Spokane County Regional Support Network

1. SPOKANE COUNTY COMMUNITY SERVICES, HOUSING, AND COMMUNITY DEVELOPMENT DEPARTMENT Spokane CountyRegional Support Network Annual Report 2010 January 2011

2. Message from the RSN • The Spokane County Regional Support Network (RSN) Annual Report belongs to every resident of Spokane County. It represents the efforts of your Regional Support Network to adequately fund and administer mental health services. The facts, figures, and stories contained herein document how funding and oversight provided to community-based programs support treatment and recovery for individuals in need. • As our state struggled to balance its budget, all public programs experienced substantial budget cuts and were challenged to do more with less funding. Together with our mental health care providers and with the advisory direction from our Board of County Commissioners and representative individuals that we serve, the RSN was able to continue to fund a broad array of community outpatient services for adults, youth, and children. • Several new community diversion programs were implemented this past year to benefit children and youth with acute mental illness. These programs are effectively stabilizing children and youth experiencing a crisis, so that they may remain in their family home and avoid costly and restrictive inpatient psychiatric hospitalization. • Our staff and providers remain committed to maximizing the impact of every dollar spent on the health and recovery of those in need of mental health services. This report illustrates how our mission to promote health and improve lives through funding of needed public mental health services is being accomplished each day in Spokane County. Thank you for your trust and support. Christine Barada, Director Page 2 of 23 Spokane County Community Services, Housing, and Community Development Department

3. Our Mission The mission of the Spokane County Regional Support Network is to assure that in Spokane County a choice of flexible and responsive community resources are available and accessible to individuals and families experiencing a mental illness. These resources will value: Safety and health Preservation of dignity and empowerment Individual and ethnic uniqueness Personal growth and enrichment Community participation What We Do Major responsibilities: • Plan and recommend how to maximize the mental health funds • Community participation/assessment of current and future community needs • Contract with providers and monitor for the expenses and quality of the programs • Provide for Medicaid and state funded psychiatric inpatient stays for Spokane County residents • Provide residential care for mental health individuals • Authorize each outpatient and voluntary inpatient service • Provide quality oversight for existing programs Eligibility for RSN Services Eligibility is subject to certain diagnostic criteria and authorization by the RSN • All persons in Spokane County may receive emergency crisis intervention, disaster mental health services, and hospitalization • Medicaid enrollees may receive all of the above and outpatient services and residential service • Low income, non-Medicaid persons who are high utilizers of services may also receive outpatient care and residential services Page 3 of 23 Spokane County Community Services, Housing, and Community Development Department

4. Outpatient Care Providers Catholic Charities Counseling Children's Home Society Community Detox Services of Spokane Excelsior Youth Center Family Service Spokane Institute for Family Development Lutheran Community Services N.W. N.A.T.I.V.E. Project Partners with Families & Children Passages Family Support Providence Sacred Heart Medical Center Service Alternatives Spokane County Jail Spokane County Juvenile Probation and Detention Spokane County Supportive Living Program Spokane Mental Health Spokane Public Schools Sunshine Health Facility Tamarack Center YFA Connections Other Providers Community Colleges of Spokane – Supported Education and Employment Rehabilitation (SEER) Spokane Neighborhood Action Program (SNAP) Residential Facilities Bethany Place Blair House Carlyle Care Center Grande Manor Mallon Place Mirabeau House Milford House Moore’s Boarding Home Oakhill Home Sunshine Health Facility Valley View Living Center Whitehouse Living Center RSN Providers Residential Supports • Medicaid Personal Care • Outpatient Provider Case Management • RSN Ombudsman • Quality Review Team (QRT) • Program for Active Community Treatment (PACT) • Phoenix Apartments • Supportive Living Program (SLP) Page 4 of 23 Spokane County Community Services, Housing, and Community Development Department

