1. Mental Health System Transformation Initiative Implementation
PACT and Beyond
Washington State
Department
of Social
& Health
Services
2SSB 6793 and Budget Initiatives
Andrew Toulon
Mental Health Division
Health & Recovery Services Administration
Department of Social & Health Services
Phone: (360)

2. Presentation Overview
Part 1: Background
Part 2: Key Provisions of 2SSB 6793 & Budget Initiatives
Part 3: Psychiatric Inpatient Capacity Changes
Part 4: Development of New Community Resources
Part 5: Long Term Planning Activities
Part 6: STI Task Force
Department of Social
Washington State
& Health Services

3. Part 1: Background Challenges Facing the 2006 Legislature
Decreasing community psychiatric inpatient capacity
State hospital waiting lists
Court rulings in September 2005
No wait for transfer of 90/180 ITA patients
Failure to follow proper procedures for assessing “liquidated damages”
Department of Social
Washington State
& Health Services

4. Part 1: Background (cont’d)
Legislative Approach
Clarified roles of State & RSNs related to community and state hospital care
Time limited investment in State Hospital capacity to deal with inpatient access issues
Investment in enhanced community resources to reduce reliance on state hospitals
Long term planning
Department of Social
Washington State
& Health Services

5. Part 2: Key Provisions of 2SSB 6793 & Budget Initiatives
Responsibility for 90/180 Commitments
Increased state hospital beds to meet court ruling
Requires state hospital bed allocation to RSN
State is financially responsible up to funded capacity
Directs RSNs pay for exceeding allocated bed days
Re-directs portion of funds collected by RSNs to other RSNs using less beds than allocated
Department of Social
Washington State
& Health Services

6. Part 2: Key Provisions (cont’d)
Community Based Care
Re-states Leg. intent for services to be provided in the community
Requires RSN to ensure discharge of state hospital patients who no longer require inpatient care
Raises RSN requirement to manage short term detentions locally from 85-90%
By January 2008, requires RSNs to pay for individuals at PALS
Department of Social
Washington State
& Health Services

7. Part 3: Inpatient Capacity
Psychiatric Inpatient Bed Reductions
180 State Hospital Beds closed (ECS)
Community Hospital Beds ↓ by 14% - Between 2000 and 2005
Involuntary Treatment Beds ↓ by 10% Between 2000 and 2005
Additional Closures Continue the Downward Trend
48 Pierce County Beds Closed in January 2006
6 Beds Closed at Fairfax in 2006
Source of Community Bed Data: Washington State Hospital Association
Department of Social
Washington State
& Health Services

8. Part 3: Inpatient Changes (cont’d)
State Hospital Increases
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun 30 30 30 30 30
Forensic
30 Bed Temporary
Pierce Contract
WSH 12 30
Forensic
ESH
Washington State
Department of Social
& Health Services

9. Part 3: Inpatient Capacity (cont’d)
State Hospital Census Trends
Sept 2006 WSH census is
11% Increase over FY04
Department of Social
Washington State
& Health Services

10. Part 3: Inpatient Capacity (cont’d)
Community Inpatient ITA Bed Increases
61 E&T Beds Will be Opened Between 2005 and 2006
Thurston County- 15 Beds Opened in April 2005
Pierce County- 30 Beds Opened in May 2006
Clark County- 16 Beds Scheduled to Open in September 2006 (also used for Acute Detox)
32 Secure Detox Beds Opened in 2006
Pierce County- 16 Beds Opened in March 2006
Skagit County- 16 Beds Opened in April 2006
Department of Social
Washington State
& Health Services

11. Part 1- 3 Questions Part 1: Background?
Part 2: Key Provisions of 2SSB 6793?
Part 3: Psychiatric Inpatient Capacity?
Department of Social
Washington State
& Health Services

12. Part 4: Community Resources
Program of Assertive Community Treatment (PACT) Teams
An evidenced based mental health service delivery model
$2.2 million for PACT development/training in FY 07
$10.4 Million Per Year to Implement PACT Teams Statewide
Gradual reduction of recently added state hospital beds
Department of Social
Washington State
& Health Services

13. Part 4: Community Resources (Cont’d)
PACT is for individuals who…?
Have the most severe & persistent symptoms of mental illness (e.g. schizophrenia, schizoaffective, bipolar)
Have high use of psych. hospitalization & crisis services
Have difficulty meeting basic needs (ADLs, housing, medical, nutrition, budget, employment)
Have difficulty benefiting from traditional services
May have co-occurring disorders
May have high risk or history of arrest and incarceration
Department of Social
Washington State
& Health Services

14. Part 4: Community Resources (cont’d)
How is PACT different from other service models?
Multi-disciplinary Team Approach
Team provides most services rather than referring- team members are cross trained
Staff share responsibilities for addressing the needs of consumers
Low caseloads allow for individualized care and frequent contacts (1-10 staffing ratio)
Services available 24/7 & directed to consumer needs
Outreach- 75%+ services delivered outside of the office
Ongoing services to support recovery
Department of Social
Washington State
& Health Services

