I 4 United States General Accounting Office GAO Report to Congressional Committees I7 !kptember 1990 MENTAL HEALTH PLANS Many States May Not Meet Deadlines for Plan Implementation United States GAO General Accounting Office Washington, D.C. 20648 Human Resources Division B-239437 September 18, 1990 The Honorable Edward M. Kennedy Chairman, Committee on Labor and Human Resources United States Senate The Honorable John D. Dingell Chairman, Committee on Energy and Commerce House of Representatives This report responds to a provision of Public Law loo-690 requiring the Comptroller General to evaluate states’ implementation of the State Comprehensive Mental Health Services Plan Act of 1986 (P.L. 99-660) and report on it by September 30, 1990. This law requires states to plan and implement community-based care for their seriously mentally ill;’ it also directs the Department of Health and Human Services (HHS)to pro- vide planning assistance. We have concluded that it is too early to fairly and adequately assess implementation because states are not required to fully implement their plans until September 1991. During discussions with the Senate Committee staff, we agreed to examine state planning activities and assess the National Institute of Mental Health’s (NIMH) role in helping states develop plans. Toward this end, the objectives of this review were to assess the usefulness and timeliness of the assistance NIMII provided to help states develop plans, processes NIMHused to review plans and the outcomes of the reviews, benefits states derived from the act, and problems states may have in meeting the act’s implementation time frames. To achieve our objectives, we carried out several activities: Scopeand Methodology . At NIMH,we interviewed officials for descriptions of the kinds of plan- ning assistance they gave to states. We also observed NIMH’Spanel ses- sions, at which the plans were reviewed, and gathered information about the final outcomes of these reviews. (We did not attempt to make ‘Althoughthelegislation usestheterm“chronically”mentallyill, subsequent legislative amendments we thepreferredterm“seriously”mentallyill. Page1 GAO/HRLHKI-142 StateMentalHealthPlans a-239437 services. (3) States complied with it by defining and identifying the seri- ously mentally ill. (4) It was also responsible, national mental health advocacy organizations said, for greater involvement of the mentally ill and their advocates in mental health planning at the state level. Most of the 51 states we contacted said they would have difficulty meeting the act’s deadlines. Forty-one states anticipated problems meeting the September 1990 deadline requiring substantial implementa- tion, and 45 states, the September 1991 deadline requiring full imple- mentation. Several problems will hamper timely implementation, such as the major changes states said they need to make in their mental health delivery systems, which will take longer than the 2 years pro- vided in the act. Title V of the 1986 act requires each state to develop and submit to HHS Background a comprehensive mental health services plan that would be used to develop community-based care for the seriously mentally ill.” To develop the plans, the Congress appropriated $4.8 million for fiscal year 1988 and $4.7 million for fiscal year 1989. The first plans were originally due September 1988, but NIMHextended the deadline to January 1989 because planning funds were not provided until June 1988. The deadline for the second set of plans was September 30, 1989. In their plans, states were to include evidence that they had responded to eight requirements set forth in the act. It directed the Secretary of HHS to assist the states, including giving them a model plan, which HHSdid in October 1987. The Secretary was to evaluate state plans against the act’s requirements and impose penalties on states if plans did not comply. Penalties could be as much as 10 percent or as little as 0.2 per- cent of a state’s Alcohol, Drug Abuse, and Mental Health block grant allotment. The Secretary could not, however, require states to spend more money on mental health services than they would have spent without the act’s planning requirement. To avoid penalties, states must (1) develop acceptable plans by Sep- tember 30, 1989, (2) substantially implement them by September 30, “Theactallowseachstateto defineitsownseriously mentallyill population. NIMHprovidedguid- ancein theformof modeldeftitionsfor adultsandchildren.According to themodel,diagnostic factorsshouldincludethe(1)typeof illness,(2)levelof disability,and(3)durationof illness. Page3 GAO/HRD90-142 StateMentalHealthPlans B239437 March 1990, most states had revised their plans and HHShad approved them. Two plans were not approved and NIMHrecommended that HHS impose the penalties called for by the act. To evaluate submitted state plans, NIMHconvened panels of mental health experts in November and December 1989. These panels consisted of medical