Transcript Learning via the Natural Environment
Texas, We Have A Crisis!
NADD 31
st
Annual Conference November 2014
Gregory Rowe, Concho Valley Maria Quintero, Harris County MHMRA
Welcome and Introductions
Goals for Today
• • • Participants will understand what a crisis is as opposed to what an emergency is for individuals with a dual diagnosis of IDD and mental illness. Participants will gain an understanding of what the 1115 Medicaid Funded Safety Net services are in Texas.
Participants will be able to identify the crisis projects in each region of the state of Texas; their similarities and uniqueness.
The Need for IDD Crisis Services
• • • • The Current System of Services When a psychiatric/behavioral health crisis occurs one of the primary means of current care is for families and residential provider staff to take an individual to the Emergency Department (ED). ED’s will provide a sedative type medication to calm the individual and then send him/her home. While in the ED the individual may become agitated and aggressive. This disturbs other patients who are at the ED for physical/medical needs and places them in danger.
If a crisis is more severe the ED will refer the individual to a local psychiatric hospital.
The Need for IDD Crisis Services
• • • • The Current System of Services If the crisis is more than a local psychiatric hospital can adequately address, the individual is sent to a State Hospital.
Law enforcement may become involved at the ED or at the individual’s home. There is a great possibility the individual may go to jail.
Due to severe psychiatric/behavioral health needs the individual is at risk of losing their home/residence. The individual could be admitted to a State Supported Living Center.
The Need for IDD Crisis Services
• • • • The Outcomes of the Current System The community has a lack of psychiatric services for both adults & children; especially for those with special needs of IDD/behavioral health. Behavior crisis often develops due to an increase need of training of direct support staff on interacting with individuals in an appropriate manner and on crisis prevention.
There is an over utilization of local & state hospitals due to a lack of community crisis resolution programs targeted for individuals with IDD/behavioral health needs.
There is a potential loss of residence when an individual is admitted to a hospital or goes to jail; or possible institutionalization at a hospital or State Supported Living Center.
The Need for IDD Crisis Services
• • • • The Outcomes of the Current System Additional trauma can occur when an individual with IDD/mental illness enters a behavioral health crisis and is admitted to a psychiatric hospital or arrested and detained in jail.
There are no alternatives in most communities at this time to address a crisis other than going to the ED. There appears to be a lack of appropriate mental health/behavioral crisis management in the community. This could lead to individuals with IDD/behavioral health needs ending up in an ED for psychiatric care, or going to a psychiatric hospital (State or private), or even to jail, which will cost more to our community and state. Providers do not have any support and are often at a loss of how to handle an individual who goes into psychiatric/behavioral crisis. Providers have no other choice but to take an individual to the ED for help.
Examples of the Need for Crisis Services
Putting a Face to the IDD Community Crisis Picture
Examples of the Need
Scotty A young man with great potential, but has been arrested 33 times since 2006, is in and out of psychiatric hospitals, lives on the streets, and partakes in dangerous and life threatening activities.
Examples of the Need
Abel A young man who lived in the community most of his life, but lost his home and was admitted to the State Supported Living Center due to aggressive behavior and unmet psychiatric issues.
IDD & Crisis What Does that Mean?
Let’s Take a Closer Look at What a Crisis Is
What is a Crisis?
A Crisis is a normal response to an incredibly stressful or overwhelming event.
What is a Crisis?
Crises are always time limited
Precipitating Event
A precipitating event is a stressor or situation that happens just before the person goes into crisis.
Factors that could Precipitate a Crisis
• The exacerbation of one’s mental illness due to problems related to medication • Environmental stressors • Psychological or interpersonal stressors • Physical stressors • Any or a combination of the above
Ingredients of a Crisis
A hazardous / traumatic event A general unsteady / unbalanced state A precipitating factor A full blown crisis state The resolution of the crisis
Physical Signs of Crisis:
Psychological / Emotional Signs of Crisis
Dynamics of a Crisis
Understanding the dynamics of a crisis is important to the development of the effective intervention, stabilization, and prevention.
