District of Columbia: Status of Reforms to the District's Mental Health System
Published: 2004-03-31T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Since 1975, the District of Columbia has operated its mental health system under a series of court orders aimed at developing a community-based system of care for District residents with mental illnesses. Placed in receivership from 1997 to 2002, the District regained full control of its mental health system in 2002 but has been ordered to implement a courtapproved plan for developing and implementing a community-based mental health system. Additionally, the District must comply with exit criteria, which must be met in order to end the lawsuit. The court expects that it will take the District 3 to 5 years to implement the courtordered plan and begin measuring performance against the exit criteria, with year 1 beginning in July 2001. GAO was asked to report on the current status of the District's efforts to develop and implement (1) a mental health department with the authority to oversee and deliver services, (2) a comprehensive enrollment and billing system that accesses available funds for federal programs such as Medicaid, (3) a consumer-centered approach to services, and (4) methods to measure the District's performance as required by the court's exit criteria.
section_title: What GAO Found
paragraphs: The District created the Department of Mental Health (DMH) in 2001 to oversee the provision of mental health services. DMH methods of oversight have included establishing certification and making use of licensing standards for participating providers and beginning to monitor provider compliance. DMH also continues to deliver direct services, acting as the primary provider for 55 percent of all consumers enrolled in the mental health system as of October 2003, and operating over 500 beds at St. Elizabeths Hospital, the District-run institution specializing in inpatient care for people with acute, intermediate, and long-term mental health needs. DMH has also implemented a comprehensive enrollment and billing system designed to coordinate clinical, administrative, and financial processes. The system links payment to consumer treatment and increases access to federal funds by providing mental health rehabilitative services through the District's Medicaid program, which reimbursed DMH $17.5 million in federal Medicaid funds in fiscal year 2003. Providers have faced challenges managing cash flow in a fee-for-service system where service demand varies throughout the year. Also, because provider contracts were tied to the feefor- service billing projections, DMH could not pay claims for providers who were exceeding their projections until their contracts were changed, and providers did not always receive timely claims payments in fiscal year 2003. DMH senior officials noted that DMH has a plan in process to prevent this problem from recurring. DMH activities to increase the involvement of consumers in their own treatment and recovery process are evolving. While DMH has established a number of requirements in two key areas--consumer choice and consumer protection--its initial review of providers' records showed gaps in documentation of consumer participation in treatment planning for 41 percent of the records reviewed. Consumer protection policies are also evolving, as DMH instituted a consumer grievance policy that provides a uniform process for ensuring that all consumer grievances are tracked. DMH is developing data collection methods for 17 performance targets aimed at determining the system's performance against the court's exit criteria. Although the court monitor expects DMH to both measure and improve its performance in fiscal years 2004 and 2005, DMH faces major challenges in accurately measuring its performance, including establishing methods to collect electronic data, correcting known data deficiencies, and working with providers to submit accurate data. In its comments on a draft of the report, DMH indicated that the report did not reflect the entire spectrum of progress made since the creation of DMH. While the progress cited by DMH is important, GAO believes that focusing on DMH's status in meeting the exit criteria is an appropriate gauge of its overall compliance with the Dixon Decree.

section_title: Letter
paragraphs: In 1997, the U.S. District Court for the District of Columbia found that the  District had failed over the previous 22 years to comply with a 1975 court  determination, known as the Dixon Decree, that District residents with  mental illnesses have a statutory right to community-based treatment  under the least restrictive conditions when that treatment is clinically  appropriate. Consequently, the court placed the District of Columbia  Commission on Mental Health Services in receivership and appointed two  successive receivers, one in 1997 and one in 2000. Both receivers were  charged with implementing the transition from treating consumers in an  institutional setting, specifically in the District-run St. Elizabeths Hospital,  to delivering a broader array of mental health services—including  counseling, supported employment, and housing—in the community. Both  receivers introduced initiatives intended to enhance the District’s  community-based mental health system. In response to congressional  concerns, we previously examined the second receiver’s plan to comply  with the Dixon Decree. In October 2000, we reported that compliance with  the Dixon Decree would require a fundamental shift in the District’s  approach to providing and financing mental health operations, including  (1) assuming the more traditional oversight responsibilities of a mental  health department and (2) increasing access to federal funds for Medicaid,  the joint federal-state program for low-income families and aged, blind,  and disabled people, to expand the scope and number of covered  community-based mental health services. We also reported on challenges  remaining to comply with the Dixon Decree.
In 2002, the District regained full control of its mental health system from  the second receiver. However, the District remains under court order to  implement a plan and comply with exit criteria for ending the Dixon  lawsuit including meeting specific performance targets. The final plan,  which was completed by the second receiver in 2001, provides an overall  framework for developing and implementing an effective and integrated  community-based system of mental health care for the District of  Columbia. Within this framework, the District is responsible for  establishing certain components, including a new department of mental  health capable of overseeing and delivering mental health services and  developing and implementing a comprehensive enrollment and billing  system for community-based providers. The final plan also highlights the  need for consumers of mental health services to be offered choices from  providers about the services they receive. In December 2003, the court  approved a set of exit criteria, which provides a basis to measure the  District’s performance in a number of areas, such as consumer satisfaction  and system performance. One exit criterion, for example, requires the  District to demonstrate that it is providing continuity of care for  consumers moving from an inpatient to a community-based setting. Until  the exit criteria are fulfilled, the Dixon lawsuit remains open. Overall, the  court expects that it will take the District 3 to 5 years to implement the  court-ordered plan and begin measuring its performance against the exit  criteria, with year 1 beginning in July 2001.
In keeping with your oversight responsibilities with regard to the District  of Columbia, you asked us to report on the status of the District’s effort to  establish a community-based system of mental health care, particularly the  District’s steps to develop and implement (1) a mental health department  with the authority to oversee—through regulation and monitoring—and  deliver mental health services, (2) a comprehensive enrollment and billing  system that accesses available federal funds, (3) a consumer-centered  approach to services, and (4) methods to measure the District’s  performance as required by the court’s exit criteria.
To review the District’s actions to implement the final plan, we analyzed  court orders, including the final plan and exit criteria; policies; reports;  and evaluations regarding the District’s implementation of a community- based mental health care system. We interviewed the court monitor, who  was also the second of the two receivers and was charged with monitoring  implementation of the final plan. Additionally, we interviewed District  officials, consumer advocates, and providers. We reviewed available data  on mental health programs and services in operation in the District for  fiscal year 2003, including data on District residents with mental illnesses  who are enrolled consumers of the mental health system. We corroborated  data and information received from the District with available data and  information from the court monitor, providers, and advocates. We  performed our work from July 2003 through March 2004 in accordance  with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: In 1974, a class action suit filed in the U.S. District Court for the District of  Columbia on behalf of individuals with mental illnesses alleged that the  practice of treating the District’s mental health patients in an institutional  setting violated the statutory rights of individuals. Specifically, the  plaintiffs asserted that patients at St. Elizabeths Hospital had a statutory  right to appropriate care in alternative care facilities when less restrictive  settings were clinically appropriate. In a ruling known as the Dixon  Decree, the court ruled in favor of the plaintiffs in 1975, ordered the  District to build a system to facilitate the provision of community-based  treatment for these individuals, and continued oversight of the District’s  progress in developing this system. In 1997, finding that the District was no  closer to complying with the Dixon Decree than it had been 22 years  earlier, the court placed the D.C. Commission on Mental Health Services in  receivership and appointed a receiver to implement the transition to a  community-based mental health system. This receiver introduced  initiatives that sought to change the way the District delivered services,  but implementation was slow and the first receiver made little progress in  implementing these initiatives during his 2-year oversight of the  commission. Thus, a second or “transitional” receiver was appointed on  April 1, 2000, to facilitate the transition from court receivership to District  control. (App. I summarizes the major court actions related to the Dixon  Decree.)
