DANIEL FISHER: I'm going to talk about the pros and cons of Medicaid billing, and as we mentioned earlier, 38 states that have peers can be billed independently, as an independent practitioner. They do need to have supervision, and their care plan needs to meet approval of the guidelines for Medicaid. So the positive thing is, it's a potentially sustainable funding source, and states are cutting back on general funds, and this is, Medicaid money is a little more stable. And there's also, increased opportunities through integration of physical care and mental health care, so that WOW workers, whole health workers, wellness workers, peers are being trained to do that, and also recovery coaches within the addiction field, peers are being trained for being recovery coaches, so these are all potentially reimbursable. The thing that started this all off was a advocacy effort over several years, so one state, Georgia, in 2001, set up a training. They wanted, the state Medicaid is pretty certification oriented, only, you know, certified practitioners, social workers, nurses, so there needed to be some criteria that peers were able to reach, and also the training helps you adapt to a difficult, at times hostile environment in the mental health system itself. It's a big switch, so you're receiving services or you're getting treated, and then you walk in, sometimes even the same place, not a good idea, but if you're in a restricted area, sometimes that is all you can do, is be a peer in the actual facility, in the community mental health center, or even the hospital where you were hospitalized in, that can be retraumatizing. I actually, during my residency, for psychiatry, I had one of my trainings was in the Bethesda Naval Hospital which I had been hospitalized in, and I was looking away wherever one of the doctors came up. I didn't want him to see that I was now a medical student, so, I left DC, the site of where I had been hospitalized. You can't always do that. So it's desirable if you can find a different facility to work in, but not always possible. There's also just the, the change in role, the change in you, so you know you've been in the culture of people getting services, consumer survivor, ex-patient, whatever. There's a certain feeling you're going over to the other side when you become a peer. Certified peer specialist. I think honestly we should make a distinction in terminology between peers who are involved in mutual support, where there's, nobody is being paid to be the peer for another person, so that would be, I would call that mutual peer support, and over here, certified peer provider, I would say. I think we should make that distinction, because a certified peer specialist who is giving services, who is paid, even not very much money but is paid to be quote, unquote, responsible somewhat for another person, you've established a hierarchy. And that's contrary to peer. It's really a oxymoron, you can't really be a peer provider. RUTHIE POOLE: You're right, and actually, sorry. Sorry. There's actually a third peer worker. We believe in Massachusetts not everybody needs to be certified, even though I talked about that. That lots of people can be good peer workers. It's certification, right, right, and so there's still the power differential what you're talking about, but just to know that we don't, I am afraid that you're getting the impression that in Massachusetts we think everyone needs certification. We don't at all. DANIEL FISHER: Certification is the Medicaid and insurance requirement so that you can be billable as a more independent practitioner, so this letter was put together by Medicaid after six years of Georgia doing, getting reimbursed, one or two other states came along, but many other states wanted Medicaid reimbursement, and this is a letter from the Medicaid director in CMS and it's not Cindy Mann anymore and I'm going to look it up. But, yeah, for many years it was Cindy Mann and she was very supportive of this. But this was actually before her, it was Dennis Smith at the time, and he did, he put a line in there that he did not, because he did not want peers supervising peers. Yeah, he really didn't like that idea, so the letter states, quote, supervision must be provided by a competent mental health professional but then it has in quotes, as defined by the state. And as I said earlier, two states have interpreted that to mean, a professional could be a peer, a certified peer specialist could be a professional. For better or for worse. So the training, there's a variety of trainings that enable a peer to be classified as certified. We don't really like the word certified because many of us are certified crazy. Certifiable. And we don't even like the word competency, because we were predetermined not competent. Many of these terms that look sort of neutral or understandable in other context, look kind of frightening when you've been hospitalized, so think about your language. What's that? We like to elope. Elopement, yeah. So the training, one is, I most recommend intentional peer support. That's developed in Vermont, Sheri Mead and Chris Hanson and the reason I think intentional peer support is especially