Agreement in Lawsuit Over Services for the Seriously Mentally Ill

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Governor Jan Brewer and plaintiffs in the 1981 Arnold v. Sarn lawsuit have signed a 2-year agreement that creates a framework for improving services for people who have serious mental illnesses. Dr. Laura Nelson, Director of the Division of Behavioral Health for the Arizona Department of Health Services, and plaintiffs’ attorney Anne Ronan discuss details of the agreement.

Ted Simons: here now to talk about the interim agreement in the Arnold v. Sarn lawsuit is Dr. Laura Nelson, director of the division of behavioral health for the Arizona department of health services. And plaintiffs' attorney Anne Ronan of the Arizona center for law in the public interest. Good to have you here. We kind of got a background from chick Arnold in how this whole thing started. What is the whole thing about?

Dr. Laura Nelson: well, i will start and then Anne can certainly jump in. Historically, in our community, and really internationally, people with serious mental illness have oftentimes found themselves warehoused in state hospitals and state institutions. And back in the 1960s, there was i think the beginning of this movement, as medications were established, to try move folks back into the community so they could live successfully there. Really that's what the root of this lawsuit was. What is Arizona going to do to try to get people out of Arizona state hospital to support them successfully in the community?

Ted Simons: there were statutes. There are obligations. Correct? The state did have obligations to meet regarding these folks.

Anne Ronan: oh, yes. I think one of the things that's really kind of significant about Arizona's statutes is that it was probably one of the first states to sort of get ahead of it and pass legislation that required the community-based services. The difficulty came in that there was their wasn't a community-based system developed and there was no funding for it. And so that was the genesis of the lawsuit.

Ted Simons: as we mentioned with chick Arnold, filed in 1981. Supreme court 10 years later. This thing has been going on for 30 years. Why?
Anne Ronan: well, i think partly because it's complicated to develop community-based services for a population with such significant needs. They have met sort of traditional medical needs, needs for psychiatric care and medication. They have needs for supported employment and housing supports, case management, and counseling and therapy and all those other sorts of things. But to create that from nothing takes a lot of time and thought. Sometimes there's some efforts made that aren't quite on the right track, need to be corrected and it's the development of a whole system.

Ted Simons: and sometimes the economy takes a deep nose dive and you wind up with a two-year stay. Talk us to about what that involved and means.

Dr. Laura Nelson: that's exactly what happened in Arizona. And we were fortunate in the behavioral health community in that we survived the first couple of years of very tough economic times. And the governor was very clear from the beginning about her commitment to behavioral health. But in fiscal year i think '11, we did see some pretty drastic reductions to state funding to support individuals with a serious mental illness. For the last two years, we have significantly reduced the benefit package for this population. As chick mentioned, folks that qualified for Medicaid really did not see any change. But it's those individuals who made too high to qualify for Medicaid that saw some significant changes to their benefit package.

Ted Simons: and the idea was, during this stay, that the state would make the best efforts in this whole situation. Did the state make its best efforts?

Anne Ronan: i think within the financial constraints they were in, yes. One of the things that was really very important, they worked very collaboratively with the access administration to make sure as many possible class members could stay on the Medicaid system & that made a huge difference. And there were a lot of folks who i think we thought would have fallen off and have the reduced benefit package that were actually able to stay on Medicaid. So that was a big, big difference. Then i think the department supported a lot of less expensive and community-based initiatives to keep folks, keep tabs on folks, support folks so there wasn't a lot of serious falling through the cracks.

Ted Simons: and after the stay now, we have got an agreement. Talk to us about the agreement. This is about a two-year agreement as well. Why two years?

Dr. Laura Nelson: yes, it is. I think primarily because there's still some uncertainty at the federal level. What's going to happen with the supreme court decision around health care reform? If that continues to move forward, that many, then many of the individuals who currently don't qualify for Medicaid will likely qualify for Medicaid come january 1st of 2014. So i think we agreed that there was some value in coming up with a two-year additional agreement at this point. We will be back at the table starting again in july of 2013 and really trying to hammer out what is it going to take to exit this case?

