Category2ProjectNarrative–Pass2

HillCountryMHDD–133340307.2.4

TitleofProjectArea, OptionandTitle:2.18.1Recruit,train and support consumers of mental health servicestoprovide peersupport services

RHPProjectIdentificationNumber:133340307.2.4

Performing ProviderName:Hill Country Community MHMRCenter(dba Hill CountryMHDD Centers)

Performing ProviderTPI#:133340307

ProjectSummary:

  • ProviderDescription:Hill Country Community MHMRCenter(Hill Country) is a communitymental health centerproviding mental health, substance use disorder, early childhood intervention and intellectual and developmental disability servicestothe following counties of RHP8:Blanco and Llano. Hill Countryservesa 2,607square mile areaof RHP8with a population of approximately 30,582in2012.
  • Intervention:This projectwill implementWhole Health PeerSupportserviceswithin the 2counties servedby HillCountry in RHP8tomeettheoverall health needs of individuals whohavebehavioralhealth issues.The projectwill identifyand train behavioral health peerson whole health riskassessmentsand workingwith peerstoaddress overall health issuestotreatsymptomsprior totheneedfor utilization ofemergencydepartments(EDs) orinpatient hospitalization.
  • ProjectStatus:This is anewprojectfor Blancoand Llanocounties.
  • ProjectNeed:According toSAMHSA,individualswith severeand persistent mentalillness die 25yearsearlierthanthegeneralpopulation. Identifying and addressing overall health symptoms,suchas hypertension, diabetes,obesity,tobaccouse and physical inactivity, of individualswith severeand persistent mental illness helps address thisissue while reducing emergencydepartmentutilization and potentially preventableadmissions to hospitals.
  • TargetPopulation:Thetargetpopulation is individuals within Blancoand Llanocounties whohavesevereand persistent mentalillness and otherhealth riskfactors.Thereare currently283individualsidentified thatmeettargetpopulation.Based on thepopulation servedin Hill Country’sbehavioral health programin RHP8,it is anticipated that approximately 26%of our behavioral health patientswithin RHP8haveMedicaid and an additional 60% who have income below 200% of the Federal Poverty Level and do not have insurance.
  • Category1or 2ExpectedProjectBenefitfor Patients:The projectseekstoprovide servicestoa minimum of 60individualsfromthe2counties servedby HillCountry in RHP 8by theend of DY5(10in DY3;20inDY4and30in DY5)
  • Category3Outcomes: IT-11.25:The following Category 3 measures have been proposed in 2014 to describe improvements to the patient population. IT-11.25 Daily Living Activities (DLA-20) In DY4 and DY5 we will report the sum of the average DLA score of all DLA-20 questionnaires completed during the measurement period for a denominator subset of all completed DLAs at Hill Country MHDD Centers divided by the total number of DLA-20 questionnaires completed during the measurement period for the same population. CMHC.5 Adherence to Antipsychotic Medications: In DY4 and DY5 will report adherence to antipsychotic medications in accordance with measure guidelines.
  • Collaboration:Therewasnot aTAMHSC allocation in Pass2and, therefore,wasnot used for a Pass2project.

ProjectDescription:

Whole HealthPeerSupport

Peersareone of themostvaluable assetsin helping consumerswith mental illness gain hope and begin to progressontheir roadtorecovery.The servicestheyprovide aresupportive in nature.Byexpanding peerservicesas an integral portion ofthesevenmental health clinics operatedbyHill Countryand including whole health riskassessmentsand supportedservices targetedtoindividualswith hypertension, diabetes,and health riskssuchas obesity,tobacco use and physical inactivity, improved Daily Living Activities and improvedhealth outcomescan beachieved,helping address thedisparate life expectancyand poor healthoutcomesand ultimatelydecreasingutilization of emergencydepartments(EDs). Hill Country’s is planningtoutilize consumers ofmental health serviceswhohavemade substantial progressin managing their own illness and recoveringa successful life in the communitytoprovide behavioralhealth services.ThroughVia Hope,a statewide organization establishedunder theState’sMentalHealth Transformationgrant,consumersarebeing trained toserveas whole healthpeersupportspecialists.Upon completion oftraining, peersare workingwith consumerstosetachievable goals topreventchronic diseasessuchas diabetes or toaddress whentheyexist.While Hill Countryhas begun theprocess of incorporating peer supportservices,therehavebeenchallengeswith maintaining peersupportspecialists and fully incorporating peerservicesthroughout thetreatmentprocess.The advancementtoWhole Health PeerSupportis neededalongwith increasedemphasis on peerservicesin ordertohelp individualsadvancein their recovery.