good is it really adheres the closest to recovery principles, especially close attention paid to mutuality and a world view that is critical of the more hierarchal medical approach. There is also a national association of peer support, it's not just peer support. Actually peer specialist, NAPS, and it's actually international now, so it's INAPS, and they have an annual conference, and if you're interested in learning more about you know, peer specialists, I would have someone on your staff go to that, it's this year in August in Austin, Texas, and they have a training curriculum also that you can actually get for free, so there's certain appeal to that. Free is good. The VA has contracted with DBSA to do training, the VA through a lot of advocacy just hired 800 peers across the country, and, but it's the VA is a tough place to work, because they're highly structured, highly structured. And the third, the last one is, state specific one, Texas has its own, Pennsylvania has its own, Massachusetts has its own. Many of which are adaptations. Do you want to go to the next? What is, does DBSA stand for? Excuse me. Thank you very much. You know the answer but you wanted me to say it, didn't you? Very good coaching here. Anyone here know what DBSA stands for? Mike does. Two people. Do you want to say? AUDIENCE MEMBER: Depression Bipolar Support Alliance. DANIEL FISHER: What did it used to be called? AUDIENCE MEMBER: Before my time. DANIEL FISHER: Before my time. It was called, before my time? MDDA, right? Manic Depressive Depressive Association. MDDA. You can see why they got rid of that. Started right off with manic, yeah. So now it's, yeah, DBSA. So starts off with depression instead of mania now. You don't have to be depressed or manic to be a member of it, but most people are diagnosis specific. Okay. So I mentioned a little bit of this yesterday, some, I bring up some of these other factors about Medicaid funding, because if you get involved, it's good to be an advocate. You probably are hearing that message a lot over the last two days, because as it stands, without any advocacy, Medicaid is a very difficult funding source. Why do you think it's a difficult funding source? What makes it a difficult funding source? AUDIENCE MEMBER: Prior approval and showing that you're making progress and DANIEL FISHER: Medical. It is medical. And you have to show progress towards, towards your treatment plan goals, and those goals are usually medical goals, usually symptom reduction goals, anxiety, depression. They are not very recovery focused in general. And, oh, sorry, yes. AUDIENCE MEMBER: Many states, growing number of people, a number of claims Medicaid to pay, sometimes not enough funding available for these extra programs. DANIEL FISHER: Not enough funding available under Medicaid? AUDIENCE MEMBER: The money is being used, depending on how it's used. I mean DANIEL FISHER: There are limitations to the money available under Medicaid. It's true. AUDIENCE MEMBER: Not just money growing off a tree. Money coming from taxpayers, going to state budget, not unlimited. DANIEL FISHER: It's not unlimited, you're right. And different plans have different amount of money available and some plans make more money available if you have, if you have somebody with more complex needs. In trouble. Going to be cuts for sure, and the idea of expansion of Medicaid, of course, under the ObamaCare was refused by at least half the states. And that was, you know, that would have made 6 million, 7 million people available for Medicaid. So, yeah, there are problems. The other problem, the major problem with Medicaid is it's medical. It's medical. So it looks at these problems as medical problems. And you know, I mean like Nassira was saying, somebody, you know, they, maybe they needed a seat to sit on, that's not exactly what a medical plan would ordinarily think of, and it's good that, you know, OneCare was able to, I assume they paid for that seat. That's terrific. That's unusual, under Medicaid they usually say that doesn't fit medical necessity. I mentioned before this medical necessity, and it seems kind of obscure, but it's amazing, those two words determine almost all of what you can or can't fund under Medicaid. And ordinarily, medical necessity is defined as that which a doctor orders. Whatever a doctor orders is medical necessity. Well, if you can find a doctor who would order a cane seat you could conceivably get that funded but it would be questionable under most state Medicaid plans. Most state Medicaid plans would say, what's medically necessary is usually what is a diagnosable, medical, or psychiatric condition, and, huh, and is in some way reducing the symptoms of that condition. That's usually what's medically necessary. AUDIENCE MEMBER: I want to be clear that it was a push for us. It was a push for us to get that. It wasn't automatic. DANIEL FISHER: I'm glad to hear that. AUDIENCE MEMBER: Built in the position of someone who could do pushing. DANIEL FISHER: Good for pushing, but hopefully, if you know, your independent living center wants to have regular services which are ordinarily outside of the medical, you know, medical community, for