Strategies to Promote SelfDetermination

1
Strategies to Promote Self-Determination

• NYAPRS Annual Conference
• September 24, 2008
• Richard Dougherty, DMA Health Strategies
• Michael Hlebechuk, Oregon Dept of Human Services
  
• Bonni Hopkins, Magellan Health Services
• Harvey Rosenthal, NYAPRS
• John Allen, NYS Office of Mental Health

2
Self-Directed Care Definitions

• A system that is intended to allow informed
  consumers to assess their own needs . . .
  determine how and by whom these needs should be
  met, and monitor the quality of services they
  receive (Dougherty, SAMHSA, 2003).
• A system in which funds that would ordinarily be
  paid to service provider agencies are transferred
  to consumers, using various formulas to account
  for direct, administrative, and other costs
  (Cook et al., 2004).
• a method of delivering services that is based on
  giving each consumer control of an individual
  budget with which to purchase goods and services
  to meet his or her needs (Alakeson, HHS, 2007).

3
Essential Elements of Self-Directed Care Systems

• Person-centered planning, which constitutes a
  comprehensive strategy for putting necessary
  services and supports in place to help people
  achieve their goals
• Individual budgeting, which enables people
  needing assistance to have some control over how
  the funds used for their care are to be spent

4
Essential Elements of Self-Directed Care Systems

• Financial management services, which encompass
  such activities as tracking and monitoring
  budgets, performing payroll services, and
  handling billing and documentation
• Supports brokerage, which includes both education
  and operational assistance, and is intended to
  help participants design and manage their
  self-directed care plans.

5
Self-Direction is a Method for Promoting
Self-Determination

• Self-determination is a philosophy designed to
  help persons build meaningful lives with
  effective opportunities to develop and reach
  valued life goals
• It focuses on the degree to which human
  behaviors are volitional . . . that is, the
  extent to which people . . . engage in their
  actions with a full sense of choice (Cook et
  al., 2004).

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5 Principles of Self-Determination (Nerney 2001)

• Freedom to choose a meaningful life in the
  community
• Authority over the funds needed for ones own
  care
• Support for participants efforts to make the
  choices that are best for them
• Responsibility for managing finances, choosing
  services, and handling the tasks of daily living,
  and for the appropriate use of public funds and
• Confirmation or Participation, that is, the
  opportunity for service recipients to participate
  in decision making about the care delivery
  system.

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Key Values

• Freedom of choice
• Control over ones own life
• Personal responsibility
• Access to services and support
• Consumer satisfaction and service quality
• Efficiency and effectiveness
• Cost effectiveness Protection of civil liberties
• Fairness
• Freedom from coercion
• Use of free market forces

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Operational Elements of a Self-Directed System of
Care

• Person-centered planning
• Individual budgeting
• Consumer and provider education
• Advocacy and coaching
• Expanded provider network
• Financial management
• Oversight/quality improvement
• Funding sources

9
2007 HHS Report Overview

• There are currently five states with
  self-directed care pilots or established programs
  for adults with serious mental illness Florida,
  Iowa, Maryland, Michigan and Oregon, with a pilot
  under development in Texas.
• These programs are in the early stages of
  development and currently serve a very small
  number of consumers.

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2007 HHS Report Overview

• The most important difference between programs
  across states is the scope of self-direction
  permitted.
• Major Variables
• the extent to which consumers are able to direct
  services provided by the traditional mental
  health system as well as recovery support
  services and
• the extent to which individual budgets are
  separate from Medicaid funding or whether
  consumers have control over the way in which
  Medicaid resources are used.

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Funding Sources for State SDC Initiatives
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2007 HHS Report OverviewChief Spending Categories

• Florida District 8
• medication (16)
• transportation (13)
• psychiatric services (12)
• counseling (8)
• Multnomah County, Oregon
• household items (15)
• alternative therapies (14)
• IT supplies (12)
• goods and services relating to personal
  appearance (10)

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2007 HHS Report OverviewSDC Funds As Last
Resort

• In all states, consumers are encouraged to
  maximize the value of the money they have at
  their disposal by drawing on resources from other
  pubic programs and from the community and only
  using their individual budget as a last resort.
• For example, if an individual requires
  transportation and can receive a bus pass through
  vocational rehabilitation, his self-directed
  budget should not be used.
• One of the important roles that counselors play
  is to knit together the disparate parts of the
  public system for consumers and help them access
  the full range of available resources.

