Iowa Department of Human Services

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					                  IOWA
      DEPARTMENT OF HUMAN SERVICES

  DIVISION OF BEHAVIORAL, DEVELOPMENTAL
   AND PROTECTIVE SERVICES FOR FAMILIES,
            ADULTS AND CHILDREN



MENTAL HEALTH BLOCK GRANT CORE MONITORING
                 REPORT



              MAY 18-20, 2004
                                  EXECUTIVE SUMMARY

The Iowa Department of Human Services (DHS) has identified a need to reform its mental health
service delivery system. The DHS has identified an urgent need to address fragmentation of
services across agencies and multiple levels of government. The lack of a coherent children’s
mental health system has been particularly cited by the Department to the point that it has noted
that no children’s system exists.

The monitoring team received information that confirmed the DHS’s assessment of the need for
system redesign. Children’s staff of the Division of Behavioral, Developmental, and Protective
Services (BDPS), parents, and advocates described the lack of coordination and integrated
information that make planning for youth services especially difficult. It was noted that services
for youth are not mandated at the county level as they are for adults. Although some counties
have developed effective services for youth, others have not. Specific opportunities for
improvement of the children’s system are addressed below.

Lack of consistency across the State was particularly noted, with the exception of the Medicaid
system, the Iowa Plan. This program is seen as providing consistent services and structures
across both the adult and children’s systems. Iowa Plan staff have initiated an effective
statewide collaborative effort involving stakeholders that has produced results, such as a Cultural
Competency plan. The involvement of the Iowa Plan with the Iowa Consortium for Mental
Health was also described by advocates and the Planning Council as being effective. The Iowa
Consortium plays an important role in providing technical assistance to DHS, to promote
collaboration, enhance research and assist providers.

The input regarding fiscal management of both the Block Grant and the system as a whole
mirrored the input given regarding programmatic areas. Although the impact of budget cuts over
the past three years was noted, structural problems within the fiscal management system have
resulted in the failure to expend over $800,000 in Block Grant funds during this period.

Fiscal structures were difficult to assess because fiscal data were unavailable onsite for the most
part. There is a lack of integrated data for BDPS, the counties, Medicaid, and providers. There
are inadequate data to understand who is being served, what are the total costs of services being
provided, and where are the gaps in service. Despite the paucity of data infrastructure, DHS has
not utilized the Data Infrastructure Grant resources available through the Center for Mental
Health Services (CMHS).

Three areas of strength in fiscal management were noted. First, contracts with local entities are
clear and detailed. Also, DHS has effectively implemented Health Insurance Portability and
Accountability Act (HIPPA) requirements. Lastly, the Adult Services Planner is proactive in
understanding both the intent and the letter of the public law funding the Block Grant. This
understanding facilitates Iowa’s ability to comply with the requirements under the law.

Fiscal management of the Block Grant experiences similar difficulties to that of the system as a
whole. Meaningful fiscal monitoring of subrecipients of the Block Grant beyond the receipt of
quarterly financial reports is lacking. There is no process to collect and review A-133 audits, and


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there is no on-site financial monitoring of subrecipients. One contract for Block Grant funds is
with a for-profit entity but, as was later clarified with the contractual restriction that it is a strict,
cost reimbursement relationship. Contracts with subrecipients do not include the required
Catalog of Federal Domestic Assistance number and language regarding prohibited expenditures.
As noted above, it was not possible to confirm compliance onsite, as data were not made
available to the fiscal monitor.

Block Grant funds are used for child welfare wraparound projects. It is not clear that these Block
Grant funds are not supplanting State funding, from the Department of Child Welfare, which
appears to fund coordinator positions for the projects. Also, these projects were funded at
midyear, without a plan modification that was advised by the Federal Project Officer, and were
funded over the strenuous objections of the sole consumer/family representative on the review
committee. Lastly, the Senate File that mandates that 70 percent of the Block Grant go to
community mental health centers seems to violate the intent/spirit of the Block Grant statute.

One impact of reorganization resulting from budget cuts has been that a single individual is the
sole source of the information and methodology for calculating Maintenance of Effort (MOE).
The current MOE calculation charts are in error, as are the children’s set-aside charts. Iowa may
benefit from technical assistance that includes an analysis and a review of the MOE and
children’s set-aside calculations in previous years.

Due to statements made during the entrance conference by State staff the issue was raised as to
whether a legal State Mental Health Authority (SMHA) existed, due to recent DHS
reorganization and administrative code changes. The Federal project officer for the State later
clarified the issue with the Substance Abuse and Mental Health Administration’s Grants
Management Office. The DHS is the legal authority that is the recipient of Mental Health Block
Grant funds and administers those funds through the designated division.

Despite the challenges that DHS has outlined in its planning process that were confirmed by the
interviews conducted by the monitoring team, there is a consensus that progress is being made.
The Mental Health Planning Council is revitalized and has taken charge of its role, purpose, and
function. The Mental Health and Developmental Disability Redesign has been widely
communicated and is being broadly implemented. The New Freedom concepts of recovery and
rehabilitation are being addressed. The EmPower-sponsored mental health consumer conference
is perceived as effective. Other areas of strength are the use of assertive community treatment,
and consumer-run drop in centers. Within the children’s system, there is a collaborative,
effective array of Early Childhood services administered by the Division of Medical Services.

Specific opportunities for improvement in the children’s system include the recommendation for
a strategy for consistent consumer and family involvement. It was noted that parents of youth
with serious emotional disturbance (SED) often have little opportunity for involvement at the
local level. Statewide, Central Point of Coordination entities generally avoid children’s service
provision.

The definition of SED is seen as irrelevant, in that many services are provided without need of
SED identification, data is not collected by this classification, and the definition is poorly


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communicated. Other related symptoms of the lack of a comprehensive children’s mental health
system include the fact that many mental health services are provided through child welfare and
the child specialty clinics under the Department of Public Health. Generally, local
decategorization boards have little mental health involvement. The current legislation which
mandates the Mental Health/Mental Retardation/Developmental Disabilities/Brain Injury
Commission to propose a redesign of the children’s disability service system is perceived as
promising. In this regard, it is recommended that DHS consider seeking technical assistance
regarding the ability of CMHS system-of-care grant funding to aid in the system redesign. There
is likely to be expertise available from existing system-of-care sites regarding several areas that
may need to be addressed in the redesign, including financing, data infrastructure, and the role of
mental health in a balanced children’s system.

A final area of focus of the monitoring process was the challenges and opportunities presented
by the existence of strong local control in Iowa. One advantage of local control is that local
resources may be fully leveraged. The team was told that there are many examples of local
communities with outstanding programs and approaches; however, such a community may exist
alongside another with much more limited benefits. Generally, it was communicated to the
monitoring team that, compared to other human service systems, the SMHA suffers from an
imbalance in its authority relative to counties. The DHS staff, consumers, and family members,
and members of the Mental Health Planning Council believe that the current system redesign
presents an opportunity for a more balanced role for the SMHA, with the goal of achieving a
more consistent array of services and supports across Iowa. During this process, it may be
important to clearly communicate DHS mental health policy as it relates to the system redesign.
One mechanism for communicating policy directives throughout the system would be through
the issuance of Commissioner Letters.

Two local programs were visited, the Everly-Ball Elderly Outreach Program, and Orchard Place
Child Guidance Center. The Elderly Outreach Program is unique to the area and provides
inhome services through a team approach, which includes specialized staff such as a
Gerontology Mental Health Nurse Clinician. This program has been proactive in identifying and
meeting the needs of seniors who are isolated by chronic mental health problems and/or a
combination of problems unique to aging, while attempting to maintain the highest level of
dignity and independence.

The collaborative Elderly Outreach Program uses traditional and non-traditional referral sources
and provides services in the client’s home or other least restrictive environments. A potential
opportunity for enhancement of this exemplary program would be the addition of a Compeer
program.

The Orchard Place Child Guidance Center has a long history of providing effective family
psychoeducation and support in normative settings such as schools and pre-schools. The Center
has a commitment to collaboration with parents and other stakeholders. With effective
management of its programs and fiscal operations, the Center maintains a focus on quality and
measurement of program outcomes. Program staff indicated that the counties which the agency
serves have chosen to fund children’s services, and that there is no statewide vision for a




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children’s mental health system. The staff expressed the belief that DHS could more effectively
maximize Federal dollars in the development of an integrated children’s mental health system.




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                                                    TABLE OF CONTENTS


EXECUTIVE SUMMARY ....................................................................................................... i

CHAPTER I: INTRODUCTION ...............................................................................................1
   Mental health services block core monitoring ...................................................................1
   The Monitoring Visit Process ............................................................................................1
   General Limitations ...........................................................................................................2

CHAPTER II: STATE AGENCY SERVICE AND SYSTEM ASSESSMENT .......................5
 STATE SYSTEM SNAPSHOT.............................................................................................5
   State Mental Health Agency and Administration of Mental Health Services ...................5
   Substate Organizations.......................................................................................................6
   Issues, Trends, and Challenges ..........................................................................................7
   Planning Process ................................................................................................................8
   Mental Health Planning Council........................................................................................9
   Management Information Systems (MIS) .......................................................................10
   Compliance Monitoring and Quality Improvement.........................................................11
   Consumer and Family Member Involvement ..................................................................11
   Consumer and Family Rights...........................................................................................12
 ADULT MENTAL HEALTH SERVICES .........................................................................13
   Target Population and Service Array for Adults .............................................................14
   Availability and Accessibility ..........................................................................................15
   Coordination and Continuity............................................................................................16
   Outreach to the Homeless ................................................................................................17
 CHILDREN’S MENTAL HEALTH SERVICES ...............................................................17
   Target Population and Service Array for Children’s Services.........................................17
   Availability and Accessibility ..........................................................................................18
   Out-of-State-Placement....................................................................................................18
   Coordination and Continuity............................................................................................18
   Outreach to the Homeless ................................................................................................19
 FINANCIAL MANAGEMENT ..........................................................................................19
   Fiscal Context of Community Mental Health Services ...................................................19
   Budgetary Planning..........................................................................................................20
   Revenues and Expenditures for Mental Health ...............................................................21
   Contracts and Grants Management ..................................................................................22
   The Community Mental Health Services Block Grant Expenditures ..............................23

CHAPTER III: LOCAL PROGRAM VISITS .........................................................................26
 URBAN ADULT PROGRAM SNAPSHOT ......................................................................26
 EVERLY-BALL COMMUNITY MENTAL HEALTH SERVICES .................................26
   Program Description ........................................................................................................26
   Quality Improvement .......................................................................................................26
   Consumer and Family Involvement .................................................................................27
 ADULT SERVICES ............................................................................................................27
   Coordination and Continuity............................................................................................27


                                                                    v
     Delivery Strategies ...........................................................................................................27
   ORCHARD PLACE CHILD GUIDANCE CLINIC ...........................................................28
     Program Description ........................................................................................................28
     Quality Improvement .......................................................................................................29
   CHILDREN SERVICES .....................................................................................................29
     Delivery Strategies ...........................................................................................................29
     Coordination and Continuity and Family Involvement ...................................................29
   FINANCIAL MANAGEMENT ..........................................................................................29
     Expenditures for Mental Health Services ........................................................................29
     The Community Mental Health Services Block Grant Expenditures ..............................30

