This proposal for a Multnomah County Atypical Anti-psychotic Medication Project (AAMP) is being submitted in response to the Mental Health and Developmental Disability Services Division’s (MHDDSD) Request for Plan Amendment Proposals to the 1999-2001 County Biennial Plan for Mental Health Services, dated February 15, 2000.
A. Qualification of Proposer and Organization
Type of organization:
This proposal is submitted by Multnomah County Department of Community and Family Services (DCFS) Behavioral Health Division (BHD), acting on behalf of the Multnomah County Board of County Commissioners, the Local Mental Health Authority for Multnomah County. Although DCFS is the proposed grantee, the proposal is submitted as a collaborative effort including not only BHD but also the affiliated Community Mental Health Networks of CAAPCare (DCFS’ Mental Health Organization) – Advanced Behavioral Health (ABH) and Human Services Alliance (HSA), Multnomah County Health Department Primary Care Centers and Corrections Health, Multnomah County Sheriff’s Department, Multnomah County DCFS BHD Commitment Services, Multnomah County Department of Community Justice Services, Adult Parole and Probation (CJS), Providence Crisis Triage Center (CTC), and Central City Concern’s Hooper Center.
Location of facility or facilities where services will be provided:
Assessment, case management and medication management services will be located within:
Advanced Behavioral Health’s Unity Site, 412 SW 12th Avenue, Portland, Oregon 97204
Human Services Alliance’s Network Behavioral Health Site, 525 NE Oregon, Portland, Oregon 97232
As described further in this proposal, outreach activities and services will also occur in a number of triage, stabilization and referral sites including:
Providence Portland Medical Center’s Crisis Triage Center, 5228 NE Hoyt, Building B, Portland Oregon 97213-2967
Central City Concern’s Hooper Center, 20 NE Martin Luther King Boulevard, Portland, Oregon 97232
Providence/Portland Medical Center, 4805 NE Glisan Street, Portland, Oregon 97213
Legacy Emanuel Hospital, 3001 NE Gantenbein Avenue, Portland, Oregon 97227
Oregon Health Sciences University, 3181 SW Sam Jackson Park Road Portland, Oregon 97201
Prescriptions for atypical anti-psychotic and other medications will be filled by 16 Participating Pharmacies as detailed in the list of Participating Pharmacies (see Attachment 1 – Multnomah County CAAPCare Plus Indigent Medication Program Participating Pharmacies).
Names, credentials, and qualifications of the program managers/administrators responsible for proposed program:
The Key Managers responsible for the program include:
Lolenzo Poe, MPA, who has been the Multnomah County Department of Community and Family Services Director for seven years. He is the Community Mental Health Program Director, and is responsible for the overall management of the County Department which includes the Behavioral Health Division. Mr. Poe holds a Master of Public Administration Degree from the City University of Vancouver, in Vancouver, Washington and has a certification in management and cultural training. In addition, Mr. Poe has been appointed by the Governor to the State’s Children, Youth and Family Services Commission and the State Juvenile Justice Council.
Floyd H. Martínez, Ph.D., who has been the Senior Manger of the Behavioral Health Division of DCFS for four years. Dr. Martínez has over 30 years of experience in managing large community behavioral health agencies. He has been active in a wide range of national and regional boards and committees, including the National Advisory Board of CMHS/SAMHSA, the Board of Directors of the National Community Mental Healthcare Council, various American Psychological Association boards and committees, and the Advisory Board of the Mental Health Division of the Western Interstate Commission on Higher Education.
The position of the Medical Director for the Behavioral Health Division is currently vacant and is under recruitment. This position provides medical oversight for both BHD Clinical Services and Managed Care Programs. This position will be filled by a Board Certified Psychiatrist who has a minimum of five years of experience in community mental health programs. Until the position is filled on a permanent basis, Dr. Marv Rosen is providing psychiatric consultation to BHD Managed Care Programs. Dr. Rosen is a Board Certified Child and Adolescent Psychiatrist.
Janice E. Gratton, LPC, who is the Clinical Services Director for the Behavioral Health Division. Ms. Gratton is a member of the Oregon Counseling Association, the American Counseling Association, and the American Professional Society on the Abuse of Children. She has a M.Ed Counseling from Lewis and Clark College in Portland, Oregon.
William B. Thomas, MSW, MSc, who is the Program Manager for Mental Health and Chemical Dependency Managed Care Programs. He has had the management responsibility for Managed Care Programs for five years, and has twenty-five years of experience in community mental health programs. He will be directly responsible the management of the Atypical Anti-psychotic Medication Project. Mr. Thomas received his master of Social Work Degree from Portland State University in Oregon and received his Master of Science in Social Administration from the London School of Economics in London, England.
Advanced Behavioral Health and Human Services Alliance, under the contractual oversight of DCFS, will be responsible for the service delivery, medication management, prescriber time, and other support services of the project. These Mental Health Service Networks will coordinate with all referral sources and their affiliated agencies under the direction of:
Susan Schwartz, MBA, who is the Executive Director of Advanced Behavioral Health. Ms. Schwartz is the Chief Administrative Officer for Unity, Inc. She has 25 years of non-profit healthcare experience. Ms. Schwartz holds a Master of Business Administration degree from Rutgers University in Newark, New Jersey.
Leslie C. Ford, LCSW, who represents the Human Services Alliance. She is the Chief Executive Officer of Network Behavioral HealthCare, Inc. Ms. Ford holds a Masters Degree in Social Work from the University of Washington and is a Licensed Clinical Social Worker in the state of Oregon.
Proposer’s experience with and knowledge of serving persons with schizophrenia and other psychotic disorders in need of anti-psychotic medications:
The experience of Multnomah County’s Department of Community and Family Services Behavioral Health Division with this population includes more than a 30 year history of providing services and acting on behalf of the Multnomah County Board of County Commissioners, the Local Mental Health Authority for Multnomah County, which is the largest metropolitan area in the State of Oregon. Within DCFS, and in conjunction with the CAAPCare Mental Health Networks (ABH and HSA) and other supporting partners of the project, there is a high level of professional experience with and knowledge of serving persons with schizophrenia and other psychotic disorders in need of anti-psychotic medications.
NETWORKS AND OTHER KEY PROVIDERS
The Networks have been in existence since 1998. They were preceded by a foundation of providing services as County Mental Health Clinics and, subsequently, following the spin-off of the County clinics in 1981, as Quadrant Community Mental Health Agencies for nearly 20 years.
The Advanced Behavioral Health provider agencies include Unity (which is the largest outpatient mental health agency in Multnomah County), Center for Community Mental Health and OHSU Psychiatric Affiliates. These agencies currently provide services to adults with severe and persistent mental illnesses. A range of outpatient, rehabilitation, case management, housing, and psychiatric services form the ABH continuum of care for adults with serious mental illness. In addition, very specialized money management services, mobile outreach and crisis services, daily dispensing of medications, and housing supports are also available. Consumer and family outreach services have been created to meet specialized needs. Successful ABH program models for this population include a continuum of community based supported housing programs, and innovative vocational and employment services.
Most provider agencies have utilized psychosocial rehabilitation strategies in the development of community based services for adults with severe mental illness. The ABH member organizations which serve adults have a strong background in designing services to manage psychotic symptoms, prevent relapse and re-hospitalization, and assist severely impaired adults with community living, particularly in the downtown core area. ABH agencies have developed several programs or clinics in response to the needs of special populations such as Project Respond, a mobile outreach, assessment, crisis response and intervention team; Project Oasis, a joint effort with Adult Community Justice Services to provide services for mentally ill individuals on probation or parole; and the OHSU International Clinic, which provides services for Asian, Eastern Europeon, and other populations in individuals’ native languages and using culturally appropriate approaches and service packages.
The Human Services Alliance (HSA) providers include Mt. Hood Behavioral Health Center and Network Behavioral Health. These agencies have extensive experience in serving persons with severe and persistent mental illness. HSA has developed a geographically dispersed network of resources to assure countywide access. Mt. Hood Community Mental Health Center, Network Behavioral Health, and Tualatin Valley Centers provide a comprehensive array of services including assessment and evaluation; crisis intervention; respite; case management and intensive case management; supported and structured housing; housing support services; psychosocial clubhouse; drop-in center; pre-vocational, vocational, sheltered and supported employment; consultation; dual diagnosis alcohol and drug programming; medication management; money management; group and individual counseling; psycho-educational groups; symptom management training; family support groups; peer counseling; and medical/health assessment, care, and referral. These services are coordinated by case managers who oversee access to the array of services that best meet the goals of the individual client.
