Williams v. Quinn Consent Decree 2011 Mandated Annual Report
||Table of Contents
||Number of Consumers, Units of Service and Expenditures for Williams Class Members and Money Follows the Person Initiative
||Number of Individuals Estimated to be Transitioned in Calendar Year 2012
||Williams Consent Decree
||Williams Consent Decree Implementation Plan
||Williams Semi-Annual Report #1
This State Mandated Report is being submitted in accordance with 20 ILCS 1705 Sect. 73(a). The statute requires the Department of Human Services to submit an annual report to the General Assembly concerning the implementation of the Williams v. Quinn Consent Decree and other efforts to move persons with mental illnesses from institutional settings to community-based settings with services and supports. The first report is due December 31, 2011. Appended to this report are data requested that specify numbers of persons who have been moved from institutions to community-based settings during the year, numbers of persons who are projected to move during the upcoming year, statistics reflecting the number and types of community-based services provided to those persons and all costs associated with transitioning residents from institutional settings.
To satisfy the requirements of the statute and to properly represent the extensive efforts of the inter-governmental agencies' collaboration (DHS/DMH, IDPH, HFS), this report seeks to offer the reader a thorough understanding of the Williams Consent Decree, the Implementation Plan and other transition efforts, such as the Federal Money Follows the Person (MFP) demonstration project and other transitional assistance activities to support relocation from institutional settings to community-based settings.
Williams Consent Decree
On September 29, 2010, the State of Illinois entered into a Consent Decree, settling the Williams v. Quinn class action lawsuit, first filed in 2005. The lawsuit alleged that Illinois was in violation of Title II of the American with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act by "needlessly segregating" Plaintiffs, a class of 4,500 Illinois residents with serious mental illnesses (SMI) living in institutional settings, nursing homes designated as Institutes of Mental Disease, and denying them opportunities to receive services in more integrated settings. Though the State denied liability and any violation of these federal laws, the Parties to the suit were always fundamentally in agreement that, when clinically appropriate, consistent with the parameters now set forth in the Williams Consent Decree, all persons with SMI currently residing in nursing facilities designated as Institutes of Mental Disease (IMD) in Illinois have the right to choose to live in community-based settings, and that the State has an obligation to expand the current community-based service system to support the needs of those individuals. This is in keeping with an aim of providing services to an individual in the least restrictive and most integrated setting possible. In addition, the State firmly asserts that Recovery Principles, a set of fundamental beliefs that persons with mental illness can recover and live purposeful lives, should guide all systems reform efforts and frame the development and expansion of all services. An effective recovery-oriented mental health service system is also individualized and person-centered, involving the individual (and, if appropriate, their families or significant others) in the planning of their services, including soliciting and respecting the individual's choices and focusing on the individual's strengths as well as their needs. The State proposes not only to expand the current system of care, but to create a number of recovery-oriented system enhancements in both services and housing, designed to assure that each person choosing to move from an IMD has the best opportunity for a successful transition to community living.
Transition Coordination/Community-Based Services
As stated in the Williams Semi-Annual Report #1 (Appendix B ), services authorized pursuant to 59 IL Administrative Code 132 (Medicaid) include the following: Mental Health Assessment, Psychological Evaluation, Treatment Plan Development, Assertive Community Treatment, Case Management, Community Support, Community Support Teams, Crisis Intervention, Community Support Residential, Mental Health Intensive Outpatient, Psychosocial Rehabilitation, Psychotropic Medication and Therapy/Counseling. After a review of the needs of a sample of IMD residents it was determined that expansion of services would be optimal and that service development should be ongoing and driven by the needs of Class Members. Initial service expansion includes the following components that are funded as indicated in the parentheses.
