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 <ul><li>Background and brief overview of STI proj...
Washington State Department of Social & Health Services Background <ul><li>Challenges Facing the 2006 Legislature </li></u...
Washington State Department of Social & Health Services Background  (cont’d) <ul><li>Challenges Facing the 2006 Legislatur...
Washington State Department of Social & Health Services Background  (cont’d) <ul><li>DSHS Approach Incorporated in Budget ...
Washington State Department of Social & Health Services Key Provisions  (cont’d) <ul><li>Community Based Care  (cont’d) </...
Washington State Department of Social & Health Services STI Implementation   <ul><li>Process </li></ul><ul><li>Consultants...
Washington State Department of Social & Health Services Benefits Package Update
Washington State Department of Social & Health Services Benefits Package- Access To Care <ul><li>Report Findings </li></ul...
Washington State Department of Social & Health Services Benefits Package- Access To Care <ul><li>Report Recommendations Pr...
Washington State Department of Social & Health Services Benefits Package- Services <ul><li>Report Findings </li></ul><ul><...
Washington State Department of Social & Health Services Benefits Package- Services <ul><li>Report Recommendations Prioriti...
Washington State Department of Social & Health Services Benefits Package- Services <ul><li>Report Recommendations Prioriti...
Washington State Department of Social & Health Services Benefits Package- Recommendations Consumer/Family Run Services <ul...
Washington State Department of Social & Health Services Benefits Package-Recommendations Integrated Dual Disorders Treatme...
Washington State Department of Social & Health Services Benefits Package- Recommendations Collaborative Care <ul><li>Colla...
Washington State Department of Social & Health Services Benefits Package- Recommendations Collaborative Care  (cont’d) <ul...
Washington State Department of Social & Health Services Benefits Package- Other Report Recommendations <ul><li>Additional ...
Washington State Department of Social & Health Services Housing Plan Update
Washington State Department of Social & Health Services Housing Plan <ul><li>Report Findings </li></ul><ul><li>All RSNs ne...
Washington State Department of Social & Health Services Housing Plan <ul><li>Report Findings  (cont’d) </li></ul><ul><li>K...
Washington State Department of Social & Health Services Housing Plan <ul><li>Report Findings  (cont’d) </li></ul><ul><li>K...
Washington State Department of Social & Health Services Housing Plan <ul><li>Report Recommendations Prioritized by MHD for...
Washington State Department of Social & Health Services Housing Plan <ul><li>Report Recommendations Prioritized by  </li><...
Washington State Department of Social & Health Services Housing Plan <ul><li>Additional recommendations which MHD will con...
Washington State Department of Social & Health Services Wrap Up For further information on STI: http://www1.dshs.wa.gov/Me...
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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
Transformation Initiative projects; a benefits package update, and a housing action plan update.

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System Transformation Initiative

  1. 1. Washington State Department of Social & Health Services Mental Health Transformation Work Group Update October 26, 2007
  2. 2. Washington State Department of Social & Health Services Agenda For Today <ul><li>Background and brief overview of STI projects </li></ul><ul><li>Benefits Package Update </li></ul><ul><li>Housing Action Plan Update </li></ul>
  3. 3. Washington State Department of Social & Health Services Background <ul><li>Challenges Facing the 2006 Legislature </li></ul><ul><li>Decreasing community psychiatric inpatient capacity </li></ul><ul><li>State hospital waiting lists </li></ul><ul><li>Court rulings in September 2005 </li></ul><ul><ul><li>No wait for transfer of 90/180 ITA patients </li></ul></ul><ul><ul><li>Failure to follow proper procedures for assessing “liquidated damages” </li></ul></ul><ul><li>Variable inpatient utilization and lengths of stay </li></ul><ul><ul><li>Long lengths of stay in Washington’s state hospitals </li></ul></ul><ul><ul><li>Significant disparities in lengths of stay when comparing state hospitals </li></ul></ul><ul><ul><li>Significant disparities between RSNs in per capita inpatient utilization </li></ul></ul>
