Eastern Region Community Access Transformation Proposal / September 18
2009
This proposal is designed to begin the fundamental transformation of the Eastern Region Public Behavioral Health Service Delivery System from one of “No Where to Go” to “Easy, Early and Equal Access” to integrated community services and supports that facilitate recovery of the region’s citizens with behavioral health needs. / A Community-wide Collaborative Approach to Transform Behavioral Health Service Delivery in Missouri’s Eastern Region
Table of Contents
Part I: Introduction & Overview 3
Part 2:Access System 7
Enhanced Access by BHR 7
Access Center 9
Part 3: Enhanced Community Serves 11
Outreach and Engagement Function 11
Enhanced Shelter Services 11
Intensive Community Supports 12
Community Crisis Stabilization Function 12
Training 12
Behavioral Healthcare Home 13
Modified Medical Detox 14
Part 4: Budget 16
Appendix 17
Endnotes 24
Part 1
Introduction and Overview
Background:
In the Spring of 2009, community leaders and stakeholders in the Eastern Region[i] collaborated with the Missouri Department of Mental Health (DMH) to initiate a community wide effort that would integrate two major initiatives underway to transform the delivery of public behavioral health services throughout the region. They are:
· The Regional Health Commission Eastern Region Behavioral Health Initiative (ERBHI)
In 2006, the St. Louis Regional Health Commission (RHC), a collaborative partnership of health service providers[ii], government and community leaders, community organizations, and consumers, launched the ERBHI, which included a region-wide planning process to transform the public behavioral health system in the region. This process resulted in the creation of a strategic plan[iii] that included a regional assessment of needs and resources along with 9 core recommendation areas for transforming the system. The RHC also estimated that the region would require an additional $86 -$111 million dollars to fully meet the needs of the community assuming no changes in system efficiency, cost structures or offsets.[iv] As a result of this planning the ERBHI launched 3 major implementation projects (Improving Entry, Coordinating Care for High Utilizers and Reducing Stigma/ Increasing Cultural Competency) led by the RHC’s Behavioral Health Steering Committee. These projects resulted in the development of a standardized screening tool that was piloted with 20 behavioral and physical health organizations, a cross-organizational treatment planning process for consumers identified as high system users, region-wide trainings on cultural competency and stigma reduction, and the RHC’s adoption of Regional Respect Principles. Additionally, proposals to create a regional Access Center and a document to address capacity, service needs and policy reform were developed for the next phase of ERBHI’s implementation and some of the concepts are incorporated into this proposal.
· The Department of Mental Health (DMH) Psychiatric Acute Care Transformation (PACT) Initiative
In 2007, the DMH initiated a plan to transform the delivery of psychiatric acute care services in Missouri. The department determined that the psychiatric acute care needs of consumers could be successfully met through local community hospital systems that provided both physical and behavioral health services. This would reduce the current system fragmentation between physical and mental health care, as well as community and acute hospital care services. Furthermore, the department determined that reimbursement for the adult Medicaid population could be maximized if acute psychiatric care is delivered by hospital systems that are not designated as Institutions for Mental Diseases (IMD) under federal regulation (a hospital is deemed an IMD and does not receive Medicaid reimbursement for adults if more than 50% of its beds/services are psychiatric in nature). Thus, DMH would be able to generate cost savings by leveraging these beds and eliminating the direct service costs associated with these facilities. The savings could then be redirected to enhance critically needed community care. As a result of this analysis and planning, DMH began working with local communities to determine their interest and capacity to transition the publically funded acute care beds to local integrated health system providers. To date, acute care services have been successfully transitioned to community providers in the central and northwestern regions of the State.
Each of these initiatives is included in Missouri’s Comprehensive Plan for Mental Health[v] developed by the Governor appointed Mental Health Transformation Working Group. Together they provide the springboard to begin fundamentally transforming the mental health system in the region. Specifically this proposal addresses the following core objectives outlined in Missouri’s Comprehensive Plan:
· Create and/or expand local public-private collaboratives to improve access, capacity, and service integration.
· Integrate public, primary and mental health care practices
· Provide timely outreach, screening and referral to care that is age and culturally appropriate
· Expand community capacity to reduce avoidable use of emergency rooms, hospitals and other institutional care.
