The Money Follows the Person
Behavioral Health Pilot
Dena Stoner, Senior Policy Advisor,
Mental Health & Substance Abuse Services
Texas Department of State Health Services
State Health Services
• Texas’ behavioral health (mental health and substance
use treatment) authority and Public Health authority
— using research to create innovative service models
— empowering the person to recover from mental
illness and / or substance use
— partnering with other service systems to address
complex mental, physical and social needs
• People with severe mental illness in Texas live 29 years
less, on average, than other Americans and have more
health problems earlier in life.1
• National data indicates that large numbers of nursing
facility residents have a primary diagnosis of mental
illness, with a disproportionate number being under the
age of 65. 2
• In 2007, over 7,000 Texas nursing facility residents were
former clients of the public mental health and / or
substance abuse system.3
1. Lutterman T, Ganju V, Schacht L, Shaw R, Monihan K, et.al. Sixteen State Study on Mental Health Performance Measures. DHHS Publication No.
(SMA) 03-3835. Rockville, MD: Center for Mental Health Services, Substance Abuse & Mental Health Services Administration, 2003
2. Bagchi, A.D., Simon, S.E. & Verdier, J.M. (2009). How many nursing home residents live with a mental illness? Psychiatric Services, 60(7), 958-964.
3. Texas Department of State Health Services and Texas Department of Aging and Disability Services (2007). Data match showing prevalence of former
DSHS clients in DADS licensed nursing facilities.
• Schizoaffective disorder
• Insulin dependent diabetes
• Street drug and alcohol addiction
• Emaciated and physically debilitated
• Lacked social, living skills and family supports
• Considered a “behavior problem”
• In and out of nursing facilities or homeless for
most of his adult life
• Age 65, was admitted to a nursing facility after she tore
apart her apartment during a psychotic episode and
broke most of her possessions.
• She had a host of mental and physical conditions,
including bipolar disorder, panic disorder, high blood
pressure, high cholesterol, diabetes, neuropathy, and
• Socially isolated and unable to manage her declining
health, Susan faced the prospect of living the rest of her
life in a nursing facility.
Behavioral Health Pilot
— Transition adults with severe mental illness and/or substance
abuse disorders from nursing facilities to the community
— Successfully support individuals in the community by
integrating evidence-based mental health and substance abuse
services with long term care services and supports
• Pilot began April 2008 and will conclude in 2016. Due to success it
expanded to serve Atascosa, Wilson and Guadalupe counties.
• The Pilot could result in systemic changes to the Medicaid long term
• Includes adults with mental health or
substance abuse conditions and functional
limitations who have resided in an institution
for at least 3 months.
• In addition to existing long term care and
relocation services, BH Pilot services are
available for participants:
• Substance abuse services
• Cognitive Adaptation Training (CAT)
Substance Use Services
• Services are customized
• Transportation provided
• Services include:
—Assessment by a Licensed Chemical Dependency
—Community-based services in nursing home, person’s
home or therapist’s office
—Linkage and transportation to other community
services (Narcotics Anonymous, Alcoholics
—Recovery support groups
Cognitive Adaptation Training
• Evidence-based intervention that helps
individuals master skills of independent living
• Uses a motivational strengths perspective to
facilitate person’s initiative and independence
• Provides assistance and simple, inexpensive
environmental modifications (e.g., calendars,
clocks, signs, organizers) to help people
establish daily routines, organize environment
and function independently
Cognitive Issues in Mental Illness
• formulate plans for goal directed behavior
• sequence behavior and thought
• maintain goal-directed-action in the face of distraction
• inhibit irrelevant or inappropriate behavior
Compensating, Not “Curing”
Training can Include…
Dressing Grocery Shopping
Dental Hygiene Transportation
Make-up Leisure Skills
Work/Vocational Skills Toileting
Social Skills, Communication
and Telephone Use
Housekeeping/Care of home
Eating, Nutrition, Cooking $ Management/Budgeting
Medication Management Orientation
• Pilot services are provided to the participant while still in
the nursing facility (up to six months before discharge) to:
— Begin development of therapeutic relationship
— Help choose the community residence and accomplish
relocation (housing voucher paperwork, physically
visiting potential residences)
— Identify potential triggers in the community for drug
or alcohol abuse
— Address potential barriers, supports, experiences, fears
• Pilot services are provided up to 365 days after discharge
• Individual Plan
• Developed with person, CAT and/or SA
therapist, HMO, and housing specialist
• Completed 60 days or more before conclusion of
• Designed to provide continuity beyond Pilot
• Evaluation continues after transition from Pilot
services to regular HMO long term services
• The long term care agency operates the overall MFP Demonstration and
provides relocation assistance.
• State Medicaid provides a broad array of home and community-based
services and transition assistance through HMOs
• The state mental health and substance abuse authority operates the MFP
BH Pilot, provides state match for BH Pilot services and contracts for Pilot
services / evaluation.
• Local Mental Health Authorities and / or University of Texas Health
Science Center-San Antonio provide the BH Pilot services.
• UT Health Science Center also provides technical assistance, training and
supervision of CAT therapists.
• UT Austin conducts the independent evaluation.
• Weekly Pilot team meetings and monthly
Community Transition Team meetings
resolve individual and systemic issues
• Training for key community partners,
such as nursing facility social workers to
“build the bridges”
The Pilot Today
• Over 280 individuals have been served
• 140 have completed a year of Pilot services
• Project findings have been recognized and
published in national journals
MFP BH Results
• To date, 71% of individuals in the Pilot have
maintained independence in the community.
• Participants demonstrate statistically significant
improvement on “Adjustment to Living/ Adaptation”
section of the Multnomah Community Ability Scale,
which measures survival in the community, independence
in daily life, managing money and coping abilities.
• Preliminary analysis indicates that Medicaid costs for
participants in the Pilot are lower on average than costs
prior to their discharge from the NF.
• Examples of increased independence include getting a
paid job at competitive wages, driving to work,
volunteering, getting a GED, attending computer classes
and working toward a college degree.
MFP: What’s Next?
• The state’s Medicaid mental health and substance abuse
services are transitioning to managed care.
• Texas could include the Pilot services in its managed
care long term services and supports system. Thousands
of Texans could benefit.
• Texas is sharing results nationally to inform federal
policy changes that support independence, recovery.
• Texas is including MFP Pilot services in a home and
community-based program for individuals with long
(1yr +), repeated stays in state mental health hospitals
• Mike’s dream was to have a job and a place of his own. With the
help of CAT, Mike set employment goals, learned to interview and
got some vocational training. He began working 20 hours a week.
• Through CAT, he learned the social skills needed to get along in the
community. He handled daily activities like catching the bus, taking
medication, doing laundry and caring for himself. CAT also helped
him learn to manage his blood sugar level and eat healthy. His
STAR+PLUS service coordinator helped him get the health services
• Through substance abuse counseling, Mike was able to understand
issues in his past and reconnected with his natural family.
• Moved from the nursing facility to an apartment complex.
• Her goals included achieving mental stability; getting involved in
her community; and focusing on her artwork, which had been very
limited in the nursing facility.
• Susan and her CAT therapist created a journal in which Susan logs
each day’s moods and their causes. They also regularly practiced
guided relaxation, which Susan learned to perform on her own .
• The CAT therapist connected her with public transportation, which
she uses for medical appointments and weekly trips to the art co-op.
• She learned to use journals to monitor her blood sugar and blood
pressure, and consequently no longer needs skilled nursing
• Her talent was noticed. She was invited to teach an art class.