dmhddsas march loc presentation show attach. no. 5€¦ · 3 mental health, developmental...

Mental Health, Developmental Disabilities and Substance Abuse Services – Legislative Oversight Committee March 2006

Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

Budget Overview

2Mental Health, Developmental Disabilities and Substance Abuse Services – Legislative Oversight Committee March 2006


Overall Division BudgetCategorical Disability FundingReceipts and AppropriationsBlock GrantsAmount of Funds Expended Per Individual by Disability Category and Funding Source (IPRS Funds and Medicaid)Target Populations DefinedEstimated Target Population for All Disability GroupsEstimated Cost to serve target population likely to seek services through the public systemIPRS/Service Funds Allocation to Local Management EntitiesHospital Downsizing UpdateUse of new funds appropriated for FY2006


Institutions, 575,965,746

53%

Administration, 36,597,727

3%

Community Programs, 489,830,130

44%


Budget Summary FY03/04 Actual FY04/05 Actual

FY05/06 Authorized Budget

Requirements $1,009,340,787 $1,102,393,603 $1,104,019,713Receipts $446,417,505 $521,914,239 $492,770,796Appropriations $562,923,282 $580,479,364 $611,248,917

Positions 11,643 11,647 11,596* Requirements & Revenues do not include federal DSH funds

SFY2005 Actual Expenditures



FY 04/05 Actual Expenditures by Source of Funds

• $521,914,239 - 47% of funds flowing to DMHDDSAS is comprised of federal funds and other receipts (not including Medicaid funds flowing to the community or direct providers)

• 67% of all receipts were used in institutions; 29% of the total receipts were used in the community and 3% in administration

Receipts 47%

$48M Substance Abuse Prevention and Treatment Block Grant

$12.9M Mental Health Services Block GrantAppropriations 53%



Non-Disability Specific,

$62,867,540, 6%

Developmental Disabilities, $384,137,151,

35%

Substance Abuse,

$66,878,942, 6%

LME Systems Management, $153,434,650,

14%

Central Office Administration, $36,597,727, 3%

Mental Health, $398,477,593,

36%

FY2005 Total Expenditures

Does not include direct bill providers for services.



Substance Abuse, $36,526,849, 7%

LME Systems Management, $90,980,810,

17%

Non-Disabilities, $9,518,718, 2%

Central Office Administration,

$16,358,328, 3%

Developmental Disabilities,

$263,954,499, 51%

Mental Health, $104,575,035,

20%

5.23%$30,352,093Substance Abuse

% of Total Appropriation

Actual AppropriationAppropriations

23.43%$136,042,061Other

20.70%$120,182,652Developmental Disabilities

50.63%$293,902,558Mental Health

FY2005 Actual Receipts



Total of Claims Paid by Disability for FY2005 from State/IPRS and Medicaid funds.

$-$100,000,000$200,000,000$300,000,000$400,000,000$500,000,000$600,000,000$700,000,000$800,000,000

IPRSMedicaid

IPRS $124,951,834 $87,037,667 $28,702,300

Medicaid $788,330,344 $663,056,581 $29,292,126

Developmental Disabilities

Mental Health Substance Abuse

$-$100,000,000$200,000,000$300,000,000$400,000,000$500,000,000$600,000,000$700,000,000$800,000,000

IPRSMedicaid

IPRS $124,951,834 $87,037,667 $28,702,300

Medicaid $788,330,344 $663,056,581 $29,292,126

Developmental Disabilities

Mental Health Substance Abuse

**Does not include individuals who appeared not to be part of the target population paid for by Medicaid. This amount totaled $26M and covered $65,000 individuals for one or two visits. Does not include prescription drugs related to MH/DD/SA within Medicaid totals. State funds/IPRS does not pay for prescription drugs.


