BHD/CSE Kelly Nieman, x4849 Leslie Weisman, x4888 Program Purpose Program Information Connect adults discharged from the state psychiatric hospital to community mental health services and stable housing, and prevent their rapid readmission to the state hospital. Discharge planning is a state-required service for individuals hospitalized at Northern Virginia Mental Health Institute (NVMHI), a state psychiatric hospital. Services include assessment of client needs and placement in appropriate clinical and residential services upon discharge. Services begin upon admission to the hospital. Staff serves Arlington residents and transient individuals. Caseloads include clients who have been involuntarily committed to the hospital, enter voluntarily, are not guilty by reason of insanity, or are transfers from other state hospitals. Some clients served are on the Extraordinary Barriers List (EBL), a list of patients at every state psychiatric hospital who are determined to be ready for discharge and who have extraordinary barriers preventing their discharge such as significant behavioral challenges, need for nursing-home placement, or legal issues. There is a full-time forensic discharge planner serving individuals from Arlington at Western State and Central State hospitals. The work of this individual is not included in this plan. Partners: Northern Virginia Mental Health Institute, Regional Aftercare Committee, Department of Behavioral Health and Developmental Services. PM1: How much did we do? Staff Customers and Service Total of 2.5 FTEs: 2.0 FTEs Discharge Planners (1 FT and 2 PT staff) 0.5 FTE Clinical Supervisor FY 2014 FY 2015 FY 2016 Clients admitted to hospital 117 142 139 Clients discharged Total / EBL 77 / 14 132 / 8 112 / 7 Clients discharged to Arlington CSB 55 85 70 Average clients served each month Total / EBL 32 / 11 28 / 7 29 / 4 PM2: How well did we do it? 2.1 Length of stay in hospital 2.2 Progress made on discharging clients from NVMHI PM3: Is anyone better off? 3.1 Clients connected with Arlington community-based treatment services 3.2 Stability of housing placement for clients discharged from hospital to placements in Arlington 3.3 Clients discharged to Arlington who remain out of the state hospital FY 2016 1
Measure 2.1 Length of stay in hospital Average Number of Days in Hospital for Clients Discharged Who Were/Were Not on the EBL 500 400 435 361 300 200 100 0 62 Non-EBL Goal: 30 days 32 EBL Goal: 180 days 263 255 71 65 FY 2014 FY 2015 FY 2016 FY 2017 (proj.) Clients who were not on the EBL Clients who were on the EBL In FY 2016, clients who were discharged from the hospital who had been on the EBL had been in the hospital an average of 263 days. Clients discharged who had not been on the EBL had been there an average of 71 days. This data is collected by averaging the amount of time each consumer discharged during the fiscal year spent in the state hospital from admission date to discharge date. There was an increase in length of stay for non-ebl clients. This may in part be due to clients being transferred multiple times within one admission to various treatment teams at NVMHI, causing individuals to not be placed on the EBL and/or potentially increasing the length of stay. There was a decrease in length of stay for EBL individuals. Several long-term EBL clients were discharged to community placements, and efforts have been made to discharge individuals prior to being placed on the EBL if clinically stable. The length of stay for EBL clients remains high. While some clients are discharged in a matter of days, others who have extraordinary barriers to community Continue to track and monitor the length of stay. Discharge planners to continue to work aggressively with clients in the state hospital to reduce the length of stay. Continue to seek regional discharge assistance funds as necessary to obtain guardianship for clients on the EBL. Continue to attend the census management meeting at NVMHI to track discharge planning efforts made as well as increase partnership with NVMHI. Continue to identify additional community placements. FY 2016 2
