Department of Mental Health

1. Department of Mental Health Overview Presentation for the Autism Commission January 24, 2011 Barbara Leadholm, Commissioner

2. DMH Statutory Mandate DMH operates pursuant to Massachusetts state statute, Mass. Gen. L. ch. 19, and DMH regulations DMH’s statutory mandate: provide treatment and services to citizens with long-term or serious mental illness(es) and research into causes of mental illness DMH • Provides or arranges for DMH services for adults and children for whom services authorized, • Establishes standards and policies to ensure effective and culturally competent care that promotes recovery and self-determination and protects human rights, and • Supports mental health training and research

3. DMH Vision/Mission The Department of Mental Health vision is Community First • DMH ensures that individuals authorized for services have access to services and supports to enable them to live, work, attend school, and live and participate as independently as possible in their communities. • "Recovery Through Partnership" is the Department’s guiding principle that supports our ability to attain this CF vision for adults, children, adolescents and families.

4. DMH Community First Focus • Accomplish vision by partnering with individuals, families, providers and communities. • Strive to ensure DMH delivery system: • Is client/family-centered, • Driven by client outcomes and experience • Increasingly relies on a peer workforce • Promotes recovery • Meets individuals’ changing needs as move through community and inpatient systems of care

5. DMH StructureSince July, 2010, DMH organized into 3 geographic regions:Central-West, Northeast-Suburban and Metro-Southeast

6. DMH Funding FY2011 Budget is $621.9M

7. DMH Allocation of Funds:Majority for Community-based Services

8. DMH Clients/Service Authorization • DMH provides services for approximately 22,000 individuals (~2,400 youth and 19,000 adults) • Determining whether to authorize DMH services for an individual depends on an assessment of whether: • Individual meets the clinical criteria for DMH services; • Individual requires DMH services and has no other means for obtaining them; • DMH has available capacity.

9. Service Authorization – Clinical Criteria To meet clinical criteria for DMH services applicant must: • Have qualifying mental disorder as primary disorder requiring treatment, and • Meet functional impairment and illness duration criteria For Adults: applicant must have serious and long term mental illness resulting in functional impairment that substantially interferes with or limits one or more major life activities • Serious and long term mental illness is disorder of thought, mood, perception, orientation, or memory that grossly impairs judgment, behavior, capacity to recognize reality, and results in inability to meet ordinary demands of life. For Youth: applicant must be 18 ¾ years of age or younger at time of application and have qualifying mental, behavioral or emotional disorder • DMH utilizes SAMHSA definition for Serious Emotional Disturbance) that substantially interferes with or limits his/her role or functioning in family, school, or community activities

10. Service Authorization - Clinical Criteria • Applicant diagnosed with one or more of following disorders/conditions must also have qualifying mental, behavioral or emotional disorder to meet clinical criteria for DMH services: • Disorders usually first diagnosed in Infancy, Childhood or Adolescence • Conditions considered delirium, Dementia and Amnestic and other Cognitive Disorders • Conditions considered Mental Disorders due to general medical condition not elsewhere classified e.g., traumatic brain injury • Conditions considered Substance-Related Disorders: • Conditions under the category of Attention Deficit/Disruptive Behavior Disorders: Conduct Disorder, Oppositional-Defiant Disorder, Disruptive Behavior Disorder NOS

11. DMH Service Authorization Process • DMH acknowledges applications received within 7 days of receipt. • DMH Clinical Service Authorization Specialist may request, as necessary, face-to-face meeting with applicant and/or legal representative, and with children, parents, to discuss and assess needs of applicant. Meetings occur at DMH offices, or, in the case of children, where family requests. • Area child & Adolescent Psychiatric Medical Directors review applications and confirms: clinical criteria met, there is need for DMH-specific services and there is service capacity. • Short-term services, which may include DMH case management or other DMH-operated or contracted services, may be provided to individuals who applied for DMH services while application processed (6-8 weeks typically) • Provision of short-term services does not indicate that application will automatically be approved, nor does it assure that short term services will continue if the application is approved.

