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BHTWG preliminary work draft strategic plan 10 mar10 review copy
 

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    BHTWG preliminary work draft strategic plan 10 mar10 review copy BHTWG preliminary work draft strategic plan 10 mar10 review copy Document Transcript

    • Governor's Behavioral Health Transformation Work Group Preliminary Working Draft Strategic Plan BHTWG Review Draft / WICHE Technical Assistance Panel Review Draft (Please provide comments and suggestions to Marsha Bracke, mbracke@earthlink.net) March 10, 2010 BHTWG: March 10, 2010
    • BHTWG: March 10, 2010
    • Governor's Behavioral Health Transformation Work Group Skip Oppenheimer, BHTWG Chairman Chairman/CEO Oppenheimer Companies, Inc. Dick Armstrong, Director Department of Health and Welfare Dr. Kenneth Coll, Institute for the Study of Addiction Boise State University Debbie Field, Administrator Office of Drug Policy Sharon Harrigfeld, Director Department of Juvenile Corrections Margaret Henbest, Citizen Consumer Representative Captain Sam Hulse Bonneville County Sheriff's Office Matt McCarter, Superintendent's Designee Department of Education Dr. Charles Novak, Chief of Psychiatry Saint Alphonsus Hospital Tony Poinelli, Deputy Director Association of Counties Brent Reinke, Director Department of Correction Patti Tobias, Chair's Designee Statewide Drug and Mental Health Court Coordinating Committee Teresa Wolf, Chair Idaho State Planning Council on Mental Health BHTWG: March 10, 2010
    • BHTWG: March 10, 2010
    • Contents Introduction .......................................................................................................................................................... 1 Vision and Goals .................................................................................................................................................. 6 Services .................................................................................................................................................................... 7 Structure .............................................................................................................................................................. 17 System ................................................................................................................................................................... 19 Strategy ................................................................................................................................................................. 20 BHTWG: March 10, 2010
    • BHTWG: March 10, 2010
    • Introduction Background In 2007, the Idaho State Legislature passed Concurrent Resolution Number 108, implementing a review of Idaho's current mental health and substance abuse treatment delivery system. The Western Interstate Commission for Higher Educations' Mental Health Program (WICHE) was commissioned to conduct the project. The study was comprehensive. Through interviews with public agencies, local officials, stakeholder groups and others, a detailed statewide survey, and meetings around the state discussing the necessity and complexity of treating mental health and substance use disorders in the public system, WICHE confirmed that Idaho's system is fragmented, and that the situation is challenging. Based on the results of the statewide study, WICHE's report proposed a shared vision and goals for transformation of the mental health and substance abuse system in Idaho. The report presented a series of recommendations to inform the state's effort to redesign the system.1 With the delivery of this report and information, the Governor's Office acted on WICHE's recommendation to "create a statewide 'transformation workgroup' to identify and address barriers to transformation." Executive Order No. 2009-04 formally convenes and tasks the Behavioral Health Transformation Work Group (BHTWG) with "developing a plan for a coordinated, efficient state behavioral health infrastructure with clear responsibilities, leadership authority and action," and to "provide for stakeholder participation in the development of the plan." The public health service delivery system is intended to assist those individuals with serious mental illness (SMI), serious and persistent mental illness (SPMI), and children with serious emotional disturbance (SED). The prevalence of mental illness exceeds that of this targeted population. The Surgeon General's Mental Health Report estimates that "during a 1-year period, 22 to 23 percent of the U.S. adult population―or 44 million people―have diagnosable mental disorders," and that "3 percent have both mental and addictive disorders." The same report clarifies that a subpopulation of approximately 5.4 percent of adults are considered to have SMI, and half of those are more seriously affected with SPMI. Children with SED are estimated to comprise approximately 5 to 9 percent of children ages 9 to 17. 2 1 Western Interstate Commission for Higher Education. Idaho System Behavioral Health System Redesign: findings and Recommendations for the Idaho State Legislature. Boulder, Co. 2008. 2 www.surgeongeneral.gov/library/mentalhealth/chapter 2/sec2_1.html BHTWG: March 10, 2010 1|Page
    • The need for a more effective service Idaho Efforts to Address Behavioral Health delivery system in Idaho is not a new concept. Idahoans have historically and diligently sought to address this Comprehensive Statewide Mental Health Transformation challenge in a number of ways. Table Action Plan 2007 1 lists a series of products produced by Statement of Needs and Gaps entities seeking to address this (Region II Mental Health Board, February 2008) important issue (including the WICHE Legislative Council Interim Committee – Mental Health and work). Developing a service delivery Substance Abuse Treatment Delivery System system that effectively crosses Mental Health Substance Abuse Workgroup systems, is outcome-oriented and Juvenile Justice Children's Mental Health Strategic Plan accountable, and provides adequate Mental Health Stakeholder Implementation Plan community supports in a resiliency (NAMI-Boise Mental Health Association) and recovery-oriented environment is Interagency Work Group on Mental Health Services a complex process. Western Interstate Commission for Higher Education Study 2008 The intent is also reflected in other Western Interstate Commission for Higher Education Report specific and collaborative initiatives. April 29, 2009 For example, the Department of Western Interstate Commission for Higher Education Health and Welfare (DHW) created the Draft Idaho Behavioral Health System Proposal and Division of Behavioral Health to Request for Information, July 2009 facilitate the integration of mental Other reports and products health and substance abuse services. Table 1: Idaho efforts to address behavioral health service delivery The DHW, Department of Juvenile Corrections (DJC), counties and other stakeholders generated the capacity to make mental health clinicians available at juvenile detention centers in order to more effectively assess and meet youth's mental health needs at this critical juncture. On a regional basis, Regional Mental Health Boards are developing collaborative initiatives with local entities to provide community-based based supports in a number of innovative ways. Clearly, many Idahoans are committed to trying to generate the cross-system capacity necessary to most effectively meet the need. A number of entities provide or secure resources to address mental health and substance abuse disorders, including School Districts, County Probation, Detention Centers and Jails, Idaho Department of Juvenile Corrections, Idaho Department of Corrections, and Mental Health Courts. Voluntary and involuntary systems exist; public and private resources are utilized; and co-occurring disorders are prevalent. Millions of dollars are spent in the state by state agencies, county governments, private contributions, and more to support people with mental illness and substance abuse disorders. Treatment for mental illness relies heavily on public funding; expenditures tend to focus on crisis rather than early intervention; and in some cases, different state agencies find themselves purchasing the same services from the same providers at different rates. BHTWG: March 10, 2010 2|Page
