A Voucher System That Enables Persons With Severe Mental Illness to Purchase Community Support Services
in the School of Social Welfare at the Nelson A. Rockefeller College ofPublic Affairs and Policy in Albany. Address correspondence to him at 1360 Wemple Lane, Niskayuna, New York 12309.
The treatments most commonly cited are medical, dental, and psychiatnic care, including emergency, inpatient, and outpatient psychiatric services. Basic supports should meet each person’s unique residential, vocational, social, and leisure interests and needs. It is also generally agreed that case management in some form must be available to provide a human link between the service user and the array oftneatmcnts and supports (8). Fragmentation, or the tack of continuity in the delivery of treatments and supports, is often identified as a major obstacle preventing persons with severe disabling mentat illness from living productively in the cornmunity (1,3,5,9). The creation of quasigovernmcntal administrative authorities with the power to mandate the coordination and integration ofactions by different treatment and support service agencies in a community is an approach suggested for reducing or eliminating fragmentation . Commonly such authorities require significant sacrifice in service flexibility while at the same time assigning a markedly passive role to the service user in choosing supports (1-3,6,10-12). The single communitywide coordinating authority as a means to address fragmentation through controlling both the suppliers and users of treatments and supports is experiencing a revival in the U.S. The Robert WoodJohnson Foundation is funding development of coordinating authorities in nine midsized American cities, and California hopes to develop integrated service agencies in two communities on a demonstration basis (10,1 1). To the extent that technology atlows, such authorities seek to ne-
Hospital
November
Elmer
F. Bertsch
Fragmentation in the delivery of community support services is often identified as a major barrier to persons with severe mental illness, preventing them from living productive lives in the community. In Nassau County, New York, in 1989 a voucher process was created to allow service users to develop individualized support networks by purchasing services directly and by poolingfunds to start new services. The voucher process is part of an intensive case management program. Goals set in the individual service plans ofusers guide voucher purchases. The localMental Health Association manages funds based on a bank credit card model. The user, the case manager, and a staff memberfrom an agency designated by the user review expenditures quarterly. The first year of operation is described, and suggestions f or developing a voucher process, such as the need for extensive retraining of users and providers, are offered. It is now widely agreed that for pensons with severe disabling mental illness to live productive lives in the community, they must have an array of treatments and supports (1-7). Mr. Bertsch is former deputy regional director of the Long Island regional office of the New
York
State
Health.
He
and
Office is currently
Community
of
Mental a student
Psychiatry
1992
Vol.
43
No.
11
create within the larger pluralistic community the conditions of Goffman’s total institution or the conditions ofthe highly planned economic systems that until recently existed in Eastern Europe (3 1 3 1 4). Because communitywide authorities are intended to prescribe, fund, and controt the residential, vocational, educational, social, and leisure options available to service users, they go well beyond the boundaries of managed health care proposals now being urged for the general public. There is little evidence that such authorities can address service fragmentation at the level of the individual service user. Tesslen and Goldman (1 5), noting the failures of earlier communitywide authorities, such as the Modet Cities Program, and their own field observations of efforts to create mental health authorities, stated, “There is little evidence to support the efficacy ofa service coordinationcollaboration approach to address the fragmentation of the service delivery system.” Mechanic (16) stated, “Non ,
is it clear
that
,
[political
authorities]
would necessarily improve the integration of service and quality of care. Yet theoretically it seems reasonable to expect . . . service wilt improve.” Creation of communitywide authonitics to coordinate the actions of the many different governmental agencies that setect and fund support services is a theoretically reasonable way to reduce discontinuity in services only if the creators of such authorities also believe that it is necessary and desirable for agencies to select and fund specific supports on behalfofeach service recipient.
A voucher each
service
process user
that
to directly
permits purchase
1109
Figure 1 Expenditures ofvoucher service users in Nassau ual
service
plans
Figure funds(totat=
$7,087)by
County, New the first two
during
mental
York,
to support
months
ofthc
health
of voucher
funds
(totat=$27,835) New York,
health service users in Nassau County, cy needs during the first two months
individ-
program
ofthe
by mental for emergen-
program
needs
Personal
needs
Personal
2
Expenditures
Clothing
Employment Clothing
Furnishings
Furnishings
housing
1 P I I U P
Medical or dental care
Medical or dental
.
Temporary
Housing or respite
care
Transportation
Transportation =
0
5
10
15
=
20
25
=
30
=
35
Other
=
40
45 0
of expenditures
Percentage
Source
for both figures:
Mental
Health
Association
5
10
Percentage
ofNassau
15
20
25
of expenditures
County
children served through management programs County, New York.
