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Nicole Norvell, Indiana Director of Disability and Rehabilitative Services
Bruce Davis, Ph.D., Tennessee Director of Behavioral and Psychological Services, Department of ID/D
Jeff Cross, President, AWS/Benchmark State agency/provider
partnerships
NASDDDS Mid-Year Conference June 6, 2014
NASDDDS Panel Presentation
Supporting Persons with Co-Occurring
Conditions in Small Home Settings
Jeff Cross
Benchmark Human Services
June 6, 2014
AWS/Benchmark (Benchmark) Company Profile
• Operations in 8 states and DC; 8,000 people in residential, work and home health services
• Specialized residential support for 400 persons with intensive medical or behavioral challenges
• Deliver specialized behavior support services
• Operate 24/7 mobile crisis services/6 IDD crisis homes for IDD and MH populations in combined 150 Georgia counties; 900+ interventions monthly. Telepsychiatry and GA Regents Medical College partnership
Supporting Persons with Co-Occurring Conditions
• Profile for 4 states: TN, IN, MO and NJ
• 128 persons w/co-occurring conditions in settings of 1 to 4 persons; 26 in TN, 36 in IN
• 16% with adjudicated forensic backgrounds
• Population includes persons with sex offending/pedophilia, arson, disabling assault, severe self injurious behavior, and extensive trauma history
• 25% positive transition out; no recidivism
GA Crisis Model
IDD Mobile Crisis: 86 Counties
• 3-person teams: BCBA, LCSW, DSP
• Avg. 68 minute response time
• 24 crisis beds/6 homes
• In-Home Supports up to 7 days
• Out-of-home supports up to 7 days
• Specialized behavior support, review and consultation
• Telepsychiatry
• Est. 90% of individuals with co-existing conditions
MH Mobile Crisis: 120 Counties
• 2-person teams: Licensed clinician and certified peer specialist(CPS)
• Avg. 51 minute response time
• Utilize existing resources for inpatient and crisis stabilization
• 24 hour follow-up by CPS
• Next day access to MH appointment
• Mandate for regional community collaborative organizations (60 to 100 members)
IDD Crisis Outcome Data
• Serve 24% children and juveniles
• 56% of persons on commitment orders are diverted from ER’s and acute hospitals
• 88% of crisis referrals are handled in the community with no inpatient placement
• Site of crisis intervention in order of occurrence: Home, ER’s, community at large, jail and day programs
Encouraging Practices—What Works
• 1-2 person settings highly effective
• “Life style engineering”—building ability to exist and thrive in the community vs. obsessive focus on negative behavior
• Person centered—toxic to healing/nurturing environments—community based reinforcement
• Decrease/manage barriers to community inclusion—increase pro-social behavior
What works . . .
• Use BCBAs—focus on extinction of restraints, unconditional respect environment, “what counts to you”, personal responsibility, managing family
• No discharge commitment—build trust and bonding
• Aggressive daily schedules/work, get out of home, physical activity, chores, gardening, shopping, pets, etc.
What works . . . • Intensive training of DSPs—regular
competency testing, modeling by clinicians
• Scenario training—practice interventions
• Environmental assessment/in-depth planning pre-move
• Aggressive risk management: Safety plans and extensive contingencies; coordination with law enforcement, crisis support—plan don’t assume!
Provider Perspective to States
• Define and monitor population at risk before making funding/policy decisions
• Seek provider/community involvement in planning strategies—e.g. Project “Resource Tennessee”, work groups on targeted populations, community collaborates (this is not a “IDD” issue only)
• Establish a comprehensive strategy now to address with existing resources/providers
Provider Perspective to States
• Crisis support systems are essential to building sustainable community capacity. Highly cost effective due to diversion, scalable to specific target populations and budgets, and build provider capacity to serve challenging individuals—reduce extraordinary costs.
Systems of Support for Persons with Dual Diagnoses
2014 NASDDDS Mid-Year Conference and Directors Forum
Bruce E. Davis, Ph.D.
Director of Behavioral and Psychological Service
TN Department of Intellectual and Developmental Disabilities
Imagine yourself as a person with an intellectual disability and a co-occurring behavioral health problem faced with:
Trying to understand what is happening with you personally
Responding to others who don’t understand your problem
Seeking to find/establish your value as a person in the midst of invalidating experiences
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Empathy
High Rates of: High rate of unrecognized abuse/trauma High rate of improperly understood behavioral health
problems
Ubiquitous invalidation Oft disrespected Low expectations Unreasonable expectations Even our help is invalidating Lack of control
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Reminders about IDD
People have behavioral health problems that occur independent of their environment.
People with ID have a greater likelihood of behavioral health problems (40-50%).
At least 24,000 – 30,000 people in TN with ID and behavioral health disorders*.
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Acceptance
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Team of Rivals
Rival Departments
MH vs. DD vs. DOC vs. DOE vs. …..
Significant barriers to cooperation
Common Ground Reduce crisis calls and unnecessary hospitalizations
Facilitate timely hospital admissions and discharges when needed
Significant barriers to cooperation
Synergy is possible! Just like in Lincoln’s cabinet.
