REGION ADULTS RECEIVING INTENSE SERVICES CHILD &ADOLESCENT RECIEIVING INTENSE SERVICES ADULT PENETRATION RATES C&A PENETRATION RATES CENTRAL 5,519 1,075 17% 9% EAST CENTRAL 4,292 1,278 11% 8% NORTH 9,573 1,458 9% 3% METRO 8,282 1,584 9% 4%
Georgia Mental Health Gap Analysis - 118 - SOUTHEAST 9,573 1,402 23% 8% SOUTHWEST 7,070 745 23% 6% WEST CENTRAL 6,751 1,999 14% 10% TOTAL 51,060 9,541 13% 6%
The gaps in providing intense services to individuals in need are clearly seen above. There is also great disparity in the penetration rates among the regions. The Southeast and Southwest are meeting the needs of more adults in need of services, whereas the Central and West Central regions are meeting the needs of more children and adolescents than other regions.
GAP:
During FY 2004, Less than 15% of adults, and less than 10% of children and adolescents were enrolled in intense community services.
Measuring Penetration as a function of Length of Stay
Access to services is a critical factor in the success of public mental health systems of care. In order to further understand access to services among mental health consumers, APS developed a system of categorization regarding service utilization for the Medicaid rehabilitation option population.
This system serves as the foundation for more in-depth analysis, e.g., access by income, race, primary language, ethnicity, etc. Using the analytic approach outlined below, it is possible to determine critical factors such as length of stay and type of service provided. As the stated Medicaid External Review Vendor, APS consistently reviews consumer access to services and utilization patterns specific to Georgia’s Medicaid Rehabilitation Option providers. This population comprises 35 – 40% of the entire population receiving services from MHDDAD. With this large of a sample size, we can apply utilization rates and the analysis to the greater population to get a better understanding of what services are truly being provided. Rehab Option providers serve approximately 63,000 people a year. Based on a 12-month analysis of Medicaid claims, the study conducted by APS categorized consumers served into four quadrants. Each quadrant represents two variables - length of stay in services and frequency/amount of contact - as follows:
Quadrant One: people who have had less than three contacts with the agency.
Quadrant Two: people who received services for less than 3 months and have received between 50 and 500 units of services.
Quadrant Three: people who received services for greater than 9 months and have received more than 500 units of services.
Quadrant Four: All other people
Using these statistically derived quadrants, analysis of data at both statewide and local levels identified the following patterns of access.
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Agencies with a significant number (greater than the state average) of people in
Quadrant One (less than 3 agency contacts) may have one or more of the following:
Barriers that may prevent timely access to services Unattractive programming
Limited MD (or other staff) availability Poor consumer screening techniques Poor consumer orientation techniques
Agencies with a significant number (greater than the state average) of people in
Quadrant Two (short length of stay and high utilization of services) may have one or more of the following:
Effective programming that met the consumer’s needs during an acute episode.
A mandated (or court ordered population) that remained in services until their obligations were met.
A chronic, but non-compliant population that were initially engaged in services but left services prematurely.
Agencies with a significant number (greater than the state average) of people in
Quadrant Three (long length of stay and high utilization of services) may have one or more of the following:
Attractive programming;
Motivated, compliant consumer population;
Utilization stagnation where consumers attend day programs long term with no real impact in learning to live independently;
A consumer being served in a residential site that requires structured programming during the day; and/or
Gridlock (or a waiting list) where no new consumers can enter a day program because no one is being discharged and the program is full.
Agencies with a significant number (greater than the state average) of people in
Quadrant Four may have one or more of the following:
A large population of consumers who are stable and receiving maintenance doses of medication or therapy, and/or
People who show up briefly several times a year for medication or supportive psychotherapy.
By offering a more thorough understanding of the consumer population to providers and state officials, APS is able to assist the system of care to improve capacity, provide timely access to care, modify the intensity of clinical programming, develop treatment alternatives, and improve outcomes for all consumers.
The graphic below provides an overview of the findings for Rehab Option Consumers for Fiscal Year 04 and their access to services in Georgia. APS titles this the Allocation of Resources Map (ARM) because it provides a snapshot of utilization. The term “Visitors” applies to those people seen less than 3 contacts. “Absentees” refers to those in services less than three months but receiving more than 50 units of service. “Family”
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refers to those in services longer than 9 months and receiving more than 500 units of service and “Members” referrers to the remaining people. This group consists of people seen occasionally throughout the year.
