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MPC Closure Workgroup Action Plan (approved by Board of Directors 1/20/2011)

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MPC Closure Workgroup

Action Plan

(approved by Board of Directors 1/20/2011)

1

BACKGROUND:

The state of Missouri announced the closure of Metropolitan St. Louis Psychiatric Center (MPC), in April 2010. As a part of the announcement, the Department of Mental Health (DMH) pledged two (2) million dollars annually to assist the region in responding to the closure.

In early May, 2010, the Community Access Transformation Team (CATT), originally established in 2009 at the request of DMH to develop a plan for Psychiatric Acute Care Transformation in the region,

convened to update its original plan in response to the impending closure. The focus of the planning was to address the gap between consumers accessing mental health care in the region’s medical facilities (both in the emergency departments and on inpatient units) and the Administrative Agents and Affiliates.

On May 19, 2010, the state made a formal request to the St. Louis Regional Health Commission (RHC) to create a local plan to address issues created by the closure. In response to the state’s request, the RHC convened a Regional Planning Group and a Short-Term Crisis Management Team to understand the scope and scale of the closure and its impact on the community and to identify and address the key issues the closure created. The RHC also convened a Regional Psychiatric Capacity Task Force to develop long-term solutions for the closure of MPC. These reports can be found at www.stlrc.org

Through the collaboration of CATT and the RHC a regional plan was submitted to DMH in for the allocation of the two (2) million dollars. The request was for one (1) million dollars to be allocated to implement the CATT recommendations with the remaining one (1) million dollars set aside to support reopening a stabilization unit if additional funding sources could be secured. The CATT was asked to revise its proposal accordingly. This was submitted to DMH in August, 2010 (Attachment 1-Proposal for Distribution and Utilization of $1 Million in DMH Funding).

CURRENT STATUS:

As of this date, the DMH has allocated a pro-rated amount of the one (1) million dollars in accordance with the CATT proposal for the balance of SFY11 and is requesting additional detail of how community mental health providers are using the designated funds. The remaining one (1) million dollars continues to be held in abeyance pending a formal proposal for a stabilization unit.

With the establishment of the Behavioral Health Network (BHN) in November, 2010, the ongoing work of the CATT has been incorporated into the BHN work plan and the Board of Directors established the MPC Closure Workgroup (Attachment 4- BHN MPC Closure Workgroup Membership Roster)to develop an immediate (Phase1) regional response to the DMH request and identify on-going (Phase 2) mechanisms to facilitate ongoing collaboration with hospitals as a definitive proposal is developed for the proposed stabilization unit .

The workgroup met in November and December 2010 and developed the following regional action plan for Phase 1.

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MPC Closure Workgroup

Action Plan

(approved by Board of Directors 1/20/2011)

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PHASE 1

ACTION PLAN:

The BHN will establish a system of “slots”, based upon the service area/provider allocations identified in the attached "Proposal for Distribution and Utilization of $1 million in DMH Funding", to facilitate hospital referrals in the Eastern Region. Each provider will make available a minimum number of slots based upon an average of $1500 per person as applied to their specific allocation as follows:

Provider Annualized Allocation* Start-up/ Direct and Indirect Costs (25%) Direct Service $$ (75%) Minimum Annual Slots FY2011 Slots (75%)

Crider $223,585 $55,896 $167,689 112 84 Comtrea $96,413 $24,103 $72,310 48 36 BJCBH $260,000 $65,000 $195,000 130 97 Hopewell $210,000 $52,500 $157,500 105 79 Ind. Center $110,000 $27,500 $82,500 55 41 PFP $110,000 $27,500 $82,500 55 41

* this amount is annualized. Actual allocation is prorated at 75% for remaining of StateFY11

The MPC Closure Workgroup recommends that the slots:

1. Be dedicated primarily to facilitate discharge from inpatient care given their limited availability. However, slots may also be used for emergency department referrals if mutually agreed to by the hospital /community provider..