$42,000 (approximate)Approximately 6,500 persons served

N/ADevelopmental Disabilities – CAP only(subset of the above category)

$2,14413,660 Persons Served


Substance Abuse

$4,507147,120 Persons Served (in community or hospital / <22 and >65 years old)


Mental Health


$5,983 (approximate) 16,841 Persons Served


N/A

Developmental Disabilities(includes CAP funding in Medicaid)Developmental Disabilities(excluding CAP and ICFMR)

Medicaid Funds per Individual Served during 2005

Average of State Funds expended per Individual Served during 2005

FY2005 Data (July 2004-June 2005)


Approximately 30% of those individuals served with State funds (IPRS) also were Medicaid recipients. Includes community services and hospital and ADACT services when claims were paid for individuals receiving treatment at these facilities. The Medicaid average annual amounts do not include operations at the state facilities or patient averages.



Mental Health Services



Target Populations - Mental HealthChildren and Adolescents (<18

years old)Severe Emotional Disturbances (SED); as indicated by a diagnosis of mental illness Co-occurring disorders Homelessness, or living in temporary housing situation orDeaf or hard-of-hearing orIn juvenile justice system orSexually aggressive

Adults (18 years and older)Severe and persistent mental illness (SPMI), as indicated by a diagnosis of mental illnessGlobal Assessment of Functioning (GAF) score of 40 or lower, or2 or more occasions of inpatient hospitalization for a psychiatric diagnosis (1 hospitalization in a state-operated psychiatric hospital) Homelessness, or living in temporary housing situation Deaf or hard-of-hearing


Major Mental Illness*• Schizophrenia – Brain disorder that impacts a person’s ability to manage emotions, make

decisions, and think clearly. Symptoms can include hallucinations and delusions. This disorder is considered highly treatable and treatment can lead to independent living. Impacts about 1% of adults nationally.

• Clinical / Major Depression – Clinical brain disorder that is greatly impacted by environmental stress. Can impact mood, concentration, appetite, and sleep. If untreated, episodes can last a year or more. 80% to 90% of case are treatable. 1 in 5 women and 1 in 15 men will suffer from major depression in their lifetime.

• Bipolar Disorder (Manic Depression) - Individuals suffer from episodes of mania and depression. Episodes can last days or months, and individuals can go years without an episode. For severe cases, treatment can partially mitigate the symptoms, but individuals require frequent monitoring and medication adjustments. Impacts about 1% of adults nationally.


*Source: National Alliance for the Mentally Ill

Impacts on Daily Living• Difficulty with Tasks• Vulnerability to stress• Potential disruptive behavior• Difficulty establishing social networks• Tendency toward not seeking help

Subpopulations with Special Needs• Homeless• Dually Diagnosed Develop. Disabled• Dually Diagnosed Substance Abuser• Children• Seniors


Mental Health Services Available

• Assessment• Assertive Community

Treatment (ACT) Teams• Social Rehabilitation• Residential Supports• Community Based Crisis

Services• Prevention

• Family/Group Living• Residential Treatment• Inpatient Services• Specialized Care for the

Deaf/MI• Individual/Group Therapy• Specialty Therapy (PT, OT,

Speech, etc.)




Calculating estimation of need of North CarolinaUsed national statistical information and the NC State Plan for prevalence information

Estimated the target populations based upon the US Census information updated for 2005

Used claims information to determine costs/individual/year by disability category for both Medicaid and IPRS funding systems (does not include costs for operating state psychiatric hospitals and Alcohol and Drug Treatment Centers, but includes claim costs for qualified individuals within the Medicaid program)

Unknown whether individuals who fall within the estimated target population are receiving services outside of the public system or who have insurance coverage for mental illness if needed

Assumptions

A range of cost of services per individual per year based on the state’s IPRS average and Medicaid payment average for each disability category

Same % of individuals who now qualify for Medicaid within the system, would qualify for Medicaid among new individuals who fall within the target populations

A percentage of individuals within the target population would show up for services in the public system; unknown exactly how many would show up in the public system and how many would not seek services that route (obtained the % from the DMH, DD, SAS)


Mental Health Services for North Carolinians

Service Need Estimated…• 5.4% of adults are estimated to have a serious mental illness and