CHAPTER IV: SUMMARY AND RECOMMENDATIONS ................................................31
 AREAS OF STRENGTH ....................................................................................................31
   Best Practices: Department of Human Services (DHS)...................................................31
   Exemplary Efforts (DHS) ................................................................................................31
   Exemplary Efforts: Everly-Ball Elderly Outreach Program ............................................32
   Best Practices: Orchard Place Child Guidance Center (OPCGC) ...................................33
   Exemplary Efforts: OPCGC ............................................................................................33
 OPPORTUNITIES TO ENHANCE AND IMPROVE THE SYSTEM ..............................33
   Department of Human Services .......................................................................................33
   Everly-Ball Elderly Outreach Program............................................................................36
   Orchard Place Child Guidance Center .............................................................................36
 CONCLUSION ....................................................................................................................36




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                                      LIST OF EXHIBITS AND TABLES




Exhibit 1: Monitoring Visit Data Sheet ....................................................................................3
Exhibit 2: Planning Council Composition by Type of Member .............................................10
TABLE 1: State Expenditures for Mental Health Services ....................................................22
TABLE 2: Iowa SFY03 Maintenance of Effort (MOE) .........................................................24
TABLE 3: Iowa SFY03 Children’s Set-Aside........................................................................24
TABLE 4: Orchard Place Expenditures FY03-04 ..................................................................29




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                               CHAPTER I: INTRODUCTION



Mental Health Services Block Core Monitoring
The passage of Public Law (P.L.) 102-321 afforded States the opportunity to receive Federal
grants for the purpose of establishing or expanding comprehensive community mental health
services to adults with serious mental illness (SMI) and children with serious emotional
disturbance (SED). Under the statute, each State must submit a State Plan for Comprehensive
Community Mental Health Services for the fiscal year involved. Each Federal grant can be used
for the purpose of planning, administration, education, and evaluation activities related to
carrying out and providing services under the State Plan.

The State Planning and Systems Development Branch, Division of State and Community
Systems Development, within the Center for Mental Health Services (CMHS), is
organizationally responsible for ensuring each State’s compliance with the array of
administrative and programmatic requirements under the law. P.L. 102-321, and as amended by
P.L. 106-310, requires that “the Secretary [of DHHS] shall in fiscal year 1994 and each
subsequent fiscal year, conduct not less than 10 State investigations of the expenditures of grants
received by the States under section 1911 . . . in order to evaluate compliance with the
agreements required under the program involved” (Subpart III, Section 1945 (g)). The CMHS
conducts these investigations in partnership with the States under the term “monitoring visit” to:

          Monitor the expenditures of Federal Block Grant funds;

          Assess compliance with the funding agreements and assurances required under the
           program;

          Identify strengths (e.g., best practices, exemplary efforts) of the State and local
           mental health systems; and

          Focus on opportunities for improvement, i.e., ascertain/recommend priority needs for
           technical assistance, identify issues that need to be addressed, as well as policy
           challenges related to the mental health program and service delivery at the State and
           local levels.

The Monitoring Visit Process
The CMHS conducts the core monitoring visits with the assistance of a team of three consultants
with fiscal, management, and/or clinical expertise in providing services to adults with SMI and
children with SED. One member of the team is designated as the Team Leader/Writer. A
Federal Project Officer makes the final selection of the members and accompanies the team. The
onsite visit of the State mental health system is usually 3 days in duration. The monitoring visit
includes an assessment of the State Mental Health Agency, along with interviews with Mental
Health Planning Council members, consumers, and family members, and a visit to one or more a

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local programs (urban, rural, or suburban) serving adults with SMI and/or children with SED and
receiving some portion of Federal Block Grant funds.

In addition to monitoring the Block Grant expenditures and compliance with the funding
agreements and assurances, the Core Monitoring process involves the assessment and analysis of
a range of planning, management, clinical, and fiscal issues as they relate to the implementation
of the five criteria. Guidelines have been developed to assist each consultant in reviewing
related materials and in conducting focused interviews to obtain necessary information to prepare
the report.

Before the monitoring visit, the State Mental Health Director and the Block Grant liaison receive
notification of the visit. The liaison is also contacted to:

      Discuss the purpose of the monitoring visit;
      Identify materials to be reviewed before and during the monitoring visit;
      Request the selection of a local program to be visited by the monitoring team;
      Assist in identifying key personnel to be interviewed by the consultants; and
      Develop the monitoring schedule.

General Limitations
The fiscal observations contained in this report do not constitute audit findings. The fiscal
information included in the report is based on the data provided by the agencies visited.
Although the fiscal consultant attempts to verify key information during the visit, the fiscal
interview is not conducted according to generally accepted auditing standards issued by the
American Institute of Certified Public Accountants or Government Auditing Standards issued by
the Comptroller General of the United States. Other limitations of the monitoring report are: (1)
the limited time spent onsite, (2) the process of selecting staff interviewed and the program
visited, (3) the process used to collect and review documents, (4) the sampling nature of the
monitoring visit, and (5) the inherent limitations and biases of the team of consultants.




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                   EXHIBIT 1: MONITORING VISIT DATA SHEET



Agency Name:               Division of Behavioral, Developmental, and Protective Services
                           for Families, Adults, and Children


Administrator Name:        Mary Nelson


Local Programs Visited:    Everly-Ball Elderly Outreach Program
                           Orchard Place Child Guidance Center

Date of Visit:             May 18-20, 2004

Team Assignments:          Michael McLaughlin, Child Monitor
                           Linda Gaddie, Fiscal Monitor
                           Mike Hammond, Adult Monitor

Federal Project Officer:   Richard di Geronimo, CMHS


Entrance Conference
Participants:              Mary Nelson, BDPS Administrator
                           Jim Overland, BDPS
                           Lila Starr, BDPS
                           Bonnie Severson, BDPS
                           Becky Flores, BDPS
                           Mary Mohrhauser, BDPS
                           Cynthia Tracy, DHS Medical
                           Joanne Kazor, DHS Medical
                           Patricia Crosley, MHPC Chair
                           Brenda Hollingsworth, MHPC Vice Chair
                           Richard di Geronimo, CMHS
                           Mike McLaughlin, Child Monitor
                           Mike Hammond, Adult Monitor
                           Linda Gaddie, Fiscal Monitor

Exit Conference
Participants:              Jim Overland, BDPS
                           Lila Starr, BDPS
                           Bonnie Severson, BDPS
                           Mary Mohrhauser, BDPS
                           Cynthia Tracy, BDPS
                           Kay Hiatt, BDPS
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                  EXHIBIT 1: MONITORING VISIT DATA SHEET



Exit Conference
Participants:           Patricia Crosley, MHPC Chair
                        Brenda Hollingsworth, MHPC Vice Chair
                        Patrick O’Brien, MHPC
                        Steven Rosner, MHPC
                        Margaret Stout, MHPC
                        Micheleen Maher, MHPC
                        Barry A. Buchanan, MHPC
                        Lowell Brandt, MHPC
                        Michael Flaum, Iowa Consortium for Mental Health
                        Richard di Geronimo, CMHS
                        Mike McLaughlin, Child Monitor
                        Mike Hammond, Adult Monitor
                        Linda Gaddie, Fiscal Monitor




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       CHAPTER II: STATE AGENCY SERVICE AND SYSTEM ASSESSMENT


STATE SYSTEM SNAPSHOT

State Mental Health Agency and Administration of Mental Health Services
Responsibility for the provision of mental health services in Iowa is a joint effort between the
Department of Human Services (DHS), the Division of Behavioral, Departmental, and Protective
Services (BDPS), and the 99 counties of Iowa. The counties have historically played the primary
role in providing mental health services to adults and have a legal mandate to provide those
services; however, the counties are not required to provide mental health services to children.

As the State Mental Health Authority (SMHA), BDPS has the responsibility to administer the
Center for Mental Health Services (CMHS) Community Mental Health Services Block Grant as
well as to accredit providers of mental health services in the State. Within BDPS the Bureau of
Community Services (BCS) administers the Block Grant.

Due to the nature of planning, the administration of services in Iowa counties, and the high
percentage of local funds utilized in funding of services, the Iowa system is uniquely
decentralized. Mental health services for children and adolescents are fragmented, with funding
managed by various State and local entities. There is no coordinated effort to fund mental health
services for children. Planning, funding, regulation, and administration of children’s services are
not vested with one single entity. These responsibilities are diffused in a number of State
agencies, including DHS, the Juvenile Court System, Department of Education (DOE), the
Department of Public Health (DPH), county governments, school districts, etc.

The Executive Summary of Iowa’s FY 2004 Block Grant Application describes a system that is
“fragmented and disorganized to such an extent that efficiency and effectiveness of our mental
health service delivery is far from optimized.” The application continues:

“It is certainly the case that responsibilities for largely overlapping populations are scattered
across multiple agencies and levels of government in Iowa. This is especially the case for
children’s services which are divided between the mental health, child welfare, educational, and
juvenile justice systems among others. On the adult side, our mental health and substance abuse
systems run mostly in parallel rather than in an integrated fashion, (e.g., administration, staff
training and credentialling, place of service, treatment modalities, etc.), despite increasing
consensus that best practices for those with co-occurring disorders requires an integrative
approach. Similarly, housing and vocational needs, both critical factors in terms of meaningful
recovery for individuals with mental illness are also inadequately integrated with the mental
health service delivery system.

“Underlying this non-cooperation is the fact that each agency is under-resourced and competing
for the same slice of the pie in the less than zero-sum game of budget cuts that are being faced by
virtually every state over the past several years. Iowa has had four rounds of state budget cuts in
the past 2 fiscal years.”




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“While these issues are probably common across most states at this time, fragmentation in
Iowa’s mental health service delivery system is further challenged by a substantial degree of
local control in the administration and delivery of mental health services. Iowa has a long
history of local empowerment, and this is very much the case in terms of mental health delivery
systems. Counties have a substantial degree of leverage in the types of services they provide,
what kinds of clinical and eligibility criteria they follow, and how they monitor quality. It is
often said that Iowa has 99 separate mental health systems, which vary significantly from one
county to the next.”

Children’s mental health services are fragmented to a greater extent than those for adults. The
DHS staff, parents, and advocates reported that there is no viable Mental Health Authority for
youth. The BDPS is the umbrella agency for children’s services. The Bureau of Protective
Services (BPS) provides child welfare and juvenile justice services. The BCS is the nominal
Mental Health and Developmental Disability (MHDD) Division.

The Division of Medical Services the lead agency for the Early Periodic Screening Detection and
Treatment (EPSDT) program and the Early Childhood program. The Iowa Plan (Iowa’s
Behavioral Health managed care contract, administered by Magellan Behavioral Care – MBC)
partners with DHS on many levels involving many programs related to the delivery of mental
health services. The DPH is involved with Early Access and oversees the specialty clinics. The
DOE is the lead for Early Access.

Substate Organizations
Iowa’s public mental health system is a county-administered system of care. There are 99
counties in Iowa, each under the auspices of a County Board of Supervisors. These counties
operate to a great degree in an independent and autonomous fashion, with the DHS providing
information and passthrough funding.

In 1996, Senate File 69 provided property tax relief to counties through an increase in State
funding for mental health services while at the same time freezing the county tax levy monies
that could be expended for services. This basically eliminated the option for county expansion of
funding for mental health services. What resulted was minimal expansion of services. The
legislation intended to increase accountability and management at the service delivery level by
requiring establishment of a Central Point of Coordination (CPC) process, and by requiring the
counties to describe how mental health services will be delivered, how planning is carried out,
provider network identification and contracting, how eligibility is determined, and which
processes are used for service evaluation and quality assurance.