The rehabilitation services offered by the two Networks typically provide daily structure and support at both clinic and housing sites, and can provide intensive treatment structure and support in residential care facilities and adult foster care settings. In addition, these providers support consumer driven service approaches through peer counselor programs and/or consumer operated drop-in resource centers. The Chinese Service Center, El Programo Hispano (Mt. Hood), and the OHSU International Clinic offer culturally specific outpatient and rehabilitation services to persons of Asian, Hispanic, and Eastern European descent, respectively.
A number of other organizations with substantial experience in the provision of services to persons with schizophrenia and other psychotic disorders also will be part of this proposed project. Community Mental Health Partners (Ryles Center) has a long history of providing sub-acute and secure residential services for individuals with psychotic and other disorders. Providence Medical Center provides emergency, sub-acute, and Day Treatment services for this population. The Providence Medical Center Crisis Triage Center provides the critical link of emergency mental health services for the behavioral health system in Multnomah County. Clinical supervision is an important element of their mental health programs. A Board Certified Psychiatrist is on duty at all times and the facility is fully staffed with qualified individuals who provide the range of services needed to meet the complex mental health service needs of the County’s acute population. The CTC has an acute assessment area that includes three secure holding rooms, one observation room for extended evaluation, and a sub-acute area for assessment with 5 interview rooms. The CTC also houses the phone triage area which provides 24 hour, 7 day a week telephone assessment, consultation and triage. There is also a 7 day a week stabilization program for those who are transitioning from the hospital to the community and moving from levels of care or between service providers.
BHD INDIGENT MEDICATION PROGRAM AND CAAPCARE PLUS
In addition to the support provided to these organizations, Multnomah County DCFS has a great deal of experience in administering funding programs for the provision of services for uninsured or medically indigent individuals. Specifically, Multnomah County Behavioral Health Division has been administering a program to provide access to psychiatric medications for uninsured or medically indigent individuals since November, 1998, known as the Indigent Medication Program. This program, using MHS 37 funding, was developed from a small pilot project with the Crisis Triage Center that was used to determine client profiles, medication costs, and optimum pharmacy protocols. Currently, the Indigent Medication Program serves approximately 55 clients per month, providing funding for medications that are dispensed through the 16 Participating Pharmacies.
The Participating Pharmacy panel includes pharmacies that are associated with all outpatient mental health network providers, CAAPCare inpatient network hospitals, Ryles Center, the CTC, Multnomah County Health Department Primary Care Clinics, Providence Day Treatment, and other mental health providers. This Indigent Medication Program operates in conjunction with CAAPCare Plus, a program using MHS 20 and 22 funding to reimburse community mental health providers for assessment, treatment and other clinical services that are provided to qualifying individuals. Outpatient services funded through CAAPCare Plus are consistent with the Oregon Health Plan outpatient benefit.
The Indigent Medication Program and CAAPCare Plus serve both adults and children who are 1) residents of Multnomah County, 2) meet income criteria, and 3) meet clinical criteria. Due to the limited funding available for these programs, clinical criteria for adults have been established to be consistent with the OAR Priority One criteria. Clinical criteria for children are consistent with the criteria for Serious Emotional Disorder. (Providers/clients are encouraged to call CAAPCare if special circumstances apply. Clinical criteria may be waived or modified at the discretion of CAAPCare clinical staff). CAAPCare Plus and the Indigent Medication Program are used conjointly in a variety of circumstances in order to begin care immediately prior to OHP enrollment, as well as to provide care for indigent individuals who cannot be enrolled on the Oregon Health Plan. (Examples would be an individual who, because of a psychotic illness, was unwilling or unable to enroll in the Oregon Health Plan, or an individual who is uninsured, working at a low wage and does not qualify for OHP benefits, but is unable to afford the psychiatric services and medication he or she needs).
Through Participating Pharmacies, the Indigent Medication Program dispenses medications prescribed through outpatient community mental health agencies, Multnomah County Health Department Primary Care Clinics, and inpatient psychiatric service providers. These pharmacies have been selected based on existing service relationships with mental health provider agencies, convenience of location to mental health agencies or major public transportation routes, and experience dealing with individuals with severe mental illnesses. In addition, the Indigent Medication Program provides reimbursement to hospital pharmacies for the cost of up to a two-week supply of psychiatric medications, in order to ensure that medically indigent clients will have an adequate supply of medications during the period in which they are becoming established with an outpatient psychiatric health care professional.
Preliminary discussions have been held with Multnomah County Jail Corrections Health staff to enable individuals, upon release, to leave with an appropriate supply of psychiatric medications until they are able to become established with a community provider. However, this expansion of the Indigent Medication Program has not been implemented because of the limited funds that are currently available through the MHS 37 allocation. Utilization data regarding current use of and expenditures on the Indigent Medication Program indicates that this program is in high demand, and that expansion to the population served by the Multnomah County Justice system would not be possible under the current funding available. However, with the addition of Atypical Anti-psychotic Medication Project (AAMP) funds, a jail discharge medication program would be able to be established, enabling continuity of medication for individuals who are released from jail, as well as significantly improved coordination between the jail system and community outpatient providers.
Although the Indigent Medication Program has not been limited to atypical anti-psychotic medications, these medications have been a large focus of prescriptions and expenditures. (Unduplicated persons who require atypical anti-psychotic medications have represented just under 47% of total clients served but nearly 150% of expenditures in the Indigent Medication Program.) This has enabled the Behavioral Health Division to build a model of projected costs of atypical anti-psychotic medications for the AAMP target population.
From its inception, the Indigent Medication Program has kept detailed data on the following: 1) name and other demographic information of individuals served, 2) name and quantity of medications prescribed 3) number of prescriptions dispensed, 4) prescribing agency 5) dispensing pharmacy, and 6) cost of each prescription medication. This has enabled the Behavioral Health Division to project average medication costs (including additional psychiatric medications) for targeted clients in the AAMP (see Attachment 2 – Monthly Average Cost Comparison of All Drugs Prescribed to Atypical Anti-psychotic Drug Clients and Clients Receiving No Atypical Anti-psychotic Drugs)
Of equal importance, the Indigent Medication Program has developed a network of relationships between prescribers, staff of provider agencies and inpatient services, pharmacies, the Behavioral Health Division, the CTC, the Multnomah County Health Department Primary Care Clinics, and other entities. This provides a solid, pre-existing foundation of joint experience, contractual relationships, and hands-on coordination, which will enable a rapid ramp-up of the project described in this Proposal.
B. Service Program Requirements
Plan for initiating contact with targeted populations, identifying persons within those populations who may be appropriate for the program and bringing them into the program:
The AAMP targets the needs of individuals with psychotic illness throughout Multnomah County. These individuals may present at or be served by crisis centers, shelters, emergency rooms, and outpatient mental health agencies, or may be in contact with law enforcement officials and the criminal justice system. These individuals may already be receiving mental health services but are otherwise unable to obtain atypical anti-psychotic medications. Participants may be employed or receiving Supplemental Security Disability Income, but will have no insurance coverage with the exception of Medicare (without medication coverage) and/or other third party coverage without medication benefits, or may have insurance but will have exhausted all medication benefits.
Persons with psychotic disorders and without insurance coverage establish contact with a variety of social service providers in Multnomah County. Those who are not connected to an outpatient provider are often seen in emergency situations at Providence’s Crisis Triage Center, acute care hospitals, jails, primary care clinics, shelters, or by police. These individuals may receive assessments, referrals, and sometimes appointments at a community agency, but frequently do not have the ongoing support to follow up with necessary treatment. Consumers may find themselves unable to negotiate movement from one system to the next, resulting in fragmented care, a revolving door syndrome, or no ongoing care at all. These persons with inadequate supports are in danger of “falling through the cracks” of the mental health system.