5. Mental Health Services Page 5 of 23 Spokane County Community Services, Housing, and Community Development Department

6. RSN Individuals Served and Their Services Unduplicated Individuals by Age October 2009 – September 2010 Number of Services by Age October 2009 – September 2010 Age: 2-17 Children & Adolescent Services 3,422 28% Age: 2-17 Children & Adolescent Services 86,903 28% Age: 18+ years Adults 224,423 72% Age: 18+ years Adults 8,833 72% Total Individuals 12,255 Total Services 311,326 Page 6 of 23 Spokane County Community Services, Housing, and Community Development Department

7. Residential Beds and Step Down Units October 2009 through September 2010 Bed Days Utilized: 80,482 Number of Bed Placements: 326 300 70,000 60,000 250 50,000 200 Number of Step Step Down 40,000 Down Unit Placements: Unit Days Utilized: 150 30,000 40 7,934 100 20,000 50 10,000 0 0 Number of Bed & Unit Days Number of Client Placements Total Clients 366 Placed Total Bed and Unit Days 88,416 In 2010, a total of 305 Beds and/or step-down units were funded by the RSN Page 7 of 23 Spokane County Community Services, Housing, and Community Development Department

8. Average State Psychiatric Hospital Bed Census Allocation: 85 beds Legend: Beds Allocated Beds Occupied RSN paid DSHS an Over-Census Reimbursement of $584 per day, per bed, when over 86 beds. Page 8 of 23 Spokane County Community Services, Housing, and Community Development Department

9. In 2010, Spokane County RSN was funded by: Medicaid (64%)($36,677,000) State Funds (20%)($11,272,000) Local 1/10 of 1% Sales Tax (12%)($7,144,000) Property Tax & Interest (2%)($885,000) Federal Programs (2%)($957,000) Total Revenue: $56,935,000 Funding Page 9 of 23 Spokane County Community Services, Housing, and Community Development Department

10. Mental Health Expenditures Page 10 of 23 Spokane County Community Services, Housing, and Community Development Department

11. Leveraged Sales Tax October 2009 through September 2010 A portion of the sales tax is utilized as local match for federal Medicaid. The RSN designated $2.2 million sales tax annually to generate approximately $3.7 million in new Medicaid funds that was utilized for Medicaid mental health programs. Sales Tax Provides $10.8 Million for Treatment, Residential Beds, and Therapeutic Courts in Spokane County Page 11 of 23 Spokane County Community Services, Housing, and Community Development Department

12. Success Stories • A new Children’s Intensive Resources Task Force achieved the desired outcome of improved access to community based care for children and youth with intensive needs. • Admissions to Children’s Long Term Inpatient Programs reduced by 53% in first year as compared to 2009 (28 admissions in 2009, 15 admissions in 2010). • Discharges from Children’s Long Term Inpatient Programs increased by 44% in first year as compared to 2009 (17 discharges in 2009, 29 discharges in 2010). • Improved census management at Eastern State Hospital (ESH) was achieved through utilization of adult hospital diversion resources. • Spokane Community Detoxification Enhancement program successfully diverted 89% of the 304 individuals served who were chronically mentally ill with chemical addiction, many of whom had histories of multiple psychiatric hospitalizations. • An innovative partnership between a high-needs mental health clinic (Family Service Spokane) and a Chemical Dependency program (YFA Connections) has successfully diverted 96% of the 161 chronically mentally ill individuals. • Spokane Mental Health’s Hartson Crisis Stabilization, a residential treatment facility (RTF), has provided effective brief stabilization services to keep 89% of their 285 residents out of the hospital and in their own community. • Foothills Evaluation and Treatment (E&T) Hospital has served 172 involuntary admissions for a fraction of the time as compared to Eastern State Hospital (9.3 days compared to 112 days). This has helped to reduce costly over-census penalty fines. For example, in October 2010, Spokane County RSN saved $106,300 in ESH repayment fines by diverting 182 ITA admission days to the E&T Hospital. Page 12 of 23 Spokane County Community Services, Housing, and Community Development Department

