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Divert to Where: Community Leadership & Cross-System Planning


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Divert to Where: Community Leadership & Cross-System Planning
Presented by: Mark A. Engelhardt, MS, ACSW

Published in: Health & Medicine
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Divert to Where: Community Leadership & Cross-System Planning

  1. 1. Divert to Where: Community Leadership & Cross-System Planning <ul><li>CIT International Conference </li></ul><ul><li>Mark A. Engelhardt, MS, ACSW </li></ul><ul><li>San Antonio, Texas </li></ul><ul><li>June 1, 2010 </li></ul>
  2. 2. Guiding Questions <ul><li>Is the your Acute Care System well “designed” or does it operate by “default”? </li></ul><ul><li>How does CIT fit into a larger system of Law Enforcement and Behavioral Healthcare? </li></ul><ul><li>Is there a full array of appropriate services based on citizen demand, community experience, access and continuing care? </li></ul><ul><li>Is there an organized acute care plan? </li></ul><ul><li>What do Law Enforcement & Citizens want? </li></ul>
  3. 3. Strategic Planning Framework <ul><li>Principles: Recovery Umbrella </li></ul><ul><li>Community Challenges: International </li></ul><ul><li>Public/Private Partnerships </li></ul><ul><li>Goals & Objectives </li></ul><ul><li>Problem Solving Variables: Leadership </li></ul><ul><li>System Service Array: Design-Elements </li></ul><ul><li>Cost-Benefits - Evaluation </li></ul>
  4. 4. Principles: <ul><li>Welcoming: No Wrong Door, Individuals </li></ul><ul><li>Integrated Assessment & Treatment </li></ul><ul><li>Immediate Diversion or Access to Care </li></ul><ul><li>Competent Recovery-Focused Providers </li></ul><ul><li>Cross-Systems Collaborations </li></ul><ul><li>Comprehensive & Continuing Care </li></ul><ul><li>Balance: Public Safety and Recovery </li></ul>
  5. 5. SAMHSA Practice Guidelines <ul><li>Core Elements in Responding to Mental Health Crisies </li></ul><ul><li>HHS Publication No. SMA-09-4427 Rockville, Md. </li></ul><ul><li>Center for Mental Health Services/SAMHSA </li></ul><ul><li>Values, Principles, Implementation </li></ul>
  6. 6. Definitions: Acute Care <ul><li>Break down of Normal Coping Mechanisms </li></ul><ul><li>Individualized Experiences (Traumatic) </li></ul><ul><li>Acuity Level: Prevention to Dangerousness </li></ul><ul><li>Ambulatory to Residential/Inpatient/Jail </li></ul><ul><li>Triage To Treatment/Recovery Models </li></ul><ul><li>Stabilization: Brief 2-6 Weeks: Episodic </li></ul><ul><li>Connection to Community System of Care </li></ul>
  7. 7. National Community Challenges: <ul><li>Lack of Acute Care Services and Community Residential Care </li></ul><ul><li>Fragmented Delivery Systems </li></ul><ul><li>Lack of Provider & Hospital Cooperation </li></ul><ul><li>“ Nearest” Receiving Facility Mandate </li></ul><ul><li>Demand on Emergency Rooms </li></ul><ul><li>Recent Hospital Closures </li></ul>
  8. 8. Community Challenges: <ul><li>Human Rights Issues or Law Violations </li></ul><ul><li>Potential Lawsuits </li></ul><ul><li>Unplanned Gate Keeping at Area Emergency Rooms </li></ul><ul><li>Coordination Among Law Enforcement and Transportation Providers (Wait times) </li></ul><ul><li>State Hospital vs. Community Care </li></ul><ul><li>Workforce Issues: Recruitment - Retention </li></ul>
  9. 9. Public/Private Partnerships: <ul><li>Persons Receiving Services & Families </li></ul><ul><li>City/County/State/Regional Substance Abuse & Mental Health Authorities </li></ul><ul><li>County Commission & Executive Staff </li></ul><ul><li>Bipartisan Legislative Involvement </li></ul><ul><li>Area Hospital Emergency Rooms, Inpatient Units & Med-Surgery Units </li></ul>
  10. 10. Public/Private Partnerships: <ul><li>Public Defenders </li></ul><ul><li>States’ Attorneys </li></ul><ul><li>In-Jail Medical Staff </li></ul><ul><li>County Criminal Justice Staff </li></ul><ul><li>Homeless Coalition Members </li></ul><ul><li>NAMI, Mental Health America, etc. </li></ul><ul><li>Psychiatric & Healthcare Associations </li></ul>
