Current Trends and Best Practices in Mental Health Settings

1. Current Trends and Best Practicesin Mental Health Settings Improving Vermont’s Adult Mental Health System: Where we have Been, where should we be going? September 10, 2014 Killington Grand Hotel Kevin Huckshorn PhD, RN, MSN

2. Introduction • Thanks for inviting me to speak to you today. • I know that VT has been thru a lot of change recently. • I am going to talk today about some of the trends and best practices going on in the US as these relate to recovery oriented systems of care that are trauma informed, evidence-based and have quality outcomes. • I want to start with a story.

3. Outline 1. The Americans with Disabilities Act and the Olmstead Decision: What it means & how implementation looks in practice. 2. Peer Inclusion in MH Services: What does that look like?

4. Outline 3. TheBuilding Bridges Initiative: New practices important for adult systems to know and supportin their states. 4. Early Detection, Intervention, and Prevention of Psychosis EBP.

5. USDOJ Settlement AgreementThe Delaware Experience Olmstead Community of Practice Kevin Huckshorn PhD, RN, MSN DSAMH Director

6. DE and the USDOJ Settlement • The Settlement Agreement between the State and the U.S. Department of Justice shifted the focus from the state hospitalto the community and ADA/Olmstead Act. • More importantly, this agreement became the blueprint for how Delaware would provide mental health services to individuals with severe and persistent mental illness, statewide. • Even more significant is this factor. The ADA and Olmstead Decision identified early what is required by all states when serving people with disabilities. Whether USDOJ is “in” your state, or not, you need to measure your progress by ADA.

7. Delaware’s OlmsteadSettlement Agreement Mandate(s)Similar to other involved states • The State of Delaware must make systemic changes that ensure that individuals with ADA covered disabilities, including those in recovery from mental illness and substance abuse receive care: • in the most integrated setting (meaning, not separate from the community in which he or she is a resident), and • in the least restrictive setting (meaning, care is provided with as few limitations as possible, e.g., community based as opposed to treatment that requires living in a treatment facility)

8. DE’s USDOJ Mandate reframed One of Delaware’s first steps were to reframe the Settlement Agreement into clear goals. These goals were as follows (and are universal for ADA/MH): • To develop, implement and monitor a process to discharge all individuals living in an institution, back to their chosen community in an integrated setting of their choice. Not an issue in VT? • To re-organize the DE Behavioral Health Crisis Response System to focus on preventing crises and unnecessary inpatient admissions, when possible.

9. DE/DSAMH History with USDOJ • The USDOJ came to DE in 2008 following over 100+ DE News Journal articles about serious problems at the Delaware Psychiatric Center (the single state hospital). • They found a state facility with over 100 clients that no longer met inpatient criteria; overuse of seclusion, restraint & involuntary medication; events of client abuse and neglect; and a lack of active treatment or choices in housing. • To list some findings…

10. DE USDOJ TargetsData Trends and Status Report • This new focus on community services made us regroup in terms of the populations we serve. Regarding the USDOJ Target Population (in DE), we currently have 11,000 persons in the target population (persons with SPMI who are at high risk for institutionalization) (DE POP is 900,000+). • Peer support, integrated housing, supported employment leading to work, and “voice and choice” are as important as hospital issues for ADA.

11. Supportive EmploymentFY12-FY14 (through May)

12. Supportive HousingFY11-FY14 (through May)

13. Inpatient Bed Day UtilizationFY11-FY14 (through May)

14. Peer Contacts FY13-14

15. MCIS Average Call Response Time ReportFY14

16. RRC & CAPES (24 hr assessment centers) and Mobile Crisis Hospital Diversion Rates-

17. Provider Staff and Law Enforcement Trained on Diversion Practices FY 13-14

18. Crisis Apartment Bed Day UtilizationFY 13-14

19. Implementing the ADALessons Learned • Implementing the community implications of the ADA requires the highest level of state leadership to buy-in on this work, for the long term. It requires an ability to see what can be” and not “what is.” • This is necessary work, for all states to move toward. • Getting your community MH stakeholder’s on board is critical. Takes a lot of communication. • Developing a manageable plan with support from the Gov Office and your legislature is also critical. • Housing issues are generally very complicated and, if you do not have that expertize, hire it.

