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Re-Balancing the Service System for People with
Mental Illness, Developmental Disabilities and Addictive Diseases
(MHDDAD)
What is MHDDAD?
Department of Human Resources
Division of Mental Health,
Developmental Disabilities and Addictive Diseases
5 MHDDAD Regional Offices
7 State Hospitals Community Providers
MHDDAD Division Director
Planning
Project Specialist
Investigations
Legal Services & Governmental Relations
Medical Director
Assistant DirectorProgram Devel. & Operations
Assistant DirectorAdministrative Services
Prevention Services
Child & Adolescent Systems of Care
Office of Mental Health Services
Office of Developmental Disabilities
Office of Addictive Diseases Serv
Financial Support
Hospital System Administration
ConsumerRelations & Recovery
Research & Grants
Provider Certification
Forensic Services
Provider Network Mgt.
Regional Operations
Regional Offices
Regional Hospital Administrators
Georgia Department of Human ResourcesDivision of Mental Health, Developmental Disabilities and Addictive Diseases
State Governor
DHR Commissioner
Case Expeditor
Constituent and Legislative Services
Quality & Operat’l Sup’t
Evaluation
Policy & Training
Information Management
Continuous Quality Improvement
Information Systems
Who we serve:
Children & Adults with:
serious mental illness
developmental disabilities
addictive diseases
Funding Sources State funds
Federal Block Grant funds
Medicaid funds
Medicare funds
Private insurance / private pay
County funds
Various public and private grants
Services for children & adolescentsMHDDAD
MHDDAD Children & Adolescents Services
Preserve families
Avoid hospitalization
Support participation in everyday life
44,696
33,076
40,06441,00439,918
35,199
0
10,000
20,000
30,000
40,000
50,000
FY 01 FY 02 FY 03 FY 04 FY 05 FY 06
Pers
on
sCommunity Services - C&A Served
Serious Emotional Disturbances
4,300
3,1212,998
2,4961,986
1,605
0
1,000
2,000
3,000
4,000
5,000
FY 01 FY 02 FY 03 FY 04 FY 05 FY 06
Per
son
sCommunity Services - C&A Served
Addictive Diseases
2,589
2,0002,0532,3502,2742,262
0
500
1,000
1,500
2,000
2,500
3,000
FY 01 FY 02 FY 03 FY 04 FY 05 FY 06
Pers
on
sHospital Services - C&A Served
Serious Emotional Disturbances
Services for adults with mental illness and/or addictive diseases
Adults (MH &AD) Services
Best Practices
Transition from institutions
Assure availability of medication
104,850100,402
84,472100,82298,902
90,716
0
25,000
50,000
75,000
100,000
125,000
FY 01 FY 02 FY 03 FY 04 FY 05 FY 06
Pers
on
sCommunity Services - Adults Served
Mental Health
40,23037,88934,717
39,43739,07836,734
0
10,000
20,000
30,000
40,000
50,000
FY 01 FY 02 FY 03 FY 04 FY 05 FY 06
Pers
on
sCommunity Services - Adults Served
Addictive Diseases
12,67014,28712,009
14,41514,95014,123
0
5,000
10,000
15,000
20,000
FY 01 FY 02 FY 03 FY 04 FY 05 FY 06
Per
sons
Hospital Services - Adults Served Mental Health
Services for people with developmental disabilities
Developmental Disabilities Services
Reduce the waiting list
Transition from institutions
Ensure provider availability
Ensure community capacity
11,391
12,67012,29312,103
11,90711,548
0
5,000
10,000
15,000
FY 01 FY 02 FY 03 FY 04 FY 05 FY 06
Per
sons
Community Services - Adults Served Developmental Disabilities
2,403 2,5802,383 2,2892,478
1,951
0
1,000
2,000
3,000
4,000
5,000
FY 01 FY 02 FY 03 FY 04 FY 05 FY 06
Pers
on
sCommunity Services - C&A Served
Developmental Disabilities
2,059 2,004 1,947
1,685 1,640 1,6371,543
1,423 1,4021,305
1,2011,064
FY96 FY97 FY98 FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07
Olmstead ‘99
Consumers with DD Served in State Hospitals
Source: BHIS Dec.’06 HB Note: FY07 Data is Oct. 31, ‘06
6,441
2,820
2,541
2,781
3,281
4,842
5,263
6,948
FY 2000
FY 2001
FY 2002
FY 2003
FY 2004
FY 2005
FY 2006
FY 2007
Developmental Disabilities Waiver Planning List Persons Waiting for Waiver Services
Source: MHDDAD Dec. ’06 HB
Nov. ‘06
Forensic Services
Forensic Services
Ensure timely movement from jails
Ensure appropriate treatment setting
State Mental Health Administrators in the major of the states report increasing percentages of forensic patients in state hospitals. Source: State Profile Highlights: National Association of State Mental Health Program Directors Research Institute, Inc. (NRI)
Division of MHDDAD - Forensic ServicesPatients Needing Secure Beds vs. Current Secure Beds
(Vertical Line represents May 1, 2006)
0
100
200
300
400
500
600
700
800
900
Date
Nu
mb
er
of
pa
tie
nts
Actual / Projected Number of Consumers
Current # of Secure Beds
465
804
Why does the system need to
be re-balanced?
