SEVENTEENTH REPORT OF THE INDEPENDENT REVIEWER ON PROGRESS TOWARD IMPLEMENTATION OF THE SETTLEMENT AGREEMENT BETWEEN THE KENTUCKY CABINET FOR HEALTH AND
FAMILY SERVICES AND KENTUCKY PROTECTION AND ADVOCACY Submitted by Diane Brewer May 14, 2018
I. INTRODUCTION
This report addresses progress by the Kentucky Cabinet for Health and Family Services (Cabinet) toward meeting the provisions and intent of the Interim and Amended
Settlement Agreements (Settlement) between the Cabinet and Kentucky Protection and Advocacy (P&A). The information provided herein represents the cumulative progress since September 1, 2013, with specific emphasis on the quarter year January 1, 2018 to March 31, 2018.
The Settlement specifies that the Cabinet will have transitioned 675 persons with serious mental illness (SMI), previously in personal care homes (PCH), to community-based housing by October 1, 2018. Individuals in this disability group are to receive Housing Assistance to attain and maintain integrated, affordable housing with full rights of tenancy. Housing Assistance as described in the Settlement also includes the receipt of needed tenancy support services to allow individuals to maintain their housing. October 1, 2018 represents the five-year mark of the Settlement with a total of $31 million pledged by the Cabinet to meet the terms of the Settlement. There have been 519 individuals transitioned, and there are currently 346 still in their housing.
The DBHDID’s behavioral health division has worked to develop and expand Assertive Community Treatment (ACT) services and Peer Support services within the 14
community mental heath center (CMHC) regions. These have been key areas on which to focus for the purpose of influencing attitudes about recovery, and for understanding the types of outcomes that can be expected when knowledgeable, recovery-oriented staffs utilize evidence based practices. Another important effort aimed in part at achieving these same goals, was contracting for the person centered planning learning collaborative provided by expert consultants, Janis Tondora and Diane Grieder. In addition to
addressing the long-standing problem of treatment plan documentation not reflecting the “golden thread” of medical necessity, the learning collaborative stressed the expectation of recovery and client self-determination in planning for goal achievement. Influencing attitudes about recovery within the leadership of provider agencies and the leadership of the Cabinet and its Departments and Offices is a key piece in the success of the
Settlement. Section I.B. of the Settlement states that in addition to ensuring services are provided in the most integrated setting, as defined in federal law, “the Parties intended that steps to achieve the goal of community integration and self-determination would be undertaken”. Stakeholders with a role in achieving this goal of the Settlement must work from a place of knowing that persons in this identified disability group can experience full community integration when provided with the necessary individualized supports and
look like in order to take action to ensure access to, and availability of those supports and services. As with any disability group, there is a wide range of support needs. This reviewer has asked direct service staff what they believe the service system needs in order to support high-need individuals with SMI in the community. Some have cited the need for 24/7 staffed houses similar to the system available for persons with intellectual and developmental disabilities. More often, these staffs talk about the desire for larger ACT teams with supportive prescribers, or just the capacity to provide more frequent in-home services by community support associates, peer specialists, and others. The supports needed to avoid institutionalization can range from simple and minimal, to extensive oversight with coordination of several resources. This reviewer spoke to a woman who had been living on her own in a rural area with support from her brother who would come by to “look in on her and take her to the store”. She stated that when “his legs got bad” he was no longer able to come by and she was taken a PCH to live. On the other end of the spectrum, a CMHC determined that they were unable to support a man who had been living in a beautiful neighborhood home staffed 24 hours a day. There was not a higher level of care available to him, though it is possible that additional resources and natural supports wrapped around him in that environment could have made a difference. He was sent to one of the most run-down PCHs in the state where he will have less oversight and receive fewer services than where he was. Section I.J. of the Settlement states that the Parties acknowledge that the terms of the Settlement are voluntarily accepted for the purpose of refocusing the Cabinet’s use of PCHs. This aspect of the Settlement remains largely unaddressed, in that there has been no change in the extent to which PCHs are used as a housing solution. Studies on the benefits of supported housing have been conducted since the late 1980’s. These studies have shown that not only is housing crucial to the recovery process, but that custodial housing is undesirable and has long-term negative affects on morale and well-being. “Assistance in finding safe and affordable permanent housing that is consistent with consumer
preferences leads to better consumer outcomes” (Corrigan, Mueser, Bond, Drake, Solomon (2008) Principles and Practice of Psychiatric Rehabilitation: An Empirical Approach). The work toward achieving the goals and substantive provisions of the Settlement will move Kentucky forward in its pursuit of an evidenced based service system that upholds the civil rights of this disability group.
