Double Trouble: A Good Presentation On Co-Occuring Disorders

Aspects of Need Addressed: Medical, Psychiatric

Many of our loved ones who struggle with mental illness also suffer from a co-occuring substance abuse disorder. This can be "double trouble". It has been for my son. But now he's been clean for about a month now. He's making progress.

I am always interested in seeing new information on this terribly vexing problem. Here's a good presentation by Hazeldon and WestBridge Community Services. I am particularly fond of WestBridge, which my son attended for a while. It does a very good job in treating dual diagnosis cases.

Here's the presentation, a slide show. (Be patient. It's a big file and will take a little while to load.)

SHIP 3: Got The Appointment... For 7 Days From Now

Aspect of Need Addressed: Medical, Financial

Still working on my son's Medicare Part D prescription drug insurance...

Background: My son's previous insurer, Fox Insurance, was kicked out of the Part D program by CMS, the Medicare administrators. So he has to find a new plan. Before he can determine which is the best option, he must determine how any of the prospective plans interface with NJ Medicaid, under which he is also covered. My research determined that there is a State Health Insurance Counseling Program, called SHIP, funded by Medicare, that can help him with that. Earlier this week I had spoken to the SHIP Coordinator for Mercer County, who was to help me get an appointment with a SHIP Counselor.

Today I spoke with The counselor she had in mind for my son isn't available. So we've scheduled for my son to visit with another counselor, on March 31.

I'm looking forward to the appointment. I am observing, however, (and not yet judging) how long it is taking to get from the decision to get help with the Medicare-Medicaid interface to the time it actually will be offered. From the time we began seeking a change in his plan to time we discovered through research of SHIP's existence: 2 days. From the time we were offered an appointment with a counselor until the time one was available to see us: 7 days. This is itself perhaps is not so extraordinary, especially when working with agencies in which the workers are certified volunteers. There must be a relative scarcity of such qualified counselors. Hence the time it takes to get an appointment. Kind of like a doctor... I am keeping track of this initiative and all my son's other various initiatives on a master to-do list, managing from it every day like a regular job. One has to keep on top of such things.

But can a mentally ill loved one with a thought disorder manage this process on his own? The complexities of Medicare and Medicaid? Finding out that there is a SHIP and what it does? Finding the right person to call? Learning the process of getting an appointment with a counselor. Getting that appointment seven days later? There's a lot to keep track of. Can this system be made more simple or direct? How will this be after ObamaCare is implemented to include 30 million more people on the Medicare/Medicaid roles? I don' t think our waiting times for appointments will be reduced...

More About SHIP: My Conversation With The County Coordinator

Aspect of Need Addressed: Medical, Financial

Picking up my search when I left off yesterday, this morning I spoke to Wendy Poulsen, Mercer County coordinator for the SHIP program. My objective is to learn more about the interface between Medicare and Medicaid to help my son enroll in a new Medicare Part D prescription drug program, now that his previous provider, Fox Insurance, was disqualified by Medicare. (See my previous post of this.)

Wendy told me that her position as the Mercer County Representative for SHIP is funded through grant from the Centers for Medicare and Medicaid Services, or CMS, which is channeled through the NJ Department of Health and Human Services. As the County representative, Wendy doesn’t actually serve clients directly. She coordinates volunteer counselors who are certified by CMS to provide help to seniors and disabled who need help enrolling in their Medicare plans. She took down my son’s information and will pass it on to one of her counselors who will get back in touch with me. There are apparently certified counselors throughout the County.

The certification process is apparently intensive. Candidates gather for a five day training course, then take an at-home examination. After they are certified, the volunteers meet again quarterly at local locations during the year for refresher courses. They then engage with Medicare recipients during the open enrollment period from November 15 to December 31 to help them navigate through the shoals of the Medicare enrollment system. These training programs are run by the SHIP Coordinator for the State of New Jersey, Ms. Deborah Breslin, who has run the program for the last 13 years.

So, I'm still haven't arrived at the destination of this search. But I'm closing in on it. At least now I know where I will likely end up.

Mental Health Parity in Medicare: Putting The Law Into The Regs

Aspects of Need addressed: Psychiatric, Medical, Financial

Last year the mental health community reached the promised land of Mental Health Parity when President Obama signed the Stimulus Bill to which the measure was amended. This made mental health care reimbursable by insurance companies at the same rate as regular medical care. This was a major step forward.

Now we have one segment of the regulations that will implement this legislation, courtesy of Open Minds, an excellent online information source for mental health issues.

Not that I have a lot of time to do so, but I like to read--or, should I say, try to read--such regulations to see how complex all of this can become. It offers a harbinger of what might be ahead with the implementation of ObamaCare.

