $500,000 for the expenses of the Office ofManagement and Budget within the Commissioner’s Office has been deducted from eachbudget allocation for Riverview and Dorothea Dix.A hiring freeze was instituted in November 2008 for all positions. Prior to that date,direct care positions were exempt.As of February 13, 2009, there were twenty-three staff vacancies including eight nurses,seven Mental Health Workers, a physician, psychologist, research assistant, officeassistant, Program Services Director, Chief Operating Officer, Quality AssuranceDirector, and the Superintendent’s position.The vacancies in nursing and direct care date back to March 2008. In recent days, theyhave been released for posting and recruitment activities but are not yet filled.Furthermore, newly vacated direct care positions are still being held for the freeze.The three leadership positions–the Superintendent, Chief Operating Officer, and QualityAssurance Director– have been vacant since September 2008, January 2009 andSeptember 2008 respectively. As a result of recent actions, they are now being posted forrecruitment.The minimum staffing ratios on the units are being covered by overtime. The overtimecosts at Riverview have been increasing steadily. In 2006, the cost was $781,672: in2007, it was $828,064: and as of February 16, 2009, it was $611,595 for the Fiscal Yearto date.Overtime is widely regarded as a strategy of last resort. Staff persons who are tired canbecome impatient or less focused on the goals of their work. An increase from 5.17percent (June 2008) to 8.18 percent (December 2008) in the number of clients beingrestrained is of concern because it is an erosion of Riverview’s policy to avoid restraint tothe greatest extent possible.{W1308851.1}11Other indicators of concern at Riverview are the decline in client satisfaction (89% to65%) and the growing number of clients clinically ready for discharge but awaitinghousing.As of February 10, 2009, there were thirteen class members waiting for discharge. Anumber of these clients are not eligible for MaineCare. Seven of these individuals requirehousing. The range of waiting time since the determination of clinical readiness fordischarge ranges from 5 days to 425 days with a median of 64 days. This has been apattern since September 16, 2008.Furthermore, development of residential mental health services for clients with complexneeds was put on hold in February 2009 due to “deterioration of the State’s financialsituation.” (See Quarterly Report of February 1, 2009, page 14.)The failure to implement timely discharges has been cited previously in the CourtMaster’s reports to the Court. In his report of October 18, 2005, for instance, the CourtMaster wrote: “Although there has been improvement, the most difficult and enduringproblem in the operation of the hospital is the inability to discharge clients in a timelymanner because of the lack of funding for community services.” (See page 2.)The lack of appropriate housing in the mental health system and its impact on dischargefrom Riverview is of serious concern. At the same time, the lack of housing and supportsexpands the risk of inpatient hospitalization for both class members and non-classmembers now living in their communities.It should be noted here that there are similar concerns evident at Dorothea DixPsychiatric Center. Although this hospital is not included in the obligations under theCourt’s Orders, it is not impossible that a class member now living in its referral areamight be admitted there for inpatient care.Dorothea Dix has three eighteen bed wards for a capacity of fifty-four clients. There are325 Full Time Equivalent positions (FTEs). At least three adults, one of whom is amember of the Pineland class, were clinically ready for discharge during my site visit onJanuary 29, 2008. Plans for their group home placements were cancelled when theanticipated funding was not made available by the Department. The hospital costs forthese three clients are high. Costs for the one on one staffing required for two of the menaverage $200,000 per year per client.Additionally, Dorothea Dix is subjected to the same hiring freeze as Riverview. Overtimeand the use of contract agency nurses are used to meet staffing standards. As of February16, 2009, overtime costs to date at Dorothea Dix were $481,763.According to budget documents distributed by the Department on February 19, 2008, theFY 2007 Actual Budget for Dorothea Dix was $26,217,896: in FY 2008, it was$26,336,670: and in FY 2009, it is projected as $26,786,082. As of February 16, 2009,the total expenditures to date for Dorothea Dix were $17,512,744.