A two year plan of the Department of Human Resources, Division of Mental Health, Mental Retardation, and Substance Abuse

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C BECOMING A WORLD-CLASS SYSTEM
A Two Year Plan ofthe
Department of Human Resources Division of Mental Health, Mental Retardation
& Substance Abuse
June, 2001

TABLE OF CONTENTS

Preface ....................................................................................... i

Introductl.on

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Evaluation of Previous Biennial Plan.................................................... 1

Serving Adults with Serious Mental Illness.............................................7

Serving Children and Adolescents with Serious Emotional Disturbance..................................................... 11

Serving Persons with Mental Retardation and Other Developmental Disabilities........................................................ 14

Serving Persons with Substance Abuse Problems .................................... 18

Overview of Prevention Services........................................................22

Regional Planning for Statewide Priorities .............................................26

Strategic Planning for the Facility System............................................. 32

Budget.......................................................................................34

Future Directions...........................................................................36

Preface
The mission of the Georgia Department of Human Resources (DHR) is, in partnership with local communities, to assist individuals and families in achieving safe, healthy, independent and self-reliant lives. The Division of Mental Health, Mental Retardation and Substance Abuse (DMHMRSA) is a division in the department and a member ofDHR's team of human service providers committed to achieving the DHR mission. The division provides the overall direction for the MHMRSA system, including the establishment of statewide priorities for mental health, mental retardation and substance abuse services.
This plan is the two-year plan of the Division of Mental Health, Mental Retardation and Substance Abuse, as required by the Official Code of Georgia Annotated 37-2-7. The purpose of this plan is to give an overview of current MHMRSA services and to lay out a two-year plan for services, organization and management. It is the third biennial plan since the reform of Georgia's MHMRSA system in 1993.
The state MHMRSA biennial plan is based on community input to Regional MHMRSA Boards, including input from citizen board members, consumers, advocates, public and private providers, and other citizens throughout the state. As required in Georgia Code, this plan reports on accomplishments since the previous plan. This biennial plan also includes an overview of current services, programs, and goals of MHMRSA Regional Boards and presents information on future directions. Finally, this plan provides an overview of the budget for the division and regional boards for Fiscal Years 2001 and 2002.
The strategic direction for the division is to improve MHMRSA service quality by making evidence-based practices - standard practice, and bringing the parts of the system into one, integrated service system. The goal for the division is to become a world class system.