practitioners, service providers, academicians, hospital per- sonnel, representatives of state mental health organizations and private nonprofit organizations, and the mentally ill or their family members or both. The use of knowledgeable reviewers outside the agency to eval- uate plans gave ~TMFIan independent perspective on the plans’ efficacy. Panel members reviewed and commented on (1) the responsiveness of each state’s plan to the eight requirements outlined in the law and (2) other issues relating to mental health planning and community-based services. Some problems include these: l Panelists raised questions about plan input from the seriously mentally ill in many states. . Panelists expressed concern that many state plans did not provide ade- quate financial support. For example, panel members noted that state mental health planners in Alaska and New Jersey acknowledged that inadequate state financing could make service goals unattainable. Panel members thought Iowa’s plan should have addressed the availability of county funds in addition to state mental health funds. . Panel members found a lack of commitment by some states to move toward a community-based system of care. In one state’s plan, for example, they found that the ratio of allocated resources between hospi- tals and community services was expected to remain constant at 80 per- cent for hospitals and 20 percent for community services. NIMH’Sreview was confined to the act’s requirements. Its primary con- cern involved the information on numbers to be served-19 state plans did not have this information. Other concerns dealt with (1) inadequate descriptions of activities that would reduce the rate of hospitalization and (2) insufficient evidence of consultation with state institutions’ and nursing homes’ employee representatives. In January 1996, I\~IMIIapproved 26 state plans as submitted and required the remaining states to revise their plans to bring them into compliance with act requirements. By March 1990, all plans but those of Guam and Puerto Rico had been revised and approved. Guam had not included information on numbers to be served, and Puerto Rico had not Page5 GAO/IUD90.142 StateMentalHealthPlans B-239437 seriously mentally ill in 1990 and 9, the same number as in 1989. State officials told us they would serve, collectively, about 5 percent more seriously mentally ill people in 1990 than in 1989. State officials also estimated they would serve, on average, almost 44 percent of their seri- ously mentally ill population, with estimates ranging widely from 15 to 89 percent. (See app. II.) Many states said, and NIMHofficials agree, that states will have diffi- Many States May Not culty meeting the act’s deadlines for full implementation. Of the 51 Meet Implementation states we spoke with, 41 said the September 30, 1990, deadline allowed Time Frames too little time to substantially implement the plans; 45 said the Sep- tember 30, 1991, deadline allowed too little time to fully implement them. Problems delaying implementation include (1) differences between the federal and state cycles for planning, budget, plan approval, and program operation; (2) the uncertainty of funds for imple- menting the plans; and (3) the major changes many states have to make to their mental health systems to comply with the act. The federal and state cycles for mental health planning, budgeting, and program operations differ. The plans submitted by the states were for the federal fiscal year, October 1, 1989, to September 30, 1990. Most state fiscal years, however, are July 1 to June 30. Twenty states sought mental health funding from their state legislatures to meet the objec- tives of their plans on or after January 1, 1990. The funding their legis- latures approve will be for the states’ fiscal years, starting July 1, 1990, leaving only 3 months for states to meet the act’s September 30, 1990, deadline. Six states told us they are under biennial planning and budgeting cycles, making it difficult to quickly change their mental health plans. Over half of the states mentioned funding and staffing problems as fac- tors that may impede plan implementation. The act requires certain ser- vices, such as case management services, but does not provide additional federal funding. Some states said staffing problems, including the need to hire and train community mental health workers, would slow the pace of implementation. In addition to resource problems, 15 states said the act requires major changes to their current systems, which will take longer than 2 years to completely implement, for example: Page7 GAO/HRD-90142 StateMentalHealthPlans IS239437 Please call me on (202) 275-1655 if you or your staffs have any ques- tions about this report. Other major contributors to this report are listed in appendix III. Linda G. Morra Director, Intergovernmental and Management Issues Page9 GAO/HRD!W142 StateMentalHealthl%tm GAO/HRD-SO-142 StateMentalHealthPlans AppendixI