Even with medication samples and prescriptions in-hand, individuals discharged from inpatient hospitalization, sub acute facilities or triage and stabilization settings such as the CTC or Hooper Center routinely fail to show for their scheduled outpatient appointment. Jails frequently release individuals with a written prescription or only a short supply of medications and leave the individual to negotiate the system of care alone. Some individuals come into repeat contact with these parts of the system and never achieve stability or consistent treatment.
The plan for initiating contact with targeted populations for the AAMP includes a number of specific referral sources that will serve as conduits to refer potential participants into the project, as well as a number of triage facilities that can identify persons who may be eligible and bring them directly into the program through coordination and outreach by AAMP staff. Referral sources may channel clients directly into the mental health service Networks and Participating Pharmacies to begin treatment, or may send them through the CTC, Hooper Center, hospitals, jails or sub-acute services for triage and stabilization services. It is anticipated that the majority of participants will enter the project following such triage and stabilization services.
This relationship includes a wide range of referral sources and a broad base of triage facilities that work in conjunction with the Mental Health Service Networks and Pharmacies, under the direction of the Project which will be coordinated by the DCFS BHD under contract with MHDDSD. The client and service flow, as well as the relative funding flow is further illustrated through the following flowchart:
Crisis Triage Center
Providence’s Crisis triage Center will serve as a triage facility as well as a primary referral source for the project. Individuals presenting to CTC who have not made a connection into the treatment system will be referred into the AAMP when appropriate. Linkages provided through the AAMP Care Coordinators will ensure that individuals referred for acute crisis services in this facility are connected to the AAMP. The Crisis Triage Center (CTC) receives both insured and indigent patients who have been brought in by the police departments, or are referred from community outpatient providers, emergency rooms, and primary care physicians, SOSCF, Juvenile Detention, the jails, BHD staff and non-referred walk-ins. The CTC is the preferred placement for police holds of persons who are in a psychotic state. The CTC has an acute assessment area that includes three secure holding rooms, one observation room for extended evaluation, and a sub-acute area for assessment with 5 interview rooms. The CTC also houses the phone triage system that provides 24-hour, 7-day a week telephone assessment, consultation and triage. There is also a 7-day a week stabilization program for those who are transitioning from the hospital to the community and moving from levels of care or between service providers.
The CTC is an ideal center to bring referrals into the project of persons who would benefit from atypical anti-psychotic medications, and to provide initial medications (generally one to two weeks of samples) and stabilization services to those who need them, ensuring a connection with the Network AAMP Care Coordinators for critical follow-up services. The Crisis Triage Center physicians and staff will work closely with the Networks to identify individuals who are eligible for the AAMP and immediately refer them to the program. This will be done through daily on-site or phone staffings which identify individuals who are referred to the AAMP for outreach and follow-up by AAMP staff. CTC physicians and staff will work closely with AAMP physicians and staff to ensure that clients’ medication and other service needs are met rapidly, appropriately, and with a minimum of disruption.
The Hooper Center serves indigent clients with chemical dependency problems. Most clients are homeless and go there in desperation, with few resources to draw from. Most of these clients have complicated medical and psychiatric problems and lack adequate care or follow-up. Approximately 90% of clients have a dual diagnosis. A recent annual chart review yielded that nearly 3% of the client population were prescribed anti-psychotic medications but were without insurance, and were not enrolled in the OHP. These clients will be referred to the CTC for psychiatric assessment, medication evaluation or acute psychiatric crisis services. Central City Concern is currently seeking to retain a psychiatric nurse practitioner for Hooper Center in order to assist in psychiatric assessments, medication stabilization and referral. This would enhance the responsiveness of Hooper Center to the needs of this special population, and increase their need for resources related to psychiatric medications. As with CTC, AAMP case management staff will provide on-site outreach services to engage persons who are referred to the AAMP directly from Hooper Center.
Persons with a history of mental health treatment, bizarre or disruptive behavior, or suicidal ideation or attempts are frequently referred to jail mental health staff for evaluation and possible treatment. A significant number of those referred have psychotic symptoms with varied causes. Individuals whose psychotic symptoms are known to be associated with a documented history of mental illness, who are in need of an atypical anti-psychotic medication and who are determined to be without medical insurance will be referred into the AAMP.
The Multnomah County Health Department Corrections Health Division has staff providing a variety of mental health services in the jails, including psychiatric evaluation and medication management. A psychiatrist and two psychiatric nurse practitioners provide the majority of psychiatric prescriptive services. A 65-bed dormitory, operated as a therapeutic milieu, has recently been implemented.
A discharge planning position is planned in as part of this unit. The discharge planner and jail mental health staff will identify potential referrals to AAMP staff.
While such persons will leave the jail with a prescription, they will not have a supply of medications. Consequently, AAMP case management staff will work closely with the Corrections Health discharge planner to bring identified persons into the project immediately upon their release from jail.
Via the discharge planning process, qualifying individuals in psychiatric inpatient units will be identified as eligible for the AAMP and services will be begun and/or arranged immediately following discharge. AAMP case managers will work closely with hospital discharge planners to engage persons in services who are referred to the project prior to discharge from the hospital. Participating hospitals will include Providence Portland Medical Center, Providence St. Vincent Medical Center, Legacy Emanuel Medical Center, Legacy Good Samaritan Hospital, and Oregon Health Sciences University.
Also via the discharge planning process, qualifying individuals in sub-acute settings will be identified as eligible for the AAMP and services begun or arranged following discharge. Participating programs providing sub-acute services include Mental Health Partners (Ryles Center), Providence Medical Center Crisis Triage Center, and Pacific View Residential Center (for older adolescents). AAMP case managers similarly will work closely with sub-acute discharge planners to engage persons in services who are referred to the project prior to discharge from the sub-acute facility.
Other referral sources for the AAMP may channel clients directly into the Mental Health Service Networks and Participating Pharmacies to begin treatment, or may send them through the CTC, Hooper Center, hospitals, jails or sub-acute services for triage. Referral sources may include:
Aging and Disability Services Department, BHD Commitment Services, Community Corrections and the Oregon Youth Authority, the Courts, Sheriff/police, group home providers, landlords, primary care physicians, Project Respond, shelters, Outside In, and other programs serving homeless individuals, self referrals.
It is anticipated that the AAMP will take some participants from each of these referral sources, which will ensure diversity and make project resources available to the variety of systems that could serve as an entry point to the project. In the detailed descriptions of the referral sources below, none of the referral sources should be considered to weighted any heavier than another. However, of necessity, some descriptions of the potential referral sources are more detailed than others to demonstrate the unique role each plays.
Aging and Disability Services Department
The Multnomah County Aging and Disability Services Department (ADSD) encounters non-insured individuals primarily through their Protective Services and/or Risk Intervention staff. Such individuals are generally staffed in this Department through a Multi-Disciplinary Team. The teams in the Aging Services offices include staff from DCFS Behavioral Health Division. Referrals will be made through the mental health staff, directly from ADSD staff to the Behavioral Health Division, or for clients in acute crisis, through CTC.
BHD Commitment Services
Multnomah County’s Commitment Services coordinates the investigations and trial visits for a subset of the hospital population. Only about 10% of those under consideration for commitment meet the criteria for commitment. Those individuals who don’t meet the criteria for commitment are discharged. Often, these individuals need rapid access to community mental health treatment. Commitment Services will provide referrals to AAMP staff of people who are uninsured and not eligible for the OHP, but who need to be supported through the mental health outpatient system. As these clients are transitioned into the community, the AAMP would provide medication support and a link with treatment services.
Community Corrections, Courts and Sheriff
Although participation in the AAMP would be strictly voluntary, the Multnomah County Circuit Court (the Court), the Multnomah County Sheriff’s Office (MCSO), and the Department of Community Justice Services Adult Parole and Probation (CJS) would be able to provide referrals for individuals to participate in the AAMP via the four following pathways:
- As a mandated condition of Court ordered pretrial release. Community supervision, in cooperation with the program’s teams, will be provided by the MCSO’s Close Street Supervision unit (CSS) and by CJS’s Pre-release Supervision Program (PRSP).
- As a Court ordered condition of sentencing in crimes resulting in community probation.