The development of the CPC function was in response to the problems that had existed with
access to services in the service delivery system. The CPC manages or provides oversight for
the management of the system outlined in the County Policy and Procedures (CPP). The CPP
identifies how the county-based system will serve individuals, including those not eligible for
Medicaid/Iowa Plan. Some of the components of the plan include designation of access points,
application process, emergency procedures, referral, quality assurance, and consumer input.




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The primary point of collaboration with DHS is accomplished at the State level through
relationships with Community Systems Consultants (CSCs), who have responsibility for certain
regional territories in the State. The CSC is responsible for providing information, consultation,
and technical assistance to County Boards of Supervisors, County CPC administrators, and other
county officials on the development and implementation of the County Policy.

The Community Mental Health Centers (CMHCs) in Iowa are accredited by DHS. The degrees
of local variation make it impossible at the current time to promote and maintain a uniform
system of care across the State. For the most part, the counties cover services for individuals that
are covered by Medicaid. There are differing degrees of services and eligibility guidelines
across counties.

Issues, Trends, and Challenges
Iowa is in the beginning stages of a redesign of the adult service system for individuals with
mental illness, developmental disabilities, and brain injuries. The redesign is being planned and
managed by the Mental Health/Mental Retardation/Developmental Disabilities/Brain Injury
Commission, generally known as the MHMRDDBI Commission. The Commission has the legal
responsibility for planning for services to these four populations in Iowa. The legislature has
mandated that this Commission also submit recommendations for the redesign of the children’s
system by December 2005.

The MH/MR/DD/BI Commission submitted recommendations to the legislature in January 2004
and is in the process of implementing the steps required of it as mandated by the legislature in
the system redesign bill. A number of major issues to be addressed by the Commission include:

      Allocation of resources to counties;

      Data for system management;

      Legal settlement policies (Legal settlement refers to a durational residency requirement in
       Iowa that means that every resident must reside in a county for 1 year without receiving
       services before that individual is considered to have legal settlement in that county. The
       legal settlement laws date to the 1800’s and create many complexities related to funding
       of services for individuals with mental illness); and

      Fiscal management of the service system.

Home rule is an issue that impacts the attempts of DHS to create a more integrated system. With
local control of eligibility criteria, for example, there were as many as 40 different levels of
income eligibility across the State. The DHS has worked with local entities to reduce this
number to six. Treatment models are also developed at the local level, which results in
differences in program design. The DHS provides training in an attempt to create more
consistency. The CMHC accreditation standards provide some framework for consistency as
well.




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The Medicaid/Iowa Plan does provide a more consistent service array. Medicaid was recently
rebid, and Magellan Behavioral Care (MBC) continues as the provider. The Iowa Plan funds
between 35 and 40 percent of mental health services. The Iowa Plan funds three assertive
community treatment programs, and Psychiatric Medical Institutes for Children (PMIC)s. There
is a broad Medicaid provider network

Medicaid match is provided in two different ways: Medicaid State Appropriation and County
Match. For some individuals without legal settlement, match is provided under the State
Payment Program (SPP), which has grown from 44 clients in the 1980s to over 2,000 (of these,
1,550 are mental health clients). The SPP care management is contracted to MBC.

Iowa is a rural State. Only 22 of the 99 counties have a population of more than 30,000. There
are seven main urban areas in the State, with a rapidly growing and increasingly more diverse
population. As this trend continues, there are large differences in local area needs.

There has been a lot of activity around Olmstead issues, which have been closely integrated with
the MHMRDDBI Redesign process. Supported by a Real Choices Systems Change grant,
Olmstead has sparked a level of interest and a sense of urgency for disability issues in the
broader community. The Governor issued an Executive Order mandating the directors of 20
State agencies to work with DHS and to formally review the agencies’ policies and programs so
as minimize barriers to community integration for persons with disabilities in Iowa. As a result,
each State agency has an Olmstead designee, responsible for collaboration with other agencies
related to implementation of Executive Order 27. DHS is the lead State agency on Olmstead
implementation and planner for adult services serves as the statewide Olmstead Coordinator as
well.

Planning Process
In the past, more systematic planning took place. In recent years, planning has been more
targeted. The DHS staff, local advocates, providers, consumers and parents indicated that
statewide planning in any organized or integrated way is almost nonexistent. Counties develop
CPPs, which are filed with the DHS. The DHS responds to legislation or other mandates to
guide its planning. The Medicaid managed-care company develops targets and services. The
MHMRDDBI Commission has a limited role, monitoring the certification standards plan put
forth by the DHS. With limited staff, it appears that DHS resources would be strained by any
involvement beyond minimal planning along with preparation and implementation of the Block
Grant.

The Mental Health Planning Council (MHPC) is attempting to return to a focus on system-wide
planning. A significant factor in planning is the MHMRDDBI Commission and system redesign.
As a part of child welfare planning process, a system-of-care approach is being considered. The
DHS staff sit on the Memorandum Of Agreement workgroup. As part of an educational
redesign, such things as positive behavior support and wraparound are being investigated. In
other words, some “planning corridors” are being opened.

Neither a children’s planning process nor a children’s mental health system exists. The
Olmstead assessment process has determined that preparatory action is being taken towards


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planning a comprehensive system. Regional planning councils were described as being
irrelevant. The Olmstead report recommends some thought provoking system change, including
such things as client self-direction.

Children’s advocates are attempting to pull together family advocates from such arenas as mental
retardation, autism, school districts, and parent education and information. These advocates
meet as the children’s mental health roundtable, a grassroots group that includes private
agencies.

In 2003, the MHMRDDBI Commission recommended that several aspects of the current system
for delivering adult disability services be changed to provide better access to services, to fund
core services to more people statewide, to equalize county funding obligations, and to distribute
funds on a more equitable basis. The recommendations will assure universal access to
information and outreach, to initial service coordination, and to crisis services. The system will
link individuals with disabilities to basic supports such as housing subsidies, utility subsidies,
food assistance, transportation subsidies, and medical and dental care. Funds will be available
where each individual resides and will not be determined on an archaic calculation of legal
settlement.

The redesigned system will provide funding for core services, including coordination and
monitoring services, community services and supports, inpatient services, and residential
services. Funds for the adult disability system will come from county property taxes, State
appropriations, Federal funds, and other sources. Counties will contribute at an equalized
property tax rate threshold. State and Federal funds will be distributed to counties or coalitions
of counties using case rates based on functional assessments of eligible individuals.

The MHMRDDBI Commission anticipates that system changes will occur over the course of the
next 6 to 8 years. In the 2004 Assembly, House File 2537 was passed and signed into law by the
Governor, putting some elements of the redesign recommendations for the system into effect
July 1, 2004.

Mental Health Planning Council
The MHPC has become more active and involved over the past year. Although members
describe their role as advisory, some members indicated that the Council has more input than
most other State-level councils and that Council recommendations usually get followed.
Consumer members of the Council reported they are not hesitant to speak up, and they are not
fearful of reprisal when they do so.

Council members believe they have had some impact in improving the system. Successes
include the fact that CMHCs are providing more innovative services, including supported
employment and school-based services. There is better planning and prioritization. The Council
has brought greater diversity to the process. The Iowa Consortium for Mental Health is seen as a
strength. There are three council members who sit on the MHMRDDBI Commission. Mental
Health services within the adult correctional services have also been enhanced.




                                                9
At the same time, members report the Council does not have a comprehensive strategy to address
the needs of youth with serious emotional disturbance (SED), as there are many systemic
problems. The child welfare redesign effort has a goal of moving to a family team model. The
schools are moving toward learning supports in their redesign.

Council members described several challenges in Iowa. These include the belief that the system
is much more fragmented than in the past. Other challenges are legal settlement issues,
children’s issues, housing and homelessness, domestic violence and substance abuse, and
transitional services.

One Council member reported that little measurement exists to support the effectiveness of
programs, and there is a great deal of variability across providers. This individual believes this
variability is related to the lack of a single Mental Health Authority, resulting in inconsistencies
and lack of coordination. The Council member has assisted in developing a standardized
reporting form for Block Grant-funded programs. He reported that he believes that if services
were more centralized and funds were blended, a special emphasis on the needs of youth with
SED could be created.

              EXHIBIT 2: Planning Council Composition by Type of Member

 Type of Membership                                     Number Percentage of Total
                                                                     Membership
 TOTAL MEMBERSHIP                                           34
 Consumers/Survivors/Ex-patients (C/S/X)                     6
 Family Members of Children with SED                         6
 Family Members of Adults Diagnosed with Serious Mental      3
 Illness (SMI)
 Vacancies (C/S/X and family members)                        0
 Others (not State employees or providers)                   7
 TOTAL C/S/X, Family Members, and Others                    22                 65                      Formatted
 State Employees                                             9
 Providers                                                   3
 Vacancies                                                   0
 TOTAL State Employees and Providers                        12                 35                      Formatted


Management Information Systems (MIS)
The overall management of MIS for all of the DHS is administratively located in the Division of
Data Management. Within the Division of BDPS, there are no dedicated resources focused on
MIS and data management.

Financial management of mental health services in Iowa is managed through the Iowa Financial
& Accounting System (IFAS). This system provides all data related to contracts, contract
payments, and grant payments and all other financial and accounting data.

There is no integrated client information management system in Iowa. Iowa’s counties are major
providers of mental health services and have been so since the health services began. Each


                                                10
county is legally responsible to provide services for its residents. The only statewide information
system that relates to mental health services is the County Management Information System
(COMIS). The COMIS was developed by the State and provided to the counties for their use.
Information in the COMIS system is segregated by disability as there is a disability code to be
entered into the system, but retrieving data from the system can be extremely difficult.

The MBC of Iowa, the contractor who is managing Iowa’s Medicaid program, is providing some
data to the BDPS relating to mental health services for Medicaid eligible persons.

Data for the Block Grant Implementation Report are drawn from the multiple sources described
above. The process for gathering the data is labor intensive and does not allow the reporting of
all services to clients or provide a method to collect unduplicated counts of clients served.

Iowa does have a Federal Data Infrastructure Grant (DIG). In spite of the information systems
challenges described above, Iowa has made little progress in expending its DIG. The Director of
the BCS stated that the Data Infrastructure Grant was insufficient to have an impact on the
overall information infrastructure needs.

The Division of BDPS states that it is fully in compliance with the Health Insurance Portability
and Accountability Act (HIPAA). The Division is in the process of doing security training
related to HIPAA and has a HIPAA Compliance Office and a HIPAA Training Officer. Because
the Division does not have a client information management system, it was not required to make
its data HIPAA compliant.

The University of Iowa Department of Psychiatry previously was the Mental Health Authority.
In 1991, the University created a substance abuse consortium. In 1994, the Iowa Consortium for
Mental Health (ICMH) was started at the University. A primary focus of the ICMH is to explore
development of evidence-based practice. The Consortium engaged in such activities as a pre-
evaluation and post-evaluation of the Iowa Plan. The Consortium is currently pursuing a grant to
improve evidence-based practice. The MBC community reinvestment funds support a technical
assistance center for two evidence-based practices, Assertive Community Treatment, (ACT) and
Wellness Management and Recovery (WMR). Current initiatives are wellness recovery action
planning (WRAP), ACT, and recovery models. There is a buy-in from CMHCs regarding
development of common outcome measures for ACT.

