HD17 - Aftercare Needs of Mentally Disabled Clients in Adult Homes

  • Published: 1988
  • Author: Department of Mental Health and Mental Retardation and Substance Abuse Services
  • Enabling Authority: House Joint Resolution 70 (Regular Session, 1986)

Executive Summary:
Homes for Adults, (HFAs) licensed by the Department of Social Services, were originally conceptualized as domiciliary care settings designed to serve primarily elderly individuals who were not able to live independently or could not be maintained at home. However, the return of mentally disabled citizens to their home communities has provided Homes for Adults with another clientele whose needs are often greater than the setting was designed to accommodate. As a result of limited Community Services Board (CSB) housing programs, many mentally disabled clients live in Homes for Adults where their SSI and auxiliary grant payments often provide the necessary package of otherwise unavailable financial supports. Thus HFAs, although not necessarily designed for this purpose, frequently offer the only residential option for many of these individuals and are being used to fill the gap in the State's system of residential services.

The 1986 General Assembly, through House Joint Resolution 70, directed the Departments of Social Services and Mental Health, Mental Retardation and Substance Abuse Services to collaborate on the study and development of a model to improve the delivery of services to mentally disabled residents of Homes for Adults in the Commonwealth of Virginia. In response, the goal of the study is to enhance the quality of services provided to mentally disabled HFA residents by:

* ensuring more adequate resources for needed specialized services;
* improving the service linkages between HFAs and mental health, mental retardation, and substance service providers; and
* assuring the quality of care through improved oversight and technical assistance for providers.

Given the specific focus of HJR 70, several major related issues, although significant, fall outside the mandated scope of the study. The areas thus not addressed include: (1) overall HFA rate structure and rate adequacy; (2) implications of the increasing physical/medical care needs of HFA residents; (3) adequacy/effectiveness of general HFA regulatory structure; and (4) overall availability/accessibility of appropriate housing and related support services for mentally disabled persons.

Resident and Facility Survey

To provide in-depth data on issues judged to be essential to the study, a major survey was conducted in a sample of 89 Homes for Adults during summer 1987. The resident survey data indicate that there are an estimated 5,190 mentally disabled residents of Homes for Adults statewide. The majority of these residents (over 78%) have a primary disability of mental illness, with the remainder having a primary disability of mental retardation or substance abuse. Of the mentally disabled HFA resident sample, 68% also receive Auxiliary Grant benefits, which indicates that approximately 3,529 persons residing in HFAs statewide are likely to be mentally disabled Auxiliary Grant recipients.

Mentally disabled residents of Homes for Adults are generally older individuals whose ability to function independently (e.g., to manage their lives in their own home) is impaired by a combination of conditions which require structure, support, assistance, training, and/or supervision. Few of these individuals are' seen as needing more intensive care (such as might be provided by a nursing home or hospital) on an ongoing basis.

The majority of these individuals are also currently receiving supportive services from agencies and organizations other than the Home for Adults. For the most part, these service providers are the local Community Services Boards, private providers, and other public agencies such as the local Departments of Social Services. However, many mentally disabled residents are not receiving the supportive services which HFA staff believe they need. The greatest disparity between the proportion of residents needing a service and those who do not receive them are found in those service areas such as day support, vocational rehabilitation, and outpatient therapy services, which are the most difficult for HFAs to make available through their own program resources (staff, space, funds, etc.).

The licensed capacity of the facilities are found to be related to several characteristics of the HFAs. Smaller HFAs tended to have a much larger percentage of mentally disabled residents than did larger HFAs. Furthermore, while the average percentage of mentally disabled residents in the smallest HFAs was 58.5%, the average percentage of mentally d1sabled residents in HFAs with more than 100 beds was 22.3%. In general, as the size of the HFAs increased they were found to have a smaller percentage of mentally disabled residents.

A breakdown of staff by position type indicates that the largest category of staff within an HFA were typically administrative staff, closely followed by other medical/direct care staff which included registered nurses, licensed practical nurses, and aides. In contrast, the HFAs typically had a small percentage of ancillary staff and an even smaller percentage of physicians and psychiatrists.

