Crisis Systems of Care:

Crisis Systems of Care: Building Competency Across Services Facilitated by: Kappy Madenwald October, 2011 Phase I Phase II Phase III Phase IV Phase V Prevention Early Intervention Acute Intervention Crisis Treatment Recovery and Reintegration

Goals of the Session O This training will focus on the Crisis System of Care and the varying role that providers across the service continuum can and do play in helping children and families navigate crisis situations. O Within the context of the larger Systems of Care framework this training will focus on strengthening the crisis continuum, identifying responsibilities, strategies and opportunities so that collectively the system offers a stronger safety net for children and families. O Throughout the day, participants will be encouraged to interface with colleagues from other levels of care, to identify priorities for local systems of care processes and to think in a transformational way about strengthening the crisis continuum in their communities. 2

Goals of the Session O Children and families remain foremost in our thinking O Wraparound Principles of Care ground, and add context to, our discussion O Today we will O Gain appreciation for alternate perspectives O Refine and redefine cross-service understanding O Build Consensus O Set Crisis System of Care development priorities 3

Quality Indicator: Location of Service O 80% of children and families will receive crisis services in the community rather than in an emergency department O What do you think is behind this target? O How does it make a difference for children and families? O How does the indicator promote the ability of the MCI team to intervene in a way that is consistent with Wraparound Principles of Care? O What questions or concerns do you have about this target? 4

The Ten Principles of Wraparound 1. Family voice and choice 2. Team-based 3. Use of natural supports 4. Collaboration 5. Community-based 6. Culturally competent 7. Individualized 8. Strengths-based 9. Persistent 10. Outcome-based Source: Eric J. Bruns, Janet S. Walker, Jane Adams, Pat Miles, Trina Osher, Jim Rast, and John VanDenBerg, (2004). The Ten Principles of Wraparound 5

Quality Indicator: Disposition of Service O 80% of youth seen by Mobile Crisis Intervention will receive community-based services and supports which are alternatives to inpatient services. O What do you think is behind this target? O How does it make a difference for children and families? O How does the indicator promote solutions that are consistent with Wraparound Principles of Care? O What questions or concerns do you have about this target? 6

Since June 3o, 2009 Children (ages 0-20) and families have received: 19,946 episodes of Mobile Crisis Service (MCI) in an emergency department setting 31% of the time (n=6192) the child was admitted to an inpatient psychiatric unit 69% of the time (n=13,817) the crisis was either resolved or subsequent care (using one or a mix of formal, informal or natural resources) occurred in a community-based setting 7

Since June 3o, 2009 Children (ages 0-20) and families have received: 19,144 episodes of Mobile Crisis Service (MCI) in a community-based setting 14% of the time (n=2699) the child was admitted to an inpatient psychiatric unit 86% of the time (n=16445) the crisis was either resolved or subsequent care--using one or a mix of formal, informal or natural resources--occurred in a community-based setting 8

A 2002 study found that a matched sample of consumers who used hospitalbased crisis services were 51 percent more likely to be hospitalized, after other variables had been controlled for, than users of community-based mobile crisis services. Shenyang Guo, David E. Biegel, Jeffrey A. Johnsen, and Hayne Dyches Assessing the Impact of Community-Based Mobile Crisis Services on Preventing Hospitalization Psychiatr Serv, Feb 2001; 52: 223-228. 9

Regional Update on Crisis Services Phase I Phase II Phase III Phase IV Phase V Prevention Early Intervention Acute Intervention Crisis Treatment Recovery and Reintegration 10

Regional Update on Crisis Services Provider Perspective O Progress on moving services into the community O Progress on stabilization without the need for hospitalization O Journey for teams in achieving these results 11

Crisis Systems of Care Development in Massachusetts O Inherent in the vision of CBHI was the expectation that systems of care be developed in communities across the commonwealth. O Rather than operating as separate and distinct, treatment programs and child-serving systems would begin to deliver treatment in a more coordinated and complimentary manner and children and families would not experience disjointed, confusing, contradictory services, guidance and directives as had sometimes been the experience in the past. 12

Crisis Systems of Care Development in Massachusetts O The systems of care concept is woven into service definitions and performance specifications in a number of ways. First, services are delivered in accordance with Wraparound principles of care. Secondly, there are cross-cutting themes and expectancies across services in two key areas: Care Coordination and Crisis Management 13

