Missouri public administrators tell House panel shortages in community placements, Medicaid delays push vulnerable adults into nursing homes and jails

St. Louis County Public Administrator Timothy Weeks told the Missouri House Committee on Health and Mental Health on Monday that lengthy Medicaid eligibility and waiver delays, combined with a shortage of crisis placements, are forcing some Missourians with severe mental illness or developmental disabilities into skilled nursing facilities or the criminal-justice system.

"It took over 13 months to get [one client] approved for Medicaid," said Timothy Weeks, St. Louis County Public Administrator. "In the meantime, he lost his waiver slot with the Department of Mental Health. He had to be moved out of a community placement where he was thriving."

Weeks said his office is responsible for more than 500 people and more than 700 cases with a staff of 12, and that the average profile of new wards is growing younger and more behaviorally acute. "We're getting individuals who are aging out of Children's Division custody at age 21 or even at 18," he said. "Families are giving up. Families need help."

Jackson County Public Administrator John Killian told the committee that Missouri's long policy shift away from state-operated habilitation centers and hospitals left a gap in higher-acuity placements and trained staffing. Killian, a lawyer who manages financial and guardianship caseloads, urged the committee to pursue a combination of federal and state-policy fixes, including support for an IMD-exclusion waiver application to allow Medicaid payment for psychiatric facilities and encouragement of psychiatric long-term acute-care units.

"A waiver from that exclusion would then allow federal money, Medicaid money, to flow to psychiatric facilities to provide that care," Killian said. He described clients who spent months in emergency departments or local jails while the state and providers worked to find appropriate placements.

Carol Johnson, Dallas County Public Administrator and past president of the Missouri Association of Public Administrators (MAPPA), said county jails are serving as de facto mental-health facilities. She told the committee that the baseline local jail cost is about $70 per day and that roughly 30 percent of inmates have a diagnosed mental illness — and in some counties the share that interact with the criminal-justice system is closer to half.

"We do not have the option to say no when the judge determines someone needs protective oversight," Johnson said, describing lengthy annual reporting duties and travel demands for elected county public administrators. She also described wide variation in county resources: some offices lack basic office space or even cell service to make required welfare checks.

Cher Caudill, president of MAPPA and public administrator for Moniteau County, said MAPPA and several counties have produced reports and a "call to action" resolution to the Missouri Association of Counties, and urged more coordinated state-level approaches. She and other witnesses described a series of incremental steps that have helped individual clients — frequent multidisciplinary meetings, provider coordination and targeted case plans — but they said those approaches are not yet available at scale.

Witnesses and committee members discussed specific policy options: reopening or repurposing state facilities for short-term crisis or transitional placements, pursuing the IMD-exclusion waiver with CMS, expanding crisis and respite beds, boosting community behavioral-health center capacity, embedding more social workers with local Crisis Intervention Team (CIT) groups, and increasing training and funding for specialized therapies such as dialectical behavior therapy (DBT).

Committee members signaled interest in continued oversight. At the hearing’s close the chair said the committee will hold additional hearings on mental-health system gaps and possible reforms on a roughly biweekly schedule.

What the witnesses asked for, repeatedly, was increased access to supervised, staffed placements, faster Medicaid determinations and more coordinated, multidisciplinary state support so public administrators can place high-acuity adults in settings that match their needs rather than defaulting to nursing homes or jails.

"This is not a popular topic," Weeks said of the issue. "But we're the boots on the ground. Without us and without help from the state agencies, we'd have a lot more homeless individuals in the state of Missouri."