THE OLMSTEAD DECISION: Oregon’s Plan for Community Integration & Recovery
Draft 3 September 29, 2009
A meeting on this DRAFT will be Tuesday, October 20, 2009 from 1:30-3:30 pm at DHS in Salem, Rooms 137 A+B. Conference call: 1-877-455-8688 – Code: 674980
The landmark 1999 Olmstead Supreme Court case, affirmed the Americans with Disabilities Act requirement to place people with disabilities in community settings, has broad application. While some state Olmstead Plans take a universal approach to community integration, Oregon is updating its 2002 plan, which focused solely on adults with psychiatric disabilities (Oregonians with developmental disabilities were placed in community settings upon the closing of the Fairview Training Center; the state also has a federal waiver which will be used to downsize and eventually close all facilities that house people with developmental disabilities).
The existing plan was refined during summer 2009, utilizing a process whereby the Addictions and Mental Health Division held a series of one-to- one meetings with key stakeholders: consumers, family members, advocates, service providers, Mental Health Organizations, community mental health programs, and others. The resulting draft document was circulated to an even broader group of stakeholders for input before being finalized.
Oregon’s revised plan is a working document, reflecting the transformational leadership and the direction of the new legislatively approved Oregon Health Authority. It is anticipated that as the activities referenced in section III of this plan are implemented, the state will be able to add target goals, outcomes and metrics to this document. With this information and additional input from stakeholders, another version of Oregon’s Olmstead Plan will emerge within the next 12 months.
I. EXECUTIVE SUMMARY
A. INTRODUCTION TO OLMSTEAD
The Americans with Disabilities Act (ADA) was signed into law on July 26, 1990. This important civil rights legislation provided a clear mandate for the elimination of discrimination against people with disabilities in the areas of employment (Title I), public services furnished by governmental entities (Title II) and public accommodations (Title III).
On June 22, 1999 the United States Supreme Court decided the Olmstead v. L.C. case, which focused on Title II of the ADA, “a public entity shall administer services, programs and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.”1 In delivering the opinion of the court in Olmstead, Justice Ginsburg noted “unjustified placement or retention of persons in institutions severely limits their exposure to the outside community, and therefore constitutes a form of discrimination.”2 Under Olmstead, states are required to place persons with disabilities in community settings rather than in institutions when the State’s treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the affected individual and the placement can be reasonably accommodated, taking into account the resources of the State and needs of others with disabilities.
Oregon has had an Olmstead Plan in effect since 2002. As Olmstead celebrates its tenth anniversary, and with the legislative support for recovery focused transformation of the mental health delivery system at the state hospital, as well as construction of the new state hospital facility, it is timely to revisit Oregon’s progress (with regard to diversion, deinstitutionalization and community integration efforts), and refine the state plan.
B. OREGON’S HISTORY
Oregon currently has two state psychiatric facilities. The Oregon State Hospital (OSH) maintains a 549 bed facility located in Salem for both forensic and civilly committed adults, and a 92 bed facility in Portland for civilly committed adults. The Blue Mountain Recovery Center (BMRC) is administered separately, and is a 60-bed facility for civilly committed adults located in eastern Oregon.
The state has historically been committed to Olmstead’s underlying thesis of community integration and recovery.3 Oregon has been intentional in its goal of keeping people as independent as possible, as demonstrated by the closure of the Dammasch State Hospital property in 1995. The Community Mental Health Housing Fund was created by the 1999 Legislature from the sale of Dammasch and is codified in Oregon Revised Statute (ORS 426.502-426.508). The statute directs 70 percent of interest earned to community housing purposes and 30 percent to improve living conditions for state hospital patients. The Legislature statutorily reserved not more than ten acres of land in the planned community development known as Villabois for housing people with serious mental illness.
AMH has demonstrated commitment to developing an increasing number of community placements for people with mental illness, as illustrated by the biennial caseload growth numbers below. These numbers are reflective of beds legislatively approved to be created with both state General Fund and federal funds.
In March 2007 the Addictions and Mental Health Division’s (AMH) Community Services Workgroup (CSWG) published its final report. The purpose of the report was to inform AMH, the Department of Human Services (DHS), the Governor and the Legislature about the range of community-based services needed to complement the replacement of state hospital facilities and to assure the successful operation of the new hospitals. The report highlights the full continuum of mental health services needed to divert people from entering the state hospital, as well as services needed for successful community integration. The report provides a narrative description of each type of service, estimates the need for and cost of these services and a timeline for implementation.
In 2008, AMH reconvened the CSWG to update the original recommendations for new community-based programs and services. The recommendations were used to develop the 2009-2011 Agency Request Budget. Due to the state’s economic circumstances, no new resources were provided to the community system of care in 2009. However, the system was spared major reductions.