- The purpose of Transition Coordination is to assure that the right systems and supports are in place to effect successful transitions for all Class Members making the choice to resettle into the community. The ultimate goal of Transition Coordination is to create a seamless interface between transition efforts and community-based supports that include community mental health services, healthcare services and other resources. (NON-MEDICAID, RULE 132 MEDICAID)
- Supported Employment is an evidence-based practice defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services as "an approach to vocational rehabilitation for people with serious mental illnesses that emphasizes helping them obtain competitive work in the community and providing the supports necessary to ensure their success in the workplace." (NON-MEDICAID)
- Supported Education provides support and prepares people with psychiatric disabilities to achieve goals in a natural school or campus setting. Built on a Psychosocial Rehabilitation model, supported education addresses problems related to achieving educational success, such as managing stress, improving academic skills, problem solving, self-confidence, and career development. (NON-MEDICAID)
- Peer Support is "a set of peer-based activities that engage, educate and support an individual successfully to make life changes necessary to recover from disabling mental illnesses." The activities that comprise this service are education and coaching. A key element contributing to the value of this service is that Peer Support Specialists appropriately highlight their personal experience of lived experience of recovery. (RULE 132 MEDICAID)
- Family Education and Support is a "method of working with families in partnership with families to impart current information about the illness and help them to develop coping skills for handling problems posed by mental illness in one member of the family." (RULE 132 MEDICAID)
- Recovery Drop-In Centers are distinct locations where individuals with mental illnesses create and operate an environment of support, socialization, self-direction, and empowerment. The environment is distinctly non-clinical in nature, and participation does not require a mental health assessment, treatment plan, or direction from other than the individual's personal expectations for themselves and their recovery. (CAPACITY GRANTS)
- Crisis Diversion provides brief periods of care to persons with mental illnesses within a Crisis Residential site when they are experiencing a psychiatric crisis to assist them to return to and maintain housing or residential stability in the community, continue with their recovery, and increase self-sufficiency and independence. Services include 24-hour room and board, supervision, therapeutic support services, medication management/stabilization and education, milieu therapy and nursing services. (CAPACITY GRANT for ROOM AND BOARD)
The DHS/Division of Mental Health (hereafter known as the Division) issued a Request For Information (RFI) in August 2011 to identify contracted community mental health service providers who are willing and capable of providing the above services and supports to the first year's target of 256 Class Members in a manner that maximizes the likelihood of Class Members long-term success in the community. Information was requested that would best clarify which agencies could partner with the Division to develop the service capacity to meet the needs and effectively provide the array of existing mental health services to Class Members in their preferred geographic area of housing relocation. A person-centered, recovery-oriented approach was required as Class Members will have several decision choices that will be honored. These include geographic preference for housing and provider selection. To this end, the selected agencies had to be willing to comply with this service provision framework, exhibit acceptable capacity, and also be able to execute considerable flexibility to effectively meet the needs and choices of individual Class Members, that may evolve and change over time. Indicators to select provider agencies were based on the following:
- Financial stability;
- Existing Assertive Community Treatment (ACT) or Community Support Team (CST) services;
- A desire and commitment to serve Williams Class Members, with preference given to agencies that have a history of serving consumers who have transitioned from nursing facility level of care;
- Ability to provide a full range of services.
After analyzing the responses to the RFI, the Division identified Trilogy, Inc. (Chicago), Thresholds (Chicago), Community Counseling Center of Chicago (Chicago), Human Service Center Peoria (Peoria), Lake County Health Department (Lake County) and Heartland Health Outreach (Chicago) as its potential partners for the provision of services to 256 Class Members in FY12. Analysis of selected agency capacity revealed that:
- These agencies could meet the initial needs of Williams Class Members by maximizing existing ACT and CST team capacity, and;
- Further capacity can be developed as it is needed by these agencies obtaining Rule 132 certification for ACT and CST service provision for some of their high intensity teams.
Further analysis of selected agency capacity revealed that in year 2 the additional 384 Class Members' needs can be met by start-up of additional ACT and CST teams. This can be accomplished by the beginning of FY13. The phased approach provides the Division with the flexibility needed to initiate services consistent with the flow of individuals from the IMDs to the community.