Crisis vs. Emergency
Crisis -An individual is evicted from their home and has nowhere to live.
-An individual says that she feels like dying because she misses her family Emergency -An individual is being chased by her ex-boyfriend who says he is going to kill her. -An individual leaves the group home and attempts to run away.
People in Crisis are Open to Receive Help
What is Crisis Intervention?
Crisis intervention techniques are direct, strategic and very goal- focused.
Definition and Components of Crisis Intervention A Texas Model
Community Safety Net Services for Persons with IDD and Their Families
• • • Developed in 2004 by a workgroup of the Executive Directors’ Consortium.
Established a vision for Safety Net services Defined key components of an effective Safety Net for people with IDD
Community Safety Net Services for Persons with IDD and Their Families
• • • The Safety Net is the short-term community response to protect the health and safety of persons with mental retardation who have an intensive need until a long-term solution can be reached. These interventions also provide critical time limited interim support to families and other caregivers to children and adults with mental retardation. The Community safety net provides effective intervention with behaviors that undermine an individual’s stability in their home or current living arrangement.
Community Safety Net Services for Persons with IDD and Their Families
• • The need for short-term community response is an essential element in supporting persons with mental retardation in their homes and community rather than more expensive residential options out of the person’s home. It is also important for persons to have choices and direct their lives especially when added choices are both economically effective as well as improves the quality of life.
Such an integrated, systemic approach results in more freedom, authority, responsibility, support, and confirmation – the tenets of self-determination.
• • • • •
Defining the Need for an Intensive Response
A danger or risk of losing support system, especially living setting or supports needed to maintain self; At risk of abuse or neglect; Basic health and safety needs not being met through current supports; At risk for functional loss without intervention or preventative/maintenance services; or, Demonstration of repeated criminal behavior or dangerous behaviors or threats.
Components of a Safety Net
• • • • • • • Information & Assistance – Initial contact – Assessment Emergency Respite Behavioral Intervention – Addition of Crisis Response Teams Partial Day Respite Coordination Residential Continued access to Respite and Coordination to promote stability and prevent crisis
1115 Medicaid Funded Safety Net Services in Texas
or
What on Earth is “DSRIP”?
The Transformation of Healthcare in Texas: Medicaid 1115 Waiver
Section 1115 of the Social Security Act
• Gives the Secretary of Health and Human Services authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and CHIP programs. • The purpose of these demonstrations, which give States additional – CHIP eligible flexibility approaches such as: to design and improve their programs, is to demonstrate and evaluate policy Expanding eligibility to individuals who are not otherwise Medicaid or – – Providing services not typically covered by Medicaid Using innovative service delivery systems that improve care, increase efficiency, and reduce costs.
