may 22, 2017 norristown state hospital...historically used fewer beds = 3.8 per 100,000 population...

May 22, 2017

Norristown State Hospital

Bucks, Chester, Delaware, Montgomery and Philadelphia

2 State Hospitals closed – Philadelphia State (1989) & Haverford State (1997)

Closed approximately 1550 state hospital beds since 1990 via Community Hospital Integration Project Programs(CHIPPs)

First in PA to begin HealthChoices (1996) First to develop Regional CHIPPs Model

(2000/01)

5/22/17 SE REGION SAP Presentation 2

OMHSAS’ “Fred L” lawsuit began in FY 2007 and concluded in FY 2012/13

210 BEDS closed as a result the “Fred L”

From FY 2006/07 to FY 2013/14, the regional bed cap dropped from 294 to 81 civil beds

Forensic to civil transfers 40+ beds

NOW

The average regional civil census between FY 13-FY 17 has been 120 beds


From FY 2012 to current, on average, 74% of total admissions to the civil units are criminal justice involved individuals

Of the current civil population, 75% of the Philadelphia County population have criminal justice oversight.

28% of the suburban Counties current population have criminal justice oversight

SE REGION SAP Presentation

4 5/22/17

5/22/17

SE REGION SAP Presentation

5


31

13

18

30

28 28

74

51

29 27

29 29

0

10

20

30

40

50

60

70

80

FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 (up

to 4/30/17)

Total Admits Total Discharges*


County FY 2016/17 CIVIL BED CAP Civil Census as of

5/8/17

Bucks 18 17

Chester 4 11

Delaware 13 13

Montgomery 22 23

Philadelphia 18 55

Total 75 119

• Gender: 92 men; 30 women

• Age: 18–64 = 111; 65 and over = 11

• Diagnosis: (Primary)

• Schizophrenia – 52

• Schizoaffective – 37

• Major Depressive – 11

• Psychosis – 6

• Bipolar - 6

• Impulse Disorder – 2

• Autistic Disorder - 1


Other Clinical Factors

• Substance Abuse

• Trauma

• Traumatic Brain Injury

• Dementia

• Intellectual Disability


• Admission/readmission rates

• 2014 – 11 admissions, 6 were readmissions





• Insurance Status: • Medicare Coverage

• Part A & B – 32%

• Part A only – 10%

• Private Ins. – .025%

• No coverage – 56%

• Past MA Eligibility

• Yes –81%

• No – 19%


• Benefits Source

• SSD – 27%

• SSD Suspended – 16%

• VA only – .008%

• Private Pension – .016%

• Multiple Sources – .03%

• None – 53%

◦ Under 2 years - 19

◦ 2- 5 years - 39

◦ 5 – 10 years - 37

◦ 10 – 20 years - 17

◦ 20 – 30 years - 7

◦ 30 – 40 years - 2

◦ 40 – 50 years - 1


Historically used fewer beds =

3.8 per 100,000 population for state hospital utilization (about 80 beds for over 3.1 million adults in the SE Region)

According to the SAMHSA Uniform Reporting System (URS) Pennsylvania State Hospital Adult Admissions rate is: .13 per 1000 population

Conclusion: the SE Region only uses the state hospital resources when all other community resources have been exhausted. However, some of the Counties do currently use and will continue to need Civil SMH beds.


Involves persons waiting in County Jails for psychiatric treatment and persons waiting to transfer from forensics (Bldg51) to civil sections at NSH

DHS Settlement in January 2016


Throughout the SE Region, a total of 93 persons have been discharged – CHIPP (As of April

2017)

We continue to assess every person for any community vacancy and appropriateness for the community placement

Thus far, development of new services and enhancing existing services

….STILL MORE TO COME….


1. Repurposing beds from civil to forensic

2. Clinical Assessment of current civil

population

3. Assess need for long term care in

community

4. Develop supports to reduce demand for

long term care and provide alternatives

to the state hospital level of care


• Step Down Units: Restoring Hope- Building Skills for a Better Tomorrow

• Ultimately 3 step down units will have a maximum of 20

consumers on each unit, with a staffing complement suitable for 30

• Currently 2 Step Down Units • Help individuals develop skills and knowledge that can

be utilized in their personal recovery by promoting self-confidence and respect for self and others which is integral in the safe and successful re-entry into the community.