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The Traditional Mental Health System

• Assumes that clients are not able to make choices
  that are in their own best interest much of the
  time.
• Believes it is often necessary to make decisions
  for clients.
• Stresses client safety far more than client
  choice.
• This results in the client growing dependent on
  the system to make life decisions. (Decreased
  client choice means increased client dependence.)

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A Transformed System that Promotes Recovery
Through Self-Determination

• Believes that people can and do recover from
  mental illness.
• Helps facilitate recovery by providing
  self-directed services and supports.
• Treatment in this system is centered around the
  goals of the person what is important to the
  person.
• Safety issues are addressed in a collaborative
  relationship between the individual and the
  provider of services and supports.
• Individuals are allowed to make, and grow from,
  their own mistakes.

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Products of the Transformed System

• People move toward recovery and become
  increasingly self-reliant.
• As people recover they use fewer services.
• It is a win-win proposition. Service dollars are
  saved. Far more importantly, people move on with
  their lives.
• Individuals gain far higher levels of dignity and
  self-respect greater self-esteem.

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Empowerment Initiatives Brokerage Oregon (EIB)

• A project of Oregons FY 2001 Real Choice Systems
  Change grant awarded to Oregon Department of
  Human Services by Centers for Medicare Medicaid
  Services.
• MH consumer operated and controlled. All board
  and staff members are consumer/survivors.
• Serving 25 individuals referred by 2 Portland MH
  agencies.
• These individuals continue receiving services
  from referring agency.

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Oregon FY 2001 Real Choice Self-Direction
Projects

• Person Centered Planning demonstrations in 4
  Oregon counties
• Employment for Life project
• Empowerment Initiatives Brokerage

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What Weve LearnedAbout Person Centered Planning

• The person centered planning (PCP) approach was
  central to the success of the Employment for Life
  project and Empowerment Initiatives Brokerage.
• The 4 PCP pilots were largely unsuccessful. In
  many cases, the plans were written by case
  managers with the assistance of the person,
  rather than the other way around. These plans
  reflected the case managers goals for the person
  more than what is important to the person.

20
Analysis

• Employment for Life and Empowerment Initiatives
  operate from the self-determination and recovery
  perspective. The 4 PCP pilots used traditional
  case management services that do not operate from
  the self-determination and recovery perspective.
• A culture change that embraces self-direction
  and recovery in mental health treatment is
  needed. The use of Person Centered Planning,
  in-of-itself, is not enough to bring this change
  about.

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How the Oregon Brokerage Works

• Using a person centered planning approach the
  customer and the broker write a goal attainment
  plan that will help the individuals goals be
  attained.
• An individual customer account is established to
  purchase services and supports on behalf of the
  customer. EIB customers have a 3,000 account.
• Donated and naturally existing resources,
  services and supports are brokered as much as
  possible.

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Oregon Goal Attainment Plans

• Written by customer and broker through a person
  centered planning process.
• Brokered services and supports are obtained
  through the implementation of this plan using the
  individual customer account.
• Two examples (next 2 slides)
• 1) Goal obtaining employment
• 2) Goal being discharged from state hospital
  with suitable services and supports.

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What Empowerment Initiatives Customers are Saying

• I think the brokerage is a great program. They
  have helped me get back to school (They)
  encourage me to find my place in the world. They
  also made me feel like I can have a real life.
• Independence - I was able to purchase my own
  manufactured home in a very low space rent park
  in the country and I am so very happy out here.
• Today I feel like have options to help me get
  back on my feet again.
• I am beginning to do things I have always
  dreamed of. I have new perspective because of
  it.
• Yes I was able to attend community college. I
  was able to end last semester with a 3.5 GPA.

