Program Purpose Program Information PM1: How much did we do? FY 2016 PERFORMANCE PLAN BHD/CSE Alexis Mapes, x4889 Leslie Weisman, x4888 Maintain safety of individuals experiencing mental health crises in the least restrictive environment possible, and link to community supports. Services are provided 24 hours a day, seven days a week, 365 days a year to individuals experiencing a wide range of mental health crises. The program is licensed by the Virginia Department of Behavioral Health and Developmental Services and offers the following services: o Crisis intervention: assisting individuals experiencing a mental health crisis. o Assessment: determining the nature of the crisis, the individual s needs and level of risk. o Referral: determining appropriate services and resources for individuals and providing information for linkage and follow-up. o Involuntary hospitalization: obtaining Temporary Detention Orders for emergency hospitalization, and completing the legal process of committing an individual to the hospital when court-ordered. o Consultation: working collaboratively with any and all parties who have information regarding the immediate crisis. o Supportive counseling: providing brief, therapeutic intervention that assists the individual with de-escalation of the current crisis. Partners: collaborates with a wide array of community groups and constituencies. These include: o CSB psychiatric services and behavioral health teams o Law enforcement (police from multiple jurisdictions, U.S. Marshalls) o Medical personnel (EMTs, emergency-room staff, hospital staff) o Fire Department o Courts/jails o Schools o State psychiatric hospitals Staff Total 12.5 FTEs: o 1.5 FTE Supervisors o 8.5 FTE Therapists o 2.0 FTE Peer Specialists o 0.5 FTE PRN Therapists (multiple staff) Customers and Service PM2: How well did we do it? FY 2014 FY 2015 FY 2016 Unduplicated clients served 1,322 1,364 1,479 Clients seen who are open to outpatient services 349 357 388 Total face-to-face contacts 2,279 2,296 2,456 Number of Temporary Detention Orders 373 396 493 2.1 Temporary Detention Order outcomes 2.2 Timeliness of documentation completion FY 2016 Page 1
FY 2016 PERFORMANCE PLAN 2.3 Documentation meets regulatory standards PM3: Is anyone better off? 3.1 Dispositions along continuum of care 3.2 Recidivism FY 2016 Page 2
Percentage of Clients Hospitalized FY 2016 PERFORMANCE PLAN Measure 2.1 Temporary Detention Order outcomes 8 6 5 4 3 73% (272/373) Hospitalization Rates for TDOs Target: 78% (279/396) 77% (379/493) 75% (371/495) FY 2014 FY 2015 FY 2016 FY 2017 (proj.) After staff obtain a Temporary Detention Order (TDO) for emergency involuntary hospitalization, a civil commitment hearing is held. At the hearing, the client may be hospitalized, or the court may dismiss the case and the individual will be free to go. TDO outcome data is updated daily by the supervisor. There is a long history of Emergency Services committing 70-75% of individuals who are psychiatrically detained. Maintaining a high rate of commitment indicates that staff has a clear and accurate understanding of commitment criteria. Common reasons for dismissals include: clients who re-stabilize after a crisis, clients who sign-in voluntarily before a commitment hearing, dismissals over objection, and technicalities with the legal process. Due to the increase in the number of TDOs, relies on hospitals outside of Arlington County. Fairfax County, with a high rate of dismissal of acute clients, is used for approximately 5 of hospitalizations. Continue to discuss appropriate use of less restrictive alternatives to hospitalization at daily team meetings. Continue to monitor appropriateness of clinicians decisions regarding TDOs through monthly chart reviews and asneeded audits. Continue to periodically review a regular sample of TDO dismissals to determine the most frequent reasons for case dismissal. Client Services Entry bureau chief and supervisor to begin attending TDO task force meetings to address concerns with the court process in Fairfax. ES Supervisor to continuously review dismissal trends. In FY 2017, it is projected that a minimum of 75% of individuals will be committed. FY 2016 Page 3
FY 2016 PERFORMANCE PLAN Measure 2.2 Timeliness of documentation completion 8 6 5 4 3 8 6 5 4 3 91% 92% 93% 95% FY 2014 1,876/2,064 38% 3,896 5%, 529 53% 5,338 FY 2014 10,157 notes Target: 95% Target: 95% 4%, 394 Assessment Timeliness FY 2015 1,971/2,140 84% 9,671 FY 2016 2,025/2,180 Progress Note Timeliness 88% 12,982 FY 2017 (proj.) 6%, 702 4%, 661 4%, 541 2% 4% 4%, 448 5%, 628 4%, 622 4% FY 2015 11,449 notes On time (within 1 business day) FY 2016 14,806 notes 2-4 business days 5-9 business days More than 9 business days FY 2017 (proj.) Emergency therapists are expected to complete all documentation within 24 hours of the intervention. is reported from the Cerner data system. Timeliness of assessments has consistently remained high. Timeliness of progress notes has improved since FY 2015. In FY 2016, the supervisor continued to monitor documentation timeliness through daily and The supervisor will continue to monitor documentation completion daily and will address issues of lateness with staff on a regular basis. FY 2016 Page 4