the case of Nassau
housing, employment, leisure, and other supports from the full range of goods and services already offered in a particular community. The Nationat Institute of Mental Health (NIMH) recognized the theoretical advantages of vouchers in providing “the ultimate in consumer choice and flexibility . . . [while putting]. . . programs in a competitive position” (6). Yet no studies of the use of such vouchers have been reported in the literature, and NIMH has no knowledge of a recipient-directed voucher system currently in operation (personal communication, Anons BS, NIMH, 1991). Therefore, in addition to any conceptuat or theoretical barriers to vouchers that might exist, the literatune offers no discussion of how a voucher option might be created and managed. The remainder of this paper describes the development of a limited voucher option for the direct purchase of supports by adults and
management program for children and adults (9,17). One feature of this program was the allocation of $40,000 pen case manager position for the purchase ofsupport goods and services. The initial OMH mandate to its five regional offices stated that these funds were not to be used to establish programs but rather to make immediate responses to users’ situationat emergencies such as an immediate need for food on shelter and to purchase goods and services needed by each user to reestablish an effective individual support network. Reinforcement for the intended use of these funds came through a new OMH dictionary of terms, which created a clear conceptual separation between psychiatric treatments (emergency, inpatient, and outpatient) and community support programs such as the intensive case management program(18). All cornmunity support programs were “to enhance the living and working
skills . . . and to strengthen natural peer and family networks” of those served. The OMH statewide operational definition of the intensive case management target population limited the program to homeless mentally ill persons, heavy users of acute inpatient psychiatric treatments, difficult-to-place state hospital patients, and persons at high risk of falling into one of these categories (9). A statewide follow-up study neported that 90 percent of those enrolled in the intensive case management program were diagnosed as having a major mental illness, with approximately half having a secondary diagnosis of alcohol on substance abuse (19). An allocation of additional positions for the new intensive case management program was made to each of the state’s regional offices. Unusual flexibility was given each regional office in working with counties and state facilities to implement the new program. Responding to this opportunity, the Long Island regional office and the Nassau County Department of Mental Health pooled the new state and nonstate intensive case management positions with existing case management posi-
1110
November
Hospital
a broad
range
of the
goods
and
ser-
vices needed in order to create a unique support network eliminates fragmentation ofserviccs. The issue a voucher process raises for users, funding authorities, and planners is how to create mechanisms that penmit
each
user
to responsibly
choose
The
voucher
system
Program history. York State Office
In 1989 the New of Mental Health
(OMH)
an intensive
initiated
1992
Vol. 43
case
No.
11
and Community
Psychiatry
Figure Voucher services
3 funds (total=$178,924)pooted in Nassau County, New York,
by mental health service users to initiate new during the first two months of the program
Self-help
Vocational
Social,
leisure
Health
#{149}
Education 0
10
20
30
Percentage
of expenditures
40
50
60
sist in development ofthc individual service plan. By completing a vouchen, the user authorizes expenditures for the purchase of goods or services needed to advance a specific goal in the plan. The voucher must be countensigned by either the assigned case manager on the user’s designated lead agency representative. Figure 1 illustrates the uses to which voucher funds were put to support individual service plans in the program’s first two months ofoperation in 1989. To disperse the funds, the Mental Health Association ofNassau County contracted to manage a process modeled on a bank credit card operation. On receipt of a completed voucher, the Mental Health Association draws a check to the merchant or vendor specified. As with bank cards, a monthly statement itemizing all expenditures along with a summary ofall contacts with the case manager is mailed
Source:
Mental
Health
Association
ofNassau
tions in the community support gram to create one countywide standing program under their direction. Money was allocated
profreejoint local-
County
sons in the community support program with case managers. The county department of mental health received and prioritized all requests for service to the consolidated case management program. Essentially the same voucher process is used by children enrolled in the intensive case management program. Initial concerns that children would use funds frivolously or that funds would create conflicts between the children and their families or guardians were not borne out. The children’s intensive case management program reported that the most common purchase by children in the first months of operation was of peer-appropriate clothes, with a reported improvement in school attendance. Three uses ofvoucherfunds. In 1989 the voucher program was fully operational only for the months of November and December. Only a small number of the adults enrolled in the intensive case management program used funds during this pen-
od. About 35 case managers were employed in the program by Decemben 1989. By the end of 1989, users had authorized vouchers worth $213,000. About 84 percent of these funds were used to establish new programs, 1 3 percent of the funds were used for emergencies, and about 3 percent supported individual service plans. Individual .rerviceplans. An mdividual service plan guides daily case management practice. The plan is completed oven an extended period by each service user with the assistance of the case manager and a lead agency representative. The individual service plan describes the user’s current housing, health, vocational, educational, social, financial, leisure, and legal situation and notes the mental health and other treatments received by the user. For each support area, users indicate if they wish to maintain the status quo, have not yet formulated a goal, or wish to sec changes. The steps to be taken by the user and others in areas in which change is desired are recorded. Each user is also encouraged to identify a recognized community agency (social, advocacy, religious, or mental health) as a lead agency to as-
Hospital
November
ly to create
a voucher
and Community
fund
for
per-
Psychiatry
1992
VoL 43
No.
