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System Transformation Initiative
 

System Transformation Initiative

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Topics covered in this 10-26-2007 presentation to the TWG include background and brief updates of System ...

Topics covered in this 10-26-2007 presentation to the TWG include background and brief updates of System
Transformation Initiative projects; a benefits package update, and a housing action plan update.

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    System Transformation Initiative System Transformation Initiative Presentation Transcript

    • Washington State Department of Social & Health Services Mental Health Transformation Work Group Update October 26, 2007
    • Washington State Department of Social & Health Services Agenda For Today
      • Background and brief overview of STI projects
      • Benefits Package Update
      • Housing Action Plan Update
    • Washington State Department of Social & Health Services Background
      • Challenges Facing the 2006 Legislature
      • Decreasing community psychiatric inpatient capacity
      • State hospital waiting lists
      • Court rulings in September 2005
        • No wait for transfer of 90/180 ITA patients
        • Failure to follow proper procedures for assessing “liquidated damages”
      • Variable inpatient utilization and lengths of stay
        • Long lengths of stay in Washington’s state hospitals
        • Significant disparities in lengths of stay when comparing state hospitals
        • Significant disparities between RSNs in per capita inpatient utilization
    • Washington State Department of Social & Health Services Background (cont’d)
      • Challenges Facing the 2006 Legislature (cont’d)
      • Other system challenges
        • Lack of clarity regarding waiver benefits
        • Idiosyncrasies of Washington’s ITA statute
        • Observable lack of residential and housing capacity
        • Goal for standardization & best practice in utilization management
    • Washington State Department of Social & Health Services Background (cont’d)
      • DSHS Approach Incorporated in Budget and Legislative Initiatives
      • Clarified roles of State & RSNs related to community and state hospital care
      • Time limited investment in State Hospital capacity to deal with inpatient access issues
      • Investment in enhanced community resources to reduce reliance on state hospitals
        • PACT
        • Funding for PALS Residents
      • By January 2008, requires RSNs to pay for individuals at PALS
      • Long term planning
    • Washington State Department of Social & Health Services Key Provisions (cont’d)
      • Community Based Care (cont’d)
      • Funding for PACT & other Expanded Community Services
        • Development funds FY 07
        • Operational Funds FY 08
        • Contract for Training & TA- WIMIRT
      • Long Term Planning – RFP for Consultant Contracts
        • Benefits Package/ Rates- TRI West
        • Involuntary Treatment Act- TRI West/ Advocates for Human Potential
        • Mental Health Housing Plan- Common Ground
        • External Utilization Review- University of Washington- Harborview
        • Employment Initiative- WIMIRT (added to STI by MHD)
    • Washington State Department of Social & Health Services STI Implementation
      • Process
      • Consultants For Each Project Initiative
      • Standing Representative Task Force
        • 35-40 members from variety of interested parties
        • Monthly meetings beginning in Oct 06
      • Community Forums- approximately 150 people each
        • November 06, January 07, May 07, and July 07
      • Tribal Roundtable and focus groups- Feb - May 2007
      • Focus Groups- by consultants as needed
      • STI Web Site
      • Product- Reports with consultant recommendations to DSHS/MHD for improvements
      • Next Step- MHD prioritize recommendations for further development with the Governor and Legislature
    • Washington State Department of Social & Health Services Benefits Package Update
    • Washington State Department of Social & Health Services Benefits Package- Access To Care
      • Report Findings
      • To receive Medicaid services through an RSN, a person must:
      • Have a covered diagnosis (there are two lists- List A & List B)
      • Have a functional impairment measured by a standard functioning protocol (GAF for adults, CGAS for children/adolescents)
      • If B diagnosis, have additional risk issues
      • Challenges
      • Barrier to early intervention for high-risk populations
      • Dilutes emphasis on managing higher need cases (long-term case management, day support, residential services)
    • Washington State Department of Social & Health Services Benefits Package- Access To Care
      • Report Recommendations Prioritized by MHD for Further Development
      • Conduct a full actuarial analysis of the financial impact of revising GAF and CGAS minimums for routine outpatient care
      • If financially feasible, raise the GAF and CGAS minimums to at least 70 for all covered diagnoses
      • Develop statewide standards for continuing care and discharge in order to shift focus from front-end restrictions for all enrollees to proactive care management of services for enrollees with intensive, ongoing needs
        • Statewide medical necessity standards for all levels of care
        • Includes criteria for initial and ongoing reviews