The transitional receiver was charged with developing a comprehensive  plan for the District to achieve compliance with the Dixon Decree and  resume full control of its mental health system. The court approved a final  plan in April 2001 and required the District to implement it; however,  before the receivership could be ended, the court required the transitional  receiver to certify that the District had the capacity to implement—and  was implementing—the final plan. Although the court originally  anticipated this certification in late 2001, in December 2001 the  transitional receiver recommended extending the date, characterizing the  implementation delay as largely unavoidable because of (1) additional  time needed for recently hired senior DMH managers to begin major  initiatives, and (2) the unexpected need for crisis services to respond to  September 11, 2001, terrorist events. Following this extension, the  transitional receiver reported to the court that the District had made  sufficient progress and, as a result, the court terminated the receivership  and appointed the former transitional receiver as a court monitor to  oversee the District’s continued implementation of the final plan in May  2002. (See table 1.)
subsections: section_title: District Mental Health System Prior to the Approval of the Final Plan
paragraphs: When the transitional receiver was responsible for overseeing the  District’s mental health system, the District was the largest provider of  mental health services to its residents, treating approximately 10,000  consumers annually and employing close to 2,000 staff in fiscal year 2000.  The focal point of the mental health system was St. Elizabeths Hospital,  which was the major point of entry for all consumers in the system. St.  Elizabeths Hospital provided a wide range of mental health services in an  acute care setting, including more than 600 beds divided among two types  of inpatient consumers, forensic and civil, for adults and children and  youth. The District also directly provided services through outpatient  facilities in the community, including two community mental health  centers and five mobile community outreach treatment teams.
In addition to providing inpatient and direct services in the community,  the District contracted with private community providers for housing,  employment, case management, and other community-based services. In  its contracts with private community providers, the District often used a  “slot” system to allocate a defined number of consumers to providers and  paid them a fixed daily rate per consumer. Under this system, providers  did not compete to attract consumers and were paid regardless of  performance, consumer satisfaction, or the actual delivery of service.
The District and its providers focused primarily on treating the medical  symptoms of the consumer without focusing as much on whether the  individual was participating in his or her recovery from mental illness and  successfully living in the community. Furthermore, the system did not  have many safeguards in place, such as uniform provider standards, to  involve the consumer in key aspects of service delivery, such as choosing  a provider and developing a treatment plan based on the consumer’s goals.  The transitional receiver identified the need for a restructured mental  health system that had the flexibility to meet individual needs and allow  consumers to successfully obtain treatment and live in the community,  maximizing principles of accessibility, recovery, and consumer choice.
In 2001, the federal share of Medicaid, an entitlement program in which  states and the federal government are obligated to pay for covered  services provided to an eligible individual, accounted for 8 percent of  District mental health system revenue as compared to the national average  of 22 percent. The transitional receiver identified the need to better  utilize Medicaid as a major funding source. The District’s access to  Medicaid funds had been limited because Medicaid did not cover most of  the services provided at St. Elizabeths Hospital, considered under the  Medicaid statute as a larger psychiatric institution. This effect was  exacerbated by the limited capacity in the developing community-based  system to support inpatients ready for discharge. For example, in October  2000, District officials estimated that approximately 60 percent of  individuals in acute care units at St. Elizabeths Hospital could be moved  into the community where outpatient services covered by Medicaid would  be available, if stable alternative housing were available.
A second limit to the District’s accessing federal funds was that the  District had not taken advantage of optional community-based mental  health services that could be reimbursed through the Medicaid program.  The transitional receiver required the District to implement a strategy  adopted by at least 40 other states to expand the services reimbursable by  Medicaid through an option to cover rehabilitative services, thus  expanding the scope of eligible services and providers beyond that of the  program’s traditional focus on services delivered by physicians and  psychiatrists who work at hospitals, clinics, and other facilities.  Rehabilitative services include crisis and emergency care, medication  treatment, and community-based interventions. The variety of  rehabilitative treatments and services covered by this Medicaid option is  intended to facilitate a consumer’s recovery from mental illness, including  restoring a consumer to his or her best possible functional level.
section_title: Final Plan and Exit Criteria
paragraphs: The court-approved final plan broadly outlines the mental health system’s  direction, philosophy, major roles, and governance. It represents a major  shift in the District’s mental health system on several fronts, including the  system’s structure and organization, method for enrolling consumers and  paying providers, and involvement of consumers in their plan for recovery.  For example, the final plan  identifies the need to create a new mental health department with the  additional responsibility of oversight along with continuing the District’s  historic role as provider;    envisions a significant change in enrollment and billing systems, such as  linking payment to the delivery of services, and developing new funding  strategies that increase federal reimbursement; and    articulates that the new system have a built-in capacity to measure itself in  key performance areas and to translate any findings into continued system  improvements.
Underpinning these structural changes is a refocusing of the mission of the  District’s mental health system toward involving the consumer in  treatment decisions and incorporating changes that facilitate the  consumer’s recovery from mental illness and away from focusing primarily  on treating the individual’s medical symptoms.
The court also approved exit criteria for the Dixon lawsuit, which provide  a basis for measuring the performance of the District’s mental health  system and which must be met in order to end the Dixon case. The criteria  cover four areas:  1.  consumer satisfaction, which assesses consumers’ satisfaction with  mental health services provided;  2.  consumer functioning, which tracks consumers’ clinical, social, and  other conditions upon entry into the mental health system and again  after receiving services for a specified period of time;  3.  consumer service delivery, which assesses the adequacy of the mental  health system’s overall performance for consumers in a range of areas  including treatment planning, coordination of care, and response to  emergent and urgent needs; and  4.  system performance, which demonstrates how well the community- based system of care is serving particular populations.
The first two areas require DMH to develop and implement methods for  reviewing and measuring consumer satisfaction and consumer functioning  and to use the data to refine the system. To fulfill the remaining criteria,  DMH is required to meet 17 performance targets, many of which measure  activities identified as national best practices in the field of mental health.
According to the court monitor, implementing the final plan, including  developing the ability to measure DMH’s progress against the exit criteria,  will take 3 to 5 years, with year 1 beginning July 1, 2001. In general,  efforts for years 1 and 2 were expected to center on planning, laying the  basic infrastructure for the system, and beginning to provide community- based services. By the end of year 3, which began October 1, 2003, DMH is  expected to be stabilizing and improving performance within the system,  and in years 4 and 5 DMH is expected to be actively measuring  performance outcomes. (See table 2.) In addition to developing  performance targets for the exit criteria, the court monitor is required to  provide the court with semiannual reports on the District’s progress in  meeting all of the exit criteria. The court monitor’s first two reports,  submitted to the court in January 2003 and July 2003, respectively, focused  primarily on DMH’s status in implementing the final plan and also included  an update on the status of meeting the exit criteria to end the Dixon case.
section_title: DMH Has Assumed Oversight Authority and Responsibility for Providing Direct Care
paragraphs: In accord with the transitional receiver’s final plan, the District  restructured its mental health system by creating DMH to oversee the  provision of mental health services, including the authority to set  regulations and monitor compliance—a shift away from the structure of its  predecessor office, which was primarily a provider of services. Under this  structure, DMH also continues the District’s historic role as a provider of  mental health services. In its oversight role, DMH has developed  certification standards and made use of licensing standards to enroll a  network of providers to deliver an array of mental health services, which  DMH continues to expand to ensure adequate capacity for community- based mental health services. DMH is in the early stages of implementing  its new monitoring framework to ensure that services are complying with  existing and newly established quality and safety standards. DMH remains  the largest provider of community-based services and continues to provide  inpatient mental health care for the District at St. Elizabeths Hospital.
