Via Email Only

December 20, 2016

Deputy Mayor Brenda Donald

Office of the Deputy Mayor for Health and Human Services
1350 Pennsylvania Avenue, NW, Suite 223
Washington, DC 20004

Councilmember Yvette Alexander

Chair, Committee on Health and Human Services
1350 Pennsylvania Avenue, NW, Suite 404
Washington, DC 20004

Dear Deputy Mayor Donald and Councilmember Alexander:

On August 1, 2016, we wrote to you about the impact of and our concerns about the
Department of Behavioral Health (DBH) DBHs failure to commit to paying for non-Medicaid
reimbursable mental health services (otherwise known as locally funded services) for the rest
of Fiscal Year 2016, an issue that was first brought to our attention in May. On August 8, 2016,
in response to our letter you raised a potential solution that would make local funds available and
stated that DBH would review all claims with eCura, and that the adjudication of claims and
reallocation of funds would be completed by August 15, 2016. It has been four months since the
reallocation of funds was supposed to have been completed, however it is our understanding that
DBHs failure to commit to paying for locally funded services for Fiscal Year 2016 has not yet
been completely resolved. Further, we are concerned about DBHs commitment to adequately
fund locally funded mental health services for the present fiscal year and beyond, and are
concerned that the amount of funding allocated for locally funded services for this fiscal year
does not adequately meet the need. Mental health consumers who are institutionalized,
undocumented, and uninsured continue to be harmed by DBHs failure to resolve the lack of
funding for locally funded mental health services for Fiscal Year 2016 and beyond.

Even now, over two months after the new fiscal year has begun, providers are still not
delivering crucial services that provide continuity of care and transition services for consumers
in institutions, including hospital, jails, and nursing facilities. Several of Disability Rights DC at
University Legal Services (DRDC) clients at Saint Elizabeths Hospital are not receiving
transitional services from their Core Service Agencies (CSAs), and their CSAs are not
participating in their treatment team meetings. Lack of services and participation from CSAs for
consumers at Saint Elizabeths can result in delays in discharge, putting consumers at risk for
decompensation, and violating their right to live in the least restrictive setting appropriate to
meet their needs. Further, lack of services and participation from CSAs is also contrary to the

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DBH Continuity of Care Practice Guidelines which require that CSAs maintain monthly face to
face contact with consumers, attend all treatment team meetings, and participate in the discharge
planning process. Failure to provide services that provide continuity of care deprives consumers
of the supports and services needed for a successful tenure in the community. For example, a
DRDC client RT (initials changed to preserve confidentiality), was finally ready for discharge
after being hospitalized for several years at Saint Elizabeths. Although RT was finally preparing
for discharge and needed intensive supports to prepare for her transition into the community, her
CSA stopped participating in treatment team meetings and stopped maintaining face to face
contact with her because of the crisis in funding for locally funded services. RT also could not
attend a day program in the community to ensure a successful transition to the community from
Saint Elizabeths because of the crisis in funding. As a result, RT could not work with her team at
her CSA that would provide her with crucial supports and services in the community, and was
not provided with the support needed to ensure a successful tenure in the community.

The Public Defender Service (PDS) remains concerned about the local dollar shortage
impact on its clients committed to DBH. The commitment laws in the District of Columbia
require treatment in the least restrictive setting. The shortage significantly impedes clients
ability to access services, comply with court orders and avail themselves of the least restrictive
treatment. For example, PDS client, KL, hospitalized over a decade, is clinically ready to live in
the community. Since early spring 2016, his court order has allowed him to enter the community
with his case manager to begin discharge preparation and develop a relationship with his CSA.
He has never utilized this provision of his court order because of the local dollar shortage: case
managers simply are not servicing hospitalized consumers. This client has yet to develop a
relationship with his CSA. Consequently, the local dollar storage will prolong his stay at Saint
Elizabeths, jeopardize his successful transition into the community and promote clinical and
fiscal irresponsibility. Similarly, AB, was connected with a CSA in a few years prior to his
commitment in 2010. This summer, he was dis-enrolled from his CSA, ending his relationship of
almost a decade, because of the local dollar shortage: his community therapeutic ties have been
severed. He is now seeking release into the community but he has not had contact with a
community support provider since his dis-enrollment. The local dollar shortage harms clients and
perverts the legal requirement of treatment in the least restrictive setting.

