allegheny healthchoices, inc. 1 allegheny county discharge and acute community support planning...

Allegheny HealthChoices, Inc. 1

Allegheny County Discharge and Acute Community Support Planning Process

TRAINING AND ORIENTATION


Goals of Today’s Training

Review data resulting from using CSP process for Mayview closure.

Describe the overall role of ACSP in the inpatient discharge planning process.

Review disposition and ACSP eligibility criteria.

In-depth training on the ACSP process Introduce the “Web-based” site and review

the use of the site in the planning process


Goal of Mayview Closure

To build stronger community support systems so people can return to their home communities from the state hospital and remain in their home communities pursing their hopes and dreams


What is a Community Support Plan (CSP)?

A comprehensive support and resource planning process that is driven by a blending of the consumer’s, family’s, and treatment/service coordination team’s preferences, recommendations, and competencies.


Key Characteristics of a CSP

Services and Supports are based on needs and strengths, not program focused

Individual assessments and plans inform system infrastructure and resource development

Shared responsibility between County, MCO, IP team, community providers, consumer, and other supports

Disciplined and highly facilitated process to ensure accountability and collaboration

Use of an independent/non-biased facilitator and recorder Consumers get to where they need to be rather than following a

continuum of care Avoid ‘one size fits all’ approach to discharge planning-

individualized


Why Do a CSP: What We Have Learned

The CSP process promotes higher levels of accountability

External facilitator is necessary to encourage new thinking and provide objective review

Web-based application ensures all parties working with the same information

Understanding and respecting the client’s choices is critical for long-term success


Why Do a CSP: What We Have Learned

With individualized planning comes individualized solutions

Folks discharged with a CSP did better than those without a CSP therefore after closure announcement, all persons discharged had a CSP

Those discharged with a CSP were not readmitted and no one has been admitted to Mayview since November, 2007


Mayview: Housing Arrangements at Discharge for those with a CSP

269 people were discharged with a community support plan (CSP)– 84% of people were discharged to residences

with 24-hour staff:

26% to long-term structured residences (LTSRs) 22% to different types of personal care homes 19% to community residential rehabilitation (CRR) group

homes or apartments 17% other categories combined


Housing Arrangements at Discharge

16% were discharged to community settings without 24-hour staff

– independent housing, living with family– permanent supported housing, supported housing


CTTs Are Providing Frequent Contacts

For people receiving CTT services:

26% of people had 6-7 average contacts per week with CTT

33% had 4-5 average contacts per week 32% had 2-3 average contacts per week

…during their first three months in the community.


Case Management/Service Coordinators Also Provide Frequent Contacts

For people receiving case management/service coordination:

– 14% had contact with their service coordinator 4-5 times per week on average

– 41% had contact 2-3 times per week on average– 26% had contact at least once per week on average

…during their first three months in the community.


Access to Supports and Activities: first three months of discharge

75% of people had contact with their peer mentor after discharge. Many peer mentors were involved during the CSP process.

20% of people visited drop-in centers 80% had some type of contact or support from

family 40% used spiritual supports Very few people were either recommended or

accessed vocational or educational activities


Incarcerations and Hospitalizations

During people’s first three months in the community:– 3% were incarcerated– 6% had psychiatric hospital days

After the first three months in the community:– 7% of people were incarcerated – 17% had psychiatric hospital days


Early Warning Signs and Critical Incidents

New online database for reporting early warning signs and critical incidents began in June 2008. Since then: – 29% have had an early warning sign report.– 29% have had a critical incident.

While it is premature to identify trends, providers are reporting incidents and counties are proactively working to address situations.


Resource Development

The counties have planned for the Mayview closure by investing funds in:

– Residential options– Treatment services– Supports and resources


New/Expanded Peer Support

Peer mentors Warmline Peer specialists Recovery specialists (County staff)


New/Expanded Community Services

Community Treatment Teams (CTT), also known as Assertive Community Treatment (ACT)

Enhanced Clinical Case Management (ECCM) Expanded Service Coordination Mobile Medication Teams/Mobile Mental Health Expanded Outpatient Expanded Psychiatric Rehabilitation Crisis Services


New Residential Options

Permanent Supportive Housing (PSH) and related services

Comprehensive Mental Health/Enhanced Personal Care Homes (CMHPCH and EPCH)

Long-term Structured Residences (LTSR) Specialized Supportive Housing (aka long-term

residences) Extended Acute Services (EAC), both hospital and

community-based Residential Treatment Facility for Adults (RTF-A) Other county-specific options


Quality Assurance and Oversight Initiatives

Quality Improvement and Outcomes (QIO) Sub-Committee

Quality Management and Clinical Consultation (QMCC) Team

Comprehensive Monthly CSP Tracking

Care Management Collaboration with CCBH Regional Reporting of Critical Incidents and Early

Warning Indicators with Automated Notification Capability


Quality Assurance and Oversight Initiatives

Failure Mode Effects Analysis (FMEA)

Root Cause Analysis (RCA)


Why ACSP?

