DDES Memo Series 2007-06

April 20, 2007

STATE OF WISCONSIN
Department of Health and Family Services
Division of Disability and Elder Services

To: Liserv

From: 
Sinikka Santala, Administrator
Division of Long Term Care 

John Easterday, Interim Administrator
Division of Mental Health and Substance Abuse Services

Re: Realignment of Program Mission for Mental Health Institutes and Centers for the Developmentally Disabled

Document Summary

This numbered memo is a follow-up to the DDES Information Memo 2007-01 issued on February 7, 2007. Due to concerns raised by counties about the fiscal impact of this proposal, DDES and WCHSA convened a small workgroup of county directors to review the fiscal implications on the counties. This numbered memo restates the programmatic issues from the DDES memo 2007-01 and clarifies the fiscal implications.

Introduction:

The Department of Health and Family Services and the Division of Disability and Elder Services are committed to improving treatment services for all people including those with developmental disabilities. Quality care for these individuals and others involves treatment that is appropriate, short-term, and coordinated with local resources to promote successful reintegration as soon as possible into the community.

DHFS Centers for persons with developmental disabilities and mental health institutes serve unique and often challenging client population. These facilities and the staff working in our facilities are our most valuable assets in providing high quality care and treatment for individuals with mental illness and developmental disabilities.

In order to maintain high quality, viable services at our centers and institutes, DDES will be implementing several actions to align the mission and activities of WMHI, SWC, CWC, and NWC during the next several months. We are committed to making those alignments with utmost care and respect towards our patients, residents, their guardians, our staff, as well as Wisconsin counties that purchase care from the institutes and centers.

These realignments impact WMHI in two important ways: WMHI mission will focus on serving individuals with a primary diagnosis of mental illness. It is also our intent to improve staffing capacity at WMHI to meet the needs of the challenging population of people with mental illness it now serves and will continue to serve in the future.

Our three developmental disability centers will further strengthen their function to provide short-term intensive treatment services for individuals with developmental disabilities who live in community settings but need short term active treatment. The strengthening and expansion of the short-term, intensive treatment program functions at SWC is also consistent with the recently released recommendations of SWC union/management task force on the future programs and mission of SWC.

The realignments that will be implemented:

To promote this goal, the Division of Disability and Elder Services has announced the transfer of treatment services from the Services for Multiply Impaired Children (SMIC) Program and the Transitional Living Center (TLC) Program at Winnebago Mental Health Institute to the Intensive Treatment Programs (ITP) at Northern Wisconsin Center (NWC), Central Wisconsin Center (CWC), and Southern Wisconsin Center (SWC). Currently, the SMIC Program is located on the Sherman Hall 1 and 2 units at WMHI and consists of 20 beds. The SMIC program primarily serves children and adolescents (under 18 years of age) with a developmental disability and whose behavior is considered difficult to manage in the community without an intensive treatment intervention. The SMIC unit has also admitted and treated children and adolescents with a diagnosis of autism and behavior considered difficult to manage in the community. Currently, the TLC Program is located on Sherman Hall 4 Unit at WMHI and consists of 14 beds. The TLC Program is designed for individuals from the ages of 17 to 65 who are dually diagnosed with a mental illness and a developmental disability and exhibit extremely challenging behavior in the community or a less secure setting.

WMHI will continue to provide psychiatric inpatient services for children and adolescents who need hospitalization. The Admissions, Treatment, and Recovery Unit (ATRU) which consists of 15 beds on Sherman 5, the Child, and Adolescent Psychiatric Services (CAPS) on Sherman Hall 8 which consists of 19 beds, and the Anchorage Program for adolescent alcohol and other drug abuse treatment in Sherman Hall which consists of 15 beds will all continue to admit and treat patients. There are approximately 800 admissions each year to these units for child and adolescent services.

This transfer of services is not intended to be solely the transfer of a particular program, in total, from one facility location to another. Rather the current ITP programs at the three Centers will be enhanced to include services for children and adolescents that will encourage short-term active treatment to facilitate each individual's return to his/her own community as quickly as possible. For individuals previously referred and now admitted to SMIC at WMHI, a full array of options should be considered starting with the county of residence and may also include CWC and NWC. Individualized planning will be based on the goal of a successful community oriented transition plan and supports.

The programmatic changes are intended for the TLC program as well. However, the transfer of the SMIC program will occur at least one year prior to the transfer of the TLC program to the Centers. This two stage approach will provide time for planning and coordination among all parts of the service delivery system. A future memo will describe in more detail the TLC Program transfer to the Centers.

This initiative and program change will require the cooperation and collaboration of different facilities, treatment staff, families, guardians, patients, County Human Service Departments, County Community Programs, County Social Service Departments, local law enforcement, and local community organizations. This will be true for the transfer planning and placement of residents currently on SMIC as well as for the future admission, treatment, and discharge of individuals for the Intensive Treatment Program. The same will be true for the transfer of the TLC program. Admissions to the Centers' short-term programs will need to be planned and coordinated across the system for children, adolescents, and adults with a developmental disability and a behavioral health issue.