instance, one of the major themes in recovery is people making friends, having friends. So a life coach who can actually be with somebody and accompany them to a new environment is extraordinarily important. You can have all the clubhouses in the world. You can have all the drop-in centers in the world but if somebody doesn't want to leave their house, they're never going to be there. They aren't going to go to independent living center because they don't want to leave their house. Won't go to AA or NA or any of these places. So having someone who accompanies someone else but that's hard under ordinary medical necessity, so I would recommend, if, you know, you're planning on it, work with other allies, coalitions and try to get medical necessity expanded. It can be. Michigan includes recovery and community integration in their medical necessity definition. We've talked about supervision. I can give people more information about, how Pennsylvania goes about redefining the, who is a mental health professional and qualified to do supervision, but we've already covered that. So any questions about supervision, by the way? Any further questions about it? I mean, you can also find a friendly, you know, professional who has got lived experience, and you know, who could conform with your values and could sign off on papers as well. AUDIENCE MEMBER: Yeah, so do we need a certificate of completion or something to be, to qualify as a peer then? DANIEL FISHER: Under Medicaid, if you want Medicaid reimbursement, usually the state Medicaid office would like to have peers have evidence of having passed a training program, yes. So a, we'll use the word certified, certification as a peer, generally say peer specialist. It's usually eight to 10-day training period, yeah. AUDIENCE MEMBER: And do you claim this is free somehow? DANIEL FISHER: One of the curriculum is free, but you still have to pay somebody to administer it. The curriculum might be free from the SNAPs but you have to have people. The Transformation Center does a training RUTHIE POOLE: The DBS, DBSA charged the VA and now the VA is sick of paying DBSA, so that's ended, actually, this year it's ended. And so the VA people are coming to us in Massachusetts, and that's okay with us, because it brings a really nice flavor DANIEL FISHER: Transformation Center. RUTHIE POOLE: In Massachusetts, but ours is 100% paid by our Department of Mental Health, our mental health authority, so even though some of the people are working in the VA, so we do not charge people. Part of it is a 3-day retreat, and the retreat, because we have 60 people at that retreat. There's, we do two classes at a time in different parts of our state. And they're about 30, they are about 30 people apiece and do a three day retreat. The retreat alone costs $16,000. We don't charge people at all. We charge no one who participates, because why? Department of Mental Health wants this because they require their residential support providers to have, and some other program providers, to have certified peer specialists. So if they're requiring that, they need to pay for the training, and so they pay us to do the training, so it costs the trainees nothing. DANIEL FISHER: But it does cost somebody. RUTHIE POOLE: Right. DANIEL FISHER: It costs the state in this case. RUTHIE POOLE: Exactly. DANIEL FISHER: Somebody is going to pay the people who do the training. It is ideal, if you can have people lived experience, like The Transformation Center is, do the training. That isn't the case in a lot of states. A lot of states do not use people lived experience, but it is good if you can. AUDIENCE MEMBER: Dan? In Wisconsin, the mental health office did fund us a number of trainings for the first few years that we had our certified peer specialist program, but they discontinued that funding, and so now a lot of the people who get the training are funded through vocational rehabilitation and other, other organizations have written grants to be able to provide training for people within the scope of the grant, or sometimes the local community foundation or you know, something like that, so then people within the area served by that foundation can get the training for free. RUTHIE POOLE: Mike, how much do you charge per person? Do they charge per person, the training? MIKE BACHHUBER: It has varied, because in Wisconsin, they have recognized at least three different curricula for peer specialists, and so you have a number of different organizations that provide peer specialist training and they all have their own charging schemes. RUTHIE POOLE: One more comment about the supervision? DANIEL FISHER: Maybe. RUTHIE POOLE: Okay. So you know, the ideal is not to be supervised by a clinician, but when it's not the ideal in agencies where it's not the ideal, we really urge all the peer specialists in that agency to work, to meet together at least once a week. Even if it's not the individual supervision, so that they can get the peer support and they can get the, like, you know, say I'm the peer specialist who is working with Justin. And like I can't figure something out in, you know, like what you work out in supervision, individual supervision