  11. 11. Public/Private Partnerships: <ul><li>Private Non-profit & For-Profit Free-standing Psychiatric Hospitals </li></ul><ul><li>Community Mental Health and Substance Abuse Providers </li></ul><ul><li>Veterans Affairs Medical Centers </li></ul><ul><li>Law Enforcement Agencies & Courts </li></ul><ul><li>Health & Human Service Planning Bodies </li></ul><ul><li>Human Rights: State/Local Advocates </li></ul>
  12. 12. Overall Goals, Objectives & Implementation Models <ul><li>Establish an “Organized” Central System (“Drop-Off”) of diversion and assessment to improve access and availability to Recovery acute care services. </li></ul><ul><li>Provide specialized services to subpopulations, CJMHSA, children and older adults/elderly. </li></ul><ul><li>Provide a dignified, streamlined method of transportation, including special needs as necessary from nursing homes and assisted living facilities. </li></ul>Reference Article
  13. 13. Strategic Goals and Objectives: <ul><li>Divert inappropriate admissions from hospital emergency rooms and jails. </li></ul><ul><li>CIT Teams and Behavioral Health Partners </li></ul><ul><li>Provide a range of acute care services that would treat persons in the community and avoid state hospital or restrictive inpatient admissions. </li></ul><ul><li>Work within existing resources…or else… </li></ul><ul><li>Obtain the necessary appropriations from the legislature to redesign/rebuild the system. </li></ul>
  14. 14. Goals & Objectives: <ul><li>Assist law enforcement with CIT training and on-site assessments (street level) </li></ul><ul><li>Develop a System that is Co-occurring capable and enhanced </li></ul><ul><li>Continue to develop pre and post booking treatment services with the Jail, Public Defender & State Attorney </li></ul><ul><li>Avoid Forensic State Hospital Admissions </li></ul>
  15. 15. Goals and Objectives: <ul><li>Work Closely with Medicaid to Ensure Access Standards & Implementation of Medicaid Managed Care MH Plans </li></ul><ul><li>Utilize Private Transportation Providers </li></ul><ul><li>Maximize Public Receiving Facility Capacity, Utilization Management and Develop Cooperative Agreements </li></ul>
  16. 16. Problem Solving Factors: <ul><li>High Level Executive Involvement </li></ul><ul><li>Inter-Governmental Unity: State and Counties (Rural, Multi-County) </li></ul><ul><li>Commitment from All Agencies and Involved Parties </li></ul><ul><li>Competent Providers – Recovery Focus </li></ul><ul><li>Examine several system change options-Replication, yet “Act Local” – Urban/Rural </li></ul>
  17. 17. Problem Solving Factors: <ul><li>Analyze the Data-admissions/pre/post discharges-length of stay, inter-facility transfers and follow up </li></ul><ul><li>Regular Meetings – Open & honest: Sharing of data – Public & private </li></ul><ul><li>Short & Long Term Plans-Flexibility </li></ul><ul><li>Establish Acute Care Action Committee – Key Leadership & Stakeholders </li></ul>
  18. 18. System Design: Divert to Where: Service Array <ul><li>Models: Practice & Research </li></ul><ul><li>Opportunity to Learn, Grow, Recover </li></ul><ul><li>In-home, Wraparound, Crisis Residential </li></ul><ul><li>Preventive or Follow Up Respite Care </li></ul><ul><li>Telephonic: “Warm” & Hot Lines </li></ul><ul><li>Suicide Prevention Task Forces </li></ul><ul><li>Cultural Diversity, Access & Competency </li></ul>
  19. 19. System Design: Service Array <ul><li>Voluntary or involuntary status of the person in need of services </li></ul><ul><li>Crisis Support-Access Centers-Central Intake for Children & Adults </li></ul><ul><li>Mobile Crisis Response Team and Crisis Intervention Teams (CIT – Police-based) </li></ul><ul><li>Integrated Co-occurring – Examine Legal, Licensure & Accreditation Barriers </li></ul>
