Self-Direction in Medicaid for Well-being and Empowerment
By Briana Gilmore, Public Policy and Advocacy Director, NYAPRS
Self-direction is a strategy in organizing and delivering Medicaid-funded services and community supports that can dramatically enhance opportunities for people living with disabilities. The process transfers some of the funds typically afforded through Medicaid payments directly to the consumer, who develops a plan to utilize the money for services and supports for increased engagement and well-being. Hundreds of thousands of people experiencing developmental disabilities already utilize the approach, and many states have implemented or are seeking pilots to bridge the method to the behavioral health recovery community.
In New York, the Office of Mental Health (OMH) selected self-direction as a new service to implement through a Health and Recovery Plan (HARP) for Medicaid recipients with enhanced BH (behavioral health) needs. Implementing the program thoughtfully will take some careful planning; therefore the program will be piloted for a few years before being brought to scale statewide as a benefit for eligible recipients.
Any self-direction model must take into consideration the particular recovery needs of the community for whom it’s modeled. For people with physical needs, funds are often self-directed to health aides, house modifications, or other consistent supports. A model to support the behavioral health needs of a community must take into account social needs that span employment, education, community inclusion, well-being, and traditional rehab supports. New York is looking at an approach that would allow recipients to buy services like habilitation (services that help a person learn, keep, or improve skills and functional abilities that they may not be developing normally) and supported employment, but also direct funds to community wellness supports like gym memberships and yoga classes, college classes and bus passes.
The implications of self-direction are vast; it is the most flexible way for consumers to take ownership over their recovery and invest in chosen supports. The success of a self-directed recovery plan is largely dependent on the relationship between each recipient and a support broker, who is a chosen navigator that helps to maximize an individual budget. A recovery plan is based on current capacities and supports, and incorporates wellness goals for overall health. A recipient uses the plan as a tool to guide their spending. Purchases of traditional services and community supports are now typically made with smart debit cards that can track allowable services and be refilled directly by the payer.
There are many considerations that go into creating a self-directed design that benefits people with BH needs. The plan must take into account accessibility and enrollment processes, ensure culturally competent approaches, and allow for creative community-based solutions for enhanced well-being. The design must also plan for a relationship between a recipient-driven recovery plan, and a treatment plan that is supported by a Medicaid Managed Care Organization. Support brokers—who in most models are peer specialists or recovery-trained life coaches—should be supported by an infrastructure that can foster innovation and adaptiveness within the model. And ultimately, the financial process has to offer an efficient transfer of funds from the state Medicaid program.
I’ve been involved in a planning process with NYAPRS and the Columbia Center for Practice Innovations to help OMH develop a draft model for BH self-direction. The team has worked for eight months to review research, meet with experts in the field from around the country, and engage Medicaid recipients, DOHMH (dept. health mental hygiene), and other stakeholders to develop a strategy for implementation. The process will continue in the coming months as OMH explores the best framework and negotiates the process with other state agencies, Managed Care Organizations, and recipients.
NYAPRS (New York Association for Psych Rehab Services) has been advocating for a self-directed model in New York for nearly a decade. It’s exciting to know that the model could be offered to tens of thousands of Medicaid recipients with BH needs in the coming years. The state agencies, particularly through the Medicaid Redesign process, recognize that innovative approaches like self-direction can contribute to long-term savings and system benefits. These gains will be as a result of quality of life improvements like reduced hospitalizations and increased community engagement, as well as better overall satisfaction with the Medicaid program. A New York State pilot will include a strong research component to look at how recipients of different ages, backgrounds, and with different geographic living settings use and benefit from self-direction.
Barriers do remain, particularly in the appropriate financing of the approach. It’s also essential that appropriate protections be in place for both consumers and insurance companies before the design is implemented as a standard benefit. The design may provide a truly fundamental shift in Medicaid programming and consumer rights, if stakeholders on both sides continue to work together to actively improve the design through emerging best practices.
Look for opportunities in your area to participate in a self-direction pilot in 2015, as well as information about how you can get involved in the state’s planning process.