subsections: section_title: Oversight Responsibilities Include Setting Regulations and Monitoring Provider Compliance
paragraphs: In 2001 the District took the first step toward implementing the final plan  by passing legislation establishing DMH and giving it new oversight  responsibilities, including setting regulations and monitoring community- based provider compliance. The significant organizational change  accompanying the addition of oversight responsibilities required hiring  new leadership and redeploying and retraining a large portion of existing  staff. For example, of DMH’s 270 administrative and oversight staff  positions, which represent approximately 14 percent of all budgeted staff  for fiscal year 2003, the majority of positions were new and required either  redeployment of existing staff or hiring new staff. Consistent with the final  plan, DMH established a training institute to provide staff training and  development, among other services. As of December 2001, a court report  indicated that key leadership positions had been filled, including that of  the director of DMH, who was hired by the mayor in April 2001.  Subsequently, however, one key leadership position, DMH’s chief financial  officer, experienced turnover, with four individuals serving in the role  since April 2001. DMH has also hired two chief executive officers with  experience in other systems undergoing reform, to run its community- based services agency and St. Elizabeths Hospital, respectively. (See table  3 for a summary of DMH’s functional responsibilities, including oversight,  by office.)
DMH became the primary entity for overseeing a mental health system  that is focused on community-based systems of care. (See table 4.) DMH’s  regulatory responsibilities include developing standards and certifying  providers of services, such as rehabilitative services and supported  housing at independent living facilities, and licensing community  residential facilities. As of January 2004, DMH had certified 22 mental  health rehabilitative services providers, licensed more than 148  community residential facilities, and was in the process of implementing a  certification program to oversee more than 400 supported independent  living facilities. DMH addressed rehabilitative services standards by  developing and publishing specific provider certification standards that  took effect on November 9, 2001.
In addition to its regulatory responsibilities, DMH must monitor providers’  compliance with existing and newly developed quality and safety  standards. DMH’s oversight division, the Office of Accountability, has  direct responsibility for monitoring compliance with standards. DMH has  developed a monitoring framework that is in the early stages of  implementation, with DMH beginning to use information from some  monitoring efforts to assess provider compliance and continuing to adjust  other efforts. The following are examples of DMH monitoring efforts:    Safety inspections, which are surveys of the sites where licensed providers  offer services, are used to ensure health and safety standards are met. In  the first 11 months of 2003, DMH conducted at least 150 inspections of 148  eligible facilities. When DMH conducts site inspections, it can issue  notices of infractions for violations of the standards. According to DMH,  from April 2002 through January 2004, it issued 46 notices to 22 providers  and issued more than $29,000 in fines for identified deficiencies, including  items such as insufficient staff on duty, failure to report unusual incidents,  inaccurate personnel records, and exceeding maximum capacity.  Increasing the number of site inspections of facilities that serve DMH  consumers is one of the goals included in the DMH annual “scorecard”  submitted to the District Mayor’s office, which tracks commitments and  deadlines set for DMH.
Provider audits, which are record reviews of certified rehabilitative  services providers, are used to analyze trends across providers and to  ensure that providers are meeting documentation and service standards. In  January 2003, DMH completed its first round of audits for the 12 providers  certified at that time. As expected by DMH for the first year of applying  standards, the audit found that providers were not in compliance with  certain documentation requirements, such as having the approving  practitioner sign the authorized treatment plan, and, as a result, all 12  providers were to implement corrective action plans. While these initial  audits focused solely on provider documentation compliance, the second  round of audits of all certified providers, which DMH expects to complete  in early 2004, will examine how well specific services (such as medication  treatment) are being provided.
Routine, biennial recertification reviews for rehabilitative services  providers, which include evaluations of recorded complaints, audits, and  public comment, are used to ensure that individual providers are  complying with certification standards. With the first round of  recertification applications, begun in December 2003, DMH will be able to  use data from these reviews to make decisions regarding providers’  recertifications.  Investigations of unusual incidents, which are conducted by the Office of  Accountability and providers, are used to ensure consumer safety and  reduce the occurrence of future incidents. DMH is expected to  investigate any major unusual incident, such as consumer deaths, adverse  drug reactions, and allegations of abuse or neglect. Providers are expected  to investigate other, less serious incidents, defined as any events that  occur outside the normal routine of care, and they are required to report  to DMH all unusual incidents and action taken to respond to them.  Unusual incidents, which vary widely in severity, were reported 1,259  times in calendar year 2003, including 336 reports of major unusual  incidents. Of the 1,259 unusual incidents reported for 2003, DMH resolved  528 cases, including 161 major unusual incident cases. The remaining 731  cases usually required additional information from providers or other  District agency investigators before DMH could take action. According to  a DMH official, on average, a case remains pending for between 30 and 90  days before a disposition is reached.
section_title: DMH Continues the District’s Historical Role as a Direct Provider of Mental Health Services
paragraphs: Through DMH, the District remains a direct provider of a significant  portion of mental health services. DMH’s own community services agency  is the largest provider of community-based services in the District, acting  as the primary provider for 55 percent of all consumers enrolled in the  District mental heath system as of October 2003. In addition, it is the sole  provider of a number of services, including crisis response services for  adult consumers through its Comprehensive Psychiatric Emergency  Program and free pharmacy services for uninsured consumers. The  number of consumers receiving community-based services directly from  DMH grew from 4,191 in October 2002 to 6,971 in October 2003. In  addition, the total number of consumers served by the 13 other  community-based providers increased from 2,612 in October 2002 to 5,631  in October 2003.
As envisioned by the transitional receiver’s final plan, DMH has also taken  steps to reduce the number of beds at St. Elizabeths Hospital, but  reductions have been limited by the lack of community-based services and  agreements with community hospitals for acute care. The intent of the  plan was for St. Elizabeths Hospital to be primarily a forensic hospital and  a safety net facility for the community-based system of services and for  community hospitals. While neither the final plan nor the exit criteria for  the Dixon Decree specify goals for the reduction in the bed census at St.  Elizabeths Hospital as a condition of ending the Dixon case, the exit  criteria specify that 60 percent of DMH’s annual expenditures must be  directed to community-based services. In DMH’s 2004 proposed budget, 41  percent of funds, approximately $80 million, are allocated for community- based providers and 42 percent, approximately $81 million, are allocated  for St. Elizabeths Hospital. The remaining 17 percent, approximately $34  million, are budgeted for administration, oversight, delivery systems  management, and other direct service costs, some of which represent  fixed costs for community-based services. DMH has decreased the  number of occupied beds at St. Elizabeths Hospital—from 628 beds in  October 2000 to 513 beds in October 2003. In July 2003, the court monitor  reported that the current model of continued reliance on St. Elizabeths  Hospital was not financially viable, did not promote the concept of  community-integrated care, and was not in compliance with the court- ordered plan. However, DMH stated that the hospital’s budget cannot be  reduced without an additional decrease in the number of occupied beds.  The chief executive officer of St. Elizabeths Hospital said that the census  would not decrease until the community can support patients upon  discharge, including providing access to affordable housing. The court  monitor estimates that for the community-based system to adequately  meet the needs of District residents, DMH would have to double the  current capacity.
