Program of Assertive Community Treatment () BHD/MH Luis Marcano, x5343 Alan Orenstein, x0927 Program Purpose Help individuals with serious mental illness achieve and maintain community integration through stable housing, employment, and reduced episodes of hospitalization. Program Information The Program of Assertive Community Treatment () is an evidence-based team treatment model that provides intensive, comprehensive, field-based, multidisciplinary treatment and support to adults with severe mental illness 24 hours a day, seven days a week. The Team serves individuals who have a primary diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder or a delusional disorder, with a history of multiple psychiatric hospitalizations, residential care, or partial hospitalization. Standard outpatient services are insufficient to serve the individual, who may be hard to engage and reluctant to participate in officebased services. Services are licensed by the Virginia Department of Behavioral Health and Developmental Services. The Team receives referrals primarily from the Mental Health Bureau outpatient teams in the Behavioral Healthcare Division. The Team collaborates with a wide array of community partners, including: Emergency Services Local and state hospitals Pharmacies and Medical Doctors Arlington County Detention Facility Property managers Community Residences ACCESS crisis stabilization home PM1: How much did we do? Staff Customers Units of Service 11.8 FTEs, 2 PRNs, and 1 Peer Specialist Contractor 1.0 FTE Program Manager 1.0 FTE Assistant Program Manager 0.8 FTE Psychiatrist 1.0 FTE Administrative Technician 3.0 FTE Psychiatric Nurses 5.0 FTE Mental Health Therapists 2 PRN Human Services Specialists 0.25 Peer Specialist Contractor Fiscal Year 2014 2015 2016 Number of clients served (unduplicated) 91 100 105 Number of new clients admitted to 19 20 15 Hours of service provided by clinicians 10,546 11,160 11,184 FY 2016 Page 1
PM2: How well did we do it? 2.1 Organizational adherence to evidence-based ACT Model 2.2 Clinical documentation compliance 2.3 Percentage of services provided in the community PM3: Is anyone better off? 3.1 Psychiatric hospitalization rate 3.2 Clients living independently (in private households) 3.3 Clients employed in competitive jobs FY 2016 Page 2
Measure 2.1 Organizational adherence to evidence-based ACT Model 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 Adherence to Evidence-based ACT Model 4.5 4.5 4.39 4.27 Goal: 4 1.0 FY 2016: Evaluated by the State ACT Coordinator Average Overall National Fidelity FY 2017 (proj.): Evaluated by Program Manager Virginia Adjusted Fidelity The Dartmouth Assertive Community Treatment (DACT) Fidelity Scale contains 28 program-specific items. The scale has been developed to measure the adequacy of implementation of programs. Each item is rated on a 5-point scale ranging from 1 ( not implemented ) to 5 ( fully implemented ). The standards used for establishing the anchors for the fully implemented ratings were determined through a variety of expert sources as well as empirical research. The scale items fall into three categories: human resources (structure and composition), organizational boundaries, and nature of services. The Program was evaluated in September 2015 by the state s ACT Coordinator. Two scores were received: o The Average Overall Fidelity score is the program s average using the DACT scale. The score was 4.27 out of 5. o The Average Overall Virginia Adjusted Fidelity Score is the program s average incorporating those items where Virginia s standard differs. scored 4.39 out of 5. The program complies with the fidelity scale and with the state s standards as evidenced by the program scoring above 4 on both the national and Virginia adjusted fidelity scales. Continue to maintain compliance with the fidelity scale through a yearly selfevaluation. FY 2016 Page 3
The program scored below a score of 4 in the following areas: o Continuity of Staffing: Program maintains same staffing over time. (Score: 1) o Dual Disorder Treatment Groups. (Score: 1) FY 2016 PERFORMANCE PLAN In order to improve the scores in the lowscoring areas of the fidelity scale, the following steps have been implemented: o Program retreats held in May 2015 and 2016 for staff development to reduce turnover. Items identified and implemented that will help maintain staff in the program: Professional growth: Staff are now receiving clinical supervision towards their licensure. Activities to promote team cohesion have been implemented. Salary study conducted by HR led to grade and salary increases. o Dual Diagnosis Group started in June 2016. FY 2017: anticipated average overall fidelity score to increase to 4.5 after self-administration of the DACT in September 2016. FY 2016 Page 4