INTRODUCTION
This plan is the third two-year plan of the Division of Mental Health, Mental Retardation and Substance Abuse (MHMRSA) [State Fiscal Years 2001 (July 1, 2000 June 30, 2001) and 2002 (July 2001- June 30, 2002]. It gives a status report of progress toward meeting the goals and objectives of the previous plan. The plan also identifies important issues for each disability group and highlights future directions in services. The plan references the division's collaborative planning with multiple state agencies and other stakeholders towards the development of an integrated service delivery system.
In 1993, the Georgia legislature passed a sweeping reform ofMHMRSA service system through passage of House Bill 100. This reform created the framework for a new MHMRSA public service system with more local control and strong input from consumers and family members. Local governing boards for planning and coordinating all MHMRSA services on a regional basis were established. These regional boards are the "front door" to the service system. They assess the needs in their regions and allocate all public funds based on regional plans to meet those needs. They contract with public and private providers for community and hospital services, monitor these services and evaluate whether or not they actually help consumers.
The members of the regional boards are appointed by county commissioners; every county has representation on the board, based on population. Most importantly, at least half of the regional board members are consumers and family mempers. These are people who know first hand what it means to have a disability or live with someone who does, and what assistance is needed to meet the daily demands of living and being a part of the community.
The Division of MHMRSA, at the state level, sets state priorities, establishes policies and communicates its expectations for operational and service-delivery improvements. These decisions are based on continuing studies of evidence-based models, contemporary research, the experiences of other states and work already done. Most influential on the state's plan, however, is the input gained from the thirteen (13) regional boards. The Regional Board Annual Plans reflect accomplishments, needs, and priorities at local levels as expressed by consumers and families, community stakeholders, and providers. The division develops a statewide plan every two years with the information gained.
The plan describes the improvement directions planned for Fiscal Years 2001 and 2002. Planning and implementation of the Governor's Revenue Maximization Initiative creates opportunities for the MHMRSA system by maximizing available resources. Movement from the Medicaid Clinic Option to the Medicaid Rehabilitation Option represents a significant philosophical shift for the provision of public behavioral health services. With the implementation of the Medicaid Rehabilitation Option, Georgia stands on the threshold of a new service capacity with a new philosophy of service focused on the concept of hope and recovery for consumers. The growth of consumer directed services, such as PEER Centers and Peer Support, in Georgia, is consistent with this philosophical shift.
Significant expansion of community MHMRSA services in FY 2001 and FY 2002 will address unmet need for many individuals. Planning for transition from institutional
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settings, including the development of state operated services, is ensuring service provision in the most integrated setting. These directions are consistent with the United State Supreme Court Olmstead decision. The plan outlines significant actions in FY 2001 and FY 2002 that will improve the availability and quality ofMHMRSA community integrated services.
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EVALUATION OF PREVIOUS BIENNIAL PLAN
The Division ofMHMRSA is required by law to include an evaluation of the implementation of the previous biennial plan. Georgia Code specifies that the division submits an analysis of the services provided, programs instituted and progress made toward achieving goals. The following evaluation focuses on FY 1999 and FY 2000.
Adult Mental Health Services
The division's multi-year strategic plan to expand community services for adults with serious mental illness, which began in FY 1988, was completed during FY 2000. Over that period, more than $56 million was appropriated or re-directed to fund the service expansion. During the initial years of the strategic plan, services were expanded in four targeted areas: 1) crisis stabilization services, 2) case management services, 3) psychosocial rehabilitation services and 4) a range ofresidential services and supports. Following the development of MHMRSA Regional Boards, the regions began to assess their specific local needs and identified the need to expand the array of services funded through this strategic plan initiative. Services funded in recent years include assertive community treatment, new generation anti-psychotic medications, supported employment, consumer operated services, a range of crisis services and consumer and family education.
Each region met the goals established by the 20 to Work by 2000 project before the end of FY 2000. The concept of the project was to move at least 20 percent of consumers enrolled in day programs into meaningful work. Regions received equal portions of the $1.2 million Mental Health Block Grant increase in FY 2000, to support employment programs for adults with serious mental illness. Many consumers who previously attended day treatment began to work in supported or competitive employment.
During FY 1999, a total of $13,239,396 was moved from state hospitals to community services. In FY 2000, no further hospital funds were moved into community services in order to maintain accessible hospital services and to meet the increasing demand for hospital forensic services.
Regional boards emphasized stronger partnerships with the criminal justice system during FY .1999 and FY 2000. The November 1998 "Best Practices Conferenc~" provided focused training to MHMRSA system stakeholders, on treatment and supports for individuals who come in contact with the criminal justice system. One program highlighted at that conference was the Treatment and Aftercare for Probationers and Parolees program (TAPP), in the Southwest Region. Intensive case management services were provided for persons with mental illness and mental retardation who were released from state prisons. The Department of Corrections funded this pilot program and based on its success, funded four more regions to replicate the program during the second half of FY 2000. In September 1999, the division provided a technical assistance workshop for regional staff about the criminal justice system and forensic services. Training focused on the roles of the courts, sheriffs, state criminal justice system and state mental health system. It also provided participants with a review ofrelevant policies and statutes.
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During FY 1999 and FY 2000, eight regions reported providing specialized services for older adults with mental illness and four regions established goals related to older adults in their regional plans. Coalition training was conducted in one locality to promote the development of cooperative interagency work, to better serve the needs of older adults with mental illness. A second region developed an interagency coalition for this purpose, utilizing materials provided from the first training.
The development of consumer and family education programs continued statewide during FY 1999 and FY 2000, with two statewide mental illness education conferences and numerous training and certification workshops held during the period. Over 120 practitioners have been certified as Mental Illness Educators as a result of this initiative.
With the development of the system-wide Performance Measurement and Evaluation System (PERMES), performance measures were established specifically for adult mental health as well as for the system as a whole. The initial set of indicators to be implemented during FY 2000 was selected based on stakeholder preferences, national research standards and priorities of the 13 regional boards. They represent both systemwide and disability-specific values and outcomes. The system-wide indicators were Availability ofServices, Accessibility to Services and Satisfaction with Services. The indicators specific to adult services were Employment, Housing Choice, Consumer Functioning/Symptoms and Hospital Utilization. The first PERMES "Performance Profile" was published during FY 2000 and was primarily based on data obtained from a survey of almost 10,000 consumers. Comparing data from this first effort, with data from future years, should provide the state and regions with information about needed system improvements.
. Changes in the Medicaid services design were implemented in FY 2000 statewide. For adult mental health, changes included establishing out-of-clinic crisis services and revising the day treatment service into three distinct levels. These levels include day treatment, day support and peer support. Consumers who no longer need the intense clinical support of day treatment may be served in day support or peer support programs. The first peer support program to begin the process of billing Medicaid was established during FY 2000 in Americus, Georgia. The Tom Perry PEER Center provides support groups, computer training and employment support for consumers under the leadership of consumers.
Another change related to the Medicaid services design was the implementation of a statewide utilization management and review system. Providers submitted requests for reauthorization of services to an external review organization. Any denials of service authorization were followed-up between the agency and the service provider, to identify potential problems. The authorization criteria were designed to serve the consumer with the most appropriate services, for the length of time needed. Providers have reported that consumers are making progress toward their goals ofrecovery and improved quality of life, as a result of the increased service level options now available.
Statewide projects such as the development of a Single Point ofEntry and Unified Transportation are important to adult consumers with mental illness and their families. Accessibility of services in terms of ease of identifying and obtaining services, as well as
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accessibility issues related to transportation, were factors in determining Mental Health Block Grant and PERMES indicators for adult mental health.
Child and Adolescent Mental Health Services
The previous biennial plan outlined the Division's effort to expand child and adolescent mental health services to youth with serious emotional disturbances (SED) and their families. Since 1989, funding for child and adolescent mental health services has grown from under $1 million to over $38 million in FY2000. Funding has been allocated to develop an array of treatment services needed in the community for youth with SED and their families. Expanded outpatient services, day treatment services, inhome crisis services, therapeutic foster care and therapeutic group home services, and respite services have been made available throughout the state. These additional services funded with new state appropriations, mental health block grant dollars and re-directs of hospital funding, complete the first half of planned service expansions statewide by 1999.
With limited resources available to further fund service expansions, the DMHMRSA considered additional_ re-directs of hospital system funding in order to expand community services. The Commissioner of the Department of Human Resources in December 1999 appointed a Child and Adolescent Advisory Group. This group studied the community service system and the hospital system to determine which direction the division and the department should take in furthering the goals of community service expansions. The Advisory Group recommended continued expansions of community based mental health treatment services in order to meet the needs of youth with SED. The Governor's Blue Ribbon Task Force that was established in 1999 made a similar recommendation.
Based on this recommendation, in FY 2000, $128,500 ofMental Health Block Grant funding was allocated to two regions of the state to early start a planned service expansion for FY 2000 resulting from the transfer of child and adolescent beds from Southwestern State Hospital to other state hospitals. The funding was used to develop crisis care managers, a crisis group home, in-home crisis services and respite care for youth with SED.
The estimated number of youth with serious emotional disturbance (SED) under the age of 18 has increased from 121,000 to 138,497 since FY 1999. Based on prevalence estimates, over 45,000 youth with SED required mental health services from the public sector in FY 2000 and over 25,000 of these youth received services. A total of 6,164 youth received best practice, non-residential treatment services (day treatment, respite care, crisis intervention services in their homes and other settings, dedicated case management) in community-based programs close to their homes.
To give consumers and families a choice of providers, agencies other than the public sector Community Services Boards have been able to provide clinic option services and bill Medicaid. The array of services for children and adolescents with SED was modified to add day support services beginning July 1, 1999. Youth with SED now have access to services designed to build and/or strengthen age-appropriate functioning that will result in improved family and community living. Day support services include an integrated set of educational, parent education/training skills, leisure and socialization training. This
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service is less intensive than day treatment but provides more support than traditional outpatient counseling services.
In FY 2000 an outcome measurement, the Child and Adolescent Functional Assessment Scale, was utilized to measure improvement in functioning of children and adolescents served in day treatment and day support programs. In addition, satisfaction surveys were administered to youth enrolled in services. Use of this initial satisfaction survey identified the need for a supplemental family survey to accurately capture the family perception of services. As a result, plans were initiated to develop a new survey.
Mental Retardation/Developmental Disabilities Services
The previous biennial plan outlined several issues that needed to be addressed: 1) development of a stable infrastructure for community services; 2) review, development and implementation of new strategies for consumer protection; 3) quality improvement of services provided by mental retardation service centers; 4) improvements for supported employment services; 5) best use of state institutions and most efficient use of financial resources; 6) family support and 7) merging the two Medicaid waivers.
Provider and staff development are receiving increased attention. Plans are to increase provider rates.
The division has created an Office of Consumer Protection to investigate and review allegations of neglect and abuse concerning consumers with MR/DD (as well as consumers with mental illness and substance abuse problems). In addition, each regional planning staff has been augmented with a consumer protection position. Consumers who receive Medicaid Waiver services are assigned a service monitor who not only assists in planning individualized services, but also evaluates the services received. The division led a study on service monitoring. Strong recommendations have been made regarding needed changes in the role and authority of monitors, as well as issues related to service monitoring staff and provider capacity enhancement.
New division performance outcome contracting has led to improvements in mental retardation service centers by setting expectations for day habilitation and supported employment. An amendment to the Mental Retardation Waiver Program (MRWP) removed significant barriers to increasing supported employment t~ people with mental retardation through the revision of the definition of supported employment.
Emphasis has been placed on the employment of persons with more severe disabilities. The possibility of a "Medicaid Buy-In" for employed people with disabilities expands the potential to develop a larger workforce pool.
Efforts have been made to maximize the efficient use of financial resources. The closure of the state facility in Bainbridge has allowed for the expansion of community residential services by the state. The development and growth of provider capacity has been and continues to be a priority within the division..
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Family support is the most flexible service provided for consumers and their families. The addition of people with autism as recipients of family support has created a new dimension in MHMRSA services. The Regional Boards contract with a qualified provider agency to assist families in identifying service needs and in developing the Individual Family Support Plan. The services identified in the plan are either provided directly or arranged fot by the contracted agency. The expansion of family support services has been beneficial, in that it assists in maintaining developmentally disabled family members in their own homes. Training and technical assistance has also been given to providers of family support services.
The division and state Medicaid agency staff agreed in 1998 that the two existing Medicaid waivers should be merged, creating one new waiver which would better meet the needs of Georgians with mental retardation. The work to accomplish this goal has continued with broad stakeholder involvement.
Substance Abuse Treatment Services
During FY 1999 and FY 2000, women's substance abuse outpatient services continued in thirty-six (36) service sites and thirteen (13) start-up residential service sites which each included a therapeutic child care component. The addition oftherapeutic child care components marked the first time in history that these consumers have been able to access residential treatment services and have their children, up to age thirteen, live with them. Providersworked diligently to develop the concept of therapeutic child care by adding evaluation, prevention and treatment to the array of services available to the children.
The need and cost of substance abuse services in Georgia has been thoroughly documented, as well as the fact that treatment works. In an effort to address the growing problem, the department earmarked $1 million for adolescent substance abuse outpatient services in its FY 2000 budget for Region 3 (Hall/Clarke), Region 6 (Dekalb) and Region 10 (Dougherty/Thomas). None of these regions had ever received funding to develop an array of substance abuse services for adolescents.
The HIV Early Intervention and Prevention Services Program began to be administered by the regional boards. Federal Substance Abuse Prevention and Treatment (SAPT) Block Grant funds were used to provide on-site HIV early intervention and prevention services in substance abuse treatment centers statewide. Local providers offered HIV prevention counseling and HIV testing to substance abuse consumers. HIV/AIDS Risk Reduction counselors at each center established linkages between related public health and social service organizations to ensure wide-based access and availability of these services.
Synar Regulations in Georgia, a requirement of the federal Substance Abuse Prevention and Treatment Block Grant, were met through continued collaborations with the public health districts, Georgia Department of Revenue, MHMRSA Regional Prevention Specialists, Center for Disease Control, American Cancer Society, American Lung Association and CHARGe. Georgia did not exceed the allowable 20% rate of noncompliance of illegal sales of tobacco to minors and therefore has avoided penalties
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associated with SAPT Block Grant funding for substance abuse prevention and treatment services.
Substance Abuse Prevention Services
Several activities occurred during FY 1999 and FY 2000 to significantly impact the Prevention Program in Georgia. A portion of the federal Substance Abuse Prevention and Treatment Block Grant (SAPTBG) funds was designated for a statewide substance abuse prevention needs assessment. A contract was awarded September 30, 1999 to the Pacific Institute for Research and Evaluation, Inc., (PIRE) of Chapel Hill, North Carolina. The needs assessment was designed to determine the degree of substance abuse prevention services required at the state, regional and local levels. This was scheduled for completion in FY 2001.
During this period, Regional Prevention Specialist positions were established in each of the 13 MHMRSA regions, as the single point of contact for prevention. Each region was responsible for prevention planning, monitoring, evaluation and coordination with the state office, as well as with prevention advocacy, stakeholder and other local organizations. These individuals were hired by and accountable to regional directors and offered a wide range of experience and strengths in the area of prevention. To date, all MHMRSA Regional Prevention Specialists have engaged in the prevention credentialing process available through the Prevention Credentialing Consortium of Georgia, Inc.
In addition to prevention credentialing, a major step toward addressing the development of standards of prevention practice has been the development of a standard contract for the provision of prevention services. All organizations and service providers at both the state and regional levels must enter into a contractual arrangement for the provision of prevention services. Prevention is currently included in the Community Mental Health, Mental Retardation and Substance Abuse Provider Manual. Copies are distributed to all providers under contract to Regional MHMRSA Boards.
Using federal data reporting requirements under the Substance Abuse Prevention and Treatment Block Grant, a Georgia Prevention Minimum Data Set (GPMDS) system and manual was developed. The GPMDS was designed to gather process and outcome data for regional and state prevention reporting and planning. Data gathered was used to report on the use of federal prevention block grant funds. The GPMDS was a major step in the direction of developing a user-friendly, efficient and effective information management system.
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SERVING ADULTS WITH SERIOUS MENTAL ILLNESS

It is estimated that 300,000 adults in Georgia have a serious mental illness. Since the

mid- l 980s, the mental health system in Georgia has been initiating changes to

continuously improve services and supports that will enable individuals, with serious

mental illness to live successful and fulfilling lives in their chosen communities. New

advances in anti-psychotic medications and evidence-based treatments are guiding the

service system toward a greater emphasis on recovery for people with mental illness,

instead of the more traditional focus on symptom reduction and medication maintenance.

With the coming change to the Rehabilitation Option under the state's Medicaid Plan, the

opportunity for even greater recovery-focused services exists.



Where the State Stands

Georgia provides a comprehensive system of care for adults with serious mental illness. The system includes a variety of services designed to enable individuals to be productive members of their communities, while experiencing fewer crises requiring inpatient hospital treatment. Crisis services, inpatient services, medications, service coordination, employment services, day programs at varying levels of intensity, residential services, counseling and training and consumer and family education are among the services provided statewide. Other services such as assertive community treatment and partial hospitalization are provided in select regions, based on funding availability or regional determination of a particular need.
The "Blue Ribbon Task Force on Home and Community-Based Services" established by the Governor in 1999, recommended for adults with serious mental illness:
moving to the Medicaid Rehabilitation Option; and
increasing services to individuals who have mental illness and are also homeless.
These recommendations were incorporated in the Governor's Budget Proposal for FY 2002. Through implementation of the Rehabilitation Option for the state's Medicaid Plan, increased federal revenue is expected that will allow Georgia to re-finance the MHMRSA service system. With this process, many MHMRSA service enhancements will occur. Region 5 (Fulton) received funding to develop specialized ACT (Assertive Community Treatment) teams to provide services to those individuals who have a mental illness and are also homeless.
The current PERMES indicators specific to Adult Mental Health are 1) Employment; 2) Housing Choice; 3) Consumer Functioning/Symptoms; and 4) Hospital Utilization. First year PERMES data indicated that many consumers with serious mental illness want to work but are not currently engaged in services that will help them achieve that goal. Regional Boards planning for FY 2001 and FY 2002 have set goals designed to improve the provision of employment services, thus improving the outcomes for consumers.

