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 2015 FY 2016 FY 2017 Clients admitted to hospital 142 139 130 Clients discharged Total / EBL 132 / 8 112 / 7 107 / 10 Clients discharged to Arlington CSB 85 70 51 Average clients served each month Total / EBL 28 / 7 29 / 4 25 / 3 PM2: How well did we do it? 2.1 Length of stay in hospital 2.2 NVMHI clients receiving discharge services at least every 14 days 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 2017 1
Measure 2.1 Length of stay in hospital 400 Average Number of Days in Hospital for Clients Discharged Who Were/Were Not on the EBL 361 300 263 200 100 0 Non-EBL Goal: 60 days 32 EBL Goal: 180 days 89 86 71 68 63 FY 2015 FY 2016 FY 2017 FY 2018 (proj.) Clients who were on the EBL Clients who were not on the EBL Summary In FY 2017, clients who were discharged from the hospital who had been on the EBL had been in the hospital an average of 89 days. Clients discharged who had not been on the EBL had been there an average of 68 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. What is the story behind the data? There was a decrease in length of stay for non-ebl and EBL clients. This could be a result of the increased collaboration between discharge planners and NVMHI staff to develop creative solutions to discharge clients from the state facility. Furthermore, additional money was granted to this region by the Department of Behavioral Health and Developmental Services (DBHDS) to discharge hard-toplace clients in the community. Bed shortages at state facilities have increased the demands to discharge individuals quickly once deemed clinically stable, which affects the number of clients discharged to stable placements in the community. Recommendations 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. 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 2017 2
There continued to be a decrease in length of stay for EBL individuals. Overall, Arlington County has had a substantial decrease in the number of clients placed on the EBL, which can be linked to the significant efforts made by the dischargeplanning team to identify appropriate discharge placements and quickly discharge clients when clinically stable. There are NGRI acquittees in the state facility who have been there significant periods of time which keep the average length of stay at an elevated level. Forecast In FY 2018, it is anticipated that the average length of stay for patients discharged from the hospital will decrease to 86 days for clients on the EBL and 63 days for clients not on the EBL. FY 2017 3
Measure 2.2 NVMHI clients receiving discharge services at least every 14 days 100% 80% 60% 40% 20% NVMHI Clients Receiving Discharge Services At Least Every 14 Days 81% 102/126 Goal: 90% 69% 9/13 95% 112/118 75% 9/12 100% 80% 0% FY 2016 FY 2017 FY 2018 (proj.) Non-EBL EBL Summary In FY 2017, discharge-planning efforts were documented at least every 14 days for non-ebl individuals 95% of the time, up from 81% in FY 2016, and 75% of the time for EBL individuals, an increase from FY 2016. obtained from reports from the electronic health record. What is the story behind the data? The Clinical Supervisor works aggressively to assist the discharge planning team 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 continued to decrease thus decreasing the average length of stay. In FY 2017, the clinical supervisor obtained weekly progress reports on each EBL and non-ebl client from discharge-planning staff during individual supervision. One staff member working with EBL individuals had challenges meeting the 14-day expectation, but this issue has been resolved. The discharge-planning team experienced staffing shortages in FY 2017 which could have contributed to occasional challenges in working towards discharge with each client every 14 days. Recommendations Continue to provide regular administrative support on contractual follow-through issues to facilitate a more timely completion of this often-complex process. Clinical supervisor to work closely with staff to monitor the progress of EBL and non-ebl clients. Revise measure to capture weekly documentation of services. Continue to track the work of dischargeplanning staff. Ensure new staff are trained and understand expectations for client contact and documentation requirements. A new FTE was hired in the fourth quarter of FY 2017 and will maintain a full caseload in FY 2018. FY 2017 4
Having the 0.5 FTE discharge planner focus on the EBL continues to be effective. Forecast FY 2017 PERFORMANCE PLAN Continue to dedicate appropriate staffing resources to finding placements for EBL clients. In FY 2018, it is anticipated that discharge-planning efforts will be made at least every 14 days for 100% of non-ebl individuals, and 80% of individuals on the EBL. FY 2017 5
