acokentucky.files.wordpress.com · web viewinterview, on a confidential ... four beds in one room...

SECOND REPORT OF THE INDEPENDENT REVIEWERON PROGRESS TOWARD IMPLEMENTATION OF THE INTERIM SETTLEMENT

AGREEMENT BETWEEN THE KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES AND KENTUCKY PROTECTION AND ADVOCACY

June 30, 2014 Submitted by: Diane Brewer

I. INTRODUCTION

This is the second report of the Independent Reviewer on the implementation of the Interim Settlement Agreement (Agreement) between the KY Cabinet for Health and Family Services (Cabinet) and Kentucky Protection and Advocacy (P&A). The voluntary Agreement was entered into on August 15, 2013, with implementation beginning on September 1, 2013. This report addresses progress made and issues encountered between April 1, 2014 and June 30, 2014. June 30, 2014 marks the first ten months into the agreement. The annual report that will address the first year’s deliverables will actually cover a 13-month period of time. The Agreement was made in the interest of Kentuckians with Serious Mental Illness (SMI) currently residing in free standing Personal Care Homes (PCH), who receive State Supplementation and who are not opposed to community placement; and, those individuals with SMI who are at risk of entry into a PCH, who would be eligible for State Supplementation, and who are not opposed to community placement. As a result, the Cabinet will willingly meet the requirements of the Americans with Disabilities Act, the Olmstead decision, and the Rehabilitation Act, which require that, to the extent that the Cabinet offers services to the aforementioned individuals, those services will be provided in the most integrated setting appropriate to meet their needs. The Agreement begins a process to achieve the goals of community integration and self-determination for these individuals and follows similar court actions and agreements recently taken in other parts of the country.

This Agreement was entered into as the result of good faith negotiations and provides for housing assistance and supports to six hundred individuals within a three year period, with one hundred individuals provided for in the first year. Approximately three hundred of the total individuals are to be state wards. The Cabinet has pledged seven million dollars in State Fiscal Year 2014 and six million dollars in 2015 and 2016 to meet the terms of the Agreement.

As referenced in the first report, the PCH level of care was established in 1974 by statute (KRS 216B.510). The care homes are licensed and regulated under Kentucky Administrative Regulation (902 KAR 20:036) and the number of available beds is governed by the Certificate of Need process administered by the Cabinet. There are approximately 4300 beds in free standing PCHs. It is in these free standing PCHs where many individuals with serious mental illness live and continue to be placed from

1

hospitals. The Cabinet and P&A have acknowledged that the Agreement does not cover the number of persons with SMI living in PCHs, but the Cabinet has offered assurances that supports and services will be expanded in a subsequent agreement.

II SOURCES OF INFORMATION

As specified in III. I. of the Interim Settlement Agreement, an Independent Reviewer was selected to monitor the Cabinet’s implementation of the Agreement. The role of the Independent Reviewer is to independently assess, review, and file quarterly status reports. Duties include reviewing the adequacy and quality of the individualized supports and services provided to persons named in the Agreement, reviewing and making recommendations regarding transition plans, as needed, and providing technical assistance, as needed. The Independent Reviewer has the authority to:- Require written reports from the State concerning compliance, as necessary- Interview any person or organization providing services to persons covered by the

Agreement- Interview, on a confidential basis or otherwise, persons affected by the Agreement- Access residents, persons, employees, residences, programs, services, documents,

records, and materials as necessary to assess the State’s implementation of the Agreement

- Convene meetings as appropriate- Have ex parte communications at any time with the Parties and their counsel

Sources of information for this report include documents developed by the Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID) and P&A; interviews and other communications with providers and persons affected by the Agreement; reports from DBHDID which include information from providers; site visits to providers, personal care homes, and individual’s homes; and information obtained through participation in DBHDID webinars, Regional Transition Team meetings and Cabinet Level Transition Team meetings. The Cabinet is utilizing an “Interim Settlement Agreement QA/PI Monitoring System Tracking Tool Spreadsheet” (Appendix A) to collect information about persons served under the Agreement from the fourteen regional Community Mental Health Centers (CMHC). In addition to demographics, the tool captures the name and county of the PCH in which the person lives; guardianship status; priority for Housing Assistance; dates of In-Reach, person centered planning, and transition to housing; and types of services delivered. The CMHCs are responsible for providing this information monthly and a DBHDID staff person compiles the information.