Compliance Monitoring and Quality Improvement
There are three staff who review programs. CMHCs are accredited for 3 years. The staff
provide an on site review covering administrative processes, random file reviews, and review of
service plans, and also meet with clients, interview staff, and provide feedback onsite.

Consumer and Family Member Involvement
The Consumer Resource and Outreach Project (CROP) supported by Block Grant funds, is
housed in the same office with the BDPS headquarters. CROP functions as Iowa’s Office of
Consumer Affairs for adults with serious mental illness. The CROP sees its mission of
promoting positive change through advocacy and education. This organization does a good job



                                                11
of advocating for consumers. The CROP is also working with the managed-care entity and the
CPCs to institute a reliable consumer satisfaction survey.

The CROP is very interested in developing a holistic wellness model to help retain/maintain
recovery. One former staff member, who is on the Planning Council, has traveled around the
State discussing incorporation of the holistic approach in peer-support and consumer-directed
programs. The CROP provides and facilitates a great deal of training and technical assistance
across the State. It has been involved in consumer conferences and consortia that provide
technical assistance to consumers and advocacy groups.

Empower 2004, Rally for the Summit: Recovery Conference for Individuals with a Mental
Illness is the sixth annual conference for consumers and family members. Conference supports
include the Iowa Office of Consumer Affairs, MBC of Iowa, and Iowa PEERS Network. This
year’s conference is being held July 23-25, 2004, in Marshalltown, Iowa.

The Federation of Families for Children’s Mental Health is not active across Iowa. One very
active statewide family organization is the Association for Special Kids (ASK) Resource Center.
The ASK Resource Center provides advocacy and linkage and brings together parent leaders
from different systems. The roundtable is attempting to influence the directors of DHS, DPS,
and DOE. The priorities for parent involvement include family support, with development of
paid parent positions that are being developed in Creston. A second priority is training.
Currently, DHS local workers do not receive any mental health training. The Rehabilitative
Treatment Services (RTS) are limited, which results in empowered parents being the only ones
to receive them. According to advocates, Family-centered really means “just a sign-off”,
indicating that the goal is often to obtain a parents signature on a treatment plan, rather that to
have meaningful parent involvement in developing the plan.

Accreditation standards for community mental health centers require that consumers and/or
family members be on governing boards, or on an advisory board. Planning council members
indicated that there is a great deal of variability across the State, and that few CMHCs have
advisory boards.

Consumer and Family Rights
The State’s administrative code mandates client rights pertaining to clients who are receiving
services financed by the State. There is assurance that due process includes the opportunity to
appeal throughout the service system up to the State level, including the MHMRDDBI
Commission. The Iowa Plan provides for a comprehensive set of client rights and appeal
processes. The CPPs also must address client rights and appeal processes. For example, in
Buena Vista County, consumers may appeal within 15 days the decision of the CPC
Administrator. Such individuals or agencies may also file a grievance, at any time, about the
actions or behavior of any party associated with the county management system. Written appeal
forms, with a description of how to complete the appeal form, are sent with the Notice of
Decision and are available at access points and the CPC office.




                                                12
ADULT MENTAL HEALTH SERVICES

There are two Bureaus in the Division of BDPS, each with a Chief who reports to the Division
Administrator. The Bureau of Community Services (BCS) provides consultation to community
providers, consumer and advocate groups, and county officials/programs. BCS also is
responsible for quality assurance and accreditation of CMHCs. Other responsibilities of BCS
include all of the administrative functions of the SMHA, administration of Interstate Compact on
Juveniles (ICJ), Interstate Compact on Placement of Children (ICPC), Independent Living and
Transition to adulthood for foster care children, and RTS authorization. The BCS provides staff
support and acts as liaison to the MHMRDDBI Commission. The Division also includes the
office of CROP/OCA and the Services, Policy, and Practice Team. The Bureau of Protective
Services (BPS) is primarily dedicated to abuse registry, adult and child protection, adoption,
foster care and foster group care, PMIC (Psychiatric Medical Institutes for Children) and juvenile
justice programs.

The Iowa Plan for Behavioral Health was implemented in January 1999. It is a managed care
plan for mental health and substance abuse services. The contractor, MBC of Iowa, is fully
capitated and at full risk for the development and delivery of Medicaid mental health and
substance abuse services for the enrollees. It is a single managed-care plan. The Iowa Plan
covers most of Iowa's Medicaid recipients except those who are over 65, those who live in
certain residential settings, and those who are medically needy. It also does not cover DPH-
funded substance abuse services and the State payment program for mental health services. It
covers all traditional mental health and substance abuse services and requires the development
and utilization of a broad range of community-based services and supports. The average
monthly Medicaid enrollment is 270,000. The minimum number of DPH clients served annually
is 27,115. The monthly average number of members in the State payment program is 1,750.
Children (through age 18) represent 60 percent of enrollees.

The Iowa Plan Medicaid goals include increasing the number of people who receive mental
health and substance abuse services, to expanding the array of services available to Medicaid
recipients, and practicing cost containment. According to information provided by the
contractor, access to mental health care has increased by 101 percent over the prior fee-for-
service system. The monthly average for Medicaid penetration under fee-for-service was 5.5
percent, compared to 8.0 percent in the Iowa Plan. There is evidence of cost containment
achieved. Independent actuarial studies document cost savings to Medicaid at $2.0 million
annually.

Iowa Plan providers focus services on recovery models of treatment. The plan initiated the
development of ACT, Intensive Psychiatric Rehabilitation, Services for Dual Diagnosis, follow
up after emergency room visits or within 7 days of discharge from an inpatient setting, and
individualized wraparound services. Services covered by the Iowa Plan include 24-hour crisis
and emergency services, 24-hour mental health services provided in a hospital, intensive
outpatient services, consumer-run services, warm line and peer support, mental health services
through a CMHC, in-home mental health services, targeted case management of individuals with
a chronic mental illness, integrated mental health services and supports, and assessment and
evaluation.



                                               13
Iowa Plan providers coordinate services through multidisciplinary utilization managers
organized in Care Teams to assure continuity and coordination of services. In State Fiscal Years
(SFYs) 2002 and 2003, the Iowa Plan facilitated 1,145 joint treatment planning conferences.
Client satisfaction surveys over the past four surveys show that 87.5 percent of
children/adolescents and 85.5 percent of adults were satisfied with the Iowa Plan.

Target Population and Service Array for Adults
The Iowa Block Grant definition of serious mental illness (SMI) is consistent with the Federal
definition. Outreach efforts are conducted at the county levels, with no real requirements or
guidance from the Division.
Prevalence rates of adults with SMI are estimates based on Kessler et al, 1996, which estimates a
national prevalence of SMI as 5.3 percent. Based on that estimate, 116,041 Iowans are estimated
to have SMI. There is no unduplicated count of all individuals served. Based on data from the
Block Grant application, 47,805 Iowans with SMI were served in FY 2003.

Supported Community Living (SCL) services assist consumers of mental health services in
living in the community. Such services include outreach and support or treatment services,
assistance or referral in meeting basic needs, assistance in housing and living arrangements,
mental health treatment, crisis intervention, and service coordination.

The small array of services accredited by the Division of BDPS by service area include
outpatient, emergency, evaluation, SCL, day treatment, partial hospitalization, education,
consultation, and Intensive Psychiatric Rehabilitation (IPR).

The Iowa Code for Human Services requires that contractors ensure, arrange, monitor, and
reimburse the following required mental health services which are not reimbursable by Medicaid
fee-for-service:

      Concurrent substance abuse and mental health services for those diagnosed with both
       chronic substance abuse and mental illness;

      Services of a licensed social worker for treatment of mental illness;

      Mobile crisis services;

      Mobile counseling services;

      Integrated mental health services and supports;

      Psychiatric rehabilitation services;

      Peer support services for persons with chronic mental illness;

      Community support services;




                                                14
      Periodic assessment of the level of functioning for each enrollee who meets the criteria of
       either a child with SED or a person with serious and persistent mental illness (SPMI); and

      Assertive Community Treatment (ACT).

Availability and Accessibility
In Iowa, case management services are used to link consumers to service agencies and support
systems responsible for providing the necessary direct service activities and to coordinate and
monitor those services. Each county ensures that targeted case management is available for
eligible persons with a chronic mental illness. Other services to assist individuals in functioning
outside of residential settings include the following:
     Supported Community Living (SCL) Programs, accredited by the Division of BDPS,
        provide supervised supported living to persons with disabilities. Approximately 90 of
        these programs currently provide services to persons with mental illness.

      Case Management for the Frail Elderly is designed to assist elderly persons who are frail
       in gaining access to a variety of services through the assistance of a case manager.

      The Senior Living Trust Fund generates funds for the development of alternative services
       for persons who are elderly and/or have disabilities and who are either residing in nursing
       homes or are at risk of such placement.

Availability and accessibility of services vary greatly from county to county, depending on the
county plan and the mental health providers who serve their respective county. There are general
service standards to which programs are required to adhere.

The Medicaid penetration rate for mental health services for the quarter ending December 2003
averaged 7.3 percent. The DHS and MBC of Iowa define a 2-percent or less Medicaid
penetration rate for 2 consecutive months in any one of Iowa’s 99 counties as potentially
underserved. For this same quarter, no Iowa counties were under the 2-percent threshold.

The MBC monitors client access to Medicaid mental health outpatient providers by tracking the
number of clients served in the county in which they live or in an adjacent county. For the
contract year-to-date (July 1, 2003, to December 31, 2003), percentages for children and adults
are 76.8 and 83.1, respectively.

Iowa Plan Performance Indicators include access goals regarding the length of time a client must
wait to obtain Medicaid-funded services. The MBC monitors access to Medicaid mental health
as part of the on-site Retrospective Clinical Review process. Access standards include that
clients with emergency needs shall be seen within 15 minutes of presentation or telephone
contact, that clients with urgent nonemergency needs shall be seen within 1 hour of presentation
or within 24 hours of telephone contact, that clients with persistent symptoms shall be seen
within 48 hours of reporting symptoms, and that clients in need of routine services shall be seen
within 4 weeks of a request for an appointment. The performance of the providers in the Iowa
Plan for these standards is 97 percent for emergency needs, 100 percent for urgent needs, 100
percent for persistent needs, and 100 percent for routine needs.


                                                15
Coordination and Continuity
In 1998, the ACT initiative began as a collaboration between DHS and MBC of Iowa; was
designed to enhance the availability of intensive behavioral health services for adults in Iowa.
Three sites in Iowa, Abbe Center in Cedar Rapids, Golden Circle in Des Moines, and the
University of Iowa in Iowa City, provide ACT services.

The MBC uses clinical criteria to identify at-risk clients for both mental health and substance
abuse problems. Such clients are identified for specific internal care management procedures to
ensure continuity of care that contributes to optimal positive outcomes.

Iowa’s Intensive Psychiatric Rehabilitation (IPR) services were developed in collaboration with
consumers, DHS, family members, the Iowa Psychiatric Rehabilitation Society, and providers.
The IPR services are designed to assist persons with SPMI to overcome disabilities in the living,
learning, working and social environments.

Joint Treatment Planning is used to define case specific treatment team roles and responsibilities,
to develop treatment plans, to build consensus among all involved parties, and to coordinate
funding for services. This is available by request to all Iowa Plan clients.