2.6% are estimated to have a severe and persistent mental illness (Mental Health, A Report to the Surgeon General, based on study by Kessler et al., 1996; North Carolina’s Plan for Mental Health, Developmental Disabilities, and Substance Abuse Services for 2005 – American Psychiatric Association, Diagnostic and Statistical Manual of mental Disorders 4th

Edition, Washington, DC 2003) 5.4% = 348,720 (of that number 167,891 are estimated to have SPMI) (US Census Bureau State and County Quick Facts)

• 10% to 12% of NC children are estimated to have a severe emotional disturbance (SED) (North Carolina’s Plan for Mental Health, Developmental Disabilities, and Substance Abuse Services for 2005 – Center of Mental Health Services) 10%-12% = 208,383 – 250,060 children and adolescents (US Census Bureau State and County Quick Facts)



$46.60 (Per capita for 2005 –state & federal funds administered through the division)

$48-$52 (per capita – state & BG funds based on serving an additional 11,142 at current state and Medicaid service levels)

$11,153,142 (based on $1,001 average spent per individual of state funds 2005)

$50,216,994 (based on $4,507 Medicaid average for 2005)

11,142 individuals 25,995 total

(Additional annual Medicaid expenditures total $117,163,521)

207,988 (children and adults)

557,103(348,720 adults and 208,383 children & adolescents)

245,125 (Approximately 44% would present in the public arena)

Additional funds needed to serve additional target population

Estimated number of new individuals to receive services paid for by state funds

Per capita FundingEstimated number of individuals eligible for Medicaid (70%)of 37,137 individuals

Approximate number of individuals served in 2005

Estimated number of individuals who meet target population


Estimated number of new individuals to be covered through state funds – 44% of target population, minus individuals served in 2005, minus those who may qualify for Medicaid

***N.C. expenditures per capita for FY03 = $50.26 and U.S. per capita expenditures = $91.14. (There is not Enough Money for Mental Health, The Second Report Card by the North Carolina Psychiatric Association, March 2006)

The expected annual expenditures for the Medicaid category includes the federal funds and state and local match amounts.

Mental Health Services – Potential Funding Needs for serving the target populations



Developmental Disability Services


Target Population – Developmentally Disabled Children, Adolescents, and AdultsPersons diagnosed with a developmental disability prior to age 22Low Support Needs Assessment Profile (SNAP) score


AutismCerebral PalsySpinal Cord InjuryTraumatic Brain InjuryMild, Moderate, or Severe Learning Disabilities


Services Available for People with Developmental Disabilities

• Assessment• Vocational Rehabilitation• Supported Employment• Personal Care Services• Habilitation• Case Management• Respite• Group Living• Intermediate Care Facilities (ICF-MR’s)



Community Alternatives Program for the Mentally Retarded or Developmentally

Disabled (CAP-MR/DD)

• Medicaid Waiver Program1) Eligibility is primarily determined by the severity of the

individual disability2) Income of the individual’s parents or spouse are not considered

when determining eligibility3) Eligible individuals who receive a CAP slot are entitled to all

Medicaid services• Provides community-based services to individual who would

otherwise be placed in an Intermediate Care Facility for the Mentally Retarded (ICF-MR)

• A CAP-MR/DD slot cannot cost more than an ICF-MR bed.



Six-Year Growth in CAP–MR/DD

• CAP-MR/DD increased by 57% from FY 1999-2000 to FY 2005.

• Continued growth is projected with the addition of new slots in 2006.


$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

$300,000,000

2000 2001 2002 2003 2004 2005


Developmental Disabilities Services for North CaroliniansService Need Estimated…• 1.58% of total population are estimated to have a severe, chronic disability which

is attributable to a mental or physical impairment or combination of mental and physical impairments (North Carolina’s Plan for Mental Health, Developmental Disabilities, and Substance Abuse Services for 2005 – University of Minnesota) 1.58% = 134,937 North Carolinians (US Census Bureau State and County Quick Facts)


$45 (based on current state & federal funds administered by the Division)$51-64 (based on additional new funds)

$58,553,040 (based on IPRS average of $10,192 spent per individual served in 2005)$162,847,770 (based on Medicaid average)

5,74517,234($488,522,050 total based on average expenditures of $28,346 in 2005)

36,393134,937

59,372(Approximately 44% would present in the public arena)

Per capita FundingAdditional funds needed to serve these individuals

Estimated number of additional individuals to target population definitions

Estimated number of additional individuals eligible for Medicaid (75%) of 22,979 individuals



$122 per capita/ An Analysis of Medicaid and Americans with Mental Retardation and Developmental Disabilities. The US average was $121 (included Medicaid claims).