On-site visits were conducted at fifteen different PCHs ranging in size from 28 to 114 beds. As referenced in P&A’s report “Personal Care Homes in Kentucky – Home or Institution” (www.kypa.net/uploads/PCH_Report.pdf), the facilities are segregated from their communities and are populated primarily with persons with disabilities. The ADA and Olmstead decision define “the most integrated setting” as “a setting that enables

2

individuals with disabilities to interact with non-disabled persons to the fullest extent possible”. Individuals in PCH’s are limited in their ability to interact with persons outside of the facility, or even to leave the facilities. The individuals do not have transportation and are often too far from any community activity or shopping area to walk. Many have little or no family or other natural supports in their lives.

Though staff in many PCH’s verbally expressed care and concern for their residents, the nature of the living situations themselves reflects an antiquated, discriminatory system for persons with serious mental illnesses who have not had options available to them for integrated housing and housing supports. Some observations include:

locked, chain link fences. a sign-out sheet indicating that every one must limit their time out of the facility

to one hour unless a family member, guardian or friend has signed responsibility for them.

disrepair of the physical structure of facilities. structured meal times and medication times. four beds in one room with no privacy curtains and little space. women whose heads had been shaved due to a lice infestation. persons sitting and smoking and otherwise unengaged.

Persons were typically eager to talk and to express their desires to return to their county of origin, to move to their own home, to work, to get a car, or other common adult aspirations. Many asked that their name be put on “a list” in order to receive assistance in moving and to receive necessary supports in their communities of choice.

III. PROGRESS/OUTCOMES

Community Integration Supplementation

The emergency regulation to provide for a Community Integration Supplementation through the Department for Community Based Services (DCBS) equal to the existing PCH State Supplementation was filed November 14, 2013 and was effective February 19, 2014. DCBS reports that 48 individuals statewide are now receiving the new supplement. There are both reports of cases processed quickly and reports of issues and delays at local offices where the staff are less familiar with the regulation. Reports of problems are being forwarded to leadership in DCBS. P&A developed a short informational document, which is available on their website, to describe what the supplement is, who qualifies, and the process for getting it. (Appendix B)

Community-Based Supported Housing Assistance

Housing Assistance and supports are to be provided to six hundred individuals within a three-year period, with one hundred individuals provided for in the first year. Half of all

3

persons provided for are to be state wards.

In Section III. C. 2. of the Agreement, priority for the receipt of community-based supported housing assistance will be given to:

a) Potential named Plaintiffs.b) Persons with SMI who reside in a PCH and receive state supplementation who

have expressed to P&A an interest in receiving services and supports in the most integrated setting.

c) Individuals with SMI who are residing in a PCH and receive the State Supplementation.

d) Individuals with SMI who are, or will be discharged from a psychiatric hospital and who are homeless or have unstable housing and are to be returned to a PCH.

e) Individuals diverted from reentry into PCHs pursuant to the pre-admission screening and diversion provision of the Agreement.

One of the purposes for the priority ranking is to honor the requests of persons who had communicated complaints and concerns to P&A, those who participated in interviews regarding life in a personal care home, and those willing to be Potential Plaintiffs in a federal lawsuit. Due to the limited community options for persons in Kentucky with SMI, it has been easy to get stuck in PCHs after discharge from state hospitals. In the aforementioned report “Personal Care Homes in Kentucky – Home or Institution”, 39% of the 218 individuals interviewed by P&A reported having lived in a PCH for five or more years. During Independent Reviewer site visits and interviews with residents, individuals reported living in their current PCH for many years or living in several different PCHs over the course of their adult lives. Some individuals reported being relocated to another PCH after breaking a rule or otherwise causing a problem to the first PCH.

Section III. C. specifies that in order to be considered Housing Assistance for purposes of the Agreement, housing settings must meet the following criteria:- Permanent housing with Tenancy Rights- Integrated, affordable housing with voluntary, flexible tenancy support services- Enables interaction with persons without disabilities- Enables access to community activities- Affords choice in daily life activities- Scattered site where no more than 20% of units in any development are occupied

by individuals with a disability known to the Cabinet- Priority for single-occupancy housing

Each CMHC has identified/hired a staff person to serve in the role of a housing specialist for their agency. The housing specialists are to develop a housing plan for their region and to become knowledgeable about the functioning of local housing authorities, housing resources, and local owners and landlords in their areas. This staff person is intended to work closely with case managers and members of growing Assertive Community Treatment (ACT) teams who are often the ones looking for apartments and acquiring the necessary identification and documentation for their clients. Individuals who have spent

4

many years in personal care homes, often need to have a birth certificate located or state ID acquired in order to move forward with securing housing. Most individuals trying to leave PCHs need some sort of support or assistance in completing applications for their local housing authority and completing applications for individual apartments.