C. HISTORICAL DATA
Traditionally, OSH has not had the technological infrastructure to track patient progress across treatment domains. The implementation of the Behavioral Health Integration Project (BHIP), which is an element of the OSH Replacement Project, will provide modern technology for hospital management. BHIP is a hospital information technology system that once operational, will support patient treatment and recovery outcomes through a transparent master treatment care plan. Phase one of BHIP is scheduled to be operational in December 2010.
The hospital’s Continuous Improvement Plan (CIP) was partially funded by the Legislature in February 2008. The CIP is a five plus year plan to improve quality in all aspects of OSH operations, and includes measurable benchmarks. The CIP includes the hiring of additional direct care staff, psychologists, social workers, psychiatrists and nurses, which will improve the effectiveness of treatment and better prepare patients for discharge. During calendar year 2008 OSH hired over 300 new employees, and recently hired a Chief Medical Officer, as well as a Chief Nursing Officer. On July 27, 2009 OSH (both campuses) had 1352 staff and 638 patients.4 The 2009 Legislature approved an additional 540 OSH positions.
The CIP also addresses the development of transition teams for the discharge of patients who are forensically committed, the adoption of a risk assessment tool to determine safety requirements for discharge and the development of a new system of communication with community partners for discharge and community re-integration. To date, all of these goals have been achieved and are being implemented.
A key goal of the CIP is that all patients will receive at least 20 hours per week of active care and treatment. During the third quarter of 2008, patients received an average of over six hours of treatment, a 55% increase from 2007. This average includes an increase of almost seven hours of treatment for Geriatric patients and over four hours a week for forensic patients. Hospital staff expect these annual upward trends to continue as staff capacity continues to rise.
Further demonstrating compliance with Olmstead AMH collects data of people leaving institutions for community based care, and mean estimated length of stay at OSH. These data are routinely reported to the Ways and Means Human Services Subcommittee of the Legislature.
The historical trend depicted in the graph above indicates that the locus of treatment for acute care has shifted to the community, and that the number of people being discharged to community-based treatment has increased. Over the past several years the number of people served in the state hospital has been decreasing. While the historical data depict a steep trend in people being served in acute care community facilities, followed by a slowing and leveling, this is due to two factors. The first factor is tied to the explicit policy to move nearly all acute psychiatric care to community-based hospitals with psychiatric units. The second factor has to do with the advent of the Oregon Health Plan (OHP) mental health benefit in 1995, followed by the development of flexible community-based services using Medicaid resources, as there has been an increase in the number of people covered under the OHP.
Mean Length of Stay data indicate that over the past several years, the length of stay at OSH for people under the jurisdiction of the Psychiatric Security Review Board (PSRB) has decreased. There has been a slight decrease in length of stay for people who are civilly committed. People who commit crimes and are deemed unable to aid and assist in their own defense5 are currently experiencing slightly longer hospital stays, however the overall trend since 2000 can be interpreted as a plateau.
Historical data illustrate Oregon’s commitment and continued progress in meeting the intent of Olmstead. Recent legislative initiatives, coupled with Oregon’s directive to create an integrated health care system, will assist in the development of data systems and performance measures which support community integration and recovery.
D. VISION AND GUIDING PRINCIPLES
“Oregon’s efforts are meaningless without consumer/survivor input.” Kerry Hawley; Greater Oregon Behavioral Health, Inc. Board
“We need more than a pill and a doctor’s appointment.” Mark Fisher; Oregon Consumer Survivor Coalition Board
In the course of updating Oregon’s Plan, AMH conducted a series of one-on-one meetings with a variety of state and community stakeholders. When asked to share a vision of Olmstead when it has been fully implemented, a universal theme of stakeholders was that the needs of individuals should be matched to the appropriate level of care and services. In developing a plan considered to be a living document, the following guiding principles were identified:
o The right services and supports need to be provided at the right time in the right place, for the right duration, and should be person-directed.
o The data that is collected at the state, county and community levels should reflect the intent of Olmstead (i.e. people are receiving the right care, services and supports to be successful).
o Metrics to measure the “health” of the system must reflect lower levels of care in order to demonstrate that treatment is working.
o There needs to be a common set of rules, definitions, policies and procedures upon which all players agree (consumers and family members, AMH, OSH, PSRB, Mental Health Organizations (MHO) and community programs). For example, there needs to be a common definition for “ready to discharge,” that is agreeable to OSH, PSRB, and community providers.
o System investments should focus on the development of local services that reach people early in the course of illness, and effectively treats them in the community.
o The most integrated community setting must reflect consumer self-determination and empowerment.
o As many people as possible should have a key to their own home.