13. Success Stories, continued. • Implementation of planned and emergent respite care for caregivers of high-needs mentally ill children and youth in response to a high priority community need. • Three programs provide facility based or foster-home based respite. • Children ages 4-17 were cared for in intervals from 4 hours to 48 hours. • Joint collaboration between Spokane Mental Health and Providence Sacred Heart Medical Center to optimize access to day treatment for children has reduced the wait list from four (4) months to four (4) weeks and successfully treated some children in the community. Page 13 of 23 Spokane County Community Services, Housing, and Community Development Department

14. Little Miracles • Spokane County RSN salutes our providers for their excellent and compassionate care to those in need by profiling two of the many, many little miracles that occur each day within Spokane County’s mental health system of care. • A teenage boy with chronic mental illness had spent almost half his life residing in locked institutional care. He and his family truly believed he would never return home to live. A multi-system collaboration implemented a graduated community transition plan. The collaboration met regularly to evaluate the plan, which included his parents, DSHS Children’s Administration, his primary RSN mental health provider, his RSN school-based therapist, the RSN day-treatment therapist, and respite care provider. As a result, he enjoyed this past Christmas season living permanently in his own home, where he is accessing community-based outpatient services to maintain his recovery. • A young adult woman with a persistent and chronic eating disorder, so severe that at one point Hospice care was considered, is now thriving in her own RSN independent housing and is attending community college. All this is the result of a community partnership that she directed between herself, her natural supports, primary RSN mental health provider, medical physician, nutritional therapist, and RSN funded eating specialist, to meet her unique and individualized treatment goals. A special thanks goes to the DSHS team that provided medical resources along the way to her recovery! Page 14 of 23 Spokane County Community Services, Housing, and Community Development Department

15. New Services • Evaluation and Treatment Facility (16 beds) • Step-down Housing (28 units) • Children’s Inpatient Diversion Services (5 programs) • Adult Inpatient Diversion Services (2 programs) • Expanded Crisis Triage (3 beds) (Spokane Mental Health) • Expanded Peer Support (2 programs) • Caregiver Respite (3 Programs) Page 15 of 23 Spokane County Community Services, Housing, and Community Development Department

16. Evidence Based Practices (EBPs) • EBPs are behavioral health interventions, which research has demonstrated statistically significant effectiveness as treatments for specific problems. EBP promotes evidence that is consumer-reported, clinician observed, and research driven. Spokane County RSN providers embrace the use of EBP driven treatment by providing training and supervision for their direct care providers for the following EBPs: Page 16 of 23 Spokane County Community Services, Housing, and Community Development Department

17. 2010 Spokane County RSN Training Spokane County RSN supports an environment in which network providers, consumers, staff, and allied systems share knowledge, expertise, and experiences in the form of training, workshops, conferences, and other learning opportunities. In 2010, the RSN attended, sponsored, presented, or sent consumers, staff, and advisory board members to many trainings and conferences. The list below is a representation of many of the diverse and cutting edge presentations offered in 2010. • Wraparound Treatment Array • Recovery and Resiliency • Mental Health Recovery & Resiliency • Person Centered Strategies & Medical Necessity Documentation Linkage Requirements • Respite Services for Caregivers of Mentally Ill Children & Youth • Cultural Competency for Lesbian, Gay, Bisexual & Transgender • Complex Trauma: Approaching Community through Trauma Sensitive Lens Page 17 of 23 Spokane County Community Services, Housing, and Community Development Department

