The Department of Behavioral Health headquarters in Northeast. (Photo by Scott Rodd)
By DCist contributor Scott Rodd
Changes enacted by the Department of Behavioral Health have left mental health service providers struggling or unable to provide services to potentially hundreds of uninsured and institutionalized patients, according to providers and advocates. And a controversial policy change will limit those providers’ work in the future.
Providers and advocates point to limits established last spring on so-called “locally funded” mental health services, which are paid for by the District and delivered by external providers to individuals who do not have Medicaid, are institutionalized in city-run facilities, or both.
“The local dollar crisis has had a devastating impact for our institutionalized clients,” said Faiza Majeed, a staff attorney at the advocacy group Disability Rights D.C. at University Legal Services.
The lack of available local funds, she explains, poses the risk of delayed discharge for clients at St. Elizabeths Hospital because providers are unable to deliver transitional services. Several providers have also curtailed visits with clients in D.C. jail, even though these services are considered integral for returning citizens’ successful re-entry after incarceration.
DBH rejects the charge, however, and says that patients are receiving adequate treatment by internal staff at city-run institutions.
During a budget shortfall earlier this year, DBH capped local funds, limiting services from external providers to institutionalized individuals in what was originally a billed as a temporary issue.
This inspired the agency to announce a recent policy change: Providers will now only be able to deliver transitional services to individuals during the final 30 days before discharge from St. Elizabeths and the final 60 days before release from D.C. jail. The policy is aimed at reducing what DBH considers “duplicative services” rendered by internal staff and external providers.
In the past, providers were able to maintain relationships with clients over the course of months — and sometimes years — regardless of whether an individual was institutionalized, but DBH now says this is unnecessary.
“Saint Elizabeths is an inpatient psychiatric hospital where these patients are already receiving intensive services on a daily basis,” said DBH director Tanya Royster. D.C. Jail, she adds, has its own contracted mental health workers. The services of external providers is not necessary for people in these institutions, as a result, until the very end of an individual’s stay—when they are transitioning out.
This morning, the DC Council’s Committee on Health will convene for a performance oversight hearing for DBH. The availability of local funds, as well as the services they support, is expected to be a central focus.
The debate has been brewing over the past year. Late last spring, following an issue with the agency’s electronic billing system, DBH set hard limits on providers’ allotment of local funds. In the past, providers were awarded a large sum of local funds at the beginning of the fiscal year, and DBH would extend each provider’s contract in small increments on an as-needed basis.
But midway through the 2016 fiscal year, Royster notified providers that they would have to live within their means, so to speak, as the issue with the billing system was addressed. Unlike past years, there would be no incremental extensions when their allotment of local funds ran out.
“We had frequent communication and provided the providers with as much information as we had through the process,” she said. “This was a difficult process, it was an anxiety-provoking process—but it was a process that had to occur.”
The problem, according to Mark LeVota, executive director of the D.C. Behavioral Health Association, was that the new budgetary approach was rolled out midway through the fiscal year and mental health providers were given little warning. A number of providers quickly reached their limit on local funds. Some had to pay for patients’ services out of their own coffers; others were forced to limit services in order to remain solvent.
Community Connections, according to one clinical administrator who isn’t authorized to speak publicly, had to “shut the front door on many consumers who sought our services.” As a result, the nonprofit curbed services delivered to inmates in DC jail.
At the McClendon Center, the outpatient day program no longer accepted individuals from St. Elizabeths because the services weren’t reimbursed through local funds, according to executive director Dennis Hobb. The program delivers services such as anger management, skills training, and trauma recovery therapy.
“For many years, [the program] took people from Saint Elizabeths before they were released into the community,” said Hobb. “Today, we don’t have anyone [from St. Elizabeths] in our day program … we just can’t accept them.”
In a series of letters to the Deputy Mayor for Health and Human Services, Disability Rights D.C. expressed its concerns over the financial strains on providers and the impact on individual patients.
“[P]roviders are still not delivering crucial services that provide continuity of care and transition services for [individuals] in institutions,” stated Disability Rights D.C. in a letter dated December 20, 2016. The letter describes a Saint Elizabeths patient who had been approved for release but was no longer receiving transitional services from her long-time provider. It also describes an inmate at D.C. jail who suffered from chronic depression and suicidal thoughts but faced significantly reduced contact with his long-time mental health provider as a result of the local funds shortage.
According to Royster, concerns from advocates are misplaced. Institutionalized individuals — including those mentioned in the letter from Disability Rights D.C. — have continued to receive sufficient treatment during institutionalization.
But Faiza Majeed from Disability Rights DC believes that disregarding the services delivered by external providers is reckless.
“DBH’s position raises serious concerns about maintaining continuity of care,” she said. “Thirty days is not enough time for individuals to prepare to successfully reintegrate into the community.”
Some advocates say that providers need at least 60-90 days from release, while others believe they should maintain relationships throughout the duration of a stay in an institution.
Leading up to Thursday’s oversight hearing, Councilman David Grosso expressed frustration over the local funds issue under DBH.
“In my letters to Department of Behavioral Health, I have repeatedly brought up concerns about individuals not receiving the services they needed,” said Grosso in an emailed statement. “Their responses have not entirely addressed the questions and concerns I’ve raised. I want to ensure that we have the appropriate funding so that our most vulnerable are getting the services they need and avoid repeating the shortfall that DBH recently experienced.”
Late last week, the mental health provider Green Door, which served approximately 1,200 patients, announced that it would be ceasing operations after 40 years. According to one senior administrator who was not authorized to speak publicly, the provider had struggled with leadership and organizational problems, but the local funding issue was “the straw that broke the camel’s back.”
Royster, citing a call with members of Green Door’s board last week, denies that the local funds issue was related to the closure. The nonprofit will be absorbed by the private MBI Health Services.