Crisis Systems of Care Development in Massachusetts O Much of the focus in the first two years of CBHI has been to strengthen capacity and competency in care coordination through IHT (In-Home Therapy) CSA s (Intensive Care Coordination and Family Support services) and to strengthen capacity and competency in crisis intervention through ESP s (Mobile Crisis Intervention). 14

Crisis-Specific Performance Specifications for MassHealth Providers By level of care, there are crisis-specific Performance Specifications related to: O Access O Responsibility for providing intervention O Continuity of Care O System Collaboration O Post-hospital services

Crisis Responsibilities (General Rule of Thumb) Outpatient Services Components of Service 3. Outpatient Service providers provide emergency services 24 hours per day, seven days per week to all Members enrolled in the outpatient program/clinic/practice. These services are intended to be the first level of crisis intervention whenever needed by the Member.

Crisis Responsibilities (General Rule of Thumb) Outpatient Services a. During operating hours, these services are provided by phone and face-to-face through emergency appointments as warranted by the Member s clinical presentation. b. After hours, the program provides an emergency phone number that accesses a clinician either directly or via an answering service. c. Any call that is identified as an emergency by the caller is immediately triaged to a clinician.

Crisis Responsibilities (General Rule of Thumb) Outpatient Services a. A clinician must respond to emergency calls within 15 minutes. This clinician provides a brief assessment and intervention minimally by phone. b. Based upon these emergency services conducted by the provider both during operating hours and after hours, the provider may refer the Member, if needed, to an Emergency Services Program (ESP) for an emergency behavioral health evaluation. c. An answering machine or answering service directing callers to call 911 or the ESP, or to go to a hospital emergency department (ED), is not sufficient.

Crisis Responsibilities (General Rule of Thumb) Outpatient Services Service, Community, and Collateral Linkages 1. In an effort to improve continuity of care, outpatient providers will have strong working relationships with Emergency Service Providers (ESPs), Inpatient, ICBAT/CBAT, and providers of other diversionary or 24-hour levels-of-care. They will have this documented through written affiliation agreements, minutes of regularly scheduled meetings, and/or evidence of collaboration in Members medical records.

Crisis Responsibilities (General Rule of Thumb) Outpatient Services Process Specifications: Access 1. Members who are not in crisis and do not require immediate services, but present with an urgent request for services, will be scheduled for an outpatient therapy appointment within 48 hours, and they will be given the after-hours telephone number with appropriate emergency instructions.

Crisis Responsibilities (General Rule of Thumb) Outpatient Services 3. Members referred from an inpatient unit will be scheduled for an outpatient therapy appointment within seven days from the date of discharge from the inpatient unit. 4. Members referred from an inpatient unit will be scheduled for a psychopharmacological appointment as soon as clinically indicated, but no longer than 14 business days post-discharge.

Crisis Responsibilities (General Rule of Thumb) Outpatient Services Process Specifications: Assessment and Treatment Planning 1. When a Member in outpatient treatment is evaluated by an Emergency Services Program (ESP) and/or admitted to Inpatient, ICBAT, CBAT, or any 24-hour level of care and/or when Members are being referred to the outpatient provider from the inpatient/icbat/cbat unit the outpatient provider will:

Crisis Responsibilities (General Rule of Thumb) Outpatient Services a. receive and return phone calls from Emergency Services Providers (ESPs)and providers of inpatient or other 24-hour levels-of-care who are servicing the clinician s outpatient client within one business day; b. provide information and consultation, with appropriate consent, in order to inform the assessment of the Member by the ESP and/or 24- hour level-of-care; c. make every effort to participate, face-to-face or by phone, in the facility treatment and dischargeplanning process;

Crisis Responsibilities (General Rule of Thumb) Outpatient Services d. provide Bridge appointments for Members on inpatient units whenever possible; e. facilitate the aftercare plan by ensuring access to an outpatient appointment that meet the access standards above; and f. support the Member in implementing his or her aftercare.

