Program of Assertive Community Treatment () BHD/MH Luis Marcano, x5343 Alan Orenstein, x0927 Program Purpose Program Information Help individuals with serious mental illness achieve and maintain community integration through stable housing, employment, and reduced episodes of hospitalization. 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. In FY 2017, the age distribution of clients was as follows: 27% under age 29; 25% ages 30-39; 28% ages 40-59; and 26% ages 60 and over. 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 and Service 11.8 FTEs and 2 PRNs 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 Fiscal Year 2015 2016 2017 Number of clients served (unduplicated) 100 105 106 Number of new clients admitted to 20 15 20 Hours of service provided by clinicians 11,160 11,184 11,263 FY 2017 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 2017 Page 2
Measure 2.1 Organizational adherence to evidence-based ACT Model Adherence to Evidence-based ACT Model 5.0 4.5 4.0 4.27 4.39 Goal: 4 4.1 4.5 4.5 4.5 3.5 3.0 2.5 2.0 1.5 1.0 : Evaluated by the State ACT Coordinator FY 2017 : Evaluated by Program Manager FY 2018 (proj.): Evaluated by Program Manager Average Overall National Fidelity 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 by the program manager. Two scores were derived: o The Average Overall Fidelity score is the program s average using the DACT scale. The score was 4.1 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 4.5 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 2017 Page 3
The program manager and assistant program manager conducted the review of the program s fidelity scale in June 2017. The program scored below a score of 4 in the following areas: o Continuity of staffing: Program maintains same staffing over time (score: 2) o Dual-disorder treatment groups. (score: 1) o Nurse on staff: At least two full-time nurses (score: 3) o Vocational specialist on staff: At least two staff members with 1 year training/experience in vocational rehabilitation and support (score: 3) o Program meetings: Program meets frequently (score: 3) FY 2017 PERFORMANCE PLAN In order to improve the scores in the lowscoring areas of the fidelity scale, the following steps will be implemented: o Dual-diagnosis group will restart after the substance abuse specialist comes on board in the second quarter of FY 2018. Clients have the option to be referred to the substance abuse groups offered by one of the outpatient teams. o Two nurses will come on board early in the second quarter of FY 2018. This will increase the number of nurses in the program to three. o Staff meetings will increase from once a week to four times a week once fully staffed in the second quarter of FY 2018. FY 2018: anticipated average overall fidelity score to increase to 4.5 after self-administration of the DACT by June 2018. FY 2017 Page 4
Measure 2.2 Clinical documentation compliance 100% 90% 80% 70% 60% 50% 40% 30% 10% 0% Percent Audited Records Compliant with Standard 72% CRT 18/25 83% Supervisor 54/65 Goal: 90% 71% CRT 15/21 81% 84% Supervisor 75/93 CRT 27/32 91% 90% Supervisor 81/89 Consensus Score FY 2015 FY 2017 FY 2018 (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 program manager using the same criteria. A clinical record must score a 90% or above to meet compliance standards. In FY 2017, compliance was 84% and 91% based on reviews by CRT and the program supervisor, respectively. CRT conducted their audits in November 2016 and May 2017. program manager conducts the records review audits each month. In FY 2018, the chart review process will change, with CRT and the program manager coming to consensus on scores when there is a discrepancy. During FY 2017, the percentage of records meeting compliance by scoring 90% or higher increased 13 percentage points for CRT reviews and 10 percentage points for the program manager s reviews compared to. Items rated noncompliant included: treatment plans not being signed on time, not using person-centered language on the needs section of treatment plans, and administrative documentation, such as the client s rights form, not being completed on time. Continue with documentation monitoring, supervision, counseling and training activities by program supervisor and CRT. Continue to provide coaching and training to staff as needed. In FY 2018, it is anticipated that 90% of audited records will meet the compliance standard. FY 2017 Page 5