FY 2016 PERFORMANCE PLAN monthly reports, which were addressed with staff in supervision. Staff were asked to complete all documentation before the end of their shift rather than within 24 hours, to reduce the likelihood of lateness due to crisis responses the next day. Lengthy shifts where staff manage multiple cases simultaneously present an ongoing challenge to achieving timely documentation. The timeliness of data entry report will be reviewed on a monthly basis and data entry issues will be addressed with staff. Additional staff will be assigned to evening hours, reducing the need for staff to work extended shifts. In FY 2017, timeliness of data entry is projected to improve to 95% for assessments and for progress notes. FY 2016 Page 5
FY 2016 PERFORMANCE PLAN Measure 2.3 Documentation meets regulatory standards 8 6 5 4 3 2% 98% Internal 64 charts Target: Documentation Compliance 21% 21% 58% Compliance 43 charts 1% 5% 5% 19% 15% 8 8 Internal 132 charts Compliance (no data) Internal 75% Compliance FY 2015 FY 2015 FY 2016 FY 2016 FY 2017 (proj.) FY 2017 (proj.) Excellent Fair Poor Internal: the supervisor reviews one chart per clinician per month using a database tool that rates charts on multiple criteria and summarizes the rating as excellent ( ), fair (89-75%) or poor (<75%). Compliance: the Compliance Review Team conducts semi-annual reviews using the same criteria. for FY 2016 is not available. Internal ratings were lower in FY 2016. A larger sample of charts was reviewed by a different group of reviewers who had more experience with chart review expectations and processes. Areas of strength included timeliness of documentation completion and the quality of documentation requesting a TDO. Challenges included capturing collateral services. The supervisor will continue daily, weekly, and monthly reviews of charts. Implement quarterly chart review meetings between and Compliance staff to promote inter-rater reliability. The Supervisor will address issues related to compliance review, including capturing collateral services. The supervisor will work with the Operations Support Team to explore options for streamlining documentation and minimizing duplicative data entry. For FY 2017, it is anticipated that 8 of charts will be rated excellent on Internal reviews, and 75% will be rated excellent on Compliance reviews. FY 2016 Page 6
FY 2016 PERFORMANCE PLAN Measure 3.1 Dispositions along continuum of care Dispositions 8 17% / 396 / 493 7% / 161 Goal: 8 6%/ 155 6% / 134 4%/ 99 14% 6% 5% 6 5 4 3 / 1,620 / 1,710 75% FY 2015 2,311 encounters FY 2016 2,457 encounters FY 2017 (proj.) Returned to community Admitted to crisis stabilization Voluntary hospitalization TDO The supervisor reviews a list of clients served each day, and records the following outcomes: TDO, voluntary hospitalization, and residential crisis stabilization admission. The remaining clients are classified as returned to the community. In FY 2016, 74% of face to face contacts resulted in community dispositions, while 26% required voluntary or involuntary hospitalization. always seeks to resolve crises with the least restrictive alternatives. Less restrictive options include returning to the community with a safety plan, and stabilization in a residential setting. Voluntary hospitalization and involuntary hospitalization through TDO are more restrictive outcomes. Clients in need of immediate medication orders may be hospitalized rather than admitted to residential stabilization, as there is currently no emergent access to prescribing psychiatrists in the community. Every effort is made to divert clients from the hospital when possible. Emergency therapists will continue to focus on less-restrictive alternatives. Continue to hold joint meetings between staff and the residential crisis stabilization program, to promote stabilization as an alternative to hospitalization. supervisor will encourage outpatient clinicians to have signed medical orders when referring a client to crisis care. This will reduce unnecessary hospitalizations. It is expected that 8 of clients will be stabilized without hospitalization in FY 2017. FY 2016 Page 7
Measure 3.2 Recidivism FY 2016 PERFORMANCE PLAN 8 6 5 4 3 21% 284/1,322 77% 1,013/1,322 2% 25/1,322 Treatment Episodes per Client 275/1,364 78% 1,061/1,364 2% 28/1,364 291/1,479 78% 1,158/1,479 2% 30/1,479 1% 14% FY 2014 FY 2015 FY 2016 FY 2017 (proj.) One episode 2-4 episodes 5 or more episodes Target: 85% One Episode 85% All client contacts are tracked in the Cerner data system. Contacts occurring within two weeks of one another constitute a single episode of care. A new episode of care begins when a new contact is recorded at least 15 days after the preceding contact. In FY 2014-2016, 77-78% of clients required only one episode of care. 2% of clients required more than four episodes. There is always a small proportion of clients who require a high number of service hours from. Usually these encounters lead to hospitalizations. Of the top 30 users of Emergency Services in FY 2016, 8 were open to DHS outpatient services. Clients were distributed across a range of outpatient programs. Review high users of on a quarterly basis to evaluate whether clients are receiving the appropriate intensity of service, and discuss development of specific plans for recidivists with their respective team leaders. Continue meetings between the PACT team and supervisors to discuss the high use of ES by PACT clients and how to better assist them. Educational presentations to staff will be conducted by the supervisor in FY 2017 to explain processes for attending rounds and improving collaboration to meet client needs. It is expected that 85% of clients will require only one episode of treatment by Emergency Services staff in FY 2017. FY 2016 Page 8