Background The plans were to address the following eight requirements: Plan Content . Establish and implement an organized community-based system of care for the seriously mentally ill. . Specify quantitative targets to be achieved in implementing such a system, including number of seriously mentally ill people residing in the areas to be served under such a system. . Describe services to be provided for the seriously mentally ill that would enable them to gain access to mental health services, including access to treatment, prevention, and rehabilitation services. . Describe rehabilitation services, employment services, housing services, medical and dental care, and other support services to be provided for the seriously mentally ill in order to enable them to function outside of inpatient institutions to the maximum extent of their capabilities. Provide “activities” (programs) that would reduce the rate of hospitali- zation for the seriously mentally ill. Provide case management services for the seriously mentally ill who receive substantial amounts of public funds or services. Provide for the establishment and implementation of a program of out- reach to, and services for, the seriously mentally ill who are homeless. Consult with representatives of employees of state institutions and public and private nursing homes who care for the seriously mentally ill. The act provides that if the Secretary of HHSdetermines that a state has Penalties for Failure to not developed the required plan by September 30, 1989, he must reduce Comply the state’s ADMSblock grant allotment for fiscal year 1990. Furthermore, if the Secretary determines that a state has not (1) developed and sub- stantially implemented its plan by September 30, 1990, and (2) devel- oped and completely implemented its plan by September 30, 1991, he must reduce the state’s ADMSblock grant allotment for the affected fiscal years and succeeding years. This reduction is to continue until the state has developed and completely implemented the required plan. Legislation (P.L. 100-690, section 2041) in November 1988 specified the amount and range of grant reductions. Grants to states may be reduced by the maximum amount the state is permitted to spend for administra- tive expenses (10 percent of the state’s allotment) for fiscal year 1986. This legislation authorizes the Secretary, after determining that the state is making a good faith effort to comply, to reduce the penalty to as little as 2 percent of the amount the state was permitted to spend on administrative expenses (0.2 percent of the state’s allotment). Page13 GAO/HRDW142 StateMentalHealthPlans Append’ix II Seriously Mentally IlI Population by State In 1990 Served To be Estimated To be served State (1989) served population (in percentP AK t h 5,750 . AL 24,378 29,000 43,000 674 AR 8,328 9,000 16,000 563 AZ 10037 10.037 h . CA 150,000 150,000 300,000 500 / r 144,300 . co CT 35.000 36,000 245,000 147 DC 1, b . DE 2 780 3.200 5,200 61 ii FL 35502 37,127 50,628 733 635 HI 3000 6,696 II ,000 60 9 IA /I 25,000 . ID 7 128 7,484 b . IL 51,850 61,589 842 IN 17884 19,000 38,000 50 0 KS -6000 8,000 10,360 772 KY 16.000 16.000 28,000 57 1 LA 23000 25.530 52,026 491 MA 35.000 57.000 61 4 MD I> 137,000 . ME 37 783 37.950 54,000 703 MI 18500 26,000 92,000 283 MN /a 85,000 . MO 20218 20.218 42,139 480 MS 18019 23,779 35,180 676 MT ,. 5.836 . NC 38667 45,286 103,218 439 ND 5550 5912 12.083 489 NE 2900 3,050 4,236 720 NH 5088 5,700 7,036 81 0 NJ 67030 67,680 108,685 623 NM 5601 5,925 12,260 483 NV 5615 7.351 11957 61 5 NY 155000 155,000 228,000 680 OH 27973 28,000 60,000 467 OK 24 000 29,434 49,056 60 0 OR 27 383 28,615 67,086 427 (continued) Page15 GAO/HRD-W-142 StateMentalHealthPlans Appendix III Major Contributors to This Report Carl R. Fenstermaker. Assistant Director, (202) 275-6169 Human Resources John M. Ka,nensky, Assistant Director Division, Robert F. Derkits, Assignment Manager Washington, D.C. Benjamin C. Ross, Evaluator Joanne R. Frankel, Senior Social Scientist Mark S. Vinkenes, Social Science Analyst Wayne L. Marsh, Evaluator-in-Charge San Francisco Susan S. Mak, Evaluator Regional Office Lisa Lensing, Evaluator (118846) Page17 GAO/HRE-SO-142 StateMentalHealthPlans Ordering Information The fit five copies of each GAO report are free. Additional copies are $2 each. Orders should be sent to the following address, accom- panied by a check or money order made out to the Superintendent of Documents, when necessary. Orders for 100 or more copies to i: mailed to a single address are discounted 25 percent. U.S. General Accounting Office P.O. Box 6016 Gaithersburg, MD 20877 Orders may also be placed by calling (202) 275-6241. . AppendixII !kiously MentallyIll Populationby State In 1990 Served To be Estimated To be SeNed State (1969) served population (in percent) PA h b 588,000 . RI 5,305 5,305 9,000 58.9 SC 11700 12,800 24,000 53.3 SD II I> 5,069 . TN 46199 48,509 61,439 79.0 TX 136,000 136,000 628,000 - 21 7 