Upon recommendation and referral of a probation officer regarding subjects who are currently serving probation sentences.
- As a condition of participation in the interagency, interdisciplinary case management support program offered through the proposed Mental Health Court docket (which could begin operation in conjunction with the proposed Westside Community Court as early as Fall 2000).
A subject’s referral for court consideration to the AAMP as either a pretrial release or sentencing/probation option will be made on the defendant’s own motion through his/her defense attorney. It would be a voluntary effort on the part of the subject to engage in treatment services, should the AAMP be recommended. Members of the criminal defense bar will be informed of the benefits of the program for their clients who meet the AAMP criteria through a Court information/education bulletin which will be sent to each of the major defense firms and posted in the various arraignment courts. Such an information bulletin will also be sent to each judge and referee of the Court, the District Attorney’s Office, CJS, MCSO’s counseling staff, and the Corrections Health Division’s mental health team. Information about the Project’s opportunities and benefits will also be provided to Multnomah County’s various police agencies for referral by each agency’s Crisis Intervention Teams as a possible alternative to arrest.
After an in-custody subject has been identified as suitable for AAMP, and he or she agrees to participate, the appropriate team intake coordinator will be notified. An evaluation can be ordered (and can be completed by either Corrections Health Division or AAMP) and medication delivery commenced while the subject is still in a custodial setting in preparation for a smooth transition to a community setting.
Advantages of including this population in the AAMP are significant. This population will be actively case managed and monitored, reducing fragmentation, improving continuity, and improving service quality. Additionally, The availability of appropriate medications, continuity in medication management, outpatient mental health services, and active case management will result in significantly reduced rates of incarceration and psychiatric hospitalization for this population.
A 1995 jail population study (Profile of Psychiatric Alert Inmates Booked at the Multnomah County Justice Center During 1995 – p.19 & p.31 – Carlson, Midkiff, McGovern, Windell. 1996) reported that enrollment in a community mental health program had a statistically significant effect on the total number of days spent in jail, i.e., those enrolled in treatment spent about 12% fewer jail days.
Group Home Providers and Landlords
Group home providers will be given information about the AAMP through Network mental health agencies affiliated with or serving clients from the group home. In addition, information to group home providers will be distributed by staff of the Behavioral Health Division Housing Coordination Unit. Staff of this unit are often in contact with clients before they are placed in housing. In this case, BHD Housing Coordinators will refer appropriate clients directly to the AAMP.
The Housing Authority Resident Services Coordinators provide support services to the tenants of ten high rise residential buildings in Multnomah County. These coordinators will serve as the referral link to bring residents who qualify into the AAMP.
Through increased case management and outreach support (funding, in part, through System Relief monies and in part through the AAMP), as well as the existing Project Respond, landlords will have rapid access to mental health professionals who will be able to provide outreach and intervention, and refer clients directly into services or, as appropriate, refer appropriate clients to AAMP staff for rapid psychiatric access.
BHD is also working with the Housing Authority of Portland, through a Housing Planning Work Group and other efforts. BHD will work with HAP, as well as existing housing support organizations (e.g. the Northwest Pilot Project) to disseminate information on outreach and other mental health support services which are available to landlords, including the AAMP program.
Primary Care Physicians
The Multnomah County Health Department Primary Care Clinics have a variety of staff providing behavioral health services, including psychiatric medication management, to clients with significant psychotic disorders and no insurance or financial means for paying for these services. The majority of these prescribing services are provided by primary care provider staff (Family Practice and Internal Medicine Physicians, and Family Nurse Practitioners), but about one third are provided by Psychiatric Mental Health Nurse Practitioners (PMHNP) and Psychiatrists who provide psychiatric evaluations and medication consultations to the primary care system. In addition, the clinics have four QMHP social workers who provide case management/linkage, brief counseling, behavioral consultation and other behavioral health services to clients receiving primary care from the Health Department, and three alcohol and drug counselors employed by the Behavioral Health Division but placed within the Primary Care Clinics.
The Multnomah County Health Department Primary Care Clinics do not identify themselves as primary providers of medication management services for the population to be served under this proposal, those with persistent psychotic disorders. Rather, the intent and need is to refer this group of clients for quick access to services in the community mental health system, where the comprehensive mix of psychiatric, case management, and psychosocial interventions can be provided. However, the clinics’ providers do provide these services to those patients who receive primary care services from the clinics and are unable or unwilling to obtain them from the community system. In addition, the clinics’ primary care providers recognize that clients on a stable medication regimen and involved in a stabilizing psychosocial treatment program can effectively have their medications managed within the primary care system, especially if prompt and coordinated access to the community mental health medical services is available if and when the patient deteriorates or becomes unstable. The PMHNP can assist with maintaining these clients within the primary care system through consultation with the primary care providers, coordination with the CMHC medical providers, and evaluation of clients who are receiving primary care from the Multnomah County Health Clinics but are unwilling to access the community mental health system. However, the PMHNP staff are only able to see patients referred to them by the clinics’ primary care providers; they are not a resource available to outside referral.
The four social workers of the primary care clinics will serve as the primary contact liaison between the primary care clinics and the community mental health agencies, Hooper Center, and the Crisis Triage Center (CTC), assuring coordination of care and smooth and effective transition from one system to the other. By establishing such liaisons within the Health Clinics, along with comparable positions within the community mental health agencies and CTC, problems with coordination of care, and differences of opinion about whether a patient is ready to transition to primary care management, can be quickly resolved, and systems improvements can be developed.
The Health Department Primary Care Clinics are active participants in the current Indigent Medication Program. However, significant differences in documentation needs have been noted between the Health Clinics and the Behavioral Health Division. Under the proposed AAMP, a coordination work group will be established to streamline documentation and reduce duplication with significant consideration given to the unique characteristics and requirements of the Primary Care system.
Project Respond is a crisis response and street outreach program that provides mobile mental health services to the community. The first priority of the Project Respond Team is crisis response, and the team members are broadly empowered to intervene in a variety of situations. When the team is not engaged in a crisis call, they regularly visit parks, shelters, freeway underpasses and other locations where homeless people frequent. Through the Project Respond Team efforts, individuals needing services for psychotic disorders will rapidly be referred to and connected with the AAMP.
Homeless Individuals Using Housing Shelters or Living on the Street
The area shelters will be an avenue where the homeless population can link into the AAMP. Psychotic individuals who present at the shelters can be referred into triage and stabilization, if necessary, and move into ongoing treatment with the support of the AAMP Care Coordinators.
Individuals qualifying for services through the AAMP and receiving housing through the shelter system will be identified in a number of ways: 1) increased information to shelter staff regarding rapid access to mental health (including AAMP) services, 2) availability of AAMP staff for consultation and rapid program response, 3) availability of Project Respond staff for on-site assessments and referrals, and 4) links with the Behavioral Health Division Housing Coordination Unit.
Network Behavioral Healthcare currently maintains a street-based HUD funded outreach program for adolescents and young adults, many of whom are eligible for the OHP and/or the AAMP. Network Behavioral Health also provides psychiatric time and consultation for primary care providers based at Outside-In, a downtown service for homeless young adults. Qualifying youth receiving psychiatric prescriptions at Outside-In by the participating psychiatrist, or by Primary Care providers in consultation with the psychiatrists, are already being enrolled in CAAPCare Plus and the Indigent Medication Program. The addition of AAMP funding would allow a significantly expanded population of young adults to be served, substantially improving access time and reaching individuals at the critical transitional period between adolescence and adulthood. The Psychiatrist providing service at Outside-In will work closely with AAMP staff and will make direct referrals to the AAMP.
An individual can self-refer by presenting at any point in the system. With the broad array of referral sources, the number of triage and stabilization facilities, the extensive networks of service providers, and the coordination of the Networks, the Multnomah County AAMP project provides connections to the project throughout all levels of service.
Experience with the current CAAPCare Plus and Indigent Medication Program indicates that individuals may hear about these programs and voluntarily come forward for service. The CAAPCare/CAAPCare Plus Access Triage and Member Services Units routinely receive calls from individuals needing mental health services and/or medications, and inquiring as to whether they would eligible for these or similar programs. Consequently, it is expected that self-referrals will increase as the AAMP program develops.
