IDHS‑ Budgeting for Results Public Hearing 
July 29, 2020 
1‑3:40 p.m. CST 
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>> Curt, do we want to begin?  Was that the technical difficulty?
>> Curt:  I think that was the technical difficulty.  We can begin.
>> Jim:  Great.  Welcome, everyone to the 2020 budgeting for results hearing.  We're doing it a little differently this year.  In past years we've done one hearing in Chicago and one in Springfield to cover our statutory requirement of reporting out to the public and being answerable to the public once a year.  Because of the COVID, we're obviously going electronic this year, which means we're able to do the Chicago and Springfield events together as one.  And so here we are.
So I'd like to begin by introducing the commissioners who are on the line and kind of calling the roll of them.  I'm Jim Lewis.  And I'm chair of the budgeting results commission.  And those of you online could just go ahead and chime in.
>> Good afternoon.
>> Go ahead, Representative Davis, please.
>> Good afternoon, Representative will dam Davis.  Thank you.
>> Wall worthington, commission member? 
[Too many talking at once.]
>> I'm sorry.  Jesse, go ahead.
>> Jesse, commission member.
Can you recall is obviously in charge of the electronics today and so will be our director and emcee of events here as we get going.
But I just invite by way of introduction want to review for everyone who we are and kind of what we're doing.  The budgeting results commission and budgeting for results statute were originally signed into law in 2011.  And budgeting for results in the state of Illinois has two major purposes.  One is to assure that program metrics and data are used to establish and operate budget priorities across the state.  And the second to remove duplicative and/or mooted statutory mandates that affect various state agencies and programs.  And so primarily the government's office of management and budget, in cooperation with the state legislature, have been implementing those two purposes over the last I don't know.  Is this our 10th anniversary, over the last 10 years.  And we are ‑‑ the original stat statute, then created the commission to provide advice and oversight to the process.  And so the commission over these years has worked very, very closely with curt and the OMB staff.
So at this time, I actually want to acknowledge those staff people who have done just great work this past year and over the life.  Some of them the life of the project.  Curt Clemons Moseby, who will be with you here in a second.  Jenifer Butler, if you're on the line.  Adam G., Sophia R. 
And the staff's newest member, Megan.
So to all of you, the Commission very much appreciates the hard work that you've been doing during this time and the great and varied products that you've created that have led an increased accountability of our budget‑making process across the state.
So, this afternoon, what we're going to do is I'm going to turn it over to curt here in a second who is going to provide us update and annual report and history of the budgeting for results process and accomplishments over the years.
And then we're going to move into the panel discussion which is going to feature a number of presenters and experts in the field of mental health, which is the next area and the budgeting for results going into in terms of developing metrics and Spart.
And then, finally, by statute, we'll be entering into the public comment period during which members of the public are free to ask us any questions or direct any comments to us that they would like to.
So at this point, let me turn it over to Curt Clemons Moseby of OMB and a commissioner.
>> Curt:  Thank you, Chairman Lewis.  A couple quick housekeeping notes.  I think I see that Commissioner Saltmars joined us.  So we want to acknowledge her.
And then also this meeting is being recorded.  So we just wanted to make participants aware of that.
And if you want the switch over to the presentation, please?
>> Good afternoon, the following is an overview of the budgeting for results process.  Those responsible in Illinois and the tools and processes we use to carry out our statutory mandate.  Next slide, please.
Budgeting for results is the state's comprehensive process to transition to a program‑based budget where programs and initiatives are funded according to performance and the value they create for taxpayers rather than the amount they were funded during the previous year.
Two key pieces of legislation established the performance budgeting component, and the budgeting for results commission to oversee the process.  They were codified into law in 2010/2011 respectively.  This makes Illinois unique where we're the only state where doing a performance‑based budget is a statutory requirement.
Next slide, please.
The following slides provide an overview of the bodies that are responsible for BFR in Illinois.  The Budgeting for Results Commission is tasked with providing ‑‑ tasked with advising the governor on best practices and next steps in performance‑based budgeting as well as to make annual recommendation for the repeal of unduly burdensome statutory mandates.  The Commission is made up of 10 members, four of which represent each of the caucuses in the General Assembly.  We also have distinguished Representatives from businesses and government and academic communities.  The commission hold two public hearings one in Springfield, one in Chicago.
The Commission reports its findings and recommendations for the coming year to the governor and General Assembly each November 1st.
The office of management website.  And we highly encourage you to visit the website and have a look.
Next slide, please.
The implementation of the Budgeting for Results project is overseen by the governor's office for management and budget and the key personnel are listed on the screen.
Next slide?
The unit provides staff support for the Budgeting for Results Commission and coordinates with the chief results officer who manages the Illinois performance reporting system or IPRS and conducts program assessments utilizing the results first benefit cost analysis tool and the Spart tools of which I will discuss in more detail later in this presentation.
Next slide, please.
The final group that has a major role to play are state chief results officers, our CROs.  We're fortunate to be joined by several CROs here in the audience.  CROs are senior level agency staff in addition to their normal responsibilities.  They are a conduit for information for the BFR unit commission and their agency.  They're responsible for coordinating the review of their agency's program inventory on an annual basis and for making sure that all programs and performance measures information in the IPRS are kept up‑to‑date.
Next slide, please.
Now that we know the key players, let's talk about the process.  Building a performance‑based budget system for the state the size of Illinois which operates on a line item budget has been a challenge.  The first step in the process was to identify the results and outcomes against which state agencies' program performance would be measured.  The Commission has identified several result areas or broad buckets of spending into which all appropriations in a given year are contained.  The result areas are further designed into nine state wide outcomes which are the goals to which ‑‑ toward which all programs in a given result area should strive to achieve.
Next slide, please.
On the screen are the current result and outcome areas.  Result from education to environment and culture.  And the outcomes include items such as free and sacred communities and increasing employment.
Next slide, please.
As I mentioned earlier under law, the state of Illinois operates a line item budget system.  And historically it has been difficult to connect line items directly to programmatic activity.  It's not easy or ideal to measure the impact of a particular line item on outcomes Illinois ands cared most about.  However, we can measure a program.  State agency programs are the linchpin that connect the budget dollars to real world activities.  Every dollar in every line item must be connected to a programmatic activity.  And starting in the spring of 2011, GOMB budget analysts and their counterparts from over 70 state agencies, universities, boards and commissions began the painstaking task of identifying programs and manually tying the line item appropriations ‑‑ 70.
And in 2011 and 12, they utilized the logic modeling process to build their program inventories.  Each of the programs identified were linked to one of the 7 result and 9 outcome areas.
Next slide, please.
Once the program inventories at the agencies were developed, we began the process of building the infrastructure to collect program performance data.  With that accomplished, we needed to build a process to assess whether a program design had fidelity to evidence‑based practices and whether or not the program has been implemented with fidelity to design and is achieving positive results.  So I'm going to discuss the three tools we have developed to meet today's tasks.
The first is IPRS, the Illinois Performance Reporting System.  The results‑first benefit cost model.  And the SPART, state program assessment rating tool.  Next slide, please?
GOMB has developed and implemented the IPRS quarterly basis.  The IPRS allows GOMB to collect and ream port on agency program performance via the Internet.
Next slide, please.  Throughout the development of the IPRS, GOMB worked with state agencies to refine their program inventories and develop program performance measures to gauge the contribution to statewide outcomes.  Many of the appreciate form answer measures currently collected are primarily oriented towards a simple measure of production.  For example, the number of people served or the time it takes to process an application.  All of these are important for the program manager to know, however they do little to convey how the program contributes to overall outcomes which are changes in conditions or quality of life this is where outcome indicators come into play.  We are constantly evaluating and switching to outcome indicators.  This is a difficult process because we must balance need for quality outcome measures with the cost and burden on agencies and their clients.  In August of 2015, GOMB posted the first program performance report by the IPSR to the website.  The BFR giant posts the updated reports the month following the end of each fiscal quarter.  And it is the hard work of the agency staff collecting the data and posting it to IPRS that makes this hole work possible.  Next slide, please.
From 2010 to 20.
, the BFR unit built the infrastructure to identify and collect program data.  Now we are transitioning to the next stage of our mandate, which is to transform raw data and the useful information for program managers and decisionmakers.  We have raw data from the IPRS.  The next step is to conduct benefit cost analysis for each program and, finally, to utilize the information from the IPRS and benefit cost to assign a universal rating for each program so that comparisons could be made between programs within and across result areas.
In July 2016, the BFR commission established through the benefit cost analysis working group to look at the feasibility of developing a new cost benefit model in‑house or leveraging a current model already being utilized in other jurisdictions.  The working group and the commission found that the best solution is the results first initiative benefit cost model.  Based on this recommendation, the working group, the commission passed a resolution and adopted results first as the primary benefit cost tool for budgeting results.
Next slide, please.