11
to each
active
user
by
the
Mental Health Association. These statements are also provided to the lead agency representative, the case manager, and any other person identified by the user. The user, the case manager, and the lead agency representative review expenditures quarterty. Users can invite others to attend these reviews. Emergencies. Using credit cards issued to them by a major bank, each case manager can access up to $ 1 5 0 a day in cash to respond immediately to any situational crisis. Receipts signed by the user are required for alt such emergency expenditures. Figure 2 illustrates the major purposes for which emergency cash withdrawals were made during the first two months ofthc program in 1989. Poolingfunds to create services. Users can also elect to pool funds to initiate new supports. In Nassau County more than 90 new support programs were proposed for funding through voucher payments in the first year of the voucher process. A proposed support program could be funded for up to 1 2 months only if a sufficient number of service users were persuaded to authorize voucher payments. Only 29 ofthe first-year proposals eventually had sufficient enrollmcnt to begin operations. Figure 3 illustrates the types of new initia-
1111
tives funded during the first two months ofthc voucher program. Eleven of the 29 new initiatives were self-help programs, including an advocacy center. Funds also paid security deposits when users rented a house. Ten other new programs stressed social and leisure activities, including a drop-in center. Six of the new programs were vocational. One was a new health program, and one was an education program.
pendent settings; only 22 percent preferred a supervised setting. Even this limited voucher process made it possible for service users to select from a broaden range of supports already existing in the community. A voucher program can also serve as a strong stimulus for changing the relationship of service users to support service providers. When a group of Nassau County providers and
Discussion Only a brief description of some of the major features of the voucher process as it was developed in 1989 has been presented. It took 12 months from conceptualization to implementation of the voucher process. Users began to access funds in the last two months of 1989. This development period is relatively brief compared with the time required for implementing communitywide coordinating authorities (10). The voucher process relies on easily available technology and is relatively inexpensive. The only additional mitial costs were those needed to estabtish the bank card operation. This process also served to stimulate a different view of supports. Identification of an unmet need for support services is often translated into the need for a new program. Examples include housing programs, leisure programs, club programs, and drop-in centers. Offering such commonplace goods and services through contracts with mental heatth service providers adds substantiatly to their cost, is often stigmatizing, overly restricts the range of user options, and frequently results in the funding of supports other than those that would be selected by users (9,14).
A proposed support program could be funded
for
up
12 months
only
a sufficient
of
service
persuaded voucher
to if
number users
were
to authorize payments.
potential providers wanted funds to start a wide variety of proposed programs in 1989, rather than following the usual practice of soliciting the regional office on the county for funding, they held a program fair. They offered more than 200 of the county’s most disabled mentally ill persons free transportation and a free lunch at the fair, where heavy manketing of the competing programs was directed to potential users. This experience shows that vouchers provide for direct accountability of providers to users.
For example, in New York one study showed that case managers in an intensive case management program recommended that 56 percent of their case load live in some supervised residential setting; they recommended that only 32 percent live in private homes, apartments, or rooms (19). In contrast, 73 percent of the users in the same study reported preferring to live in the more mdc-
Conclusions As long as state hospitals were the primary residences for persons with serious mental illnesses, there was little point to drawing sharp distinctions between treatment and supportive services. In 1984 Anthony and associates (20) presented compelling arguments for distinguishing between supportive services (that is, skills, goods, and services needed to live productively in the community) and treatment (that is, medical interventions intended to disrupt the natural history ofdiscase) (20). Once this distinction between supports and treatment is made, the issue of fragmentation of support services
1112
November
1992
Vol.
43
No.
11
can be redrawn. Rather than controlting the supply of supports, mechanisms such as vouchers that allow targeted users to responsibly purchase supports become a reasonable alternative. The experience described here suggests five issues that need to be weighed when a voucher program is considered. First, a vehicle for linking the user to the voucher process is needed. Case management is well suited for this purpose. Second, if case management is selected as the mode of delivery, it must be a stable resource for each user. The availability of case management cannot be made contingent on the user’s enrollmcnt in another treatment or support program. Too often case management funding schemes link a case management service to some other third-panty reimbursable 5crvice. Strategies that permit case management itself to be a freestanding reimbursable service need to be adopted. New York State amended its federal
Medicaid
plan
intensive case management reimbursable by Medicaid The
third
issue
to make
its
program (9).
to weigh
when
considering a voucher program is that it is essential to base the program on each user’s individualized service plan. Case management standards that call only for assessment, planning, linkage, advocacy, and monitoring (7) are too general and too provider controlled (that is, case manager controlled) to serve as an appropriate guide to users on case managers in a voucher process. The broker case management model (8) used in Nassau County was greatly strengthened by identifying each user’s unique goats for housing, financial support, education, work, personal living, skill development, social and recreational support, support by family and friends, and health, dental, and mental health services. Fourth, users should be allowed to identify another person from a recognized human service organization who may countersign voucher authonizations. This addition lessens the likelihood of inappropriate controt of the user’s access to voucher
Hospital
and
Community
Psychiatry
funds by a case manager. At the same time, it lessens the strain between the user and case manager when the case manager does not endorse a proposed voucher expenditure. When the user’s lead agency nepresentative shares the case manager’s judgment about the inappropriateness of a proposed expenditure, the user’s relationship with the case manager is tess likely to be strained. Fifth, a substantial amount of training is needed for case managers and established support service and treatment providers to understand and accept a voucher process. Even though extensive training was done in Nassau
County,
contract
In retrospect, it is clean that no less attention must be given to training users in the concepts and rules for voucher use. As a consequence of inadequate training of users, they used voucher funds less aggressively than might otherwise have been the case. Although the voucher program nemains in force, the amount of funding available has been reduced since 1989 both by the state and the county departments of mental health. Funds once budgeted for voucher usc reassigned at the regional county levels to increase
contract funding for a variety of more traditional treatment and support agencies. In addition, since 1989 system managers have interposed severat administrative reviews as pncrcquisites for users accessing funds.