Crisis Responsibilities (General Rule of Thumb) In-Home Therapy Components of Service 3.d. Review/development of a risk management safety plan in collaboration with the youth and parent/guardian/caregiver. g. Phone and face-to-face coordination with collateral providers, state agencies, ESP/Mobile Crisis Intervention, and other individuals or entities that may impact the youth s treatment plan, subject to required consent. i. Coaching in support of decision-making in both crisis and non-crisis situations

Crisis-Specific Performance Specifications: In-Home Therapy Services 6. The In-Home Therapy Services provider has 24-hour urgent response accessible by phone to the youth and family, 365 days a year. In the event of an emergency, the In-Home Therapy Services provider engages the ESP/Mobile Crisis Intervention (24 hours a day, 365 days a year) and supports the Mobile Crisis Intervention team to implement efficacious intervention. An answering machine or answering service directing callers to call 911, ESP/Mobile Crisis Team, or to go to a hospital emergency department (ED), is not acceptable.

Crisis-Specific Performance Specifications: In-Home Therapy Services Service, Community, and Collateral Linkages 1. The In-Home Therapy Services team maintains a linkage and working relationship with the local ESP/Mobile Crisis Intervention team in their area in order to provide youth and their families with seamless and prompt access to In-Home Therapy Services upon referral from a Mobile Crisis Team following a crisis period or to ESP/ Mobile Crisis Intervention team in an emergency.

Crisis-Specific Performance Specifications: In-Home Therapy Services 3. If referral to a higher level of care (e.g., Crisis Stabilization, CBAT, IP) is necessary, the In-Home Therapy Services team provides a focused treatment plan to help guide and expedite treatment by the provider of the higher level of care.

Crisis-Specific Performance Specifications: In-Home Therapy Services Process Specification: Treatment Planning and Documentation 1. The In-Home Therapy Services provider is available 24 hours a day, seven days a week, 365 days a year to take referrals. The provider responds telephonically to all referrals within one business day. During daytime operating hours (8 a.m. to 8 p.m.), the In-Home Therapy Services provider responds by offering a faceto-face encounter to referrals within 24 hours. Providers are required to engage in assertive outreach regarding engaging in the service, track the outreach, and follow-up.

Crisis-Specific Performance Specifications: In-Home Therapy Services 2. The In-Home Therapy Services provider participates in discharge planning at the referring treating facility/provider location. If the referral is initiated as a diversion by a Mobile Crisis Team in an effort to divert out of home placement or psychiatric hospitalization, the In-Home Therapy Services provider makes every effort to meet with the youth and parent/guardian/caregiver and the Mobile Crisis Team clinician at the time of referral or as soon as possible thereafter.

Crisis-Specific Performance Specifications: In-Home Therapy Services 3. With the youth s and parent/guardian/caregiver s consent, the In-Home Therapy Services team will visit the youth and family in any safe setting within 24 hours of the referral if referred from an inpatient unit/cbat/crisis Stabilization. If referred from a Mobile Crisis Team, the first In-Home Therapy meeting will be offered within 24 hours of the initial referral or as negotiated with the youth and parent/guardian/caregiver and the Mobile Crisis Team in any safe setting. Initial treatment goals and planning will be initiated at this meeting.

Crisis-Specific Performance Specifications: Intensive Care Coordination Components of Service 4. The ICC provider must be available by phone and staff on-call pagers to monitor the need for ESP/Mobile Crisis Intervention services and assist with access to those services for the youth and their families 24 hours a day,365 days a year. An answering machine or answering service directing callers to call 911 or the ESP, or to go to a hospital emergency department (ED), is not acceptable.

Crisis-Specific Performance Specifications: Intensive Care Coordination Service, Community, and Collateral Linkages 7. The ICC provider maintains linkages and working relationships with the local ESP/Mobile Crisis Intervention provider in their service area in order to facilitate referrals from the Mobile Crisis Intervention provider and to ensure care is properly coordinated for youth and families served by ICC and ESP/ Mobile Crisis Intervention.

Crisis-Specific Performance Specifications: Intensive Care Coordination With consent from the parent/guardian/caregiver, if required, when a youth and family involved in ICC is in need of intervention from ESP/Mobile Crisis Intervention, as determined by the ICC provider, family and the ESP provider, the care coordinator is in contact with the ESP/Mobile Crisis Intervention staff at the time of referral (or if not, the referral source immediately upon learning of referral to ESP/Mobile Crisis Intervention) to provide relevant information, assistance, and recommendation for how ESP can best intervene to the ESP/Mobile Crisis Intervention staff.