Discharge planning, including placement and coordination of services, is outlined in policies and
procedures of the Mental Health Institutes (MHI). The policies are consistent with standards
delineated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
The MHI policies specifically state that all patients will have a comprehensive discharge plan
completed by social work staff, with appropriate referrals for aftercare, based on diagnosis and
patient needs. The social work discharge plan will be developed in collaboration with the
patient, family, significant others when possible, other members of the treatment team, and
community resource providers. The MHI policies further state that discharge planning begins at
the time of admission, continues through assessment and treatment, with goals of assuring
successful outcomes through referral and coordination with community support systems.

Case management does not provide direct client services, but rather is a service that assists
clients with access to and coordination of available community services. Medicaid pays for most
of the case management services for clients that are covered by Iowa’s Medicaid program. The
State of Iowa and the client’s county of legal settlement also share in the cost.

In Iowa, case managers for persons with SMI are required to have a bachelor’s degree in a
human services field, and 1-year experience in the delivery of services to the populations groups
they serve; or an Iowa license to practice as a registered nurse with 3 years experience in the
delivery of services to the population groups they serve. All counties provide case management
to their counties by one of three methods or by a combination of methods. These include case
management by: (1) DHS, (2) contract to outside individual or agency, or (3) the county’s own
county government organization. Counties that wish to provide their own case management
services must meet conditions necessary to be a provider.




                                                16
Outreach to the Homeless
Homeless outreach efforts are funded through federal Projects to Assist in the Transition from
Homelessness (PATH) grant funds in the amount of $300,000.

In 1999, an estimated 18,592 homeless people and 7,306 near-homeless people lived in Iowa. Of
these, approximately 75 percent were estimated to be adults. The Iowa Mental Health Plan
estimates that 25 percent of those homeless adults have SMI. That equates to an estimate of
3,000 adults who are homeless.

The State uses PATH funds to provide mental health and community support services, including
outreach, mental health evaluation and treatment, consultation, and education services. In SFY
2001, 827 homeless were served by PATH. In SFY 2002, that number grew to 847. In SFY
2003, that number increased to 855. For SFY 2004, Iowa estimates they will serve 860.

There is a statewide interagency task force on homelessness, the Iowa Council on Homelessness,
that meets once every other month to plan and coordinate expanded housing options for the
State’s homeless population. The Adult Planner, who also serves as Iowa’s PATH Coordinator,
has been participating in this task force since September 2002. In December 2002, it was
decided to include all PATH program providers at the table of the Iowa Council on
Homelessness.

CHILDREN’S MENTAL HEALTH SERVICES

Target Population and Service Array for Children’s Services
The target population served by the children’s mental health system is youth with SED. The
definition in the 2004 Iowa Block Grant application states that “children with a serious emotional
disturbance are persons from birth to age 21, who currently, or any time during the past year
have had a diagnosable, mental, behavioral, or emotional disorder of sufficient duration to meet
diagnostic criteria specified within DSM-IV that resulted in function impairment which
substantially interferes with or limits the child’s role or functioning in family, school, or
community activities.” The DHS staff reported that the definition has limited functionality, in
that youth and families receive a range of services and supports through the child welfare,
juvenile justice and school systems. In many cases, the requirements for eligibility for services
from these agencies are broader than those in the mental health system. In addition, there is
limited availability of children’s mental health services. CPCs are not required to provide a
range of children’s services. The lack of service availability is sufficiently significant that
advocates, planning council members, and DHS reported that there is no children’s mental health
system in Iowa.

The Children’s Mental Health Initiative (CMHI), a partnership of Departments of Human
Services, Public Health, and Education, addressed the lack of a children’s system. With broad
stakeholder input, the CMHI produced the report “Creating a System of Mental Health Services
for Children In Iowa.” The report addressed four key issues:

      Lack of understanding of children’s mental health needs;
      Inadequate resources for detection and treatment;

                                               17
      A fragmented mental health system; and
      No point of accountability.

The array of DHS-funded mental health services primarily includes PMICs, and outpatient
therapy. There is a range of services available that is funded by the Iowa Plan, the State’s
Medicaid program, which is administered by the Department of Human Services (DHS).
Families receive in-home services, family foster care, and group foster care through the child
welfare system, also funded through DHS. There is a limited Children’s Health Insurance Plan
(CHIP) benefit administered by three private carriers.

Availability and Accessibility
Access to the array of mental health services for youth and their families is limited, particularly
in rural communities that make up most of the State. The CPC system, which generally assures
that there is a range of services available for adults with serious mental illness, does not routinely
address children’s services. Children’s services are seen as optional by the CPCs.

The CMHI report previously described noted that, “Access to good quality clinical mental and
behavioral health and substance abuse services has declined.” Children’s advocates reported that
children are removed from their homes according to their behavior. Families are not generally
involved. Parent blame is reinforced in schools and other settings. There is a need for public
awareness of the need for mental health services for youth. Many services provided through the
child welfare system and RTS are geared to address safety and protection issues and do not
address mental health needs.

For the most part, large urban centers are driving the funding structures. There are local
initiatives to develop children’s mental health systems. Creston is a multi-county effort using a
child health specialty clinic as the lead. Ottumwa is seeking a Federal system-of-care grant. The
area education authority is the lead agency in this effort.

Out-of-State-Placement
There are currently 173 youth placed out of the State. The out-of-State placement rate has been
relatively stable for the past five years. There is no current initiative to return youth from these
placements, though BDPS is sending two staff to visit some youth in other States to determine
whether they can be returned. Advocates indicated that the number of youth placed out-of-State
reflects the lack of sufficient specialized intensive services for youth in Iowa.

Coordination and Continuity
The CMHI report included the following statements: “The system is fragmented and confusing.
Iowa has no comprehensive system of mental health care for children. Although community
mental health centers serve every county, the State lacks a coordinated mental health care
infrastructure for children. The current system is multifaceted and complex, involving many
players and sectors: public-private, specialty-general health, health-social welfare. The system is
also financed from many funding streams, adding complexity. Families are often caught in the
middle, receiving no information or conflicting information.”




                                                 18
Despite the recommendations made by the CMHI report in 2001, there has been little progress in
achieving the goals of the partnership. A single children’s mental health specialist is employed
by DHS. At the time of the visit, there had been no appplication for the CMHS Children’s
System of Care grant program. The DHS staff reported that there is resistance to exploring
funding from this source because of the possibility that additional State funding will be required.

A bill that will become effective July 1, 2004, requires the MH/MR/DD/BI Commission to
propose a redesign of the children’s disability service system. The MH/MR/DD/BI Commission
has determined that there will be a Child System Design Oversight Committee. The goal of the
Oversight Committee will be to “design a system that will serve the developmental and
behavioral needs of Iowa’s children and their families.” The process of nominating the 15 to 17
members of the Oversight Committee has just begun.

Some progress has been made outside of the DHS infrastructure. The Iowa Plan has provided
leadership in development of evidence-based services for Medicaid-eligible youth. Advocates
have participated in a series of roundtables, one of which has brought together parent leaders
across child-serving systems and advocacy groups, to support and steer the planned children’s
mental health design. The Iowa Consortium for Mental Health recruited a half-time child
psychiatrist 3 years ago, and is exploring such areas as family psychoeducation, school-based
clinical mental health services, and family support.

Outreach to the Homeless
Homeless programs in Iowa also serve youth and families. With only six PATH programs in the
state, there are insufficient services to the homeless.

FINANCIAL MANAGEMENT

Fiscal Context of Community Mental Health Services
Operationally, the Iowa DHS’s, Division of BDPS functions as the SMHA. The Division is the
result of a reorganization that occurred approximately 3 years ago. Prior to the Division, the
Mental Health and Developmental Disabilities Division was the SMHA. During the monitoring
visit, the legal status of the BDPS as the SMHA was raised. According to participants in the
Entrance Conference, Iowa Administrative Code was not changed to reflect the change in SMHA
when the Division of MHDD was eliminated.

Within DHS, primary financial management functions are administratively located in the
Division of Fiscal Management. Responsibilities of this section are budgeting and accounting,
purchasing, payments, receipts, collections, and provision of support services. Financial
management functions for mental health services, including the administration of the CMHS
Block Grant, are split between DHS, Division of Fiscal Management and BCS. The DHS is
responsible for the following:

       Cash management;

       Federal funds drawdowns;



                                                19
       Making and monitoring of payments to subrecipients; and

       Processing payments and allocations to counties and other sub-recipients of State funds
        and grants.

The BCS’s responsibilities are as follows:

       Developing the budget for mental health services;
       Tracking expenditures and forwarding invoices from providers for payment;
       Developing contracts;
       Determining allocations to counties and other subrecipients of State and grant funds;
       Monitoring subrecipients and receipt of audits; and
       Submitting grant applications.

With the exception of State inpatient psychiatric hospitals, the DHS does not provide direct
services to consumers of mental health services. Counties, through contracts with CMHCs or
other provider organizations, provide all services. Every county is required to submit a
management plan which details the mental health services that it will provide. Services vary
greatly by county.

Budgetary Planning
The legislature meets annually in Iowa and the budget is developed annually. As is true in most
States, the budget process is managed by an entity that is separate from the Mental Health
Authority. In the case of Iowa, the Department of Management (DOM), with the release of a
Planning/Budget Calendar, initiates the budget process. The SFY 2005 budget process began on
May 20, 2004, with a Cabinet meeting to review the process and parameters. The State fiscal
year is July 1 through June 30. Within the Division of BDPS, the redesign of the mental health
delivery system is driving budget priorities and allocations.

The Governor's budget is due to the legislature in January. Once the budget is submitted and
approved by the general assembly, changes in the budget are accomplished through the budget
revision process. Special appropriations are made for Federal funds and allocations. Over the
past 3 years, the budget for mental health services has been essentially flat, except for the growth
appropriation to counties which has grown 2.3937 percent in SFY2003 and 2.142484 percent is
SFY2004. The Division of BDPS is required to submit a zero growth budget for SFY 2005.

Because of growth in the Medicaid program, Iowa was projecting a $100,000,000 shortfall in the
Medicaid program. The State “borrowed” some funding from the Senior Living Trust Fund and
the balance will be required in a supplemental appropriation in the SFY 2005 budget session, or
cuts will have to be made.

A key issue in Iowa, both in the fiscal and programmatic sense, is the system redesign that was
initiated with legislation in SFY 2003 that combined the Mental Health and Developmental
Disabilities Commission with the State County Management Committee to form the
MH/MR/DD/BI Commission. The Commission is mandated by the legislature to recommend
changes that would improve the system and include in those recommendations:


                                                20
      Assurance that individuals with mental illness, mental retardation, developmental
       disabilities, or brain injury have access to services, regardless of where they live;

      Assurance that individuals have access to available funding, based on their individual
       needs;

      Statewide standards for clinical and financial eligibility;

      A minimum set of core services that will be funded for eligible individuals based on their
       individual unmet needs; and

      A new funding process that equalizes distribution of MHDD funds.

The recommendations above are related to the adult service system and the report delivered to
the legislature on December 31, 2003. A similar study is due to the legislature on December 31,
2005, for children’s services.