Anticipated number of persons within the targeted population who will be served – at a minimum 300:
Based on the full funding of this proposal at $1.65 million, a minimum of 300 uninsured psychotic clients will receive psychiatric assessments, atypical anti-psychotic medications, other necessary medications, case management services, and other necessary services during the 13.5 month life of the project from May 15, 2000 to June 30, 2001. This will be in addition to persons who will be served through CAAPCare Plus and the current Indigent Medication Program, both of which will continue and are expected to be fully utilized. The cost of providing medications to these 300 clients, at an average of $407 per client month plus laboratory fees, is projected at nearly $1.125 million of the $1.6 million request, leaving $0.525 million for services.
Based on a recent informal survey, the Behavioral Health Division was able to identify 4570 annual contacts with seriously mentally ill individuals that met the criteria prescribed under the proposed project (CTC = 2,366; Network Behavioral Health = 1,606; Primary Care = 173; Corrections Health = 170; Unity, Inc. = 90; Hooper Center = 85; Community Justice = 50; and Aging and Disability Services = 30; – See Attachment 5 – Letters of Support and Participation). BHD estimates that this represents a minimum of 1400 unduplicated clients. Consequently, BHD anticipates that, with the full funding of this proposal, there will be no difficulty in identifying and serving a minimum of 300 additional persons who qualify under the criteria of the proposed project. In fact, BHD anticipates that referrals to the program will be far in excess of 300 persons. In addition to the referral contacts detailed in the letters of support and participation, thse letters provide evidence of significant numbers of individuals with untreated psychotic disorders who meet the criteria for participation in the AAMP.
It is anticipated that at least one-third or 100 of the AAMP participants who are uninsured and in need of atypical anti-psychotic medications will receive triage and stabilization services through the CTC or Hooper Center before entering the project. As described below, case management staff funded through the AAMP will regularly be on-site at the CTC and Hooper Center to engage persons who are referred to AAMP so that they do not fall through the cracks.
It is anticipated that at least 20% or 60 of the AAMP participants may be referred into the project directly from the jail or Community Corrections. (During calendar year 1999, 170 persons with diagnoses of psychotic disorders were booked into the Multnomah County Jail 223 times. The number of persons is unduplicated. The number of bookings is duplicated; i.e., the same person could have been booked more than once during the calendar year. The jail study did not track how many are without health insurance. Corrections staff do know that 79% (134 people) return to the community in Multnomah County, based on records of charge disposition. Additionally, a June 1999 medication audit showed that Corrections Health providers were the initial prescribers of approximately 50% of the psychotropic medications required by the incarcerated population. Since Corrections Health staff cannot say exactly how many are without insurance benefits and because publicly funded benefits are definitely lost after 30 days in custody, this proposal anticipates the number of persons with diagnosed psychotic disorders who remain in custody 30 days or longer as the minimum number expected to be eligible for the AAMP. This unduplicated number is 71).
It is anticipated that at least 20 % or 60 of the AAMP participants will be referred to AAMP staff by acute care and sub-acute discharge planners and BHD Commitment Services staff. Commitment Services performs approximately 2700 Multnomah County investigations per year of people with major mental illnesses. Of the 90% of persons who don’t meet the criteria to be committed, 30% (619) are indigent and a large proportion of those persons are in need of anti-psychotic medications.
Detailed description of the program philosophy and the treatment approach, appropriate to the needs of persons with schizophrenia and other psychotic disorders
The proposed Multnomah County Project is intended to facilitate the availability of Clozapine (Clozaril), Olanzapine (Zyprexa), Quetiapine (Seroquel), and Resperidone (Resperdal) to those individuals who will benefit from an atypical anti-psychotic medication, but are uninsured and not enrolled in the Oregon Health Plan (OHP). However, the likelihood that treatment with such medications will have a positive impact relies greatly on a well supervised treatment protocol, and the ability to provide adequate support services for the ongoing participation in treatment. The ability to engage people in treatment and the provision of wrap-around services is crucial to the program design.
The partners in this project recognize the importance of community based, flexible treatment, which is tailored to the needs of the individual consumer. The program philosophy will be based on respectful, culturally relevant, services delivered, in so far as possible, in the individual’s natural environment. Individuals with psychotic disorders often require a lengthy period of relationship and trust-building before they will agree to a medication trial, and some are never willing to try medications. These attitudes will be respected and the individual’s preferences will be the starting point of treatment. Through development of relationships with Health Department and other primary care providers, clients will experience improved coordination of medical, psychiatric, and community mental health care. Individuals in this project will participate fully in their treatment planning.
Treatment will be provided in a setting most comfortable for the consumer, appropriate to the needs of clients with schizophrenia and other psychotic disorders who fit within the target populations. Consumer participation in treatment and treatment planning, cultural sensitivity, and multi-disciplinary approaches are stressed in this model. In the AAMP, both the client and the professional will possess equal treatment authority.
The system of care occurring across four major outpatient providers (ABH, HSA, CTC and the Health Department) has a significant potential for fragmentation of care for individual clients. Many disenfranchised consumers prefer receiving medication management through the Health Department and will never accept traditional mental health services. While the Health Department has prescribing resources for these consumers, the Health Clinics lack the capacity to provide care coordination services to them. Other consumers may initiate crisis services, including medications at CTC, then not return for follow-up medication management services or may not follow through on outpatient referrals. Both ABH and HSA are experiencing difficulty in providing urgent access to psychiatric prescribing, particularly for those consumers who are accessing services for the first time. This Project will link these four and other entities to respond more rapidly to individuals’ needs, and to provide improved service coordination and integration.
Case Managers/Care Coordinators, while housed with either ABH or HSA, will provide a continuum of services across the entire provider system. CTC and the Health Department, in return for care coordination and support for their consumers, will increase the availability of prescriber appointments to consumers from both provider networks. ABH and HSA will also add prescriber time at their outpatient networks to alleviate the enormous backlog of need for provider services.
The key to the success of this Project will be engaging and maintaining consumers in treatment through the use of outreach, so that they do not fall through the cracks of the system. AAMP care coordination staff housed at ABH and HSA will be expected to engage in considerable outreach activities to triage and stabilization sites – particularly CTC, Hooper, hospitals, jails and sub-acute facilities –to bring stabilized participants into the program. (On the other hand, it is anticipated that Project Respond and the CTC mobile outreach team will be the first responders to provide outreach to unstable clients in other community settings, such as housing placements and shelters.)
Experience gained in the Indigent Medication Program has enabled the Behavioral Health Division to build a model of the typical episode that describes treatment with atypical anti-psychotic medications. Data from the Indigent Medication Program has led to the development of a projection of how the 300 client minimum will receive medication and services. This model projects the current experience of Indigent Medication Program clients over a period of nine months of medications and services to the full 13.5 months of the AAMP (see Attachment 3 – Length of Time CAAPCare Plus/Indigent Medication Clients Received Atypical Anti-psychotic Prescriptions and Attachment 4 – Client time of Service for CAAPCare Plus/Indigent Medication Clients Receiving Atypical Anti-psychotic Prescriptions).
Development of this model of a course of treatment with atypical anti-psychotic medications assumes an average of four months longer in services for non-OHP eligible clients than has been the case in the first year or so of the initial Indigent Medication Pilot Project and the current Indigent Medication Program. It is anticipated that this additional time in treatment will be a result of successful client engagement in medication management and case coordination services which will be funded through the AAMP, as well as increased system capacity for outreach, urgent access, dual diagnosis, housing stabilization and related services (which will be funded through State System Relief Funds available throughout the duration of the project).
A primary assumption of the AAMP model (consistent with experience in the CAAPCare Plus and Indigent Medication Programs) is that three scenarios would apply to those individuals participating in the project (see IMP data attachments). There will be approximately 30% or 90 clients who are not eligible for the OHP and who will receive medications and services for the full 13.5 months of the project. Approximately 50% or another 150 clients who also are not eligible for the OHP, with a delayed entry into the Project due to case finding over the first six months, will receive medications and services for an average of nine months. Only a relatively small percentage, the remaining 20%, or another 60 clients, will be OHP eligible but not yet enrolled. This group of OHP eligible persons generally are too psychotic or too unwilling to enroll in the OHP, requiring interim assistance with medications and services for an average of three months until they are sufficiently stabilized to enroll.
