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SUMMARY
The Office of the Auditor General has conducted a
performance audit of the House Bill 2003 Children’s Services monies (HB2003)
that the Legislature appropriated to the Department of Health Services,
Division of Behavioral Health Services (Division) for children’s behavioral
health services and programs in compliance with Laws 2000, Fifth Special
Session, Chapter 2, §5.1.1 The Legislature appropriated $20
million from the State General Fund’s tobacco litigation settlement account
to be used for children’s behavioral health services. The legislation also
stipulated that the Office of the Auditor General complete a performance
audit of the program on or before January 1, 2003.2
In 2001, the Legislature made a one-time, non-lapsing
appropriation of $20 million for children’s behavioral health programs. The
legislation mandated that the monies be used to provide services to children and
families served by the Department of Health Services, the Department of Economic
Security, the Administrative Office of the Courts, or the Arizona Department of
Juvenile Corrections. The legislation also authorized the money to support
telemedicine programs to make it easier to provide behavioral health services to
people who live in the State’s medically underserved areas. The legislation did
not establish a deadline for spending the money.
The Division is distributing most of this funding to its five
Regional Behavioral Health Authorities (RBHAs) to provide services. The Division
has allocated $17.85 million to the RBHAs based on population. To obtain the
money, the RBHAs were required to submit spending plans consistent with
legislative intent. In addition, the Division directed the RBHAs to focus mainly
on serving children who are ineligible to receive medical and behavioral health
services through the federally funded Medicaid and KidsCare programs
administered by the Arizona Health Care Cost Containment System (AHCCCS). The
Division reserved the remaining $2 million for training RBHA staff and others on
a new system-of-care approach to service provision.
This audit focuses on three areas related to the Division’s
use of HB2003 monies: programs created with these monies, training on the new
system-of-care approach, and collaboration between the Division and other state
agencies listed in the legislation.
Enrollment and services increasing after
slow start (see pages 9 through 18)
Behavioral health programs developed with HB2003 monies
target the population specified by the Legislature and are consistent with
court-ordered reform, but they had a slower start than the RBHAs had planned.
The Division has used HB2003 monies to provide services to children involved in
one or more of the four state agencies specified in legislation—the Department
of Health Services, the Department of Economic Security, the Administrative
Office of the Courts, and the Arizona Department of Juvenile Corrections. The
RBHAs proposed several programs and services tailored to these children’s
behavioral health needs. For example, several RBHAs developed programs for
children in the juvenile justice system, such as assessment and transitional
services for incarcerated children. Although some of these children may be
Medicaid-eligible, Medicaid will not reimburse services provided to incarcerated
individuals. More than half of the 938 enrolled children as of July 1, 2002,
were involved with the Division as well as at least one of the three other
agencies. In addition, as permitted in legislation, two rural RBHAs used their
monies to expand telemedicine services.
The Division has also used HB2003 monies to develop programs
that are consistent with the State’s new child- and family-centered
system-of-care approach to service provision. This new approach is the result of
the J.K v. Eden settlement agreement, which addressed Medicaid-eligible
children who need mental health services.3 Consistent with the
settlement agreement, the RBHAs developed some programs with HB2003 funding to
reflect the new system’s principles and family-centered nature, such as
intensive in-home services and multi-agency teams.
However, due to a variety of factors, behavioral health
programs developed with HB2003 monies had a slower start than the RBHAs had
originally planned. For example, the Maricopa County RBHA ValueOptions started
its program 3 months after the Division’s proposed July 1, 2001, start date to
allow its HB2003 programs to coincide with changes in Medicaid coverage. The
Yuma RBHA Excel broadened the eligibility criteria for its program in November
2001 because it had not received the expected number of referrals under its
original, narrower criteria. Two new policy changes in the State’s Medicaid
program, administered by AHCCCS, that became fully effective in October 2001
also contributed to the slower than expected program start. During HB2003
program implementation, the State expanded Medicaid eligibility and also
expanded the list of Medicaid-covered services. According to department
officials, these changes required planning and time to ensure that they were
implemented effectively, delaying the Division’s and RBHAs’ ability to focus on
planning and implementing the HB2003 programs. Due to the delayed program
starts, total enrollment was less than expected in the program’s early months.