Here's the summary:

I. SUMMARY OF CHANGES: Section 102 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 amends section 1833(c) of the Social Security Act (the Act) to phase in a 5-year reduction to the payment that Medicare patients are required to make for outpatient mental health services that are subject to the outpatient mental health treatment limitation (the limitation). Payment for outpatient mental health services will gradually reduce from 2010-2014. Effective January 1, 2014, the limitation will no longer exist and Medicare will pay outpatient mental health services at the same level as other Part B services. Hence, the limitation will change as follows: 2009 and prior years=62.5 percent: 2010-2011=68.75 percent; 2012=75 percent; 2013=81.25 percent; and, 2014 and onward=100 percent.

Got that? Here's the link to the full text of this enacting regulation.

SHIP: State Health Insurance Counseling and Assistance Program

Aspects of Need Addressed: Medical, Financial

OK, I found out what SHIP really is.

It is a program linked to Medicare, but not controlled by it. See this link.

In New Jersey, it is a program run by the NJ Department of Health and Human Services. See this link.

The SHIP Counselors are distributed around the State, by county. See this link.

In my county, Mercer County, the SHIP Counseling franchise is held by a private agency called Family Guidance Center Corporation. See this link.

Tomorrow I'll see if I can get through to the lady who is the Mercer County SHIP counselor.

Bureaucratic Encounter with NJ Medicaid: My Son's Future Under Obamacare?

Aspects of Need Addressed: Medical, Financial

Although Medicare Part D offered my disabled son a choice of 45 prescription drug providers, only one of these included in its formulary all the medications he is using or might need. But the one program requires payment of a monthly premium. Given my son's "extra help" status with Medicare, he has been entitled to have NJ Medicaid pick up all that Medicare does not pick up, such as premiums, co-pays, and payments beyond caps and in the Part D "doughnut hole".

So I got to wondering... Does NJ Medicaid cover those costs such as premiums that Medicare plans would require of my son?

I called the NJ Medical Hotline at 1-800-356-1561. As I worked myself through the recorded messages to the destination I wanted, I reflected on last night's vote in Washington for Obamacare, which would extreme Medicaid coverage to several million more people. Here was an initial test of the Medicaid system. How responsive would it be? How friendly? How effective? I went on hold at 2:54 pm.

Medicaid On The Phone

At 3:01 pm, a woman curtly answered. "Medicaid!" I asked where I might be directed to get the formulary of medications available from NJ Medicaid. "Well," the female voice responded, "I know that there are certain medications that Medicaid no longer pays for." Such as what, I asked. "Asthma. Medicaid no longer pays for asthma medication." Well, that is an issue for my son, since he has asthma. But that wasn't the purpose of my call. I repeated my question.'

"Where can I find the formulary of prescription medications offered by Medicaid?"

"Just a minute. Let me put you through to our pharmacist."

A Dr. Yablonksy came on the line. Dr. Yablonsky spoke with a distinct New York accent and a mildly aggressive tone.

"Speak up!" he said. "I can't hear you." I channeled my voice directly into the mouthpiece as repeated my question: does Medicaid have a printed formulary, and where can I find it?

"Medicaid has no formulary. A pharmacist will bill Medicaid directly."

We were not communicating too well, it seemed. So I tried to explain my son's ailments.

"Call Unisys, the fiscal agent for NJ Medicaid at 609 588 3397. Maybe they can answer your question. What kind of medications are we talking about here?" asked Dr. Yablonsky.

I mentioned the anti-psychotics like Geodon and benzodiazepines like Clonazepam (Klonopin).

"Benzodiazepines might require a prior authorization. The doctor would have to call first. Unisys gives the prior authorizations. Call Unisys."

Unisys On The Phone... Not.

So I called the number that Dr. Yablonsky gave me. A man named Jeff answered. I repeated my son's dilemma.

"No, Medicaid will not pay the premiums of Medicare Part D plans that require them. Only the "benchmark" plans require no premiums. And no Medicare Part D plan will cover benzos..."

This initial response sounded a little disjointed and not quite correct.

"Well," I countered, "we have actually found that one of the 45 suggested plans will cover his benzodiazepines. But that one, Aetna Rx Plus, requires a monthly premium. That's one of the reasons I am calling: to see if Medicaid helps a covered individual pay for such premiums."

"No, it doesn't," said Jeff. He paused. "Medicaid will cover benzodiazepines as a "wrap around".

Wrap around? "What's a wrap around?" I asked.

"It means that Medicaid pays."

I was still a little confused. I wondered whether I might be able to see something in print about all this. "Does Medicaid have a posted formulary somewhat, as do Medicare Part D prescription drug plans, right on Medicare's website?"

