SALISH BHO ADVISORY BOARD MEETING A G E N D A

SALISH BHO ADVISORY BOARD MEETING DATE: Friday, May 4, 2018 TIME: 10:00 AM 12:00 PM LOCATION: City of Sequim, Transit Center 190 W Cedar Street, Sequim WA 98382 A G E N D A 1. Call To Order 2. Announcements/Introductions 3. Opportunity to Address the Board on Agenda Topics (limited to 3 minutes each) 4. Approval of Agenda 5. Approval of April 6, 2018 Minutes (Attachment 5) 6. Action Items a. Out of State Travel Request 7. Informational Items a. Jefferson Healthcare Medication Assisted Treatment Support b. Budget Mental Health Service Enhancements (Attachment 7.b.1) Rates (Attachment 7.b.2) c. Changes in Utilization Management (Attachments 7.c.1, 7.c.2) d. Jail Issues e. MCO RFP (Attachment 7.e) f. Wraparound with Intensive Services (WISe) (Attachments 7.f.1, 7.f.2) g. Quality Assurance (Attachment 7.g) 8. Opportunity for Public Comment (limited to 3 minutes each) 9. Board Member Check-in 10. Adjournment SBHO Advisory Board Page 1 May 4, 2018

ACRONYMS ACH Accountable Community of Health ASAM Criteria used to determine substance use disorder treatment BHO Behavioral Health Organization, replaced the Regional Support Network CAP Corrective Action Plan CMHA Community Mental Health Agency CMS Center for Medicaid & Medicare Services (federal) DBHR Division of Behavioral Health & Recovery DCFS Division of Child & Family Services DDA Developmental Disabilities Administration DMHP Designated Mental Health Professional DSHS Department of Social and Health Services E&T Evaluation and Treatment Center (i.e., AUI, YIU) EBP Evidence Based Practice EPSDT Early and Periodic Screening, Diagnosis and Treatment EQRO External Quality Review Organization FBG Federal Block Grant (specifically MHBG and SABG) FIMC Full Integration of Medicaid Services FYSPRT Family, Youth and System Partner Round Table HARPS Housing and Recovery through Peer Services HCA Health Care Authority HCS Home and Community Services HIPAA Health Insurance Portability & Accountability Act HRSA Health and Rehabilitation Services Administration IMD Institutes for the Mentally Diseased IS Information Services ITA Involuntary Treatment Act LOC Level of Care MAT Medical Assisted Treatment LRA Least Restrictive Alternative MCO Managed Care Organization MOU Memorandum of Understanding OCH Olympic Community of Health OST Opiate Substitution Treatment PACT Program of Assertive Community Treatment PATH Programs to Aid in the Transition from Homelessness PIHP Prepaid Inpatient Health Plans PIP Performance Improvement Project P&P Policies and Procedures QA, QI Quality Assurance, Quality Improvement QUIC Quality Improvement Committee QRT Quality Review Team RCW Revised Code Washington RFP, RFQ Requests for Proposal, Requests for Qualifications SAPT Substance Abuse Prevention Treatment SBHO Salish Behavioral Health Organization SUD Substance Use Disorder UM Utilization Management WAC Washington Administrative Code WM Withdrawal Management WSH Western State Hospital, Tacoma SBHO Advisory Board Page 2 May 4, 2018

SBHO Advisory Board Agenda Briefings May 4, 2018 Action Items a. OUT OF STATE TRAVEL REQUEST Advisory Board member, Sandy Goodwick, has requested travel support to attend a recovery conference in Washington D.C. Sandy has requested that the Salish BHO provide airfare, while she would pay for conference attendance and lodging. The Advisory Board bylaws allow for out of state travel with the authorization of the board. Informational Items a. JEFFERSON HEALTHCARE MEDICATION ASSISTED TREATMENT SUPPORT The Executive Board met on April 20 and approved the MAT funding for Jefferson Healthcare. The Advisory Board s subcommittee met on April 27 to discuss the parameters on the funding, put together questions for Jefferson Healthcare, and develop a suggested framework for expenditure of these funds. The subcommittee and staff will present. b. BUDGET Mental Health Service Enhancements The legislature included substantial new funding, a total of over $69,000,000, for community based behavioral healthcare in the supplemental budget. The state has put together planning requirements for the funds, which are attached to this agenda packet. The Salish allocation of these funds will be approximately $3,600,000, and we have embarked upon preliminary discussions with our providers on their use. Planning for the funds is required to be accomplished in collaboration with the MCOs, at least one of which has a differing opinion on use of the funds. Staff will discuss the planning process and results of our initial discussions with providers and Executive Board. Rates The Actuarial Rate Certification for the period beginning July 1 has been submitted to the Centers for Medicaid and Medicare Services, and the news for the Salish BHO is very good. Our total rate increases from $49.03 to $58.12, though most of this funding is targeted at specific projects or expenses, including the enhancement money discussed above. A table laying out our current expenses and the various additional costs is attached to this mailing, as is a description of how we will be distributing the rates in the new budget year. This is the first step in developing the budget, which will be presented next month. SBHO Advisory Board Page 3 May 4, 2018