Substance Abuse Services



Target Populations – Substance AbuseAdults (18 years and older)

Diagnosis of substance abuse disorder

Using drugs that are injectedSuffering from a communicable

diseaseHomeless or living in temporary

housingInvolved in criminal justice

systemInvolved in child welfare systemPregnant female or women with

custody of minor childrenCharged or convicted of Driving

While Impaired if completed assessment and treatment ordered

Deaf or hard-of-hearing.

Children and Adolescents (under age 18)

Diagnosis of substance abuse

Criminal Justice System

Teen girls pregnant

DWI treatment for teens

MAJORS


Available Substance Abuse Services and Programs

Services• Assessment• Detoxification• Outpatient Treatment• Residential Treatment• Outpatient• Intensive Outpatient Treatment


Programs• Treatment Alternatives to Street Crime (TASC)

1) Targets offenders whose criminal behavior is driven by drug use2) Services include identification, assessment, treatment referral and management3) Drug testing and judicial sanctions used as incentives for compliance


Available Substance Abuse Services and Programs (Cont.)


Programs• Residential Treatment for Women

1) Target women receiving public assistance and their children2) Apartment Setting3) Services include: treatment, case management, employment training, child care,

transportation, and child MH interventions

• Managing Access for Juvenile Offender Resources and Services (MAJORS)1) Targets adolescents at risk for placement in a Residential Treatment Facility or Juvenile

Detention Center or following placement in one of these facilities2) Outpatient services that are case managed by a substance abuse counselor3) Currently available in all judicial districts


Substance Abuse Services for North CaroliniansService Need Estimated…• 6% of the adult population are estimated to have addictive disorders and are in need of comprehensive treatment

for alcohol or illicit drug use (Mental Health, A Report of the Surgeon General, (Regier et al., 1993b; Kessler et al., 1994; North Carolina’s Plan for Mental Health, Developmental Disabilities, and Substance Abuse Services for 2005 – Research Triangle Institute) 6% = 387,442 North Carolinians

• 2% of children and adolescents are estimated to have substance use disorders (Mental Health, A Report of the Surgeon General, The Fundamentals of Mental Health and Mental Illness). 2% = 41,676 (US Census Bureau State and County Quick Facts)


Per capita Funding

Additional funds needed to serve these individuals

Estimated number of new individuals to be covered by state funds

Estimated number of individuals eligible for Medicaid (32%) of 147,171



$7.82 (current, based on state and federal funds admin. through division)

$20-33(including new funds)

$102,879,156 (based on average expenditures per person of $1,028 in 2005 –state funds)$214,565,088 (based on average Medicaid expenditures per individual in 2005)

100,07747,094$100,971,079 (based on average expenditures per person for 2005 of $2,144 - Medicaid)

41,640429,118

188,811(Approximately 44% would present in the public arena)



Estimated State Funds Needed to Serve Estimated Target Populations who would seek services in the public arena

$172,585,338 - $427,629,852TOTAL RANGE of NEW FUNDS

$102,879,156 - $214,565,088Substance Abuse Services

$58,553,040 - $162,847,770Developmental Disabilities

$ 11,153,142 - $ 50,216,994Mental Health Services

Additional State Funds Needed to Serve New Individuals in the Public System



Local Management Entities and the funding of Community MH/DD/SA Services


LME Funding -

State Appropriations• Most of the State Appropriation is divided into Disability

Categories, and LME's are restricted from shifting funds betweendisabilities.

• State Funding has been stagnant:– Small, isolated budget expansions in recent years, mixed

with budget reductions– No inflationary increases

• Main source of funds for Indigent Care and services not covered by Medicaid.