3.
mentally
of Orthopsychiatry
14.
ill
15.
Community
B: Toward
Support
Mauch D, Morrison E: Refining and Promoting Action: Identifying firmative Approaches to Sound
Systems.
Newport,
Department
and Hospitals, patients:
Mental Is-
Health,
current
to individualized services: the impact ftinding and conceptual Mental
Health
1991
Tessler R, Goldman H: The Chronically Mentallylll: AssessingCommunitySupport Programs. Cambridge, Mass, Bal-
Fisher
G, Landis
analysis.
138:
K: Case
man-
agement change.
service provision and client Community Mental Health Journal 24:134-137, 1988
J: Improving the quality of care for the chronically men-
8. Intagliata community
disabled: the role of case management. Schizophrenia Bulletin 8:65 5674, 1982 tally
Shern
D, Surles
R, WaizerJ:
Designing
community treatment systems for the most seriously mentally ill: a state administrative perspective. Journal of SocialIssues45:105-1 17, 1989 Shore
M,
Cohen
M:
The
Robert
Wood
J ohnson
Foundation Program on Chronic Mental Illness: an overview. Hospital and Community Psychiatry 41:12 121216, 1990 Hargreaves W: The California Integrated Service Agency. Berkeley, Calif. Institute for Mental Health Services Re-
search,
1990
Stein L, Test M (ccli): The Training Community Living Model: A Decade Experience.
New
Services,
1992
D: Strategies for integrating mental health services. Hospital and Community Psychiatry 42:797801, 1991 Surles
R, Blanch
A: Case
management
Dictionary
ofMental
bany,
York
New
Health
State
Office
as Albany,
Health, Terms.
Al-
of Mental
Health, 1989 19.
Donahue Intensive Second
20.
5, Martin R, Shern D: Adult Case Management Evaluation: Year Final Report. Albany, New
YorkStateOfficeofMentalHealth,
1990
Anthony
W, et
al: Psychiatric and current
W, Kennard
W, O’Brien
rehabilitation: past myths realities. Community Men-
tal HealthJournal
22:249-264,
1986
forchron-
of Psychiatry
D, Clark
Mechanic
Re-
6. Toward a Model Plan for a Comprehensive, Community-Based Mental Health System: Administrative Document. Rockville, Md, National Institute of Mental Health, 1987
November
Bertsch E: Barriers community support
1989
a conceptual
Journal 1981
Vision Al-
Rhode
ofMental
L: Continuityofcare
1449-1456,
Health
So-
and
York, Doubleday,
a strategy for systems change. New YorkStateOfficeofMental 1989 18.
1987
Stroul
American
12.
on the
Patients
public
50:43-53,
317: 1634-1638,
ic mental
1 1.
New
models. Community Journal 27:337-345,
17.
tardation,
9.
Inmates.
ofsome
Mechanic D, Aiken L: Improving the care ofpatients with chronic mental illness. New England Journal of Medicine
5. Bachrach
7.
Essays
of Mental
1961
policy on the patient.’American
chronic
Health
Many of the essential features of the voucher process and the case management approach created in 1989 remain in place today, and the number ofpensons served continues to increase. As interest in managed
Psychiatry
Other
a public
Journal 1980
land,
10.
and Community
Toward
Systems for the Mentally Disabled: The NIMH Community Support Program. Boston, Boston University Center for Rehabilitation Research and Training in Mental Health, 1984 4.
E: Asylums:
Situation
linger,1982
1. TalbottJ:
2.
Goffman
cial
16.
In sum, without a well-trained user group to serve as a constituency to protect the annual voucher funds budget and the process itself, funds are too easily reallocated to other purposes, and controls that primarily serve to reassert the authority of sysrem managers and providers oven users are reintroduced.
Hospital
13.
References
providers
perceived funds allocated to the voucher process as money that should have been directly contracted by the state on county with their agencies.
have been office and
cane for health and mental health grows, interest in vouchers as a means to directly fund individual users’ supports may also increase. Since 1989 a similar case management and voucher process has been introduced on Long Island in Suffolk County, New York.
Directions
in of
for Mental
H&CP to Require Structured Abstracts Beginning in January 1993, H&CP wilt publish structured abstracts (maximum 250 words) with alt litcrature reviews and full-length research reports. Abstracts for research reports must include the following headings and information: Objective, the study purpose or research question; Met/iods, including study design, setting, subjects, intervention(s) if any, and main outcome measure(s); Results, the main results of the study; and Condusions directly supported by the data. Abstracts for literature reviews must include the following headings and information: Objective, the pnimary purpose of the review; Methods, data sources searched, how studies were selected on excluded, and (if applicable) how data were abstracted; and Results and Conclusions, the main findings or conclusions from the review and their clinical or other applicability.
no 26, 1985
VoL 43
No.