While Oregon has taken steps to comply with the Olmstead settlement, recent initiatives demonstrate an accelerated momentum towards fulfilling the true spirit of Olmstead. The next section of the plan will discuss these efforts. The third section of the plan addresses actions currently being implemented. The fourth section of the plan utilizes information from stakeholder interviews to identify systemic constraints and challenges. The plan concludes with recommendations and next steps that DHS believes will address these constraints.
II. RECENT INITIATIVES
AMH’s 2009 Ways and Means presentation to the Legislature acknowledged that even though there is currently an unmet need for mental health services in Oregon, of the adults served during fiscal year 2007-2008 a vast majority received treatment services in the community (71,204) versus the state hospital (1,594). In interpreting Olmstead as it relates to people with psychiatric disabilities, there are three applications. The first application is diversion: what can communities do to prevent people from entering an institutional setting?6 The second application is facilitating community readiness at the state hospital, and the third application is that once back in a community setting having access to the appropriate level of care and supports to be successful in recovery.
1. Young Adults in Transition (YAT)
One of the biggest barriers that the 14-25 year old population face is the loss of Medicaid benefits at age 18. Over the past year, Oregon has been aggressively developing policies and programs to address the needs of young adults in transition, and actively involving youth in the process. Efforts to date include the launch of the Early Assessment and Support Team (EAST) program in 2001 by the Mid Valley Behavioral Care Network (a Medicaid Managed Care entity covering five counties). The EAST program intervenes early to prevent the tremendous social and economic consequences of untreated schizophrenia and related psychotic disorders. The program offers evidence-based treatment to teens and young adults who have had a first experience with psychosis within the past twelve months. The focus for youth is on maintaining progress in school, work and independent living, while at the same time supporting the family. The EAST program teaches skills needed for long-term success, as well as prevention of future hospitalizations and acute episodes. This programmatic focus leads to increased community tenure and diverts young adults from the multiple challenges associated with institutionalization. In 2007 the Oregon Legislature funded replication efforts called the Early Assessment and Support Alliance (EASA). Services include intensive community education, outreach and engagement, vocational and academic support, medical assessment and prescribing, counseling and case management and occupational therapy. EAST/EASA services are currently available in 16 of Oregon’s 36 counties, covering 60% of Oregon’s population. As of May 2009 there were 411 families being served in EAST and EASA programs, with 220 families receiving ongoing services.
2007 federal Mental Health Block Grant Funds were used to create a statewide Warmline. Initially in operation only five hours a week, the Greater Oregon Behavioral Care Network (GOBHI), a MHO, and Community Counseling Solutions, a community mental health program, each donated $30,000 to expand the David Romprey Oregon Warmline to a statewide operation. Counties may purchase five hour blocks of time to provide peer counselor training.
The David Romprey Oregon Warmline is designed and provided by people who have or had mental health challenges and are able to support their peers who are struggling with a variety of mental health differences. Since its inception in 2008, the Warmline has increased its hours of operation to fifty hours per week. In February 2008 the Warmline received a total of 16 calls per month; this number leaped to 321 by February 2009 (Warmline Coordinator estimates approximately 500 missed calls per month).7 The Warmline currently has 60 trained operators. Oregon’s Warmline Coordinator is developing a process to evaluate the program’s effectiveness with regard to diverting callers from accessing more costly services, such as doctor’s offices, emergency room treatment, 911 emergency assistance and the need for more intensive care including psychiatric hospitalization.
A promising practice analyzed by the Bazelon Center for Mental Health Law is the use of mental health courts. The goal of these specialty courts is to reduce incarceration and recidivism by linking people to community mental health services and supports. In their report entitled The Role of Mental Health Courts in Systems Reform,8 the Bazelon Center reviewed twenty mental health courts around the country. Results found that there is no single model for a mental health court, and that operational policies and procedures vary widely. Additionally, services and supports differ by community, making it difficult to evaluate the efficacy of the mental health court system across communities. Oregon currently operates mental health courts in ten counties: Clackamas, Clatsop, Coos, Deschutes, Lane, Malheur, Marion, Multnomah, Washington and Yamhill counties. Currently there is no central repository on outcome data for these programs.
2. COMMUNITY READINESS AT OSH
OSH administration remains committed to systems transformation at all levels of the hospital, as demonstrated in the CIP. The CIP is a comprehensive quality improvement and planning document encompassing all areas of hospital administration and treatment at OSH: physical plant and safety; leadership and organization; staffing; admissions and assessments; formulation and treatment care planning; active care and treatment; transition, discharge and community reintegration; integrated physical health care; protection from harm; medical records, documentation and information management; and staff education and development.