c. CHANGES IN UTILIZATION MANGEMENT One of the pieces of the Affordable Care Act that is often overlooked is the requirement for Parity in insurance coverage. The Parity requirement requires that plans cover all aspects of care delivery equally - physical health as well as mental health and substance use disorder treatment. As a result of this new requirement, the state was required to analyze their Medicaid program for access through a Parity lens and found that there are barriers (created by the State in a previous change) to behavioral health access that are not present for primary care. The new stance of the state, in light of the new Federal requirements, is that there must be no prior authorization requirements for outpatient behavioral health services. Staff will present on our planning efforts and what will change. d. JAIL ISSUES There are many ways that the behavioral health system and the criminal justice system interface, and these interactions are increasingly important. One facet which impacts the outpatient mental health system most directly is the issue of competence to stand trial, and the current lawsuit against the state (the Trueblood lawsuit). Competency evaluations and competency restoration waits have backed up into county jails, forcing individuals who may have significant mental health issues to wait for extended periods prior to be transferred to Western State Hospital for competency restoration. Staff will discuss jail issues, as well as our new access to jail inmate data and what we hope to do with it. e. MCO RFP The Health Care Authority issued a Request for Proposals for Managed Care Organizations to provide healthcare through an Integrated Managed Care methodology throughout Washington State. The RFP was due April 12, and pertinent portions are attached to this mailing. Apparently successful bidders will be announced in May. f. WRAPAROUND WITH INTENSIVE SERVICES (WISe) The WISe program was established by the State in response to a lawsuit, and the Salish BHO is one of the last BHOs to embrace its implementation. The program was created in negotiations between State staff and a set of lawyers, without any input from BHOs or provider organizations. It is premised on high staff to client ratios, and the provision of services through small teams. Staff will present the program and answer questions. g. QUALITY ASSURANCE Data regarding our program delivery system is attached for the Board s review. SBHO Advisory Board Page 4 May 4, 2018

MINUTES OF THE SALISH BEHAVIORAL HEALTH ORGANIZATION ADVISORY BOARD Attachment 5 10:00 a.m., Friday, April 6, 2018 City of Sequim, Transit Center 190 W Cedar Street, Sequim WA 98382 CALL TO ORDER Russell Hartman, Chair, called the meeting to order at 10:01 a.m.. INTRODUCTIONS Self introductions were conducted around the room. OPPORTUNITY FOR PUBLIC TO ADDRESS THE BOARD ON AGENDA TOPICS: It was noted that ADA Assistive Listening Devices were provided for board members and members from the public to use during the meeting. APPROVAL OF THE AGENDA The following items were added to the Agenda as Informational Items: DCR Update, Rates for July 2018, Report on Prosecutors Response. The amended agenda was approved without motion. APPROVAL OF March 2, 2018 MINUTES It was requested to update the board priorities listed in the March minutes from Budget with Admin to SBHO Budget Matters. MOTION: Lois Hoell moved to approve the amended minutes of the March 2, 2018 meeting. Helen Morrison seconded. Motion carried unanimously. ACTION ITEMS Jefferson County MAT Medication Assisted Treatment (MAT) refers to care provided in a physician s office for Opiate Use Disorder. Physicians are responsible for prescribing Suboxone or Vivitrol in Washington State, two medications that are used to treat Opiate Disorders. Currently, there are no MAT prescribers in Jefferson County that participate in the Medicaid program. One of the barriers to the delivery of MAT in Jefferson County is the cost of the required training to be certified to prescribe these medications. The issue was brought to the Executive Board to review. However, the Executive Board requested more details on the budget. The Advisory Board reviewed the issue with the requested updates. Anna McEnery from Jefferson Public Health provided a handout on statistics supporting MAT services in Jefferson County. The Advisory Board discussed the issue and developed a list of concerns for the proposal: o Most physician contracts include a budget for continuing education training and days; so why should the SBHO pay for something already covered? o The lost revenue to the primary care clinics was concerning and hard to

Attachment 5 justify; why is the SBHO paying an alleged lost revenue? o What is the Opioid Prevention protocol at Jefferson Health Care? How are physicians being retrained on prescribing practices at Jefferson Health Care and should be included in the proposal. o The proposal is for training to treat the addiction and not assessing an opiate addiction. Access to care should be included in the proposal. o The proposal should also include a plan for coordinating care with Discovery Behavioral Health and Beacon of Hope. o Provider buy-in is difficult for MAT services. o Backfill of hourly employees at $600/ hour is questionable. MOTION: Lois Hoell moved to table the issue and develop a subcommittee to address the issue further and report back at the next Advisory Board meeting. Sandy Goodwick seconded. Motion carried unanimously. After a discussion and addressing concerns over including consumers on the subcommittee, the board determined that the committee would include the five members from Jefferson County (Stephen Workman, Freida Fenn, Catharine Robinson, Helen Morrison, and Anne Dean). Helen Morrison was appointed to serve as the Chair for the subcommittee. The subcommittee will pull the concerns of the entire board together and address these concerns in a meeting with Jefferson Health Care, Discovery Behavioral Health, and Beacon of the Hope. All board members should email specific questions or concerns to Salish BHO staff, Alexandra Hardy, by Friday, April 13. Staff will assist with coordinating the meeting. Mental Health Block Grant Project The Salish BHO receives just over $344,000 in Federal Block Grant funding per year from the State. We are required to prepare a MH Block Grant plan each year, which needs the approval of the Advisory Board and a signed letter from the chair of the Board. Staff has worked with our providers and the Advisory Board subcommittee to develop the plan. SBHO staff, Jolene Kron, and the subcommittee comprised of Janet Nickolaus, Jennifer Kreidler-Moss, and Sandy Goodwick reviewed the submitted proposals and made the final recommendations. Concerns were brought up over the Salish BHO and the subcommittee incorporating cultural competency by using individuals in recovery as a steering board for plan development when making the recommendations. The subcommittee was questioned on whether they included recovery in in their discussions when developing the recommendations? After a detailed discussion by the board, it was determined that the Advisory Board subcommittee fulfilled the requirements of including recovery in its discussions when making its recommendations. MOTION: Jennifer Kreidler-Moss moved to approve the Mental Health Block Grant plan as submitted. Helen Morrison seconded. Motion carried unanimously.