regularly, to get supervised by your peers. So to get that support. So if it's not the ideal situation, and you have to answer to a clinician who doesn't really know the job, we really urge people to do the once a week group supervision. Did you have a thought about that? AUDIENCE MEMBER: Just a quick question. It sounds as though from your perspective you've really blended administrative and clinical supervision through your process? RUTHIE POOLE: Yes, I, yes. We are, our ideal would be the, like the man I told you about who for 25 years was a clinical social worker and then came out and he really gets the peer specialist role. He doesn't do clinical social work anymore. I need to put you, put that. He's the lead peer specialist but he's management in this humungous agency so he has a lot of respect and power. That's always good. People who have respect and power in an agency, it's better for the people working for them. Does that make sense? DANIEL FISHER: He's at the administrative level and there are, he has ten or 12 peers that are in his division, and some of them actually supervise online. Yeah. So there's, there's both. He meets with the top management though. He's a top manager. And that gives a lot of protection, if there's a problem he can help work it out at a management level. I wanted to just also mention, I really can't go into details, there are so many waivers. Who said Massachusetts has 13 waivers? Maybe you did. Yeah. I mean, they're not all, they're not all Medicaid, mental health waivers. There are developmental disability waivers and elder care waivers, but this, this is probably the most comprehensive one is the 1115 waiver. That's the statewide waiver. And the other one that they think is the best, federal Medicaid, and that's 1915(i), just in case you want to, I don't know, advocate for waivers in your state. They give you more flexibility. Michigan and Tennessee, I just called a few peers who are running, there is for instance, in Tennessee and in Georgia, the consumer organization actually runs the Medicaid reimbursement mechanism. Yeah. And they, so there is a precedent for a nonclinical, non-mental health center actually hiring, supervising, and billing for peer specialists, and they, they don't love it but they're locked into this 15 minute unit of service. But that's their mechanism for funding, and they have been able to work it out. You might want to talk to them about how they worked it out. Part of is volume. You know, you really need a large volume, and they cover the entire state, and they have, you know, regional directors and they, they have additional funding from the state. You do RLC, additional funding for infrastructure, so maybe between, you know, talking with them and I think for independent living centers, you have infrastructure funding, right? I mean, you have the federal government guarantees a certain amount of money per independent living center. Okay. So the, I think, we've looked at some of these others, the rehab option has been discussed here. That's really not where you have independent practitioners, they're part of a team, they're part of a package. That's difficult to be in that position. You're part of a clinical team. I mean, you have to meet with the clinicians and you have to conform with their clinical approach, and, but if you don't have a job, that looks pretty good for a while. The money follows the person, difficult, I mentioned that because we have this IMD exclusion. I won't go into that again, personal care in 38 states. I do want to say something about this last one, because it's a real, real big problem. Peers, especially intentional peer support, and also the International Association of Peer Specialists, INAPS, has come up with a set of ethical guidelines and standards of practice, and they're very important and they should be adopted by each state. They should be adopted by the federal government, anyway, they've been out for about a year. RUTHIE POOLE: I would be happy to share with anyone what our, there's, on the INAPS website, I think you can get theirs, but I would be happy to share Massachusetts. We actually publicly make people sign our code of ethics and that's partly why we do that is we want to publicly acknowledge they are saying they will follow the code, even under pressured times from their agency, and also, it protects them with their agency. They can say, when their agency wants them to do something that they know violates the code, they'll say, hey, I signed the code of ethics and the state agrees with our code so I really shouldn't be doing what you're asking me to do. DANIEL FISHER: I'll give you a few, I'll have to see how much Massachusetts is the same or differently. Here are a few, the ones that INAPS put together. That services by peers should only be voluntary. Not coercive. They should nurture hope. They should be nonjudgmental. They should be respectful, empathetic, foster change, be honest and direct, share power. That's where it's a problem. You can only share so much power if one person getting paid and the other person isn't, and be as mutual as possible, but also I'd say, be honest and share the fact, if you're getting