Concomitant to the ground breaking for the new hospital building in 2008, OSH is currently operating three treatment malls in the Salem and Portland facilities with another opening later this year. The new treatment mall is based on a treatment philosophy utilized by new and renovated psychiatric hospitals. It employs a community design of centralized care in which the patients’ living areas are connected to a “neighborhood” mall that connects to a larger “downtown” mall so that patients can access services provided in the facility and have more opportunities for healthy socialization. In the past, all of a patient’s meals, care and treatment have been provided on the ward. Activities were limited, and patients spent a lot of time sleeping and watching television. While patients will live on a unit, they will receive treatment, eat meals, attend classes and participate in activities in the mall areas. There is growing evidence that this centralized model can provide lasting benefits, including a decrease in hospital readmission rates, increased skills in symptom management and improved quality of life.
OSH tries to place as many patients as possible into employment. Some patients work in sheltered employment settings, which provide training in job skills needed for community employment. Many patients also have the ability to work in a competitive environment, providing them with economic reward for their hard work. In 2008, on average, 120 patients were employed in sheltered workshops and 57 in competitive jobs. Patients who participate in employment receive the opportunity for social interaction with multiple individuals, learn how to accept feedback responsibly, work cooperatively with others and become more flexible in dealing with change. When people succeed at assigned tasks their self-esteem increases.9
Patients in education programs at OSH learn new skills and are achieving great success. In the first three quarters of 2008, 30 patients were enrolled in college; this is a 233 percent increase from the number enrolled the previous year. Between winter and summer terms of 2008, OSH patients successfully completed a total of 134 college credits; one or two patients will complete degrees in 2009. Fifteen patients are currently in General Education Diploma (GED) preparation. Between fall 2007 and summer 2008, seven patients gained GED level competency in reading, six in science, three in math and three in writing-representing an additional 14 individuals who completed these areas in the previous year. Such skills play a critical role in patients’ successful transition to the community, equipping them with knowledge and the ability to succeed in community placement.10
OSH completed restoration of six cottages on the Salem campus in spring 2009. The cottages have been completely remodeled, are ADA accessible and can either accommodate five or eight patients. The cottages denote a marked shift in transition of patients to the community. Since the closure of the Transitional Living Cottage as a result of the 2003 budget cuts, OSH patients were discharged directly from the hospital into the community. The cottages represent a new pre-community placement option for low-risk individuals who have progressed in treatment and are nearing hospital discharge. Although patients will be living in a home-like setting, their schedules will be highly structured and supervised. Individuals residing in the cottages will do chores, including meal preparation and clean-up, attend classes or meetings and participate in group activities. This type of residential setting affords greater opportunities to socialize, acquire important life skills and better prepares patients to leave the state hospital setting.
OSH adopted a Peer Bridgers Program in 2008. The program uses peers who have received inpatient public mental health services to formally support and mentor patients ready to be discharged. A Peer Bridgers’ representative will work closely with the person once s/he has been discharged into the community. A multi-year evaluation of the New York Peer Bridgers program demonstrated that state hospital patients participating in the program were re-hospitalized an average of 19%, while a control group of patients averaged a 60% re-hospitalization rate. OSH has four Peer Bridgers/Recovery Specialists.
3. COMMUNITY INTEGRATION AND RECOVERY
The current adult system continues to develop intensive in-home supports, intensive case management, supportive employment and education and peer delivered services. The state has a rich array of residential services that range from secure facilities to small treatment homes, and includes homelike foster care settings.
Safe and Affordable Housing
Pendleton Cottage, a 16 bed state operated secure residential facility opened January 2009 and is currently operating at capacity. In 2007-2009, AMH initiated several residential development projects to provide housing resources for individuals transitioning from institutions and homelessness, creating additional housing opportunities for people with barriers to residential stability. Forty-six projects were initiated in seventeen counties, accommodating 430 people with serious mental illness, including residential capacity to serve 214 individuals leaving state psychiatric hospital facilities. The projects include eleven Residential Treatment Facilities, eleven Residential Treatment Homes and nineteen supported housing projects. Additionally, Oregon Recovery Homes outreach coordinators have increased the number of peer-run Oxford Houses in Oregon to 178, the highest per capital of any state and second in overall development. The 2009 Legislatively Approved Budget includes funding to complete an additional 314 community placements during the 2009-2011 biennium: 42 for adults under the jurisdiction of the PSRB, five for juveniles under the jurisdiction of the PSRB and 267 for adults who are civilly committed.11
Supported Employment and Education
In 2007 AMH issued a competitive Request for Proposals for a statewide Supported Employment Center for Excellence.
