Mayview Regional Service Area Plan

 

Allegheny, Beaver, Greene, Lawrence and Washington counties have spent the past several months planning and working together on building stronger communities systems to help individuals return home from Mayview State Hospital, or – if individuals do go to the state hospital – to make their stay as short as possible.  From the outset, the counties have been committed to doing this in a recovery oriented fashion which we believe is reflected in this plan.  This approach has formed the basis for the five counties, working with a variety of stakeholders, to develop a Mayview Regional Service Area Plan. 

 

In order to understand what the counties are proposing in the next two years, it is important to understand the work the counties have done thus far and how this work has had an impact on the counties planning efforts for the future.   

 

Work to Date

 

The five counties have worked together on previous submissions of a Service Area Plan.  The feedback from DPW, however, suggested there was a need for the counties to be more specific in their plans, show better use of data, and show greater evidence of “regional’ planning.   While the counties recognized the need to heed the feedback from DPW, the counties also wanted to plan for a significant reduction of beds and that caused them to come together.  The four suburban counties wanted to close several beds, but realized that they would be more likely to achieve their goals if Allegheny County participated in the process allowing for a greater number of beds to be closed.  Allegheny County agreed to participate.  After discussion among themselves, the counties felt they needed some outside assistance in the planning process and contracted with Allegheny HealthChoices, Inc. (AHCI) to coordinate the planning process. 

 

Very quickly after the counties began meeting together, they decided they wanted to be very aggressive in their efforts to plan for future use of Mayview State Hospital.  This was driven primarily by three factors including, the belief the individuals should have every opportunity to live in their home communities, the feeling they needed to be ready in the event DPW decided to close Mayview and the recognition that the state hospital is likely to be the only significant source of new dollars for enhancing community systems.  Within that context, the counties began to view the planning and process for closing the 25 to 30 beds as the process for building the infrastructure and planning processes to more significantly reduce utilization of Mayview State Hospital.  Thus, the process in which the counties is now engaged is Wave I and is described here; the next section will describe the proposal for the next two years.

 

Planning Structure

 

The five counties moved quickly to put in place a planning/coordination structure to implement this effort and use going forward in working together around Mayview.   The structure is as follows:

 

·                    A Steering Committee comprised of the administrators from the five counties; consumer and family representatives of Allegheny and the suburban counties, provider representatives, advocates, Mayview leadership, VBH-PA and Community Care, AHCI staff and representatives from DPW.  The Steering Committee oversees all aspects of the project and is the primary decision making group.

·                    An Assessment and Discharge Planning Committee comprised of approximately 50% consumers, including patients from Mayview State Hospital; hospital staff; hospital liaisons from the community providers; DPW staff and representatives of the five counties.   This committee has been charged with developing the assessment tools, coordinating and overseeing the assessment process, and developing and monitoring the community support planning process (formerly known as the discharge planning process).

·                    The Finance Committee is comprised of the administrators of the five counties with staff and consultant assistance provided by AHCI.  The goal of this committee has been to develop a proposal for long – term funding.  The group has wanted to move away from a traditional CHIPP model of funding and develop a model that provides more flexibility within the region and provides greater stability over time.

 

Wave I (Current fiscal year)

 

The five counties are proposing to discharge 25 to 30 individuals who have been at Mayview two years or longer.  As these individuals are discharged, the beds would then be closed.  Discussions with Mayview staff indicate this would represent the closure of one unit.  It should be noted that this plan is dependent on the counties being able to reach agreement with DPW on the amount of funds to be distributed from Mayview to the counties.

 

In preparation for Wave I, the counties developed an assessment process modeled on the process used at Harrisburg State Hospital, although the assessment instruments were significantly modified based on consumer input from the five counties.  Thirty eight individuals were assessed with the goal of identifying the 25 to 30 people for discharge.  Upon completion of the assessments, facilitated community support plan (discharge planning) meetings are being held to ensure adequate planning for patients returning to the community.  Again the community support planning process was modeled after the process used for Harrisburg State Hospital and the counties propose to continue using it over the phases of the proposal.

 

This process has allowed the participants to “think outside the box.”  The results have been that far fewer patients than typical have been determined upon discharge to need locked residential care or highly structured group living.  To the contrary, community support plans are focused on helping clients find homes in clustered apartment settings with more limited on site staff.  Given the long lengths of stays of these patients and the fact that many have highly complicated medication regimens and institutionalized behaviors along with serious co-morbid medical conditions, this has been a significant shift.   The emphasis is on bringing in supports to the greatest extent possible by relying more extensively on community treatment teams and intensive case management. 

 

Services and Support Needs

 

The counties are involved in system planning at several levels for purposes of enhancing the community systems.  Based on the needs of clients for Wave I, the focus of initial service and support developing will be on:

 

·                    Finding housing that meets consumers preferences and provides the flexibility for the level of staffing both consumer and staff have indicated is needed

·                    Enhancing or expanding intensive case management services and/or community treatment teams to provide the level of in-home services needed

·                    Developing peer services and supports to address the isolation these individuals feel that they may experience in the community

·                    Developing and/or enhancing mobile psychiatric rehabilitation services

·                    Providing transportation support especially in more suburban or rural areas

·                    Beginning development of community based employment opportunities

 

Specific activities in these areas can be found in the individual county’s Community Mental Health Plans.

