Gateway’s ASPIRE Program Achieves Top Dual Diagnosis Rating

New York Center for Living is a nonprofit dual diagnosis treatment facility that works specifically with teenagers and adolescents. Though the specific treatments are meant to address the needs of these young adult clients, family members and loved ones are also encouraged to participate in these outpatient programs. Clients will have access to a nurturing and healing environment in which they are provided with care and comfort. Various treatment options include cognitive behavioral therapy, dialectical behavior therapy, mindfulness, nutritional guidance, the development of different life skills, education, creative arts therapies, and yoga. New York Center for Living also offers a Signal Program for their adolescent clients in which services such as 12-step meetings and psychoeducation are utilized. This program also incorporates parents, allowing them to learn skills such as conflict resolution, boundaries, and communication skills to help them deal with their children who may be suffering from the negative consequences of drug abuse.

Phoenix House is a dual diagnosis treatment center that helps men and women address mental health disorders and co-occurring substance abuse disorders. Though they do work with both men and women, these programs are separate and gender-specific. Both include treatment services such as trauma-informed therapies, anger management, relapse prevention, medication assistance, motivational interviewing, recreational services, vocational support, and various types of counseling. They also provide outpatient services at a location next door, allowing these men and women to continue receiving care even after the residential program has ended. The outpatient program takes the skills developed in the residential program and continues utilizing them so that clients are able to maintain those habits even after these programs do end.

Arms Acres is a dual diagnosis treatment facility that prioritizes the use of evidence-based therapies and outcome-based treatment plans to help clients reach their recovery goals. The inpatient program is designed to help clients who need 24-hour medical supervision as well as a structured schedule. Though each program involves a combination of services, clients may participate in therapies such as motivational interviewing, CBT, rational emotive behavioral therapy, and trauma-informed techniques. Arms Acres also offers gender-specific treatments. Separating the men and women allows clinicians to provide more intensive programs and create individualized and unique programs for each person. Some of the other available treatment options include family therapies, nutrition education, stress management, relapse prevention, yoga, art therapy, and 12-step programs.

Advocates for persons with disabilities argue that use of the work incentive provisions has not grown even more rapidly for several reasons. First, there is an absolute cap on income for eligibility for every case (although the cap amount varies from individual to individual). Thus, however high that limit may be, there is an absolute drop-off point at which increased additional earning will result in losing Medicaid eligibility. Second, low limits on resources or assets mean that working persons with disabilities are also unable to increase their savings without jeopardizing their Medicaid eligibility. Third, receipt of SSI benefits was the gateway to receipt of medical assistance, thus making work a less viable option than dependence on public programs.

To be eligible for HCB waiver services, individuals must first meet a waivers targeting criteria, such as age and diagnosis or condition. For example, a state may have a number of waivers targeting different groups: persons age 65 and older, persons ages 18 to 65 with physical disabilities, children who are technologically dependent, persons with mental retardation and other developmental disabilities, persons with AIDS, and persons with traumatic brain injury. (See Chapter 4 for a full discussion of waiver programs.)

To remain in their homes and communities, many people with disabilities and chronic conditions need long-term services and supports that can range from personal assistance to more specialized services. Federal Medicaid law and policy give states great latitude to offer individuals a wide range of home and community services through the states regular Medicaid program. States can offer an even more comprehensive service range by operating one or several home and community based services (HCBS) waiver programs. This chapter explores Medicaid coverage options, including important issues states need to consider in selecting the particular combination of home and community services and benefits that best suits their respective needs.

A few states operate relatively extensive Medicaid personal care programs (e.g., New York, California, and Texas). Elsewhere, provision of such services is more limited.11 Many states that offer personal care have strict limitations on its delivery. Some either stringently regulate the amount of personal care services an individual can receive or cap the dollar value of such services at a level well below the cost of nursing facility services.12 Others limit eligibility for personal care services by identifying a population or level of functional limitation for which they will provide assistance. However, states must be careful not to violate Medicaid comparability requirements by restricting services to those with a particular diagnosis or condition, such as by making benefits available only to people who use wheelchairs, or to people who are likely to require nursing facility services. Nine states provide personal care services only to the categorically eligible.13 A few states do not include personal care in their state plan, but provide this service to children covered by the EPSDT mandate.

With respect to individuals with developmental disabilities, prevocational services cannot be provided under the Medicaid state plan except to residents of an ICF/MR. A state may include in the scope of these services costs of transportation to and from the site at which this training takes place. About three-quarters of the states operating HCBS waiver programs for people with developmental disabilities offer this service, generally at fixed sites in the community.30

A state may cover three specialized services for individuals who have serious persistent mental illness: (a) clinic services; (b) day treatment or other partial hospitalization services; and (c) psychiatric rehabilitation services. These services also may be offered in HCBS waiver programs serving other target populations that include individuals who have a dual diagnosis (e.g., mental retardation and a psychiatric condition). Clinic and day treatment services are primarily for diagnosis and treatment of mental illness. In contrast, psychiatric rehabilitation services are aimed primarily at achieving maximum reduction of physical or mental disability and restoration of maximum functioning.

Home and community service programs are frequently criticized for operating under a so-called medical or professionally managed model, under which professionals decide what services will be provided and how, when, and by whom. Many individuals feel these models do not meet their needs. Consumer-directed (CD) services first emerged in personal assistance services as an alternative to the individuals being limited to obtaining attendant services only from employees of professional agencies or from specific agencies licensed, certified, or otherwise authorized under a public program. A CD service model: (a) gives beneficiaries (and/or their families) the authority to develop service and support plans that reflect their wishes and preferences, and (b) gives them the choice of hiring/firing, scheduling, training, supervising, and purchasing services and, within the boundaries established by law, directing the payment of personal assistance workers and other service and support providers.2

Operating distinct waiver programs that target mainly individuals who live with their families has both pros and cons. One of the main advantages is that state officials and other stakeholders are often willing to entertain new approaches to furnishing home and community services when they are creating a program as opposed to modifying one that already exists. Supports and services can be selected that are especially relevant to meeting the needs of people who live with their families, paying particular attention to strengthening informal caregiving. The main disadvantage appears to be the administrative complications associated with operating multiple HCBS waiver programs for the same general target population.

Activities can include collaborating in outreach with the "generic" human services networks individuals are likely to access or contact when they seek services (e.g., Area Agencies on Aging, seniors programs, Independent Living Centers, community developmental disabilities agencies, mental health centers, public health agencies that provide Maternal and Child Health Services, and homeless shelters). For example, a state may provide periodic, repeat orientation training for a network's intake staff to make sure they are well acquainted with what home and community services are available. In addition, states can reach out to other community networks (e.g., faith-based organizations) to which individuals might turn for assistance and guidance. These activities may be reimbursable under Medicaid when all Federal requirements are met.

Case management/service coordination must be conflict free. This will help ensure that individuals and families are made aware of all service options, that they can exercise free choice of provider(s), and that there is a third party to whom consumers can turn if service problems are encountered. There should also be safeguards to ensure that service coordination is operating in the best interests of consumers. For this purpose, several state HCBS waiver programs are structured so that certain key aspects of service coordination may not be provided by any agencies or individuals also paid to furnish direct services to the individual. 2b1af7f3a8