form o consolidated local service plan (clsp)€¦ · county services & populations ......

Health and Human Services Commission

Form O Consolidated Local Service Plan (CLSP)

for Local Mental Health Authorities/ Local Behavioral Health Authorities

March 2018

FY2017 Form O 1

Prepared by

For More Information please contact:

Lee Brown, Director of Contracts Management

[email protected]

903.237.2341

FY2017 Form O 2

mailto:[email protected]

Contents

Introduction ........................................................................................................................................................................................................................................... 3 Section I: Local Services and Needs ................................................................................................................................................................................................. 4

I.A. Mental Health Services and Sites .................................................................................................................................................................................... 4 I. B Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver Projects ....................................................... 4 I.C Community Participation in Planning Activities ..................................................................................................................................................... 6

Section II: Psychiatric Emergency Plan ......................................................................................................................................................................................... 7 II.A Development of the Plan .................................................................................................................................................................................................... 8 II.B Crisis Response Process and Role of MCOT .......................................................................................................................................................... 8 II.C Plan for local, short-term management of pre- and post-arrest patients who are incompetent to stand trial ...................... 12 II.D Seamless Integration of emergent psychiatric, substance use, and physical healthcare treatment .............................................. 13 II.E Communication Plans .......................................................................................................................................................................................................... 14 II.F Gaps in the Local Crisis Response System .................................................................................................................................................................. 14

Section III: Plans and Priorities for System Development ................................................................................................................................................. 14 III.A Jail Diversion .......................................................................................................................................................................................................................... 14 III.B Other System-Wide Strategic Priorities .................................................................................................................................................................... 18 III.C Local Priorities and Plans ................................................................................................................................................................................................. 20 III.D Priorities for System Development ............................................................................................................................................................................. 20

Appendix A: Levels of Crisis Care ................................................................................................................................................................................................. 22

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Introduction The Consolidated Local Service Plan (CLSP) encompasses all of the service planning requirements for LMHAs/LBHAs. The CLSP has three sections: Local Services and Needs, the Psychiatric Emergency Plan, and Plans and Priorities for System Development.

Local planning is a collaborative activity, and the CLSP asks for information related to community stakeholder involvement in planning. HHSC recognizes that community engagement is an ongoing activity, and input received throughout the biennium will be reflected in the local plan. LMHAs/LBHAs may use a variety of methods to solicit additional stakeholder input specific to the local plan as needed.

The Psychiatric Emergency Plan is a new component that stems from the work of the HB 3793 Advisory Panel. The panel was charged with assisting HHSC to develop a plan to ensure appropriate and timely provision of mental health services. The Advisory Panel also helped HHSC develop the required standards and methodologies for implementation of the plan, in which a key element requires LMHAs/LBHAs to submit to HHSC a biennial regional Psychiatric Emergency Plan developed in conjunction with local stakeholders. The first iteration of this Psychiatric Emergency Plan is embedded as Section II of the CLSP.

In completing the template, please provide concise answers, using bullet points. When necessary, add additional rows or replicate tables to provide space for a full response.

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Section I: Local Services and Needs

I.A. Mental Health Services and Sites • In the table below, list sites operated by the LMHA/LBHA (or a subcontractor organization) that provide mental health

services regardless of funding (Note: please include 1115 waiver projects detailed in Section 1.B. below). Include clinics and other publicly listed service sites; do not include addresses of individual practitioners, peers, or individuals that provide respite services in their homes.

• Add additional rows as needed. • List the specific mental health services and programs provided at each site, including whether the services are for adults,

children, or both (if applicable): o Screening, assessment, and intake o Texas Resilience and Recovery (TRR) outpatient

services: adults, children, or both o Extended Observation or Crisis Stabilization

Unit o Crisis Residential and/or Respite o Contracted inpatient beds

o Services for co-occurring disorders o Substance abuse prevention, intervention, or

treatment o Integrated healthcare: mental and physical

health o Other (please specify)

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Operator (LMHA/LBHA or Contractor Name)

Street Address, City, and Zip

County Services & Populations

Community Healthcore 105 & 107 Woodbine Pl, Longview

Gregg • Other, Administrative Complex

Community Healthcore 1300 N. Sixth Street, Longview

Gregg • Screening, assessment, and intake • Texas Resilience and Recovery (TRR) outpatient

services: adult Community Healthcore 950 N. Fourth Street,

Longview Gregg • Screening, assessment, and intake

• Substance Abuse prevention, intervention, and treatment

Community Healthcore and Special Health Resources for Texas

703 Marshall Ave, Suite 310 Longview

Gregg • Screening, assessment, and intake • Texas Resilience and Recovery (TRR) outpatient

services: children • Integrated healthcare: mental and physical

health

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Community Healthcore 101 Madison, Gilmer Upshur • Screening, assessment, and intake

• Texas Resilience and Recovery (TRR) outpatient services: both

Community Healthcore 106 North MLK Drive, Clarksville

Red River • Screening, assessment, and intake • Texas Resilience and Recovery (TRR) outpatient

services: both Community Healthcore 2435 College Dr., Texarkana Bowie • Screening, assessment, and intake


• Integrated healthcare: mental and physical health • Substance Abuse prevention, intervention, and

treatment Community Healthcore 1008 N. Louise Street,

Atlanta Cass • Screening, assessment, and intake


Community Healthcore 1701 S. Adams, Carthage Panola • Screening, assessment, and intake • Texas Resilience and Recovery (TRR) outpatient

services: both Community Healthcore 209 N. Main, Henderson Rusk • Screening, assessment, and intake


Community Healthcore 401 North Grove St Marshall, TX

Harrison • Screening, assessment, and intake • Texas Resilience and Recovery (TRR) outpatient

services: adults Community Healthcore

114 Jordan Plaza Blvd, Tyler TX

Out of Catchment Smith

• Substance Abuse prevention, intervention, and treatment

Community Healthcore 1007 South William Street, Suite 5, Atlanta

Cass • Crisis Stabilization Unit (opens May 2018) • Crisis Residential • Extended Observation

