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Divert to Where: Community Divert to Where: Community Leadership & Cross-System Leadership & Cross-System

PlanningPlanning

CIT International ConferenceCIT International Conference

Mark A. Engelhardt, MS, ACSWMark A. Engelhardt, MS, ACSW

San Antonio, Texas San Antonio, Texas

June 1, 2010June 1, 2010

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Guiding QuestionsGuiding Questions

Is the your Acute Care System well Is the your Acute Care System well “designed” or does it operate by “default”?“designed” or does it operate by “default”?

How does CIT fit into a larger system of Law How does CIT fit into a larger system of Law Enforcement and Behavioral Healthcare?Enforcement and Behavioral Healthcare?

Is there a full array of appropriate services Is there a full array of appropriate services based on citizen demand, community based on citizen demand, community experience, access and continuing care?experience, access and continuing care?

Is there an organized acute care plan?Is there an organized acute care plan? What do Law Enforcement & Citizens want?What do Law Enforcement & Citizens want?

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Strategic Planning Strategic Planning FrameworkFramework

Principles: Recovery UmbrellaPrinciples: Recovery Umbrella Community Challenges: International Community Challenges: International Public/Private PartnershipsPublic/Private Partnerships Goals & ObjectivesGoals & Objectives Problem Solving Variables: LeadershipProblem Solving Variables: Leadership System Service Array: Design-ElementsSystem Service Array: Design-Elements Cost-Benefits - EvaluationCost-Benefits - Evaluation

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Principles:Principles:

Welcoming: No Wrong Door, IndividualsWelcoming: No Wrong Door, Individuals Integrated Assessment & TreatmentIntegrated Assessment & Treatment Immediate Diversion or Access to CareImmediate Diversion or Access to Care Competent Recovery-Focused ProvidersCompetent Recovery-Focused Providers Cross-Systems CollaborationsCross-Systems Collaborations Comprehensive & Continuing CareComprehensive & Continuing Care Balance: Public Safety and Recovery Balance: Public Safety and Recovery

SAMHSA Practice GuidelinesSAMHSA Practice Guidelines

Core Elements in Responding to Core Elements in Responding to Mental Health Crisies Mental Health Crisies

HHS Publication No. SMA-09-4427 HHS Publication No. SMA-09-4427 Rockville, Md. Rockville, Md.

Center for Mental Health Center for Mental Health Services/SAMHSAServices/SAMHSA

Values, Principles, ImplementationValues, Principles, Implementation

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Definitions: Acute CareDefinitions: Acute Care

Break down of Normal Coping MechanismsBreak down of Normal Coping Mechanisms Individualized Experiences (Traumatic)Individualized Experiences (Traumatic) Acuity Level: Prevention to DangerousnessAcuity Level: Prevention to Dangerousness Ambulatory to Residential/Inpatient/JailAmbulatory to Residential/Inpatient/Jail Triage To Treatment/Recovery ModelsTriage To Treatment/Recovery Models Stabilization: Brief 2-6 Weeks: EpisodicStabilization: Brief 2-6 Weeks: Episodic Connection to Community System of CareConnection to Community System of Care

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National Community National Community Challenges:Challenges:

Lack of Acute Care Services and Lack of Acute Care Services and Community Residential CareCommunity Residential Care

Fragmented Delivery Systems Fragmented Delivery Systems Lack of Provider & Hospital CooperationLack of Provider & Hospital Cooperation ““Nearest” Receiving Facility MandateNearest” Receiving Facility Mandate Demand on Emergency RoomsDemand on Emergency Rooms Recent Hospital ClosuresRecent Hospital Closures

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Community Challenges:Community Challenges:

Human Rights Issues or Law ViolationsHuman Rights Issues or Law Violations Potential Lawsuits Potential Lawsuits Unplanned Gate Keeping at Area Unplanned Gate Keeping at Area

Emergency RoomsEmergency Rooms Coordination Among Law Enforcement and Coordination Among Law Enforcement and

Transportation Providers (Wait times)Transportation Providers (Wait times) State Hospital vs. Community CareState Hospital vs. Community Care Workforce Issues: Recruitment - RetentionWorkforce Issues: Recruitment - Retention

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Public/Private Partnerships:Public/Private Partnerships:

Persons Receiving Services & FamiliesPersons Receiving Services & Families City/County/State/Regional Substance City/County/State/Regional Substance

Abuse & Mental Health AuthoritiesAbuse & Mental Health Authorities County Commission & Executive StaffCounty Commission & Executive Staff Bipartisan Legislative InvolvementBipartisan Legislative Involvement Area Hospital Emergency Rooms, Area Hospital Emergency Rooms,