Measure 2.3 Percentage of services provided in the community 100% 90% 80% 70% 60% 50% 40% 30% 10% 0% 84% FY 2015 (2919/3466 hours) Percentage of Services Provided in the Community Licensure Standard: 75% 80% 79% 80% (3661/4601 hours) FY 2017 (3861/4872 hours) FY 2018 (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 79%, 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 2018, it is anticipated that the percentage of services provided in the community will continue to meet or exceed the 75% standard. FY 2017 Page 6
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 Benchmark: <0.49 0.42 0.40 FY 2015 42 episodes 100 clients served 42 episodes 105 clients served 0.59 FY 2017 62 episodes 106 clients served 0.40 FY 2018 (proj.) 40% 35% Percent of Clients Hospitalized 30% 25% Benchmark: <28% 21% 24% 26% 15% 10% 5% 0% FY 2015 21/100 25/105 FY 2017 28/106 FY 2018 (proj.) The psychiatric hospitalization rate reflects the number of hospitalizations that occurred during each fiscal year. In FY 2017, there were 62 episodes among 106 clients served for a rate of 0.59 episodes per person served. is collected manually by program staff. In FY 2017, 28 clients were hospitalized, which is 26% of the 106 clients served. The benchmarks for psychiatric hospitalizations are based on the FY 2015 State Report. FY 2017 Page 7
In FY 2017, 19 of the 28 hospitalized clients were admitted to the hospital due to severe psychotic symptoms such as paranoia, hallucinations, and delusions. Newly admitted clients tend to be hospitalized more frequently during the first year of services, as the program accepts individuals who are severely ill. 32% of the clients hospitalized (9 of the 28), were hospitalized due to drug-induced psychiatric problems. Two clients were hospitalized primarily due to behavioral issues. One of the clients was hospitalized seven times, and one was hospitalized 10 times in FY 2017. These episodes were a contributing factor in the increase from. Without these outliers, the number of episodes would have been 0.43, which is below the benchmark. Services have been put in place to address the specific needs of these two clients. Continue to assess clients on an ongoing basis and provide early intervention. Continue to collaborate with emergency services staff on assessment of highrisk clients and admission to ACCESS if warranted. Continue to incorporate DBT interventions to treat consumers with issues related to borderline personality disorder. FY 2018, it is anticipated that the hospital episode rate will be 0.40 episodes per person served, with about of the clients served having at least one episode. FY 2017 Page 8
Measure 3.2 Clients living independently (in private households) Clients Living Independently 100% 90% 80% 70% 60% 50% 40% 30% 10% 0% 74% FY 2015 74 clients Benchmark: 71% 61% 64 clients 70% FY 2017 74 clients 75% FY 2018 (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 2017, 70% of clients lived independently. This percentage increased from 61% in. The benchmark for clients living independently is based on the FY 2015 State Report. The percentage of clients living independently increased due to more housing availability through state grants received by the permanent supportive housing program to help the homeless population. In FY 2017, of the 74 clients who were housed, an additional 7 clients had stable housing. These individuals resided with family members, in group homes or assisted living facilities. Continue to 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 2018, 75% of clients are projected to be living independently. FY 2017 Page 9
Measure 3.3 Clients employed in competitive jobs Clients Employed in Competitive Jobs 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Benchmark: 9% 5% FY 2015 5/100 8% 8/105 14% FY 2017 15/106 14% FY 2018 (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 2017, 14% of clients held competitive jobs. This is a 6-point increase from Of the 106 clients served, 15 were able to find competitive employment. The program s vocational specialist was not able to place some clients in competitive jobs. However, the specialist assisted by: o Helping clients apply for jobs. o Providing vocational support to employed and unemployed clients. o Helping with resume-building, GED exploration, and providing engagement services. o Meeting with at least one employer in the community as part of job development. Vocational Specialist will work on providing rapid employment by resuming job development in the community once is fully staffed in the second quarter of FY 2018. Continue to work with clients to help them achieve a level of stability that will enable them to find competitive employment. Explore feasibility of capturing this data electronically in the future. The anticipated percentage of clients to be competitively employed in FY 2018 is 14%. FY 2017 Page 10