Glen Oaks Greenville, TX Out of Catchment

Contracted inpatient beds

East Texas Medical Center, Psychiatric Unit

Tyler, TX Out of Catchment

Contracted inpatient beds

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Texoma Sherman, TX Out of

Catchment Contracted inpatient beds

Magnolia Behavioral Hospital

Longview, TX Gregg Contracted inpatient beds

I. B Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver Projects • Identify the RHP Region(s) associated with each project. • List the titles of all projects you proposed for implementation under the Regional Health Partnership (RHP) plan. If the title

does not provide a clear description of the project, include a descriptive sentence. • Enter the number of years the program has been operating, including the current year (i.e., second year of operation = 2) • Enter the static capacity—the number of clients that can be served at a single point in time. • Enter the number of clients served in the most recent full year of operation. If the program has not had a full year of

operation, enter the planned number to be served per year. • If capacity/number served is not a metric applicable to the project, note project-specific metric with the project title.

1115 Waiver Projects

RHP Region(s)

Project Title (include brief description if needed) Years of Operation

Capacity Number Served/ Year

1 137921608.1.1: 1.13 - Development of behavioral health crisis

DY 6 16 665 1 137921608.1.4: 1.13 - Development of behavioral health crisis

DY 6 24 1,559

1 137921608.2.1: Integrate Primary and Behavioral Health Care Services DY 6 16/day 275

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I.C Community Participation in Planning Activities Identify community stakeholders who participated in your comprehensive local service planning activities over the past year.

X Consumers X Advocates (children and adult) □ Local psychiatric hospital staff X Mental health service providers □ Prevention services providers X County officials X FQHCs/other primary care providers

X Hospital emergency room personnel □ Faith-based organizations X Probation department representatives

X Court representatives (judges, DAs, public defenders) □ Education representatives X Planning and Network Advisory Committee X Veterans’ organization

X Family members X Concerned citizens/others X State hospital staff □ Substance abuse treatment providers □ Outreach, Screening, and Referral (OSAR) X City officials □ Local health departments X Emergency responders □ Community health & human service providers X Parole department representatives X Law enforcement □ Employers/business leaders X Local consumer-led organizations

Stakeholder Type Stakeholder Type

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List the key issues and concerns identified by stakeholders, including unmet service needs. Only include items that were raised by multiple stakeholders and/or had broad support.

• Need for local inpatient psychiatric services • Reduction of time peace officers wait at the ER with persons in need of Psychiatric Crisis Services • Obtaining physical medicine and behavioral health services from the same location – (integrated health) • Access to lower cost psychiatric prescriptions • Good housing that is available to low income persons or families that is also safe and meet ADA • Transportation to get to and from home and work, store, and appointments. Explore community network to assist with

transportation. • Lack of community awareness of vital services and supports available at the Federal, State, and Local levels. • Need for community resources to address significant but non-qualifying diagnosis.

Section II: Psychiatric Emergency Plan

The Psychiatric Emergency Plan is intended to ensure that stakeholders with a direct role in psychiatric emergencies have a shared understanding of the roles, responsibilities, and procedures that will enable them to coordinate their efforts and effectively use available resources. The Psychiatric Emergency Plan entails a collaborative review of existing crisis response activities and development of a coordinated plan for how the community will respond to psychiatric emergencies in a way that is responsive to the needs and priorities of consumers and their families. The planning effort also provides an opportunity to identify and prioritize critical gaps in the community’s emergency response system. Planning should consider all available resources, including projects funded through the 2015 Crisis and Inpatient Needs and Capacity Assessments.

The HB 3793 Advisory Panel identified the following stakeholder groups as essential participants in developing the Psychiatric Emergency Plan:

• Law enforcement (police/sheriff and jails) • Hospitals/emergency departments • Judiciary, including mental health and probate courts • Prosecutors and public defenders

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• Other crisis service providers • Users of crisis services and their family members

Most LMHAs/LBHAs are actively engaged with these stakeholders on an ongoing basis, and the plan will reflect and build upon these continuing conversations, including those related to the 2015 Crisis Needs and Capacity Assessment.

Given the size and diversity of many local service areas, some aspects of the plan may not be uniform across the entire service area. If applicable, include separate answers for different geographic areas to ensure all parts of the local service area are covered.

II.A Development of the Plan Describe the process you used to collaborate with stakeholders to develop the Psychiatric Emergency Plan, including:

• Ensuring all key stakeholders were involved or represented • Ensuring the entire service area was represented • Soliciting input

• CHRISTUS/Texarkana monthly meeting including law enforcement, county officials • CHRISTUS Good Shepherd Medical Center/Longview quarterly meeting including law enforcement, county officials • CHRISTUS/Cass County monthly meeting including law enforcement, county officials • Additional meetings as needed with county judges, county sheriff offices, police chiefs, etc.

II.B Crisis Response Process and Role of MCOT 1. How is your MCOT service staffed?

a. During business hours

b. After business hours

o Longview – 4 QMHPs on 12 hour shifts on alternating days – 1 licensed intern, 1 licensed counselor, 1 QMHP 8-5

o Texarkana – 2 QMHPs on 12 hour shifts on alternating days – 2 QMHPs available 8-5

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c. Weekends/holidays

2. What criteria are used to determine when the MCOT is deployed?

3. What is the role of MCOT during and after a crisis when crisis care is initiated through the LMHA/LBHA (for example, when an individual calls the hotline)? Address whether MCOT provides follow-up with individuals who experience a crisis and are then referred to transitional or services through the LMHA/LBHA.