Measure 3.1 Clients connected with Arlington community-based treatment services Percent of Clients Discharged to Arlington CSB Who Kept First Appointment 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 88% 75/85 Goal: 90% 83% 58/70 86% 44/51 94% 45/48 FY 2015 FY 2016 FY 2017 FY 2018 (proj.) Summary In FY 2017, 86% 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. What is the story behind the data? Recommendations The percentage of clients who kept their first appointment with Arlington CSB increased from FY 2016 to FY 2017. 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. Continued efforts were made to involve the peer specialists in Emergency Services for clients 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. Forecast 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 aftercare appointment with a case management appointment whenever possible, and, when appropriate, link clients to the peer specialists. Continue to monitor clients 30 days postdischarge from the state hospital to increase the likelihood of remaining connected to outpatient mental health services. New expectations for outreach to clients who do not keep their appointment with the CSB were implemented in early FY 2018. In FY 2018, it is anticipated that 94% of clients discharged to Arlington will keep their first appointment with the CSB. FY 2017 6
Measure 3.2 Stability of housing placement for individuals discharged from hospital to placements in Arlington 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 20% 27% Housing Placements for Clients Discharged from Hospital Goal: 90% green 36% 14% 53% 50% 19% 15% 18% 18% 63% 67% FY 2015 FY 2016 FY 2017 FY 2018 (proj.) Stable Housing Other Treatment-related Placements Shelter Summary In FY 2017: 63% of clients (32 of 51) were discharged to stable housing: their own apartment, a group home, or a residential placement. 18% of clients (9 of 51) were discharged to other treatment-related placements, such as residential crisis stabilization (ACCESS), residential substance abuse programming, or hospital (medical). 19% of clients (10 of 51) were discharged to shelter/motel placements. was obtained through monthly reports collected from each staff member regarding discharge placements of consumers. What is the story behind the data? Significant gains were made in FY 2017 in the percentage of clients who were discharged to stable housing. The program continues to work with partners to stabilize housing prior to discharge. Clients whose housing is stable before hospitalization are often able to return to it after discharge, while clients whose housing placement prior to hospitalization is unstable have challenges with obtaining stable housing after discharge. Many clients still continue to be discharged to shelter or other temporary placements before appropriate housing options can be arranged. These clients Recommendations Continue to develop discharge placements as well as advocate for continued hospitalization for clients when appropriate. Continue to locate more stable, appropriate placements for these individuals. Explore additional strategies with DHS Housing Bureau leadership to facilitate FY 2017 7
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. 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 DBHDS to acquire funding for specialized placements. more rapid housing placements for homeless individuals. 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. Funding to begin in FY 2018 for 10 permanent supportive housing slots for individuals discharging from the state facility. Forecast In FY 2018, it is anticipated that 67% of clients will be discharged to stable housing. FY 2017 8
Measure 3.3 Clients discharged to Arlington who remain out of the state hospital Discharged Clients Who Remain Out of State Hospital for at Least 30 Days 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 91% 77/85 Goal: 97% 76% 53/70 69% 35/51 77% 36/47 FY 2015 FY 2016 FY 2017 FY 2018 (proj.) Summary In FY 2017, 69% 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. What is the story behind the data? The recidivism rate increased in FY 2017. One factor contributing to the increase is that pressures at the state hospital to discharge individuals quickly has increased as a result of the chronically high census at all hospitals statewide. This may result in discharge of some individuals prior to achieving optimal clinical stability. Recommendations Continue to aggressively negotiate readiness for discharge with hospital staff, and negotiated removal of 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 stepdown option when appropriate to ensure compliance with aftercare treatment recommendations. FY 2017 9
Recidivist clients often have numerous prior admissions, require PACT team services, and need housing or intensive residential placements. 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. Use new permanent supportive housing funding for clients discharging from the state hospital when appropriate. Forecast In FY 2018, it is anticipated that 77% of clients will remain out of the hospital for at least 30 days. FY 2017 10