“How Do We Force Six Visits on a Consumer?”: Street-Level Dilemmas and Discretionary Strategies for Recovery-Oriented Practice Under Medicaid Fee-for-Service

Background and Purpose: This qualitative study explores frontline provider perspectives on the delivery of recovery-oriented rehabilitation services within Medicaid-funded supportive housing programs for adults with serious mental illness. Mental health consumers, advocates, and the United States federal government have all called for the “fundamental transformation” of the existing mental health system to a recovery-oriented system of care – an approach that promotes consumer choice and self-determination. Yet little is known about how street-level workers negotiate a consumer-centered approach within an era of New Managerialism. This study utilizes a theoretical framework of street-level policy implementation to discuss the dilemmas that frontline workers encounter in a Medicaid-funded service environment, as well as the discretionary strategies that they use to negotiate potential barriers to recovery-oriented practice. Methods: Semi-structured interviews (N=84) were conducted with a purposive sample of frontline housing providers (N= 35) from three different Medicaid-funded supportive housing programs for adults with serious mental illness. Interviews broadly explored providers’ perceptions of the barriers to and facilitators of recovery-oriented practice in these settings. Additionally, this study utilized 106 hours of observations of frontline provider practice (e.g. ride-alongs with providers and agency site visits). Data were consensus coded and inductively analyzed using a grounded theory approach. Several “strategies for rigor” in qualitative research were also employed, including peer-debriefing, use of an audit trail, negative case analysis, memo-writing and prolonged engagement with study participants. Results: Frontline providers described competing mandates between the expectation that services would be consumer-driven and the requirements of Medicaid-specified reimbursable goals for service. At the organizational level, providers also noted the negative impact that accountability measures had on an organizational recovery culture.  Discretionary strategies used in service to the delivery of recovery-oriented care included making consumer service goals broader and keeping them vague; fudging the (reimbursement) numbers; and offering consumers small choices in the delivery of services. Discretionary strategies used in spite of a recovery mission included redirecting engagement-building small talk to get to Medicaid-billable goal talk and telling consumers to stay at home so that providers could make enough billable contacts for the full month claim. Conclusions and Implications: Findings from this study highlight the tension between existing accountability mechanisms and person-centered, recovery-oriented frontline practice. As Medicaid continues to expand across the United States, states will need to consider the impact that fee-for-service payment reforms could have on efforts to realize the “fundamental transformation” of existing services to a recovery-oriented system of care.