4. Describe MCOT support of emergency rooms and law enforcement:

a. Do emergency room staff and law enforcement routinely contact the LMHA/LBHA when an individual in crisis is identified? If so, is MCOT routinely deployed when emergency rooms or law enforcement contact the LMHA/LBHA?

o Longview – 1 QMHP, 1 licensed intern on 12 hour shifts on alternating nights o Texarkana – QMHP on 12 hour shifts on alternating nights

o The schedule remains the same through weekends and holidays with current staffing of screeners on 12 hour shifts

• All calls from the community come through AVAIL Solutions – Calls are vetted and determined by AVAIL operators to be emergent, urgent or routine – MCOT workers are called and activated according to their county of coverage.

• The MCOT can refer a client to the Crisis clinic for LOC 5 services which can include physician services, service coordination, skills training, and counseling. This services is available for up to 90 days. The client will be constantly assessed for needs. After the 90 day period the client can be referred to a FLOC or into the community for ongoing services.

o Emergency rooms: calls go through AVAIL and then to the MCOT worker o Law enforcement: calls go through AVAIL and then to the MCOT worker unless other specific arrangements

have been made.

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b. What activities does the MCOT perform to support emergency room staff and law enforcement during crises?

5. What is the procedure if an individual cannot be stabilized at the site of the crisis and needs further assessment or crisis stabilization in a facility setting?

a. Describe your community’s process if a client needs further assessment and/or medical clearance:

b. Describe the process if a client needs admission to a hospital:

c. Describe the process if a client needs facility-based crisis stabilization (i.e., other than hospitalization–may include crisis respite, crisis residential, extended observation, etc.):

o Emergency rooms: Crisis assessment of the identified client, collaboration with staff on planning to help the client, facilitating placement of client, education of staff on MH issues and community resources.

o Law enforcement: Crisis assessment of the identified client, collaboration with staff on planning to help the client, facilitating placement of client, education of staff on MH issues and community resources.

o If the client is in need of further services, MCOT can coordinate with local law enforcement or EMS to transport the client to the nearest Emergency Department for medical clearance.

o If it is determined that the client is in need of a higher level of care, the MCOT will call to obtain a bed at one of many psychiatric facilities in and around the area. If the crisis assessment occurs in the community, the MCOT will pursue the EDW for local law enforcement to take custody of the client and transport them to the nearest ER for medical clearance. If the crisis assessment is taking place within an ER or jail, the staff of that facility will complete the necessary paperwork for transport by law enforcement (EDW or OPC).

o Client is assessed by crisis workers and/or RN triage Nurse. If client meets criteria for admission, the client is transported by law enforcement or RCRC staff for evaluation by the Psychiatrist for continued services.

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6. What steps should emergency rooms and law enforcement take when an inpatient level of care is needed?

a. During business hours

b. After business hours

c. Weekends/holidays

7. If an inpatient bed is not available:

a. Where is an individual taken while waiting for a bed?

b. Who is responsible for providing continued crisis intervention services?

o Call Crisis Line 1.800.832.1009 o Crisis Office Longview – 903.757.1106 o Crisis Office Texarkana – 903.831.7585

• Call Crisis Line 1.800.832.1009

• Call Crisis Line 1.800.832.1009

• If not currently at an ER, the client should remain in the community with a well-crafted safety plan. A client should not go to an ER simply to wait for a bed. Placement will be established before sending a client for any medical clearance. However, if the client is in the ER at the time of the assessment, the client will remain there until a bed becomes available.

• The Mobile Crisis Outreach Team

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c. Who is responsible for continued determination of the need for an inpatient level of care?

d. Who is responsible for transportation in cases not involving emergency detention?

Crisis Stabilization 8. What alternatives does your service area have for facility-based crisis stabilization services (excluding inpatient

services)? Replicate the table below for each alternative.

Name of Facility Community Healthcore Crisis Stabilization Unit Location (city and county) Atlanta in Cass County (opening in May 2018) Phone number 903.796.1278 Type of Facility (see Appendix B) Crisis Stabilization Unit

o The Mobile Crisis Outreach Team

• MCOT may transport as they feel comfortable. Also, minimal funds are available to assist the client with a ride in a taxi depending on their location, distant of travel and time of day.

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Key admission criteria (type of patient accepted)

Admission Criteria: A. Validated principal DSM-IV Axis I or II diagnosis, and B. Treatment at a lower level of care has been attempted or

given serious consideration, and C. GAF < 50, and D. Capacity to make a decision to enter into voluntary

treatment. One of the following must be present:

1. Loss of ability to perform activities of daily living due to moderate impairment in judgment, poor impulse control, or moderate impairment in cognitive perceptual abilities arising from:

Acute psychiatric condition or dual disorder condition

Acute exacerbation of chronic psychiatric condition;

Significant decrease in functioning in several activities of daily living as measured against baseline function over the preceding year.

2. Danger to self as evidenced by: Specific plan to harm self with, high lethality

and/or availability of means but ambivalence in intention with desire to seek treatment, or

A level of suicidality that cannot be safely managed at a lower level of care; or

Moderate to severe suicidality accompanied by a rejection or lack of available social therapeutic support, and

Absence of a high lethality attempt within the last 48 hours

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3. Dangerousness to others as evidenced by: Specific plan to take a life threatening action with

high lethality and availability of means but ambivalence in intention with desire to seek treatment; or

Moderate to significant violent / homicidal ideation accompanied by a rejection or lack of available social/therapeutic support, and

Absence of a significant violent attack within 48 hours.

4. Danger to property where such danger includes: Specific plan to take destructive action that may

result in life threatening situation with high lethality and availability of means to take such action

5. The presence of a coexisting medical condition that would complicate or interfere with the treatment of the psychiatric disorder at a less intensive level of care.

6. A high risk for placing self or others at risk for significant harm through impulsive behavior or exercising poor judgment, as evidenced by:

A documented pattern of ongoing and recent impulsive behavior that puts self or other at risk; or

Documented evidence of a plan to behave in a manner that will place self or others at significant risk and documented evidence of a lack of ability to control one's behavior to avoid enacting such a plan. Or, documented evidence of a clear intention to enact such a plan in the immediate future.