12. DMH Service Authorization Process – (cont’d) DMH Area Director or designee makes decisions regarding service authorization determination Timing: • When applicant hospitalized at time of application, service authorization determination rendered within five (5) days after receiving necessary information • For other applicants DMH determines whether applicant meets clinical criteria within 20 days of receipt of completed application • If DMH determines applicant meets clinical criteria for DMH services, DMH determines within 20 days from clinical determination whether applicant needs DMH services • All decisions must be made within 90 days after DMH receives application • Area Director or designee may extend time period for good cause • Applicant is informed of decision

13. DMH Services Community-based Services include: • Community Based Flexible Supports (CBFS) • Program of Assertive Community Treatment (PACT) • Clubhouses • Case Management • Recovery Learning Communities • Forensic - Court Clinic and Jail Diversion services • Respite Services • Homeless Support Services • Child and Adolescent Residential Services • Child and Adolescent Flexible Supports

14. DMH Services – Brief Descriptions • Community Based Flexible Supports (CBFS) • CBFS was implemented in July 2009 via a competitive procurement process and replaced freestanding delivery of adult residential and community-based rehabilitation services. CBFS contractors work with clients to develop individual service plans that meet their individual level of service needs. • Program of Assertive Community Treatment (PACT) • PACT is a multidisciplinary team approach for providing ongoing, community-based treatment, outreach and rehab services often serving individuals who previously have been unable to engage in their treatment. • Clubhouses • Comprehensive, self-help community-based centers that provide support, outreach, psycho-social rehab services and a range of employment services including assistance with placement and maintenance of independent work. • Case Management • State-operated services that provide service authorization, screening, assessments, information and referral, family and caregiver support, and case management/monitoring services for those individuals in the community who are not enrolled in CBFS. • Recovery Learning Communities • Consumer-operated networks of self help/peer support, offering advocacy, certified peer specialist and other training, supportive groups, and information and referral services. • Respite Services • Temporary community-based living arrangements often used to help individuals transition from acute inpatient care and sometimes for diverting an acute admission. • Homeless Support Services • Comprehensive screening, engagement, stabilization, needs assessment and referral services for adults residing in shelters.

15. DMH Services – Brief Descriptions (cont’d) • Child/adolescent services – Children’s Behavioral Health Initiative (CBHI) • Pursuant to the settlement of a court case known as “Rosie D,” in the spring of 2009, the MassHealth Office of Behavioral Health’s managed behavioral health contractor Massachusetts Behavioral Health Plan (MBHP) in conjunction with the other MassHealth-contracted managed care entities, selected provider agencies to serve as Community Service Agencies (CSAs) to provide Intensive Care Coordination (ICC) and family support services, as well as in-home behavioral services and therapeutic mentoring, based on the wraparound model, to youth and their families determined eligible. There are currently 29 contracted CSAs operating statewide, including three that offer culturally specialized services. • Child and Adolescent Residential Services • These are community-based therapeutic services provided in supervised community-based residential settings, often provided in conjunction with treatment and rehabilitative services. DMH is in the process of reprocuring these services jointly with the Department of Children & Families (DCF). • Child and Adolescent Flexible Supports • This is principally a set of services and funding to assist families with obtaining services and supports including therapeutic after school services, therapeutic groups and other family training and supports.

16. DMH Services – Brief Descriptions (cont’d) • Forensic – Court Clinic and Jail Diversion • Court Clinic services include court-based forensic mental health assessments and consultations for persons who are facing criminal or delinquency charges and civil commitment proceedings. These court-based services involve the provision of individual statutory and non-statutory evaluations regarding persons with mental health and substance abuse difficulties as well as mental health liaisons to adult and juvenile justice court personnel. • The Forensic Transition Team provides reentry services for DMH clients who are transitioning from prisons, jails and other places of detention to the community. • Jail Diversion – DMH operates jail diversion activities in partnership with other agencies on federally-funded projects aimed at minimizing or preventing the involvement of persons with mental health histories in the criminal justice system