The Williams Consent Decree requires that the State of Illinois offer 256 Class Members the opportunity to transition from the IMD to the most integrated community-based options, specifically Permanent Supportive Housing in the first year of implementation (July 1, 2011-June 30, 2012). By the close of the second full year of implementation (July 1, 2012-June 30, 2013) a cumulative total of 640 Class Members are to have been offered the opportunity to transition to community-based settings. It is anticipated that the State will meet these benchmarks. Thus far, efforts have been directed toward developing an operational infrastructure in accordance with the Court approved Implementation Plan. Outreach and Information Dissemination activities began in October 2011. These activities, contracted and provided by the National Alliance for the Mentally Ill of Greater Chicago, assured that all Class Members have comprehensive information about the Williams Settlement, their rights as Class Members for choice and decision-making, and full knowledge of the next steps in the implementation design, e.g., resident review assessment and transition coordination/community services. As of this writing, more than eight hundred Class Members have received information about their rights under the Williams Settlement in individualized, private meetings with Outreach Workers. Resident Reviews will begin in mid-January 2012. It is anticipated that the first Class Members to transitions from IMDs to community-based settings will occur in mid-February or early March 2012.
The Consent Decree stipulates that a Compliance Report be submitted to the Court Monitor, Dennis Jones, MBA/MSW, and Plaintiffs on a semi-annual basis with sufficient information and detail to evaluate the State's compliance with the requirements of the Consent Decree. The first Williams Semi-Annual Report was submitted to the Court Monitor November 30, 2011 (see Appendix C).
The Consent Decree also stipulates that within 60 days after the end of each year of service the Court Monitor will prepare a written report to the Court and the Parties regarding the Defendants' compliance with the Consent Decree. The Court Monitor's report will be submitted as an amendment to this State Mandated Report no later than 10 days after receipt.
Status of Named Plaintiffs
In accordance with the request of the Consent Decree, attempts were made to transition all four of the named plaintiffs. The current status of the named plaintiffs is as follows: Two of the four moved into their own apartments and have been living in these settings since January 2011. One plaintiff, who carries a dual diagnosis of mental illness and developmental disability, chose to transition to a Community Integrated Living Arrangement (CILA) and has been there for almost one year. The named plaintiff, due to healthcare challenges and cognitive impairments, currently is a resident of a Supportive Living Facility (SLF).
Money Follows the Person
The Division of Mental Health has been a partner agency in the Federal Money Follows the Person demonstration since its inception in 2009. With the Illinois Department of Healthcare and Family Services (HFS) as the lead agent for MFP, the Department of Human Services, Divisions of Mental Health, Development Disabilities and Rehabilitation Services, and the Illinois Department of Aging have made aggressive efforts to collectively change the lives of many former residents of non-IMD nursing homes and afford them opportunities to move, live and thrive in the community in their own apartments or homes with support services. More specifically to the Division of Mental Health, the work efforts of Heartland Health Outreach, a Division contracted vendor which serves as the Transition Coordination entity for MFP in Cook County, the twelve contracted Division community mental health centers in Region 1, and MFP in Rockford (Winnebago County) have assisted more than two hundred individuals to move from non-IMD nursing home settings to the community. Each of these individuals has had an opportunity to move into their own apartments, to be lease holders and to assume responsibilities in the fabric of the larger community networks.
In calendar year 2011 (to date), ninety former residents of non-IMD nursing homes in Cook County who have diagnosed serious mental illnesses (SMI) moved into their own apartments. These former residents, now tenants, received community-based mental health services within the array of existing services available in the Division service taxonomy. Services are geared toward the individualized needs of each person, so there are varying levels and intensity of services provided. It is important to note that there are additional cost factors associated with the transition of these former residents that are outside of a cost analyses that can be compiled by the Division of Mental Health. This is particularly true with the costs associated with medications and inpatient medical care. Further analysis of this information will have to be completed in concert with the Department of Healthcare and Family Services.