Attachment 5 INFORMATIONAL ITEMS Legislative Update The financial portion was the focus during the short session. Two items of importance were: 1.) $40 million was allotted to put towards new housing to address the homelessness issues. This was a substantial increase for housing support. This is not specific to behavioral health. 2.) The sun setting of recording fees that counties are mandated to collect to support housing programs were permanently taken off. The legislature included substantial new funding, a total of over $69,000,000, for community based behavioral healthcare in the supplemental budget. The Salish BHO allocation of these funds will be approximately $3,600,000, and we have embarked upon preliminary discussions with our providers on their use. Planning for the funds is required to be accomplished in collaboration with the MCOs and should focus on the following: o Reduction and the use of long-term commitment beds through community alternatives. o Compliance with the requirement to transition state hospital patients into community settings within 14 days of the determination that they no longer require active psychiatric treatment at the inpatient level of care. o Improvement of staff recruitment and retention at community behavioral health facilities o Diversion of individuals with behavioral health issues from the criminal justice system o Efforts to improve recovery-oriented services. Bill 1388 divided the Behavioral Health Administration into three pieces: State Hospitals with DSHS, Behavioral Health and Recovery Outpatient services to the Health Care Authority, and Licensing Section is with Department of Health. Only 50 percent of the requested funds were received but they are still moving forward with the various moves. Last week the state sent a letter to all county commissioners informing them that they can take over the administration of CJTA funds from the BHOs. Staff is currently working with the county commissioners in our region to assist the counties in the decision-making process. Rates Update Salish BHO staff updated the board on the final rates. The Salish BHO region received a significant rate increase; the rates are higher than any other region in the state. Our providers have done an extraordinary job ensuring services were delivered to help increase our rates. DCR Update SBHO staff provided a handout and an update on the ITA changes that went into effect on April 1, 2018. Designated Mental Health Professionals (DMHPs) are now Designated Crisis Responders (DCRs) and can detain individuals for both MH and SUD needs. Only 32 beds are available in the state for detaining an individual for SUD needs; if a bed is not available for SUD individuals, the individual will be released back into the community. Salish BHO staff have been working hard to educate and update the community on the changes.

Attachment 5 QRT Report Mary Hancock, Executive Director of the Dispute Resolution Center, provided an update and report on its Quality Review Team (QRT). The QRT team visited the four different day centers in our region and conducted a survey with individuals who participate in services at the centers. The results indicated that the day center services are an essential service for the population and often serve as a social network. Many of the day centers need more funding and supplies to offer more services and programs. Concerns were brought up with the QRT incorporating recovery into the work they are completing and having staff that are familiar with the recovery process. Integration Issues The five BHOs that are becoming fully integrated in January are all struggling. King County is creating an Independent Practice Association (IPA) which has all the providers contracting with King County and King County contracting with the MCOs to administer services. The other four BHOs are struggling to get the ASO budget to work. The SBHO is in the early stages of its pilot project and has plans to move forward with it this calendar year. Performance Reports QA staff provided an update on the Quality Assurance Program Evaluation. The Advisory Board brought up its concerns over the evaluation lacking outcomes to show how successful our region is. It was requested that QA staff work on finding a way to measure success. The Salish BHO recently reached an agreement with Kitsap County to receive data on jail inmates so that the SBHO can better track individuals and services. The board requested that QA staff start looking at value-based elements in MCO contracts of the regions that have already integrated so that we can start assist our region with the integration process. QA staff also provided an update on the performance reports. QA staff asked for Advisory Board feedback on which peer measure to continue monitoring; please email Salish BHO staff Richelle Jordan or Alexandra Hardy, with any questions or concerns. Update on Prosecutors Response Russell Hartman, Chair, submitted the following questions to Salish BHO staff to pass along to the Kitsap County Prosecuting Attorney s Office regarding the Advisory Boards requirements to disclose the individuals on the board who identify as consumers. 1.) Is the identity of those on the Advisory Board who identify themselves as a consumer (personally or family member) public information? 2.) If it is public information, are they required to disclose how they are considered a consumer? The Kitsap County Prosecuting Attorney s Office reviewed the two questions and determined that the board is not required to disclose members who identify as being a consumer nor is the board required to disclose how an individual meets the consumer requirements due to HIPAA laws. Salish BHO staff tracks board members to ensure the Advisory Board is meeting

Attachment 5 the requirement of having 51 percent of its board members coming from a consumer background (personally or family members). Concerns over how the board is incorporating recovery and peer support in its discussions and decisions when the board is not open with its consumer identity were brought up. Most of the board requested that the issue not be brought up again as it has been reviewed and discussed with questions being asked and appropriately answered. Board member, Sandy Goodwick, respectfully disagreed with the decision made by the Kitsap County Prosecuting Attorney s Office as she has concerns over how the board is in compliance with the law as defined by DSHS exhibit F. Washington State Behavioral Health Conference The 2018 Washington State Behavioral Health Conference will be held June 20-22 in Kennewick, WA. Any board member interested in attending, please email Salish BHO staff, Alexandra Hardy, by Friday, May 4 th. OPPORTUNITY FOR PUBLIC COMMENT None FOR THE GOOD OF THE ORDER Charles Pridgen: Is looking for a ride to the conference, please let him know if you can assist him. Freida Fenn: A student at Port Townsend High School put on a fantastic suicide prevention event. Over 275 students participated in small group discussions which led to several students being identified as high risk for suicide and are now receiving treatment. Sandy Goodwick: Port Angeles recently had a town hall meeting on suicide prevention. Stephen Workman: Money for the MAT proposal was possibly coming out of the reserves; a discussion on the process/procedure for using reserve funds should be held. Helen Morrison: Requested that Salish BHO staff present at the next meeting on Ricky s Law. Jennifer Kreidler-Moss: Acknowledged Anders and Russ for keeping the board together and moving. ADJOURNMENT - The meeting adjourned at 12:01pm.