15. Part 4: Community Resources (cont’d)
PACT Recommended Clinical Staffing per National Standards
Note: 1 or more members expected to have training and experience in vocational and substance abuse services
Source: National Program Standards for ACT Teams; Deborah Allness M.S.S.W & William Knoedler, M.D.; June 2003
Department of Social
Washington State
& Health Services

16. Part 4: Community Resources (cont’d)
What Types of Services Are Provided by PACT Teams?
Department of Social
Washington State
& Health Services

17. Part 4: Community Resources (cont’d)
◆ = Full Team
▲ = Half Team
13 Regional Support Networks (RSNs)
Effective 9/2006
Whatcom
Okanogan
Ferry
Stevens
Pend
Oreille
San Juan
Skagit
North
Central
North Sound ◆
Chelan
Clallam
Island
Peninsula ▲
Douglas
Spokane
Jefferson
Snohomish
Chelan-Douglas ▲
Grant
Lincoln
Spokane ◆
Kitsap
King ◆◆
Mason
Grays Harbor
Grays
Harbor
King
Kittitas
Adams
Thurston
Mason ▲
Pierce ◆
Whitman
Thurston
Pierce
Yakima
Franklin
Timberlands
Benton
Garfield
Pacific
Lewis
Walla
Columbia
Southwest
Asotin
Wahkiakum
Greater
Columbia ◆
Cowlitz
Clark ▲
Klickitat
Skamania
Department of Social
Washington State
& Health Services
Clark

18. Part 4: Community Resources (cont’d)
PACT Implementation Timeline
Train West Teams
Monitor and Evaluate Outcomes & Fidelity
Recruit West Teams
West Teams
Operational
July – Dec
2006
Jan – Mar
2007
April – Jun
July - Sept
Oct →
Develop Training Curriculum
Train East Teams
Development
Activities
Recruit East
Teams
East Teams Operational
Washington State
Department of Social
& Health Services

19. Part 4: Community Resources (cont’d)
PACT Outcomes Being Considered for Review
Consumer Satisfaction
State Hospital Utilization
Community Inpatient Utilization
Crisis Service Utilization
ER Utilization
Housing
Employment
Arrests and Incarcerations
Department of Social
Washington State
& Health Services

20. Part 4: Community Resources (cont’d)
PACT Keys to Success
90 percent+ fidelity (external fidelity reviews)
Treatment plans are client centered
Services are recovery oriented
Non-coercive and non-paternalistic
Incorporate EBPs and promising practices into individualized service planning
Cultural competency
Department of Social
Washington State
& Health Services

21. Part 4: Community Resources (cont’d)
PACT Resources
National Program Standards for ACT Teams (Allness & Knoedler)- handout
Dartmouth Assertive Community Treatment Fidelity Scale (Teague, Bond & Drake)- handout
PACT Toolkit-
“PACT Model of Community-Based Treatment for Persons with Severe and Persistent Mental Illness: A Manual for PACT Start–up” by D. Allness & W. Knoedler:
Washington Institute for Mental Illness Research and Training (WIMIRT):
Maria Monroe-DeVita (206) or
Department of Social
Washington State
& Health Services

22. Part 4: Community Resources (cont’d)
PACT Comments & Concerns
What issues do you think the state should consider in implementing PACT teams?
PACT Questions?
Department of Social
Washington State
& Health Services

23. Part 4: Community Resources (cont’d)
Expanded Community Services
Additional funding for other services which reduce dependence on state hospitals
$650,000 for development in FY 07
$6.5 million per year for ongoing operating costs
Process for allocating and selecting services still being determined
Department of Social
Washington State
& Health Services

24. Part 4: Community Resources (cont’d)
Expanded Community Services
In addition to PACT, what types of services are most needed in your community to support recovery and reduce dependence on state hospitals
ECS Questions?
Department of Social
Washington State
& Health Services

25. Part 4: Community Resources (cont’d)
Children’s Mental Health EBP Pilot Program
$450,000 for FY ’07
RFP open to counties / groups of counties & or Indian Nations released August 2006
Expert panel convened to rank EBPs, report available
Community planning process and EBP selection by Dec. 2006
WSIPP separately funded to conduct evaluation
Department of Social
Washington State
& Health Services

26. Part 5: Long Term Planning
Overview of Long Term Planning
$600,000 for consultants and planning activities
Four areas of focus
Mental Health Benefits Package
Involuntary Treatment Act Study
External Utilization Review
State Mental Health Housing Plan
Department of Social
Washington State
& Health Services

27. Part 5: MH Benefits Package
MH Services Included in Current Medicaid Benefits Package
Department of Social
Washington State
& Health Services