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Another statewide priority for adults with serious mental illness has been the availability of new-generation anti-psychotic medications. These medications have been shown to be more effective in treating the symptoms of mental illness, with fewer disabling side effects, affording individuals greater opportunities for achieving a better quality of life. Regions are consistently increasing resources to make these medications available to the consumers in each region.
PEER centers in three (3) regions have established models for other regions to emulate. One of the peer centers has begun the process of billing Medicaid for reimbursement - the first time nationally that peer services have qualified for reimbursement. In the peer centers, people who are consumers of mental health services assist other consumers through mental illness education, support groups, employment assistance and social activities.
Housing for people with severe and persistent mental illness is a major concern of the state mental health system. During FY 2000, eleven mental health service providers in
rural areas applied for HUD Shelter + Care grants through the Georgia Department of
Community Affairs. Nine of the applicants were awarded grants which provide funds to pay rent for people with mental illness, who have been homeless. The service providers must arrange for the rental units and provide appropriate supports and services, to help consumers live successfully in the community and stay out of institutions. A second application in FY 2001 produced similar results, with a total of more than $7,000,000.00 in new rental assistance made available to mental health consumers through the two applications.
In December 1999, Surgeon General David Satcher released the very first Surgeon General's "Report on Mental Health." This document may be one of the most significant developments in the elimination of stigma and the acceptance of mental illness as a part of the public health continuum. Georgia's MHMRSA Regional Boards have responded by developing a variety of plans to utilize the information contained in the report to educate their communities about mental illness and the services and treatments necessary to address the problems.
A variety of collaborative efforts are underway to advance services for adults with serious mental illness. Through the Employment Committee of the Mental Health Planning and Advisory Council, co~sumers, family members, regional board representatives, representatives from the Division of Rehabilitation Services and mental health service providers are studying mental health supported employment. Their goal is to develop a challenge to the regional boards that will further enhance the efforts of the system to help more consumers obtain competitive employment.
Homelessness is still a significant problem for individuals who have a mental illness. Because of the enormity of the problem in the metropolitan Atlanta area, a coalition of advocates for individuals who have a mental illness and are homeless has formed. Adult Mental Health program staff at the Division's State Office have been participating in the work of the coalition to identify potential solutions to this problem.
As the population ages, many regions are beginning to explore more ways to provide appropriate services or to access existing services through other agencies. This has led to
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the development of several coalitions and some important linkages for mental health consumers who are aging and require additional services beyond the traditional array of mental health services. With the assistance of the American Association of Retired Persons (AARP) Foundation, which provided a trainer and materials, the state was fortunate to receive some training on building these coalitions.
Plans for the Future
Intensive case management services are funded statewide for FY 2001, for people with mental illness or mental retardation who are released from prison. The Treatment and Aftercare for Probationers and Parolees (TAPP) program was successfully piloted in Southwest Georgia in previous fiscal years.. It demonstrated that providing supports to individuals needing mental health services, as they are released from prison, helps them stay in treatment, obtain employment and stay out of prison.
The division received $5,000,000.00 in TANF resources in FY 2001 to provide mental health treatment services to TANF recipients for whom mental health issues have been identified as a barrier to employment. The service availability also extends to their children and their spouses or domestic partners if mental health issues experienced by either of these impacts negatively on the ability of the TANF recipient to become employed. The services that can be provided utilizing this funding source are more flexible and do not require the service recipient to have a serious mental illness or to meet the most-in-need eligibility criteria. Funding was distributed to regions based on percent ofTANF eligible persons in the regions, with all but one region receiving a portion of the resources. Providers have been developing specialized programs to meet the needs of this new service group. Implementation is requiring a high level of collaboration between DMHMRSA and the Division ofFamily and Children Services (DFCS). As these new services are implemented more individuals will receive the help they need to improve the quality of their lives.
Region 11 has been awarded Mental Health and Substance Abuse Block Grant funding to initiate the first Dual Disorder PEER (PEER supports Education and Employment for Recovery) Center Program in the country. This service will provide an integrated approach in treating both mental illness and substance abuse problems supportive of the recovery philosophy. This will be the sixth PEER Center initiative in Georgia.
A PEER Center for youth aged 17 to 25 will be developed outside of Metro Atlanta to help them transition from adolescent to adult mental health services. This is considered an area of unmet need and requires specialized services to prevent young adults from dropping out of service due to stigmatization and negative identifications with older mental health consumers.
In order to ensure a full range of services to people who are homeless, an Outreach Team will be initiated in Metro Atlanta. This team will engage those individuals who live on the streets, have a mental illness and/or substance abuse problem and are less likely to utilize existing homeless assistance programs.
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Individuals with mental illness, who belong to ethnic minority groups, are frequently under-served in the public mental health service system. Georgia has a large African American population and has rapidly increasing populations of other ethnic minority groups, including people whose primary language is not English. Because of this factor and increasing research and knowledge about providing culturally competent mental health services, the Georgia Mental Health Planning and Advisory Council identified training in cultural c.ompetence for service providers as a high priority need. In response, the state is developing this training to begin in FY 2001. During the first year of this five-year project, contractors are assessing the current level of cultural competence among providers statewide, relative to demographic factors. Training will be provided in subsequent years as well as an evaluation of the project and technical assistance for regional boards.
With the implementation of the Medicaid Rehabilitation Option slated for July 1, 2001, Georgia stands on the threshold of a new service capacity, with a new service philosophy. The traditional approach to services has been based on symptom reduction, treatment compliance and medication maintenance. In the new paradigm, providers will focus on the concept of hope and recovery for persons with mental illness. This philosophical shift could not happen under the Clinic Option for Medicaid services, with the tightly prescriptive services provided in the mental health center. As services move out of the clinic and become available to consumers where they are located, in a manner that encourages them to achieve their fullest potential, Georgia will truly achieve the value of consumer empowerment that has driven the development of the MHMRSA system since the reform in 1993.