    • The BHTWG embraces the Vision WICHE proposed as a result of its process to reflect the perspective and preferences of Idahoans. BHTWG members have clearly articulated their commitment to this Vision and their intent to secure it. The Vision is clear, the path to get there is complex. The effort to realign systems and build capacity is daunting enough, but in this economic climate, with the DHW facing hundreds of millions of dollars in budget shortfalls over the next several years and other agencies facing similar challenges, the effort can seem overwhelming. What BHTWG acknowledges is that given the economic realities, any expansion of effort or influx of funding is unrealistic. Consequently, they are attempting to contract in a manner that both responds to the economic crisis and strategically aligns with the transformation vision. Implementation is intended to proceed in a manner that is methodically phased, measured and informed. The BHTWG is working to articulate that vision, services, structure, system and strategy in this Behavioral Health Transformation Work Group Preliminary Draft Strategic Plan (Plan). The Plan and the process to develop the system are clearly iterative. Important questions remain, the answers of which will be generated based on public input, regional needs and preferences, data, and lessons learned as the state moves through the various phases of transformation. As the process evolves, the recommendations generated by WICHE help inform and shape those steps, and outcome measurements help check them. The ultimate end, of course, is to provide an effective, community-based and outcome-oriented service delivery system for children and adults that enable resiliency and recovery. This kind of delivery system demands the coordination and leveraging of the state's collective resources. When the state's resources are collectively known and strategically distributed based on shared vision and outcomes in a manner most responsive to need, they can be most effectively used. This Plan lays the foundation to make that coordination of resources possible. While the current economic climate makes the task increasingly challenging, it also makes it increasingly necessary. It will take a true collaboration and hard work to make it a reality. BHTWG: March 10, 2010 3|Page
    • Scope This Plan outlines the ultimate Vision for Idaho's behavioral health system and the effort s of state agencies, regional bodies, and other stakeholders to achieve it. The strategy to achieve the vision is presented in three phases. The reality is that it may take three―or six―phases. Activities proposed within different phases may overlap or occur concurrently. While many action strategies are listed here, any one action strategy may inform another, prompting additional system work and informing ongoing revisions to this document. The BHTWG expects this effort to take a number of years, but with diligent attention paid to its implementation, the vision can and will become a reality. The initial restructuring as proposed focuses on the mental health system first, even while BHTWG continues its efforts to pursue integration of the mental health and substance abuse systems. As the restructuring evolves during phase one, a hard look at how to integrate the substance use delivery system within that structure can be more practically explored. In writing a draft Plan to achieve a shared vision, as many questions are generated as are answered. This Plan is a guide and a commitment, but it is also an evolution. Its results rely on the collective and interdependent input, leadership, and commitment of all who have a role, responsibility and interest. Stakeholder and public input are integral to the further development and refinement of transformation. DHW will pursue its reorganization as proposed, and other partner agencies will develop their strategies to align with the proposed vision and structure. As the initial phase begins and the regions consider and develop their own roles and responsibility within this vision, additional detail, refinements and realities will inform this proposal. This specific draft will be subject to review by experts in the field, the public at large, regional mental health and substance use advisory bodies, other advisory bodies, consumers, government officials, legislators and more. This Preliminary Working Draft of the BHTWG Strategic Plan presents the visionary outcomes the state seeks as well as the strategic initiatives underway to achieve it. The Plan presents: 1. Vision and Goals for Transformation 2. Services to be made available in each region of the state 3. Structure to support community-based service delivery 4. Systems that ensure accountability, inform effectiveness and generate efficiencies, and 5. Strategy to be undertaken to transform the system from today's current environment to that envisioned for the future. BHTWG: March 10, 2010 4|Page
    • Scope This Preliminary Draft Strategic Plan presents the proposed: Vision and Goals for a transformed system Services An array of core services to be made available in each region of the state Structure to support community-based service delivery Systems that ensure accountability, inform effectiveness and generate efficiencies, and Strategy to be undertaken to transform the system from today's current environment to that envisioned for the future. The BHTWG is very specifically relying on mental health and substance abuse system stakeholders, consumers and the public at large to review this proposal and provide inputs and suggests for its further refinement and development. BHTWG: March 10, 2010 5|Page
    • Vision and Goals The BHTWG adopted a Vision for behavioral health in Idaho that is informed by and complimentary to Idaho's history of reports, studies and collaborative efforts. The group has affirmed by unanimous vote at its December 2, 2009 meeting the intent to work to realize this vision, and to proceed with a phased-in approach to achieve it, generating measures and data that will inform its further development. Vision BHTWG Commitment Idaho citizens and their families have The BHTWG affirms their intent to appropriate access to quality services provided work to realize this vision, and to through the publicly funded mental health and proceed with a phased-in approach substance abuse systems that are coordinated, to achieve it, generating measures efficient, accountable, and focused on and data that will inform its further recovery. development. Goals 1. Increase the availability of, and access to, quality services. 2. Establish a coordinated, efficient state and community infrastructure throughout the entire mental health and substance abuse system with clear responsibilities and leadership authority and action. 3. Create a comprehensive, viable regional or local community delivery system. 4. Make efficient use of existing and future resources. 5. Increase accountability for services and funding. 6. Provide authentic stakeholder participation in the development, implementation and evaluation of the system. BHTWG: March 10, 2010 6|Page
