Preventing Rather Than Responding to Crisis: Building Wrap-Around Medical,

1. Preventing Rather Than Responding to Crisis: Building Wrap-Around Medical, Behavioral Supports to Prevent Institutionalization Michael A. Mayer, PhD Derrick Dufresne,MBPA michaelmayer@earthlink.net cra@aol.com

2. Initial Questions:…What is a Crisis? • Crisis: “An urgent situation that must be addressed immediately due to an existing or predicted medical or behavioral situation where the individual has historically demonstrated, is currently demonstrating, or can be predicted to demonstrate an inability to safely and effectively manage the circumstances without significant assistance that is likely to directly and immediately result in the harm to themselves or someone else, or will otherwise result in serious negative consequences for the individual and/or someone else.”

3. Initial Questions….Why bother? • Law • Cost • Efficacy/Public Trust • Ethics/Need

4. The Law • ADA Integration Mandate“A public entity shall administer services, programs and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.” 28 CFR Section 35.130(d)

5. The Law Section 504 of the Rehabilitation Act of 1973, and the Americans withDisabilities Act of 1990…prohibits discrimination against people with mental retardation who are otherwise qualified for services but who are denied services based on having a secondary disability or because of the degree or severity of their disability… US District Court, Martin v. Voinovich

6. The Costs • Illinois already ranks 9th in public and private institutional spending in the U.S. (2005); over 65% of state DD budget spent in institutions (fewer people get very costly services) • Per capita total population expenditures of $53.92 vs. National average per capita expenditures of $36.86

7. The Costs • Illinois ranks 46th in per capita Medicaid spending on home and community services and supports in 2005 • States that rank lower are: Arkansas, Mississippi, Nevada and Texas

8. Efficacy: Areas of Major Concern • Services that are Available vs. Services that are Functional • Recycling • Short Term Intervention vs. Long Term Stability – Efficacy • Containment vs. Treatment • Primary Cost per Participant • Secondary Costs

9. The Public TrustAmerican Psychiatric Assn. Model Program Recommendations • Mobile Psychiatric Emergency Service • Mobile Psychiatric Urgent Care Service • Psychiatric Urgent Care Facility • Psychiatric Emergency Services in Medical ED • Psychiatric Emergency Service Facility • 23 hr. observation • 72 hr. extended observation • Psychiatric Urgent Care Residential Facility (Crisis Residential Facility) • Psychiatric Emergency Residential Facility (Acute Diversion)

10. The Need PUNS Data • 1,708 define service need: EMERGENCY • 1,052 for out of home residential • 667 for behavioral support • 1,085 for day supports

11. Initial Questions… • Why do crises occur? • Are there degrees of crisis? • Where are we at? Is the system prepared to effectively manage crises? • What do we know that doesn’t work? • How flexible is the crisis response system? (Can we make it work?) • Should we build something new based on what we know works or should we add onto something that we know is not as effective?

12. Initial Questions • Efficacy: • Is there any evidence that state facilities are more effective than community based respite and enhanced local emergency services? • Is there any evidence that state operated crisis services are more effective than community based crisis services?

13. Initial Questions • Cost: • Does the community currently rely on state facilities because of the lack of other community support options? • Can effective and efficient community support options be developed at a cost lower than continued or expanded reliance on state facilities? • Is it more cost effective to provide for flexible, mobile wrap around supports, including respite, and enhanced local emergency response options than continuing to rely on state facilities?

14. Initial Questions • Management Issues: • Personnel: Can state employees be expected to be as flexible with their supports and time as private employees? • Is there any incentive for state employees to assure the provision for the least restrictive and most cost effective service? What about for the private provider? • Where is the evidence for the most cost effective service delivery based upon cost relative to outcomes?

15. Rule: You must know what you want before you order “Crisis services shall be designed for prevention, intervention, and resolution, not merely for triage and transfer and shall be provided at the least restrictive setting possible, consistent with the individual and family need and community safety.” (North Carolina G.S. 122C-117(a)(14) , 2006)

16. Scaled Responses • Acuity? Perceptions of intensity • Use/abuse of emergency services and back-up services • Threats to self, others, property • Supplemental Behavior Support

17. Cost Model: Institutional Based Service • Number Served = 24 • Staffing Ratio = ~1:8 • Median Annual Rate = $129,429 • Cost = $3,106,296 • Major Concern: Expensive with poor outcomes/efficacy

18. Cost Model: Facility Based Service • Number Served = 6 • Staffing Ratio = 1:2 • Assumptions: • Benefits 26% • Pay Rate $12.50/hr • Program Costs = $10,000/mo • Administrative Overhead = 12%

19. Cost Model:Facility Based Service Building = $360,000 Upfit/hardening = $60,000 24/7/365 staffing + = $737,000 Housing, transport, program supplies + = $120,000 Administrative Overhead = $88,452 Year 1 Start Up = >$420,000 Year 1 Core Cost = >$955,000 Total Year 1 = >$1,375,000 Total Year 1 Per Resident (6) = $229,167 Year 1 Core Cost Per Resident = $159,167

