Southwest Washington Plans for Regional Behavioral Health Initiatives and ESSB 6032 Section 213 (5)(pp) Funds for Enhancements to Community Behavioral Health Programs On behalf of the Southwest Washington (SWWA) community, we respectfully submit a regional plan for behavioral health initiatives and ESSB 6032 Section 213 (5)(pp)funds for enhancements to the Community Behavioral Health Programs. In May 2018, community meetings were convened to solicit input from behavioral health providers, Clark and Skamania counties, the Southwest Accountable Community of Health (SWACH), consumer representatives, hospitals and local law enforcement. The MCOs in the region (Community Health Plan of Washington, Molina and Amerigroup), Southwest Washington Accountable Community of Health (SWACH), Counties (Clark and Skamania) and the ASO (Beacon) convened several Capacity Building Committee meetings to discuss process for developing a regional plan and review community input on new funds available. Based on the local needs and priorities, this plan addresses the five priority areas below with a focus on new initiatives and programs, as well as existing programs that target the priority areas. Priority Area #1: Reduction in the use of long-term commitment beds through community alternatives; for this planning process long-term commitment means 90 and 180-day involuntary inpatient commitment currently provided by state hospitals. Adult Mobile Crisis Intervention (AMCI)- This program is launching in July 2018 in Clark County. AMCI will provide a short-term service that is a mobile, on-site, face-to-face therapeutic response to an individual experiencing a behavioral health crisis. The delivery of strengths-based and solution-focused intervention is aimed at resolution of the crisis, mobilization of natural supports, and rapid linkage to the right level of care. Initial hours of operation will be 10am-10pm, 7 days per week, 365 days per year. The population served will include adults age 18 and over and their families/caregivers/natural supports in Clark County. AMCI will utilize a multidisciplinary model, with both Clinical and Peer staff who will work in a braided fashion to ensure crisis resolution and successful linkage. The service will be staffed with certified Peer Specialists with lived experiences and Master s level clinicians trained in working with individuals and families experiencing a crisis. (Also addresses priority area #5) Skamania County Peer Network- Five local organizations were awarded startup funds in March 2018 to expand the role of volunteers and peers in the delivery of non-traditional pathways for prevention, early intervention and crisis services to Skamania County individuals and families. All funded initiatives will launch in 2018. (Also addresses priority area #5) Crisis Triage and Stabilization Facility- In Spring 2019, a Crisis Triage (6 chairs) and Crisis Stabilization (16 beds) Facility will be opening in Vancouver. It will be an adult-focused facility serving men and women. It is projected that the facility could serve roughly 1,300 people annually and the Crisis Stabilization Unit Is projected to admit roughly 700 people annually. Medicaid beneficiaries are the primary target population. However, in line with the facility vision not to turn anyone away, the facility will serve all individuals regardless of coverage status. The key goals and core values of the crisis diversion center are to: decrease inpatient and emergency department utilization, decrease behavioral health-related jail bookings, increase access to recovery-oriented stabilization services, improve care coordination between behavioral health and primary care, and keep people in their homes versus admission to higher, more expensive levels of care such as Western State Hospital or inpatient facilities outside of the community. (Also addresses priority areas #4 and #5) 1
Priority Area #2: Compliance with RCW 71.05.365 requirements for transition of state hospital patients into community settings within 14 days of the determination that they no longer require active psychiatric treatment at an inpatient level of care; Peer Bridger- The Peer Bridger Program assists individuals discharging from Western State Hospital by engaging individuals while still residing in the state hospital prior to discharge and continuing the relationship post-discharge into the community. The Peer Bridger functions as a role model, peer support, mentor, teacher, advocate, and ally. The Peer Bridger transitions from focusing on building social support to teaching independent living skills, coping skills, community adjustment skills and gradually handing off to a community provider. The anticipated duration of in-community Peer Bridger services is 120 days, with extensions granted on a case-by-case basis. (Also addresses priority area #5) Hospital Liaisons- Each MCO (and the ASO) has a designated hospital liaison to assist in all treatment and discharge planning in coordination with Western State Hospital treatment staff, Peer Bridger (if involved), community providers and natural supports. The hospital liaison ensures there is comprehensive