Proposed Dsrip Project: Crisis Stabilization – Idd Population

PROPOSED DSRIP PROJECT: CRISIS STABILIZATION – IDD POPULATION

IDENTIFYING INFORMATION Category 1: Infrastructure Development Project Area II: Expand Behavioral Healthcare Capacity Project/Intervention Title: Expand behavioral healthcare capacity to include assessment and development of long-term crisis intervention and stabilization services to patients with intellectual and developmental disabilities (IDD) and a co-occurring serious and persistent mental illness (SPMI) and/or serious behavioral challenges. Performing Provider Name: Texana Center Texas Provider Identifier: 081522701

PROJECT GOAL There are an increasing number of patients with a diagnosis of intellectual and developmental disability (i.e., autism, pervasive developmental disorder (PDD) or mental retardation (MR)) who have a co- occurring serious and persistent mental illness and/or a history of challenging and harmful behaviors. When a behavioral crisis occurs, patients and caregivers typically seek crisis intervention services either through the emergency room or law enforcement. In these cases, the general outcome is hospitalization, incarceration or institutionalization. Patients with IDD who have a co-occurring SPMI/challenging behavior enter into a cycle of crisis driven care: the patient receives long term supports from a designated in-home caregiver who is unable to manage challenging behaviors; the behaviors result in an acute crisis; the treatment for the crisis is hospitalization or out of home institutional care, which does not involve the caregiver in the treatment plan; the crisis resolves and the patient returns home to the caregiver who still lacks competencies for managing the behaviors; the challenging behaviors reoccur and result in an acute crisis; and the cycle repeats.

This project proposes a solution to the cyclic pattern of long term support and acute crisis intervention for patients with a diagnosis of intellectual and developmental disability (i.e., autism, pervasive developmental disorder or mental retardation) who have a co-occurring serious and persistent mental illness and/or a history of challenging and harmful behaviors. As a solution, this project proposes an evidenced-based long-term crisis intervention and stabilization services model [START: Systemic Therapeutic Assessment Respite and Treatment].1 The model will build upon two best practice delivery system components: wraparound supports in response to acute crisis and a continuum of care to prevent reoccurring crisis. Wraparound supports is defined as a set of principles about how family members, people in their support system, and service providers work together to support the family or individual who needs help.2 The project proposes the development of a crisis behavioral healthcare team and expanded out-of-home respite care to provide wraparound supports in response to an acute crisis, and also to provide long term supports to the patient with IDD and complex behavioral healthcare needs. The crisis behavioral health care team will meet regularly to design, implement, and monitor an individualized plan to meet the unique needs of the patient with IDD. A key component of the project is intensive training in Applied Behavior Analysis supports to caregivers, teaching them to manage behaviors, stabilize patients in the home, and avoid acute crisis events. The crisis behavioral healthcare team will be responsible for ensuring that caregivers are trained in the behavior strategies most effective for the individual.

The proposed model will incorporate the following elements:

1 Source: The Center for START Services website: http://www.centerforstartservices.com/

2 Source: Texas Health and Human Services website: http://www.hhsc.state.tx.us/tifi/

1 PROPOSED DSRIP PROJECT: CRISIS STABILIZATION – IDD POPULATION

 Development of behavioral healthcare teams responsible for early intervention and intensive wraparound services and supports o Board Certified Behavior Analysts o Psychiatrist o Registered Nurse o Licensed Social Worker o Direct care staff credentialed, or seeking credentialing, in the management of challenging behaviors for both respite and in-home supports o Provide intensive training in Applied Behavior Analysis (ABA) techniques to individuals, family members and caregivers.  Development of continuum of care supports and services o Establish more out of home respite locations designed for crisis stabilization and based on population needs o Expand crisis stabilization care hours in both respite locations and settings where crisis most frequently occurs (e.g., home, school and other community settings) o Expand access to Board Certified Behavior Analysts in clinical settings and through remote monitoring technologies to prevent exacerbation of challenging behaviors and improve patient quality of life. o Expand access to crisis prevention knowledge and wellness education for patients, educators and caregivers for the IDD population, to include training and certification in crisis stabilization (Project will offer the NADD Competency-Based Direct Support Professional Certification Program to caregivers who support people with a dual diagnosis)3 Eligible persons are individuals of all ages with an intellectual and developmental disability, who have a co-occurring serious and persistent mental illness and/or history of challenging and harmful behaviors, and who reside in one of the following six counties: Austin, Colorado, Fort Bend, Matagorda, Waller and Wharton. The caregivers for this population are eligible recipients for training and education.