20. Cost Model: Mobile Crisis Service • Number Served = 24 • Staffing Ratio = .75:1 • 8 Direct Crisis Support Personnel • 4 Crisis Respite Staff/Homes • .5 Psychiatrist/MD • .75 RN/NP • 1 Social Worker • 1 Psychological Associate (Masters Prepared) • 1 Psychologist • .75 Manager/1 Clerk • Assumptions: • Most – Same… • Different - Program Costs = $6,583/mo

21. Cost Model: Mobile Crisis Service Building = $0 Upfit/hardening (4 + equipment) = $60,000 24/7/365 staffing + = $788,000 Housing, transport, program supplies + = $79,000 Administrative Overhead = $88,452 Year 1 Start Up = ~$100,000 Year 1 Core Cost = ~$955,000 Total Year 1 = ~$1,055,000 Total Year 1 Per Enrolled (24) = $43,958 Year 1 Core Cost Per Resident = $39,792

22. Cost Model Comparison… • Enrolled • Facility 6 • Mobile 24 • Cost Per Enrolled • Facility $159,167 • Mobile $ 39,792 • Service Duration (hrs) • Facility ~8,760 • Mobile ~1,250 • Start Up • Facility $420,000 • Mobile $100,000 • Operations • Facility $955,000 • Mobile $955,000

23. Sample of 2006 Data – Mobile Crisis Supports • 138 Served - 83 “on-going”/55 single incident • 60% “Repeats” (declining) • 166 Events (up to 24 hrs./event) • 126 Remained at Home (91.3%) • 12 Served Temporarily in Crisis Facility or Psychiatric Unit, or Residential Placement • 0 Placed in State Facilities • <2% require law enforcement involvement * Collaborating Agency - Rolling 12 Months as of 12/1

24. Ohio IACOT Data • Served 60 people over 3 years • Focus on highest need/cost • Focus on highest utilization of in-patient services (public and private) • Outcomes • None placed in state facilities for 3 years • Baseline year prior = 11,286 days = 282 days/person • No court probate actions (prior average annual IVC = 7) • No criminal charges (prior average annual = 5) • Saved state $8,000,000 even with community residential supports and full funding of the team

25. COMPRHENSIVE COMMUNITY CRISIS RESPONSE SYSTEM HOSPITALS • Psychiatric Hospitals • General Hospitals COMMUNITY-BASED CRISIS STABILIATION • In-Home Intervention Teams • Crisis Stabilization Units • Safe houses • Short-term Respite Beds CRISIS RESPONSE, AND RESOULUTION, AND REFERRAL • 24-hour telephone crisis lines • 24-hour walk-in services, ER • Mobile outreach services • Peer crisis support networks PRE-CRISIS SUPPORT • Crisis planning • Warm lines • Outreach/engagement • Vacations/respite • Peer-support networks • Drop-in centers • Intensified support • Case management ONGOING SUPPORTIVE SERVICES AND WELLNESS • Case Management/ in-home support • Financial Supports • Medications • Basic needs (decent housing, food, safety) • Natural supports/ friends • Identification of coping strategies

26. One Hierarchy of Supports • Enhanced Routine and Preventive Supports • Person Centered Planning, including a crisis plan • Natural supports such as family and friends • Vacations • Financial and other generic supports meeting basic needs • Medication management • “Warm Lines” (phone calls to therapists before a crisis) • Peer support – individual or group, paid or volunteer (not the same as “friends”) • Drop-in centers • Specialized supports

27. Support Hierarchy continued • Wrap-Around supports • In home respite • Out of home respite (short term) • Case Management • Outreach • In home counseling/supervision • In home skills training/supervision • ACT, Multi-Systemic Therapy Teams, etc.

28. Hierarchy continued • Crisis Response Services and Supports • 24 hr. “Hot Lines” • Peer crisis supports • In home mobile crisis response team • Safe-houses, specialized/crisis respite, specialized foster care • Urgent care clinics • Crisis stabilization “units” (such as 23 hr. observation chairs) • Law enforcement and EMS

29. Hierarchy continued • Medical Intervention • General hospital (Specialized triage or Emergency Department) • General hospital (medical, detoxification, or psychiatric unit admission) • Psychiatric hospital

30. Developing Crisis Services • New engagement – true collaboration • Developing, supporting, and funding capacity • Before more continuums • What are the purposes of services at various levels? Can we help them be more effective? • Accountability • Prevention!