For the purposes of penetration, APS will focus on the Visitors to services, that is individuals who received less than 3 contacts within the year. Individuals may have shown up for a few initial appointments but were not engaged in ongoing services, thus not utilizing a great deal of agency resources, unlike the FAMILY who received more than 500 units of service in the same time frame. The statewide average for Visitors to all agencies is 20%. So, 1/5 of all consumers enrolled in services, received less than 3
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contacts by the provider agency. Table VI-34 below is a regional distribution of Visitors and new penetration rates for services when you remove the Visitors from the client enrollment.
Table VI- 34: Visitors By Region and Adjusted Penetration
Region # of People Enrolled % Of Visitors per Region # Of Visitors Adjusted # Truly Served (Minus Visitors) New Penetration Rates based on Adjusted Total Served Central 17,743 16% 2,838 14,905 33% East Central 17,152 20% 3,430 13,722 25% Metro 34,328 21% 7,208 27,120 18% North 42,166 21% 8,854 33,312 26% Southeast 23,531 24% 4,000 19,531 34% Southwest 18,506 17% 3,146 15,360 35% West Central 21,552 18% 3,879 17,673 26%
By applying the percentage of Visitors by region to the total EARF enrollment figures, it allows one to see regional differences in access to services. The Southeast region has the highest percentage of visitors in the state, whereas the Southwest region has one of the lowest rates yet they represent similar geographic areas – vast, rural communities. As stated before, regions with higher visitor percentages might have specific barriers that affect access to services: geographic barriers, unattractive programming, limited workforce (creating long waiting lists), poor consumer screening techniques, or poor orientation to services. A complete Allocation of Resources Map Table is provided as APPENDIX VI-1: Allocation of Resources Map.
Table VI-34 below illustrates the differences in penetration rates by region after adjusting to remove the visitors from the total number of individuals removed. Penetration rates drop from 4% – 7 % overall.
Table VI-35: Adjusted Penetration vs. Original Penetration Region Penetration Rates Adjusted Original Penetration Rates
Central 33% 39% East Central 25% 31% Metro 18% 22% North 26% 32% Southeast 34% 40% Southwest 35% 42% West Central 26% 32%
Studying the adjusted rates for penetration paints a more accurate picture of service utilization and of who is truly receiving the services that they need.
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Penetration as a Percentage of Services Recognized as “Best Practice”
Earlier in the Gap Analysis there was a discussion and information on Evidence Based Practices and best practices. To get a better idea of how available these specific services are, APS studied enrollment rates and utilization for the following services:
Intensive Family Intervention Psychosocial Rehabilitation Community Support Individual Community Support Team
Assertive Community Treatment Team Peer Support
Supported Employment Family/Consumer Education
Integrated Mental Health and Substance Abuse Treatment Medication Algorithm s
Table VI-36 below illustrates the extent to which most of Georgia’s evidence based practices are received throughout Georgia:
Table VI-36: Penetration by Utilization of Evidenced Based Practices Service # of Individuals Served Penetration Rates for those in need
Penetration for 200% Poverty
Level in need
Assertive Community Treatment 735 < 1% > 1%
Community Support Team 3,678 1% 3%
Community Support Individual –
Adult 24,919 7% 17%
Community Support Individual –
Child and Adolescent 13,011 8% 18%
Supported Employment 3,086 < 1% 2%
Psychosocial Rehabilitation 5,137 1% 4%
Peer Support 3,315 1% 2%
Intensive Family Intervention 1,283 1% 2%
Family/Consumer Education (All
ages) 9,140 2% 4%
The rates at which Assertive Community Treatment and Community Support Teams are provided to individuals in need is extremely low across the state. Less than 1% in need
GAP:
After controlling for Utilization, the number of people in need of services who are receiving them ranges from 18% - 35%.
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receive these services, and then when controlling for individuals under the 200% poverty level, the number increases to 3% for Community Support Team, but remains below 1% for Assertive Community Treatment. Providers have called their Community Support Teams “ACT Lite” because they can provide similar services in the community, without the requirement of having a dedicated psychiatrist on the team. Supported Employment, Psychosocial Rehabilitation, and Peer Support are all day services that are provided to less than equal to 1% of the population in need. Intensive Family Intervention is
provided to 1% of the total population in need, and 2% of the population under 200% of the federal poverty limit.
The highest penetration comes from Community Support Individual, which is shown for adults and for children and adolescents. Table VI-37further illustrates the extent to which Community Support Individual is provided, based on Community Service Board catchment areas. In several areas additional providers have been contracted to provide this service, but the numbers are extremely small so the focus remains on the CSB catchment area.
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Table VI-37: Community Support Individual by Adult and Child & Adolescent
CSB CATCHMENT