The four-year expected outcomes are  A significant decrease in the number of behavioral crisis resulting in hospitalization or institutional care for individuals with IDD  A significant increase in the number of individuals with IDD who have access to behavior supports provided by Board Certified Behavior Analyst and who have access to emergency respite

RATIONALE The NADD, an association for persons with developmental disabilities and mental health needs, reports that many professionals have adopted the estimate that 30-35% of all persons with an intellectual developmental disability have a psychiatric disorder.4 By applying the NADD estimated percentage (30- 35%) to the intellectual and developmental disabilities population (3,650: 1,250 served; 2,400 not served), it is estimated that the baseline population is 1,100-1,300 people with potential needs for the crisis stabilization services proposed in this project. This number is consistent with state data source (CARE), which reported 1,427 individuals with IDD and a co-occurring SPMI or diagnosis of autism or PDD being screened, assessed or served through Texana Center in 2011. Based on provider service data

3 Source: NADD website: http://acp.thenadd.org/dsp.htm

4 Source: NADD website: http://thenadd.org/resources/information-on-dual-diagnosis/

2 PROPOSED DSRIP PROJECT: CRISIS STABILIZATION – IDD POPULATION for 2011, it is estimated that about 50% of the baseline population received some type of crisis stabilization service (i.e., intensive behavior supports and/or emergency respite), meaning that there were approximately 600 under served patients. This project proposes to expand the services of the behavioral healthcare team and emergency respite to the estimated 600 under served patients. The provider network includes Texana Center, an additional 101 active Medicaid program providers, and an estimated 2,000 caregivers. This behavioral health expansion project includes the on-going assessment of  Need and capacity for long-term intervention/stabilization capability to improve access to behavioral health care in the most appropriate, cost effective setting  Need and capacity for a continuum of care in the community for this targeted behavioral health population.

The significance of the project to Texana Center and the RHP is a reduction in the cost of long term crisis intervention. Consider the following costs for more restrictive care: hospitalization for a person with IDD, Fort Bend County, is 4.1 days at an average cost of $20,0825; daily rate at the State Supported Living Center is $547.47 for an annual cost of $199,8276; daily incarceration rate at State prison is $50.91 for an annual cost of $18,0317. A service delivery system model based on in-home and community setting care will significantly reduce the cost of care for this targeted IDD population. The significance to patients is better coordinated care, which treats the patient as whole person and potentially leads to better outcomes and experience of care. The implementation of a long-term crisis intervention and stabilization services model is intended to promote health and safety, to promote self-management of challenging behaviors, and to avoid risks requiring hospitalization, incarceration or institutionalization.

Texana Center selected this project based on the following reasons:  Statewide System Changes: There is an on-going agreement settlement between the State and the Department of Justice for ensuring access to community services for persons served in institutions. Access to crisis intervention and stabilization services in the community is an expectation of the Department of Justice through this agreement.8  Regional Pilot: MHMRA of Harris County implemented a behavioral healthcare crisis intervention team for this targeted IDD population in 2011. The model has been well received at the local and state level.

 Experience: Texana Center is an experienced provider of behavioral healthcare supports, including the following:

5 Source: Texas Price Point website, Fort Bend County, Psychiatric care, Mental Retardation population: http://www.txpricepoint.org/Report.