II. SOURCES OF INFORMATION
Information for this report was obtained though a combination of Cabinet reports, data reports from the Kentucky ISA/ASA Tracking Tool, and participation in meetings. KY ISA/ASA Tracking Tool reports:
Referrals Aftercare report User report 2 - Time
Referrals not transitioned after 119 days Referrals currently transitioned
DIVERTS EBP Status form and summaries Meetings this quarter have included:
1 Cabinet level meeting
5 Regional Transition Team meetings 1 P&A/DBH meeting
1 meeting with P&A staff 1 DBH Statewide meeting Observations in the field
visit to Centerstone staff and client visit to Bluegrass staff and client
visit to Mountain Comp. staff and clients visit to Venture Homes PCH
III. CABINET ACTIONS/PROGRESS
The Cabinet has made progress toward each of the Settlement’s substantive provisions. A Compliance With Substantive Provisions Grid was included as part of the first
quarterly report and was first scored in the third quarterly report using a 5-point Likert scale ranging from ‘No Progress’ to ‘Complete’. Some of the Cabinet’s ongoing ratings of ‘Modest Progress’ (progress by roughly 50%) or ‘Minimal Progress’ (progress by roughly 25%) have been a result of uneven implementation across the state. There are pockets of excellence across the state where provider agencies do effective in-reach and take action to transition individuals with high need, while other provider agencies might determine similar individuals are inappropriate for Housing Assistance. There are provider agencies that add and modify services when faced with barriers to maintaining successful community tenure, while other provider agencies go directly to the PCH system as a back-up housing solution. These differences, in part, reflect recovery attitudes and the agencies’ prioritization of effective tenancy support services; but the CMHCs also face barriers of poorly funded services and difficulties having services authorized and/or reauthorized by the managed care organizations. As efforts continue for the improvement of service quality and service access, the Cabinet must determine how the service system for adults with SMI will move toward the evidence based practice of permanent supportive housing and away from an antiquated system of large
congregate housing. This report is structured to address each of the sections in the Compliance with Substantive Provisions Grid along with scoring explanations. Section III.A.1 Adequate and Appropriate Public Services
This provision is measured by the extent to which the Cabinet has provided adequate and appropriate community based services to persons residing in or at risk of entry into a PCH, so that they have the choice to live in the community. This has been rated Modest Progress, acknowledging that choice has been made available to 519 individuals. Areas
Availability of choice for community services upon discharge from state psychiatric facilities to avoid trans-institutionalization.
Need for consistency of opportunity for community integration regardless of which PCH you reside in.
Development of, and access to services that will allow choice to persons whose needs exceed the capabilities of the service providers and/or the limits of existing services.
Adequate tenancy support services that will allow choice to continue to live in the community without being returned to a PCH.
In Regional Transition team meetings, the state hospital representatives report on the numbers of discharges to the different PCHs. They have admitted that the discharge location is often not the choice of the client, but instead, is due to the lack of community based service options. State guardians have also stated that their decision to place a ward in a PCH, or have them discharged to a PCH from a state psychiatric facility is based less on client choice and more on whether or not they believe sufficient community services will be available and ongoing for their ward. Many understand that this is not a ‘level of care’ decision, in terms of the PCH offering a higher level of mental health and physical health services; but instead, a decision based more on the availability of some
surveillance, meals, and medications at the PCH. An indicator of progress in the area of true client choice will be the reduction of hospital discharges to PCHs. This is one indicator that has remained relatively unchanged throughout the time of the Settlement. The chart below shows the quarterly comparisons between first time PCH discharges from state psychiatric hospitals and total transitions. This quarter there were a total of 147 persons discharged from state hospitals to PCHs, with 40 of those being discharged to a PCH for the first time.
31 36 30 53 54 43 32 3530 18 44 23 30 15 26 0 5 10 15 20 25 30 35 40 45 50 55 60 10/14 1/15 4/15 7/15 10/15 1/16 4/16 7/16 10/16 1/17 4/17 7/17 10/17 1/18 4/18
Quarterly Comparison:
Number of Transitions and
Number of Hospital Discharges to PCH-1st time
D/C to PCH Transitions
The average annual percentages of PCH discharges across the 4 hospitals have been consistent each year from FY ’15 to present. There has been an average of 52 discharges to PCHs each year with an average of 14 not in a PCH prior to admission (or 28%
discharged to a PCH for the first time). The majority of PCH discharges are made by ESH and WSH. The numbers of persons going to a PCH for the first time are a little larger at ESH, but with the prevalence of PCHs in the WSH area, there is a greater chance that the WSH patients have come to the hospital from a PCH.
Differences in opportunities for choice depending on the PCH in which you reside, can be seen in the numbers of discharges from each of the free-standing PCHs. This chart shows the number of transitions from each PCH, and one boarding home in the Bluegrass region that was included in the Settlement. It is divided by service region and includes the number of licensed PCH beds, the number of transitions, and the number of state wards represented in the total number transitioned.
REGION PERSONAL CARE HOME PCH BEDS Number of persons transitioned State Guardianship (from total) 1
Fern Terrace of Mayfield 104 38 2
Autumn Ridge Personal Care 24 5 0
Totals 128 43 2
2
Christian County Manor 78 21 3
Highland Homes 100 3 0
The Oaks PCH/Madisonville 58 6 2
Pennyrile Home 94 8 2
The Homestead 58 13 3
Trigg County Manor 68 2 0
Sparks Nursing Center 88 1 0
Totals 544 54 10
3
DAVECO Rest Home 92 10 1
Sunny Acres 32 7 4
Henderson Manor 64 2 0
The Oaks PCH/Lewisport 56 7 4
Bishop Soenneker Home 66 2 0
Fern Terrace of Owensboro 68 2 1
Totals 378 30 10
4
Fern Terrace of Bowling Green 114 20 5
Hart County Manor 54 11 5
Cornerstone Manor 36 23 9
Harper’s Home for The Aged 27 10 5
Scottsville Manor 40 8 2
Totals 271 72 26
Breckinridge Manor 40 (now closed)
5 2
Totals 5 2
6
Colonial House of Shepherdsville 62 25 3
Colonial Hall Manor 57 21 3
Totals 119 46 6
7
Colonial Gardens 80 1 1
Valley Haven Rest Home 45 7 2
Carrollton Manor 32 5 4
Jonesville Rest Home 26 0 0
Falmouth Nursing Home 28 5 0
Regency Manor North 30 4 1
Regency Manor 59 5 0
Front Gate 19 2 0
Totals 319 29 8
9/10
Russell Convalescent Home 28 15 6
Frasure’s Personal Care Home 61 16 8
Artrips Personal Care Home 22 3 2
Hamilton’s Personal Care Home 22 1 0
Hilltop Manor 36 1 0
Totals 169 36 16
11
Venture Home of Paintsville 56 12 2
Golden Years Rest Home 84 8 3
Totals 140 20 5
12
Caney Creek Rehabilitation
Complex 80 (now closed) 2 0 Totals 2 0 13 Generations Center of Middlesboro 64 4 1 The Laurels 82 3 0 Totals 146 7 1 14
Dishman Personal Care Home 49 5 3
Somerview Personal Care Home 50 3 0
Cumberland Manor Rest Home 49 1 0
Totals 148 9 3
15
Rose Terrace Lodge 40 3 0
Central KY Recovery Center 32 69 10
Shady Lawn 75 3 1
Parkside Manor 51 3 1
Waynesburg Manor 28 0 0
Totals 264 79 13
Grand Total 2,626 432 102
The chart seems to show that opportunity for transition is greater in region 4, region 6, or if you are at Central KY Recovery Center. Also affecting choice is whether or not the opportunity exists to be sufficiently supported in the community. A region may have several transitions from PCHs in their area, but then have for example, a 52% loss of housing. The following chart reflects the number of transitions in each region with the top shading indicating the number no longer in housing.
