Draft STATEWIDE COMMUNITY/HOSPITAL INTEGRATION PLAN I. Introduction II. Participants in Planning Process III. Executive Summary [Currently under construction] IV. Background V. Guiding Principles VI. Recommendations VII. How to Make it Real VIII. Charge to the Regions [Currently under construction] APPENDICES [Currently under construction] Southeast Plan CHIPP Guidelines POMS State Hospitals at a Glance Summary of Current CHIPP Funded Initiatives Essential Community Resources 2/01/01
Dear Stakeholder: Draft It is with great pleasure that I present this Statewide Planning document on behalf of the Office of Mental Health and Substance Abuse Services. Beginning in February 2000, a dedicated group of consumers, family members, advocates, providers, county DPW and legislative representatives began a planning initiative to recommend the future configuration of our community mental health system. Because a similar effort was already underway in the southeast area of the state, the Community Hospital Integration Statewide Plan Committee focused on the remaining regions of the state. Committee members talked about the current system, its strengths and successes, as well as, community service needs. Discussion incorporated not only the needs of current state hospital patients, but also those of the community for whom the state hospital would no longer be a resource. Such diversionary resources become even more critical as the Commonwealth continues to formalize its commitment to re-orienting the focus of mental health services away from reliance on state-run institutions to community care alternatives. Not surprisingly, common themes emerged across stakeholders and across the state. These themes express a strong vision for the future, which reaffirms the OMHSAS vision that Every person with serious mental illness and/or addictive disease, and every child/adolescent who abuses substances and/or has serious emotional disturbances will have the opportunity for growth, recovery and inclusion in their community. This report is more than merely a summary of constituent comments. It is a compilation of the themes identified for system goals and service improvement and steps needed to make them real. The result is a long range Plan, which will drive our work into this next century. As always, there is more to be done. Following release of this Plan and Executive Summary, efforts will move to the regional level to implement the recommendations made. You may be called upon to participate in this process and I hope that you will be able to lend your expertise and energy to this important next phase. This report acknowledges the tremendous strides made over many years. It allows us to build on that foundation and continue our efforts to enable persons with mental illness to live successfully in their community. Sincerely, Charles G. Curie 2
II. Draft PARTICIPANTS IN THE PLANNING PROCESS The Office of Mental Health and Substance Abuse Services would like to recognize the members of the Community Hospital Integration Statewide Planning Committee for their hard work. First and foremost, OMHSAS recognizes the leadership and commitment made to this effort by the Secretary of Public Welfare, Feather O. Houstoun. Special thanks go to the Committee s Co-Chairs for their leadership throughout the process: Ms. Shelley Eppley Bishop, Executive Director of the Pennsylvania Mental Health Consumers Association (PMHCA); and Ms. Sue Walther, Policy Coordinator, Mental Health Association in Pennsylvania. We would also like to give special recognition to Ms. Nancy Dering Martin, Ms. Franca D Agostino and Mr. Ed Uravic of the Bureau of Management Consulting of the Governor s Office of Administration for their assistance and expertise in facilitating the work of this Committee. Our thanks also go to the following: Veral Adair Errol Aksu, MD Jim Bernard Donna Bauer Wilson and Andrea Beauregard Gene Bianco Karen Black James Bobeck Dave Brown Joan Bruce Kevin Casey Michael Chambers Mary Rita Duvall-Brown Laura Hawkins Rebecca Heidenheim Jim Henry Kathleen Hubert Scott Johnson Eileen Joseph Alice Kauffman Joe Keller Doug Lee-Lampshier Rex McClure James Martin William McCarthy Ann McDonald Linda Miller Marta Peck Bette Peoples Sharon Potter Loretta Quarmley 3 Consumer Hershey Medical Center NAMI PMHCA NAMI PARF AFSCME Step-by-Step PAPSRS PSSU PP&A Youth Advocate Program PNA MH Assoc. Westmoreland PCPA DPW/Budget PA Counties D&A Admin. Senator Hal Mowerey, Jr. PAPSRS NAMI NAMI MH Central Susquehanna Valley Clfd/Jeff CMHC Susquehanna Co D&A PARF. Community Integration Inc. NAMI Berks Co MH PMHCA PP&A CMP MH/MR Program
Mary Ellen Rehrman Lucia Roberto Jyoti Shah MD Nancy Stapleton JoEllen Steinbrunner Bonnie Summers Scott Tait Wendy Till John Voron Julie Weaver Doug Williams Draft NAMI, PA Governor s Budget Office Veterans Administration Blair Co MH/MR D&A Administrator PMHCA PMHCA Westmoreland Co CST Community Services Group PARF 4