Crisis-Specific Performance Specifications: Intensive Care Coordination 9. With consent, if a youth is admitted to a 24-hour behavioral health level of care (e.g., Crisis Stabilization, inpatient hospital, CBAT, PHP), the care coordinator contacts the facility at the time of referral and provides preliminary treatment recommendations to initiate and guide treatment, and schedules a CPT meeting at the facility within two (2) days for care coordination and disposition planning. The CPT meeting includes the participation of the family and facility staff. The ICC provider and facility staff communicates and collaborate on a youth s treatment throughout his/her admission to develop, in concert with the family, a disposition plan that is consistent with his/her ICP...

Crisis-Specific Performance Specifications: Intensive Care Coordination Process Specifications: Treatment Planning and Documentation 16. The ICC provider is available to provide support by phone or staff on-call pager to the youth and the family 24 hours a day, 365 days a year. During business hours (M-F, 8 a.m. - 8 p.m.), the ICC provider provides phone and face-to-face assessment of the need for ESP/Mobile Crisis Intervention or emergency services and assistance with access to such services, including mobilizing to the home or community settings (e.g., school) to assess the youth s needs and coordinate responses to emergency situations

Crisis-Specific Performance Specifications: Intensive Care Coordination After hours (i.e., between 8 p.m. and 8 a.m. and on weekends), the ICC assesses the youth s need for crisis services and provides crisis support by phone. If, based upon the ICC s clinical assessment of the youth s needs, Mobile Crisis Intervention is required, or in the event of an emergency, the ICC provider shall engage the ESP/Mobile Crisis Intervention. ICC providers shall remain actively involved in monitoring and assessing the youth s need for services during the course of Mobile Crisis Intervention. An answering machine or answering service directing callers to call 911 or the ESP, or to go to a hospital emergency department (ED), is not acceptable.

Sample (for Illustrative purposes only) of a graduated scale of crisis management responsibility by service MCI ICC IHT Outpt 38

Deep Thoughts 1. How does attention to crisis management by all levels of care reduce real risk?* 2. How does adherence to Wraparound Principles of Care in crisis situations reduce real risk? * as opposed to the false sense of confidence kind of risk reduction 39

Standing in Each Other s Shoes 40

Standing in Each Other s Shoes O To build and improve a system of care requires that we have to understand many perspectives. O In the process of doing so, we refine our own perspective to align with a greater good a macro view that attends to those collective perspectives at the same time O and that considers the pros/cons of any action in a comparably broad fashion 41

Standing in Each Other s Shoes O When I get in a pushing match, I am so busy defending and strengthening my position that I fail to see the value of yours leaving real risk on the table. O When I seek to understand your position and the reasons behind it I illuminate the idiosyncratic risk as you see it, can add it to a macro view and use it to guide a consensus-based planning process. 42

Standing in Each Other s Shoes O The leap of faith is that in giving up MY position WE attain the greater good illuminate any gaps in thinking, planning or understanding O I have to let go of an I m right mentality O understand that doing so is not ceding power O and watch as the result exceeds expectations 43

The best way to take control is to give it away 44

Standing in Each Other s Shoes...Group Exercise O We will go through a series of scenarios O As directed, imagine yourselves being in the shoes and having the perspective of the other person O Tell the best (realistic) story you can tell about the experience from his or her shoes O We will reality check it, O Identify the most illuminating new knowledge, O And, use later in the session to consider Crisis Systems of Care development priorities 45

Standing in Each Other s Shoes SCENARIO 1 MCI managers and directors, please imagine yourselves in the shoes of an Outpatient Therapist who is making a call to the MCI team because a child they are working with is in the midst of a crisis. What is that experience like for you? What is the easiest part? What is the hardest part? 46

Standing in Each Other s Shoes SCENARIO 2: MCI managers and directors, please imagine yourselves in the shoes of an In-Home Therapist who is making a call to the MCI team from a family s home because their child is in the midst of a crisis. What is that experience like for you? What is the easiest part? What is the hardest part? 47