discharge plan that includes service provision from a community behavioral health provider. The liaison typically works with the individual and treatment team post discharge to support a successful transition to the community. There is a high degree of coordination and resource sharing amongst the hospital liaisons and Peer Bridger. Liaisons also address priority area #1 by developing community alternatives to state hospital admission. Foundational Community Supports (FCS)- This program includes targeted benefits for supportive housing and supported employment for Medicaid beneficiaries in the Southwest Washington region. The goal is to enhance the availability of these services through contracting with local providers for those who are the most vulnerable and have complex care needs. Services for supportive housing include housing assessments, identifying housing resources, support obtaining al ease, independent living skills development, landlord relations and crisis management. Services for supportive employment include vocational/job related discovery and assessment, planning for employment, job placement, development and coaching and skill building for negotiating with prospective employers. Amerigroup as the third party administrator (TPA) has contracted with 9 organizations in Southwest Washington to provide the above mentioned services. Priority Area #3: Improvement of staff recruitment and retention in community behavioral health facilities; Behavioral health staff recruitment and retention- Behavioral health workforce shortages have a direct impact on the ability to implement and expand programs to meet community needs. Southwest, similar to other regions in the state, struggles to recruit and retain sufficient staffing levels for all positions, but in particular licensed or certified positions such as mental health counselors, social workers, psychologists, psychiatrists, advanced registered nurse practitioners, peers, chemical dependency professionals, etc. especially for positions that serve individuals with complex, intensive behavioral health challenges. Positions have sat vacant and unfilled for years. Agencies have implemented various strategies such as increasing salaries, signing bonuses and developing training programs with varying levels of success. The Southwest Accountable Community of Health (SWACH) is working with state partners on incumbent workforce development and new/emerging workforce, specifically community colleges, The University of Washington AIMS Center, Washington State University, and Center for Excellence. Locally, SWACH is working with Work source Southwest on mid-level incumbent and new workforce development opportunities, such as exploring opportunities with the three nursing programs in the region to develop community based advanced registered nurse practitioner (ARNP) placements. SWACH is completing behavioral health and primary care assessments that will provide 2
specific workforce needs of local providers in the region to assist in targeted regional investments. SWACH is also focusing on workforce development efforts for Community Health Workers and Peers to expand their roles into different care settings. Lastly, SWACH is exploring rural workforce development through Area Health Education Center for Western Washington on distance learning opportunities and team based workforce needs. Priority Area #4: Diversion of individuals with behavioral health issues from the criminal justice system; Crisis Triage and Stabilization Facility- In Spring 2019, a Crisis Triage (6 chairs) and Crisis Stabilization (16 beds) Facility will be opening in Vancouver. It will be an adult-focused facility serving men and women. It is projected that the facility could receive roughly 1,300 people annually and the Crisis stabilization unit Is projected to admit roughly 700 people annually. Medicaid beneficiaries are the primary target population. However, in line with the facility vision not to turn anyone away, the facility will serve all individuals regardless of coverage status. The key goals and core values of the crisis diversion center are to: decrease inpatient and emergency department utilization, decrease behavioral health-related jail bookings, increase access to recovery-oriented stabilization services, improve care coordination between behavioral health and primary care, and keep people in their homes versus admission to higher, more expensive levels of care such as Western State Hospital or inpatient facilities outside of the community. (Also addresses priority areas #1 and #5) Law enforcement engagement and 911 triage- In Clark County, 911 operators warm transfer behavioral health calls to the regional crisis line for counseling and crisis support prior to or instead of dispatching law enforcement for in person response. There are also preliminary discussions with law enforcement patrol units and jails on how to quickly involve various crisis providers prior to any formal involvement in the criminal justice system, such as intervening at the jail prior to a booking. The Clark County Sheriff s Re-entry program is applying for a Department of Justice Grant to improve