Options for Southern Oregon was awarded a contract to provide training and technical assistance to local providers to deliver evidence-based supported employment with fidelity to the model. Options is working in partnership with Portland State University to offer technical assistance and fidelity monitoring for fourteen supported employment programs, assisting individuals with the necessary skills and tools needed to obtain and maintain competitive employment.12 According to Options data, of the 646 individuals participating in programs, approximately 40% have obtained competitive employment.
Research demonstrates that supported education is twice as effective as prevocational training at helping people with severe mental illness obtain competitive employment.13 There are currently three programs operating in the following counties: Josephine, Multnomah and Washington. After one year, 141 people had completed intakes for supported education services. Sixty-five percent of those enrolled in classes for college credit completed their course work, with a grade point average of 3.2.
Peer Delivered Services for Recovery and Wellness
Building on the research contained in the 2006 National Association of State Mental Health Program Director’s (NASMHPD) report, Morbidity and Mortality in People with Serious Mental Illness, AMH updated a 2005 statewide report in June 2008 detailing years per life lost for Oregonians who receive public mental health and/or addictions treatment. The risk factors associated with early death (smoking, obesity, lack of exercise, etc.) can be managed, and if managed, would make a difference in the overall health of mental health consumers. The Oregon study concludes that premature mortality among this population is a health care crisis and recommends AMH (via a Wellness Task Force) work with community agencies to implement changes in care coordination, wellness screening and use of peer-to-peer support services to empower people with serious mental illness and/or substance use disorders in achieving lifestyle changes that will improve their overall health. In a report of the 2008 federal monitoring review of the Mental Health Block Grant, it was noted that, “the creation of a Wellness Initiative as a consumer-directed effort to address the issues of mortality and morbidity in individuals with mental illness is forward thinking and among the first in the nation.”
Research indicates that the delivery of peer support by people who have themselves experienced mental illness is a successful model.14 Towards this end, AMH distributed a solicitation in 2007 to award federal Mental Health Block Grant funds to assist with the expansion of peer delivered services. Awards were made to Benton, Malheur, Lane and Josephine counties.
AMH is in the process of implementing rules, policies and procedures to promote and increase the utilization of peer delivered services (PDS) in Oregon. AMH aligns its focus with national and international recovery thinking, person-centered health care planning, client self-determination and a holistic wellness approach in its mental health and addiction services delivery transformation. Part of this service delivery transformation is demonstrated by a policy and procedure for reviewing and approving peer delivered services training and curricula which meet Center for Medicare and Medicaid Services (CMS) and national consumer run organization standards. AMH is currently streamlining and consolidating service delivery Administrative Rules, including language defining peer delivered services and identifying service areas for employment and volunteer opportunities.
3. CURRENT ACTIONS
In 2007, under the leadership of Dr. Bruce Goldberg, DHS Director and currently the Director of the newly created Oregon Health Authority (2009), the agency embarked on a Transformation Initiative. Transformation is the agency’s approach to fundamentally changing the way business is done to provide more and effective client services and improved accountability. The goal is to build a foundation for continuous improvement by repeatedly measuring performance, quickly resolving problems and efficiently using resources. Oregon currently has several initiatives underway which will address the barriers to diversion, de-institutionalization and community integration previously outlined in this plan.
A. 370 PILOT
Oregon Revised Statute 161.370 states, “the court may release the defendant on supervision if it determines that care other than commitment for incapacity to stand trial would better serve the defendant in the community.” AMH has pilot projects in four Oregon counties which will support diversion from the state hospital (the pilot title, “370” references the statute). The pilot projects are in Josephine, Lane, Marion and Multnomah counties. AMH is working with judges, defense attorneys and public defenders to divert the people from being committed to OSH. The focus of these pilots is public safety, while providing people the community-based help and treatment that they need. While the specific target goals for maintaining an average number of people with a 370 designation vary by county, the contracts allow the counties to provide funding for rent deposits for people being discharged from OSH, create diversion agreements with courts and jails, begin long term discharge planning with OSH to assure community success and offer access to various dual diagnosis services for those people who need them.
On September 30, 2009 a five bed residential facility will open in Lane County specifically for individuals with a 370 designation. The long term sustainability of these pilot programs will be monitored, and AMH is hopeful that the local models currently being developed will demonstrate success.
B. AMH DEMONSTRATION PILOT PROJECTS
The 2009 Legislature requested that AMH develop an integrated management and service delivery model concept paper for the Joint Committee on Ways and Means Subcommittee on Human Services. The concept paper recommends the establishment of two to three collaborative demonstration projects that meet specified criteria. At the end of the demonstration, AMH expects to:
o Integrate the addictions, health and mental health service payment system;
o Develop an outcomes-based contracting and payment system;
o Develop a consolidated funding and management system;
o Understand the restrictions on funding services that must be changed to allow greater flexibility in service delivery while meeting federal requirements; and
o Identify a model to braid funding, including the use of federal waivers if necessary while identifying cost savings and efficiencies in service delivery.
