Allegheny County Discharge and Acute Community Support Planning Process

1. Allegheny County Discharge and Acute Community Support Planning Process TRAINING AND ORIENTATION Allegheny HealthChoices, Inc.

2. Goals of Today’s Training • Review data resulting from using CSP process for Mayview closure. • Describe the overall role of ACSP in the inpatient discharge planning process. • Review disposition and ACSP eligibility criteria. • In-depth training on the ACSP process • Introduce the “Web-based” site and review the use of the site in the planning process Allegheny HealthChoices, Inc.

3. Goal of Mayview Closure • To build stronger community support systems so people can return to their home communities from the state hospital and remain in their home communities pursing their hopes and dreams Allegheny HealthChoices, Inc.

4. What is a Community Support Plan (CSP)? • A comprehensive support and resource planning process that is driven by a blending of the consumer’s, family’s, and treatment/service coordination team’s preferences, recommendations, and competencies. Allegheny HealthChoices, Inc.

5. Key Characteristics of a CSP • Services and Supports are based on needs and strengths, not program focused • Individual assessments and plans inform system infrastructure and resource development • Shared responsibility between County, MCO, IP team, community providers, consumer, and other supports • Disciplined and highly facilitated process to ensure accountability and collaboration • Use of an independent/non-biased facilitator and recorder • Consumers get to where they need to be rather than following a continuum of care • Avoid ‘one size fits all’ approach to discharge planning-individualized Allegheny HealthChoices, Inc.

6. Why Do a CSP: What We Have Learned • The CSP process promotes higher levels of accountability • External facilitator is necessary to encourage new thinking and provide objective review • Web-based application ensures all parties working with the same information • Understanding and respecting the client’s choices is critical for long-term success Allegheny HealthChoices, Inc.

7. Why Do a CSP: What We Have Learned • With individualized planning comes individualized solutions • Folks discharged with a CSP did better than those without a CSP therefore after closure announcement, all persons discharged had a CSP • Those discharged with a CSP were not readmitted and no one has been admitted to Mayview since November, 2007 Allegheny HealthChoices, Inc.

8. Mayview: Housing Arrangements at Discharge for those with a CSP 269 people were discharged with a community support plan (CSP) • 84% of people were discharged to residences with 24-hour staff: • 26% to long-term structured residences (LTSRs) • 22% to different types of personal care homes • 19% to community residential rehabilitation (CRR) group homes or apartments • 17% other categories combined Allegheny HealthChoices, Inc.

9. Housing Arrangements at Discharge • 16% were discharged to community settings without 24-hour staff • independent housing, living with family • permanent supported housing, supported housing Allegheny HealthChoices, Inc.

10. CTTs Are Providing Frequent Contacts For people receiving CTT services: • 26% of people had 6-7 average contacts per week with CTT • 33% had 4-5 average contacts per week • 32% had 2-3 average contacts per week …during their first three months in the community. Allegheny HealthChoices, Inc.

11. Case Management/Service Coordinators Also Provide Frequent Contacts For people receiving case management/service coordination: • 14% had contact with their service coordinator 4-5 times per week on average • 41% had contact 2-3 times per week on average • 26% had contact at least once per week on average …during their first three months in the community. Allegheny HealthChoices, Inc.

12. Access to Supports and Activities: first three months of discharge • 75% of people had contact with their peer mentor after discharge. Many peer mentors were involved during the CSP process. • 20% of people visited drop-in centers • 80% had some type of contact or support from family • 40% used spiritual supports • Very few people were either recommended or accessed vocational or educational activities Allegheny HealthChoices, Inc.

13. Incarcerations and Hospitalizations • During people’s first three months in the community: • 3% were incarcerated • 6% had psychiatric hospital days • After the first three months in the community: • 7% of people were incarcerated • 17% had psychiatric hospital days Allegheny HealthChoices, Inc.

