Dana Stoner, Senior Policy Advisor with Texas Department of State Health Services, shared three examples of "changing the system" at the June 3, 2014 workshop on Designing Healthcare in Texas. The presentation was part of a Medicaid 101 overview and started the two day event sponsored by One Voice Texas, Harris County Healthcare Alliance, and Kinder Institute.

1. New Directions in Medicaid
Initiatives for People with Mental Illness
Dena Stoner, Senior Policy Advisor
Texas Department of State Health Services

2. The Most Dangerous Phrase in the
English Language
“We’ve Always
Done It This Way”
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3. 3
Innovation Cycle

4. Medicaid Opportunities
• Demonstrations - Money Follows the
Person Behavioral Health Pilot
• State Medicaid Plan Options – Home and
Community-based Services for People
with Severe Mental Illness
• Grant Opportunities – Incentives for
Prevention of Chronic Disease
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5. Why focus on Mental Illness?
• Mental illness has costly human and financial consequences
• Texans with severe mental illness live 29 years less than other
Americans and have more health problems earlier in life.
• Mental health and substance abuse conditions comprise 9
percent of initial Texas Medicaid initial inpatient admissions
but represent 27 percent of potentially preventable
readmissions.
• Institutional care in state mental health hospitals costs the
state $500 or more dollars per day.
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6. Money Follows the Person
Behavioral Health Pilot
(MFP BH)
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7. The Challenge
• National data indicated that large numbers of
nursing facility residents have a primary diagnosis
of mental illness, with a disproportionate number
being under the age of 65.
• In 2007, over 7,000 Texas nursing facility residents
were former clients of the mental health system.
• People with mental health and substance use
disorders experience special challenges in returning
to the community.
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8. Video: In the Nursing Home
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9. The Opportunity
• 2008- Texas awarded MFP demonstration
grant, funded by the Centers for Medicare
and Medicaid Services
• The grant allows Texas to test innovations,
including the Behavioral Health Pilot
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10. MFP BH Pilot Goals
• Transition adults with severe mental illness
and/or substance abuse disorders from
nursing facilities to the community
• Help people be successful in the community
by integrating mental health and substance
abuse services with long term care services
and supports
• Result in positive, long-term changes to the
Medicaid system
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11. BH Pilot Scope
• Includes adults with mental health or substance
use conditions and functional limitations who
have resided in a nursing facility for 3+ months.
• Two pilot sites in San Antonio (Bexar County) and
Austin areas.
• Partnership of State’s Medicaid, Mental Health
and Long Term Care systems.
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12. BH Pilot Services
• Coordinated with other services provided
through Medicaid managed care
• Pre-Transition Services - up to six months
before discharge to help prepare for
community life.
• Post-Transition Services - up to one year of
Pilot services post-discharge
• Transition plan – to regular Medicaid
services and community resources
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13. Cognitive Challenges
• Apathy
– A person does not start necessary activities on
their own or does not complete all the steps
• Disinhibition
– A person acts in a way that is not appropriate
to a situation, gets easily distracted, or
behaves very impulsively
• Mixed
– Both challenges present
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14. Cognitive Adaptation Training
(CAT)
• Evidence-based psycho-social intervention
• Uses a motivational strengths perspective
to facilitate person’s initiative and
independence
• Provides environmental modifications
(e.g., calendars, clocks, signs, organizers)
to help people bypass cognitive challenges
and organize their environment and
function independently
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15. Organizing Activities
Sam’s Daily Checklist
MON TUE WED THU FRI SAT SUN
Charge
phone
Use
Deodorant
Put on
shoes
Put on
clean shirt
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16. Adaptations
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17. Organizing the Environment
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Apathy Disinhibition Mixed