IV. Background Draft Pennsylvania is a large geographically, demographically, and politically diverse state with a mix of town, city, county, and state jurisdictions spanning across 67 counties. As of July 2000 the Commonwealth s population approached 12 million people. State government has the statutory responsibility to oversee the provision of community mental health services in the Commonwealth and has the direct operational responsibility for Pennsylvania s nine state psychiatric hospitals and one long-term care nursing center. Through the Office of Mental Health and Substance Abuse Services (OMHSAS), the state develops programs and policies, allocates funds for services, and develops guidelines for county planning and outcome reporting. County government, through the MH/MR Act of 1966 and the Mental Health Procedures Act (MHPA) of 1976, has the responsibility to provide a full array of mandated services to its citizens within each county geographic area. Services are operated by the county or contracted out to provider agencies. In 1997, Pennsylvania introduced a new integrated and coordinated health care delivery system to serve Medical Assistance eligible persons requiring medical, psychiatric, or substance abuse services through a capitated, mandatory managed care program called HealthChoices (HC). OMHSAS oversees the behavioral health (mental health and substance abuse) component. OMHSAS has demonstrated a long-term commitment to the development of a comprehensive array of quality mental health services and supports which, as stated in the office s Vision Statement are intended to provide consumers with the opportunity for growth, recovery, and inclusion in their community. It began a formal initiative in fiscal year 1991/92 called the Community/Hospital Integration Projects Program (CHIPP) as the mechanism for refocusing reliance on large mental health institutions to community care alternatives. CHIPPs was designed to promote the discharge of persons with long-term histories of hospitalization or complex service needs who had not previously succeeded in the community. Hospital beds are closed and alternative services and supports are developed in the consumer s community. Not only are services to be built to meet the assessed needs of the individual being discharged, but because the bed is closed at the time of discharge, the projects are also expected to build capacity for diversionary services which would prevent the need for hospitalization of additional community members in need of, or are at risk for, future state hospital admission. CHIPP funding has increased from $6.5 million in FY 1991/92 to just over $132 million in FY 2000/01. Almost 2000 beds have been closed across all state hospitals with services provided to approximately 8000 former state hospital patients and community residents. Between FY 1991/92 and 1999/00, the state hospital patient census declined from 5,979 to 3,070. State Mental Hospital admissions declined from 4,682 to 1,743 during the same period; The aggregate number of persons served in the state hospitals declined from 11,293 to 5,065. While each county s CHIPP initiatives have been unique, there were numerous services and supports, which were consistently part of program development. Consumers, families, providers, and county representatives agreed during Planning Committee discussions that such resources were critical to successful outcomes for people. 5
Draft The most consistently developed resource was intensive case management (ICM) or other enhanced case management options. Also frequently developed were a wide range of community residential opportunities including: crisis residential; community residential rehabilitation (CRR); personal care homes; supported living services, and other specialized residential environments. Projects often included a variety of consumer-run, consumer-directed resources including clubhouses, drop-in centers, and social rehabilitation options. In addition, beyond crisis residential services, enhancements to other crisis intervention programs were found to enhance consumer recovery and stabilization, including: mobile crisis, warm lines and other telephone crisis services, walk-in services, and crisis companion programs. Also, consumers and families continue to stress the critical role the consumer/family satisfaction teams (CSTs) play in assessing the quality of county resources. While the above have been identified as core services, the Planning Committee also came to consensus on an array of essential community resources. One of the guiding principles for all future behavioral health planning put forth by OMHSAS is that a comprehensive array of treatment, rehabilitation, and support services must be available to consumers and their families. The essential community resources that must be striven for include the following venues: living environments; community supports; advocacy; treatment; and quality initiatives. A recommended array is included in the plan document as Appendix. The list is not intended to be exhaustive, nor to prescribe the local service system, but to serve as the foundation for local planning. 6
Draft V. Guiding Principles Pennsylvania s state hospital population declined from 35,000 in 1966 to 5,129 by July 1994 to just fewer than 3200 as of December 1999. Between 1976 and 1998 the Department of Public Welfare closed thirteen state-run psychiatric facilities. Since 1991, with the implementation of the Community/Hospital Integration Projects Program (CHIPP), the Office of Mental Health and Substance Abuse Services (OMHSAS) has closed over 1600 hospital beds, resulting in over $115 million being transferred to the community system for development of service options. To formalize the Commonwealth s longtime commitment to re-orienting the focus of mental health services away from reliance on large institutions to community care alternatives, DPW Secretary Feather Houstoun asked that the Community/Hospital Integration Statewide Planning Committee be formed. Committee members were appointed by Charles Curie, Deputy Secretary of OMHSAS and began meeting in February 2000. The Community/Hospital Integration Statewide Planning Committee embraced the philosophy of a consumer-centered value system that encourages consumer empowerment, family involvement, and collaboration of professionals