With any change in state policy there is always unintended consequences. Jacksonville is home to a large population of persons who have a serious and persistent mental illness. Some of these people with the greatest needs are persons with schizophrenia.
It is estimated by researchers that 44% of all cigarettes sold in the United States are sold to people with mental illness. Studies show that persons with mental illness spend 27% of their income seeking tobacco products. It is well known there is a strong connection between schizophrenia and how nicotine works in the brain. The nicotine provides brief alleviation of psychotic symptoms or voices and can help improve memory for persons with this disabling condition.
In Florida there are 5379 individuals with a mental illness who are reported to live in a state licensed limited mental health assisted living facility. Many of these residents have a primary diagnosis of schizophrenia and 90% are addicted to smoking or nicotine products.
For most of these people the terrible consequences of nicotine addiction include cardiac problems, COPD, bladder cancer and a host of other complications. It seems to make sense, just raise the price and they will quit. This is a case of easily said than done.
Even though residents will seek to quit smoking and we get them started on the nicotine patch, because of the diminished insight that accompanies schizophrenia many will keep on smoking cigarettes in addition to using the nicotine patch, a very dangerous combination. Often once the physician knows they are doing both they will discontinue the patch out of caution.
For many of the state funded residents who reside in Florida's licensed limited mental health assisted living facilities they received $9.28/day from Medicaid to help pay for their care and services they need and they received $54/month in a personal needs allowance that is to pay for dental care, vision, clothing, shoes and personal care products.
At our facility we have a tobacco resale license which allows us to purchase cigarettes from a wholesaler. We will purchase the cigarettes each month on behalf of the residents, for what we consider to be a month's supply would generally be $38/month at wholesale prices. This provides enough tobacco for 4 cigs per time four times per day.
The new federal cigarette tax will pay for children's health insurance will exact a significant toll on persons with mental illness. According to our sources the average cost of cigarettes will increase by $6/carton and so what use to cost $38/month will now be around $56/month just for cigarettes. The next proposed wave of taxes from the state will drive up costs another $10/carton for a total of $86/month.
Recent DCF data demonstrates clearly that stable housing and stable services are keys to keeping people with schizophrenia, for instances of 5329 mentally ill residents who were reported living in an ALF only 26 per year get charged with a crime and sent to an expensive ( $140,000/bed) forensic mental health treatment facility.
By contrast if you are enrolled in one of Florida Assertive Community Treatment Teams which serve 3200 adults you have 200 per year headed to forensic care costing taxpayers $28 million.
It is well established fact that when persons with schizophrenia re psychotic and aggressive having available a small supply of cigarettes can help everyone stay in control and avoid someone getting hurt. When you think about the problem this can create, Florida spends $250 million each year caring for the mentally ill who have committed a crime, 48% of the people charged in FS 916 are charged with battery on a law enforcement officer.
Absent doing nothing here is a description of the unintended consequences, as the price of cigarettes go up, residents will only be able to purchase a smaller quantity, residents who have higher demand for cigarettes will start to engaged in "panhandling" behaviors, they will commit petty crimes that include stealing cigarettes from local stores or friends. The utilization rates of hospital emergency rooms, already "psychosis" is the number three diagnosis seen in Florida's hospital emergency rooms.
You will likely have people decide they would prefer to get their nicotine needs met and will elect to live at a homeless shelter, take up housing in an unlicensed assisted living facility where there is no supervision or will seek housing in settings that could be best described as unstable. This all creates a tsunami for state budget planners and new dangers for patients and families.
Douglas D. AdkinsExecutive DirectorDayspring Village, Inc.PO Box 1080Hilliard, Florida 32046
Friday, May 1, 2009
Saturday, April 18, 2009
Optional State Supplementation - Florida Trends Down
Access to care for low income individuals with mental illness to stable housing and stable services is one step closer to a crisis. The Optional State Supplementation Program which helps fund access to state funded ALF care in Florida is collapsing. Recent numbers show that in 2001 there were 10,272 and in 2008 according to the Department of Children and Families which runs the OSS program there were only 7935 funded OSS slots.
