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) 902-0818 Email: touloan@dshs.wa.gov

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

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

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

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

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

Part 3: Inpatient Capacity Psychiatric Inpatient Bed Reductions 180 State Hospital Beds closed 01-03 (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

Part 3: Inpatient Changes (cont’d) State Hospital Increases 2005-2006 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 2005 2006 Washington State Department of Social & Health Services

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

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

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

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

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

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

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

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

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

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

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

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

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- www.samhsa.gov “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: www.nami.org Washington Institute for Mental Illness Research and Training (WIMIRT): Maria Monroe-DeVita (206) 384-7372 or mmdv@u.washington.edu Department of Social Washington State & Health Services

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

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

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

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

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

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

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

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

Part 5: ITA Study Mental Health ITA Statutes Included RCW 71.05 (Adults) RCW 71.34 (Children) RCW 70.96B (Integrated Crisis Response Pilots) Excluded from scope of review RCW 10.77 (Forensic) RCW 70.96A (CD ITA) Sexual Offender Commitment Statutes Department of Social Washington State & Health Services

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

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

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

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

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

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

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

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

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

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

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

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

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

Part 6: STI Task Force Contact Information for STI Public Forums: Gaye Jensen Phone: (360) 902-7789 e-mail jensegf@dshs.wa.gov Contact Information for STI Implementation: Andy Toulon Phone: (360) 902-0818 e-mail: touloan@dshs.wa.gov Department of Social Washington State & Health Services

Questions? Department of Social Washington State & Health Services