Ted Simons: the idea that this agreement has to be approved by a court as well. That's true. Correct?

Anne Ronan: that's correct.

Ted Simons: any questions regarding that court? Will the court look over and say, i don't think so?

Anne Ronan: well, i can't speak for the court.

Ted Simons: sure.

Anne Ronan: but i think historically the court has relied on the parties working through some of the difficult issues and presenting compromised agreements and has generally supported the agreement when is they have been presented to the court.

Ted Simons: and the obligation now for Arizona looks to be something called a recovery model, something along these lines. What exactly changes? What does the agreement do?

Anne Ronan: well, i am not sure it changes. It specifically emphasizes and supports in a financial way the services that we all know who do this work, really work for people with serious mental illness to help them stay in their homes, to get jobs, and to have a life in the community. So it identifies very specific services that have been research based that we know supports individuals such as supported housing, supported employment, peer and family supports. For the first time they are articulated in a way that's tied to a set of national standards which is very critical.

Ted Simons: i was going to mention that, the best practice standards. Talk to us about that. How important is that? And was that something easy to come to terms with or debatable?

Dr. Laura Nelson: i think we were actually on the same page around that. We all agreed that we wanted to move to more outcome-based types of assessments. We turned to the substance abuse and mental health services administration off the department of health and human services at the national level and looked for some of the best practice models that they have developed and been promoting nationally. And those include the supported housing, the supported employment, peer operated programs as well as intensive case management approach called assertive community treatment. And so those are models that we have already endorsed and embraced in Arizona but we have not specifically been monitoring to the fidelity of what those models are about and that's the new piece here.

Ted Simons: i was going to ask accountability? How is that handled? How would that be measured now in these two years?

Anne Ronan: i am not sure we have resolved that completely. I think that's part of what we are going to be working on in the next year and a half and with, as dr. Nelson said, in the work we are going to do starting in july of 2013. But the initial step, which is a critical step, that is these standards will be incorporated into the new contract in maricopa county. You know, the contract for mental health services in maricopa county is up for renewal or recontracting this coming fall, i believe. Correct?

Dr. Laura Nelson: well, it's going out in the fall. But it's for an october 1, 2013 start date, our new contract officially.

Anne Ronan: so these standards that dr. Nelson spoke about, these national standards, will be required in the new contract. And so as that evolves we will be developing the monitoring and basically the compliance standards for how to measure whether they are doing the job according to these national standards.

Ted Simons: and Anne mentioned the money that now would be maybe things didn't change. But certainly the money changes everything. 39 some odd million dollars from the state.

Dr. Laura Nelson: yes. Thanks to the legislature and the governor, we have secured approximately $39 million new state dollars to support adults with serious mental illness who don't qualify for Medicaid. And the services in particular that these funds will go to support are these community-based services. So, in fact, this week we're having some stakeholder meetings. We are going to be meeting with plaintiffs again on friday to really talk about our strategy in regards to how we can most effectively use those dollars to support community-based services.

Ted Simons: that compares to what? 50, 60, some odd million cut?

Anne Ronan: it's hard to put a specific amount. That's really easy number to go to because that was the number that was deleted from the specific line item. But there were cuts to provider operators and that sort of thing, that sort of added to the complexity of the cuts. But it's not far off from the actual dollar figure. The other thing that has happened is with the transition of so many of the folks on to the Medicaid rolls, that brings down more federal dollars for a group of people who are primarily served by state-only dollars. So it should be a pretty good match. The other big piece, i think, is that we agreed to a process, and we are going to have to discuss what it all looks like but the outline of the process is that we are going to actually look at the elements of the data that the department has and some new data sources to make sure we are filling the gaps in these specific services. So we know there's some of these services that aren't out there anywhere near the volume. And we are going to work to get them up to speed.

Ted Simons: very good. We got to stop right there. Good to have you both here.

Both: thank you.

Dr. Laura Nelson:Director, Division of Behavioral Health for the Arizona Department of Health Services; Anne Ronan:Attorney, plaintiffs;

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