20. Implementing the ADALessons Learned For Vermont, specifically with regards to the ADA: • You have already started to do work on reducing SR and forced medications and you are to be congratulated for this. ROSC that are “trauma informed” do not use SR or forced meds except as the very last resort. • You may need to evaluate your policies on full participation in treatment and discharge planning, by clients in care, as this process is core to ADA. • Community re-integration into “normal living arrangements (one adult=one apt or home) is also key • As is the integrated use of Peer Support staff.

21. Peer Support… What makes us Unique! Gayle Bluebird, RN Director, Peer Services Mental Health Association, MHA Kevin Huckshorn Ph.D Delaware Substance Abuse and Mental Heath, DSAMH Artwork by: Knicoma Frederick Creative Arts Factory

22. Peer Support Information for VT • This work is going on all over the country • Is still a pretty new model and subject to all kinds of interpretations and definitions • The integration of Peer Support is also the most powerful tool I have seen in three decades • These people/staff innately understand “how to engage”; how to share “what recovery is”; and are inclusive and always respectful • Here are some lessons learned about Peer Support

23. The Power of Peer Support Peer Support is not like clinical support nor is it just about being friends. Peer Support helps people to understand each other because they’ve been there, shared similar experiences and can model for each other a willingness to grow. (Mead & MacNeil, 2003)

24. Where We Are Now in DEOr, what can be done in 4 years • 14 Peer Trauma Grant Specialists in Community and Substance Abuse Agencies. • Delaware Community Resource Coalition (DCRC) in place with a Director. Our statewide Peer Network. • Five Peer-Operated DE Recovery and Resource Centers (RVRC, ACE, Hopes & Dreams, Open Door, Creative Vision) • Common Ground Program implemented (EBP) • Peers hired in the community for ACT teams, and Community agencies. • 16 Peer Specialists working, as staff, at the state hospital • Mental Health Court Peer Team developed (most recent). • Over 160+ Peer staff now employed. Was “1” in 2009.

25. Peer Certification Training • Peers designed the training curriculum for certification • The Emphasis was on creativity • All Peers must currently be working to be trained • Consists of 72 hours • To be certified with the State Certification Board • Also developed Peer Support 101 Training for Peers and Providers. 1st Peer Certification Training

26. Peers are Unique Because they… • Provide transitional services from hospital to community • Can provide Medicaid reimbursable services on ACT teams (January, 2015) • Provide individual support to frequent users of service. • Use prevention tools to help individuals avoid crisis, in and out of hospitals.

27. Peers Are Unique Because… • We dress casually. • We talk naturally. • We share handshakes and hugs. • We “tell our stories.” • We do not use jargon • We do not have rigid rules Dara Hagans Inpatient Peer Specialist

28. Peers Are Unique Because… • We prioritize finding out about a person's interests and strengths so that he/she can use their own individualized approaches to healing including alternative methods. • This work teaches “illness management” in a normative manner.

29. Peers Are Unique Because… We use a person’s full name whenever possible and with his/her consent. HIPPA laws are meant to protect confidentiality but often have an opposite effect. People often begin to think of themselves as non-persons. The key is to ask; the purpose is to honor.

30. Peers Are Unique Because… We introduce wellness techniques creatively and YOU could also! • Examples: • Engagement • Employment • Searching on Internet for services • Healthy Snacks • Walking/exercise • Affirmation • Drop Zone “DIC Resource Center” • Creative Arts Projects • Restaurant Outings • Hands and Heart Project

31. Peers Emphasize Arts and Creativity: Examples: • “Creative Arts Factory”- Peer-Run Arts Center. • Art Exhibits • Drumming Circle • Note card Project • Arts Carnivals • Decorating Comfort Rooms • Special Outings “Henrietta”

32. Peers Deliver Hope Totes • Admission Comfort Bags: • Given to all Clients on admission. • Contains rights information • Client Handbook • Peer Support information • Peers orient new clients being admitted which can be a stressful time • “All items selected with safety in mind.”