BHD’s experience in the Indigent Medication Program has demonstrated that the OHP eligibility rules (enrollment based on application date) result in only a small gap in coverage for people who are OHP eligible, and so the number of OHP-eligibles to be served in AAMP is projected to be relatively small and not a significant cost factor, only 20% of the population participating in the AAMP. Should the relative percentage of OHP eligible clients be greater than anticipated, and consequently the average length of stay in the AAMP be shorter than projected, it would be possible to serve more than the projected 300 uninsured psychotic clients during the 13.5 month life of the project.
Proposer must describe in detail the staffing (including qualifications, training, and experience of personnel), for both treatment needs and social assistance (such as housing, insurance enrollment)
Psychiatric assessment and medication prescribing services will be provided by licensed medical providers. The AAMP project will fund the equivalent of a half time MD and a full time PNP to enhance the availability of prescriber time. (Prescriber time will be further enhanced based on System Relief Funds).
Assessments and reassessments will be provided by Board Certified Psychiatrists with experience in Community Mental Health Programs, and are projected at two hours each for 300 clients or 600 hours over 13.5 months. This is the equivalent of a 0.25 FTE Psychiatrist for each of the two Networks for the 13.5 months of the AAMP. At least an hour of psychiatric assessment will be during the consumer’s initial period of engagement with the AAMP
Medication monitoring would be performed by a Psychiatric Nurse Practitioner with at least two years experience in a Community Mental Health Program setting, and is projected at an average of four hours per client at one half (1/2) hour per month of “billable” services for each client over the eight months after the first month of services, or a total of 1200 hours. This is the equivalent of 0.5 FTE for each of the two Networks over the 13.5 months of the project and an annual total of 1066 “billable” hours or 51.25% productivity.
Care Coordination, for both treatment needs and social assistance (food, health care, housing, income maintenance, insurance) will be a core service to the AAMP participants. The AAMP project will fund the equivalent of five (5) Masters level Qualified Mental Health Practitioner (QMHP) Case Coordinators with at least two years of experience in a Community Mental Health setting, thereby creating a case coordination team which will be available to participants on a regular basis. These case managers will be mobile to enable a quick response when an individual is identified as eligible for the AAMP through one of the triage and stabilization sites or one of the other referral sources listed in Section B. It is anticipated that the highest number of referrals (and potentially most critical cases) will come from the CTC, Hooper, hospitals, jails and Project Respond. AAMP case managers will maintain regular and close contact with these referral sources in order to provide immediate follow-up after the initial intervention.
Case managers will move freely among social service providers to link individuals to the most appropriate services. This team, while housed at the two major outpatient Networks, ABH and HSA, will primarily work in the community settings where there is the highest concentration of the population which is the target of this project. The case management team will be available to all service providers for identification and referral of new clients through the development of clear referral protocols. This will require developing strong relations with all of the AAMP referral sources, with the care coordinators being available to be on site in order to provide support for those people who may otherwise fall through the cracks.
Proposer must identify caseload sizes for case management and a minimum schedule of face to face meetings with the clients.
Care coordination will be provided by five (5) Qualified Mental Health Professional (QMHP) staff. Care coordination capacity will be developed at each community outpatient site, creating a team linking the various sites. Care Coordinators will provide direct links into supported housing teams, psychosocial services, money management, and dual diagnosis treatment.
At a minimum, the schedule for case management/care coordination by a QMHP is projected at an average of 20 hours for each of the 300 clients, with an average of six “billable” services within the first two months of services for each client and an average of two “billable” hours per month of services for the next seven months, or a total of 6,000 hours. This could provide a minimum schedule of face to face contacts with clients as high as two hours per month for the first two months, with as much as an hour of face to face contact per month for subsequent months. (As these are averages, the number of hours of actual case management for individual clients will vary.) This is the equivalent of 2.5 FTE QMHP Case Managers for each of the two Networks during the 13.5 months of the Project who are working at 51.25% productivity. This productivity level is somewhat high based on industry standards, but will be efficiently maximized with the support of other system resources.
Caseload sizes at full capacity are projected at 40 to 60 per Case Manager for the total of 200 to 300 clients in service per month served by the five FTE. However, as clients will be rapidly assessed, stabilized and linked to appropriate services and social assistance programs, including Network psychiatric, outpatient, and community and housing support services, it is expected that the number of clients requiring intensive case management at any given time would be closer to 20-30.
Describe in detail the programming to be used in addressing the needs of persons in the program.
The programming to be used to meet the needs of persons in the project will include a QMHP and psychiatric assessment, prescription administration, medication monitoring, care coordination, mental health treatment including integrated mental health and chemical dependency services for individuals with co-occurring disorders, OHP and other application assistance, and housing assistance.
The team resources used to implement and maintain the project will be a Project Team of five Case Managers/Care Coordinators, Care Coordinators working in close conjunction with designated Medical staff, including the equivalent of a 0.5 FTE Psychiatrist and a 1.0 FTE Psychiatric Nurse Practitioner. The team will offer flexible and mobile resources to respond to the needs of individuals identified through the multiple system points of entry. This team will respond to referrals from CTC, Hooper Center, hospitals, jails, sub-acute facilities, Corrections, Project Respond, landlords, shelters, Health Department Primary Care Clinics, and any other sites where members of the targeted population are identified. The team’s primary responsibilities are to facilitate the engagement in atypical anti-psychotic treatment through the AAMP resources (or other appropriate resources should the individual not be eligible for the AAMP), assure linkage across agencies, assist eligible individuals in applying for financial assistance and the Oregon Health Plan, and provide care coordination until the individual has established a secure connection with on-going services.
Each consumer referred to AAMP will receive a mental health screening or assessment at the point of referral, and a complete mental health assessment by a project case manager or QMHP at a participating organization. Based on this assessment, as appropriate, expedited psychiatric assessment and medication management services will be arranged. When appropriate, individuals will be seen immediately by a Psychiatrist or Psychiatric Nurse Practitioner, through a same day appointment at an Outpatient Network agency, Project Respond, or the Crisis Triage Center. All participants will be assessed by a Psychiatrist as part of the initial entry into the project, with on-going medication management provided by the PNP.
Initial psychiatric assessment will included administration of the AIMS scale, and a physical exam which looks for signs and symptoms of conditions like Tardive Diskinesia (TD) and Extra Pyramital Symptoms (EPS), which are common side effects of anti-psychotic medications. Although atypical anti-psychotic medications may reduce or mitigate TD or EPS, consideration of existing or potential side effects is a primary consideration in medication management, including the possible need for side effect medication in the individual’s overall medication regime.
After receiving a psychiatric assessment, and as medically appropriate, atypical anti-psychotic and related medications will be prescribed. (Any necessary laboratory work for medication administration and/or monitoring will be funded through the AAMP). A minimum of two additional half-hour sessions for medication monitoring will be scheduled within the first month of the project in order to ensure the participant’s stabilization on the medications. Medication monitoring and laboratory testing will be scheduled as appropriate in subsequent months. Through the Participating Pharmacies, the AAMP will provide all needed atypical anti-psychotic medications, associated side effect medications, and other psychiatric medications necessary to ensure an optimal medication response.
To maximize efficiency in the use of funding for medications, prescribers will work closely in conjunction with area drug representatives in order to ensure that samples of the atypical anti-psychotics are available to provide an initial supply of medications to clients upon discharge from the referring agencies, particularly the CTC. These samples have been instrumental to initiating treatment with atypical anti-psychotics in the past, and the AAMP does not expect their availability to be reduced.
Multnomah County recognizes the potential for service gaps and poor linkage between the provider networks, the CTC, and the Health Department. The proposed program is designed to significantly improve service linkages for one of the most vulnerable mental health populations through interagency coordination, shared prescriber access and care coordination services. Care coordinators will physically follow consumers as they move from one program to the next, achieving a more integrated continuum of care.