    • Services Array of Core Services The BHTWG proposes a meaningful and efficient system of care in the State of Idaho. This system of care features availability and access to an array of behavioral health services (both mental health and substance abuse) on as local a level as possible. Core services are defined as an array of services including those that are community based, emergent, medically necessary, and required by law. The intent is to provide a “floor” of services, available in each region, that span prevention, intervention, treatment and recovery so that coordinated efforts are enabled to redirect supports from the more expensive emergent and medically necessary services to more effective and less costly prevention, intervention and recovery services. Core services will be provided in accordance with statewide standards which will include, at minimum, monitoring for quality, consistency and timeliness. These services will be delivered from a client-centered perspective. Effectiveness of service delivery will be determined by examining quality of life measures as well as other standardized outcome-based instruments. The array of core services will be provided for in a way that:  Is outcome oriented.  Features accessibility on as local a level possible  Is integrated across responsible agencies and entities  Distinguishes between, accommodates the differences, and meaningfully supports the child, the adult, and the transition between them. Within the context of this proposal, the BHTWG recognizes certain realities, all of which will influence transformation development in a given region. The BHTWG acknowledges that: 1. Each region features a different mix of professional expertise, and that the array of services might be achieved through different types of venues or may have a different configuration from one region to another; 2. Core services will be available in all regions, but the prevalence of any core service may vary among regions as appropriate to reflect the needs of a region's targeted population; 3. Regions will develop local access standards using their own demographics, geography and availability of services within pocketed areas of their region; 4. Some regions might look to their neighboring regions to help make a service available that is not available in their own; BHTWG: March 10, 2010 7|Page
    • 5. There may be an inclination for providing emergent and medically necessary services as a priority over other services, and that preventative and recovery services are critical to effectively supporting an individual; 6. The delivery of preventative and community-based services can in some cases be provided at relatively low cost, and with effective delivery of these services, enhance an individual's quality of life while decreasing the cost of emergent and medically necessary services; 7. The goal is for regions to be able to deliver this array of services without depending upon the state to provide the same services; 8. Regions have the authority and flexibility to build their service delivery systems in good faith, making reasonable attempts to make all core services available; 9. Regions be poised to succeed in ultimately delivering the complete array of core services; 10. This array of core services is intended to provide a consistent "floor" of services for individuals throughout Idaho; regions may opt to provide an array of services that exceed those proposed here, and that such an initiative is desirable; 11. The development of the regional system will occur in a transitional manner, potentially learning from the experience of a pilot region and/or by a phased in approach to making the array of services available. 12. Some functions now managed by the state may be phased into regional responsibility. Core services are to be targeted to citizens of the state of Idaho on a sliding fee scale basis (to be determined) and will include adults with severe mental illness, children and adolescents with serious emotional disorders, and individuals with substance use and co-occurring disorders. The Regional Behavioral Health System shall provide for the following array of services (draft definitions follow on subsequent pages), resulting in a comprehensive behavioral health system in each of the seven judicial regions of the state of Idaho. BHTWG: March 10, 2010 8|Page
    • Structurally Necessary Medically Necessary Community-Based Medicaid covered Emergent No. Service 1. Assertive Community Treatment (ACT) and Intensive Case Management Services X X X +/- 2. Assessments and Evaluations X X X X +/- 3. Case Management Services X X X 4. Designated Examinations and Dispositions X X X X 5. Intensive Outpatient Treatment X +/- 6. Illness Self-Management and Recovery Services X 7. Inpatient Psychiatric Hospitalization X X X 8. Medication Management X X X 9. Peer Support Services X 10. Prevention Services X 11. Early Intervention Services for Children and Adolescents X 12. Psychiatric Emergency and Crisis Intervention services (24/7 with open door access) X X X +/- 13. Psychotherapy (including trauma-informed care and cognitive behavioral therapy) 1 X X X 14. Alcohol and Drug Residential Treatment X X 15. Supported employment X 16. Supported housing X 17. Transportation X X X 18. 24-Hour Out-Of-Home Treatment Interventions For Children And Adolescents X X 19. Day Treatment/Partial Care for Children and Adolescents X X X Table 2: Core Services to be made available in each region of the state Definitions of Core Services 1. Assertive Community Treatment (act) and Intensive Case Management Services a. Assertive Community Treatment (ACT) ACT consists of proactive interventions provided to adults with serious, disabling mental illness for the purpose of increasing community tenure, elevating psychosocial functioning, minimizing psychiatric symptomatology, and ensuring a satisfactory quality of life. Services include the provision and coordination of treatments and services delivered by multidisciplinary teams using an active, assertive outreach approach and including comprehensive assessment and the development of a community support plan, ongoing monitoring and support, medication management, skill development, crisis resolution, and accessing needed community resources and supports. BHTWG: March 10, 2010 9|Page
    • b. Intensive Case Management Intensive case management is an intensive community rehabilitation service for individuals at-risk of hospitalization or for crisis residential or high acuity substance abuse services. Services include: crisis assessment and intervention; individual restorative interventions for the development of interpersonal, community coping and independent living skills; development of symptom monitoring and management skills; medication prescription, administration and monitoring; and treatment for substance abuse or other co-occurring disorders. Intensive case management also includes coordinating services, referral, follow-up, and advocacy to link the individual to the service system. Services can be provided to individuals in their home, work or other community settings. Services may be provided by a team or by an individual case manager. c. Wraparound Wraparound is an intensive and individualized care management process for youths with serious or complex needs. During the wraparound process, a team of individuals who are relevant to the well-being of the child or youth (e.g., family members, other natural supports, service providers, and agency representatives) collaboratively develop an individualized plan of care, implement this plan, and evaluate success over time. The wraparound plan typically includes formal services and interventions, together with community services and interpersonal support and assistance provided by friends, kin, and other people drawn from the family’s social networks. The team convenes frequently to measure the plan’s components against relevant indictors of success. Plan components and strategies are revised when outcomes are not being achieved. 