reentry for adults with co-occurring substance abuse and mental illness. This grant, due in June 2018, allows standardizing screening processes for all individuals in a correctional facility, completing assessments for co-occurring conditions during incarceration and prior to release, providing pre and post release evidence based treatment and developing comprehensive case plans. In Skamania County, the Skamania County Sheriff responds in person to all requests that come to their office. In Fall 2017, a new process was implemented for the Sheriff s office to transfer behavioral health requests to the regional crisis line as well as for deputies to be able to call the regional crisis line from the field for intervention and support. Priority Area #5: Efforts to improve recovery oriented services, including, but not limited to, Adult Mobile Crisis Intervention (AMCI)- This program is launching in July 2018 in Clark County. AMCI will provide a short-term service that is a mobile, on-site, face-to-face therapeutic response to an individual experiencing a behavioral health crisis. The delivery of strengths-based and solution-focused intervention is aimed at resolution of the crisis, mobilization of natural supports, and rapid linkage to the right level of care. Initial hours of operation will be 10am-10pm, 7 days per week, 365 days per year. The population served will include adults age 18 and over and their families/caregivers/natural supports in Clark County. AMCI will utilize a multidisciplinary model, with both Clinical and Peer staff who will work in a braided fashion to ensure crisis resolution and successful linkage. The service will be staffed with certified Peer Specialists with lived experiences and Master s level clinicians trained in working with individuals and families experiencing a crisis. (Also addresses priority area #1) Crisis Triage and Stabilization Facility- In Spring 2019, a Crisis Triage (6 chairs) and Crisis Stabilization (16 beds) Facility will be opening in Vancouver. It will be an adult-focused 3
facility serving men and women. It is projected that the facility could receive roughly 1,300 people annually and the Crisis stabilization unit Is projected to admit roughly 700 people annually. Medicaid beneficiaries are the primary target population. However, in line with the facility vision not to turn anyone away, the facility will serve all individuals regardless of coverage status. The key goals and core values of the crisis diversion center are to: decrease inpatient and emergency department utilization, decrease behavioral health-related jail bookings, increase access to recovery-oriented stabilization services, improve care coordination between behavioral health and primary care, and keep people in their homes versus admission to higher, more expensive levels of care such as Western State Hospital or inpatient facilities outside of the community. (Also addresses priority areas #1 and #4) Skamania County Peer Network- Five local organizations were awarded startup funds in March 2018 to expand the role of volunteers and peers in the delivery of non-traditional pathways for prevention, early intervention and crisis services to Skamania County individuals and families. All funded initiatives will launch in 2018. (Also addresses priority area #1) Peer WarmLine- The Peer WarmLine received continued funding in FY 18-19 through Mental Health Block Grant and expanded hours of availability to 4 PM 12 AM. The WarmLine is staffed with Peers and operated by a Peer run organization. ESSB 6032 Funded programming Specific to funding available to the region through ESSB 6032 Section 213 (5)(pp)- $4,483,497 Medicaid and $293,411 General Funds- the regional plan requests to fund the following target areas to meet the intended objectives: Program Medicaid GFS Priority Area Addressed Adult Mobile Crisis X X Priority Area #1: Reduction in the use of longterm commitment beds through community alternatives; for this planning process long-term commitment means 90 and 180-day involuntary inpatient commitment currently provided by state hospitals. Priority Area #4: Diversion of individuals with behavioral health issues from the criminal justice system; Priority Area #5: Efforts to improve recovery oriented services, including, but not limited to, Community Support Team (CST) expansion X X Priority Area #1: Reduction in the use of longterm commitment beds through community alternatives; for this planning process long-term commitment means 90 and 180-day involuntary inpatient commitment currently provided by state hospitals. Priority Area #2: Compliance with RCW 71.05.365 requirements for transition of state hospital patients into community settings within 14 days of the determination that they no longer require active psychiatric treatment at an inpatient level of care 4