paid and they're not getting paid, this is inherently an unequal situation and share what are the limits? If you're told that, you know, you have to, to share with the clinical team, if somebody says that they're not sure about, you know, their life, you have to say, well, it's not in my code of ethics but I understand I am paid by you all. RUTHIE POOLE: And Dan, what we do in our, because I'm someone who tests people all the time. You know, we ask, what's the most important code of ethics and the most important code, the answer to that question in the oral exam is, to support someone's self-determination. That's our first DANIEL FISHER: Don't be coercive, within limitations of what you can do within your organization. Now, I have recommended that there be a code of ethics and standards of practice for organizations that hire peers and it's very simple. What I did was take each of the code of ethics of the peers and they should be applied to the organization. So we would then say that the organization should work towards not being coercive, and not interfere, and only build trust and build recovery. And that alternatives to hospitalization should always be supported first, if possible. That the organization should nurture hope. And believe in recovery. That the organization should be nonjudgmental. So just take each one of the code, the factors in the code of ethics and say, these need to be a systemic part of the organization that's hiring peers. That means training of your entire staff, and the reason for this is, not only is this good practice, but also it is a reasonable accommodation, because if you're in your own recovery as a peer, you don't want to work in an organization that takes away hope and is judgmental and is coercive. You're looking around and go being, ha, this is traumatizing me because it's contrary to my own values of recovery. So hiring, if you want to hire peers, I think you really need to adhere as an organization to these code of ethics and practice guidelines for all your, all your practitioners, whether they're peers or not peers. Is that clear? Is that, what do you think about this idea? You understand why as a peer you'd want to have this occur? Do you think it's possible? I mean, as an organization, you could be faced just as a community mental health center is, with some very hard choices. You could be faced with having to answer to a funder that said, we need diagnostic categories, we need, you know, treatment plans, we need progress notes. I mean, the keeping of progress notes, that should be in here actually too. I don't know if it's in the Massachusetts code of ethics, but you're asked by a lot of providers, a lot of, you know, insurers to come across with a progress note every time you see somebody. RUTHIE POOLE: And that I can't speak to directly because I don't work on a CBFS team and maybe you can, Justin, but I think Zeray King is the queen of knowing how to write that stuff, that's acceptable to rehab option. Zeray King. Do you know her? Well, she's at a provider in Boston. It's very interesting, a tragedy happened there where a staff person was killed by a client. You know, it's one of those one in a million things. And what's wonderful about that agency is they kept with their values and ethics and they could have gone a completely different way. It's a Boston-based agency, and so what was, what's pretty cool is, this woman is just incredibly creative. She comes from both nonprofit and for profit world and she's brilliant, and so she has a way of doing progress notes that keeps people's confidentiality and it keeps Medicaid happy. So I would recommend contacting Zeray King at North Suffolk Mental Health Center in east Boston. JUSTIN BROWN: Some peers will simply say, I have to write a progress note, can we sit down and do this together? And then it's not the providers' note, it's the team or even the persons who is served, it becomes their note. AUDIENCE MEMBER: For the centers for independent living, do you have different rules around what population you're working with, so if you're working with people with psychiatric disabilities, your data collection may be different than other peoples? JUSTIN BROWN: Northeast Independent Living Program and maybe Sarah can speak to this, we have various programs or departments so my recovery learning community, we are totally cost reimbursement, so we do none of the Medicaid billing. And we have, you know, very minimal reporting requirements. Other billing structures for other departments are very different and so, yes, there's a very different set of rules, depending on the funding source. AUDIENCE MEMBER: Those folks aren't showing up in your 704 report? JUSTIN BROWN: Excuse me? AUDIENCE MEMBER: Those folks aren't showing up in your 704 report? SARAH LAUNDERVILLE: For us, they are, yeah, just so we don't accept, or we don't use Medicaid money at all, though, so we're using our 704 money, so of course, providing that peer to peer service we're documenting the way, so, that's our federal funding that comes to centers for independent living. DANIEL FISHER: You all I don't that. Every state gets 704, yeah. SARAH LAUNDERVILLE: So Mike, I think, though