Inpatient Units & Med-Surgery UnitsInpatient Units & Med-Surgery Units

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Public/Private Partnerships: Public/Private Partnerships:

Public DefendersPublic Defenders States’ AttorneysStates’ Attorneys In-Jail Medical StaffIn-Jail Medical Staff County Criminal Justice StaffCounty Criminal Justice Staff Homeless Coalition MembersHomeless Coalition Members NAMI, Mental Health America, etc.NAMI, Mental Health America, etc. Psychiatric & Healthcare AssociationsPsychiatric & Healthcare Associations

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Public/Private Partnerships:Public/Private Partnerships:

Private Non-profit & For-Profit Free-Private Non-profit & For-Profit Free-standing Psychiatric Hospitalsstanding Psychiatric Hospitals

Community Mental Health and Community Mental Health and Substance Abuse ProvidersSubstance Abuse Providers

Veterans Affairs Medical CentersVeterans Affairs Medical Centers Law Enforcement Agencies & CourtsLaw Enforcement Agencies & Courts Health & Human Service Planning Health & Human Service Planning

BodiesBodies Human Rights: State/Local AdvocatesHuman Rights: State/Local Advocates

Reference ArticleReference Article 1212

Overall Goals, Objectives & Overall Goals, Objectives & Implementation ModelsImplementation Models

Establish an “Organized” Central System Establish an “Organized” Central System (“Drop-Off”) of diversion and assessment to (“Drop-Off”) of diversion and assessment to improve access and availability to improve access and availability to RecoveryRecovery acute care services.acute care services.

Provide specialized services to subpopulations, Provide specialized services to subpopulations, CJMHSA, children and older adults/elderly.CJMHSA, children and older adults/elderly.

Provide a dignified, streamlined method of Provide a dignified, streamlined method of transportation, including special needs as transportation, including special needs as necessary from nursing homes and assisted necessary from nursing homes and assisted living facilities.living facilities.

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Strategic Goals and Strategic Goals and Objectives:Objectives:

Divert Divert inappropriateinappropriate admissions from hospital admissions from hospital emergency rooms and jails.emergency rooms and jails.

CIT Teams and Behavioral Health PartnersCIT Teams and Behavioral Health Partners Provide a range of acute care services that Provide a range of acute care services that

would treat persons in the community and would treat persons in the community and avoid state hospital or restrictive inpatient avoid state hospital or restrictive inpatient admissions.admissions.

Work within existing resources…or else…Work within existing resources…or else… Obtain the necessary appropriations from the Obtain the necessary appropriations from the

legislature to redesign/rebuild the system.legislature to redesign/rebuild the system.

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Goals & Objectives:Goals & Objectives:

Assist law enforcement with CIT training Assist law enforcement with CIT training and on-site assessments (street level)and on-site assessments (street level)

Develop a System that is Co-occurring Develop a System that is Co-occurring capable and enhancedcapable and enhanced

Continue to develop pre and post Continue to develop pre and post booking treatment services with the Jail, booking treatment services with the Jail, Public Defender & State AttorneyPublic Defender & State Attorney

Avoid Forensic State Hospital Avoid Forensic State Hospital AdmissionsAdmissions

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Goals and Objectives:Goals and Objectives:

Work Closely with Medicaid to Ensure Work Closely with Medicaid to Ensure Access Standards & Implementation of Access Standards & Implementation of Medicaid Managed Care MH PlansMedicaid Managed Care MH Plans

Utilize Private Transportation ProvidersUtilize Private Transportation Providers Maximize Public Receiving Facility Maximize Public Receiving Facility

Capacity, Utilization Management and Capacity, Utilization Management and Develop Cooperative AgreementsDevelop Cooperative Agreements

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Problem Solving Factors:Problem Solving Factors:

High Level Executive InvolvementHigh Level Executive Involvement Inter-Governmental Unity: State and Inter-Governmental Unity: State and

Counties (Rural, Multi-County)Counties (Rural, Multi-County) Commitment from All Agencies and Commitment from All Agencies and

Involved PartiesInvolved Parties Competent Providers – Recovery FocusCompetent Providers – Recovery Focus Examine several system change options-Examine several system change options-

Replication, yet “Act Local” – Replication, yet “Act Local” – Urban/RuralUrban/Rural

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Problem Solving Factors:Problem Solving Factors:

Analyze the Data-admissions/pre/post Analyze the Data-admissions/pre/post discharges-length of stay, inter-facility discharges-length of stay, inter-facility transfers and follow uptransfers and follow up

Regular Meetings – Open & honest: Regular Meetings – Open & honest: Sharing of data – Public & privateSharing of data – Public & private