• In general, section 1115 demonstrations are approved for a five-year period and can be renewed, typically for an additional three years. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By Topics/Waivers/1115/Section-1115-Demonstrations.html
Acronym
RHP UPL UC IGT HHSC CMS DSRIP
Terminology
Meaning
Regional Healthcare Partnership Upper Payment Limit Uncompensated Care Intergovernmental Transfer Health and Human Services Commission of Texas (state) Centers for Medicare and Medicaid Services (federal) Delivery System Reform Incentive Payment
Category 1 Category 2 Category 3 Category 4
DSRIP Projects
Infrastructure Development Program Innovation and Redesign Quality Reporting Population-based Reports
The 1115 Medicaid Waiver in Texas
• Designed to build on existing Texas health care reforms and to redesign health care delivery in Texas consistent with the CMS triple aim to: – Improve the experience of care – – Improve the health of populations, and Reduce the cost of health care without compromising quality http://www.hhsc.state.tx.us/1115-waiver.shtml
• • • •
The 1115 Waiver in Texas
In 2011: – HHSC sought a waiver to allow the state to expand managed care throughout the state while maintaining historic supplemental Medicaid funding to hospital providers In 2012: – Texas was divided into 20 Regional Healthcare Partnerships (RHP) – Each region is coordinated by an Anchor – Each region developed a plan: • To address regional needs, contains DSRIP projects, their milestones, metrics and expected outcomes • To identify IGT to use as match for federal dollars • To establish the value of each project and the subsequent incentive funds for successful performance – The plans were submitted to HHSC, revised as needed, then submitted to CMS for review and approval In 2013: – CMS approved projects in Texas DSRIP years (D1 – D5) – October 1 through September 30 – October 2013 – September 2014 was DY3
Projects Throughout Texas
Concho Valley MHMRA Tropical Texas BH Austin Travis Co Integral Care Metro Care Helen Farabee Behavior Health Center of Nueces Alamo Area Council of Governments Gulf Coast Center Bluebonnet Trails Heart of Texas MHMRA Emergence Health El Paso Andrews Center Lifepath Systems Spindletop Center Tricounty Services Tarrant County MHMRA Harris County MHMRA Hill Country MHMRA Texana Center Lakes Region MHMR
Projects Throughout Texas
First Stops: Harris County Concho Valley
• • Austin, Calhoun, Chambers, Colorado, Fort Bend, Harris, Matagorda, Waller, Wharton Anchor is the Harris Health System (formerly known as the Harris County Hospital District)
Region 3
MHMRA of Harris County
• • 27 DSRIP projects –
3 IDD/ASD
IDD/ASD Projects are collaborating statewide to exchange information and expand the presence and impact of these specialty projects
Gap Analysis
• • Most projects undertook an analysis of needs in their areas to inform their efforts.
In Harris County, 87 crisis cases that had been served in DY2 were analyzed.
Method
• The cases that were analyzed for this report were derived from two sources: – 87 cases referred to the Community Behavioral Supports (CBS) team at MHMRA of Harris County and – Two months’ of identification of gaps in services and staff training in an inpatient setting, The Harris County Psychiatric Center (HCPC) through our embedded Consultation and Liaison (C&L) team
Population Profile
Client Age
Adult 44% Child 25% Unspecifie d 13% Profound 4%
Intellectual Disability
Mild 27% Adole scent 31% Aspergers 12%
Autism Spectrum Disorders
PDD 18% Severe 19% Moderate 34% Autism 70% Borderline 3%
Major Depressive Schizoaffective 4% 2% Tourettes 1% Intermittent Explosive Schizophrenia 3% PTSD 3% OCD 2%
Secondary Diagnoses
Pica 1% Alcohol Abuse 1% 4% Learning NOS 1% Anxiety 3% Bipolar 6% Cannabis Abuse Disruptive 1% Behavior Disorder 7% ADHD 17% Dysthymic 1% Impulse Control 3% Depressive NOS 4% Adjustment 1% Mood NOS 28% Psychotic NOS 7% ODD 3%
Disposition
66% of the crises were successfully resolved either by the team or by linking and transferring the case to resources at an appropriate level of care.
18% the family or individual declined assistance of failed to follow through on recommendations 5% were ineligible for services 5% moved/could not locate/died 3% had no need for services 2% were incarcerated (2 cases) 1% limited progress
Gaps
• • • • • • • • • Family Issues Medical Problems Dental Problems Dual and Triple Diagnoses Guardianship Adjunctive Services/Wrap Around Mental Health Services for Children Communication Therapist Issues
Family Issues
• • • • • • • Parent/adult child conflicts, often compounded by the parent being a single caregiver Need for education about the individual’s condition and management of the presenting problem Complex family dynamics; e.g., siblings as caregivers Multiple children with disabilities in the same family Aging caregivers (grandparents) Caregiver health Transportation
Family Issues
• • • • • Financial burdens Substandard, overcrowded dwellings Parent overprotection and indulgence Disagreement among parents on the extent of the offspring’s disability, cause of the disability and/or methods of intervention Families do not have access to therapy to assist them in working through these issues
Medical Problems
• • • Inpatient care is difficult to find – For physical health problems – For mental health problems • Exclusionary IQ criterion Not connected to a medical home Few doctors who accept Medicaid
Dental Problems
Little access to dentists who accept and know how to work with people who have disabilities
Dual and Triple Diagnoses
• • • Private clinicians have limited understanding of ID or ASD – Specialists in ID/ASD and co-occurring MI are difficult to find.