The underlying philosophical approach to the pilot projects is that a competent utilization management and quality improvement system is necessary to manage the guiding principle of the “right service at the right time for the right duration at the right cost,” manage the issues surrounding diversion and community integration from inpatient and longer-term residential facilities, improve access at each level of care so that individuals are served at the time need arises in the appropriate level of care, increase access to preventative services, screening, assessment, brief treatment strategies and to routine medical care for people with addictions and mental health disorders. The 2009 Legislature used a budget note on the DHS Budget bill to direct AMH to establish the demonstration projects.
C. MENTAL HEALTH ORGANIZATION (MHO) CONTRACTOR RECOMMENDATIONS
In July 2009 the MHO Contractors presented a set of recommendations to AMH designed to build on local systemic strengths and support community-based health care integration. The first key recommendation suggests implementing a planning process for an adult system change initiative that would consider options for management of extended care services and long-term psychiatric care, currently managed by the State, within local acute care settings. The second key recommendation encourages AMH to improve the integration of services at the local level via increased flexibility in contracting and reporting requirements, as well as update administrative rules which currently inhibit community placement options.
D. INTEGRATED LEVEL OF CARE PROJECT
Resulting from an August 2009 commendation from Richard Harris, AMH Interim Assistant Director, and supported by Dr. Bruce Goldberg, the Governor’s office supported the creation of a position to lead, investigate and make specific recommendations to facilitate the community integration of individuals under the jurisdiction of the PSRB at OSH. This is the first time that the Governor’s office has specifically assigned a position to solely focus on this issue and give it the in-depth attention it requires. The work will build upon earlier studies and determine whether recommendations made in 2006 are still valid.15 As the positions will operate independently and report directly to the Governor, there is opportunity for increased objectivity in the study of this issue and an increased likelihood that necessary changes will be made. The recommendations and implementation strategies are due to the Governor’s office in December 2009.
E. AMH O1 TRANSFORMATION INITIATIVE
Beginning in August 2009, key staff initiated a transformational planning process to investigate, track and develop solutions to the transition of people though the addictions and mental health system. Germane to the Olmstead settlement, the O1 initiative will address the isolation, lack of communication and common definitions for placement between OSH, AMH and community providers.
In order to establish standardized outcome metrics, AMH will be tracking cycle time (the amount of time it takes to transition people who are clinically ready to move to a less intensive or restrictive type of residential care), customer satisfaction and wait lists.
AMH and OSH have already designated team leads for the O1 Transformation Initiative, which will hold its first meeting in September 2009. Accountability criteria have been established, which will keep the process of defining roles and responsibilities on track. The initiative will also give AMH clear data on how residential placements are being utilized, which will assist in moving people to the most integrated setting possible.
The advent of DHS’ Transformation Initiative in 2007, coupled with the support of the 2009 Legislature for health care transformation and reform efforts, provides the opportunity for AMH to develop metrics that will allow Oregon to more accurately measure its progress in meeting the intent of the Olmstead decision.
4. SYSTEM CONSTRAINTS AND CHALLENGES
Improving the quality of life for people with psychiatric disabilities, and facilitating their recovery in the community through higher levels of inclusion and involvement in work, social and community life can be a challenging task. The process involves multiple stakeholders and systems that must interface with each other, each of which has differing roles and responsibilities. The previous two sections outlined progress Oregon has made to date. Based on input from stakeholder interviews, this section outlines current system constraints and challenges facing Oregon and identifies opportunities for change.
A. ROLES AND RESPONSIBILITIES
Multiple stakeholders pointed to the need for all players in the system to agree on a common set of rules, definitions, policies and procedures (AMH/OSH and AMH/community). The O1 Transformation Initiative is designed to address this issue by focusing on intra and inter-agency collaboration between AMH, acute care providers, OSH, community mental health programs and contracted providers to clarify roles and responsibilities and improve the placement process. The expected outcomes include:
o Decrease in average length of stay at OSH;
o Decrease in the number of steps to transition individuals between levels of care;
o Decrease in the time required to transition individuals between levels of care; and
o Decrease community placement vacancies.
Several stakeholders also mentioned the lack of commitment from legislators and other policy makers for the development of an adult version of Children’s System Change Initiative, which would allow communities local control of wraparound services. Consumer stakeholders expressed concern about the second state hospital facility being built, as funding for that project could be better spent on the development of an infrastructure that supports local diversion and recovery efforts (i.e. peer delivered services, Warmline, etc.).