 

In addition to the services identified in the community support plans, the counties are also focusing on identifying and developing the services and supports that would be needed if Mayview State Hospital was not available.  Those will be key components of the budgeting for both Wave I and the subsequent years proposals discussed later.

 

Financial Considerations

 

The counties clearly put a significant amount of effort in the efforts to plan for the needs of clients discharged from Mayview; they have also put a considerable amount of thought and effort into how to finance this initiative both for Wave I clients and subsequent activities.   

 

The initial activity was to look at overall utilization of Mayview as compared to other areas.  The consultant to the counties was able to easily obtain data from the Ohio system and determined there was sufficient comparability to make the comparisons valid.  The utilization of Mayview compared to state hospitalization use in Ohio is illustrated below.

 


 

 

Service Area

CY 2004 ADRP

Estimated 2004 Population

ADRP/100K

Population

Allegheny

227.0

1,250,867

18.15

Beaver

27.5

178,601

15.40

Greene

2.5

40,133

6.23

Lawrence

6.5

93,374

6.96

Washington

24.0

205,738

11.67

Service Area Total

287.5

1,768,713

16.25

Ohio

538.0

11,459,011

4.69

 

The difference in utilization is even more pronounced when it is taken into account that the Ohio state hospitals provide acute care while Mayview is strictly a long-term care facility.  In addition, in all state hospitals in Ohio there are only 90 persons who have been in the hospital more than 90 days, compared with 165 persons at Mayview from the five counties.                                               

 

The second comparison made was to look at the pattern and funding sources of services provided to individuals who had been discharged from Mayview. The data indicate that approximately 80% of the services provided are funded by base dollars with only 20% paid for by HealthChoices dollars.  While some of that is accounted for by persons who are not HealthChoices eligible, the driving factor is that individuals are generally discharged into residential placements that are not HealthChoices eligible.  It is here that the assessment and community support plan data dovetail nicely with the financial realities.  Individuals generally don’t want to go to the kinds of residential facilities they have been referred to in the past and, continuing that practice would not be financially viable.  The counties recognized that reality and it has become a key consideration in developing the financial strategy.

 

Mayview Cost Profile

 

One of the first work tasks was the identification and timing of funding which will become available for community based services as utilization of Mayview declines and capacity is reduced over the two or three year time period.  The consultant worked with Mayview staff to identify various cost components as variable, step-variable or fixed costs.  The variable costs are subject to transfer on a per ward basis.  The step-variable costs are not transferable until there is a significant reduction in direct service capacity (estimated to be two wards and greater).  Fixed costs are not subject to transfer until all direct non-forensic service capacity is liquidated.

 

For Wave I, the counties, with the cooperation of the hospitals have identified the variable costs associated with one ward closure.  (The specific are provided in a separate document with the financial proposal for Wave I.)  The counties also are proposing that the money not be distributed on a per diem basis but as a lump sum amount to be distributed across the counties based on an agreed upon formula.  This formula would be a reflection of both prior utilization and county population.  This approach does not penalize or reward counties for prior utilization to the extent a per diem distribution would do so.

 

In budgeting for the use of these funds the counties will be using the following categories:

 

·                    Services and supports for persons discharged from Mayview

·                    Services and supports for persons averted from admission to Mayview

·                    Community based alternative services for persons currently in structured residential facilities who no longer require that level of care

·                    Enhancements to the current array of community services to better support the recovery needs of all persons at risk of intensive mental health treatment.

 

As referenced above, the counties are also proposing a higher utilization of HealthChoices eligible services thereby providing a higher degree of flexibility for the use of the Mayview funds.

 

Service Area Plan for FY2007-2008

 

The counties are proposing an ambitious plan that would significantly alter the counties’ use of Mayview by June 30, 2008.  As indicated previously, however, plans proposed here are contingent upon reaching agreement regarding the financing of the plan.

 

During the period July 1, 2006 through June 30, 2007, the counties propose to reduce average daily resident population at MSH to 199 for the annual period, with an ending census of 129 (see attached table for planning detail ) .  This would be accomplished through cutting overall admissions in half, eliminating the waiting list from Allegheny County, and targeting 90 patients for discharge, over and above the normal rate of discharge.  This approach ensures the counties will continue to emphasize DPW Goal 1 (no person in state hospital greater than two years), it also will provide a process for ensuring that individuals don’t “age” into the two plus year group.  The counties would reduce the 90 beds by conducting the assessment and community support planning process for approximately 98 individuals falling into the following categories of length of stay:  0-5 months, 6-17 months, 18-23 months, 2 plus years. This plan also provides for the suburban counties to close admissions by January 1, 2007 with Allegheny County closing admissions sometime within nine months following.

 

During the period July 1, 2007 through June 30, 2008, the counties propose to close the approximately 125 beds remaining at MSH.  This proposal assumes that there would be no further admissions to Mayview after October, 2007, and that all non-forensic patients would be discharged by the end of April, 2008 (see attached table for planning details).At that point, the counties would not be using MSH as a state hospital.  They remain open, however, to further discussion about a role that the “hospital” might play as a provider of needed community based services.