The results first benefit cost model uses validated research to predict the outcomes of each program, taking into account the state's unique population characteristics.  The model, which utilizes Illinois‑specific data calculates the cost to produce outcomes including separate projections for benefits that would be realized by taxpayers and others in society.  The model allows BFR unit to calculate an optimal return on investment or OROI ratio for each program reviewed.  The OROI suggests that if a program is run according to best practices and evidence‑based principles, we can expect to see the predicted OROI for each tax dollar spent.  The model also allows us to calculate the percentage chance that the actual benefits will exceed costs.
Next slide, please.  The results first model is currently configured for 10 policy domains that you see listed on your screen.  Next slide, please.  The final phase of program analysis is to incorporate the results from the benefit analysis into an overarching assessment framework which is the state program assessment rating tool or SPART.  It was developed for the Federal Government.  And the BFR unit worked with the creator of the federal part to modify the evaluation tool specifically for Illinois use.  It is weighted questionnaire that helps the reviewer determine if the program is designed ‑‑ the program's design is based on best practices and whether or not the program implementation is done with fidelity to the design.
Next slide, please.
The SPART combines the information into a rating that can be utilized by policymakers to help inform policy decision.  It's important to note that the BFR commission does not have any of the analysis generated by any of these tools to be used.  But rather they serve as an additional lens in the policymakers' toolkit to help make the best evidence‑based decisions.  Next slide, please.
On your screen, you see a dashboard representing the 10 programs from the adult and juvenile justice policy domains BFR has reviewed to date.  All the programs reviewed have an optimal return on investment of greater than $1 for every tax dollar spent.  Some programs like post secondary education and the correctional institutions have a ratio of nearly $39 for every dollar spent.  4 of the 9 programs received the highest SPART rating of effective three received the highest rating ‑‑ the next highest rating of moderately effective.  And two programs received a marginal rating.
Next slide, please.
Every person and every governmental entity has been affected by COVID‑19 pandemic and BFR has been no exception.  However, despite the pandemic's impacts our work goes on.  In the coming year the BFR unit will complete its analysis of programs in the substance use disorder policy domain.  We will expand our program analysis into the mental health policy domain.  And we will work with pew to transition the benefit cost model to state control.
BFR unit will continue to leverage data visualization of geospatial mapping for better program analysis.  And we will work with partner agencies to conduct more comprehensive evaluations of underperforming programs.
Next slide, please.
Of course over time, this is only the broadest overview of the work of the commission.  We encourage you to visit budget.illinois.gov and click on the results tab to learn more.  Thank you very much.
Now I turn it over to chairman Lewis, if you'd like to lead us through the introduction of the panel.
>> Chairman Lewis:  Yes, so we have two sets of panelists that are going to work essentially together this afternoon during this stage of the hearing.  And they consist of people, leaders, leadership, I should say, from the Division of Mental Health and the Department of Human Services as well as key people across the provider community statewide.
So joining us from the Department of Human Services is David Albert.  Who is director of the division of mental health.  Lee Rhinehart, who is Deputy Director of policy and planning, Rock Dunlap, Deputy Director of business policy and fiscal operations, and Meredith Kiss, Deputy Director of hospital administrators.
And then from the provider community, we have Debbie Pavick, who is chief clinical officer for thresholds, Stacy Brown, who is Vice President for behavioral health services with Bridgeway.  Tammy Stewart, who is associate Director of Adult services for ‑‑ centers.  Adrian brown program director, individual placement support for Thresholds.  And Matt Buckman, Executive Director of stress and trauma treatment centers.  So, what we will do is ask I believe ‑‑ Curt, correct me if I'm wrong, but Mr. Albert will give an opening presentation on behalf of the division of mental health.  And then we'll follow that with introductory remarks from the five members of the practitioner community.  So if that sounds good to you, Curt, then we can proceed with welcoming Director Albert to the hearing.
>> Thank you, Chairman Lewis, Senator Stains, Leader Davis, Director Clemons Moseby and Commissioners, for this opportunity to share the information from the division of mental health and the evidence‑based practices that we support throughout the state.
Next slide, please?
One change in our DMH lineup today we have Dr. Hughes, Deputy Director for clinical inpatient services, with us.  Meredith Kiss is unavailable today to join us.  Next shied, please?
Be and next slide.
I've been asked to begin with a brief overview of the division of mental health or DMH.  Broadly speaking, DMH's operations can be divided into two main categories:  Inpatient services and community‑based services.  With regard to the former, DMR directly operates seven state psychiatric hospitals providing care to those who require psychiatric hospitalization.  With regard to the latter, DMH has responsibility to ensure the safety net of publicly funded mental health services throughout Illinois.  This safety net consists of 207 certified community mental health centers, each of which operates as a separate private entity utilizing a variety of funding streams.  Federal funding and regulatory agencies require that each state have a designated mental health authority.  In Illinois, DMH serves this role.  This involves providing both programmatic and regulatory oversight of the state‑operated hospitals and of the community‑based services that are supported through federal funding.  The division accomplishes this through two central offices, one in Chicago and one in Springfield, which house DMH leadership as well as the support staff responsible for policy and contract development.
Programmatic oversight is extended through utilization of regional offices that include three in the Chicagoland area, regions 1 north, 1 central and 1 south.  Region 2 in Elgin.  Regions 3, 4, 5 and 5 metro, which is the East St. Louis area.
Regional staff provide a bridge between the policies developed by central office and the implementation of those within the communities served.  They also provide a valuable feedback loop that informs ongoing policy development at the central office level.
Next slide, please.
Our state‑operated psychiatric hospitals are fully accredited through the joint commission.  They provide direct inpatient care and as such have significant staffing needs.  This includes a management team, a full array of treatment staff, including doctors, nurses, social workers, as well as the support staff necessary to operate a hospital, dietary, housekeeping, pharmacy and engineering.  Our hospitals served 4,849 people during our most recent reporting year, and our current head count for hospital staff is 2,531.
During the COVID‑19 pandemic, the number of admissions to DMH's hospitals has significantly slowed in order to make room for triaging incoming patients for social distancing and for quarantining when necessary.  Our hospitals operate both civil and forensic treatment units.  Civil units treat individuals who cannot be treated in local community hospitals psychiatric giants either because they have no funding for care, there are no beds available, or they have had multiple admissions and have been determined to need a more intensive or longer hospital stay.
Forensic units treat individuals who are sent through the criminal court system.  Each of them has been charged with a crime.  For those found unfit to stand trial, the focus is on restoration so that they can participate in their own defense.
When discharged, they return to court for adjudication.  The other forensic population consists of individuals who are charged with a crime and went through a court hearing where they were found not guilty by reason of insanity.  These individuals are then remanded to the Department of Human Services instead of being sentenced to prison.  Individuals found NGRI are not guilty by reason of insanity, have lengths of stay of many years within the hospitals, as these are determined by the criminal court.
Next slide, please.
As you can see, our hospitals are located throughout the state, with Chicago reed mental health center and Madden mental health center serving region 1, Elgin serving region 2, McFarland serving Springfield primarily 3 and 4.  Alton serving the metro east area around St. Louis.  And Choate that serves the remainder of region 5.  In addition, Chester mental health center in Chester serves patients from throughout the state who are in need of our most secure treatment center.
This chart on the right of the slide reflects the annual admissions numbers from our most recent reporting period.  Please note that during the pandemic, admissions to our hospitals have been reduced by nearly 50 percent due to the operational impact of the virus.
In addition to these seven hospitals, DMH also operates a treatment and detention facility in Rushville who houses individuals are determined to be sexually dangerous and remanded to DMH after doing sentence in prison for the commission of sexual offenses.
Next slide, please.
On the community side of DMH's operations, we have 207 DHS‑certified community mental health centers operating throughout the state.  DMHCs include both private not‑for‑profit agencies as well as some county‑based agencies operated primarily within the public's health departments.  These agencies are supported through a variety of funding streams that can include state and federal grants, and they also bill for services through insurers such as private health insurance as well as Medicaid.
DMHCs provide critical safety net services within their communities as well as more traditional treatment services.  Some individuals come into the office for services, but many are also served through home visits or services provided within other community settings.
We know from research that services provided within natural settings are particularly effective for helping individuals develop skills and generalized learning which supports their recovery from mental illnesses.
DMR's community funded services also include approximately 3,000 residential treatment beds located throughout the state.
Needless to say, community operations have been significantly impacted by COVID‑19.  Through the adoption of telehealth and other programmatic innovations, providers have demonstrated an ability to adapt to ensure that the needs of some of our most vulnerable Illinoisans continue to be met.  Still, the challenges facing community providers during this pandemic are significant and ongoing.
Next slide, please.  In bodes our hospitals and our CMHCs we promote the use of many evidence‑based practices.  SAMSAH, the federal administration, maintains EBPs, evidence‑based practices maintains treatment facility and other services.  DMH has supported the development and implementation of a number of EBPs that have been vetted through our stakeholders and then developed utilizing funding streams to support this work.  Our analysts today represent several established EBPs developed to cover a variety of needs of individuals across the life span.  Assertive community can treatment, ACT, is one of the oldest and most studied EBPs.  Developed in 1970 in Wisconsin by a team of state hospital staff, ACT has been in Illinois since 1992.