2. Be made available onlyto hospitals that operate both behavioral health inpatient units and an Emergency Department as the intent is to reduce unnecessary ED utilization over time. All participating hospitals must accept involuntary commitments.

The BHN is committed to accomplishing the following tasks within ninety (90) days to ensure that a system of “slots” is being used effectively. After the initial ninety (90) days, the plan submitted to DMH will be refined to accurately reflect the needs identified in the initial trial period and from the data gathered during this time period.

1.

Establish clear channels of communication between hospitals and community mental

health providers.

a. Community providers will meet with and communicate the number of available slots to each hospital in their area . Slots will be used for the purpose of facilitating hospital discharge and linkage to community services. BJCBH, Hopewell, Independence Center and Places for People will meet to develop plan and communications specific to St. Louis City/County.

b. A contact person will be assigned at each provider(hospital and community) site to act as liaison between hospitals and CMHCs to coordinate the referral and linkage of patients for their service areas .

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MPC Closure Workgroup

Action Plan

(approved by Board of Directors 1/20/2011)

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across the system and potentially share slots as needed.

e. Community providers are committed to having their own liaison at the hospital within twenty-four (24) hours prior to inpatient discharge , given sufficient lead time, to manage the transfer of the patient once a person has been evaluated and meets the needed criteria (see #2 below). f. Discharge planning will be performed collaboratively, taking into consideration the

recommendations of the treating provider(s) and the community services available to best meet the needs of the patient.

g. The BHN will assist in facilitating liaison meetings for the purposes of information sharing and mutual problem-solving.

2.

Use agreed upon eligibility criteria for referrals into a “slot” at a community provider.

a. Language used will be based on criteria already established in CATT proposal (Attachment 2-Access Criteria) with the following amendments:

 Criteria related to discharges from EDs are optional if mutually agreed to by providers. Criteria related to children under the age of 17 are not included.

 Will require additional discussion to ensure all parties are using same criteria.

3.

Utilize existing systems to exchange information on what services a patient is receiving

and what services the patient is already linked to.

a. Use Cyber Access for Medicaid patients.

b. Use CIMOR (DMH system) for non-Medicaid patients which includes:

 Where the person is receiving care

 If they are “active” (defined as having received service within six months)

c. Pursue expansion of regional health information exchange in the future to provide greater detail on behavioral health patients.

4.

Create Business Associate Agreement between DMH, hospitals, and community providers

as necessary to facilitate care coordination.

a. Agreement to allow coordination of treatment.

 Need to consider legal constraints of coordination

 BHN will pursue possible templates that can be used for this purpose

5.

Finalize accountability metrics and begin tracking data

a. Metrics collected directly by community providers must include:

 # of slots assigned per hospital

 # of referrals made per hospital

 Hospital discharge date and assessment/follow-up appointment date

 # of referrals resulting in community provider admission

b. Upon admission, community providers will assign CIMOR identification/case number. The BHN will work with DMH to regularly collect information from both the CIMOR and/or MO HealthNet data systems to include the following information:

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MPC Closure Workgroup

Action Plan

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 Number and type of services provided during tenure

 Provider Type (i.e. physician, etc.) to extent possible based on service codes

 Dollars spent per patient/number of units per patient

 # of people admitted to Community Psychiatric Rehab Services

 Recidivism/other data as defined in DMH 3700 (Attachment 3) to extent possible d. BHN will establish agreed upon reporting template for data submission and aggregation.