Attachment 5 ATTENDANCE MEMBERS GUESTS STAFF Present Freida Fenn Sandy Goodwick Russell Hartman Lois Hoell Jennifer Kreidler-Moss Helen Morrison Sally O Callaghan Charles Pridgen Catharine Robinson Jon Stroup Stephen Workman Eric Osborne, DBHR Ford Kessler, Beacon of Hope Wendy Sisk, Peninsula Behavioral Health Joe Roszak, Kitsap Mental Health Services Vivian Morey. Ombuds Kim Yacklin, Clallam County HHS Andy Brastad, Clallam County HHS Ellen Epstein, RMH Services Tanya MacNeil, West End Outreach Services Anna McEnery, Jefferson County Public Health Anders Edgerton Alexandra Hardy Richelle Jordan Jolene Kron Ileea Nehus Absent/Excused Roberta Charles Anne Dean Jolene George Janet Nickolaus

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Attachment 7.b.2 New Behavioral Health Funding Funding Purpose Mental Health Funding Substance Use Disorder Funding New E&T Facilities $ 50,732 New SUD Residential and Detox $ 186,800 New MH Residential Facilities $ 11,569 New Crisis Facilities $ 1,427,356 New Secure Detox $ 275,593 IMD Backfill $ 2,000,000 Behavioral Health Enhancements $ 3,600,000 Total New Funding $ 5,089,657 $ 2,462,393 SBHO Advisory Board Page 17 May 4, 2018

Medicaid Funding Distribution for July 1, 2019 Attachment 7.b.2 Existing Rates Disabled Adults Non Disabled Adults Disabled Children Non Disabled Children Expansion MH $ 152.53 $ 24.46 $ 91.50 $ 16.70 $ 34.79 SUD $ 8.29 $ 12.23 $ 3.68 $ 2.64 $ 18.07 $ 160.82 $ $ 36.69 $ $ 95.18 $ $ 19.34 $ $ 52.86 Disabled Adults Estimated FY 2019 Member Months Non Disabled Adults Disabled Children Non Disabled Children Expansion 87,570 118,839 19,956 368,227 368,018 Estimated Revenue with Existing Rates and 2019 Member Months Disabled Adults Non Disabled Adults Disabled Children MH $ 13,357,270 $ 2,906,802 $ 1,825,928 6,149,705 Non Disabled Children Expansion Total Revenue $ $ 12,803,176 $ 37,042,881 SUD $ 725,737 $ 1,453,401 $ 73,484 $ 971,805 $ 6,650,255 $ 9,874,683 Total $ 14,083,007 $ 4,360,203 $ 1,899,412 $ 7,121,510 $ 19,453,431 $ 46,917,564 SBHO Advisory Board Page 18 May 4, 2018

Attachment 7.b.2 Proposed Revenue Projections MH SUD Existing Revenue* $ 37,042,881 $ 9,874,683 New Revenue $ 4,887,985 $ 2,464,393 Total Needed $ 41,930,866 $ 12,339,076 * using existing rates and estimated 2019 member months Disabled Adults Proposed Rate Split Non Disabled Adults Disabled Children Non Disabled Children Expansion MH $ 172.19 $ 30.46 $ 99.14 $ 19.72 $ 41.50 SUD $ 16.00 $ 15.49 $ 7.00 $ 4.00 $ 21.42 $ 188.19 $ 45.95 $ 106.14 $ 23.72 $ 62.92 Revenue with Proposed Split Disabled Adults Non Disabled Adults Disabled Children Non Disabled Children Expansion 2019 Member Months 87570 118839 19956 368227 368018 Total Revenue MH $ 15,078,678 $ 3,619,836 $ 1,978,438 $ 7,261,436 $ 15,272,747 $ 43,211,136 SUD $ 1,401,120 $ 1,840,816 $ 139,692 $ 1,472,908 $ 7,882,946 $ 12,737,482 Total $ 16,479,798 $ 5,460,652 $ 2,118,130 $ 8,734,344 $ 23,155,693 $ 55,948,617 SBHO Advisory Board Page 19 May 4, 2018

Utilization Management Report Attachment 7.c.1 KMHS Late PRAT Requests by Month FY 2017 DBH Late PRAT Requests by Month FY 2017 % of Late Requests 18% 13% 8% 3% -2% FY 17 Avg 6.94% FY 2018 FY 18 Avg 6.4 % of Late Requests 18% 13% 8% 3% -2% FY 17 Avg 3.03% FY 2018 FY 18 Avg 0.5 % of Late Requests 18% 13% 8% 3% -2% PBH Late PRAT Requests by Month FY 2017 FY 17 Avg 4.06% FY 2018 FY 18 Avg 5.52% % of Late Requests 18% 16% 14% 12% 1 8% 6% 4% 2% WEOS Late PRAT Requests by Month FY 17 Avg 7.42% FY 2018 FY 18 Avg 8.4 Outpatient Admission Authorizations by Agency and Month DBH KMHS PBH WEOS Total Admisison Authorizations 300 250 200 150 100 50 0 242 209 206 209 198 193 193 198 197 176 179 185 166 167 156 152 187 185 91 85 89 73 63 71 77 84 71 69 57 63 71 62 70 33 38 42 45 53 52 50 33 31 35 25 28 34 34 35 37 21 26 33 27 30 16 20 23 18 17 11 13 15 12 12 23 20 12 12 12 8 16 25 196 183 166 149 143 151 153 80 83 69 72 76 57 65 40 21 20 22 28 20 25 10 12 7 8 7 5 7 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2016 2017 2018 SBHO Advisory Board Page 20 May 4, 2018