With one exception, based on a contract with DBH, CSAs are also not providing services
for DRDC clients in jail. DRDC clients in jail are not receiving services while in jail from their
CSAs to maintain contact, to prepare for re-entry by applying for housing for those who are
homeless, and to ensure continuity of care. For example, SD (initials changed to preserve
confidentiality) is currently incarcerated at the DC Jail, where he is chosen to be housed in
protective custody for his own safety. SD experiences chronic depressive symptoms and chronic
suicidal thoughts. Many of his supportive relatives have passed away, so he has no community
support. SD has established a good therapeutic relationship with his CSAs Assertive
Community Treatment (ACT) team, but their visits have decreased to once a month due to the
locally funded services issue. DRDC visits SD more often than his CSA. Another client at the
jail was told by his CSA that they cannot visit him at all while hes incarcerated due to the local
dollars issue. This client has a longstanding relationship with his CSA, and their contact with
him at the jail gives him the support he needs to stay in the general population rather than on the

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more restrictive and stigmatizing mental health unit.

Further, some CSAs are continuing to turn away consumers who do not have Medicaid at
intake even when the consumer is clearly Medicaid-eligible. For example, although the Access
Helpline is telling currently uninsured consumers that they can go to MBI Health Services, a
local CSA for intake, MBI is turning away those consumers--even those who are Medicaid-
eligible and just need assistance applying. This has happened at least five times within the last 60
days with DRDC clients. These consumers are left with no mental health services at all, due to
the lack of CSAs accepting currently uninsured consumers and the difficulty in navigating the
Medicaid application process without support. Additionally, DRDC continues to receive
complaints from clients who are Qualified Medicare Beneficiaries (QMB) who are being told by
their CSAs that they can no longer receive crucial community support services that enable them
to live independently in the community if they do not also qualify for Medicaid.

It is our understanding that although DBH took some steps to remedy the fiscal issues for
Fiscal Year 2016 by paying most providers for locally funded services rendered in Fiscal Year
2016, DBH has failed to take steps to ensure that the funding crisis does not continue into Fiscal
Year 2017. It is also our understanding that DBH has failed to issue Task Orders for some locally
funded services to providers for Fiscal Year 2017; to the extent that Task Orders have been
issued they are insufficient to meet the demand for locally funded services. Local dollars Task
Orders have certainly not kept pace with the national inflation rate for mental health services,
which averaged approximately three percent annually from 2000-2012.1 DBHs failure to
remedy the funding crisis for locally funded services in Fiscal Year 2016 and 2017 continues to
harm consumers. Further, steps taken by DBH to remedy the funding crisis, such as retroactively
issuing task orders to some providers for services rendered in Fiscal Year 2016, does not resolve
the harm that consumers continue to experience. While providers can be made whole for services
provided, consumers cannot be made whole retroactively for the loss in services that were not
provided because CSAs did not know that DBH would eventually issue task orders for a past
time period.

DBH has further exacerbated the access issue by cancelling contracts mid-year and not
replacing them with comparable services. In Fiscal Year 2016, DBH cancelled a contract with
the Psychiatric Institute of Washington (PIW) to provide detox services. DC residents who are
uninsured now have no funding source for their treatment and must go to hospital emergency
rooms seeking detox services. Further, last spring DBH cancelled contracts for Options and
Linkage Plus, programs designed to assist criminal justice-involved consumers in need of
behavioral health services. Under Linkage Plus, one CSA had a dedicated person at the jail and
the Correctional Treatment Facility (CTF) to ensure regular contact and continued case
management with detained clients. This jail liaison coordinated with the rest of the CSAs staff
to maintain or secure housing while the person was incarcerated and set up appointments in the

1
Peterson-Kaiser Health Services Tracker: Measuring the Performance of the U.S. Health System, available at
http://www.healthsystemtracker.org/chart-collection/what-are-the-current-costs-and-outcomes-related-to-mental-
health-and-substance-abuse-disorders/ (last viewed December 16, 16).

