ACUTE-CRISIS PSYCHIATRIC SERVICES DEVELOPMENT INITIATIVE

1. ACUTE-CRISIS PSYCHIATRIC SERVICES DEVELOPMENT INITIATIVE DC Hospital Association Department of Mental Health June 30, 2004

2. DMH PROPOSALS • SHIFT ALL CIVIL ACUTE CARE TO GENERAL AND SPECIALTY HOSPITALS • EXPAND ALTERNATIVES TO HOSPITALIZATION • CREATE EXTENDED OBSERVATION SERVICES • EXPAND ASSERTIVE COMMUNITY TREATMENT • EXPAND CRISIS RESIDENTIAL SERVICES • EXPAND CRISIS INTERVENTION AND STABILIZATION THROUGH MOBILE CRISIS SERVICES • BETTER UTILIZATION OF CARE COORDINATION

3. 2001 Dixon Court Ordered Plan “acute care services for both children and adults will be provided under agreements with a number of willing and qualified local acute care hospitals.” “these agreements are important because general hospitals can be reimbursed for Medicaid-eligible psychiatric admissions and will very likely be less stigmatizing, and more likely to result in integrated healthcare and shorter lengths of stay (based on national statistics) than emergency admissions to Saint Elizabeths have been.”

4. Why provide all acute care for adults in community hospitals? • Persons with psychiatric illnesses need first class medical care • High incidence of associated medical illnesses • State psychiatric hospitals not equipped to provide medical care

5. Why provide all acute care for adults in community hospitals? Saint Elizabeths and all state and free standing hospitals are Institutes for Mental Diseases (IMDs) and are not eligible for Medicaid for patients between ages 22 and 64

6. Why provide all acute care for adults in community hospitals? • Patients do better when they integrated health care • Persons with a mental illness want treatment in the community--where they go for other medical care • Persons with a mental illness tend to do better when they choose the treatment setting

7. DMH has prepared for shift • Access HelpLine (AHL) provides 24/7 care coordination---AHL takes 900 calls a week and helps triage and track all new crisis and urgent referrals, enrolls consumers into the Mental Health Rehabilitation Services (MHRS) system • Civil commitment statute has been modernized; involuntary patients are more easily managed in community hospitals

8. DMH has prepared for shift • In less than 3 years, a $40 million and growing outpatient rehabilitation services developed—DMH also operates its own administration services organization internal to DMH: certifying providers, managing provider relations, adjudicating and paying claims, managing transfers, conducting quality improvement activities, • 27 community outpatient providers certified by DMH for a range of community services; most of these providers are Core Service Agencies meaning they serve as the clinical home for consumers.

9. New Facility at St E’s • The City is constructing a 292 bed facility that will accommodate 175 forensic and 117 long term civil patients • Size of new facility based on Court Ordered Needs Assessment conducted in 2001 • 3 buildings to be renovated to accommodate a larger population if needed • Construction will be completed in early 2007

10. In FY 2005, DMH will contract for acute care in DCHA Hospitals • Option 1: Community-wide Purchasing Plan • Option 2: Acute Care Network • Option 3: Hospital Single Purchase Plan

11. Option 1: Community-Wide Purchasing Plan • DMH purchases psychiatric acute care service from any hospital who provides care to indigent persons • DMH provides prior authorized coverage for up to 15 days based on DMH medical necessity criteria

12. Option 2: Acute Care Network • DMH contracts with 2-4 hospitals who commit sufficient beds to meet need • DMH and Hospitals will work closely in a network approach to assure admissions can be managed---up to 15 day lengths of stay

13. Option 3: Single Hospital Plan • A single hospital makes a proposal to shift beds from the Saint Elizabeths complement to manage the psychiatric acute care program • DMH will issue a single contract for days based on projected need, with an approved 15 day length of stay

14. Children’s Crisis System • Closed DMH Children’s Crisis unit October, 2002 • CNMC had seen 80% of the District’s ER psychiatric visits for children and youth • CNMC has a contract to see all children; DMH supplements CNMC with 2 social workers for crisis stabilization and continuity of care

15. Additional Children’s Services • 2 Mobile Crisis Teams—2nd one to be added in August, 2004 • Multi Systemic Therapy Teams (MST)—up to 4 teams to be added this calendar year • Intensive in-home services—begun in 2002, being expanded this year • Preferred provider agreements for Intensive Care Management—to begin in September, 2004

16. Adult Crisis System needs more…. • District hospital's ED’s at or above capacity • ED’s poorly connected to the Mental Health System • Based on contemporary practice the City needs to expand crisis alternatives • DMH and APRA agree to combine efforts to improve system –”no wrong door”—needed for persons with substance abuse and psychiatric problems

17. Adult Crisis System needs more…. • Breakdown in continuity of care of consumers leaving St Elizabeths and acute hospitals • Community Service Agencies certification requirements include their meeting emergent, urgent and routine access—greater compliance needed

18. DMH Proposal for Psychiatric Emergency and Crisis Services • DMH-Hospital Emergency Departments: develop cooperative agreements for DMH to come on site to assist with intervention, disposition and transport • Mobile Crisis Teams: expand and become primary mode of DMH crisis intervention, 24-7

19. DMH Proposal for Psychiatric Emergency and Crisis Services • Extended Observations Units: expand capacity to serve persons in crisis for up to 72 hours when hospitalization not indicated but additional stabilization is needed • Expand Crisis Residential Capacity by up to 8 beds • Expand Assertive Community Treatment—double capacity in FY 2004-2005

20. Next Steps • DMH will solicit interest in Option 1, 2 or 3 this month with projected start date---October-December 2004. • DMH committed to Crisis Expansion beginning in early 2005 Fiscal Year, will solicit proposals for expansion in July and August • DMH will host discussions on Collaboration with ED’s to begin immediately

21. Marti Knisley Director 202-673-2200 Marti.knisley@dc.gov Steve Steury Chief Clinical Officer 202-673-1939 Steve.steury@dc.gov Contact Information