Data collected to date from the fourteen CMHCs indicate that a total of 14 individuals have been provided Housing Assistance as defined in the Agreement. Nine of these individuals have moved from PCHs and are considered a part of the first three priority categories for the receipt of Housing Assistance. These 9 individuals include 1 potential named plaintiff, 4 individuals from the “original expresser” list, and 4 others in PCHs who requested to move. Five of the 14 individuals are considered a part of the fourth and fifth priority categories for receipt of Housing Assistance, representing persons who were discharged directly from a state hospital into housing, or otherwise diverted from residing in a personal care home.

PERSONS RECEIVING HOUSING ASSISTANCE UNDER AGREEMENT

Potential Plaintiff from PCH to scatter site housing(Priority category a.)

1

Expressers and others from PCHs to scatter site housing(Priority categories b. and c.)

8

Hospital discharges or diverted from PCH to scattered site housing(Priority categories d. and e.)

5

STATUS OF POTENTIAL PLAINTIFFS

There were 6 Potential Plaintiffs at the time of the Agreement’s signing. The following lists their current status with receiving Housing Assistance:

1. moved to own apartment 6/1/14 (listed above)2. has a move-in date but has not yet moved3. in a PCH and recently sustained a broken arm; wife was moved from his PCH to

an SCL placement in another region4. in PCH planning to move to temporary housing in another region in order to

secure permanent housing in that region5. in rehab. facility due to health complications6. no longer chooses to be a potential plaintiff and may move out of state

ESTIMATED NUMBERS FOR STATUS OF OTHER EXPRESSORS(Estimates were compiled from Regional Transition Team meeting minutes and CMHC reporting.)

From PCH to agency-run housing 2

5

Placement or referral to Supports for Community Living 25

From PCH to Family Care Home 1

From PCH to temporary housing 2

Moved in with family 4

Deceased 4

Community-Based Mental Health Services

Section III. D. 2. of the Agreement specifies that services and supports for persons covered by the Agreement are to be recovery-focused and evidenced based. They are to be flexible, individualized, and designed to increase an individual’s network of natural supports. A person centered planning process is to be used with each individual. The five key services to be utilized to satisfy the requirements of the Agreement are Assertive Community Treatment, Supported Employment, peer support services, crisis services, and case management services.

Person Centered Planning

Section III. D. 5 of the Agreement specifies that a person centered plan is required for each individual receiving services under the Agreement. The plans are to include psychiatric advance directives and/or crisis plans so that such measures can be incorporated into the response to any behavioral health crisis. Data received from CMHCs and compiled by DBHDID as of May 2014 indicate that an initial person centered planning meeting has occurred for 59 individuals. DBHDID has determined that the date of the first person centered planning meeting would serve as the date of an individual’s assignment to a transition team. Section III E. 3. e. of the Agreement specifies that individuals will be transitioned from PCHs to community-based housing within 90 days of assignment to a transition team provided that Housing Assistance is then available. By DBHDID’s Tracking Tool data for May, eight individuals have had a person centered plan completed. (The eight include two individuals in agency housing and one in temporary housing).

Information gathered through interviews with CMHC staff and the review of a few plans, show a wide range of approaches to the practice. Providers have expressed questions regarding what the Cabinet’s expectations are and what criteria will be used in determining an acceptable plan. Trainings in person centered planning have been provided to increase provider awareness, but this has been without the on-going technical assistance needed for implementation. The Cabinet has reported working on a plan for the roll out of statewide training, coaching and technical assistance in order to clarify expectations for the person centered planning process and assist provider agencies in developing their own systems for change. Each provider agency must determine how

6

best to implement the practice within its own documentation protocols in order to balance the person centered approach with medical necessity requirements. For some providers, this could involve both a culture change and a documentation process change that would require the support of all levels of their agencies. In order to incorporate this person centered planning practice statewide, it will be important to have all clinical staff who work with persons with SMI well versed in, and supportive of the practice. Practitioners involved in the planning process will require the on-going guidance from their supervisors in order to sustain the practice.

Assertive Community Treatment

Kentucky has done a good job over the years of researching and communicating the evidence-based practice of ACT. A power point presentation “Assertive Community Treatment. Evidence-Based Practices: Shaping Mental Health Services Toward Recovery” describes the intensity level of the service and the population intended to be served by ACT (https://dbhdid.ky.gov/dbh/documents/bp/ebp-act.ppt). This population is described as “persons who experience the most severe and persistent symptoms of mental illness and who have frequent episodes of very severe symptoms that are difficult to manage. Because of the severe nature of their symptoms, individuals may have a lot of trouble simply taking care of their basic needs, protecting themselves, keeping safe and adequate housing, or staying employed. They are often people who have a problem with drugs or alcohol or who have been in trouble with the police because of their illness.” It goes on to describe the multidisciplinary ACT team as a “hospital without walls”.

