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Policy Innovation Profile

Self-Directed Budget for Health and Other Services Enhances Ability of Those with Mental Illness to Function and Live Independently


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Summary

Authorized by the Florida legislature, a state-funded program known as Florida Self-Directed Care gives persons with mental illness a quarterly allowance to purchase mental health and wellness services at their own discretion, with the goal of better integrating these individuals into their communities. With the help of life coaches, participants create a recovery plan and individual budget for traditional mental health recovery services (including psychotherapy, counseling, and medications) and other, nontraditional goods and services that facilitate recovery and successful living in the community (e.g., self-help services, exercise classes, transportation, dentistry services). The program has allowed participants to spend more time living in the community (instead of in psychiatric facilities or criminal justice settings), enhanced their ability to function, and increased their satisfaction with access to services and progress toward established goals.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons among participants of the number of days spent living in the community and their ability to function, along with comparisons of satisfaction with availability of services and progress toward established goals between participants and nonparticipants.
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Developing Organizations

Florida Department of Children and Families
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Date First Implemented

2002
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Patient Population

Vulnerable Populations > Mentally illend pp

Problem Addressed

Programs that allow health care consumers to make their own care and service decisions enhance quality and patient satisfaction and reduce costs, which has led to growing support for their broad dissemination. Yet people with severe mental illness typically do not have access to such programs.1
  • Multiple benefits to financing models that allow self-determination: Self-determination refers to the right of individuals to control their own lives.2 In health care, including mental/behavioral health care, self-determination involves consumers being intimately involved in and controlling all decisions related to their care, including the services they receive.2 Health care financing models that support self-determination have proven successful. The Commonwealth Fund has found that such payment models increase patient satisfaction and quality of life and reduce costs.3 The Centers for Medicare and Medicaid Services (CMS) found that the Cash and Counseling demonstration project—which featured self-directed budgets for the elderly, individuals with disabilities, and children with special needs—reduced unmet care needs while maintaining or improving health outcomes.4
  • Unheeded calls to promote self-determination for those with mental illness: The evidence highlighted above has led to growing support for programs that promote self-directed care, especially for seniors and those with physical and mental disabilities. For example, a Commonwealth Fund report found that self-directed care models for these vulnerable populations are a growing international trend,3 while the President’s New Freedom Commission report called for “self-directed services and supports for people with mental illnesses.5 "Yet, few individuals with mental illness currently have access to programs that support self-determination. In fact, the managed care models that have been embraced by many public mental health systems generally reduce consumer control over their care, including choice of treatment options.2

What They Did

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Description of the Innovative Activity

Authorized by the Florida legislature, a state-funded program known as Florida Self-Directed Care (FloridaSDC) gives persons with mental illness a quarterly allowance to purchase mental health and wellness services at their own discretion, with the goal of better integrating these individuals into their communities. With the help of life coaches, participants create a recovery plan and individual budget for traditional mental health recovery services and other nontraditional goods and services that facilitate recovery and successful living in the community. Participants obtain services from a preapproved provider network (for traditional services) or community organizations (for nontraditional services) and then submit receipts for reimbursement up to the budgeted amount. Key program elements include the following:
  • Authorizing legislation: In January 2000, the Florida Legislature passed the Self-Directed Care Bill (Florida House Bill 421) establishing FloridaSDC under Chapter 2001-152 of the Laws of Florida. The bill authorized a grant to fund a small monthly payment to 210 community-dwelling individuals with mental disorders.
  • Referral, screening, and enrollment: Individuals self-refer to the program (often after hearing about it from a current participant) or are referred by providers. Those interested are screened for eligibility via telephone by a staff member. To qualify, an individual must be a legally competent adult (age 18 or older) and a current or past recipient of disability income, and have an axis I or axis II mental disorder with or without a co-occurring substance abuse disorder. (Examples of axis I disorders include major depression, bipolar disorder, schizophrenia, schizoid affective disorder, whereas axis II disorders include, among others, borderline personality disorder.) Qualified participants cannot be concurrently enrolled in state-funded case management services. If an individual is determined to be eligible, the staff member completes an application for the SDC program. Once all the paperwork and information are received, the individual is placed on the waiting list. When they are ready to be enrolled, a life coach contacts the potential participant, schedules an appointment for an indepth interview, reiterates the program rules and guidelines, and determines the admission date (see bullet below for more information).
  • Recovery plan and self-directed budget, with support of life coach: Participants choose a life coach after reviewing their biographies on the program’s Web site; many life coaches are peers also in recovery from serious mental illness. The life coach meets with the participant to design a recovery plan, review and authorize the participant’s self-directed budget, and provide ongoing support as outlined below:
    • Mandatory recovery plan: Every participant develops and maintains a recovery plan that outlines his or her goals for recovery, reviews progress towards these goals, and describes how expenditures from the self-directed budget (see below) will help to achieve these goals.
    • Self-directed quarterly budget for recovery-related services: Each participant has access to a quarterly allowance for services directly related to the recovery plan. With the assistance of the life coach, participants design a personalized budget each quarter, listing services that will help them achieve their recovery goals and live in the community successfully and independently. Participants purchase services from a prescreened provider network (see bullet below for more details) or community-based organization and then submit receipts to their life coaches, who send them to the program office for review and processing of reimbursement up to the budgeted amount.
      • Size of allowance: The size of the allowance is set for a 3-year period based on a contract between the state and FloridaSDC. Participants currently receive an allowance of $418.35 per quarter; this figure was determined based on the annual program grant from the state, which provided $87,853.50 to serve 210 individuals.
      • Coverage of traditional and nontraditional services: The allowance can be used on any service that helps to promote recovery and independent living in the community. Roughly half the budget must be spent on traditional behavioral health services, such as psychotherapy, counseling services, and medications. Funds can also be spent on nontraditional services such as peer support; self-help, wellness, and exercise classes (e.g., Weight Watchers, YMCA memberships, yoga classes); services that promote community integration (e.g., food, clothing); transportation; education and job-related activities; and certain medical services (e.g., dentistry, ophthalmology, optometry, alternative medicine). While the program allows latitude in the kinds of services eligible for reimbursement, all services must be justified based on the individual’s diagnosis and recovery plan. For example, clients with a socialization issue or certain phobias can be reimbursed for movie tickets.
      • Ongoing support: Life coaches work with participants on an ongoing basis to identify and access needed goods and services within the community; act as an advocate when necessary; and generally support the participant’s efforts to live a successful, independent life in the community. Life coaches and participants talk on the telephone or meet face-to-face at least twice a month, and meet more frequently if necessary. For participants who sign a “release of information” form, life coaches may also talk with their providers to discuss any concerns or participant needs. Either party—the life coach or provider—can initiate this conversation.
  • Accessing services through provider network or community organizations: Participants agree to obtain traditional services from providers that are part of the FloridaSDC network, which includes mental health providers and one dentist. These providers contract with the program via service agreements that specify service rates and lay out key program principles, including self-determination, a commitment to recovery, and a willingness to offer prompt access to services. Participants access nontraditional services from any community-based organization as long as the service received is related to recovery goals.
  • No time limit: There are no discharge criteria for the program, and clients can conceivably participate indefinitely. Participants typically leave the program for any of several reasons, including departure from the service area or a need for more intensive services through Florida's case management program.