6 Source: Texas Public Policy Foundation website. December 2010. Policy Perspective: http://www.texaspolicy.com/center/health-care/reports/privatize-state-supported-living-centers

7 Source: Texas Public Policy Foundation website. February 17, 2011. House Appropriations Subcommittee on Criminal Justice Summary: http://www.texaspolicy.com/center/effective-justice/reports/written-testimony-house- appropriations-subcommittee-criminal-0

8 Source: Texas Department of Aging and Disability Services website: http://www.justice.gov/crt/about/spl/documents/TexasStateSchools_settle_06-26-09.pdf

o Out of home emergency respite: Texana Center has operated an out of home respite facility for over 20 years.

o Applied Behavior Analysis: Texana Center employs Board Certified Behavior Analyst to assess, treat and monitor challenging programs in four program area: day program, residential, site-based and outreach. These programs have an excellent reputation for successful treatment of challenging behaviors.

 Texana Center maintains data regarding the priorities of patients requesting IDD services: the top two priority requests are respite and behavioral supports.

 As a starting point, Texana Center has the administrative support and clinical expertise to assess and develop a plan a long term crisis intervention and stabilization model for this targeted population.

CHALLENGES/BARRIERS

 Knowledge about available resources

 Accessing services and supports

 Internal Barriers between IDD and BH services

 Lack of knowledgeable/willing clinicians for post-crisis care

 Bed Day availability at state hospitals, inpatient psychiatric, care facilities

 Staff Training

 Secure resources of qualified professionals in the community with expertise in serving individuals with dual diagnosis (including direct care and medical experts)

RELATED PROJECTS

The development and improvement of services for patients with behavioral health disorders is a focus of multiple projects throughout the RHP, including those in Category I for expanding access and Category II for developing innovative solutions to priority issues. This project supports areas focusing on the expansion and development of medical home models, expansion and development of preventive and urgent care, and improvement in the quality of life for patients.

This project supports and reinforces Quality Improvement projects in Category III and Population Based Improvement projects in Category IV related to potentially preventable admissions and readmissions for behavioral health population.

LIST OF OTHER-RELATED PROJECTS WITHIN THE CATEGORY OR WITH PROJECTS/INTERVENTIONS IN THE OTHER CATEGORIES

 Increase access to primary care providers

 Establish a behavioral health critical care center

 Integrate behavioral health treatment with physical health treatment

 Create school based clinics

 Implement a care coordination model for chronic healthcare conditions

 Training for healthcare providers for behavioral health patient base

 Wrap around service

YEAR 1

1.1 Process Milestone: Develop plan for the expansion of behavioral healthcare capacity to include the assessment and development of long-term crisis intervention and stabilization services to the targeted behavioral health population: patients with intellectual developmental disabilities and a co-occurring serious and persistent mental illness (SPMI) and/or serious behavioral challenges. Metric: Submission and approval of DSRIP plan Documentation of Expansion: Planning documents Data Source: Baseline assessment of behavior and health risks for IDD population with challenging behaviors. Rationale/Evidence: There are an increasing number of individuals with diagnosis of IDD who have a history of challenging and harmful behaviors. This is evidenced by the increased frequency of crisis interventions resulting in hospitalization, incarcerations or institutionalization.

YEAR 1 Estimated DSRIP Funding: $25,000

$25,000 for Consultant and staff hours

______

YEAR 2

2.1 Process Milestone: Assess need and capacity for long-term crisis intervention/stabilization capability to improve access to behavioral health care in the most appropriate cost effective setting. Metric: Needs assessment Documentation of Expansion: Submission of assessment findings Data Source: Assessment Rationale/Evidence: With inadequate long-term crisis stabilization capacity in communities, individuals are placed in substitute higher cost, less appropriate settings. Having long-term care stabilization options will improve access to appropriate, cost effective care.

2.2 Process Milestone: Develop and implement long-term crisis intervention/stabilization model. Metric: Implementation of evidence-based intervention/stabilization model based on needs assessment. Documentation of Expansion: Submission of implementation plan and evidence of implementation. Data Source: Implementation plan and implementation documentation. Rationale/Evidence: Determined by Needs assessment.