The distinguishing factor for ACT is a focus on assertive outreach and engagement to provide more effective treatment for adults with serious mental illnesses who have not benefited from more an traditional office‑based mental health services.  ACT teams include prescribers, advanced nurse practitioners, registered nurses, therapists, certified recovery support specialists, substance use treatment specialists and employment specialists.  DMH has ACT teams working in all regions of the state, and they are a primary provider of care within our Williams and Colbert consent decrees.
The primary outcome measure for ACT typically includes length of stay in the community without need for hospitalization.  Wellness recovery action planning, or grab, is evidence‑based practice that was developed by a person in recovery as a tool that focuses on the individual's wellness and on prevention.  It has been studied extensively and has a significant research base supporting its utility in assisting individuals with mental illnesses to get well and stay well.
DMH has certified wrap trainers working within our central and regional offices and certified wrap facilitators working both within our hospital system as well as throughout the state in our CMHCs.  We have provided ongoing support of this EBP since 2005 and its philosophies and approaches are embedded within the Medicaid service called community support.
The outcome measures most commonly associated with wrap is the recovery assessment scale, RAS, which is conducted pre, post and in six‑month followup.  Coordinated specialty care was developed about 10 years ago through federal studies investigating the most effective early intervention methods for psychosis.  These studies found that the best for individuals on set of psychotic illness is the on set of untreated psychosis or DUP.  To reduce the DUP through early intervention with the intention of interrupting the trajectory into a more disabling course of illness.
In Illinois, we have 15 teams which we refer to as first.IL.  The intention is to engage young people and their families within 18 months or less of the onset of psychosis providing an intensive, multidisciplinary treatment team approach, including a team leader, therapists, prescriber, a recovery support specialist, and a supported employment or education specialist.
Teams utilize additional EBPs including cognitive behavioral they are think for psychosis, supported education and supported employment.
Outcomes are measured through an assessment instrument called the outcome review form, which is administered after entry into the program and then at six‑month intervals.
Individual placement and support, or IPS, is the evidence‑based practice model of supported employment.  At least 27 separate research studies have demonstrated that it is the most effective approach to helping individuals with serious mental illnesses return to the workforce.  Now an internationally recognized EBP, IPS was developed at Dartmouth, and Illinois has been an active member of their international learning collaborative for 15 years.  The goal of IPS is to assist individuals in attaining and maintaining a competitive, preference‑based job within the community.
Outcomes of IPS are monitored through the maintenance ‑‑ the attainment and maintenance of employment with milestone payments made through the division of rehab services.
Practice‑wise is a set of online tools designed to assist clinicians in assessing, planning and delivering care to children, adolescents and their families.  It was created through a comprehensive examination of manualized evidence‑based treatments that identified 41 common elements across EBPs.
Outcomes are measured through a set of self‑administered tools that include the Ohio and Columbia scales, depending upon the age of the child.  These include separate scales that the children, parents and teachers may complete.  DMH has a web‑based reporting system called dat stats where these scales are reported and these are incorporated into practice wise.
With that, I will hand things over to Debbie Pavick who will speak to assertive community treatment.
Thanks, Debbie.
>> Debbie:  Thank you.  Can everybody hear me?  Thank you for the introduction.  It's an honor to be able to talk about assertive community treatment.  Doing it for a long time and it is a huge passion of mine.  So thresholds is one of the 207 certified community health providers that we just heard about.  We have a real strong focus on the social determinants of health, such as employment, housing, transportation, nutrition, and primary care.  We first and foremost focus on improving the quality of people's everyday lives.  How do we do this?  Well, pre‑COVID, our community support staff, including our ACT teams do 85 percent of their team outside of four walls.  That's very unique for a community mental health center to do that much work outside of four walls.
We go to wherever our clients are and need us.  So we go to their homes.  We'll go to the streets, jails, emergency rooms, hospitals, nursing homes, et cetera, to ensure that people get the care that they need and remain connected to that care.
Our overall goal is the triple aim to improve our population's health, decrease their cost to the system, and improve their patient's experience.
ACT.  Why does ACT exist?  Well after the community mental health center act of 1963, there was a huge deinstitutionalization movement.  People came out into the community.  And the system wasn't set up in the way that it needed to be to support many folks.  And so what you had was what we referred to as revolving door patients.  People who were going in and out of state hospitals.
So, ACT was developed in response to that.  As was noted, it started in Illinois in 1982.  Thresholds was participating in a demonstration project in the model as early as 1978.  Since then, this model has been adapted to support people with mental illnesses who are also homeless, have involvement with the justice system, and are in long‑term care nursing homes.  The explicit mission of ACT is to prevent institutional station, including homelessness of individuals with serious mental illnesses and improve the quality of life through intensive in vivo, in life, help with everyday activities.
As mentioned, assertive community treatment is the most researched model of mental health case management and we've learned a lot from those studies.
Who do we serve on ACT?  The average thresholds act client is a 45‑year‑old African‑American male with a diagnosis of schizophrenia, co‑occurring substance use disorder, a trauma history, history of multiple emergency room visits, psychiatric hospitalizations, justice‑involvement, homelessness, who's unemployed, underhoused, has few social supports, comormid disorders of diabetes and cardiovascular disease, on 6.6 medications, a smoker, and headed to an early death in 10 years.
Thresholds' clients like others with other serious mental illnesses are some of the most vulnerable and disenfranchised individuals in our communities.
Some of our ACT successes:  We have 14 teams.  We are the largest ACT provider in Illinois, and I'd go so far to say in the country.  We serve more than 550 persons across cock, lake, McHenry and Kankakee counties.  Last year, in FY20, we did 56,000 face‑to‑face visits with our ACT clients.  And as mentioned, we are a participant in helping people who are class members through the Williams and Colbert consent decrees transition out of long‑term care into the community.  45 percent of our ACT clients are class members who were transitioned from those institutions to the community in greater than 70 percent of those transitioned are still in the community.
Talking a little bit about metrics, measurements and outcomes, I think that with evidence‑based practices, if you have God fidelity, if you are doing well on the anchors to the fidelity scale, you are assured to have good outcomes.  Though there's really no body that is doing regular fidelity visits in Illinois, the rules that we need to follow dictate how we have to do the model.  So I think that helps us adhere to fidelity.
In talks about the triple aim, in terms of patient health, 100 percent of our clients have housing, although not all of them have safe, decent, affordable housing.  And 94 percent are connected to primary care, 85 percent of them connected to psychiatry.
In terms of the patient experience, 64 percent of our ACT clients report satisfaction with their housing.  And I think that's because some of them don't have safe, decent, affordable housing.  And 72 percent of them have residential stability.  84 percent of our ACT clients report a positive care experience.
Are we saving money?  Those with behavioral health diagnoses make up 25 percent of the Medicaid population, but they make up 56 percent of the total Medicaid spend.  We currently don't have the data to know if we are saving the system money or not.  We don't have access to Medicaid claims data, which would let us know which part of the system our patients have accessed and what the cost associated with them is.  It would also help us establish some sort of baseline for the year prior to when we started to work with them to see if we've been able to decrease that cost.
Are we meeting our explicit mission of keeping clients out of institutions?  We think so.  Jail, maybe.  Long term care, definitely.  Emergency rooms and psychiatric hospitals, maybe.  We don't have the data to prove it that lets us know when one of our clients has shown up at an emergency room or has been hospitalized.  Sometimes we do know and so we do collect that data.  But many times we don't know.
And that ends my presentation.  Thank you.
>> Jim:  Thank you.
>> Okay.
>> I think that means I am up next.  Can you hear me okay?
>> Debbie:  Yes.
>> Tammy stew wart.  I am the associate Director of ‑‑ which is a community mental health center in Northwestern Illinois.  We currently serve approximately 3200 clients across the life span over a four‑county area.  Our focus is centered upon the wellness and recovery of all the individuals we support during their recovery journey, in particular we recognize the importance of WRAP, wellness, recovery, action planning, as a central component of mental health recovery, which promotes self‑management of behavioral health conditions.
I became certified as a WRAP facilitator in 2005 and have facilitated around 30 classes at our agency, give or take.  I have supported and also mentored and continue to mentor three additional staff within our agency who became certified in WRAP as well and we had 45 WRAP classes.  So within the state of Illinois, WRAP facilitators attend WRAP refreshers every quarter, each region to enhance and learn best practices of WRAP in order to maintain the fidelity that's needed to support this evidence‑based practice.  So the monies given for these trainings are absolutely valuable and necessary for the continued efficacy in this area.  Currently the most common measure as indicated previously, is the recovery assessment scale, or RAS.  This measurement tool is not widely used throughout the State of Illinois.  And additional funding would be necessary to train the existing and future WRAP facilitators as well as supporting agencies in gathering this data.
How the data is collected is participants would use the RAS as a pre, post, and a six‑month followup of their WRAP experience.
And we've discovered the roadblocks consist of the RAS not being utilized across the state wherever WRAP is occurring.  If it were required, it would be an unfunded mandate.  Larger CMHCs have the ability to analyze this data in‑house, but the smaller ones do not.