11
1113
in the School of Social Welfare at the Nelson A. Rockefeller College ofPublic Affairs and Policy in Albany. Address correspondence to him at 1360 Wemple Lane, Niskayuna, New York 12309.
The treatments most commonly cited are medical, dental, and psychiatnic care, including emergency, inpatient, and outpatient psychiatric services. Basic supports should meet each person’s unique residential, vocational, social, and leisure interests and needs. It is also generally agreed that case management in some form must be available to provide a human link between the service user and the array oftneatmcnts and supports (8). Fragmentation, or the tack of continuity in the delivery of treatments and supports, is often identified as a major obstacle preventing persons with severe disabling mentat illness from living productively in the cornmunity (1,3,5,9). The creation of quasigovernmcntal administrative authorities with the power to mandate the coordination and integration ofactions by different treatment and support service agencies in a community is an approach suggested for reducing or eliminating fragmentation . Commonly such authorities require significant sacrifice in service flexibility while at the same time assigning a markedly passive role to the service user in choosing supports (1-3,6,10-12). The single communitywide coordinating authority as a means to address fragmentation through controlling both the suppliers and users of treatments and supports is experiencing a revival in the U.S. The Robert WoodJohnson Foundation is funding development of coordinating authorities in nine midsized American cities, and California hopes to develop integrated service agencies in two communities on a demonstration basis (10,1 1). To the extent that technology atlows, such authorities seek to ne-
Hospital
November
Elmer
F. Bertsch
Fragmentation in the delivery of community support services is often identified as a major barrier to persons with severe mental illness, preventing them from living productive lives in the community. In Nassau County, New York, in 1989 a voucher process was created to allow service users to develop individualized support networks by purchasing services directly and by poolingfunds to start new services. The voucher process is part of an intensive case management program. Goals set in the individual service plans ofusers guide voucher purchases. The localMental Health Association manages funds based on a bank credit card model. The user, the case manager, and a staff memberfrom an agency designated by the user review expenditures quarterly. The first year of operation is described, and suggestions f or developing a voucher process, such as the need for extensive retraining of users and providers, are offered. It is now widely agreed that for pensons with severe disabling mental illness to live productive lives in the community, they must have an array of treatments and supports (1-7). Mr. Bertsch is former deputy regional director of the Long Island regional office of the New
York
State
Health.
He
and
Office is currently
Community
of
Mental a student
Psychiatry
1992
Vol.
43
No.
11
create within the larger pluralistic community the conditions of Goffman’s total institution or the conditions ofthe highly planned economic systems that until recently existed in Eastern Europe (3 1 3 1 4). Because communitywide authorities are intended to prescribe, fund, and controt the residential, vocational, educational, social, and leisure options available to service users, they go well beyond the boundaries of managed health care proposals now being urged for the general public. There is little evidence that such authorities can address service fragmentation at the level of the individual service user. Tesslen and Goldman (1 5), noting the failures of earlier communitywide authorities, such as the Modet Cities Program, and their own field observations of efforts to create mental health authorities, stated, “There is little evidence to support the efficacy ofa service coordinationcollaboration approach to address the fragmentation of the service delivery system.” Mechanic (16) stated, “Non ,
is it clear
that
,
[political
authorities]
would necessarily improve the integration of service and quality of care. Yet theoretically it seems reasonable to expect . . . service wilt improve.” Creation of communitywide authonitics to coordinate the actions of the many different governmental agencies that setect and fund support services is a theoretically reasonable way to reduce discontinuity in services only if the creators of such authorities also believe that it is necessary and desirable for agencies to select and fund specific supports on behalfofeach service recipient.
A voucher each
service
process user
that
to directly
permits purchase
1109
Figure 1 Expenditures ofvoucher service users in Nassau ual
service
plans
Figure funds(totat=
$7,087)by
County, New the first two
during
mental
York,
to support
months
ofthc
health
of voucher
funds
(totat=$27,835) New York,
health service users in Nassau County, cy needs during the first two months
individ-
program
ofthe
by mental for emergen-
program
needs
Personal
needs
Personal
2
Expenditures
Clothing
Employment Clothing
Furnishings
Furnishings
housing
1 P I I U P
Medical or dental care
Medical or dental
.
Temporary
Housing or respite
care
Transportation
Transportation =
0
5
10
15
=
20
25
=
30
=
35
Other
=
40
45 0
of expenditures
Percentage
Source
for both figures:
Mental
Health
Association
5
10
Percentage
ofNassau
15
20
25
of expenditures
County
children served through management programs County, New York.