Short & Long Term Plans-FlexibilityShort & Long Term Plans-Flexibility Establish Acute Care Action Establish Acute Care Action

Committee – Key Leadership & Committee – Key Leadership & StakeholdersStakeholders

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System Design: Divert to System Design: Divert to Where: Service ArrayWhere: Service Array

Models: Practice & ResearchModels: Practice & Research Opportunity to Learn, Grow, RecoverOpportunity to Learn, Grow, Recover In-home, Wraparound, Crisis Residential In-home, Wraparound, Crisis Residential Preventive or Follow Up Respite CarePreventive or Follow Up Respite Care Telephonic: “Warm” & Hot LinesTelephonic: “Warm” & Hot Lines Suicide Prevention Task ForcesSuicide Prevention Task Forces Cultural Diversity, Access & CompetencyCultural Diversity, Access & Competency

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System Design: Service System Design: Service ArrayArray

Voluntary or involuntary status of the Voluntary or involuntary status of the person in need of servicesperson in need of services

Crisis Support-Access Centers-Central Crisis Support-Access Centers-Central Intake for Children & AdultsIntake for Children & Adults

Mobile Crisis Response Team and Crisis Mobile Crisis Response Team and Crisis Intervention Teams (CIT – Police-based)Intervention Teams (CIT – Police-based)

Integrated Co-occurring – Examine Integrated Co-occurring – Examine Legal, Licensure & Accreditation BarriersLegal, Licensure & Accreditation Barriers

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System Design: Service System Design: Service ArrayArray

Priority Assessments – Service PlanningPriority Assessments – Service Planning Emergency MedicationsEmergency Medications Supportive & Housing First OptionsSupportive & Housing First Options Transportation “Exception” Plans – Transportation “Exception” Plans –

Option to Contract with Transportation Option to Contract with Transportation Provider (s), Central or Co-located IntakeProvider (s), Central or Co-located Intake

Law Enforcement Coordination in the Law Enforcement Coordination in the Absence of a CIT TeamAbsence of a CIT Team

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System Design: Service System Design: Service ArrayArray

Peer Navigators – Consumer Supports At All Peer Navigators – Consumer Supports At All Levels, In Reach and Respite CareLevels, In Reach and Respite Care

International Peer Support TrainingInternational Peer Support Training Case Management Services: Intensive and Case Management Services: Intensive and

ACT Team ReferralsACT Team Referrals Homeless Interventions (Path Outreach) – Homeless Interventions (Path Outreach) –

Police – Social Services Team ModelsPolice – Social Services Team Models Specialized Children & Elder Services: Specialized Children & Elder Services:

Wraparound Services - Assisted Living Wraparound Services - Assisted Living Facility/Nursing Home “Overlay” – In-vivo Facility/Nursing Home “Overlay” – In-vivo

Secure and/or Non-secureSecure and/or Non-secure 2222

System Design: Free StandingSystem Design: Free Standing“Divert to Where: Alternatives”“Divert to Where: Alternatives” Children’s Crisis Stabilization Unit (CCSU)Children’s Crisis Stabilization Unit (CCSU) Adult Crisis Stabilization Unit (CSU)Adult Crisis Stabilization Unit (CSU) Short Term Residential Treatment (SRT)Short Term Residential Treatment (SRT) Residential Treatment Facility (RTF)Residential Treatment Facility (RTF) Detoxification: Ambulatory & Secure & Detoxification: Ambulatory & Secure &

Non-Secure Residential Options: Addiction Non-Secure Residential Options: Addiction Receiving Facilities (ARF): Low DemandReceiving Facilities (ARF): Low Demand

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System: Use of ER’s By Design System: Use of ER’s By Design or by Default – EMTALA Issuesor by Default – EMTALA Issues

Medical Clearance – Written Protocols, Medical Clearance – Written Protocols, Community Standards & AgreementsCommunity Standards & Agreements

COBRA Revisions – Examination, COBRA Revisions – Examination, Treatment & Transfer (Anti-Dumping) 42 Treatment & Transfer (Anti-Dumping) 42 CFR-489.24(a) GuidelinesCFR-489.24(a) Guidelines

EMTALA – Emergency Medical Treatment EMTALA – Emergency Medical Treatment and Active Labor ACT (emtala.com) and Active Labor ACT (emtala.com)

ER Model with “6 -12 - 23 Hour” ScreeningER Model with “6 -12 - 23 Hour” Screening Cost of Inpatient Days, Discharge Cost of Inpatient Days, Discharge

Planning, RiskPlanning, Risk

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Emergency Room ModelsEmergency Room ModelsA Few FactorsA Few Factors