7. Consumer has deteriorated to level of disorganization and dysfunction that they cannot cooperate with outpatient care or treatment plan.

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Circumstances under which medical clearance is required before admission

MEDICAL EXCLUSION CONDITIONS Although the Regional Crisis Response Center has access to a full range of auxiliary services, it is not staffed or equipped to treat those individuals whose problems are primarily medical in nature or who are in need of immediate medical emergency treatment. Individuals who present themselves for admission with overriding medical conditions are referred to the most appropriate care provider. Exclusion criteria are listed immediately below. Exclusion Criteria with Exceptions by Medical Director

Need of IV therapy Need of nasogastric suction or feeding Need of catheter care by staff Need of stoma care by staff Tracheal stoma requiring suctioning Decubitus ulcers (Stages 2 – 4) or other deep wounds requiring strict isolation techniques Asthma or COPD requiring ongoing nebulization therapy Ongoing need for physical therapy or peritoneal/hemo-dialysis Altered mental status with impaired sensorium (other than secondary to known substance abuse) Chest pain of probable cardiovascular, pulmonary, or severe traumatic origin with elevated cardiac enzymes Suicide attempt or injury ( < 12 hours) requiring immediate medical treatment Fever >101 F, productive cough, or rashes that indicate need for isolation Untreated active tuberculosis Head trauma + loss of consciousness < 24 hr Uncontrolled diabetes with blood glucoses > 400 OR < 60 prior to admission and requiring IV insulin for continued glucose control Elevated blood pressure > than 180/100.

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Other medical or neurological conditions requiring intensive ongoing medical supervision

Pregnancy: Greater than second trimester at time of admission Medical isolation Methadone/Suboxone maintenance

Service area limitations, if any Serves nine counties: Bowie, Cass, Gregg, Harrison, Marion, Panola, Red River, Rusk, and Upshur.

Other relevant admission information for first responders

All units are nonsmoking, no e-cigarettes, chewing tobacco, snuff etc. No cell phones allowed Noninvasive body searches for contraband on admission

Accepts emergency detentions? 48 hour EDW accepted in EOU, when CSU will be able to take OPC for up to 14 days.

Inpatient Care 9. What alternatives to the state hospital does your service area have for psychiatric inpatient care for medically

indigent? Replicate the table below for each alternative.

Name of Facility Glen Oaks Location (city and county) Greenville – Hunt County Phone number 903.454.6000 Key admission criteria short-term, inpatient stabilization services for those who at risk for suicide, as

Service area limitations, if any Other relevant admission information for first responders

For clients outside of Hunt county, all admissions require an OPC.

Name of Facility Texoma Location (city and county) Sherman Phone number 903.416.3000 Key admission criteria short-term, inpatient stabilization services for those who at risk for suicide, as well

as those who are experiencing severe mood and thought disorders, serious emotional trauma or psychotic disorders

Service area limitations, if any N/A

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Other relevant admission information for first responders

Name of Facility ETMC-Behavioral Health Location (city and county) Tyler – Smith County Phone number 1.800.566.0088 Key admission criteria short-term, inpatient stabilization services for those who at risk for suicide, as well


Service area limitations, if any N/A Other relevant admission information for first responders

Name of Facility Magnolia Behavioral Hospital Location (city and county) Longview – Gregg County Phone number 903.291.3456 Key admission criteria short-term, inpatient stabilization services for those who at risk for suicide, as well


Service area limitations, if any N/A Other relevant admission information for first responders

Cannot take clients with MDCD

II.C Plan for local, short-term management of pre/post-arrest patients incompetent to stand trial 10. What local inpatient or outpatient alternatives to the state hospital does your service area currently have for competency

restoration? a. Identify and briefly describe available alternatives.

b. What barriers or issues limit access or utilization to local inpatient or outpatient alternatives? If not applicable, enter N/A.

• Transitional Care through Outpatient Competency Restoration to divert consumers from state inpatient forensic beds into the community setting for restoration.

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c. Does the LMHA/LBHA have a dedicated jail liaison position? If so, what is the role of the jail liaison? At what point is the jail liaison engaged?

If the LMHA/LBHA does not have a dedicated jail liaison, identify the title(s) of employees who operate as a liaison between the LMHA/LBHA and the jail.

d. What plans do you have over the next two years to maximize access and utilization of local alternatives for competency restoration? If not applicable, enter N/A.

11. Does your community have a need for new alternatives for competency restoration? If so, what kind of program would be suitable (i.e., Outpatient Competency Restoration Program, inpatient competency restoration, jail-based competency restoration, etc.)?

o The rural setting often has fewer defendants across a vast area becoming incompetent and therefore the justice system often fails to notify LMHA of the potential consumers request for evaluation by the judges or defense attorneys which forces a systems reliance on the clearing house list. Another barrier is the acceptance of defendants being in the community by smaller counties due to the insecurity of safety to the people. Lastly, demands of the criteria put forth in smaller system forces actions to break the silo of typical health services which may cause confusion for the different entities to understand one another’s roles.

• Yes, the jail liaison intercepts calls and messages from courts and jail staff for the LMHA. The liaison spends a majority of their time travelling across the catchment to visit the jails to ensure the mental health needs are met and expedites early releases and court appointments to the extent the LMHA is allowed in that setting.

• The Community Healthcore liaison title is Criminal Justice Project Lead.

• With the increase of Outpatient Competency usage over the past 4 years we may extend the number of individuals at baseline in the contract. As opportunities become available to restore offenders through a jail-based competency restoration, this may help us to deflect more defendants from the state hospital system.

• Jail-based competency restoration would tremendously impact our deflection of state hospital beds and our county stakeholders are interested in having the option of treatment and training for these defendants without the risk of safety by their release and the use of funds to transport to facilities as far away as 7 to 13 hours for inpatient competency restoration.

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12. What is needed for implementation? Include resources and barriers that must be resolved.