The ACT service is in the early stages of development throughout the state. To date, five of the fourteen CMHC regions (36%) have at least the minimum staff to meet the state’s expectation of a four-person team consisting of a full-time team leader/qualified mental health professional (QMHP), a full-time case manager, a part-time Peer Support Specialist (PSS), a part-time nurse, and another full-time staff member. A ten-person team is the standard for a high fidelity score in the category of ‘Program Size’, but the modification of a four-person team was made in DBHDID’s contracts with the CMHCs. There are currently no ten-person ACT teams, although at least one region is working to that end. The Cabinet’s expectation is still to maintain overall good fidelity to the Dartmouth Assertive Community Treatment (DACT) model with a four-person team. The ACT Consultant, Jon Ramos has just begun conducting the first fidelity reviews, though no scores have been distributed. The Consultant also provided a training to ACT team leaders on meeting fidelity and on the use of the scoring tool.

ACT team representatives from the fourteen CMHCs have verbally reported serving a total of approximately 110 persons with their emerging ACT teams. Approximately 31 of those are persons who intend to move out of PCHs or have already moved out of PCHs.

The varying sizes and degrees of experience of emerging ACT teams have inherent limitations. Teams do not have the capacity to serve all of the counties in which persons in PCHs want to move and some teams do not have the capacity to provide the intensity

7

https://dbhdid.ky.gov/dbh/documents/bp/ebp-act.ppt

of services expected from fully functioning ACT teams. There have been situations where emerging ACT teams have determined that they cannot serve someone due to the individual’s functional limitations and symptoms in combination with their team’s current abilities.

CMHC providers have expressed concerns regarding initial requests for ACT service authorizations with some of the Medicaid Managed Care Organizations (MCO’s). Some of the concerns expressed to the Independent Reviewer have included: being asked to submit service requests monthly or that authorizations will be limited to 60 or 90 days at a time; that coverage would not exceed 8 months; and that services to persons currently in personal care homes would not be reimbursed due to PCHs being considered by the MCO as a stable living situation. The Cabinet reports that they will continue their discussions with their Department of Medicaid Services and with MCOs regarding the evidence base and expected outcomes of ACT services, in order to sustain the service beyond the 600 individuals covered under the Interim Settlement Agreement.

Supported Employment/Individualized Placement and Support

Supported Employment services are defined in the Agreement as services that will assist individuals in preparing for, identifying, and maintaining integrated, paid, competitive employment. Programs are to meet fidelity to an established scale, such as the one included in SAMHSA’s Supported Employment Evidence-Based Practices Kit. SAMHSA’s toolkit is based on the work of the Dartmouth Psychiatric Research Center that developed the Individual Placement and Support (IPS) model of supported employment. The Cabinet has addressed this service need in the contracts with CMHCs, which specify that each CMHC must have at least a two-person supported employment team and that they must reach good fidelity within twelve months of program implementation.

Seven of the fourteen regions (50%) have been assessed by a review team as operating at fidelity to the IPS model of Supported Employment. Five regions achieved scores reflecting Good fidelity and two regions achieved scores reflecting Exemplary fidelity. DBHDID reports that fidelity reviews are conducted using 2-4 reviewers. The team consists of one of the two state trainers or the DBH program staff assigned to IPS; other DBH staff; and/or someone from the University of Kentucky Human Development Institute. Supervisors within the IPS Supported Employment programs have recently been trained to serve as peer reviewers in order to be a part of future fidelity reviews.

Numbers were not available to the Independent Reviewer regarding IPS program caseload sizes or outcomes of persons employed or starting jobs. The DBHDID Tracking Tool indicates that three of the individuals who received Housing Assistance under the Agreement are receiving Supported Employment services.

Peer Support Services

CMHC regions have hired or are in the process of trying to hire persons who have been

8

trained and certified as Peer Specialists in Kentucky. This service is intended to provide social, emotional, and practical support in order to bring about a desired social or personal change. The benefits of shared personal experience and empathy are well documented in psychiatric rehabilitation literature and other health literature.