Additionally, WRAP facilitators would need to be trained on this particular tool.  And it's been quite a while since that's been done in the WRAP refresher trainings that are offered.
The recommendations would include providing the funding for the time needed to conduct the pre, post, and followups.  Supporting agency infrastructure development for analyzing the data in‑house, and recommend the state provide refresh your training on the use of the RAS for WRAP facilitators.
Currently, my agency tracks outcomes through training tools like GAD, the PHQ and Locus.  We additionally track outcomes thank you our assessment and translating tool called the IMcams.  But to date, we can only anecdotally state that WRAP is producing solid progress since we have not been using the RAS as a more targeted way to see how WRAP has been influencing our client's progress over time.
Incorporating the RAS as a standard measurement tool would be a highly beneficial way to support how RAS continues to be a valuable intervention.
And, additionally, collecting data across the entire state would showcase how WRAP is benefiting behavioral healthcare across‑the‑board.
Thank you.
And I'd like the turn things over to Stacy Brown, who is going to speak about coordinated specialty care, first episode psychosis.
>> All right, thank you, Tammy.  Can everyone hear me okay?  Perfect.  So thank you for having us this afternoon.  My name is Stacy Brown, I'm the Vice President of ‑‑ services in Bridgeway.  Our primary clinic locations for mental health and substance use are located in the west central area.
So I'm here today to speak with you about the first Illinois program which is also more commonly known as FEP, or first episode psychosis.
It is a specialized treatment approach based on a team presence in order to help those with treated or untreated type of psychotic illness.
As Dr. Albert had said in the beginning when talking about the system, it is specifically based on individuals who are experiencing some type of psychosis.  So when we originally started the program, it was anybody who was present on the schizophrenia type spectrum.  But we also then did expand it to include people who may have bipolar disorder with psychotic symptoms, major depressive disorder with psychotic symptoms, and PTSD with dissociative symptoms.
So, because it is a very specialized group, we very much have the ability to focus on the individual, the symptoms and their family unit in order to help best educate and treat them in order to be a full functioning member of society.
So the program basically will serve anywhere from age 14 up to age 40 because as we find, that is primarily the age range where we're seeing these symptoms.  And it is also for someone who is experiencing this for the first time within an 18‑month window.  Because the goal is really to bring a person into services during that first episode so that we can WRAP them in as many opportunity services as possible so that it is their only episode and they can move forward from that.  The team approach for this evidence‑based practice consists of a lot of different providers.  But primarily it's what's called the IRT, which is the individual resiliency trainer or the actual clinician, which also incorporates family psycho education into the system because as much as we can train and educate those who support the individual, then it's the outcomes are even better, we know, because then they have that great support system.  It also includes psychiatry, medication management, case management, which many times can be done by a recovery support specialist which is also its own evidence‑based program.  As well as IPS, which one of my peers will talk about in a bit, which is individual placement and support.  So that's educational and vocational support.
So we started the program and partnered and collaborate with the northeast Ohio university as well as the Best center, which is the best practices in schizophrenia treatment.  So we're not only using the evidence‑based practice, we're also collaborating with other best practices around the country.
We started in 2016 with 12 teams throughout the state.  And in 2018, we brought in more partners and now have 15 teams.  There are 6 in the Chicago area.  And then there are 9 throughout the remaining southern area of the state.
So, up‑to‑date we've had over 1,000 referrals for this program specifically.  And we currently have 282 enrollees.  We've had 228 discharges from the program and that's for various reasons.  90 of those have been either successfully discharged because they've met their outcomes, they have moved out of their area who they're being followed by, or they no longer meet the criteria to maintain in the program.  The one area where we've seen a significant metrics is the 138 who have actually dropped out of the program, and I'll talk about that in a quick second.
The one metric that we found is that we have 20 percent of enrollees who are below age 18.  So that 14 to 18 age with young people having psychotic symptoms is 20 percent of our caseload, which is pretty significant.
Also another metric we found is 70 percent of those that we have enrolled are either in school or looking for work.  So we are able to be wrapping people with services, and they're able to be back in their communities and functioning very well.
We have a statewide data system.  And as Dr. Albert talked about previously, we do utilize the outcome review form, which gives us a ton of information and data metrics on the individual.  It's done every six months.
And then we also have a clinician‑rated dimension of psychosis symptoms severity scale.  It's a very long title but it's also a clinical way for us to gauge progress over every six months of someone who may have psychotic symptoms and be in the program.
So, quickly the challenges that we find are not necessarily capturing data and metrics; it's getting the individuals literally into the program.  Folks who experience some type of psychosis don't always readily come into services.  We find that we are able to engage their families.  And then once we can train and educate them, we can get people in and really understand the importance.
And as many of you may know, once people start to feel better, especially in regards to psychotic symptoms, they'll stop taking their meds or they'll stop coming to treatment.  And so we really work hard to find a way to engage them.  It's probably our biggest challenge.
It's a very brief overview of the first episode psychosis program.  And it feels like it's very new, but we're continuing to see strides as we go along each year.
So now I'm going to turn it over to Adrienne Brown who is the program Director of Thresholds who is going to speak to you about individual placement and support.  Adrienne?
>> Hi, thank you.  Can everyone hear me?  Can everyone hear me?
>> Yes.
>> Good afternoon, everyone.  Thank you for the opportunity to speak to you today about the evidence‑based practice individual placements and support which is commonly known as IPS.  My name's Adrienne are Brown, I am the program director the AIP in thresholds.  We operate as one of the largest providers of it in the State of Illinois.  We provided services IPS services for over 1100 clients last year.
I have the privilege of overseeing 8 IPS employment teams in the Chicagoland area including lake, DuPage, Kankakee, and McHenry County.
Three of our teams provide services to specialty populations including veterans, youth and adults which happens to be the only IPS service provider for youth in Illinois, and currently the only existing IPS team or program that serves individuals who are deaf and hard‑of‑hearing anywhere.
Additionally, we also provide supported education services for our young adult clients.
The evidence‑based practice of IPS in Illinois have several tangible outcomes.  One of these measurements is the annual IPS fidelity reviews done by representatives from DMH and the division of rehab services.  At Thresholds we closely adhere to the IPS fidelity scale and we are considered an exemplary fidelity program as 7 of our 8 teams are exemplary scores at your their most recent fidelity reviews.  We believe in the outcomes IPS models when programs are using it as a recovery tool.  The fidelity review process helps our program to stay true to the heavily researched criteria that helps get more people working and on a road to recovery.  The end results, to name a few, are better support systems for our clients, greater community engagement with employers and other community partners, less hospitalizations and incarcerations, immediate individualized and intensive services and collaborative expectations of the IPS model.
The success of the IPS model is clearly evident in the IPS employment rate threshold.  53 percent of individuals receiving IPS services in the last year gained competitive employment.  The national benchmark for this measurement is only who percent.  This is accomplished by maintaining high IPS fidelity standards.  Throughout evaluations department at Thresholds we utilize data provided by employment specialists on a daily basis allows for quality improvement on IPS services.  Timely reporting affords us the opportunity to make adjustments to items on the fidelity scale such as time spent in the community, job placements or even employer contacts to constantly improve employment outcome.
Another important regiment in providing IPS services in Illinois is the ability to capitalize on the IPS program milestones contract with the division of rehab services.  The milestone contract provides the majority of the funding for the IPS program as revenue is generated when clients reach 15, 45 and 90 days of competitive employment.  Through the lens of BRS a successful employment outcome is considered when the person reaches 90 days of supported employment.  Last year of the 413 competitive employment obtained by Thresholds, I am proud to say we had 174 clients reach 90 days of employment.  Although this is an impressive number of successful outcomes, it is important to note that employment services are unfunded through DRS and those clients are eligible for milestone payments, meaning they are currently working towards a competitive job by DRS or they have an open case with the DRS.
Our program is dependent on generating Medicaid revenue to support clients for pre‑employment job readiness services such as job searching, mock interviewing, résumé writing, among other activities.  This is an area where success is difficult to measure and, quite frankly, emphasis is placed on the funding generated through placements in 90‑day outcomes.  This is despite IPS being a model of long term, time unlimited supports.  Clients could work with employment specialists for months or in some cases even years before finding a job.  Efforts in providing pre‑employment services is not widely tracked or measured through any centralized system.  And this also applies to post 90 day employment services for long term services, as well.
Last year, the average time at Threshold client was in a competitive job was just over 13 months.  In the past, these services were ‑‑ vocational goals approved by DMH.  Navigating the decentralized services and systems of DRS with a large IPS program like Thresholds can be challenge in itself let alone what happened to allowed DMH to offset costs of running the program through Medicaid revenue.
I can honestly say over the past 14 years in this field, I have been able to see daily basis just how impactful employment interventions are to recovery.  IPS has proven to be the most effective supported employment model for individuals with serious mental illness.  The research and evidence shows that IPS works.
That concludes my portion.  I'd like to turn this over to Dr. Mike Buckman to speak.