14. Early Warning Signs and Critical Incidents • Newonline database for reporting early warning signs and critical incidents began in June 2008. Since then: • 29% have had an early warning sign report. • 29% have had a critical incident. • While it is premature to identify trends, providers are reporting incidents and counties are proactively working to address situations. Allegheny HealthChoices, Inc.

15. Resource Development The counties have planned for the Mayview closure by investing funds in: • Residential options • Treatment services • Supports and resources Allegheny HealthChoices, Inc.

16. New/Expanded Peer Support • Peer mentors • Warmline • Peer specialists • Recovery specialists (County staff) Allegheny HealthChoices, Inc.

17. New/Expanded Community Services • Community Treatment Teams (CTT), also known as Assertive Community Treatment (ACT) • Enhanced Clinical Case Management (ECCM) • Expanded Service Coordination • Mobile Medication Teams/Mobile Mental Health • Expanded Outpatient • Expanded Psychiatric Rehabilitation • Crisis Services Allegheny HealthChoices, Inc.

18. New Residential Options • Permanent Supportive Housing (PSH) and related services • Comprehensive Mental Health/Enhanced Personal Care Homes (CMHPCH and EPCH) • Long-term Structured Residences (LTSR) • Specialized Supportive Housing (aka long-term residences) • Extended Acute Services (EAC), both hospital and community-based • Residential Treatment Facility for Adults (RTF-A) • Other county-specific options Allegheny HealthChoices, Inc.

19. Quality Assurance and Oversight Initiatives Quality Improvement and Outcomes (QIO) Sub-Committee Quality Management and Clinical Consultation (QMCC) Team Comprehensive Monthly CSP Tracking Care Management Collaboration with CCBH Regional Reporting of Critical Incidents and Early Warning Indicators with Automated Notification Capability 19 Allegheny HealthChoices, Inc.

20. Quality Assurance and Oversight Initiatives Failure Mode Effects Analysis (FMEA) Root Cause Analysis (RCA) 20 Allegheny HealthChoices, Inc.

21. Why ACSP? • Based on the Mayview project: • Positive consumer outcomes • Greater satisfaction • Improved quality of life • Greater ownership in discharge process • Positive system outcomes • Improved collaboration among key stakeholders • Services/supports match consumer needs • Reduced inpatient Allegheny HealthChoices, Inc.

22. More… • County driven vs. OMHSAS • No additional financing • Initiated to improve consumer outcomes not to access resources Allegheny HealthChoices, Inc.

23. Acute CSP Disposition Meetings Acute In-Patient Multi-Disciplinary Treatment Team Acute Inpatient Discharge Process: Overview Discharge Planning Facilitated by ACSP Facilitator Level 3 Discharge Planning Facilitated by County Disposition Coordinator Level 2 Multi-Disciplinary Treatment Team on Inpatient Unit Level 1 Allegheny HealthChoices, Inc.

24. Level 1: Exclusion Criteria • Consumer has a Community Support Plan (CSP) via a Mayview or Torrance State Hospital discharge process Allegheny HealthChoices, Inc.

25. Level 1: Acute Inpatient Discharge Process • IP multi-disciplinary treatment team, the consumer, family, and, when indicated, the outpatient provider, meet for the discharge planning process. • If additional assistance in discharge planning is required, the above team has the option to coordinate with County Disposition Coordinator and the MCO without going to Level 2 (Disposition Process) Allegheny HealthChoices, Inc.

26. Level 2 Eligibility Criteria (Draft) Inpatient hospitalization must be > 14 days, plus one of the following criterion: • Multiple acute IP admissions in past 12 months • Disagreement among IP treatment team, OP provider, consumer, and/or consumer support system regarding the Level 1 discharge plan. • Anticipated need for extended community based care and support, i.e. EAC, RTFA, LTSR. Allegheny HealthChoices, Inc.