As part of their case coordination services, participants in the AAMP will receive support in obtaining Public Assistance such as Food Stamps, Supplemental Security Income, and other financial entitlements, and will be provided linkages into primary care services when health issues are identified. In addition, Care Coordinators will provide assistance with the application process to ensure rapid enrollment into Medicaid or the OHP and/or other health care coverage for which the individual may be eligible (e.g. Medicare). Based on present experience in the Indigent Medication Program, this project assumes that approximately only 20% of the population participating in the AAMP will be eligible for the OHP.
Housing Assistance will also be available to participants in the AAMP. There has been no significant increase or new funding into homeless services by federal, state, or local jurisdictions for several years, so the continuum of services is significantly under funded. Cutbacks and scarcity of services for the mentally ill has impacted all of the shelter services. Along with the concentration of shelter access and services in one agency, provider agencies have been working to develop a mutually reinforcing constellation of services. The work of Project Respond has made a significant contribution to the awareness of the impact that mentally ill consumers have to the housing dilemma. Accompanied by the concern for inadequate housing and services for the mentally ill, linkages are being reinforced between the two systems.
Due to financial restrictions, ABH and HSA have limited the amount of housing support services available to consumers. Newly eligible consumers, in particular, often lack access to appropriate safe housing, which detracts from their ability to benefit from medication management services. Under this proposal, coupled with System Relief Funds, both Networks plan to rebuild housing support services to include housing finding assistance, assistance in developing relationships with apartment managers and housing programs, in-home individual and group skills training, eviction prevention, tenant/landlord consultation, and mediation services.
Under the System Relief proposal, Supportive Housing Specialists will assist consumers wanting to locate and maintain appropriate housing. These housing support staff will work with consumers who are residents of a variety of independent and semi-independent housing, offering home-finding, in vivo supports, tenant and landlord consultation, mediation, short term problem solving and other supportive housing services. A primary focus will be to facilitate early and effective intervention in budding lease compliance issues. Appropriate linkages between housing providers and case managers will be facilitated, thus increasing the level of understanding, timeliness of communications, and cooperative efforts between the two groups. A regular presence will be maintained at housing sites that rent to multiple consumers, adding an element of predictability, reassurance and increased accessibility for the property management staff.
Describe an integrated approach to serving persons with both psychotic illnesses and substance use problems.
A large percentage of clients receiving services through the AAMP (up to 70%) are expected to have concurrent substance abuse problems. A number of flexible options will be available to support individuals with both psychotic and substance abuse disorders.
Initial Detoxification and Stabilization
AAMP Case Managers and medical staff will work closely with Hooper Center (and local hospitals) to ensure the provision of initial detoxification when appropriate, 2) provide immediate linkage with outpatient psychiatric, mental health, and chemical dependency resources upon discharge and 3) provide immediate follow-up for individuals identified by Hooper Center, hospital staff and other during the detoxification process who are eligible for and in need of AAMP services.
The Crisis Triage Center has extensive experience in the assessment of dually diagnosed individuals and co-located mental health and chemical dependency stabilization services through it’s Sub-Acute service. AAMP Case Managers will conduct daily phone staffings with the CTC to identify individuals appropriate for AAMP services, including those requiring dual diagnosis services or immediate linkage to both mental health and chemical dependency treatment.
AAMP Case Managers and Medical staff will also work closely with local hospitals to identify individuals with dual diagnoses prior to discharge and arrange appropriate services.
Treatment Resources for Dually Diagnosed Individuals
AAMP Case Managers will link clients with the most appropriate combination of services based on individual needs. Both ABH and HSA have successful dual diagnosis treatment programs tailored for clients with severe mental health disorders and concurrent chemical dependency problems. Some clients will function most successfully in separate but coordinated mental health and chemical dependency treatment programs. In this case, AAMP Case Managers will facilitate entry into both programs and ensure that treatment for both conditions is coordinated.
It is expected that a portion of AAMP clients will be most appropriately served through programs providing synthetic opiates (methadone). AAMP Case Managers will make appropriate linkages with methadone programs and will ensure that both chemical dependency and mental health/psychiatric treatment are coordinated. Both ABH and HSA have working relationships with methadone providers to help facilitate such coordination.
Community support resources will be critical to the long-term recovery/stabilization of dually diagnosed clients served by the AAMP program. Housing (particularly substance-free housing) will be particularly important. AAMP Case Managers, working closely with ABH, HSA , the Behavioral Health Division Housing Support Unit, and chemical dependency housing providers, will determine (jointly with the client) the most appropriate housing program. AAMP Case Managers will work with community providers to gain access to housing and will provide active case management, monitoring and outreach in the event there is a waiting period prior to a resource becoming available.
Other critical community support resources will be active case management, assertive outreach when needed, appropriate outpatient treatment, rehabilitation activities including daily structure and support, and on-going follow-up. AAMP Case Managers will provide active case management and outreach, including linking clients with appropriate and on-going support and rehabilitation services.
Describe how the project will develop interagency coordination and linkages to assure adequate crisis and acute care services to participants of the project.
The Multnomah County Crisis Triage Center will be a full and active partner in the AAMP. Daily phone staffings will be held between CTC staff and AAMP case managers to ensure that 1) clients served at the CTC qualifying for and needing AAMP services receive immediate follow-up and active case management, and 2) clients served by the AAMP experiencing psychiatric emergencies have immediate access to the CTC when needed. It is expected that some clients experiencing emergencies will be immediately assessed by AAMP or outpatient psychiatric staff, Network Outpatient staff, Project Respond, or other teams/individuals. In many cases, this intervention (possibly including a telephone consultation with the CTC) will be sufficient. However, if immediate services are not available, or if medical intervention is needed and/or the individual needs to be seen in a secure setting, the CTC will provide assessment, crisis, and triage services, including inpatient admission when appropriate. AAMP Case Managers will follow-up to ensure immediately linkage to post-crisis resources.
AAMP case management staff will also work closely with Project Respond to identify and follow-up individuals identified as eligible for and needing the services of the AAMP. Project Respond will also serve as a resource for AAMP clients experiencing a crisis and requiring immediate assessment and intervention.
Describe how the project will develop interagency coordination and linkages to assure adequate crisis and acute care services to participants of the program.
ABH and HSA both have provision for same day and following day appointments, including psychiatric appointments, and will work closely with AAMP case managers to ensure that needs of individuals served through the AAMP are met. Under the AAMP and System Relief proposals, both Networks have proposed to increase Psychiatrist and Psychiatric Nurse Practitioner time for emergent and urgent appointments.
The AAMP Case Management Team will be available for rapid response to referrals from CTC, acute care settings, sub-acute facilities, jails, shelters, primary care clinics and any other sites where members of the targeted population are identified in order to reduce the number of crises experienced by individuals who may “fall through the cracks” between one system and another. This is anticipated to reduce the need for crisis services, hospitalizations, and incarcerations for the individuals served by the AAMP. The goal of the AAMP, so far as possible, will be to prevent crises. When they do occur, the team will intervene immediately to lessen the disruption, distress, and negative impact for individuals served and those around them.
Affirm participation in the OHSU program evaluation to include a comprehensive system for recording, maintaining and reporting information about the program as it progresses.
DCFS has gained valuable experience through the work of the CAAPCare Plus Indigent Medication Program and will bring that experience to the evaluation design of the AAMP. There is also a vested interest in participating in the evaluation program to help clarify a number of procedural and clinical questions that have arisen from the Indigent Medication Program. Information gained through this evaluation can be used not only to improve on the services provided under the CAAPCare Plus Indigent Medication Program, but to seek additional funding to continue the project, and to provide a basis for exploring the cost benefit of treating psychotic illnesses with atypical anti-psychotic medications.
Project staff will work with the MHDDSD under the independent evaluation of OHSU to determine specific measures for the tracking of outcomes. Initially, specific outcomes will be determined relating to a reduction in the severity and duration of symptoms, in the incidents of relapse in the course of illness, in acute psychiatric care, medical care, hospitalization, criminal justice system and law enforcement costs, as well as a general increase in a participant’s functioning and satisfaction in life.