2. Assessment and Evaluation Assessment and evaluation define or delineate the individual’s mental health/substance abuse diagnosis and related service needs. Assessment and evaluation services are used to document the nature and status of the individual’s mental health status in terms of interpersonal, situational, social, familial, economic, psychological, and other related factors. These services include at least two major components: 1) screening and evaluation (including medical, bio-psychosocial history; home, family, and work environment assessment; and physical and laboratory studies/testing and psychological testing as appropriate); and 2) a written report on the evaluation results to impart the evaluator's professional judgment as to the nature, degree of severity, social-psychological functioning, and recommendations for treatment alternatives. 3. Case Management (service coordination) (case load capacity to be determined by an acuity-based formula) This service provides supportive interventions to assist individuals to gain access to necessary medical, habilitative, rehabilitative and support services to reduce psychiatric BHTWG: March 10, 2010 10 | P a g e
    • symptoms and to develop optimal community living skills. Service Coordination needs are assessed and documented on the comprehensive treatment plan to meet the individual’s specific needs. Service Coordination services may include coordinating services, referral, follow-up, and advocacy to link the individual to the service system and to coordinate the various system components to assure that the multiple service needs of the individual are met. Service Coordination may also provide assistance for obtaining needed services and resources from multiple agencies (e.g., Social Security, Medicaid, Prescription Assistance Programs, food stamps, housing assistance, health and mental health care, child welfare, special education, etc.), advocating for services, and monitoring care. 4. Designated Examinations and Dispositions A designated examination is a personal examination of a proposed patient to determine if the proposed patient is: (i) mentally ill; (ii) likely to injure himself or others or is gravely disabled due to mental illness; and (iii) lacks capacity to make informed decisions about treatment and should be involuntarily committed to the Department of Health and Welfare (Department). A designated examiner must be a psychiatrist, psychologist, psychiatric nurse, social worker or other mental health professional designated in rule and specially qualified by training and experience in the diagnosis and treatment of mental illness. A dispositioner is a designated examiner employed by or under contract with the Department to determine the least restrictive appropriate location for care and treatment of involuntary patients. 5. Intensive Outpatient Treatment a. Home-Based Mental Health Services Intensive home-based treatments are time-limited intensive therapeutic and supportive interventions delivered in the home and are intended to prevent the utilization hospitalization. These services are available twenty-four hours a day, seven days a week. Services are multi-faceted in nature and include: situation management, environmental assessment interventions to improve individual and family interactions, skills training, self and family management, and independent living skills training. b. Intensive Outpatient Substance Use Disorder Treatment This service provides a time limited, multi-faceted approach treatment service for persons who require structure and support to achieve and sustain recovery. Intensive outpatient treatment programs generally provide nine or more hours of structured programming per week, consisting of group and family counseling, job preparedness, relapse prevention, and education. Programming may be delivered during the day, evenings, and/or weekends. The amount of weekly services per individual is determined by the individualized treatment plan, and may flexibly vary from nine through twenty (20) hours. The patient's needs for medical services are addressed through consultation or referral arrangements. BHTWG: March 10, 2010 11 | P a g e
    • 6. Illness Self-Management and Recovery Services Illness self-management uses structured techniques and strategies for managing mental illness and ongoing self-assessment and self-monitoring to facilitate recovery from mental illnesses. Several manualized self-management programs have been developed in recent years, including Copeland’s Wellness Recovery Action Planning known as WRAP (Copeland 1997). WRAP is a program in which participants identify internal and external resources for facilitating recovery, and then use these tools to create their own, individualized plan for successful living. 7. Inpatient Psychiatric Hospitalization The goal of inpatient care is to stabilize the individual displaying the acute symptoms. This service is available for individuals who are in direct danger to self or others, and/or in acute crisis, including substance use withdrawal. This service provides twenty-four (24) hour care in a hospital requiring short-term, intensive, medically supervised treatment, consistent with the individual’s needs. Services provided in an acute psychiatric hospital include, but are not limited to, psychiatric care, monitoring of medication, health assessment, nutrition, therapeutic interventions, observation, case management and professional consultation. 8. Medication Management a. Medication Management/Pharmacotherapy Medication management is a pharmacotherapy service provided by a physician or other individual licensed to prescribe medications to assess and evaluate the individual’s presenting conditions and symptoms, medical status, medication needs and/or substance abuse status. This includes evaluating the necessity of pharmacotherapy or other alternative treatments, prescribing, preparing, dispensing, and administering oral or injectable medication. Informed consent must be obtained for each medication prescribed. b. Medication Administration/Monitoring Medication services are goal-directed interventions to administer and monitor pharmacological treatment. Oral, injectable, intravenous, or topical medications and treatments are administered and their positive and negative effects monitored. This includes medications used to treat substance abuse or addiction. There is a focus on educating and teaching individuals and members of their support system as to the effects of medication and its impact on alcohol/drug abuse/dependence and/or mental illness. Counseling related to medication management and case coordination with other practitioners involved with the individual is necessary to assure continuity of care. These are primarily face-to-face services contacts, rendered as both facility-based and "in vivo." BHTWG: March 10, 2010 12 | P a g e