  20. 20. System Design: Service Array <ul><li>Priority Assessments – Service Planning </li></ul><ul><li>Emergency Medications </li></ul><ul><li>Supportive & Housing First Options </li></ul><ul><li>Transportation “Exception” Plans – Option to Contract with Transportation Provider (s), Central or Co-located Intake </li></ul><ul><li>Law Enforcement Coordination in the Absence of a CIT Team </li></ul>
  21. 21. System Design: Service Array <ul><li>Peer Navigators – Consumer Supports At All Levels, In Reach and Respite Care </li></ul><ul><li>International Peer Support Training </li></ul><ul><li>Case Management Services: Intensive and ACT Team Referrals </li></ul><ul><li>Homeless Interventions (Path Outreach) – Police – Social Services Team Models </li></ul><ul><li>Specialized Children & Elder Services: Wraparound Services - Assisted Living Facility/Nursing Home “Overlay” – In-vivo </li></ul>
  22. 22. System Design: Free Standing “Divert to Where: Alternatives” <ul><li>Children’s Crisis Stabilization Unit (CCSU) </li></ul><ul><li>Adult Crisis Stabilization Unit (CSU) </li></ul><ul><li>Short Term Residential Treatment (SRT) </li></ul><ul><li>Residential Treatment Facility (RTF) </li></ul><ul><li>Detoxification: Ambulatory & Secure & Non-Secure Residential Options: Addiction Receiving Facilities (ARF): Low Demand </li></ul>Secure and/or Non-secure
  23. 23. System: Use of ER’s By Design or by Default – EMTALA Issues <ul><li>Medical Clearance – Written Protocols, Community Standards & Agreements </li></ul><ul><li>COBRA Revisions – Examination, Treatment & Transfer (Anti-Dumping) 42 CFR-489.24(a) Guidelines </li></ul><ul><li>EMTALA – Emergency Medical Treatment and Active Labor ACT ( </li></ul><ul><li>ER Model with “6 -12 - 23 Hour” Screening </li></ul><ul><li>Cost of Inpatient Days, Discharge Planning, Risk </li></ul>
  24. 24. Emergency Room Models A Few Factors <ul><li>The psychiatric emergency room model may be the preferred model in some communities </li></ul><ul><li>Integrated health screening & substance abuse identification </li></ul><ul><li>Financial Issues +/- </li></ul><ul><li>Many ER’s want community-based alternatives (CSU’s) </li></ul><ul><li>Police want a “drop-off point” ER or not </li></ul><ul><li>Risk assessment & continuing care is key </li></ul><ul><li>Legislative partners with providers </li></ul>
  25. 25. System Elements: Public Sector <ul><li>Basic Understanding of Insurance Plans </li></ul><ul><li>Medicaid Recipients: (Access Standards) </li></ul><ul><li>Medicaid Managed Care Plans </li></ul><ul><li>Fee for Service Medicaid/Medicare </li></ul><ul><li>Indigent – State & County/City Funding </li></ul><ul><li>Exparte: Judicial Intervention </li></ul><ul><li>Forensic Issues </li></ul>
  26. 26. System Elements: <ul><li>Acute Care Training: Crisis Intervention Teams (CIT) Fidelity - Law Enforcement and Behavioral Health Cross-training </li></ul><ul><li>Resolve Any State Licensing or Local Zoning Issues </li></ul><ul><li>Contractual – State/County Funds, Medicaid – Local Match, Private Sector </li></ul>
  27. 27. System Leeadership Governance: <ul><li>System Mandate or Oversight: State/County/City Substance Abuse & Mental Health Authority </li></ul><ul><li>Solution Focused Meetings with Community Partners: County, Providers, Law Enforcement, Public Defender, States Attorney, Consumers/Families, Advocates, Open Meetings </li></ul><ul><li>Shared Community Leadership </li></ul><ul><li>Strategic Plans with Follow Through Actions </li></ul>
  28. 28. Leadership: Action Plans <ul><li>A Call To Action – Strategic Plans </li></ul><ul><li>Establish a City Acute Care Leadership Group Task Force or Operations Committee </li></ul><ul><li>Assess Current Treatment Capacity </li></ul><ul><li>Assess Competencies Across Disciplines </li></ul><ul><li>Manage with Open & Honest Data </li></ul><ul><li>Conduct a Funding Analysis & Plan </li></ul>