The relatively high percentage of persons no longer in housing as specified in the Settlement is an indicator that the system cannot yet provide adequate and appropriate public services and supports in the most integrated setting.
CMHCs enter a post transition code in the KY ISA Tracking Tool when someone is no longer in their housing, to indicate the nature of the housing status change. The
following pie chart separates out seven categories of housing status changes within the current total of all transitions.
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110
Total Transitioned by Serving Region
Of the 519 total transitions, 173 persons (33%) are no longer in housing under the Settlement. There have been 25 deaths. Ninety-two (92) have been re-institutionalized in a PCH. Twenty-six (26) needed a higher level of care through staffed residences, nursing homes, or SCL placement. Thirteen (13) left their housing to live with family or friends. Fourteen (14) were evicted, left their housing, or otherwise were considered lost by the CMHC. Three (3) lost housing due to incarceration.
Section III.A.2. Involvement of all guardians
All guardians are to receive information from the Cabinet to encourage their wards to participate in decisions affecting them to the maximum extent of their abilities. Decisions made by the guardian about where the individual will live are to reflect the individual’s written preferences to the extent possible. This provision is rated Substantial Progress due to the level of involvement of the Department of Aging and Independent Living (DAIL) and their training of field workers to support transitions to the most integrated setting appropriate to meet the needs of their wards. More work needs to be done to get information to private guardians and the one public guardian in Paducah who works with some of the persons referred for Housing Assistance. This could potentially be addressed through brochures given to private guardian by CMHCs describing the community based service they offer and through courts providing potential guardians information on the Settlement’s services and on KRS 387.640.
Section III.B.1 Regulation
This provision is rated Complete. 908 KAR 2:065 was filed Dec. 2, 2015 and finalized June 3, 2016.
Section III.C.1.2. Community Based Supported Housing
Status Changes after Transition
Still in housing that meets criteria-346 Deaths-25 Returned to PCH-92 To Staffed residences-8 To friends/family-13 Nursing home/SCL-18 Homeless/unable to locate-14 Incarcerated-3
This provision is evaluated by the extent to which eligible persons have access to community based supported housing. The provision is rated Modest Progress, acknowledging the Housing Assistance provided to 519 individuals, while also acknowledging the extent of housing needed to accelerate transitions from PCHs and allow hospital discharges to the community. CMHCs that have a designated staff person for housing can do more toward developing relationships with local landlords and local housing authorities; they can ensure a smooth process in submitting housing vouchers and requests for OHI funding; and they can better manage existing vouchers being used by the agency’s clients. The housing specialist’s supervisor and CSP Director must also be knowledgeable about housing issues, so that when there is turnover in the housing specialist position, it doesn’t result in loss of knowledge and in clients falling through the cracks. Housing specialist turnover has at times left the job of training new CMHC staff, and/or the job of intervening with local landlords, to the Kentucky Housing Corporation (KHC). There are several CMHCs that have reported good relationships with local landlords, so that the landlord calls them when apartments become available. The landlord is able to trust that rent will be paid, that their tenants will receive on-going support, and that there is someone to contact with any issues that may arise. Section III.C.3.(a) Schedule for Housing Assistance
This provision spells out the target dates and benchmarks for the required number of transitions to the community. The benchmark for Oct. 1, 2017 was 600 and the benchmark for Oct. 1, 2018 is 675. At this second quarter of the Settlement year, the benchmark is 637.5. This provision is rated Substantial Progress because 519 transitions represents 81% of this quarter’s benchmark. The chart below shows the total number of persons transitioned at the time of each reporting period in relation to the target goals as specified in the Interim Settlement Agreement, then the Amended Settlement Agreement.
8 21 52 88 118 171 225 268 300 335 365383 427 450480 493 519 0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 4/14 7/14 10/14 1/15 4/15 7/15 10/15 1/16 4/16 7/16 10/16 1/17
Number of Persons Transitioned in Relation to Target
(targets adjusted 10/19/15 retroactive to 10/1/15)
Target Actual
The KY Housing Corporation has funding for approximately 25 housing vouchers, depending on how many of the recently issued vouchers are used and how many tenants discontinue use of current vouchers. It is anticipated that there will be a waiting list for vouchers in the near future.