The service is to be separate from peer support services that are provided as part of the ACT team. DBHDID contracts developed with CMHC’s specify that each region must hire at least 2.5 full-time equivalent (FTE) employees who are certified through the state as Peer Support Specialists with .5 FTE to work with ACT teams. Data provided by the CMHCs to date indicate there are 39.75 FTE Peer Support Specialists (PSS) working outside of the ACT teams. Seven CMHC regions (50%) reported having the number of Peer specialists required by DBHDID. Three regions reported having no staff hired to provide Peer Support services. Further monitoring will be required to learn how the Peer Support services are structured in each region and how persons under the Agreement are receiving and benefitting from the services.

Crisis Services

In Section III. D. 7., the Agreement specifies that the Cabinet shall require the CMHCs to develop a crisis service system to include mobile crisis teams, Crisis Stabilization Units (CSU), and 24/7 crisis phone lines in order to provide timely and accessible services and supports to persons under the Agreement. The crisis services are to be provided in the least restrictive settings, including an individual’s residence whenever practicable. As mentioned above, an individualized crisis plan is to be a part of the person centered plan in order to minimize the risk of persons being re-institutionalized in PCHs, hospitals, or jails. The DBHDID Tracking Tool indicates that three individuals have a crisis plan completed. Two of those were individuals who moved to agency run housing.

Future monitoring will need to include a review of crisis services and crisis plans. The Cabinet must ensure that any service gaps or weaknesses in crisis service systems are identified are addressed.

Case Management

Case management services are designed to assist persons in gaining a variety of necessary medical and support services. These services may include coordinating and arranging services as specified in the person centered plan; assisting in accessing resources; advocating; intervening in crises; and providing case consultation. For Medicaid reimbursement in Kentucky, the case management service requires a minimum of four monthly contacts in order to receive a set monthly reimbursement rate. Two of the four contacts must be face to face, while the other two contacts can be by phone.

The current best estimate of the number of case managers in the state is 203.6 FTE. This is based on the state fiscal year (SFY) 2015 Plan and Budget Documents in conjunction with the DIVERTS Form 102/Peer Support for the third quarter of SFY 2014.

9

As with Peer Support, the service of Case Management is to be considered separate from the case management services that are a part of the ACT team. According to the DBHDID Tracking Tool, one of the fifteen individuals receiving Housing Assistance under the Agreement (the Potential Plaintiff) is receiving Case Management services and Peer Support services in place of ACT services.

Regional Service Capacity

The following table shows the above referenced information that was reported to DBHDID by representatives from the CMHCs. The CMHC region is indicated along with the number of counties for which the region is responsible. Staffing numbers continue to change as regions work to build service capacity or conversely, as staff leave the agencies.

Abbreviations not previously referenced include:emp. spec. = employment specialist SA specialist = substance abuse specialist

CHMC Region

ACT by FTE’s Case Managersby FTE’s

Crisis Service System

Peer Support by FTE’s

IPS Supported Employment

1(9counties)

1.0 leader/QMHP1.0 case manager.75 PSS

7 mobile crisisCSU24/7 crisis line

3.75 3.0 emp. spec..25 supervisorGood fidelity

2(8counties)

1.0 leader2.0 case managers

8 mobile crisis24/7 crisis line

0 1 emp. spec.1 supervisorTransitioning to IPS

3(7counties)

.25 leader/QMHP

.5 therapist1.0 case manager1.0 nurse

9 CSU24/7 crisis line

0 Starting up program

4(10 counties)

1.0 leader/QMHP1.5 case managers.8 PSS.5 emp. spec.



5(8 counties)

1.0 Leader1.0 QMHP.5 PSS.5 nurse1.0 emp. spec.1.0 housing spec.


4.0 10 emp. spec.3 supervisorExemplary fidelity

6(7 counties)

1.0 leader/QMHP3.0 case managers1.0 PSS1.0 nurse

25.6 CSU24/7 crisis line

16.5 2.0 emp. spec.1.0 supervisorGood fidelity

10

1.0 SA specialist1.0 emp. spec.

7(8 counties)

1.0 leader/QMHP1.0 case manager.5 PSS.5 nurse



8(5 counties)

1.0 leader/QMHP1.0 case manager1.0 PSS.5 nurse.5 emp. spec.


0 2.0 emp. spec.1.0 supervisorExemplary fidelity

9/10(10 counties)

1.0 leader/QMHP1.0 case manager1.0 housing spec..5 PSS.5 nurse


2 1.0 emp. spec..25 supervisorTransitioning to IPS

11(5 counties)

1.0 leader/QMHP1.0 case manager.5 nurse.5 housing spec.