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Some Findings From EIB Pilot Study

• EIB customers are moving toward employment in
  response to brokered self-directed services and
  supports.
• Employment (competitive) increased to 300 of
  baseline.
• Education leading to employment increased to 600
  of baseline.
• None of the participants were hospitalized or
  otherwise incarcerated during the project.
• Surveys indicate that EIB customers are more
  engaged in their recovery.

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Savings in Clackamas County2007 HHS Report
Excerpt

• It costs the county between 40,000 and 60,000 a
  year to house an individual with a serious mental
  health condition in a group home.
• For 10,000 per person per year, EI has
  successfully helped 14 people since June 2006 to
  move into supported independent housing. This
  figure includes the value of the individual
  budget, the costs of a resource broker and the
  administrative costs of the program.
• The housing itself is paid for by the individual
  and by rent subsidies but is not funded by mental
  health services.
• Freeing up places in group homes has allowed the
  county to move people out of the state mental
  hospital, saving in the region of 70,000-80,000
  per person per year.

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EIB Community Development Project

• Contracted with State Addictions Mental Health
  to transition 13 individuals from structured
  group home settings to supported housing with
  self-directed wrap-around supports.
• Project was successful, allowing 13 individuals
  to be discharged from Oregon State Hospital into
  the openings at group homes created by the
  individuals who transitioned to more integrated
  community settings.

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Transformation V Transition

• Incremental systemic transition tends to not
  bring about system transformation. Incremental
  change generally takes years and usually results
  in a modified version of what currently exists.
• Successful system-wide transformation requires
  extensive planning, technical know-how,
  dedication, and sustained commitment.
• Responsible transformation requires that the
  various elements that compose the desired
  transformed system have been demonstrated to be
  beneficial for the persons receiving MH services.

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Demonstrations and PilotsThings to Consider

• Until a a systemic transformation to a
  self-directed care service delivery system is
  embarked upon, working collaboratively with
  existing providers of case management services
  will help avoid an us against them climate. For
  example, EIBs customers were referred by
  provider agencies and continued to receive
  services from referring agencies.
• Collect qualitative and quantitative evidence
  that captures changes in customer self-esteem,
  employment and education status, living
  situation, AD recovery, and service utilization.

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Oregon Contact Information

• Michael Hlebechuk
• Department of Human Services
• Addictions and Mental Health Division
• 500 Summer St NE, E-86
• Salem, Oregon 97301
• Ph. 503.947.5536
• Email. michael.hlebechuk_at_state.or.us

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Floridas Self Directed Care Program

• The FloridaSDC program gives each participant
  control of the public financial resources to
  access mental health services that are normally
  directly contracted to a public community mental
  health provider.
• FloridaSDC participants can use their budgets
  to purchase Clinical Recovery Services, Recovery
  Support Services, and Recovery Enhancements.

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Clinical Recovery Services

• Clinical Recovery Services are traditional
  mental health services.
• For individuals who receive Medicaid these
  services are paid for through that system.
• Medicaid recipients receive only 52 of the SDC
  allotment. These funds can be used for
  non-Medicaid services and supports.

34
Recovery Support Services

• Recovery Support Services are services that are
  alternatives to traditional mental health
  services but likely to produce the same outcomes.
• Example Instead of attending a psychotherapy
  group for depression at a local mental health
  professionals office, an individual might choose
  to participate in a Weight Watchers meeting.
  The outcomes might be similar but the cost and
  experience are different.

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Recovery Enhancements

• Recovery enhancements are tangible items or
  services that relate to the individuals recovery
  as they work towards the goal of employment or
  other productive activity such as volunteer work,
  training or education.
• Participants must take responsibility to see
  that other sources of funding are explored prior
  to requesting FloridaSDC funds for the purchase.

36
The Funds

• Funding for District 8 Participants Annually
• Indigent 3,700.00
• Medicaid/VA Eligible 1,924.00
• Medicare Eligible 2,811.00
• Indigent participants must allocate 48 of the
  total amount awarded for the purchase of clinical
  recovery services. Medicare participants must
  allocate 31.58 of the total amount awarded for
  those same services.

