May 22, 2017 Norristown State Hospital Bucks, Chester, Delaware, - - PowerPoint PPT Presentation

May 22, 2017 Norristown State Hospital

 Bucks, Chester, Delaware, Montgomery and

Philadelphia

 2 State Hospitals closed – Philadelphia State

(1989) & Haverford State (1997)

 Closed approximately 1550 state hospital

beds since 1990 via Community Hospital Integration Project Programs(CHIPPs)

 First in PA to begin HealthChoices (1996)  First to develop Regional CHIPPs Model

(2000/01)

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 OMHSAS’ “Fred L” lawsuit began in FY 2007 and concluded in FY

2012/ 12/13 13

• 210 BEDS closed as a result the “Fred L”

 From FY 2

2006/ 06/07 07 to FY FY 2013/ 3/14 14, the regional

• nal bed cap dropped from

294 4 to 8 81 civil beds

 Forens

nsic c to c civil transfers fers 40+ beds NOW W

 The average

rage regional

• nal civil census betwe

ween n FY 13-FY 17 has been n 120 beds

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 From

m FY 2012 to curren rent, t, on ave verage, rage, 74% of total admis missions sions to the e civi vil units ts are e crimi minal nal ju justi tice e invo volved ved indi divid viduals uals

 Of the curren

rent t civi vil populat ulation, ion, 75% of the Ph Philad adelp elphia a County nty popul pulation ation have ve crimin minal al ju justi tice e ove versig sight. ht.

 28% of the suburba

burban n Counti nties es curren rent popul pulation ation have ve crimi minal nal ju justi tice e ove versigh sight

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31 13 18 30 28 28 74 51 29 27 29 29 10 20 30 40 50 60 70 80

FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 (up to 4/30/17) Total Admits Total Discharges*

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County FY 2 2016/1 /17 7 CIVIL BED D CAP Civil Censu sus s as o

• f

5/8/1 /17 7 Bucks 18 18 17 17 Chester ter 4 11 11 Delaware e 13 13 13 13 Montg tgom

• mer

ery 22 22 23 23 Philadel elphia 18 18 55 55 Total 75 75 119 119

• Gender: 92 men; 30 women
• Age: 18–64 = 111; 65 and over = 11
• Diagnosis: (Primary)
• Schizophrenia – 52
• Schizoaffective – 37
• Major Depressive – 11
• Psychosis – 6
• Bipolar - 6
• Impulse Disorder – 2
• Autistic Disorder - 1

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Ot Other r Clinica cal Fact ctors

• rs
• Substance Abuse
• Trauma
• Traumatic Brain Injury
• Dementia
• Intellectual Disability

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• Admission/readmission rates
• 2014 – 11 admissions, 6 were readmissions
• 2015 – 12 admissions, 4 were readmissions
• 2016 – 10 admissions, 4 were readmissions
• 2017 – 3 admissions, 4 were readmissions

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• Insura

surance nce Status: tus:

• Medicare Coverage
• Part A & B – 32%
• Part A only – 10%
• Private Ins. – .025%
• No coverage – 56%
• Past MA Eligibility
• Yes –81%
• No – 19%

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• Benefits Source
• SSD – 27%
• SSD Suspended – 16%
• VA only – .008%
• Private Pension – .016%
• Multiple Sources – .03%
• None – 53%

• Under 2 years - 19
• 2- 5 years - 39
• 5 – 10 years - 37
• 10 – 20 years - 17
• 20 – 30 years - 7
• 30 – 40 years - 2
• 40 – 50 years - 1

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• Historically used fewer beds =
• 3.8 per 100,000 population for state hospital utilization

(about 80 beds for over 3.1 million adults in the SE Region)

• According to the SAMHSA Uniform Reporting System (URS)

Pennsylvania State Hospital Adult Admissions rate is: .13 per 1000 population

• Con
• nclu

lusio ion: : the e SE Regio gion only nly uses es the e state e hos

• spit

pital al resour

• urces

ces when hen all l other her com

• mmu

munit ity resour

• urces

ces have e been en exhau haust sted ed. . Howev

• wever

er, , some me of the e Counti

• unties

es do cur urrentl rently y use e and d will ll con

• nti

tinue e to need ed Civil vil SMH H beds. .

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

Involves persons waiting in County Jails for psychiatric treatment and persons waiting to transfer from forensics (Bldg51) to civil sections at NSH



DHS Settlement in January 2016

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 Throughout the SE Region, a total of 93

persons have been discharged – CHIPP (As of April

2017)

 We continue to assess every person for any

community vacancy and appropriateness for the community placement

 Thus far, development of new services and

enhancing existing services ….STILL MORE TO COME….