Standing in Each Other s Shoes SCENARIO 3: Outpatient and In-Home Therapy managers and directors, please imagine yourselves in the shoes of an MCI clinician who is taking a call from an outpatient or IHT clinician that is working with a child and family in crisis. What is that experience like for you? What is the easiest part? What is the hardest part? 48

Standing in Each Other s SCENARIO 4: Shoes ICC, IHT and Outpt managers and directors, please imagine yourselves in the shoes of the MCI clinician who is making a call to the ICC, IHT or Outpatient program on-call person to coordinate treatment for a child and family in crisis. What is that experience like for you? What is the easiest part? What is the hardest part? 49

Standing in Each Other s Shoes SCENARIO 5 All managers and directors, please imagine yourselves in the shoes of a parent whose child is in crisis that is trying to figure out who to call, what to say, and what to expect? What is that experience like for you? Where did you get your information about what to do? What is the easiest part? What is the hardest part? 50

When we change the way we look at a person, the person we look at changes 51

Comparing Old and New Models of Crisis Intervention 52

Outdated Crisis Model Crisis Systems of Care Model O O O O O O O O O Default crisis service pathways Limited array of crisis experts Single-system responsibility and ownership Program-level outcomes Crisis Intervention with a goal of level of care determination Professional expert makes the decision Over-reliance on formal Solutions (i.e. hospitalization) Insufficient Service Pathways (in and out of crisis care) Inconsistent/absent care coordination and data transfer between services and systems O O O O O O O O O Planned Crisis Service pathways Crisis expertise at all levels of care Multi-system responsibility and ownership System-level outcomes Crisis Intervention with a goal of resolution, recovery and community tenure Shared Decision-Making Mutual consideration of formal, informal and natural solutions Planned, facile pathways for referral in and out of crisis care Formalized mechanisms for care coordination and data transfer between services and systems

Because only a portion of real-life crises may actually result in serious harm to self or others, a response that is activated only when physical safety becomes an issue is often too little, too late or no help at all in addressing the root of the crisis. And a response that does not meaningfully address the actual issues underlying a crisis may do more harm than good. Source:Practice Guidelines: Core Elements for Responding to Mental Health Crises. HHS Pub. No. SMA-09-4427. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2009. 54

How Have the Changes Made a Difference to Children and Families? O Examples from the field 55

Deep Thoughts 1. How does over-reliance on psychiatric hospitalization increase risk for children and families? 2. When is a weekend at Uncle Bernie s safer than an psychiatric admission? 56

Comparing Old and New Models of Crisis Intervention--Exercise O From your own shoes think about any remnant language from the old way of doing crisis intervention. O What are the updated ways to discuss crisis services with families? with peers? across levels of care? O Instead of we will say/ask 57

Infusing Crisis Management Strategies into Community- Based Treatment Programs 58

Infusing Crisis Management strategies into Community-Based Treatment Programs As an ICC, IHT or Outpatient service provider O What are the pros of calling MCI when a family is in crisis? O What are the cons? 59

Infusing Crisis Management strategies into Community-Based Treatment Programs O How are you currently incorporating crisis management strategies into your program? O What new processes, strategies are you considering in the near future? 60

Deep Thoughts Stand in the shoes of a family in crisis 1. Why might a family call you (provider) first? 2. Why might a family not call you first? 61

Infusing Crisis Management strategies into Community-Based Treatment Programs What is the business case O For expanding your crisis management capacity? O For building crisis competency among your staff? 62

Phase I Phase II Phase III Phase IV Phase V Prevention Early Intervention Acute Intervention Crisis Treatment Recovery and Reintegration 63

Crisis Systems of Care O Are made up of an infrastructure of services, systems, processes that promote early, incommunity response to and management of behavioral health crises O Promote upstream interventions to reduce risk of harm and to keep children in the community O Are philosophy-rich O Consistent with Wraparound principles O Use change-oriented interventions O Attend to all levels of the Continuum Phase I Prevention Phase II Early Intervention Phase III Acute Intervention Phase IV Crisis Treatment Phase V Recovery and Reintegration 64

