Mental Health System Transformation Initiative Implementation PACT and Beyond

Washington StateDepartment

of Social & Health Services

2SSB 6793 and Budget InitiativesAndrew ToulonMental Health DivisionHealth & Recovery Services AdministrationDepartment of Social & Health ServicesPhone: (360) 902-0818Email: touloan@dshs.wa.gov

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Washington StateDepartment of Social

& Health Services

Presentation Overview

• Part 1: Background

• Part 2: Key Provisions of 2SSB 6793 & Budget Initiatives

• Part 3: Psychiatric Inpatient Capacity Changes

• Part 4: Development of New Community Resources

• Part 5: Long Term Planning Activities

• Part 6: STI Task Force

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Washington StateDepartment of Social

& Health Services

Part 1: Background

Challenges Facing the 2006 Legislature• Decreasing community psychiatric inpatient capacity

• State hospital waiting lists

• Court rulings in September 2005 No wait for transfer of 90/180 ITA patients

Failure to follow proper procedures for assessing “liquidated damages”

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Washington StateDepartment of Social

& Health Services

Part 1: Background (cont’d)

Legislative Approach • Clarified roles of State & RSNs related to

community and state hospital care

• Time limited investment in State Hospital capacity to deal with inpatient access issues

• Investment in enhanced community resources to reduce reliance on state hospitals

• Long term planning

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Washington StateDepartment of Social

& Health Services

Part 2: Key Provisions of 2SSB 6793 & Budget Initiatives

Responsibility for 90/180 Commitments

• Increased state hospital beds to meet court ruling

• Requires state hospital bed allocation to RSN

• State is financially responsible up to funded capacity

• Directs RSNs pay for exceeding allocated bed days

• Re-directs portion of funds collected by RSNs to other RSNs using less beds than allocated

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Washington StateDepartment of Social

& Health Services

Part 2: Key Provisions (cont’d)

Community Based Care• Re-states Leg. intent for services to be

provided in the community

• Requires RSN to ensure discharge of state hospital patients who no longer require inpatient care

• Raises RSN requirement to manage short term detentions locally from 85-90%

• By January 2008, requires RSNs to pay for individuals at PALS

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Washington StateDepartment of Social

& Health Services

Part 3: Inpatient Capacity

Psychiatric Inpatient Bed Reductions• 180 State Hospital Beds closed 01-03 (ECS)

• Community Hospital Beds ↓ by 14% - Between 2000 and 2005

• Involuntary Treatment Beds ↓ by 10% Between 2000 and 2005

• Additional Closures Continue the Downward Trend

48 Pierce County Beds Closed in January 2006

6 Beds Closed at Fairfax in 2006

Source of Community Bed Data: Washington State Hospital Association

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Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

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30 Bed TemporaryPierce Contract

Forensic

30303030

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ESH

Part 3: Inpatient Changes (cont’d)

2005 2006

Forensic

WSH

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Washington State Department of Social

& Health Services

State Hospital Increases 2005-2006

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Washington StateDepartment of Social

& Health Services

Part 3: Inpatient Capacity (cont’d)

State Hospital Census Trends

217 196 199

765

643716

0

200

400

600

800

1,000

FY 2000 FY 2004 Sept. 06

Sept 2006 WSH census isSept 2006 WSH census is11% Increase over FY0411% Increase over FY04

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Washington StateDepartment of Social

& Health Services

Part 3: Inpatient Capacity (cont’d)

Community Inpatient ITA Bed Increases

• 61 E&T Beds Will be Opened Between 2005 and 2006

Thurston County- 15 Beds Opened in April 2005

Pierce County- 30 Beds Opened in May 2006

Clark County- 16 Beds Scheduled to Open in September 2006 (also used for Acute Detox)

• 32 Secure Detox Beds Opened in 2006 Pierce County- 16 Beds Opened in March 2006

Skagit County- 16 Beds Opened in April 2006

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Washington StateDepartment of Social

& Health Services

Part 1- 3 Questions

• Part 1: Background?

