Mental Health Services Act Steering Committee

1. Mental Health Services Act Steering Committee September 14, 2009 Health Care Agency/Behavioral Health Services

2. Welcome Sharon Browning, Facilitator

3. Consumer Perspective Mary Walker, Family Member

4. Local/State Updates Mark Refowitz, BHS Director

5. Anthony Delgado, Program Manager FSP Data Report

6. Full Service Partnership (FSP)Performance Outcomes & Data Tony Delgado Keith Erselius Christina Cordova Adapted from a presentation from Dave Pilon, Ph.D., CPRP

7. People only supportwhat they create:Re-visioning theFull Service Partnership Dave Pilon, Ph.D., CPRP Executive Vice President, MHALA dpilon@mhala.org

8. Today’s Goals Reveal my own biases and potential blind spots as Chair of the Data, Accountability and Policy Subcommittee Begin to establish a framework by which to evaluate FSP performance Begin to craft a plan to access and use existing FSP (and other) performance data Begin to establish a process to explore alternative approaches to performance measurement and alternative data elements / measures

9. A Brief History of FSPs • Modeled after the successful AB 34/2034 (Primarily Adult) Program • Originally designed to serve “highest need” individuals (51% of MHSA CSS to “unserved, underserved, inappropriately served”) - Led to dissatisfaction with the two-tiered system • Lack of direction / standards from the State led to much confusion among counties • Recent loosening of State regulations appears to re-define/ expand who can be served by FSPs

10. How do we arrive at standards? • Practice vs. Outcomes • The problem with “whatever it takes” (or, How do we measure “culture?”) • Clinician judgment and the need for measurement • What we choose to measure reflects our implicit philosophy

11. Recovery is not a Unitary Concept • Many consumers speak of recovery in terms of their own internal experience – often phrased in such terms as “becoming empowered,” “taking charge of their own lives,” “improving their self-esteem,” or “becoming responsible for themselves.” • The mitigation of psychiatric symptoms (or symptom distress) and improvement in functioning. • Identifying and taking on meaningful roles in one’s life.

12. Recovery Definition Matrix

14. GENERIC TREATMENT (EVIDENCE-BASED PRACTICE) LOGIC MODEL Input Mission Members Staff Resources Processes/ Interventions Assertive Community Treatment (ACT) Medications Supported Employment Integrated Dual Diagnosis Treatment Supported Education Short-Term (Intermediate) Outcomes Increased skills and functioning (Behaviors) “Recovery”, internal experience of empowerment, meaningful roles, self-responsibility, hope (perceptions) Decreased symptoms and symptom distress (Behaviors and internal experience) Decreased Substance Abuse (Behaviors) Long-Term Outcomes Increased Residential Independence and Stability Reduced Hospitalization Reduced Incarceration Increased Employment Increased Education

16. GENERIC “RECOVERY CULTURE” LOGIC MODEL Input Mission Members Staff Stakeholders (Taxpayers) Resources Program/System Culture Welcoming Charity Treatment Rehabilitation Advocacy Graduation Internal (Consumer) Outcomes Increased skills and functioning “Recovery” (Empowerment, hope, meaningful roles, self-esteem) Decreased symptoms Decreased substance abuse External (QOL) Outcomes Increased Residential Independence/Stability Reduced Hospitalization Reduced Incarceration Increased Employment Increased Education

17. What is Culture? The predominant attitudes and behavior that characterize the functioning of a group or organization.

18. Kansas Supported Employment Study Comparison of “high performing” (31.9%) supported employment programs vs. “low performing” (16.6%) supported employment programs.

19. Characteristics of High-Performing Supported Employment Programs • Program leaders emphasize the value of work in people’s lives and the belief that people can work. • Program leaders emphasize strengths-based practices as an explicit part of supported employment work with consumers. • Program leaders use vocational data to guide programming and practice. • Staff do not view stigma against people with psychiatric disabilities as a barrier to consumers’ ability to obtain employment. • Staff perceive that consumers have a desire and motivation to work. • Staff share stories about consumers’ vocational experiences in a way that reflects their belief that consumers have the ability to negotiate and succeed in the work world. • Gowdy, Carlson, and Rapp (2004). Organizational Factors Differentiating High Performing from Low Performing Supported Employment Programs. Psychiatric Rehabilitation Journal, 28,2, 150-156.

20. Performance Measurement Issues: A Summary Differences in our assumptions about the ways people improve / get better / recover Should we measure “internal” variables (symptoms, ADL skills, increased sobriety) or should we measure “external” variables (increased school performance, increased social support, increased independence, reduced hospitalization)? Should we measure outcomes or practices (or both)? Should we measure fidelity to specific practices or the influence of organizational culture (or both)?