II.D Seamless Integration of emergent psychiatric, substance use, and physical healthcare treatment 13. What steps have been taken to integrate emergency psychiatric, substance use, and physical healthcare services?

14. What are your plans for the next two years to further coordinate and integrate these services?

• Additional resources to fund increase in staffing to provide treatment for jail based competency restoration for our existing eleven jails in our nine county catchment area.

• At this time the state approval for treatment to occur in the jail setting is limited. Currently there is no allowable billing from sources or GR funds allotted for the services rendered since the benefits would be suspended after 90 days. The resources are the stakeholder’s interest and ability to provide a place within the jail structure to support training of the defendants toward restoration. The other resource is the staff already trained and their ability to access these county jails already makes them familiar with the different leadership within the 9 counties and beyond we serve through Outpatient Competency, Mental Health Court, and Jail Diversion already.

• At this time Community Healthcore is collocated at one of our Outpatient Mental Health Clinics with 1 Federally Qualified Health Center. The site meets the SAMHSA’s Level 6 – Full Collaboration in a transformed/merged integrated practice. Services are in the same place, in the same facility sharing the same EMR. These services achieved a full collaboration level 6 as a result of a four year SAMHSA integration grant period.

• The Regional Crisis Response Centers is located within a hospital.

• Continue to build on the relationships with our FQHC partners and also to develop the capacity to provide whole care approaches (wellness approaches with behavioral health populations) as part of our comprehensive service delivery.

• Recently notified by the Texas Council and HHS to be a part of a select group of centers to receive consultation and technical assistance to obtain a state certification as a Certified Community Behavioral Health Center (CCBHC)

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II.E Communication Plans 15. How will key information from the Psychiatric Emergency Plan be shared with emergency responders and

other community stakeholders? Consider use of pamphlets/brochures, pocket guides, website page, mobile app, etc.

16. How will you ensure LMHA/LBHA staff (including MCOT, hotline, and staff receiving incoming telephone calls) have the information and training to implement the plan?

II.F Gaps in the Local Crisis Response System 17. What are the critical gaps in your local crisis emergency response system? Consider needs in all parts of your

local service area, including those specific to certain counties.

Counties Service System Gaps Bowie, Cass, Gregg, Harrison, Marion, Panola, Red River, Rusk, and Upshur

Ability to care for physically aggressive patients requiring local hospital emergency departments to continue to hold until a state psychiatric bed is available. Many private psychiatric hospitals will not take physically aggressive patients.

• It will be posted on our Website. • Community Healthcore pamphlets and brochures will list the website address.

• The information contained in the plan is information already provided to AVAIL (Crisis Line), MCOT, and staff receiving incoming calls.

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Bowie, Cass, Gregg, Harrison, Marion, Panola, Red River, Rusk, and Upshur

• Psychiatric Inpatient facilities exclude the following conditions making resources scarce for these populations:

o Late stage Pregnancy o Individuals with IDD o Individuals with pending criminal charges.

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Section III: Plans and Priorities for System Development III.A Jail Diversion Indicate which of the following strategies you use to divert individuals from the criminal justice system. List current activities a n d any plans for the next two years. Include specific activities that describe the strategies checked in the first column. For those areas not required in the HHSC Performance Contract, enter NA if the LMHA/LBHA has no current or planned activities.

Intercept 1: Law Enforcement and Emergency Services Components o Current Activities

□ Co-mobilization with Crisis Intervention Team (CIT) X Co-mobilization with Mental Health Deputies □ Co-location with CIT and/or MH Deputies □ Training dispatch and first responders X Training law enforcement staff

X Training of court personnel X Training of probation personnel □ Documenting police contacts with persons with mental illness □ Police-friendly drop-off point □ Service linkage and follow-up for individuals who are not

hospitalized □ Other:

• Community Healthcore works with Mental Health Deputies from Gregg County and Harrison County.

• MCOT team as needed or requested will meet with MH Deputies or other law enforcement to address emerging mental health crisis situations.

• Community Healthcore has a community collaboration to create a Crisis Intervention Team.

• Collaborating with local law enforcement, courts, etc. to provide MH First Aid training to as many of their staff as possible. We are offering this at cost so that expenses for the training would be easier to attain.

• During the year staff are providing 4 hours of the CIT training for local law enforcement.

• Quarterly there are pre-hearing sessions which include training of District Attorney, Judge, Probation Officer’s, and defense attorneys.

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Plans for the upcoming two years:

• Work with local law enforcement and implement a CIT approach by August 2018.

• Through the Gregg County Wellness Collaborative develop ways to track and divert high risk behavioral health populations who are high utilizers of preventable ER admissions and law enforcement engagement. These individuals would be diverted to more appropriate community based services.

Intercept 2: Post-Arrest: Initial Detention and Initial Hearings Components Current Activities

X Staff at court to review cases for post-booking diversion X Routine screening for mental illness and diversion

eligibility X Staff assigned to help defendants comply with conditions of

diversion X Staff at court who can authorize alternative services to

Incarceration X Link to comprehensive services □ Other:

• We have staff on site at Gregg county to assist them in assessing clients at booking that have been identified for suicide watch and other mental health concerns. We provide additional assessment of these individuals so that jail staff have adequate information to determine the placement or removal of persons on suicide watch.

• Staff for the past 7 years review the daily bookings of individuals in Gregg County for potential clients in Jail Diversion, we are in court hearings when a potential diversion candidate appears.

• Staff monitor individuals weekly in Jail Diversion for treatment compliance and adherence to orders.

• On a case by case basis staff provides the courts throughout the catchment area with alternative strategies to incarceration. This includes resources not necessarily provided by this Center.

• Staff assist clients with linkage to comprehensive services through FQHC o other services including medication management.


• To expand criminal justice projects through MHC, JD, OCR, JBCR, and the CIT.