Priority Area #3: Improvement of staff recruitment and retention in community behavioral health facilities Priority Area #4: Diversion of individuals with behavioral health issues from the criminal justice system; Priority Area #5: Efforts to improve recovery oriented services, including, but not limited to, Crisis Triage and Stabilization X X Priority Area #1: Reduction in the use of longterm commitment beds through community alternatives; for this planning process long-term commitment means 90 and 180-day involuntary inpatient commitment currently provided by state hospitals. Priority Area #4: Diversion of individuals with behavioral health issues from the criminal justice system; Priority Area #5: Efforts to improve recovery oriented services, including, but not limited to, Staff recruitment and retention X Priority Area #1: Reduction in the use of longterm commitment beds through community alternatives; for this planning process long-term commitment means 90 and 180-day involuntary inpatient commitment currently provided by state hospitals. Priority Area #2: Compliance with RCW 71.05.365 requirements for transition of state hospital patients into community settings within 14 days of the determination that they no longer require active psychiatric treatment at an inpatient level of care Priority Area #3: Improvement of staff recruitment and retention in community behavioral health facilities Priority Area #4: Diversion of individuals with behavioral health issues from the criminal justice system Priority Area #5: Efforts to improve recovery oriented services, including, but not limited to, Implementation and Financial Plan for ESSB 6032 funds Adult Mobile Crisis Adult Mobile Crisis Intervention (AMCI) is launching in July 2018 in Clark County. AMCI will provide a short-term service that is a mobile, on-site, face-to-face therapeutic response to an individual experiencing a behavioral health crisis. The delivery of strengths-based and solution-focused intervention is aimed at resolution of the crisis, mobilization of natural supports, and rapid linkage to 5
the right level of care. Initial hours of operation will be 10am-10pm, 7 days per week, 365 days per year. The population served will include adults age 18 and over and their families/caregivers/natural supports in Clark County. AMCI will utilize a multidisciplinary model, with both Clinical and Peer staff who will work in a braided fashion to ensure crisis resolution and successful linkage. The service will be staffed with certified Peer Specialists with lived experiences and Master s level clinicians trained in working with individuals and families experiencing a crisis. The awarded agency underestimated hiring needs and needs additional funds to hire staff to ensure adequate crisis response. Additionally, the role of crisis services has expanded statewide to include serving individuals with substance use disorders; AMCI can be further expanded to join efforts with local law enforcement to divert individuals from the criminal justice system. $120,000 in General funds and $300,000 in Medicaid funding will be dedicated to this program to support the launch date of July 2018. Startup funds have already been provided to the provider. This program is contracted through the BH-ASO and is funded through Medicaid and non-medicaid funds. Community Support Team (CST) expansion Intensive home based services are a needed level of care that needs further capacity in the region. There are several provider agencies who offer Community Support Team (CST) programs for the Medicaid population. The CST team draws on service modalities similar to Assertive Community Treatment (ACT), including a multidisciplinary team approach (behavioral health professionals, care coordinators, and peers), ability to respond 24/7 to crisis, scheduling during days/times that are most convenient for the client, providing multiple face to face services per week in the community and a modest staff to client ratio (1:14). $1,000,000 in Medicaid funding and $100,000 in General Funds will be dedicated to this expansion, including services for the non-medicaid population which is not currently offered. Targeted expansion will focus on individuals who reside in Adult Family Homes, those that need a higher intensity service but do not qualify for Expanded Community Services (ECS) funding, diverting individuals from the state hospital and hospital emergency departments. There are several providers in the region already providing CST services to adults and youth who can expand capacity upon receiving funding. Medicaid funds will be contracted through each MCO and General funds will be contracted by the BH-ASO. Crisis Triage and Stabilization In Spring 2019, a Crisis Triage (6 chairs) and Crisis Stabilization (16 beds) Facility will be opening in Vancouver. It will be an adult-focused facility serving men and women. It is projected that the facility could serve roughly 1,300 people annually and the Crisis stabilization unit is projected to admit roughly 700 people annually. Medicaid beneficiaries are the primary target population. However, in line with the facility vision not to turn anyone away, the facility will serve all individuals regardless of coverage status. The key goals and core values of the crisis diversion center are to: decrease inpatient and emergency department utilization, decrease behavioral health-related jail bookings, increase access to recovery-oriented stabilization services, improve care coordination between behavioral health and primary care, and keep people in their homes versus admission to higher, more expensive levels of care such as Western State Hospital or inpatient facilities outside of the community. $750,000 in Medicaid funding and $73,411 in General Funds will be dedicated to this focus for Medicaid billable services and room and board charges not billable to Medicaid. Medicaid funds and General funds for room and board will be contracted through each MCO. The provider has several other funding sources to support the launch, including $1 million in capital funding support from Clark County as well as $613,250 in SSB 5883 2017, Section 204(e) startup funds. 6