Impact on Clients:

The Centers, through the ITP, have developed programming that specifically addresses the needs of individuals with developmental disabilities at all ages. This focus results in the potential for a shorter overall length of stay, by focusing specialized services to assist the individual to attain the skills necessary for increased personal independence, community integration and the coordination of services with families, guardians, and community resources. The current length of stay at the ITP units is 30 to 90 days.

Impact on Counties:

For children and adolescents under the age of 22 who are appropriate for admission, counties will become responsible for the state match of federal Medicaid funding at an ITP. Currently, counties are not financially responsible for the state share of Medicaid reimbursement for children and adolescents with developmental disabilities admitted to the SMIC program at WMHI. For adults, however, counties will no longer be responsible for the full cost of care for adults between the ages of 22 and 64 who were admitted previously to the TLC program and now qualify for admission to one of the ITPs at the Centers. For adults, as with children and adolescents, counties will only be responsible for the state match of federal Medicaid funding at the Center's ITP.

Joint WCHSA/DHFS Review and Decision on the Fiscal Implications and Responsibilities on Counties:

The DHFS and WCHSA workgroup reviewed the projected costs on counties using two scenarios:

1) what would be the total cost on counties if lengths of stay at the ITP units were as long as those currently at SMIC and TLC?

2) What would be the total cost on counties if the lengths of stay at ITP units were 60 days? (The length of stay of current ITP clients is 30-90 days, so the mid-point of 60 days was used for purposes of analysis.)

When the costs were reviewed it was determined that a 60-day length of stay would be virtually cost neutral on counties.

However, DHFS was sensitive to the concern of counties that there is a need to develop service capacity in the counties to address the needs of these children so that shorter lengths of stay at the ITP can be reached. DHFS also acknowledged that full fiscal benefit will not be achieved by the counties until 2008 when the TLC unit services have been transferred to Southern Wisconsin Center.

After review of the full impact on counties of these transfers, once fully implemented, the DHFS with WCHSA representatives concurrence will apply the following fiscal processes:

1. DHFS will fund the non-federal share of costs for any child or adolescent under the age of 22, who are receiving active treatment and voluntarily transfers from SMIC or TLC to a DD center between April 1, 2007 and December 31, 2007.
2. DHFS will fund the non-federal share of costs, during the short term stay for children and adolescents who are otherwise eligible for admission to an ITP as subsequently defined in this Numbered Memo and who are voluntarily admitted to a DD center and are in need of active treatment between April 1, 2007 and December 31, 2007 as determined by a pre-admission assessment. These are children or adolescents with an intellectual disability who would have been admitted to SMIC but will not be admitted due to the SMIC unit not accepting admissions as of April 1, 2007.
3. DHFS will waive the 10% surcharge to counties for those children who were transferred from SMIC/TLC during calendar year 2007.
4. Beginning in calendar year 2008, DHFS will impose the appropriate ITP costs and surcharges for former and future SMIC and TLC clients admitted to the ITP.

In the workgroup with WCHSA representatives, we also identified the following critical issues on which we will work collaboratively:

1. Discharge planning for ITP clients is critical to ensure that lengths of stay for these children are short, with the goal of a maximum stay of 90 days.
2. It is important to identify and address community capacity needs to serve these children and adolescents. The DHFS Community Integration Initiative will be a partner with counties in this effort.
3. Counties need resources to serve these challenging children and adolescents. DHFS will coordinate the children's waiver program with counties to assist in providing waiver funds when possible to assist counties.
4. DHFS will coordinate regional information sessions to counties to brief them on ITP units and how to access the ITPs in a planned way to serve children and adolescents.

Target Dates:

After March 31, 2007 the SMIC Unit is no longer accepting voluntary or involuntary admissions (i.e., emergency detentions and commitments). Discharge planning for the current residents of SMIC has started. The SMIC Unit will close as of June 30, 2007. The short-term services at NWC are available for immediate admissions based on the criteria and process for admissions presented below. For those children and adolescents who are on a waiting list for admission to SMIC, staff from NWC and CWC will work with SMIC staff, counties, guardians, and others to assess children and adolescents for the most appropriate and available treatment setting. Most admissions to SMIC occur on a voluntary basis and this will continue to be the case in the short term admissions to ITPs. Further planning will be done to appropriately handle any Emergency Detentions that occur before and after the SMIC Unit Services are transferred to the Centers.

The TLC Program will be transferred by the end of 2008. A separate memo will be issued before that time to describe the transfer in more detail.

