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Fiscal Years 2004 and 2005 Performance Oversite Hearing

Sunday, March 9, 2003
Martha B. Knisley

Good afternoon, Chairperson Catania, members of the Committee on Health, members of the Council and staff.  I am Martha B. Knisley, Director of the DC Department of Mental Health.  Thank you for this opportunity to share with you our accomplishments and challenges.  I have with me at the table Marcia Jones, Chief of Staff; Joyce Jeter, DMH Fiscal Officer; Don Bryant, Acting Director of Contracts and Procurement; and Anne Sturtz, General Counsel.

The Department of Mental Health’s performance can largely be set in the context of  meeting the requirements of the 2001 Dixon Court-ordered Plan and the Exit Criteria Performance Targets.  This Plan serves as the blueprint for the District’s mental health system. 

In April 2001, the Court, as part of the Dixon lawsuit, approved a plan for the development of a new Department of Mental Health.  This Court-ordered Plan predicted that the new Department “will be in a state of dynamic (and at times dramatic) change for a period of three to five years.”

This Plan served as the basis for the Mental Health Establishment Act of 2001, the Ervin Act amendments passed by this body and by Congress, the enactment of reform to the District’s criminal commitment statutes, and a host of reforms set forth as policy in rules.


Additionally, the Plan prompted significant change to the District’s Medicaid Plan, the enacted budgets for FY 2003, FY 2004, and FY 2005, and other changes most notably in the District’s approach to mental health services for children in the child welfare system and now in the District’s juvenile justice system.  In 2002 the mental health system had substantially met the first phase of this Plan and emerged from Receivership.  In FY 2004 the exit criteria and associated performance targets to exit the Dixon case were set as a result of meeting critical benchmarks in this Plan.

In summary, in less than four years, the Department of Mental Health has substantially implemented the Court-ordered Plan for the District’s public mental health system, one year ahead of the Court Monitor’s prediction for implementation.



As stated above, DMH has substantially implemented the requirements of the Plan and Court oversight for the next few years will be more and more based on performance-based outcomes and less on developmental processes.  In FY05 we are moving into the final phase of Court oversight in Dixon.

The first phase of the Plan entailed many requirements and improvements related to establishing the Department and its operations, including creating Care Coordination and the Access HelpLine, a whole new accountability system, and opportunities for agencies to provide community mental health services.  This phase also features expanding housing opportunities and services to persons who are homeless, adding new consumer rights requirements, modernizing commitment statutes, creating a new grievance system and contracting with an external advocacy organization to advocate on behalf of consumers.  We also began maximizing the use of available federal and local funds thus requiring DMH to substantially change the financial foundation of the mental health system by utilizing and maximizing Medicaid as a major funding source for community-based services at both the service and administrative levels of the Department.


The Plan outlined a vision for St. Elizabeths Hospital and a DMH-operated Core Service Agency.  It articulated programmatic, policy and organizational strategies to provide effective services for persons dually diagnosed with mental illness and substance abuse disorders.  Today, we have a strong team of providers and advocates assisting us in turning policies and other strategies into action for consumers with co-occurring disorders.


The Dixon Court Monitor has stated in his reports to the Court that DMH has put considerable effort into the development and implementation in every major area of the Court-ordered Plan.  He has cited “exemplary” practices and improvements,  but he stated that  he would like to see progress in several areas, namely the implementation of the acute care project with general hospitals, expansion of crisis services and Assertive Community Treatment, and passage of the Ervin Act in Congress, which has occurred since the Court Monitor finished his last report.  

Separate from implementation of the Plan, which is nearly complete, is the actual work toward ending this three-decade suit by meeting very explicit exit criteria.   In November 2003, the District and plaintiffs filed exit criteria and 15 performance targets for each of the criteria in US District Court.  The Dixon exit criteria build upon the requirements in the Court-ordered Plan and more narrowly define actual outcomes that demonstrate system improvement and the provision of quality services to consumers.

