# Presentation: 043333

- Comprehensive and Coordinated Systems of Care:
- Eligibility and Access Barriers
- Kenneth Ritchey, Director
- Ohio Department of Mental Retardation and Developmental Disabilities

## Ohio’s Current System

- Department level agencies
- 88 CBMRDD
- 51 Mental health boards
- Local authority
- Local taxes

**Notes:**
Each department (ODMRDD & ODMH) are cabinet-level departments. Some mental health boards are multi-county.
CBMRDD and MHB  have local taxing authority. CBMRDD have local authority to administer Medicaid, determine eligibility, etc. Services are county-based. 

## The “State” of Ohio 

- Services were fragmented
- Systems did not talk to each other
- Each system “blamed” the other
- “Primary diagnosis”
- Virtually no shared funding

**Notes:**
In many cases, there was no communication at the local or state level. Each system would try to “pass the buck” to the other system. There were long memories of the “other”system not doing anything. Individuals were excluded from services as their “primary diagnosis” was Mi or MR. Funding was not shared( now the MH system may put up the match for a waiver).

## Ohio’s Efforts to Coordinate Care

- Directors Ritchey and Hogan(ODMH) establish MI/MR Advisory Board to:
- Identify Best Practices
- Recommend ways to overcome barriers between systems
- Train staff in both systems.

**Notes:**
Best Practices document published and distributed during series of regional trainings.
6 regional trainings held fall of 2001.
ODMRDD and ODMH helped sponsor NADD conference last 2 years.

## More Efforts

- Interagency Agreement between ODMRDD and ODMH
- Ohio’s Coordinating Center of Excellence for MR/MI
- Professorship in MR/MI at Wright State University funded by ODMRDD, ODMH, Montgomery CBMRDD, and Montgomery County Board of Alcohol, Drug Addiction, and Mental Health Services
- ODADAS has become a part of CCOE Advisory Board.
- Currently developing an interagency agreement between ODMRDD and ODADAS

**Notes:**
Interagency Agreement calls for staff that work in state psychiatric hospitals to exhibit core competencies in working with MI/MR.
CCOE funded by ODMRDD,ODMH, and DD Council
WSU trains psychiatric residents to work with individuals with disabilities.
ODADAS has joined the CCOE Advisory Board to help with those individuals who also have a substance abuse problem. ODADAS also joined planning committee for NADD- Ohio conference. Representatives from ODMRDD and Ohio Department of Alcohol and Drug Addiction Services(ODADAS) have been working on an interagency agreement. 

## Access to Better Care

- Leading adolescent health challenge
- Leading cause of death among teens via suicide
- Major driver of school failure
- Major challenge in Ohio’s child welfare system
- Major challenge in juvenile justice

**Notes:**
OFCF Cabinet Council identified children’s behavioral health needs as single new area of focus; Governor Taft directed CC to begin planning around this issue.

## ABC Recommendations

- Focus prevention efforts
- Intervene earlier with children and their families
- Reduce treatment gaps and empower parents so children with behavioral disorders do not fall through the cracks, and families do not have to trade custody for care.

## Ohio Autism Taskforce

- HB 95 required that OAT investigate the increasing incidence of autism and to determine what gaps exist in the delivery of service.

**Notes:**
Incidence of autism increasing at alarming rate. Estimate is that 1 out of 250 children are born with autism.

## Autism Taskforce Recommendations

- Establish a standard practice of autism diagnosis
- Regional disparity of services be eliminated.
- Maintain or increase funding for programs
- Quality and quantity of family support services increased
- Autism waiver should be submitted to CMS

**Notes:**
1.Enormous variability throughout the state and within the medical community regarding the diagnostic process.
2.Regional service delivery system will positively impact this situation.
3.Quality and quantity of services provided to individuals with autism is dependent upon an adequate amount of resources.
4. Many parents testifying highlighted the financial and emotional strains caused by lack of adequate support services.
5.Medicaid waivers represent an important funding alternative in resource limited fiscal enviroments.

## Screening and Eligibility

**F**ederal **E**ligibility **D**etermination
- COEDI (MRDD System)
- DSM IV Diagnosis** **

**Notes:**
COEDI/OEDI is functional eligibility determination. Must have substantial limitations in 3 out of 7 areas(mobility,receptive & expressive language, self-care, self-direction, capacity for independent living, learning, and economic self-sufficiency(Does not apply to children) Eligibility locally determined. Can be eligible in one county but not in another. Can appeal eligibility determination to the Director.
MH-based on diagnosis- mental illness seen as “behaviors” in individuals with MR
Coordinating eligibility across systems is difficult- systems continue to try to exclude the other.
Still need to develop single plan

## Barriers

- Qualified and trained staff in both systems
- Housing
- Employment
- Lack of waivers for mental health services
- Lack of waivers for children

**Notes:**
IMD Exclusion- Institution for Mentally Disabled. Freestanding psychiatric facility that has more than 16 beds is not eligible for Medicaid. Individuals that are in these facilities lose Medicaid eligibility.
Waivers are for people who meet ICFMR level of care. Children typically do not meet this. Far less waivers for kids versus adults.

## More Barriers

- Funding in silos
- Parents relinquish custody
- Waiver match
- Significant barriers exist as a result of the institutional bias of Medicaid.

**Notes:**
Services for children is funded categorically (schools, child welfare, MRDD,MH, Juvenile Justice) Difficult to blend.
Not all counties have tax levies to provide local match.
Institutional bias results in ICF/MR facilities having rules that fall outside of the purview of state regulation, and in a mindset that drives the MR/DD system to view medications as restraints as restraints, and that often prevents people from seeing behavior as symptomatic. 

## Recommendations for Federal government

- Create incentives to serve children in the community.
- Medicaid waivers for services across systems.
- National Centers of Excellence
- ICF/MR should not be required to be offered but should be last resort.
- Funding should be same between ICF/MR and waivers.

**Notes:**
Too many individual funding streams that come from feds.. This complex funding only increases difficulties with access and tends to lead to more institutional responses as there seems to be more funding for those, albeit at the cost of custody relinquishment.
Children should be served and raised in the community and not in institutions.
Waivers for services across systems would make it easier to blend funding from different systems.
National Centers of Excellence could provide states with invaluable training, consultation, and education.
ICF/MR program pays for room and board and waiver program does not so we treat same population differently.