SERVING CHILDREN AND ADOLESCENTS WITH SERIOUS EMOTIONAL DISTURBANCE (SED)
In Georgia, an estimated 138,000 children and adolescents under the age of 18 have a serious emotional disturbance (SED). These youth have diagnosable mental, behavioral and emotional problems that are persistent and substantially interfere with their family life, community activities and school functioning. Many of the youth with SED have also had involvement in the child welfare system, the juvenile justice system and special education services. Youth who suffer from SED must have mental health treatment and support services to develop into healthy, productive adults. They need a range of treatment services that allow them to live at home whenever possible, continue school and take part in typical childhood activities with family members and friends. Due to limited community resources, they have often been served in inpatient hospital settings and expensive residential treatment programs.
Based on national prevalence estimates, approximately 46,000 children and adolescents with SED in Georgia need services from the public mental health services sector. Over 25,000 youth with SED received services in FY2000 from providers of Regional MHMRSA Boards.
Where the State Stands
In 1988, a snapshot of services for children and adolescents with SED would have shown the following: limited outpatient services; three (3) small group homes; a few after school programs; minimal crisis services; two (2) outdoor therapeutic programs; intensive residential treatment for several hundred youth; and roughly 200 short-term hospital beds. Many youth and their families received limited or no help until their problems became crises that could not be ignored. At that point, they were sent to state hospitals or intensive treatment programs away from home.
To change this picture, in 1989, DMHMRSA began to implement a plan to create a network of treatment services. These services offered a full array of treatment options that varied in intensity and restrictiveness to meet the needs of youth and their families. With the service array, a philosophy of providing "whatever it takes" to maintain the youth in their communities became the focus of individualized service-planning efforts. The service array included:
Expanded outpatient services including diagnostic assessment, nursing assessment, service coordination, case management, individual, family and group counseling, day treatment, wrap-around services, family support, psychiatric services, treatment with new generation medications, parent education, activity therapy, and consumer education;
Crisis services, including intensive in-home therapeutic services to families in highly volatile situations, to help prevent out-of-home placements;
Respite care that provides parents and foster parents, temporary relief from the strenuous demands of caring for youth with SED on a daily basis; and
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Therapeutic foster care and therapeutic group homes for children who require treatment outside of their homes. This service can be provided in the community in a home setting with foster parents specifically recruited and trained to provide treatment to youth with-SED.
By 1999, the first phase of plan development had been implemented statewide. The services identified as needed in 1989 had been developed to 50 percent of the capacity needed. Services were funded through new state appropriations, redirection of funding from state hospitals and Mental Health Block Grant funding. Funding was utilized to implement expanded outpatient services, in-home crisis services, day treatment, respite care, therapeutic foster care and therapeutic group home services. The second phase of plan development would bring the amount and types of services needed in the community to full capacity in order to meet the needs of youth with SED. This phase of plan development was estimated to cost approximately $20 million.
The Child and Adolescent Advisory Group, a group of key stakeholders from around the state, recommended that funding be secured to complete community capacity prior to extensive reductions in state hospital bed capacity. As a result of this recommendation, the division and the Mental Health Planning and Advisory Council made a decision to allocate new Mental Health Block Grant funding for child and adolescent mental health service expansion. These additional dollars, $2,225,498, were used to increase case management, respite care, in-home crisis, day treatment and day support services for youth with SED, in six (6) regions of the state. In addition, with the transfer of child and adolescent beds from Southwestern State Hospital to other state hospitals, $940,000 of state funds was re-directed to two regions to fund crisis care managers, a crisis group home, in-home crisis services, wrap-around services and respite care services.
Plans for the Future
The Division of Mental Health, Mental Retardation and Substance Abuse and the Department of Human Resources included $2.8 million for child and adolescent service enhancements in the DHR budget request for FY 2002. These recommendations were incorporated in the Governor's Budget Proposal for FY 2002 and successfully carried forward through the 2001 legislative session. This was possible due to the Governor's revenue maximization initiative and implementation of the Rehabilitation Option for the state's Medicaid Plan. This change will allow for increased federal revenue and will enable Georgia to re-finance the MHMRSA service system. With this process, many MHMRSA service enhancements will occur. For children and adolescents with SED, the enhancements for FY 2002 include mobile crisis services and crisis group homes for six regions of the state.
In addition to the FY 2002 state funding, the DMHMRSA received an increase of $2,163,564 of Mental Health Block Grant Funding. The division and the State Mental Health Planning and Advisory Council decided to allocate these funds to further expand child and adolescent mental health services. As a result, utilizing the state funding for FY 2002 and this new federal funding, 11 regions, instead of six regions, will be able to fund mobile crisis services and crisis group homes for youth with SED.
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Since completion of the first phase of SED plan development in 1999, over $8,145,125 in hospital re-directs, new state appropriations and new federal funds have been allocated for community-based child and adolescent mental.health services. These funds provided the opportunity to begin the second phase of plan development for service expansions for child and adolescent mental health services for youth with SED.
The Division of Mental Health, Mental Retardation and Substance Abuse will continue to request funds to further needed service expansions. The "Blue Ribbon Task Force on Home and Community-Based Services," established by the Governor in 1999, recommended expansion of child and adolescent mental health services. Various service models, such as intensive family intervention, transitional support teams and peer supports for older adolescents, are under consideration for further service expansions. These models and others, such as specialty services for youth involved with juvenile justice, have evolved since development of the child and adolescent plan.
Any service expansions planned will consider evidence-based practices for child and adolescent mental health services. With the implementation of the Medicaid Rehabilitation Option slated for July 1, 2001, there will be a focus on providing services in homes, schools, courts, and any other community settings. This new approach to service delivery will lend itself well to providing services to youth and their families using the true model of the wrap-around approach. This approach is to provide individualized services in the community using a philosophy of "whatever it takes, where ever it is needed." Intensive family intervention services will be a key service in keeping youth with their families and out of more restrictive residential and hospital services.
As mentioned above, a tremendous service expansion has occurred over the last 12 years of child and adolescent mental health services. The PERMES indicators specific to child and adolescent mental health are: family supports; consumer and family involvement; consumer functioning /symptoms and out of home placements. It is hoped that data generated through this PERMES process will show positive outcomes from the services now available.
Several initiatives are being pursued in FY 2001 and FY 2002 to ensure crossdivisional and cross-departmental planning and implementation of services that more fully meet the needs of children arid adolescents with serious emotional disturbances and other problems such as substance abuse. For example, the division will continue to have ongoing meetings with the Department of Juvenile Justice on joint planning for children and adolescents that are served by both agencies. The Council of Juvenile Court Judges initiated a cross-agency planning group to develop a plan to meet the multiple needs of children and adolescents with problems. The Governor's Office will be setting up a study group on out-of home placements for children and adolescents. The division will be an active participant in this study of various placements, including foster care, shelters, community residential treatment settings, and hospitals.
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SERVING PERSONS WITH MENTAL RETARDATION AND OTHER DEVELOPMENTAL DISABILITIES
The demand for publicly funded services and supports for people with mental retardation and other developmental disabilities is increasing nationally at a rate that exceeds the growth of the general population. Over the last decade, Georgia has made remarkable progress in the number of people served in community mental retardation services and funding for community services. Yet, the state still ranks behind most other states in funding for services, and the planning lists for community services continue to grow.
One reason for increased demand is the growing number of people with severe disabilities who are living with elderly parents. It is estimated that there are 11,503 Georgians with developmental disabilities, living in households with caregivers age 60 and over (12th highest nationally). National data also indicates that the average age of children of the "Baby Boom" generation is 22 years, meaning that those with severe disabilities are now leaving special education and arriving at the door of the adult system. In the United States, about 40 percent of all individuals with developmental disabilities, who live with their families, reside in homes headed by a single parent. These individuals are twice as likely to live in single parent homes than offspring in the general population.
These population trends have clear implications for Georgia. At the beginning of 2001, there were over 2,000 people with mental retardation on the state's planning lists and the majority of these individuals were waiting for comprehensive 24-hour services. It is estimated that there are almost 90,000 people in Georgia with developmental disabilities. Services must change and grow to meet the increasing needs of this group.
Where the State Stands
The Division of Mental Health, Mental Retardation and Substance Abuse provides services to approximately 13,135 persons with mental retardation. FY 2000 data shows that day services were provided to 2,517 people, 3,112 people received specialized employment services and 1,928 people received supported employment services. Residential services were provided to 2,448 people. There are still approximately 1,460 people with developmental disabilities residing in state operated Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) and skilled Nursing Facilities (SNFs). In addition, approximately 110 people live in Georgia's one privately operated ICF/MR, and it is estimated that as many as 1,700 people with developmental disabilities live in private nursing homes around the state.
Over the last two years, the state has witnessed a significant increase in advocacy for this population. The most visible example of this upsurge has been the "Unlock the Waiting List Campaign," which is a broad-based effort focusing on increasing home and community-based (Medicaid Waiver) services for people with mental retardation physical disabilities and seniors needing community care. For FY 2001, the Georgia legislature appropriated funding to move 296 people from the Mental Retardation Planning Lists to community services. The state continued to reduce its dependence on
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ICF/MR services with the closure of the facility at Bainbridge, in December 2000. As a result, 129 ICF/MR beds are being closed statewide and 129 people are being moved into comprehensive community services.
The final FY 2000 supplemental budget included funding for family support, for individuals diagnosed with autism who are living at home. The FY 2001 Appropriations Act allocated $770,000 to continue this service. These appropriations represent several firsts for the state;
Statewide direct services funding allocated specifically for "autism;"
MHMRSA Regional Boards received appropriations designated for "family support;" and
Services offered (except in exceptional cases) to individuals who have autism, but have no mental retardation diagnosis.
~P-Ia_n_s_i_o_r_t_h_e_F_u_t_u_r_e_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____,I
On December 8, 1999, the Governor created the "Blue Ribbon Task Force on Home and Community-Based Services." Its mission was to study how to create and provide desirable community-based services to allow persons with developmental and physical disabilities to receive the support necessary to live independent and productive lives. Findings and recommendations proposed by this committee will be used to formulate future budget and programmatic requests initiated by the Governor and the division.
Directly related to the Blue Ribbon Task Force's recommendations, the Governor's FY 2002 budget included:
Services for 1,232 people on the Mental Retardation Planning Lists, including 366 people to receive residential services, 324 families to receive family support, and supported employment/day habilitation services targeted for 542 young adults exiting special education.
A four percent provider rate increase for MR waiver providers and a four percent rate increase in mental.retardation grant-in-aid funding.
Funding to serve 85 people with developmental disabilities (other than mental retardation and autism), in family support services.
The services targeted for the 1,232 people on the Mental Retardation Planning Lists will be provided through the Mental Retardation Waiver Program (MRWP). The MRWP has been amended to include new services that were recommended by Governor Barnes. The new services to the MRWP include Day Support Services, Natural Support Services and Natural Support Coordination. A description of these new services follows:
Natural Support Services are offered to individuals who do not have the necessary natural support system to assure that services are delivered appropriately to allow the
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individual to live at home and in the community. These services are focused on promoting greater inclusion and integration of individuals. The services will be offered both in and out of the home.
Natural Support Services are comprised of two services, Enhancement Services and. Therapeutic Supports. The_Natural Support Enhancement Service includes training or assistance in self-help, social interaction, daily living and adaptive skills, assistance with participation in social and leisure activities, managing health and dietary needs, respite and the training of the consumer's natural support members. The Natural Support Therapeutic Services include speech therapy, physical therapy, occupational therapy and nutritionist services as indicated and training of natural support members. The training under both services will also be used to prepare the consumer's natural support members to support the individual so that they may more adequately and appropriately take on an active support role in the consumer's life. The goal of the training in the home and community is to address self-help skills, community living skills and to promote independence.
Day Support Services are designed to assist persons in the acquisition, retention and/or improvement of skills that create a quality and appropriate day for the consumer. This service offers a combination of supports by addressing the multiple needs for an individual on any given day. This services is intended to assist the individual with community activities, facility-based training activities, pre-vocational activities, and supported employment activities and includes the administration of medication (in compliance with all state laws) during the day while participating in the service. The Individual Service Plan for persons receiving this service will reflect the specific support components as well as their frequency and duration. Individuals authorized to receive Mental Retardation Waiver Program (MRWP), Day Habilitation or Supported Employment will not be eligible for this Day Support Service.
Natural Support Coordination is an enhanced coordination of services offered to individuals who do not have the necessary natural support system to assure the delivery of services that will allow the individual to remain at home and in the community. Therefore, the individual requires a more intense and extensive monitoring of services to compensate for the identified additional need of the individual that will assure the appropriate and necessary delivery of services.
The further expansion and development of family support services, not only to people with mental retardation but also to people with developmental disabilities, including autism, will be a major goal over the next few years. The division must address major issues related to expanded consumer eligibility as well as provider capacity enhancement. As part of this process, a major statewide conference on Family Support, with an autism track, was held in June 2001. The conference was sponsored by MHMRSA, the Governor's Council on Developmental Disabilities and the State Department of Education. During the summer and fall of 2001, there will be regional training on family support and autism for family members, regional planning staff, regional board members and providers.
In FY 2001, the division set up three state-operated group homes for persons with mental retardation in Thomasville. These homes represent the first time that the division
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has established state-operated services under the Home and Community-Based Waiver Program. Staff members of Southwestern State Hospital, Gracewood State School and Hospital, and Central State Hospital are planning additional state-operated group homes under the waiver to complete the state ICF/MR discharges to the community related to the Bainbridge closure. State-operated services in the community will continue to be developed to address specialty functions, such as residential services for consumers who are very difficult-to-serve and special teams who can provide trouble shooting, technical assistance and training to any community provider when difficult situations arise.
The state of Georgia is fully committed to maintaining quality of care for consumers of mental retardation waiver services through compliance with the HCFA Protocol. The Quality Assurance Plan for the State Medicaid Home and Community-Based Services Waiver Programs ensure consumer protection, health and welfare. The division's system focuses on program quality that includes the following: quality system design, quality assurance and quality improvement. Some efforts to ensure that our system is providing the highest quality services are:
organization of a HCFA Protocol Workgroup to review the Protocol Outline, and development of tasks and strategies necessary to meet the requirements in the outline;
development of a Quality Assurance Plan for State Medicaid Home and CommunityBased Services Waiver Programs;
development of a new state policy designed to establish guidelines for tracking the monitoring and evaluation of activities and corrective action planning of all providers authorized to provide CHSS and/or MRWP waiver services to individuals with mental retardation;
revision of several existing applicable Division policies for annual review;
conducting several in-service training events; and standardized Service Monitoring and Service Coordinator reports and forms.
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SERVING PERSONS WITH SUBSTANCE ABUSE PROBLEMS
Conclusions of a study, National Estimates ofExpenditures for Substance Abuse Treatment 1997, released in April 2001, indicate that national expenditures for alcohol and drug abuse amounted to only $6.4 billion for alcohol abuse and $5.5 billion for other drug abuse, in spite of total social costs that topped $177.3 billion. Data from the study released by the Substance Abuse and Mental Health Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) show that spending on substance abuse treatment between 1987 and 1997 shifted heavily from private to public support. This trend placed an increased burden on the state to provide the bulk of substance abuse treatment services. The public sector's share of substance abuse expenditures increased from 53 percent in 1987 to 64 percent in 1997, greatly exceeding the percentage increase of all public spending on all health, which increased from 41 to 46 percent.
Current estimates from the Georgia Telephone Household Survey of Substance Abuse Treatment Need indicate that 453,583 adults are in need of some level of substance abuse treatment, and 17,208 adolescents (ages 12 - 17) are in need of some level of substance abuse treatment. Recent national surveys indicate that less than 20 percent of persons needing substance abuse services will receive treatment.
Effective treatment of substance abuse and dependence utilizes a comprehensive, biopsychosocial treatment approach; is provided by a multidisciplinary staff who are knowledgeable, qualified and specifically trained in addiction treatment and co-occurring disorders; and is based on current evidenced-based practices that have flexible and variable levels of service and lengths of treatment determined by clinical and other individual needs of the consumer.
Where the State Stands
During the past two years, Georgia has implemented a number ofmajor substance abuse initiatives. At the forefront were the implementation and expansion ofthe Ready for Work Program. In collaboration with the Division of Family and Children Services (DFCS), the Division ofMental Health, Mental Retardation and Substance Abuse (MHMRSA) received $12 million in federal "Temporary Assistance for Needy Families" funds (TANF) and $4.9 million in federal "Substance Abuse Block Grant" funds to provide gender-specific substance abuse residential treatment services for women and their minor children, age 13 years and younger, who meet the needy family definition requirements and for whom substance abuse is a barrier to employment. This collaboration has resulted in 19 gender-specific women's substance abuse residential treatment services sites throughout the state, with a capacity to provide services to 165 women. There are also 29 outpatient gender-specific substance abuse treatment program sites across the state for women who meet the needy family definition requirements and for whom substance abuse is a barrier to employment.
Therapeutic Child Care is a service provided to the children of substance abusing women who are in treatment. These children often suffer from the traumas of sexual abuse, child abuse, affection and nurturing deprivation, physical neglect, post-traumatic
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stress, lack of proper nutrition, unattended medical needs, delayed developmental issues, fear, anger, embarrassment, low self-esteem or other issues resulting from a substance abusing environment. Therapeutic Child Care provides a nurturing environment that addresses and resolves behavioral issues from a therapeutic perspective. It provides a healing atmosphere where various traumatic issues can be surfaced, addressed and resolved, resulting in healthier behavioral and relational patterns. The environment consists of nurturing, therapeutic, constructive and pro-active activities rather than punitive reactions to behavior. Therapeutic child care takes a holistic approach to children, providing the necessary resources to address their physical, mental, emotional and social development. Appropriately trained, pediatric medical and mental health professionals are available either on-site or through a professional network via contract. Therapeutic child care also provides an environment where women in recovery can learn or re-learn to interact in a nurturing, constructive and healthy manner with their children.