DANIEL FISHER: How much that is? Percent AUDIENCE MEMBER: It depends. Our center does not have any federal money but we have state money but we have the same reporting requirements using the same forms, so DANIEL FISHER: 250,000 per center, something like that? AUDIENCE MEMBER: It varies widely. There is no rough number. DANIEL FISHER: Mike would know. PAULA MCELWEE: I'll help. A couple of things, first of all, the way that centers evolved, there were some centers that applied for federal funds directly, and the numbers are all over the map. And then there are some states that get an allotment and some of those are part B centers, that's the state dollars, all of them do the same report. The word we have about that report, although all this may change, you know, because we're changing who oversees the centers we have, we have changed who oversees the centers, the last word we had on the 704 report, you report everyone you serve regardless of funding source. AUDIENCE MEMBER: For Virginia, because we're different, we have actual state dollars, and we have part B dollars and six CILs PAULA MCELWEE: Lots of CILs do. AUDIENCE MEMBER: Every state is different. PAULA MCELWEE: Lots of CILs. Most states have part B and part C. But you still put 704 report, that was your question, right? You count everybody on your 704 report. JUSTIN BROWN: So we report across departments, but the reporting requirements for each department are different, at least in terms of internal, you know, progress notes or something like that are quite different, even though, of course, even though we want to talk about all the persons served across the whole independent living center. AUDIENCE MEMBER: Expand for a minute on that, it's very prescriptive of who you're going to report on, because you have to have five components of that, consumer service record, blah, blah, blah, so I'm wondering if some of the CILs that provide those peer supports don't put them in as a CSR and have a different program, much like for example, we have a durable medical equipment program so we don't do the five components of a CSR, we count them but not in that, not in our numbers of direct service. MIKE BACHHUBER: I know that the center in Wisconsin, that's most heavily invested in certified peer specialists, uses the same reporting system for CPS clients as they do for other IL center clients, and reports them all in the 704 report. I think the, the extent that you make notes do tend to be determined a little bit by the funding source, so you have to make sure that you meet whatever requirements your funding source is putting up and so if, if these are Medicaid funded folks, they're going to have to keep notes that are sufficient for the Medicaid program. If they're funded out of some kind of private funding, for instance, a health insurance, they're going to have to keep whatever kinds of notes the insurance company is requiring. So they use the same system, but what kind of, how extensively you note and what kinds of things you put in the notes may differ from, depending upon the funding source. AUDIENCE MEMBER: I just, I think it's mostly been covered. I wanted to clarify, the reason that was coming up was because on 704 report, in a lot of state reports, things like demographics are required, so we do have to record diagnostic categories to some extent. And I remember someone yesterday was horrified at the idea that you would ask a caller immediately what their disability is. We're kind of stuck because we have to. We can put someone down as did not disclose, but we're technically required to ask. Just you know if someone calls to ask what the phone number is for the accessible taxi company, we have to ask them, you know, their date of birth, their name, their disability, their address, their phone number, like all these kinds of, their gender, all these kinds of information that people don't really want to divulge when they're calling I&R for a simple question, but some of it is really reporting driven. So, it stinks but there we are. AUDIENCE MEMBER: Different states with funding streams, they often see people that are on Medicaid, which is a majority, which I think is, transitioning people, because many people don't live with their parents and you have to report them as separate. So I mean, it makes it kind of tricky. I think it would be good if more states had more funding stream to help people become more independent and I know Missouri has a couple of them. Works differently, 44, but generally they like to divide services by county and the county has a board to decide where to fund the money and a lot of the activities, services are very, there's very reduced fee and often they are free, but also individuals with Autism in Missouri, there are Missouri regional centers and different regional centers, they provide sometimes over a thousand dollars in funding to each person, and come up with, funding you go to, and I think that's often, it's quite successful in many states where maybe Medicaid isn't paying for all the peer to peer independent living services. SARAH LAUNDERVILLE: So we've come to the end of our funding conversation time, and just want to thanks everybody.