"Medicaid has no formulary", Jeff tersely replied. "If a drug is not covered by Medicare Part D, Medicaid usually doesn't pick up."

"Except for benzodiazepines, as you just said?" I asked cautiously. "Right. Except for the benzos. But prescriptions have to billed to Part D first."

Another pause.

"You know what?" Jeff said, "Talk to the SHIP counselor at the Local County Board of Social Services. They can help your son pick a Medicare Part D plan.

This seemed a strange suggestion from someone at Unisys whom Dr. Yablonsky had told me administers the NJ Medicaid program. "No, I'm not with Unisys," Jeff clarified. He was a pharmacist in the Division of Medical Assistance and Health Services, part of the New Jersey Department of Human Services.

Hunting Down The SHIP: Call to Mercer County Board Of Social Services

I called the Mercer County Board of Social Services. The recording identified the number as the screening line. To be screened, I was asked to leave a recording or go personally to the Trenton office. That wouldn't do. I then called another number offered by the recording, 989 4491, "to speak to your worker directly". I called it to speak to Mr. Holloway in Section F, who has helped my son before. His recorded voice answered and asked for me to leave a message. It also gave me another number "in case you need to speak to someone immediately". So I called that number. As it happened, Mr. Holloway answered that line! Good!

Again I described my son's situation.

"You have to speak to someone in Medical. That's a whole different department." What he meant by "Medical" was the Medicaid Department of the MCBOSS. [Note: All Medicaid cases in Mercer County, except for those on General Assistance (Welfare) or those like my son on SSI are handled by the 11 workers in this department. -Ed.] Mr. Holloway then transferred me.

"Medicaid. Mr. Fultini speaking". Another person. I began my explanation. Before I could finish, Mr. Fultini told me that I would have to speak to the Social Security Administration. I immediately countered to say that the matter is not about how my son got his Medicaid, but how Medicaid co-ordinates with Medicare. I explained that someone in the Medicaid pharmacy at Division of Medical Assistance (Jeff) said that I should speak to a SHIP counselor.

"What is a SHIP counselor?" I asked. "When they first came out with Part D," Mr. Fultini began, "they had some people helping the transition..."

"Who runs the SHIP counselors?" I asked.

"I'm not really sure," said Fultini. "I think it is another division of the State Let me find out. Sorry to put you on hold again." So the phone went quiet while he looked for the information.

He came back on the line. He gave me a number in Princeton, 609 924 2098 x14, someone sponsored by the NJ Department of Health and Senior Services. They are counselors for the general public to coordinate Medicare matters. "By the way," Mr. Fultini reported, "SHIP stands for State Health Insurance Assistance Program."
Call to SHIP

I then called the number Mr. Fultini gave me. "Family Guidance", a woman answered. It turns out that I had reached the Princeton office of Family Guidance, a private social services agency that had recently merged with the Family and Children Services. I asked to speak to the SHIP Counselor. "Oh, you need to speak to Wendy Polsen. She's not in today. She's at a seminar. Can you call back tomorrow?"

Well, we're still not finished. So many calls. So little progress. My God. Is this the future under Obamacare?

Medicare Part D: Is What I Need In The Formulary?

Aspects of Need Addressed: Medical, Financial

My son's pharmacy called the other night. The pharmacist wanted to know the details of my son's new Medicare Part D drug plan. Even though he is 24 years old, my son participates in Medicare Part D, and Parts A and B well, because he has been declared disabled by the Social Security Administration because of his schizophrenia.

I took the call. "What are you talking about?" I asked.

"The insurer needs to know your son's Medicare number," responded the lady pharmacist.

"Wait a minute. His prescription drug company already knows his number. Who is asking for this?" I countered.

"Humana, the plan administrator," came the answer.

"What? His plan is with Fox Insurance, not Humana!

"Well," said the pharmacist, "it seems that Medicare has changed his prescription drug plan."

Now I was worried.

Medicare Changes My Son's Plan, But With Good Cause

What happened? Fox Insurance apparently ran afoul of the Medicare system, and so Medicare apparently disqualified it with immediate effect from participating as a Medicare Part D provider, as explained in the recent press release of the Centers for Medicare and Medicaid (CMS). It is the first time in its young history that the Medicare Part D program has banished one of its approved providers.

Actually, I'm pleased by this action. I appreciate that a CMS audit has ratted out Fox. My son's interactions with Fox over the past year proved it to be a squirrely outfit. Good riddance to it.

But the change now requires my son to begin anew the process of selecting a new prescription drug provider. That means having to hassle with the clunky Medicare website.

