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Texas Money Follows the Person Behavioral Health Pilot
Pilot Description
[Marc S. Gold, Special Advisor for Policy and Promoting Independence, Office of the Commissioner, Texas Department of Aging and Disability Services]
Mark The United States Supreme Court made a ruling in 1999 that’s known as the “Olmstead Decision.” The Olmstead Decision says that individuals who are receiving long-term services and supports have the right to receive those services in the community. The response to Olmstead and the Promoting Independence Initiative was the creation of Money Follow the Person on September 1, 2001. That program allows individuals who reside in nursing facilities to move back into the community without having to be on a long waitlist to receive those community services.
The Texas program was so successful that the federal government with the Deficit Reduction Act of 2005, put in place an initiative called “Money Follows the Person Demonstration” very much modeled off of the Texas program. Originally in the program we really only had basic services for people with pure physical disabilities. However, as we operated the program we realized that a large part of the population of individuals who reside in the nursing facility have a co-occurring behavioral health issue – either a mental health issue or an issue with substance abuse.
[Dena Stoner, Senior Policy Advisor, Department of State Health Services, Mental Health and Substance Abuse]
Dena The Department of State Health Services got involved in Money Follow the Person because we saw a real opportunity to integrate long-term services and supports with recovery-based based mental health and substance use treatment for people who had disorders like severe mental illness: Schizophrenia, Bi-Polar Disorder, Severe Depression, and people who had substance use disorders. These people were entering nursing homes at an increasing rate, and this is a national as well as a state phenomenon. Integrating services provides an opportunity for these people to recover which doesn’t necessarily mean that people are cured of a disorder but that they can live full and meaningful lives in the community, have relationships, have homes, have jobs or other activities that provide meaning to them every day and do what the rest of us do.
Natalie Maples-Aguilar, MA, LPA, Faculty-Specialist, Department of Psychiatry, UT Health Science Center San Antonio
Natalie UT Health Science Center began working with the Texas Money Follows the Person Behavioral Health pilot in 2008. The behavioral health pilot helps people with both physical and behavioral health problems get out of a nursing facility and into the community living as independently as possible.
The pilot targets persons who have a mental illness such as Depression, Anxiety, Bi-Polar Disorder, Schizophrenia, or any substance abuse diagnosis. This pilot provides two important add-on services for one year after discharge that are not available through the larger MFP Demonstration. Specifically, we provide Cognitive Adaptation Training or CAT and substance abuse treatment. CAT is designed to help the individual who is leaving a nursing facility where almost everything is done for them adjust to independent life and help with the deficits that can accompany mental illness. CAT targets specific areas in daily functioning including hygiene, orientation, housekeeping, nutrition, budgeting, transportation, medication management, and leisure, vocational, social, and coping skills.
Dawn Velligan, Director and Professor, Division of Schizophrenia and Related Disorders, Department of Psychiatry, UT Health Science Center San Antonio
Dawn When an individual with serious mental illness leaves an institutional setting, they often go to a place with no structure so it’s very difficult for them to initiate routine daily tasks without the prompting of the institutional staff or to take their medication on time. Sometimes, these individuals might end up going back to the hospital or nursing facility. Cognitive Adaptation Training is a home-delivered treatment using environmental supports such as signs, checklists, and special pill containers with alarms and the organization of belongings to help bypass problems with motivation and problems with thinking and planning so that a person can perform the everyday tasks they need to do to stay healthy while also living independently.
Someone who has apathy has difficulty initiating each step of a task so it’s challenging to start and to sustain a behavior. Someone with apathy may have a hard time getting up, getting into the shower, getting dressed. The more steps that are involved, the more trouble the person is going to have.
Someone with disinhibition tends to be highly focused on external cues so what happens is when they’re shopping, they want one of these to two of these or three of these and they don’t really think much about whether or not they’re going to have enough money to last them until the end of the month.
CAT addresses both types of behavior, apathy and disinhibition. When we go to a person’s home, the first thing that we do is we complete an environmental assessment so we look at any safety hazards that need to be fixed. Is the rat poison next to the breakfast cereal? Are there tripping hazards? We look in the drawers and the cabinets and the closets to find out of the person even has the supplies they need to perform basic activities of daily living. Next, we get them the needed supplies and help them to organize their belongings so that their belongings actually cue what they need to do every day. So for example, we would take their toothbrush and toothpaste out of a bottom dresser drawer and attach it to a basket in a basket to their bathroom mirror so that every time they go in the bathroom, they would see their toothbrush and toothpaste and they would be more likely to use them.