Low reimbursement rates offered by Medicaid, the primary benefit plan for people with ID/ASD Substance Abuse (Triple Dx: ID/MI/SA) – The incidence of SA in people with ID/ASD is lower than in the general population; however, when a person has all three diagnoses, services are unavailable.
– Treatment programs for SA do not accept people with an ID or ASD, and 12-Step groups operate at a cognitive level higher than the intellectual ability of the people with ID and many with ASD.
Guardianship
• • Finding a person who is willing to be a guardian or, if willing, who can pay the legal fees for the process For people with higher cognitive ability, issues of choice and right of risk become points of discussion – Guardianship may be recommended when a person with ID/ASD has problem behaviors, more readily than would be recommended for the general population who, in contrast, may be likelier to be arrested and jailed
Adjunctive Services/Wrap Around
• • • Speech and Language Pathologists, Occupational Therapists, Physical Therapists, Nutritionists/Dieticians, and other adjunctive health professionals are seldom skilled in the assessment and treatment of people with ID/ASD When found, they are hesitant to accept low Medicaid reimbursement rates. Services for children are easier to obtain and fund under health plans, but not for adults
Mental Health Services for Children
• • • Services for children have traditionally been the domain of Early Childhood Intervention programs, followed by school districts. These systems, however, are not equipped to address mental health problems of people with ID/ASD Programs that are in place for children with MI and no ID/ASD do not accept children of lower cognitive abilities No options for short-term alternative residential treatment
Communication
• • Barriers in communication generally fell into two categories: (1) a primary language that was not English, and (2) limited communication skills. Need for interpreters and for bilingual clinicians. Need for affordable alternative communication devices and clinicians who know how to adapt these supports for people with ID and ASD
Therapist Issues
• • • Aggression is a common presentation in these cases Some cases were more challenging to resolve because the family/individual were resistant to the clinician’s race/ethnicity Therapist “burn out”
Summary
• • • • Multiple issues come together to create a crisis In most cases, complex family issues must be addressed before resources can be used effectively.
Access to IDD/ASD competent care is limited Need to – Facilitate access; develop capacity – – Develop supports for during and after the crisis Educate systems of care about the needs of this population; develop the workforce
Develop supports for during and after the crisis Develop the workforce Facilitate access; develop capacity
Concho Valley – RHP 13
•
3 DSRIP Projects:
1. Expand & Enhance 2. Primary Care Integration 3. IDD Dual Diagnosis Crisis Services
Objective
• Provide specialized community based behavioral health services to adults and children who have a dual diagnosis of Intellectual & Developmental Disabilities and a behavioral/psychiatric illness through wrap around services that include: Mobile Crisis Response Team Crisis Respite Psychiatric Outpatient Services
Goals
• • • • Create & implement a high quality behavioral health continuum of care for individuals with IDD & behavioral health needs living in Concho Valley’s service area. Emphasis will focus on avoiding unnecessary use of more restrictive and higher cost services through local ERs, local and state psychiatric hospitals, jail, and State Supported Living Centers. Provide immediate behavioral health crisis response services, as well as, crisis avoidance services in the community. Allow an individual to retain their residential placement and avoid more costly and traumatic alternatives.
Characteristics
• • • • • Team Approach Integrated Services Service Planning – Not a “One Size Fits All” Approach Team Members: Crisis Coordinator, Psychiatrist, Counselor, BCBA, RN, Respite Coordinator, Respite Staff Training & Education
Crisis Coordinator Psychiatrist Counselor / BCBA Nurse Crisis Response Team Outpatient Clinic t s i g h o l o P c y s Crisis Respite
The Watch List
Bag o’ Help The List
The Learning Collaborative
• • • IDD Projects in Texas have come together to form a Learning Collaborative This activity is required by the 1115 Medicaid Waiver It benefits the state by bringing together projects with similar functions and goals.