Clicking around in Medicare.gov

Medicare has a reasonably serviceable website. It is clunky to the extent that it doesn't easily loop back and forth, but requires a rigid linear approach. Several times in processing my son's medications information, I had to start the process over at the beginning, entering in his ID and password again and again. But eventually we got it worked out.

The challenge for my disabled son is to find a prescription plan that does two things: keep costs down (to zero, if possible, since he is technically indigent) and find a plan formulary that includes all the medications he needs (including the controversial benzodiazepines he needs to reduce anxiety caused by his schizophrenia).

After he listed all the medications he currently needs and could possibly need to address psychosis, depression, anxiety and ADHD, Medicare.gov researched all its providers and came up with 45 possible plans for my son's consideration. That looked encouraging. But a closer look revealed that only seven plans has no required premium payment. But none of these included all the required medications. As it happened, only one of the 45 suggested plans, Aetna Medicare Rx Plus (PDP) included all my son's medications in its formulary. But it also required a monthly premium of $7.90. That may seem a pittance to a regular person. It is not inconsequential to an SSI and SSD recipient living on $695 of monthly revenue and monthly rental expense of $388.

Well, we have to check one more thing: would NJ Medicaid cover the premiums that a Medicare Part D plan might require. I suspect it will, since my son is deemed totally disabled. But this will require a call to NJ FamilyCare which administers NJ Medicaid, which does not maintain a comparably serviceable website.

So, it is not easy for the psychiatrically disabled when Medicare has to change your drug plan...

Court Date: Consequences Of The Relapse

Aspects of Need Addressed: Legal

Last Monday my son went to court. I tagged along. He went to answer two misdemeanor charges issued to him during his blacked-out relapse bender now three weeks ago, just before he was admitted to the Emergency Room with a Blood Alcohol Content nearly five times the legal limit. The case offered an opportunity to encounter The System in its legal guise at the local level. We also learned about seeking out a court-appointed attorney.

The charges were Disorderly Conduct and Harassment. My son somehow wound up in the kitchen of a local downtown restaurant during dinner time, entering from a service alley through the back door. The restaurant owner called the police. When they saw my son, the police called for an ambulance. As the police and EMS were trying to get him in the ambulance, my son launched a swearing tear, tongue-lashing the cops and the two lady EMS drivers. My son doesn't have any recollection of this episode at all.

Court-Appointed Attorney?

Before appearing before the municipal judge, my son first spoke with the prosecutor, who had not read the police report, but first asked if my son had a lawyer. When my son said no, the prosecutor asked if he would like to have one appointed to him. Given his indigent status as an SSI and SSD recipient, my son was theoretically entitled to have one. He said yes.

Back he went to the judge, who gave him an application to complete stating his financial status. With his meager personal income just about equaling his meager expenses and no assets besides a car, my son qualified financially. But as it turned out the charges would only permit the engagement of a court-appointed attorney if there was to be a "consequence of magnitude." The judge turned to the prosecutor and asked what he would seek a "consequence of magnitude". In other words, was the prosecutor seeking a jail sentence?

"My God!" I whispered under my breath. Would he really seek a jail sentence for my son?

Thankfully, my anxiety was quickly dispelled when the prosecutor confessed, while now quickly scanning the police report, that jail was probably not necessary in this case. There had been no physical contact. No one had been hit or harmed. He also surmised that there might be something more behind the case that perhaps he ought to explore further with my son before recommending a consequence. The judge agreed. She directed the prosecutor and my son to step out into the hallway to work something out.

Working Things Out

The prosecutor read through the report more carefully and asked my son what happened. Having blacked out, my son couldn't remember, but he did confess that he had been drinking heavily. He then explained his recent treatment at Princeton House, without going into too much detail. He also described his previous challenges with substance addictions. The prosecutor now understood better the situation. He proposed two options to my son.

If he wanted to settle the case that day and been done with it, my son could plead guilty and pay a fine. That would create a mark on his record, but it could be expunged after five years upon my son's initiative to get it expunged. The alternative was to dismiss the case, subject to the court receiving testimonial letters. One would have to report a professional evaluation of my son by a licensed drug and alcohol counselor. The others would be letters from both his psychiatrist and psychologist that he was complying with their recommended regimens (which he is). If that course was agreeable, the prosecutor would ask the judge to postpone resolution of the case one month, pending receipt of the letters.

Good Outcome

The choice was simple: go for the dismissal. In short order, they were back before the judge to explain their agreement, and the judge agreed to postpone the case. This was a very good outcome.