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Intercept 3. Post-Initial Hearing: Jail, Courts, Forensic Evaluations, and Forensic Commitments Components Current Activities

□ Routine screening for mental illness and diversion eligibility X Mental Health Court X Veterans’ Court □ Drug Court X Outpatient Competency Restoration □ Services for persons Not Guilty by Reason of Insanity □ Services for persons with other Forensic Assisted Outpatient

Commitments □ Providing services in jail for persons Incompetent to Stand

Trial □ Compelled medication in jail for persons Incompetent to

Stand Trial □ Providing services in jail (for persons without outpatient

commitment) X Staff assigned to serve as liaison between specialty courts. X Link to comprehensive services □ Other:

• Mental Health Court is currently part of our services provided. Staff work primarily with Gregg County who currently have MH courts to facilitate treatment for identified individuals or to provide case management type services while connecting identified individuals to community resources as well.

• Veterans Treatment Court has been part of the Center since 2016. Gregg County is the primary county with a working court; Marion and Bowie are counties that will be expanding in the next two years.

• Outpatient Competency Restoration (OCR) has been part of the Center since 2012 and continues to exceed the clients proposed in our service agreement. The counties participating are Gregg, Rusk, Harrison, and Upshur.

• There is one staff person dedicated to the criminal justice approaches we’ve taken. All counties are provided the service. Due to the OCR specialty courts involved, some individuals have been treated outside of our catchment as a convenience to the individuals involved.

• Staff assist clients with linkage to comprehensive services through FQHC o other services including medication management.


• Νο Plans for this Intercept at this time; see Intercept 1 and 5.

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Intercept 4: Re-Entry from Jails, Prisons, and Forensic Hospitalization Components Current Activities

□ Providing transitional services in jails X Staff designated to assess needs, develop plan for services,

and coordinate transition to ensure continuity of care at release

X Structured process to coordinate discharge/transition plans and procedures

X Specialized case management teams to coordinate post- release services

□ Other:

• Nearly every facet of the Outpatient Competency Program and our Jail Diversion provides interaction prior to release from jail. By the time a person appears in court for Restoration a full assessment has been completed with a personalized initial treatment plan and court order specific to the individual also attached. This involves close communication with defense attorney’s and district attorney’s. Case management utilizing intensive services is coordinated during this time, so to be prepared to receive and individual out of jail within 24 to 72 hours.


• No further plans for this Intercept at this time.

Intercept 5: Community corrections and community support programs Components Current Activities

X Routine screening for mental illness and substance use disorders

□ Training for probation or parole staff X TCOOMMI program □ Forensic ACT

• TCOOMMI assists in providing outpatient services at the request of parole or probation referral.

• There is not currently any pre-booking activities.

• Post-booking activities occur when crisis assesses an individual in the jail for MH needs and/or hospitalization necessity.

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□ Staff assigned to facilitate access to comprehensive services; specialized caseloads

X Staff assigned to serve as liaison with community corrections □ Working with community corrections to ensure a range of

options to reinforce positive behavior and effectively address noncompliance

□ Other:

• We at times provide assessment per judge request to identify individuals with need MH treatment.

• Our crisis staff also provide assessment on Magistrate orders.

• The Criminal Justice Project Lead is available for support and as a resource to assist staff with community corrections and court orders.


• TCOOMMI does not currently have a jail diversion program but we will be requesting one for next FY to serve at least our 6 southern counties if not all 9.

• We are looking at broadening the criminal justice involvement with MH overall. Most likely starting with Gregg County.

III.B Other System-Wide Strategic Priorities Briefly describe the current status of each area of focus (key accomplishments and current activities), and then summarize objectives and activities planned for the next two years.

Area of Focus Current Status Plans Improving continuity of care between inpatient care and community services

• Community Healthcore has reconfigured its Continuity of Care team so the designated staff are tracking residents from our nine counties from admission to discharge. Caseloads are assigned based upon which hospital (state and private) the resident was admitted into. By this tracking staff are then able to support a more seamless transition from hospital discharge to community services.

• Continue to monitor continuity of care and meet all HHSC metrics for 7/30 day follow up on a quarterly basis.

Reducing hospital readmissions

• Clients not previously admitted into services, are admitted into a LOC 5 and are seen within 7 days after

• No further plans at this time.

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discharge from an inpatient facility. Based upon the initial assessment, frequency of services is determined.

• Clients currently in services, are also

seen within 7 days of discharge from an inpatient facility. Case workers are notified of all discharges.

Transitioning long-term state hospital patients who no longer need an inpatient level of care to the community

• Center will work with any area provider serving as a HCBS-AMH. Currently no providers actively service persons in our catchment area.

• Center periodically reviews cases of long-term state hospital patients to determine if they no longer need inpatient level of care.

• Center is currently reviewing the revised Home and Community Based Services waiver for adults with Severe Mental Illness. Review by Aug 2018. If favorable will make application to become a AMH HCBS provider by Aug 2019

Reducing other state hospital utilization

• Opened a 9 bed Crisis Stabilization Unit as a local resource.

• Purchased inpatient beds from contracted facilities.

• Move Kilgore nine bed CSU to Atlanta and expand to fourteen bed CSU May 2018.

• Maintain a census of 11 CSU beds by Sep 2018 thus reducing the need for state hospital beds.

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Tailoring service interventions to the specific identified needs of the individual

• Community Healthcore initiated a Trauma Informed Care approach. This is a training that every Community Healthcore staff person completes on an annual basis to heighten the understanding and approach from a Trauma Informed approach.

• Information is gathered at assessment as well as annually to incorporate any history of trauma and is incorporated in to the treatment plans as needed.

• Community Healthcore has adopted a whole health emphasis that focuses on 7 Dimensions of Wellbeing & Healthy Lifestyles: Spiritual, Social, Occupational, Environmental, Intellectual, Emotional, and Physical.

• MyStrength App, in partnership with Cornerstone Quarters and EHF to expand care outside the traditional care and treatment setting. This is a free app for all clients, employees, employee families, and community partners. MyStrength is recognized by the Texas Council and National Council for its analytics and population health, and person centered care.