18. Cultural Competency Training Addressing Cultural Awareness through Cultural Competency Training • The Spokane County RSN contracted with the Kalispel Tribe of Indians’ Camas Path Program to provide cultural awareness and cultural competency training. The 5th Annual Tree of Healing Conference was held on June 3-4, 2010. The conference provided an array of national and locally recognized speakers and events, which provided in-depth cultural competency awareness, cultural traditions, and evidence based practice applications to 224 participants including mental health professionals, social workers, and consumers ranging from youth to elderly. • Presentation Topics: • Early Childhood Trauma-Tribal Community • Trauma Informed Care • Power of Native Spirituality • Suicide • The Indigenous Worldview • Self Care for Service Providers • Mindfulness Psychotherapy and Gambling Addiction • The Impact of Culture on Mental Health • The Importance of Interpersonal Skills and Healthy Relationship Building • How Does Millon Clinical Multiaxial Inventory Findings Relate to Historical Trauma • Native HIV Community Planning • Indian Child Welfare Act of 1978 • Two Spirit History: A Personal Journey • Loving the Warrior Home: How to Help the Healing of PTSD • Earth, Wind, Water and Fire; Rediscovering the Healing Power of Nature • What Does ‘Culture’ Really Mean…An Examination of Cultural Distinctiveness • Indian Boarding School: Impact on Native Populations • The Biology of Culture • The Medicine Wheel • The RSN provides services to individuals and families of all ethnic backgrounds. In 2010, the following ethnic backgrounds were self-identified by individuals receiving services: American Indian, Alaska Native, Asian, Pacific Islander, Black/African American, Cambodian, Chinese, Guamanian and Chamorro, Hispanic, Japanese, Korean, Laotian, Native Hawaiian, Pacific Islander, Russian, Samoan, Vietnamese, and White. Page 18 of 23 Spokane County Community Services, Housing, and Community Development Department

19. Spokane County RSN Applauds the Outcomes of the Annual Mental Health Provider Monitoring Results: • Spokane County RSN funded outpatient programs were extensively monitored in 2010. A total of eighteen (18) agencies, thirty-two (32) clinical programs, and three hundred eighty-one (381) clinical records were reviewed and evaluated against sixty-one (61) established criteria that measured the agencies performance in conducting clinical assessment, individualized treatment plans, provision of services, both crisis and risk management, and discharge process. • System-wide, 69% of the clinical criteria were fully met, with 95 – 100% compliance scores. Among the criteria scored at this high level were those pertaining to services to minors, client needs, strengths, and goals documented in their own words, treatment plans and goals. These were individualized and specific to the expressed needs, supports, and desired outcomes of the individual, and progress notes which detailed treatment and outcomes. • Recommendations were made on 21% of the criteria or those which scored 85 – 94% compliance with the standards. These scores indicated strengths, which still need growth in areas such as timeliness of conducting assessments and development and updating treatment plans, establishing treatment goals which are measurable, and identification of disabilities which may impact client recovery. • Only 10% of the criteria questions scored compliance at less than 85% and had findings. In response, the agencies which had findings submitted Corrective Action Plans to Spokane County RSN. Both the provider and the RSN worked together to enhance documentation and continue to monitor for compliance as part of its system of care quality improvement process. Page 19 of 23 Spokane County Community Services, Housing, and Community Development Department

20. Provider Spotlight EXCELSIOR YOUTH CENTER Established in the early 1960s by the Sisters of Good Shepherd, Excelsior Youth Center has a long history of helping disadvantaged youth and takes pride in meeting each youth’s individual mental health and chemical dependency needs with a mission of connecting youth to their future. Excelsior employs one hundred and twenty (120) treatment staff at their campus located in Northwest Spokane and serves a primary male Medicaid population by providing psychiatric day treatment and respite care for the caregivers of acute and chronically ill adolescents. Excelsior’s on- campus school is nationally accredited, so credits earned transfer to any school district in the U.S.A! For more information contact, Admissions Coordinator, (509) 328-7041 x 116 FAMILY SERVICE SPOKANE (FSS) FSS serves all ages at its one (1) Spokane Valley and two (2) downtown Spokane locations. Approximately 90% of those accessing FSS are funded by Medicaid. FSS also provides mental health care professionals for children and youth attending the East Valley School District. In 2010, FSS provided services to more than two thousand, five hundred (2,500) individuals and their families. A tenet of FSS is to assist individuals with a mental illness and their recovery, drawing upon family supports. FSS is proud of its long history in Spokane, having been established in 1905 by a group of Spokane civic leaders. For more information contact, Clinical Director, (509) 838-4128 INSTITUTE FOR FAMILY DEVELOPMENT (IFD) Providing an evidence based program, Homebuilders™, that is replicated across the world, IFD brings trained therapists in to the family home to provide short-term intensive stabilization services for children and youth at risk for hospitalization. IFD employs four seasoned, masters-prepared therapist staff that share seventy-six (76) years of combined clinical experience! The families served with RSN funds are all Medicaid. IFD’s mission is to improve the lives of children and families through the provision of high quality, cost effective, community-based services and supports. For more information contact, Program Supervisor, (509)328-3802 Page 20 of 23 Spokane County Community Services, Housing, and Community Development Department