As DMH meets each requirement, the Court dismisses the requirement and the case ends after all 15 requirements are met. These requirements mirror the recommendations of the 2003 President’s Commission on Mental Health for state and local mental health systems across the country.  Meeting these requirements is unquestionably the best proxy we can offer as progress in the District’s ability to meet the needs of its most vulnerable citizens who have serious emotional and mental disabilities and problems.  Below is a brief synopsis of our progress on each of these requirements in the past year.





Exit Criterion #1 – Demonstrated Implementation and Use of Functional Consumer Satisfaction. 

The performance level for this criterion is to develop and implement consumer satisfaction methods.  In September 2003, DMH contracted with a local consumer organization, Consumer Action Network (CAN), to develop a consumer satisfaction system.  CAN conducted its first consumer satisfaction survey in the fall of 2004.


Exit Criterion #2 – Demonstrated Use of Consumer Functioning Review Methods as part of the DMH Quality Improvement System for Community Services. 

DMH has proposed utilizing two methods to determine consumer functioning and both methods are acceptable to the Court Monitor.  DMH has formed a Quality Council, made up of the Quality Improvement Directors of each community provider, which will play a significant role in the implementation of this exit criterion.  The Quality Council, which meets monthly, will review and analyze consumer functioning information (as well as consumer satisfaction information) and provide feedback to DMH on systemic changes that may need to occur.


Exit Criterion #3 – Demonstrated Planning for and Delivery of Effective and Sufficient Consumer Services.


This criterion is implemented and measured through the Monitor’s annual Community Services Reviews (CSRs) for children/youth and for adults.  The actual performance measurement for this criterion is that 80 percent of the individuals whose lives and services are reviewed will be found to be receiving adequate or above adequate services.  We deliberatively sought a process that gives both a detailed yet comprehensive view of how well our system performs for actual people rather than selecting a review process that can easily mask problems.


The sample size for both children/youth and adults is 54 and the reviews will be conducted again this year in March and April.  The child review actually began this past Monday.


Exit Criterion #4 – Penetration Rates for Adults, Children, SMI Adults and SED Children.

Penetration rates refer to the percentage of children, youth and adults seen in the public mental health system compared to the District’s population size.  For children and youth, the overall penetration rate is 5 percent of the total population of children and youth in the District.  It also is broken down further into the number of children and youth with a serious emotional problem.  It is estimated that 3 percent of the total child and youth population has a serious emotional disorder.  Among adults, the overall need for mental health services is estimated at 3 percent; adults with a serious mental illness is estimated at 2 percent. 

DMH and its contract providers have made extraordinary progress in both enrolling and serving children, youth and adults.  Today, we have 37 certified providers delivering services with 23 of these providers serving children.  There are 4,115 active (meaning seen within the last 90 days) children and youth enrolled in the Mental Health Rehabilitation Services system.  This includes 2,267 children ages 3-12 and 1,848 youth ages 13 to 18.   This is an increase from approximately 1,500 children and youth two and a half years ago. We have 11,765 active adult consumers, an increase from 5,668 in FY 2002.


Exit Criterion #5 – Demonstrated Provision of Supported Housing for Adults with Serious Mental Illness.


The performance measure for this criterion is that 70 percent of those referred for supported housing receive services within 45 calendar days of referral.  During the past year, DMH has made significant progress in securing affordable housing and permanent vouchers through agreements with the DC Housing Authority and the DC Housing Finance Agency. We have created a public/private housing partnership among several housing and economic development agencies to implement a supportive housing program for mental health consumers.

Although DC has the dubious honor of being the fastest growing jurisdiction for “unaffordability” of housing for persons with disabilities of any jurisdiction in the country, DMH continues to work to provide housing which requires only 30 percent of the consumer’s income as rent.


Today, approximately 894 consumers are receiving housing subsidies from DMH housing programs and permanent subsidy programs.  The new DCHA Partnerships for Affordable Housing Program will add 120 permanent project-based vouchers over the next several months. 


Exit Criterion #6 - Demonstrated Provision of Supported Employment for Adults with Serious Mental Illness.

The performance measure for this criterion is that 70 percent of persons referred for supported employment will receive supported employment services within 120 calendar days of the referral.