· Expand and integrate peer and family support services into the system of care
Planning Process:
To achieve the mutual goals of the ERBHI and PACT initiatives to improve system access and service delivery, the DMH worked with regional providers to move forward. The CATT was formed in the Spring of 2009 to manage the design and implementation of these two initiatives. The RHC was approached to assist with project management. With staff support from the RHC and DMH Office of Transformation, the CATT created the following 4 workgroups (see Appendix C for membership) comprised of key stakeholders representing providers, consumers and advocacy organizations:
· The Access Center Workgroup developed requirements for a comprehensive access center/system, crisis stabilization services and linkages with law enforcement.
· The Urgent Care Hand-off Workgroup identified key urgent care services and supports needed to reduce avoidable use of emergency room and inpatient services.
· The Modified Medical Detox Services Workgroup developed requirements for acute ADA services transition to a 24 hour secure community modified detox setting.
· The Funding and Database Design & Management Workgroup developed access system data requirements, as well as an overall cost and reimbursement structure.
The workgroups reviewed and analyzed existing cost, utilization and clinical data to determine priority recommendations. Throughout the planning process the CATT provided planning updates and sought input and feedback from community stakeholders including, but not limited to, the RHC committees at their regularly scheduled meetings. Given the short timeframe required for the development of this proposal (completion was required prior to DMH FY11 Budget cycle beginning) CATT will now accelerate and expand this process during the upcoming weeks and months to assure broad-based support for the initiative. Modifications will be made to the plan as needed to reflect the input received.
Desired Outcomes:
· Increased access
· Increased linkage/fluidity within the system
· Maximize and leverage existing funds
· Increased capacity for innovative community based services to reduce hospitalization and emergency care
Summary of Proposed Plan and Phases of Implementation:
As a result of the initial planning process this proposal incorporates a 4 phased approach to transforming access and service delivery in the Eastern Region. Over the course of the next three years, the CATT proposes public acute care bed capacity be downsized at the Metropolitan Psychiatric Center with concurrent increases in:
· Private bed capacity provided by community hospitals who agree to serve as designated public entities for the purposes of providing acute psychiatric care, and
· Community behavioral health service capacity to improve access and increase community-based alternatives to hospital care
To the extent feasible the use of current staff and existing space at MPC will be maximized throughout the transition.
The CATT proposes that all savings generated from the transition of state-operated acute care services be redirected and fully leveraged to increase regional safety net access and service capacity in two core areas:
· An Enhanced Regional Access System that incorporates outreach and engagement, warm hand-offs, and assignment to behavioral health care homes, when appropriate, which have the capacity to provide/coordinate the full array of needed behavioral and physical health care. This includes the conversion of the MPC Emergency Department (ED) to an Access Center that is fully integrated into the Access System.
· Increased Regional Service Capacity that is designed to reduce the avoidable use of expensive emergency and inpatient care through the delivery of evidence-based services and that support and promote consumer recovery. This includes the development of behavioral healthcare home capacity, expanded capacity for outreach and engagement, crisis stabilization, intensive community services, and modified medical detox services.
The following parts of this proposal provide additional detail on the proposed enhancements in the above two areas. To ensure that a well-planned and orchestrated transition takes place, the CATT recommends that it occur in four phases.
