This investigation surveyed Michigan’s Community Mental Health Services Programs (CMHSPs) on seven topics of importance during a three month period from late 2012 through early 2013. Responses were received from 32 of the state’s 46 CMHSPs, representing 75% of Michigan counties.
The topics covered were:
1. Prevention services
2 Percentage of clients possessing dual Medicaid-Medicare eligibility, and levels of reimbursement received from serving such individuals
3. Effects of a 2009 Attorney General Opinion on jail mental health services and costs
4. Criteria employed to respectively determine severity-of-condition and level-of-function among service applicants/recipients
5. Respective utilization of state-operated psychiatric hospitals and psychiatric beds in private and community hospitals
6. Screening criteria for and consumer acceptance of recommendations to voluntarily undertake psychiatric hospitalization
7. Restructuring of the state’s Prepaid Inpatient Health Plan (PIHP) configurations- from 18 to 10- among the CMHSPs
Key findings were:
1. In the absence of a specific state office (closed in 2002) to provide prevention service leadership and assistance, respondents in the aggregate were doing a commendable job of attempting to maintain prevention initiatives targeted to youth at risk of emotional disorder.
2. IN the aggregate, respondents were serving a sizable number of dually enrolled Medicaid-Medicare beneficiaries, and such service represented a considerable portion of CMHSP reimbursement income. However, the correlation between number served and reimbursement generated was weak- i.e., the number served by a CMHSP was not a strong statistical predictor of the CMHSP’s resulting reimbursement income.
3. The majority of respondents did not think quality and/or quantity of jail mental health service had been affected by the Attorney General;s ruling on service payment responsibilities. However, almost 30% of respondents felt quality/quantity had been lessened. The predominant view was that related costs of CMHSPs had not been impacted. A quarter of respondents said their costs had decreased, while a small number stated their costs had gone up.
4. Respondents were not uniform in how they determine “the most severe forms” of mental illness and emotional disorder (which qualify for priority service consideration under Michigan law but are not defined). Considerable variability existed in criteria for these determinations. There was more uniformity in terms of the instruments used to assess consumer level-of-functioning.
5. Respondents reported 413 consumers in state-operated psychiatric hospitals at time of the survey. The median length of state reported for state hospitals was six month; the average (weighted mean) was five months. Another 535 consumers were reported to be in the other types of psychiatric hospitals (private/community) at the time of the survey. Both the median and average length of state for these other hospitals was less than seven days.
6. In the absence of legal guidance on criteria for recommending voluntary hospitalization, a majority of respondents used Michigan’s three legal required criteria for involuntary hospitalization decisions. Almost half of respondents (44%) used only one or two of these three criteria. The majority of respondents rarely experienced a consumer declining a recommendation for voluntary hospitalization. But for 38% of respondents, such recommendations ere declined occasionally.
7. Respondents were generally split on the reconfiguration of PIHP regions and affiliations with Michigan’s CMHSP network. One-third saw no compelling reason for the reconfiguration, 27% believed 9-10 regions (10 was settled upon by the state) represented an ideal number for reconfiguration, and another 27% had no opinion.
1. A prevention services until should be re-established with in DCH so that greater assistance can be rendered to the many CMHSPs that have shown commendable interest and involvement in primary prevention services targeted to youth at risk of emotional disorder.
2. Whether a new dual-eligible (Medicaid-Medicare) project with capitated funding (being negotiated by Michigan and the federal government) proves helpful, harmful or neither to CMHSP resources for the service provision will have to be monitored and assessed on a case-by-case basis.
3. The Departments of Community Health (DCH) and Corrections should convene a summit of stakeholders, including but not limited to CMHSPs and sheriffs, to review where jail mental health services stand four years after the Attorney General’s Opinion on payment responsibilities, and to recommend what regulatory changes Michigan may need to foster service improvements and take advantage of new funding opportunities (If Medicaid is expanded in the state).
4. DCH should follow-up on this investigation and ascertain additional commonalities and differences among CMHSPs in determining severity-of-condition. This analysis should be followed by state regulatory action to see that the same criteria (operationalized in the same way) are employed by all CMHSPs in identifying “the most severe forms” of SMI and SED. The importance to a service applicant/recipeint of achieving or missing out of priority status under Michigan law is too great to be left to local variances.
5. All CMHSPs should employe standardized functional assessment tools, with reasonable reliability and validity ratings, for youth and adults. The vast majority of CMHSPs covered by this survey met such a criterion. Additionally, all standardized instruments for assessment of functioning should be signed off on by DCH as being acceptablel and appropriate to the Department.
6. DCH should prepare and publish- for the state-operated adult psychiatric hospitals other than the Forensic Center- a report breaking down per forensic status utilization variables such as those from this study.
7. The state needs to develop psychiatric hospital beds or alternative residential options- and assure adequate funding and clinically appropriate usage- for person who require protected intensive care for a period that is in -between acute (i.e., typically one week) and long -term (i.e., often 5-6 months or longer). We respectfully suggest that Governor Snyder’s Mental Health and Wellness Commission (established in early 2013, with a report due December of 2013) incorporate planning for this in its work.
8. Section 409 of the Mental Health Code should be revised to specify uniform statewide criteria for CMHSP preadmission screening criteria. Until this happens, all CMHSPs should apply each of the Code section 401-hospitalization criteria for preadmission screening determination.
9. DCH should follow-up this survey ascertaining and reporting: (a) the annual number of statewide cases seen by CMHSP preadmission screening, and how many screenings result in hospitalization recommendations; (b) whether CMHSPs across the state employ common and effective practices to protect the health and safety of those declining inpatient recommendations. If investigation of the latter does not yield satisfactory information, state law should be revised os there are specific next steps for CMHSPs to follow in such situations.