Based on the Mayview project:– Positive consumer outcomes

Greater satisfaction Improved quality of life Greater ownership in discharge process

– Positive system outcomes Improved collaboration among key stakeholders Services/supports match consumer needs Reduced inpatient


More…

County driven vs. OMHSAS No additional financingInitiated to improve consumer

outcomes not to access resources


Acute Inpatient Discharge Process: Overview

Level 1

Level 2

Level 3 Discharge Planning Facilitated by ACSP Facilitator

Multi-Disciplinary Treatment Team on Inpatient Unit

Acute In-Patient Multi-Disciplinary Treatment Team

Acute CSP

DispositionMeetings

Discharge Planning Facilitated by County Disposition Coordinator


Level 1: Exclusion Criteria

Consumer has a Community Support Plan (CSP) via a Mayview or Torrance State Hospital discharge process


IP multi-disciplinary treatment team, the consumer, family, and, when indicated, the outpatient provider, meet for the discharge planning process.

If additional assistance in discharge planning is required, the above team has the option to coordinate with County Disposition Coordinator and the MCO without going to Level 2 (Disposition Process)

Level 1: Acute Inpatient Discharge Process


Level 2 Eligibility Criteria (Draft)

Inpatient hospitalization must be > 14 days, plus one of the following criterion:

- Multiple acute IP admissions in past 12 months

- Disagreement among IP treatment team, OP provider, consumer, and/or consumer support system regarding the Level 1 discharge plan.

- Anticipated need for extended community based care and support, i.e. EAC, RTFA, LTSR.


• When d/c does not occur at Level 1, and Level 2 or Level 3 criteria is met, the IP team and consumer have the option to make a referral to the Disposition process

Once Level 2 criteria is met, there is no required timeframe to complete the disposition process

Whether Level 2 or 3 criteria is met, SW makes referral to the Disposition Coordinator and the Disposition Coordinator reviews referral.

Disposition Coordinator schedules disposition meetings and facilitates disposition process.

Level 2: Disposition Discharge Process


Level 3 Eligibility Criteria (Draft)

To be eligible, consumer must meet one of the following criterion:– 4 inpatient admissions in last 12 months– 2 prior state hospitalizations or any continued

state hospital stay > 2 years in duration– An acute inpatient hospitalization > 90 days in

duration in past 12 months– EAC, RTFA, LTSR treatment in the last 12

months


Level 3 Eligibility Criteria Continued

– Has had Disposition meeting within the last 12 months

– Consensus that a ACSP process is necessary to assure the development of a plan that promotes recovery, safety and community stability.


When discharge does not occur at Level 2 and Level 3 criteria is met, the County Disposition Coordinator and inpatient treatment team has the option to refer to the ACSP process.

Level 3: Acute CSP Discharge Process

31

Discharged?

Acute In-Patient

Unit

Discharged? Community

Discharged?

Y

N

Y

N

Level 1

N

Individual Agrees to

ACSP?

N

Community

Y

CommunityY

Level 2

Level 3Referral

Accepted?N

Conduct Disposition

Meetings

N

Y

Disposition Eligibility Criteria and

Process

Acute CSP Eligibility Criteria and

Process

Acute In-Patient Discharge Process

Complete ACSP Assessments:Clinical, Peer (CART), Family (CART) ACSP Stages: Information Gathering/Options,

Resource Coordination/ Transition, Final Plan

Allegheny HealthChoices, Inc.1/20/2009

Engage Consumer to Participate


Goals of the Acute Community Support Plan Process

Provide opportunity for individuals to express their needs & wants for successful living in the community through an assessment process

Provide an analysis of the assessments conducted in preparation for the plan process.

Provide opportunity for all ACSP team members to understand the strengths, challenges, and desires of the person for whom the plan is being developed

Develop strategies and secure resources to help support the person to effectively live in the community

Develop an ACSP that is congruent with the opinions of the individual and that is likely to succeed


Assessments: Peer, Family, Clinical

Assessments are the basis for the ACSP

All three assessments consider the following life areas or domains:

Living/housing Cognitive Abilities

Physical Health Psychiatric Health

Education and Work Social and Relationships

Supports Legal


CSTAP Peer Assessment

The emphasis is “what does the individual want and need for community living.” The language used in the assessment is understandable to most persons.

The assessment is conducted “peer to peer,” in private.

Participation in the assessment is entirely voluntary.


Family Assessment

The family assessment is conducted by a family member of a mental health consumer.

The assessment is accomplished either “face to face” or by telephone interview.

This assessment asks questions related to type of housing thought to be necessary; the amount of assistance/support the individual may need, the presence of physical and other impairments not known, for example.

Participation in the assessment is entirely voluntary and most families willingly participate.


Clinical Assessment

The clinical assessment is completed by a Social Worker and other key staff including community providers.