The psychiatric The psychiatric emergency room emergency room model may be the model may be the preferred model in preferred model in some communitiessome communities

Integrated health Integrated health screening & screening & substance abuse substance abuse identificationidentification

Financial Issues +/-Financial Issues +/-

Many ER’s want Many ER’s want community-based community-based alternatives (CSU’s)alternatives (CSU’s)

Police want a “drop-Police want a “drop-off point” ER or notoff point” ER or not

Risk assessment & Risk assessment & continuing care is continuing care is keykey

Legislative partners Legislative partners with providers with providers

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System Elements: Public System Elements: Public SectorSector

Basic Understanding of Insurance PlansBasic Understanding of Insurance Plans Medicaid Recipients: (Access Standards) Medicaid Recipients: (Access Standards) Medicaid Managed Care PlansMedicaid Managed Care Plans Fee for Service Medicaid/MedicareFee for Service Medicaid/Medicare Indigent – State & County/City FundingIndigent – State & County/City Funding Exparte: Judicial InterventionExparte: Judicial Intervention Forensic Issues Forensic Issues

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System Elements:System Elements:

Acute Care Training: Crisis Acute Care Training: Crisis Intervention Teams (CIT) Fidelity - Intervention Teams (CIT) Fidelity - Law Enforcement and Behavioral Law Enforcement and Behavioral Health Cross-training Health Cross-training

Resolve Any State Licensing or Local Resolve Any State Licensing or Local Zoning IssuesZoning Issues

Contractual – State/County Funds, Contractual – State/County Funds, Medicaid – Local Match, Private Medicaid – Local Match, Private SectorSector

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System Leeadership System Leeadership Governance:Governance:

System Mandate or Oversight: System Mandate or Oversight: State/County/City Substance Abuse & Mental State/County/City Substance Abuse & Mental Health AuthorityHealth Authority

Solution Focused Meetings with Community Solution Focused Meetings with Community Partners: County, Providers, Law Enforcement, Partners: County, Providers, Law Enforcement, Public Defender, States Attorney, Public Defender, States Attorney, Consumers/Families, Advocates, Open Consumers/Families, Advocates, Open MeetingsMeetings

Shared Community LeadershipShared Community Leadership Strategic Plans with Follow Through ActionsStrategic Plans with Follow Through Actions

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Leadership: Action PlansLeadership: Action Plans

A Call To Action – Strategic PlansA Call To Action – Strategic Plans Establish a City Acute Care Leadership Establish a City Acute Care Leadership

Group Task Force or Operations Group Task Force or Operations CommitteeCommittee

Assess Current Treatment CapacityAssess Current Treatment Capacity Assess Competencies Across DisciplinesAssess Competencies Across Disciplines Manage with Open & Honest DataManage with Open & Honest Data Conduct a Funding Analysis & PlanConduct a Funding Analysis & Plan

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Planning & Implementation:Planning & Implementation:Statewide, Regional or LocalStatewide, Regional or Local

Strengths-Based Facilitation – LeadershipStrengths-Based Facilitation – Leadership System = Consensus & Organized CareSystem = Consensus & Organized Care Strategic Planning with MOU’s* Strategic Planning with MOU’s* System Mapping or Logic ModelsSystem Mapping or Logic Models Evidenced-Based and Local Best Evidenced-Based and Local Best

Practices Practices Financial Model With IncentivesFinancial Model With Incentives Long-Term Stakeholder CommitmentsLong-Term Stakeholder Commitments

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Implementation: SystemsImplementation: Systems

Systems LevelSystems Level – Policy, Direction, Funds, – Policy, Direction, Funds, Recovery Planning, Legal Issues, Cross-Recovery Planning, Legal Issues, Cross-Systems Partnerships, Data, Regulatory Systems Partnerships, Data, Regulatory Barriers or New Rule Development Barriers or New Rule Development

RFP/RFA/RFI – Design, Best Practices, RFP/RFA/RFI – Design, Best Practices, Technical Assistance – Pre/Post, Technical Assistance – Pre/Post, TimetableTimetable

Outcomes – Realistic in the First Couple Outcomes – Realistic in the First Couple of Years, Evaluation – Process & Clinicalof Years, Evaluation – Process & Clinical

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Legislative or Rule Changes: Legislative or Rule Changes: ExamplesExamples

Creation of Secure Addictions Creation of Secure Addictions Receiving “Emergency Petition” for SAReceiving “Emergency Petition” for SA

Co-occurring LicensureCo-occurring Licensure Mandated Strategic Planning (LA.)Mandated Strategic Planning (LA.) Transportation OptionsTransportation Options Data Reporting by ProvidersData Reporting by Providers ER – 12 Hour Rules, Treat TransferER – 12 Hour Rules, Treat Transfer