While the stakeholders contacted for this report clearly advocated for more local control of housing and treatment options, as well as wraparound services, it is important to note the vast differences inherent in Oregon communities and the culture in which they operate. Community systems have not yet developed a standardized methodology for consistently evaluating outcomes across levels of care. This is in part due to the vastly different economic resource base that exists across Oregon, but it also has to do with the MHO under which the community operates. Community networking and communication are also diverse; in many cases people do not know where to go for assistance until they reach a level of crisis in which some entity must intervene.
B. PSYCHIATRIC SECURITY REVIEW BOARD (PSRB)
When a person commits a crime and is found by the Courts to be “guilty except for insanity,” he or she is placed under the jurisdiction of the PSRB for the maximum sentence length provided by statute for that crime. While under PSRB jurisdiction, an individual may reside at OSH or in a variety of residential treatment settings, ranging from Secure Residential Treatment (locked facility, staffed 24 hours per day) to independent living. The PSRB determines what kind of facility is appropriate based on the level of treatment, care and supervision required. Oregon state law16 specifically states that the PSRB must make public safety its primary focus, “in determining whether a person should be committed to a state hospital or to a secure intensive community inpatient facility, conditionally released or discharged, the board shall have as its primary concern the protection of society.”
As of April 2009, there were a total of 766 people under the jurisdiction of the PSRB, 360 of whom resided at OSH. Based on the number of new felonies, the recidivism rate for PSRB patients leaving OSH has remained constant at 2.3% since 1997.17
Conditional release from the state hospital to community-based placements occurs after a four-tiered review process that includes evaluations from hospital staff, the proposed community supervisor and treatment provider, and the PSRB. While the number of people under the jurisdiction of the PSRB has remained relatively constant over past several years, between 2006-2008 the number of conditional releases has declined from 17% to 9% of the total PSRB population.18
Every stakeholder interviewed for this report identified the bottleneck of forensic patients waiting to be released from OSH as a significant barrier. Oregon needs to adopt a standardized methodology/tool for risk assessment that will be utilized across agencies and communities. OSH has already taken steps towards this end by researching the Short Term Assessment of Risk and Treatability (START) clinical guide for the assessment of short term risk. This tool guides the evaluator in evaluating acute risk across seven domains: violence to others, suicide, self-injurious behavior, self-neglect, unauthorized absence, substance use and risk of being victimized. The START tool is currently in use in Canada, England, Ireland, Norway, Australia and the Netherlands, and has been found to be significant in predicting adverse events over a short-term duration with forensic inpatients.19 Keeping in line with its recovery orientation, OSH has obtained consent from the creators of START to add a Success Formulation, in addition to the Risk Assessment, to the pre-formatted patient summary sheet. The assessment is currently being used with populations that are forensically and civilly committed, and some geriatric patients. OSH has been in discussion with the PSRB regarding their use of this tool.
The PSRB Siting Workgroup was appointed by the Governor in 2008, and included a balanced representation of public safety and victim interests, mental health consumers and advocates, local government officials, state legislators and other stakeholders relevant to the topic. The group was charged with reaching consensus on ways to strengthen the process for siting residential treatment facilities that serve individuals under the jurisdiction of the PSRB. The group released their recommendations in February 2009. Since that time, the Oregon Legislature passed two pieces of legislation arising from the report: Senate Bills 529 and 911. Senate Bill 529 addresses the issue of local communities not being made part of the siting process by directing DHS to establish a position to act as a liaison between the department and the communities in which the department plans to establish housing for people conditionally released by the PSRB. Senate Bill 911 addresses the need for DHS to adopt administrative rules defining secure residential treatment homes and facilities related to minimal security health and safety standards. DHS is also in the preliminary stages of responding to the workgroup’s issue surrounding the lack of shared data about PSRB siting programs by developing a consolidated database with integrated applications that incorporate data from the PSRB, OSH and AMH. The recommendations, implementation strategies and timelines to the Governor contained in the Integrated Level of Care Project will assist in providing the necessary momentum to improve the PSRB placement system.