It is important to recognize that there is also an associated cost for individuals to access and maintain affordable housing. The majority of residents of nursing homes do not have the financial means to access competitive rental housing. Supplemental Security Income (SSI), at approximately $700.00 per month, does not allow most people to live with any quality of life without other outside supports. Coincidentally, one of the major factors for Long Term Care admission and subsequent readmission is the lack of affordable housing stability, which exacerbates psychiatric and medical decompensation and slows the recovery processes. As planned with the Williams v. Quinn implementation, the Money Follows the Person demonstration has overlaid a Permanent Supportive Housing/Bridge Subsidy model and an associated Transition Fund amount for each person who meets income eligibility (30% or below Area Median Income). This means is that a resident who transitions from the nursing home under the MFP demonstration will have a rental subsidy, similar to a Section 8 Housing Choice Voucher, to assist in making rent affordable.
Scattered-site apartments are located on the open rental housing market, through existing housing stock. Eligible apartments for these state-funded assistance programs can cost no more than the Fair Market Rental (FMR) analysis as determined by the Department of Housing and Urban Development (HUD) for the county of location. The individual must pay 30% of his or her income toward the rent (e.g., 30% of their monthly SSI) and the Bridge Subsidy pays for the remaining amount of the rental balance. While the Bridge Subsidy is conceptualized to be a "bridge" (not an entitlement) to a more permanent rental voucher, the reality is that many individuals in Long Term Care settings would not be able to afford to live outside of these settings without assistance. The ongoing annual average cost to maintain an individual in a PSH unit is $9,200. In calendar year 2011, the Division incurred a cost of $354,340.55 to assist the ninety MFP participants live in their own apartments; this cost must be annualized for subsequent years. Additional costs are incurred as new MFP participants are transitioned out of the nursing facility settings to their own apartments.
Another non-direct service cost associated with the transition process is that of Transition Funds. As with Williams Class Members, for each MFP participant to be transitioned, a one-time allocation, averaging $2,000, is identified for the purpose of paying security deposit and utility connection (but not arrearages) and to assist the MFP participant in establishing basic household needs, e.g., a bed, bedding, linens, pots and pans, cleaning supplies, table, lamps, etc. The Transition Fund in handled by a Division contracted Subsidy Administration entity and the assigned community mental health center. Neither the MFP participant, guardian nor family members have access to these funds.
The Division assisted HFS and the Illinois Department of Public Health (DPH) with the closure of the Wincrest Nursing Home in May 2011. Wincrest, classified as an IMD, was the 25th nursing facility originally identified in the Williams lawsuit. This facility was decertified by the Federal Center for Medicaid/Medicare Services (CMMS) and its license was subsequently terminated by the Illinois Department of Public Health. The Wincrest Nursing Home formally closed in May of 2011. Twenty-one (21) residents of Wincrest transitioned from this facility into the community, into either Permanent Supportive Housing or into Division contracted Supervised Residential settings. The service hours and array of services are depicted on Appendix D. Eight of the former Wincrest residents transitioned into a Division contracted community mental health center's Supervised Residential settings. The remaining individuals moved into their own apartments with the assistance of a Permanent Supportive Housing/Bridge Subsidy and Transition Funds. As with those residents who were identified and moved under the MFP demonstration, the acuity levels and service needs of the Wincrest residents who transitioned to community-based Permanent Supportive Housing were closely assessed to assure that the existing service system had the right supports in sufficient quantity to appropriately meet the needs of each individual.
Both the Wincrest closure and the MFP demonstration have an infrastructure base with partnerships and intergovernmental planning with other bodies, including HFS, DHS and DPH. However, Division agencies have historically been proactive in assisting individuals to move out of nursing home settings to the community, specifically residents of IMDs. This pattern continued in calendar year 2011. Several of the Divisions' contracted vendors moved an additional nineteen residents from IMD settings into the community.