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Implementation: ProgramsImplementation: Programs

Program LevelProgram Level – Range and Depth of – Range and Depth of Current Acute Care & Community-Current Acute Care & Community-Based Care, Provider Competency – Based Care, Provider Competency – Workforce Issues, Experience, Workforce Issues, Experience, Facilities – Capacity Issues, New Facilities – Capacity Issues, New ServicesServices

Co-occurring Capability – ExpectationCo-occurring Capability – Expectation Target PopulationsTarget Populations Mid-Course CorrectionsMid-Course Corrections

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Implementation – Clinical- Implementation – Clinical- Consumer IssuesConsumer Issues

Clinical/Consumer LevelClinical/Consumer Level – Recovery – Recovery Philosophy – Baseline – Attitudes, Skills, Philosophy – Baseline – Attitudes, Skills, Ability – Staff Training, Consumer/Family Ability – Staff Training, Consumer/Family InvolvementInvolvement

Short-term Intervention – Road to Recovery – Short-term Intervention – Road to Recovery – Advance Directives – Transition PlansAdvance Directives – Transition Plans

“ “Welcoming, No Wrong Door”Welcoming, No Wrong Door” Person-centered (driven) PlanningPerson-centered (driven) Planning Wellness Recovery Action Planning (WRAP)Wellness Recovery Action Planning (WRAP) People Recover at “Home”.People Recover at “Home”.

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Costs Benefits:Costs Benefits:

State-Local Match; MedicaidState-Local Match; Medicaid Private Hospitals Commit $Private Hospitals Commit $ Economy of Scale CSU/SRT/RTFEconomy of Scale CSU/SRT/RTF Transportation – Relief for Law Transportation – Relief for Law

Enforcement with Private ProvidersEnforcement with Private Providers Diversions From ER’s, Jails, HospitalsDiversions From ER’s, Jails, Hospitals Cost Savings-Cost AvoidanceCost Savings-Cost Avoidance

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Recommendations:Recommendations:

Address Co-Occurring Disorders and Address Co-Occurring Disorders and Related Health/Social ServicesRelated Health/Social Services

Integrate Acute Care Plan with other Integrate Acute Care Plan with other System Development: Housing, ACT System Development: Housing, ACT Teams, Medications, Outpatient Teams, Medications, Outpatient Supports, Recovery & Rehabilitation Supports, Recovery & Rehabilitation ModelsModels

Develop Advocacy Mechanisms: Develop Advocacy Mechanisms: Consumer Rights Process - GrievancesConsumer Rights Process - Grievances

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Recommendations:Recommendations:

Assess Current Political EnvironmentAssess Current Political Environment Expand or Redesign ServicesExpand or Redesign Services Buy or Build Bed Capacity Only if Buy or Build Bed Capacity Only if

NeededNeeded Community Reinvestment IdeasCommunity Reinvestment Ideas On-going Evaluation, Mid-course On-going Evaluation, Mid-course

Corrections, Education and TrainingCorrections, Education and Training COOPERATION, COLLABORATION & COOPERATION, COLLABORATION &

COMMITMENT = LeadershipCOMMITMENT = Leadership

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Recent State Examples:Recent State Examples:

New Jersey – Leadership, New Collaborations, New Jersey – Leadership, New Collaborations, Regional Crisis Coordination, HealthcareRegional Crisis Coordination, Healthcare

Texas - $ Allocations – Comprehensive Plans Texas - $ Allocations – Comprehensive Plans with Targeted Urban/Rural Initiativeswith Targeted Urban/Rural Initiatives

Iowa – State Task Force, $ 1.5 RFPIowa – State Task Force, $ 1.5 RFP Florida – Co-occurring capability – Pursuing Florida – Co-occurring capability – Pursuing

Licensure Changes, New SA Medicaid CodesLicensure Changes, New SA Medicaid Codes Louisiana: ACT 447 – Crisis Response SystemLouisiana: ACT 447 – Crisis Response System

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Contact Information: Follow Up Contact Information: Follow Up Technical AssistanceTechnical Assistance

Mark A. Engelhardt, MS, MSW, ACSWMark A. Engelhardt, MS, MSW, ACSW 813-974-0769813-974-0769 mengelhardt@fmhi.usf.edu University of South Florida - Tampa, University of South Florida - Tampa,

FloridaFlorida www.floridatac.org = CJMHSA = CJMHSA http://mhlp.fmhi.usf.edu – FMHI – FMHI

“Baker Act” Data Reporting Center“Baker Act” Data Reporting Center