Admission Criteria for State Center Intensive Treatment Programs at Northern Wisconsin Center Excel, Central Wisconsin Center Short Term Assessment Program and Southern Wisconsin Center Intensive Treatment Program:

Individuals eligible for Intensive Treatment Program (ITP) services are children and adults with mental retardation who meet the diagnostic eligibility criteria for residential services consistent with the requirements of the Developmental Disabilities Medicaid Waiver and:

1. Whose preadmission assessment has identified active treatment needs which cannot be adequately met elsewhere due to significant maladaptive and inappropriate behaviors which are due to social, psychological, psychiatric, and medical factors and;
2. Whose preadmission assessment has identified active treatment needs that can be met at an ITP and;
3. Whose need for active treatment can be best met by decreasing the frequency of those behaviors which are interfering with other active treatment needs and simultaneously increasing those skills necessary to achieve functioning with as much self determination and independence as possible, and preventing the loss or regression of functioning and;
4. Consistent with the ICFMR standards, individuals who need a program of active treatment that includes aggressive, consistent implementation of a program of specialized and generic training, treatment, and health services and;
5. Whose needs include acquiring the skills essential for privacy and independence and includes, but is not limited to: toilet training, personal hygiene, dental hygiene, self feeding, bathing, dressing, grooming, communication of basic needs, self-medication, use of medical devices and money management and;
6. Whose needs for medical services and supports can be adequately met by the ITP.

ITP services are not for individuals who are able to function with little supervision or in the absence of a program of continuous active treatment or for persons who are generally able to independently take care of most of their personal care needs, and effectively and appropriately make known to others their basic needs and wants.

ITP services are not intended for emergency detentions under Chapter 51.

Note: Specific admission decisions will consider gender, age, compatibility, and the availability of necessary programs and services based on the preadmission assessment.

How to Initiate Admission to an ITP:

Referrals may be made to the following:

CWC
Joe Stoffels, STAP Coordinator
608-301-9244
Theresa Wright, STAP Social Worker
608-301-9233

NWC
Rebecca Graham, EXCEL Unit Director
715-723-5542 extension 5100
Admissions Coordinator
715-723-5542 extension 5115

Admissions will occur after a determination is made by a preadmission assessment that the individual's needs could be met at an ITP and the individual meets the criteria for admission.

Each admission to a Center ITP is for the purpose of helping the individual attain increased personal independence and to successfully transition to his/her own community. In order to accomplish this, transition planning starts at the time of admission. The programmatic, habilitative, and clinical emphasis at the ITP includes consideration of where each individual will live, work, recreate, go to school, and receive health care in the future. The typical length of stay is 30 to 90 days. A mutually agreed upon discharge date is determined for the preadmission agreement. The preadmission agreement must be signed by the county and the center prior to admission.

Transitional Planning for Current Residents of SMIC:

1. Each county and parent/guardian has been notified. We intend to have a reasonable amount of time to engage in planning activities for each person guardian/ward and responsible county agency.
2. In the event that more detailed or specific planning is needed, an interdisciplinary team meeting will be scheduled. The team would include county staff, parents/guardians, the child or adolescent, WMHI staff, NWC-ITP & CWC-ITP designees, and others as appropriate. These meetings will be organized and led by the WMHI team and held at WMHI.

Admissions to WMHI after June 30, 2007:

It is the intent of this policy and programmatic change to encourage the placement of children and adolescents with a developmental disability or autism, and behavioral challenges in the most appropriate treatment setting that will encourage community integration. The SMIC program will no longer operate by the end of June, 2007 and admissions to WMHI for this target population, either on a voluntary or involuntary basis, will not be appropriate. Any admission on an involuntary basis will lead to a discharge as soon as possible after appropriate arrangements have been made for the safety and treatment of the child or adolescent. It is our intent that such transfers, either to alternative community settings or one of the ITP's at the Centers will not be necessary. Our goal is to have all admissions to one of the ITPs occur in a planned and coordinated manner after assessing each child and adolescent for the most appropriate short and long term treatment settings.

WMHI CONTACT:
Byran Bartow, Interim Director
920-235-4910 extension 2550

BUREAU OF CENTER OPERATIONS and CWC CONTACT:
Theodore Bunck, Ph.D., Director
608-301-9229

NWC CONTACT:
Louise Ramseier, Director
715-723-5542 extension 4100

SWC CONTACT:
Jim Henkes, Interim Director
262-878-2411

CENTRAL OFFICE CONTACT:
John Easterday, Interim Administrator
608-267-9391

Theodore Bunck, Ph.D., Director
608-301-9229

REGIONAL OFFICE CONTACT:
Area Administrators

MEMO WEB SITE: http://dhfs.wisconsin.gov/dsl_info/ 

Links: 

• DDES Information memo 2007-01: Realignment of Program Mission for Mental Health Institutes and Centers for the Developmentally Disabled
• DDES numbered memo 2006-12: Rate Information For Billing For Services Provided By The Centers For Persons With Developmental Disabilities

cc: Wisconsin Council on Developmental Disabilities
Disability Rights of Wisconsin
Mental Health Council
Wisconsin Family Ties

Return to Numbered Memos Index