31. Service Perspective • Cross Systems Efforts • Interaction Guidelines for Personnel Across Agencies • Protocols for all agents • MOA’s in place • Collaborative Service Development and Support • Includes Cost and Revenue Sharing • Hospitals • LEA engaged and informed

32. Service Perspective • Multiple Level Contingency Planning • "Typical" Home Environment (by external appearance) • Community and Support System Re-Engagement/Membership • Support to Other Providers Regardless of Location

33. Service Perspective • Follow all principles of Effective Consumer Based Planning • Planned Responses – Scaled to Intensity • Interaction Guidelines for Personnel to Consumer • Active Supportive Psychotherapy • Individual Behavior Support Plans

34. Service Perspective • Active Clinical Team • Careful Staff Selection • Extensive Staff Training • No Aversives • Can Include Electronic Surveillance • Staff to Consumer Ratio Varies by Person (from 3:1 to 1:3)

35. Service Examples • Mobile Crisis Prevention • Mobile Crisis Intervention • “Wrap-Up” • 23 hr. support to E.D. • Triage support to E.D. • High Needs Residential – individual • High Needs Residential – small group • Intensive Probation/Alternative Sentencing

36. “As important as your past is, it is not as important as the way you see your future.” -Tony Campolo

37. “It is the greatest of all mistakes to do nothing because you can only do a little. Do what you can.” Sydney Smith

38. Excellence can be attained if you… Care more than others think is wise. Risk more than others think is safe. Dream more than others think is practical. Expect more than others think is possible.

39. Crisis Services Resources • Evaluating and Reporting Outcomes: A Guide for Respite and Crisis Care Program Managers - Revised Edition Ray Kirk, Univ. of NC, revised by Casandra Wade • Planned and Crisis Respite for Families with Children: Results of a Collaborative Study archrespite • Risk Management Robert Horowitz and Marcia Sprague • Securing a Stable Funding Base Sue McKinney-Cull • The Crisis Services Crisis Michael A. Mayer, Ph.D.

40. A Model of Community and Clinical Support for Persons with a Dual Diagnosis and Their Families Ian Gilmour & Greg Gravelle • Community Safety Nets for Individuals with Dual Diagnosis in Crisis Harold Woodward • Community Services For The Individual Who Has a Dual Diagnosis: Practical Considerations Michael A. Mayer, Ph.D. • Contemporary Dual Diagnosis MH/MR Service Models Volumes I & II: Residential and Day Services John W. Jacobson, Ph.D., ed. • Crisis Prevention and Systems Consultation: Let's Get Personal Diana J. Antonacci, MD, et al • Effective Crisis Prevention and Intervention Through Cross-Systems Collaboration and Community Support Planning Joan B. Beasley, Ph.D.

41. An Open-Systems Consultation Model for the Care of Dually-Diagnosed Individuals in a large Rural CommunityThaddeus P.M. Ulzen, M.D. • Program Design/Implementation/EvaluationMichael A. Mayer, Ph.D. and Terrence McNelis • The START/Sovner Center Program in Massachusetts Joan B. Beasley, Ph.D. • Stealth Mental Health: Secrets of Effective Community Based Therapy for People Who Have a Dual DiagnosisMichael A. Mayer, Ph.D. • Stop the Insanity! Community Diversion Models That Really Work Michael A. Mayer, Ph.D. • Strengthening Local Capacity to Deal with Challenging Behaviors Through Crisis Response Matt McCue, M.A.; John Gatling, Ph.D.; Dianne Nunn • Crisis: Prevention and Response in the CommunityRonald H. Hanson, Norman A. Weiseler, and K. Charlie Lakin

42. Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation NICHD • Building Bridges for Services: DD/MI Collaborative Clinical Services Development New Mexico Developmental Disabilities Planning Council • Report and Recommendations Regarding Psychiatric Emergency and Crisis Services: A Review and Model Program Descriptions Michael H. Allen, MD, et al • Several Factors Critical in Ability to Handle Crises Joan Arehart-Treichel • Crisis Planning, Prevention, and Management: DMH/DD/SAS Endorsed Trainer Materials Michael A. Mayer • Finance and Value in Mental Health Care Project Hope

43. Evidence-Based Services and Emerging Best Practice for Treating Mental Disorders in Adults and Children www.mhreform.org • The Struggle to Provide Community-Based Care to Low-Income People with Serious Mental Illnesses Peter Cunningham, et al • IMPACT: Feature Issue on Behavior Support for Crisis Prevention and Response • The Inter-Agency Aggressive Community Outreach Team (IACOT) for the Dually Diagnosed Michael A. Mayer, PhD • State Funding of Community Agencies for Services to Illinois Residents with Mental Illnesses and/or Developmental Disabilities; Final Report to the IL. General Assembly Requesters Pursuant to Public Act 93-842 Elizabeth T. Powers and Nicholas J. Powers

44. Other resources: • http://www.mentalhealth.samhsa.gov/features/surgeongeneralreport/chapter3/sec7_1.asp#crisis • www.mentalhealth.samhsa.gov • www.thenadd.org • http://www.mhaspectsofdd.com • http://www.qualitymall.org