 Aggregate reports will be submitted to DMH per agreed upon schedule to track progress

TIMELINE:

1. 11/30/10-12/15/10: draft ninety day (90) action plan

2. 11/30/10-12/15/10: seek input from CMHCs not present at workgroup meeting to ensure their support

3. 12/15/10: present draft to BHN Board for final modifications and adoption 4. 12/15/10: present adopted action plan to DMH for approval

5. 12/15/10-03/16/11: Community providers and hospitals meet to implement. Implementation will commence once the meeting is completed. MPC Closure Workgroup continue meeting to monitor progress of action plan and ensure that the needed data is being collected and reviewed; develop Phase 2 of Action Plan

6. 03/16/11: formerly review Phase 2 with BHN Board and discuss needed refinement

7. 03/16/11-06/15/11:MPC Closure Workgroup continue meeting to monitor progress of action plan and ensure that the needed data is being collected; develop Phase 3 of Action Plan if indicated. 8. 06/15/11:formerly review Phase 3 with BHN Board and discuss needed refinement

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MPC Closure Workgroup

Action Plan

(approved by Board of Directors 1/20/2011)

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ATTACHMENT 1

CATT Proposal for Distribution and Utilization of $1 Million in DMH Funding

August 26, 2010

Background:

In the spring of 2009, community leaders and stakeholders in the Eastern Region collaborated with the Missouri Department of Mental Health (DMH) to initiate a community wide effort that would integrate two major initiatives then underway to transform the delivery of public behavioral health services throughout the region. The on-going initiatives were the St. Louis Regional Health Commission (RHC) Eastern Region Behavioral Health Initiative (ERBHI), and DMH’s Psychiatric Acute Care Transformation Initiative (PACT). The Community Access Transformation Team (CATT) was formed to design and manage the design and implementation of the two initiatives.

Anticipating that significant funds would be made available through PACT, CATT completed a proposal for a comprehensive, multi-phase system transformation. The proposed system included a greatly enhanced regional access system, and enhanced regional service capacity that would have included outreach and engagement, crisis stabilization functions, intensive community supports, availability of behavioral healthcare homes and peer support services. The CATT proposal was submitted to DMH in November 2009 and received an initial positive response.

PACT did not proceed in the Eastern Region due to the absence of a community hospital partner. Drastic cuts in the DMH budget drove the department to announce the closing of the Emergency Department and acute care services at Metropolitan Psychiatric Center (MPC). With the announcement of the changes at MPC, DMH also announced that $2 million would be made available to enhance community services to mitigate the impact of the ED and unit closures. In early May, 2010 CATT reconvened to develop a proposal and budget, originally due on July 31st, for the use of the $2 million.

In mid-May 2010, DMH requested the assistance of the RHC to create a local plan to address the closures. RHC convened a Regional Planning (advisory) Group and a Short-term Crisis Management Team. As the deadline approached, a group of community hospitals began to explore the feasibility of developing a crisis stabilization unit to mitigate the impact of the MPC ED closing on their EDs. That group’s recommendations influenced the work of the Short-term Crisis Management Team. DMH extended the deadline and requested that CATT and the Short-term team convene jointly to approve the regional proposal and budget. On August 16th the groups met and agreed to propose a plan that would make half of the funds immediately available for community services and hold half in abeyance pending a potential proposal for development of a crisis stabilization unit. CATT was asked to revise the budget proposal accordingly.

Proposal:

CATT met on August 25th and reached consensus on the following:

1. Distribution of the $1,000,000 will be on the basis of each Service Area’s adult population, which has been partially adjusted for poverty.

Budget Proposal

Service Area Amount

16 $ 223,585

22 96,413

23 461,924

24 94,230

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MPC Closure Workgroup

Action Plan

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2. The St. Louis City and St. Louis County funds will be pooled. Hopewell, BJC, Places for People and Independence Center will meet to decide about the distribution and administration of the pooled funds.

3. Each provider will decide what the BHR responsibilities will be within its respective Service Area and will negotiate and contract with BHR accordingly.

4. Each provider will also decide what its relationship will be with the Bridgeway detox services and will negotiate and contract accordingly.

As the CATT proposal outlines, the funds will be used to provide additional services in response to the MPC ED and acute unit closures. These services include (but are not limited to):

 Increased Mobile Outreaches

 Improved linkage and coordination of care between EDs, acute units and Community Providers

 Increased Urgent Appointments and follow-up with those who miss urgent appointments

 Psychiatric Services

 Intensive Case Management/Community Support

 Wrap-around services.