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This Battle is “Epic”
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Utilization Data
July 1, 2011 - June 30, 2012 TOTAL Adults DIDD clients
Total Telephone Contacts 115,345
(all contacts)
570
Total Face to Face Assessments 60,253 -------
Total Admitted to State Hospital 6,797 -------
Total Psychiatric Admissions 20,404 302
Utilization Data
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July 1, 2012 - June 30, 2013 TOTAL Adults DIDD clients(all contacts)
549
Total Face to Face
Assessments 67,958 na
Total Admitted to State
Hospital 6,533 na
Total Psychiatric Admissions 23,674 326
Total Telephone Contacts 142,323
For 7 /1/ 2011 – 6 /30/ 2012:
128 people were admitted only once
68 people were admitted to a facility more than once
For 7/1/2012 – 6/30/2013
115 people admitted once
74 people admitted more than once
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Utilization Data: DIDD
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Constellation of Supports
Person and Family centered supports Cross-systems Crisis Planning Safety Net
24/7 Crisis support network Diversion works Experienced/Trained Staff
Personal Interactions – “Redirectional Prowess” Identifying Resources - “Systemic Awareness” Maneuvering resources – “Political Saavy”
Behavior Analyst Services Therapeutic Services (Family, Individual, Group, Medication Management) Assessment and Stabilization Inpatient Psychiatric Services
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Our Goal: The Complete Constellation
Appropriate – Do the services offered meet people’s needs?
Accessible – Can people get the service?
Accountable – Do the services offered adhere to standards and measure outcomes.
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Dr. Joan Beasley – Center for START Services – The Three As
Full development of our constellation of support
Stars we have: Agencies like Benchmark committed to dual diagnosis Support Solutions behavioral respite facility in West TN Medicaid Waiver funding for behavioral respite START Training for Mobile Crisis and DIDD Intensive Consultation Teams/Resource Centers Behavior Analysis services Intensive Behavior Residential Services (New Waiver Service) Harold Jordan Center
Stabilization unit Intermediate Care Facility
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Tennessee DIDD Vision
Widely available therapeutic services
Crisis response network devoted to IDD
Statewide stabilization (respite)
Easier access to psychiatric hospitalization
In home crisis supports
Interdisciplinary assessment
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Stars We Need
Relative fiscal austerity means maximizing existing resources.
An efficient system is a money saver and quality of life improver.
Therapeutic respite can provide a diversionary resource.
In TN, 4 respite beds could result in a 20% decrease in hospitalizations for DIDD.
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A Step Forward – Resource Tennessee
Improvement in system functioning
Quicker response times
Better support for agencies
Net increase in quality of life
Increased availability of hospitals
Better assessment and treatment
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A 20% reduction leads to…
TN-START Demonstration Project – 2004-2009.
Resource Tennessee goals for persons with IDD
Improve existing resources to fit
Ensure new (already planned) resources fit.
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TN-START
Emergency Service TN-START Clients Average Cost Non-TN-START Clients Average Cost
Emergency Room Visits
0.47
$39.34* 5.2
$435.24
# of Psychiatric Hospitalizations
0.67
2.6
Hospital Days
7.3
$4,403.21 19.93
$12,021.38
Crisis Contact (TN-START Crisis)
2.7
(Community-Based Mobile Crisis)
2.7
# of Police Contacts
0.67
4.13
# of Arrests** 0.27 0.2
Incarceration Days**
6.4
$384.51 0
$0.00
Respite Days
7.6
$3,274.00
32.2
$15,778.00
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Savings Comparison of Average Emergency Service Usage (and Associated Costs) of Clients with and
Clients without TN-START Services * Cost based on BlueCoverTN 7/1/06 fee schedule; CPT code #99284
** One client was arrested four (4) times and incarcerated twice.
The Indiana Family and Social Services
Administration
Division of Disability and Rehabilitative Services
June 2014
Systems of Support for Persons with Dual Diagnosis
Current Models of Care
Home and Community Based Services: Community Integration and Habilitation (CIH) Wavier: 8,379
Family Supports Waiver (FSW): 8,122
Waiver is caped at $16,545.00
Supervised Group Living (Group Homes) Supervised group living programs, which serve at least four (4) individuals and not more than eight (8) individuals and are funded by Medicaid
Adult support residence
Basic developmental residence
Child rearing residence
Child rearing residence with a specialized program
Comprehensive rehabilitative management needs facility" or "CRMNF
Developmental training residence
460 IAC 9-1-2 Types of facilities defined
• Intensive training residence
• Residence for adults with extensive support needs
• Sheltered living residence
• Small behavior management residence for children
• Small residence for adults with extensive medical needs
Types of Facilities
(5) "Comprehensive rehabilitative management needs facility" or "CRMNF" means a residential setting with supports and services for adults who meet the definition of federal intermediate care facility for the mentally retarded (ICF/MR) level of care who may have a dual diagnosis, have acute and high-risk challenges, and are in need of comprehensive service delivery in the area of behavior and psychiatric supports and habilitation services that has:
(A) A behavior support plan supervised by a health service provider in psychology (HSPP) in conjunction with behavior consultants to develop and monitor behavior training, developmental training, and support in specific areas for all individuals receiving services who function on a similar level as follows:
(i) The HSPP and behavior consultant must have twenty-four (24) hour availability and must be familiar with the specific needs of the consumer in the facility.
