PROS Update

by Karen Welch

The last issue of Mental Health World (Spring 2004) had two articles on the Personalized Recovery Oriented Services (PROS) program. PROS is a comprehensive recovery oriented program for individuals with severe and persistent mental illness. As stated by the Department of Mental Health, the goal of the program is to integrate treatment, support and rehabilitation in a manner that facilitates the individual’s recovery. However, it is also a way for New York State to shift some of its mental health costs to the federal Medicaid program.

I recently spoke with Jack Guastaferro, the CEO/CFO of Restoration Society, Inc. (RSI), and a former board president of NYAPRS. Restoration Society is a not-for-profit corporation that provides recovery-oriented psychiatric rehabilitation services for individuals who suffer from long term mental illnesses. RSI offers social, pre-vocational, and vocational rehabilitation, and recreational activities through the operation of three clubhouses, two supported employment programs and a homeless drop-in center.

PROS will require almost all mental health rehabilitation and vocational programs to participate in the federal Medicaid program. The rehabilitation programs include psychosocial clubs, vocational support programs, on-site rehabilitation programs and Intensive Psychiatric Rehabilitation Treatment programs. These programs will become fee for service models and will have to bill Medicaid in order to finance their operations.

In the last several months, Jack has devoted most of his time to working on converting the majority of Restoration Society’s programs to a PROS model. In Erie County, Restoration Society and the Mental Health Peer Connection have created the Recovery Partnership to offer PROS services. As co-chairman of NYAPRS’ committee on PROS, Jack has also been an advocate for peer-run programs in Albany. The following are some of the issues that may affect peer-run programs that will have to convert to a PROS license.

Jack stated that for clubhouses (psychosocial clubs), PROS means that members will now have to be “carded” to determine their insurance coverage. This is necessary since billing Medicaid will be the only way clubs will be funded. He estimates that about 85 percent of his current customers are Medicaid eligible. Currently, those who attend a psychosocial club give out personal information on a voluntary basis. Carding may have a chilling effect on people who attend clubhouses since some individuals may not wish to give out personal information. For those individuals who are not Medicaid eligible and those on spend-downs, the clubhouse will have to engage in benefits counseling and planning as well as case management-like activities oriented to achieving Medicaid eligibility. This is potentially an enormous administrative burden to traditional clubhouses. Additionally, clubhouses will have to deal with many consumers who previously did not have to pay for services but now must because of the billing rules and Medicaid restrictions. Clubhouses will have to create new ways for financing services for these folks such as creating a sliding fee scale for services. For example, those who are Medicare only may have to pay in order to get services previously underwritten by the Office of Mental Health. Agencies running clubs will have to absorb some of the non-reimbursable costs for these individuals.

Jack says that clubhouses will have to do due diligence to insure that the PROS model does not change the culture of the clubhouses. Clubhouses must remain voluntary and flexible. In addition, Jack says that any fees charged to those who are Medicaid ineligible must be done in a way that does not exclude individuals who need these types of services.

A benefit of moving to the Medicaid model is that case files will have to be maintained for all participants and clubhouses will have to maintain an Individualized Recovery Plans with each customer. Having data on individuals served will help serve them better since there will be a record of services and a record of the person’s progress. The PROS Recovery Partnership consumers have full and total access to their records and files and will partner with staff in every aspect of planning and service provision.

The current model for financing psych rehabilitation services comprises agencies funded with mental health appropriations in order to provide rehabilitation services to consumers. The agencies that provide these services consist of traditional providers, peer-run services and recovery run models. Consumers currently have the ability to go to any provider they choose. Under the current PROS proposal, this choice will be significantly reduced due to enrollment restrictions. Therefore, there will be enormous competition among providers to attract Medicaid eligible consumers to enroll in their services. This provides some unique problems for agencies like Restoration Society which does not provide traditional clinical services to consumers and PROS requires clinic affiliations.

In Erie County, Restoration Society and the Mental Health Peer Connection have created the PROS Recovery Partnership in order to create a unique program that promotes consumer choice, growth and recovery. However, one of the problems for them is that they will not directly provide clinical services to its participants. Therefore, it must get affiliation agreements with traditional providers so that their participants can continue to utilize clinical services. Jack indicated that he would be working on this issue in the coming months. One difficulty is that the PROS Recovery Partnership is in direct competition with the traditional providers and that they may not want to enter into these agreements since they will be competing with the Recovery Partnership for Medicaid eligible clients. It helps their competitive edge if the Recovery Partnership cannot directly offer clinical services to its clients.

As of this writing, the implementation date for PROS is still uncertain. Final regulations on the program have not been established. Jack believes that implementation may be delayed as late as the fall of 2004. Regardless of the time-line, this program poses unique challenges to peer-run and consumer-centered programs who have always relied on direct financial assistance from the Office of Mental Health. The Office of Mental Health has made this transition less difficult for agencies like Restoration Society by giving two months of start-up costs, holding it harmless financially for the first year of implementation and providing a year’s worth of enhanced technical assistance.

Finally, Jack says that he welcomes the challenge that PROS will bring to his agency. He believes that an increase in funding for his agency by Medicaid billing is possible. This increase in funding would allow him to pay better wages to his workers which will lead to greater work satisfaction, job retention and to provide other needed resources. In turn, this would lead to better programs for consumers. Let’s hope things go well for consumer-centered recovery-based programs such as those run by Restoration Society.

Jack is happy to discuss PROS with interested individuals. Feel free to contact him at JR6126@aol.com or phone him at 716/886-3246(office) or 716/432-0153(cell).