  4. 4. Washington State Department of Social & Health Services Background (cont’d) <ul><li>Challenges Facing the 2006 Legislature (cont’d) </li></ul><ul><li>Other system challenges </li></ul><ul><ul><li>Lack of clarity regarding waiver benefits </li></ul></ul><ul><ul><li>Idiosyncrasies of Washington’s ITA statute </li></ul></ul><ul><ul><li>Observable lack of residential and housing capacity </li></ul></ul><ul><ul><li>Goal for standardization & best practice in utilization management </li></ul></ul>
  5. 5. Washington State Department of Social & Health Services Background (cont’d) <ul><li>DSHS Approach Incorporated in Budget and Legislative Initiatives </li></ul><ul><li>Clarified roles of State & RSNs related to community and state hospital care </li></ul><ul><li>Time limited investment in State Hospital capacity to deal with inpatient access issues </li></ul><ul><li>Investment in enhanced community resources to reduce reliance on state hospitals </li></ul><ul><ul><li>PACT </li></ul></ul><ul><ul><li>Funding for PALS Residents </li></ul></ul><ul><li>By January 2008, requires RSNs to pay for individuals at PALS </li></ul><ul><li>Long term planning </li></ul>
  6. 6. Washington State Department of Social & Health Services Key Provisions (cont’d) <ul><li>Community Based Care (cont’d) </li></ul><ul><li>Funding for PACT & other Expanded Community Services </li></ul><ul><ul><li>Development funds FY 07 </li></ul></ul><ul><ul><li>Operational Funds FY 08 </li></ul></ul><ul><ul><li>Contract for Training & TA- WIMIRT </li></ul></ul><ul><li>Long Term Planning – RFP for Consultant Contracts </li></ul><ul><ul><li>Benefits Package/ Rates- TRI West </li></ul></ul><ul><ul><li>Involuntary Treatment Act- TRI West/ Advocates for Human Potential </li></ul></ul><ul><ul><li>Mental Health Housing Plan- Common Ground </li></ul></ul><ul><ul><li>External Utilization Review- University of Washington- Harborview </li></ul></ul><ul><ul><li>Employment Initiative- WIMIRT (added to STI by MHD) </li></ul></ul>
  7. 7. Washington State Department of Social & Health Services STI Implementation <ul><li>Process </li></ul><ul><li>Consultants For Each Project Initiative </li></ul><ul><li>Standing Representative Task Force </li></ul><ul><ul><li>35-40 members from variety of interested parties </li></ul></ul><ul><ul><li>Monthly meetings beginning in Oct 06 </li></ul></ul><ul><li>Community Forums- approximately 150 people each </li></ul><ul><ul><li>November 06, January 07, May 07, and July 07 </li></ul></ul><ul><li>Tribal Roundtable and focus groups- Feb - May 2007 </li></ul><ul><li>Focus Groups- by consultants as needed </li></ul><ul><li>STI Web Site </li></ul><ul><li>Product- Reports with consultant recommendations to DSHS/MHD for improvements </li></ul><ul><li>Next Step- MHD prioritize recommendations for further development with the Governor and Legislature </li></ul>
  8. 8. Washington State Department of Social & Health Services Benefits Package Update
  9. 9. Washington State Department of Social & Health Services Benefits Package- Access To Care <ul><li>Report Findings </li></ul><ul><li>To receive Medicaid services through an RSN, a person must: </li></ul><ul><li>Have a covered diagnosis (there are two lists- List A & List B) </li></ul><ul><li>Have a functional impairment measured by a standard functioning protocol (GAF for adults, CGAS for children/adolescents) </li></ul><ul><li>If B diagnosis, have additional risk issues </li></ul><ul><li>Challenges </li></ul><ul><li>Barrier to early intervention for high-risk populations </li></ul><ul><li>Dilutes emphasis on managing higher need cases (long-term case management, day support, residential services) </li></ul>
  10. 10. Washington State Department of Social & Health Services Benefits Package- Access To Care <ul><li>Report Recommendations Prioritized by MHD for Further Development </li></ul><ul><li>Conduct a full actuarial analysis of the financial impact of revising GAF and CGAS minimums for routine outpatient care </li></ul><ul><li>If financially feasible, raise the GAF and CGAS minimums to at least 70 for all covered diagnoses </li></ul><ul><li>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 </li></ul><ul><ul><li>Statewide medical necessity standards for all levels of care </li></ul></ul><ul><ul><li>Includes criteria for initial and ongoing reviews </li></ul></ul>