{W1308851.1}12Community Services BudgetThere are three introductory comments to this section.First, all budget information was provided to me in the form of documents issued by theDepartment or, responding to my questions, in correspondence from the Office of AdultMental Health Services (OAMHS) or Departmental staff. It has been observed that thereis no user friendly method to track expenditures by client or provider. Financial reportingdoes not provide a method to compare providers on service utilization and budgeting inorder to determine relative value.Second, it is recognized at the outset that the Department has worked strenuously tomaximize federal reimbursement for mental health services. Over the years, GeneralFunds have been replaced by Medicaid reimbursement as the Department has increasedMaineCare expenditures.The reliance on MaineCare, however, has meant that grant funding is still essential forthe support of uninsured or non-MaineCare eligible adults. Additionally, grant fundingmanaged at the local level has been a key resource for flexible individualized servicesthat can be initiated with minimal delay.Unless services are funded adequately for non-MaineCare clients, there can never becompliance with the Consent Decree.Third, at this time, there are three critical outstanding issues that may affect the deliveryof mental health services in the near future: the proposed changes in funding for crisisservices: rate standardization: and restructuring of the Private Non-Medical Institutions.Each of these issues is controversial: none of these issues have been resolved.Crisis ServicesIn 2008, the Department proposed reductions in grant funding for crisis services. Bylegislative amendment (LD2990), the proposed cut was reduced to $300,000 and it wasrequired that the reductions in cost come from the elimination of duplication in areaswhere multiple crisis service providers exist. A report by the Department on the progressof the consolidation efforts was required to be submitted by January 1, 2009. This did notoccur.With limited provider input, the Department has booked the $300,000 in its proposedsavings for this fiscal year and has mandated the redistribution of grant funds for crisisservices.{W1308851.1}13Although this issue is complicated by differences of opinion in the provider community,and more discussion is warranted, it is my opinion that further changes to the “safety net”at this point in time would be harmful and should be reconsidered.Furthermore, the Department’s current decision in this matter does not appear to beinformed by any evaluation or assessment of the quality of existing crisis services in anyCommunity Service Network. The lack of correlation between payment and performanceoutcomes should be remedied before major changes in the system are proposed.Rate StandardizationReportedly, rate standardization was to be accomplished in the context of systemredesign and the reduction of administrative burdens. Although work was accomplishedthrough task forces focused on the latter initiatives, no decisions were implemented.Clearly, some caution should be used in comparing Maine’s cost for mental healthservices to those in other states. Cost comparisons between states are influenced by theexpenditures actually included in the overall cost and the manner in which services areorganized. States differ in what costs are included in a particular rate.The cost of overall health care spending is also influenced by geography. Maine is amongthe most rural of all states and it is included in a high cost region. In general, NewEngland’s spending on health care is the highest in the United States. Also, Maine has asignificant proportion of elderly residents and individuals with a disability. These factorsalso influence cost. (See Maine Center for Economic Policy, February 29, 2008.)Private Non-Medical Institutions (PNMI)As a result of changes in the Centers for Medicare and Medicaid Service’s (CMS) rulesregarding reimbursement for rehabilitation, the Department is planning to restructure theuse of the residential services known as Private Non-Medical Institutions. Meetings havebeen underway to analyze any potential cost savings as well as the programmatic impactof redesigning these services. Final decisions about the eligibility for and functions of thiscategory of residential services most likely will impact the availability of residentialservices across the State. The 2010 budget plan reduces this funding.The Adult Mental Health Services PlanIn order to move towards compliance with the provisions of the Settlement Agreement,the parties agreed to a Plan which, among other obligations, establishes the intent toensure a basic array of community mental health services in each distinct geographicalarea of the State. In the Plan, geography is defined through a Community ServiceNetwork (CSN). There are seven such Community Service Networks: CSN 1 includesAroostook County: CSN 2 includes Washington, Penobscot, Hancock and PiscataquisCounties: CSN 3 includes Somerset and Kennebec Counties: CSN 4 is comprised of{W1308851.1}14Waldo, Knox, Lincoln and Sagadahoc