Perceptions of Recovery While Delivering Medicaid Covered Rehabilitation Services
Many states have shifted to Medicaid reimbursement methods to cover behavioral health services. In doing so, state mental health authorities have incorporated the concept of recovery into mental health policy. Integrating recovery into mental health policies provides a framework that, if applied, can lead to both cost benefits and valuable behavioral health outcomes (Jacobson & Curtis, 2000). Not surprisingly, practitioners play a critical role in the implementation of recovery policies and practice approaches. Emerging best practices in supporting recovery stress the importance of the individual practitioner viewing recovery as central to practice rather than an additional responsibility (Slade et al., 2012). Thus, gaining a better understanding of practitioners’ perceptions of recovery in a new fiscal environment is warranted and can have implications for future practice.
In 2011, the Centers for Medicare and Medicaid approved a State Plan Amendment for New Jersey to provide Medicaid covered mental health Community Support Services (CSS; State Plan Amendment, 2011). CSS consists of mental health rehabilitation services and supports that help individuals achieve identified recovery goals, community integration, and remaining independent in the community (State Plan Amendment, 2011). Additionally, CSS is grounded in psychiatric rehabilitation goals and values such as self-determination, the promotion of valued social roles, recovery, and quality of life (Pratt et al., 2014). Many CSS programs in the state welcomed the clear focus on recovery and would argue that their policies and practices emphasized recovery approaches. Nevertheless, the state mental health authority contracted with an east coast University to facilitate a statewide training and consultation initiative in New Jersey to ensure that the workforce delivering CSS acquired the knowledge and skills necessary to deliver recovery-oriented services.
Recovery in Mental Health
The recovery movement began in the 1970s, placing focus primarily on individual experiences of people living with a mental illness (Davidson, 2016). Following this movement, recovery was defined in many different ways, with overlapping themes focusing on recovery as person and choice focused, a fluid process, strengths-based, and individualized (Slade et al., 2014). Although there is an agreement that recovery is multidimensional and rooted in choice and hope, there are competing views of recovery from service recipients and service providers (Frost et al., 2017). Frost et al. (2017) points out that many mental health services are medically focused, and in fee for service environments, billable services may be geared towards what Medicaid constitutes as billable services, shifting focus away from individual need and individual definitions of recovery, towards fulfilling service criteria requirements (Slade & Longden, 2015).
With the deinstitutionalization movement in the 1970s, definitions of recovery began to shift, as individuals with a mental health diagnosis desired more than a reduction in their symptoms, as they sought education, vocational, and social opportunities (Anthony, 1993). By the end of the next decade, long term research altered previous ideas of quality of life for individuals with a mental illness, as it showed that, regardless of psychiatric diagnosis, people were able to fully participate in their lives through recovering from symptoms or adapting to their illness (Davidson, 2016). With the passing of the Americans with Disabilities Act in 1990, the language adopted characterized individuals diagnosed with a mental illness as those with disabilities, in turn granting them the same rights as individuals with physical disabilities, conveying inclusivity for people, regardless of physical disability or mental health diagnosis (Davidson, 2016). By the end of the century, Surgeon general David Satcher outlined the need for services driven by the individual, focusing on recovery (Davidson, 2016). By 2010, the US Substance Abuse and Mental Health Services Administration further focused on recovery by introducing its Recovery Support Strategic Initiative, which focused on recovery topics like hope, community, and strengths (Pincus et al., 2016).
Over the last five decades, the overall definition of recovery has deviated from concentrating on medically oriented definitions of recovery, focused on individual diagnosis, towards the notion that a person is more than their diagnosis and should be treated as a person, as opposed to a person with a mental illness (Anthony & Mizock, 2014). Psychiatric rehabilitation philosophy further disputes more traditional ideas and perceptions of individuals with a mental illness, as it focuses on respect, choice, strengths, and the thought that recovery is achievable and individualized (Frost et al., 2017). With this change in the definition of recovery, service models of recovery are shying away from focusing on concepts within the medical model, instead of acknowledging a person’s individual goals, life roles, and wellness (Ahmed et al., 2016). Ahmed et al. (2016) further state that recovery-oriented models can focus on various interventions, including services provided by peers, illness self-management strategies, a focus on individual strengths, and a focus on employment.
Recovery focused service models may also support providers in shifting their focus toward more person-centered thinking as opposed to focusing on medical aspects, altering provider’s definition of recovery away from one rooted in the medical model (Dalum et al., 2015). In the past, professionals have emphasized recovery through their viewpoint and have not focused as much on individual definitions of recovery (Slade et al., 2014). Certain professionals, like nurses, may have medically oriented definitions of recovery due to their education, training, and work experience or define recovery as a process dictated by service provision to individuals as opposed to a process that individuals experience (Aston & Coffey, 2012). Along with the competing views of recovery from professionals and individuals receiving services, there is also competition between service recipient’s ideas of recovery and types of services that will help promote their recovery, with provider’s desire to provide individualized recovery-oriented services while staying within Medicaid’s definition of billable services (Spitzmueller, 2014).
Spitzmueller (2014) acknowledges that since the 2000s, community mental health providers have transitioned from funding services through state grants to funding services through Medicaid fee-for-service contracts, as a result of Medicaid expansion and reform. Some fee-for-service models are conceived to reduce government spending, opening up funds that can then be repurposed in other ways within the mental health system (Clay et al., 2016). Medicaid funded programs must follow Medicaid definitions of recovery and what constitutes a billable service, which can differ from how service recipients define recovery and limit their choice in the services that may help further their recovery (Spitzmueller, 2014). Medicaid funded fee-for-service programs follow a structured format, whereas service recipients have found that unstructured services are comfortable to engage in, as they are individually driven and emphasize choice (Spitzmueller, 2014).
Citation
Clay, Zakia; Zazzarino, Anthony; Banz, Emilie; and Reilly, Ann. (2020). “Perceptions of Recovery While Delivering Medicaid Covered Rehabilitation Services,” Journal of Human Services: Training, Research, and Practice: Vol. 6 : Iss. 1 , Article 1. Available at: https://scholarworks.sfasu.edu/jhstrp/vol6/iss1/1
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