    • Washington State Department of Social & Health Services Benefits Package- Services
      • Report Findings
      • Analysis of Washington’s State Medicaid Plan compared to AZ, CO, NM and PA
        • WA’s State Plan is very flexible; able to promote wide range of practices
        • CMS is increasingly strict
        • RSNs choose EBPs and develop within current funds
      • Major limitations applying EBPs / Promising Practices in “real world”- efficacy in studies does not equal effectiveness and efficiency in financial modeling, practice and cultural relevance
      • It does not work to simply mandate Best Practices across the board- systematic promotion of limited EBPs without development of infrastructure (training, monitoring, rates, and time)
      • “ Centers of Excellence” generally tied to successful statewide promotion of specific services (ACT, Peer Support)
    • Washington State Department of Social & Health Services Benefits Package- Services
      • Report Recommendations Prioritized by MHD for Further Development
      • Do not propose any changes to CMS regarding the structure of the State Plan for Rehabilitative Services
      • Prioritize the following 3 EBPs for Statewide Implementation
        • Peer support services provided directly by Consumer and Family Run Organizations
        • Integrated Dual Disorder Treatment for persons with co-occurring mental health and substance use disorders
        • Collaborative Care in Primary Care Settings for populations most effectively served by clinicians located in primary care settings (e.g. older adults)
        • Note- 2 EBPs recommended for children (MTFC & Wraparound) will be considered as part of input process for 1088
      • For any EBPs promoted statewide and paid for under Medicaid, conduct a formal actuarial analysis prior to implementation and at the end of each year to determine if RSNs have developed the service
    • Washington State Department of Social & Health Services Benefits Package- Services
      • Report Recommendations Prioritized by MHD for Further Development (cont’d)
      • Primary goals used to prioritize practices for statewide promotion:
        • Biggest clinical impact (with emphasis on appropriate inpatient utilization)
        • Promotion of recovery and resilience
        • Promotion of culturally relevant practices and cultural competence
        • Promotion of consumer/family-driven care
        • Distribution across age groups
        • Widest and most immediate possible impact
        • Potential cost offsets
    • Washington State Department of Social & Health Services Benefits Package- Recommendations Consumer/Family Run Services
      • Washington’s Peer Support modality is very broad and superior to those of most of the comparison states
      • However, requirement that the service must be provided by a CMHA complicates the peer-nature of service delivery by requiring that it take place in a professional setting
      • The 1915(b) waiver could allow delivery of this service in other defined consumer and family-run settings similar to those allowed under Arizona community support agency provider type
      • While this adds to the administrative burden of provider oversight by the State and RSNs, it also allows delivery of these peer-run services by less costly providers
      • Could also facilitate interventions such as drop-in centers, family psychoeducation, and other consumer / family supports
    • Washington State Department of Social & Health Services Benefits Package-Recommendations Integrated Dual Disorders Treatment
      • IDDT provides mental health and substance abuse services through one practitioner or treatment team and co-locates all services in a single agency (or team)
      • IDDT encompasses 14 components, each of which is evidence-based, including:
        • Screening and assessments that emphasize “no wrong door”
        • Stage-wise treatment that recognizes that different services are helpful at different stages of the recovery process
        • Motivational interviewing and treatment
      • IDDT is effective at engaging people with both diagnoses in outpatient services, maintaining continuity of care, reducing hospitalization, decreasing substance abuse, and improving social functioning
    • Washington State Department of Social & Health Services Benefits Package- Recommendations Collaborative Care
      • Collaborative Care is a model of integrating mental health and primary care services in primary care settings in order to:
        • treat the individual where he or she is most comfortable
        • build on the established relationship of trust between a doctor and consumer
        • better coordinate mental health and medical care
        • reduce the stigma associated with receiving mental health services
      • Two key principles form the basis of the model:
        • Mental health case managers and professionals are integrated into primary care settings
        • Psychiatric and licensed clinical consultation and supervision is available to provide additional mental health expertise where needed
    • Washington State Department of Social & Health Services Benefits Package- Recommendations Collaborative Care (cont’d)
      • Key components include screening, consumer education and self-management support, mental health specialty referrals as needed, and linkages with other community services