5.5 2 emp. spec.1 supervisorTransitioning to IPS

12(8 counties)

.5 leader/QMHP1.0 case manager.5 nurse


2.0 1 emp. spec.1 supervisorStarting up program

13(8 counties)

1.0 leader/QMHP1.0 case manager.5 PSS.5 nurse


1.0 2 emp. spec.1 supervisorGood fidelity

14(10 counties)

1.0 leader/QMHP1.0 case manager.5 PSS1.0 nurse


1.0 1.0 emp. spec..25 supervisor Transitioning to IPS

15(17 counties)

1.0 leader/QMHP2.0 case managers.5 PSS1.0 nurse


.5 1.0 emp. spec..25 supervisorStarting up program

Regional Transition Teams

The four Regional Transition Teams continue to meet on a monthly basis at Western State Hospital in Hopkinsville, Eastern State Hospital in Lexington, Appalachian Regional Hospital Psychiatric Center in Hazard, and Central State Hospital in Louisville. During these Regional Transition Team meetings, CMHC representatives (often the ACT team leaders or In-reach staff) report on their progress with obtaining Housing Assistance

11

for persons identified under the Agreement. Other participants include the DBHDID regional liaison, the P&A regional liaison, State Guardianship representatives, State Ombudsman representatives, MCO case managers, hospital staff and other relevant staff. In addition to the originally developed list of 121 Potential Plaintiffs and Expressers, a secondary list is expanding which includes other individuals encountered during the in-reach process who have also expressed their desire to move to their chosen community with appropriate supports. In order to account for the additional individuals desiring services and to track their priority status, DBHDID developed and distributed a protocol to the June Regional meetings on “Managing the Expresser List” (Appendix C). DBHDID plans to keep the list of all expressers in chronological order and distribute the names to CMHC staff according to each region’s capacity to serve them. CHMC in-reach staffs have also identified individuals wanting to receive Housing Assistance in a county served by another CMHC region. In response to Provider’s questions, DBHDID also developed a protocol on “Transfer Between Regions” (Appendix D) to clarify the responsibilities of the transferring and receiving agencies. There have been discussions regarding the facilitation of Regional Transition Team meetings and ways to insure sufficient time to discuss follow-up in-reach visits and action steps to overcome barriers to transitioning out of PCHs.

Cabinet Level Transition Team

The Cabinet Level Transition Team continues to meet monthly with participation from P&A, DBHDID, DCBS, Department for Aging and Independent Living (DAIL), Kentucky Housing Corporation (KHC), Office of Health Policy (OHP), Long Term Care Ombudsman’s office, PAIMI Advisory Council, and the Independent Reviewer. The Team discusses issues with the implementation of the Agreement and areas for needed improvement. There will most likely be more conversation in these meetings regarding individuals’ barriers and the larger issues of barriers to the transition of persons in PCHs to appropriate Housing Assistance.

In-Reach

Monthly in-reach follow-up webinars continue to be provided by DBHDID. For the June meeting, CMHC representatives were asked to provide regular information regarding their services. The information requested includes staffing for ACT teams, including numbers served; staffing for Peer services and Supported Employment; and a name of the supportive housing coordinator along with the completion date of their housing plan. Webinar participants have used the forum as an opportunity to ask questions of DBHDID staff and problem solve with each other.

The DBHDID Tracking Tool indicates that the CMHCs have made at least an initial in-reach contact with 186 individuals. By priority category, this represents 6 of the 6 Potential Plaintiffs, 83 of the 115 initial Expressers, 17 of 80 individuals on a secondary expresser list, 64 of 107 others in PCHs, and 16 others under the headings of ‘hospital discharges to PCH’ or ‘diverted from PCH’. Return in-reach visits are not tracked, but it

12

may be important to discuss these visits during the Regional Transition Team meetings to better understand and overcome barriers to transition.

Quality Assurance and Performance Improvement

Section III. G. 1. of the Agreement specifies that the Cabinet will develop and implement a quality assurance and performance improvement monitoring system to ensure that persons are receiving the services and supports that they need for their health, safety and welfare. The services are to be of good quality and result in persons obtaining and maintaining stable housing in the community. Currently the plan for monitoring the quality of services is through fidelity reviews of Supported Employment and ACT. The Cabinet has reported its intention to identify and include the use of a quality of life survey.

The primary tool for the collection of data has been the Tracking Tool Spreadsheet. It has been clear that coordinating fourteen Excel spreadsheets is increasing difficult to manage. Though trainings have been provided on use of the Tracking Tool, there are still reporting inconsistencies by the CMHCs resulting in the need for further clarification of the data presented. In terms of an improved system, the Cabinet is working on a stopgap solution. They plan to use an interim data management system using MS Access and a Structured Query Language server until an Internet web application is developed. The issue of consistency in reporting will still need to be a focus.