5. RECOMMENDATIONS AND NEXT STEPS
AMH will continue to advocate for funding to implement the continuum of services outlined in the CSWG report. These recommendations support mental health recovery, self-determination and empowerment. The six year implementation timeline calls for funding to enhance the following services:
1. Early Intervention and Prevention, via the expansion of EAST and EASA;
2. Expansion of community-based crisis services;
3. Creation of alternatives to community acute care, typically provided in hospital settings;
4. Development of Assertive Community Treatment (ACT) teams, particularly in rural areas of the state;
5. Continued expansion of supported employment and supported education efforts;
6. Provision of forensic intensive case management services to people being diverted from jail or upon release from jail;
7. Provision of community technical assistance to develop residential co-occurring detoxification beds;
8. Development of affordable housing and housing subsidies; and
9. Growth of the peer delivered service model.
Oregon’s revised Olmstead plan demonstrates progress since the initial 1999 Supreme Court decision. Activities and initiatives currently underway at DHS further substantiate the state’s continued commitment to Olmstead principles:
o EAST and EASA programs for young adults in transition;
o Peer staffed David Romprey Oregon Warmline;
o Expansion of safe and affordable housing;
o Promotion of Peer Delivered Service projects for recovery and wellness;
o Community Services Workgroup Report recommendations;
o AMH and OSH promotion of supported education and employment programs;
o OSH Continuous Improvement Plan;
o Transitional living cottages at OSH;
o OSH Peer Bridgers Program; and
o PSRB Siting Workgroup recommendations.
Future iterations of Oregon’s plan, including metrics and outcomes, will add supplementary measures of our success.
Oregon is dedicated to systems transformation both in the spirit and intent of the Olmstead decision as evidenced by the following continuing projects:
o 370 Pilots;
o AMH Demonstration Pilot Projects;
o MHO contractor Recommendations;
o Integrated Level of Care Project; and
o AMH O1 Transformation Initiative.
There is still much work to be done. The state is committed to meeting its guiding principle of “as many people as possible should have the key to their own home.”
HISTORY OF CHILDREN’S SYSTEM
AMH began to develop systematic alternatives to state hospitalization for children with serious emotional disorders in 2001. The first milestone in that process was the creation of the community-based Secure Children’s Inpatient program (SCIP), which opened in January 2002. The program provides highly specialized intensive services to children under age 13 who were previously treated at OSH. The services are provided under state contract in secure 24-hour medically monitored facilities within a community setting. With the creation of this program, the numbers of children served at this level of care were reduced from twenty beds at OSH, to twelve community beds.
In 2003, AMH started a broad scale planning process to provide a more integrated community-based system of care for children and their families. This planning led to the implementation of the Children’s System Change Initiative (CSCI) in 2005. The CSCI ensures that the management of resources, decision-making and delivery of services occur at the local level, through local or regional Mental Health Organizations (MHO) and Community Mental Health Programs (CMHP) managing resources for intensive treatment services with single points of access, authority and accountability. The CSCI is designed to create a standardized method of determining a child and family’s level of service need, assure care coordination, increase service flexibility and interagency collaboration and increase accountability at local and state levels. Meaningful family involvement is emphasized.
On March 1, 2005 AMH closed the Adolescent Treatment Services unit at OSH. To make the transition successful, AMH worked with community providers to develop alternative services. The state contracted with Trillium Family Services to operate a new program called the Secure Adolescent Inpatient Program (SAIP). Capacity was reduced at the highest level of care from forty beds at OSH to sixteen community beds. The program continues to provide for the specialized public safety and treatment needs of adolescents.
AMH continues to make great strides with regard to the CSCI. Some of the results brought about by this initiative include:
* significant development of community-based and in-home services such as skills training, respite, care coordination and family support;
* increased services in flexible locations, such as in homes and schools;
* provision of a service coordination plan for every child approved for Intensive Community-Based Services; and
* meaningful family involvement at state and local levels.
Children are currently being screened and served according to a standardized needs determination process. All children with mental health needs who go through the screening process receive a dramatic increase in the range, type and frequency of community-based mental health services. During fiscal year 2007-2008, 88 percent of children screened were approved for services. Of those children with the most intensive needs for care treated through CSCI, 58 percent were treated in community-based settings, and 42 percent were treated in facility-based care. Prior to CSCI, nearly all of these children would have been treated in facility-based care.20
The CSCI has fundamentally changed the way children and their families receive services. During calendar year 2007, 90 percent of all children with mental health challenges were served in a community-based setting. The number of children admitted to psychiatric day treatment settings decreased by 25 percent, and the number of children admitted to psychiatric residential treatment settings decreased by 34 percent. The number of Medicaid eligible children receiving services increased from an average of 11,500 per quarter in 2005, to an average of 13,056 per quarter in 2008.21
House Bill 2144, the Statewide Wraparound Initiative, was passed during the 2009 Legislative Session. It provides the statutory authority for partner agencies to blend funds, reform the system of services and supports, and operationalize the changes needed to provide integrated services to children who are served by multiple agencies. The law created by this legislation is based on system of care values and principles, and directs child serving state agencies to ensure integrated services and supports for children and their families in their communities. Child serving state agencies include DHS, the Oregon Youth Authority, the Department of Education and the Commission on Children and Families.