CMH/API 2000 Project
Summary
Alaska Community-based Intensive Services Program (ACISP)
This fall the CMH/API 2000 Project staff circulated a proposal to mental health services consumers, consumer family members, providers and other stakeholders about a proposal to increase the capacity of the Anchorage community-based mental health system with the addition of a program based on the “program for assertive community treatment” model. The purpose for introducing a new community program is to reduce the total number of inpatient days attributable to the highest users of API acute care. These are Alaska residents who spend 30 days or more on the API acute care units (Susitna and Denali) over the course of a year.
Project staff met with stakeholders throughout October in groups and individually to discuss the proposal. There were also lively e-mail discussions, related issue papers, and an alternative program proposal posted on the Alaska Mental Health Consumer’s web site, akmhcweb.org. Outcome notes from the meetings and discussions are available from project staff and are also posted on the project and AKMHC web sites.
In response to the October discussions, project staff returned to the drawing board to develop a second approach to achieving the original goal while addressing the concerns, desires and recommendations voiced by consumers, family members, and providers. The result is a totally new and much different program proposal: the Alaska Community-based Intensive Services Program, ACISP. A new incomplete discussion draft of the request for grant proposals, RFGP, and a proposed budget are now under review.
The ACISP Concept
Like the preceding proposal, ACISP targets individuals who either already are, or who are likely to soon become, high users of API acute care services. The objective is to shift from over reliance on hospitalization in response to psychiatric crises to more effective use of community support services to promote recovery and prevent crises. Consumers and providers made it clear that they did not believe that a “one size fits all” program model will succeed at doing this. Both consumers and providers stressed the importance of program flexibility and consumer choice. In response, project staff took their advice and turned to the precedent set by Alaska Youth Initiative, AYI, and designed a program that provides for individualized services through grant funding that follows the adult consumer.
As with AYI, the purpose of the ACISP RFGP process is to approve providers in advance who are then eligible to receive grant funding to provide services to specific ACISP consumers who choose to work with them. A plan is then crafted by the provider and the consumer to meet the consumer’s individualized needs accompanied by an individualized budget for spending grant funds.
Section Two of the draft RFGP provides a scope of work describing the services grantees will be expected to deliver and how. Section Three, proposal submission requirements, among other things asks applicants for evidence of their capability to provide these services to ACISP consumers, to state the number of consumers they will commit to serving over the contract period (15 months), and to tell how they will provide for consumer choice in creating service teams.
Following are some highlights of the proposed ACISP program.
Consumer choice and service flexibility
· Because grant funding follows the consumer, the ACISP approach opens the door for large and small nonprofit Alaska mental health services providers alike to become eligible to receive program funds. Consumers then may choose from the eligible providers capable of serving them. Further, this allows the grant program to extend beyond Anchorage. Eligible providers in other Alaska communities may receive grant funding to deliver services to the consumers in their communities who fall within the target group.
· The grantee is responsible for directly providing personal services coordination (case management), individualized services planning and budgeting, and crisis intervention services. The grantee has the option of either employing or subcontracting with other professionals as needed to complete the consumer’s interdisciplinary team to deliver substance abuse, psychiatric, vocational, consumer peer specialist, and other services specified in the consumer’s individualized services plan. Case loads and minimum hours of service are specified in the RFGP for key professionals.
· The diversity of professional expertise to be made available to the consumer looks much like that of the previous proposal; but for each ACISP consumer, the team includes only the professionals needed based on that consumer’s individualized services plan. Proposing providers are encouraged in the RFGP to provide for consumer choice in selecting the members of their professional services team and to allow for consumers to continue to work with professionals who have provided services to them in the past, e.g. a preferred psychiatrist. The extent to which applicants provide for consumer choice in their proposals enters into the proposal evaluation criteria scoring.
Oversight -- A 10- to 15-member stakeholder committee will keep the ACISP on track with 51 percent consumer and family member representation; at least 3 who will be consumers. Consumers and family members strongly advocated for this level of inside quality control involvement in the new program.
Crisis response -- Consumers and providers alike support advance planning for crisis response to allow consumers to receive the assistance they want and need at times when they may not be able to express their desires or may not otherwise be heard. The ACISP also provides for the grantee to respond to the consumer in their home when the consumer or someone else reports the warning signs of crisis. Consumers repeatedly reported the effectiveness of someone the consumer knows and trusts responding when the consumer is concerned but not yet in crisis. Consumers gave personal accounts of how a “warm response” at the initial signs of stress has or could have prevented psychiatric decompensation and lengthy hospitalization.
Assessment, planning and budget – In accordance with Medicaid regulations, the ACISP proposal requires the development of a budget for serving the consumer based on an individualized services plan resulting from a three-pronged comprehensive assessment that, among other things, documents medical necessity. Eligibility to receive Medicaid reimbursement and willingness to aggressively pursue prior authorization as needed is a grant requirement. Grant funds are to be used only for services approved in the consumer’s individualized services plan that are not eligible for reimbursement by other payers. This is intended to stretch the more flexible state grant dollars to provide more services to more consumers.
Continuity of psychiatric care – A major concern voiced by consumers, family members, and providers a like is the disconnect that often happens between inpatient and community-based services. Consumers report inpatient and outpatient psychiatrists not communicating about medication changes. Case managers report not having an avenue to coordinate with inpatient treatment teams when important decisions are made including how long the consumer needs to remain in the hospital.
Woven throughout the draft RFGP are provisions for the consumer’s ACISP provider to play an active role in the consumer’s inpatient care and in providing for smooth transitions. In addition to placing responsibilities on the grantee, success in providing the degree of continuity of care envisioned here requires grant funds to cover the costs of community-based services when Medicaid does not reimburse the community provider while the consumer is receiving inpatient care. With this funding, the ACISP grantee can continue to work with the consumer and the inpatient medical and social services staff. The ACISP case managers and psychiatrists become consultants to the inpatient treatment teams.
Consumer peer specialists. Consumers advocated strongly for services delivered by people who have experienced mental illness and have received psychiatric treatment. The ACISP proposal provides for consumer peer specialists to be part of the consumer’s services team and doubles the required number of positions of the previous proposal. The peer specialists may either work directly as employees of the grantee or under subcontracts. This flexibility allows grantees to subcontract with individuals and organizations for peer support services that best meet the consumers needs and desires. Further, the grantee may fill or subcontract for any of the other professional positions with qualified individuals who are or have been consumers of psychiatric services.
24-hour, 7 days-per-week service – Case management and emergency assessment and intervention services are to be provided as needed by the ACISP grantee around the clock. The grantee is to be the first responder should the consumer experience crisis and have face-to-face contact with the consumer no less than three times a week. The grantee is to be able to increase that to several times a day when necessary. As with the former proposal, 75% of the ACISP services are to be delivered outside the office to support consumers in their natural living environments in concert with the normal flow of events and activities of the consumer’s daily life.
Other important features of the ACISP program include the following:
· provisions for psychiatric and substance abuse professionals to gain an understanding of the consumer’s personal perspective, experience with, and desires regarding the use of medications, alcohol, and drugs and alternative approaches to controlling the symptoms of mental illness as a context for prescribing medications and other symptom management tools that the consumer finds effective;
· communication and coordination between service providers to assist the consumer in monitoring the impacts of changes in the consumer’s medication, relationships, housing, and daily routine;
· services planning that places the consumer in control of when and how planning is accomplished; and
· support for community involvement and for developing and pursuing recreational, educational and employment aspirations.