    • c. Laboratory Tests Laboratory tests are also used to diagnose and treat behavioral health and medical disorders and provide pharmacologic management. Laboratory tests may include, but are not limited to: urinalysis and other formal drug screenings, blood tests, and tests for sexually transmitted diseases. 9. Peer Support Services Peer support services provide an opportunity for individuals to direct their own recovery and advocacy process and to teach and support each other in the acquisition and exercise of skills needed for management of symptoms and for utilization of natural resources within the community. This service provides structured, scheduled activities that promote socialization, recovery, self-advocacy, development of other natural supports, and maintenance of community living skills. Trained and certified consumers actively participate in decision-making and the operation of the programmatic supports. 10. Prevention Services The goal of this service is to prevent and/or treat mental illness and/or substance abuse. Prevention activities include various strategies aimed at educating the community at large and selective educational and informational strategies for certain individuals who are at greatest risk for mental illness and/or substance abuse. A system of prevention involves clear boundaries and expectations, and a comprehensive scope of pro-social activities and educational services designed to increase protective factors and reduce risk factors among all in a community (universal). 11. Early Intervention Services for Children and Adolescents Early intervention services are designed to address problems or risk factors that are related to mental illness and substance abuse. These services are designed to provide information, referral and education regarding symptoms and treatment to assist the individual in recognizing the risk factors for mental illness and substance abuse. Early intervention and education is an organized service that may be delivered in a wide variety of settings. Early intervention may include time-limited respite care services. 12. Psychiatric Emergency and Crisis Intervention Services (24/7 with open door access) a. Crisis Intervention/Mobile Crisis Crisis intervention services are immediate, crisis-oriented services designed to ameliorate or minimize an acute crisis episode and to prevent inpatient psychiatric hospitalization or medical detoxification. Services are provided to adults, adolescents and their families or support systems who have suffered a breakdown of BHTWG: March 10, 2010 13 | P a g e
    • their normal strategies or resources and who exhibit acute problems or disturbed thoughts, behaviors or moods. The services are characterized by the need for highly coordinated services across a range of service systems. Crisis intervention services should be available on a 24-hour, seven-day per week basis. Services can be provided by a mobile team or by a crisis program in a facility or clinic. Crisis intervention services include: crisis prevention, acute crisis services, and support services. b. Crisis Residential Treatment/Respite Care Services Crisis residential treatment services provide 24 hour supports for adults for the purpose of ameliorating a crisis in the least restrictive setting while trying to maintain the person’s linkages with their community support system. Services include: continuous and close supervision, medical, nursing and psychiatric services and referral to community-based services. Crisis residential treatment services are provided in non-hospital setting. Crisis residential lengths of stay generally should not exceed 10 days. 13. Psychotherapy (including trauma-informed care and cognitive behavioral therapy) a. Individual Psychotherapy Individual counseling consists of various evidence-based professional therapeutic interventions and is used to address an individual’s alcohol or drug abuse and/or emotional, behavioral or cognitive problems. Personal trauma, family conflicts, responses to medication, connecting with and utilizing natural supports, and other life adjustments reflect a few of the many issues that may be addressed. Services may be provided in various settings. b. Group Psychotherapy Group psychotherapy consists of therapeutic interventions provided to a group of children, adolescents or adults to address an individual’s alcohol or drug abuse and/or emotional, behavioral or cognitive problems. Personal trauma, family conflicts, responses to medication, and other life adjustments reflect a few of the many issues that may be addressed. Services may be provided in various settings. Group size should be at least three or more, but fewer than 10 individuals. c. Family Psychotherapy for Children and Adolescents Interventions directed toward an individual and family to address emotional or cognitive problems which may be causative/exacerbating of the primary mental disorder or have been triggered by the stress related to coping with mental and physical illness, alcohol and drug abuse, and psychosocial dysfunction. Personal trauma, family conflicts, family dysfunction, self-concept responses to medication, and other life adjustments reflect a few of the issues that may be addressed. Includes Multi-Systemic Therapy (MST), Functional Family Therapy (FFT) and Parenting with Love and Limits (PLL). BHTWG: March 10, 2010 14 | P a g e
    • 14. Alcohol and Drug Residential Treatment This service is a twenty-four hour residential rehabilitation treatment for adults or adolescents with chronic alcoholism or drug dependency who lack an adequate social support system and need supervised treatment to achieve a substance-free lifestyle and explore and instill ways of functioning in a work setting, within the family, and in the community in accordance with the individual’s treatment plan. Services include: medication administration, case management and monitoring and individual and group recovery-based services. Some individuals may be experiencing and be monitored for minor detoxification. 15. Supported Employment, including Vocational Rehabilitation when needed a. Supported Employment Supported employment provides on the job supports in an integrated work setting with ongoing support services for adults with the most severe disabilities for whom competitive employment: a) has not traditionally occurred; b) has been interrupted or intermittent as a result of severe disability; and c) who, because of the nature and severity of their disability, need intensive supported employment services in order to perform work. Activities are performed by a job coach and/or job specialist/case manager in conjunction with a job developer to achieve a successful employment outcome. b. Job Preparedness Job preparedness consists of activities directed at assisting individuals to develop skills to gain and maintain employment. Job preparedness services include: providing instruction in the areas of resume writing, job application preparation, and appropriate job interview responses. These activities also emphasize the importance of being ready to seek and hold employment is discussed, including proper nutrition, cleanliness, and physical appearance, allocating daily costs, and taking prescribed medication. 16. Supported Housing (housing first, etc.) Supported housing is a safe and secure place to reside which is affordable to consumers and permanent as long as the consumer pays the rent and honors the conditions of the lease. In some models, consumers are not required to participate in services to keep their housing, although they are encouraged to use services. Supported housing should be individualized services available when the consumer needs them and where the consumer lives. 17. Transportation (to and from covered services when determined to be clinically necessary) BHTWG: March 10, 2010 15 | P a g e