Revenues and Expenditures for Mental Health
As reported by the Director of the BCS, revenues and expenditures for total mental health
services in Iowa have been relatively flat for the last 3 fiscal years. The budgeted MHDD
allocations to counties in SFY 2004 are $135,891,461, and the allocation in SFY 2003 was
$132,498,823. The totals in each case include funding for developmental disability services as
well as mental health services. These totals do not include Medicaid or institutional services,
which are funded separately, but do include county match for Medicaid and the county portion of
institutional services.

Iowa has focused on utilization of Medicaid to expand the service system for mental health
services. In addition, the level of county funding for services and the requirement that counties
fund services for persons with legal settlement in their county has strengthened the overall
funding of services in Iowa; however, Iowa does not have the information systems capability to
track services provided to individual clients that would allow them to ensure that all sources of
funding for services are maximized.

Mental health services to Medicaid-eligible populations are provided through a carve-out of the
services to MBC of Iowa. Iowa also has a Home and Community Based Care Medicaid waiver.




                                                 21
                   TABLE 1: State Expenditures for Mental Health Services


Categories                 SFY04      Percent       SFY03         Percent     SFY02           Percent
                        Projected               Estimated                     Actual
Adults with           $10,693,070        12.89 $10,398,612        13.01% $10,037,038            12.92
Mental Illness
Adults with           $28,786,979        34.71 $27,994,264           35.03 $27,020,865          34.79
Chronic Mental
Illness
Mental Illness                  $0            0             $0           0       $121,200       00.15
Housing Services
State Medicaid        $31,821,146        38.37 $30,574,327           38.25 29,576,076           38.08
State Payment         $11,633,669        14.03 $10,959,055           13.71 $10,918,602          14.06
Program for
Adults

Total              $82,934,864        100 $79,926,258                  100 $77,673,761            100
Expenditures
Source: James Overland, Section 1, Maintenance of Effort.


State mental health expenditures have risen from $77,673,761 in SFY02 to $82,934,864 in
SFY04. The total increase was the result of small increases in all sources of funds.

Contracts and Grants Management
As noted above, no integrated information system exists to track consumers across the system of
care or within the providers with the exception of the tracking being done by MBC and the
counties through COMIS. These two databases are not integrated. No plan is in place to create
an integrated information system that allows for a systemic view of services to consumers.

A portion of the CMHS Block Grant funds is allocated to counties based on a formula that
provides one-half of the funding available as equal shares and the other half is based on county
population. Without input from the MHPC in its advisory capacity and through the influence of
the CMHC provider association, the Iowa legislature passed a bill in 2004 that requires that 70
percent of the CMHS Block Grant funds be allocated to CMHCs. This legal mandate seems to
violate the intent, if not the letter, of the Mental Health Block Grant statute that indicates that the
Block Grant application and Plan with advice from the MHPC determine the allocations of Block
Grant funds. The balance of Block Grant funds not allocated to counties is awarded based on
request for proposals (RFPs).

The CMHS Block Grant funds are in fact allocated to a for-profit entity through a contract. The
for-profit entity receiving Block Grant funds is ResCare, Inc. According to the Bureau Chief of
BCS, for a period of time, ResCare operated a nonprofit entity, but declined to continue to do so
when it was apparent that there was not a financial advantage.. ResCare, Inc., received $153,139
in Block Grant funding in SFY 2003. After the monitoring visit, the Federal project officer for
the State received assurance from the Bureau Chief of BCS that current and future contracts with


                                                  22
ResCare, Inc., will be on a “strict, cost-reimbursement basis,” thus falling within Mental Health
Block Grant (MHBG) compliance.

Awards of Block Grant funds are made in the form of cost-reimbursement contracts.
Subrecipients are required to submit quarterly financial reports and invoices for payment.
Program reports are also required on a monthly basis. While subrecipients, by contract, are
required to submit an A-133 audit if they meet the criteria, there is not a consistent process for
collecting or reviewing the audits. Providers are expected to self-identify if they are required to
provide the A-133 and submit any comments from the audits. There is not a cost-settlement
process at the end of a contract. In addition, there is no onsite fiscal monitoring of subrecipients
and no method to ensure compliance with applicable cost allowability requirements such as A-
122.

In cases where Block Grant funds are set aside for special purposes or programs, an RFP method
is used to determine the recipients. The RFP includes the project deliverables, types of award,
deadlines for submission and compliance reports, and the evaluation method.

In the contract documents provided to the fiscal monitor, the Catalog of Federal Domestic
Assistance (CFDA) number and specific language regarding prohibited expenditures with Block
Grant funds were not included in the contract language.

Iowa does have a State-imposed limit on administrative costs that can be charged to the State in
the contracts related to the Block Grant. That administrative limit is 5 percent.

The DHS Division of Fiscal Management is responsible for cash management and payments to
subrecipients. No issues related to cash management, including the requirements of the Federal
Cash Management Act, were noted in the latest DHS audit. Since Block Grant funds are in a
cost-reimbursement methodology, the funds are expended before they are requested from the
Federal Government.

The Community Mental Health Services Block Grant Expenditures
The Division of BDPS operates on a State fiscal year of July 1 to June 30. The amount of the
CMHS award for Federal Fiscal Year (FFY) 2003 was $3,704,896. In the Iowa DHS Annual
Report for SFY 2003, the actual amount expended of CMHS Block Grant funds was $3,286,098
(page 16 of 84). In the last 3 fiscal years, Iowa has not expended its total Block Grant funding
and has had approximately $800,000 revert to the Federal Government from unspent funds.

Iowa defines an obligation as a contract for goods or services. A signed contract creates the
obligation. Iowa has until September 30, 2004, to expend the full FFY 2003 Block Grant award.

Maintenance of Effort (MOE)

A review of Iowa’s calculations of Maintenance of Effort (MOE) could not be completed during
the monitoring visit. The data necessary to complete the calculations were not made available at
that time to the fiscal monitor. The data in the FFY 2004 Application for CMHS Block Grant
regarding MOE are in error. The calculations include inpatient services and Medicaid
reimbursed services that are unallowable for MOE under the Block Grant.


                                                23
At least two major issues need to be addressed by Iowa in determining MOE. First, all the data
are retained by a single individual, the Bureau Chief of BCS, who also completes the
calculations of MOE. This presents issues regarding internal control and reporting. The
Division of Fiscal Management, as an independent source, would ideally provide the sources of
the data for MOE and the methodology for calculating it. Second, the current calculations
include unallowable expenses. Iowa may benefit from a review of the procedures it has used to
calculate MOE; such a review could lead to consistent definitions of allowable and unallowable
costs. In addition, the review could assist Iowa in developing methods for allocating to the
appropriate disability categories State funds that are provided to counties on a reasonable basis.

The following information was received subsequent to the monitoring visit.

                   TABLE 2: Iowa SFY03 Maintenance of Effort (MOE)


Fiscal Year                             Expenditures     2-Year Average                 Increase
SFY01                                    $62,528,980
SFY02                                    $62,901,873         $62,715,427
SFY03                                     $64,654,39                                  $ 1,939,312

Source: James Overland, Maintenance of Efforts for Adults, FY2000 through FY2004.

Iowa met the requirement for MOE for SFY03. The MOE amounts are different than the
amounts contained in the FFY04 Application. Because the previous MOE amounts contained
inpatient service amounts in Medicaid and County funding, the amounts were recalculated.

Children’s Set-Aside

                        TABLE 3: Iowa SFY03 Children’s Set-Aside


 Calculated 1994 Base                       SFY01           SFY02          SFY03
 $11,851,615                        $12,042,293   $16,491,673     $16,982,093
Source: James Overland, Children’s Set Aside.

Iowa is in compliance with the requirements for the Children’s Set Aside. The amounts above
are different than the amounts in the FFY04 Application for CMHS Block Grant. The amount
above is reduced from application amount because the application amount included inpatient
services and total State expenditures for children rather than State expenditures for children’s
outpatient services.

Administrative Expenditures

Iowa does have an approved Cost Allocation Plan. Based on the allowable 5% for administrative
costs that can be charged to the Block Grant, allowable administrative expenses in FFY 2002
were $179,391. Iowa charged a total of $137,215 in administrative expenses to the Block Grant




                                               24
in SFY 2002. All administrative costs charged to the Block Grant are tracked through a detailed
account code system.

During SFY 2003, a material change was made to the Children’s Plan through the reallocation of
resources that had been targeted to services that were redirected through the Department of
Human Services for planning efforts. Although the goals of the projects are commendable in
that they are focused on planning for wraparound services, the Children’s Plan as submitted and
approved indicated that $1,530,575 would be spent for advocacy, support, training, and research.
An additional $182,250 would be spent for other, and $91,728 would be spent for administrative
services.

There are three major issues with the reallocation:

      A Block Grant Plan modification, which is required for material changes and was advised
       by the Federal Project Officer (FPO), was not completed;

      An Ad Hoc committee of the MHPC consisting of five individuals, four of whom were
       State employees, made the decision to fund the planning process. The decision was made
       against the strenuous objections of the only consumer/family representative; and

      The CMHS Block Grant funds are allocated in ways that raise questions as to whether the
       funds are expended as administrative or program dollars.

Annual Audit

Iowa does conduct a State single audit. There were no findings related to the CMHS Block
Grant in the SFY 2002 audit.

Other Requirements

In the Block Grant, there are specific limits on the uses of funds. The limits are called prohibited
expenditures and include such things as using the funds to renovate facilities, etc. The Division
of BDPS contracts with subrecipients do not include specific language regarding prohibited
expenditures and other limitations of the law including providing grants to for-profit agencies.

Finally, Block Grant funds cannot be used to satisfy a requirement for expenditures of non-
Federal funds as a condition for the receipt of Federal funds. This means that Block Grant funds
cannot be allocated to local programs and entities and then be used to match Federal funds as if
they were local funds. Iowa appears to be in compliance with this requirement.




                                                25
                        CHAPTER III: LOCAL PROGRAM VISITS


URBAN ADULT PROGRAM SNAPSHOT

EVERLY-BALL COMMUNITY MENTAL HEALTH SERVICES

Program Description
The Elderly Outreach Program (EOP) is located in the lower level of Westminster House located
in Des Moines. It is designed to provide services of a preventative and sustaining nature for
elderly citizens whose mental health and well-being are being threatened by the aging process.

Polk County, through the Everly-Ball Community Mental Health Services, developed an EOP in
1989 that is funded with Block Grant dollars. The program provides in-home mental health
assessments and ongoing mental health interventions as long as they are needed and desired.
The EOP also provides consultation and education to local senior centers and the community at
large.

The mission of the EOP is to provide services of a sustaining nature for elderly citizens who
experience losses and other challenges of normal aging. The goal is to make mental health
services accessible to elders who are isolated by chronic mental health problems or a
combination of problems unique to the aging process.

Persons eligible for EOP services must be 60 years of age or older who have difficulty getting
out to access mental health treatment. Mental health issues must be present. Anyone who
resides in Polk or Warren County can make a referral by calling the program. Funding sources
include Polk County Health Services, the Center for Mental Health Services (CMHS) Block
Grant, Senior Living Program funds, and Elderly Waiver Program Funds.

Included among the major issues include the fact that the program is serving more individuals
with SMI, despite decreasing funding. There remains a significant stigma regarding mental
illness in the elderly population. Prior to this program, police were sending many of these people
to jail or hospitals. There were many suicide pacts among the elderly in the community. The
community is not aware that many of those attempting suicide suffer from mental illness. The
biggest challenge faced by the program is finding ways to help clients remain in the home.

