MDCH UPDATE

1. MDCH UPDATE Improving Outcomes, Finance & Quality Through Integrated Information December 5, 2008

2. Agenda • Concept Paper • PPGs and ARR • TR on Behavior Treatment • Safety Net Plan • Federal Concerns • Evidence-base, Best & Promising Practices

3. Concept Paper • Foundation for Program Policy Guidelines (PPGs), and • Application for Renewal & Recommitment (ARR) • Focuses on key areas for improvement: quality and appropriateness of care • Presents some topics for TSG work • Assumes PIHPs “compliance” with their own 2002 AFP responses (and the Balanced Budget Act)

4. Concept Paper: Domains • Improving the Culture of Systems of Care • Welcoming • Creating culture of gentleness* • Trauma • Recovery* • Resiliency • Children’s system of care*

5. Concept Paper Domains, II • Assuring Active Engagement * • Supporting Maximum Consumer Choice & Control* • Expanding Opportunity for Integrated Employment • Assuring Opportunity for Needed Treatment for People in the Criminal Justice System • Assessing needs & managing demand*

6. Concept Paper Domains, III • Coordinating and Managing Care* • Improving the Quality of Supports & Services* • Developing and Maintaining a Competent Workforce* • Achieving Administrative Efficiencies*

7. Concept Paper Topics Referred to TSG • Some Concept Paper Topics that are more developmental will be addressed, in part, by TSG such as: • Active engagement: define it, describe it, how will we know it when we see it • Assessing needs & managing demand: develop standards for needs assessments; determine who goes on waiting lists, for how long, in what order are people removed

8. Concept Paper Topics Referred to TSG, II • Coordinating and managing care: standard methods for assuring that people receive the health care services they need – addresses co-morbidity • Developing and maintaining a competent workforce: case management/supports coordination core competencies, standard training curriculum

9. Concept Paper Topics Referred to TSG, III • Achieving administrative efficiencies: training and monitoring reciprocity, standard reporting requirements

10. Concept Paper Topics to be Quantified by the PPGs • Some Concept Paper Topics will be further (but not wholely) explored through the PPG process which will ask CMHSPs to analyze the needs and submit baseline data (what they are doing now) to MDCH, and to draft plans for improvement that will be used in the PIHP response to the ARR: • Recovery: CMHSP’s plans for implementing the Recovery Enhancing Environment (REE) scale • Children’s system of care

11. Concept Paper Topics to be Quantified by the PPGs, II • Active engagement: the number of adults with DD who on average do not participate in any activity* of their choice outside their home in a week during FY08; number of adults who on average had between 2 and 4 different activities of their choice in a week; and number of adults who on average had 5 or more activities of their choice outside their home in a week.

12. Concept Paper Topics to be Quantified by the PPGs, III • Culture of gentleness: • Number of people with DD who in FY08 had behavior treatment plans, and/or whose behaviors have resulted in emergency interventions, residential movement, suspension from activities, delays in returning from state/private facilities, or arrest, booking, incarceration or conviction • Number of people who received medication for behavior control, and who have medication monitoring plans

13. Concept Paper Topics to be Quantified by the PPGs, IV • Assessing need & managing demand: • The number of adults served and un-served who currently live with natural or adoptive family caregivers; of those, the number who have family caregivers who will be unable to provide care within 1 year, within 5 years, and who have requested independent or supported independent living • The number of students aged 14 or more who have school transition plans that ID CMHSP as the service provider when they exit education; number who will graduate within one year; number who will graduate within five years

14. Concept Paper Topics to be Quantified by the PPGs, V • Improving the Quality of Supports & Services: • The number of adults who live in large (more than 6 beds) licensed congregate settings, cost per day, average length of stay, whether they have transition plans • The number of children who live in any licensed facility, cost per day, average length of stay, whether they have permanency plans • Names & addresses of the providers

15. Concept Paper Topics to be Quantified by the PPGs, VI • Supporting Maximum Consumer Choice and Control • Number of individuals who are using self-determination as a vehicle for hiring and managing staff • Number of individuals who have control of their individual budgets • Number of trained independent facilitators of person-centered planning • How many people use independent facilitators

16. Concept Paper Topics to be Addressed by ARR • The revised ARR will cover the same topics as the draft ARR • Feedback from the forums told MDCH that some topics are too developmental (e.g., trauma, active engagement) for measuring performance • Other topics like Consumer Choice and Control (person-centered planning and self-determination), and Integrated Employment are ready for DCH to expect higher standards of performance

17. ARR • MDCH is re-writing the document. The topics will remain the same, the dimensions of performance will not. Some topics will be further clarified. The document is moving from a compliance model to a quality improvement model

18. ARR, II In the meantime, PIHPs should focus on: • Assembling consumers, families, advocates, providers and other community stakeholders to help answer the questions: • What are we currently doing to achieve the vision described in the narrative? • How will we improve on this over time?