Utilization Management Report Attachment 7.c.1 DBH New Admit Authorizations KMHS New Admit Authorizations DBH - Level 0 DBH - Level 1 DBH - Level 2 KMHS - Level 0 KMHS - Level 1 KMHS - Level 2 10 9 8 7 6 5 4 3 2 1 34.62% 45.63% 75.29% 61.54% 51.21% 23.26% 3.16% 1.45% 3.85% 2016 2017 2018 10 9 8 7 6 5 4 3 2 1 31.19% 35.96% 31.37% 63.6 58.65% 64.71% 5.22% 5.39% 3.92% 2016 2017 2018 PBH New Admit Authorizations WEOS New Admit Authorizations PBH - Level 0 PBH - Level 1 PBH - Level 2 WEOS - Level 0 WEOS - Level 1 WEOS - Level 2 10 9 8 7 6 5 4 3 2 1 4.13% 10.95% 8.33% 90.48% 83.57% 81.94% 5.39% 5.48% 9.72% 2016 2017 2018 10 9 8 7 6 5 4 3 2 1 44.44% 60.77% 74.82% 33.33% 34.93% 21.58% 22.22% 4.31% 3.6 2016 2017 2018 Table 1. Admission PRAT Comparison 2013-2017* 2013 2014 2013-2014 % change 2015 2014-2015 % change 2016 2015-2016 % change 2017 2016-2017 % change DBH 298 373 25% 447 2 412-8% 344-17% KMHS 1666 2055 23% 2251 1 2453 9% 2133-13% PBH 632 885 4 924 4% 872-6% 912 5% WEOS 113 174 54% 161-7% 209 3 139-33% *Admission PRATs include: Level 1 Admit, Level 2 Admit, and Level 0 Admit SBHO Advisory Board Page 21 May 4, 2018

Utilization Management Report Attachment 7.c.1 Top 10 Most Utilized Psychiatric Inpatient Facility Discharges January 2017 - Current Recovery Innovations E&T 17 2% Children's Hospital 14 Cascade Bx Health 2% 26 Skagit Valley Hospital 28 4% St. Joseph's Hospital Tacoma 30 4% Olympic Medical Center 46 6% YIU 107 14% Fairfax (all locations) 134 17% AIU 368 47% Jefferson Healthcare 12 1% 10 9 8 7 6 5 4 3 2 1 Voluntary and Involuntary Hospitalizations by Provider and Year Comparison 26 40 76 104 4 1 Involuntary 236 179 15 403 304 29 Voluntary 34 29 195 152 0 13 10 16 8 2 17 4 2016 2017 2018 2016 2017 2018 2016 2017 2018 2016 2017 2018 DBH KMHS PBH WEOS Utilization of Hospital Type by Agency, Year, and Admission Type Community Hospital E&T DBH KMHS PBH WEOS Voluntar Voluntar Voluntar Voluntar y Involunta ry y Involunta ry y Involunta ry y Involunta ry 2016 2017 2016 2017 2016 2017 2016 2017 2016 2017 2016 2017 2016 2017 2016 2017 1 7 2 129 103 7 8 14 87 97 75 80 14 22 42 55 9 27 6 274 201 9 9 15 108 139 104 72 12 18 34 49 1 2 3 4 5 6 7 8 9 10 SBHO Advisory Board Page 22 May 4, 2018

THIRTY DAY READMISSIONS Attachment 7.c.2 SBHO MH Readmissions Report The SBHO's Over-Utilization Project, is one component of the SBHO Utilization Management Plan. Over Utilization is defined as: an individual who has had more than one hospitalization within a thirty (30) day time period. This is an inpatient utlization project. Of note, on occasion, there are individuals that have brief inpatient respite episodes built into their discharge plan; these individuals are not included in this definition. The SBHO montiors for inpatient over-utilization through the evaluation of regional database reports and targeted clinical chart reviews. Jan '17 Feb '17 Mar '17 Apr '17 May '17 June '17 July '17 Aug '17 Sept '17 Oct '17 Nov '17 Dec '17 Average ADMISSIONS Total # of Admissions 83 72 89 68 70 75 61 69 51 59 60 72 DBH 11 1 14 3 6 4 3 7 2 11 10 6 78 KMHS 53 50 49 45 44 63 44 45 32 32 42 49 548 PBH 17 15 25 18 19 8 14 14 13 15 6 12 176 WEOS 2 6 1 2 1 0 0 3 4 1 2 5 27 READMISSIONS Total # of Readmissions within 30 days 9 6 7 6 4 6 6 6 10 6 4 7 AGENCY READMISSIONS DBH 2 1 0 0 1 0 0 0 0 0 0 1 4 (5%) KMHS 7 4 6 5 0 5 4 5 7 4 4 3 54 (1) PBH 0 1 1 1 3 1 2 1 3 2 0 2 17 (1) WEOS 0 0 0 0 0 0 0 0 0 0 0 1 1 (4%) HOSPITALS READMISSIONS WERE DISCHARGED FROM: AIU 5 1 6 2 0 5 4 4 7 3 3 3 YIU 0 1 0 1 0 0 0 1 2 0 0 1 Fairfax Kirkland 2 4 1 2 1 0 0 0 0 1 0 1 Paradise Valley Hospital in California 1 0 0 0 0 0 0 0 0 0 0 0 St. Joseph's Tacoma 1 0 0 0 0 0 0 0 0 0 0 0 Harrison Medical Center 1 0 0 0 0 0 0 0 0 Harborview 1 0 0 0 0 0 0 0 Olympic Medical Center 1 0 0 0 0 0 0 0 Recovery Innovations E&T 1 0 0 0 0 0 0 0 Cascade Bx Health 1 0 0 0 0 0 0 Fairfax Everett 1 0 0 1 0 0 Seattle Children's Hospital 1 0 0 0 0 0 Lourdes Counseling Center 1 0 0 0 0 Skagit Valley Memorial Hospital 1 1 1 1 Telecare North Sound E&T 1 NOTES/COMMENTS: SBHO Advisory Board Page 23 May 4, 2018