• Maintain and monitor existing Trauma Informed Care activities.

• Continue to support Peer Activities to increase awareness of Trauma Informed Care.

• Continue to build out elements of Wellbeing & Healthy Lifestyles within the services provided.

• Continue to roll out the use of the app throughout the Center and Community.

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MyStrength app combines the broadest range of evidence –based models. It is highly interactive, individually tailored application empowers users to address depression, anxiety, stress, substance use, chronic pain and sleep challenges while also supporting the physical and spiritual aspects of whole person health.

Ensuring fidelity with evidence-based practices

• Community Healthcore works on specific projects to quantify improvement. Projects include tracking key performance objectives, SAMHSA measures, and the triple aim.

• Continue to ensure fidelity and improvement using continuous quality improvement processes.

Transition to a recovery- oriented system of care, including development of peer support services and other consumer involvement in Center activities and operations (e.g., planning, evaluation)

• Using funding from the HOGG Foundation and the Episcopal Health Foundation, Cornerstone Quarters Peer Run 501 c3 was created. The model is a Consumer Operated Service Program and services are open to CHC adult outpatient and the community who are working on recovery.

• Community Healthcore also uses peers in our MCOT, Job Development, and Veteran programs.

• Continue the contractual relationship with HOGG through September 2019.

• Expanding recovery within Community Healthcore evidenced based practices such as Seeking Safety, Wellness Recovery Action Plan, and social skills development.

• Continue MyStrength app support. • Development of a Consumer Operated

Service Program, a peer run services program that has opportunities for members to participate in the administration of the project.

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Addressing the needs of consumers with co-occurring substance use disorders

• Community Healthcore works simultaneously in the provision of mental health services and addiction recovery services out of our hub in Longview as a part of the Co-Occurring Psychiatric & Substance Disorder (COPSD) program and dual treatment program.

• Program in conjunction with MCOT staff, other mental health professionals, addiction recovery services and referrals to multiple community resources as needed and available in the community.

• Provides the mental health component of other regional COPSD programs as needed within our nine-county catchment area.

• There are no plans beyond continued operations and coordination of services.

Integrating behavioral health and primary care services and meeting physical healthcare needs of consumers.

• Currently working with two Federally Qualified Health Centers at a SAMHSA Level 4 of Integration.

• In the third year of a four year SAMHSA Grant.

• Continue to learn from the integrated sites and pair physical medicine with behavioral health as often as we can.

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III.C Local Priorities and Plans • Based on identification of unmet needs, stakeholder input, and your internal assessment, identify your top local priorities for

the next two years. These might include changes in the array of services, allocation of resources, implementation of new strategies or initiatives, service enhancements, quality improvements, etc.

• List at least one but no more than five priorities. • For each priority, briefly describe current activities and achievements and summarize your plans for the next two years. If

local priorities are addressed in the table above, list the local priority and enter “see above” in the remaining two cells.

Local Priority Current Status Plans Local County Jail to provide jail screening for suicide threats.

• Actively provide eight hours, M-F coverage at the Gregg County jail with Community Healthcore crisis staff.

• Exploring expansion into other counties with a high volume of crisis calls.

Wellness Collaborative • Have developed an active collaborative of local Law Enforcement, Hospitals, FQHCs, Emergency First Responders, and local city government. Group is targeting high risk and need individuals and better coordination of care.

• Received a grant from the Episcopal Health Foundation to support the effort.

• Exploring effective ways to share personal health information across partners after having proper consent with the individual.

• Create an Assessment Center to reduce wait time for officers, provide medical clearance, and divert preventable psychiatric ER admissions.

• Expand membership to include UT Health Science Center for research, best practices for collaborative care and create a social return on investment model; this will demonstrate to stakeholders the benefits of collaborative care.

• Construct within the collaborative the ability to apply and receive Federal, State, and Local Grants as a Lead Agency.

• The collaborative would be a place to share about new services.

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DSRIP 1115 Waiver • Collecting key health measures and developing strategies to improve better health and while decreasing risk.

• Develop and align the measures with the CCBHC measures.

• To continue to improve health outcomes. • Purchase Business Intelligence Software

that will allow Community Healthcore to develop population health approaches that will assist us in achieving the triple aim.

• Develop strategies and a culture for sustaining 1115 Waiver projects beyond the 1115 Waiver funding.

Certified Community Behavioral Health Center (CCBHC)

• Community Healthcore has been selected to participate in the next round of Centers to become qualified CCBHC. Center currently completing Criteria Readiness Assessment.

• Will work with state representatives and other Centers to transform processes and services to the standards of a CCBHC.

• Expand lessons learned from the SAMHSA Integrated Health project for application within the CCBHC project.

III.D Priorities for System Development Development of the local plans should include a process to identify local priorities and needs, and the resources that would be required for implementation. The priorities should reflect the input of key stakeholders involved in development of the Psychiatric Emergency Plan as well as the broader community. This will build on the ongoing communication and collaboration LMHAs/LBHAs have with local stakeholders, including work done in response to the 2015 Crisis Needs and Capacity Assessment. The primary purpose is to support local planning, collaboration, and resource development. The information will also provide a clear picture of needs across the state and support planning at the state level. Please provide as much detail as practical for long-term planning.

In the table below, identify your service area’s priorities for use of any new funding for crisis and other services. Consider regional needs and potential use of robust transportation and alternatives to hospital care. Examples of alternatives to hospital care include residential facilities for non-restorable individuals, outpatient commitments, and other individual needing long-term care, including geriatric patients with mental health needs. Also consider services needed to improve community tenure and avoid hospitalization.

a. Assign a priority level of 1, 2 or, 3 to each item, with 1 being the highest priority.

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b. Identify the general need. c. Describe how the resources would be used—what items/components would be funded, including estimated

quantity when applicable. d. Estimate the funding needed, listing the key components and costs. For recurring/ongoing costs (such as staffing),

state the annual cost.