27. Level 2: Disposition Discharge Process • When d/c does not occur at Level 1, and Level 2 or Level 3 criteria is met, the IP team and consumer have the option to make a referral to the Disposition process • Once Level 2 criteria is met, there is no required timeframe to complete the disposition process • Whether Level 2 or 3 criteria is met, SW makes referral to the Disposition Coordinator and the Disposition Coordinator reviews referral. • Disposition Coordinator schedules disposition meetings and facilitates disposition process. Allegheny HealthChoices, Inc.

28. Level 3 Eligibility Criteria (Draft) To be eligible, consumer must meet one of the following criterion: • 4 inpatient admissions in last 12 months • 2 prior state hospitalizations or any continued state hospital stay > 2 years in duration • An acute inpatient hospitalization > 90 days in duration in past 12 months • EAC, RTFA, LTSR treatment in the last 12 months Allegheny HealthChoices, Inc.

29. Level 3 Eligibility Criteria Continued • Has had Disposition meeting within the last 12 months • Consensus that a ACSP process is necessary to assure the development of a plan that promotes recovery, safety and community stability. Allegheny HealthChoices, Inc.

30. Level 3: Acute CSP Discharge Process • When discharge does not occur at Level 2 and Level 3 criteria is met, the County Disposition Coordinator and inpatient treatment team has the option to refer to the ACSP process. Allegheny HealthChoices, Inc.

31. Level 1 Acute In-Patient Discharge Process Acute In-Patient Unit Discharged? Y Community N Disposition Eligibility Criteria and Process Level 2 Conduct Disposition Meetings N Discharged? Community Y N Acute CSP Eligibility Criteria and Process Level 3 Referral Accepted? N Y Individual Agrees to ACSP? N Engage Consumer to Participate Y Complete ACSP Assessments: Clinical, Peer (CART), Family (CART) ACSP Stages: Information Gathering/Options, Resource Coordination/ Transition, Final Plan Discharged? Allegheny HealthChoices, Inc. 1/20/2009 N Community Y

32. Goals of the Acute Community Support Plan Process • Provide opportunity for individuals to express their needs & wants for successful living in the community through an assessment process • Provide an analysis of the assessments conducted in preparation for the plan process. • Provide opportunity for all ACSP team members to understand the strengths, challenges, and desires of the person for whom the plan is being developed • Develop strategies and secure resources to help support the person to effectively live in the community • Develop an ACSP that is congruent with the opinions of the individual and that is likely to succeed Allegheny HealthChoices, Inc.

33. Assessments: Peer, Family, Clinical • Assessments are the basis for the ACSP • All three assessments consider the following life areas or domains: Living/housing Cognitive Abilities Physical Health Psychiatric Health Education and Work Social and Relationships Supports Legal Allegheny HealthChoices, Inc.

34. CSTAP Peer Assessment • The emphasis is “what does the individual want and need for community living.” The language used in the assessment is understandable to most persons. • The assessment is conducted “peer to peer,” in private. • Participation in the assessment is entirely voluntary. Allegheny HealthChoices, Inc.

35. Family Assessment • The family assessment is conducted by a family member of a mental health consumer. • The assessment is accomplished either “face to face” or by telephone interview. • This assessment asks questions related to type of housing thought to be necessary; the amount of assistance/support the individual may need, the presence of physical and other impairments not known, for example. • Participation in the assessment is entirely voluntary and most families willingly participate. Allegheny HealthChoices, Inc.

36. Clinical Assessment • The clinical assessment is completed by a Social Worker and other key staff including community providers. • The assessment is current and completed prior to the first ACSP meeting. • This assessment focuses on historical and current clinical information related to what type, frequency, and intensity of support/supervision may be needed for the consumer to live successfully in the community Allegheny HealthChoices, Inc.

37. ACSP Participants • First and foremost, the consumer who is to be discharged and anyone the consumer invites • Family members of the consumer or representatives of the family • Members of the hospital treatment team and community provider (SC or CTT is critical) • MHA Advocate • County ACSP Coordinator • MCO representative • The facilitator and recorder Allegheny HealthChoices, Inc.