section_title: Enrollment and Billing System Is Designed to Coordinate Clinical, Administrative, and Financial Processes
paragraphs: In its first 2 years, DMH developed and implemented a comprehensive  enrollment and billing system that coordinates clinical, administrative, and  financial processes. Two key attributes of this system that were described  in the final plan are that it (1) links payment with planning for individual  treatment and the provision of services and (2) increases access to federal  funds through the development of mental health rehabilitative services,  which are community-based mental health services that a state’s Medicaid  program can choose to provide. DMH has developed and implemented a  system to link payment to authorized treatment plans, enroll consumers,  reimburse providers, and bill Medicaid for rehabilitative services provided.  However, moving to an FFS billing system for services has resulted in  difficult adjustments, including managing cash flow, for some DMH  providers.
subsections: section_title: Enrollment and Billing System Links Payment to Treatment
paragraphs: DMH’s enrollment and billing system that links payment to treatment, as  envisioned by the final plan, is in place and operating. Consumers can  enter into the mental health system through a variety of points in the  community, including calling DMH’s Access Helpline, visiting a DMH- certified community-based service provider, receiving treatment in  hospitals or emergency rooms, and receiving mental health assistance  through other DMH outreach efforts. All District residents needing  mental health services are eligible to receive them regardless of insurance  coverage. The Access Helpline—which is a telephone hotline that  provides crisis emergency services, enrollment assistance, and  information and referral 24 hours a day, 7 days a week—or a certified  CSA—which is responsible for acting as a clinical home and therefore  assessing consumer needs and coordinating care—will enroll eligible  consumers within 3 days of initial contact. When enrolling in the system,  the consumer chooses a CSA as a clinical home based on a number of  preferences such as location and treatment specialties. (See fig. 1.) After  choosing the CSA, a consumer meets with a clinical manager to develop a  treatment plan, which includes objectives and a plan of services, called an  individualized recovery plan for adults and an individualized plan of care  for children and youth. Once a clinical manager and a consumer develop a  treatment plan, it is submitted by the CSA to DMH for authorization. Upon  authorization of the treatment plan, a consumer can begin accessing the  approved services. These services must be provided by a CSA or by  another DMH-certified provider; once services are delivered, the providers  then bill DMH on an FFS basis for reimbursement. Screening consumers  for eligibility to receive mental health services and billing DMH for  services rendered are new responsibilities for providers. Providers will be  paid only for services delivered that are identified by the treatment plan  and authorized by DMH.
As of December 2003, DMH had transitioned 12 of its 27 community-based  services to the FFS enrollment and billing system, including all nine  rehabilitative services, but 15 other services, such as consumer advocacy  and peer support, had yet to be added. Services that have not been  transitioned to the FFS system do not have to be identified in an  authorized treatment plan; however, community-based providers must  deliver these services according to their contractual agreements with  DMH.
In order to develop a system that links payment to services provided, DMH  purchased management information systems that coordinate clinical,  administrative, and financial processes for mental health services. These  systems allow CSAs to enroll consumers in the mental health system,  submit claims electronically, and retrieve their consumers’ demographic  data. These systems also streamline DMH’s administrative efforts by  allowing DMH to electronically enroll consumers, authorize services,  adjudicate claims, and generate payment reports for providers. The system  further helps DMH monitor how much individual providers are billing,  which helps DMH project expenditures. DMH received the first batches of  claims in June and July 2002, and as of October 2003 it reported that its  mental health system had 12,602 consumers enrolled. However, DMH  could not report the number of consumers who received services within a  90-day period, which is consistent with the court’s definition of provision  of services to enrolled consumers. As of January 2004, DMH had paid  rehabilitative services providers $30.4 million for claims submitted in fiscal  year 2003. DMH projects that it will have paid these providers a total of  $35 million to $40 million for claims submitted in fiscal year 2003.
section_title: DMH Has Increased Access to Federal Funds through a Medicaid Mental Health Rehabilitation Services Option
paragraphs: In December 2001, the Centers for Medicare & Medicaid Services  approved the District’s request to add the mental health rehabilitation  services option to its Medicaid program. (See table 5.) Approval of the  option increased both the number and scope of mental health services  reimbursable by Medicaid. Under the option, DMH certifies and contracts  with community providers to deliver covered services. DMH pays  providers for any DMH-authorized service and, on behalf of contracted  providers, files claims with the District Medicaid office for reimbursement  of the federal share of the cost of Medicaid-covered services. Thus, there is  no relationship between the District Medicaid office and the local  providers for these services, nor is payment to providers contingent upon  reimbursement by Medicaid. Other District community-based service  providers that do not contract with DMH bill the District Medicaid office  directly for their services.
DMH built mechanisms into the enrollment and billing processes to help  providers and DMH work together to obtain Medicaid reimbursement.  Access Helpline counselors work with providers to identify consumers  who are eligible and enrolled in the Medicaid program using eligibility data  from the District Medicaid office. Before transmitting Medicaid- reimbursable claims to the District’s Medicaid office, DMH checks each  claim to ensure that the consumer is currently enrolled in Medicaid, that  the provider is eligible, and that the covered service has been paid by  DMH. Upon submittal for reimbursement to the District’s Medicaid office,  DMH tracks the status of claims, receiving reports that detail the claims  paid, waiting to be paid, and denied payment. The report also provides  reasons that claims were denied.
DMH is improving its overall enrollment and billing system to decrease the  time providers spend on administration and to increase the time they  spend serving consumers. For example, in October 2003, DMH changed a  component of the billing system that delayed providers from offering  services. The system had required providers to electronically update  treatment plans every 90 days. To reinforce this requirement, the  information system prevented the provider from entering any other  consumer data, such as claims data for a service provided, until the plan  was updated. DMH realized that requiring providers to do this was  burdensome and prevented them from serving consumers. As a result,  DMH removed the requirement to update the treatment plan from the  electronic billing system and is monitoring compliance with the 90-day  requirement through an alternative mechanism.
DMH projects that as the enrollment and billing system improves and the  provision of community-based services continues to expand, mental health  rehabilitative services will eventually generate approximately $36 million  to $38 million annually in federal Medicaid funds. As of November 2003,  the District’s Medicaid office had reimbursed DMH $17.5 million for fiscal  year 2003—over 50 percent of the amount DMH paid to providers for  rehabilitative services. As one condition of ending the Dixon case, federal  Medicaid funds must cover at least 49 percent of all mental health  rehabilitative services provided. Although DMH expects future growth in  Medicaid revenue, many individuals served by the District’s mental health  system, especially adults, are not eligible for Medicaid.
section_title: New System Presents Challenges to Providers
paragraphs: According to DMH officials, moving to an FFS system represented a major  change in business operations for DMH providers and has presented  challenges for them; however, DMH has offered assistance to all certified  rehabilitative providers. DMH offered training for providers on service and  billing requirements and grants for building the infrastructure required to  participate in the system. In addition, consultants funded by DMH can  work with providers on developing sound business practices, including  cash flow analysis, budgeting in an FFS environment, staff assignments  and productivity, record keeping, and billing.
Even with assistance, providers experienced challenges since beginning to  bill DMH on an FFS basis. Two providers reported that there are  considerable investments of time and money necessary to be certified as a  CSA. According to one provider, the new system requires more “business  savvy” and planning by providers for revenue peaks and valleys because  providers are no longer guaranteed revenue regardless of the level of  services provided. Thus, as stated by the same provider, they must plan  ahead to ensure they can meet payroll in months like December and  February, when fewer consumers seek services because of holidays and  winter weather.