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SBHO Advisory Board Page 35 May 4, 2018 Attachment 7.e

WISe Wraparound with Intensive Services Attachment 7.f.1 K-12 EDUCATORS AND PROFESSIONALS What is WISe? Washington State s Wraparound with Intensive Services (WISe)* provides comprehensive behavioral health services and supports to Medicaid eligible youth, up to 21 years of age, with complex behavioral health needs. WISe is designed to provide individualized, culturally competent services that strive to keep youth with intense mental health needs safe in their own homes and communities, while reducing unnecessary hospitalizations. WISe offers a higher level of care through these core components: The Time and Location of services: WISe is community-based. Services are provided in locations and at times that work best for the youth and family, such as in the family home and on evenings and weekends. Team-based Approach: Using a Wraparound model, WISe relies on the strengths of an entire team to meet the youth and family s needs. Intensive care coordination between all partners and team members is essential in achieving positive outcomes. Each team is individualized and includes the youth, family members, natural supports, a therapist, a youth partner and/or family partner, and members from other child-serving systems when they are involved in a youth s life. Other team members could include family friends, school personnel, a probation officer, a religious leader, a substance use disorder treatment provider, or a coach/ teacher. The team creates ONE Cross-System Care Plan that identifies strategies and supports, using the youth and family s voice and choice to drive their plan. Help during a crisis: Youth and families have access to crisis services any time of the day, 365 days a year. Youth receive services by individuals who know the youth and family s needs and circumstances, as well as their current crisis plan. Whenever necessary, this includes face-to-face interventions at the location where the crisis occurs. How Does Someone Access WISe? A youth must receive Medicaid or be Medicaid eligible to receive WISe services. Referrals for a WISe screen can be made at any time in counties that have implemented WISe. WISe is rolling out across Washington through June 2018; therefore it may not be available yet in your part of the state. To find out if WISe is available in your area and who to contact go to: http://www.dshs.wa.gov/dbhr/cbh-wise.shtml and click on the WISe Referral Contact List by County document. If WISe is not yet available in your part of the state, and you believe a youth would benefit from mental health services, use the contact information found on this site: https://www. dshs.wa.gov/bha/division-behavioral-health-and-recovery/ mental-health-services-and-information to make a referral, or call the Recovery Helpline, toll free at 866-789-1511. When Should I Refer Youth for a WISe Screen? A WISe screen is required when: Youth and families self-refer, by requesting a screen for WISe. There has been a request for out-of-home treatment or placement substantially related to unmet mental health needs. There has been a step-down request from institutional or group home care. There has been crisis intervention and the youth presents with past or current functional indicators* of need for intensive mental health services. * Functional indicators include: an inpatient mental health stay; multiple out of home placement stays; Juvenile Rehabilitation services or adjudication; use of multiple psychotropic medications; anorexia/bulimia; substance use disorder; and suicide attempt or self-injury *Washington s Wraparound with Intensive Services (WISe) Overview of the T.R. et al. v. Kevin Quigley and Dorothy Teeter Lawsuit In November 2009, a Medicaid lawsuit was filed (formerly called T.R. v. Dreyfus) against the Department of Social and Health Services and the Health Care Authority about intensive mental health services for children and youth. The lawsuit is based on federal EPSDT (Early and Periodic Screening, Diagnosis and Treatment) laws that require states to provide mental health services and treatment to children who need them, even if the services have not been provided in the past. After several years of negotiations, both sides agreed on a plan that they believe will put them in compliance with the laws, and most importantly, work for youth and families in Washington State. The federal court approved this Settlement Agreement on December 19, 2013. The goal of the Settlement Agreement is to develop a system that provides intensive mental health services in home and community settings that work - for Medicaid eligible youth up to 21 years of age. DSHS SBHO 22-1602 Advisory (Rev. Board 8/16) Page 36 May 4, 2018