The federal Department of Health and Human Services, (HHS) adopted mandatory rules in 1996 that were designed to limit the sale of tobacco products to minors under 18 years of age. This legislation, known as the Synar Amendment, required that all states receiving Substance Abuse Block Grant funds:

make it illegal to sell or distribute tobacco and tobacco related products to persons under the age of 18;

provide for enforcement of these laws in such a way as to reduce tobacco availability . to minors; and

conduct annual, random, unannounced inspections of tobacco to ensure State . compliance with O.C.G.A. 16-12-170-175 enacted in 1993.

The Georgia Department of Revenue is the designated agency responsible for tobacco enforcement in Georgia. However the federal Synar regulations are tied to the Substance Abuse Prevention and Treatment Block Grant which is received by the Georgia Department of Human Resources (DHR). DHR is therefore responsible for compliance with the Synar regulations.

As evidenced below, our baseline year of 1996 shows that the rate of illegal sales to youth (non-compliance rate) was 48 percent. This baseline rate provided Georgia a point for establishing negotiated target rates for future years of Synar. For FFY 2000 and beyond, Georgia's non-compliance rate is required to be at 20 percent or less. (See table below)

Federal Fiscal Year (FFY)
Baseline 1996 1997 1998 1999 2000 2001

Negotiated Non-compliance Rate
44% 35% 28% 20% 20%

Actual Non-compliance Rate 48% 20.5% 12.9% 24.5%
19.99% TBD

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The consequence of not meeting the 20 percent non-compliance rate could mean up to a 40 percent loss in funding for the federal Substance Abuse Prevention and Treatment Block Grant. This penalty could calculate into a $17 million dollar loss of funding that would directly impact substance abuse prevention and treatment services in Georgia.
In FY 2001, the Georgia legislature allocated an additional $961,500 to the department for adolescent substance abuse services. These funds are currently purchasing outpatient treatment and intensive case management substance abuse services. The FY 2001 funds were distributed to the regions using the division's funding formula, a distribution formula based on prevalence of substance abuse and other relevant demographics.
Regions continue to purchase sub-acute detoxification and crisis stabilization services for substance abuse consumers. Intensive outpatient services and other outpatient services are available in most of the regions and their respective service areas. Regions contract for HIV Early Intervention services. Local substance abuse treatment providers collaborate with local public health departments to help substance abuse consumers assess their risk for HIV, access testing if indicated or requested, receive HIV counseling to prepare for testing or to receive counseling to learn to cope with the reality of being HIV positive.
In FY 2001 substance abuse treatment providers have participated in statewide training, in preparation for a transition to the Medicaid Rehabilitation Option in Georgia. New utilization guidelines and standards have been developed, which will give substance abuse providers new options for providing services that are Medicaid billable and not confined to being delivered in a clinic. It is anticipated that additional substance abuse services will be developed and delivered in the community.
Plans for the Future
The Department of Family and Children Services (DFCS) entered into an agreement with Division of Mental Health, Mental Retardation and Substance Abuse for a $1.2 million TANF funded pilot program. Named the SafePort pilot, it is a replication of the Safe Port, Key West, Florida program. Participation in this substance abuse residential treatment program for low-income families is earmarked for persons who receive Temporary Assistance to Needy Families (TANF) from the Department of Family and Children Services. Pilot partners include the West Central Georgia Regional Board, New Horizon's Community Service Board, Southwest Georgia Housing Development Corporation and the Department of Community Affairs.
The SafePort pilot will be located in the MHMRSA region 9 in Cuthbert, Randolph County, Georgia within a gated six-acre track. Twenty (20) apartment units will occupy this area for the pilot, to include one recreation center, one treatment and teaching building. There will also be a therapeutic component for children. It will serve approximately 20 families, recruited primarily from DFCS Child Protective Services cases. Referrals will also be accepted from the courts, parole officers and judges. In collaboration with DFCS, the Division ofMHMRSA received $7.5 million TANF funds for an expansion of the Ready for Work Residen~ial Treatment Program. This expansion
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was implemented in the Fall of 2000. A total of 145 additional slots were added across eight regions.
Georgia has the eighth highest number of AIDS cases in the United States, with 22,377 cases reported as of September 30, 2000. In the early stages of the epidemic, most people with HIV were men. However, from 1984 to 1999, the proportion of female AIDS cases increased from four percent to 28 percent. Plans to address this problem include two training conferences, each lasting two days, for staff from substance abuse treatment programs, public health services, and Ryan White programs. These training initiatives will emphasize women and HIV, including education on how to reduce the risk of perinatal transmission and the stigma attached to HIV. Regional Boards will continue to contract for HIV early intervention services with local substance abuse treatment providers, under the auspices of the HIV Early Intervention and Prevention Services Program. Monitoring and technical assistance, including a quarterly newsletter, will continue to be provided by the Program Manager.
In federal Fiscal Year 2001 Georgia received increased Federal Substance Abuse Block Grant Prevention and Treatment funds. With the federal FY 2001 Substance Abuse Block Grant Treatment increase, Georgia will begin to meet documented need for ASAM Level 11.3 and 111.5 residential substance abuse treatment services for adult males. Based on Georgia's demonstrated need for added adolescent substance abuse treatment services, a portion of the Substance Abuse Block Grant increase will be used to purchase additional outpatient slots for adolescent substance abuse treatment services. Funds from the Substance Abuse Block Grant will also be used to fund the treatment component of a Drug Court, and some funds from the increase will also be used to co-fund an SA/MH PEER Center in large rural region in South Georgia. This will be the first initiative of its kind in Georgia.
Finally, the movement to the Medicaid Rehabilitative Option will impact substance abuse services. There will be an array of Medicaid billable services, i.e., residential treatment services, peer supports, community support team, and assertive community treatment. This provides a creative opportunity to develop new treatment services that will enhance the quality of substance abuse treatment, as well as the quality of services available to individuals with co-occurring substance and mental health disorders.
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OVERVIEW OF PREVENTION SERVICES
Prevention services promote health and well-being for individuals, families and communities through a variety of strategies and activities. The division provides prevention services specifically designed to reduce the risks associated with substance abuse. While the vast majority of current funding is for services for substance abuse and violence prevention, it is recognized that these services can also be effective with the risk factors 'associated with mental illness, mental retardation, and social problems such as violence, domestic violence, crime, child maltreatment, school failure, adolescent pregnancy, HN exposure, and delinquency.
In FY 1999, 514,848 and in FY 2000: 521,473 Georgians received MHMRSA prevention services. These services were funded primarily by the federal Substance Abuse Prevention and Treatment Block Grant (SAPTBG) and the Governor's designated portion of the federal Safe and Drug Free Schools and Communities Act Grant (SDFSCG). Significant accomplishments occurred in FY 1999 and FY 2000 in the areas of service delivery and population penetration through additional state level contracting and expansion of services and provider pools, development and use of prevention needs assessment data for prevention planning, prevention specialty personnel, increased awareness of and use of research-based prevention programs and strategies, development of a data collection methodology, training, and tobacco use prevention.
IWhere the Sta.te Stands
Twenty percent of the federal Substance Abuse Prevention and Treatment Block Grant (SAPTBG) funding is allocated for primary substance abuse prevention activities. As in previous years, most of these funds are used by regional boards for continued development of their community-based prevention system. Similarly, most SDFSCG funding is used for community prevention activities and programs, contracted through the regional boards.
The 13 MHMRSA Regional Boards continue to improve in their efforts to deliver, and/or coordinate the delivery of effective, evidence-based prevention programs and activities through contractual agreements with prevention providers. The Prevention Gontract Template was revised in April 2001 to reflect more accurately Federal Ce_nter for Substance Abuse Prevention (CSAP) requirements. The planning parameters for the regions' annual planning process included requirements for reporting on prevention in the areas of needs assessment and estimates of need, service array, prior and current fiscal year funding, contracting and grant compliance.
Part of the funding from the Governor's portion of the Safe and Drug Free Schools and Communities Act Grant (SDFSCG) was used in FY 1999 and FY 2000 to continue three statewide prevention programs. In addition to these efforts, federal Substance Abuse Prevention and Treatment Block Grant funding was used to continue a fourth state level contract, the Maternal Substance Abuse Prevention and Child Development Project of Emory University. A summary of state level contracts follows:
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PROGRAM Georgia Helpline
Drugs Don't Work- operated by the Georgia Chamber of Commerce. Red Ribbon Campaign
Maternal Substance Abuse Prevention and Child Development Project