>> thank you, my name is Matt Buckman.  Good afternoon, I'm an a licensed clinical psychologist.  For the treatment center.  I've been fortunate enough to be able to be trained and internationally or nationally certified in several different evidence‑based practices specifically to children.  Something nice about this is that really in my practice and in many those of who are using practice wise tools, we're really focusing on that earlier intervention to improve a better outcome and trying to address these issues earlier on in the life span, hoping that some of these programs that are really some of the best in the nation for some of our youth that we may serve, they may never even need that.  And so that's the hope through our programming.
Practice‑wise, as Dr. Albert had talked about, is a set of tools.  And within those tools, we've had for the last decade or so this availability of these tools.  And we've even had publication and research that have found that statewide in Illinois, I think the publication's like 2013, that the statewide implementation of this can improve the outcomes and can improve outcomes specific in a statewide protocol.
Now, we have probably the broadest application or availability of practice wise tools or these particular tools to practitioners that serve children of all of the practices that we've talked about.
We're fortunate that DMH does provide and thank you the state funding, that it does provide these tools to everyone.  And then additional training can be available to those practitioners that might need it so that they can really dig more into it.  And we know that the training works from our previous research that's been done in the state.
Practice‑wise, does something a little different whereas we've talked about some specific practices today, I want to talk specifically this is an evidentiary practice system.  And so first out of UCLA and John wise out of Harvard and Eric, who was in Hawaii at the time but now he's over practice wise, what they were able to do was develop this line of research around common elements.
So it was around 1300 different evidence‑based practices that exist nationally.  And although I've been fortunate to be certified and trained in several different practices, my list is still about 8.  And my list, I'm probably one of the 1 percenters as far as who's been trained the most in evidence‑based practices in our state.
I point out that the feasibility to be able to train folks in every practice for every different condition or focus area, that that is a barrier to disseminating on a wide scale the practices and the tools to be able to help child providers or youth and adolescent providers who will provide these effective services.
Within that, we boiled down through common elements what are the most common practices and the most common processes of evidence‑based practices?  The 1300 practices across all the literature for trying to address children's mental health needs.
We found that through a demonstrate, through modular approach to children, to treatment of children, for anxiety, depression, disruptive behavior concerns, and trauma, that when you compare this treatment to many others that are out there that are established like Russell Barclays' defiant child or Philip kindle's coping cats, when you compare them, this modular approach is actually more effective.
And what we find in community‑based practice is that children are not coming ‑‑ youth are not coming into our practice with simple issues, simple challenges.  In fact, it's complex challenges in community‑based systems in that it's not just having anxiety or not just experiencing trauma, but it's also having disruptive behavior concerns.  We know and I do work in the justice system, juvenile justice system, we know that 90, 95 percent depending upon the study of individuals in the justice system have experienced multiple adversities, adverse child experiences and trauma.  But I would still be addressing the disruptive or the conduct issues, but it's more complicated than that.  I need to be able to create a treatment that can address all things.
Within this, we develop clinical dashboards.  So it's not on a large‑scale that this works that we've proven but also every single case we have a process of developing measures that's using the family voice and the youth voice in this to be able to develop measures of what do we want to see change?  And then we're measuring that every time.  So not only do I know it works from a research perspective, but I'm seeing it's proving itself as effective in every case that I'm using these tools.
Now, many times we are using things like the Ohio scale, which we have, different things like functioning and problem scale.  Within that, we want to see those global changes, the Columbian scale with the youth and the care giver are completing that or the DEKA, which is an early childhood scale.  And so many times we're incorporating this, we're also allowing clinicians and we're developing clinicians to be able to make good clinical decisionmaking and support families in that process so that if there's something specific that isn't included in one of those measures, we can add something to it.  Or we can do idiographic measures that shows a direct correlation between what they're looking for to get out of this, maybe it's reduced police interaction, reduced panic attacks that we're actually measuring the number of panic attacks, measuring the number have police interactions.  And it's that continuous quality improvement that makes this work.
Now, some of the challenges we have is training and equipping clinicians.  Although this is available to all practitioners across the State of Illinois, which is wonderful, and there's distance learning, online tools, all the tools are available.  Few or not enough are utilizing these tools.  Leonard bike man's research shows that 85 percent of all practitioners in children's mental health services are using nonevidence‑based practices.  And so what we want to be able to do is we want to reduce that number of people that are not using evidence‑based practices to try to get the tools.  I think training and support is probably a little bit of a challenge in that process.  And I'll end with this idea of really children's focus in this idea of the earlier we intervene, the better the outcome.
And Benjamin Franklin's quote of an ounce of prevention is worth a pound of cure.  And early intervention is prevention when it comes to a lot of this.  And we want to address these.  And the environment and ecology that some of our children are living in in the state and practice‑wise gives us the tools to do that.
Now I'll turn it over to Mr. Chairman and the committee or the Commission to be able to ask any questions that you might have for us.
>> Chairman:  Thank you.  This is Jim again.  And so at this point we will turn it over to Commissioners to ask questions.  And just to get us started with it, I'll throw one out myself first.
Just in hearing all of the different presentations from everyone, I get the sense that if I were to generalize that outcomes tend to be measured more by behavioral results such as hospitalizations or incarcerations or police contacts or jobs or independent living as opposed to underlying assessments of the actual mental condition that a person might be experiencing.  So my question it's not so much a question, to comment on that.  Do you think that's correct?  How would you qualify it?
I know certainly I heard some of you talk about different scales you I don't that seem to go more to mental condition.  But just in general, is it more about your behavioral health?  Is it more about the underlying mental condition in terms of what you measure as an outcome?
>> This is Stacy from Bridgeway and the program.  I can answer for first Illinois it's actually both.  You know, we do want to see decrease in the hospitalizations and decrease in incarcerations and those types of area.  But for the FEP and that psychosis specifically, we do rate the clinical severity every six months to ensure that those behavioral health symptoms are decreasing.  So the different areas of psychosis, depression, disorganized thought process, we are looking to make a difference in those systems, as well.
>> Debbie:  I will say that ‑‑ can you hear me?  Okay, thank you.  I will say that, you know, mental illness is ‑‑ people can recover to achieve the goals that they set for themselves if they have the right WRAP‑around services to help them be successful.  But sometimes, you know, there isn't ‑‑ obviously there's no cure.  And some people will live with extreme symptoms their whole entire life.
But what we've learned is that despite symptomatology with the right services and supports, they can still achieve goals.  And some people will do well for a while but mental illness, especially serious mental illness, is not linear.  So some people will do well and they might have a relapse and develop symptoms again.
So I don't know if that sort of gets to the essence of your question, but despite the symptoms that people have to learn to manage, they can still achieve their goals.
>> And I'll add a little bit, too, that from practice‑wise standpoint, one of the goals, we want to really stick with what is measurable so that we can ‑‑ and maybe the tip of the iceberg, right?  But if this changes, whether it's contact or even if it's grades or certain type of functioning may change, that it should represent change that's happening beneath and internally for certain folks.
And I'll tie this together with a very effective approach.  Activity selection, behavior activation for depression in that there are multiple aspects or ways of treating depression.  But if I can help or support or coach an individual to do the things that they would normally do even during depression, what happens is as they're doing those things, their depression is lifting.  And so the answer probably is both.  And so how do we have measures of depression but also some of these like behavioral outcomes.  But really sticking with something that's measurable so that what ends up happening is that I don't really tap into a person's mood or maybe how their day's going because if somebody's having a bad day, they're going to tell me they're doing bad or poorly.  They're having a good day, they're telling me they're doing well or good.  And so I want to be able to get something that has reliability and has that measurable aspect.
>> Hi, this is Lee Ann Reinert.  And I would just add.  From kind of a global perspective for the division of mental health and the way that we try to steer our system, for many years we have been very focused on developing recovery‑oriented system of care.  And when you talk to people that have mental illnesses, the things that they want to get out of their treatment are the types of things you talked about.  They want to work.  They want to have a family life.  They want to have a home.  They want to have all the things in life that anyone wants.  And so those are the types of measures that when you talk to someone that's going through treatment for mental illness, those are the things that are meaningful for them.  And so that is the way that mental healthcare in general looks at measuring outcomes is it's less about focusing on what we would call symptoms and more about focusing on the quality of life.
>> Chairman:  Other Commissioners?
>> Jim, I have a question, it's Will Davis.
>> Chairman:  Yeah.
>> Will Davis.  I missed some of the presentation.  I apologize if some of this was said and may be redundant but nevertheless a question I need to ask.
A little context.  I have had the pleasure of serving on this Commission from its inception going back to 2011 as was mentioned earlier now serving under three Administrations.  And I have always maintained that when we are looking at measuring outcomes and looking at outcomes, if you will, as a way to help inform our budgetary decisions, that somewhere you have to take into consideration that not everybody starts from the same place.  That there are some communities that are just simply underresourced and that it's hard to use the same measurement for communities that are underresources versus those that are very well resourced.  We know who they are.  We no where they are.  So that being said, in this mental health space, is it fair to have definitive measurable outcomes for, say, the African‑American population versus other populations?  And when you all talk about your evidence‑based processes that you're using do they make distinctions in a certain way that evaluate groups of people differently in different ways?  And that in doing so, that you can make, I guess, different decisions on how somebody from this community is either needs to be addressed or needs to be resourced needs to be treated versus another community and that there's no one‑size‑fits‑all.  And again I think it's important to acknowledge that.  Whether it happens or it doesn't happen, it's important to acknowledge in these conversations.