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Profile of Individuals Served and Program Cost

• Approximately 60 of the people in the SDC
  program receive Medicaid, Medicare or VA
  benefits.
• The total cost of a Self-Directed Care program
  serving 200 adults, as it is now operated, is
  approximately 930,000.

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Who is Eligible for SDC?

• An individual who is age 18 or older and who has
  a diagnosis or diagnostic impression of an Axis 1
  or Axis 2 mental disorder AND
• Receives supplemental security income (SSI),
  social security disability income (SSDI),
  disabled veterans income or any other type of
  disability income. OR
• Does not receive disability income, but has an
  application in process or has received such
  income within the last 5 years AND
• Is legally competent to direct his or her own
  affairs AND
• Lives in the departments district in which the
  program they participate in is located AND
• Applies for Medicaid and other income support
  programs for which he or she may qualify.

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Who is Eligible for SDC?

• People at all levels of recovery are eligible
  for SDC.
• The ability to complete a Life Analysis and
  develop a Life Action plan and budget, with the
  assistance of a Life Coach, is the primary
  qualification.

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The Process

• Eligibility
• Orientation
• Enrollment
• Life Analysis
• Life Action Plan
• Budget
• Receive Services Supports
• New Life Action Plans Budgets Quarterly

41
The Life Analysis

• The Life Analysis is a tool that helps an
  individual plan their life activities and to
  determine how to get where they want to be in
  life.
• The Analysis is similar to an assessment that a
  mental health professional would do in
  traditional services.
• In the Life Analysis, the person
• Looks at their life.
• Assesses the state of their personal health,
  recovery from mental illness and symptom
  management skills, substance use as they relate
  to their health, and at their level of meaningful
  activity, including work.
• Identifies their goals.
  
  

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The Life Action Plan

• The Life Action Plan is where a persons goals
  are translated into a plan for specific actions
  related to achieving those goals.
• In this way, expected expenditures can be
  related directly to the recovery goals identified
  in the Life Analysis. It is a requirement of the
  program that all such expenditures are targeted
  to address these goals.
• The Life Action Plan is similar to a treatment
  plan that would be developed in partnership with
  a mental health professional in traditional
  services.
• In Self-Directed Care the person is their own
  Case Manager.

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The Life/Recovery Coaches

• Life Coaches orient the individual to the
  process involved in the program, provide referral
  information, advocate for the participants and
  promote self-advocacy, and help them to explore
  their personal recovery goals and to prioritize
  and plan for the use of their budgets.
• Life Coaches help broaden a persons world view.

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Program Supervision

• The SDC program is supervised by a Masters level
  mental health professional.
• It is their responsibility to assure that each
  individuals budgeted expenses match up with the
  recovery goals identified in their Life Analysis
  and Action Plan and to approve each plan and
  budget.
• The program supervisor takes responsibility for
  the day to day operations of the program.

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Participant Expenditures District 8

• Food 20
• Auto Insurance 14
• Arts Craft Supplies 14
• Computer Supplies 13
• Utilities 13
• Social Club 12
• Computer 10
• Haircut 10
• Phone 9
• Furniture 9
• Software 8

• Medicine 181
• Psychiatrist 121
• Transportation 87
• Dental 74
• Counseling 72
• Clothing 61
• Rent 49
• Vision 39
• Health Club 32
• Car repair 30
• School 22

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Evaluating Success

• The Self-Directed Care program is evaluated on
  several levels. The purpose of the evaluation is
  to assess the performance of the SDC program for
  adults with severe and persistent mental illness,
  as compared to the performance of other
  outpatient mental health treatment programs in
  Floridas public mental health system.
• A comprehensive evaluation was implemented in
  January, 2007 to compare these groups on the
  following outcome measures re-hospitalization
  rates, levels of satisfaction, service
  utilization rates, residential stability, and
  level of community integration.