the case of Nassau
housing, employment, leisure, and other supports from the full range of goods and services already offered in a particular community. The Nationat Institute of Mental Health (NIMH) recognized the theoretical advantages of vouchers in providing “the ultimate in consumer choice and flexibility . . . [while putting]. . . programs in a competitive position” (6). Yet no studies of the use of such vouchers have been reported in the literature, and NIMH has no knowledge of a recipient-directed voucher system currently in operation (personal communication, Anons BS, NIMH, 1991). Therefore, in addition to any conceptuat or theoretical barriers to vouchers that might exist, the literatune offers no discussion of how a voucher option might be created and managed. The remainder of this paper describes the development of a limited voucher option for the direct purchase of supports by adults and
management program for children and adults (9,17). One feature of this program was the allocation of $40,000 pen case manager position for the purchase ofsupport goods and services. The initial OMH mandate to its five regional offices stated that these funds were not to be used to establish programs but rather to make immediate responses to users’ situationat emergencies such as an immediate need for food on shelter and to purchase goods and services needed by each user to reestablish an effective individual support network. Reinforcement for the intended use of these funds came through a new OMH dictionary of terms, which created a clear conceptual separation between psychiatric treatments (emergency, inpatient, and outpatient) and community support programs such as the intensive case management program(18). All cornmunity support programs were “to enhance the living and working
skills . . . and to strengthen natural peer and family networks” of those served. The OMH statewide operational definition of the intensive case management target population limited the program to homeless mentally ill persons, heavy users of acute inpatient psychiatric treatments, difficult-to-place state hospital patients, and persons at high risk of falling into one of these categories (9). A statewide follow-up study neported that 90 percent of those enrolled in the intensive case management program were diagnosed as having a major mental illness, with approximately half having a secondary diagnosis of alcohol on substance abuse (19). An allocation of additional positions for the new intensive case management program was made to each of the state’s regional offices. Unusual flexibility was given each regional office in working with counties and state facilities to implement the new program. Responding to this opportunity, the Long Island regional office and the Nassau County Department of Mental Health pooled the new state and nonstate intensive case management positions with existing case management posi-
1110
November
Hospital
a broad
range
of the
goods
and
ser-
vices needed in order to create a unique support network eliminates fragmentation ofserviccs. The issue a voucher process raises for users, funding authorities, and planners is how to create mechanisms that penmit
each
user
to responsibly
choose
The
voucher
system
Program history. York State Office
In 1989 the New of Mental Health
(OMH)
an intensive
initiated
1992
Vol. 43
case
No.
11
and Community
Psychiatry
Figure Voucher services
3 funds (total=$178,924)pooted in Nassau County, New York,
by mental health service users to initiate new during the first two months of the program
Self-help
Vocational
Social,
leisure
Health
#{149}
Education 0
10
20
30
Percentage
of expenditures
40
50
60
sist in development ofthc individual service plan. By completing a vouchen, the user authorizes expenditures for the purchase of goods or services needed to advance a specific goal in the plan. The voucher must be countensigned by either the assigned case manager on the user’s designated lead agency representative. Figure 1 illustrates the uses to which voucher funds were put to support individual service plans in the program’s first two months ofoperation in 1989. To disperse the funds, the Mental Health Association ofNassau County contracted to manage a process modeled on a bank credit card operation. On receipt of a completed voucher, the Mental Health Association draws a check to the merchant or vendor specified. As with bank cards, a monthly statement itemizing all expenditures along with a summary ofall contacts with the case manager is mailed
Source:
Mental
Health
Association
ofNassau
tions in the community support gram to create one countywide standing program under their direction. Money was allocated
profreejoint local-
County
sons in the community support program with case managers. The county department of mental health received and prioritized all requests for service to the consolidated case management program. Essentially the same voucher process is used by children enrolled in the intensive case management program. Initial concerns that children would use funds frivolously or that funds would create conflicts between the children and their families or guardians were not borne out. The children’s intensive case management program reported that the most common purchase by children in the first months of operation was of peer-appropriate clothes, with a reported improvement in school attendance. Three uses ofvoucherfunds. In 1989 the voucher program was fully operational only for the months of November and December. Only a small number of the adults enrolled in the intensive case management program used funds during this pen-
od. About 35 case managers were employed in the program by Decemben 1989. By the end of 1989, users had authorized vouchers worth $213,000. About 84 percent of these funds were used to establish new programs, 1 3 percent of the funds were used for emergencies, and about 3 percent supported individual service plans. Individual .rerviceplans. An mdividual service plan guides daily case management practice. The plan is completed oven an extended period by each service user with the assistance of the case manager and a lead agency representative. The individual service plan describes the user’s current housing, health, vocational, educational, social, financial, leisure, and legal situation and notes the mental health and other treatments received by the user. For each support area, users indicate if they wish to maintain the status quo, have not yet formulated a goal, or wish to sec changes. The steps to be taken by the user and others in areas in which change is desired are recorded. Each user is also encouraged to identify a recognized community agency (social, advocacy, religious, or mental health) as a lead agency to as-
Hospital
November
ly to create
a voucher
and Community
fund
for
per-
Psychiatry
1992
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to each
active
user
by
the
Mental Health Association. These statements are also provided to the lead agency representative, the case manager, and any other person identified by the user. The user, the case manager, and the lead agency representative review expenditures quarterty. Users can invite others to attend these reviews. Emergencies. Using credit cards issued to them by a major bank, each case manager can access up to $ 1 5 0 a day in cash to respond immediately to any situational crisis. Receipts signed by the user are required for alt such emergency expenditures. Figure 2 illustrates the major purposes for which emergency cash withdrawals were made during the first two months ofthc program in 1989. Poolingfunds to create services. Users can also elect to pool funds to initiate new supports. In Nassau County more than 90 new support programs were proposed for funding through voucher payments in the first year of the voucher process. A proposed support program could be funded for up to 1 2 months only if a sufficient number of service users were persuaded to authorize voucher payments. Only 29 ofthe first-year proposals eventually had sufficient enrollmcnt to begin operations. Figure 3 illustrates the types of new initia-
1111
tives funded during the first two months ofthc voucher program. Eleven of the 29 new initiatives were self-help programs, including an advocacy center. Funds also paid security deposits when users rented a house. Ten other new programs stressed social and leisure activities, including a drop-in center. Six of the new programs were vocational. One was a new health program, and one was an education program.