In response to the low enrollment, the Division and the RBHAs
have made changes in the program plans and worked with other state agencies to
increase referrals. The Division needed to educate other agencies on the
availability of new services. In the past, agencies did not always refer
non-Medicaid clients because services were not always available. After the slow
start, enrollment appears to be increasing. Between July and October 2001,
average new enrollments were 15 per month. By contrast, between November 2001
and June 2002, new enrollments per month averaged 104. Altogether, as of July 1,
2002, 938 children had enrolled in the program, and participation rates may
ultimately reach the RBHAs’ estimates of over 1,200 total enrollments. Due to
the slower than expected enrollments, analysis of program expenditures shows
that total spending appears low, compared to the amount appropriated. Although
complete service data is unavailable, the Division’s records indicate that more
than 80 percent of the program’s allocation remained unspent as of June 30,
2002. Those records reflect expenditures for hiring staff and purchasing
equipment as well as the value of services reported by providers. At that time,
ValueOptions had spent only 9 percent of its total $10.5 million allocation.
Total spending in some other regions came closer to the total budgeted,
particularly at Excel, which provides services directly and does not have to
wait for providers to report services. Delays in reporting services to the
Division may result in understating actual program expenditures and services
provided to date, since by law the RBHAs are allowed to take up to a year to
submit accurate service data.
The Division should continue efforts to ensure state-wide
training on its new system (see pages 19 through 24)
In accordance with the J.K. v. Eden settlement
agreement, the Division is using $2million to provide training on the required
new system. The J.K. v. Eden lawsuit, which was filed in 1991 and
certified as a class action lawsuit in 1993 on behalf of Medicaid-eligible
children, and the resulting settlement agreement, provided the foundation for a
new philosophy for caring for children in the State’s behavioral health system.
The settlement agreement emphasizes a number of principles, including partnering
with families and children, collaborating with other agencies, and providing
individualized services aimed at achieving meaningful outcomes for families and
children. The new system of care emphasizes the strengths of a child and family
instead of their problems and deficits.
The Division has retained a consultant to develop and
initially provide this training, which is consistent with best practices
identified in federal studies and in interviews with officials from similar
programs in other states. This training has been provided in several regions of
the State. So far, 38 training sessions have been provided, with total
attendance of over 2,300 including representatives from the Division, the RBHAs,
service providers, and other child-serving agencies. The Maricopa County RBHA
ValueOptions and the Northern Arizona Regional Behavioral Health Authority have
received most of the training, since they are part of a pilot program to
implement the new system of care across the State.
The Division has taken steps to expand ongoing training
throughout the State after its contract ends with its training consultants, as
other agencies, locations, and new staff continue to need training on the
State’s new child- and family-centered system of care. To ensure training
continuity, the Division is developing training kits, identifying internal
trainers to facilitate future training, and providing supervisory training in
order to obtain management support for the new system. As it expands training
state-wide, the Division should also assist the RBHAs with future training
plans. It has already approved the ValueOptions training plan, and has asked the
other four RBHAs to submit training plans by January 1, 2003. As it reviews
these plans, the Division should ensure that they include key factors, such as
detailed tasks and time frames. In addition, the Division should ensure that the
RBHAs plan to include employees of other state agencies in future training.
The Division can further foster interagency collaboration
(see pages 25 through 28)
While the Division and the RBHAs took steps to collaborate
with other agencies, they can take further action to promote interagency
collaboration for children served by multiple agencies. Overall, the RBHAs
solicited input from all the agencies mentioned in the legislation prior to
submitting program plans for using their HB2003 monies, although not all county
probation offices were consulted, and an official at the Arizona Department of
Juvenile Corrections stated that two RBHAs did not discuss regional service
priorities with them before the RBHAs submitted their program plans to the
Division. In most cases, the RBHAs incorporated other agency priorities into
their program plans, although they could not adopt all service-planning
priorities. The Division has also made collaborative inroads at the state
leadership and client levels. For example, the Division is working to develop
agreed-upon clinical protocols for treating children involved in multiple state
agencies. In addition, the Division has a full-time executive-level position
dedicated to fostering collaboration.
To continue its focus on collaboration, the Division should
continue to work with the other state agencies to strengthen local commitment to
the new system of care within each RBHA’s service area. Most of the RBHAs’
service areas have interagency teams and steering committees or councils in
place to foster collaboration. However, the Maricopa County Steering Committee
has taken this process a step further by developing a formal agreement that
commits each individual state agency to actions such as supporting service plans
designed by child and family teams, providing a representative at team meetings,
incorporating the collaboratively designed service plan into the agency’s
service plan, and collaborating with the team before changing the approved plan.
1 The Division refers to this funding as
“House Bill 2003” funding, and to the programs as “House Bill 2003
Programs,”after the legislation that created the funding.
2 Laws 2000, Fifth Special Session,
Chapter 2, §5 also appropriated $50 million for funding housing and recovery
supportservices for adults with serious mental illness. A separate audit on
the House Bill 2003 Adult Services Program is due onor before January 1,
2004.
3 J.K. v. Eden, Arizona Federal District
Court Case, No. CIV91-261.
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