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Personal Outcome Measures

• 13. Interact With Others in Community
• 14.Perform Different Social Roles
• 15. Have Friends
• 16. Are Respected
• 17. Choose Services
• 18. Realize Personal Goals
• 19. Are Connected to Natural Supports
• 20. Are Safe
• 21. Exercise Rights
• 22. Are Treated Fairly
• 23. Have Best Possible Health
• 24. Are Free From Abuse Neglect
• 25. Experience Continuity Security

• 1. People Choose Personal Goals
• 2. Choose Living Arrangements
• 3. Choose Where They Work
• 4. Have Intimate Relationships
• 5. Are Satisfied With Services
• 6. Are Satisfied With Life Situation
• 7. Choose Their Daily Routine
• 8. Have Privacy As Needed
• 9. Decide To Share Information
• 10. Decide When To Share Info.
• 11. Live In Integrated Environments
• 12. Participate in Life of Community

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Challenges for Future Expansion

• 1. Cost reimbursement contracts versus unit
  based.
• 2. Centralized fiscal agent versus community
  based.
• 3. Mechanisms for disbursement of funds to
  participants.

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The Florida Peer Network

• 13301 Bruce B. Downs Blvd.
• MHC 2505
• Tampa, Florida 33612
• 877 352-7337 813 974-2851
• info_at_floridapeernetwork.org
• www.floridapeernetwork.org
• Patrick Hendry Executive Director

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The Michigan Experience

• Pamela C. Werner
• Office of Consumer-Directed Home and Community
  Based Services
• Bureau of Community Mental Health Services
• Michigan Department of Community Health
• [phone]
• email wernerp_at_michigan.gov

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Building the Foundation for Systems Change

• 1996 Mental Health Code changes
• Consumers and family members on CMH Boards
• Person-Centered Planning Process Requirement
  Established statutory right for all individuals
  served through the public specialty service
  system to have their Individual Plan of Service
  developed thorough a person-centered planning
  process
• 2003 Contract Requirements
• All adults have the option to request a
  Self-Determined Arrangement

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What is the Difference Between Person-Centered
Planning and Self-determination?

• Person-Centered Planning is the process of how
  the plan of service is developed.
• Self-determination is a method of using Medicaid
  funds you are eligible for.
• It emphasizes freedom of choice, control over
  ones own life, personal responsibility and
  access to services and support that are listed in
  your person-centered plan.

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SELF-DETERMINATION BEGINS WITH YOUR
PERSON-CENTERED PLAN

• You talk about your dreams.
• You decide who will help you reach your dreams
  and goals.
• The family and friends you choose support your
  choices about where you want to live, work, and
  have fun.

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Self-Determination Involves

• Rethinking how money is spent
• Letting go of the old ways of doing business
• Supporting not controlling
• Making a power shift to people with disabilities
• Providing what people truly need
• Funding people not providers
• Unbundling services
• Seeking better value for public dollars

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How Do You Request A Self -Determined
Arrangement?

• Tell your case manager/support coordinator that
  you are interested in developing an arrangement
• Set a person-centered planning meeting to talk
  about your dreams and goals
• Get information on how much each of the services
  and supports you are using costs.
• Surround yourself with creative people to find
  ways to meet your goals that are different from
  what you are doing now.
• Hire a peer to help

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Kalamazoo County Results from SAMHSA Block Grant
Funding

• 67 people have been offered the opportunity to
  view their cost budget and self-determine
  services.
• Of those, 44 individuals have reviewed their cost
  budgets.
• 5 individuals leased staff from the Center for
  Disability Services
• 5 currently employ their own staff
• 1 more anticipated next month

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Model Consumer Budget for Kalamazoo County
Mental Health Services 2005 - 2006, Michigan

• Service Yearly Cost ()
• Pathways Clubhouse 3,416.88
• Psychiatric outpatient evaluation 339.74
• Interact RN service 248.88
• Pathways supported employment 493.78
• Interact support employment 1,887.00
• Rent subsidy -- transitional 2,172.00
• Interact medication review 135.00
• Hope Network -- case management 272.67
• Interact case management 2,999.37
• Interact RN service 497.76
• Annual total 12,463.08

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Success Stories Jeff

• Hired a micro-enterprise assistant
• She gave feedback and advice, helped with pricing
  and finding venues to display his art
• Experienced growth in both his art and sales
• Had his artwork placed in a local institute
  showcasing his work.