Staff recruitment and retention Behavioral health workforce shortages have a direct impact on the ability to implement and expand programs to meet community needs. Southwest, similar to other regions in the state, struggles to recruit and retain sufficient staffing levels for all positions, but in particular licensed or certified positions such as mental health counselors, social workers, psychologists, psychiatrists, advanced registered nurse practitioners, peers, chemical dependency professionals, etc. especially for positions that serve individuals with complex, intensive behavioral health challenges. Positions have sat vacant and unfilled for years. Agencies have implemented various strategies such as increasing salaries, signing bonuses and developing training programs with varying levels of success. The remaining Medicaid funds, $2,433,497, will be used to target recruitment and retention efforts in the region. Several initiatives are already in process in the region and the MCOs will initiate planning meetings with providers in the region for targeted staff recruitment and retention efforts. For example, the WISe provider in the region has faced challenges in meeting capacity goals established for the region as part of the TR lawsuit settlement, primarily due to challenges in workforce recruitment and retention. The provider, in collaboration with the MCOs in the region, and allied system partners, has developed a plan to address these challenges, including improved recruitment strategies (expanded advertising through social media, further developing relationships with universities and increasing number and types of interns, and increasing salaries) and retention strategies (retention bonuses, dedicated supervisory support for interns, reduced on-call schedules, and opportunity for staff to develop clinical expertise in working with specific populations or evidence-based or promising practices). Medicaid funds will be expended for services for more children and families (current caseload is 140 with expansion to 180 planned for FY 2019) and enhanced quality of care that results from reduction of staff turnover, less stressful working conditions, and increased supervision and support. The target is reducing turnover rates (96% during the past year). Another example is a 32 bed residential facility that is underutilized; the facility has consistently operated below capacity, at approximately 60% overall, despite referral needs (referral sources for the residential treatment program include state and community hospitals, the crisis stabilization program, Home and Community Services, and outpatient programs). The Facility, MCOs, and BH- ASO review of the low census concluded that workforce recruitment and retention challenges are an underlying theme in many of the barriers identified by the group. A planning meeting is already scheduled in June 2018 with the MCOs, BH-ASO and Facility to develop a plan and strategies to increase the census. The goal of focusing on improving staff recruitment and retention is to increase the number of individuals served by the program as well as the level of acuity and complexity of individuals admitted. Potential strategies include reviewing the staffing pattern to meet client needs (family nurse practitioner to address co-morbid medical needs; chemical dependency professional to address co-morbid substance use disorders, peers), identifying clinical competencies of staff and subsequent staff training, supervision, and clinical consultation to improve clinical skills and provide team-based support for staff, increase salaries for staff, provide review and consultation in program design, including admission procedures and exclusion criteria. Additional providers and programs with staff recruitment and retention needs will be identified by the MCOs to expend the funds, including providers in Klickitat County who will be joining the Southwest region in January 2019. Staff recruitment and retention is a priority and key to success in effective service delivery in our community. 7
Summary of ESSB 6032 Funding Medicaid Programs Medicaid $ Adult Mobile Crisis 300,000 Community Support Teams 1,000,000 Crisis Triage and Stabilization 750,000 Staff Recruitment and Retention 2,433,497 Grand Total $4,483,497 State General Funds Beacon MCO s Adult Mobile Crisis 120,000 Community Support Teams 100,000 Crisis Triage and Stabilization 73,411 Total $220,000 $73,411 Grand Total $293,411 8