IV. SUMMARY/RECOMMENDATIONS

The Cabinet, through DBHDID, has been active in its focus on the full implementation of the Interim Settlement Agreement, though significant outcomes have yet to be realized. The Independent Reviewer recommends that the Cabinet consider the following:

The Cabinet needs to build capacity for the provision of adequate services and supports for persons with SMI represented under the Agreement. In addition to getting the sufficient number of service providers in place, there is an overarching need for workforce development and consistency in the delivery of evidence-based practices. Service capacity and provider competencies must be such that persons with the most complex needs are receiving Housing Assistance with supports and services that ensure successful community tenure.

The priority categories for Housing Assistance must be emphasized throughout the state. The need for diversion from personal care home placement is clearly a part of the Interim Settlement Agreement; but the Agreement was developed to afford relief to persons stranded in personal care homes. As only 600 individuals are represented in the first three-year period, the priority is written in such a way as to act in the interest of persons long institutionalized.

Consider a structure for state leadership over the implementation of the Agreement and all staff involved; and, influence over, and guidance to the leadership of provider agencies. As the Cabinet has control over the use of the

13

$19 million allocated to the implementation of the Agreement for the first three years, outcome expectations can be tied to provider funding.

Each provider agency needs to develop protocols and processes for the implementation of person centered planning within their agencies. This should be done in collaboration with a state-identified expert on person centered planning with persons with SMI in the context of meeting medical necessity. The Cabinet has discussed bringing in an expert to provide technical assistance and to advise agencies on best practices in establishing on-going oversight and clinical supervision for maintaining the practice. An aspect of the Cabinet’s quality assurance monitoring would then be the review of individualized person centered plans to ensure that sufficient measurable objectives are developed to increase individual skills, self-sufficiency and independence.

The Cabinet needs to establish a more advanced system for reporting and collecting data. DBHDID is currently managing and coordinating 14 different Excel spreadsheets from the reporting CMHC regions while working on an alternate collecting system, with the longer term goal of a web based system. This data collection system will need to be one piece of a larger quality assurance and performance improvement monitoring system that can determine whether Housing Assistance meets criteria, whether services are bringing about intended outcomes, and whether persons under the Agreement are thriving in the community.

Clarify to providers, hospitals, and all stakeholders that the Cabinet does not recommend PCH placement for persons with serious mental illnesses (or developmental and intellectual disabilities). Commissioner Begley’s letter to State Hospital Directors clearly states that it is the policy of DBHDID that individuals with SMI are to transition to permanent community-based housing, whenever possible, and not to PCHs. The form “State Psychiatric Hospital Discharge Placement Form” which accompanied the letter could be confusing to some as it makes reference to a Level of Care Utilization System (LOCUS) score that could determine that a PCH placement is appropriate (Appendix E). It is recommended that the form be revised to indicate that a state hospital may have to discharge to a PCH if it is an individual’s choice after being informed of available community resources, or if community resources are not yet available.

Adequate service capacity; the availability of the full array of services and supports as specified in the Agreement; and service provider competencies in the provision of evidence based practices are current challenges that can affect compliance with the Interim Settlement Agreement. Another challenge is adequate reimbursement by Medicaid for services that meet evidence based practice fidelity. The Cabinet has the potential to overcome these challenges in the interest of persons with SMI living in personal care homes, and has expressed that it will honor its obligation to comply with the Substantive Provisions of this Agreement.

COMPLIANCE WITH SUBSTANTIVE PROVISIONS

14

SettlementAgreementReference

Provision Rating Comments

III.A.1Most Integrated Setting

The Cabinet will develop and implement effective measures to provide adequate and appropriate public services and supports identified through person centered planning in the most integrated setting appropriate to meet the needs of individuals with SMI, and who are residing in or at risk of entry into a PCH.

III.A.2 Guardians will encourage their wards to participate to the maximum extent of his/her abilities in all decisions that will affect him/her

III.B.1State Supple-mentation

Cabinet will propose and submit an amendment pursuant to KRS13A.120 by 10-1-13 to make the State Supplement for community placement commensurate with the amount offered to persons residing in PCHs

III.B.2 …will be able to continue to receive the State Supp. at the PCH level in order to live in the comm.

III.C.1CommunityBasedSupported Housing Assistance

Cabinet will provide access to community-based supported housing.

