Saturday, January 24, 2009

Florida Care

Florida is a unique state and perhaps one of the most important elements of its health care delivery system is the housing and support provided by the 858 state licensed limited mental health assisted living facilities. These facilities care for around 10,000 adults with serious mental illness. According to state data approximately 90% of the residents who choose to live in these settings have a diagnosis of schizophrenia.

The challenges faced in Florida with the serious budget shortfalls creates a chance to examine the cost effectiveness of various programs and systems of care. What we know is people with schizophrenia need stable housing and stable service delivery system. The limited mental health ALF in Florida has some unique capabilities that have long gone under utilized in how state policy addresses the needs of this with the greatest level of functional impairment.

The average GAF score ( global assessment functioning) is around 45, whereas the average for those community mental health clients who reside in the community in Florida is about 55, a full ten point drop this is because people with schizophrenia who reside in the LMH-ALF setting have greater needs.

A review several years ago of these residents showed that they consumer services at 4 times the rate that those in the community do. Now some of this is because of the level of need and some is due to over utilization or billing practices associated with the mental health agencies that are responsible for supervising their clinical needs.

The current rate of reimbursement for care in these facilities has not changed since the lawmakers last increased the funding in 2001 when lawmakers authorized medicaid proceed with a plan to create a state plan amendment that would allow state policy planners to move some of the nearly $32 million in optional state supplementation ( general revenue) into the new medicaid assistive care services. There were only two other states that were doing this Vermont and North Carolina at the time. The medicaid rate was $9.28/day for assistive care services in 2001 and it has not changed since. What is interesting when you review the medicaid claims data it shows that the facilities actually only recover on average $5.28/day for each day a resident lives in their facility. This income erosion seriously compromises what a facility can provide and limits their ability to create the type of stable housing routines that all persons with schizophrenia to propsper.

When you think about it the residets spend 70% of their day where they live and 30% at the community based mental health center. When you look at how we fund access to care or allocate dollars we spend 80% of the funds where the residents spend 30% of their time, so when we ask what is wrong with the care of these individuals and why so many end up in the jails and prison systems we dicover we have inverted the funding for care at the expense of creating a balance between stable housing and stable services.

Lets face it one of the most critical elements that affect the sucess of care with this adversely selected subgroup is the development of stable routines. It is these predictable routines that have a stablizing influence on care over the course of time. These routines must be paired with appropriated array of targeted clinical mental health services that allow for ongoing assessment of medicaitions, individual and group therapy and of course an ability to respond to psychiatric emergencies. Too often the mental health system is AWOL when it comes to effective response to emergency psychiatric care and this where things deteriorate and law enforcement gets involved.

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