  29. 29. Planning & Implementation: Statewide, Regional or Local <ul><li>Strengths-Based Facilitation – Leadership </li></ul><ul><li>System = Consensus & Organized Care </li></ul><ul><li>Strategic Planning with MOU’s* </li></ul><ul><li>System Mapping or Logic Models </li></ul><ul><li>Evidenced-Based and Local Best Practices </li></ul><ul><li>Financial Model With Incentives </li></ul><ul><li>Long-Term Stakeholder Commitments </li></ul>
  30. 30. Implementation: Systems <ul><li>Systems Level – Policy, Direction, Funds, Recovery Planning, Legal Issues, Cross-Systems Partnerships, Data, Regulatory Barriers or New Rule Development </li></ul><ul><li>RFP/RFA/RFI – Design, Best Practices, Technical Assistance – Pre/Post, Timetable </li></ul><ul><li>Outcomes – Realistic in the First Couple of Years, Evaluation – Process & Clinical </li></ul>
  31. 31. Legislative or Rule Changes: Examples <ul><li>Creation of Secure Addictions Receiving “Emergency Petition” for SA </li></ul><ul><li>Co-occurring Licensure </li></ul><ul><li>Mandated Strategic Planning (LA.) </li></ul><ul><li>Transportation Options </li></ul><ul><li>Data Reporting by Providers </li></ul><ul><li>ER – 12 Hour Rules, Treat Transfer </li></ul>
  32. 32. Implementation: Programs <ul><li>Program Level – Range and Depth of Current Acute Care & Community-Based Care, Provider Competency – Workforce Issues, Experience, Facilities – Capacity Issues, New Services </li></ul><ul><li>Co-occurring Capability – Expectation </li></ul><ul><li>Target Populations </li></ul><ul><li>Mid-Course Corrections </li></ul>
  33. 33. Implementation – Clinical- Consumer Issues <ul><li>Clinical/Consumer Level – Recovery Philosophy – Baseline – Attitudes, Skills, Ability – Staff Training, Consumer/Family Involvement </li></ul><ul><li>Short-term Intervention – Road to Recovery – Advance Directives – Transition Plans </li></ul><ul><li>“ Welcoming, No Wrong Door” </li></ul><ul><li>Person-centered (driven) Planning </li></ul><ul><li>Wellness Recovery Action Planning (WRAP) </li></ul><ul><li>People Recover at “Home”. </li></ul>
  34. 34. Costs Benefits: <ul><li>State-Local Match; Medicaid </li></ul><ul><li>Private Hospitals Commit $ </li></ul><ul><li>Economy of Scale CSU/SRT/RTF </li></ul><ul><li>Transportation – Relief for Law Enforcement with Private Providers </li></ul><ul><li>Diversions From ER’s, Jails, Hospitals </li></ul><ul><li>Cost Savings-Cost Avoidance </li></ul>
  35. 35. Recommendations: <ul><li>Address Co-Occurring Disorders and Related Health/Social Services </li></ul><ul><li>Integrate Acute Care Plan with other System Development: Housing, ACT Teams, Medications, Outpatient Supports, Recovery & Rehabilitation Models </li></ul><ul><li>Develop Advocacy Mechanisms: Consumer Rights Process - Grievances </li></ul>
  36. 36. Recommendations: <ul><li>Assess Current Political Environment </li></ul><ul><li>Expand or Redesign Services </li></ul><ul><li>Buy or Build Bed Capacity Only if Needed </li></ul><ul><li>Community Reinvestment Ideas </li></ul><ul><li>On-going Evaluation, Mid-course Corrections, Education and Training </li></ul><ul><li>COOPERATION, COLLABORATION & COMMITMENT = Leadership </li></ul>
  37. 37. Recent State Examples: <ul><li>New Jersey – Leadership, New Collaborations, Regional Crisis Coordination, Healthcare </li></ul><ul><li>Texas - $ Allocations – Comprehensive Plans with Targeted Urban/Rural Initiatives </li></ul><ul><li>Iowa – State Task Force, $ 1.5 RFP </li></ul><ul><li>Florida – Co-occurring capability – Pursuing Licensure Changes, New SA Medicaid Codes </li></ul><ul><li>Louisiana: ACT 447 – Crisis Response System </li></ul>
  38. 38. Contact Information: Follow Up Technical Assistance <ul><li>Mark A. Engelhardt, MS, MSW, ACSW </li></ul><ul><li>813-974-0769 </li></ul><ul><li>[email_address] </li></ul><ul><li>University of South Florida - Tampa, Florida </li></ul><ul><li> = CJMHSA </li></ul><ul><li> – FMHI “Baker Act” Data Reporting Center </li></ul>