• Re- entry may not mean discharge to community living but rather for some to return to court to face legal situation/issues. 5/22/17 SE REGION SAP Presentation 17

Utilizing a validated clinical tool by independent outside assessors

The assessments are used to inform the counties and the hospital of the treatment services and residential supports necessary for successful community inclusion

To inform mental health and criminal justice authorities of the relative clinical risks associated with release of those individuals under judicial oversight


• WHERE: • NSH civil units, forensic treatment units (as identified by Counties) and in County jails

• HOW/WHO?: • Regional 4 Suburban Counties & Philadelphia Process (separate)

• WHAT THEN?: • Assessments & recommendations are then shared with the NSH clinical team and become an integral part of the Community Support Plan (CSP) for each individual


• Assessment & discharge planning process • Goals:

• Identify individuals for potential discharge

• Identify supports needed for individual to be successful in the community

• Provide support and continuity of care throughout discharge planning process

• Process

• Outcomes

• Challenges


Norristown State Hospital

54 Philadelphians discharged since

1/27/16

NSH Civil Unit

29

NSH Forensic

Unit

25 Data as of 4/30/17 5/22/17 SE REGION SAP Presentation 23

NSH Civil Unit

56 Philadelphians

Currently

Assessed and

engaged in

discharge

planning

27

Of the remaining

29, we are

working with our

CJ and DBHIDS

partners

To be assessed

4

Extra-ordinary legal

barriers

25 Data as of 4/30/17 5/22/17 SE REGION SAP Presentation 24

Over 150 (95 suburban counties and 56 Philadelphia) assessments assigned and approximately 70% completed to date

Individuals need intensive therapeutic support which

includes: ◦ psychiatric medication management, intensive staff support,

community and clinical supports to maintain stability, assistance with managing and achieving goals in the community, medical and physical healthcare monitoring, etc.

Some individuals may require intensively staffed, secure, 24/7 residential supports that have a clinical component

Some individuals need specialized clinical supports (TBI, Cognitive impairments, community risk and safety issues, physical and medical supports, etc.)


Legal Barriers Clinical Barriers

High level open charges

Concerned about community safety from Courts, objections from District Attorney

Special needs

◦ Medical

◦ Psychiatric

◦ Cognitive Co-occurring

needs Don’t want to

leave NSH


Current State Hospital Population

Current Forensic Wait List population

Extended Acute Care (EAC) Utilization

Acute Inpatient Hospitalizations – High Utilization population


•Philadelphia and Suburban Counties have ~90 beds for EAC •On average the length of stay for EAC is between 170-277 days inpatient*

•Managed Care funded - HEALTHCHOICES ONLY

• Typical discharge to structured community treatment supports and structured housing

* Philadelphia’s Average Length of stay days ~ 277 days and suburban ~170 days


• Looked at persons who had over 60 days inpatient within a 12 month period

• Data collected from 2012 – 2017 from the BHOs

EACH COUNTY:

• Looked at # of people per County

• Looked at # of days per person

• Looked at average days per person/per year

• Looked at average costs per person/per year


We DO have “long term” care in the community – but…

Do we have enough resources??

The majority of community based treatment and rehab and support services are disproportionately covered by HealthChoices (Medical Assistance)

Medicare doesn’t cover community supports that an individual may need such as Extended Acute Care (EAC) inpatient, Assertive Community Treatment(ACT), Specialized residential ie: LTSR or RTFA, Psychiatric Rehab Services, and peer support, just to name a few

FACT: There are a number of persons who will NOT be eligible for HealthChoices



Requires Clinical

Expertise

Require DHS commitment for ongoing funding

to the community in order to share the

responsibility for “long term care”

Requires

flexibility in

funding

Requires

community

support and

acceptance

Requires 100% collaboration

from all stakeholders, e.g.

Department of Corrections,

Aging, MCOs, Criminal

Justice Partners, etc

Requires willing and

able providers

Requires innovation

and planning for

years to come

Bucks County Department of Mental

Health/

Developmental Programs

Service Area Plan Meeting

May 22, 2017

1/2 of all long-

term mental

illnesses begin by

the age of

24.