• Not equitably distributed across the LME's




2005 Service Dollar Allocation Per Capita of catchment area (Annualized)

$26

$37

$60

$38

$0

$10

$20

$30

$40

$50

$60

$70

Mecklenburg Southeastern Riverstone State Average

Unit Cost Reimbursement Funds managed through the IPRS system.



Unit Cost Reimbursement Funds managed through the IPRS system.

2005 Average Expenditures Per Client

$884.40 $952.66

$1,386.67

$404.85

$0.00$200.00$400.00$600.00$800.00

$1,000.00$1,200.00$1,400.00$1,600.00

Wilson-Greene SoutheasternRegional

Cumberland OPC


Hospital Downsizing

S.L. 2001-242, Section 21.63 (c) “…any nonrecurring savings in State appropriations that result from reductions in beds or services shall be placed in the Trust Fund for Mental Health, Developmental Disabilities, Substance Abuse Services and Bridge Funding Needs”“Recurring savings…shall be retained by the Department…for implementation of subsections (a) and (b) of this section, and (II) to support recurring costs of additional community-based placements from Division facilities in accordance with Olmstead vs. L.C. & E.W.”

GS 143-15.3D(c). Trust Fund for Mental Health, Developmental Disabilities, and Substance Abuse Services and Bridge Funding Needs.“…Notwithstanding…recurring savings realized from the closure of any State psychiatric hospitals shall not revert to the General Fund but shall be used for the payment of debt service on financing contract indebtedness authorized pursuant to Article 9 of Chapter 142…for the construction of a new State psychiatric hospital. Any remainder not needed for this debt service shall be credited to the DHHS to be used only for the purposes of …”(facilitating reform)

S.L. 2005-276, Section 10.28( c) Transition Planning for State Psychiatric Hospitals“…any nonrecurring savings in State appropriations that result from reductions in beds or services shall be placed in the Trust Fund for Mental Health, Developmental Disabilities, Substance Abuse Services and Bridge Funding Needs”“Recurring savings…shall be retained by the Department…for implementation of subsections (a) and (b) of this section, and (II) to support recurring costs of additional community-based placements from Division facilities in accordance with Olmstead vs. L.C. & E.W.”




< Total Check for Community Services Transfer$13,345,893

< Total of Recurring State Savings to Child MH$1,220,744

< Total of Recurring State Savings to Adult DD$102,090

< Total of Recurring State Savings to Adult MH$12,023,059

< Net State Savings Transferred for Community Svs.$13,345,893

< Downsizing State $ Reduction by the G.A.$999,973 $4,382,032

Balance of Reduction (all

Medicaid except $73,600) >

< Total State $ for COPS Debt Service$2,172,636 $1,122,516

Medicaid Realigned for

CAP-MR/DD >

$16,518,502 $5,504,548 $22,023,950

State $ReceiptsTotal

Annual Recurring Savings

34

Hospital Downsizing

• Downsizing Plan was implemented starting in FY 2001-02.

• No Acute Beds have been closed. Crisis capacity has not been reduced.

• DMHDDSAS has slowed the Downsizing Plan, due to lack of community capacity.

• Total Beds Closed = 539


FY 2001-02 FY 2002-03 FY 2003-04 FY 2004-05 FY2005-06 (Estimated)

Dix HospitalAdult Longterm 39 24 0 0 0

Geriatric Longterm 0 15 16 0 0Total 39 39 16 0 0

Umstead HospitalAdult Longterm 0 30 30 37 0Nursing Facility 25 0 0 0 0


Broughton HospitalAdult Longterm 0 25 20 0 0Nursing Facility 13 0 0 0 0


Cherry HospitalAdult Longterm 0 0 31 31 0Nursing Facility 15 16 10 74 0

Total 15 16 41 105 0

Statewide Bed Closures 112 154 131 142 0

35

Rising Acute Care Admissions

• The State’s Psychiatric Hospitals have witnessed a rapid increase in acuteadmissions

