The Federal government has approved Personalized Recovery-Oriented Services (PROS), a Medicaid-funded system of mental health services to replace some of the current State-supported programs. Instead of New York paying for 100% of these programs when it has a large budget deficit, Medicaid will pick up half the cost of Medicaid recipients and some non-Medicaid clients. The State Office of Mental Health (OMH) will phase in PROS during the next year or two.
Voices has published several articles questioning aspects of PROS, which is a complicated system. Although Medicaid pays for mental health rehabilitation in 46 states, and OMH has promised to subsidize providers of services during the first year, advocates are anxious because they fought so long and hard for the current recovery programs funded by Community Reinvestment.
Our reporter, Carl Blumenthal, has read OMH's draft regulations and the questions and answers on OMH's website. He attended a recent briefing on PROS by the New York Association of Psychiatric Rehabilitation Services (NYAPRS). That briefing did not lessen the fears of the mostly small agencies in attendance.
As a result, Carl submitted a long list of questions to OMH and to the New York State Association for Community Living, a major critic of PROS in the past. At press time, OMH said it was working on the answers; ACL had not responded. Thus, what follows is one reporter's effort to make sense of PROS with limited information. As Voices learns more about PROS, we will share it with our readers.
Build a clubhouse with community rehabilitation services (CRS), insulate it with intensive psychiatric rehabilitation treatment (IPRT), and insure the job with ongoing rehabilitation and support (ORS). What sounds like a blueprint by Bob Villa for refurbishing Dr. Freud's old house is the formula for Medicaid-funded, Personalized Recovery-Oriented Services (PROS) conceived by the New York State Office of Mental Health (OMH) to replace such Community Reinvestment programs as clubhouses, Intensive Psychiatric Rehabilitation Treatment (IPRT), and Supported Employment.
Why make fun of such a serious undertaking? Because PROS makes mental health consumers nervous and with good reason. We won Community Reinvestment 11 years ago. Sure, we had friends in the executive and legislative branches who helped us, but it was our hard-fought victory. The programs funded by Community Reinvestment are just now reaching maturity. So why get rid of a good thing?
Furthermore, consumers define recovery as self-determination. PROS is not our idea. However well-intentioned and hard-working the Office of Mental Health, PROS is a top-down initiative at a time when the success of Community Reinvestment has spread far and wide among the consumer grassroots.
Can We Have Our Recovery Cake and Eat it Too?
The driving force behind PROS is Medicaid reimbursement. Instead of the State paying 100% of services as with Community Reinvestment, the Federal and State governments will split the cost 50:50. For decades, New York State has used this provision in the Medicaid law to expand health care benefits for poor and disabled people. According to OMH, 46 states are using Medicaid to pay for psychiatric rehabilitation; many of them, such as New York, need a better financial deal because they are suffering budget shortfalls.
In spite of the rising cost of Medicaid and attempts by Congress to cut the entitlement, OMH thinks PROS is a safer bet in the future than totally State-funded initiatives. Community Reinvestment has stalled in recent years because saving money by eliminating State hospital beds has become harder. Still, many advocates are working to revive Community Reinvestment (CR). For them, the sacrifice of CR program autonomy is a precious loss.
Given that the Federal government has approved New York's PROS program, consumers will have to make the most of this new payment system. From now on, we will find clubhouses, IPRTs, and supported employment combined in one program.
Community Rehabilitation and Support form Foundation of PROS
With PROS, Community Rehabilitation and Support (CRS) is the basic level of care, "designed to engage and assist individuals in managing their illness and in restoring those skills and supports necessary to live in the community. These services will be provided in an atmosphere that promotes friendship, safe surroundings and a sense of belonging."
If this description sounds like a clubhouse, that's because clubhouses are one of the three programs required to convert to PROS. This paragraph could also describe Continuing Day Treatment (CDT). Though not required, CDTs have the option of joining PROS.
PROS providers can also combine forces with psychiatric clinics.
Among the components of CRS are basic living skills, benefits/financial management, community living exploration, crisis intervention, structured skill development, and wellness self-management. An individualized recovery plan (IRP) is the basis of all rehabilitation.
Given the number of activities approved for CRS and the higher financial incentives for this level of care, the Feds and State expect consumers to use these services more than other types.
