IOWA
DEPARTMENT OF HUMAN SERVICES
DIVISION OF BEHAVIORAL, DEVELOPMENTAL
AND PROTECTIVE SERVICES FOR FAMILIES,
ADULTS AND CHILDREN
MENTAL HEALTH BLOCK GRANT CORE MONITORING REPORT
MAY 18-20, 2004
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EXECUTIVE SUMMARY
The Iowa Department of Human Services (DHS) has identified a need to reform its mental health service delivery system. The DHS has identified an urgent need to address fragmentation of services across agencies and multiple levels of government. The lack of a coherent children’s mental health system has been particularly cited by the Department to the point that it has noted that no children’s system exists.
The monitoring team received information that confirmed the DHS’s assessment of the need for system redesign. Children’s staff of the Division of Behavioral, Developmental, and Protective Services (BDPS), parents, and advocates described the lack of coordination and integrated information that make planning for youth services especially difficult. It was noted that services for youth are not mandated at the county level as they are for adults. Although some counties have developed effective services for youth, others have not. Specific opportunities for improvement of the children’s system are addressed below.
Lack of consistency across the State was particularly noted, with the exception of the Medicaid system, the Iowa Plan. This program is seen as providing consistent services and structures across both the adult and children’s systems. Iowa Plan staff have initiated an effective statewide collaborative effort involving stakeholders that has produced results, such as a Cultural Competency plan. The involvement of the Iowa Plan with the Iowa Consortium for Mental Health was also described by advocates and the Planning Council as being effective. The Iowa Consortium plays an important role in providing technical assistance to DHS, to promote collaboration, enhance research and assist providers.
The input regarding fiscal management of both the Block Grant and the system as a whole mirrored the input given regarding programmatic areas. Although the impact of budget cuts over the past three years was noted, structural problems within the fiscal management system have resulted in the failure to expend over $800,000 in Block Grant funds during this period.
Fiscal structures were difficult to assess because fiscal data were unavailable onsite for the most part. There is a lack of integrated data for BDPS, the counties, Medicaid, and providers. There are inadequate data to understand who is being served, what are the total costs of services being provided, and where are the gaps in service. Despite the paucity of data infrastructure, DHS has not utilized the Data Infrastructure Grant resources available through the Center for Mental Health Services (CMHS).
Three areas of strength in fiscal management were noted. First, contracts with local entities are clear and detailed. Also, DHS has effectively implemented Health Insurance Portability and Accountability Act (HIPPA) requirements. Lastly, the Adult Services Planner is proactive in understanding both the intent and the letter of the public law funding the Block Grant. This understanding facilitates Iowa’s ability to comply with the requirements under the law.
Fiscal management of the Block Grant experiences similar difficulties to that of the system as a whole. Meaningful fiscal monitoring of subrecipients of the Block Grant beyond the receipt of quarterly financial reports is lacking. There is no process to collect and review A-133 audits, and there is no on-site financial monitoring of subrecipients. One contract for Block Grant funds is with a for-profit entity but, as was later clarified with the contractual restriction that it is a strict, cost reimbursement relationship. Contracts with subrecipients do not include the required Catalog of Federal Domestic Assistance number and language regarding prohibited expenditures. As noted above, it was not possible to confirm compliance onsite, as data were not made available to the fiscal monitor.
Block Grant funds are used for child welfare wraparound projects. It is not clear that these Block Grant funds are not supplanting State funding, from the Department of Child Welfare, which appears to fund coordinator positions for the projects. Also, these projects were funded at midyear, without a plan modification that was advised by the Federal Project Officer, and were funded over the strenuous objections of the sole consumer/family representative on the review committee. Lastly, the Senate File that mandates that 70 percent of the Block Grant go to community mental health centers seems to violate the intent/spirit of the Block Grant statute.
One impact of reorganization resulting from budget cuts has been that a single individual is the sole source of the information and methodology for calculating Maintenance of Effort (MOE). The current MOE calculation charts are in error, as are the children’s set-aside charts. Iowa may benefit from technical assistance that includes an analysis and a review of the MOE and children’s set-aside calculations in previous years.
Due to statements made during the entrance conference by State staff the issue was raised as to whether a legal State Mental Health Authority (SMHA) existed, due to recent DHS reorganization and administrative code changes. The Federal project officer for the State later clarified the issue with the Substance Abuse and Mental Health Administration’s Grants Management Office. The DHS is the legal authority that is the recipient of Mental Health Block Grant funds and administers those funds through the designated division.