pendent settings; only 22 percent preferred a supervised setting. Even this limited voucher process made it possible for service users to select from a broaden range of supports already existing in the community. A voucher program can also serve as a strong stimulus for changing the relationship of service users to support service providers. When a group of Nassau County providers and
Discussion Only a brief description of some of the major features of the voucher process as it was developed in 1989 has been presented. It took 12 months from conceptualization to implementation of the voucher process. Users began to access funds in the last two months of 1989. This development period is relatively brief compared with the time required for implementing communitywide coordinating authorities (10). The voucher process relies on easily available technology and is relatively inexpensive. The only additional mitial costs were those needed to estabtish the bank card operation. This process also served to stimulate a different view of supports. Identification of an unmet need for support services is often translated into the need for a new program. Examples include housing programs, leisure programs, club programs, and drop-in centers. Offering such commonplace goods and services through contracts with mental heatth service providers adds substantiatly to their cost, is often stigmatizing, overly restricts the range of user options, and frequently results in the funding of supports other than those that would be selected by users (9,14).
A proposed support program could be funded
for
up
12 months
only
a sufficient
of
service
persuaded voucher
to if
number users
were
to authorize payments.
potential providers wanted funds to start a wide variety of proposed programs in 1989, rather than following the usual practice of soliciting the regional office on the county for funding, they held a program fair. They offered more than 200 of the county’s most disabled mentally ill persons free transportation and a free lunch at the fair, where heavy manketing of the competing programs was directed to potential users. This experience shows that vouchers provide for direct accountability of providers to users.
For example, in New York one study showed that case managers in an intensive case management program recommended that 56 percent of their case load live in some supervised residential setting; they recommended that only 32 percent live in private homes, apartments, or rooms (19). In contrast, 73 percent of the users in the same study reported preferring to live in the more mdc-
Conclusions As long as state hospitals were the primary residences for persons with serious mental illnesses, there was little point to drawing sharp distinctions between treatment and supportive services. In 1984 Anthony and associates (20) presented compelling arguments for distinguishing between supportive services (that is, skills, goods, and services needed to live productively in the community) and treatment (that is, medical interventions intended to disrupt the natural history ofdiscase) (20). Once this distinction between supports and treatment is made, the issue of fragmentation of support services
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1992
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can be redrawn. Rather than controlting the supply of supports, mechanisms such as vouchers that allow targeted users to responsibly purchase supports become a reasonable alternative. The experience described here suggests five issues that need to be weighed when a voucher program is considered. First, a vehicle for linking the user to the voucher process is needed. Case management is well suited for this purpose. Second, if case management is selected as the mode of delivery, it must be a stable resource for each user. The availability of case management cannot be made contingent on the user’s enrollmcnt in another treatment or support program. Too often case management funding schemes link a case management service to some other third-panty reimbursable 5crvice. Strategies that permit case management itself to be a freestanding reimbursable service need to be adopted. New York State amended its federal
Medicaid
plan
intensive case management reimbursable by Medicaid The
third
issue
to make
its
program (9).
to weigh
when
considering a voucher program is that it is essential to base the program on each user’s individualized service plan. Case management standards that call only for assessment, planning, linkage, advocacy, and monitoring (7) are too general and too provider controlled (that is, case manager controlled) to serve as an appropriate guide to users on case managers in a voucher process. The broker case management model (8) used in Nassau County was greatly strengthened by identifying each user’s unique goats for housing, financial support, education, work, personal living, skill development, social and recreational support, support by family and friends, and health, dental, and mental health services. Fourth, users should be allowed to identify another person from a recognized human service organization who may countersign voucher authonizations. This addition lessens the likelihood of inappropriate controt of the user’s access to voucher
Hospital
and
Community
Psychiatry
funds by a case manager. At the same time, it lessens the strain between the user and case manager when the case manager does not endorse a proposed voucher expenditure. When the user’s lead agency nepresentative shares the case manager’s judgment about the inappropriateness of a proposed expenditure, the user’s relationship with the case manager is tess likely to be strained. Fifth, a substantial amount of training is needed for case managers and established support service and treatment providers to understand and accept a voucher process. Even though extensive training was done in Nassau
County,
contract
In retrospect, it is clean that no less attention must be given to training users in the concepts and rules for voucher use. As a consequence of inadequate training of users, they used voucher funds less aggressively than might otherwise have been the case. Although the voucher program nemains in force, the amount of funding available has been reduced since 1989 both by the state and the county departments of mental health. Funds once budgeted for voucher usc reassigned at the regional county levels to increase
contract funding for a variety of more traditional treatment and support agencies. In addition, since 1989 system managers have interposed severat administrative reviews as pncrcquisites for users accessing funds.