placements may remain in the hospital for years. Not Guilty by Reason of Insanity (NGRI) clients often have lengthy stays in the hospital awaiting conditional release status. These individuals may or may not be on the EBL. There is generally an average of four to five NGRI patients in the hospital at any given time and their lengths of stays in the hospital tend to be between one and three years. Clients in the hospital may or may not need a guardian. However, if it is determined that a client needs a guardian, it can significantly increase the length of time in the hospital. No NGRI individuals were in need of a guardian in FY 2016. Three non- NGRI individuals needed a guardian. In FY 2017, it is anticipated that the average length of stay for patients discharged from the hospital will decrease by at least 3% for clients on the EBL and 8% for clients not on the EBL. FY 2016 3
Measure 2.2 NVMHI clients receiving discharge services at least every 14 days 100% 40% 20% NVMHI Clients Receiving Discharge Services At Least Every 14 Days 81% 102/126 69% 9/13 Goal: 0% FY 2016 FY 2017 (proj.) Non-EBL EBL In FY 2016: Discharge-planning efforts were being made at least every 14 days for non-ebl individuals 81% of the time and 69% of the time for EBL individuals. obtained from reports from the electronic health record. The Clinical Supervisor who was hired to work closely with the discharge planners works aggressively to locate placements and follow through on the contractual processes. As a result of the progress made over the last year, the average number of EBL individuals served each month has decreased from approximately 7 individuals to 4 individuals. In FY 2016, the manager obtained weekly progress reports on each EBL and non-ebl client from discharge-planning staff during individual supervision. Having the 0.5 FTE discharge planner focus on the EBL continues to be effective. Continue to provide regular administrative support on contractual follow-through issues to facilitate a more timely completion of this oftencomplex process. Furthermore, clinical supervisor to work closely with staff to monitor the progress of EBL and non- EBL clients. Continue to track the work of discharge-planning staff. Ensure new staff are trained and understand expectations for client contact and documentation requirements. Continue to dedicate appropriate staffing resources to finding placements for EBL clients. In FY 2017, it is anticipated that discharge-planning efforts will be made at least every 14 days for 85% of non-ebl individuals, and 75% of individuals on the EBL. FY 2016 4
Measure 3.1 Clients connected with Arlington community-based treatment services 100% 70% 50% 40% 30% 20% 10% 0% Percent of Clients Discharged to Arlington CSB Who Kept First Appointment 87% 48/55 Goal: 88% 75/85 83% 58/70 86% 60/70 FY 2014 FY 2015 FY 2016 FY 2017 (proj.) In FY 2016, 83% (58/70) of clients discharged to Arlington kept their first scheduled appointment post-discharge with CSB Emergency Services or outpatient mental health services. is obtained from monthly reports completed by staff. The percentage of clients who kept their first appointment with Arlington CSB decreased from FY 2015 to FY 2016. The new practice instituted in FY 2014 in which all clients discharged to Arlington CSB from the state hospital are transported directly from the hospital to the office has continued to be effective. Efforts were made to involve the peer specialists in Emergency Services for the client s check-in visits with Emergency Services when appropriate. Clients who did not attend their first appointment typically refused services. These clients were often discharged while still symptomatic, and/or without stable housing. Continue transporting clients to Arlington CSB from the hospital for a check-in appointment. Continue making efforts to engage clients with their ongoing case manager immediately upon discharge. This will continue to be accomplished by pairing their Emergency Services aftercare appointment with a case management appointment whenever possible, and, when appropriate, link clients to the peer specialists who joined the team in FY 2016. Continue to monitor clients 30 days postdischarge from the state hospital to increase the likelihood of remaining connected to outpatient mental health services. Develop expectations for outreach to clients who do not keep their appointment with the CSB. In FY 2017, it is anticipated that 86% of clients discharged to Arlington will keep their first appointment with the CSB. FY 2016 5