No one likes to go to court. It is especially hard for someone with a mental disability. As a father, I was worrying about possible harsh, awkward or embarrassing handling which might to further stigmatization. In this municipal court, the process went better than expected. The judge and prosecutor, though business-like, sensed the underlying situation and led the case in a good direction, while also treating my son in a regular and respectable way. In this case, The System was benign. Thank God.

Home Care Psych Nurse: Mercer Street Friends

Aspect of Need Addressed: Medical, Psychiatric

The other day I picked up a brochure at NAMI Mercer for Mercer Street Friends, which is an active social service agency in the Trenton area. Mercer Street Friends is a Quaker-affiliated, nonsectarian human care organization working to provide compassionate and practical solutions to the problems of poverty.

Inspired by the Quaker spirit and recognizing the inherent worth of all people, it is dedicated to the creation of a nurturing environment in which individuals may achieve independence, community, and quality of life. It's a pretty big outfit. Revenues as recorded on its 2008 Form 990 were $11 million, of which about $3 million comes from government sources and $5 million from program revenues.

(Mercer Street Friends is the service arm of the Quaker meeting by the same name of long standing in Trenton dating back to the late 1600s. If you have a Quaker heritage or interest in the early Orthodox Quakers who settled West Jersey region, the short history of the Mercer Street Friends is worth your time.)

Mercer Street Friends is well known as a local purveyor of donated food to needy people. Its Food Bank serves nearly 40,000 people in the area.

For the psychiatrically disabled, Mercer Street Friends also has a home care behavioral health service. It employs two psychiatric nurses, one an RN, the other an LPN, who will make periodic home visits to psychiatrically disabled at their homes. In their visits, they provide medications advice, counseling, coping skills education, and other services. Their clients tend to be "stable", meaning compliant with medications and not actively psychotic.

I called to see if their service was one from which my son might benefit. I am keen that my son, now at home with us as he continues his recovery from relapse three weeks ago, be touched by as many resources as possible, especially since he does not do well in group therapy settings as are common within partial hospitalization (full-day) or intensive outpatient (half-day) programs. That they come to the place of the disabled is like the service of the PACT Teams, although the Mercer Street Friends nurses visit less often, more on the order of once every two weeks and not every day, like PACT.

As it happens, Mercer Street Friends is not allowed to offer its home health care service in my town of Princeton, even though it is in the same county. The regulating agency for home health care agencies in New Jersey apparently issues Certificates of Need enabling only certain agencies to serve certain areas. Thus Mercer Street Friends provides this service in Trenton, Ewing, Hopewell, Pennington, Hamilton, and Robbinsville, but not East Windsor, West Windsor, Hightstown, or Princeton. I was told that the Certificate of Need in Princeton for home health care is with Princeton Home Care, a division of the same hospital which manages Princeton House Behavioral Health. But Princeton Home Care does not offer the same psychiatric home-based outreach as Mercer Street Friends. This constitutes a minor but annoying aspect of The System: a specific psychiatric service that is available from one agency in the county is not available from another in the same county, even though both are regulated and funded by the same government agency. Go figure.

Anyway, Mercer Street Friends is a very good outfit. Its home health care psychiatric nurses might be just the ticket for a home-bound or isolating loved one with a mental illness who is compliant with meds and otherwise stable, but needing a little extra support.

Housing Authority Notifies My Son Of A Vacancy

Aspect of Need Addressed: Residential

My son recently received a notice from the public Princeton Borough Housing Authority. A subsidized studio apartment became available for which he could apply. Fortunately, he has already secured housing through a different private local agency, Princeton Community Housing. But the letter provided an opportunity to remind ourselves about this particular--and critical--Aspect of Need.

One of most challenges aspects of mental illness is housing. Studies show that stable and adequate housing is a critical element in recovery. But housing for disabled mentally ill is extremely hard to get, especially in high-cost places like New Jersey.

Housing: Three Kinds

For afflicted loved ones, there are basically three kinds of housing: supportive, subsidized, and "affordable".

Supportive housing is usually group or cluster housing where the psychiatrically diagnosed can receive low-cost housing with various supports, like medications management, transportation, assistance with financial management, emergency services, and other services mentally ill residents may need from time to time. Rents are usually assessed as a percentage of a resident's income, no matter how low, usually at 30% of deemed income. Thus for disabled consumers receiving only SSI and SSD, which in total might only amount to about $700 per month, supportive housing rent might be assessed at only $210.

Clearly such low rents hardly suffice to cover costs, so funding for supportive housing usually requires two other sources: rental subsidies and program sources. Rental subsidies include so-called HUD Section 8 vouchers, either "project-based" or "individual-based". They also include state subsidies. In New Jersey, this subsidy is called the NJ State Rental Assistance Program, or SRAP, managed by the NJ Department of Community Affairs, which serves about 430,000 families currently. Program sources are funds for the specific program supports. One such support is the Program of Assertive Community Treatment, or PACT, which for certain consumers provides an outreach full-service of psychiatric supports where a consumer lives. But PACT only serves a restricted number of consumers who fit certain recovery needs criteria.