3.
mentally
of Orthopsychiatry
14.
ill
15.
Community
B: Toward
Support
Mauch D, Morrison E: Refining and Promoting Action: Identifying firmative Approaches to Sound
Systems.
Newport,
Department
and Hospitals, patients:
Mental Is-
Health,
current
to individualized services: the impact ftinding and conceptual Mental
Health
1991
Tessler R, Goldman H: The Chronically Mentallylll: AssessingCommunitySupport Programs. Cambridge, Mass, Bal-
Fisher
G, Landis
analysis.
138:
K: Case
man-
agement change.
service provision and client Community Mental Health Journal 24:134-137, 1988
J: Improving the quality of care for the chronically men-
8. Intagliata community
disabled: the role of case management. Schizophrenia Bulletin 8:65 5674, 1982 tally
Shern
D, Surles
R, WaizerJ:
Designing
community treatment systems for the most seriously mentally ill: a state administrative perspective. Journal of SocialIssues45:105-1 17, 1989 Shore
M,
Cohen
M:
The
Robert
Wood
J ohnson
Foundation Program on Chronic Mental Illness: an overview. Hospital and Community Psychiatry 41:12 121216, 1990 Hargreaves W: The California Integrated Service Agency. Berkeley, Calif. Institute for Mental Health Services Re-
search,
1990
Stein L, Test M (ccli): The Training Community Living Model: A Decade Experience.
New
Services,
1992
D: Strategies for integrating mental health services. Hospital and Community Psychiatry 42:797801, 1991 Surles
R, Blanch
A: Case
management
Dictionary
ofMental
bany,
York
New
Health
State
Office
as Albany,
Health, Terms.
Al-
of Mental
Health, 1989 19.
Donahue Intensive Second
20.
5, Martin R, Shern D: Adult Case Management Evaluation: Year Final Report. Albany, New
YorkStateOfficeofMentalHealth,
1990
Anthony
W, et
al: Psychiatric and current
W, Kennard
W, O’Brien
rehabilitation: past myths realities. Community Men-
tal HealthJournal
22:249-264,
1986
forchron-
of Psychiatry
D, Clark
Mechanic
Re-
6. Toward a Model Plan for a Comprehensive, Community-Based Mental Health System: Administrative Document. Rockville, Md, National Institute of Mental Health, 1987
November
Bertsch E: Barriers community support
1989
a conceptual
Journal 1981
Vision Al-
Rhode
ofMental
L: Continuityofcare
1449-1456,
Health
So-
and
York, Doubleday,
a strategy for systems change. New YorkStateOfficeofMental 1989 18.
1987
Stroul
American
12.
on the
Patients
public
50:43-53,
317: 1634-1638,
ic mental
1 1.
New
models. Community Journal 27:337-345,
17.
tardation,
9.
Inmates.
ofsome
Mechanic D, Aiken L: Improving the care ofpatients with chronic mental illness. New England Journal of Medicine
5. Bachrach
7.
Essays
of Mental
1961
policy on the patient.’American
chronic
Health
Many of the essential features of the voucher process and the case management approach created in 1989 remain in place today, and the number ofpensons served continues to increase. As interest in managed
Psychiatry
Other
a public
Journal 1980
land,
10.
and Community
Toward
Systems for the Mentally Disabled: The NIMH Community Support Program. Boston, Boston University Center for Rehabilitation Research and Training in Mental Health, 1984 4.
E: Asylums:
Situation
linger,1982
1. TalbottJ:
2.
Goffman
cial
16.
In sum, without a well-trained user group to serve as a constituency to protect the annual voucher funds budget and the process itself, funds are too easily reallocated to other purposes, and controls that primarily serve to reassert the authority of sysrem managers and providers oven users are reintroduced.
Hospital
13.
References
providers
perceived funds allocated to the voucher process as money that should have been directly contracted by the state on county with their agencies.
have been office and
cane for health and mental health grows, interest in vouchers as a means to directly fund individual users’ supports may also increase. Since 1989 a similar case management and voucher process has been introduced on Long Island in Suffolk County, New York.
Directions
in of
for Mental
H&CP to Require Structured Abstracts Beginning in January 1993, H&CP wilt publish structured abstracts (maximum 250 words) with alt litcrature reviews and full-length research reports. Abstracts for research reports must include the following headings and information: Objective, the study purpose or research question; Met/iods, including study design, setting, subjects, intervention(s) if any, and main outcome measure(s); Results, the main results of the study; and Condusions directly supported by the data. Abstracts for literature reviews must include the following headings and information: Objective, the pnimary purpose of the review; Methods, data sources searched, how studies were selected on excluded, and (if applicable) how data were abstracted; and Results and Conclusions, the main findings or conclusions from the review and their clinical or other applicability.
no 26, 1985
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