33. Creative Vision FactoryA Peer Run Arts Program

34. RVSC is a DIC that provides MH and PC (with UD APRNS); a 24/7 homeless shelter; homeless services; full kitchen; laundry; and events all year long. First Health Home!

35. Peer Developed Trauma Booklet • Created in 2011 • Written, and designed by Peer Support staff • In easy-to-understand language. • Illustrated with national artists’ artwork. • Designed for persons receiving services… and others • Describes what being a victim of trauma is about and how to understand this experience. • And how to get help. “Hugging Form” Meghan Caughey

36. The Building Bridges Initiative (BBI):Advancing Partnerships. Improving Lives.Building Bridges Initiative represents a huge change in approach to children and families in child MH programs. This information is important for adult systems of care as we get these referrals into our adult systems and we can start to provide “early interventions” to reduce this. Developed by Beth Caldwell Director of the Building Bridges Initiative Presented by Kevin Huckshorn with BBI approval September 10, 2014

37. BBI Mission 1. To identify and promote practice and policy initiatives that create strong and closely coordinated partnerships and collaborations between families, youth, community- and residentially-based service providers, advocates and policy makers. 2. To ensure that comprehensive services and supports are family-driven, youth-guided, strength-based, culturally and linguistically competent, individualized, evidence and practice-informed, and consistent with the research on sustained positive outcomes.

38. Some of the Critical Issues • Emerging research on residential effectiveness, for example: • Recidivism/Readmissions • 68% of all youth discharged from out-of-home programs in one state (2009) were back in out-of-home care within 1 year -for all licensed residential programs VA. Damar Services, IN (BBI implementer) with ranges from 3-11% each year for 5 years post discharge (including hospitalizations

39. Critical elements 39 • Residential-specific research shows improved outcomes with: • shorter lengths of stay, • increased family involvement, and • stability and support in the post-residential environment (Walters & Petr, 2008).

40. Why is BBI important to Adult MH Systems? • Effective “Prevention and Early Interventions” could prevent youth from entering the adult MH system of care • We all need to work together, in our state systems, to change from what we have always done to “what works” by evidenced outcomes!

41. Why is BBI important to Adult MH Systems? • Currently, and historically, troubled kids go into residential services, often from months to years. • Current evidence is that these services do not work for these kids. Not in terms of learning new skills or being successful once discharged. • Neither does expecting that children will “willingly separate” from their families, no matter how dysfunctional. • Most of these children end up right back in residential, in Juvenile Justice, in adult jails or in adult MH systems of care.

42. Why is BBI important to Adult MH Systems? • What BBI now knows is that kids need individualized activities that keep them in the community, in school, and or work (for older youth). • Residential Services should be short term and used to re-integrate into community life. • Community services should focus on life skills, illness management, and hopes/dreams. • And family re-unification services are critical even if they are delayed till youth are almost adults.

43. Preventing Psychotic Disorders by Early Detection and Intervention William R. McFarlane, M.D. Maine Medical Center Research Institute Portland, Maine USA Tufts University University of Vermont Kevin Ann Huckshorn (partial Presentation with PIER approval)

44. Early detection and prevention in another illness “If you catch cancer at Stage 1 or 2, almost everybody lives. If you catch it at Stage 3 or 4, almost everybody dies. We know from cervical cancer that by screening you can reduce cancer up to 70 percent. We’re just not spending enough of our resources working to find markers for early detection.” ---Lee Hartwell, MD Nobel Laureate, Medicine President and Director, Hutchinson Center New York Times Magazine December 4, 2005, p. 56

45. Early detection and prevention in psychotic illness “The psychiatrist sees too many end states and deals professionally with too few of the pre-psychotic.” --Harry Stack Sullivan, 1927

46. Shortened productive lives Source: Mental Health Report of the Surgeon General

47. $10 million Lifetime costs for each new case of schizophrenia

48. 25% Proportion of hospital beds occupied by, and disability payments to, people with severe mental disorders

49. 75% Proportion of people who have one psychotic episode and schizophrenia and then develop disability

50. 10% Proportion of people with schizophrenia who are gainfully employed