(By the way, one such PACT client, in Mercer County, NJ, is Nobel Prize Winning Physicist John Nash, subject of the movie and book, A Beautiful Mind. Click here to read an article about his involvement in PACT.)

Supportive housing is in extremely short supply. Priority at the moment is given to institutionalized consumers. Certain judicial decisions, like the Olmstead Decision requires New Jersey to find community housing for consumers in mental hospitals who qualify for discharge but who are not able to be released for lack of adequate housing. Such cases usually receive priority in the assignment of supportive housing. Local examples of supportive housing include SERV Behavioral Health's apartment building on Belmont Avenue in Trenton, NJ, or Catholic Charities On My Own Supportive Housing Program in Mercer County and elsewhere in the Trenton Diocese.

Subsidized Housing is the second subset. Unlike Supportive Housing, Subsidized Housing addresses only financial need. And the financial need addressed tends to be very low income. Rents for subsidized housing also tend to be based on a percentage of income, i.e., 30%, no matter what amount. "Section 8" housing from the HUD constitutes a major source of such subsidized housing.

And then there is Affordable Housing, which addresses a wider range of financial need, not only the poorest of the poor, but also the poor and sometimes even the less poor. "Affordable Housing" is a relative term. In the State of New Jersey, a whole scheme of affordable housing is governed by the controversial Council on Affordable Housing, or COAH, which has set regulations and rates for affordable housing in response to the New Jersey Supreme Court decision in the landmark Mt. Laurel case, which ruled that the State of New Jersey had a constitutional obligation to provide for affordable housing. (New Jersey is the only state in the Nation to have such a constitutional obligation.) Every municipality has now been required to organize its own COAH plan, resulting in numerous (and often disparate) programs.

The Housing Authority's Notice

The Princeton Borough Housing Authority is a regular Public Housing Authority, or PHA. PHAs tend to be public agencies (as opposed to private non-profit organizations). They have governmental sanction and connection to the U.S. Department of Housing and Urban Development, which maintains a section about them on its website. New Jersey alone has scores of PHAs.

The letter to my son was the first step in the Housing Agency's facility allocation process. He has been on their waiting list for over two years. His waiting list position is #17. When a unit becomes available, the Princeton Housing Authority notifies all on its waiting list and asked those interested to respond. Those who respond are invited to submit additional information about themselves and submit to a background and credit check. Those who pass these tests are then eligible to be considered for the available unit. The Housing Authority then proceeds sequentially down the waiting list until a qualified candidate is founded, who is then invited to take the unit. If that candidate does not accept, then the next qualified person on the waiting list is invited. And so on.

Well, this part of The System seems random, arbitrary and officious. Such is probably to be expected in a government program that is managing a scarce resource in high demand.

Depression And BiPolar Support Alliance: Great Resource

Aspects of Need Addressed: Medical, Psychiatric, Functional, Informational

One of the good websites out there is that of the Depression and BiPolar Support Alliance. I particularly like the many informative brochures DBSA publishes. In my local area, the DBSA Princeton chapter is also a fine resource, offering very intelligent and helpful speakers and good fellowship among many very engaged consumers.

Indefinite Medical Leave: Insufficient Cause For Unemployment Comp

Aspects of Need Addressed: Occupational, Financial

Surely one of the most vexatious areas of The System for a disabled loved one must be the Division of Unemployment and Disability Insurance Services in the NJ Department of Labor and Workforce Development. Nothing about it is easy or transparent--not the way of determining unemployment, the methods of applying for unemployment compensation, the automated telephone means of reporting status, on and on and on.

So I suppose I shouldn't be surprised by the computerized form letter my son received today from this office. It reads:

YOU ARE HEREBY NOTIFIED THAT BASED UPON THE FACTS OBTAINED AND IN ACCORDANCE WITH THE NEW JERSEY UNEMPLOYMENT COMPENSATION LAW, THE DEPUTY (NAMED BELOW) HAS DETERMINED THAT:

YOU ARE DISQUALIFIED FOR BENEFITS FROM 02/14/10 AND WILL CONTINUE TO BE DISQUALIFIED UNTIL YOU HAVE WORKED IN FOUR OR MORE WEEKS IN EMPLOYMENT AND HAVE EARNED AT LEAST SIX TIMES YOUR WEEKLY BENEFIT RATE.

