State expecting mental health redesign recommendations soon

State lawmakers are expected to receive preliminary recommendations next week on how best to redesign the current county-based mental health system into a statewide effort, under which services will be administered regionally and delivered locally by July 1, 2013.

Iowa Department of Human Services officials have been conducting community meetings and coordinating five working groups made up of stakeholders, county supervisors, service coordinators, providers, parents, consumers and others. The groups have been studying issues related to regionalization, adult and children's services, judicial advocacy and commitments, and brain injuries. Their goal is to report their initial findings to legislators by Oct. 31, with a more comprehensive report due by mid-December.

“It's been a big undertaking,” DHS Director Charles Palmer said in an interview last week. “I think this is the right direction, and you don't make this kind of significant change in how things are done without it being a major undertaking.”

The reform effort got rolling earlier this year when the Legislature approved and Gov. Terry Branstad signed a measure calling for the “sunset” of the current mental health system in two years. The effort will also direct DHS officials to engage Iowans in discussions about core services, outcomes, delivery and funding, with an expectation that lawmakers will craft legislation in their 2012 session that will spell out the particulars of the new system. A legislative mental health and disability services study committee held its first meeting on Monday in that process.

Initial discussions have pointed toward the establishment of a governance board, likely dominated by elected county supervisors from around Iowa, that will oversee a new process of directing the $1.3 billion in federal, state and county funds for adult and children's mental-health services throughout the new regions, Palmer said. Current projections call for the creation of 10 to 15 regions that would be made up of three or more counties serving population bases targeted in the range of 200,000 to 700,000 people. The plan would be for counties to choose their own partnering arrangements, rather than prescribing the county makeup of regions.

“We're trying to let it be created more by natural partners coming together than imposing a map,” Palmer said.

The new regional focus is designed to bring consistency and equity to a county-based delivery system currently carved up 99 different ways in treating or serving people with mental health issues or intellectual disabilities.

“Right now what you get depends on where you live, and what people pay for services depends on which county is negotiating which rates, which makes it difficult for providers that serve multiple counties,” Palmer said. “The set of core services that is proposed is an enrichment of what is out there today.”

In cases where service duplication and redundancy can be addressed, there will be opportunities for savings, he noted. However, providing the same set of services in rural and urban areas equally likely will mean increased costs for a system already underfunded and facing the loss of federal stimulus money and reductions in Title XIX matching dollars – a reality that could require a phasing strategy to implement the redesign.

Bill Peterson, executive director of the Iowa State Association of Counties, said there are a lot of unanswered questions that county officials have as the modernization moves forward.

“I certainly think the concept of raising tax dollars locally and then having to move them to a regional entity where a board of supervisors that levied that tax might lose what they would view as some control, I'm sure that that has individuals concerned,” he said. “But at this point, there are a lot of issues to be discussed and decided before there is any final decision made on what the outcome is.

"Like everyone else, we'll be very interested in the outcome.”

Peterson noted the state partnered with counties in 1995 to devise the current mental-health system but never fully funded its financial commitment which forced counties to “gather all of the efficiencies out of the system that they possibly could” with the funding they have available.

County officials also note with interest the mixed results that have come with reorganizing the DHS offices regionally and also the state takeover of the court system in the mid-1980s that has since resulted in cutbacks in clerk of court offices while driving up pay scales without necessarily improving services, Peterson said.

“In my view, it's all going to come down to money and saying that two years from now you're going to implode the current system and rebuild a new system, that doesn't seem like the right way to go about it to me,” he said. “I'm not a proponent of blowing up the bridge that provides the connection in terms of funding and services between the counties and the clients and then making everyone frantically go to work to construct a new bridge. I'm not sure that's good public policy. I don't agree with that approach to change.”