Allegheny County Discharge and Acute Community Support Planning

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

Goals of Today’s Training l l l 2 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 Health. Choices, Inc.

Goal of Mayview Closure l 3 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 Health. Choices, Inc.

What is a Community Support Plan (CSP)? l 4 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 Health. Choices, Inc.

Key Characteristics of a CSP l l l l 5 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 planningindividualized Allegheny Health. Choices, Inc.

Why Do a CSP: What We Have Learned l l 6 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 Health. Choices, Inc.

Why Do a CSP: What We Have Learned l l l 7 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 Health. Choices, Inc.

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: l l 8 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 Health. Choices, Inc.

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

CTTs Are Providing Frequent Contacts For people receiving CTT services: l l l 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. 10 Allegheny Health. Choices, Inc.

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. 11 Allegheny Health. Choices, Inc.

Access to Supports and Activities: first three months of discharge l l l 12 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 Health. Choices, Inc.

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

Early Warning Signs and Critical Incidents l l 14 New online 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 Health. Choices, Inc.

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

New/Expanded Peer Support l l 16 Peer mentors Warmline Peer specialists Recovery specialists (County staff) Allegheny Health. Choices, Inc.

New/Expanded Community Services l l l l 17 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 Health. Choices, Inc.

New Residential Options l l l 18 l 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 Health. Choices, Inc.

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

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

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

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

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

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

Level 1: Acute Inpatient Discharge Process 25 l IP multi-disciplinary treatment team, the consumer, family, and, when indicated, the outpatient provider, meet for the discharge planning process. l 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 Health. Choices, Inc.

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. 26 Allegheny Health. Choices, Inc.

Level 2: Disposition Discharge Process • l 27 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 l Whether Level 2 or 3 criteria is met, SW makes referral to the Disposition Coordinator and the Disposition Coordinator reviews referral. l Disposition Coordinator schedules disposition meetings and facilitates disposition process. Allegheny Health. Choices, Inc.

Level 3 Eligibility Criteria (Draft) To be eligible, consumer must meet one of the following criterion: – – 28 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 Health. Choices, Inc.

Level 3 Eligibility Criteria Continued – – 29 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 Health. Choices, Inc.

Level 3: Acute CSP Discharge Process l 30 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 Health. Choices, Inc.

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

Goals of the Acute Community Support Plan Process l l l 32 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 Health. Choices, Inc.

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

CSTAP Peer Assessment l l l 34 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 Health. Choices, Inc.

Family Assessment 35 l The family assessment is conducted by a family member of a mental health consumer. l The assessment is accomplished either “face to face” or by telephone interview. l 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. l Participation in the assessment is entirely voluntary and most families willingly participate. Allegheny Health. Choices, Inc.

Clinical Assessment l l l 36 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 Health. Choices, Inc.

ACSP Participants l l l 37 l First and foremost, the consumer who is to be discharged 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 Health. Choices, Inc.

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

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

The Advocates Role l To assist the consumer in the ACSP planning process by: – – – 40 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 Health. Choices, Inc.

Hospital, Community Provider, and County Roles 41 l The person’s social worker and psychiatrist are important participants; typically their contribution is clinical in nature l The county ACSP coordinator and/or provider liaison and/or SC/CTT members bring knowledge of the community and potential resources to the table l 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 Health. Choices, Inc.

Role of Social Worker l 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. l The Social Worker will invite ACSP key attendees: inpatient psychiatrist and team, outpatient provider, individual, family, MCO, County, hospital liaison, and others. – 42 The facilitator will invite the advocate and the county Allegheny Health. Choices, Inc.

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

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

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

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

The Planning Meeting: Tips for Success l l l 47 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 Health. Choices, Inc.

The Planning Meeting: More Tips for Success l l l 48 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 Health. Choices, Inc.

ACSP Meeting Stages Information Gathering and Options l Resource Coordination and Transition l Final Plan l 49 Allegheny Health. Choices, Inc.

Stage One – Information Gathering/Options Stage l l 50 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 Health. Choices, Inc.

Stage Two – Resource Coordination and Transition Stage l l l 51 Locate or create resources which are congruent with the consumer’s stated needs and wants. The consumer may visit places that he/she will use in the community Ensure all resources are secured and in place prior to discharge Identify and plan for all ‘transition’ activities Allegheny Health. Choices, Inc.

Stage Three – Final Plan l l l 52 Status of community supports and resources are discussed and reviewed with the consumer, supports and ACSP participants The ACSP form is finalized with the consumer, supports and ACSP participants The final plan is posted on the website and monitored by OBH Allegheny Health. Choices, Inc.

Contact Information l l l 53 Grace Cannon (Disposition Coordinator) Email: Grace. cannon@alleghenycounty. us Phone: 412 -350 -6401 Cecilia Reinheimer (ACSP Coordinator) Email: Cecilia. reinheimer@alleghenycounty. us Phone: 412 -350 -5015 Sally Crompton (ACSP Facilitator) Email: Scrompton@ahci. org Phone: 412 -867 -5685 Allegheny Health. Choices, Inc.