• • • • • • • •
Definition of Learning Collaborative
Group of people work on and learn about something together.
Capitalize on one another’s resources and skills Members actively interact by sharing experiences. Learners engage in a common task where each individual depends on and is accountable to each other. Includes both face-to-face conversations and other methods such as email and conference call.
Combine subject matter experts in specific clinical areas with operations experts to assist organizations to implement changes.
Work together toward a common end.
Share data and measure improvements toward goals/objectives.
Description of Various Projects
• • • Improved crisis response to individuals with co-occurring IDD and MH conditions. Provide IDD MCOT, provision of contracted Behavioral Analysis and crisis respite.
Crisis Respite Services provides for short-term 24 hour care in a least restrictive residential environment to persons who are vulnerable for hospitalization because they are a risk to self and/or others.
Implement an IDD Behavioral Health Crisis Response System to provide community based crisis intervention services to individuals with IDD and mental illness in order to prevent hospitalization and inappropriate utilization of local emergency departments. This crisis response system includes an IDD BH: Mobile Crisis Outreach Team (MCOT), crisis respite program, and outpatient clinic (OPC) wraparound services.
Description of Various Projects
• • • Crisis Stabilization using the START Model from the University of New Hampshire.
The project seeks to expand specialty services for children and adults with co-occurring psychiatric/behavioral and IDD/ASD by increasing staffing at MHMRA’s Specialized Treatment and Rehabilitative Services (STARS) clinic.
Develop wrap-around and in-home services for high risk consumers with Intellectual and developmental Disabilities and Autism Spectrum Disorders and their families to avoid utilization of intensive, costlier services.
Description of IDD Crisis Services
• • • Ages Served : All ages, Ages 3, 6, 10, 12, 16 to senior adult, 2-12 years, Over 18 Geographic area served: 20 Local Authorities covering 96 Counties.
Diagnoses served or excluded: • Served: Dual DX of IDD & Mental Illness, IDD &/or ASD with severe behaviors, typically with co-occurring MI (although not required to have MI). • Excluded: None excluded within the above included population.
IDD Crisis Services Cont.
• Facility type/licensure: Several projects do not offer respite services; focusing on an outpatient clinic and MCOT. Many projects offer respite services without a license, but follow the HCS guidelines & principles for respite and/or residential. Others provide inpatient care and are certified by JCAHO. One program classifies their project as an Assisted Living Facility and has a license through DADS. Some projects operate their respite internally, while others contract for this service.
IDD Crisis Services Cont.
• • • Facility Bed number: Four beds are the norm.
Is the facility locked: Projects offering respite services do so utilizing an unlocked facility that employees trained awake staff 24 hours a day, 7 days a week.
Do they have an on-call team that responds to crises in home settings? If so, what is the response time expectation: The majority of projects are developing an MCOT to respond to crisis calls. Some projects are planning to utilize the existing MH team, while others are developing a separate IDD team. A central crisis hotline is used to activate the MCOT. This crisis line is either contracted and operated in conjunction with the MH crisis line, while some projects utilize an independent line specific for IDD crisis’.
• • •
IDD Crisis Services Cont.
Expected length of treatment: Some projects do not have a limit for treatment provision, while others have created a 90 180 day limit with availability of re-enrollment Expected length of residential treatment: As previously stated, not all projects offer residential treatment (respite). Those who do offer between 14 to 30 calendar days with availability of re enrollment.
General description of place of treatment (family homes, group homes, inpatient facility, respite facility): Services are being offered in the community, inpatient , and on an outpatient basis. Services in the community are offered in the patient/family home and residential provider homes. These usually consist of caregiver training. Inpatient services is offered as crisis respite/residential. Outpatient services include pharmacological management, nursing, counseling, and service coordination.