Strategic Development of the Crisis System of Care O Assure depth and breadth in crisis system development O Attend to all levels of the crisis continuum O Include non-traditional partners O Include non-categorical services O Include effective processes, efficiencies, logistical strategies that streamline, bridge services, track capacity, aid in continuity O Include technological tools Phase I Prevention Phase II Early Intervention Phase III Acute Intervention Phase IV Crisis Treatment Phase V Recovery and Reintegration 65

Strategic Development of the Crisis System of Care O Seek community ownership, vision, voice O Recognize that it is a dynamic, maturational process you never get it done O There are lots of places to start O Start where there is good bang for the buck O Readiness for change O Where there is game-changing potential Phase I Prevention Phase II Early Intervention Phase III Acute Intervention Phase IV Crisis Treatment Phase V Recovery and Reintegration 66

Strategic Development of the Crisis System of Care O Deliberately reorient from silos to systems in all aspects of crisis service delivery O Identify essential partners O Apply Stage of Change principles in building relationship O Strength s-based O Match strategy to stage of readiness O Roll with resistance O Inform with data that is meaningful to the prospective partner Phase I Prevention Phase II Early Intervention Phase III Acute Intervention Phase IV Crisis Treatment Phase V Recovery and Reintegration 67

Strategic Development of the Crisis System of Care O Seek to understand the crisis system from your partner s vantage point O Its inefficiencies O Its barriers O Its unknowns O Develop mutual understanding O Language differences O Rules and standards that guide each partner s work Phase I Prevention Phase II Early Intervention Phase III Acute Intervention Phase IV Crisis Treatment Phase V Recovery and Reintegration 68

Most performance measurement efforts tend to operate in isolation from one another to meet the specific needs of their sponsors. Frequently, data collection efforts are particular to specific care settings such as hospitals or ambulatory care organizations or to particular payers, whether private or public Since data are collected and used in fragmented ways, they rarely provide a picture of the overall quality of performance for a specific clinician or organization, or how well patients fare, or the state of the public s health at large. Health Care at the Crossroads: Development of a National Performance Measurement Data Strategy. The Joint Commission, 2008, p.8. 69

Strategic Development of the Crisis System of Care O Identify change that is meaningful to the partner O Until system partners can make their own business case for change they will act in a manner that diffuses your performance O Until you understand what is meaningful for your system partners, you will have a hard time helping them to see the business case for change O Develop consensus O Points of interface O Mutual Agreements O Shared outcome measures O Methods of communication, including sharing of records and data O Consider formalizing relationship through a non-binding written agreement 70 Phase I Prevention Phase II Early Intervention Phase III Acute Intervention Phase IV Crisis Treatment Phase V Recovery and Reintegration

Strategic Development of the Crisis System of Care O Use data to develop individualized change strategies O Cannot apply a blanket approach O Example: The factors leading to overuse of the ED at one hospital do not necessarily pertain to the next hospital O Example: The reasons behind the reluctance of schools to allow on-site interventions vary from school to school Phase I Phase II Phase III Phase IV Phase V Prevention Early Acute Intervention Intervention Crisis Treatment Recovery and Reintegration 71

Strategic Development of the Crisis System of Care: Exercise O Think through each of the levels of care O If you were building the ultimate crisis system of care, what key attributes would you find within each level of care and each level of the crisis continuum? O Program structures O Staff competencies O Tools/resources O Which elements already exist at least in part? O Which elements are priorities? O Which elements seem most readily doable? Phase I Prevention Phase II Early Intervention Phase III Acute Intervention Phase IV Crisis Treatment Phase V Recovery and Reintegration 72

Level of Care Prevention Early Intervention Acute Intervention Crisis Treatment Recovery and Reintegration Outpatient Therapy In-Home Treatment Intensive Care Coordination Urgent Outpatient Service Mobile Crisis Intervention 73

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Deep Thoughts If consensus cannot be reached on a formal solution, ask a provocative question? 1. 1. What are the pros/cons? 2. 2. Pretend there were no categorical services. How could the need be met? Phase I Prevention else Phase II Early Intervention Phase III Acute Intervention Phase IV Crisis Treatment Phase V Recovery and Reintegration 75

Building a Crisis Systems of Care Agenda O Within your team O Within your Agency O Within your Community Phase I Phase II Phase III Phase IV Phase V Prevention Early Acute Intervention Intervention Crisis Treatment Recovery and Reintegration 76

Final Thoughts 77