Prevention/Early

Intervention: Both educational and enhanced community-based supports to prevent the need for higher levels of institutional care

1. Educational Efforts

a. Question, Persuade, and Refer (QPR)

b. Suicide Awareness/Prevention Annual Walk

c. NAMI Educational Series

Peer-to-Peer; Family-to-Family; Ending the Silence

d. Youth Mental Health First Aid through Now Is The Time (NITT): Healthy Transitions - SAMHSA Grant

e. Crisis Intervention Training (CIT) for law enforcement officers

f. Crisis Response Training for correctional facility officers and 911 Dispatchers


Prevention/Early Intervention

(cont’d):

2. Community-Based Collaboration with the Criminal Justice

System to Reduce Institutional Care

a. Forensic Support Program Bridge Subsidy (PCCD Grant)

b. Magisterial District Justice Engagement Pilot (PCCD Grant)

c. Natale North (RTF-A):

Regional collaboration with Delaware & Montgomery Counties

Access to two beds


FY 16/17 CHIPPs

Planning/Implementation:

Focus on meeting the support needs of individuals at

NSH, Bucks County Correctional Facility (BCCF), and individuals in the community with complex needs

Since August 2016, four (4) individuals have been discharged from Norristown State Hospital.

One individual discharged from forensic unit to the newly developed Natale North (RTF-A)

Three individuals discharged from the Civil Section to existing housing resources with enhancements as necessary to accommodate specialized support needs

17 additional individuals are in the assessment/planning process for discharge from the Civil Section of NSH.

15 individuals are awaiting treatment at BCCF.


FY 16/17 CHIPPs

Planning/Implementation:

Enhancement of Community-

Based Infrastructure

Housing (Current)

1. Evaluation of existing housing programs for

opportunities to enhance supports, both from a

rehabilitative and clinical perspective

2. Housing Reinvestment Project to Create Flow

Capital Project for 8-12 housing units

Tenant-Based Rental Assistance

Contingency Funding


Further CHIPPs Planning/Implementation:

Enhancement of Community Infrastructure

1. Housing (Exploration/Development)

a. Increase capacity for all-inclusive

intensive supports through RFP Process

2. Crisis Residential (Reinvestment Plan)

a. Groundbreaking for a ten (10) bed facility


Further CHIPPs Planning/Implementation:

Enhancement of Community Infrastructure

(Cont’d)

3. Psychiatric Rehabilitation (Exploration/Development)

a. Develop capacity to provide psychiatric rehabilitation to

support individuals in the Central and Lower Bucks areas

4. Workforce Competencies

a. Housing: MH Residential Staff Training Initiative

b. Peer Support: Evaluation of recommendations and

implementation of training and supervision strategies

identified through a May 2017 Peer Support Forum.

c. Evidence-based Clinical Interventions, e.g. DBT


Person-Centered Program Model:

◦ Identification of Individualized Strengths & Needs

◦ Team-Based Program Development

◦ Establishment of community-based home

◦ Clinical and supportive programming

◦ Goals of the program


Identification of Individualized Needs: ◦ Comprehensive Assessment

Clinical

Medical

Historical Experiences

◦ System of Care Planning

Family/Friends

Treatment Providers

Community Supports



Community

Integration

Skill Building

Culture

Historical

Experience

Legal

Responsibilities

Interests

Clinical

Treatment

Medical Needs

Home

Program Goals: Wellness ◦ Mental

◦ Physical

◦ Emotional

Education/Employment

Community Integration

Family Re-unification/Establishing Natural Supports


Significant DelCo Forensic Demand (Information as of 5/1/2017)

# Individuals NSH Civil = 13

7 in Civil (54%)have criminal justice oversight

# Individuals NSH Bldg.#51 = 23 (19% of RFPC Patients)

# Individuals NSH Bldg.#51 Wait List = 26 (12% of RFPC Wait List)


Delaware County Dedicated Forensic Services Crisis Intervention Team (CIT) Police Training Forensic Peer Support Jail In-reach and

Community Support Forensic Liaisons and Restoration of Competency

@ DelCo Prison Mental Health Court Forensic Assertive Community Treatment (FACT)

Team Forensic Residential Services: ◦ Supported Housing - Master Leasing ◦ Forensic Transitional Housing Program ◦ Residential Treatment Facility - Adult (RTF-A)


Forensic Transitional Housing Program (FTHP)