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• 1. Repurposing beds from civil to forensic
• 2. Clinical Assessment of current civil

population

• 3. Assess need for long term care in

community

• 4. Develop supports to reduce demand for

long term care and provide alternatives to the state hospital level of care

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• Step Down Units: Restor
• ring

ing Hope- Build lding ing Skills s fo for a Better r Tomorrow row

• Ultimately 3 step down units will have a maximum of 20

consumers on each unit, with a staffing complement suitable for 30

• Currently 2 Step Down Units
• Help individuals develop skills and knowledge that can

be utilized in their personal recovery by promoting self- confidence and respect for self and others which is integral in the safe and successful re-entry into the community.

• Re- entry may not mean discharge to community living

but rather for some to return to court to face legal situation/issues.

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 Utilizing a validated clinical tool by

independent outside assessors

 The assessments are used to inform the

counties and the hospital of the treatment services and residential supports necessary for successful community inclusion

 To inform mental health and criminal justice

authorities of the relative clinical risks associated with release of those individuals under judicial oversight

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• WHERE:
• NSH civil units, forensic treatment units (as identified

by Counties) and in County jails

• HOW/WHO?:
• Regional 4 Suburban Counties & Philadelphia Process

(separate)

• WHAT THEN?:
• Assessments & recommendations are then shared

with the NSH clinical team and become an integral part of the Community Support Plan (CSP) for each individual

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• Assessment & discharge planning process
• Goals:
• Identify individuals for potential

discharge

• Identify supports needed for individual

to be successful in the community

• Provide support and continuity of care

throughout discharge planning process

• Process
• Outcomes
• Challenges

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Norristown State Hospital 54 Philadelphians discharged since 1/27/16 NSH Civil Unit 29 NSH Forensic Unit 25

Data as

• f

4/30/17

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NSH Civil Unit 56 Philadelphians

Currently Assessed and engaged in discharge planning 27 Of the remaining 29, we are working with our CJ and DBHIDS partners

To be assessed 4 Extra-ordinary legal barriers 25

Data as

• f

4/30/17

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 Over 150 (95 suburban counties and 56 Philadelphia) assessments

assigned and approximately 70% completed to date

 Individuals need intensive therapeutic support which

includes:

• psychiatric medication management, intensive staff support,

community and clinical supports to maintain stability, assistance with managing and achieving goals in the community, medical and physical healthcare monitoring, etc.

 Some individuals may require intensively staffed, secure,

24/7 residential supports that have a clinical component

 Some individuals need specialized clinical supports (TBI,

Cognitive impairments, community risk and safety issues, physical and medical supports, etc.)

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Legal Barriers Clinical Barriers

 High level open

charges

 Concerned about

community safety from Courts,

• bjections from

District Attorney

 Special needs

• Medical
• Psychiatric
• Cognitive

 Co-occurring

needs

 Don’t want to

leave NSH

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 Current

rrent St State e Ho Hospit ital al Po Popul ulation ation

 Current

rrent Forens ensic c Wa Wait List t popu pulation ation

 Extended

ended Acute te Care e (EAC) C) Utilization ation

 Acute

e Inp npatient atient Ho Hospit itali alizati zations

• ns – Hi

High gh Utilization ation popu pulation ation

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• Phila

ladelp delphia hia an and S d Subu burban ban Cou

• unti

ties es ha have e ~90 ~90 be beds ds for

• r EAC
• On average the length of stay for EAC is

between 170-277 days inpatient*

• Managed Care funded - HEALTHCHOICES ONLY
• Typical discharge to structured community

treatment supports and structured housing

* Philadelphia’s Average Length of stay days ~ 277 days and suburban ~170 days

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• Looked at persons who had over 60 days

inpatient within a 12 month period

• Data collected from 2012 – 2017 from the

BHOs EACH COUNTY:

• Looked at # of people per County
• Looked at # of days per person
• Looked at average days per person/per year
• Looked at average costs per person/per year

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

We DO have “long term” care in the community – but… Do we have enough resources??



The majority of community based treatment and rehab and support services are disproportionately covered by HealthChoices (Medical Assistance)



Medicare doesn’t cover community supports that an individual may need such as Extended Acute Care (EAC) inpatient, Assertive Community Treatment(ACT), Specialized residential ie: LTSR or RTFA, Psychiatric Rehab Services, and peer support, just to name a few FACT: T: There re are a nu number ber of pe persons

• ns who will NOT be eligi

gible le for HealthCh thChoic

• ices

es

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Requires Clinical Expertise

Require DHS commitment for ongoing funding to the community in order to share the responsibility for “long term care”

Requires flexibility in funding Requires community support and acceptance

Requires 100% collaboration from all stakeholders, e.g. Department of Corrections, Aging, MCOs, Criminal Justice Partners, etc Requires willing and able providers Requires innovation and planning for years to come

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Bucks County

Department of Mental Health/ Developmental Programs

Service Area Plan Meeting May 22, 2017

1/2 of all long- term mental illnesses begin by the age of

24.