21. Special Recognition SUNSHINE HEALTH FACILITIES Sunshine provided fifty-four (54) hours of caregiver training in First Line and First Aid to each of their behavioral health staff in 2010. They expanded their mental health services by adding a new Mental Health Technician position for around the clock coverage at Sunshine Terrace, their residential treatment facility. Sunshine ARTF has added a Compliance Officer position to enhance consumer experience.  Sunshine is proud to have achieved an 80% success rate for individuals that transition in a step down process from residential treatment to board & care to independent housing, some of whom have now lived on their own now for seven (7) years. The Boarding Home program has provided ongoing care that allows a client the ability to progress toward a more positive living experience.  The involvement of Sunshine Behavioral Health (SBH) mental health agency has strengthened the transition of care to enable the client to move forward into a more independent setting.        For more information contact, Administration, (509) 892-4342. SPOKANE PUBLIC SCHOOLS (SPS) SPS is one of three school districts in the nation to provide licensed mental health counselors for school based outpatient mental health services to Medicaid funded children and youth ages 5-18 and their families. This model has been very effective in reducing barriers to access to care, and it is a cost effective use of space and resources. In addition, SPS provides five school programs that are designed to meet the intensive needs of students with chronic and acute mental illness from 4th grade to high school. For more information contact, Clinical Director, (509) 354-7946. TAMARACK CENTER During this year, Tamarack Center made a major clinical commitment of incorporating Dialectical Behavior Therapy (DBT) into their adolescent resident’s treatment. To accomplish this, Tamarack sent key clinical leadership staff to two intensive DBT trainings, one week in April 2010 and one week in September 2010, both facilitated by nationally recognized DBT expert and founder, Dr. Marsha Linehan. The incorporation of DBT into Tamarack’s milieu programming has proven a useful compliment to the already high quality programming that Tamarack has been providing to its residents since 1984. For more information contact: Clinical Director, (509) 326-8100 Ext 23 Page 21 of 23 Spokane County Community Services, Housing, and Community Development Department

22. 2010 & 2011 Planning Issues & Challenges • Planning and maintaining an adequate system of care for Spokane citizens with a declining state budget. • Reduced non-Medicaid funding in 2010 and 2011, which currently pays for Eastern State Hospital penalties. To help people out of the hospital, we need additional housing and diversion programs for individuals. • We have a need for a dementia and developmentally disabled facility to house stabilized individuals who live at Eastern State Hospital for lack of adequate placement. • Maintain and expand existing mental health and chemical dependency (co-occurring) services. • Collaboration and planning for Washington State Healthcare Reform in a manner that addresses the needs of the Spokane community for 2011 forward. • Forming community stakeholders and healthcare partnerships for healthcare reform to ensure a regional approach. Page 22 of 23 Spokane County Community Services, Housing, and Community Development Department

23. Effective monitoring and review of contracts for cost, services, and programs Reduction in Eastern State Hospital use and over-census reimbursement Reduction in homelessness Strong leadership & community partnerships that are committed to excellent care in our community Mental Health Quality Plan: Evaluation of the cost efficiency and effectiveness of all the mental health children and adult inpatient diversion programs Benchmarks of Systems Stabilization • Consistent data definitions and data collection, on a timely basis • Models to track the effectiveness of programs • Reduced length of stay at psychiatric inpatient facilities • Method to track cost of treatment of individuals • Performance based contracts demonstrate improvement or meet the goals outlined Page 23 of 23 Spokane County Community Services, Housing, and Community Development Department