Table 1, Number of Consumers Seen, Number of Units of Service and Expenditures for Williams Class Members and Money Follows the Person Initiative - Calendar Year 2011
||Williams Consent Decree
||Money Follows the Person Initiative
|Number of Consumers Seen
|Number of Units
|Expenditures/Community MH Services**
|Average Expenditure/Community MH Services
|Total Expenditures-Service and Transition
* 5 individuals classified as Williams Consent Decree did not receive community based services; Average Community Service Cost is based on 44 individuals
** Includes Estimated Costs for Residential Services
Table 2, Number of Consumers Seen, Number of Units of Services and Expenditures for Williams Class members and Money Follows the Person Initiative Partitioned by Type of Service - Calendar Year 2011
|Type of Service
||Unduplicated Count Consumers
||Avg Cost Per Consumer Per Service
|Williams Consent Decree (N=49*) -Psychological Evaluation
|Williams Consent Decree (N=49*) -Treatment Planning
|Williams Consent Decree (N=49*) -Crisis Intervention
|Williams Consent Decree (N=49*) -Case Management-LOCUS
|Williams Consent Decree (N=49*) -Case Management
|Williams Consent Decree (N=49*) -Medication Monitoring
|Williams Consent Decree (N=49*) -Medication Training
|Williams Consent Decree (N=49*) -Medication Administration
|Williams Consent Decree (N=49*) -Assertive Comm. Treatment
|Williams Consent Decree (N=49*) -Community Support
|Williams Consent Decree (N=49*) -Therapy/Counseling
|Williams Consent Decree (N=49*) -Psychosocial Rehabilitation
|Williams Consent Decree (N=49*) -Intensive MH Outpatient
|Williams Consent Decree (N=49*) -Supervised Residential$8,083 *
|Williams Consent Decree (N=49*) -Supervised Residential 2*
|Williams Consent Decree (N=49*) -CILA
|Williams Consent Decree (N=49*) -Sub Total - Services**
|Williams Consent Decree (N=49*) -Transition Fund Security Deposits/Utilities
|Williams Consent Decree (N=49*) -Transition Fund Card
|Williams Consent Decree (N=49*) -2011 Monthly Rental Subsidy/Total Dollars YTD
|Williams Consent Decree (N=49*) -Subtotal Rental/Transition Funds
|Williams Consent Decree (N=49*) -Total - Community Service and Rental/Transition Funds
|Money Follows the Person (N=90) -Psychological Evaluation
|Money Follows the Person (N=90) -Treatment Planning
|Money Follows the Person (N=90) - Crisis Intervention
|Money Follows the Person (N=90) - Case Management-LOCUS
|Money Follows the Person (N=90) - Case Management
|Money Follows the Person (N=90) -Medication Monitoring
|Money Follows the Person (N=90) -Medication Training
|Money Follows the Person (N=90) -Medication Administration
|Money Follows the Person (N=90) -Assertive Comm. Treatment
|Money Follows the Person (N=90) -Community Support
|Money Follows the Person (N=90) -Therapy/Counseling
|Money Follows the Person (N=90) -Psychosocial Rehabilitation
|Money Follows the Person (N=90) -Intensive MH Outpatient
|Money Follows the Person (N=90) -Supervised Residential*
|Money Follows the Person (N=90) -Supervised Residential 2*
|Money Follows the Person (N=90) - CILA
|Money Follows the Person (N=90) - Sub Total - Services**
|Money Follows the Person (N=90) -Transition Fund Security Deposits/Utilities
|Money Follows the Person (N=90) -Transition Fund Card
|Money Follows the Person (N=90) - 2011 Monthly Rental Subsidy/Total Dollars YTD
|Money Follows the Person (N=90) -Subtotal Rental/Transition Funds
|Money Follows the Person (N=90) -Total - Community Service and Rental/Transition Funds
*5 individuals did not receive community based services
** Includes Estimated Costs for Residential Services
Number of Individuals Estimated to Be Transitioned in Calendar Year 2012
||Number of Individuals
|Williams Consent Decree - Year 1
| Williams Consent Decree - First 6 Months - Year 2
|Money Follows the Person Initiative - First 6 Months
|Colbert Consent Decree
Appendix C (see Williams Consent Decree)
Appendix D (see Williams Consent Decree Implementation Plan)
Appendix E (see Williams Semi-Annual Report #1)