So if anyone could talk about practices that they use and can describe the nuances that exist for looking at people from different walks of life, I'd love to hear some of that commentary.  Thank you.
>> Leader Davis, this is Dave Albert.  I'll let our expert panelists weigh in on the specifics to the extent they can of the metrics that these particular practices use.  But I want to thank you for raising the question because particularly now, for a variety of reasons, many of which are related to this pandemic we're all experiencing, I think we're all very focused upon just how disparate health outcomes can be for different communities.  I'm going to be interested to hear what we learn from our panelists because I think it's just a really great question.  We in DMH have been very focused on thinking about what can we do to address these outcomes?  What can we do to address the fact that various communities in our state have varying levels of access to services, services that may or may not be as well attuned as they could be to the needs of these specific communities, which differ.  And so I'm glad you raise this because I think we need to be thinking and talking internally also about how we measure success and how we measure outcomes and how define outcomes in communities, especially black and brown communities, communities that are dealing with generational poverty and are really not ‑‑ doesn't have the same resources available to them that other communities in the state have.  So I'm more thanking you for the question and I'll be interested to see and hear what our panelists have to say.
>> It looks like Dr. Buckman has a response for us.
>> Sure.  Thank you.  Representative Davis I think it's a good question.  And I remember you presenting on some of the R3 work, as well.  And that is really looking and hopefully trying to address in just a small way what this looks like.  And I'll just add and I agree.  I guess I'll echo and say thank you for the question.  And I'll add this even differences in quality that we may find or the number of service providers or the types of services and where it is provided in different neighborhoods and different communities, what does the providers even look like within that that we're still looking at there's a significant difference between what our consumers or clients look or have experienced versus our practitioners and what they look like and have experienced and what kind of effect is that having in our communities like that?
And so from a measurement standpoint, I think from practice wise and I'll just say in general, it's important to note what is available?  So practice wise is taking all the evidence‑based literature and then we get to put in demographics.  And we get to say "my client is a 15‑year‑old male and then it boils down the research and says how many protocols have actually been tested for that.  For a 15‑year‑old male that's African‑American as an example, that has ever been tested for that.  And what we find is that there's very scarce results.  You still look at, we're still dealing with consequences of who was studied even 30 years ago and 40 years ago and still white females are still the prevalent, the most prevalent of the foundation for most of these research protocols, evidence‑based protocols.  And now we're just now putting this let's say in the last decade, decade and a half, we're actually testing in the field.  And white females, because that's the primary person who goes to college.  And that then creates this bias across all the literature on what works and what doesn't work.  And then tries to put everybody in one box.  And so within practice wise, within managing and adapting practices is to be able to create this individualized approach.
And like Lee had said, too, in that if I'm talking with a family and the family really gets to drive that process, they get to tell me what is it?  What does it look like to have a better life right now?  So we have to be able to really incorporate something that doesn't ‑‑ it's not like a standard, well maybe we have some standard ones, but sometimes there's something that's more meaningful to the outcomes here that is like for me and my world, if I can just have this happen, if this changes in my world, it matters a lot.  And I would be in a better place.  Then we have to let them drive that process and have enough space and training equip the practitioner to be able to say hey, it's not everyone that has to get higher on this one particular measure, but, instead, if you're higher in this area but maybe not this area, because there's structural differences and biases and lack of opportunity that not everybody will be able to meet up to the same standard when we see that it was actually developed for a different demographic of people.
But how do we let them drive the process?  That's an important piece of that.  Be and then how do we individualize it?  And we do that within map.  But it does require training and improving the quality.  And then it's important to also make sure that quality is available in every neighborhood.  And maybe with intentional effort, I'll just add this piece, how do we get individuals of color and different demographics and backgrounds in the roles and positions to be able to help others that look or sound or maybe perceived as similar to our clients.  That's a lot.  I apologize if it was too much.  But that's my thoughts.
>> Thank you, Dr. Buckman.  It locks like Stacy has a response for us, as well.
>> I would just agree with Dr. Buckman in the FEP or the first IL program in regards to psychosis, everything is very individualized to the person who's right there in front of us at the time.  And that's why a huge stress is put also on family psycho education because everybody's family, everybody's support system, everybody's community where they come from is very different.  And so we want to provide that service also to those supports so that they can best help the individual.
So another thing and I know that Dr. Buckman alluded to this, as well.  It's not really just training for the people that we're serving and their supports and family, but it's also for our staff.  We all have very strong cultural diversity training in our programs.  And within the first IL, we're all over the State of Illinois.  So I come from a very rural area.  But we have six programs that are up in the Chicagoland area.  So what they see is very different than what I see.  And so that's why it does have to be very individualized to make sure that we're able to serve any single person in that evidence‑based program who comes in our door.
Thank you.
>> Thanks, Stacy.  Looks like there's a comment for ‑‑ Adrienne Brown?
>> Yeah, thank you.  I definitely probably raised my hand too soon because both of you said a lot of what I said.  But the great thing about the IPS model is the individualized planning, goal planning assessments that takes into account different cultural differences and backgrounds, whether it's where they live, their age, their physical disabilities, all of those things take place in initial meeting with clients.  And the most important part is that they're met where they're at.  They're not expected to be where the next person is at a month from now or three years from now.  It's so individualized that those goals are planned out very thoroughly.  And it takes into account those different lack of resources or ability to gain access to resources.  I agree we have a Chicago area clients.  But in our rural communities like McHenry, Kankakee and DuPage and Will County, those transportation is an issue.  You can't just jump on a train or a bus and get to work every day, right?  Or even in the city in some of the more urban areas on the north side of Chicago versus the south side of Chicago, access to actual employers.  And specifically over the last few months have been very difficult.  So I think that IPS affords the ability to really navigate it on an individual basis and provide supports to address individual needs.
[Too many talking at once.]
>> It sounds like the individual ‑‑ so it sounds like your methods account for some of the things that I'm asking about.  And I just want to make sure that they are measurable as to the extent to which we as a Commission are looking at ways to measure these outcomes and that we can make those distinctions that if you're implementing the same model.  But because it has individual aspects of it that we can account for how that model's implemented in rural white areas versus urban black areas so to speak.  Is that fair?
>> Yeah, that's very fair.
>> Yep.
>> I'll just add one more thing.  I apologize I didn't raise my hand.  But representative Davis, as much as possible, if there's ways to be able to get to the literature of different ethnic groups, you may want to see that maybe there's different cutoffs or different types of expectations of one group versus another or even urban versus rural if that's possible.  That is what's always best if we can get that norm.
>> Did you have something you wanted to add?
>> Debbie:  Yeah, I just wanted to say, I don't know particularly but everyone with a serious mental illness is living a life of poverty.  But many of our African‑American clients, because of racism and institutional racism, come from a culture of poverty.  And so there's a difference.  And we are in those neighborhoods.  We're in awes tin.  We're in Englewood.  And we hear all the time how difficult it is to find the resources that our staff need to bring to their clients in those communities.  Huge, huge difference.  I think that because we're so focused on the social determinants of health that we do whatever it is that we can do to find those resources for individual people.  I don't know that we're making huge changes in the whole community.  I don't know that that's really something that we can do by ourselves, but we have invested in housing.  We have housing in those communities.  So that people can have safe, decent and affordable housing.  We partnered with the urban growers, that bring fresh produce that our members can afford to buy to our south side locations.
So, I hear this all the time from our staff.  We just don't have that.  We can't ‑‑ doing our work in these neighborhoods is so much more difficult because their resources don't exist.  Trying to find psychiatry in those neighborhoods.  Trying to find primary care.  It's a problem.  I think the only thing that I can say is that at least those folks that we're serving in those communities have people who are doing everything they can to try to get those resources for them.  So I don't know if that adds anything other than to say yeah, it's a problem.  It's a big problem.
>> Okay.  And last one I got, Lee.
>> My final comment will be sometimes it's just a matter of acknowledging.  Sometimes we don't get the acknowledgment necessary to say that we need to do things differently.  Again, our job here is to look at how we're funding programs and to look at whether or not they're effective budgetary wise.  Again, we just have to, for me it's all about being deliberate in this conversation and walking into this conversation.  So, again, as you are out in the field and you're implementing and you're what have you, just wondering are you taking those things into consideration?  Certainly sounds that you are.  Because again at the end of the day, if state resources are funding this, I just want to make sure that, A, you know, we are using our dollars effectively.  And that we're also taking into consideration the facts that some communities are dealing with things a lot differently than others and as some of the institutional challenges, the systemic challenges, as well.  And that we're taking those into consideration, as well.