Measure 2.2 Clinical documentation compliance 100% 90% 80% 70% 60% 50% 40% 30% 10% 0% 72% CRT 18/25 Percent Audited Records Compliant with Standard Goal: 90% 68% Supervisor 57/84 72% CRT 18/25 83% Supervisor 54/65 71% CRT 15/21 81% Supervisor 75/93 90% 90% CRT Supervisor FY 2014 FY 2015 FY 2016 FY 2017 (proj.) The data is based on periodic audits performed by the DHS Compliance Review Team (CRT) using a set of clinical record item standards, as well as monthly reviews performed by s program manager using the same criteria. A clinical record must score a 90% or above in order to meet compliance standards. In FY 2016, compliance was 71% and 81% based on reviews by CRT and the program supervisor respectively. CRT did not conduct a full record audit in FY 2016. The data collected for FY 2016 comes from quarterly CRT record reviews conducted during the months of January, March, and June (in conjunction with program manager) to assess inter-rater reliability. During FY 2014 and FY 2015, audits were conducted twice a year (a full audit and an audit on assessments). The results led to corrective actions, including review of records by the program manager, staff counseling, and arrangement of needed training. Continue with documentation monitoring, supervision, counseling and training activities by program supervisor and CRT. Items rated noncompliant were timing of quarterly reviews or service plans, justification of diagnoses according to DSM criteria and administrative documentation, Continue to provide coaching and training to staff as needed. FY 2016 Page 5
such as releases of information and client rights forms, not being up to date. Program supervisor and CRT met in of January, March, and June of 2016 to review inter-rater reliability. On average, the supervisor s audit reviews matched CRT s scoring 89% of the time. The inter-rater agreement scores per month were: o January: 67% (4/6) o March: 100% (7/7) o June: 100% (8/8) FY 2016 PERFORMANCE PLAN Collaborate with CRT in training aimed at the consistency of CRT and supervisor ratings. In FY 2017, it is anticipated that 90% of both CRT-audited and internally audited records will meet the compliance standard. FY 2016 Page 6
Measure 2.3 Percentage of services provided in the community 100% 90% 80% 70% 60% 50% 40% 30% 10% 0% 83% 84% Licensure Standard: 75% FY 2014 (2922/3540 hours) Percentage of Face-to-Face Services Provided in the Community FY 2015 (2919/3466 hours) 80% 80% FY 2016 (3661/4601 hours) FY 2017 (proj.) Because is a community-focused treatment modality, in accordance with licensure regulation, a minimum of 75 percent of total face-to-face contacts must be provided in the community. is extracted from the Cerner data system. At 80%, the percentage of time spent in the community exceeded the standard. The program is meeting and exceeding the licensure standard by meeting clients primarily in the community. Most in-office appointments are for psychiatric services, one-on-one therapy sessions, and for clients who are transitioning out of. Continue to meet licensure standards by providing community based services at least 75% of staff s time. FY 2017: anticipated percentage of services provided in the community to meet or exceed the 75% standard. FY 2016 Page 7
Measure 3.1 Psychiatric hospitalization rate 0.70 0.60 0.50 0.40 0.30 0.20 0.10 - Number of Psychiatric Hospitalization Episodes Per Client Served 0.35 FY 2014 32 episodes 91 clients served 0.42 0.40 FY 2015 42 episodes 100 clients served FY 2016 42 episodes 105 clients served Benchmark: <0.49 0.30 FY 2017 (proj.) 40% 35% Percent of Clients Hospitalized 30% 25% 23% 21% 24% Benchmark: <28% 15% 10% 5% 0% FY 2014 21/91 FY 2015 21/100 FY 2016 25/105 FY 2017 (proj.) The psychiatric hospitalization rate reflects the number of hospitalizations that occurred during each fiscal year. In FY 2016, there were 42 episodes among 105 clients served for a rate of 0.40 episodes per person served. is collected manually by program staff. In FY 2016, 25 clients were hospitalized, which is 24% of the 105 clients served. The benchmarks for the psychiatric hospitalizations are based on the FY 2015 State Report. FY 2016 Page 8