EFFECTIVE 2/15/10, YOU VOLUNTARILY LEFT YOUR JOB AS YOU CANNOT RETURN TO WORK FROM A MEDICAL LEAVE OF ABSENCE. WHILE THIS MAY BE A COMPELLING REASON FOR LEAVING, IT IS CONSIDERED PERSONAL AND WITHOUT GOOD CAUSE ATTRIBUTABLE TO WORK. THEREFORE, YOU ARE DISQUALIFIED FOR BENEFITS. THIS IS THE SECOND OF TWO DETERMINATIONS.

DEPUTY: A RIVERA
FOR:
DIRECTOR, DIVISION OF UNEMPLOYMENT INSURANCE

All this arose when my son had to leave his retail store cashier's job last December 15 to enter a partial care hospitalization program. He had to leave to address an addiction relapse. It was triggered on the job, where a couple of low-life co-workers were selling marijuana during the lunch hour to which my son succumbed.

Uncertain of how long he needed treatment, my son arranged with his employer a medical leave of absence. After a month, he still needed to continue his medical treatment. So he decided that he should formally end his job and reapply to his employer whenever he was better. After this decision, he reported his new status to the Social Security Administration, which revised his SSI and SSD to their maximum possible amounts. It was during this process that the Mercer County Board of Social Services sent him to the Division on Unemployment Insurance to determine his eligibility for unemployment compensation prior to any revision in his SSI and SSD. As it happened, The System in this case exercised correct policy: a disabled mentally ill worker could revert to higher SSI and SSD if he should have to leave his job, as long as he would not be receiving revenue from unemployment insurance.

What would be good to research is a question of relative benefit. For such a disabled person who might have to leave a job to enter treatment, which situation would allocate him more benefit? In other words, would the incremental SSI and SSD be less or more than the revenue he might have received from unemployment compensation? I have a hunch that the unemployment compensation would be more. In any event, it is worth reflecting on the occupational challenges the psychiatrically afflicted face on the road to recovery. Frequently cycling in and out of jobs as dictated by medical requirements requires enormous administrative and organizational effort.

More Helpful Information, From The Feds

Aspect of Need addressed: Informational

Here's another good general site for information about mental health, from SAMHSA:

SAMHSA: Helpful Federal Info Resource

Aspect of Need addressed: Informational

Somewhere in every afflicted loved one's odyssey, there will be reference to or contact with SAMHSA, the Substance and Mental Health Services Administration, part of the US Department of Health and Human Services. SAMHSA has a lot of information. A visit to its website is worth the effort, just to get familiar with what SAMHSA is and has on offer.

SAMHSA is cooking up something called The Co-Occurring Disorders Initiative, or CODI, which looks like something to keep on the radar screen. CODI supports SAMHSA's goal to improve the quality of life for persons with mental health and substance abuse disorders. CODI provides information and resources to promote access to effective integrated services for persons with co-occurring disorders.

WRAP: Strengthening The Inner System

Aspects of Need addressed: Psychiatric, Medical, Spiritual

When The System from the outside beats down our mentally ill loved ones that it is supposed to serve, a good way to respond is for them to strengthen their own systems from the inside.

That is the premise behind a holistic, consumer-focused approach called Mental Health Recovery and Wellness Recovery Action Plan (WRAP), the brainchild of Mary Ellen Copeland. Afflicted also with mental illness, Copeland discovered the surprising possibilities for "recovery" from mental illness, helped devised a methodology for consumers to achieve such recovery and now runs a renowned training enterprise to promote this evidenced-based practice.

Consumers applying the principles of WRAP learn that they could identify triggers of their illness and establish plans of action in advance to address and reduce them. WRAP is a program of self management and recovery, unique to every individual who uses it. Each plan is designed and set up by each consumer. Each consumer may choose to have selected supporters (family and friends) and health care providers assist and support them as they work on their own plans.

Here's an example of a WRAP plan outline.

Copeland's enterprise, Mental Health Recovery, through its Copeland Center, conducts training sessions around the country regularly. A WRAP training class will soon begin in my area of Central New Jersey, beginning on Wednesday, April 14 at 6:30 pm at the offices of NAMI Mercer. For more information about this class, click here.

Ticket To Work: Help for the Disabled

Aspect of Need Addressed: Occupational

One of the benefits of The System that comes to a consumer who qualified to received Social Security Disability Income (SSDI) is a "Ticket to Work", a program of the Social Security Administration.

The Ticket to Work and Self-Sufficiency Program is an employment program for people with disabilities who are interested in going to work. The Ticket Program is part of the Ticket to Work and Work Incentives Improvement Act of 1999 – legislation designed to remove many of the barriers that previously influenced people’s decisions about going to work because of the concerns over losing health care coverage. The goal of the Ticket Program is to increase opportunities and choices for Social Security disability beneficiaries to obtain employment, vocational rehabilitation (VR), and other support services from public and private providers, employers, and other organizations.