The work toward developing and expanding access to safe, affordable housing can positively impact the overall costs of caring for this disability group. Stable housing has long been considered one of the important social determinants of health, and there is extensive literature linking housing instability and health care costs. A 2016 study conducted by the Center for Outcomes Research and Education found that affordable housing reduced overall health care expenditures by 12% for Medicaid recipients. This is partly due to the increase in primary care visits that in turn, decrease emergency room use. Persons that have supports attached to housing usually have increased monitoring of health issues to avoid emergencies, and have assistance with general wellness activities, thus decreasing health costs. (Health in Housing: Exploring the Intersection Between Housing and Health Care, August 29, 2016)
Section III.C.3.(b) Transition of state wards
The Settlement was written that out of the 675 provided Housing Assistance, approximately 335 are state wards and approximately 340 are not state wards. This provision is rated Modest Progress. Currently 119 state wards have been transitioned which represents 23% of all transitions. The 26 transitions this quarter included 9 state wards. Of the 173 persons who transitioned but are no longer in housing as defined by the Settlement, 54 (31%) are state wards.
Section III.C.6.7. Housing criteria
Housing under the Settlement is to be permanent with full Rights of Tenancy; it is to include support services needed to maintain housing; and it is to be fully integrated, scattered site housing. Housing cannot include group homes, boarding homes, or supervised living settings. This provision is scored Substantial Progress. Transitions counted under the Settlement have generally met these criteria. Exceptions would be apartment complexes that may have had more than 25% of the units occupied by persons transitioned, or situations where the transition was counted but there were insufficient support services to maintain housing.
Section III.D.1.2. Array and intensity of services
Persons represented under the Settlement are to have access to the array and intensity of services necessary to successfully transition to and live in community based housing. The services are to:
a. be evidence-based, recovery-focused and community based; b. be flexible and individualized to meet needs
c. help individuals recognize and deal with situations that may otherwise result in crisis; and
d. increase and strengthen individuals’ networks of community and natural supports.
This provision is rated Modest Progress due to uneven availability of services that meet this criteria. There are service teams that are recovery focused and that strive to provide evidence based services to fidelity. There are other areas where services are limited and narrowly defined, such that the client must possess prerequisite skills or attitudes in order to qualify, rather than individualizing services to meet client needs. ACT has been described as requiring a “whatever it takes” approach by the service team. This is also true when planning for, and coordinating other services and supports. The Cabinet must determine the array and intensity of services needed across the state that will enable persons to be supported in a less restrictive environment. The belief that a person must stay in a PCH because they are incapable of “living on their own” or “living
independently” does not take into account the purpose of the Settlement. The expectation should not be that the individual can succeed on their own, or that they will not be
dependent on a variety of supports. An individual’s support needs are to be identified through assessment, with appropriate coordination of services occurring as part of the person centered planning process. In addition to the Cabinet identifying and putting in place the needed service array, areas for improvement include ensuring a thorough person centered planning process that identifies needs and anticipates potential crises. There also needs to be a stronger focus on the development of natural supports.
Section III.D.3. Five named services
The Settlement specifically requires that ACT, case management, crisis services, peer support, and supported employment be available to persons transitioned to the
community. This provision is rated Substantial Progress in that these services are available to some degree in almost all areas. Areas for improvement include ensuring that services can be authorized and sufficiently reimbursed, and that services are not siloed to the extent that clients are unaware of what is available to them.
Section III.D.4. ACT teams that meet fidelity
ACT is one of the oldest evidenced based practices in the field of psychiatric
rehabilitation, with over 40 years of research reporting outcomes that can be expected when the service is provided to fidelity. All ACT teams are required to operate to fidelity to either the Dartmouth Assertive Community Treatment (DACT) scale or the Tool for Measurement of Assertive Community Treatment (TMACT) scale. This provision is rated Minimal Progress based on the last fidelity reviews conducted that showed only five ACT teams met a good or acceptable level of fidelity.
The success of ACT in Kentucky is a key component in achieving the goals of the Settlement. Most of the ACT teams seem to be invested in the success of their clients, though some may differ in who they believe can be successful or appropriate for their services. ACT team members and other in-home service providers often have the “best view of recovery” and serve as advocates within their own agencies for the community
integration of persons previously institutionalized. During this reviewer’s home visits to persons who have transitioned, the tenants invariably credit ACT team staff for helping them achieve their goal. ACT teams need the support of their agencies; a lessening of barriers to service authorization and payment; a caseload size that will help cover service costs; and on-going training in how to work with the high-need clients for which ACT was designed. Solutions must be found to adequately address frequently encountered issues such as substance use and diabetes so that these do not rule out clients from
receiving Housing Assistance. An ACT team leader at Centerstone talked about his harm reduction approach with a client. He encouraged the client to “just stay sober” until the ACT team staff arrived each day. After experiencing some repeated successes with that, the client was asked to “just stay sober until your [substance abuse] group in the
evening”. This approach to his treatment has helped him greatly reduced the frequency of his use. The client was not very verbal when visited but was able to say he liked where he was living. He was someone who had previously moved, was returned to a PCH, then moved again with more intense services. Another young man in Paintsville was asked about his hopes for his life. He said he would like to meet a girl his own age for company and said that his long-term goal was to go back to school and get a two-year business degree. He stated that he wants to get a desk job and to wear a tie.
Below is the story of a man in Lexington receiving supports from the Bluegrass.Org ACT team.
“I feel like I have succeeded quite a bit.”