      • Multiple studies have documented the effectiveness of collaborative care models to treat anxiety and panic disorders, depression in adults, and depression in older adults
      • IMPACT (Improving Mood: Providing Access to Collaborative Treatment for Late Life Depression) is a multi-state Collaborative Care program with study sites in five states, including Washington
      • Focus on older adults found 1)Higher satisfaction with depression treatment 2) Reduced prevalence and severity of symptoms, and 3) Complete remission as compared to usual primary care
    • Washington State Department of Social & Health Services Benefits Package- Other Report Recommendations
      • Additional recommendations which MHD will continue to study:
        • Revise current RSN contract requirements for Statewideness and provide definitive guidance to RSNs on implementation
        • Develop encounter coding protocols to allow MHD and RSNs to track the provision of other best practices
        • Develop Centers of Excellence to support the implementation of those best practices prioritized for statewide implementation
    • Washington State Department of Social & Health Services Housing Plan Update
    • Washington State Department of Social & Health Services Housing Plan
      • Report Findings
      • All RSNs need a range of housing options
        • Licensed residential facilities
        • Community based housing
        • Crisis respite beds
      • Permanent Supportive Housing (PSH) most appropriate for most MH consumers
        • All RSNs need additional PSH
        • Estimated need for up to additional 5000 units in WA for people served by the public mental health system
        • Initial goal should be for development of 760 PSH units for mental health consumers between 2007-2010
    • Washington State Department of Social & Health Services Housing Plan
      • Report Findings (cont’d)
      • Key elements to successful PSH Implementation
        • Capital financing for new units- approximately 60% of needed dollars are committed and there are sufficient capital investment dollars available within current state and federal allocations if subsidies & direct care and support services are secured
        • Rental subsidies (Section VIII wait lists)- 65% of units can be funded through existing sources leaving a gap of 35% (260 units)
        • Operating subsidies (e.g. landlord incentives, risk mitigation funds)- for excess costs related to renting to mental health consumers based on $1200 per unit per year
    • Washington State Department of Social & Health Services Housing Plan
      • Report Findings (cont’d)
      • Key elements to successful PSH Implementation
        • Access to on site supportive services
          • Case manager caseloads ranging from 1:8-1:20 depending on needs of consumers
          • access to 24/7 crisis response from MH provider
          • Estimate that 480 of 760 units can be supported by new PACT or programs created related to PALS community funds
          • Remainder of services will need to come from either new funds or redirection of current RSN service dollars
    • Washington State Department of Social & Health Services Housing Plan
      • Report Recommendations Prioritized by MHD for Further Development
      • Secure rent subsidies funding for 35% of units that can’t be funded through existing sources (260 units)
      • Secure funding for operating subsidies (e.g. landlord incentives, risk mitigation funds)- for excess costs of renting to consumers
      • Identify whether additional funding for PSH services can be met through current allocations or require any new funds
      • Promote the creation of PSH at the RSN and local level by providing best practice information on models, partnerships, and financing and funding TA to build capacity
    • Washington State Department of Social & Health Services Housing Plan
      • Report Recommendations Prioritized by
      • MHD for Further Development (cont’d)
      • Ensure PIHP benefit design includes flexible modality for services in home settings with rate sufficient to cover costs
      • Suggest standard to identify number of crisis respite beds needed and identify funding if needed
      • Develop a closer working relationship with CTED and consider a joint PSH funding proposal for 2009
    • Washington State Department of Social & Health Services Housing Plan
      • Additional recommendations which MHD will continue to study:
      • Explore the use of the Charitable, Educational, Penal, and Reformatory Institutions Trust Fund to support PSH for mental health consumers
      • Capitalize on the opportunities offered through the Governor’s Mental Health Transformation Grant to further design and delivery of the landlord incentive package and peer support for PSH
      • Collect data at RSN/provider level and publish an annual statewide report on the housing status and tenure of all consumers served in the public mental health system
      • Promote the development of an additional 1600 PSH units for mental health consumers between 2010 and 2015 including a plan for securing adequate capital, rental subsidies, operating subsidies, and services
    • Washington State Department of Social & Health Services Wrap Up For further information on STI: http://www1.dshs.wa.gov/Mentalhealth/STI.shtml Andy Toulon DSHS Health and Recovery Services Administration Mental Health Division (360) 902-0818 [email_address]