17. DMH FacilitiesDMH also provides and directly funds Inpatient Continuing Care services ($143M in FY10)

18. Other DMH Functions • Quality Management/Contract Performance monitoring • Facility Licensure • Investigations • Training (e.g. trauma-informed care, restraint reduction, wellness promotion) • Mental Health Services Research – DMH contracts with two academic Centers for Excellence • Collaboration with MassHealth Office of Behavioral Health regarding: • management of managed behavioral health services and • implementation of Children’s Behavioral Health Initiative

19. DMH’s Quality/Performance Management Vision Better Utilize Data and Consumer Experience to Continuously Improve Program and Fiscal Performance and Accountability Strategy • Identify person-level outcomes and system-level performance measures for all state-operated and contracted services. • Develop mechanisms for providers to submit person-level data to DMH. • Routinely solicit consumer input into policy and program development and improvement • Implement wide-scale mechanisms for effectively measuring consumer experience with specific services & delivery system • Enhance DMH data capabilities to produce reports on performance • Establish Area and Statewide Performance Management teams to monitor performance, and recommend program and policy changes for improvement.

20. DMH’s Quality/Performance Management Process: Measurement Examples • DMH Inpatient System • Decrease number of reported incidents of restraints in DMH inpatient facilities per 1000 patient days • Increase number of DMH patients in continuing care facilities on antipsychotic mono-therapy • Increase percentage of individuals discharged from DMH continuing care facilities within 180 days of admission • Increase percentage of people who report satisfaction with quality of care • Community Based Flexible Supports (CBFS) • Increase percentage of people served who are employed • Increase percentage of people served who remain in the community (without hospital, de-tox, skilled nursing facility admissions or incarceration) • Decrease number of people served who are arrested

21. DMH Private Facility Licensure Facility Licensure: • DMH Inpatient Continuing Care beds (~656 including 30 adolescent beds) represent less than 25% of the total inpatient psychiatric beds operating in the Commonwealth of Massachusetts. • DMH oversees the licensure of approximately 2407 beds in 65 private psychiatric facilities: • private acute psychiatric hospitals and behavioral health units in general hospitals • intensive residential treatment programs for children • DMH ensures that licensed hospitals are in compliance with regulatory requirements based on bi-annual licensing survey

22. DMH Investigation Functions The Office of Investigations • Investigates allegations of abuse by DMH providers/employees and at DMH licensed facilities pursuant to DMH regulations 104 CMR 27.00 and 32.00through investigatory work in response to complaints and critical incidents. • Investigates issues related to workplace violence, stalking and hostile workplace violence complaints. • Is responsible for providing all local Police Departments with mental health background checks on individuals applying for FID cards, LTC’s and all other applications for Firearms Permits. • Submits CORI requests to the Massachusetts Department of Criminal Justice Information Services on behalf of DMH on all DMH applicants to whom a conditional offer of employment has been made.

23. DMH Contracts with Research Centers of Excellence • UMASS: Center for Mental Health Services Research • BIDMC: Commonwealth Research Center for clinical neuroscience and psychopharmacological research • DMH Guiding Priorities for Research: • Culturally competent research and evidence-based practices • Consumer Involvement in Research • Dissemination of Research Finding to Accelerate the adoption of evidence-based practices

24. DMH and Individuals with ASDs • DMH provides linkages or educational advocacy during application process before applicant ultimately denied for DMH services • There are many instances in which children are approved for services but it becomes evident that they have an autism spectrum illness and different set of services needed. In these instances, as long as DMH feels providing our services is helpful to the youth/family we strongly consider continuing them. • System tailored to individuals with primarily serious and persistent mental illness/serious emotional disturbance. Majority of clients are those with: • schizophrenia and other psychotic disorders (66%), • bipolar/psychotic depression (30%) and • others, such as those with problematic sexual behaviors (~4%) • Individuals without these diagnoses often unable to benefit from DMH service system/clinical services.

25. Improving EOHHS Delivery System for Persons on Autism Spectrum • See opportunity for EOHHS agencies to collaborate to create services, including residential, specifically tailored to needs of individuals on ASD spectrum. • DMH, as mental health authority, can provide expert consultation to ensure that EOHHS delivery systems meet behavioral health needs of individuals served.

26. Resources For information about DMH, including services covered and how to apply for them, human rights, and contact information go to www.mass.gov/dmh.