In implementing thisproject,Hill Country will continue totrain and educateclinicians on the importance of peerservices,recruitand train peerspecialists in theprovision of Whole Health PeerSupport, and utilize peerservicestoidentify health risksand provide appropriate education and referralsregardingthehealth risksidentified.Peerserviceswill betrackedin Hill Country’sinformation technology system(Anasazi) by location and consumer in orderto monitor servicesdeliveredand outcomes of theservices.Inaddition, Hill Country will conduct consumer satisfaction surveysfor individualsreceivingpeersupportservices.

GoalsandRelationshiptoRegionalGoals:

ProjectGoals:

The goal of this projectis toestablishWhole Health PeerSupportthroughout thetwocounties servedby Hill Country in RHP8. The projectwillconsist of identifying and training peersof mental health servicesin thedeliveryof WholeHealth PeerSupportand integrating their work intotherecoveryorientedtreatmentplan of theindividual being served.The primary challenge of theprojectwill berecruitment,training and retention of peersfor implementation of Whole Health PeerSupport.

ThisProjectmeetsthefollowingRegionalGoals:

The goal of this projectis touse Whole HealthPeerSupporttoprovide guidance and support for theconsumer’sjourney of recoverybased on eachindividual’sneeds within thecommunity setting.Byproviding theseservicesin thecommunity, Hill Country will bemeetingtheregional goals of:

  • Increasing coordinationof prevention and carefor residents,including those with behavioral and mental health needs;and
  • Reducing inappropriateutilization ofservices.

Challenges:

The challengesHill Country has facedin establishing a robustpeersupportprogramhavebeen in relation toretaining individualsinthepositions for extendedperiods of time.Hill Country plans toaddress thischallenge by shifting thefocus of peersupporttoawhole healthmodel that becomesmorefully integratedintotheregularpracticeof themental health clinics.In addition, Hill Country intends toincreasethepercentageof full timeequivalent for peer supportspecialistsin ordertoincreaseretention.

5‐YearExpectedOutcome for ProviderandPatients:

Bytheend of fiveyears,Hill Country’s goal is tohavepeersupportspecialists ateachmental health clinicwith a minimum full timeequivalency of 1.0.Currently,Hill Country has 0.07full timeequivalencyfor peersupport servicesattheLlanoMental HealthClinic withinRHP8.

StartingPoint/Baseline:

Hill CountryMHDD Centershas utilizedPeerSpecialists in a limitedcapacityoverthepast seven yearsas a meanstohelp supportindividualswith behavioral health issues deal with their symptomsand advancein their recovery.Currently,Hill Country has tenpeerspecialists with only four having certifications through thestatetraining program.The LlanoMental Health Clinic withinRHP8currentlyhas 0.07full‐timeequivalency for provisionof peersupport services.Inordertoreemphasizetheimportanceof peersupportservices,tofully integrate peersupportservicesintothenetworkof servicesprovidedthroughtheLlanoMental Health Clinic operatedby Hill Country withinRHP8and toexpand thepeersupport servicesofferedto include whole health interventions including health riskassessments,Hill Country will recruit additional peerspecialists,arrangefor appropriate training,and emphasisthepeerspecialists roles regardingwhole health and servingas navigatorfor consumers.

Rationale:

CommunityNeedAddressed:

  • CommunityNeedArea:CN.2– Limited accesstomental health/behavioral health services
  • SpecificCommunity Need:CN.2.22 – Limited accesstowhole health peerbehavioral health servicesfor individualsin Llanoand Blancocounties

Peersareone of themostvaluable assetsin helping consumerswith mental illness gain hope and begin to progressontheir roadtorecovery.The servicestheyprovide aresupportive in nature.Byexpanding peerservicesas an integral portion oftheLlanoMentalHealthClinic operatedbyHill Countryand including whole health riskassessmentsand supportedservices targetedtoindividualswith hypertension, diabetes,and health riskssuchas obesity,tobacco use and physical inactivity, improved Daily Living Activities and improvedhealth outcomescan beachieved,helping address thedisparate life expectancyand poor healthoutcomesand ultimatelydecreasingutilization of EmergencyDepartments.Throughthis projectHill Country will acquireand maintain Whole Health PeerSupportSpecialists equivalent toa minimum of

1.0full timeequivalencyattheLlanoMental Health Clinic operatedby HillCountry.