UT 10500 11,500 42,500 27 1 VA 18500 22.000 60.000 367 VT 2.656 2,880 3,500 823 WA 27650 28,341 32.000 886 WI 33000 35,000 b . WV 18,132 18,132 24,605 73.7 WY 4974 5,855 8,821 66.4 TotaP 1,145,304 1,203,264 2,709,966 “Average percent to be served during 1990 IS 44 4 “State could not prowde total population estimates for the seriously mentally III that included Institution- allzed and nonlnstltut~onallzed adults. adolescents and children, and homeless %cludes only the 37 states provldlng complete InformatIon for all three categories Page16 GAO/~W-142 StateMentalHealthPlans AppendixI Backgmund For each of fiscal years 1988 and 1989, the 1986 act authorized Federal Funds for $10 million to aid states in developing their plans. The Congress appro- Planning priated about $4.8 million for fiscal year 1988 and about $4.7 million for fiscal year 1989. HHSretained $101,600 of the fiscal year 1988 appropri- ation and $113,000 of the fiscal year 1989 appropriation to provide technical assistance to the states. Each state received $82,200 in fiscal year 1988 and $81,000 in fiscal year 1989. The Congress did not authorize any funds for mental health planning for fiscal year 1990. In 1989,’ we reported that of 14 states surveyed, 13 (1) used their fiscal Use of Federal Funds year 1988 funds to hire new staff within their mental health planning offices to do planning, coordination, and clerical activities or (2) con- tracted with mental health consultants to write their plans. The other state used its funds to support administrative expenses, such as printing and data processing costs. Ten states also used the funds for travel expenses incurred by their planning councils. Several states supple- mented the federal funds with their own funds-for example, New Mexico and Puerto Rico each provided an additional $50,000 for devel- oping their plans. ‘MentalHealth:FundsYcedvd for FuturePlanning Activities(GAO/HRD-89-94, Apr.28,1989). Page14 GAO/HRD-90.142 StateMentalHealthPlans Appendix I Background Millions of people in this country suffer from some serious-that is, per- sistent and severe-form of mental illness. Many reside in institutional settings, such as state mental hospitals and nursing homes. Others live in residential treatment centers, group homes, and sheltered apartments, as well as independently or with their families. Still others move between hospitals, homelessness, and jails due to inadequacies in state and local service systems. The Congress and the federal government, for over 20 years, have been working to develop programs to assist in the treatment and rehabilita- tion of the seriously mentally ill; the goal of the programs has been to move these mentally ill from institutions to community-based systems. Primary among these programs was the Community Mental Health Cen- ters Act of 1963 (P.L. 88-164), which provided federal funds to states for the construction of community-based mental health centers. This act was amended and extended several times between 1963 and 1981. In 1981, the Congress created the Alcohol, Drug Abuse and Mental Health Services (ADMS)block grant (P.L. 97-35), which consolidated several cat- egorical programs, including the Community Mental Health Centers pro- gram, into a single block grant to the states. Despite the federal support provided during the past 20 years, the Con- gress has continued to express concern about the frequency with which people with long-term mental illness fall through the cracks of mental health and social service systems. These people frequently have been unnecessarily rehospitalized, placed in the criminal justice system for minor infractions, or become homeless. To help establish or further develop comprehensive systems of ser- vice-including Medicaid, vocational rehabilitation, psychosocial reha- bilitation, housing, income support, education, and health and mental health services-the Congress, in November 1986, passed the State Comprehensive Mental EIealth Services Plan Act of 1986 (P.L. 99-660). Title V required each state to develop and submit to the Department of IIealth and Human St>rvices (HHS)comprehensive mental health services plans that would establish and implement community-based systems of care for the seriously mentally ill. In developing their plans, states were to consult with employee representatives of (1) state mental institutions and (2) public and private nursing homes who care for the seriously mentally ill. Page12 GAO/HRD-W-142 StateMentalHealthPlans Contents Letter 1 Appendix I 12 Background Plan Content Penalties for Failure to Comply 13 13 Federal Funds for Planning 14 Use of Federal Funds 14 Appendix II 15 Seriously Mentally Ill Population by State Appendix III Major Contributors to This Report Abbreviations ADMS Alcohol, Drug Abuse, and Mental Health Services HHS Department of Health and Human Services NASMHPDNational Association State Mental Health Program Directors NIMH National Institute of Mental Health Page10 GAO/HRD9@142 