A referral was made for Richard in June of 2016 so that he could receive Housing
Assistance and services that would allow him to live outside of the personal care home he was in. The possibility of “guesting” in one of Bluegrass’ transitional housing units was discussed with Richard in October of that year. After waiting for a unit to become
available, he guested for 3 days in March of 2017, then moved into the transitional unit in April. When he left the PCH, the administrator gave him his card and told him that he could come back. On September 5, 2017, Richard moved to his own apartment. I had visited Richard last year when he was in the PCH and was able to visit him recently in his home. He was comfortable talking about his life and how things have changed for him. He said that the most difficult part of being in the PCH was being surrounded by people, not being left alone, having difficulty getting along with some people, and having a roommate who insisted on leaving the door open all the time. He also talked about having a romantic relationship with one of the staff that resulted in the staff person being fired. Richard shared that in his family home he had experienced his mother’s struggle with untreated schizophrenia and his father’s drinking. He talked about living in the dorm at Eastern Kentucky University for a couple of years where he studied Art and got A’s in English; and then, the resulting panic of experiencing some of the same symptoms he had seen in his father and mother. He was sent to the PCH after a psychiatric
hospitalization. When asked how he felt living in the PCH, he said “ashamed of myself for letting my world crumble and having to be put in a place like that”. When asked how he feels now, he was able to say that he believes he has “succeeded quite a bit”, though he added that his family still does not yet see him that way.
Section III.D.5. Person-Centered Plans
Each person transitioning is to have a person-centered service plan done with a qualified professional who is clinically responsible for coordinating all aspects of the plan. The Person Centered Recovery Plan (PCRP) learning collaborative has reached all 14 CMHC regions, and to a lesser extent has involved MCOs, Peer Specialists, and prescribers. Each CMHC has had to determine if, or how they would make changes within their electronic health records to better capture aspects of this approach to planning, such as goal statements in the client’s own words, the listing of strengths to be referenced within objectives, and the inclusion of non-billable natural support interventions. This provision is rated Modest Progress. A great deal of work has been done by DBHDID toward the implementation of PCRPs. What is unknown at this point is the result of that work. DBHDID has a PCRP Quality Indicator Tool that was developed by the consultants. This tool is to guide practitioners in their work and is also to be used by Department staff to conduct reviews of plans with follow-up feedback on points for improvement. This reviewer has seen the results from the Department’s review of a small sample size from three different CMHCs. More reviews will provide information needed to better evaluate the success of the learning collaborative. Some CMHC compliance officers/performance improvement staffs were a part of the trainings provided by the consultants. Their
understanding of the quality indicators and their involvement in intra-agency reviews and training will be important for the continuation of the practice and dissemination of the practice’s underlying values. The learning collaborative was not specific to working with persons leaving PCHs or state psychiatric hospitals. Person-centered planning is written into the Settlement to ensure that client wishes, and service and support needs have been identified before leaving an institution; and that persons responsible for the safety and success of an individual know the actions they need to take, with timelines for taking action. In addition to treatment and care coordination, the plan would include the very practical details of who is getting utilities turned on, who is ensuring food and
medications are at the apartment, who is visiting or calling the client that first weekend at home, getting crisis numbers on the refrigerator, ensuring the client knows what to do in the case of problems or perceived emergencies, etc.
Section III.D.6. Case Management
Case management has always been a key service in supporting persons with SMI. When clients do not need the intensity of ACT, they typically receive case management. Some CMHCs have used case management along with other services to wrap support around persons who qualify for ACT, but do not have ACT services available to them where they want to live. This provision is rated Substantial Progress. Case management has always been a strength in Kentucky, but barriers to service authorization have recently been an issue in maintaining client stability in the community. Clarifying these issues will be essential for this service to be an available tenancy support to persons in need.
Crisis services are to include mobile crisis teams, community-based residential crisis services, and 24/7 crisis phone lines. The Cabinet is to monitor crisis services in order to identify service gaps and implement effective measures to address any gaps or
weaknesses. Crisis services provided to persons who have transitioned are to be consistent with an already developed individual crisis plan in order to prevent
unnecessary hospitalization, incarceration, or institutionalization. This provision is rated between Modest and Substantial Progress. All regions have a 24/7 crisis phone line, but not all regions have mobile crisis teams or community-based residential crisis services. Areas of improvement include determining where service gaps exist and how those gaps might affect the unnecessary hospitalization, incarceration, or institutionalization of persons transitioned. Considering the role of crisis services can be an aspect of “post-mortem” reviews of failed transitions, particularly those with very short community tenure. It is important for the Cabinet to know if, and how individualized crisis plans are completed and used, in order to assess crisis service needs in each region.