Context of the Innovation

The State of Florida is home to roughly 660,000 adults with serious mental illness. The impetus for FloridaSDC came from the lobbying efforts of consumer and family mental health advocates, who convinced the legislature of the need to pass the Self-Directed Care Bill in 2001. This legislation extended the CMS Independence Plus Initiativewhich provides cash allowances to elderly individuals and people with disabilities to purchase services that allow them to remain in the community—to individuals with psychiatric disabilities. (CMS established this initiative in response to a 1999 Supreme Court decision that found that unjustified segregation of persons with disabilities violates the Americans with Disabilities Act, and that states are responsible for ensuring the right of individuals to live in integrated environments rather than institutions.) The Self-Directed Care Bill authorized the Florida Department of Children and Families (the department responsible for mental health services in the state) to pilot test an alternative service delivery payment program based on self-directed care models for people with developmental disabilities. The resulting program eventually became FloridaSDC.

Aging True is a nonprofit organization that provides health, housing, financial, educational, and nutritional services to community-dwelling seniors that help them live safely at home. Since 2009, the state has contracted with Aging True to serve as the fiscal intermediary and administrative service organization for FloridaSDC in the 4th Congressional District, the initial pilot location of the program. Previous fiscal intermediaries in this district included Florida State University and the Mental Health Resource Center, a community-based mental health services provider. As the program expanded, the state contracted with other organizations to serve as the fiscal intermediary in these new geographic areas.

Did It Work?

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Results

The program has allowed participants to spend more time living in the community (instead of in inpatient psychiatric facilities or criminal justice settings), enhanced their ability to function, and increased their satisfaction with access to services and progress toward goals.
  • Significantly more days in the community: An evaluation of 106 participants enrolled in the program between November 2002 and June 2004 found that they spent significantly more days living in the community (rather than in psychiatric inpatient facilities or criminal justice settings) in the year after enrolling than in the year before (354 days vs. 337 days, respectively).
  • Enhanced ability to function: In the year after enrollment, participants scored an average 58.3 (out of 100) on the Global Assessment of Functioning Scale, well above the 50.9 average in the year before enrollment. After a year, over one-third (34 percent) of participants held paid employment, 19 percent were enrolled in vocational skills training, and 16 percent were participating in volunteer activities. Many participants had achieved meaningful recovery goals, such as holding a job, obtaining education, or living independently in an apartment.
  • Higher satisfaction than similar nonparticipants: A qualitative analysis conducted in 2003 found that participants were highly satisfied with the availability of services and their rate of progress toward achieving established goals. In contrast, nonparticipants frequently reported not being able to obtain needed services and being less satisfied with progress toward their goals. The same analysis identified clear links between the goals listed in recovery plans and the goods and services purchased to meet these goals.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons among participants of the number of days spent living in the community and their ability to function, along with comparisons of satisfaction with availability of services and progress toward established goals between participants and nonparticipants.