with consumers and family members at all levels of planning, implementation, and evaluation. CSP principles have been an essential element of the mental health planning process and human services program design for many years in Pennsylvania. They have been the philosophical base upon which adult human services programs have been established. The CSP principles are used at all levels of program planning and implementation. The expectation of the planning committee is that the following principles, as should the CSP principles, be an integral part of all future behavioral health planning. The principles that follow offer a vision of accomplishing the goal put forth by OMHSAS: All services and resources shift from the state operated institution to the community. A comprehensive array of treatment, rehabilitation, and support services, that promote least restrictive, least intrusive approaches, must be available to consumers and their families. This array must also address educational/vocational/spiritual/social needs. Services should be voluntary and provide the greatest degree of choice possible and appropriate with the goal of true integration, participation and full inclusion in the community. Consistent with CSP principles, consumers, family members and persons in recovery must play key roles at every level throughout every phase of behavioral health system planning and quality assurance. Continuous quality improvement will play a significant role in the development and delivery of services and supports, consumer satisfaction is a priority and must be monitored by adequately funded consumer satisfaction teams. 7
Draft Services and supports must embrace recovery principles. The community system of mental health services and supports must be based on a strong fiscal foundation, which maximizes current resources. The system must reflect cultural competency. The system must establish consumer safety as a priority. A comprehensive monitoring system should be incorporated into the community-based mental health system that includes independent investigations of abuse, neglect, and death. 8
Draft VII. Recommendations OMHSAS began its systemic downsizing in FY 1991/92 with the implementation of the Community/Hospital Integration Projects Program (CHIPPs). Since then, through FY 99/00 1,646 placements from the state hospitals have been made using the funds coming from the state hospital budgets, largely though a planned reduction in hospital operating costs and reduced complement. In addition, counties served an additional 6,900 persons able to be diverted from state hospital placement as a result of the community resources developed through the CHIPP initiative. During the time period from FY 1990/91, counties have been successful in closing, on average, 200 or more state hospital beds a year. As the community infrastructure became stronger as a result of the resources made available through the CHIPP initiative, there has been support for an accelerated effort over the past five years. The CHIPP initiative maintains a two-fold emphasis: first meeting the service and support needs of the individual being discharged from the state hospitals; secondly, development of the community resources so as to provide alternative opportunities for community members who would no longer have access to the hospital bed closed through CHIPP. This concept of the need to develop resources not only for the patient being discharged from the hospital but for a population to be diverted from the hospital is equally critical in the design of a county s CHIPP initiative. The following Recommendations support the Office of Mental Health and Substance Abuse Services commitment to its vision of opportunity for growth, recovery and inclusion in community. The specific recommendations represent the consensus of the Planning Committee participants. Recommendation #1: OMHSAS will support the development of a comprehensive array of treatment, rehabilitation and support services that promote least restrictive, least intrusive approaches, including educational, vocational, spiritual, and social needs. Implementation Strategies: Establish formal regional planning groups that involve all relevant stakeholders including, but not limited to: OMHSAS Regional Field Offices; state hospitals; county MH/MR offices; consumers; family members; providers; advocates; and representatives of other services systems which impact consumers of mental health services. Implement assessment strategies to identify the resource needs of individual consumers currently residing in state hospitals. 9
Recommendation #2: Draft Implement community assessments to determine individual county/joinder/regional infrastructure resource needs and to identify existing resources which might be better used. Identify specialized county/joinder/regional resource needs including short term and long term secure treatment settings. Identify short term and long-term roles of the state hospital within the catchment area of the regional planning groups. Submit budget requests based on regional planning activity, using the county annual plan as the vehicle. OMHSAS will maintain its commitment to re-orienting the focus of the mental health system away from reliance on large institutions to community care alternatives. Recommendation #3: Implementation Strategies: Continue downsizing state hospital census at minimum 250 beds annually. Ensure that all CHIPP plans include resource development for both persons being discharged and community members who would no longer have access to the state hospital bed (diversion population). Continue annual evaluation of all state hospitals for consolidation or closing. The community mental health service system for adults must be founded on the principles of the community support program (CSP), embrace recovery principles, reflect cultural competency and meet the needs of any identified special populations. Implementation Strategies: Include consumers, family members, and persons in recovery in all aspects of system planning and quality assurance. Adequately fund and expand involvement of Family and Consumer Satisfaction Teams. Continue OMHSAS implementation of its Cultural Competency Strategic Plan including stakeholders in the plan s training and technical assistance activities. Assess the mental health needs of special populations, including, but not limited to: persons who are aging and/or medically fragile; persons 10