StateMentalHealthPlans B239437 Four states said that they needed additional time to coordinate and inte- grate the efforts of various service providers. One state said it would have to significantly expand community-based services to reduce its hospitalization rate, explaining that it would take more than 2 years to set up local management systems and to redirect resources to meet local needs. Because states realized that these changes would take a long time to implement, 18 plans covered periods ranging from 4 to 10 years. Full implementation, in these cases, within the 2 years provided by the act would not occur. States and NIMHhave complied with the act’s planning requirements. In Conclusions addition, the act has achieved beneficial results, including a greater role for the mentally ill, their families, and advocates in mental health plan- ning, as well as, in many states, more money for community mental health services. However, it appears that many states will have diffi- culty meeting the act implementation deadlines and, as a result, will be subject to reductions in block grant allotments in fiscal years 1991 and 1992. States believe, and NIMHagrees, that it will take more time than provided in the act to implement their plans. - HHSand the National Association of State Mental Health Program Direc- Agency Comments tors (NASMHPD)provided comments on this report. HHSsaid the report (1) was helpful in understanding the act’s initial effects on state mental health systems and (2) accurately reflected NIMH'Srole and responsibili- ties under the act. HHSalso suggested some technical corrections that we have incorporated into the report as appropriate. NASMHPD agreed that the act stimulated increased state planning and actions for the seriously mentally ill and that many states may not be in full compliance by the act’s September 1991 deadline. NASMHPD pointed out that some states clearly chose longer time frames for their plans and frequently presented optimal sets of goals, many of which depend on additional funding. Copies of this report will be sent to the Secretary of HHSand other appropriate congressional committees. Copies will also be made avail- able to others on rcqucxst,. Page8 GAO/HHD9O-142 StateMentalHealthPlans H-239437 provided information on consultation with employee representatives of nursing homes. In March, NIMHrecommended that the Secretary of HHS impose the penalties provided for in the act. The act’s planning requirements achieved some beneficial results. States Act, Has Been (1) involved state mental health planning councils, including the men- Beneficial tally ill and their family members, in the mental health planning pro- cess; (2) directed more funds toward community-based services; and (3) defined and identified their seriously mentally ill populations. States’ estimates of the mentally ill to be served vary widely, ranging between 15 and 89 percent of the identified seriously mentally ill population. At least 31 states intend to serve more of this population in 1990 than in 1989. NIMHencouraged states to develop their plans in consultation with ser- vice users and their advocates. Our survey of state mental health offi- cials disclosed that this occurred frequently. States told us their planning councils, which included the seriously mentally ill and their advocates, (1) reviewed and commented on their plans and (2) wrote parts of 25 plans and formally approved 18. Officials of three major mental health organizations-the National Alliance for the Mentally Ill, the National Mental Health Association, and the National Association of State Mental Health Program Directors-also cited increased involve- ment by service users and advocates as one of the act’s major accomplishments. Many states attributed to the act increased funding for community- based mental health services in 1990. Eighteen states said the act was “definitely responsible” for funding increases, and another 18 states said it was “probably responsible” for the increases. Most states also defined and identified their seriously mentally ill popu- lation. Although NIMHprovided guidance in the form of a model defini- tion, the act allowed each state to define its population. We reviewed 28 plans and found that 16 definitions were equal to, or broader than, the model definition and 8 were narrower. We were unable to characterize the definitions in 4 plans. Forty-seven states were able to estimate the size of their seriously men- tally ill populations; 40 states provided the number served in 1989 and 42, the number they expect to serve in 1990. Of the 40 states that pro- vided both 1989 and 1990 data, 31 estimated they would serve more Page6 GAO/HRD90142 StateMentalHealthPlans H-239437 1990, and (3) fully implement them by September 30, 1991.4 As of June 1990, NIMHhad not defined “substantially implement,” but was studying different methods to be used to assess states’ implementation of their plans. The legislative