Of the 25 hospitalized clients in FY 2016: o one client was hospitalized four times o three clients were hospitalized three times o eight clients were hospitalized twice o thirteen clients were hospitalized once In FY 2016, 18 of the 25 hospitalized clients were admitted to the hospital due to severe psychotic symptoms such as paranoia, hallucinations, and delusions. Even though there were more clients hospitalized in FY 2016, the clients length of hospital stay decreased by 30% as compared to FY 2015. Total number of days clients were hospitalized: o FY 2015: 1,311 o FY 2016: 916 The decrease in hospital stay could be due partially to a relative high number of clients with psychiatric symptoms that were not as acute or severe enough to warrant longer hospital stays. In addition, there were clients who were hospitalized due to issues related to substance use or personality disorder traits. One consideration to note was the increase in use of ACCESS crisis stabilization beds, which increased from 5 in FY 2015 to 24 in FY 2016. This helped maintain the number of hospitalizations at the FY 2015 level. Continue to assess clients on an ongoing basis and provide early intervention. Continue to coordinate with the State s ACT coordinator with regards to outcome measures. Continue to collaborate with emergency services staff on assessment of highrisk clients and admission to ACCESS if warranted. FY 2017: anticipate hospital episode rate will be 0.30 episodes per person served and about of the clients served having at least one episode. FY 2016 Page 9
Measure 3.2 Clients living independently (in private households) 100% 90% 80% 70% 60% 50% 40% 30% 10% 0% 73% 74% FY 2014 67 clients Clients Living Independently FY 2015 74 clients Benchmark: 71% 65% 61% FY 2016 64 clients FY 2017 (proj.) This data represents the number of clients served who lived independently in the community and were psychiatrically stable. Independently is defined as those clients who lived by themselves in their own apartment. is collected manually by program staff. In FY 2016, 61% of clients lived independently. The benchmark for clients living independently is based on the FY 2015 State Report. The percentage of clients living independently decreased due to the program admitting clients with more housing barriers. The program transferred more clients to lessintensive services in FY 2016 than in previous years. The transferred clients had stable housing and demonstrated psychiatric stability. Clients transferred out of : o FY 2015: 15 (15%) o FY 2016: 19 (18%) In FY 2016, a total of 77 (73%) clients served had stable housing. These individuals resided with family members, in group homes or assisted living facilities. Work and collaborate with housing specialist and staff from permanent supportive housing program to find housing for homeless clients who are willing to go through this process. If consent is given by client, work with landlords to ensure that clients are not being evicted prematurely. Explore feasibility of capturing this data electronically in the future. Stay the course. For FY 2017, 65% of clients are projected to be living independently. FY 2016 Page 10
Measure 3.3 Clients employed in competitive jobs Clients Employed in Competitive Jobs 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 8% FY 2014 7/91 Benchmark: 9% 5% FY 2015 5/100 8% FY 2016 8/105 9% FY 2017 (proj.) This data reflects the number of clients who held part-time or full-time employment during each fiscal year. is collected manually by program staff. The benchmark for clients employed in competitive employment is based on the FY 2015 State Report. In FY 2016, 8% of clients held competitive jobs. At end of FY 2016, the program census was 88 clients; 28 of them were able to work due to being able to manage their mental health symptoms. However, these individuals have barriers to employment including legal problems, active substance use, and intermittent psychiatric issues. Continue to work with clients to help them achieve a level of stability that will enable them to find competitive employment. Vocational specialist to work on placing clients in competitive jobs. Explore feasibility of capturing this data electronically in the future. The anticipated percentage of clients to be competitively employed in FY 2017 is 9%. FY 2016 Page 11