DESCRIPTION A toll-free line providing prevention information and assistance to residents of Georgia. Designed to assist employers and employees in developing drug-free workplaces. An annual weeklong prevention and awareness campaign that celebrates drug-free living and promotes community-based prevention activities and programs contracted through the 13 regional boards. Dedicated to the prevention of multiple negative consequences of maternal substance abuse. It offers a broad range of prevention services and activities based on four of the six CSAP strategies, specifically: inform~tion dissemination, education, problem identification and referral and community- based processes.

A portion of new federal Substance Abuse Prevention and Treatment Block Grant funds is designated for a statewide substance abuse prevention needs assessment. Using a framework adapted from CSAP's needs assessment model, it included: 1) a social indicator study coiprised of county level archival data indicating risk and protective factors as well as problem behaviors associated with substance abuse; 2) a youth survey, sampled at the DMHMRSA regional level and capturing the prevalence of alcohol, tobacco, and other drug use as well as risk and protective factors among youth, ages 12 to 18 years; and 3) a resource assessment identifying prevention services throughout the state.

The report on findings of the statewide substance abuse needs assessment provides information on the demographics and indicators for each region and the counties in each region. It also provides outcome recommendations for each region and counties of each region based on study findings. Regions and other prevention stakeholders can now draw comparisons of their region to others, as well as to the state average, along specific indicators. More importantly, regions are now in a better position to plan for prevention services targeted at real and specific needs identified by the data.

The awareness of the importance of prevention as well as best and promising prevention practices are among the many accomplishments in the area of prevention. All regions are utilizing research-based methods in their prevention programming. And many of the regions have contracted for outside program evaluations.

The State Office has been successful in collaborating with the Center for Substance Abuse Prevention to re-establish membership in the Regional Alcohol and Drug Awareness Resource Network (RADAR). Future plans include establishing a RADAR site at the State Office and establishing a statewide network of active RADAR sites. To date, there are seven active RADAR Georgia sites.

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A significant step in the development of a Management Information System for Prevention Program data during this period was the development of the Georgia Prevention Minimum Data Set (MDS). Designed to gather process and outcome data for regional and state prevention reporting and planning, the MDS consists of two primary forms: 1) the Summary Report, which captures general program information such as contract and funding information; and 2) the Service Report, which details numbers served and risk factors addressed for each of the service components indicated. The manual provides definitions and descriptions of evaluation methodologies as well as descriptions and examples of each of the six CSAP Primary Prevention Strategies. The data collected from the MDS is used to report prevention services to the federal government as a condition of funding and is included in the SAPTBG application submitted by the division. During FY 2000 the Minimum Data Set was used successfully by all 13 regions to report prevention services. The MDS is currently in the process of being enhanced to include the data reflecting specific regional needs.
IPlans for the Future
In FY 2001 and FY 2002 continued implementation of the State Substance Abuse Prevention Plan will occur. Focus will be on the following goals:
Strengthening the regional prevention specialist network - Increased training of Regional Boards, Regional Directors, Regional Prevention Specialists and local prevention providers Continued site visits to regions to provide technical assistance and foster planning Regularly scheduled Regional Prevention Specialist Meetings to encourage collaboration and provide networking opportunities
Establishment of measurable goals and objectives for regional prevention services Continued promotion, use and/or replication, where appropriate, of researchbased prevention programs - Use of statewide needs assessment research as a tool for regional and state-level prevention planning - Use of additional resources of data for needs assessments
Development of standards of prevention practice Expansion of the use of the "Principles of Effectiveness" (SDFSC)
- Development of state prevention practice standards
Increase in the use and awareness of research-based prevention programs - Increased application of the six CSAP strategies with special attention to initiatives in strategies 4 (Identification and Referral) and 6 (Environmental)
Development of a prevention management information system Fine tune MDS instrument and process
- Electronic submission of MDS - Develop expertise in Geographical Information Systems (G.I.S.)
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Web Site development to promote prevention in Georgia through the division website, including links to each region for information and education Development of Prevention Compilation of prevention program profiles and Georgia exemplary programs Training in CSAP Exemplary Program identification process and procedures Enhancement ofprevention programming via a Statewide Prevention Evaluation Continued and enhanced collaborative efforts with other state-level departments andDHR Re-establish partnership with Georgia Air National Guard Demand Reduction for training and technical assistance (Dobbins AFB, GA) Establish relationship with Suicide Prevention Advocacy Network (SPAN) for the development of Suicide Prevention activities Targeted initiatives by pilot programs and projects Establishment of a multi-division/departmental and community State Incentive Grant (SIG) Taskforce for the expressed purpose of developing a strong, viable, and competitive SIG proposal for submission in 2002, to include a sound plan for the sustainability of prevention services Commitment of financial resources will play a key role in the future of prevention programming. Increased federal Substance Abuse Prevention and Treatment Block Grant funding will be used for the following: A Synar media blitz as well as data tracking for enforcement validation of sample vendors; Development ofCSAP strategy #6 (Environmental) through activities such as enforcing or changing alcohol, tobacco and other drug policies, regulations or laws; and Two Ready for Work Program pilots involving the use of Therapeutic Childcare.
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REGIONAL PLANNING FOR STATEWIDE PRIORITIES

Each Regional MHMRSA Board submits to the division an annual plan at a time and in a manner determined by the division. The annual plan serves as the strategic planning and implementation document that outlines the mechanism for the funding and the provision ofMHMRSA services in the region. The plan informs the division, the Department and other oversight bodies of the Regional Boards' work in the prior year and the goals of the Regional Board for the coming year. The MHMRSA Regional Board plans provide a foundation for development of overall state plans for services that synthesize and integrate the visions, accomplishments and future work plans of all Regional Boards. The following are the Regional Boards' goals for statewide priorities for FY 2001 and FY 2002.

Access to New Generation Medication

Region 1
Region 2
Region 3
Region 4 Region 5 Region 6 Region 7
Region 8 Region 9 Region 10
Region 11 Region 12 Region 13

FY2001
Ensure access to new generation medications for all consumers for whom it has been determined that treatment with these medications would be clinically indicated. Ensure existing funding for new generation atypical anti-psychotic medications are being utilized appropriately in community-based settin s. Work with providers to increase use of indigent drug programs and develop performance contracts to encourage the usage of the new, more effective medications. Add a minimum of$25,000 from Peach Care revenue for child and adolescent medications. Centralize drug purchases in the Region in order to maximize the use of funds allocated for new generation medications. Increase the number of consumers receiving new generation medication. Continue use of new generation medications to enhance the quality of life of consumers and to maintain the Region's low utilization rate at state hospitals. Ensure optimal utilization of new generation anti-psychotic medications. Ensure consumer access to the new generation anti-psychotic medications. Ensure that consumers currently receiving new generation medications, including consumers leaving hospitals, will continue to receive these medications. Coordinate with providers to ensure access to new generation atypical anti-psychotic medications. Enhance nursing supports for new generation medication services. Continue to make new generation antipsychotic medications available to consumers who need them.

FY2002
Continue to support implementation of Patient Outcomes Research Team (PORT) for pharmactherapeutics and continue to increase access to new generation medications. Continue support for funding new generation medications.
Specify outcome measures regarding the number of adults receiving the new medications.
Use any income from Peach Care for new generation medications for children and adolescents. Ensure continuity in treatment with medications as the consumer transitions from the hospital to the community. Increase the numbers of consumers receiving new medications. Ensure continued access to new generation medications.
Utilize the PORT-based clinical criteria as a measurement process on a monthly and quarterly basis. Increase consumers' access to new generation medications. Develop a tracking protocol to assure that consumers receiving new generation medications at the time of discharge from the hospital to the community.
Coordinate with providers to ensure access to new generation medications.
Ensure access to new generation medications for individuals with severe mental illness. Continue to ensure the availability of new generation medications for individuals with severe mental illness.