The following table outlines the phases, target dates and key implementation steps that are described in this proposal:
PHASE 1:(January 1, 2010) / Ø Transition of ADA beds to Regional Modified Medical Detox provider (note: completed September, 2009)
Ø Begin Transition of Public Behavioral Health Acute Care Services to Integrated Community Hospital System (1 Inpatient unit)
Ø Develop Enhanced Community-wide Access System
Ø Targeted Expansion of Community Service Capacity
PHASE 2:
(July 1, 2010) / Ø Begin transition of Public Emergency Department into a Regional Access Center/Emergency Department
Ø Expansion of Regional Modified Medical Detox Capacity
PHASE 3:
(January 1, 2011) / Ø Continue Transition of Public Acute Care Services to Integrated Community Hospital System (1 inpatient unit)
Ø Continue Transition of Public Emergency Department into a Regional Access Center/Emergency Department
Ø Targeted Expansion of Community Service Capacity
PHASE 4:
(July 1, 2011-June 30, 2012) / Ø Complete Transition of Public Emergency Department to Regional Access Center
Ø Complete planning for the Transition of remaining Public Acute Care Services and Targeted Expansion of Community Service Capacity
Part 2
Regional Access System
Enhanced Access through Behavioral Health Response (BHR)[vi]:
The purpose of enhancing access through BHR is to make it easier for individuals to gain access to the Eastern Region’s behavioral health system and to help facilitate better linkage between individuals seeking services and healthcare providers. The proposed enhancements for a regional access system incorporate recommendations from the Access and Urgent Care Workgroups. The rationale for these recommendations, in part, was based upon a clinical review of 64 MPC charts (32 inpatient charts and 32 ED charts of individuals who were not admitted to an inpatient bed) and 18 community provider records that produced the following findings:
· 31.25% of the individuals admitted into inpatient services showed evidence of poor past linkage to care
· 18.75% of the individuals who presented to the ED could have been diverted by better outreach, counseling, and engagement (including BHR Mobile Outreach)
· 9% of the individuals admitted to an inpatient unit at MPC could have been diverted with an urgent care appointment
Phase I:
BHR will continue to use the current Access Crisis Intervention (ACI) line, preventing the duplication of services and mitigating any confusion that might be associated with an additional number.
BHR currently provides the following services to a caller depending on the assessed level of care that the client needs (e.g. routine, urgent, or emergent):
· Routine: Cases where Crisis Intervention Counselors (CICs) are able to rule out immediate safety threats, urgent needs and significantly de-escalate or resolve presenting problem via the initial phone contact[vii].
o Linkage to a community provider
Ø An ADA provider
Ø A CPS Provider (Administrative Agents and Affiliates)
Ø Veteran Services
Ø Other Community Providers
Ø A mobile outreach team (MOT)
· Urgent: Cases where CIC’s provide more extensive assistance to de-escalate clients, including: contacting on-call workers, sending outreaches, working with family/friends/agency to facilitate service delivery or ensure safety and/or arranging callbacks[viii].
o A mobile outreach team (MOT)
Ø Including outreaches with CIT officers
o An urgent care appointment[ix]
· Emergent: Cases where emergency personnel are contacted as part of the treatment plan, typically a High Risk safety level[x].
o Referral to a hospital
o A mobile outreach team (MOT)
The CATT proposes that the following changes be made to enhance access through BHR:
· Increase mobile outreach service capacity
· Employ peer specialists to go on mobile outreaches and provide additional follow-up to ensure a client is linked to services.
· Employ a Family Support Liaison to provide linkage and support resources to families.
· Provide linkage to a Behavioral Healthcare Home (for Behavioral Healthcare Home definition and entry points see appendices A and B)
· Expanded Urgent Care Appointments, including providing true next day appointments (e.g. weekend and holiday appointments)
· Linkage to services recommended by the Urgent Care Workgroup as alternatives to hospitalization when appropriate (see Part 3 for identified services)
Increasing the Mobile Outreach Service Capacity of BHR:
Increasing the number of mobile outreaches BHR can do in a year, will help to reduce the number of cases seen at the ED at MPC and reduce the number of admissions to MPC’s inpatient unit. BHR will modify its current Mobile Outreach Team (MOT) protocols to maximize utilization.
Peer Support:
Peer specialists will play a vital role in linking consumers with recovery services. Peer specialists will be located at BHR. Peer specialists will be a part of Mobile Outreach Teams during community outreaches and will have a complimentary, but unique role. Peer Specialists will act as consumer advocates and guides through the Access System. Peer specialists will provide peer centered and relationship based support services, explain how the service linkage system works and assist with the warm-handoff between BHR and Behavioral Healthcare Homes (BHH). Peer specialists will follow-up with consumers who have been linked with a BHH on a daily basis until the BHH has fully engaged consumer. Peer specialists will work closely with the Access System and BHH providers, providing consumer feedback and operational suggestions from a consumer perspective. Additionally, the Access System will assist with peer specialist functions at the MPC ED, with the goal being to have a peer specialist based at MPC to enhance service and ensure linkage between MPC and the Access System.