    • Transportation services are used to move individuals to and from covered clinically necessary medical or behavioral health examinations, treatment and services. This service may be provided in staff-driven vehicles, or by assistance with the cost or process of arranging for and/or using public or private transportation. 18. 24-hour Out-of-Home Treatment Interventions for Children and Adolescents a. Residential Treatment Time limited services are designed to assist children or adolescents to develop skills necessary for successful reintegration into the family or transition into the community. Residential treatment centers provide an interdisciplinary psychotherapeutic treatment program on a 24-hour basis to eligible recipients. Services provided in this setting include: individual, groups and family therapy, behavior management, skill building and recreational activities. Services must be rehabilitative and provide access to necessary treatment services in a therapeutic environment. b. Treatment Foster Care Time limited community based treatment services provided to children or adolescents who are placed in 24-hour supervised, trained and surrogate family settings. Intensive therapeutic foster care services incorporate clinical treatment services, which are behavioral, psychological and psychosocial in orientation. Services must include clinical interventions by the specialized therapeutic foster parent(s) and a clinical staff person. Services included in individualized care plans are designed to assist the child or adolescent to develop skills necessary for successful reintegration into the natural family or transition into the community. The family living experience is the core treatment service. 19. Day Treatment/Partial Care Services for Children and Adolescents A non-residential treatment program designed for children and adolescents who may be at high risk of out-of-home placement. Therapeutic Day Treatment services are a coordinated and intensive set of therapeutic, individual, family, multi-family and group services and social recreational services. Day Treatment Services provide a minimum of three hours of structured programming per day, two-to-five times a week, based on acuity. BHTWG: March 10, 2010 16 | P a g e
    • Structure The BHTWG works to create an integrated system featuring certain structural elements: While some of the specific details of those elements are yet to be developed pending public input, flexibility to honor the regional need and experience, and lessons learned through a methodical and measured phased-in approach, the proposed structural elements include:  A Regional Authority will exist in each of no less Conceptualized structure than seven regions to ensure that the range of  Substance use and mental health systems core services are available are integrated to its targeted audience, identify regional needs and  An array of Core Services are available in gaps, work to fill them, each Region develop access standards,  Regional Provider Network delivers and develop community- services based services capitalizing  Regional Authority builds capacity and on regional strengths and directs resources based on local needs the directing and  Guarantor of Care (DHW) oversees leveraging of collective standards, quality assurance, evaluation, resources. It is anticipated that regional authorities and provides crisis and hospitalization will be business entities services with the ability to conduct  Formal advocacy process exists business and secure  State coordination body ensures plan funding. Recognizing that implementation and coordination the initial reconfiguration focuses on mental health, the existing Regional Mental Health Boards are likely to evolve with this capacity until that time substance use is integrated and Regional Behavioral Health Boards become the more appropriate authority.  The structure will require a regionally administrated Provider Network that can contractually fulfill the service delivery function within a capitated environment. Data generated in the earlier phases of this transformation will inform the development of capitated rates and the managed care system. The Provider Network will be accountable to the standards articulated by the Guarantor of Care. Within the envisioned structure, DHW will be providing only crisis and hospitalization services; other core services will contracted to a provider entity as established through an RFP process. The recipient of this contract might be a Health Group, a Public Health District, a Community Health Clinic or another entity.  The Guarantor of Care function is generated out of a reorganization of the Department of Health and Welfare Division of Behavioral Health. It is responsible to provide policy and standards, regulatory oversight, and quality assurance to the system. It will also BHTWG: March 10, 2010 17 | P a g e
    • provide for basic crisis and hospitalization services. Through the results of an effective data collection and claims management system, DHW will be able to lead the development of a capitated program, as well as hold the Provider Network accountable through outcome-based contract requirements. The phase one reorganization will focus on piloting the concepts of the proposed mental health delivery system in DHW's proposed Area 3 (which includes DHW Regions VI and VII), and informing the integration of the substance use system at the earliest possible juncture. By dividing into three administrative areas, the DHW is able to respond to its current budget shortfalls, focus on providing crisis and hospitalization services for all regions, generating the data that enables the transfer of other services into a managed care system, and begin to develop the standards, quality assurance processes, data management systems and oversight responsibility that supports the envisioned transformed system and structure.  A formalized advocacy process will exist. The State Planning Council on Mental Health has the specific responsibility to serve as an advocate and provide recommendations to the State Mental Health authority. This formalized advocacy process will continue as the State Planning Council provides system-wide (as opposed to specifically DHW) input and recommendations, participates on the BHTWG-Statewide Behavioral Health Board and has increased responsibility for overseeing capacity-building activities in the regions.  A BHTWG/Statewide Behavioral Health Board will oversee implementation of this strategic plan. It is envisioned that the composition of this group will be an extension of the existing BHTWG. It will specifically be structured to facilitate interagency coordination specific to transformation, data collection and service delivery, guide braided funding processes, and complete the transformation process; it will not be empowered to micro-manage agency operational activities. BHTWG: March 10, 2010 18 | P a g e
    • System The transformation features the continuation and enhancement of a number of systemic opportunities to generate efficiencies, leverage resources, develop capacity, and support the opportunity to create better outcomes for consumers. While managed, developed and coordinated within the various structural elements articulated above, the system is intended to include:  A needs assessment process which identifies gaps and works to provide the array of service in a prevalence consistent with the actual needs of the targeted population within a given region;  A braided funding system, where funding amounts for all entities using the system are known, responsibilities accounted for, and distributions are made consistent with each entities' responsibility;  Statewide service standards monitored by the Guarantor of Care;  A data-gather system which, among other outcomes, provides the ability to collect billing transactions and claims in a manner that can be shared amongst partners (like a Health Data Exchange System);  A process for ensuring effective, outcomes-based services, including an quality assurance and evaluation component managed by the Guarantor of Care;  A managed care system, providing for consistent and finite expenditures on known services and outcomes;  A performance measures process which reflects the extent to which the system is meeting needs in the most effective and efficient manner. BHTWG: March 10, 2010 19 | P a g e