Recommendation #4: Draft with dual diagnosis, both mental health/mental retardation or persons with mental illness who abuse substances (MISA); persons with serious mental illness involved with the criminal justice system; and fire setters. Recommend county/joinder/regional resources to meet the service needs of the locally identified special needs population(s). Continuous quality improvement will play a significant role in the development and delivery of all mental health services and supports. Recommendation #5 Implementation Strategies: Continue to require (per the OMHSAS CHIPP Guidelines) and fund Consumer and Family Satisfaction Teams, to monitor and evaluate the satisfaction of people being served in the system. Monitor consumer outcomes through statewide implementation of the Performance Outcome Measures System (POMS). Assure that services developed meet all applicable regulations or standards through licensure, certification and/or accreditation. Maintain CHIPP reporting requirements (per OMHSAS CHIPP Guidelines), both programmatic and fiscal. The community system of mental health services and supports must be based on a strong fiscal foundation, which maximizes current resources. Implementation Strategies: Ensure planning and subsequent budget requests demonstrate: o cost-effectiveness o strong fiscal discipline Ensure county/regional plan submissions identify what and how current resources (including base funds and existing CHIPP funds) have been maximized and fully justify the need, if and when new funds are requested. Ensure county/regional plans identify all revenues/resources available and/or anticipated in support of the services and supports to be developed and the individuals anticipated being served. Pilot models of a unified system of care to determine feasibility of county fiscal management of all state funding, including state hospital funding. Monitor fiscal accountability through annual reporting requirements per the OMHSAS CHIPP Guidelines. 11
VIII. How to Make it Real Draft Because of the unique environments within each of the state hospital s catchment area, the next phase of planning must occur at the local level. While the statewide planning document provides the broad parameters for future actions, it is at the county and regional levels where a plan becomes reality; that is, where specific needs and resources must be identified. While OMHSAS has historically used a county planning process as a tool to assess the community mental health service system s needs, the process being proposed is inclusive of both the community and state hospital systems of care. The counties needs-based annual plans should become the conduit for the needs identified through a regional planning process. That regional planning process should include stakeholder involvement parallel to that of the statewide committee, including but not limited to, state hospital representatives, county government, consumers, families, providers and advocates. Consideration should likewise be given to other service systems, which impact the mental health service system and its consumers: aging, children and youth, juvenile justice, corrections, mental retardation, drug and alcohol, and others as relevant. Inclusion of representatives from these arenas, on either regional planning or specialized workgroups, is recommended. Their participation becomes particularly critical as the needs of special populations are identified and resources planned for. Current joint efforts between OMHSAS and the Department of Aging, the Department of Health, the Bureau of Drug and Alcohol Programs, the Office of Mental Retardation, the Department of Corrections and others should be extended to determine how the identified statewide issues impact a particular county or region. Through the work of the Statewide Planning Committee and as noted in Section IV of this document, several common themes emerged which must be addressed systemically, at both the state level as well as the local level. An overwhelming issue that local planning groups must address is human resources. Staff availability, training and other personnel factors must be incorporated in the assessment of community resources. One avenue recommended for consideration by the statewide committee is the pool of caregivers currently employed by the state hospitals. With the anticipated ongoing downsizing of the state-run psychiatric hospitals, staff complement would likewise continue to decrease, leaving a qualified pool of personnel potentially available to fill a community service system need. Both local and statewide responsible parties must deal with how to create opportunities for such transition. Human resource needs should be clearly delineated in the county plans presented annually to OMHSAS, specific to the service development being requested. Likewise, training