Problems managing cash flow were exacerbated because provider  contracts with DMH were tied to the billing projections, which meant that  DMH could not pay claims for providers who exceeded their projections  until their contracts were changed. The Mental Health Coalition, whose  members are primarily DMH-certified providers, wrote to DMH several  times in fiscal year 2003 listing a number of concerns with the billing  process, and its primary concern was the lack of timely payment on a  consistent basis. By August 2003, DMH made the necessary contract  changes to allow providers to be paid for the remainder of the fiscal year  and, according to senior officials, had a plan in process for fiscal year 2004  to prevent this problem from recurring. DMH provided data showing that  in fiscal year 2003 it adjudicated—that is, made a decision to pay or  deny—79 percent of submitted claims within 30 days; however, after  adjudication, the District of Columbia Treasury must then pay the  approved claims, which, according to DMH, took an average of 15  additional days. The court monitor has identified claims payment as an  area of concern that will continue to be monitored. DMH did not provide  the court monitor with a measure of timely reimbursement in 2003, but,  according to the court monitor, in fiscal year 2004 DMH will be required to  report the percentage of claims being paid within 30 days of submission.
section_title: Consumer-Centered Approach Blending Choice and Protection Is Evolving
paragraphs: Also central to DMH’s new mental health system is facilitating consumers’  participation in their recovery from mental illness, an approach that is  consistent with the final plan, as well as national trends. Consistent with  this focus, DMH has established requirements in two key areas, consumer  choice and consumer protection. With regard to consumer choice, DMH  has requirements in place to ensure that consumers participate in the  selection and receipt of services. However, DMH’s initial review of  rehabilitative services provider records showed gaps in documentation of  consumer participation, such as a lack of documentation of the  consumers’ participation in—and agreement with—their treatment plans  for 41 percent of the records reviewed. DMH is addressing these gaps with  providers to ensure that their practices comply with these requirements  and adequately involve consumers in their treatment. Consumer  protection policies are also evolving, with DMH publishing a uniform  consumer grievance policy in October 2003. DMH officials emphasized  that moving to a consumer-focused model is a long-term change that will  take place gradually.
subsections: section_title: With Requirements in Place, DMH Is Addressing Gaps in Consumer Choice
paragraphs: Consumers entering the District’s mental health system are faced with  important choices that help shape the provision of care they receive,  including the choice of a CSA as a clinical home that will provide and  coordinate care, choice of other DMH-certified providers, and choice of  services through involvement in treatment planning. As part of the  enrollment process, both the CSA and the Access Helpline are required to  present consumers with the option to select any DMH-certified CSA to  serve as the clinical home, a choice typically made based on their  preferences, such as location and treatment specialties provided. Every  CSA that serves as a consumer’s clinical home is required by DMH’s  certification standards to have a policy in place to inform consumers  about these and other choices available to them. For example, each CSA’s  consumer choice policy must also inform consumers about the availability  of peer and family support services—such as transportation, education,  nutrition services, and recreation activities—as well as how to access the  services. DMH’s certification standards also require CSAs to coordinate  the treatment planning process for their consumers and to document  consumer participation. For example, CSAs are required to develop a  diagnostic assessment and treatment plan for each consumer that follows  the consumer throughout the service delivery and reimbursement systems.  Each CSA acting as a clinical home is required to obtain a consumer’s  written consent to treatment as well as provide all consumers with a  statement outlining their rights and responsibilities during the enrollment  and treatment process.
To assist consumers in obtaining mental health services, the Director of  DMH’s Office of Consumer and Family Affairs (OCFA) told us that DMH  employs 15 to 20 mental health consumers as enrollment specialists who  are available to other consumers as a resource in making these choices.  DMH also offers training, some of which is conducted by other mental  health consumers, that is available to consumers and their families on  selecting providers and planning treatment. In addition, DMH’s enrollment  handbook for new consumers summarizes aspects relating to the  enrollment process, such as the types of mental health services available,  range of consumer choices, and activities a consumer can expect during  enrollment. Intended for use in the second quarter of 2004, DMH is  developing a provider report card that contains specific information about  each rehabilitative services provider to better facilitate consumer choice.  For example, the provider report card will give providers a numerical  score in areas, such as consumer access, billing and claims, and consumer  complaints, that would enhance the consumers’ basis for selecting a  provider. Finally, OCFA is also responsible for overseeing the  development and implementation of the consumer satisfaction review  required in the Dixon exit criteria, an initiative that DMH envisions as  expanding the role of consumers in measuring the quality of services they  receive in the District’s mental health system.
The court monitor and District mental health advocates have highlighted  areas relating to consumer choice that need attention and that are  consistent with DMH’s plans for additional development. In a January 2003  report to the court, the court monitor recommended that DMH develop a  system for tracking consumer choice to help determine whether choices  truly are available. The Director of OCFA told us that DMH would begin  addressing this issue by identifying concerns relating to choice through  consumer focus groups planned for each CSA in 2004. In addition,  University Legal Services, the designated protection and advocacy  program for the District, told us that consumers do not have enough  information about how to access providers in the mental health system,  and therefore it has published its own consumer rights manual. For  example, an official with this organization told us that District consumers  often do not have a choice among the full range of providers because  many CSAs have limited capacity and have had to develop waiting lists.  University Legal Services also cited a delay for consumers in receiving  community-based services who are discharged from St. Elizabeths  Hospital. While DMH is not required to report current baseline data  regarding the receipt of community-based services for consumers  following a hospital discharge, one condition for ending the Dixon case  will be to demonstrate that 80 percent of known discharged inpatients  receive services in a non-emergency, community-based setting within 7  days of a hospital discharge.
DMH’s initial audits of documentation practices of each of its certified  rehabilitative services providers showed gaps in documentation of  consumer participation in development of their treatment plans. Of the 740  unique consumer records DMH reviewed in its audit completed in January  2003, 38 percent did not have a consumer’s signature on the treatment plan  and 41 percent did not document the consumer’s participation in and  agreement with the treatment plan. Each of the 12 providers reviewed by  DMH was asked to develop a self-audit program and implement staff  training to address areas of deficiency in the audits, which, according to  DMH, were to be expected in the first year of applying provider standards.  Concerns raised by other stakeholders were consistent with the results of  DMH’s audits of provider documentation practices. For example, in a July  2003 letter to DMH, University Legal Services noted systemic problems  with treatment plans relating to consumer participation and accuracy,  such as being unsigned, lacking consumer preferences, and failing to  reflect consumer medical needs. DMH’s written response to University  Legal Services highlighted the provider documentation audits completed  by DMH as evidence that the department is identifying treatment plan  issues but acknowledged that these problems will take time to resolve.
section_title: Consumer Protection Mechanisms Are Evolving
paragraphs: In October 2003, DMH published a consumer grievance policy, required by  the legislation creating DMH, which strengthened the basic consumer  protection provisions in DMH’s provider certification standards. Prior to  publication of this policy, CSAs and other mental health providers were  required to establish written complaint and grievance policies and  procedures but did not have to include specific criteria consistent with an  overall and uniform DMH policy. For example, the DMH policy published  in October 2003 required providers to review, investigate, and respond  within 5 business days to grievances alleging abuse or neglect or denial of  a service. While consumers can continue to file grievances with CSAs or  DMH, the new policy also specifically outlines the conditions under which  consumers can request an external review of a grievance that can result in  a fact-finding hearing or mediation process. The new policy also requires  DMH to facilitate and fund peer advocacy programs that are independent  of providers to assist consumers throughout the grievance process. In  addition, providers are required to take specific steps to increase  consumer awareness about their grievance policies, such as posting the  various options and procedures for filing a grievance and documenting  that the consumer received a copy of the provider’s policy.
