The National Association of State Directors of Developmental Disabilities Services (NASDDDS) is completing a multi-part study of state strategies for supporting individuals with co-existing developmental disabilities and mental health or behavioral conditions. The project has gathered data through a nationwide survey of state officials, an invitational symposium of state developmental disabilities agency directors and national experts and currently, a qualitative study of the strategies thirteen states employ to support individuals with co-existing conditions (see box below). The national survey results and a report of the findings and recommendations of the symposium are available on the NASDDDS website, www.nasddds.org.
This paper summarizes selected preliminary findings emerging from the in-depth assessment of state practices for supporting individuals with co-existing or dual diagnoses being completed by the author. Data were gathered through interviews with state officials and analyses of state policies, procedures, laws and regulations regarding the organization and delivery of services to individuals with dual diagnoses.
Service Funding and Provision. States generally use the same mechanisms for funding services provided to individuals with co-existing conditions, but allocation strategies differ, sometimes dramatically, from one jurisdiction to another. In all of the thirteen states, long-term community services are furnished to individuals with co-existing conditions by the state developmental disabilities agency and funded through Medicaid under section 1915(c) or, in the case of one state, section 1115 waiver programs.
Although, episodic mental health treatment, counseling and psychiatric care are covered Medicaid State Plan services in twelve of thirteen states, many state developmental disabilities officials reported that cuts or restrictions in mental health funding during the past five years have decreased the capacity of community mental health centers to provide timely services. Because individuals' needs must be addressed, in many areas service costs and responsibilities have shifted to developmental disabilities programs. Respondents in five of the thirteen states describe the state mental health agency has having minimal involvement in financing mental health services for persons with developmental disabilities. In one state, mental health covers only in-patient care. In three states the costs of community mental health services for individuals with developmental disabilities are shared between the state developmental disabilities and mental health agencies. One state developmental disabilities agency addressed the problem by providing additional funding to community mental health programs to improve staffing levels.
Clinical Services. In the current study, all of the state developmental disabilities agency officials reported difficulty in securing effective and appropriate diagnostic, clinical and psychiatric services. Respondents noted that many community mental health centers lack staff with the expertise necessary to effectively treat individuals with cognitive disabilities. States offering mental health services through managed care arrangements expressed conflicting opinions regarding the benefits and weaknesses of the approach. Access to psychiatric services was said to have improved in one state as a result of contract requirements obligating managed care entities to ensure the availability of all covered mental health services. Respondents in another state, by contrast, reported that access by individuals with co-existing conditions was limited by restrictive eligibility criteria employed by the managed mental health care program. The lack of sufficient numbers of qualified mental health providers was also identified as a significant barrier to service provision resulting in an excessive use of medication and the provision of inadequate care and treatment.
Case Management/Service Coordination. State developmental disabilities agencies are responsible for service coordination, planning and monitoring in twelve of the thirteen states reviewed. In three of the twelve states, the responsibility is shared with the mental health state agency. In one state, service coordination is assigned to either the developmental disabilities or mental health program, but not both. Case management services are not generally permitted to be provided by agency(ies) delivering direct services to the same individual.
Collaboration. Collaboration between state agency officials is frequently good, but consistent cooperation between local developmental disabilities and mental health providers appears to be difficult to achieve and highly dependent on program characteristics and personalities. As noted above, mental health funding and service cuts have curtailed the ability of local mental health agencies to participate with developmental disabilities agencies as full partners in service planning, coordination and delivery.
Emergency Intervention and Crisis Support. Over half (56%) of state officials responding to the NASDDDS survey on state strategies for supporting individuals with co-existing conditions identified the lack of effective crisis response capacity as a frequent or consistent barrier to the provision of supports to individuals with co-existing conditions . Although officials in the thirteen in-depth review states expressed some concern over access to emergency support generally, they each reported that their state was able to adequately address the need.
Emergency crisis response services are provided to individuals with co-existing conditions by the developmental disabilities system in five of the thirteen states under review, by the mental health system in three of thirteen states and by both systems in five of thirteen states. Crisis response teams are regionally organized in most states and able to offer a wide range of clinical and direct support services to individuals in crisis in community settings.
Summary. This paper describes some of the preliminary findings of an in-depth assessment of the policies and practices employed by thirteen states to address the needs of individuals with co-existing conditions. The data reveal strong similarities and significant differences in states' strategies for funding, coordinating and delivering supports to eligible individuals. A complete analysis of state support strategies will be available in the fall, 2005.
Charles Moseley Ed.D.
National Association of State Directors of Developmental Disabilities Services