60
Success StoriesElizabeth

• Hired a wellness coach to work on health issues.
• Hired a social coach to assist in exploring
  community options and resources for evenings and
  weekends

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Success Stories Jake

• Hired a coach to support him as he moved from
  an Adult Foster Care into an apartment.
• Hired a supported employment coach to help him
  find and maintain his current job.

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Lessons Learned in Michigan

• Certified Peer Support Specialists will be needed
  in all areas of the state to assist peers with
  options for self-direction.
• Using existing funding without adding additional
  dollars is beneficial for future stability.
• Technical guidance is needed to reference the
  Balanced Budget Act and other frameworks for
  consumer choice and control without additional
  administrative costs.
• Models and programs that offer staff leasing need
  to be expanded.
• Unbundling of services and providing budget
  information is fundamental.
• We need more information to support
  person-centered process and self-determination as
  evidenced based practice in mental health
• You are never there as there is no there

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For Further Information

• Michigan Department of Community Health Website
• http//www.michigan.gov/mdch
• Medicaid Provider Manualhttp//www.michigan.gov/
  mdch/0,1607,7-132--87572--,00.html

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HHS Report on Consumer SatisfactionSupport As
Well as the Budget

• An important part of the support consumers felt
  they received came through the person-centered
  planning process. Counselors tend to work with
  consumers for several hours to identify goals and
  then develop a spending plan.
• In the case of EI, for example, the planning
  process has three stages which require separate
  meetings and involve a consumer and his resource
  broker spending 6-8 hours together.
• Furthermore, counselors in SDC are able to
  provide ongoing support to ensure that consumers
  make progress in achieving their goals.
• Consumers commented that creating a
  person-centered plan was only a starting point
  and that plans were meaningless without good
  follow up.

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HHS Report on Consumer SatisfactionPeer Support

• In the majority of SDC programs, counselors are
  peers.
• Peers bring additional value to the relationship
  between consumers and counselors.
• First, consumers do not perceive the same
  imbalance of power between themselves and peers
  as they do with professionals. This facilitates a
  true partnership that underpins the success of
  self-direction.

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HHS Report on Consumer SatisfactionPeer Support

• Second, peers act as effective role models for
  consumers who are seeking to rebuild a life in
  the community.
• They have unique knowledge that comes from their
  personal experience of living with a mental
  illness.
• This allows them to act as expert guides and to
  work with consumers to knit together various
  recovery support services and resources.
• Peers combine learned knowledge of how to access
  public support such as vocational rehabilitation
  and Ticket to Work programs with real life
  experience of finding housing, cheap haircuts and
  free food in the community.
• Many facets of this knowledge are beyond the
  reach of professionals.

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HHS Report on Consumer SatisfactionGreater
Flexibility Meeting Needs

• Consumers valued the flexibility that SDC gave
  them to meet their individual needs. This is
  reflected in the diversity of goods and services
  purchased under self-direction.
• Other types of flexibility were also important to
  consumers, for example, the ability to schedule
  services when they needed them rather than having
  to fit around providers.
• With an individual budget, a consumer in Michigan
  has been able to hire an assistant to work with
  her on social skill development at times that
  meet the consumers need and not vice versa.
• Overall, the flexibility of SDC comes from giving
  consumers control over all the dimensions of
  service provision -- the who, what, where and
  when.

68
HHS Report on Consumer SatisfactionRecovery
Orientation

• Consumers identified two important ways in
  which they felt self-direction was
  recovery-focused.
• First, it provided consistent support that helped
  them stay well and did not mimic the cyclical
  nature of the traditional system. Consumers
  reported that traditional services tended to step
  in at times of crisis and then withdraw once they
  were stable rather than being provided on an
  ongoing basis.
• Second, they felt that SDC demanded a certain
  amount of responsibility and active participation
  from them and this was seen to be a positive
  aspect of the approach. They felt that the
  traditional system demanded little of them and
  made it difficult for them to be involved in
  their own care, in part reflecting a view that
  they were incapable of taking control.