Priority Need How resources would be used (brief) Estimated Cost

1 Example: Detox Beds

• Establish a 6-bed detox unit at ABC Hospital. •

2 Example: Nursing home care

• Fund positions for a part-time psychiatrist and part-time mental health professionals to support staff at ABC Nursing Home in caring for residents with mental illness.

• Install telemedicine equipment in ABC Nursing Facility to support long-distance psychiatric consultation.

•

1

Replicate the emerging collaborative model developed in Gregg County within other geographic areas within our nine county catchment area.

• Identify Foundations and other entities that can help support resources and funding for identified gaps in services.

• Provide leadership and training for collaborative partners.

• Develop and implement Releases, Processes, MOUs and agreements to allow the appropriate sharing of Personal Health Information.

• Develop a system of care to minimize the duplication of services and improve the wellbeing of citizens.

• Construct within the collaborative the ability to apply and receive Federal, State, and Local Grants as a Lead Agency.

• The collaborative would be a place to share about new services.

• Time and commitment of collaborative partners.

• Cost to be determined by each community.

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2

Transportation • Work with local, regional, and state transportation

authorities to better meet the needs of persons served.

• Develop a transportation collaborative to work with the Regional Eastex Connect.

• Work with the business community to assist with sponsoring and funding for individualized transport.

•

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Appendix A: Levels of Crisis Care Admission criteria – Admission into services is determined by the individual’s rating on the Uniform Assessment and clinical determination made by the appropriate staff. The Uniform Assessment is an assessment tool comprised of several modules used in the behavioral health system to support care planning and level of care decision making. High scores on the Uniform Assessment module items of Risk Behavior (Suicide Risk and Danger to Others), Life Domain Functioning and Behavior Health Needs (Cognition) trigger a score that indicates the need for crisis services. Crisis Hotline – The Crisis Hotline is a 24/7 telephone service that provides information, support, referrals, screening and intervention. The hotline serves as the first point of contact for mental health crisis in the community, providing confidential telephone triage to determine the immediate level of need and to mobilize emergency services if necessary. The hotline facilitates referrals to 911, the Mobile Crisis Outcome Team (MCOT), or other crisis services. Crisis Residential – Up to 14 days of short-term, community-based residential, crisis treatment for individuals who may pose some risk of harm to self or others, who may have fairly severe functional impairment, and who are demonstrating psychiatric crisis that cannot be stabilized in a less intensive setting. Mental health professionals are on-site 24/7 and individuals must have at least a minimal level of engagement to be served in this environment. Crisis residential facilities do not accept individuals who are court ordered for treatment. Crisis Respite – Short-term, community-based residential crisis treatment for individuals who have low risk of harm to self or others and may have some functional impairment. Services may occur over a brief period of time, such as 2 hours, and generally serve individuals with housing challenges or assist caretakers who need short-term housing or supervision for the persons for whom they care to avoid mental health crisis. Crisis respite services are both facility-based and in-home, and may occur in houses, apartments, or other community living situations. Facility based crisis respite services have mental health professionals on-site 24/7.

Crisis Services – Crisis services are brief interventions provided in the community that ameliorate the crisis situation and prevent utilization of more intensive services such as hospitalization. The desired outcome is resolution of the crisis and avoidance of intensive and restrictive intervention or relapse. (TRR-UM Guidelines) Crisis Stabilization Units (CSU) – Crisis Stabilization Units are licensed facilities that provide 24/7 short-term residential treatment designed to reduce acute symptoms of mental illness provided in a secure and protected, clinically staffed, psychiatrically supervised, treatment environment that complies with a Crisis Stabilization Unit licensed under Chapter 577 of the Texas Health and

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Safety Code and Title 25, Part 1, Chapter 411, Subchapter M of the Texas Administrative Code. CSUs may accept individuals that present with a high risk of harm to self or others. Extended Observation Units (EOU) – Emergency services of up to 48 hours provided to individuals in psychiatric crisis, in a secure and protected, clinically staffed, psychiatrically supervised environment with immediate access to urgent or emergent medical and psychiatric evaluation and treatment. These individuals may pose a moderate to high risk of harm to self or others. EOUs may also accept individuals on voluntary status or involuntary status, such as those on Emergency Detention. Individuals on involuntary status may receive preliminary examination and observation services only. EOUs may be co-located within a licensed hospital or CSU, or be within close proximity to a licensed hospital. Mobile Crisis Outreach Team (MCOT) – Mobile Crisis Outreach Teams are clinically staffed mobile treatment teams that provide 24/7, prompt face-to-face crisis assessment, crisis intervention services, crisis follow-up, and relapse prevention services for individuals in the community. Psychiatric Emergency Service Center (PESC) and Associated Projects – There are multiple psychiatric emergency services programs or projects that serve as step down options from inpatient hospitalization. Psychiatric Emergency Service Center (PESC) projects include rapid crisis stabilization beds within a licensed hospital, extended observation units, crisis stabilization units, psychiatric emergency service centers, crisis residential, and crisis respite. The array of projects available in a service area is based on the local needs and characteristics of the community and is dependent upon LMHA/LBHA funding. Psychiatric Emergency Service Centers (PESC) – Psychiatric Emergency Service Centers provide immediate access to assessment, triage and a continuum of stabilizing treatment for individuals with behavioral health crisis. PESCs are staffed by medical personnel and mental health professionals that provide care 24/7. PESCs may be co-located within a licensed hospital or CSU, or be within close proximity to a licensed hospital. PESCs must be available to individuals who walk in, and must contain a combination of projects. Rapid Crisis Stabilization Beds – Hospital services staffed with medical and nursing professionals who provide 24/7 professional monitoring, supervision, and assistance in an environment designed to provide safety and security during acute behavioral health crisis. Staff provides intensive interventions designed to relieve acute symptomatology and restore the individual’s ability to function in a less restrictive setting.

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