• Part 2: Key Provisions of 2SSB 6793?

• Part 3: Psychiatric Inpatient Capacity?

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources

Program of Assertive Community Treatment (PACT) Teams

• An evidenced based mental health service delivery model

• $2.2 million for PACT development/training in FY 07

• $10.4 Million Per Year to Implement PACT Teams Statewide

• Gradual reduction of recently added state hospital beds

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (Cont’d)

PACT is for individuals who…?• Have the most severe & persistent symptoms of mental

illness (e.g. schizophrenia, schizoaffective, bipolar)

• Have high use of psych. hospitalization & crisis services

• Have difficulty meeting basic needs (ADLs, housing, medical, nutrition, budget, employment)

• Have difficulty benefiting from traditional services

• May have co-occurring disorders

• May have high risk or history of arrest and incarceration

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

How is PACT different from other service models?

• Multi-disciplinary Team Approach

• Team provides most services rather than referring- team members are cross trained

• Staff share responsibilities for addressing the needs of consumers

• Low caseloads allow for individualized care and frequent contacts (1-10 staffing ratio)

• Services available 24/7 & directed to consumer needs

• Outreach- 75%+ services delivered outside of the office

• Ongoing services to support recovery

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

PACT Recommended Clinical Staffing per National Standards

Position Urban (Serves 100-120) Rural (Serves 42-50) Team Leader 1 FTE 1 FTE Psychiatrist 16 hours for every 50

clients 16 hours for every 50 clients

Registered Nurse 5 FTE or at least 3 FTE 2 FTE Peer Specialist 1 FTE 1 FTE Master’s Level 4 FTE 2 FTE Other Level 1-3 FTE 1.5 – 2.5 FTE

Source: National Program Standards for ACT Teams; Deborah Allness M.S.S.W & William Knoedler, M.D.; June 2003

Note: 1 or more members expected to have training and experience in vocational and substance abuse services

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

What Types of Services Are Provided by PACT Teams?

Service Coordination Activities of Daily Living Crisis Assessment &

Intervention Social/Interpersonal

Relationship Symptom Assessment &

Management Leisure Time Skill

Training Medication (Prescript.,

Admin., & Monitoring Peer Support

Substance Abuse Services

Education & Support to Families/Others

Work Related Services Other Support Services

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

13 Regional Support Networks (RSNs)Effective 9/2006

Chelan-Douglas

▲

Clark

▲

Southwest Greater Columbia

◆

GraysHarbor

King

◆◆

North Central

North Sound

◆Peninsula

▲

Pierce

◆Timberlands

Spokane

◆

Whatcom

Skagit

Snohomish

Clallam

Jefferson

Grays HarborMason

Thurston

King

Pierce

LewisPacific

Wahkiakum

Cowlitz

Clark

Okanogan Ferry Stevens PendOreille

Lincoln

Chelan

Douglas

Grant

AdamsKittitas

Yakima

Skamania

Klickitat

BentonFranklin

WallaWalla Columbia

Garfield

Asotin

Whitman

Spokane

Kitsap

San Juan

Island

ThurstonMason

▲

◆ = Full Team▲ = Half Team

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July – Dec2006

Jan – Mar2007

April – Jun2007

July - Sept2007

Oct → 2007

Part 4: Community Resources (cont’d)

Washington State Department of Social

& Health Services

PACT Implementation Timeline

Recruit West Teams

Develop Training CurriculumDevelopment

Activities

Train West Teams

West TeamsOperational

Recruit EastTeams

Train East Teams

Monitor and Evaluate Outcomes & Fidelity

East Teams Operational

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

PACT Outcomes Being Considered for Review

• Consumer Satisfaction

• State Hospital Utilization

• Community Inpatient Utilization

• Crisis Service Utilization

• ER Utilization

• Housing

• Employment

• Arrests and Incarcerations

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

PACT Keys to Success• 90 percent+ fidelity (external fidelity reviews)