11/17/2010 Addendum to

Proposal for Distribution and Utilization of $1 Million in DMH Funding

The following providers met and agreed to the distribution of allocation St. Louis City and County (Service area 23, 24, 25):

BJC Behavioral Health (City and County) $ 260,000 The Hopewell Center $ 210,000 Places for People $ 110,000 The Independence Center $ 110,000.

This agreement is in line with the $690,000 remaining from the $1,000,000 originally earmarked for the Eastern Region's community based system.

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MPC Closure Workgroup

Action Plan

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ATTACHMENT 2:

ACCESS CRITERIA

(As defined in CATT Proposal with amendments noted in MPC Closure Workgroup Action Plan)

Criteria for services include the following:

 Consumers with ongoing behavioral health needs upon discharge from acute units of hospitals that provide inpatient psychiatric services and accept involuntary admissions.

 Consumers with ongoing behavioral health needs upon discharge from Emergency Departments of hospitals that provide inpatient psychiatric services and accept involuntary admissions. (this criteria only applies if mutually agreed to by both hospital and community provider)

 Identified priority groups are:

 High utilizers as identified by –

o Cyber Access

o Frequency of ED visits or admits at given hospital and/or across hospitals

o Frequency of contact with criminal justice system

 Those experiencing first-onset psychotic episodes

 Survivors of suicide attempts serious enough to warrant medical intervention

 Consumers who have been active in CIMOR within the previous 12 months

Basic Qualifications

 Uninsured or Straight Medicaid Insurance Status

 Not currently linked with a service provider who can oversee/coordinate care.

 One (or more) of the following provisional diagnoses:

o Schizophrenia

o Delusional Disorder

o Bipolar I Disorders (I & II)

o Psychotic Disorders NOS

o Major Depressive Disorder-Recurrent

o (Age 60 and older) Major Depressive Disorder-Single o Obsessive-Compulsive Disorder

o Post Traumatic Stress Disorder

o Borderline Personality Disorder

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MPC Closure Workgroup

Action Plan

(approved by Board of Directors 1/20/2011)

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 Serious to Severe impairment in Global Functioning (GAF between 50 and 20) but consumer is appropriate for outpatient services.

 Requires ongoing services for symptom stabilization and relapse prevention.

Basic Exclusion Criteria

 Private Medical Insurance

 Medicaid MC+ Insurance with Behavioral Health MCO

Veteran’s Benefits Eligible-Access System at BHR will identify appropriate linkage

system for

these consumers.

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MPC Closure Workgroup

Action Plan

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ATTACHMENT 3: OUTCOMES AND DATA (FROM DMH 3700)

DM 3700 clients must have an Adult Status report entered in CIMOR within 30 days of

admission. In addition, a Metabolic Screening must be completed within 180 days of admission.

Other outcome collection data:

ER visits per thousand patient months

Hospital admissions per thousand patient months

Hospital re-admissions within 30 days of discharge per thousand patient months

Episodes of outpatient care per thousand patient months (excluding CPRC)

Aggregate MPR by drug class (antipsychotics, antidepressants, mood stabilizers, diabetes

medications, antihypertensives, cardiovascular medications)

HEIDIS indicators

Total healthcare utilization (cost and units) trended for inflation and broken out by:

inpatient, outpatient, pharmacy, CPRC, and categorized by behavior health vs. not

behavior health

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MPC Closure Workgroup

Action Plan

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ATTACHMENT 4: BHN "MPC CLOSURE WORKGROUP" ROSTER

John Eiler,

SSM, Co-chair

Karl Wilson

, Crider Center, Co-chair

Tim Dalaviras

, St. Anthony's Medical Center

Laurent Javois

, DMH Eastern Region Hospital System

Lesley Levin,

Behavioral Health Response

Mike Morrison,

Bridgeway Behavioral Health

Rob Poirier, MD,

Barnes-Jewish Hospital

Mark Stansberry,

BJC Behavioral Health

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