    • Strategy This Plan pursues a Vision and Goals not significantly different from many that have come before. However, this Plan is unique. It presents a specific strategic for how to achieve transformation. Recognizing that DHW's reorganization into three mental health areas is driven in part by economics, the DHW and its BHTWG partners specifically intend to contract within this economic environment in a manner that positions them to collectively continue to work toward the Vision and structure articulated here. The pages that follow depict the three phases of transformation in a simplified Gantt Chart format. Within the chart are action strategies designed to pursue and develop the transformational elements of the services, structure, and systems. The first phase features reorganization of DHW into three areas where one administrator oversees existing in- and out-patient services. Starting in Area 3 (DHW Regions VI and VII), DHW will begin the process of gathering data in a manner that enables the development of a capitated environment. This data will inform an eventual RFP process to secure the provision of all but crisis and hospitalization services by an entity in the regions that is not the state. The RFP will secure the compliance with standards and policy also generated and managed by DHW. Concurrent work to enhance the role and authority of the Regional Mental Health Boards in that Area to fulfill their responsibilities will also occur during this time. By testing the structure and developing the system in the context of Area 3 first, partners will learn important lessons about how to best develop and implement the structure in other Areas and Regions of the state in the future phases outlined here. Clearly the action strategies described in the following pages are an important guide to the phases development and interagency/stakeholder coordination required to make the Transformation Vision a reality. The realities of implementation are certain to further inform and refine the strategy as time goes by, guiding it to its intended delivery system and environment as articulated in the Vision, where " Idaho citizens and their families have appropriate access to quality services provided through the publicly funded mental health and substance abuse systems that are coordinated, efficient, accountable, and focused on recovery." BHTWG: March 10, 2010 20 | P a g e
    • This is a working document, intended to describe the evolution from the current system to the ultimate system. It is intended that all entities will articulate their action strategies within this context, and acknowledges that this document is specifically subject to public and stakeholder review and input. While the action strategies outlined are those anticipated to create transformation, the BHTWG also recognizes that with the compilation of experience and data as this process evolves, adjustments to the approach may be appropriate. Strategic Action Plan 27FEB10 Project Further articulation of roles and Dev. Vision issues Action Lead/Support Phase Phase 1 Phase 2 Phase 3 This initiative is intended to provide a Inventory what agencies provide what services BHTWG x Core Services available to every Region consistent "floor" of core services in Regional Mental Health Boards every region of the state. The scope Inventory availability of services by region and Regional Advisory Councils x and arrangement of any set of core BHTWG/State Planning services within any region may vary Solicit public/stakeholder input on core services Council/Regional Boards x depending on the needs of their Revise core services based on public/stakeholder input BHTWG x targeted population, but all core services will be available in some Distribute Core Services to Regional Mental Health Boards in Regions VI manner. Services will be subject to and VII for capacity building BHTWG x standards established by DHW and Regional Authorities in VI and outcome-based. A separate core Develop Core Service capacity VII x services document exists which outlines Distribute Core Services to Regional Authorities in Regions I, II, III, IV and the core services proposed by the V for capacity building BHTWG x BHTWG. Regional Authorities in I, II, III, Develop Core Service capacity IV and V x Develop criteria for determining Regional Behavioral Health Board's A regional authority will be established operational, structural and financial readiness BHTWG x in each region for the purposes of BHTWG/State Planning ensuring that the range of core services Solicit public/stakeholder input on draft composition Council/Regional Boards x are available, identifying regional needs Revise proposed structure based on public/stakeholder input BHTWG/Public/Stakeholders x and gaps and working to fill them, and for developing community-based Test concept in area three pilot project with Regions VI and VII/articulate BHTWG Implementation Regional Authority services based on access standards set ultimate configuration Board/Regions VI and VII x by the region. Regional authorities will Generate business structure/charter and by-laws/membership Regional Authorities in VI and VII x be business entities with the ability to Identify needs and gaps Regional Authorities in VI and VII x conduct business and secure additional funding. Recognizing that the initial Develop proposed distribution of braided funding resources by region Regional Authorities in VI and VII x reconfiguration focuses on mental Develop access standards Regional Authorities in VI and VII x health, the existing Regional Mental Health Boards are likely to evolve with Explore opportunities/advantages/strategy for integrating mental health and this capacity until that time substance substance use/report to BHTWG Implementation Regional Authorities in VI and VII x use is integrated and Regional Develop/Implement Capacity Building Strategic Plan Regional Authorities in VI and VII x Behavioral Health Boards are more BHTWG-State Behavioral appropriate. Utilize that configuration for development of other regions allowing for Health Board/Regional regional flexibility Authorities in I, II, III, IV, V x BHTWG: March 10, 2010 18 | P a g e
    • Revise statues to reflect new purpose, function and configuration of BHTWG-State Behavioral Regional Behavioral Health Boards Health Board/Legislature x Regional Authorities in I, II, III, Generate business structure/charter and by-laws/membership IV and V x Regional Authorities in I, II, III, Identify needs and gaps IV and V x Regional Authorities in I, II, III, Develop proposed distribution of braided funding resources by region IV and V x Regional Authorities in I, II, III, Develop access standards IV and V x Regional Authorities in I, II, III, Develop Capacity Building Strategic Plan IV and V x Develop criteria to determine Provider Network operational, structural and financial readiness BHTWG x Develop Provider Network Administrator RFP/Contract (with data component) DHW x Issue RFP in Area 3 to support Pilot Phase DHW x Issue Area 3 contract Dept of Admin x Within the envisioned structure, DHW Develop Award Assessment/Evaluation Contract DHW x will be providing only crisis and Transition Medication Management and Care Management to Provider Regionally-administered Provider Network hospitalization services and other core network DHW x services contracted to another entity Collect and report data to inform subsequent RFPs/regional development DHW x through an RFP p. The recipient of this Share data results with BHTWG-State Behavioral Health Board/Regional contract might be a Health Group, a Administrators/Regional Authorities DHW x x