The assessment is current and completed prior to the first ACSP meeting.

This assessment focuses on historical and current clinical information related to what type, frequency, and intensity of support/supervision may be needed for the consumer to live successfully in the community


ACSP Participants

First and foremost, the consumer who is to be discharged and anyone the consumer invites

Family members of the consumer or representatives of the family

Members of the hospital treatment team and community provider (SC or CTT is critical)

MHA Advocate County ACSP Coordinator MCO representative The facilitator and recorder


The Consumer’s Role

Offers as much information about his/her TX progress as possible

Validates assessment summary information

Talks about the “best time” in his or her life and what his/her desires are now

Assists in developing a strengths list related to what he/she wants and needs to live in the community

Assists in development and review of strategies, ideas, and resources for supports and housing


The Family/Significant Other’s Role

Assists in the presentation of additional pertinent information about the consumer

Assists in the development of strengths list

Presents a favorite memory

Offers ideas about supports they believe are necessary


The Advocates Role

To assist the consumer in the ACSP planning process by:– Assisting in preparing for the ACSP meetings– Advocating for what the consumer wants– Ensuring supports are in place prior to discharge– Assisting ACSP team in staying focused on what

the consumer’s strengths– Assisting the ACSP team in staying focused on

the needs and wants of the consumer


Hospital, Community Provider, and County Roles

The person’s social worker and psychiatrist are important participants; typically their contribution is clinical in nature

The county ACSP coordinator and/or provider liaison and/or SC/CTT members bring knowledge of the community and potential resources to the table

All staff have to be particularly cautious not to discourage the consumer and may have to be willing to negotiate to reach agreement with the consumer


Role of Social Worker

The Social Worker will work with the ACSP Facilitator to complete the clinical assessment within 2 weeks of consumer consent to participate in ACSP process.

The Social Worker will invite ACSP key attendees: inpatient psychiatrist and team, outpatient provider, individual, family, MCO, County, hospital liaison, and others.

– The facilitator will invite the advocate and the county


Facilitator Role

Facilitator introduces process and engages consumer throughout the process

Facilitator coordinates completion of assessments

The facilitator “chairs” the meeting The facilitator posts the current ACSP to the

website


Recorder Role

Recorder is present to assist all ACSP team members focus on tasks associated with the development of the CSP

The recorder keeps copious notes and writes the ACSP for the group after each meeting

The recorder ensures the final plan is comprehensive and complete


ACSP Coordinator Role

Holds participants accountable for completing tasks between meetings

Provides county support Inquires at first ACSP meeting if consumer

would like a Peer Mentor


Peer Mentor (if consumer chooses)

To assist the consumer in the ACSP planning process by:– attending ACSP meetings– building a relationship so the consumer becomes

more comfortable with moving back into the community

– visiting consumer on the unit and taking the consumer into the community


The Planning Meeting: Tips for Success

It is important that meetings be as free of conflict as possible.

It is essential that verbal and body language be clear and understandable

Direct every comment to the consumer unless there was a direct question by someone else

Interruptions and sidebars slow down the process Feel free to offer compliments and support to other

people at the table


The Planning Meeting: More Tips for Success

Think positively and creatively. Remain open to ideas.

Statements like “We’ve already tried that” close opportunities. Say instead, “When we try this again, we’ll need to be sure that adequate or different supports are present”

Saying “yes but” – this little comment is probably the greatest killer of ideas ever

Full and positive participation by everyone at the table ensures the development of a possible ACSP

Speak out and offer information


ACSP Meeting Stages

Information Gathering and OptionsResource Coordination and TransitionFinal Plan


Stage One – Information Gathering/Options Stage

Information is obtained by the consumer, supports, and treatment agencies

Service options which are congruent with the consumer’s stated needs and wants

Most of the content is information brought by the ACSP team members

A list of tasks are agreed upon and assigned prior to the end of the meeting


Stage Two – Resource Coordination and Transition Stage

Locate or create resources which are congruent with the consumer’s stated needs and wants. The consumer may visit places that he/she will use in the community

Ensure all resources are secured and in place prior to discharge

Identify and plan for all ‘transition’ activities


Stage Three – Final Plan

Status of community supports and resources are discussed and reviewed with the consumer, supports and ACSP participants

The ACSP form is finalized with the consumer, supports and ACSP participants

The final plan is posted on the website and monitored by OBH


Contact Information

Jamie Moses (Disposition Coordinator)

Email: [email protected]

Phone: 412-350-7087 Cecilia Reinheimer (ACSP Coordinator)


Phone: 412-350-5015 Sally Crompton (ACSP Facilitator)


Phone: 412-867-5685

allegheny healthchoices, inc. 1 allegheny county discharge and acute community support planning...

Documents

housingallegheny healthchoices

dreamsallegheny healthchoices

learnedthe csp process

resource planning process

community providers

community settings

community support plan

allegheny county discharge