Attachment 7.f.1 You should consider referring youth for a WISe screening if the youth who, primarily due to a suspected or identified mental health difficulty, is: Receiving frequent Behavioral Referrals, has frequent absences, and has frequent referrals to school health services. Exhibiting behavior that leads to expulsions and suspensions. Involved in multiple systems (i.e. child welfare, juvenile justice, substance use disorder treatment). At risk of out-of-home placements, such as foster/ group care, Children s Long Term Inpatient (CLIP) or acute hospitalization. In Special Education and/or has a 504 Plan, with multiple school suspensions for mental health and/or behavioral issues. At risk based on a history of running away or disengaging from care due to mental health difficulties. Additionally, you should consider referring youth for a WISe screening when a family requests assistance in resolving complex behavioral health challenges with their child and are in need of targeted support. What Information is Needed for the Referral? When making a referral, please have as much of the following information available as possible: Youth s name and date of birth Youth s Provider One Identification Number Caregiver s name and relationship Any known child-serving system involvement (legal/ justice involvement) Risk factors (i.e., suicide risk, danger to self or others, runaway, medication management) Knowledge of the youth s personal life (i.e., living situation, school functioning, physical health) Known arrests and number of convictions Number of hospital emergency room visits (any for mental health or substance use) Any psychiatric prescription medications taken (currently or in the past) Reported diagnoses Need for spoken language or American Sign Language interpreter services Special Considerations Follow all internal school protocols and policies related to making health related referrals with full consideration of Family Educational Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA) regulations. What Happens Once I Make a Referral? When working with a youth who is not currently receiving but is eligible for Medicaid-funded mental health services: Youth and family are educated about WISe and its benefits, and agree to participate. Youth are referred to a screening entity. A screen is completed by a designated provider to determine whether a youth s needs appear to rise to the WISe level of care. They use the administration of the Washington Child and Adolescent Needs and Strengths (CANS) tool to make this initial screening determination. This screening tool can be completed over the phone or in-person. When the screening tool shows that WISe services could potentially benefit a youth, youth are referred to a WISe agency so that an intake evaluation can be completed. The intake process is used to determine whether services are medically necessary and whether the youth meets Access to Care standards. Determining whether a youth meets medical necessity is required to provide any Medicaid mental health service to a person. Eligibility for WISe services is also determined at this time. When it is determined that a youth does not meet the WISe level of care, they are referred to other mental health services, as appropriate, to have their needs addressed. When working with a youth who is currently receiving Medicaid-funded mental health services: Youth and family are educated about WISe and its benefits, and agree to participate. Referral to a WISe service provider can be done through coordination with the youth s current clinician, or by making a referral to a screening entity. As a Key Partner, What is my Role? WISe uses a team-based approach to meeting the needs of each youth and family. You may be invited to participate on a youth s Child and Family Team, to strategize and support the team in meeting the team s mission. Child-serving system partners are critical for achieving successful outcomes. Additionally, you are encouraged to participate in the Family, Youth, System Partner Round Tables (FYSPRTs). The FYSPRTs serve as an integral part of the Children s Behavioral Health Governance Structure, which informs and provides oversight for high-level policy-making, program planning, and decision-making related the children s behavioral health system, including the implementation of WISe. Learn more here: FYSPRT.com. SBHO Advisory Board Page 37 May 4, 2018

WISe Wraparound with Intensive Services Attachment 7.f.2 HEALTH CARE AUTHORITY (HCA) AND CONTRACTED PROVIDERS Introduction The Washington State Health Care Authority (HCA) is the single State agency designated to administer or supervise the administration of the Medicaid program under title XIX of the Social Security Act. HCA covers mental health services for all clients. Mental health services are provided by licensed professionals including: psychologists, mental health counselors, independent clinical (or advanced) social workers, and marriage and family therapists. Psychiatric services are provided by licensed psychiatrists and psychiatric advanced registered nurse practitioners (P-ARNPs). Benefits managed by the Health Care Authority are available to: 1) those clients who do not meet the Access to Care Standards (ACS) as established in the Washington State Mental Health Plan and in compliance with Title XIX of the Federal Social Security Act, and therefore are not receiving care through the Behavioral Health Organization (BHO) community mental health clinics, or 2) those clients who no longer require the intensity of mental health service available through the BHO and can be managed under the mental health providers available through Apple Health. In regions that have Fully Integrated Managed Care (FIMC), these services are coordinated through a managed care plan. HCA contracted providers support the WISe program by assuring all youth are appropriately referred to the BHO or a FIMC Managed Care plan for mental health services. What is WISe? Washington State s Wraparound with Intensive Services (WISe)* provides comprehensive behavioral health services and supports to Medicaid eligible youth, up to 21 years of age, with complex behavioral health needs. WISe is designed to provide individualized, culturally competent services that strive to keep youth with intense mental health needs safe in their own homes and communities, while reducing unnecessary hospitalizations. WISe offers a higher level of care through these core components: The Time and Location of services: WISe is communitybased. Services are provided in locations and at times that work best for the youth and family, such as in the family home and on evenings and weekends. Team-based Approach: Using a Wraparound model, WISe relies on the strengths of an entire team to meet the youth and family s needs. Intensive care coordination between all partners and team members is essential in achieving positive outcomes. Each team is individualized and includes the youth, family members, natural supports, a therapist, a youth partner and/or family partner, and members from other child-serving systems when they are involved in a youth s life. Other team members could include family friends, school personnel, a probation officer, a religious leader, a substance use disorder treatment provider, or a coach/teacher. The team creates ONE Cross-System Care Plan that identifies strategies and supports, using the youth and family s voice and choice to drive their plan. Help during a crisis: Youth and families have access to crisis services any time of the day, 365 days a year. Youth receive services by individuals who know the youth and family s needs and circumstances, as well as their current crisis plan. Whenever necessary, this includes face-to-face interventions at the location where the crisis occurs. How Does Someone Access WISe? A youth must receive Medicaid or be Medicaid eligible to receive WISe services. Referrals for a WISe screen can be made at any time in counties that have implemented WISe. WISe is rolling out across Washington through June 2018; therefore it may not be available yet in your part of the state. To find out if WISe is available in your area and who to contact go to: http:// www.dshs.wa.gov/dbhr/cbh-wise.shtml. If WISe is not yet available in your part of the state, and you believe a youth would benefit from mental health services, use the contact information found on this site: https://www.dshs. wa.gov/bha/division-behavioral-health-and-recovery/mentalhealth-services-and-information to make a referral, or call the Recovery Helpline, toll free at 866-789-1511. *Washington s Wraparound with Intensive Services (WISe) Overview of the T.R. et al. v. Kevin Quigley and Dorothy Teeter Lawsuit In November 2009, a Medicaid lawsuit was filed (formerly called T.R. v. Dreyfus) against the Department of Social and Health Services and the Health Care Authority about intensive mental health services for children and youth. The lawsuit is based on federal EPSDT (Early and Periodic Screening, Diagnosis and Treatment) laws that require states to provide mental health services and treatment to children who need them, even if the services have not been provided in the past. After several years of negotiations, both sides agreed on a plan that they believe will put them in compliance with the laws, and most importantly, work for youth and families in Washington State. The federal court approved this Settlement Agreement on December 19, 2013. The goal of the Settlement Agreement is to develop a system that provides intensive mental health services in home and community settings that work - for Medicaid eligible youth up to 21 years of age. DSHS SBHO 22-1599 Advisory (Rev. Board 8/16) Page 38 May 4, 2018