Section III.D.8 Peer Services
DBHDID’s push to expand peer support services in Kentucky has paid off. Every CMHC region has at least one peer specialist employed, even if they do not have the minimum .5 FTE on their ACT team (only one region does not) or the minimum 2.0 FTE for services that are separate from ACT (four regions do not). Peer support certification trainings have continued and there have been training opportunities for the required continuing education. The PCRP consultants recently provided a training for peer support specialists regarding their role in the person-centered planning process. This provision is rated Substantial Progress. Areas of improvement include better clarifying the peer support services provided to clients who have transitioned, and ensuring that more CMHCs offer this separate service to persons transitioned. Nine regions report providing peer support services to persons who have transitioned and five regions report serving no one who has transitioned, separate from contact made by the ACT team staff. Section III.D.9. Supported Employment
Supported employment services that meet fidelity to the Individual Placement and Support (IPS) model are to be available to persons transitioned, for their pursuit and maintenance of integrated, paid, competitive work opportunities. There are 11 IPS supported employment programs across the state that have achieved Good or Exemplary fidelity scores. These include 8 CMHCs and 3 other Behavioral Health Organizations. This provision is rated Modest to Substantial Progress because of Kentucky’s strong efforts over the years to establish this service and maintain regular fidelity reviews. The concern in terms of the Settlement is that reports show only 15 persons statewide have received the service post-transition. Verbal reports in regional transition team meetings indicate fewer than 5 people are employed. It will be important to determine the causes of this lack of service use and take actions needed to improve these numbers. A lack of natural supports has often been cited when persons are unsuccessful post-transition. Competitive employment offers a strong natural support. A 2008 study published in the Psychiatric Rehabilitation Journal reported that participants were able to describe a
variety of positive benefits associated with paid employment. They discussed ways in which work fostered pride and self-esteem, offered financial benefits, provided coping strategies for psychiatric symptoms, and ultimately facilitated the process of recovery. (Dunn, Wewiorski, Rogers. ‘The meaning and importance of employment to people in recovery from serious mental illness: results of a qualitative study’, Psychiatric
Rehabilitation Journal, 2008 Summer;32(1):59-62). Some barriers are known, such as minimal employment opportunities in rural areas, and potential hesitancy of the client to take on another environmental goal soon after moving. Possible recommendations for improvement include:
1. Ensure widespread benefits counseling to persons who are transitioning or who have transitioned. This will often require persons outside of the supported employment program such as in-reach workers, case managers, and ACT team members, to understand how employment impacts benefits, and to also promote the positive personal benefits of employment.
2. Improve statewide access to IPS supported employment services, including Lexington and its surrounding counties.
3. Highlight the role of employment in fostering recovery, and the importance of revisiting the goal of employment with persons who have adjusted to their new living environment.
Section III.E.1. Informed Decision Making
The Cabinet is to ensure that individuals residing in or at risk of entry into a PCH are accurately and fully informed in writing, and signed by the individual, about the
community based options provided under the Settlement. This provision is rated Modest to Substantial Progress due to improvements made in getting information to persons in PCHs. DBHDID has created posters that are displayed in PCHs regarding the
Settlement, and some CMHCs initially distributed brochures about ACT services. There has not been a process for obtaining client signatures to indicate they have been fully informed in writing. A complicating factor for compliance with this provision is that the necessary community based options are not available to some persons wanting to leave PCHs. This is particularly true for those being discharged from state psychiatric
facilities. Hospital staffs have reported patients wanting to be discharged to community housing with services, but the only option available to them is discharge to a PCH. Section III.E.2. Cabinet Level team
This provision was Complete with the establishment early on, of the Cabinet Level Transition team. The team meets approximately twice a quarter and includes the Cabinet Secretary’s office, representatives from key Cabinet Departments and Offices, P&A, and the Independent Reviewer.
DBHDID has developed requirements and materials for in-reach and transition teams so this provision is rated Complete. The Cabinet must monitor for needed revisions or adjustments, as these procedures were put in place early in the Settlement.
Section III.E.3.b. On-going in-reach
The Cabinet is to ensure that ongoing in-reach is occurring in PCHs and in state psychiatric hospitals. This provision is rated Substantial Process due to overall
improvement in the frequency of in-reach. There are several issues that complicate full compliance with this provision. Not all CMHCs regularly provide in-reach to all of the free standing PCHs in their area, nor in the Cabinet owned or operated psychiatric hospital in their area. There are also issues with the effectiveness of in-reach in some areas. Effective in-reach can be negatively impacted by:
the lack of services available to address clients’ presenting needs; the in-reach workers lack of knowledge about supports, services, or the
Community Integration Supplement;
a lack of experience with clients’ positive change and growth as a result of change in their environment;
the inability to recognize recovery potential; or
working within an agency that does not prioritize full community integration of persons in this disability group.
Section III.E.3.c. Assignment to Transition Team
Persons who request community housing and services are to be assigned to a transition team within 15 days of initial contact by the CMHC. The Time report on the Tracking Tool indicates that this reporting quarter, only 15% of eligible referrals were assigned to a transition team in 30 days or less. This parameter takes into account that the CMHC has 14 days to make their initial contact once a referral is made for a total of 29 days from the time of referral until assignment to the transition team. This provision is rated Minimal to Modest Progress considering the current percentage of 15%, and the overall percentage of reaching the benchmark over the life of the Settlement of 52%.
Section III.E.3.d. Communicating available options
The Cabinet is required to share the in-reach and education materials with P&A, DAIL, the MCOs, and Clerks of Court to ensure guardians understand the options available to individuals under the Settlement. This provision is rated Complete, although it is unclear if, or how materials are shared with Clerks of Court.
Section III.E.3.e. P&A’s representation
State guardians, P&A, and case managers are to work together to find the most integrated setting appropriate to meet individual needs. This provision is rated Substantial Progress.
Efforts have been made throughout the time of the Settlement to improve communication and better coordinate efforts.
Section III.E.3.f. Transition within 90 days
Transition and discharge planning is to be complete within 45 days after assignment to a transition team. The actual discharge is to be completed within 90 days of assignment to the transition team. This results in a combined total of 119 days when adding the 14-day time frame for making the first contact, the 15-day timeframe for assignment to a
transition team after making the first contact, and the 90-day timeframe to transition. The Tracking Tool’s ‘Total Time to Transition’ report shows only 15% of transitions meet this required timeframe for discharge. There are currently 105 on the list of persons who have been waiting between 120 days and 1,460 days for transition. There are additional persons not on this list of 105, whose guardians do not approve transition from a PCH, or the individual is coded as ‘clinically inappropriate’ to move, for example. This provision is rated Minimal. Locating housing in a timely manner is one barrier to achieving
compliance with this provision. Improvements can be made by more quickly pulling together a transition team of all persons who will play a role in ensuring a successful transition. A more responsive person-centered transition planning process, along with the strengthening of relationships with private landlords and local housing authorities, can help improve the timeliness of transitions.