Counties: CSN 5 is made up of Franklin, Oxfordand Androscoggin Counties: CSN 6 is Cumberland County and CSN 7 is York County.Client representation in the Community Service Networks occurs formally through theLocal Consumer Councils. A statewide Consumer Council is now active. The Councilsare funded by the Department.Community Service Networks are expected to be active participants in planning andproblem solving about local services. As noted above, this has not happened to the extentenvisioned in the Plan.In order to be in compliance with the Plan, each Community Service Network was toensure the full availability of certain core services: 1) peer services: 2) crisis services,including Crisis Stabilization Units: 3) Community Support Services, includingCommunity Integration, Intensive Community Integration (now unavailable): AssertiveCommunity Treatment: Daily Living Skills, Skills Development and Day SupportServices: 4) outpatient services: 5) medication management: 6) residential services: 7)vocational services: and 8) inpatient services.Gaps in these services were to be documented so that resources could be requested andallocated as needed. The collection of Unmet Needs Data has been the primarymechanism for quantifying the absence of necessary resources. As noted above, althoughimproving, this process has been flawed.The budgets for community mental health services are reported as follows:• Fiscal Year 2006-07: Total General and Federal Funds (i.e. Block Grant) of$34,797,619. Community Medicaid Funds totaled $40,088,232. Federal MedicaidFunds (payments to providers) totaled $68,788,009.• Fiscal Year 2007-2008: Total General and Federal Funds of $33,973,827. Thisrepresents a decrease of 2.37% over the previous year. Community Medicaidfunding was increased to $44,903,331. Federal Medicaid payments totaled$77,449,070.• Fiscal Year 2008-2009: Total General Funds decreased by 14.3% to $29,113,965.Community Medicaid payments rose to $51,414,324. Federal Medicaid paymentstotaled $91,935,175.• The Governor’s Emergency Supplemental Budget Proposal in Fiscal year 2008-2009 resulted in an additional reduction of $361,657 (1.24%) in General Funds.The lack of funding for uninsured non-class members, the limitations on funding for classmembers without MaineCare and the loss of flexibility through the reduction of suchresources as Wrap Around funding are all related to the decrease in General Funds andthe shift to Medicaid reimbursement.Additionally, there was a change from cost-settled contracts to fee for service payments.{W1308851.1}15The introduction of the authorization process through the Administrative ServiceOrganization also affected billing practices in provider agencies.Changes in the FY 2008 (July 2007 through June 2008) budget for community servicescan be analyzed according to the requisite core services. (In this report, only the budgetsfor inpatient hospitalization at Riverview and Dorothea Dix Psychiatric Centers areincluded. They have been referenced earlier in this narrative.)1. Peer ServicesFollowing a recommendation made by the Court Master on September 5, 2008,the Department provided additional funding to Amistad to increase staffingcoverage for the Warm Line on the 1 a.m. to 8 a.m. shift. As a result, Warm Linefunding for Amistad has increased from $279,877 in FY 2007 to $321,877 in FY2008. Anticipated funding for FY 2009 is $372,546. There is a continuingallocation of $43,748 in the proposed budget for 2010. Funding for the WarmLine in Aroostook County has remained constant at $66,292 since FY 2006.There is funding ($12,479) for a Warm Line in CSN 2.In FY 2008, the total funding for peer services was $2,482,830 in General andFederal Funds. This includes support for social clubs.2. Crisis ServicesAs referenced above, the funding formula for crisis services is under review bythe Department. If current plans proceed, the geographical funding allocationswill be shifted significantly. A reduction of $100,000 occurred in FY 2009: afurther reduction of $300,000 is projected in FY 2010.Overall, in Fiscal Year 2008, funding for crisis services totaled $15,650,224. Ofthis amount, $10,419,354 was in MaineCare expenditures: the remaining$5,230,870 was in General and Federal Funds.Crisis Stabilization Units were funded at $3,408,162. This includes $2,064,197 inMaineCare funds and $1,343,965 in General and Federal Funds. AlthoughAroostook County, CSN 1, has an adult Crisis Stabilization Unit, it is inadequateto meet the need. The CSN has voted twice to support the redesign of this facility.Requests to the Department for funding were denied both times.Outpatient providers billed $53,011 in MaineCare funds when seeing clients on anemergency basis. This service was deleted in July 2008 and services are nowbilled under Outpatient rates.3. Community Support ServicesThe Intensive Community Integration program was eliminated in July 2008.