  11. 11. Washington State Department of Social & Health Services Benefits Package- Services <ul><li>Report Findings </li></ul><ul><li>Analysis of Washington’s State Medicaid Plan compared to AZ, CO, NM and PA </li></ul><ul><ul><li>WA’s State Plan is very flexible; able to promote wide range of practices </li></ul></ul><ul><ul><li>CMS is increasingly strict </li></ul></ul><ul><ul><li>RSNs choose EBPs and develop within current funds </li></ul></ul><ul><li>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 </li></ul><ul><li>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) </li></ul><ul><li>“ Centers of Excellence” generally tied to successful statewide promotion of specific services (ACT, Peer Support) </li></ul>
  12. 12. Washington State Department of Social & Health Services Benefits Package- Services <ul><li>Report Recommendations Prioritized by MHD for Further Development </li></ul><ul><li>Do not propose any changes to CMS regarding the structure of the State Plan for Rehabilitative Services </li></ul><ul><li>Prioritize the following 3 EBPs for Statewide Implementation </li></ul><ul><ul><li>Peer support services provided directly by Consumer and Family Run Organizations </li></ul></ul><ul><ul><li>Integrated Dual Disorder Treatment for persons with co-occurring mental health and substance use disorders </li></ul></ul><ul><ul><li>Collaborative Care in Primary Care Settings for populations most effectively served by clinicians located in primary care settings (e.g. older adults) </li></ul></ul><ul><ul><li>Note- 2 EBPs recommended for children (MTFC & Wraparound) will be considered as part of input process for 1088 </li></ul></ul><ul><li>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 </li></ul>
  13. 13. Washington State Department of Social & Health Services Benefits Package- Services <ul><li>Report Recommendations Prioritized by MHD for Further Development (cont’d) </li></ul><ul><li>Primary goals used to prioritize practices for statewide promotion: </li></ul><ul><ul><li>Biggest clinical impact (with emphasis on appropriate inpatient utilization) </li></ul></ul><ul><ul><li>Promotion of recovery and resilience </li></ul></ul><ul><ul><li>Promotion of culturally relevant practices and cultural competence </li></ul></ul><ul><ul><li>Promotion of consumer/family-driven care </li></ul></ul><ul><ul><li>Distribution across age groups </li></ul></ul><ul><ul><li>Widest and most immediate possible impact </li></ul></ul><ul><ul><li>Potential cost offsets </li></ul></ul>
  14. 14. Washington State Department of Social & Health Services Benefits Package- Recommendations Consumer/Family Run Services <ul><li>Washington’s Peer Support modality is very broad and superior to those of most of the comparison states </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Could also facilitate interventions such as drop-in centers, family psychoeducation, and other consumer / family supports </li></ul>
  15. 15. Washington State Department of Social & Health Services Benefits Package-Recommendations Integrated Dual Disorders Treatment <ul><li>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) </li></ul><ul><li>IDDT encompasses 14 components, each of which is evidence-based, including: </li></ul><ul><ul><li>Screening and assessments that emphasize “no wrong door” </li></ul></ul><ul><ul><li>Stage-wise treatment that recognizes that different services are helpful at different stages of the recovery process </li></ul></ul><ul><ul><li>Motivational interviewing and treatment </li></ul></ul><ul><li>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 </li></ul>
  16. 16. Washington State Department of Social & Health Services Benefits Package- Recommendations Collaborative Care <ul><li>Collaborative Care is a model of integrating mental health and primary care services in primary care settings in order to: </li></ul><ul><ul><li>treat the individual where he or she is most comfortable </li></ul></ul><ul><ul><li>build on the established relationship of trust between a doctor and consumer </li></ul></ul><ul><ul><li>better coordinate mental health and medical care </li></ul></ul><ul><ul><li>reduce the stigma associated with receiving mental health services </li></ul></ul><ul><li>Two key principles form the basis of the model: </li></ul><ul><ul><li>Mental health case managers and professionals are integrated into primary care settings </li></ul></ul><ul><ul><li>Psychiatric and licensed clinical consultation and supervision is available to provide additional mental health expertise where needed </li></ul></ul>