• Treatment plans are client centered

• Services are recovery oriented

• Non-coercive and non-paternalistic

• Incorporate EBPs and promising practices into individualized service planning

• Cultural competency

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

PACT Resources• National Program Standards for ACT Teams (Allness

& Knoedler)- handout

• Dartmouth Assertive Community Treatment Fidelity Scale (Teague, Bond & Drake)- handout

• PACT Toolkit- www.samhsa.gov

• “PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental Illness: A Manual for PACT Start–up” by D. Allness & W. Knoedler: www.nami.org

• Washington Institute for Mental Illness Research and Training (WIMIRT):

Maria Monroe-DeVita (206) 384-7372 or mmdv@u.washington.edu

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

PACT Comments & Concerns• What issues do you think the state should

consider in implementing PACT teams?

• PACT Questions?

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

Expanded Community Services• Additional funding for other services which

reduce dependence on state hospitals

• $650,000 for development in FY 07

• $6.5 million per year for ongoing operating costs

• Process for allocating and selecting services still being determined

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

Expanded Community Services• In addition to PACT, what types of services are

most needed in your community to support recovery and reduce dependence on state hospitals

• ECS Questions?

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Washington StateDepartment of Social

& Health Services

Part 4: Community Resources (cont’d)

Children’s Mental Health EBP Pilot Program

• $450,000 for FY ’07

• RFP open to counties / groups of counties & or Indian Nations released August 2006

• Expert panel convened to rank EBPs, report available

• Community planning process and EBP selection by Dec. 2006

• WSIPP separately funded to conduct evaluation

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Washington StateDepartment of Social

& Health Services

Part 5: Long Term Planning

Overview of Long Term Planning• $600,000 for consultants and planning activities

• Four areas of focus Mental Health Benefits Package

Involuntary Treatment Act Study

External Utilization Review

State Mental Health Housing Plan

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Washington StateDepartment of Social

& Health Services

Part 5: MH Benefits Package

MH Services Included in Current Medicaid Benefits Package

Brief Intervention Treatment

Individual Treatment Services

Rehabilitation Case Management

Crisis Services Intake Evaluation Special Population Evaluation

Day Support Medication Management Stabilization Services Family Treatment Medication Monitoring Therapeutic

Psychoeducation Freestanding E&T MH Services Provided in

Residential Settings Supported Employment

Group Treatment Services

Peer Support Respite Care

High Intensity Treatment Psychological Assessment

Mental Health Clubhouse

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Washington StateDepartment of Social

& Health Services

Part 5: MH Benefits Package (cont’d)

Scope of Planning Activities• Review current menu of required clinical

services and supports

• Identify EBPs & Promising Practices for inclusion

• Consider cultural relevance issues

• Develop rate methodology

• Prioritize new benefits menu within allocated resources

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Washington StateDepartment of Social

& Health Services

Part 5: MH Benefits Package (cont’d)

Expected Benefits• Recovery oriented benefits design

• Transparent rate structure

• Prioritize EBPs & Promising Practices / culturally relevant

• More efficient use of service dollars

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Washington StateDepartment of Social

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Part 5: ITA Study

Mental Health ITA Statutes Included• RCW 71.05 (Adults)

• RCW 71.34 (Children)

• RCW 70.96B (Integrated Crisis Response Pilots)

Excluded from scope of review• RCW 10.77 (Forensic)

• RCW 70.96A (CD ITA)

• Sexual Offender Commitment Statutes

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Washington StateDepartment of Social

& Health Services

Part 5: ITA Study (cont’d)

Scope of Planning Activities• Review and comparison of Washington MH

commitment laws with other states

• Objective review of hot button issues (e.g. Grave Disability, Age of Consent)

• Develop Options for Reform

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Washington StateDepartment of Social

& Health Services

Part 5: ITA Study (cont’d)

Expected Benefits• Improve balance of civil liberty and public

safety

• Improve consistency across the state

• Ensure best use of inpatient and community based care to support recovery

• Identify best use of State Hospitals

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Washington StateDepartment of Social

& Health Services

Part 5: External Utilization Review

What is Utilization Review?• Process of assessing delivery of services to

determine if care provided is Appropriate Medically necessary High quality

• Includes review of appropriateness of Admissions Services ordered and provided Length of stay Discharge practices

• Concurrent and retrospective basis.