Ongoing Rehabilitation and Support Keeps Consumers on Top
Ongoing Rehabilitation and Support is the most "advanced" service, "designed to assist individuals in managing symptoms and overcoming functional impairments as they integrate into a competitive workplace. ORS interventions focus on supporting individuals in maintaining competitive integrated employment [of at least 15 hours per week]." Thus, PROS absorbs supported employment. ORS is the equivalent of follow-along services or job coaching.
Intensive Rehabilitation Bridges the Gap between CRS and ORS
Intensive Rehabilitation (IR) is "designed to intensively assist individuals in attaining specific life roles such as those related to competitive employment, independent housing and school. The IR component may also be used to provide targeted interventions to reduce the risk of hospitalization or relapse, loss of housing or involvement with the criminal justice system, and to help individuals manage their symptoms."
Among the components of IR are a grab bag of family psycho-education, intensive rehabilitation, goal acquisition, and intensive relapse prevention. Apparently, OMH believes consumers "on the way up or down" are more vulnerable than folks at the "top or bottom."
Choice is in the Eye of the Consumer
In name, these components resemble many of the recovery programs in which consumers have participated. But will existing activities fit into these categories? Providers won't know until they submit bills and Medicaid approves or rejects them; getting paid can take time. Designing program alternatives also requires approval but it is not clear how often and quickly the Feds/State will grant such exemptions.
Another question is whether offering multiple activities in one location equals the present choice among fewer activities in many places. A client is allowed the basic Community Rehabilitation and Support (CRS) along with either Intensive Rehabilitation or Ongoing Rehabilitation and Support. Yet, a client is not allowed to be in two CRS programs of different agencies at the same time. Clients can switch agencies from month to month. Yet, given the increased paperwork burden with PROS, this practice could be another hurdle for agencies.
Instead of presently voting with their feet, consumers will need to demand more of agencies, the very agencies struggling to meet new administrative requirements. Until now, all consumers were served for free. In the future, clients without Medicaid may have to pay according to income.
Confronting the Challenges of PROS
The major concern of the mostly small organizations that have been the backbone of Community Reinvestment is that they will not survive even with subsidies from OMH during the first year of PROS. Whether or not they are consumer-run, many small providers may have a hard time competing with large mental health agencies, especially those with Medicaid billing experience, extensive administrative procedures, marketing programs, multiple sites, better-paid workers, and cash reserves. These larger groups usually have clubhouses, IPRTs, and supported employment in place, whereas a free-standing employment program, for example, will need to invent the equivalent of a clubhouse and an IPRT or combine with those in another agency. Some of the small groups formed to serve a particular need. Merging with another entity might compromise their mission. But it may be the only way for them to survive.
Will increased administrative demands balance higher reimbursement rates? So much of what is good about Community Reinvestment (CR) are the individual workers. How will PROS create the working conditions, including adequate pay, so these workers can perform optimally? Many employees appreciate CR's flexibility even if the pay is modest. What if the flexibility disappears under a pile of paperwork?
PROS does not seem to value consumer-providers as much as Community Reinvestment does. Only 20% of workers per agency are allowed to qualify for the kind of professional certificate peer counselors usually obtain. There are reimbursement limits on the social and recreation activities that peer advocates often run. Self-help is not reimbursable, though education about self-help is. Finally, as non-professionals leave, organizations are encouraged to replace them with professionals. No doubt these are Federal rather than State requirements. But these are tough nuts to crack for consumers who benefit so much from peer counseling and advocacy.
How Amateurs Can Win at PROS
For those seeking a guide to recovery with PROS, the New York Work Exchange (NYWE) offers an alternative. In a January 30, 2004 memo, NYWE suggested, "Many Community and Rehabilitation Support (CRS) services can be used to help a consumer attain and sustain employment—they can be utilized in preparing someone for work (before) as well as helping someone sustain work (after), even when Ongoing Rehabilitation and Support (ORS) off-site services are billed. CRS services can be delivered both on and off site. Delineated below are some examples of how CRS services can include employment-related services." In the memo, NYWE lists 10 components of CRS that can be adapted for employment. NYWE lists three more work adaptations for the Intensive Rehabilitation level.
Creativity and energy are the hallmarks of Community Reinvestment. We need to apply that creativity and energy to PROS. Recovery is a collective as well as personal achievement. Contrary to the competitive forces at work, PROS is a challenge we must face together. We may be amateurs at Medicaid reimbursement, but we are pros at running our lives. In the long run, we shall overcome.