ProjectComponents:

Through theWhole Health PeerSupport, Hill Country proposestomeetall required project components.

a) Train administratorsandkeyclinical staff in theuseof peerspecialists as an essential componentof a comprehensivehealthsystem.Hill Countryis currentlyparticipatingin the PersonCenteredRecoveryInitiativethrough ViaHope.The initiativeis designedto promote mental health systemtransformation by 1) helping organizationsdevelop culture and practicesthat support and expectrecovery,and 2) promoting consumer voicein the transformation processand thefuture,transformed mental healthsystem.OnOctober 24,2012,theclinical leadership of Hill Countrycompleted aone day training on integratingpeersupportand incorporating thepatient in developing and implementing their treatmentplan.

b) Conduct readinessassessments of organization thatwill integratepeerspecialists intotheirnetwork.Hill Country will reviewreadinessateachof thesevenmental health clinics within RHP8and address any potential barrierstofull integration of Whole Health Peer Support.

c) Identifypeerspecialists interestedin this typeof work.Hill Country will recruitpeer specialists whohaveinterest,first and foremost,in helping otheron their journey of recoveryand whoalsowish toreceivetraining in providingwhole healthpeerservices and areinterestedin employmentwithHill Country MHDD toprovide whole health peer services.

d) Train identifiedpeerspecialists in wholehealthinterventions,including conducting health risk assessments,settingSMARTgoals, providingeducationaland supportiveservicesto targetedindividuals withspecific disorders (e.g.hypertension,diabetes,orhealth risks (e.g.obesity,tobacco use,physical inactivity).Hill Country will makearrangementsfor interestedpeerspecialists toattendWhole Health PeerSupporttrainings and certifications available through thestateof TexasVia Hope program.Iftraining space becomesrestrictive,HillCountry will find ordevelop similar training tobring peer specialists on board until suchtimeas thecertification training is available.

e) Implementhealth riskassessments to identifyexistingand potential healthrisks for behavioral healthconsumers.Hill Country will havetrainedpeerspecialists utilize the health riskassessmenttool to determinepotential orcurrenthealth risks,will trackthe completion of health riskassessmentsin theinformation technology system,and will address potential healthriskswith thepatient.

f) Identifypatients with serious mentalillness whohavehealth risk factors that can be modified.Patients identifiedthrough thehealthriskassessmenttool will receive education and information regardingpotential health risksand, if appropriate,referredto primarycareand preventiveresources.

g) Implementwhole healthpeersupport.Hill Country will tracktheoccurrenceof health risk assessmentsby location and patient in ordertodeterminetheprojectis fully implemented.

h) Connectpatientto primarycareandpreventiveservices.If riskfactors ormedical conditions areidentifiedthat requiremorethan basic education, individualswill be referredtotheappropriate primarycareand preventiveservices.

i) Trackpatientoutcomes.Reviewtheintervention(s)impact on participants and identify“lessons learned,”opportunitiesto scale all orpartof theinterventions(s)to a broader patient population, and identifykeychallengesassociatedwith expansionof the intervention(s),includingspecial considerationsfor safety‐netpopulations.Hill Country will utilize theDaily Living Activitiesassessmenttodetermineprogression of individuals receivingWhole HealthPeerSupportservices.In addition,Hill Countrywill dofollow up surveyswith individualswhoreceiveWhole Health PeerSupportservicestodetermine satisfaction with servicesand tohelp ensurestabilization ofsymptoms.

ContinuousQualityImprovement:

Hill Country is committedtocontinuous quality improvement and learning relatedtothisproject. Wewill establish quality improvement activitiessuchas rapid cycleimprovementandwill performotheractivitiessuchas “lessons learned” and identifyingprojectimpacts.In addition, weareparticipatingin a regional learning collaborativewhich shareinformation suchas challenges, lessons learned and considerations for safetynetpopulations.

Howtheprojectrepresentsanewinitiativeorsignificantlyenhancesanexistingdeliverysystemreforminitiative:

Hill Country has utilizedPeerSpecialists ina limitedcapacityoverthepast sevenyearsas a meanstohelp support individualswith behavioral healthissuesdeal with their symptomsand advancein their recovery.The LlanoMental Health Clinic currentlyhas 0.07full‐ timeequivalency of peersupportservices.Inordertoreemphasizetheimportanceof peer supportservices,tofully integratepeersupportservicesintothenetworkof servicesprovided through theLlanoMental Health Clinicoperatedby Hill Country MHDD CenterswithRHP8and toexpand thepeersupport servicesofferedto include whole health interventions including health riskassessments,Hill Countrywill recruitadditional peerspecialists,arrangefor appropriatetraining, and emphasisthepeerspecialists roles regardingwhole health and servingas navigator forconsumers.

Hill Countryreceivesfunding fromtheU.S.Departmentof Health and Human Services; however,none of thefunds will beusedfor thisproject.

RelatedCategory3Outcome Measure(s):

The following Category 3 measures have been proposed in 2014 to describe improvements to the patient population.