DCFS has a longstanding relationship with Oregon Health Sciences University, the program evaluator of the Project. Currently, the Indigent Medication Program has an existing protocol for the recording and maintenance of data to start from, and will make adjustments to this protocol to meet the evaluation paradigm. DCFS affirms that it will fully cooperate in the program evaluation being conducted by OHSU including participation in a comprehensive system for recording and maintaining data in accordance with the evaluation protocol designed for this project. Throughout the duration of the project, AAMP will report information about the project as directed by OHSU.
In addition, DCFS BHD will share with OHSU all information collected previously through CAAPCare Plus and the Indigent Medication Program, to determine if there are significant differences in populations served and to provide additional comparison data on services, medications used, and costs.
A detailed budget of all expenses to be incurred for medication administration and ongoing administration of the program. Clearly show the amount of new funds to be requested and include specific line item expenditures for prescribing and purchasing the medications, monitoring of medication use and safety and other services to be provided.
Funding for the AAMP will be administered through the Multnomah County Behavioral Health Division’s CAAPCare Plus Indigent Medication Program. New funds for services requested under this proposal would be $1,650,000.00, as detailed in the budget expenditures described in the New AAMP Funding section of Table 1 – Multnomah County Atypical Anti-psychotic Project Budget Matrix.
The cost of the drugs in this project will constitute the major expenditure of AAMP resources. Based on experience in the Indigent Medication Program, the cost of atypical anti-psychotic drugs and the associated side effect medications is projected to be an average of $407.00 per client per month. To serve 300 clients based on a nine month average length of service will cost $1,098,900, 67% of the new service resources requested in this proposal. Of that amount, again based on current experience, approximately 61% or $671,700 would be for atypical anti-psychotic medications, and approximately 39% or $427,200 will be for other necessary psychiatric medications.
Care Coordination will be a core service to the AAMP participants. The AAMP project will fund the equivalent of five QMHP Care Coordinators to form a care coordination team available to the participants on a regular basis. Case management by a QMHP is projected at an average of 20 hours for each of the 300 clients with an average of six “billable” services within the first two months of services for each client and an average of two “billable” hours per month of services for the next seven months or a total of 6,000 hours. This is the equivalent of 2.5 FTE QMHP Case Managers for each of the two Networks at a total cost of $292,500 for the 13.5 months of the Project (at an annual cost of $52,000 for 1.0 FTE or $58,500 for 13.5 months- which includes salary, fringe, materials and services and agency indirect costs – , and an annual total of 1066 “billable” hours per case manager or 1200 hours for 13.5 months which equates to 51.25% productivity). The $292,000 for care coordination represents 17.7% of the new service resources requested in this proposal.
Prescriber time, including the psychiatric assessments and medication use and safety monitoring are essential services in the Project. Assessments and reassessments by a Board certified Psychiatrist are projected at two hours each for 300 clients or 600 hours for 13.5 months. This is the equivalent of a 0.25 FTE for each of the two Networks at a total cost of $112,500 for the 13.5 months of the AAMP (at an annual cost of $200,000 for 1 FTE which includes salary, fringe, materials and services and agency indirect costs). Medication monitoring by a Psychiatric Nurse Practitioner is projected at an average of four hours at one half (1/2) hour of billable services for each client over the eight months after the first month of services or a total of 1200 hours for 13.5 months. This is the equivalent of 0.5 FTE for each of the two Networks at a total cost of $120,500 for the 13.5 months of the AAMP ( at an annual cost of $107,110 for 1 FTE which includes salary, fringe, materials and services and agency indirect costs). The total funding required for these prescriber services will be $233,000, approximately 14% of the new service resources requested in this proposal.
Lab fees will also be a necessity in the project, varying from participant to participant depending on the specific medications prescribed and the presenting issues. Based on the experience of the Indigent Medication Program, laboratory costs will be relatively low for this population, and are projected at $25,600 for 10 clients (just over 3%) on Clozapine at $2,560 total for each client over the average of nine months. This amount represents 1.5% of the new service resources requested in this proposal.
All of the requested $1.6 million will be passed through for medications, lab fees and Network personnel. DCFS is not requesting any funds for administration of this grant. County administration will be an in-kind contribution.
Provide a detailed statement of Base Budget Community Funds, Grant Award Funds and other local sources of funding that will be combined with the funds available through this proposal – including those that will continue beyond 6/30/01.
Further, as described in Table 1 – Multnomah County Atypical Anti-psychotic Project Budget Matrix, other sources available to support the AAMP include Base Budget Funding, System Relief Funding, County General Funds and other funding sources. CAAPCare and Sub-acute Plus funds are derived from the MHS 20, MHS 22, and MHS 24 funding streams. Portions of the System Relief Funding requested under a separate proposal through the MHDDSD will provide supporting access, outreach, dual diagnosis and housing resources. As an additional measure of commitment and dedication to the target population, Multnomah County is one of the few counties in Oregon that provides substantial additional support for mental health programs through County General Funds.
Medications for non-OHP eligible clients who do not need atypical anti-psychotic medications and necessary treatment services will be provided to these persons through Base Budget State General Funds (MHS 20, 22) contracts with Outpatient providers for services provided under the CAAPCare Plus Program and the Indigent Medication Program. It is assumed that the population of non-OHP clients in general will grow as a result of increased outreach and case-finding for the AAMP.
Triage and stabilization will be provided through the Crisis Triage Center and Hooper Center, funded with base budget State and County General Funds; calculated at $1,438 per indigent person served through the CTC or Hooper for a projected 100 people, or $143,800.
Treatment services through outpatient providers, including individual and group therapy, skills-building and other medically appropriate interventions will be provided to this target population through base budget State and County General Fund (MHS 20 and 22) contracts for CAAPCare Plus between DCFS and these providers; calculated at an average of $1,000 for 300 people served through AAMP, or $300,000
Sub-acute services purchased through CTC, Ryles Center and other sub acute settings with base budget MHS 24 funds contracts with community providers; calculated at an average cost of $5,200 per episode at an average length of stay of 13 days @400 per day for a projected 75 episodes of care for this 300 people served through AAMP, of $390,000.
Medications for non-OHP eligible clients who do not need atypical anti-psychotic medications at an average cost of $129 per client per client month and necessary treatment services will be provided to these persons through Base Budget State General Funds (MHS 37,20, 22) contracts with Pharmacies and outpatient providers for services provided under the Indigent Medication Program and CAAPCare Plus. It is assumed that this population of indigent persons who need psychiatric medications but who do not need atypical anti-psychotics will grow as a result of increased outreach and case-finding for the AAMP.
Housing stabilization and housing specialist funds for the non-OHP population are a total of $ 260,000 in County General Funds; $225,000 is contracted to Unity to support Project Respond and $35,000 for BHD Housing Specialists.
DCFS in-kind administration is calculated at 12% of a total AAMP cost of $1,875,000, or $225,000 of in-kind administration.
Outreach, urgent access, dual diagnosis, housing stabilization and other necessary services will be provided to this target population through the additional system capacity which will be funded with State System Relief Funds contracted by DCFS to the two outpatient Networks.
It is projected that the initial AAMP services will be implemented on May 15, 2000, and careful financial management will continue the Project through June 30, 2001. Clearly, the MHDDSD will need to await review of the evaluation of the AAMP before there are any plans to expand the project funding beyond June 30, 2001.
To ensure that the Project has strong support for continuation, DCFS will engage the pharmaceutical company representatives in forming a working partnership around treatment and medication. This partnership will form a platform on which to build a foundation for possible funding to continue with private sector funding from the pharmaceutical companies. While the System Relief Funding is limited duration support for the system, it will provide the initial resources for the infrastructure for the project. County government has a long history in making substantial contributions to further such projects and will move to support at least a portion of the AAMP as an add on package to the regular budget. The CAAPCare Plus MHS 20,22 and 24 funding will continue beyond the scope of this project.
Through the efforts of this Project, once established, the AAMP intends to demonstrate how a legislative request for continuation of funding would be critical. At all levels of involvement, the support of an effective treatment solution that can make positive impact on the most vulnerable and seriously mentally ill populations will show progress toward the improvement of a system in which a plentiful and needy supply of consumers exists. DCFS and the AAMP partner organizations will work closely with elected officials and MHDDSD involvement to encourage the continuation and increase of this funding in the future.
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