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community for when the individual would be released.2 Under the Options program, another
CSA provided transitional housing for criminal justice-involved consumers, a critical resource
for returning citizens such as our clients in the Jail and Prison Advocacy Project (JPAP) at
DRDC. Both of these programs, which were ended six months ago, were to be reorganized and
new request for proposals (RFPs) issued, but it is our understanding that a reconstituted Linkage
Plus program will not be up and running until at least the spring of 2017. The new RFP does not
contain any housing. Continuity of care and supported housing are evidence based programs for
reentering individuals with psychiatric disabilities. DBHs latest actions represent a large step
backward for the city. It is unclear what happened to the funds that were allocated for both
Options and Linkage Plus now that those programs are no longer running.

Over two months into the new fiscal year, some CSAs continue to turn away consumers
and refuse to provide certain services due to uncertainty about locally funded services for Fiscal
Year 2017. It is our understanding that funding for locally funded services for Fiscal Year 2017
will be consistent with Fiscal Year 2016 (and several years prior). We remain concerned that the
amount of funding allocated toward locally funded mental health services does not adequately
meet the need. We already have sufficient evidence that Fiscal Year 2016 funding was
insufficient, since the most highly rated CSAs were told in April that they had overspent funding
for locally funded services. In our experience these were the only CSAs that consistently
provided transition planning services at the jail. DBH is compounding the problem by using
billing from Fiscal Year 2016 that is artificially low, because these CSAs ceased to accept new
clients and cut back on services they have traditionally provided. DBH has stated that there are
other CSAs willing to provide locally funded services to consumers who have been turned away.
While some consumers are willing to go to lower ranked providers, many refuse because they or
people they know have had poor experiences with these providers. In addition, there are limited
CSAs who provide ACT services. In JPAPs experience, only two ACT providers are
experienced with going into the jail and CTF and participating in videoconferences with clients
in the Federal Bureau of Prisons. Because these providers are not accepting uninsured
consumersand all incarcerated consumers are uninsured under federal Medicaid lawDCs
right to choice law is effectively significantly restricted.

We are concerned about DBHs commitment to allocate sufficient resources for locally
funded mental health services for Fiscal Year 2017 and beyond. DBHs failure to anticipate and
quickly address the Fiscal Year 2016 locally funded mental health services issue for the most
highly rated CSAs continues to harm mental health consumers in the District who rely on locally
funded mental health services, many of whom are ultimately found to be Medicaid eligible. We
remain concerned because the lack of funding for locally funded services has not been resolved
in the new fiscal year, and we are concerned about DBHs commitment to pay for locally funded
services moving forward, particularly when other locally funded programs such as Options and
Linkage Plus have been discontinued or disrupted.

2
It appears that Linkage Plus has been reinstated for one CSA to provide linkage services at the jail, but all CSAs
with clients in prison or jail should be providing active in-reach to prepare them for a successful reentry.

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 Due to our concerns and the lack of transparency, we are requesting an audit of DBHs
use of local funds to determine how many individuals are being served (in whole or in part), how
many have been turned away from the highest rated providers and whether DBH proactively
linked them to other CSAs, how consumers rate their experiences with CSAs after being moved
from their preferred providers, how many people in need of ACT services have been turned away
from ACT providers, what services are being provided by local dollars, and the number of DBH
clients in St. Elizabeths or in criminal justice custody and how many of these individuals are
receiving services funded by local dollars, particularly for transition planning.

Thank you for your attention to this important matter. We look forward to hearing how
the District plans to continue to provide locally funded mental health services for all mental
health consumers. If you have any questions, please contact Kimberly Clark at 202-824-2857 or
KClark@PDSDC.ORG or Tammy Seltzer at 202-527-7033 or tseltzer@ULS-DC.org.

Sincerely,

/s/

Disability Rights DC at University Legal Services

Public Defender Service of the District of Columbia
NAMI DC
DC Reentry Task Force
Patient Advisory Council at Saint Elizabeths Hospital

cc: Dr. Tanya Royster, DBH

Mr. James Wotring, DBH
Chairman Phil Mendelson
Councilmember Kenyan McDuffie
Councilmember Vincent Orange
Councilmember Anita Bonds
Councilmember David Grosso
Councilmember Elissa Silverman
Councilmember Brianne Nadeau
Councilmember Jack Evans
Councilmember Mary M. Cheh
Councilmember Brandon T. Todd
Councilmember Charles Allen
Councilmember LaRuby May