  17. 17. Washington State Department of Social & Health Services Benefits Package- Recommendations Collaborative Care (cont’d) <ul><li>Key components include screening, consumer education and self-management support, mental health specialty referrals as needed, and linkages with other community services </li></ul><ul><li>Multiple studies have documented the effectiveness of collaborative care models to treat anxiety and panic disorders, depression in adults, and depression in older adults </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  18. 18. Washington State Department of Social & Health Services Benefits Package- Other Report Recommendations <ul><li>Additional recommendations which MHD will continue to study: </li></ul><ul><ul><li>Revise current RSN contract requirements for Statewideness and provide definitive guidance to RSNs on implementation </li></ul></ul><ul><ul><li>Develop encounter coding protocols to allow MHD and RSNs to track the provision of other best practices </li></ul></ul><ul><ul><li>Develop Centers of Excellence to support the implementation of those best practices prioritized for statewide implementation </li></ul></ul>
  19. 19. Washington State Department of Social & Health Services Housing Plan Update
  20. 20. Washington State Department of Social & Health Services Housing Plan <ul><li>Report Findings </li></ul><ul><li>All RSNs need a range of housing options </li></ul><ul><ul><li>Licensed residential facilities </li></ul></ul><ul><ul><li>Community based housing </li></ul></ul><ul><ul><li>Crisis respite beds </li></ul></ul><ul><li>Permanent Supportive Housing (PSH) most appropriate for most MH consumers </li></ul><ul><ul><li>All RSNs need additional PSH </li></ul></ul><ul><ul><li>Estimated need for up to additional 5000 units in WA for people served by the public mental health system </li></ul></ul><ul><ul><li>Initial goal should be for development of 760 PSH units for mental health consumers between 2007-2010 </li></ul></ul>
  21. 21. Washington State Department of Social & Health Services Housing Plan <ul><li>Report Findings (cont’d) </li></ul><ul><li>Key elements to successful PSH Implementation </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Rental subsidies (Section VIII wait lists)- 65% of units can be funded through existing sources leaving a gap of 35% (260 units) </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  22. 22. Washington State Department of Social & Health Services Housing Plan <ul><li>Report Findings (cont’d) </li></ul><ul><li>Key elements to successful PSH Implementation </li></ul><ul><ul><li>Access to on site supportive services </li></ul></ul><ul><ul><ul><li>Case manager caseloads ranging from 1:8-1:20 depending on needs of consumers </li></ul></ul></ul><ul><ul><ul><li>access to 24/7 crisis response from MH provider </li></ul></ul></ul><ul><ul><ul><li>Estimate that 480 of 760 units can be supported by new PACT or programs created related to PALS community funds </li></ul></ul></ul><ul><ul><ul><li>Remainder of services will need to come from either new funds or redirection of current RSN service dollars </li></ul></ul></ul>
  23. 23. Washington State Department of Social & Health Services Housing Plan <ul><li>Report Recommendations Prioritized by MHD for Further Development </li></ul><ul><li>Secure rent subsidies funding for 35% of units that can’t be funded through existing sources (260 units) </li></ul><ul><li>Secure funding for operating subsidies (e.g. landlord incentives, risk mitigation funds)- for excess costs of renting to consumers </li></ul><ul><li>Identify whether additional funding for PSH services can be met through current allocations or require any new funds </li></ul><ul><li>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 </li></ul>
  24. 24. Washington State Department of Social & Health Services Housing Plan <ul><li>Report Recommendations Prioritized by </li></ul><ul><li>MHD for Further Development (cont’d) </li></ul><ul><li>Ensure PIHP benefit design includes flexible modality for services in home settings with rate sufficient to cover costs </li></ul><ul><li>Suggest standard to identify number of crisis respite beds needed and identify funding if needed </li></ul><ul><li>Develop a closer working relationship with CTED and consider a joint PSH funding proposal for 2009 </li></ul>
  25. 25. Washington State Department of Social & Health Services Housing Plan <ul><li>Additional recommendations which MHD will continue to study: </li></ul><ul><li>Explore the use of the Charitable, Educational, Penal, and Reformatory Institutions Trust Fund to support PSH for mental health consumers </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
  26. 26. 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]

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