Attachment 7.f.2 When Should I Refer Youth for a WISe Screen? A WISe screen is required when: Youth and families self-refer, by requesting a screen for WISe. There has been a request for out-of-home treatment or placement substantially related to unmet mental health needs. There has been a step-down request from institutional or group home care. There has been crisis intervention and the youth presents with past or current functional indicators* of need for intensive mental health services. * Functional indicators include: an inpatient mental health stay; multiple out of home placement stays; Juvenile Rehabilitation services or adjudication; use of multiple psychotropic medications; anorexia/bulimia; substance use disorder; and suicide attempt or self-injury You should consider referring youth for a WISe screening if the youth who, primarily due to a suspected or identified mental health difficulty, is: Eligible for BHO level of services, but has needs at a higher than average severity Presenting with serious behavioral health issues Having a high-level of parent-child or family conflict due to a mental health difficulty Involved in with multiple systems (i.e., child welfare, juvenile justice, substance use disorder treatment) At risk of out-of-home placements, such as foster/group care, Children s Long Term Inpatient Program (CLIP) or acute hospitalization In Special Education and/or has a 504 Plan, with multiple school suspensions for mental health and/or behavioral issues At risk based on a history of running away or disengaging from care due to mental health difficulties What Information is Needed for the Referral? When making a referral, please have as much of the following information available as possible: Youth s name and date of birth Youth s Provider One Identification Number Caregiver s name and relationship Any known child-serving system involvement (legal/ justice involvement) Risk factors (i.e., suicide risk, danger to self or others, runaway, medication management) Knowledge of the youth s personal life (i.e., living situation, school functioning, physical health) Known arrests and number of convictions Number of hospital emergency room visits (any for mental health or substance abuse) Any psychiatric prescription medications taken (currently or in the past) Reported diagnoses Name of current insurance plan (managed care or Fee-For- Service) Need for spoken language or American Sign Language interpreter services What Happens Once I Make a Referral? When working with a youth who is not currently receiving but is eligible for Medicaid-funded mental health services: Youth and family are educated about WISe and its benefits, and agree to participate. Youth are referred to a screening entity. A screen is completed by a designated provider to determine whether a youth s needs appear to rise to the WISe level of care. They use the administration of the Washington Child and Adolescent Needs and Strengths (CANS) tool to make this initial screening determination. This screening tool can be completed over the phone or in-person. When the screening tool shows that WISe services could potentially benefit a youth, youth are referred to a WISe agency so that an intake evaluation can be completed. The intake process is used to determine whether services are medically necessary and whether the youth meets Access to Care standards. Determining whether a youth meets medical necessity is required to provide any Medicaid mental health service to a person. Eligibility for WISe services is also determined at this time. When it is determined that a youth does not meet the WISe level of care, they are referred to other mental health services, as appropriate, to have their needs addressed. When working with a youth who is currently receiving Medicaid-funded mental health services: Youth and family are educated about WISe and its benefits, and agree to participate. Referral to a WISe service provider can be done through coordination with the youth s current clinician, or by making a referral to a screening entity. As a Key Partner, What is my Role? WISe uses a team-based approach to meeting the needs of each youth and family. You may be invited to participate on a youth s Child and Family Team, to strategize and support the team in meeting the team s mission. Child-serving system partners are critical for achieving successful outcomes. Special Considerations HCA s role is unique in that our providers have an opportunity to serve youth with a lower level of need. When a client is identified as needing a higher level of care, referrals to the BHO are made; a screening for WISe may be part of that referral. HCA contracted providers have a responsibility to assure appropriate level of care, in an appropriate place, at the appropriate time. SBHO Advisory Board Page 39 May 4, 2018

Attachment 7.g SALISH BEHAVIORAL HEALTH ORGANIZATION: BEHAVIORAL HEALTH QUALITY INDICATORS FY 17/18 Guide to Interpretation All measures reviewed are based upon SBHO funded services only. It is not meant to be interpreted as all-inclusive of behavioral health service delivery. When interpreting these measures there could be a variety of uncontrolled factors contributing to results including but not limited to: - The impact of client characteristics and behaviors - Factors affecting the need for services, such as variation in regional economic conditions - Random variation - The degree of stability of a measure: for those measures that are based on a small sample size, the measure is inherently less stable and more prone to variability Legend Key: FY Fiscal Year - This timeframe runs from July 1 - June 30 CY Calendar Year - This timeframe runs from January 1 - December 31 Crisis Response Timeliness - Mental Health Inpatient Psychiatric Readmission - Mental Health Access (Penetration Rate) - Mental Health Peer Services - Mental Health Request for Services - Substance Use Disorder Access (Penetration Rate) - Substance Use Disorder This measure is designed to monitor compliance with SBHO PIHP Contract Requirements that response time to crisis requests occur within 2 hours This measure is designed to monitor hospital readmissions as this is a widely accepted outcome measurement for assessing performance of healthcare systems This measure is designed to monitor the rate of service penetration of Mental Health Services for our population as a measure of ensuring adequate access to services This measure is in process. The SBHO QUIC is currently working to define measurement methodology to best capture peer service delivery This is a data quality and integrity measure designed to increase the quantity of individuals seeking services having a documented request for service This measure is designed to monitor the rate of service penetration of Substance Use Disorder Services for our population as a measure of ensuring adequate access to services SBHO Advisory Board RPM 201805 SBHO Advisory Board Page 40 May 4, 2018