28. Part 5: MH Benefits Package (cont’d)
Scope of Planning Activities
Review current menu of required clinical services and supports
Identify EBPs & Promising Practices for inclusion
Consider cultural relevance issues
Develop rate methodology
Prioritize new benefits menu within allocated resources
Department of Social
Washington State
& Health Services

29. Part 5: MH Benefits Package (cont’d)
Expected Benefits
Recovery oriented benefits design
Transparent rate structure
Prioritize EBPs & Promising Practices / culturally relevant
More efficient use of service dollars
Department of Social
Washington State
& Health Services

30. Part 5: ITA Study Mental Health ITA Statutes Included
RCW (Adults)
RCW (Children)
RCW 70.96B (Integrated Crisis Response Pilots)
Excluded from scope of review
RCW (Forensic)
RCW 70.96A (CD ITA)
Sexual Offender Commitment Statutes
Department of Social
Washington State
& Health Services

31. Part 5: ITA Study (cont’d)
Scope of Planning Activities
Review and comparison of Washington MH commitment laws with other states
Objective review of hot button issues (e.g. Grave Disability, Age of Consent)
Develop Options for Reform
Department of Social
Washington State
& Health Services

32. Part 5: ITA Study (cont’d)
Expected Benefits
Improve balance of civil liberty and public safety
Improve consistency across the state
Ensure best use of inpatient and community based care to support recovery
Identify best use of State Hospitals
Department of Social
Washington State
& Health Services

33. Part 5: External Utilization Review
What is Utilization Review?
Process of assessing delivery of services to determine if care provided is
Appropriate
Medically necessary
High quality
Includes review of appropriateness of
Admissions
Services ordered and provided
Length of stay
Discharge practices
Concurrent and retrospective basis.
Department of Social
Washington State
& Health Services

34. Part 5: External UR (cont’d)
Current External UR for Psychiatric Inpatient Services
RSNs required by contract to do UR for community inpatient days
No external UR for State Hospital days (State Hospitals conduct their own UR process)
Department of Social
Washington State
& Health Services

35. Part 5: External UR (cont’d)
Scope of Planning Activities
Establish acuity levels to be supported in community settings
Develop sampling methodologies & processes for independent review of 90 and 180 day commitments
Include State and community inpatient settings
Identify resources required for statewide implementation
Draft RFP for External UR services
Department of Social
Washington State
& Health Services

36. Part 5: External UR (cont’d)
Expected Benefits
Prevent over and under utilization of inpatient care
Increase RSN & provider accountability
Improve consistency for consumers throughout the state
Identify state and local community resource gaps
Department of Social
Washington State
& Health Services

37. Part 5: State MH Housing Plan
Scope of Planning Activities
Review RSN housing collaboration plans
Identify best practices and areas of need
Develop guidelines for future RSN contracts
Technical assistance
Department of Social
Washington State
& Health Services

38. Part 5: State MH Housing Plan (cont’d)
Expected Benefits
Improve collaboration with existing planning groups
Prioritize independent housing which supports recovery
Increase access to available housing stock by leveraging PACT & ECS services
Action plan for further housing development
Department of Social
Washington State
& Health Services

39. Part 5: Long Term Planning (cont’d)
Implementation Timeline
Evaluate RFPs & Contract for Services
Final Consultant Reports
July – Sept
2006
Oct – Nov
Dec – Apr
2007
May - June
July - Oct
Options For Policy Makers
RFPs for Consultant
Initial Consultant Draft Reports
Washington State
Department of Social
& Health Services

40. Part 5: Long Term Planning (cont’d)
Questions
Mental Health Benefits Package?
Involuntary Treatment Act Study?
External Utilization Review?
State Mental Health Housing Plan?
Department of Social
Washington State
& Health Services

41. Part 6: STI Task Force Process Standing Representative Task Force
35-40 members from variety of interested parties
Monthly meetings beginning in Oct 06
Consumer, family, and advocate representatives
Public Forums
2-3 large forums (approx 150 people) over the next 9 months
1st forum scheduled for November 15, 2006
Stipends for up to 40 consumers, family, and advocate representatives
Department of Social
Washington State
& Health Services

42. Part 6: STI Task Force Goals
Share information regarding STI implementation
Gather input & shape implementation activities
Provide ongoing input on consultant reports
Department of Social
Washington State
& Health Services

43. Part 6: STI Task Force Values Participatory Process Recovery Oriented
Evidence Based & Promising Practices/ Cultural Relevance
Consumer Preferences
Build on Strengths
Work within Existing Resources
Local Governance
Strive For Consensus
Address Needs of All Ages
Department of Social
Washington State
& Health Services

44. Part 6: STI Task Force
Contact Information for STI Public Forums:
Gaye Jensen
Phone: (360)
Contact Information for STI Implementation:
Andy Toulon
Phone: (360)
Department of Social
Washington State
& Health Services

45. Questions?
Department of Social
Washington State
& Health Services