 

Service Priorities

 

In order to be successful in carrying out this plan, the counties realize that several things must occur.  On their part the counties must carefully evaluate their systems to ensure that current dollars are being spent in an optimal way including maximizing the use of HealthChoices dollars.  They will need to make difficult decisions regarding the current expenditure of funds to support the kinds of supports and services being identified in the Community Support Plans and that are necessary to keep people from being admitted to the state hospital.  While more detail is provided in county-specific plans, the types of activities being conducted or planned in various counties include:

 

·                    Review of individuals currently residing in LTSRs and other highly structured residential environments

·                    Consideration of the conversion of social rehabilitation programs to psychiatric rehabilitation programs

·                    Review of reimbursement structures to support increased implementation of evidence-based practices and other recovery oriented services

·                    Enhancement of crisis systems most likely requiring a redirection of other service dollars

·                    Review of case management services to ensure their capacity to provide the level of services needed

·                    Conversion of LTSR beds to Fairweather Lodge models

·                    Continued conversion of CRR beds to supported housing models

 

The counties also are going to be looking at new service development through the use of MSH dollars, reinvestment dollars and redirection of funds (in addition to examples above).  The types of services that will be required include:

 

·                    Supported housing in a “housing as home” model

·                    New or expanded community treatment teams

·                    In-home supports in addition to the level of care that might be provided by a community treatment team

·                    Clustered apartments or very small homes with limited live-in staff and most services provided by community treatment team or case management

·                    Extended acute care

·                    Non-hospital crisis capability

·                    Comprehensive personal care homes

·                    Peer support across a variety of settings and services

·                    Psychiatric supports for persons in nursing homes

·                    Mobile medication programs

·                    Contingency funds for a variety of things including helping individuals become established in their homes

 

The list above is not meant to be all –inclusive but perhaps best illustrates how flexible the counties will need to be in their ability to deploy services in support of individuals.  This undoubtedly will require flexibility in funding and regulation, although the need for the latter has not yet been determined.

 

With respect to the services above and other needs that are likely to be identified, the counties also are looking for opportunities to develop services and supports on a more regional basis.  They feel that those opportunities are likely to arise around very specialized needs of clients and/or very high cost/low demand services.

 

Goals 2 and 3

 

Clearly, the counties have focused the vast majority of their group work in further of Goal I although they have had discussions around Goals 2 and 3.  Those discussions have focused primarily on reaching agreement on what to measure and how to measure it.  Going forward the counties will be able to report and their progress in meeting those goals and will do so.

 



 

 

 Plan to Reduce Utilization of Mayview-FY 2007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FY 2007

 

Starting Census

255

 

 

 

 

 

 

 

 

Admissions

Normal Discharges

LT Discharges >Normal Rate

Total

Discharges

Discharges-Admissions

Ending Census

Average Monthly Census

Days in Month

Patient Days

 

July

13

 

13

7

20

7

248

251.5

31

7796.5

 

August

12

 

13

7

20

8

240

244

31

7564

 

September

12

 

13

8

21

9

231

235.5

30

7065

 

October

11

 

13

8

21

10

221

226

31

7006

 

November

11

 

13

7

20

9

212

216.5

30

6495

 

December

10

 

13

7

20

10

202

207

31

6417

 

January

10

 

13

8

21

11

191

196.5

31

6091.5

 

February

9

 

13

6

19

10

181

186

28

5208

 

March

9

 

13

8

21

12

169

175

31

5425

 

April

8

 

13

8

21

13

156

162.5

30

4875

 

May

8

 

13

8

21

13

143

149.5

31

4634.5

 

June

7

 

13

8

21

14

129

136

30

4080

 

 

120

 

 

90

246

 

 

 

 

72657.5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADRP

199

 

 

Plan to Reduce Utilization of Mayview- FY 2008

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FY 2008

 

Starting Census

129

 

 

 

 

 

 

 

 

Admissions

Normal Discharges

LT Discharges >Normal Rate

Total

Discharges

Discharges-Admissions

Ending Census

Average Monthly Census

Days in Month

Patient Days

 

July

7

 

13

10

23

16

113

121

31

3751

 

August

6

 

12

9

21

15

98

105.5

31

3270.5

 

September

5

 

11

8

19

14

84

91

30

2730

 

October

4

 

10

7

17

13

71

77.5

31

2402.5

 

November

0

 

9

6

15

15

56

63.5

30

1905

 

December

0

 

8

6

14

14

42

49

31

1519

 

January

0

 

7

6

13

13

29

35.5

31

1100.5

 

February

0

 

6

6

12

12

17

23

28

644

 

March

0

 

5

5

10

10

7

12

31

372

 

April

0

 

3

4

7

7

0

3.5

30

105

 

May

0

 

0

0

0

0

0

0

31

0

 

June

0

 

0

0

0

0

0

0

30

0

 

 

22

 

84

67

151

 

 

 

 

17799.5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADRP

49