Nicole Norvell, Indiana Director of Disability and Rehabilitative Services

Transcription

1 Nicole Norvell, Indiana Director of Disability and Rehabilitative Services Bruce Davis, Ph.D., Tennessee Director of Behavioral and Psychological Services, Department of ID/D Jeff Cross, President, AWS/Benchmark State agency/provider partnerships NASDDDS Mid-Year Conference June 6, 2014

2 NASDDDS Panel Presentation Supporting Persons with Co-Occurring Conditions in Small Home Settings Jeff Cross Benchmark Human Services June 6, 2014

3 AWS/Benchmark (Benchmark) Company Profile Operations in 8 states and DC; 8,000 people in residential, work and home health services Specialized residential support for 400 persons with intensive medical or behavioral challenges Deliver specialized behavior support services Operate 24/7 mobile crisis services/6 IDD crisis homes for IDD and MH populations in combined 150 Georgia counties; 900+ interventions monthly. Telepsychiatry and GA Regents Medical College partnership

4 Supporting Persons with Co-Occurring Conditions Profile for 4 states: TN, IN, MO and NJ 128 persons w/co-occurring conditions in settings of 1 to 4 persons; 26 in TN, 36 in IN 16% with adjudicated forensic backgrounds Population includes persons with sex offending/pedophilia, arson, disabling assault, severe self injurious behavior, and extensive trauma history 25% positive transition out; no recidivism

5 GA Crisis Model IDD Mobile Crisis: 86 Counties 3-person teams: BCBA, LCSW, DSP Avg. 68 minute response time 24 crisis beds/6 homes In-Home Supports up to 7 days Out-of-home supports up to 7 days Specialized behavior support, review and consultation Telepsychiatry Est. 90% of individuals with co-existing conditions MH Mobile Crisis: 120 Counties 2-person teams: Licensed clinician and certified peer specialist(cps) Avg. 51 minute response time Utilize existing resources for inpatient and crisis stabilization 24 hour follow-up by CPS Next day access to MH appointment Mandate for regional community collaborative organizations (60 to 100 members)

6 IDD Crisis Outcome Data Serve 24% children and juveniles 56% of persons on commitment orders are diverted from ER s and acute hospitals 88% of crisis referrals are handled in the community with no inpatient placement Site of crisis intervention in order of occurrence: Home, ER s, community at large, jail and day programs

7 Encouraging Practices What Works 1-2 person settings highly effective Life style engineering building ability to exist and thrive in the community vs. obsessive focus on negative behavior Person centered toxic to healing/nurturing environments community based reinforcement Decrease/manage barriers to community inclusion increase pro-social behavior

8 What works... Use BCBAs focus on extinction of restraints, unconditional respect environment, what counts to you, personal responsibility, managing family No discharge commitment build trust and bonding Aggressive daily schedules/work, get out of home, physical activity, chores, gardening, shopping, pets, etc.

9 What works... Intensive training of DSPs regular competency testing, modeling by clinicians Scenario training practice interventions Environmental assessment/in-depth planning pre-move Aggressive risk management: Safety plans and extensive contingencies; coordination with law enforcement, crisis support plan don t assume!

10 Provider Perspective to States Define and monitor population at risk before making funding/policy decisions Seek provider/community involvement in planning strategies e.g. Project Resource Tennessee, work groups on targeted populations, community collaborates (this is not a IDD issue only) Establish a comprehensive strategy now to address with existing resources/providers

11 Provider Perspective to States Crisis support systems are essential to building sustainable community capacity. Highly cost effective due to diversion, scalable to specific target populations and budgets, and build provider capacity to serve challenging individuals reduce extraordinary costs.

12 Systems of Support for Persons with Dual Diagnoses 2014 NASDDDS Mid-Year Conference and Directors Forum Bruce E. Davis, Ph.D. Director of Behavioral and Psychological Service TN Department of Intellectual and Developmental Disabilities

13 Empathy Imagine yourself as a person with an intellectual disability and a co-occurring behavioral health problem faced with: Trying to understand what is happening with you personally Responding to others who don t understand your problem Seeking to find/establish your value as a person in the midst of invalidating experiences NASDDDS Mid Year Conference 13 6/6/2014

14 Reminders about IDD High Rates of: High rate of unrecognized abuse/trauma High rate of improperly understood behavioral health problems Ubiquitous invalidation Oft disrespected Low expectations Unreasonable expectations Even our help is invalidating Lack of control NASDDDS Mid Year Conference 14 6/6/2014

15 Acceptance People have behavioral health problems that occur independent of their environment. People with ID have a greater likelihood of behavioral health problems (40-50%). At least 24,000 30,000 people in TN with ID and behavioral health disorders*. NASDDDS Mid Year Conference 15 6/6/2014

16 Team of Rivals NASDDDS Mid Year Conference 16 6/6/2014

17 This Battle is Epic Rival Departments MH vs. DD vs. DOC vs. DOE vs... Significant barriers to cooperation Common Ground Reduce crisis calls and unnecessary hospitalizations Facilitate timely hospital admissions and discharges when needed Significant barriers to cooperation Synergy is possible! Just like in Lincoln s cabinet. NASDDDS Mid Year Conference 17 6/6/2014