Despite the challenges that DHS has outlined in its planning process that were confirmed by the interviews conducted by the monitoring team, there is a consensus that progress is being made. The Mental Health Planning Council is revitalized and has taken charge of its role, purpose, and function. The Mental Health and Developmental Disability Redesign has been widely communicated and is being broadly implemented. The New Freedom concepts of recovery and rehabilitation are being addressed. The EmPower-sponsored mental health consumer conference is perceived as effective. Other areas of strength are the use of assertive community treatment, and consumer-run drop in centers. Within the children’s system, there is a collaborative, effective array of Early Childhood services administered by the Division of Medical Services.
Specific opportunities for improvement in the children’s system include the recommendation for a strategy for consistent consumer and family involvement. It was noted that parents of youth with serious emotional disturbance (SED) often have little opportunity for involvement at the local level. Statewide, Central Point of Coordination entities generally avoid children’s service provision.
The definition of SED is seen as irrelevant, in that many services are provided without need of SED identification, data is not collected by this classification, and the definition is poorly communicated. Other related symptoms of the lack of a comprehensive children’s mental health system include the fact that many mental health services are provided through child welfare and the child specialty clinics under the Department of Public Health. Generally, local decategorization boards have little mental health involvement. The current legislation which mandates the Mental Health/Mental Retardation/Developmental Disabilities/Brain Injury Commission to propose a redesign of the children’s disability service system is perceived as promising. In this regard, it is recommended that DHS consider seeking technical assistance regarding the ability of CMHS system-of-care grant funding to aid in the system redesign. There is likely to be expertise available from existing system-of-care sites regarding several areas that may need to be addressed in the redesign, including financing, data infrastructure, and the role of mental health in a balanced children’s system.
A final area of focus of the monitoring process was the challenges and opportunities presented by the existence of strong local control in Iowa. One advantage of local control is that local resources may be fully leveraged. The team was told that there are many examples of local communities with outstanding programs and approaches; however, such a community may exist alongside another with much more limited benefits. Generally, it was communicated to the monitoring team that, compared to other human service systems, the SMHA suffers from an imbalance in its authority relative to counties. The DHS staff, consumers, and family members, and members of the Mental Health Planning Council believe that the current system redesign presents an opportunity for a more balanced role for the SMHA, with the goal of achieving a more consistent array of services and supports across Iowa. During this process, it may be important to clearly communicate DHS mental health policy as it relates to the system redesign. One mechanism for communicating policy directives throughout the system would be through the issuance of Commissioner Letters.
Two local programs were visited, the Everly-Ball Elderly Outreach Program, and Orchard Place Child Guidance Center. The Elderly Outreach Program is unique to the area and provides inhome services through a team approach, which includes specialized staff such as a Gerontology Mental Health Nurse Clinician. This program has been proactive in identifying and meeting the needs of seniors who are isolated by chronic mental health problems and/or a combination of problems unique to aging, while attempting to maintain the highest level of dignity and independence.
The collaborative Elderly Outreach Program uses traditional and non-traditional referral sources and provides services in the client’s home or other least restrictive environments. A potential opportunity for enhancement of this exemplary program would be the addition of a Compeer program.
The Orchard Place Child Guidance Center has a long history of providing effective family psychoeducation and support in normative settings such as schools and pre-schools. The Center has a commitment to collaboration with parents and other stakeholders. With effective management of its programs and fiscal operations, the Center maintains a focus on quality and measurement of program outcomes. Program staff indicated that the counties which the agency serves have chosen to fund children’s services, and that there is no statewide vision for a children’s mental health system. The staff expressed the belief that DHS could more effectively maximize Federal dollars in the development of an integrated children’s mental health system.