Public Health District, or a Community Health Clinic that can contractually fulfill Expand WITS system to private Substance Use provider network DHW x the service delivery function within a Refer services to Provider Network IDJC capitated environment. Data generated Refer services to Provider Network DOC in the earlier phases of this Refer services to Provider Network Medicaid transformation will inform the Refer services to Provider Network DoE development of capitated rates and the Refer services to Provider Network Medicaid managed care system. The Provider Refer services to Provider Network Supreme Court Network would be accountable to the Refer services to Provider Network ODP standards articulated by the Guarantor Refer services to Provider Network Counties of Care and in the contract. Refer services to Provider Network Others as identified BHTWG-State Behavioral Health Board/Regional Administrators/Regional Provide input on potential revisions to subsequent contract Authorities x Consider Area 3/Regional Mental Health Board VI and VII inputs respective to integration of substance use/respond as appropriate in subsequent BHTWG Implementation phases Board/DHW/ODP x BHTWG: March 10, 2010 19 | P a g e
    • Prepare and Issue RFP in Areas 1 and 2 DHW x Issue Areas 1 and 2 contract Dept of Admin x Refer services to Provider Network IDJC Refer services to Provider Network DOC Refer services to Provider Network Medicaid Refer services to Provider Network DoE Refer services to Provider Network Medicaid Refer services to Provider Network Supreme Court Refer services to Provider Network ODP Refer services to Provider Network Counties Refer services to Provider Network Others as identified Collect and report data to refine delivery system DHW x The Guarantor of Care is generated Restructure to support transformation vision DHW out of a reorganization of the Develop criteria to determine Regional and Central Office operational, Department of Health and Welfare structural and financial readiness DHW x Division of Behavioral Health to provide Identify resources for Central Office regulatory and quality assurance policy and standards, regulatory and functions DHW x quality assurance oversight to the Develop Comprehensive Policy continuum to direct mental health service system, as well as to provide for basic delivery DHW x crisis and hospitalization services. Conduct system quality assurance and utilization review DHW x Through the results of an effective data Guarantor of Care collection process, DHW will be able to Realign DHW Regions IV and VII to coincide with judicial districts DHW x lead the development of a capitated Develop service standards DHW x program, as well as hold the Provider Restructure Region DHW VI and VII into Area 3 with single administrator Network accountable through outcome- over outpatient and inpatient services DHW x based contract requirements. The Transition Outpatient Services to Provider Network DHW x phase one reorganization will focus on Conduct Quality Assurance Activities DHW the mental health delivery system, with Realign DHW Regions I, II, III, IV and V to coincide with judicial districts DHW x the pilot phase informing the integration of the substance use system at the Update service standards as appropriate DHW x earliest possible juncture. By dividing Restructure DHW Regions I and II into Area 1 and III, IV and V to Area 2 first into three areas, the DHW is able to with a single administrator in each are over outpatient and inpatient respond to its budget shortfalls while services DHW x still positioning itself to support the Transition Outpatient Services to Provider Network DHW x envisioned transformed system. Conduct Quality Assurance Activities DHW BHTWG: March 10, 2010 20 | P a g e
    • The State Planning Council on Mental Participate in implementation of Public Outreach effort State Planning Council x Health has the specific responsibility to Review and potentially revise Council Section 39-3125 to align BHTWG/State Planning Formalized advocacy process serve as an advocate and provide responsibilities with transformed structure Council/Legislature x recommendations to the State Mental Participating member on BHTWG-State Behavioral Health Board State Planning Council Health authority. This responsibility to Oversee capacity building efforts of Regional Behavioral Health Boards State Planning Council continue with State Planning Council Participating member on BHTWG-State Behavioral Health Board State Planning Council providing system-wide (as opposed to Secure reports and needs as articulated by the Regional Authorities and specifically DHW) input and present to the BHTWG-Statewide Behavioral Health Board to incorporate in recommendations, participation on the coordination processes State Planning Council BHTWG-Statewide Behavioral Health Board and increased responsibilities for Present to the Governor and Legislature by June 30 of each year a report overseeing the development of capacity on the council's achievement and the impact on the quality of life that in the regions. mental health services have on the citizens of Idaho State Planning Council Develop/implement public/stakeholder outreach plan on draft BHTWG x Articulate role, responsibility and composition of Implementation Board BHTWG x Present agency-specific plan for integrating programs and services IDJC x Present agency-specific plan for integrating programs and services DOC x Present agency-specific plan for integrating programs and services Medicaid x Present agency-specific plan for integrating programs and services DoE x Present agency-specific plan for integrating programs and services Supreme Court x A BHTWG-Statewide Behavioral Health Present agency-specific plan for integrating programs and services ODP x Board will oversee implementation of this strategic plan and ensure Present agency-specific plan for integrating programs and services Others as identified x interagency coordination on shared Articulate all agency expenditures on mental health and substance abuse Statewide Coordination Body outcomes for transformation and at state and regional level BHTWG x specifically as related to braided Generate a plan for integrating substance use into the transformed system BHTWG X funding practices, data collection, and Develop process for ensuring braided funding scenario/distribution of BHTWG-Statewide Behavioral interagency engagement in the collected funds based on regional needs Health Board x process. Its envisioned that the composition of this group will be an BHTWG/BHTWG-Statewide extension of the existing BHTWG. It Assess and update Strategic Plan Behavioral Health Board x x x x will specifically be structured to facilitate Participate in braided funding process/coordination of resources IDJC interagency coordination, guide braided Participate in braided funding process/coordination of resources DOC funding processes, and complete the Participate in braided funding process/coordination of resources Medicaid transformation process; it will not be Participate in braided funding process/coordination of resources DoE empowered to micro-manage agency Participate in braided funding process/coordination of resources Supreme Court operational activities. Participate in braided funding process/coordination of resources ODP Participate in braided funding process/coordination of resources Counties Participate in braided funding process/coordination of resources Others as identified BHTWG-Statewide Behavioral Evaluate, update and refine Strategic Plan on a quarterly basis Health Board BHTWG-Statewide Behavioral Present status report to the Governor in January of every year Health Board BHTWG: March 10, 2010 21 | P a g e
    • BHTWG: March 10, 2010 22 | P a g e