IDD Crisis Services Cont.
• • General description of treatment modalities (group therapy, play therapy, behavior analysis, cognitive therapy): Pharmacological management, behavior analysis, nursing, counseling, crisis management , skills training (individual, family/caregiver), and Clinical Respite Care.
Disciplines included in their team: Psychiatrist, Board Certified Behavior Analyst, RN, LPC/LPA, Social Work, LPHA, QIDP/QMHP, Skills Trainer (with enhanced experience/education).
Coverage Areas within the State
Inception
• Crisis LC began in April of 2013. It has been led by Greg Rowe Director of IDD Community Services for MHMRA for the Concho Valley
Format
• • • Formal agenda/minutes Bi-weekly meetings via conference calls – Typically one hour in duration Face to face meetings: – Crisis—quarterly face to face at IDD Directors’ Consortia
Agenda and Minutes
• • • Roll call for provider participation Formal minutes reflecting individual provider participation and contributions Based on Appendix 1 of the Regional Healthcare Partnership Planning Protocol
•
Examples of Content Exchanged in LC Meetings
Share – Documents • Exchange of draft policies, tracking tools, assessments, etc.
– Processes • Comparison of models for providing crisis respite • Ways to measure consumer satisfaction – Problem-solving • Conversation with Mark Blockus about delivering crisis services to waiver consumers • Understanding of how DSRIP services relate to Encounter data • Discussion of the use of professionals and paraprofessionals on crisis teams, using paraprofessionals under the supervision of a master’s level staff with intense training.
Examples of Content Exchanged in LC Meetings
• • • New ideas to test – Concho Valley developed a watch list to identify which consumers are at high risk, prevent crises and see how they are responding to medication changes Innovator agent activities – Spindletop presented on a program for individuals with IDD and Co-Occurring issues of alcohol and substance abuse Field reports – Harris County formally establish a committee of Stakeholders – – Gulf Coast started seeing clients in February Texana developed a discharge policy – Metrocare developed a Family Service Agreement
• • •
Examples of Content Exchanged in LC Meetings
Measurement system development – – Discussions of Category 3 metrics and assessment tools Exchange of information about baselines Celebrate success – – – Spindletop received approval for an IDD wellness program Lakes hired an intensive services director Using Career Builder to advertise positions, Lifepath successfully hired PT/OT and RN. – Programs submitted mid-year and October reports on time!
– – Alamo had their three-year projects approved Programs have begun delivering services and collecting data Other – Guest speakers: Dr. Joan Beasley from the START model
IDD Crisis website
As prescribed in the RHP elements of a learning collaborative, Crisis LC has a website where minutes, contact information, documents, and weblinks can be shared.
Goal
The IDD Crisis Services Learning Collaborative overall goal is to share, support, and learn to improve our services and to maximize the usefulness of the learning collaborative requirement in our project plans.
Summary – Meeting the 11 Key Elements for LC
Review data & respond to it Bring all sites together by phone bi-weekly Set 1-2 quantifiable, project level goals with deadlines Invest more in learning than teaching Support a small, lightweight web site to share ideas & data Set up simple interim self-report measurement systems Innovator agents to travel from site to site Include face-to-face learning at least 2x per year Celebrate success each meeting Should mandate improvements to “raise the bar” Use metrics to measure success
Outcomes
• • • • Project: shared training material, policies and procedures, resources, hiring information 1115/DSRIP: reporting clarifications, milestone and metric measurement, Performance Logic, templates, stretch activity collaboration Overall: It has informed discussions on pros and cons of different types of facilities, hiring resources, shaping policies, clinical support, program development, navigating DSRIP, etc.
Challenges: Continue to share higher level data and measure improvements toward 1115 Waiver goals/objectives.
The Next Frontier
The Changing Model of IDD Services
• Impact of the following on crisis services – Integrated physical and behavioral healthcare – Transition of long-term services and support to managed care