DMH is completing its second year of our partnership with the Department of Human Services, Virginia Commonwealth University, Dartmouth College and the Johnson and Johnson Foundation.  A process for tracking and monitoring services has also been devised.  Today, over 300 persons receive services through this program from six providers.  Two additional providers will be added in FY05 for a total of eight providers.  We are on track to meet this requirement this year and we stand out nationally as a supported employment site.


Exit Criterion #7 – Demonstrated Provision of Assertive Community Treatment (ACT) for Adults with Serious Mental Illness.


The performance measure for this criterion is that 85 percent of persons referred for ACT services will receive ACT services within 45 calendar days of the referral.  Today, 430 consumers are enrolled in ACT services.  However, DMH projects the need to be closer to 1,500 consumers who qualify for this service.  Three new ACT teams of 100 persons each will start this spring.

ACT remains a challenging service for DMH and its contract providers to offer.  Only 19 percent of the ACT programs nationwide meet “best practice standards” adopted by SAMHSA (the Dartmouth ACT Fidelity Scale).  DMH will significantly expand its training and oversight of ACT teams to support teams in moving toward service fidelity this fiscal year.


Exit Criterion #8 – Demonstrated Provision of Newer Generation Anti-psychotic Medication for Adults with Schizophrenia.


The performance measure for this criterion is that 70 percent of adults served by DMH with a DSM IV diagnosis of schizophrenia will be prescribed the newer generation medications.  Thanks to implementation of DC MAP in FY 2001, we believe that we are meeting this criterion at this time and will be requesting that we be certified as meeting this requirement this year.


We now have an agreement with the Medical Assistance Administration to receive the data on prescriptions filled.  The data will permit us to track utilization of commonly used psychiatric medications to identify clinical problems with polypharmacy, high dose users, and high costs of medications.  We are gathering data to enroll as many consumers as possible into drug company Patient Assistance Programs, which provide free medications to indigent consumers who are not eligible for Medicaid.


Exit Criterion #9 – Demonstrated Provision of Services to Adults who are Chronically Homeless and have a Serious Mental Illness.


The performance measure for this criterion is that 150 individuals identified as chronically homeless who have a serious mental illness will be engaged by a DMH approved provider in the Housing First Initiative and DMH will demonstrate the implementation of a comprehensive strategy to engage and serve persons who are seriously mentally ill and temporarily or chronically homeless.


DMH has taken a very bold step to introduce “housing first” for 65 consumers this year and to add an additional 75 consumers by July 2006.  Pathways to Housing, a successful housing first provider from New York City that has demonstrated the ability to successfully serve persons who are chronically homeless, is our major provider of this service for streetbound people who have a serious mental illness and a co-occurring substance abuse disorder.  To date they have enrolled 40 persons into their program.  We also hope that other ACT providers will work closely with Pathways so that we can achieve our goal of serving 150 persons by the end of FY 2006.


Exit Criterion #10 – Demonstrated Provision of Services to SED Children/Youth in Natural Settings (home, school) and Other Community Integrated Settings (e.g., churches, youth centers, recreational settings, etc.).


The performance measure for this criterion is that 75 percent of all SED children/youth served by DMH will have received a service in a natural setting.  This measurement will not occur until DMH has achieved a penetration rate for SED children/youth of at least 2.5 percent.  However, DMH is actively engaging providers in changing and updating practice to provide wrap around services to children, youth and their families in their own home and community settings.  DMH is pleased to report two very promising practices that are part of our service delivery system for children and youth today that will enable us to meet and exceed this criterion.

First, we have created and carefully nurtured our School Mental Health Program. During the past year, we provided direct services to more than 2,000 children in 29 schools.  We recorded more than 23,000 prevention contacts with students, more than 700 prevention contacts with parents and guardians, and almost 1,400 such contacts with school staff.  We are exploring options for expanding this program in the future.

Our second practice is our joint project with the Child and Family Services Agency to improve and expand services to children and youth in the foster care system.  This project provides us the opportunity to be more efficient in reducing duplication and minimizing. Fragmentation, including integrating our staff and co-selecting providers.  We are building infrastructure for serving children and youth in the foster care system and we are increasing capacity to provide court-ordered assessments in a timely fashion.  In January, three providers began serving youth as a part of this project.


