Allegheny County Acute Community Support Plan (ACSP) Process

1. Allegheny County Acute Community Support Plan (ACSP) Process MRSAP Steering Committee August 21, 2009

2. Acute Community Support Plan (ACSP) • Comprehensive support and resource planning process that is driven by a blending of the consumer’s, family’s, and treatment/service coordination team’s preferences, recommendations, and competencies. • Promotes higher levels of accountability • Uses external facilitator to encourage new thinking and provide objective review • Supported by web-based application to ensures all parties working with the same information • Modeled after the Mayview CSP discharge process

3. Key Characteristics of a CSP • Shared responsibility between County, MCO, IP team, community providers, consumer, and other supports • A disciplined and highly facilitated process using a non-affiliated facilitator and recorder • Consumers get to where they need to be rather than following a continuum of care • Avoid ‘one size fits all’ approach to discharge planning • An incremental approach to discharge planning • Recovery focused and person-centered

4. Why do an ACSP: Outcomes • Positive consumer outcomes • Understanding and respecting the client’s choices is critical for long-term success • Greater satisfaction • Improved quality of life • Greater ownership in discharge process • Positive system outcomes • Improved collaboration among key stakeholders • Higher level of accountability • Services/supports match consumer needs • Reduced inpatient recidivism • Initiated to improve consumer outcomes and not just to increase access to resources

5. Acute Inpatient Discharge Process: Overview Acute CSP Disposition Meetings Acute Inpatient Multi-Disciplinary Treatment Team Discharge Planning Facilitated by ACSP Coordinator Level 3 Discharge Planning Facilitated by County Disposition Coordinator Level 2 Multi-Disciplinary Treatment Team on Inpatient Unit Level 1

6. ACSP Eligibility Criteria (Draft) To be eligible, consumer must meet one of the following criterion: • 4 inpatient admissions in last 12 months • 2 prior state hospitalizations or any continued state hospital stay greater than 2 years in duration • An acute inpatient hospitalization greater than 90 days in duration in past 12 months • EAC, RTFA, LTSR treatment in the last 12 months • Has had disposition meeting within the last 12 months • Consensus that the ACSP process is necessary to assure the development of a plan that promotes recovery, safety and community stability.

7. Acute CSP Discharge Process • The County Disposition Coordinator and inpatient treatment team can refer to the ACSP process when ACSP criteria is met. • ACSP Facilitator introduces process to consumer • If consumer is not ready to participate in the ACSP process, the Facilitator works to the engage consumer • Assessments are completed • CART completes Peer and Family assessments • SW completes Clinical Assessment • Facilitated ACSP meetings are conducted according to phases • Information Gathering and Options • Resource Coordination and Transition • Final Plan

8. ACSP Participants • Consumer and anyone the consumer invites • Family members of the consumer or representatives of the family • Members of the hospital treatment team and community provider (Service Coordinator or CTT is critical) • MHA Advocate • County ACSP Coordinator • MCO representative • Peer support • The facilitator and recorder

9. Current Status • Piloted at the TRU in Fall 2008 • A phased roll-out started in January 2009 that included seven training sessions which occurred from January through July 2009 • All hospitals (11) and service coordination units (9) in Allegheny County have received training • Currently 14 consumers are in some part of ACSP process, 3 of which are transition age. • There have been 2 discharges from the ACSP process with an average of 4 meetings each. • Barriers

10. What we’re working on… • Psychiatrist attendance in meetings • Providing community supports including service coordination and housing to insure desired match • Continuous education to providers about supports in the community • A conflict resolution process is in development

11. ACSP: Other Supports and Activities • The ACSP Advisory Committee meets every other month. Participants include Allegheny County OBH, DRN, MHA, PSAN, St. Clair Hospital, Mercy Behavioral Health, WPIC, OMSHAS, CCBHO and AHCI. • Weekly meetings occur between Allegheny County OBH and AHCI to discuss referrals to the process. • Pamphlets have been developed to guide families and consumers through the process