The legislature over the last 10 years would hold funding for this program at $26 million. The last two years saw significant "raids" on the limited funds in this vulnerable program by lawmakers. The program was reduced in 2008 to $18 million and in 2009 it is projected to drop to $15 million.
The last time there was any increase in Florida was in response to the 1999 OSS workgroup that was authorized by the legislature. This workgroup recommended a $100 increase in OSS funding and what was funded in 2000 was an increase of $35/month for room and board and they moved the personal needs allowance from $43/month to $54/month.
The need for an increase in the rate for care for the state funded ALF residents has been a constant need for years. There have been numerous attempts to increase the OSS rate of funding only to be vetoed by then Gov Jeb Bush.
In Florida the OSS funding is used to as a state match to pull down medicaid resources under the state plan amendment called the medicaid assistive care services program. The rate of reimbursement for a low income individual is $9.28/day a rate that has not been adjusted since 2001.
The decreasing number of beds in Florida is a critical concern for persons with serious mental illness. We know that of the 7935 beds for OSS residents that 5379 are occuippied by persons with mental illness, the vast majority of these located in Miami Dade County. The major diagnosis associated with this population is schizophrenia.
Florida lawmakers should discontinue the practice of holding the rate of funding for care at the 2001 rate and "raiding" this fund for surplus funds to use in other programs. These funds should be utilized if surplus to increase the rate. The low rate of reimbursement has led to the closure of many facilities in Florida eliminating access to housing that offers some supervision and assistance with medications.
The decline of state funded ALF beds in Florida only spells that Florida taxpayers will pay an increased cost associated with greater demand and use of institutions; whether they are jails, nursing homes or state mental health treatment facilities.
The ALF model is a low cost and effective system of care for many people with chronic long term needs like those with schizophrenia. The absence of quality and available supply of beds will only lead to an expanding crisis that will drive up health care costs.
Even if lawmalkers started now to address the emerging policy and budget crisis facing state funded ALFs, there would be several years to correct the many issues that years of neglect have brought.
The legislature over the last 10 years would hold funding for this program at $26 million. The last two years saw significant "raids" on the limited funds in this vulnerable program by lawmakers. The program was reduced in 2008 to $18 million and in 2009 it is projected to drop to $15 million.
The last time there was any increase in Florida was in response to the 1999 OSS workgroup that was authorized by the legislature. This workgroup recommended a $100 increase in OSS funding and what was funded in 2000 was an increase of $35/month for room and board and they moved the personal needs allowance from $43/month to $54/month.
The need for an increase in the rate for care for the state funded ALF residents has been a constant need for years. There have been numerous attempts to increase the OSS rate of funding only to be vetoed by then Gov Jeb Bush.
In Florida the OSS funding is used to as a state match to pull down medicaid resources under the state plan amendment called the medicaid assistive care services program. The rate of reimbursement for a low income individual is $9.28/day a rate that has not been adjusted since 2001.
The decreasing number of beds in Florida is a critical concern for persons with serious mental illness. We know that of the 7935 beds for OSS residents that 5379 are occuippied by persons with mental illness, the vast majority of these located in Miami Dade County. The major diagnosis associated with this population is schizophrenia.
Florida lawmakers should discontinue the practice of holding the rate of funding for care at the 2001 rate and "raiding" this fund for surplus funds to use in other programs. These funds should be utilized if surplus to increase the rate. The low rate of reimbursement has led to the closure of many facilities in Florida eliminating access to housing that offers some supervision and assistance with medications.
The decline of state funded ALF beds in Florida only spells that Florida taxpayers will pay an increased cost associated with greater demand and use of institutions; whether they are jails, nursing homes or state mental health treatment facilities.
The ALF model is a low cost and effective system of care for many people with chronic long term needs like those with schizophrenia. The absence of quality and available supply of beds will only lead to an expanding crisis that will drive up health care costs.
Even if lawmalkers started now to address the emerging policy and budget crisis facing state funded ALFs, there would be several years to correct the many issues that years of neglect have brought.
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.
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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