One of these services, Multi-systemic Therapy (MST), is widely known to have positive effects on youth with serious behavior problems.  Across the country where this intervention is implemented successfully, youth are half as likely to be re- arrested, and they have reductions in arrests for violent and substance-related crimes.  Our MST provider has admitted 23 consumers and two are awaiting assessments.

A second provider is offering Intensive Home and Community-Based Services. This provider is working at maximum capacity treating 36 youth in just one month.  Throughout the first year, we expect the provider to deliver in-home treatment to between 72 and 90 youth with serious emotional disturbance and behavioral problems.  This service is designed to help families resolve serious issues and prevent removal of children from the home.  The third service we have contracted for is crisis intervention and crisis stabilization.  Services are provided at a site where a child’s behavior escalates.  Within one hour our team can be on site and will continue to work with the child, family and others for up to eight weeks to help stabilize the situation.


Tomorrow, we will testify before the Senate Appropriations Committee about the benefits being realized from federal grants received in FY 2004 and FY 2005 for these services for children and youth in the foster care system. 

Exit Criterion #11 – Demonstrated Support for Children/Youth with SED to Live in Their Own Home or Surrogate Home.


The performance measure for this criterion is that 85 percent of all SED children/youth served by DMH will be living in their own home or surrogate home.  The above-mentioned programs getting underway with CFSA will enable us to more quickly meet this target.  However, we have been actively working toward this target since we began a program entitled MAPT (Multi Agency Planning Team) in FY 2003.  Then, we began focusing on reducing the number of youth being placed in institutions.  MAPT has received 951 referrals, conducted 896 MAPT clinical reviews, issued 204 Levels of Care for residential placement, and most importantly, diverted 692 or 73 percent of the children and youth it reviewed. 


This project is supported with federal funds through a Cooperative Agreement with SAMHSA.  While we are hugely successful in diverting youth, our efforts to track youth who have been returned to the District from residential treatment centers needs to be bolstered.  This week I assigned Shauna Spencer to focus on assuring all youth are successfully tracked and receiving services when they return to the District.  


Exit Criterion #12 – Demonstrated Provision of Services to Children/Youth who are Homeless.


The performance measure for this criteria is that 100 children/youth identified as homeless will be engaged by a DMH approved provider and DMH will demonstrate the implementation of a comprehensive strategy to engage and serve children/youth who are temporarily or chronically homeless.

DMH and its provider agencies have been receiving referrals for children and youth who are homeless, and this year are working with a broader base of community advocates and providers to develop a plan to assure services are available to children and youth in shelters across the city.

Exit Criterion #13 – Demonstrated Continuity of Care Upon Discharge from Inpatient Facilities.


The performance measure for this criterion is that 80 percent of known discharges from an inpatient psychiatric hospital (St. Elizabeths) or community hospitals will have a non-emergency contact within seven calendar days.  This performance measure is for both children/youth and adults.


DMH has created an electronic process for collection of this information.  Training for providers on this new process will begin the week of March 14, 2005.  We expect to begin collecting data electronically beginning next quarter.


Exit Criterion #14 – Demonstrated Increase in the Percentage of Total Resources Directed toward Community-based Services.


The performance measure for this criterion is that 60 percent of the total annual DMH expenditures will be directed toward community-based services.

DMH has met this requirement.  Over the past two years, DMH has plowed every available dollar from its efficiency projects into community services.  When we began this effort we were only allocating 41 percent of the Department’s budget into community services.  This year we hit the 60 percent target and recently requested the Court Monitor certify this accomplishment.


This represents a major milestone in Dixon. Given that the original complaint in the Dixon case over 30 years ago was for the District to develop a community- based system of care, we have achieved in these past years a shift in actual resources that would enable us to meet this target.

Exit Criterion #15 – Demonstrated Maximization of Use of Medicaid Funding to Support Community-based Services.


The performance measure for this criterion is that 49 percent of total MHRS billings for community services (Medicaid approved services) will be reimbursed by federal Medicaid dollars.

