The court also approved exit criteria for the Dixon lawsuit, which provide  a basis for measuring the performance of the District’s mental health  system and which must be met in order to end the Dixon case. The criteria  cover four areas:  1.  consumer satisfaction, which assesses consumers’ satisfaction with  mental health services provided;  2.  consumer functioning, which tracks consumers’ clinical, social, and  other conditions upon entry into the mental health system and again  after receiving services for a specified period of time;  3.  consumer service delivery, which assesses the adequacy of the mental  health system’s overall performance for consumers in a range of areas  including treatment planning, coordination of care, and response to  emergent and urgent needs; and  4.  system performance, which demonstrates how well the community- based system of care is serving particular populations. DMH remains  the largest provider of community-based services and continues to provide  inpatient mental health care for the District at St. Elizabeths Hospital. DMH’s own community services agency  is the largest provider of community-based services in the District, acting  as the primary provider for 55 percent of all consumers enrolled in the  District mental heath system as of October 2003. Enrollment and Billing System Is Designed to Coordinate Clinical, Administrative, and Financial Processes

In its first 2 years, DMH developed and implemented a comprehensive  enrollment and billing system that coordinates clinical, administrative, and  financial processes. Two key attributes of this system that were described  in the final plan are that it (1) links payment with planning for individual  treatment and the provision of services and (2) increases access to federal  funds through the development of mental health rehabilitative services,  which are community-based mental health services that a state’s Medicaid  program can choose to provide. Problems managing cash flow were exacerbated because provider  contracts with DMH were tied to the billing projections, which meant that  DMH could not pay claims for providers who exceeded their projections  until their contracts were changed. By August 2003, DMH made the necessary contract  changes to allow providers to be paid for the remainder of the fiscal year  and, according to senior officials, had a plan in process for fiscal year 2004  to prevent this problem from recurring. Consistent with  this focus, DMH has established requirements in two key areas, consumer  choice and consumer protection. However, DMH’s initial review of  rehabilitative services provider records showed gaps in documentation of  consumer participation, such as a lack of documentation of the  consumers’ participation in—and agreement with—their treatment plans  for 41 percent of the records reviewed. Consumer  protection policies are also evolving, with DMH publishing a uniform  consumer grievance policy in October 2003. Although the court  monitor envisioned fiscal years 2004 and 2005 as the appropriate time  frame for DMH to both measure and improve its performance, DMH faces  major challenges to collecting and verifying the accuracy of the  performance data, including developing methods to electronically collect  the data, correcting known data deficiencies, and working with providers  to submit accurate data. In commenting on a  draft of this report, DMH noted that it was unable to identify comparable  baselines from other jurisdictions. Developing the Capability to Measure and Meet Performance Targets Will Take Time

Meeting the exit criteria performance targets, and thus ending the Dixon  case, is a multiyear effort that requires DMH to develop and carry out a  plan that will satisfy the court on three levels: (1) developing policies and  practices that address the requirements of the exit criteria and  demonstrating that DMH monitors the extent to which these policies are  implemented, (2) developing specific methods for DMH’s collection and  verification of the accuracy of the data, and (3) meeting the required  performance targets for one full year as defined by the court. DMH  described six broad changes to the District’s mental health system in the  court-ordered implementation plan. We believe that making a  comprehensive assessment of the system’s performance before DMH  begins reporting on the exit criteria is premature. As such, we reported on the status  of the District’s effort to establish a community-based system of  mental health care, with a focus on four key areas of reform that were  confirmed by the court monitor to be central to compliance with the  Dixon Decree.
Why GAO Did This Study

Since 1975, the District of Columbia has operated its mental health system under a series of court orders aimed at developing a community-based system of care for District residents with mental illnesses. Placed in receivership from 1997 to 2002, the District regained full control of its mental health system in 2002 but has been ordered to implement a courtapproved plan for developing and implementing a community-based mental health system. Additionally, the District must comply with exit criteria, which must be met in order to end the lawsuit. The court expects that it will take the District 3 to 5 years to implement the courtordered plan and begin measuring performance against the exit criteria, with year 1 beginning in July 2001. GAO was asked to report on the current status of the District's efforts to develop and implement (1) a mental health department with the authority to oversee and deliver services, (2) a comprehensive enrollment and billing system that accesses available funds for federal programs such as Medicaid, (3) a consumer-centered approach to services, and (4) methods to measure the District's performance as required by the court's exit criteria.

What GAO Found

The District created the Department of Mental Health (DMH) in 2001 to oversee the provision of mental health services. DMH methods of oversight have included establishing certification and making use of licensing standards for participating providers and beginning to monitor provider compliance. DMH also continues to deliver direct services, acting as the primary provider for 55 percent of all consumers enrolled in the mental health system as of October 2003, and operating over 500 beds at St. Elizabeths Hospital, the District-run institution specializing in inpatient care for people with acute, intermediate, and long-term mental health needs. DMH has also implemented a comprehensive enrollment and billing system designed to coordinate clinical, administrative, and financial processes. The system links payment to consumer treatment and increases access to federal funds by providing mental health rehabilitative services through the District's Medicaid program, which reimbursed DMH $17.5 million in federal Medicaid funds in fiscal year 2003. Providers have faced challenges managing cash flow in a fee-for-service system where service demand varies throughout the year. Also, because provider contracts were tied to the feefor- service billing projections, DMH could not pay claims for providers who were exceeding their projections until their contracts were changed, and providers did not always receive timely claims payments in fiscal year 2003. DMH senior officials noted that DMH has a plan in process to prevent this problem from recurring. DMH activities to increase the involvement of consumers in their own treatment and recovery process are evolving. While DMH has established a number of requirements in two key areas--consumer choice and consumer protection--its initial review of providers' records showed gaps in documentation of consumer participation in treatment planning for 41 percent of the records reviewed. Consumer protection policies are also evolving, as DMH instituted a consumer grievance policy that provides a uniform process for ensuring that all consumer grievances are tracked. DMH is developing data collection methods for 17 performance targets aimed at determining the system's performance against the court's exit criteria. Although the court monitor expects DMH to both measure and improve its performance in fiscal years 2004 and 2005, DMH faces major challenges in accurately measuring its performance, including establishing methods to collect electronic data, correcting known data deficiencies, and working with providers to submit accurate data. In its comments on a draft of the report, DMH indicated that the report did not reflect the entire spectrum of progress made since the creation of DMH. While the progress cited by DMH is important, GAO believes that focusing on DMH's status in meeting the exit criteria is an appropriate gauge of its overall compliance with the Dixon Decree.