III.C.2.a Priority for Housing Assistance will be given to potential named Plaintiffs

III.C.2.b. Individuals with SMI who are residing in a PCH and receive state supplementation and have expressed to P&A

III.C.2.c. Individuals with SMI who are residing in a PCH and receive state supplementation

III.C.2.d. Individuals with SMI who are or will be discharged from a psychiatric hospital and who are homeless or have unstable housing and are to be returned to a PCH

III.C.2.e. Individuals diverted from reentry into

15

PCHs pursuant to the pre-admission screening and diversion provisions

III.C.3,4,5. Provide Housing Assistance to 600 individuals with 300 of those being state wards (100 by Oct. 1, 2014)

III.C.6.a. Housing is permanent with tenancy rights

III.C.6.b. Support services that enable individuals to attain and maintain integrated, affordable housing

III.C.6.b. Support services are flexible and are available as needed and desired, but are not mandated as a condition of tenancy

III.C.6.c. Individuals with and without disabilities have opportunities to interact

III.C.6.d. Do not limit ability to access community activities at times, frequencies, and persons of their choosing

III.C.6.e. No more than 20% of units in development are occupied by individuals with a disability known to the Cabinet

III.C.6.f. Choice in daily life activitiesIII.C.6.g. Priority of single-occupancyIII.C.7. Housing cannot be in PCHs, group

homes, nursing facilities, boarding homes, assisted living residences, supervised living settings, or any setting required to be licensed

III.D.1. Access to array and intensity of services and supports necessary to successfully transition to and live in community-based settings.

III.D.2.a. Array of services are evidenced-based, recovery-focused and community-based

III.D.2.b. Flexible and individualizedIII.D.2.c. Help individuals to increase their

ability to recognize and deal with situations that may otherwise result in crises

III.D.2.d. Increase and strengthen individuals’ networks of community and natural supports

16

III.D.3. Community mental health services of ACT teams, case management services, crisis services, peer support services, and Supported Employment Services

III.D.4. ACT teams meet fidelityIII.D.5. Person-centered plans with

coordinating professional which include psych. advance directives and/or crisis plans

III.D.6. Case management services leading to goal achievement

III.D.7.a. Crisis service systems including mobile crisis teams, CSUs, and 24/7 telephone lines

III.D.7.b. Cabinet identifies any service gaps and develops and implements effective measures to address gaps and weaknesses.

III.D.7.c. Crisis services occur in least restrictive setting, consistent with plan, preventing unnecessary hospitalization, incarceration, or institutionalization.

III.D.8. Provision of peer support services per definition

III.D.9.a. Will develop and implement measures to provide Supp. Employment

III.D.9.b. IPS fidelityIII.E.1. Individuals are accurately and fully

informed in writing and signed by individual about community-based options

III.E.2. Cabinet level transition team to provide oversight and assist in identifying barriers to transition

III.E.3.a. DBH and CMHCs develop requirements and materials for in-reach and transition

III.E.3.b. CMHC conduct in-reach in PCHs, state psych. hospitals within 120 days of Sept. 1, 2013

III.E.3.c. P&A, DAIL, Clerks of Court receive in-reach and education materials to ensure guardians understand options available to individuals

III.E.3.d. State guardians will participate with P&A and CMHC case managers in

17

finding the most integrating setting and allow P&A to represent wards

III.E.3.e. Transition and discharge planning completed within 90 days of assignment to transition team – Discharge is housing assistance is available

III.F.1. Those being considered for PCH placement are referred to CMHC to determine eligibility for services under the agreement

III.F.2. Eligible individuals receive assistance from CMHCs to develop and implement a community integration plan

III.F.3. For persons choosing PCH placement, the CMHC documented steps to show it was an informed decision, implemented individualized strategies to address concerns and objections, and continued to provide in-reach

III.G.1. Cabinet will develop and implement a quality assurance and performance improvement monitoring system to insure a quality service system sufficient to help individuals achieve increased independence, gain greater integration into the community, obtain and maintain stable housing, avoid harms, and decrease the incidence of hospital contacts and institutionalization.

III.G.2. Collect, aggregate, and analyze data related to in-reach and person-centered discharge and community placement efforts (successful and unsuccessful placements, problems/barriers to keeping). Review semi-annually and develop and implement measures to overcome barriers

III.G.3. QA information will be shared with P&A quarterly unless requested sooner

III.H. Cabinet will use best efforts to obtain 1915(i)

III.I. Agree on an Independent ReviewerIII.J. Quarterly status reports

18

III.K. Agreement begins Sept. 1, 2013 with substantial compliance by Sept. 1, 2016

III.O. Cabinet will maintain sufficient records to document that the requirements are being properly implemented and make records available to P&A

19