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HHS Report on Medicaid

• The extent to which self-direction can be
  supported through Medicaid is highly significant
  for the expansion and sustainability of programs.
  Self-direction pushes at the limits of what
  Medicaid will support.
• States have overcome this issue to date by
  relying on general revenue funding but general
  revenue funds face many competing priorities.
• There is a need to develop a funding model for
  self-direction that will better ensure
  sustainability at the same time as maintaining
  the flexibility that consumers value.

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HHS Report on Medicaid

• The joint federal-state Medicaid program is the
  single largest source of funding for public
  mental health services and is expected to account
  for an increasing share of the resources that
  underwrite state administered mental health
  services.
• Therefore, although there are other funding
  sources that can be used to develop
  self-direction, the extent to which this approach
  can be supported through Medicaid is highly
  significant for the future of SDC.

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CMS 1915.j InitiativeState Medicaid Director
Letter

• Under section 1915(j), States have the option to
  amend their State plan to provide self-directed
  PAS (personal assistance services) to
  beneficiaries, without regard to the Medicaid
  requirements of comparability or statewideness.
• This legislation permits States the flexibility
  to amend their State plans to offer a more
  comprehensive self-directed PAS program than
  under the traditional personal care services
  option and also relieves States of the
  administrative burden of submitting a waiver or
  demonstration proposal.

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CMS 1915.j InitiativeState Medicaid Director
Letter

• The State may elect to permit individuals to
  choose to receive cash disbursements, on a
  prospective basis, with which to purchase the
  self-directed PAS identified in their
  self-directed service plan.
• If this option is made available by the State,
  individuals selecting the cash option are not
  required to utilize a fiscal management entity.

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CMS 1915.j InitiativeState Medicaid Director
Letter

• Individuals must be given flexibility to
  determine the functions, if any, to be performed
  on their behalf by the fiscal management entity.
• Also, the State may elect to permit individuals
  to use their funds to acquire items that increase
  independence or substitute for human assistance,
  to the extent that expenditures would otherwise
  be made for the human assistance.

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CMS 1915.j InitiativeState Medicaid Director
Letter

• States may limit the population eligible to
  self-direct and the number of individuals
  self-directing.

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Consumer-Directed Care in Alabama

• Alabama first state to make consumer directed
  (also known as self-directed) care for Medicaid
  home and community-based services a permanent
  part of its State Plan.
• Alabama worked closely with Centers for Medicare
  and Medicaid Services to ensure successful
  completion of the application.

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Alabama Program Value

• Budget-neutral
• Offers consumer satisfaction and enhanced quality
  of life
• Reduces unmet care needs, and
• Increases access to authorized services

77
Alabama Expected Consumer Outcomes

• Increased access to paid personal care
• Increased satisfaction with services
• Increased overall quality of life
• Positive health and safety outcomes
• Decreased stress on families and informal
  caregivers

78
Expected Outcomes for Alabama

• Making consumer-directed care a permanent part of
  the State Plan will relieve Alabama of the
  intensive and repeated waiver renewal process.
• Potential cost reduction and quality improvements

79
HHS Report RecommendationBraided Funding

• This kind of coordinated funding approach has
  been more successfully developed for children
  with serious emotional disturbance than it
  currently has for adults with SMI.
• Wraparound Milwaukee pools funds through case
  rates paid by the child welfare and juvenile
  justice systems, receives a monthly capitation
  payment for each Medicaid child enrolled, and
  coordinates other insurance and SSI payments to
  form a type of insurance pool.
• Blending or braiding different budgets together
  would increase the financial support available
  for SDC, while only using the most appropriate
  source to fund each particular service.

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Key Resources

• Free to Choose Transforming Behavioral Health
  Care to Self-Direction Richard Dougherty
• Derived from SAMHSAs Consumer Direction
  Initiative Summit March 22-23, 2004 in in
  Washington, DC http//mentalhealth.samhsa.gov/publ
  ications/allpubs/SMA05-3982/FREE_TO_CHOOSE_CDI_Man
  ual.pdf
• Bazelon Center for Mental Health Law Study
  October 17-18, 2006
• The Contribution of Self-Direction to Improving
  the Quality of Mental Health Services, Vidhya
  Alakeson, HHS 2007