Lack of rules confuses supervisors in mental health care decision
In May, Gov. Terry Branstad signed new legislation shifting control of Medicaid-funded mental health services from counties to the state, a change that is part of larger reforms for Iowa’s mental health care system designed to make services more uniform, in part by taking control away from each of Iowa’s 99 counties.
The state has legislated a mental health service delivery plan to regionalize services instead of having all 99 counties be individually responsible for county programs.
Regionalization is still in the implementation process, but has been the subject of several discussions for the Jefferson County Board of Supervisors and the county’s Central Point of Contact Sandy Stever.
Stever and supervisor Lee Dimmitt, who represented Jefferson County on the Southeast Iowa Case Management Advisory Board for four years, have expressed frustration due to a lack of rules about regionalization of mental health services and the probability of it in practice.
Monday, newly seated supervisor Becky Schmitz shared she was a member of the Iowa Legislature (2007-2011) when the initial legislation began to regionalize mental health care.
“I worked with the pilot project in northern Iowa to look at regional mental health services and talked with many people,” she said. “I’ve also been in this career field for 30-plus years.”
Schmitz is a licensed independent social worker with 27 years working in public schools through the local Area Education Agency. She now works as a mental health therapist in Mount Pleasant.
When Schmitz was in the state Senate, she was the only licensed mental health professional member, and she met regularly with providers and recipients of mental health services to lay the groundwork for the current mental health reform effort to regionalize.
At a supervisors candidates’ forum in October, Schmitz had said the issue that came before the Legislature was mental health services varied county to county.
“The amount or level of service should not depend on residency,” she had said at the forum.
“The requirements for counties about providing mental health services — I don’t see how counties of our size can provide all the services the Legislature intends,” said Schmitz Monday.
Stever said clients in Jefferson County have been well served.
“We’ve never had a waiting list, we operate within our core services, and everyone gets served,” Stever said. “We’ve always done it on our own and always will. No one who is disabled [in Jefferson County] goes without services.”
Dimmitt asked how regionalizing care changes the service.
With more than one county forming a region, it can provide intermediate care to a client without going to psychiatric hospitalization, said Schmitz.
“But how does merging Jefferson County with Washington County or Wapello County or any county; how does that help?” asked Dimmitt. “The real problem has not been addressed by the Legislature — bed space. Sometimes a mental-health provider has to call all over the state for a few hours, looking for a space.”
Stever supports the idea of Jefferson County being its own region in the state’s new mental health design.
“If regionalized, emergency services would be at one building, and we’d still be driving to a facility,” said Stever. “Currently in Jefferson County, we use Jefferson County Health Center and it’s up to a judge whether someone should be hospitalized.”
Schmitz said if Jefferson County goes alone, Iowa Department of Human Services director Charles Palmer would determine whether to let the county stand-alone or assign it to a region with other counties.
“That’s Palmer’s assessment — that bigger is better,” said Stever. “The new law says to pool resources. It does not designate that it has to be bigger — or smaller.”
Stever said counties have not been given rules yet about how regional delivery systems will run, nor has anyone received rules for counties wanting to remain stand-alone mental health service providers. Counties can apply for exemptions to join a region if the county can prove it can meet the minimum standards of care and remain cost-effective on its own.
“I want someone who can take care of the county’s clients, and I know Sandy uses every facility available,” said Dimmitt.
“No rules and funding are difficulties,” said Dimmitt. “The state said it put aside $20 million to help counties transition to regions, but of 32 [county] applicants, 28 were denied. Only four counties were given funding, and Scott County is getting a big chunk of $1.4 million divided among those four.”
At a June supervisors’ meeting, Dimmitt also said the state is planning to spend $25 million less per year on mental health.
“This law takes away county control of county taxes for mental health services and gives the control to regional directors,” Dimmitt said in June. “The Department of Human Services is planning to lay off 100 workers statewide, through attrition and retirements. We’ll still be required to have a local coordinator, but it’s the regional director that makes decisions.”
Stever, Dimmitt and supervisor Dick Reed all agreed Monday they’ve heard administrators say the rules for the delivery system are not yet written.
“Our position is how can we do something without guidelines?” asked Dimmitt. “I’m for it if someone can come down here and tell us the rules.
“If we can get our questions answered, we can make a decision. For the past two years we’ve asked the Legislature how regions will improve delivery of services. What’s the purpose of regions? It doesn’t increase beds. We use everything available to us here.”
Reed said he agreed.
“We’ve been taking good care of our county’s population,” Reed said. “I commend Becky for working on this in the Legislature, but it’s not done yet.
“I’ve heard the state initially wanted regions to have populations of 200,000 to 300,000.”
Schmitz said it was a good idea to have someone come to the supervisors’ meeting and speak to the board about regionalization.
“If we’ve not voluntarily joined a region, the county will be forced to,” she said.
Dimmitt said he didn’t like the state taking away local control.
“How can we be told we’re not meeting standards when standards have not yet been established?” asked Dimmitt.