Another thing we can do with CAT in the community is use the environmental supports so that people can function better in their jobs. For example, we had an individual who worked at a fast food restaurant and his job was to fill the french fries, and when there was no french fries, he would just stand there because he wasn’t able to initiate what to do next. The boss thought, you know, this guy is lazy. The truth was he just couldn’t initiate so when we put up a CAT sign that said, when there’s no french fries, do x, y, or z, ask someone if you can help them with this or that, he was able to get the employee of the month award.
In several different studies, we were able to show that CAT improved specific behavior such as taking medication as directed and overall level of social and occupational functioning. We also found that individuals who participated in CAT therapy were less likely to have relapses and hospitalizations than individuals who were not in CAT treatment.
My goal for Cognitive Adaptation Training is that the program would be available for anyone who wanted it or needed it. It’s much cheaper than keeping people in a hospital or nursing facility or re-hospitalizing people because they can’t adjust to the community.
[A montage of program participants plays. A male participant is shown sitting in a wheelchair playing a guitar hooked up to an amp. A female participant is shown admiring a knitted blanket. Another female participant is shown taking notes in a book.]
Dawn We make a difference one person at a time. It’s always a pretty rewarding thing to do for us and for the individuals that participate in CAT.
Jennifer N. Coulthurst, LPC, Substance Abuse Counselor, Austin Travis County Integral Care
Jennifer We provide substance use treatment for Money Follows the Person Behavioral Health Pilot. We offer individual and group counseling both in the community and the office. We offer twenty-four/seven on-call crisis support and peer support specialist services to help model recovery and link people to additional community resources such as 12-step programs. Plans of care are individualized based on the participant’s needs and goals, ultimately working toward stable recovery in the community. However, the individual defines recovery.
Of pilot participants receiving our services, 84% use tobacco, 44% use alcohol, 20% use opioids, and 45% have two or more active substance use disorders. Integral Care uses a person-centered approach that starts with examining someone’s environment, social influences, history, and current ideas or goals. Depending on the goals of the individuals and their readiness to change, we may utilize harm reduction psychotherapy versus a more conventional approach such as abstinence only.
Our counselors meet with individuals in the rehabilitation facility such as a nursing home. We offer assistance such as coping with anxiety and stress, normalizing the individual’s experiences, relapse prevention, understanding their role in relation to their providers, and collaborating with other agencies to ensure a seamless transition into independent living.
The main goal of working with individuals prior to their discharge into the community is to prevent the use of alcohol and drugs during potentially a stressful and emotional transition where the possibility of relapse can be high. This pilot is evolving the way our community provides treatment for a population that has most definitely been challenged enough.
Dena So what we want to do is provide the tools for people to really become independent. Recovery is about empowerment, recovery is about choice, and recovery is about meaning in life. The money in Money Follows the Person is flexible. It follows the individual from the institution. It provides the opportunity for people to receive services and supports both before and after they leave the institution both to prepare them for life in the community and to follow them into the community and make sure that they can be successful.
Natalie Since its conception in 2008, we’ve adapted the services provided through the behavioral health pilot to better serve these particular participants. For instance, we’ve added on some case management services like helping to transfer their social security benefits to themselves or a payee or completing applications for transportation and food stamps after they first transition. We’ve also added on more specialized vocational services. After working with these participants, it became obvious that they didn’t just want to get out of the nursing facility, they also wanted to go on to get a job or volunteer.
To date, over 260 individuals have been transitioned into the community through this pilot. Based on independent ratings of these participants, we see a significant improvement in targeted functional outcomes on the Multnomah Community Ability Scale, the Quality of Life Scale, and the Social and Occupational Functioning Scale. These results are incredibly positive but mostly they demonstrate that this group as a whole is able to be independent, fulfilled, and happier outside of the nursing facility, and this is what really matters.
Mark The Money Follows the Person Demonstration, specifically the behavioral health pilot, has been hugely successful and has received significant national attention. It’s a model for other states to look at in terms of setting up their own behavioral health type of programs. The hope is that we will expand this program statewide. Everyone who has been involved in this program sees the great success and the great benefit not only for the state of Texas but most importantly for the individuals with a co-occurring behavioral health issue. This is allowing individuals a quality of life, a choice, an opportunity to live back in their communities that they wouldn’t have had without this pilot program.
[The Money Follows the Person logo]