(ii) The behavior consultant must provide at least fifteen (15) hours per week of behavior services in the facility for direct monitoring, assessment, intervention, and staff training.
Indiana
(iii) Psychiatric services must be available at a minimum of twenty (20) hours in the facility and have twenty four(24) hour availability.
(iv) A medical director, a director of nursing, and nursing personnel to coordinate health care needs of the
individuals residing in the facility for access to twenty-four (24) hour nursing care and medical supervision as the individuals' needs warrant.
Types of Facilites
(B) A CRMNF for adults with comprehensive management needs must provide the following:
(i) A continuous active treatment program to address the acute and high-risk positive behavior support needs of the individuals receiving services.
(ii) The qualified developmental disability professional (QDDP) must provide at least twenty (20) hours per week of direct client intervention, monitoring, assessment, and staff training with the individuals receiving services.
(iii) Training for individuals receiving services to address community integration skill needs include training in one (1) or more of the following areas:
(AA) Activities of daily living or life skills.
(BB) Communication.
(CC) Vocational skills.
(DD) Personal maintenance and development.
(EE) Positive behavior supports.
(FF) Self direction and leisure time.
(GG) Active treatment.
(HH) Home skills.
(C) A CRMNF under this subdivision shall not have more than one hundred (100) residential beds.
Extensive Support Needs (ESN)
(8) "Residence for adults with extensive support needs" means a residential setting as follows with supports and services for adults with extensive supervision needs and intense behavioral support needs that has:
(A) A behavior support plan supervised by a behavioral consultant to develop and monitor behavior training, developmental training, and support in specific areas for all individuals receiving services who function on a similar level as follows:
(i) The behavioral consultant or consultants must have twenty-four (24) hour availability and must be familiar with the specific needs of the consumers in the home.
(ii) The behavioral consultant or consultants must provide at least ten (10) hours per week of behavior services in the home for direct monitoring, assessment, intervention, and staff training.
(iii) Psychiatric services must be available to meet the needs of the individual or individuals.
Extensive Support Needs (ESN)
(B) A residence for adults with extensive support needs must provide the following:
(i) A continuous active treatment program to address the extensive positive behavioral support needs of the individuals receiving services.
(ii) Training for individuals receiving services to address community integration skill needs, including training in one (1) or more of the following areas:
(AA) Activities of daily living.
(BB) Communication.
(CC) Personal maintenance and development.
(DD) Behavior supports with emphasis on positive measures.
(EE) Leisure time.
(FF) Active treatment.
(GG) Home skills.
(C) A residence under this subdivision shall not have more than four (4) beds.
“Other Requirements”
ESN homes will provide specialty services on a time-limited basis and should not be considered a “final” placement for people.
Individuals living in ESN residences must be supervised at all times and the
staffing pattern should be a minimum of: Three (3) staff on the day shift; Three (3) staff on the evening shift; and Two (2) staff on the night shift
The Bureau of Developmental Disabilities Services Coordinator will be a member of the individuals support team. The provider must notify the Service Coordinator of all meetings and if the Service Coordinator is not notified the meeting may be reconvened at the discretion of the Service Coordinator.
“Other Requirements”
Patterns of behavior including non-targeted or novel behaviors are to
be tracked utilizing an ABC tracking sheet and are to be analyzed monthly by the support team.
A pharmacist must review the individual’s drug regimen, lab work, and documented behaviors, at least quarterly. The pharmacist must report any irregularities found with the drug regimen, lab work, or diagnosis as they relate to the behaviors(s) of the individual to the prescribing physician and the support team within (7) calendar days. If the irregularities present a serious risk to the health and safety of the individual, the irregularities must be reported to the physician and the support team immediately.
There are currently 21 ESN homes in Indiana
84 individuals are served in those settings with 60 being male and 23 being female. There is currently only 1 vacancy.
The average age of the individuals is 35
The average daily rate is $467.00 per day/per person
Current Locations:
Strengths of the Model:
System of structure and support
Family satisfaction
Limited law enforcement contact
Intense behavioral training for Direct Support staff
Weaknesses of the Model:
Little to no movement in
placement
Unclear discharge expectations
Limited community involvement
Consistent waitlist for placement
Consistency in implementation
Undergoing a gap analysis performed by the University of New Hampshire (START)
Take the analysis and recommendations to the DD commission next legislative session
Next Steps for Indiana:
Work with current ESN providers to come to agreement regarding expectations
Evaluate the lack transitions that occur and identify root cause
Implement strategies to ensure fluidity and sustainability