Bum's Rush? Moving The Dually Diagnosed Through Levels Of Care

If you're reading my other blog, PsychOdyssey, you'll know that my son is now in the throes of a major relapse. At present, he is being detoxified at the Dual Diagnosis Unit, Unit 3, of Princeton House Behavioral Health in Princeton. He is there after a worrisome night at the Emergency Room at Princeton Hospital, where he was brought by ambulance last Wednesday night... with a blood alcohol content of 3.24 [0.324%], nearly five times the legal limit and just a few 100ths of a point away from a lethal level of intoxication.

He arrived last Thursday morning. His social worker is Miss Hilary D'Angelo, assigned to him the next day. As are all the detoxifying patients in Unit 3, he is under the medical care of Nurse Pracitioner Ric Pagsane, RN. [Note: Nurse Practitioners are nurses trained to a higher level for most responsibilities. They enjoy the privilege of prescribing medications, among others. --Ed.] My wife and I met both on Monday in a family visit to Adam.

Unit 3 at Princeton House is designated as an acute care facility within the definitions of the American Society of Addiction Medicine, or ASAM. As such, it can treat its patients until such time as their medical conditions warrant a transfer to a lower level facility. Such determinations are made in reference to ASAM's Patient Placement Criteria (ASAM PPC-2R), the most widely used and comprehensive national guidelines for placement, continued stay and discharge of patients with alcohol and other drug problems.

ASAM PPC-2R specifies four levels of care:

I. Outpatient Treatment
II. Intensive Outpatient and Partial Hospitalization
III. Residential/Inpatient Treatment
IV. Medically-Managed Intensive Inpatient Treatment

[to be continued...]

Telephone and Internet: How to Maximize Verizon's Lifeline

Aspects on Need addressed: Residential, Financial

My son's new subsidized apartment was ready two weeks ago, so we ordered telephone services from Verizon. One service is basic voice service. The other service is DSL high-speed internet service.

When ordering phone services, the first consideration was to qualify the voice phone line for the Verizon Communications Lifeline subsidy, as is possible for lines of disabled customers. This subsidy helps to reduce the cost of phone service to a cap of $14 per month, saving a disabled customer a few dollars each month. To qualify, the phone service must be only Verizon's most basic service. That service permits no long distance calling, indeed no regional calling. Calls are permitted only in the most local area.

But the plan's limitation to the most basic service immediately created a problem. A call from my son's land line, for instance, to his mother's cell phone albeit in the same town cannot be completed. Somehow that kind of call doesn't qualify as a local call. The issue has probably something to do with Verizon's internal difficulties. The regular landline service and the Verizon wireless service (to which his mother's cell phone is connected) operate very seperately. The two units do not mesh well, as I know from my own experiences as a customer of both.

So, while the Lifeline subsidy is needed and much appreicated, the plan that it requires doesn't permit a critical aspect of connectivity for a psychiatrically disabled customer.

Our second consideration when ordering service is to gain access to the Internet. My disabled son makes extensive use of the internet to research his medications, to read about developments in the care of schizophrenia, and to entertain himself. He is also considering to enroll in an online university to complete his studies. But DSL internet service is not part of Verizon's most basic voice service. Lines thus being billed for DSL service do not qualify for the Verizon Communications Lifeline subsidy.

There is a way around this problem. It requires a small adjustment in the way DSL service is billed to the consumer. By having DSL billed seperately to a customer's credit card (and not billed to the voice line's phone bill itself), the presence of DSL service does not jeopardize the Lifeline subsidy. To achieve this seperation requires an arrangement with the Verizon Internet Billing Department. It can change the billing location from the phone bill to a credit card and thus preserve the subsidy. But this approach requires the disabled customer to have a credit card in the first place.

How does someone on SSI and SSD, Medicare, Medicaid and foodstamps get a credit card? What credit card company will qualify a candidate who can maintain no more than $2000 of personal assets?

In my son's case, I agreed to be a co-owner of the credit card, leveraging my personal credit to his benefit. I did this so that he could establish in time his own credit history. This would be important later should he ever need to borrow money to buy a house or car, or for any other so-called normal purpose. Having a credit card proved helping in this case as well. By charging his DSL service to the credit card, he will be able to maintain the Verizon Lifeline subsidy on his basic phone service. But not every psychiatrically disabled customer will be able to find this out or manage this administrative adjustment without help.

Such again are some of the challenges of The System.