{W1308851.1}16Total expenditures in FY 2008 for Community Integration totaled $31,861,900.Of this, $29,771,074 was in MaineCare expenditures.In FY 2008, Assertive Community Treatment was funded for $10,036,724,including $9,648,237 in MaineCare funding and $388,487 in General and/orFederal Funds.Intensive Case Management is used to support adults in jails and shelters. Theapproximate cost of these services, calculated from the average salaries andbenefits for forty-seven case managers and six supervisors, is $3,510,153. Thesecosts are offset by MaineCare revenue of $214,606. Therefore, the total cost ofthe program is $3,295,547.Daily Living Supports were funded by $2,334,545 in MaineCare expenditures and$363,798 in General Funds for a total of $2,698,343.Skills Development was funded primarily by MaineCare ($8,014,517) with anadditional $363,798 in General Funds.Wraparound/Flexible Funds decreased substantially from FY 2007 ($1,258,590)to FY 2008 ($1,002,443) to FY 2009 ($551,132). The loss of these funds reducedthe capacity of providers to respond quickly to client requests for individualizedsupport. Furthermore, decisions about these funds were centralized at OAMHSand not at the local level. As of January 2009, there have been changes made inallocation levels and in the decision-making process for the expenditure of theseresources. There appear to be significant differences, which defy rationalexplanation, in how these funds are now handled by each CSN.4. Outpatient ServicesOutpatient services included Day Treatment and Habilitation, Individual andGroup Counseling and other professional services for a total in FY 2008 of$19,148,549. MaineCare expenditures totaled $18,269,377.5. Medication ManagementMedication Management costs totaled $9,569,974 including $8,102,543 inMaineCare expenditures and the remaining $1,467,431 in General Funds.6. Residential ServicesThere were General and Federal Fund expenditures totaling $1,088,529 for suchcosts as emergency shelter, rent, rental subsidies, supported housing.{W1308851.1}17Residential PNMI costs totaled $51,966,862 with $3,245,238 in General andFederal Funds but this includes out of state placements and skilled nursing homecosts as well as residential treatment, community residential services andsupported housing.Bridging Residential Assistance Program (BRAP) funds were drawn from theGeneral Fund and totaled $2,805,508. There has been insufficient funding to meetclient needs for rental subsidies. By March 31, 2009, there will be at least 266people on the BRAP waiting list. There were unmet needs documented in allPriority categories. (See OAMHS memo, December 31,2008.) A supplementalrequest for additional funding ($421,723) was not included in the Governor’ssupplemental budget.7. Vocational ServicesStatewide vocational services are provided through a contract with Maine MedicalCenter. Effective December 1, 2008, the contract for Community EmploymentServices was reduced by 5.8% from $675,679 to $636,264. The contract for WorkIncentives Planning and Incentives (which includes benefits counseling) was alsoreduced by 5.8% from $173,082 to $162,986. Furthermore, in June 2008, fourstate positions (three Long Term Employment Specialists and an InteragencyProgram Coordinator) were eliminated as part of the Governor’s curtailment.These positions were seen as integral to the supported employment contract withMaine Medical Center.8. OtherTransportation costs are funded from General and Federal Funds for a total of$295,061.Contracts with NAMI and the University of Maine for information and referralwere funded from General and Federal Funds for a total of $269,719. The NAMIcontract was reduced substantially in 2008.Additional savings have been proposed for the FY 2010-11 budgets. The Department hasproposed reducing the funding for PNMI residential services ($1,700,000 in each year.)Savings are also projected to be obtained by changing the eligibility criteria for certainMaineCare Section 17 services. The basis for such savings has not been articulated at thistime.Despite long term waiting lists, chronic shortages and Departmental requests foradditional funding, Bridging Rental Assistance Program (BRAP) funding appears toremain unchanged at $2,972,414.{W1308851.1}18ConclusionIn summary, after reviewing the above issues and changes in the mental health system, itis my conclusion that the Department has failed to balance funding for all individualswith serious and persistent mental illness. Furthermore, significant shifts and reductionsin funding for certain programs and/or services have negatively impacted the delivery ofmental health services throughout the State. These actions are inconsistent with therequirements of the Consent Decree and bar attainment of substantial compliance.Respectfully submitted,_____ /s/________Elizabeth Jones, Court MonitorMarch 4, 2009