• According to DMH/DD/SAS:– Admissions increased by 17% between FY2003 and FY2005– 30%-40% of acute admissions have never been previously served in a state

hospital– Primary substance abuse diagnoses are common

• Possible Contributing Factors*– Lack of community substance abuse services– Decreasing crisis care capacity in community hospitals– Fragmentation of services through LME divestiture– Increases in illicit drug and alcohol abuse– Increases in the population– Stresses associated with high unemployment and other economic factors

• * Contributing factors provided by the LME’s as reported by DMH/DD/SAS to the Joint Legislative Oversight Commission on MH/DD/SA Services 9/2004.


36

State Psychiatric Hospitals• Dorothea Dix Hospital - Raleigh• Persons Served (FY04/05) – 4,799• Positions (FY05/06) – 1,110• Authorized Budget (FY05/06)

– With DSH - $106 M– Without DSH - $67 M

• Scheduled to close in late 2007• To be replaced with a 432 Bed Hospital in

Granville County

• John Umstead Hospital – Butner *• Persons Served (FY04/05) – 4,653• Positions (FY05/06) – 1,193• Authorized Budget (FY05/06)


• Also scheduled to close in late 2007• Will be combined with Dix Hospital in

Granville County

• * Includes the R. J. Blackley ADATC

• Broughton Hospital - Morganton• Persons Served (FY04/05) – 4,091• Positions (FY05/06) – 1,172• Authorized Budget (FY05/06)


• Replacement Planning complete• No Authorization to finance a Replacement

• Cherry Hospital - Goldsboro• Persons Served (FY04/05) – 4,892• Positions (FY05/06) – 1,159• Authorized Budget (FY05/06)


• Replacement Planning complete• No Authorization to finance a Replacement




USE OF NEW FUNDS FOR FY2006

Crisis Intervention Services - $2M among 8 LME’s

60,824 Smoky Mountain

180,935 Southeastern

134,672 Eastpointe

193,290 OPC

428,230 Guilford

274,890 Durham

373,159 Pathways

354,000 Catawba

Long Term Vocational Support Services - $1.5M All LME’s received some amount of funds for supportive employment for vocational rehabilitation (allocations ranged from $10,540 - $131,644)


Long Term Vocational Support Services - $1.5M

17,209 Neuse

92,903 Mecklenburg

14,645 Johnston

131,644 Guilford

59,322 Pathways

19,026 Foothills

58,122 Five County

12,330 Edgecombe-Nash

48,940 Eastpointe

39,247 Durham

64,800 Cumberland

39,450 Crossroads

83,648 CenterPoint

10,540 Catawba

15,195 Albemarle

28,282 Alamance-Caswell-Rockingham

17,230 Wilson-Greene

125,091 Western Highlands

129,388 Wake

33,028 Tideland

41,047 Southeastern Regional

89,036 Southeastern

27,972 Smoky Mountain

79,970 Sandhills

20,960 Roanoke-Chowan

17,898 Pitt

96,542 Piedmont

34,440 OPC

30,259 Onslow-Carteret

21,836 New River






Intensive Substance Abuse Services for Children $1,250,000M – LME’s selected for funds were those with existing MAJORS programs for expansion of that initiative. 208,330

Southeastern Regional


208,330 OPC

208,330 Onslow-Carteret

208,350 Mecklenburg

208,330 Edgecombe-Nash

AmountLME




Adult Substance Abuse Services -$750,000 – LME’s were selected based upon their current services for drug court consumers. Funds will be used to subsidize their care.

104,175 Western Highlands

145,200 Wake


24,150 Sandhills

148,575 OPC

37,575 Onlsow-Carteret

44,400 Neuse

99,075 CenterPoint

17,025 Alamance-Caswell-Rockingham




System of Care – Child and Family Teams

Each LME received $66,667 for the development and implementation of system of care for child and family support teams.

Mental Health Treatment Court - $258,000, $129,000 for Mecklenburg and Orange/Chatham Courts.

dmhddsas march loc presentation show attach. no. 5€¦ · 3 mental health, developmental...

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