Single Point of Entry

Region 1 Region 2 Region 3
Region4 Region 5 Region 6 Region 7 Region 8 Region 9

FY2001
Establish a standardized Single Point of Entry process based on uniform disability criteria, for all services in each of the 16 counties of the Re ion. Implement a Single Point of Entry for MR waiver and non-waiver consumers.
Establish a fully operational Single Point of Entry system which will improve consumer access to needed services and level of care demonstration system will be evaluated for increasing accessibility, reduced time from request to service provision, reduced consumer complaints and increased quality of initial evaluations. Ensure that people who call the crisis or intake lines or request service through any other route are given a choice of provider for any needed service. Complete and expand Single Point of Entry process to ensure appropriate referrals for service and approved face-to-face crisis assessment and intervention. SPOE providers will be specified and contracts entered. Provide Single Point of Entry as a central access to services. Work with providers to plan for the development and implementation of a Single Point of Entry for persons with mental retardation in concert with the Division's plan to merge the MRWP and CHSS. Implement a single point of access system within each of the four service delivery areas to include face-to-face emergency services and screening evaluation capacity 24-hours a day, seven days a week. Implement a Single Point of Entry process in the region including a concise initial assessment form used at central intake.

FY2002
Continue the Single Point of Entry approach with each of the regions respective behavioral health contract providers.
Study and evaluate access systems with the intent to improve access to publicly supported MHMRSA services. Require the two Community Service Boards to provide Single Point of Entry functions regarding acceptable response times for emergencies, urgent situations and routine care.
Ensure provider choice is offered whenever such choice is available.
Improve integration, system design and utilization of current regional crisis services.
Provide a Single Point of Entry as a central access to services. Work with providers to develop and implement a separate Single Point of Entry for persons with mental retardation.
Examine the possibility of a centralized phone system and linkage with state database in order to appropriately track individuals. Develop an assessment and referral process that is similar throughout the region. Ensure a Single Point of Entry process in each service area of the region.

Region 10
Region 11 Region 12 Region 13

Implement a centralized point for new consumers as a part of the region's Single Point of Entry system
Implement the Single Point of Entry system including the development of a MIS plan and a crisis plan to support the system. Add services to adults with mental retardation to existing Single Point of Entry network.
Establish a region-wide standard entry form and referral network through the Single Point of Entry system.

Create a plan for integration of "state operated services" in Regions 10 and 11, including a Single Point of Entry process for utilization of State Hospital and Community Crisis Stabilization services. Increase consumer choice and implement the Single Point of Entry system.
Contract for a Single Point of Entry service that provides emergency services throughout the region and meets the guideline for core functions for this service. Develop a focal point (Access to Care Unit) which acts as a region-wide access point and which facilitates people to get to the services they need.

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Service Integration with the Criminal Justice System

FY2001

FY2002

Region 1

Have at least one case manager to provide services to Encourage contractual providers to maintain a viable working consumers enrolled in the Transition and Aftercare for relationship with DFCS and DJJ as evidenced by participation

Probationers and Parolees (TAPP) services.

in the regional CAP meetings. Implement a minimum of one

additional youth program that targets individuals involved

within DJJ, such that both mental health and substance abuse

needs are addressed.

Region 2

Improve service integration and continuity with the criminal justice system in each community.

Improve and develop communications and coordination between regional providers of children and adolescent services

and RYDC consumers.

Region 3

Increase in linkage and continuity of care for forensic juveniles in need of treatment.

Provide Intensive Case Management Services to adolescents within the juvenile justice system with substance abuse

problems. Identify local court systems and judges who have an

interest in establishing a drug court.

Region 4

Continue operation of TAPP program for probationers Negotiate inclusion of sensitivity to issues and behavior of

and parolees referred by Department of Corrections

persons with mental illness, mental retardation or substance

and track the program's service.goals. Work within the abuse in the training of all police and sheriffs.

Cobb NAMI to plan for priorities around jail diversion

or other forensic issues.

Region 5

Continue collaboration with community court. Improve services for children and adolescents with

Work in partnership with the Fulton County Juvenile Court in an effort to implement Multi-Systemic Therapy for children and

serious emotional disturbances who become involved adolescents involved with the court.

with the juvenile justice system and specifically the

adjudication system.

Region 6

Work with the juvenile court system to identify youth who need MHMRSA services and ensure their

Increase MHMRSA services to consumers in the criminal justice system.

awareness of how to access services.

Region 7

Develop an action plan in partnership with Department Identify needs of consumers involved with the criminal justice of Juvenile Justice (DJJ) for the census reduction at the system and propose new services.

Regional Youth Detention Center (RYDC). Initiate a

request to DJJ to increase case management services.

Redirect adolescents with substance abuse problems

from criminal diversion system into treatment and

develop services for adolescents with mental illness

and mental retardation. Work with Department of

Corrections (DOC) to develop a case management

program for adults with MHMRSA needs and provide

training to law enforcement officers.

Region 8

Offer case management and after-care community

Increase coordination and support of psychological assessment

services to offenders with mental health and/or mental to courts and jails throughout the region. Plan for a mental

retardation diagnosis upon their discharge from the

health court. Reduce the census in the Youth Detention Center.

state prison or detention center.

Region 9

Provide treatment and aftercare services to probationers and parolees. Enhance treatment

Enhance treatment programs for youth in, or recently released from, the juvenile justice system. Enhance treatment services

programs for youth in or recently released from the

for consumers recently released from the corrections system.

juvenile justice system.

Region 10 Reduce re-incarceration/re-entry into the criminal
justice system by 50% from the 1999 rate.

Work with court systems to provide community-based alternatives to inpatient services for forensic consumers.

Region 11 Develop services for the forensic population.

Continue TAPP services to address the service gap between discharging inmates and entry into the MHMRSA system.

Region 12 Provide treatment and aftercare services to

Increase services to consumers and the criminal justice system.

probationers and parolees through the TAPP Program. Continue working with court system to enhance timely access to

MHMRSA services by individuals in local jails. Continue

\

mental health service to probationers and parolees through the

TAPP ro am.

Region 13 Make MHMRSA services available to adolescents in
or recently released from the juvenile justice system

Require providers to continue meetings with the Department of Juvenile Justice in order to respond to the mental health needs

who need these services. Support the continued

of children and adolescents under control of the Department of

enhancement of collaboration between community and Juvenile Justice. Continue to work with the forensic system to

hospital forensic resources.

ensure that individuals are not inappropriately detained in jails.

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Dual Disabilities Integrated Services

Region 1 Region 2 Region 3
Region 4
Region 5 Region 6 Region 7 Region 8
Region 9 Region 10 Region 11 Region 12 Region 13

FY2001
Implement a pilot program to serve adults with multiple diagnoses.
Expand community treatment options for consumers with dual diagnoses. Provide case management services for DOC probationers and parolees with mental illness and/or mental retardation.
Explore alternatives to current structure and financing for the CSB operated MH/MR dual diagnosis day treatment program in order to enhance choice and appropriateness of services for this
o ulation. Let RFP to purchase additional dual diagnosis services and thus, the number of consumers receiving services. Ensure integrated services for consumers with dual disabilities. Ensure access to and integration of services for persons with dual disabilities. Implement a centralized intake system adequate to detect consumers with dual diagnoses. Provide for clinical programming and case management services targeted to consumers with dual disabilities. Enhance and measure each consumer's treatment progress including those with dual diagnoses. Develop training curriculum for all staff working with the dually diagnosed population.
Develop needs assessment for specialized services for the dual diagnosis population. Provide comprehensive residential supports for consumers with multiple diagnoses of mental illness, mental retardation and/or substance abuse. Ensure access to and integration of services for people with dual disabilities.

FY2002
Provide a comprehensive workshop which addresses assessment, access and integration of services for persons with dual disabilities. Expand community treatment and employment options for consumers with dual disabilities. Provide specialized respite services and supports to individuals with mental retardation and mental illness. Continue to provide specialized residential treatment services to males who abuse substances and have a mental illness. Improve mental health/substance abuse treatment services.

Continue to develop providers of service to the dual disabilities population.
Ensure the provision of integrated services for consumers with dual disabilities Identify the strategies used by the Region's providers to serve persons with dual disabilities. Require the identification and progress reporting of individuals with dual disabilities. Include outcome measures in contracts for efficiency, effectiveness, and satisfaction for this population.

Increase substance abuse treatment programs for adolescents with co-occurring SED and substance abuse. Develop a training curriculum for staff working with the dually diagnosed population. Develop at least 4 new residential placement options for individuals with dual disabilities. Develop services for the dual diagnosis population.

Implement and ensure access to services for persons

with dual disabilities.



Continue providing crisis stabilization services, treatment and support to individuals with dual disabilities.

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Research or Evidence-Based MHMRSA Services

Region 1 Region 2 Region 3 Region4
Region 5 Region 6 Region 7 Region 8
Regioii9 Region 10 Region 11 Region 12
Region 13

FY2001
Provide risk-focused prevention activities and require prevention providers to adhere to the Communities That Care model. Improve prevention outreach efforts in high risk communities through researchbased initiatives. Measure the effectiveness of current prevention activities utilizing best practices and research-based methods. Continue efforts to increase the number of consumers employed in all three disabilities, increase use of new generation medications, use ofresearch-based substance abuse prevention programs and move toward less reliance on facilitybased supports for adults with mental retardation. Include in performance contracts the requirement for providers to implement the Patient Outcome Research Team (PORT). recommendations. Increase the use of research-based MHMRSA services.
Continue to study the research on new MHMRSA practices and how such research may inform the Board's service improvement decisions. Ensure the provision of services that encompass best practices and quality improvement measures and the use of science-based strategies and activities by prevention providers. Adopt the "promising programs" approach to funding all substance abuse prevention services. Ensure implementation of at least one research-based therapeutic model by each provider.
Begin to conduct a review of the implementation and/or integration of research-based programs into MHMRSA services. Increase use of research-based substance abuse programs.
Implement best practices through distribution of current research articles to providers.