needs should be identified to enable OMHSAS to collaborate with existing and future training institutes so as to take full advantage of existing options. Another reality check which must be undertaken if local planning is to produce successful outcomes is community acceptance. Stigma, while many positive strides have been made, continues to be identified as a barrier to the full acceptance of persons with mental illness in their community of choice. Planners will have to gauge the acceptance or resistance to existing and future growth of the full range of community resources, particularly residential options and options for persons with special needs, including dual diagnoses of mental illness and substance abuse or forensic background. Political supporters and foes alike should be part of an audience for ongoing education and advocacy efforts. 12
Draft While the Statewide Committee had access to and reviewed aggregate data, each regional planning group should have access to comprehensive data specific to its catchment area, both hospital and community-based. Hospital data should include patient census, admission and discharge information and eventually, patient specific information. Several tiers of patient-specific assessments have been used successfully in several state psychiatric hospitals in planning for downsizing initiatives, including: consumer to consumer; family to family; and personal plans for recovery or individual patient assessments to plan his/her specific community services and supports. In addition to hospital and patient-specific information, the local planning group must have access to community information including existing services and supports, service gaps, barriers to development and incentives to development. Planning must also incorporate county and regional infrastructure needs to provide alternatives (diversions) for community residents who no longer have access to the closed hospital beds. Given the rural nature of many of the catchment areas served, and when considering some of the specialized needs of consumers, the need for county-specific AND regional resource development should be accessed. As noted in the Strategic Plan Report of the Southeast Region County/State Integration Coalition (Appendix ) the concept of regionalization offers an opportunity to develop state-ofthe-art specialized treatment programs for small groups of people with similar challenging needs as a collaborative effort with two or more counties. Collaboration would not only allow for the development of more specialized services which might otherwise be cost-prohibitive, but would allow for efficiency in staff recruitment, training and the administration of such services. As community service options are identified and infrastructure, both county-specific and regional is further developed, local planning should also consider the short and long-term role of the state hospital itself. OMHSAS is committed to continuing to build on the foundation of the CHIPP model, intended to reinforce treatment and support options in the most integrated setting. As hospitals patient census continue to decline, the need for maintaining the state operation of nine (9) facilities becomes increasingly challenged. OMHSAS will look to each regional planning group for recommendations as to the future role of the facility in their purview. More specifically, the regional planning groups will be expected to identify what it would take to meet the needs of current patients and future referrals from the community were the state psychiatric hospital no longer available as a service alternative. Planning efforts and budget requests will be expected to reflect these community infrastructure needs. In her charge to the Statewide Planning Committee, DPW Secretary Houstoun challenged the group to undertake its initiative within a framework of strong fiscal discipline, with a long term goal of budget neutrality as the funding currently available within the state psychiatric hospital system is moved into community options through ongoing CHIPPs. It is recognized that budget neutrality becomes more feasible when facilities close. As facilities downsize, but remain open, economies of scale are reduced, thereby reducing the amount of the hospital budget which can initially be reallocated through CHIPPs. CHIPP requests may need to identify start-up costs that would be in excess of the funds available initially from the state hospital. However, all planning efforts will need to consider and take into account all other resources available to support new development, including existing county MH base funds, existing CHIPP funds, federal resources (such as, housing, transportation, employment), other county or local funds (such as HSDF, United Way), and other state funding (such as Transportation, Health, OVR). Current services and supports will need to be assessed locally 13
Draft for need and outcome to determine if their funding might be reallocated and put to better use. As new technology, new treatment and rehabilitation techniques, new best practices are identified; current resources can be redirected to support their development. The Department, through OMHSAS, will be closely assessing the fiscal accountability of all county/regional plan submissions. The mechanism for implementing county/regional plan recommendations will be the Community Hospital Integration Projects Program (CHIPP) Guidelines which became effective July 1, 1999. Using the recommendations referenced in Section VII, OMHSAS will use the requests submitted by each county/region to develop its annual budget request to the Department. 14