Section III.F.1. Quality Assurance and Performance Improvement
The Cabinet is required to have a quality assurance and performance improvement monitoring system to ensure placements and services are developed in accordance with the Settlement; and to ensure that the individuals who receive Housing Assistance are provided the services and supports they need for their health, safety, and welfare.
Services and supports are to be “of good quality and sufficient to help individuals achieve increased independence, gain greater integration into the community, obtain and maintain stable housing, avoid harms, and decrease the incidence of hospital contacts and
institutionalization”. This provision is rated Modest Progress, acknowledging the processes the Cabinet has put in place to:
1. prioritize housing vouchers for persons under the Settlement; 2. maintain standards of housing quality through inspection by KHC;
3. implement and monitor the practice of person centered recovery planning; 4. monitor ACT, supported employment, and peer support staffing, including the
numbers served;
5. regularly meet with CMHC and hospital representatives to review persons waiting more than 119 days to transition, and persons discharged from the hospital to PCHs; and
6. conduct Quality of Life surveys pre-transition, 6 months post transition, and I year post transition.
Improvements are needed in tracking whether or not there is greater access to safe, affordable housing, and whether or not services are sufficient to obtain and maintain stable housing.
Section III.F.2. Data for performance improvement
The Cabinet is required to collect, aggregate, and analyze data related to in-reach and person-centered discharge and community placement efforts. The KY ISA Tracking Tool has largely accomplished this. The tool also tracks persons who maintain community tenure for 6 months and for 1-year post transition. This provision also requires the identification of problems and barriers to placing and keeping individuals in the community so that the Cabinet can review this information every 6 months, then develop and implement measures to overcome those problems and barriers. This
information is currently not captured in a way that can inform performance improvement actions. This provision is rated between Modest and Substantial Progress. The quality assurance and performance improvement system must be able to inform actions
necessary to achieve the outcomes described in the Settlement. Section III.F.3. Sharing of data
The Quality Assurance System is to be shared with P&A on at least a quarterly basis unless requested sooner. This provision is rated Modest Progress. The Cabinet has been responsive in getting the information they have to P&A, but is lacking in needed
information about improved housing access, the quality and sufficiency of services, the problems that result in re-institutionalization, and the needed action steps to address service gaps. This is the last substantive provision included in the Compliance with Substantive Provisions Grid.
Section III.G.3. requires an accounting of the original expressers, indicating where they are in the process of being transitioned from PCHs. There have been no reported changes since last quarter. P&A reported speaking with 9 original expressers (including 1 who transitioned then returned to a PCH) who want to leave the PCH they are in.
Since the start of the Settlement, Housing Assistance has been provided to 29 (including 4 potential plaintiffs) of the original 133 expressers. For these 29:
18 are still in housing 4 returned to a PCH 3 are deceased 2 to a nursing home 1 to a staffed resident 1 to family Of the remaining 96:
12 died before transitioning
22 received ID/DD Supports for Community Living 10 went to nursing homes
7 could no longer be located
3 were deemed ineligible for services 6 were deemed clinically inappropriate, and
36 changed their original request to leave the PCH (or guardian intervened to prevent them from leaving)
IV. SUMMARY/RECOMMENDATIONS
Several recommendations have been made throughout this report and do not need to be repeated in this section. The Cabinet has expressed its desire to meet the terms of the Settlement for the benefit of Kentuckians with psychiatric disabilities. This requires a well-coordinated effort that will need to include sufficient service reimbursement, a determination on how provider agencies can best be utilized, and a system that allows for the funding of provider agencies based on the achievement of meaningful outcomes. COMPLIANCE WITH SUBSTANTIVE PROVISIONS GRID
April 1, 2018 Ratings
4 - Complete – fully met as determined by Agreement 3 - Substantial Progress – progress by roughly 75% 2 - Modest Progress – progress by roughly 50%
1 - Minimal Progress – some progress made, approx. 25% 0 - No Progress – no progress made
Amended Settlement Agreement Reference Provision Rating 0-4
Rating What’s being monitored
III.A.1 Appropriate Supports and Services in the Most Integrated Setting
The Cabinet will continue to develop and implement effective measures to provide adequate and appropriate public services and supports identified through person centered
planning in the most integrated setting appropriate to meet the needs of individuals with SMI, and who are residing in or at risk of entry into a PCH.
2 Modest
Progress
The extent to which services and supports are adequate to meet the needs of persons with SMI in the most integrated setting appropriate, as evidenced by persons able to leave PCHs and/or having community options other than PCHs.
III.A.2 All guardians shall receive information from the Cabinet to encourage their wards…to
3 Substantial
Progress
The extent to which all guardians have
extent of his/her abilities in all decisions that will affect
him/her…including…treatment discussions and discharge planning…Any decisions made by the guardian about where the individual will live should reflect the individual’s written preferences, to the extent possible.
wards to be a part of all discussions/decisions affecting them and that decisions reflects the preferences of the wards
Averaged score 2.5
III.B.1 Regulation
Cabinet agrees to promulgate a new regulation encompassing and further describing the services and supports in the ISA and this Settlement Agreement prior to December 1, 2015.
4 Complete Existence of Regulation
filed Dec. 2, 2015 and finalized June 3, 2016 Averaged score 4 III.C.1.2. Community Based Supported Housing Assistance
Cabinet will develop and implement measures to provide individuals outlined in
III.C.2.a-c access to
community-based supported housing.