So in some ways it's good, in some Wales it's bad, probably, because when you have communities that are just severely underresourced, sometimes there is just not enough money to put into that community, which means that you're not using dollars effectively.  But, again, I know that we have to take into account that, again, not everybody is starting at the same place.  And that in some cases we have to be able to be a bit more deliberate particularly under resourced communities as we are in other communities.  But again making sure we asking, as you are, are you going into communities providing the services?  Are you able to make those kind of distinctions and how do you go about doing so?
Again, thank you all for your comments.
>> Chair:  Other commissioners?
>> Chairman, I have a quick question.  Debbie and the presentation, you pointed out that you have anchors to the fidelity result and good outcomes.
I think when we're dealing with evidence‑based programs, obviously having as much fidelity to the original design and its implementation is very important thing.
This question is for the entire panel.  Are there for each of your programs or just for the mental health provider community at large are there mechanisms or processes that you have to help ensure fidelity after implementation?  Any sort of post implementation followup that you have to check on that fidelity, the design.
>> Debbie?
>> Debbie:  Yeah, I think that for us, for assertive community treatments, it's actually written into the state, the two rules.  One that the overseen by the division of mental health and the other rule that is overseen by the Illinois Department of Health care and family services.  And the way the rule is written, in order to be able to provide ACT, you have to adhere to basically the fidelity elements that are written right into the rule.  So I think that helps reinforce people adhering to fidelity because if you don't adhere to the rule, you risk not getting paid for the service that you're delivering if you're out of compliance.  Again, there's things that are just built into the fidelity model that just makes so much sense.  I think that for me, anyway, I think that we need to go back and look at the fidelity for ACT, because I think the times have changed and we probably need to re‑examine some of the pieces of it.  But I think just because of the way it's written into the rules, it encourages adherence to the actual fidelity.
>> Dr. Buckman?
>> Dr. Buckman:  Yes, Commissioner, very similar.  I would say that for practice‑wise, the fidelity's a very important piece.  And a lot of it we do management and we do adaptability.  And so.  So a lot of it is that management, what did I intend to do and what are the practices?  So checking in on my adherence or fidelity to it.  But I also want to recognize like this fidelity with flexibility.  In that when it comes down the model, the model probably came from like I practice primarily in a rural area in Southeastern Illinois, the model probably came from an urban area or maybe the model came from a place in New York City or New York.  And so it's very hard to be able to say ‑‑ and I think this is where quality comes in.  That when practitioners are given the tools to make good clinical decisions and to be able to know what is fidelity?  What do I have to keep to?  And what can I adjust?  How can I adjust this idea of like behavioral activation, maybe in the model it says specifically that the more a person goes and walks outside of their house and they go to the store and they buy their own groceries, the better that outcome is.  But I don't know their life.  I don't know their neighborhood, right?  Like some people don't have.  You can't walk to a store.  Some people, the place you can walk to is not safe for you or you don't feel comfortable with that.  So how to we have that fidelity which is really important but the quality clinicians we really want to be building in our state, that they know enough to be able to adjust that or adapt it to that particular person's needs if that makes sense.  And so it's one thing to just ‑‑ and I've seen people to just stay on model and they sound like a robot.  Like I'm literally reading.  And sometimes mental health issues can be ‑‑ and that doesn't create this therapeutic reliance and relationship that might be necessary.  So I think it speaks to quality.  So we definitely I know all the practices model fidelity but also create that adaptability to individualize it specific to it.  So we manage first and we adapt second.
>> Thank you.  Stacy?
>> And just similar to what Debbie has said in regards to maintaining the Fidelity, I know that for some of us and for many evidence‑based programs and practices, there's a specific review.  There are literally people who will come out and review the programs that we are providing to ensure that we are sticking to the Fidelity of the evidence‑based practice.  And so literally not only is it like Debbie said written into the rule and the expectations are there for us, but many of those have those Fidelity reviews where people come out to make sure that we're doing that.  It's a good check for any of us.  And like Debby said, maybe we do need to look at the overall Fidelity.  How do things need to be updated and changed?  And that gives us a good opportunity and time do that.  And I think all of us probably have our own internal quality programming that is a secondary layer to that that just helps us do that, as well.
>> Thank you.  Tammy?  Yes.  So I'd like to talk about RAS and the fidelity associated with that.  I had alluded to previously as a RAS facilitator, we have to attend that quarterly what we call refresher training that really speaks to the best practices that are associated with the RAS curriculum.  And it's really a priority for all RAS facilitators to be attending the refresher on a very regular basis to maintain the fidelity across‑the‑board, where I think improvements could be made to that potentially an auditing component much like we do for mental health first aid training just to ensure that that is happening across‑the‑board.  But I think that the state has done a phenomenal job really standardizing those trainings across all of the region.  I think probably over the past five years have really refined what is needed every quarter to really work with our facilitators in the way that everybody's getting the same information and implementing that consistently through out all of the classes being offered.
So, again, I think that an auditing feature would be useful.  But I think what we're currently doing is much, much more effective than what had happened when you first rolled out WRAP back in I think 2002 we started WRAP.  I became facilitate or in '05.  It did not become an evidence‑based practice until 2012.  So I think we're heading in the right direction.  I think, yes, there is room for some refinements moving forward.
>> Thank you.  Lee?
>> Chairman:  I have a question.  I think it's directed toward Dr. Albert and his people.  But the question is:  To what extent and what ways do you use performance metrics or data to make decisions about budget allocations either between different programs of the state operates or to put more money on a particular program?  Or I suppose conceivably put less and, or, do a lot of these programs tend to be Medicaid entitlements.  And so the actual metrics maybe aren't as important.
>> Thank you, Chairman.  I'll start off ‑‑ might want to chime in here.
Certainly when we're thinking about our priorities for the state and looking at programs that we would like to support and that we believe could be beneficial to our residents, the efficacy of a particular intervention is very high on the list of the things that we consider.
So that's part of it.
I think Brock might speak more broadly to how some of our funding decisions are made.  And then I may share some additional thoughts.  Brock?
If we still have Brock?
>> I think he's on mute.
There you go.
>> Hear me now?
>> Okay.
>> All right.  Thank you, Dave.  So, our funding for these services are that many of these are funded through Medicaid.  And, therefore, you're right.  There's not necessarily a budgetary decision to be made.  They are service that as long as they're appropriate for an individual, Medicaid provider can provide those services.  The others are ‑‑ two of the others are based on grants that we have.  And some of these are federal grants like the FEP.  And so in that regard, right now we have federal funding for that.  Down the road, if there's a change, then we will use the information that we gather through that time period to determine if there's something that we believe the state would be interested in pursuing for the long term out of general revenue funds.  And so that's what we'd be looking at there.
So, we do use those.
But, of course, as you know and everyone on this call knows, we don't necessarily decide our funding.  And so it depends on what's in the budget bill and ultimately what authority we have from the governor's office, also.
So it's not a simple thing:  Yes, this works, we want to throw a bunch of money at it or not.  But that's the overall answer.
>> If you have a "yes this works" program, how do you ‑‑ what do you do with that information?
>> So, in a more recent example, we have a yes, it works program.  It's not one of the programs from today, but it meets the definition of what you're referring to.  And in that particular case, we have locked at how we can expand that using other funds.  One of the funds that we've looked at was using some of the new cannabis tax money to increase funding.  We would keep the original program intact.  And then we want to consider looking at expanding on that.  There are some difficulty there because of the federal program.  And there's some federal restrictions when it comes to cannabis tax money.  But we do actually look at that going forward and plan around it.
We've also in the past looked at things that worked when it comes to rate.  And so there's some discussions regarding the rates that we pay.  And if we have a program that's highly successful, we would prefer to put more money into that program, rather than into ones that we have questions about or concerns.
>> Does that apply to the ‑‑ do you apply that logic to the rates you pay for Medicaid‑funded services?  Yeah, the rates, the Medicaid.
>> The Medicaid rates are originally were calculated between IDHS, DMH and HFS.  And as you know, they have to have federal CMS about approval to go forward.
We have done, over the past with the years, we've done a couple across‑the‑board rate increases to Medicaid because so many of our Medicaid rates are low.  And in many cases they do not cover the actual cost of services.  So our community providers are having to rely on other things like fundraising and stuff to help fill in the gaps for that cost.
We're currently working right now at looking at particular services that are most beneficial in the community and have the better outcome.  And so due to timing constraints, you know, we were doing it more across‑the‑board where now we've got a little bit of time and we're taking more of the kind of a approach where we're really digging down to see what services we need to look at increases for.
So before that, before the last couple years, I've been around here over 11 years and I had never seen a Medicaid rate increase.  So I can tell you that I don't have a lot of good examples to use because it's something we've not seen a lot of in quite a while.  I was going ask the question a little differently until you added that last part on it which I sort of already knew.  But is the Medicaid rate increase about staying in the field at all, or doesn't have ‑‑ I suppose it's a philosophical view at this point since you just kind of said, not that much experience with it.  Or does it actually have value in a market sense of drawing more providers into a field?  Or is it just about the surviving?