requirements, the nature of the penalties, and additional background information are in appendix I. NIMHprovided several types of planning assistance that were timely and NIMH’s Technical useful. One type consisted of technical papers and a manual, including Assistance WASTimely (I) a model plan provided early to states as a guide in developing their and Useful plans, (2) two technical papers addressing ways to finance a mental health system and methods of gathering data to support mental health planning, and (3) a handbook on how to evaluate a mental health system. Another type consisted of NIMH’Sreviewing and commenting on state plans. NIMHasked states to submit initial plans by danuary 10, 1989, to strengthen state-planning capacity and establish baselines for future compliance reviews. KIMHprovided timely written feedback to the states on how they could improve their plans for the submissions due Sep- tember 30, 1989. A third type consisted of workshops and on-site visits conducted by the COSMOS Corporation, a research organization, under contract with NIMH.COSMOS also (1) disseminated a newsletter, Mental Health Planning News, and (2) developed planning case studies as well as key documents to assist in planning activities. Most states found NIMH’Stechnical assistance helpful. For example, 46 of the 5 1 states we contacted reported that the publications were “helpful”; only 5 said they were “of little or no help.” Of the 43 states that asked for additional assistance, 28 rated the assistance as “very helpful”; 12 said “moderately helpful”; and only 3 said “little or no help.” NIMHassembled panels of mental health experts to evaluate and com- Most Plans Approved ment on state plans and also used its own staff to review the plans. NIMH approved 26 plans in January 1990 as meeting the act’s requirements and questioned the completeness of the rest, particularly the adequacy of the information on the number of people to be served. NIMHadvised the states of its concerns and required them to revise their plans. By ‘%.tesarepermittedanadditionalyear,untilSeptember 30,1992,to phasein casemanagement services for all theseriously mentallyill whoreceive substantial amounts of publicfundsor serwces. Page4 GAO/HHLHO-142 StateMentalHealthPlans 5239437 any independent judgments on plan adequacy, but, rather, relied on NIMH’Sand panel reviewers’ judgments.) l By telephone, we surveyed state mental health officials in all 50 states and the District of Columbia to obtain their views of the usefulness and timeliness of the assistance NIMHgave them in developing their plans. We also asked these officials to comment on the (1) benefits, if any, they derived from the act and (2) problems they might face in meeting the implementation deadlines. (We did not independently verify all the information provided by the states.) . Finally, we interviewed officials of public interest groups for their opin- ions on the effects the legislation might have on state mental health programs. We did our review from January to March 1990 in accordance with gen- erally accepted government auditing standards. Fifty states, the District of Columbia, and seven territories submitted Results in Brief plans by the required date, September 30, 1989 (hereafter, the term “states” will include the District and the territories).l NIMHprovided timely and useful technical assistance to help states prepare the plans, including a model plan, technical papers, and contract support. Many states told us this assistance was helpful in developing their plans. In November and December 1989, NIMHconvened panels of experts to review the state plans and reviewed the plans itself. In January 1990, NIMII approved the 26 plans that met the act’s requirements. Reviewers noted that the remaining state plans did not meet one or more of the requirements. NIMHgave these states added time to revise their plans in response to reviewers’ comments. By March 1990, most states had revised their plans so they would conform to the act’s requirements and NIMHhad approved all but two plans, for which it recommended penal- ties for noncompliance. The act has achieved some beneficial results: (1) States and organiza- tions told us it enhanced the participation of the mentally ill and their advocates in state mental health planning. (2) Many states also said it increased the funds directed toward community-based mental health ‘TheterritoriesareAmerica~rSamoa,Federated Statesof Micronesia.Guam,theMashallIslands, the NorthernMarianaIslands.PuertoRico,andtheRepublic of I’alau.TheVirginIslandswereexempt fromthesubmissmn deadhnrbecausetheirplanning-related materialsweredestroyed by hurncanr Hugo.TheVu-gm Islands‘planwassubmittedin April 19RO Page2 GAO/HRDW-142 StateMentalHealthPlans
Mental Health Plans: Many States May Not Meet Deadlines for Plan Implementation
Published by the Government Accountability Office on 1990-09-18.
Below is a raw (and likely hideous) rendition of the original report. (PDF)