DMH has made significant progress in meeting this goal and we hover close to the 49 percent.  However, recently this percentage began to slip a bit and given our review of claims, it appears that agencies need to do a better job meeting their certification requirements for assuring they have determined third party liability before they submit their claims to DMH.  They also must make Medicaid application if a person is eligible at the time they are seen.  DMH will strictly reinforce these requirements and by doing so will not only assure we can meet this criterion but more importantly assure that persons coming to the mental health system for services are getting resources to which they are entitled to cover their medical and mental health needs.


As you can see, the Dixon Court-ordered Plan and the exit criteria have had and will continue to have a major impact on system reform, program development, and program monitoring.  But continued focus on these Court requirements also will lead the District toward having an effective mental health system and will support other District-wide initiatives related to children/youth and families as well as homeless adults and families.

Major Challenges for the Remainder of this Fiscal Year

In the above sections we allude to a number of challenges facing the system. Below is more detail on our top three challenges:

1.  Provider Payments:  We have heard criticism today regarding the DMH payment system.  Without offering excuses, I’d like to offer some explanations.  First, the District has checks and balances for payments that require a certain amount of time when any request for payment is received.  In addition, within any fiscal year, there are additional checks and balances at the close and commencement of each fiscal year to ensure that agencies are not deficient.  These processes can delay payments at the “year end close,” and during the time the DMH budget for the next fiscal year is loaded.  Second, certain monies are delayed because they are held in reserve until the agencies have demonstrated that the funds are necessary for efficient agency operations.  Third, DMH’s own claims processing system has caused delays because it has not consistently met the challenging demands of an evolving mental health system.  To address this, DMH has monitored the information systems vendor contract and has worked closely with the vendor to improve the applications performance.  Finally, the new PASS system has presented its own set of challenges to the District generally, and DMH specifically.  DMH is working to improve its performance in each of these areas, but recognizes that such efforts are not a substitute to timely claims payment.  Critically, DMH’s goals are not limited to simply speeding up the time that it takes to pay for what DMH is now receiving for the services it is buying.  Instead, DMH is striving to create a payment system that demands from its providers that they deliver high quality, medically necessary and appropriate services in order to receive payment.  However, solving those issues without creating payment system that efficiently distributes money for services for the benefit of consumers—not providers—will not address the problem.  DMH’s budget for community services should not go to the fastest provider and biller of services. 

2.  Continuity of Care:  DMH is committed to ensuring that consumers maintain a consistent relationship with their community treatment teams, even when the person goes into crisis, becomes homeless, is jailed or hospitalized or when long-term residential treatment becomes necessary, so that the person can more smoothly transition back to his or her own home and community-based services.  We have developed policy and procedures detailing the responsibilities and requirements of each clinical team to support consumers regardless of where they reside.   While we have monitored continuity of care, we believe we need to take a much stronger stance, through more focused monitoring, training, and where necessary, enforcement action with providers.

3.  Improving Services at DMH-operated Programs: DMH is committed to assuring the safety net of services we provide at the DC Community Services Agency is of the highest quality and is delivered as efficiently as possible.  We have trimmed this agency’s budget significantly over the past three years and will monitor their productivity and progress carefully taking actions where needed.   Similarly DMH is working closely with Saint Elizabeths to assure the hospital continues to make performance improvements in the face of the challenges presented by the physical plant.

In addition, an issue has surfaced recently regarding the personal needs allowance for SSI recipients living in mental health Community Residences Facilities (CRF)'s. Although the amount of SSI payments made to consumers has steadily increased over the last few years, the consumer’s personal need allowance has remained the same -- $70.00.  In an effort to rectify this situation, DMH staff issued a letter to CRF providers in January 2005, increasing the allowance to consumers from $70 to $90 per month.  The providers also received an additional $20 per month per consumer. 


I would like to conclude my testimony by thanking the Chair and Committee on Health for your interest in our work.  I look forward to working with you as we continue to proceed with meeting the needs of the District’s mental health services consumers.  My staff and I will be happy to respond to your questions.