IT11.25 Daily Living Activities (DLA-20) In DY4 and DY5 we will report the sum of the average DLA score of all DLA-20 questionnaires completed during the measurement period for a denominator subset of all completed DLAs at Hill Country MHDD Centers divided by the total number of DLA-20 questionnaires completed during the measurement period for the same population.CMHC.5 Adherence to Antipsychotic Medications: In DY4 and DY5 will report adherence to antipsychotic medications in accordance with measure guidelines

Reasons/rationaleforselectingtheoutcomemeasure: Whole Health PeerSupportservicesimpact an individual’smental and physical healthand thus their quality of life. Itimpacts theindividual’sself‐careas wellas their ability tocope with their environment.Whenanindividual isunable toproperly carefor themselvesortocope with their local environment,theyareatgreaterriskof unemployment and poor health.The Activities of Daily Living (DLA‐20)willbeutilized toprovide anoverviewoffunctional status, determineactivity limitations, establish a baseline for treatment,and provide a guide for intervention planning, to evaluateinterventions and monitorprogressand toplan forfuture and for discharge.The Activities of Daily Living will bemeasuredutilizingtheDLA‐20Functional Assessment.

The DLA‐20Functional Assessmentis a functional assessment,provento bereliable and valid, designedtoassess what daily living areasareimpactedby mental illness ordisability.The assessmenttool identifieswhereoutcomesareneededsoclinicians canaddress those functional deficits on individualizedserviceplans.THE DLA‐20is intended tobeusedby all disabilities and ages.DevelopmentalDisabilities and Alcohol/Drug Abuse forms are personalized for daily functional strengthsand problemsassociatedwith those diagnoses. THE DLA‐20utilizesthefollowing 20domains:Health Practices,HousingStability and Maintenance,Communication, Safety,Managing Time,Nutrition, ProblemSolving, Family Relationships,Alcohol/DrugUse,Leisure,Community Resources,Social Network,Sexuality, Productivity,Coping Skills, BehaviorNorms,Personal Care/Hygiene,Grooming,andDress.

RelationshiptoOtherProjects:

ProvisionofWhole Health PeerSupportservicesas an alternativetoinpatient and ED services reinforcesobjectivesforall otherbehavioral health servicesprovidedby Hill Countrythrough RHP8(#133340307.2.1Co‐occurringPsychiatricand Substance UseDisorder,#1333340307.2.2 Trauma InformedCare,and #133340307.2.3Virtual Psychiatric and Clinical Guidance, and #133340307.2.5VeteranServices)byproviding specializedservicesaddressing Whole Health PeerSupportfor an individual that if not addressed in thecommunity mayresult inneeding inpatient psychiatric servicesorinpatient medicalservices.Providing theservicesin the communityenables theindividual to moveforward with treatmentsand tobemoresuccessful in their recovery.In addition, by providing servicesin thecommunity, exacerbation of symptomsarereduced,resulting in a reduction of ED utilization and potentially preventable hospital admissions(RD‐1‐3).

RelationshiptoOtherPerforming Providers’ Projects inRHPandPlanfor LearningCollaborative:

Hill CountryMHDD Centersis thelocal mental health authority that providesserviceswithin the following counties of RHP8:Blanco and Llano. The otherthreelocal mental health authorities (BluebonnetTrails, Centerfor Life Resourcesand Central Counties) providesmentalhealth servicestotheremaining counties within RHP8and serviceareasdonotoverlap.However, someof theprojects proposedby theseauthorities aresimilar in nature.One suchproject (#081771001.2.1)is proposedby Central Counties, which addresseschronic diseasesthat result fromprolongeduse of psychotropicmedications.

Hill Countryis committed toongoingadvancementof servicesfor theindividualsweserveand is willing to participate in learning collaboratives with otherproviders within theregionto continually improveservicesand datacollection and toidentify how toaddress additional needs that mayarise.

Hill CountryMHDD Centerswill participate in a learning collaborativethat meetsannually to discuss local disparities in careand thewaystheyhavesuccessfully gatheredrelevantdata and ultimatelybetterservedthepopulationsin theprojects.

ProjectValuation:

Projectvaluation is based on a weightedaverageof AchievingWaiverGoals, Addressing CommunityNeeds,ProjectScope, and ProjectInvestment.The valuation for thisprojectwas based on aneconomic evaluation model and extensiveliteraturereviewconducted by professorsattheUniversityof Houston SchoolofPublic Health and Universityof Texasat Austin Centerfor Social WorkResearch.The valuation is supportedby cost‐utility analysis which measuresprogramcost in dollarsand thehealth consequencesin utility‐weightedunits called quality‐adjustedlife‐years(QALYs).QALYsincorporatecosts avertedwhenknown (e.g., emergencyroom visits thatareaavoided).The proposedprogram’svalue is based on the averageof benefit‐cost studiesfromSari etal.2008and Kuykenetal.(2008)with anaverage benefit cost ratio of $23.36for everydollar invested,resultingin an averagecost of$15,573per patient served.