Quality Improvement
Client satisfaction is measured through monthly telephone calls. While they have a grievance
policy in place, they have never had a grievance filed in the 15-year history of the program. The
EOP focuses on the following system outcomes:

      To strive to increase the number and quality of linkages with community service agencies
       that provide supports to maintain independence for the population serviced;

      To participate in coalitions, committees, and government panels that influence public
       policy and administrative rules for elderly with mental illness; and


                                               26
      To seek public education opportunities to raise awareness to the issues of elderly with
       mental illness.

Individual consumer outcomes measured include number served, independent living time
lengthened through development of network of services, and the number of individuals linked to
primary care.

Consumer and Family Involvement
Staff work together with consumer and family members on services available and what is wanted
and needed. Staff make every attempt to honor the request for family involvement. Based on an
interview with a client served by the program, it is clear consumers are actively involved and
engaged in their service planning, treatment, and provision of services.

ADULT SERVICES

Coordination and Continuity
The program Initial Assessment identifies the client needs and their referral source. If served by
an Area Agency on Aging (AAA), the program staff will work to connect with the Case Manager
at the AAA if the client is participating in case management. If the client is not participating in
case management, program staff will make contact with AAA staff to coordinate treatment and
planning. They will also hold bimonthly meetings for shared clients.

The Department of Human Services (DHS) and Polk County utilize multidisciplinary team
meetings to ensure all providers who come in contact with this client or from whom the client
could benefit from are at the table to plan for services to meet the client’s needs. Several local
substance abuse treatment centers serve older adults in the community. The program also has a
retired doctor who provides aftercare groups.

Program staff work with hospital staff to secure releases of information so program staff can stay
connected to hospital staff. To make sure service provisions continues, program staff will also
secure a release of information with the family so staff know when discharge occurs and the
client goes home.

Delivery Strategies
Access to services can occur if a senior attends meal sites. Access can also occur through a
physician’s office or from a neighbor, a church, or a mobile crisis team. The program also
utilizes Gatekeeper training. Program staff trained Des Moines Water Works employees, postal
employees, and church staff to help identify potential aging/mental health issues. Staff send out
a follow-up questionnaire to referral sources to determine whether the need for the referral was
met.

Program staff look at norms of aging family members in various cultural populations. The EOP
employs a Spanish speaking clinician, two African American therapists and a male therapist on
staff. Staff at the program have translated the handbook into Spanish. They also use a local
employee and family resource agency for interpreters. Senior Services also provides outreach to


                                                27
Asian and Bosnian immigrants. Staff outreach to minority populations is provided through the
Bureau of Refugee Services.

ORCHARD PLACE CHILD GUIDANCE CLINIC

Program Description
Orchard Place Child Guidance Clinic (OPCGC) is a comprehensive children’s mental health
agency located in Des Moines. OPCGC was started in the 1930s, one of the original child
guidance clinics nationwide. Six years ago the original program merged with a residential
facility named Orchard Place. A not-for-profit, 501(c)3 corporation, OPCGC operates a l03-bed
Psychiatric Medical Institutes for Children (PMIC) for youth aged 11 to l8 and, under a juvenile
justice branch called PACE, provides diversion, monitoring, and tracking and an academy for
delinquents. Highlights of the PACE program are (1) a dual diagnosis program for substance
abuse and mental health and (2) an early diversion project for youth 13 and under referred to
juvenile court for assessment (and treatment if needed). Originally funded through a
discretionary Block Grant, PACE is now sustained without Block Grant funding.

The OPCGC provides direct clinical services and aftercare, including medication management.
The agency is also moving into school-based services, promoting three classrooms that support
mental health treatment and that function as a step-down for youth returning from group care.
The agency employs a specialist in co-occurring conditions.

The program featured during the monitoring visit was the OPCGC outreach program. Thirty
years ago, OPCGC received a staffing grant to develop outreach services. Using a community
involvement approach, outreach was provided to local schools. Called the Coordinated Services
Program (CSP), the outreach program is partially funded with the carve-out of the Block Grant
for children’s mental health. The goal of the project is to provide families what they need to be
successful in managing their children in the home. Examples of services include providing
school supplies and clothes, providing activities for children during the summer, and providing
unfunded services that assist the child/family in being successful. Referrals for the program
comes from schools and through word-of-mouth from other parents. All children served by the
program have serious emotional disturbance (SED).

The program has served 238 primarily inner-city youth and families in Polk and Warren
Counties in the past 9 months.

The CSP consists of a team of 17 licensed staff. Eleven of these individuals are housed full-time
in school settings. The remaining staff travel extensively to schools and other community
settings. There are currently two early childhood specialists who work with seven day care
centers. Another specialist works with Headstart and other day care programs. These early
childhood specialists are the focus of the services funded by the Block Grant.

The CSP provides consultation and training to school system staff, such as counselors and
nurses, and to the local organization of community therapists. The CSP recently collaborated in
the development of a therapeutic daycare program and has also recently received a separate
contract to provide outreach in 10 counties.


                                               28
Quality Improvement
The OPCGC is accredited by the Joint Council on Accreditation of Healthcare Organizations
(JCAHO). As such, the agency complies with all 16 required performance improvement
standards. In addition, OPCGC utilizes a range of performance measures tailored to individual
programs. Current results indicate that performance has exceeded the benchmark in all areas
measured. Consumer satisfaction surveys are routinely completed for all OPCGC programs.
Results of performance measures are reviewed by a standing Quality Improvement Committee.

In addition to clinical measurements of both the child’s and parent’s progress and level of
functioning, the CSP works with family members to construct a Self-Developed Rating Scale to
measure their own goals during the treatment process.

CHILDREN SERVICES

Delivery Strategies
The OPCGC has a long history of community collaboration in the development of consumer-
driven and family-oriented services. One of the core agency strategies for over 25 years has
been to provide both clinical services and supports in natural community and home settings.

Coordination and Continuity and Family Involvement
The CSP provides a case management and wraparound approach that is family-centered.
Program staff ask families to define their own needs. Parents are involved in all aspects of
coordination of their child’s care, and are taught skills to maintain the continuity of care after
CSP services are terminated. There is a commitment to provide community supports.
Approximately half of the youth receiving outreach services receive special education services
due to emotional disturbance. There is frequent consultation with school staff. Flexible funding
is used to meet family needs.

FINANCIAL MANAGEMENT

Expenditures for Mental Health Services
The total budget for Orchard Place for SFY 2004 is $12,723,301, all of which is for the provision
of mental health services for children. Revenues for SFY 2003 were $12,253,718. Revenue for
SFY 2004 is projected to increase by $469,583, or 3.8 percent. The growth in the revenue is
primarily the result of increases in the residential program. Of the total budget of $12,723,301,
$86,360 is Block Grant funds.

                    TABLE 4: Orchard Place Expenditures FY 2003-04

 Service Category         SFY 04     Percent       SFY 03     Percent        SFY 02       Percent
 Residential           $5,401,524      42.62    $5,357,377      43.21     $5,378,815        42.60
 PACE                  $2,629,411      20.75    $2,568,469      20.71     $2,605,845        20.64
 Child Guidance        $3,279,792      25.88    $3,169,632      25.56     $3,344,630        26.49
 Administrative        $1,326,978      10.75    $1,304,324      10.52     $1,297,872        10.27
 Totals               $12,637,705     100.00   $12,399,802     100.00    $12,627,162       100.00



                                               29
The Community Mental Health Services Block Grant Expenditures
Orchard Place is the recipient and the provider of services through the Block Grant. There are no
subrecipients. Orchard Place was aware that it is receiving Block Grant funds. The Block Grant
funding actually recorded for Orchard Place in SFY 2003 was $84,314. This amount represented
only 11 months of payments.

Orchard Place’s contract with the State does not include language regarding the specific uses and
expenditure prohibitions of Block Grant funds. The contract does specifically state that Orchard
Place is required to abide by all requirements related to Federal funds. The Catalog of Federal
Domestic Assistance (CFDA) number is not in the contract language. The Chief Financial
Officer was not aware of specific expenditures prohibited under the Block Grant.

Orchard Place is not required to have an A-133 audit completed by an independent auditor
 because it does not yet receive $300,000 in Federal funds. Orchard Place does have an annual
 independent audit. The audit for SFY 2003 was available for review. There were no adverse
 audit findings.




                                               30
                 CHAPTER IV: SUMMARY AND RECOMMENDATIONS


This chapter outlines the areas of strength and opportunities to enhance or improve the system
observed by the monitoring team or identified by State, local staff, the Mental Health Planning
Council, and/or consumers. Examples of strengths of the system may include examples of best
practice, which are evidence-based interventions that the State or local program has deployed in
a consistent and deliberate way. They also can include exemplary efforts, which are program or
organization features that are worthy of note and could be shared with other States, but are not
evidence based. Examples of opportunities to enhance and improve the system may include
priority needs for technical assistance identified by the State, local programs, or the monitoring
team; issues that need to be addressed; and policy challenges.


AREAS OF STRENGTH

Best Practices: Department of Human Services (DHS)
Assertive Community Treatment (ACT) services provided in three Iowa sites meet the criteria of
a best practice.

Exemplary Efforts (DHS)
There is a collaborative, effective array of early childhood services available to families of youth
aged birth to five. These services range from Basic Family Support, including Family
Education, Parent Support Networks, Respite, Individual and Family Outpatient Therapy, and
Medication Therapy; to Intermediate Family Support, which includes Intensive Outpatient
Therapy, Day Treatment, and Intensive Family Support, to Therapeutic Family Support, which
provides 24-hour treatment in Therapeutic Family Foster Care, Psychiatric Medical Institutes for
Children, and Psychiatric Hospitalization. These services are family-centered and include
extensive involvement of parents in planning and implementation. The system is accessed
through the regional network of 14 Child Health Specialty Clinics across the State. An Early
Childhood Comprehensive Systems Grant from the Federal Health Resources and Services
Administration has funded these efforts.

The Iowa Plan has provided a degree of leadership in improving access to children’s mental
health services. Iowa Plan staff have shown initiative and willingness to collaborate with
parents, advocates and others, such as the Iowa Consortium for Mental Health. One example of
such initiative is the development of a cultural diversity committee that is working to improve
cultural competency of those providing Iowa Plan services. There is no other such effort within
BDPS or other child-serving agencies.

The Iowa Consortium plays an important role in providing technical assistance to DHS, to
promote collaboration, enhance research, and assist providers.

Iowa’s contracts with subrecipients are clear and detailed. The contracts include fiscal and
programmatic quarterly reporting requirements.      Because the Iowa contracts are cost
reimbursement, challenges related to cash management and drawdown of Federal funds are


                                                31
minimized. The limits in contracts for administrative expenses, increases the amount of Block
Grant funds that are used to provide services.

Iowa has implemented the Health Insurance Portability and Accountability Act (HIPAA)
requirements in a manner that demonstrates a real focus on the requirements. Training has been
provided to staff and HIPAA Compliance Officers have been identified for key sections of the
Division.

The Adult Services Planner is proactive in understanding both the intent and letter of the public
law funding the Block Grant. This proactively facilitates Iowa’s ability to comply with the
requirements under the law.

The long-standing requirement that counties accept legal responsibility for the mental health
services for its citizens creates an opportunity for a unique partnership with the State to leverage
all available resources to develop a model system of care of Iowans.