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Prevention/Early Intervention:

Both educational and enhanced community-based supports to prevent the need for higher levels of institutional care

• 1. Educational Efforts
• a. Question, Persuade, and Refer (QPR)
• b. Suicide Awareness/Prevention Annual Walk
• c. NAMI Educational Series

Peer-to-Peer; Family-to-Family; Ending the Silence

• d. Youth Mental Health First Aid through Now Is The Time (NITT):

Healthy Transitions - SAMHSA Grant

• e. Crisis Intervention Training (CIT) for law enforcement officers
• f. Crisis Response Training for correctional facility officers and 911

Dispatchers

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Prevention/Early Intervention (cont’d):

• 2. Community-Based Collaboration with the Criminal Justice

System to Reduce Institutional Care

• a. Forensic Support Program Bridge Subsidy (PCCD Grant)
• b. Magisterial District Justice Engagement Pilot (PCCD Grant)
• c. Natale North (RTF-A):

Regional collaboration with Delaware & Montgomery Counties

 Access to two beds

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FY 16/17 CHIPPs Planning/Implementation:  Focus on meeting the support needs of individuals at

NSH, Bucks County Correctional Facility (BCCF), and individuals in the community with complex needs

 Since August 2016, four (4) individuals have been

discharged from Norristown State Hospital.

 One individual discharged from forensic unit to the newly

developed Natale North (RTF-A)

 Three individuals discharged from the Civil Section to

existing housing resources with enhancements as necessary to accommodate specialized support needs

 17 additional individuals are in the assessment/planning

process for discharge from the Civil Section of NSH.

 15 individuals are awaiting treatment at BCCF

.

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FY 16/17 CHIPPs Planning/Implementation: Enhancement of Community- Based Infrastructure Housing (Current)

• 1. Evaluation of existing housing programs for
• pportunities to enhance supports, both from a

rehabilitative and clinical perspective

• 2. Housing Reinvestment Project to Create Flow

 Capital Project for 8-12 housing units  Tenant-Based Rental Assistance  Contingency Funding

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Further CHIPPs Planning/Implementation: Enhancement of Community Infrastructure

• 1. Housing (Exploration/Development)
• a. Increase capacity for all-inclusive

intensive supports through RFP Process

• 2. Crisis Residential (Reinvestment Plan)
• a. Groundbreaking for a ten (10) bed facility

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Further CHIPPs Planning/Implementation: Enhancement of Community Infrastructure (Cont’d)

• 3. Psychiatric Rehabilitation (Exploration/Development)
• a. Develop capacity to provide psychiatric rehabilitation to

support individuals in the Central and Lower Bucks areas

• 4. Workforce Competencies
• a. Housing: MH Residential Staff Training Initiative
• b. Peer Support: Evaluation of recommendations and

implementation of training and supervision strategies identified through a May 2017 Peer Support Forum.

• c. Evidence-based Clinical Interventions, e.g. DBT

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Person-Centered Program Model:

• Identification of Individualized Strengths & Needs
• Team-Based Program Development
• Establishment of community-based home
• Clinical and supportive programming
• Goals of the program

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Identification of Individualized Needs:

• Comprehensive Assessment

Clinical Medical Historical Experiences

• System of Care Planning

Family/Friends Treatment Providers Community Supports

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Community Integration Skill Building Culture Historical Experience Legal Responsibilities Interests Clinical Treatment Medical Needs Home

Program Goals:

Wellness

• Mental
• Physical
• Emotional

Education/Employment Community Integration Family Re-unification/Establishing Natural

Supports

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Significant DelCo Forensic Demand (Information as of 5/1/2017)

 # Individuals NSH Civil = 13  7 in Civil (54%)have criminal justice oversight  # Individuals NSH Bldg.#51 = 23

(19% of RFPC Patients)

 # Individuals NSH Bldg.#51 Wait List = 26

(12% of RFPC Wait List)

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Delaware re County nty Dedicated ted Forensi nsic c Service ces

 Crisis Intervention Team (CIT) Police Training  Forensic Peer Support Jail In-reach and

Community Support

 Forensic Liaisons and Restoration of Competency

@ DelCo Prison

 Mental Health Court  Forensic Assertive Community Treatment (FACT)

Team

 Forensic Residential Services:

• Supported Housing - Master Leasing
• For
• rens

nsic ic Transitional ansitional Hou

• using

ing Prog

• gra

ram

• Residen

dential tial Treatment tment Faci cili lity y - Adul ult (RTF TF-A) A)

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Forens ensic c Transit nsitio ional nal Ho Housi sing ng Pr Program gram (FTHP) HP)

 Developed as a partnership with a local

Community Corrections Center (CCC)

 9-Bed Pilot Project for Men with Justice

Involvement

 Dedicated/Segregated quadrant of the CCC

Facility

 Diversion/Re-entry Resource  Successful Initial Placements

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Forens ensic c Transit nsitio ional nal Ho Housi sing ng Pr Program gram (FTHP) HP) Pi Pilot Expans ansion

• n

 Success of Pilot led to Expansion Plan  ACLU/CHIPP funding added 3 new beds for

Men and is developing a new dedicated quadrant for 9 Women

 FTHP capacity will be expanded to 21-Beds  Demand for Diversion/Re-entry transitional

housing for Women will be addressed

 FTHP quadrant for Men is fully utilized and

perceived as a valuable forensic resource

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New RT RTF-A Program, gram, Natale le North, th, May 20 2016 16

 Program planned jointly with OBH, Magellan, and

Criminal Justice

 NSH offered access to a vacant quadrant of Bldg.#9  The quadrant was renovated to be a more home-

like setting

 OBH/Magellan/Criminal Justice, and Elwyn

collaborated on Program Description

 Bucks and Montgomery Counties share in referrals,

placements, and operating costs

 Licensed by OMHSAS, the RTF-A is a new Regional

Diversion/Re-entry Resource

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The new Natale North RTF-A opened in May 2016

 Delaware County has a full census of 12 with a

Waiting List

 Bucks and Montgomery Counties have also made

initial placements

 Delaware County has had several individuals step-

down to the community

 HCR20 Assessments are used to determine

appropriate step-down Level of Care

 Step-Down has been to FTHP and other Community

Residential Service Programs

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Current rent Planni ning ng in Respo pons nse to N NSH Civil Closure re and ACLU Class Action

 Use Clinical/Risk Assessments to inform the NSH CSP planning

process and to inform case planning forums with Criminal Justice

• fficials

 Develop individualized plans/funding requests for 6 non-forensic

Civil cases and for any of the 7 forensic Civil cases approved for discharge by Criminal Justice officials

 Include new Diversion/Infrastructure development in the funding

request to address current Community Residential Services gaps and meet future housing demand

• New forensic supported housing resources to enable RTF-A/FTHP

residents to access less restrictive levels of care in the community

• New non-forensic housing resources to enable medically-fragile

residents to age in place with necessary specialized services and supports

 Continue participating in all planning and case review forums to

provide as many opportunities as possible, for forensic and non- forensic individuals alike, to live in the community

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Montgomery County

Partnership for Recovery

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 Mobile Crisis  Combined Children and Adult Mobile Crisis  99% Hospital Diversion Rate  Additional Crisis Residential Service  Began operation in January 2017  Provides alternative to inpatient hospitalization  Justice Related Services  Expanded service  81 served in the first quarter  Stepping Up Initiative  Montgomery County Proclamation – May 2017  Forensic RTFA

Recent Enhancements

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Partnering for a Successful Future

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Program Enhanced Capacity Post Arrest Crisis Screening (PACS) Expansion to 2 additional districts, addition of peers Forensic Support Team Forensic Waitlist (n = 141) APPD Navigation Crisis support and linkage, APPD MH Unit MacArthur Safety & Justice VOPs in jail Forensic Peer Support Team Forensic peer support throughout system Training Forensic training throughout system

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Program Enhanced Capacity Girard Recovery Center (EAC) 20 beds Gaudenzia RTFA 14 beds New Vitae (6th) RTFA 12 beds New Vitae (Walnut West) RTFA 12 beds New Vitae (Walnut East) RTFA 12 beds Specialized DBT Program 6 beds Specialized TBI Program 4 beds Recovery Oriented Cognitive Therapy (CT-R) Tailored for individuals with SMI, emphasizes community reintegration, values individual choice and feedback, promotes individual passions, fosters community involvement

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Funding Capacity Clinical Expertise Diversion Integrated work to develop community alternatives Planning for future “to be served” populations We have done CHIPPs for years…, But this is different…

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Assessments & Consumer Support Planning for NSH population Community Service Planning and Program Development for NSH population Program Development and Diversion Supports to Criminal Justice involved and Diversion population

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ALL AT THE SAME TIME…

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 Stakeholder meetings  Monitoring of the discharged

State Hospital Population

 Monitoring from the Coalition for

the Proper Closure of NSH for the future

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