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Washington StateDepartment of Social

& Health Services

Part 5: External UR (cont’d)

Current External UR for Psychiatric Inpatient Services

• RSNs required by contract to do UR for community inpatient days

• No external UR for State Hospital days (State Hospitals conduct their own UR process)

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Washington StateDepartment of Social

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Part 5: External UR (cont’d)

Scope of Planning Activities• Establish acuity levels to be supported in

community settings

• Develop sampling methodologies & processes for independent review of 90 and 180 day commitments

• Include State and community inpatient settings

• Identify resources required for statewide implementation

• Draft RFP for External UR services

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Washington StateDepartment of Social

& Health Services

Part 5: External UR (cont’d)

Expected Benefits• Prevent over and under utilization of inpatient

care

• Increase RSN & provider accountability

• Improve consistency for consumers throughout the state

• Identify state and local community resource gaps

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Washington StateDepartment of Social

& Health Services

Part 5: State MH Housing Plan

Scope of Planning Activities• Review RSN housing collaboration plans

• Identify best practices and areas of need

• Develop guidelines for future RSN contracts

• Technical assistance

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Washington StateDepartment of Social

& Health Services

Part 5: State MH Housing Plan (cont’d)

Expected Benefits• Improve collaboration with existing planning

groups

• Prioritize independent housing which supports recovery

• Increase access to available housing stock by leveraging PACT & ECS services

• Action plan for further housing development

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July – Sept2006

Oct – Nov2006

Dec – Apr2007

May - June2007

July - Oct 2007

Part 5: Long Term Planning (cont’d)

Washington State Department of Social

& Health Services

Implementation Timeline

Evaluate RFPs & Contract for Services

RFPs for Consultant

Final Consultant Reports

Initial Consultant Draft Reports

Options For Policy Makers

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Washington StateDepartment of Social

& Health Services

Part 5: Long Term Planning (cont’d)

Questions• Mental Health Benefits Package?

• Involuntary Treatment Act Study?

• External Utilization Review?

• State Mental Health Housing Plan?

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Washington StateDepartment of Social

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Part 6: STI Task Force

Process• Standing Representative Task Force

35-40 members from variety of interested parties Monthly meetings beginning in Oct 06 Consumer, family, and advocate representatives

• Public Forums 2-3 large forums (approx 150 people) over the next 9

months

1st forum scheduled for November 15, 2006

Stipends for up to 40 consumers, family, and advocate representatives

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Washington StateDepartment of Social

& Health Services

Part 6: STI Task Force

Goals• Share information regarding STI

implementation

• Gather input & shape implementation activities

• Provide ongoing input on consultant reports

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Washington StateDepartment of Social

& Health Services

Part 6: STI Task Force

Values• Participatory Process

• Recovery Oriented

• Evidence Based & Promising Practices/ Cultural Relevance

• Consumer Preferences

• Build on Strengths

• Work within Existing Resources

• Local Governance

• Strive For Consensus

• Address Needs of All Ages

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Washington StateDepartment of Social

& Health Services

Part 6: STI Task Force

Contact Information for STI Public Forums:

Gaye JensenPhone: (360) 902-7789 e-mail jensegf@dshs.wa.gov

Contact Information for STI Implementation:

Andy ToulonPhone: (360) 902-0818e-mail: touloan@dshs.wa.gov

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Washington StateDepartment of Social

& Health Services

Questions?