The issue of written service agreements between the HFAs and CSBs was also addressed. It should be noted that HFAs are required by licensing requirements to have an agreement with the local CSBs if they serve residents who have been discharged from DMHMRSAS facilities. Only 39.3% of the HFA operators reported that there was a written service agreement between their HFA and the local CSB. However, of those operators who reported an ongoing relationship with the local CSB, 56.5% reported that they have a written service agreement. For those" HFAs which have agreements, 51.4% reported that the agreement is updated annually, while 34.3% reported that it had not been updated in more than two years. Nearly all of the operators with service agreements reported that they were satisfied with the agreement (88.6%).
Issues Analysis

The major issues emerging from the study data and the analysis of other background information are described in more detail in the attached report, and are summarized as follows:

1. HFAs play a major role in serving the mentally disabled population, and improvements in rate structures, service planning mechanisms, and staff/service resources are needed.
2. The patterns of similarity among the mentally disabled HFA resident population suggest that differential levels of care may not be necessary to meet service needs.
3. The administrative orientation of HFA staff unfavorably influences the ability of HFAs to meet the needs of mentally disabled residents.
4. Many mentally disabled individuals are screened out or discharged from HFAs due to a lack of specialized services.
5. HFAs could expand the availability of services to mentally disabled residents with additional funding.
6. Smaller homes for adults would be most greatly impacted by changes in financing, regulation, or services for the mentally disabled.
7. There is a need for incentives to induce closer cooperation between CSBs and HFAs with respect to the mentally disabled population.

Proposed Model

Using the above information, the two Departments have developed and recommended a model to enhance the quantity, quality, and coordination of supportive services available to mentally disabled HFA residents. The proposed approach also would result in closer linkages between CSBs and HFAs, allowing for more effective service coordination. The proposed model, described in the attached report, would make available to qualified HFAs a supplemental payment of approximately $1,800 per year for each eligible mentally disabled resident within the home. These funds would be used by HFA operators to access or provide additional rehabilitative and supportive services which are needed by mentally disabled residents and which are currently not available to the extent needed to ensure an appropriate level of care and support for these residents. For homes with a significant number of mentally disabled auxiliary grant recipients the aggregate level of funding would be sufficient to allow for hiring of additional staff to increase on-site service provision. For homes with fewer eligible residents, funds can be used for transportation to off-site services or limited contracts for supplemental services provision.

HFAs would continue to be licensed by the Department of Social Services. However, those serving mentally disabled residents could also apply to be certified by DMHMRSAS. This voluntary certification would qualify the home to receive supplemental funding for services to eligible individuals. The intent of the certification would be to provide basic, initial assurances that the home is willing and able to make effective use of these funds for better services to mentally disabled residents.

HFAs could then propose selected residents for the supplemental funding program. These residents would be both (a) eligible for/already receiving auxiliary grants, and (b) mentally disabled. The determination that a given resident is mentally disabled will be made on the basis of CSB assessment, at the request of the HFA operator. Those persons deemed to need long-term mental health, mental retardation, and substance abuse services will be defined as mentally disabled for the purposes of this program.

Services for each eligible client would be outlined in individual supplemental service plans to be jointly developed by the HFA and a CSB coordinator. Appropriate services might include:

* Transportation to specialized day support, vocational rehabilitation, or outpatient services.
* Contractual arrangements for on-site special services.
* Off-site special services requiring fees.
* Supplemental part- or full-time qualified staffing for enhancing behavior management, resident skill training and special supervision.
* Salary incentives for staff who obtain special training or credentialing for work with this population.

As access to information on client functioning improves, fewer people should "fall through the cracks" within the case management system. CSB's will be more aware of HFA operators' needs for support, training and consultation and will have some resources to be more responsive. Case planning and consultation can occur more regularly, so that service goals can be better coordinated.

This proposal represents a significant first step in addressing the needs of clients served in Homes for Adults. By design, it focuses on a specified mentally disabled population. It does not attempt to resolve related current concerns with general rate structures or the demands for enhanced medical care for frail or physically disabled elderly residents. These issues will continue to be addressed by the Department of Social Services as part of its licensure and service delivery processes.