DMH’s monitoring of consumer complaints and grievances is also  evolving. As of January 2004, DMH had contracted with an organization to  create a database that will allow OCFA to track consumer grievances and  identify systemic issues. OCFA expects that the database will be  developed in the first few months of 2004. The new grievance policy also  specifies that DMH will periodically review the implementation of the  provider policies and publish a semiannual report on the types and  dispositions of all grievances filed as well as highlight noteworthy trends,  patterns, and other statistical information. Prior to this policy, DMH could  not ensure that grievances were being tracked and did not review the  extent to which providers were implementing their grievance procedures.
section_title: DMH Faces Challenges in Developing the Capability to Measure Performance against Exit Criteria
paragraphs: The court monitor worked with DMH and others to develop performance  targets to measure compliance with the Dixon exit criteria. On December  11, 2003, the court approved qualitative requirements for two exit criteria  measures relating to consumer satisfaction with services and level of  functioning. In addition, the court approved 17 performance targets for 17  exit criteria measures relating to system performance. Although the court  monitor envisioned fiscal years 2004 and 2005 as the appropriate time  frame for DMH to both measure and improve its performance, DMH faces  major challenges to collecting and verifying the accuracy of the  performance data, including developing methods to electronically collect  the data, correcting known data deficiencies, and working with providers  to submit accurate data.
subsections: section_title: Methods to Measure Performance against the Exit Criteria Approved in December 2003
paragraphs: In working to measure the District’s compliance with the exit criteria, the  court monitor, in conjunction with an outside expert and the legal parties  to the Dixon case, developed two qualitative requirements and 17  performance targets, which were approved by the court in December  2003. The qualitative requirements address two of the exit criteria  measures—consumer functioning and consumer satisfaction. For these  two measures, DMH is required to develop and implement consumer  satisfaction and functioning review methods and begin using the data  obtained by these methods to make refinements to service delivery. DMH  has contracted with a consumer organization to build a consumer  satisfaction initiative patterned after model programs around the country.  As of December 2003, OCFA had conducted a telephone survey of  consumers to help DMH develop this consumer satisfaction review. In  addition, DMH officials told us that they are testing the effectiveness of a  tool for assessing consumer functioning. According to the court monitor,  DMH will provide a progress report in early 2004 on the status of these two  reviews, but is not likely to submit the methodologies to the court  monitor—which is required to comply with the exit criteria—for several  more months.
The court also approved 17 exit criteria measures, each with a specific  performance target. (See table 6.) Two of the 17 measures articulate  overall system performance targets that DMH must meet in annual reviews  of the services provided to adult and child and youth consumers. For  example, DMH’s system must perform positively for 80 percent of the  adults who are sampled and reviewed. The remaining 15 measures define  specific system performance targets that DMH must meet in the aggregate  for 4 consecutive quarters, such as demonstrating the timely receipt of  supported housing services for a specific percentage of persons referred to  supported housing. Once DMH meets these targets for the specified time  frame, the court monitor ends active monitoring of the measure. However,  according to the court order, DMH is required to continue to submit data  to the court monitor for all exit criteria measures regardless of their  monitoring status, giving the court the ability to require that DMH meet the  performance targets for any exit criteria measure showing a substantial  drop in performance. The Dixon case can be dismissed when the court  monitor submits a report to the court affirming that the District has  achieved compliance with all required performance targets and qualitative  requirements for all of the exit criteria, and the court accepts that finding.
Originally, the court expected the proposed performance targets  submitted by the court monitor to be accompanied by baseline measures  of performance. The proposal approved by the court in December 2003,  however, did not include previous requirements for DMH to submit  baseline measurement data along with the performance targets. According  to the court monitor and a DMH official, baseline data were omitted  because (1) historical data are generally incomplete because of problems  with data systems as well as a general lack of reliable and consistent  previous data, and (2) many of the performance targets require  information that was not collected by DMH and its providers, such as the  number of consumers referred to supported housing. In commenting on a  draft of this report, DMH noted that it was unable to identify comparable  baselines from other jurisdictions.
section_title: Developing the Capability to Measure and Meet Performance Targets Will Take Time
paragraphs: Meeting the exit criteria performance targets, and thus ending the Dixon  case, is a multiyear effort that requires DMH to develop and carry out a  plan that will satisfy the court on three levels: (1) developing policies and  practices that address the requirements of the exit criteria and  demonstrating that DMH monitors the extent to which these policies are  implemented, (2) developing specific methods for DMH’s collection and  verification of the accuracy of the data, and (3) meeting the required  performance targets for one full year as defined by the court. In November  2003, the court monitor anticipated that reviews relating to the first two  requirements—policies and procedures and data collection and  verification methods—will start in early 2004, but it may be a year before  these two requirements are met for all of the exit criteria measures. The  court monitor expects that DMH will concurrently develop and implement  a plan to measure performance on all three levels that will allow the  department to begin generating valid performance data in 2004. Although  DMH began to collect data in July 2003 for some of the exit criteria  measures based on the earlier methodologies approved by the court in  May 2002, DMH officials told us in November 2003 that this data collection  was preliminary and that they would not begin to develop a specific plan  for meeting these three requirements until the court approved the final  performance targets, which occurred in December 2003.
Satisfying the court regarding DMH’s demonstration of specific methods  for collecting and verifying the accuracy of the performance data is likely  to be challenging because of impediments to data collection as well as the  fact that collected data may be incomplete or inaccurate. DMH and its  providers face three major obstacles in collecting accurate data used to  meet the actual performance targets: (1) establishing methods to collect  electronic data, (2) correcting known data deficiencies, and (3) ensuring  the accuracy of information collected and reported by providers. A  description of each of these challenges follows.
subsections: section_title: Data Not Collected Electronically
paragraphs: Although the final exit criteria measures and performance targets were not  approved until December 2003, DMH began collecting monthly data  nonelectronically for 8 of the 17 exit criteria measures from providers in  July 2003. For example, mental health rehabilitative services providers  submit nonelectronic monthly reports to DMH on services provided to  homeless consumers who are diagnosed with a serious mental illness.  However, because the court approved revisions to some of the exit criteria  measures in December 2003, providers will have to refine some of the  information that they collect and report to DMH. In addition, the  performance targets themselves, which did not exist prior to December  2003, will also affect the types of data collected. DMH officials told us that  the department may be able to modify its enrollment and billing  information system to collect some—but not all—of the data for the exit  criteria measures, thus developing a central repository of information is  still under discussion between DMH and the court monitor. Beyond this,  a related issue will be developing the capacity to appropriately factor in  other data currently collected by DMH in a way that is not duplicative of  the monthly data submitted by mental health rehabilitative services  providers. For example, officials told us that DMH’s school-based services  program collects information that could be used as part of the calculation  to meet the performance target requiring 75 percent of children and youth  with serious emotional disturbances to receive services in a natural setting  such as the home or school. However, the information collected through  this program is not consumer-specific, nor is it linked to DMH’s enrollment  and billing information system, which may, according to DMH officials,  eventually be the primary mechanism for collecting data on many of the  performance targets.