How They Did It

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Planning and Development Process

As the current (but not original) fiscal intermediary of the program, the Aging True staff was not involved in the original planning and development of the program. Suggested planning and development steps include the following:
  • Set up advisory council: This council, composed of individuals recovering from mental illness, providers, and other community stakeholders, can help advocate for and develop the program and offer ongoing feedback on program services. FloridaSDC currently maintains an advisory council made up of program participants, their family members, and community stakeholders. The council advocates to ensure ongoing support for the program, discusses issues of concern to participants and coaches, serves as a liaison with legislators, and offers strategic feedback on program services and operations.
  • Market program broadly: Key steps in building awareness include creation of a marketing plan, meeting with mental health providers and representatives of community-based organizations, and engaging in other activities to generate program referrals.
  • Establish provider network: Meet with providers to determine their interest in the principles of self-directed care and their willingness to participate in a network.
  • Hire staff: Hire a program director, finance personnel, and life coaches based on educational and experience requirements set by the state.
  • Set up financial tracking system: Identify software programs that can be used (or modified) to track reimbursement to participants.
  • Start small and expand over time: Begin implementation in a single geographic area and expand to others after the program has been refined and proven effective. For example, FloridaSDC began in the state’s 4th Congressional District (which includes most of Jacksonville and other parts of northern Florida) and later expanded throughout the state.

Resources Used and Skills Needed

  • Staffing: Program staff includes seven life coaches and four part-time staff—the program director, the director of finance and operations, a fiscal assistant, and an administrative assistant. (These four individuals represent three full-time equivalent staff.) To work for FloridaSDC, the state requires that life coaches have a bachelor’s degree from an accredited university and 3 years’ experience in the mental health field.
  • Costs: Annual program costs total $470,000 to cover staff and administrative expenses. The state allocates an additional $87,853.50 to cover the cost of services for program participants.
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Funding Sources

Florida Department of Children and Families
Florida’s Self-Directed Care Bill allocated annual funding of $470,000 for program administration under the Florida Department of Children and Families’ Alcohol, Drug Abuse, and Mental Health (ADM) Trust Fund. Funding for services comes from the local District 4 ADM budget for community mental health services.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Contract with independent intermediary: Having an independent organization serve as fiscal intermediary increases the program’s credibility and avoids potential conflicts of interest.
  • Choose customizable tracking software: Tracking expenditures can be complicated, as they will vary with respect to service type, cost, and location. Commercial software for tracking health expenditures may not work that well, since these systems generally allow tracking of only a few different types of expenditures from a defined list of providers. Instead, choose a system that can be easily adapted to accommodate a variety of expenditures and providers.
  • Choose life coaches carefully: While requirements related to education and experience will likely be defined by the contract, other qualities should also be considered when hiring life coaches, including financial skills, familiarity with the local community, ability to resolve conflicts and establish boundaries with clients, flexibility, professionalism, and empathy.

Sustaining This Innovation

  • Advocate for program: A strong advisory council can help advocate for the program on an ongoing basis, thus increasing the odds that the state maintains or increases program funding over time.

More Information

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Contact the Innovator

Joan Thurston, LMHC
Self Directed Care Program Coordinator
Aging True - Community Senior Services
4250 Lakeside Drive Suite 116
Jacksonville, FL 32210
Main: 904-807-1203
Direct: 904-807-1306
Fax: 904-807-1351
Website: www.agingtrue.org
Email: jthurston@agingtrue.org

Innovator Disclosures

Ms. Thurston reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Further information about the program is available at: http://www.floridasdc4.com/about_detailed.htm.

Cook JA, Russell C, Grey DD, et al. A self-directed care model for mental health recovery. Psychiatr Serv. 2008 June;59(6):600-602. Available at: http://cpmcnet.columbia.edu/dept/pi/ppf/Cook.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.). [PubMed]

Spaulding-Givens J. Florida self-directed care: an exploratory study of participants’ characteristics, goals, service utilization, and outcomes. The Florida State University College of Social Work. Doctoral Dissertation (unpublished). Available at: http://diginole.lib.fsu.edu/etd/1615/.

Footnotes

1 Cook JA, Russell C, Grey DD, et al. A self-directed care model for mental health recovery. Psychiatr Serv. 2008 June;59(6):600-602. Available at: http://cpmcnet.columbia.edu/dept/pi/ppf/Cook.pdf. [PubMed]
2 Cook JA, Jonikas JA. Self-determination among mental health consumers/survivors: using lessons from the past to guide the future. Journal of Disability Policy Studies. 2002;13(2):87-95.
3 Alakeson V. International Developments in Self-Directed Care. The Commonwealth Fund. February 2010. Available at: http://www.commonwealthfund.org/Publications/Issue-Briefs/2010/Feb
/International-Developments-in-Self-Directed-Care.aspx
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4 Carlson BL, Foster L, Dale SB, et al. Effects of cash and counseling on personal care and well-being. Health Serv Res. 2007;42:467-487. [PubMed]
5 Department of Health and Human Services. President’s New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America. 2003. Pub No. SMA-03-3832.
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Original publication: September 26, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.