>> Brock Dunlap:  So I'm an accountant by trade.  So we're fairly absolute in general.  But I would say that it's alt built of all.  We want to make sure that we have consumer access to care.  And to make sure the people with serious mental illnesses around the State of Illinois have care, we have to make sure that there are providers around the state that provide it.
If we're not providing a rate that is ample enough that a provider can pay their own bill, then they will cease to exist and therefore there will not be services for these individuals with mental illness.
So, you know, there is a part of the rate and stuff that is about insuring consumer access.  I personally I never looked at it as saving a provider or in that regard.  I view it more as insuring there's access for consumers around the state.  That's who we're really here to assist.
>> Well in that sense, then, you could, in fact, I mean, just in the abstract, it would make logical sense if there were increases to put Medicaid increases on the services you most valued so you wouldn't lose access.
>> Brock Dunlap:  Right.  That is correct.  That is correct.
>> Chairman:  But it would also be true, I think from what said that hasn't actually been a practical question in a very long time.
>> Brock Dunlap:  Right.  Our first funding, under the current administration has been our first funding increases for Medicaid in sometime.
>> Chairman.  Other questions or comments by commissioners?  I'll keep going if there isn't.  But I want to make sure everyone gets their chance.
>> Mr. Chairman if you have a few more questions, I think we should probably open it up for public comment.  Let me ask a little more then.  I'd be interested if any of you know of formal evaluations that have been done of any of your programs that were done in a rigorous manner that can be made publicly available or available to the BFR process?
>> Yes, I've been happy to send those in.  There have been randomized control trials to make sure they are effective compared to gold standard as well as treatment as usual.  And we can share those with you.
>> Chairman:  Great.  Yes.  Send those over to Curt, yeah.
>> You got it.
>> Chairman:  Anyone else know of anything?  Yeah, I mean on your program specifically in Illinois as compared to the national literature.
>> Debbie:  I'm clarifying.  Are you asking.
>> Lee:  Are you asking like fidelity reviews that programs have had on their specific program?  Or are you asking for the literature and research?
>> Well, yeah, I mean more the things that have to do with outcomes or cost benefit of what's been done in Illinois in this field.  We're certainly aware of the national literature.  So interested in things that didn't get into the journals that are about Illinois.  That were done without sufficient rigor.
But, yeah, we're all ware of the fidelity reviews you've all said that are kind of the ongoing things.  I think we're aware of that.
>> Matt Buckman:  Chairman Lewis we're currently piloting in the southeastern region something similar to what you're talking about in that we're using an enhanced reimbursement rate using a grant to be able to pilot ‑‑ it's currently in progress, though, so I don't really have the outcomes yet.  But preliminary, more people are going to trainings, getting certification, the training dollars basically have a better return on investment.  But we are piloting that for enhancing the rates for those particular practices that we want to see more of.
>> Chairman:  Okay.  Great.  Thanks.
Okay.  Well, I will open it at this point to the public comment portion of the hearing.  So anyone on the call is welcome to address a question.  Certainly to the Commissioners.  And since we've got the panelists, to them, as well, if it's of interest.  So feel free to jump in here.
>> Adam?  Do you have a question?
>> Yes, thank you.  My name is Adam Aldridge with the center of ‑‑ here in Springfield.  First wanted to thank you all for your comments and listened to all those really insightful.
I just had a couple of questions if that was all right for a couple of the presenters.
The first question I had was for Ms. Stewart regarding the WRAP program.
You talked about that some of the certified mental health centers are able to have the trainings and refreshers and use the recovery assessment scale, but it sounds like the smaller mental health centers don't have the ability?  I guess I wanted to see:  Do you have ‑‑ would you have an idea about a percentage in terms of out of the 207 how many of them are able to analyze this data?
And the second question was:  As best you can to see about some sort of dollar amount that would possibly be able to allow all 207 mental health centers to analyze this data for the program.
>> Yes, thank you.  I would not have that information readily at hand.  I'd have to take a deeper dive on that.  But what I can say is that I do believe that the majority that are probably not utilizing this, the information that I did get.  So I don't have any hard numbers on that.  But I certainly could look to find that out for you.
And then as far as ‑‑ what was your second question?  I'm sorry.
>> Well, the same question just basically be if you had to more or less extrapolate the cost for, you know, the mental health centers for all 207, if they were able to get this, analyze this data and use this measurement, is there ‑‑ are we talking about a million?  Are we talking about a bunch of million?  Do you have any idea of what that would cost and the trainings, that what would cost?
>> I would not have that information on hand, no.  Definitely.
>> That's all right.  I appreciate it.
The second question I had was for Adrienne Brown I had a quick question.  I want to make sure I had the numbers correct.  You were talking about the numbers of supported employment for the IPS program.  Correct me if I'm wrong, but the area that you oversee the 413 clients that you all have and the 174 of them gained 90‑day employment?
>> Adrienne Brown.  No we actually had 1100 clients we serviced.  We placed 413 of those clients last year in competitive employment and 174 of those individuals made it to 90 days of employment.
>> Adam:  Okay.
And then kind of related to that, please correct me if I'm wrong.  It sounded like that the program ‑‑ basically the reimbursements that thresholds would get from the division of rehabilitation services was based on the success for lack of a better word of the number of people that were reaching employment and sustaining employment.  Is that accurate?
>> Yes.  So we're paid at milestones 15 days of employment, 45 days and 90 days of employment.
>> Okay.  So then I guess my final followup to that is:  How do you balance the need for generating revenue, which is obviously important for probably everyone right now versus maybe making sure that there's the best fit of the employment that they have?  How revenue important for all the mental health centers?  My question is how do you go about doing that?  Do you see if there are any challenges in getting the employment the revenue can come back to Thresholds?
>> You're kind of breaking up a little bit.  So I don't understand the question.  Are you asking how do we prioritize maybe the individualized preferences versus the need for revenue?
>> Adam Aldridge:  Yes.  It sounds like IPS, from what I understood, was dependent on the Medicaid revenue.  And that Medicaid revenue, if I'm correct, is based on the number of clients you have that reach gainful employment.  And so just trying to understand the difference or the dichotomy between getting ‑‑ obtaining revenue from those successes and helping clients reach and find employment.
>> Sure.  And like I mentioned, we could work for clients for various amounts of time from that time that was spent in nonplacement status would be.  We would spend utilizing Medicaid revenue to offset the cost.
We don't push towards the chasing of revenue.  We really do honor our members, our clients' preferences.  Because even if we are placing a client in a position that is easily accessible, if it's not a match for their preference, they're not going to stick around.  We know that.  It's a waste of our time.  It's a waste of their time.  It's definitely a waste of the employers' time.  We don't chase the revenue.
The beauty of the IPS model is that if you follow the fidelity, you will find the placements.  You will be able to get that client from Point A to Point B.  And the offset, again like I said there's additional funding for clients when DRS clients after 90 days placement, but there's a case‑by‑case basis that's no where near the amount that we get for a full 890‑day successful outcome.  90 day.
>> Okay.  Thank you for that information.  I apologize for the question, not giving the question perfect there.  But thank you for that information.
And then if it's okay with the Commission, I have one other question for Dr. Buckman.  And I wanted to ask I think he knows Matt and my dad worked together in southern Illinois in the same area, so it's good to hear from you, Matt, and listen to you talk about the tools and resources that you mentioned.  I just wanted to ask if the state has any sort of toolbox that or would need to establish some sort of toolbox to be able to put as many resources, trainings, tools, basically anything together in an area that regardless if you live in one part of the state or another, you're able or you have one set of clients or completely different set of individuals that you're focusing on that everyone could be able to get to that same toolbox to access information that's important for them.
>> Yeah, good question.  I just texted your dad.  I was like hey!
And so it's nice to talk with you.
I would say that what we're ‑‑ so we have some good toolbox in that.  What we don't have is specific to Illinois.  And for a lot of the fidelity in this, right now we can get people access.  It's kind of stagnant.  But really having that individualized consultation, individualized supervision or discussion about how to apply these practices that is really needed for the quality.  And that's probably what the study I'm going to send in to the commission will be, is that with the training, we know the outcomes can be there.  Without the training, without a training arm to it, I'm not sure in that.  We don't know that it doesn't, though.  We just don't have the data.  So I think to answer your question, I think there's pretty good tools, but we could tailor some stuff to Illinois.  And I think the consultation and support, as people are acquiring these skills and applying them, that would improve quality significantly.  Thank you for the question.
>> Yeah.  Good to talk with you.  Thank you.  Thank you, everyone.
>> Thank you.
>> Chairman:  Any other public questions?  Comments?
[Silence.]
Well, thank you.  On behalf of the Commission, we appreciate everyone who participated in the hearing this afternoon from among the practitioners and from the Department of Mental health.  And thank you, Commissioners, for being with us this afternoon.  So without further ado, you can catch Commission meetings on the web these days every two months or so if you're interested.  And otherwise, we will be back to our public hearing again about a year from now.
Curt, if anymore to add, I'll give you a second?
I believe we're adjourned.
(end of hearing)

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