section_title: Deficiencies in Service Utilization Data
paragraphs: As part of the exit criteria requirements for the Dixon case, DMH  conducted an initial consumer services review in the spring of 2003 that  identified two major service provision gaps relating to services provided to  children and youth that need to be addressed to ensure the accuracy of the  performance target data collected by DMH. The court monitor’s  semiannual reports to the court have similarly highlighted these findings  as areas requiring action. First, the review showed that many of the  children and youth placed in residential treatment centers (RTC) do not  have a clinical home at a CSA as intended and thus are not receiving DMH  services. In addition to raising concerns about the coordination between  DMH and RTCs, the lack of services for these individuals could also affect  the accuracy of the data collected by DMH to meet a performance target  that requires DMH to demonstrate that 85 percent of children and youth  with serious emotional disturbances served by the system are living in  their own or surrogate homes. Second, according to the court monitor,  the consumer services review also revealed a significant gap between the  number of children and youth enrolled in DMH’s system and the number  who are actually receiving services. The court monitor’s report  acknowledged that the source of this gap, while unknown, could reflect  flaws in DMH’s data management system, its disenrollment policy, or  clinical standards, such as required follow-up with consumers who have  missed an appointment. Since the four penetration rate performance  targets are calculated using the number of enrolled consumers who  received at least one service in the past quarter, DMH will need to  determine the cause of this gap to ensure that its performance data are  accurate. As of March 2004, DMH had not provided us with the number of  consumers who were enrolled and receiving services within a 90-day  period.
section_title: Accuracy of Information Reported by Providers
paragraphs: Beginning in July 2003, DMH began collecting unaudited monthly data  from mental health rehabilitative services providers for a range of exit  criteria measures, including the provision of supported housing and  supported employment. The department has also begun to collect  preliminary discharge data from St. Elizabeths Hospital and local hospitals  providing acute care to mental health care consumers. However, as of  November 2003, neither the mental health rehabilitative services providers  nor the local hospitals were required to track this information, and DMH  did not have processes in place for verifying the accuracy of these data.  DMH’s Director told us in December 2003 that DMH is planning to  incorporate reporting requirements as part of the recertification process  for mental health rehabilitative services providers. As of January 2004,  DMH was planning to collect quarterly discharge data from local hospitals  but was still working out the details. Until these reporting processes are  put in place, DMH will continue to collect discharge data from a  combination of St. Elizabeths Hospital (for adults) and mental health  rehabilitative services providers (for children and youth). Even after  hospital reporting processes are implemented, the court monitor and DMH  expect some difficulties in collecting comprehensive discharge data. For  example, a DMH consumer may seek care in a local hospital that does not  typically serve DMH consumers and thus does not provide quarterly data  to DMH. Recognizing potential challenges in collecting data from local  hospitals, the court monitor proposed—and the court approved—as one of  the 17 performance targets, a continuity of care performance target that  allows DMH to limit its measurement against this exit criteria measure to  “known” inpatient hospital discharges. The court monitor expects DMH  to include in its plan specific strategies for obtaining and verifying the  accuracy of these data. The potential lack of accurate data—for example,  from local hospitals—may mean that some discharged individuals are not  factored into the data used to measure performance. In addition, the lack  of consumer-specific data collected by DMH to meet the performance  targets will also be a challenge. For example, because mental health  rehabilitative services providers do not submit the names of each  homeless consumer served, just the total number of these individuals  served, information submitted is not consumer-specific and thus may be  duplicative, compromising the accuracy of the measurement. The court  monitor has also told us that DMH will need to verify that the performance  target data are unduplicated.
section_title: Comments from DMH and the Court Monitor and Our Evaluation
paragraphs: DMH provided written comments on a draft of our report. DMH’s  comments are included, with our detailed responses, in appendix II. The  court monitor provided technical comments, which we incorporated as  appropriate.
In its comments, DMH stated that the court-ordered plan for the reform of  the District’s mental health system envisioned comprehensive and  sweeping reforms, noting that accomplishing such reforms would result in  over 50 percent of DMH’s budget being redirected in a 5-year period. DMH  described six broad changes to the District’s mental health system in the  court-ordered implementation plan. These changes included (1)  implementing a mental health authority, (2) instituting systems of care,   (3) developing a new set of accountability functions and changing the  oversight and monitoring of mental health services, (4) incorporating  consumer protections, (5) shifting the methods and operations for  financing the delivery of inpatient and outpatient mental health services,  and (6) creating a new Department of Mental Health with new  responsibilities for operating within the city government. In addition, DMH  stated that in spite of the District’s failure to meaningfully participate in  the last 20 years of mental health reform, DMH is moving aggressively to  become a positive contributor to the health and well being of the  community and to persons in priority service groups.
DMH commented that the draft report addressed several issues in depth  while overlooking other reforms prominent in the final plan and the  legislation creating DMH and other services such as Assertive Community  Treatment, Supported Employment, and Supported Housing. The scope of  our work was the status of DMH’s efforts to establish a community-based  system of mental health care, focusing on four key areas of reform central  to meeting the exit criteria for the Dixon Decree. While we believe that the  other reform initiatives and services are important, we believe that DMH’s  status with regard to meeting the exit criteria is an appropriate gauge of  compliance with the Dixon Decree. We believe that making a  comprehensive assessment of the system’s performance before DMH  begins reporting on the exit criteria is premature.
DMH also provided specific comments that clarified, updated, or added  information regarding its status in implementing the final plan (see app.  II). Where appropriate, we incorporated these changes into the report.
As agreed with your office, we plan no further distribution of this report  until 30 days from its date of issue, unless you publicly announce its  contents. At that time, we will send copies of this report to the Director of  the District of Columbia Department of Mental Health. We will also make  copies available to others upon request. In addition, the report will be  available at no charge on the GAO Web site at http://www.gao.gov.
Please call me at (202) 512-7118 or Carolyn Yocom at (202) 512-4931 if you  have questions about this report. Major contributors to this report are  listed in appendix III.
section_title: Appendix I: Major Court Actions Related to District Compliance with the Dixon Decree
subsections: section_title: A class action lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of District residents institutionalized at St. Elizabeths Hospital.
paragraphs: The court determined that the District and the federal government had a joint responsibility to provide the plaintiffs  community-based treatment in the least restrictive conditions. This ruling is known as the Dixon Decree.
To comply with the court order, the involved parties drafted a final implementation plan that generally required an  assessment of the plaintiff class members and periodic reports on progress in establishing a community-based system.
Congress passed legislation that required the District to complete implementation of an integrated coordinated mental  health system by October 1, 1991. Congress transferred sole responsibility of establishing the required local mental health  services to residents of the District. The transfer was not effective until October 1, 1987.
The court determined that no progress had been made to comply with the final implementation plan. The involved parties  therefore developed a second plan. This plan is known as the service development plan.
The court appointed a special master to oversee implementation of the service development plan.
The court determined that the District was still unable to comply with the terms of the service development plan. As a  result, the involved parties negotiated a third plan, whose goals the District met. This plan is referred to as the Phase I  agreement.
The parties negotiated and began to implement a fourth plan, which was significantly broader in scope and required  activities such as hiring personnel and developing a homeless service plan. This plan is referred to as the Phase II plan.
The District admitted noncompliance with the fourth plan, and the plaintiffs requested the appointment of a receiver.
On September 10, the court appointed a receiver on the basis that only a receiver provides the court with enough day-to- day authority to force compliance without causing confusion and ambiguity in the administration of the commission.
On March 6, with agreement of all parties, a new receiver, referred to by the court as a transitional receiver, was appointed  and officially assumed this role on April 1. The transitional receiver was scheduled to return control of the mental health  system to the District between January 1 and April 1, 2001.
On April 2, the court approved the transitional receiver’s final plan and required the District to implement it. The plan  provided a policy framework for meeting the Dixon mandate, including developmental milestones but not specific service  targets.
On May 22, the court found that the District was capable of implementing and was in fact implementing the final plan and  thus terminated the receivership. The order also appointed the former transitional receiver as court monitor of District  compliance with the final plan, and it approved exit criteria agreed upon by all parties. The monitor was directed to report to  the court and the parties no less frequently than every 6 months.