2.3 Process Milestone: Implement evidenced-based plans to expand crisis stabilization through the hiring, training and credentialing of behavioral healthcare team. Metric: Submission of curriculum and credentialing protocol. Submission of proof of hiring. Documentation of Expansion: Submission of hiring documents, position descriptions, and policies and procedures, and training sign in sheets. Data Source: Needs assessment. Rationale/Evidence: Determined by Needs assessment.

YEAR 2 Estimated DSRIP Funding: $400,000

$50,000 for training materials, training development, training completion, training of staff.

$ 350,000 crisis stabilization team staffing for 3 months.

YEAR 3

3.1 Process Milestone: Implement evidenced-based plans to expand crisis stabilization locations, to include emergency respite location. Metric: Plan, approval, and contract for purchase, lease and/or renovation of expansion site. Documentation of Expansion: Submission of planning documents, contracts for purchase, lease and/or renovation of expansion site. Data Source: Needs assessment. Comparables for purchase and/or lease. Rationale/Evidence: Determined by Needs assessment.

3.2 Process Milestone: Implement evidenced-based plans to expand crisis stabilization through the hiring, training and credentialing of respite care staff. Metric: Submission of proof of hiring. Documentation of Expansion: Submission of hiring documents, position descriptions, and policies and procedures. Data Source: Needs assessment. Rationale/Evidence: Determined by Needs assessment.

3.3 Improvement Milestone: Increase volume of behavioral health services provided in long term crisis intervention and stabilization locations and programs to this targeted IDD population Metric: Increase in volume of long term crisis intervention and stabilization services by 10% over baseline for targeted population. Documentation of Expansion: Encounter data Data Source: Internal and State Reporting Systems

3.4 Improvement Milestone: Reduce use of less clinically appropriate or desired care or care sites by targeted IDD population when long-term crisis intervention and stabilization services are implemented. Metric: Reduction in less clinically appropriate or desired care or care sites by targeted IDD population when alternative option implemented Documentation of Expansion: Admission and discharge date Data Source: Internal and State Reporting Systems

YEAR 3 Estimated DSRIP Funding: $1,180,000

$1,180,000 for Salaries (12 months crisis stabilization team and 6 months respite staff), Respite Facility lease/purchase, renovation design and construction, and utilities for 6 months.

YEAR 4

4.1 Process Milestone: Develop and implement evidenced-based plans to expand access to crisis stabilization hours through remote monitoring technology. Metric: Plan, approval, and contract for purchase and installation of remote monitoring technology. Documentation of Expansion: Submission of planning documents, contracts for purchase and installation of remote monitoring technology. Evidence of installation in respite facility and upon request, in patient homes. Data Source: Needs assessment. Rationale/Evidence: Determined by Needs assessment. Remote monitoring technology is a cost effective method to increase on site monitoring by a clinicians (BCBAs) of patients and caregivers. Such monitoring promotes crisis prevention through early intervention.

$1,280,000 for respite home, crisis stabilization team staffing $100,000 for implementation of remote monitoring technology.

YEAR 5

5.1 Process Milestone: Develop and implement evidenced-based plans to expand knowledge of crisis prevention and stabilization through wellness education campaign and community training opportunities, with a focus on self-management of challenging behaviors through the use of applied behavior analysis, for patients, caregivers, and the IDD provider base. Metric: Number of touches for community outreach. Documentation of Expansion: Submission of planning documents, contracts for purchase and installation of remote monitoring technology. Data Source: Needs assessment. Training documents. Rationale/Evidence: Determined by Needs assessment. When patients/caregivers possess core competencies to self manage care and to prevent the behavioral crisis, quality of life improves and cost of care is reduced.

$70,000 for training materials, training development, training completion, certification program, staffing $1,350,000 for respite home, crisis stabilization team staffing, community training

Total Estimated DSRIP Funding for 5 years: $4,380,000