19. Revised Timelines • Send a draft of the PPGs to the CMHSPs for feedback – next week? • Issue both PPGs and ARR at the end of December – 31st? • Expect responses in mid- to late March

20. Technical Requirement on Behavior Treatment Plan Review Committees • Attached to the FY09 MDCH/PIHP and CMHSP contracts • Prohibits certain interventions • Calls for data collection on other interventions • MDCH to facilitate a dialog in January with Committee Chairs and Clinical Directors: • Alternatives to the prohibited interventions • Barriers to implementing the TR • Interventions identified as sentinel events are to be reported as such to MDCH

21. Mt. Pleasant Discharges • Opportunity to look closely at people with the most severe reputations 1. What kinds of environments and supports do they need to predict success? • Beth Barol: Biographical timelines identify when, how and where trauma occurred during a person’s lifetime and how current reminders of those experiences trigger negative reactions • Chris Hiemerl: make ready the environment receiving people, rather than make them ready for the environment

22. Mt. Pleasant Discharges, II 1. (continued) What kinds of environments and supports do they need to predict success? • Wayne State University’s Developmental Disabilities Institute (DDI) visiting each person discharged to evaluate the quality of his/her experience in the community • Many successes • Tracking issues in data base • Urgent issues reported to the Community Transition Leader • What is the service utilization: amount, scope and duration for these people?

23. Mt. Pleasant Discharges, III 2. Will use of a functional assessment tool help in making decisions about what will best meet the needs, and in tracking whether the supports and services are helping people with DD function better? • Pilot test with the MPC current residents and discharges (back to 10/1/07) a standardized instrument that looks at many aspects of an individual, such as status of health, relationships, behaviors, ability to communicate, performing activities of daily living, work, etc. • Long term, consider its use for broader population (e.g, HSW enrollees) and for risk adjustment

24. Mt. Pleasant Discharges, III 3. What is the “safety net” plan in case a placement does not work for an individual who was discharged from Mt. Pleasant? • Mt. Pleasant alternatives committee recommended to MDCH that it establish in calendar year 2009: • A statewide DD Training Unit that focuses on training and mentoring the CMHSP trainers on Gentle Teaching and other positive approaches • A Mobile Crisis Response Team that will go on site to help, teach and mentor the caregivers • A Crisis Assessment and Support Unit(s) • Frequent follow-up and Evaluation of Individual’s Experiences

25. Mt. Pleasant Discharges, IV 4. How can we use the lessons learned in the discharge initiative to bring people with DD who have “reputations” home, or divert them from going to, private facilities? • Generalize the tested/proven approach for assessing the need for the most likely successful environment • Expand the capacity of the safety net

26. Federal Concerns • 1915(b) waiver to be renewed in 2009 • CMS to take a more critical look at Michigan’s use of: • Sole source (non-competitive) contracting • 1915(b)(3)s • Moratoria on DRA Case management regulation and Rehabilitation Option regulation to expire in the spring • 1915(c) waiver to be renewed in 2010: • CMS concerned about how the state learns about and follows up on critical incidents and sentinel events

27. Evidence-based, Promising, and Best Practices Initiative • More than 11,000 clinicians trained as of June 2008 • Over 450 individuals trained and certified as Peer Support Specialists • Adoption of EBPs, Best & Promising Practices is growing: • ACT MST • FPE CBT • IDDT-COD DBT • PMTO SE

28. Improving Practices, Next Steps • DD Peer Support Specialists • Positive Behavioral Supports • Measurement: “If you’re not Keeping Score, You are Just Practicing” • Ways to track the practices (procedure codes and modifiers) -> costs, utilization • Need to move to tracking outcomes

29. Our Challenge in the Coming Years • Measuring more, but turning data into useful information • Using the information in decision-making • Tightening our belts without doing harm • Staying on the road toward our vision at the same time we are keeping remnants of a traditional service system

30. Final Challenge • Improving the Culture of Our Organizations (or making Finance, IT and QI decisions in the context of who we serve): • Welcoming • Seeing the Whole Person • Involving individuals we serve, and their families and advocates

31. And, As You Make Decisions in the Years Ahead Ask yourself: • Is it Necessary? • Is it Truthful? • Is it Kind?