Developed as a partnership with a local Community Corrections Center (CCC)

9-Bed Pilot Project for Men with Justice Involvement

Dedicated/Segregated quadrant of the CCC Facility

Diversion/Re-entry Resource

Successful Initial Placements


Forensic Transitional Housing Program (FTHP) Pilot Expansion Success of Pilot led to Expansion Plan ACLU/CHIPP funding added 3 new beds for

Men and is developing a new dedicated quadrant for 9 Women

FTHP capacity will be expanded to 21-Beds Demand for Diversion/Re-entry transitional

housing for Women will be addressed FTHP quadrant for Men is fully utilized and

perceived as a valuable forensic resource


New RTF-A Program, Natale North, May 2016

Program planned jointly with OBH, Magellan, and Criminal Justice

NSH offered access to a vacant quadrant of Bldg.#9

The quadrant was renovated to be a more home-like setting

OBH/Magellan/Criminal Justice, and Elwyn collaborated on Program Description

Bucks and Montgomery Counties share in referrals, placements, and operating costs

Licensed by OMHSAS, the RTF-A is a new Regional Diversion/Re-entry Resource


The new Natale North RTF-A opened in May 2016

Delaware County has a full census of 12 with a Waiting List

Bucks and Montgomery Counties have also made initial placements

Delaware County has had several individuals step-down to the community

HCR20 Assessments are used to determine appropriate step-down Level of Care

Step-Down has been to FTHP and other Community Residential Service Programs


Current Planning in Response to NSH Civil Closure and ACLU Class Action Use Clinical/Risk Assessments to inform the NSH CSP planning

process and to inform case planning forums with Criminal Justice officials

Develop individualized plans/funding requests for 6 non-forensic Civil cases and for any of the 7 forensic Civil cases approved for discharge by Criminal Justice officials

Include new Diversion/Infrastructure development in the funding request to address current Community Residential Services gaps and meet future housing demand ◦ New forensic supported housing resources to enable RTF-A/FTHP

residents to access less restrictive levels of care in the community ◦ New non-forensic housing resources to enable medically-fragile

residents to age in place with necessary specialized services and supports

Continue participating in all planning and case review forums to provide as many opportunities as possible, for forensic and non-forensic individuals alike, to live in the community


Montgomery County

Partnership for Recovery

Mobile Crisis

Combined Children and Adult Mobile Crisis

99% Hospital Diversion Rate

Additional Crisis Residential Service

Began operation in January 2017

Provides alternative to inpatient hospitalization

Justice Related Services

Expanded service

81 served in the first quarter

Stepping Up Initiative

Montgomery County Proclamation – May 2017

Forensic RTFA

Recent Enhancements


Partnering for a Successful Future


Program Enhanced Capacity

Post Arrest Crisis Screening (PACS)

Expansion to 2 additional districts, addition of peers

Forensic Support Team Forensic Waitlist (n = 141)

APPD Navigation Crisis support and linkage, APPD MH Unit

MacArthur Safety & Justice VOPs in jail

Forensic Peer Support Team Forensic peer support throughout system

Training Forensic training throughout system


Program Enhanced Capacity

Girard Recovery Center (EAC) 20 beds

Gaudenzia RTFA 14 beds

New Vitae (6th) RTFA 12 beds

New Vitae (Walnut West) RTFA 12 beds

New Vitae (Walnut East) RTFA 12 beds

Specialized DBT Program 6 beds

Specialized TBI Program 4 beds

Recovery Oriented Cognitive Therapy (CT-R)

Tailored for individuals with SMI, emphasizes community

reintegration, values individual choice and feedback, promotes

individual passions, fosters community involvement


Funding Capacity Clinical Expertise

Diversion

Integrated work to

develop community

alternatives

Planning for future

“to be served”

populations

We have done CHIPPs for years…, But this is

different…


Assessments &

Consumer Support

Planning for NSH

population

Community Service

Planning and Program

Development for NSH

population

Program Development

and Diversion Supports

to Criminal Justice

involved and Diversion

population


ALL AT THE SAME TIME…

Stakeholder meetings

Monitoring of the discharged State Hospital Population

Monitoring from the Coalition for the Proper Closure of NSH for the future


may 22, 2017 norristown state hospital...historically used fewer beds = 3.8 per 100,000 population...

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