38. The Consumer’s Role • Offers as much information about his/her TX progress as possible • Validates assessment summary information • Talks about the “best time” in his or her life and what his/her desires are now • Assists in developing a strengths list related to what he/she wants and needs to live in the community • Assists in development and review of strategies, ideas, and resources for supports and housing Allegheny HealthChoices, Inc.

39. The Family/Significant Other’s Role • Assists in the presentation of additional pertinent information about the consumer • Assists in the development of strengths list • Presents a favorite memory • Offers ideas about supports they believe are necessary Allegheny HealthChoices, Inc.

40. The Advocates Role • To assist the consumer in the ACSP planning process by: • Assisting in preparing for the ACSP meetings • Advocating for what the consumer wants • Ensuring supports are in place prior to discharge • Assisting ACSP team in staying focused on what the consumer’s strengths • Assisting the ACSP team in staying focused on the needs and wants of the consumer Allegheny HealthChoices, Inc.

41. Hospital, Community Provider, and County Roles • The person’s social worker and psychiatrist are important participants; typically their contribution is clinical in nature • The county ACSP coordinator and/or provider liaison and/or SC/CTT members bring knowledge of the community and potential resources to the table • All staff have to be particularly cautious not to discourage the consumer and may have to be willing to negotiate to reach agreement with the consumer Allegheny HealthChoices, Inc.

42. Role of Social Worker • The Social Worker will work with the ACSP Facilitator to complete the clinical assessment within 2 weeks of consumer consent to participate in ACSP process. • The Social Worker will invite ACSP key attendees: inpatient psychiatrist and team, outpatient provider, individual, family, MCO, County, hospital liaison, and others. • The facilitator will invite the advocate and the county Allegheny HealthChoices, Inc.

43. Facilitator Role • Facilitator introduces process and engages consumer throughout the process • Facilitator coordinates completion of assessments • The facilitator “chairs” the meeting • The facilitator posts the current ACSP to the website Allegheny HealthChoices, Inc.

44. Recorder Role • Recorder is present to assist all ACSP team members focus on tasks associated with the development of the CSP • The recorder keeps copious notes and writes the ACSP for the group after each meeting • The recorder ensures the final plan is comprehensive and complete Allegheny HealthChoices, Inc.

45. ACSP Coordinator Role • Holds participants accountable for completing tasks between meetings • Provides county support • Inquires at first ACSP meeting if consumer would like a Peer Mentor Allegheny HealthChoices, Inc.

46. Peer Mentor • To assist the consumer in the ACSP planning process by: • attending ACSP meetings (if consumer chooses) • Helping consumer become more comfortable with moving back into the community by talking about options Allegheny HealthChoices, Inc.

47. The Planning Meeting: Tips for Success • It is important that meetings be as free of conflict as possible. • It is essential that verbal and body language be clear and understandable • Direct every comment to the consumer unless there was a direct question by someone else • Interruptions and sidebars slow down the process • Feel free to offer compliments and support to other people at the table Allegheny HealthChoices, Inc.

48. The Planning Meeting: More Tips for Success • Think positively and creatively. Remain open to ideas. • Statements like “We’ve already tried that” close opportunities. Say instead, “When we try this again, we’ll need to be sure that adequate or different supports are present” • Saying “yes but” – this little comment is probably the greatest killer of ideas ever • Full and positive participation by everyone at the table ensures the development of a possible ACSP • Speak out and offer information Allegheny HealthChoices, Inc.

49. ACSP Meeting Stages • Information Gathering and Options • Resource Coordination and Transition • Final Plan Allegheny HealthChoices, Inc.

50. Stage One – Information Gathering/Options Stage • Information is obtained by the consumer, supports, and treatment agencies • Service options which are congruent with the consumer’s stated needs and wants • Most of the content is information brought by the ACSP team members • A list of tasks are agreed upon and assigned prior to the end of the meeting Allegheny HealthChoices, Inc.