• Isolation of people with mental illness, addictive diseases and developmental disabilities in hospitals and institutions
• Use of hospitals as the preferred treatment forced people and resources into “deep end” services
- Example: Central State Hospital housed 13,000+ people in the 1960s. Today’s system of 7 hospitals has 2,513 beds
Old Paradigm
Old Paradigm
• Historical grant-in-aid funding to CSBs not driven by need, demographics or outcomes
• Children not considered priority customers
• Lack of accountability for the people most in need getting effective services
New Paradigm
• People served as close to home, family and community as possible
• Provider competition affords greater consumer choice
• Fee for service and utilization review ensure that the right people are getting the right services in the right amount at the right price
• Children get their fair share of the resources
• Nobody should live in a hospital (particularly children and people with developmental disabilities)
Hospitals are our Burning Platform• Public behavioral health system is the “safety net” when
private systems are exhausted
• Increased demand for substance abuse treatment is driving people into deep end services such as emergency rooms and state hospitals
• Courts are increasingly relying on state hospitals
• Mental illness causes more disability than any other class of medical illness in America.
Distribution of Georgia's Mental Health Expenditures Betweeen State Hospital Inpatient Care and Community-Based Programs, 1981-2004
54%
7%
43%
91%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1981 1983 1985 1987 1990 1993 1997 2001 2002 2003 2004
Georgia Community Georgia State Hospital
Distribution of U.S. Mental Health Expenditures Betweeen State Hospital Inpatient Care and Community-Based Programs, 1981-2004
69%
33%28%
63%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1981 1983 1985 1987 1990 1993 1997 2001 2002 2003 2004
U.S. Community Avg. U.S. State Hospital Avg.
Georgia’s Mental Health System…
…is about 8 years behind other states in transitioning resources to community-based services
…only since 2001 has Georgia been spending more resources on community services than hospital services
Burning Platform
• Children are hospitalized at 3X the national rateAdults are hospitalized at 3.5X the national rate Elderly are hospitalized at 24X the national rate
• 417 people currently in state hospitals could be discharged, but lack needed community services
• People are living in hospitals - 66% have been in the hospital for over 1 year; 25% for 10+ years
• Hospital readmission rates are twice the national rate
• Currently exceeding forensic bed capacity by 35% (164 beds). Projecting a 89% capacity shortfall by 2010 (417 beds)
• 64% of forensic consumers have had previous MHDDAD contact = missed opportunity
• Resources of other systems are drained- Examples: Sheriff’s Offices, DFCS, DJJ, DOE, local
emergency rooms
Burning Platform
Burning Platform
• 2001 - Revenue Maximization projected Medicaid revenue would replace $37.4M in state funds annually (did not occur)
• Medicare earnings were over-projected due to seriously mentally ill consumers exhausting their lifetime benefit
• Because public system is “safety net” when other resources are exhausted, most consumers come with no insurance or ability to pay
• Olmstead Decision accelerated community placements
• Escalating costs – utilities, medical treatment , staff…
Actions Taken1) Consistent statewide set of standards for the community:
• Defined who will be served
• What basic services will be available to all Georgians
• Redistributed funding so every area gets their fair share
Actions Taken 2) Created a front door to service system:
• Established Single Point of Entry (1-800-715-4225)
• Funded Crisis Intervention Training for 20% frontline law enforcement officers to divert mentally ill from jails
• Created 23 hour observation units at 4 hospitals to avoid 66% of hospital admissions
• Established crisis stabilization services for children to avoid 60-75% of hospital admissions
• Increased adult crisis stabilization services by 30% since FY04
3) Increased the number of people that can be served in the community:
• Steady increase in number of MR/DD waivers
• Open competitive market place with fee-for-service to increase # of providers, consumer choice and number of people served
• Use of Case Expeditors to safely move consumers from hospitals to the community
• External utilization review of hospital and community services to ensure the right services for the right people in the right amount
Actions Taken
Actions To Be Taken
• Reduce the cost of pharmacy operations and medications (estimated annual savings $1.2M)
• Operate smaller, more specialized hospitals
• Privatize specific services such as billing
• Consolidate selected hospital functions
• Potential federal funding of Money Follows the Person Grant
• Legislative proposal allowing misdemeanor defendants found incompetent to stand trial to be evaluated and treated for competency restoration in the community
• Consolidation of MHDDAD and DFCS child and adolescent behavioral health systems - positioning MHDDAD to provide treatment and DFCS to provide protection
• Consolidation of MHDDAD and Public Health substance abuse prevention services - positioning DHR to impact health behaviors
Future Initiatives
Future Initiatives
Restructuring Child & Adolescent Substance Abuse Services
Current System
• $4.9M funding
- 142 inpatient beds
- Length of stay 9-12 months
- 150-200 adolescents served annually
New System
• $2.5M funding
- 32 inpatient beds
- Length of stay 3-6 months
- 120-150 children served annually
• $2.4M funding
- Outpatient, community-based services
- 1,350 adolescents served annually
Future Initiatives
• Sheriff’s Tele-medicine Pilot– technology to link Sheriff’s Offices and state
hospitals; only transport those who must be moved
• Crisis Services for children– add mobile crisis services and funds to purchase
additional crisis beds
• Child & Adolescent Parent-to-Parent Peer Support Program:- links parents of emotionally disturbed children
with other parents who have successfully navigated the service delivery system
• Increase Medicaid waiver service slots and expand supports to families & consumers with the new developmental disability waiver:– Individual Budgets– Supports Intensity Scale– Choice of Services– Financial Support Services
Future Initiatives
Characteristics of the Reformed System
Every area of the state will have:• A true single point of entry
• Crisis stabilization for children and adults
• A set of core services
Deinstitutionalization of developmentally disabled and long term mental health consumers
Individualized treatment planning and utilization management
Maximum self-sufficiency and independence for adults with appropriate supports