TABLE OF CONTENTS
EXECUTIVE SUMMARY i
CHAPTER I: INTRODUCTION 1
Mental health services block core monitoring 1
The Monitoring Visit Process 1
General Limitations 2
CHAPTER II: STATE AGENCY SERVICE AND SYSTEM ASSESSMENT 5
STATE SYSTEM SNAPSHOT 5
State Mental Health Agency and Administration of Mental Health Services 5
Substate Organizations 6
Issues, Trends, and Challenges 7
Planning Process 8
Mental Health Planning Council 9
Management Information Systems (MIS) 10
Compliance Monitoring and Quality Improvement 11
Consumer and Family Member Involvement 11
Consumer and Family Rights 12
ADULT MENTAL HEALTH SERVICES 13
Target Population and Service Array for Adults 14
Availability and Accessibility 15
Coordination and Continuity 16
Outreach to the Homeless 17
CHILDREN’S MENTAL HEALTH SERVICES 17
Target Population and Service Array for Children’s Services 17
Availability and Accessibility 18
Out-of-State-Placement 18
Coordination and Continuity 18
Outreach to the Homeless 19
FINANCIAL MANAGEMENT 19
Fiscal Context of Community Mental Health Services 19
Budgetary Planning 20
Revenues and Expenditures for Mental Health 21
Contracts and Grants Management 22
The Community Mental Health Services Block Grant Expenditures 23
CHAPTER III: LOCAL PROGRAM VISITS 26
URBAN ADULT PROGRAM SNAPSHOT 26
EVERLY-BALL COMMUNITY MENTAL HEALTH SERVICES 26
Program Description 26
Quality Improvement 26
Consumer and Family Involvement 27
ADULT SERVICES 27
Coordination and Continuity 27
Delivery Strategies 27
ORCHARD PLACE CHILD GUIDANCE CLINIC 28
Program Description 28
Quality Improvement 29
CHILDREN SERVICES 29
Delivery Strategies 29
Coordination and Continuity and Family Involvement 29
FINANCIAL MANAGEMENT 29
Expenditures for Mental Health Services 29
The Community Mental Health Services Block Grant Expenditures 30
CHAPTER IV: SUMMARY AND RECOMMENDATIONS 31
AREAS OF STRENGTH 31
Best Practices: Department of Human Services (DHS) 31
Exemplary Efforts (DHS) 31
Exemplary Efforts: Everly-Ball Elderly Outreach Program 32
Best Practices: Orchard Place Child Guidance Center (OPCGC) 33
Exemplary Efforts: OPCGC 33
OPPORTUNITIES TO ENHANCE AND IMPROVE THE SYSTEM 33
Department of Human Services 33
Everly-Ball Elderly Outreach Program 36
Orchard Place Child Guidance Center 36
CONCLUSION 36
LIST OF EXHIBITS AND TABLES
Exhibit 1: Monitoring Visit Data Sheet 3
Exhibit 2: Planning Council Composition by Type of Member 10
TABLE 1: State Expenditures for Mental Health Services 22
TABLE 2: Iowa SFY03 Maintenance of Effort (MOE) 24
TABLE 3: Iowa SFY03 Children’s Set-Aside 24
TABLE 4: Orchard Place Expenditures FY03-04 29
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CHAPTER I: INTRODUCTION
Mental Health Services Block Core Monitoring
The passage of Public Law (P.L.) 102-321 afforded States the opportunity to receive Federal grants for the purpose of establishing or expanding comprehensive community mental health services to adults with serious mental illness (SMI) and children with serious emotional disturbance (SED). Under the statute, each State must submit a State Plan for Comprehensive Community Mental Health Services for the fiscal year involved. Each Federal grant can be used for the purpose of planning, administration, education, and evaluation activities related to carrying out and providing services under the State Plan.
The State Planning and Systems Development Branch, Division of State and Community Systems Development, within the Center for Mental Health Services (CMHS), is organizationally responsible for ensuring each State’s compliance with the array of administrative and programmatic requirements under the law. P.L. 102-321, and as amended by P.L. 106-310, requires that “the Secretary [of DHHS] shall in fiscal year 1994 and each subsequent fiscal year, conduct not less than 10 State investigations of the expenditures of grants received by the States under section 1911 . . . in order to evaluate compliance with the agreements required under the program involved” (Subpart III, Section 1945 (g)). The CMHS conducts these investigations in partnership with the States under the term “monitoring visit” to:
· Monitor the expenditures of Federal Block Grant funds;
· Assess compliance with the funding agreements and assurances required under the program;
· Identify strengths (e.g., best practices, exemplary efforts) of the State and local mental health systems; and
· Focus on opportunities for improvement, i.e., ascertain/recommend priority needs for technical assistance, identify issues that need to be addressed, as well as policy challenges related to the mental health program and service delivery at the State and local levels.
The Monitoring Visit Process
The CMHS conducts the core monitoring visits with the assistance of a team of three consultants with fiscal, management, and/or clinical expertise in providing services to adults with SMI and children with SED. One member of the team is designated as the Team Leader/Writer. A Federal Project Officer makes the final selection of the members and accompanies the team. The onsite visit of the State mental health system is usually 3 days in duration. The monitoring visit includes an assessment of the State Mental Health Agency, along with interviews with Mental Health Planning Council members, consumers, and family members, and a visit to one or more a local programs (urban, rural, or suburban) serving adults with SMI and/or children with SED and receiving some portion of Federal Block Grant funds.