On December 11, the court approved a revised set of exit criteria, which replaced the criteria approved in May 2002, with  measurement methodologies, definitions, performance targets and qualitative requirements. In addition, the court ordered  that the case would be dismissed when (1) the court monitor affirms that the District has complied with all of the  performance targets and qualitative requirements and the court accepts that finding; or (2) the District moves for dismissal  and demonstrates “substantial” compliance with the performance targets and qualitative requirements and the court  determines the case should be dismissed.
section_title: Appendix II: Comments from the District of Columbia Department of Mental Health and GAO’s Response
paragraphs: The following is our response to DMH’s letter dated March 18, 2004.
subsections: section_title: GAO’s Response to DMH’s Comments
paragraphs: Our responses below correspond to the comments numbered in the  margin of DMH’s letter.  1.  DMH commented that the draft report references only a portion of the  requirements of the Mental Health Reform Act and the court-ordered  plan and does not discuss the development of “systems of care,” which  it characterizes as cornerstones of the court-ordered plan and the  legislation creating DMH. We believe that the report adequately  characterized the immensity of the tasks faced by DMH. The scope of  this report encompassed the actions taken by DMH since its creation  to comply with the Dixon Decree. As such, we reported on the status  of the District’s effort to establish a community-based system of  mental health care, with a focus on four key areas of reform that were  confirmed by the court monitor to be central to compliance with the  Dixon Decree. Because many of the services and initiatives under way  were still evolving and had incomplete data at the time of our work, we  did not believe that a comprehensive assessment of DMH’s progress on  all activities was appropriate. As a result, we focused on the data  collection methods for the 17 performance targets relating to the  District’s compliance with the court’s exit criteria.  2.  We modified the report where appropriate to address information  about the additional consumer protections, the number of supportive  housing arrangements, the relocation of acute care beds, the hiring of  senior managers, the status of leadership positions at DMH, the  increases in service provision at the public CSA, the difficulty of  adding new psychiatric services in local hospitals, and the results of  provider audits.  3.  DMH stated that the draft report did not accurately portray payments  made to providers in fiscal year 2003 and that our findings on slow  payments to providers could not be substantiated. We modified the  report to reflect the updated data on billings for fiscal year 2003.  However, we disagree that payment problems could not be  substantiated. Provider contracts with DMH were tied to the billing  projections, which meant that DMH could not pay claims for providers  who exceeded their projections until their contracts were changed.  The court monitor’s 2003 reports also indicate that claims payment has  been an area of concern. Our draft report acknowledged that DMH had  made the necessary contract changes to allow providers to be paid for  the remainder of fiscal year 2003. Additionally, we cited DMH’s plan  for fiscal year 2004, which aimed to prevent similar billing problems  from occurring.  4.  With regard to our assessment of DMH’s status in meeting court  expectations, DMH commented that it believes table 2 reflects our  assumption that DMH has not begun work on meeting the 15 system  performance targets or begun using consumer functioning and  consumer satisfaction data. DMH stated that it has not reported on  these steps but has initiatives under way to meet each one and  therefore the table should reflect that the “step has been started.” As of  March 2004, the court monitor had not received evidence that these  steps were in process, but confirmed that DMH had conducted  preliminary work that had not been captured in court documents.  Thus, we modified the report to reflect that these steps were “in  planning.” In addition, the report refers to the work under way to meet  the exit criteria, such as the consumer telephone survey conducted in  2003 to help DMH develop its consumer satisfaction review and data  collection efforts from providers for some of the exit criteria  measures.  5.  DMH commented that the draft report did not indicate that there were  no standards for provider audits, that provider audits had never been  conducted, and that DMH expected that providers would not be in  compliance. The draft report stated that DMH’s new responsibilities  for regulating and monitoring providers, including conducting audits,  were a shift away from the structure of its predecessor office and that  the monitoring framework was in the early stages of implementation.  We revised the report to reflect DMH’s expectation that providers  would not be in compliance with the new standards.  6.  With regard to the draft report’s discussion of unusual incidents, DMH  noted that the District’s mental health system had never experienced a  review of unusual incidents and stated that unusual incidents ranged in  severity from consumers returning late for dinner to injury and abuse.  DMH also stated that it is faced with thousands of unusual incidents  and said that it sorts through incidents quickly and is beginning to  identify trends. We modified the report to reflect the range of severity  of unusual incidents.  7.  DMH commented that the report’s subheading, “Enrollment and Billing  System Is Designed to Coordinate Clinical, Administrative, and  Financial Processes” represents a significant misapprehension. DMH  stated that the enrollment and billing systems are not the major  functions in the design of the clinical, administrative, and financial  processes. DMH characterized the billing system as an administrative  function that helped with the transition from a grants-based system of  delivering services to a performance-focused fee-for-service (FFS)  system. We believe that the enrollment and billing system is an  important design component. For example, the final court-ordered  plan outlines that a comprehensive enrollment and billing system that  links payment to treatment is necessary to access federal Medicaid  revenue through the mental health rehabilitation services option,  which was identified in our October 2000 report and in the final plan as  a key component for reforming the District’s mental health system.  Further, DMH’s enrollment and billing information system is used to  enroll consumers, reimburse providers, and, according to DMH  officials, may eventually be the primary mechanism for collecting the  performance data required to meet the Dixon exit criteria.  8.  Regarding our findings on consumer choice and community follow-up  after a consumer’s discharge from the hospital, DMH stated that  comments from the court monitor and the local Protection and  Advocacy for Individuals with Mental Illness (PAIMI) agency  (University Legal Services), were not quantified and that the report  provides no other basis upon which to assess their reliability. As of  January 2004, DMH was in the process of developing methods to track  consumer choice and had not reported data to the court on community  follow-up after discharge from the hospital. Absent that data, we relied  on the court monitor’s judgments regarding DMH’s progress in  implementing the court-approved plan. Additionally, the District  mental health advocates with whom we spoke are part of the federally- mandated protection and advocacy system.  9.  DMH commented that our findings on DMH’s capability to measure  performance against the exit criteria (1) presented an incomplete  account of events leading to the development of the performance  targets and (2) missed critical factors for why baseline data were not  included in the exit criteria requirements, specifically, that having a  baseline would be impossible because services did not exist before  DMH became a department and there was no basis for comparison  with other jurisdictions. In response to DMH’s first concern, we  revised the report to clarify that the court monitor did not act alone to  develop the targets for measuring performance against the exit  criteria. Regarding the second concern, the draft report stated that  baseline data were omitted because historical data are generally  incomplete and many of the performance targets require the collection  of new information from DMH and its providers. We modified the  report to reflect that DMH was unable to identify comparable baselines  from other jurisdictions.  10.  With regard to our findings on data collection and integrity, DMH  commented that the draft report did not take into account the  developmental stage of the data collection process. DMH noted that  some of the performance criteria do not lend themselves to electronic  data collection, gaps in service utilization data for children and youth  placed in residential treatment centers must be viewed in the context  that five city departments carry out placements, and the draft report’s  statement that there is a gap between the number of children and  youth enrolled and the number receiving services lacks quantitative  support. We modified the draft to reflect that the two performance  measures related to homeless consumers do not lend themselves to  electronic data collection, which was confirmed by the court monitor,  and that addressing the gap in service utilization data requires  coordination with other District agencies that typically have their own  tracking systems. The draft report stated that according to the court  monitor, the first consumer services review for children and youth  revealed a gap between the number of children and youth enrolled and  the number receiving services. DMH did not provide us with the  number of children and youth enrolled and receiving services. In the  absence of that data, we relied on the court monitor’s report, which  cited the gap identified by the consumer services review.
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: Major contributors included Susan Barnidge, Laura Sutton Elsberg, Kevin  Milne, and Elizabeth T. Morrison.