18 Utilization Data July 1, June 30, 2012 TOTAL Adults DIDD clients Total Telephone Contacts 115,345 (all contacts) 570 Total Face to Face Assessments 60, Total Admitted to State Hospital 6, Total Psychiatric Admissions 20, NASDDDS Mid Year Conference 18 6/6/2014

19 Utilization Data July 1, June 30, 2013 Total Telephone Contacts TOTAL Adults 142,323 DIDD clients (all contacts) 549 Total Face to Face Assessments 67,958 na Total Admitted to State Hospital 6,533 na Total Psychiatric Admissions 23, NASDDDS Mid Year Conference 19 6/6/2014

20 Utilization Data: DIDD For 7 /1/ /30/ 2012: 128 people were admitted only once 68 people were admitted to a facility more than once For 7/1/2012 6/30/ people admitted once 74 people admitted more than once NASDDDS Mid Year Conference 20 6/6/2014

21 Constellation of Supports NASDDDS Mid Year Conference 21 6/6/2014

22 Our Goal: The Complete Constellation Person and Family centered supports Cross-systems Crisis Planning Safety Net 24/7 Crisis support network Diversion works Experienced/Trained Staff Personal Interactions Redirectional Prowess Identifying Resources - Systemic Awareness Maneuvering resources Political Saavy Behavior Analyst Services Therapeutic Services (Family, Individual, Group, Medication Management) Assessment and Stabilization Inpatient Psychiatric Services NASDDDS Mid Year Conference 22 6/6/2014

23 Dr. Joan Beasley Center for START Services The Three As Appropriate Do the services offered meet people s needs? Accessible Can people get the service? Accountable Do the services offered adhere to standards and measure outcomes. NASDDDS Mid Year Conference 23 6/6/2014

24 Tennessee DIDD Vision Full development of our constellation of support Stars we have: Agencies like Benchmark committed to dual diagnosis Support Solutions behavioral respite facility in West TN Medicaid Waiver funding for behavioral respite START Training for Mobile Crisis and DIDD Intensive Consultation Teams/Resource Centers Behavior Analysis services Intensive Behavior Residential Services (New Waiver Service) Harold Jordan Center Stabilization unit Intermediate Care Facility NASDDDS Mid Year Conference 24 6/6/2014

25 Stars We Need Widely available therapeutic services Crisis response network devoted to IDD Statewide stabilization (respite) Easier access to psychiatric hospitalization In home crisis supports Interdisciplinary assessment NASDDDS Mid Year Conference 25 6/6/2014

26 A Step Forward Resource Tennessee Relative fiscal austerity means maximizing existing resources. An efficient system is a money saver and quality of life improver. Therapeutic respite can provide a diversionary resource. In TN, 4 respite beds could result in a 20% decrease in hospitalizations for DIDD. NASDDDS Mid Year Conference 26 6/6/2014

27 A 20% reduction leads to Improvement in system functioning Quicker response times Better support for agencies Net increase in quality of life Increased availability of hospitals Better assessment and treatment NASDDDS Mid Year Conference 27 6/6/2014

28 TN-START TN-START Demonstration Project Resource Tennessee goals for persons with IDD Improve existing resources to fit Ensure new (already planned) resources fit. NASDDDS Mid Year Conference 28 6/6/2014

29 Savings Comparison of Average Emergency Service Usage (and Associated Costs) of Clients with and Clients without TN-START Services * Cost based on BlueCoverTN 7/1/06 fee schedule; CPT code #99284 ** One client was arrested four (4) times and incarcerated twice. Emergency Service TN-START Clients Average Cost Non-TN-START Clients Average Cost Emergency Room Visits 0.47 $39.34* 5.2 $ # of Psychiatric Hospitalizations Hospital Days 7.3 $4, $12, Crisis Contact (TN-START Crisis) (Community-Based Mobile Crisis) # of Police Contacts # of Arrests** Incarceration Days** 6.4 $ $0.00 Respite Days 7.6 $3, $15, NASDDDS Mid Year Conference 29 6/6/2014

30 The Indiana Family and Social Services Administration Division of Disability and Rehabilitative Services June 2014

31 Systems of Support for Persons with Dual Diagnosis Current Models of Care Home and Community Based Services: Community Integration and Habilitation (CIH) Wavier: 8,379 Family Supports Waiver (FSW): 8,122 Waiver is caped at $16, Supervised Group Living (Group Homes) Supervised group living programs, which serve at least four (4) individuals and not more than eight (8) individuals and are funded by Medicaid

32 460 IAC Types of facilities defined Adult support residence Intensive training residence Basic developmental residence Child rearing residence Child rearing residence with a specialized program Comprehensive rehabilitative management needs facility" or "CRMNF Residence for adults with extensive support needs Sheltered living residence Small behavior management residence for children Small residence for adults with extensive medical needs Developmental training residence