Measure 3.2 Stability of housing placement for individuals discharged from hospital to placements in Arlington 100% 70% 50% 40% 30% 20% 10% 0% 69% Housing Placements for Clients Discharged from Hospital 17% Goal: 20% 36% 25% 14% green 27% 15% 14% 53% 50% FY 2014 FY 2015 FY 2016 FY 2017 (proj.) Stable Housing Other Shelter In FY 2016: 50% of clients (35 of 70) were discharged to stable housing: their own apartment, a group home, or a residential placement. 14% of clients (10 of 70) were discharged to other placements, such as residential crisis stabilization (ACCESS), residential substance abuse programming, or hospital (medical). 36% of clients (25 of 70) were discharged to shelter/motel placements. was obtained through monthly reports collected from each staff member regarding discharge placements of consumers. When clients housing placement prior to hospitalization is unstable, it is more difficult for them to obtain stable housing before discharge. Explore developing a way to capture housing status at admission in the electronic medical record to facilitate reporting and analyze the effect of clients initial housing status on this measure. Many clients still continue to be discharged to shelter or other temporary placements before appropriate housing options can be arranged. These clients often experience legal involvement and other barriers to obtaining housing. Clients who go to the shelter have access to a range of services through the Treatment on Wheels team, including therapy and assistance with obtaining housing. Continue to locate more stable, appropriate placements for these individuals. Explore additional strategies with DHS Housing Bureau leadership to facilitate more rapid housing placements for homeless individuals. FY 2016 6
A stronger partnership has been developed with state-hospital treatment teams to identify stable housing options for clients. Advocacy efforts are made on a local, regional and statewide level through the Community Services Board, Regional Aftercare Committee, and with key personnel from the Virginia Department of Behavioral Health and Developmental Services to acquire funding for specialized placements. Continue advocacy efforts. Continue partnering with colleagues in supportive housing and the Economic Independence Division. Train discharge-planning staff to screen and facilitate direct transfers from NVMHI to residential crisis stabilization, to streamline the admission process. In FY 2017, it is anticipated that of clients will be discharged to stable housing. FY 2016 7
Measure 3.3 Clients discharged to Arlington who remain out of the state hospital 100% 70% 50% 40% 30% 20% 10% 0% 93% 51/55 Discharged Clients Who Remain Out of State Hospital for at Least 30 Days Goal: 97% 91% 77/85 76% 53/70 FY 2014 FY 2015 FY 2016 FY 2017 (proj.) In FY 2016, 76% (53/70) of clients discharged to Arlington remained out of the state hospital for at least 30 days. The goal of 3% recidivism is set by National Association of State Mental Health Program Directors Research Institute, Inc., which established a Behavioral Healthcare Performance Measurement System. is obtained from readmission statistics supplied by the Northern Virginia Regional Projects Office. The recidivism rate increased in FY 2016, which may be attributed to clients being discharged from the hospital prior to achieving optimal psychiatric stability. Continue to aggressively negotiate readiness for discharge with hospital staff. Remove clients from EBL if they are not ready for discharge by CSB standards. Upon admission to NVMHI, continue to identify clients who have had a readmission within 30 days in the previous fiscal year, and strategize with case manager and/or discharge planner to build in extra supportive measures upon discharge. Continue to use the crisis stabilization programs as an initial post-discharge stepdown plan whenever appropriate. Continue to encourage Mandatory Outpatient Treatment (MOT) as a step-down option when appropriate to ensure compliance with aftercare treatment recommendations. FY 2016 8
Recidivist clients often have numerous prior admissions, require PACT team services, and need housing or intensive residential placements. In FY 2016, 17 clients were readmitted to the hospital within 30 days. Of these clients: o o 82% were engaged in mental health services with PACT (35%), Treatment on Wheels (29%), or Outpatient Community Support Teams (18%) 47% were homeless Continue to explore factors related to recidivism, and maintain efforts to engage these hard to serve clients. Continue to engage clients family members for support when possible. Continue to work with other CSB staff and/or vendors providing post-discharge housing/services (assisted living facilities, group homes, etc.) to be flexible and able to manage clients with significant impairments. In FY 2017, it is anticipated that of clients will remain out of the hospital for at least 30 days. FY 2016 9