A tremendous amount of effort has been directed at envisioning the future of the mental health
system in recent years. Seven long-term goals and subsequent actions have been identified that
are necessary to move toward achieving those goals.

The effort to link psychiatrists to rural parts of Iowa through the 15 child health specialty clinics
across the State is laudable.

Grass roots efforts are aligned with the President’s New Freedom Commission, promoting
recovery and prevention.

Consumer-run drop-in centers and the annual Empower Mental Health consumer conference are
all excellent examples of consumer involvement and empowerment opportunities.

The Planning Council is revitalized. They are in the process of taking charge of their role,
purpose, and function, as envisioned by the Mental Health Block Grant statute.

Exemplary Efforts: Everly-Ball Elderly Outreach Program
This exemplary program is unique to the area and provides in-home services through a team
approach. Members of the team include licensed social workers, nurses, a consulting physician,
and a consulting psychiatrist. Senior paraprofessionals provide additional support and peer
experience. The program also includes specialized staff, such as a Gerontology Mental Health
Nurse Clinician.

The mental health center has been proactive in identifying and meeting the needs of seniors who
are isolated by chronic mental health problems and/or a combination of problems unique to
aging, while attempting to maintain the highest level of dignity and independence for elderly
residents of the catchment area. The Elderly Outreach Program (EOP) strives to prevent the
premature institutionalization of seniors with mental illness who may have no relatives or other
advocates.



                                                 32
Block Grant dollars are used for this program using a best-practices model to serve elders with
serious and persistent mental illness (SPMI). First, the program uses traditional and
nontraditional referral sources. Second, it provides a significant amount of education and
training within the community to facilitate nontraditional referral sources. The third key
component is the site of service. All EOP services are provided in-home or in another natural
environment such as a meal site. Finally, collaborative, cooperative relationships have been
developed and continue to be developed with other community providers. A very noteworthy
aspect of this program is its commitment to making a concerted effort to provide services for
specialized populations.


Best Practices: Orchard Place Child Guidance Center (OPCGC)
The OPCGC has a long history of providing family psychoeducation and support with
demonstrated effectiveness. The program has done this within the context of a normative
relationship with children and their parents, mostly in school and preschool settings.

Exemplary Efforts: OPCGC
The OPCGC has a commitment to cooperate and collaborate with parents and other community
stakeholders, coupled with a focus on quality and a measurement of program outcomes.

The OPCGC seems to be very well managed, both programmatically and financially. The Center
benefits from having a Chief Financial Officer who is a former auditor. She has in-depth
understanding of the financial management requirements of grants and contracts. She was
extremely responsive to requests.

OPPORTUNITIES TO ENHANCE AND IMPROVE THE SYSTEM

Department of Human Services
The consensus of those interviewed during the monitoring visit is that there is no comprehensive
children’s mental health system in Iowa. Services for children are indeed fragmented and
confusing. Despite the creation of the Children’s Mental Health Initiative over 3 years ago, there
has been little progress towards creating the envisioned system. There is much hope for the
effort to design a children’s mental health system. Whether or not this will create a mental
health system will be dependent upon the makeup of the oversight committee.

The following two points regard the planning process. First, although the Block Grant provides
limited funding, it does create the need for the Mental Health Planning Council (MHPC) to plan
and advise for the entire State mental health system. With the requirement of the involvement of
stakeholders come challenges that are both difficult and rewarding. Second, stakeholder
involvement means greater transparency. While good planning may be cumbersome, it is more
effective. Ideally, planning means there are not surprises. For example, if an initiative is
brought to the Planning Council at midyear, it may interrupt a single coherent planning process,
and work to the detriment of the MHPC.

Several challenges face the children’s mental health planning process. Central Points of
Coordination (CPCs) generally avoid children’s service provision. Many mental health services

                                               33
are provided through child welfare and the child health specialty clinics under the Department of
Public Health (DPH). The coordination necessary for the development of a system of care lies
within decategorization boards, many of which have little mental health involvement.

Evaluating availability and accessibility is virtually impossible due to degree of fragmentation
that exists in the children’s system. Many services are provided through Rehabilitative
Treatment Services (RTS), and it is impossible to identify the numbers and types of services
provided to youth. It is clear there is a lack of data, which makes it nearly impossible to plan.

The definition of serious emotional disturbance (SED) is fairly broad but is perceived as
irrelevant in that it is poorly communicated, data are not collected according to the SED
definition, and many mental health services are provided without need of SED identification
being required.

Although parts of a children’s service array exist in some fashion in the State, most types of
services are not available in many places, especially rural communities. There is a lack of
intensive services, which results in out-of-State placement of many youth. Accessibility is very
limited outside of the Iowa Plan. For example, RTS are generally restricted to youth who are in
need of protection or supervision.

It is recommended by the monitoring team and the Federal project officer for the State that DHS
seek technical assistance regarding several aspects of a system-of-care grant for youth. Issues
regarding financing, data infrastructure, and the role of mental health in a balanced children’s
system would be addressed. These grants have been around for some years, and a growing body
of information would be available to the Division of Behavioral, Developmental, and Protective
Services (BDPS) in its efforts to create a focus and to provide leadership in the development of
an Iowa children’s mental health system-of-care.

Although there is evidence of consumer and family member involvement in various aspects of
the system, additional opportunities for consumer and family member involvement could and
should occur – at the local level in the county system and at the local provider level.

The State continues to struggle with the challenge to exert influence in a system that is county
driven. One opportunity the State should consider in promoting policy directives throughout the
system is the issuance of Commissioner Letters or Commissioner Advisories on critical policy
issues that arise. Initiatives should be undertaken by the Division in collaboration with the
MHPC (perhaps in consultation with the Iowa Consortium for Mental Health) that would present
information to the counties on the cost savings of coordinated systems of care that utilize
evidence-based practices.

The Senate File (SF2288) that passed during the 2004 session of the Iowa Legislature, which
mandates that 70 percent of the Block Grant allocation go to Community Mental Health Centers
(CMHC), seems to violate the intent and spirit, if not the letter, of the Mental Health Block Grant
statute. The intent of the law is that the MHPC be actively involved in the determination of the
priorities for services and the allocation of the Block Grants based on these priorities. A law that




                                                34
mandates allocations to certain entities deprives the MHPC of one of its key roles, which is to
assist in the identification and advocacy for changes in the systems of care.

Iowa is severely hampered by a lack of integrated data from the Division of BDPS, the counties,
Medicaid, and the provider systems. There are not adequate data to understand who is being
served, what are the total costs are of services being provided, and where gaps in service exist.
In spite of the paucity of data infrastructure, Iowa has failed to utilize Data Infrastructure Grant
resources. The monitoring team recommends an appropriate plan be adopted by the Division
that would incrementally improve data collection.

In a system that has been acknowledged by everyone to have severe resource constraints, Iowa
has failed to take advantage of numerous financial opportunities available to it, including system-
of-care grants, full utilization of the Center for Mental Health Services (CMHS) Block Grant,
and the Data Infrastructure Grants. In the last 3 Federal fiscal years (FFYs), Iowa has failed to
expend a total of more that $800,000 in Block Grant funds. Appropriate changes to its fiscal
management system should be implemented to reduce/eliminate the loss of Federal funds.

Meaningful fiscal monitoring of subrecipients of the Block Grant beyond the receipt of quarterly
financial reports is totally lacking. There is not a process to collect and review A-133 audits if
they are required.

There is no onsite financial monitoring of subrecipients. The contract language leaves it to
subrecipients to self-identify if there are findings or questioned costs in their audits.

Contracts with subrecipients do not include the required Catalog of Federal Domestic Assistance
(CFDA) number and the language regarding prohibited expenditures. Expenditures that are
prohibited uses of Block Grant funds are also not listed in the subrecipient contracts.

A single individual, the Bureau Chief of the Bureau of Community Services (BCS), is the sole
source of the information and methodology for calculating Maintenance of Effort (MOE). This
raises two questions: The first is continuity, should the Bureau Chief become unavailable or
unable to perform these functions. The second is related to the wisdom and advisability of an
internal control structure that vests both funding and monitoring decisions in the same individual.

The MOE charts in the FFY 2004 Application for the CMHS Block Grant are in error. The
charts include spending for inpatient services and for individuals who are not identified as having
serious mental illness (SMI) or serious emotional disturbance (SED).

The children’s set-aside charts in the FFY 2004 Application for the CMHS Block Grant are in
error. The charts include spending for inpatient services and for children who are not identified
as having SED. Iowa may benefit from technical assistance that includes an analysis and review
of the MOE and children’s set-aside calculations in previous years.

As noted previously, the use of Block Grant funds for planning granted through the Child
Welfare agency of the State raises questions as to whether the funds are expended as
administrative or program dollars. The fiscal monitor reviewed the concept papers and budgets


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from some of the projects. Although the intent of the projects is commendable in that they are
focused on wraparound services for children, they seem to have constituted a material change
from the State Plan, but a plan modification which was advised by the Federal Project Officer
was not sought.

Finally, an Ad Hoc committee of the MHPC, consisting of four State employees and a
consumer/family representative reviewed the projects. The projects were funded over the
strenuous objections of the consumer/family representative. The Division of BDPS and the
MHPC may want to discuss ways to ensure that the voice of the consumer/families on the
Council have the full weight intended by the law in its decisionmaking processes.

Everly-Ball Elderly Outreach Program
Companionship plays a critical role in the aging process, especially as spouses and other family
members pass away. Exploring a Compeer program for older adults presents opportunities to
enhance supports. Compeer is a not-for-profit organization that matches community volunteers
in supportive friendship relationships with children and adults receiving mental health treatment.
These programs are found in CMHCs across the country, as well as in other community
organizations. Consumers are referred to the program by mental health professionals.
Community volunteers, who are trained and screened, visit their friend for a minimum of o1 hour
per week for a year and provide rehabilitative social support, advocacy, educational and
vocational mentoring, and access to community resources. Ongoing training, supervision and
support are also provided.


Orchard Place Child Guidance Center
The OPCGC staff indicated that many counties do not fund children’s mental health, which is
perceived as a subspecialty. The OPCGC director stated, “There is not a cohesive vision at the
State level -- not a critical mass. The perception is that there is no mental health authority. We
clearly do not maximize Federal dollars in development of children’s mental health. There is a
huge lack of vision. It would be a missed opportunity not to attempt to engage the counties in
developing a children’s mental health system.”

CONCLUSION

The core issues addressed in Iowa’s FY 2004 Block Grant application were apparent in the
presentation made to the monitoring team. Iowa’s local empowerment provides opportunities
which have created dynamic and highly effective mental health systems in many Iowa counties
that exist alongside fragmented and ineffective systems in others. This is particularly the case in
services for youth, which are not mandated. The ability of the Iowa Mental Health Authority to
impact the system is limited, but is greatly enhanced by the growing involvement of consumers
and their families in systemwide efforts to make planned improvements.

Fiscal administration, including data management, seems to have been impacted by
reorganization brought on by budget cutting. This has resulted in limited oversight of the Block
Grant and led to errors that include the failure to expend over $800,000 in available Federal
funds.

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The monitoring team and the Federal project officer for the State encourage Iowa to make full
use of Federal and State resources in responding to the challenges it faces in developing its
systems of care for adults with SMI and children with SED. The Center for Mental Health
Services (CMHS) and the monitoring team wish to thank the staff of BDPS for the time, energy,
and effort put into this monitoring process.




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