2 Modest The extent to which
there is access to supported housing and access to state or federal housing vouchers or subsidies.
III.C.3. The Cabinet will provide Housing Assistance to 150 individuals by Oct. 1, 2015; 350 individuals by Oct. 1, 2016; 600 individuals by Oct. 1, 2017; and 675 individuals by Oct. 1, 2018 3 Substantial Progress Achievement of benchmark numbers. Currently 80%
III.C.3. …with approximately half given to state wards and half to others 2 Modest Progress Achievement of benchmark percentage. Currently 22%
III.C.6,7 Housing is permanent with Tenancy Rights; Tenancy support services enable
residents to attain and maintain housing; Services are available but not a condition of tenancy; Individuals with and without disabilities have opportunities to interact; Does not limit ability to access community activities; Scattered site housing with no more than 25% of units in development occupied by
3 Substantial
Progress
Extent to which housing meets all specified criteria.
individuals with a disability known to the Cabinet; Choice in daily life activities; Priority of single-occupancy housing; cannot be PCHs, group homes, nursing facilities, boarding homes, assisted living residences, supervised living settings, or any setting required to be licensed. Averaged score 2.5 III.D.1.2. Behavioral Health Services
Access to services and supports which are evidence-based, recovery-focused and
community-based; Flexible and individualized; Help individuals to increase their ability to recognize and deal with situations that may otherwise result in crises; Increase and strengthen individuals’ networks of community and natural supports
2.0 Modest
Progress
Extent to which services are accessible and meet listed criteria, allowing persons to live in community-based settings.
III.D.3. Community mental health services of ACT teams, case management services, crisis services, peer support services, and Supported Employment Services
3 Substantial
Progress
Number of regions providing all 5 services.
III.D.4. ACT teams meet fidelity 1 Minimal Progress
Number of teams achieving fidelity to EBP and serving persons under
settlement. Last fidelity reviews showed 5 teams at acceptable to good fidelity.
III.D.5. Person-centered plans with coordinating professional which include psych. advance
directives and/or crisis plans
2 Modest
Progress
Evidence of person-centered planning for persons under
settlement. Small sample sizes from 3 CMHCs averaged 40 out of 52 possible points on the Quality Indicator Tool. All CMHCs have
received TA
III.D.6. Case management services leading to goal achievement
3 Substantial Progress Case management services sufficient to support community tenure.
III.D.7. Crisis service systems are timely and accessible, crisis services monitored and service gaps are addressed, services are in least restrictive setting.
2.5 Modest
Progress
Extent to which crisis services are accessible and extent to which Cabinet monitors service gaps.
III.D.8. Provision of peer support services
3 Substantial
Progress
Number of regions offering peer support services to persons under settlement
III.D.9. Will develop and implement measures to provide Supported Employment with fidelity to IPS
2.5 Modest
Progress
Number of programs meeting fidelity and serving persons under settlement. Averaged score 2.38 III.E.1. Discharge and Transition Process
Individuals are accurately and fully informed in writing and signed by individual about community-based options
2.5 Modest
Progress
Evidence of the extent to which persons are fully informed about community-based options available to them under the Settlement.
III.E.2. DBHDID will create an overall transition team at the Cabinet level which will provide oversight and assist local transition teams in overcoming identified barriers to transition
4 Complete Cabinet level team
formed
III.E.3.a. DBHDID will develop
requirements and materials for in-reach and transition
coordinators and teams.
4 Complete Requirements and
materials may need revisions over time.
III.E.3.b. DBHDID will ensure on-going in-reach to individuals in PCHs and Cabinet owned and
operated psychiatric hospitals for individuals meeting requirements of Amended Agreement.
3 Substantial
Progress
Extent to which regular, effective in-reach occurs in all free-standing PCHs and state psychiatric hospitals
III.E.3.c. Within 15 days of initial contact, individuals who have indicated they do not want to
1.5 Minimal
Progress
For this reporting quarter, the benchmark was met 15% of the
receive services in a PCH shall be assigned to a transition team.
time. The overall percentage for all quarters is 52%
III.E.3.d. P&A, DAIL, Clerks of Court receive in-reach and education materials to ensure guardians understand options available to individuals
4 Complete Has occurred, but must
continue
III.E.3.e. State guardians will cooperate with P&A and CMHC case managers in finding the most integrated setting and allow P&A to represent wards
3 Substantial
Progress
Level of cooperation among state guardians, P&A, and CMHCs in finding the most integrated setting and accessing services.
III.E.3.f. Transition and discharge planning completed within 45 days of assignment to transition team. Discharge if appropriate will occur within 90 days of assignment to transition team.
1 Minimal
Progress
90 day benchmark + 29 days. Overall 20% completed within 119 days (12% this quarter)
Averaged score 2.88
III.F.1. Cabinet will develop and implement a quality assurance and performance improvement monitoring system to ensure a quality service system sufficient to help individuals achieve increased independence, gain greater integration into the community, obtain and
maintain stable housing, avoid harms, and decrease the incidence of hospital contacts and institutionalization.
2 Modest
Progress
Implementation of a quality assurance and performance
improvement
monitoring system for service quality and effectiveness.
III.F.2. Collect, aggregate, and analyze data related to in-reach and person-centered discharge and community placement efforts (successful and unsuccessful placements, problems/barriers to integration). Review semi-annually and develop and implement measures to overcome barriers
2.5 Modest
Progress
Extent to which data identifies problems/barriers to integration and measures are implemented to overcome barriers.
P&A quarterly unless requested sooner
improvement data.
Averaged score 2.3