21. Problems in Existing FSP Performance Measurement Data • Where are the data? • Are the data accurate? • Are the data elements useful across all age groups? • Are the data elements appropriate for the “expanded” version of the FSP? • Data collection resources at “lower” levels of care may not be adequate • Are the data capable of helping us to improve our practices (quality improvement)

22. Where we go from here?A suggested plan • The data we have • How can we best use the FSP (and other) data that we have been collecting? • The Mental Health Planning Council efforts as a starting point • The data we would like • Formation of age-specific groups to arrive at a consensus about the basic data set that we need given 1) that the existing FSP data are based on an adult model, and 2) the FSP model has been expanded to a population that may not be well-served by existing outcome approaches

23. Utilizing the FSP Data • Data Analysts at Adult and Older Adult FSPs • The Data Outcomes Committee • The MHSA Newsletter • The MHSA Website

24. Adults Enrolled (As of 7/31/09) Total Adult FSP Enrolled: 551 Total Adult FSP Capacity: 560

25. Adult Homelessness (Annualized on 7/31/09) Pre Enrollment • 73.95% Decrease Post Enrollment N = 551 * Includes shelters and temporary housing (e.g.) motels Number of Days Homeless*

26. Adult Incarcerations (Annualized on 7/31/09) Pre Enrollment • 84.51% Decrease • Savings of $1,572,330 Post Enrollment N = 551 Number of Days Incarcerated*

27. Adult Hospitalizations (Annualized on 7/31/09) Pre Enrollment Post Enrollment • 52.22% Decrease • Savings of $2,196,468 N = 551 Number of Days Hospitalized

28. AdultEmployment (Annualized on 7/31/09) Post Enrollment • 12.48% Increase Pre Enrollment N = 551 Number of Days Employed

29. * 12 Month History Taken from the PAF Adult Education (Pre and Post Enrollment) Post Enrollment Pre Enrollment* • 80.39% Increase N = 551 Number of Consumers In School

30. Contracted Slots Older Adults Currently Enrolled Older Adults Enrolled (As of 7/31/09) OASIS

31. Older Adult Homelessness (Annualized on 7/31/09) Pre Enrollment • 60.07% Decrease Post Enrollment N = 100 * Includes shelters and temporary housing (e.g.) motels Number of Days Homeless*

32. Older Adult Incarcerations (Annualized on 7/31/09) Pre Enrollment • 87.25% Decrease Post Enrollment N = 100 Number of Days Incarcerated*

33. Older Adult Psychiatric Hospitalizations (Annualized on 7/31/09) Pre Enrollment Post Enrollment • 18.33% Decrease N = 100 Number of Days Hospitalized

34. www.ochealthinfo.com/mhsa

36. DRAFT

37. DRAFT

38. DRAFT

39. Karen Roper, Director O.C. Community Services Housing

40. Orange County’s10 Year Plan to End Homelessness

41. What is a 10 Year Plan to End Homelessness? A Ten Year Plan to End Homelessness is a regional planning effort that focuses community resources toward clearly defined strategies that address the multiple facets of why we have a homeless problem in our community.  This Plan outlines the key goals and strategies necessary to successfully eliminate homelessness in Orange County.

42. Why Create a 10 Year Plan? To remain competitive for Federal SuperNOFA Continuum of Care funding, the U.S. Department of Housing and Urban Development (HUD) strongly encourages counties to develop 10 Year Plans to end chronic homelessness. Since 1996, Orange County has received $111 million in Continuum of Care Homeless Assistance funding. Lack of such a plan will eventually threaten continued Federal and State funding for homeless assistance. Orange County needs to develop a more strategic, focused effort to end homelessness. A 10 Year Plan will lead to positive, systematic changes in the way we address homelessness.

43. Why Create a 10 Year Plan? • The County’s overarching goal is to maximize public and private resources to address and improve Orange County’s system of care for at-risk and homeless populations. • Although the development of the 10 Year Plan is based upon HUD’s requirements for funding and demonstrated best practices, it is also an opportunity to engage stakeholders in developing a regional solution to an issue that crosses all systems and affects all communities.

44. Homelessness in Orange County • 2007 Point In Time Count • 3,649 homeless persons were identified in shelters and on the streets • 2009 Point In Time Count • 8,333 homeless persons were identified in shelters and on the streets • Based upon survey data, 21,479 persons experience homelessness in Orange County over the course of one year

45. Homelessness in Orange County • 2008 Client Management Information System Year End Summary (48% of shelters reporting at year-end) • 5,081 homeless clients and 1,207 at risk clients were served by 26 participating agencies. • Each of Orange County’s 34 cities were reported as a last permanent place of residency prior to homelessness.

46. Overview of Planning Structure Working Group: The 16-person group responsible for providing input to the Plan; receiving, evaluating, and integrating stakeholder and expert input to the 10 Year Plan, and finalizing the 10 Year Plan. Stakeholder Comment Group(s): Two Categories- A) A group of approximately 25 agencies and individuals established in 2007 who responded to a request to be involved in the 10 Year Plan and were known as the Continuum of Care 10 Year Plan Committee; and B) Other interested stakeholder groups. These groups will comment on the Working Group’s work and provide advisory input. Expert Implementation Group(s): These are groups that may be formed at the direction and discretion of the Working Group. The participants in these groups typically may be extremely busy people who would not have the time to participate in a regular series of meetings but could make one meeting and/or would have valuable information and insights to provide. County of Orange Homelessness Planning Group: This group consists of County Department Heads whose agencies are serving the homeless. The group has been working since May 2008 to determine where the County can provide leadership and resources for the 10 Year Plan.

47. The 10 Year Plan Stakeholder Comment Group was asked to nominate “transformational thinkers” to serve on the 10 Year Plan Working Group The 16 Member Working Group was convened in September 2008 to: Review best practices and other regional plans Discuss the scope of homelessness in Orange County Develop goals and strategies to be included in the 10 Year Plan Compose draft elements of the 10 Year Plan Overview of Planning Structure

48. Plan Components Mission/Vision/Values Current Data Number of homeless individuals and families Current services available At Risk of Homelessness Goals, Strategies, and Implementing Actions

49. To effectively end homelessness in Orange County over the next decade Mission Statement

50. A dynamic, comprehensive system of services, proportionate to the need, that effectively ends homelessness Vision