FY2002
Continue to incorporate cultural and ethnic knowledge and sensitivity into treatment and prevention services. Evaluate and improve the delivery of science-based substance abuse prevention services to the underserved high-risk populations of the region. Develop one new residential and/or supported housing program based on research obtained from a three-year study on successful housing models. Develop services for aging consumers.
Evaluate current Dedicated Case Management Services in the region in accordance with the evidence-based model for these services.
Implement Training Transfer of Learning Strategy for implementation of Assertive Community Treatment. Reduce admissions to state hospitals or crisis stabilization programs through access to new generation medications in the community.
Require use of the PORT recommendations by all four Community Service Boards in the region.
Use the research-based and promising programs approach to funding all prevention services in the region. Provide "Best Practices" training for Day Treatment, Day Support and Peer Support programs. Require all providers to implement at least one additional research/evidence-based model. Integrate the Search Institute's Developmental Assets model in assessing substance abuse risk factors and establishing protective factors.
Require providers to incorporate a family and/or mentoring component to their youth programming in order to enhance the protective factors surrounding family issues. Continue funding the research-based Life Skills Training program. Increase the number of prevention providers utilizing science-based prevention strategies and targeting specific regional needs.

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Implementation of Surgeon General Report on Mental Health (To be implemented in selected regions)

Region 3
Region4 Region 5
Region 6
Region 7 Region 11
Region 12

FY2002
Provide on-sight technical assistance and training to the Assertive Community Treatment teams. Improve treatment of co-occurring substance abuse and mental illness. Evaluate the effectiveness of the best practice training coupled with the Transfer of Learning training. Measure and evaluate Assertive Community Treatment Teams after Transfer of Learning training. Implement consumer self-help groups as a best practice. Disseminate the key messages contained in the Surgeon General's report. Develop a community education program on mental illness. Ensure continued availability of new generation medications for consumers as they move from one service to another.

, Plan for Addressing the Long Term Planning List

Region 1 Region 2 Region 3 Region 4
Region 5 Region 6 Region 7 Region 8 Region 9
Region 10
Region 11
Region 12
Region 13

FY2002 Assess the needs of individual consumers and their families on the planning list. Reduce the number on the long-term planning list by expanding services. Increase accessibility of adult mental retardation services within the region. Provide respite services and case management services to individuals on the planning list, and plan for additional services within existing resources. Develop an integrated system of care for mental retardation. Review consumers' status on the planning list for services. Evaluate the need for additional services by all persons on the planning list. Monitor and update needs of consumers on planning list. Reduce the planning list through provision of residential, supported employment, and day services. Ensure an appropriate continuum of care and prevent inappropriate admissions to the state facility system. Monitor residential capacity quarterly. Encourage providers to share information about vacancies in their residential programs. Continue to support people moved from institutions to the community. Hold monthly meeting's with providers to review long-term planning needs. Continue to serve individuals who have been moved from mental retardation facilities to community-based options.

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STRATEGIC PLANNING PROCESS FOR THE FACILITY SYSTEM
Strategic planning for the DMHMRSA Facility System is a two-year cycle that occurs through a systematic process of assessing, planning, implementing and evaluating the goals and strategic objectives that are established. The strategic plan is developed by the Facility System Leadership Team, which is comprised of the Facility System Medical Director, the ChiefFacility Administrator and the Facility Superintendents and Administrators. Planning is based on departmental and division plans and budgets, including applicable re-directs, and is also driven by the Facility System's Mission, Vision and Guiding Principles. The planning cycle is summarized in the diagram below:

(Report to Governing Body) Quarterly Annually (Annual Report)

ESTABLISH: MISSION VISION GUIDING PRINCIPLES

Annual Report Strategic Objectives Performance Measures Utilization Measures

IMPLEMENT: Actions as specified in the plan
PLAN: Facilities establish
strategic plans

Establish strategic goals / priorities, including performance improvement priorities
For each strategic goal, establish objectives, target dates, responsibility, performance measures

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DMHMRSA Facility System
The following Facility's System's Vision, Mission and Guiding Principles provide the basis for Strategic Planning for the DMHMRSA facility System:
Vision:
Full partnership in a unified system of behavioral health care valued by consumers and their families in our community.
Mission:
To help people severely affected by mental illness, mental retardation and/or substance abuse attain the health, skills and knowledge necessary for a more selfdirected, meaningful and satisfying life.
Guiding Principles:
People are treated with dignity, respect and compassion. Consumers and families have choice in the services they receive. People are provided opportunities to learn and grow. All staff are competent, sensitive and committed. Services are continuously evaluated and improved. The understanding and acceptance of persons with mental retardation, mental illness
and/or substance abuse are promoted. Resources are managed efficiently. Best practices are continuously sought and implemented. Diversity is valued and celebrated.
FY 2001 - 2002 Strategic Goals:
To successfully implement required directives. To increase specialized, state-of-the-art inpatient services. To promote a safer and more respectful therapeutic environment in the least
restrictive manner. To recruit, develop and retain competent and caring staff. To design and implement a comprehensive risk management program. To improve operational efficiency and effectiveness through information- driven
decision-making. To improve continuity of care between the facilities and community providers.
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BUDGET

Georgia's Mental Health,

Mental Retardation and

Source of Funds

Substance Abuse service system

operates with funds allocated to

Other

the division and funds received

at the local level. The largest

fund source in FY 2000 is state

general revenues (55 percent).

Local

The other forty-five percent of

22%

State

the funds come from a variety of

55%

sources including: (1) federal

funds through direct grants to the

division (10 percent); (2)

10%

community sources such as

county and municipal funds,

contributions and direct federal

grants to local agencies (23 percent); and (3) other sources which include patient fees and

third party reimbursements paid directly to the provider such as Medicaid and Medicare

(13 percent). The total expenditure for state fiscal year 2000 was approximately $968

million.

Thirty-five percent of the total funds in FY 2000 provided services and support for

institutional care. Sixty-five percent was used to provide services for consumers in their

home communities. Some

How Funds are Applied

of the more common services include supported

employment, substance

abuse treatment and

prevention, child and

adolescent services, adult

Institutions 35%

mental health services, outdoor therapeutic and

community programs for

persons with mental

Community

retardation.

65%

Fiscal Year 2002
In fiscal year 2002 the state budget will implement several activities that will "maximize revenues" to meet the needs ofpersons with disabilities. These changes include an unprecedented expansion for community services for people with mental
34

retardation and a change to more flexible Medicaid-funded treatment and support for people with mental illness and substance abuse problems. Both changes are being funded by using existing state dollars as a match to "draw down" more federal Medicaid dollars under the Governor's Revenue Maximization Project. Medicaid will help pay for services that previously were funded by state dollars. DHR, working with the Department of Community Health, implemented a comprehensive Medicaid Rehabilitation Option on July 1, 2001. The Rehabilitation Option makes it possible to bill Medicaid for additional services offered outside of a clinic such as intensive case management, assertive community treatment and some components of residential services.
New funds will carry out many of the recommendations from the Governor's Blue Ribbon Task Force on Community-Based Services. The task force looked at the longterm care needs of older adults and people with mental retardation/developmental disabilities, as well as people with mental illness.
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FUTURE DIRECTIONS "Becoming a World Class System"
In recent years, Georgia's public mental health, mental retardation and substance abuse service system has experienced important changes:
A major reform of the system to create regional governing boards who plan, purchase and monitor services at a more local level
Closure of four hospitals and movement from a predominantly hospital-based to a predominantly community-based service system
A major expansion of community services for all three disabilities.
Now, the focus is on improving service quality- to make "evidence-based practices" standard practice - and bringing the parts of the system into one, integrated service system. The agenda for the future includes the following:
Services that promote self determination, consumer independence and recovery Services will no longer be satisfied with the goal of stabilization and maintenance. Rather, consumers will set their own goals, and services will support them in reaching those goals, including developing skills and finding and keeping real jobs. Consumer-driven services will be the key, and consumer-operated services will be an important part of the system. Recent changes in Medicaid supported services for people with mental retardation and for people with mental illness or substance abuse problems clearly move Georgia's system in this direction.
Community integrated services - When a consumer's need for assistance is assessed, any resource that can be brought to bear on meeting his needs will be considered. Services and professional expertise will not be restricted to a single disability, if that service or expertise has value in assisting someone with a different disability. Similarly, resources outside of the service system will be considered. The service system will need to have partnerships with other community agencies, churches, civic groups and families themselves to bring resources together creatively.
New roles for state hospitals - Children under 12 should receive the intensive level of service provided by a state hospital in a community setting, not in an institution. And people with mental retardation should be living in the community with the supports they need to ensure their safety and well-being. Moreover, admissions to state hospitals are increasingly becoming forensic admissions. It is appropriate that hospitals may begin to specialize in serving this population, and would not be a reasonable place to continue serving children or people who need long-term residential care.
Provider development - This is a major issue related to becoming world class. It includes recruitment of new providers into the service system, raising the bar on service quality for all providers, and recruitment and retention of qualified staff. Training to help providers stay abreast of evidence-based practices will be key. Another effort will be to develop "state-operated services" in the community for some specialty functions, such as residential services for consumers who are very difficult to serve and special teams who can provide trouble shooting, technical assistance and
36

training to any community provider when difficult situations arise. As hospitals continue to downsize and become specialized, hospital resources, including staff, can be redeployed to work in partnership with community staff to carry out these new functions. These efforts will strengthen the service system. Moreover, they are an important way of retaining valuable hospital resources in the system, when we no longer need the institutional setting. A "business approach" to services - Government is not a private business, and cannot operate like a business, but we can adopt many business approaches to make our agencies more accountable. With current changes in how services are financed more Medicaid dollars in the funding pot - service providers will have to be more "business-like" in documenting that the right services were provided and in billing for services. This is a major change for public providers who have received regular allocations of state funding. In addition, providers will need to look for ways to generate new revenues. Each of these efforts requires major work. These changes will not be accomplished in one or two years, though we will make good progress. In five years, Georgia's MHMRSA system will have a very different look. Hospitals will be playing a different role. Consumers and their families will have more of a voice in their services. A wider variety of resources will be available to meet consumer and family their needs. The network of services will work together as one integrated system.
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