18. Compensating, Not “Curing”
Executive
Function
Attention
Memory
Psychomotor
Speed
Performance
of ADL’s
Social
Function
Occupational
FunctionCAT
Compensatory strategies
Environmental supports
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19. CAT Intervention Categories
• Hygiene
• Medication
Management
• Orientation
• Money Management
• Transportation
• Eating/Nutrition
• Cooking
• Toileting
• Dressing
• Housekeeping
• Social Skills
• Stress Management
• Vocational Skills
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20. Substance Use Services
• Assessment
• Individual &
Group Counseling
• Tobacco Cessation
Counseling
• Peer Support
• 24-hour On-Call
Support
• Motivational
Interviewing
• Harm Reduction
• Person-centered
care planning
• Interdisciplinary
team approach
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21. Participant Characteristics
• Average Age was 59 (range 26-89)
• 54% are female
• 29% Hispanic, 17% African American,
52% Anglo
• 72% with serious mental illness (28% with
other mental illness or substance misuse)
• 5% with dementia
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22. Functional Measures
• The Quality of Life Scale (QLS) (21 items) was developed to
evaluate deficit symptoms and impaired functioning in
people with schizophrenia.
• The Multnomah Community Ability Scale (MCAS) (17 items)
measures the functioning of chronically mentally ill persons
living in the community.
• The Social and Occupational Functioning Assessment Scale
(SOFAS) is a single item that measures an individual’s level of
social and occupational functioning resulting from mental
and physical health problems.
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26. The Pilot Today
• Over 291 people have been served since 2008
• Approximately 70% of BHP participants served remain in the
community up to 5 years.
• Examples of increased independence include getting a paid job at
competitive wages, driving to work, volunteering, getting a GED,
teaching art classes, leading substance use peer support groups and
working toward a college degree.
• After initial relocation expenses, the Pilot annually saves Medicaid
money since community care costs about 40 percent less than nursing
facility care.
• Overall impact of program appears strong with additional data being
collected to expand analysis.
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27. The Future
• Managed care organizations will provide Medicaid
rehabilitative and case management services for
people with severe mental illness. (They already
provide substance abuse and other mental health
services.)
• Texas could include the Pilot’s evidence-based
practices in its managed care system. Thousands of
Texans could benefit.
• Texas is sharing results nationally to inform federal
policy changes that support independence, recovery.
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28. Video: A New Beginning
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29. MFP-BH Return to NF Outcomes
• Medicaid data showing nursing facility stays were
obtained for 213 participants to determine whether they
were still in the community.
• 150 or 70% of participants remained in the community
o Median tenure was 24 months
o Longest tenure was 65 months
o Total community time in years for group is 314 years
• Over 50% of those who returned to nursing facility (n=63)
were in community for 24 months or longer; Total time in
community was 76 years
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30. Home and Community-based
Services – Adult Mental Health
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31. The Challenge
• Some adults who have severe mental illness
experience extended inpatient commitments –
sometimes lasting for years
• These individuals have very complex needs –
cognitive, physical, social
• They require individualized home and
community-based services (HCBS) to successfully
attain and maintain independence
• They could not get HCBS services through
existing waivers or Money Follows the Person
because of Medicaid regulations (IMD exclusion)
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32. The Opportunity
• 1915(i) of SSA enables states to provide HCBS
under a Medicaid state plan amendment
• Can target a broad range of customized services
to populations such as adults with SMI, which
are not otherwise available under Medicaid (e.g.
residential supports, respite care, transition
assistance, specialized therapies, peer support)
• Rider 81: pursuing 1915(i) amendment for adults
with complex needs and very long, repeated
stays in psychiatric hospitals
• A complex, but worthwhile endeavor!
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33. Moving Upstream:
Incentives for Prevention of
Chronic Disease
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34. The Challenge
• The leading causes of death for people with severe mental
illness are chronic health conditions such as heart disease,
cancer and lung disease. Despite overall declines in cigarette
smoking, a high prevalence of smoking persists among
Americans with mental illness.
• Taking atypical antipsychotic medications puts an individual
at risk for developing type 2 diabetes.
• Alcohol misuse is one of the greatest risk factors for the
development of some cardiovascular diseases, cancer, chronic
lung diseases, and diabetes.
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35. The Opportunity
• Texas awarded a Medicaid Incentives for Prevention of
Chronic Disease (MIPCD) Federal Grant
• Texas MIPCD study is known as WIN (Wellness
Incentives and Navigation)
• Large Randomized trial in Harris SDA (1250+ adult SSI
participants), operating through December 2015
• Provides evidence-based incentives to help Medicaid
clients adopt healthy behaviors, improve outcomes
• STAR+PLUS is Texas Medicaid’s dominant health care
delivery system for adults with disabilities. Potential for
large scale impact, if successful.
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WIN Interventions
• Person-centered wellness planning with professional
health navigators, who are trained in Motivational
Interviewing (MI) techniques.
• Flexible wellness account to support specific health goals
defined by the participant in the individual wellness
plan. ($1150 / yr., administered through the navigator)
• Wellness Recovery Action Planning training (WRAP) to
enable participants to better manage mental and
physical challenges.

37. WIN Features
• Rapid cycle improvement process
• Partnership: Stakeholder Advisory Group, Medicaid
Office, Medicaid MCOs
• Uses technology to collect data, reach participants and
manage workload
• Tracks outcomes including weight, BMI, clinical
indicators (e.g., HBa1c) health care utilization,
engagement in interventions, satisfaction, costs
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38. The Goal
• People with mental illness less likely to
become or remain institutionalized
• People with behavioral health conditions
will be able to manage their physical and
mental health.
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40. Contact Information
Dena Stoner, Senior Policy Advisor
Texas Department of State Health Services
dena.stoner@dshs.state.tx.us
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