33 Types of Facilities (5) "Comprehensive rehabilitative management needs facility" or "CRMNF" means a residential setting with supports and services for adults who meet the definition of federal intermediate care facility for the mentally retarded (ICF/MR) level of care who may have a dual diagnosis, have acute and high-risk challenges, and are in need of comprehensive service delivery in the area of behavior and psychiatric supports and habilitation services that has: (A) A behavior support plan supervised by a health service provider in psychology (HSPP) in conjunction with behavior consultants to develop and monitor behavior training, developmental training, and support in specific areas for all individuals receiving services who function on a similar level as follows: (i) The HSPP and behavior consultant must have twenty-four (24) hour availability and must be familiar with the specific needs of the consumer in the facility. (ii) The behavior consultant must provide at least fifteen (15) hours per week of behavior services in the facility for direct monitoring, assessment, intervention, and staff training. Indiana (iii) Psychiatric services must be available at a minimum of twenty (20) hours in the facility and have twenty four(24) hour availability. (iv) A medical director, a director of nursing, and nursing personnel to coordinate health care needs of the individuals residing in the facility for access to twenty-four (24) hour nursing care and medical supervision as the individuals' needs warrant.

34 Types of Facilites (B) A CRMNF for adults with comprehensive management needs must provide the following: (i) A continuous active treatment program to address the acute and high-risk positive behavior support needs of the individuals receiving services. (ii) The qualified developmental disability professional (QDDP) must provide at least twenty (20) hours per week of direct client intervention, monitoring, assessment, and staff training with the individuals receiving services. (iii) Training for individuals receiving services to address community integration skill needs include training in one (1) or more of the following areas: (AA) Activities of daily living or life skills. (BB) Communication. (CC) Vocational skills. (DD) Personal maintenance and development. (EE) Positive behavior supports. (FF) Self direction and leisure time. (GG) Active treatment. (HH) Home skills. (C) A CRMNF under this subdivision shall not have more than one hundred (100) residential beds.

35 Extensive Support Needs (ESN) (8) "Residence for adults with extensive support needs" means a residential setting as follows with supports and services for adults with extensive supervision needs and intense behavioral support needs that has: (A) A behavior support plan supervised by a behavioral consultant to develop and monitor behavior training, developmental training, and support in specific areas for all individuals receiving services who function on a similar level as follows: (i) The behavioral consultant or consultants must have twenty-four (24) hour availability and must be familiar with the specific needs of the consumers in the home. (ii) The behavioral consultant or consultants must provide at least ten (10) hours per week of behavior services in the home for direct monitoring, assessment, intervention, and staff training. (iii) Psychiatric services must be available to meet the needs of the individual or individuals.

36 Extensive Support Needs (ESN) (B) A residence for adults with extensive support needs must provide the following: (i) A continuous active treatment program to address the extensive positive behavioral support needs of the individuals receiving services. (ii) Training for individuals receiving services to address community integration skill needs, including training in one (1) or more of the following areas: (AA) Activities of daily living. (BB) Communication. (CC) Personal maintenance and development. (DD) Behavior supports with emphasis on positive measures. (EE) Leisure time. (FF) Active treatment. (GG) Home skills. (C) A residence under this subdivision shall not have more than four (4) beds.

37 Other Requirements ESN homes will provide specialty services on a time-limited basis and should not be considered a final placement for people. Individuals living in ESN residences must be supervised at all times and the staffing pattern should be a minimum of: Three (3) staff on the day shift; Three (3) staff on the evening shift; and Two (2) staff on the night shift The Bureau of Developmental Disabilities Services Coordinator will be a member of the individuals support team. The provider must notify the Service Coordinator of all meetings and if the Service Coordinator is not notified the meeting may be reconvened at the discretion of the Service Coordinator.

38 Other Requirements Patterns of behavior including non-targeted or novel behaviors are to be tracked utilizing an ABC tracking sheet and are to be analyzed monthly by the support team. A pharmacist must review the individual s drug regimen, lab work, and documented behaviors, at least quarterly. The pharmacist must report any irregularities found with the drug regimen, lab work, or diagnosis as they relate to the behaviors(s) of the individual to the prescribing physician and the support team within (7) calendar days. If the irregularities present a serious risk to the health and safety of the individual, the irregularities must be reported to the physician and the support team immediately.

39 There are currently 21 ESN homes in Indiana 84 individuals are served in those settings with 60 being male and 23 being female. There is currently only 1 vacancy. The average age of the individuals is 35 The average daily rate is $ per day/per person

40 Current Locations:

41 Strengths of the Model: Weaknesses of the Model: System of structure and support Family satisfaction Limited law enforcement contact Intense behavioral training for Direct Support staff Little to no movement in placement Unclear discharge expectations Limited community involvement Consistent waitlist for placement Consistency in implementation

42 Next Steps for Indiana: Undergoing a gap analysis performed by the University of New Hampshire (START) Take the analysis and recommendations to the DD commission next legislative session Work with current ESN providers to come to agreement regarding expectations Evaluate the lack transitions that occur and identify root cause Implement strategies to ensure fluidity and sustainability