INTRODUCTION
Anne Arundel County’s demographics have remained relatively unchanged since oursubmission of the plan update twelve months ago. Information that we have, at the time of this writing, is that ourliaison with the county government,also a member of our Board of Directors, will beremaining the same.
The Anne Arundel Countypopulation is approximately 544,000 residents (9.3% ofthe state population), with 23% under the age of 18 and 12% over the age of 65. The racial make-up of the county is about 72% Caucasian, 16% African American,with Hispanic and Asian populations at 6.4% and 3.6% respectively. Our public school system has an enrollment of approximately 74,000 students, with 88% of the countypopulation over the age of 25 being high school graduates, and 31% in the same age group holding a Bachelors degree or higher.
Anne Arundel County has 8 psychiatric beds, which is about 8% of the capacity that other counties in Maryland with populations over 100,000 have available. The Medicaid penetration rate isabout 16%, a rate comparable to the statewide penetration. Anne Arundel County consumers make up about 6% of the total number of consumers in the state Public Mental Health System (PMHS), using a little less than 6% of the total PMHS dollars. However, Anne Arundel County consumers utilize more than 10% of the Statewide Residential Rehabilitation expenditures. This is likely the result of the CSA’s diligent efforts to reduce State Hospital usage and place consumers in the community.
The county again saw a decrease in the number of uninsured consumers, due in part to the implementation of the Primary Adult Care (PAC) waiver. The average cost per consumer in Anne Arundel County is $4,247 which is a decrease of $342 from the FY 2011 cost per consumer of $4,589. This is an8% reduction.However, Anne Arundel County’s average cost per consumer for the elderly (65+) is higher than the statewide average by $3,682.
The FY13strategies included in this plan update,as well as the FY14 goals, are fluid and represent the most current demands within our County’s PMHS. However, these can be changed depending upon the needs of our consumer population, changes in the budgetary environment and/or changes due to National Health Care Reform.
SERVICE INITIATIVES AND SPECIAL ACTIVITIES FOR PRIORITY POPULATIONS
Veterans
Service to our Veterans remains a top priority in Anne Arundel County. In FY13 the CSA, in conjunction with the Anne Arundel County Department of Health,continues to provide oversight of mental health services for Veterans and their families who have been part of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Therapists specializing in Post Traumatic Stress and Combat Fatigue related disorders continue to provide services. These services include psychiatric evaluations, medication management/follow-up and mental health therapy for individuals, families, couples, adolescent and children. The program anticipates an increased number of Veterans and family members over 12. The CSA is constantly seeking additional funding to serve the increasing number of returning Veterans with mental health needs.
Through Maryland’s Commitment to Veterans Program, four Regional Resource Coordinators work with veterans and their families throughout the State to provide information and referral services, identify and address needs, and assist in navigating support systems to access services and benefits. This is a new contract for the CSA and is expected to continue through FY14.
Medically Fragile Adults
As the geriatric population of Anne Arundel County continues to grow, service to the growing number of medically fragile adults remains challenging. The Anne Arundel County Mental Health Agency continues to fund nursing and medical support for 24 adult consumers. This service enables our county to provide services to this population without placing them in a high-cost nursing home or other higher levels of care. The results indicate a significant cost savings as the entire cost of the program is less than the cost of placing just one consumer in an institutional setting for one year. As the population ages and, considering the side effects of psychotropic medications, the CSA anticipates an increased need in this area.
Garrett Lee Smith Suicide Initiative
This initiative to raise awareness and strengthen suicide prevention efforts for our youth was completed in FY12. However, the CSA continues to partner with the school system and the Anne Arundel county Partnership for Children, Youth and Familites to try to gain additional funds and support any on-going effort to reduce suicide.
Jail Diversion
Although funding is no longer available, the CSA continues to seek opportunities to partner with the Anne Arundel County Detention Center to provide Jail Diversion-like services. The Agencycontinues to provide consultation and support on cases that could prevent individuals from re-entering the Justice System. Comprehensive Case Management Services and entitlements support is provided to inmates who are released from the Detention Centers. The Crisis Response System provides on-going Urgent Care services, including psychiatry and mental health therapy. The primary focus for FY13 is on entitlements and ensuring inmates have access to health care and treatment, as needed. The Case Management component of this project remains critical to its success. As this is not covered by Fee For Service, the CSA would like to hire one Case Manager to serve inmates within the jail.
Samaritan Housing
Housing remains a critical issue with the population served by the PMHS. The Samaritan Housing project provides funding for five individuals to live in the community. This program, funded through the Arundel Community Service Development (ACDS) Programwas extended to FY13. Although this project is primarily housing funds with a very limited allocation for administering the project, the Agency is pleased with the renewal. Any reduction in funding for housing special populations impacts the communities within the county as these mentally fragile people often become part of the homeless population with no access to necessary medications and support. However, it is becoming an increasing burden to the CSA staff to continue to add projects that require tremendous documentation and oversight without additional funding for administration.
Mental Health Services at the Waxter Children’s Center
The CSA continues to provide psychological and psychiatric services to detained and committed girls through the Department of Juvenile Services. The CSA administers and manages clinical mental health services provided by a psychologist and psychiatrist.
In FY13, psychiatric services are being provided by a board-certified psychiatrist who is in private practice and a board-licensed psychologist. The goal is to provide direct treatment services to girls who are detained and to provide both consultation services and supervision of the direct-care staff. This service is very well received by the Waxter staff and could be expanded, if the budget permits.
SSI/SSDI (Social Security Income/Social Security Disability Income) – Outreach and Recovery (SOAR)
As the Mental Health Authority for the Public Mental Health System in Anne Arundel County, the Core Service Agency implemented the county SOAR project in FY11 and this has been a continuing effort. A staff member, who is a SOAR certified trainer, continues to manage the project and conducts trainings as needed. The CSA has contracted with an experienced provider, Partnership Development Group (PDG), who screens applicants and prepares applications for SSI and SSDI benefits.
The intensive record gathering as part of the SOAR process and the completeness of the claims has enabled us to earmark these applications as “SOAR” for the Social Security Administration and the Department of Disability Services, thereby allowing the consumerto proceed more quickly through the system. A successful application can now be processed in 90 days versus the current average of 360 days.
Peer Employment Resource Specialist (PERS) – Tool Kit and Training Sessions
Unfortunately, this formal approach to workforce development has been discontinued due to lack of funding. However, the CSA remains committed to developing a workforce in order to meet the increasing demands placed on the Public Mental Health System to provide service. The CSA does this through continued partnership with the local community college and an emphasis on training.
Describe new developments, issues, changes or legislative initiatives that affect mental health/behavioral health service delivery in the jurisdiction.
Continual changes within the Healthcare system are inevitable. The CSA is facing these modifications in a number of ways. Most notably, the Director serves on committees locally, statewide and nationally to keep informed of the most current issues in healthcare, especially in reference to mandated changes in the Affordability of Care Act. Within the Anne Arundel County Mental Health system, the Director, in consultation with the Board of Directors and many local stakeholders, continues to position the Agency for outcome-based, affordable behavioral healthcare envisioned in the Act. There are countless variables that influence the adjustments needed to make the vision a reality. These include: anticipated growth of the system, need for additional capacity, access to affordable care, focus on prevention, services to those most disenfranchised, such as the elderly, homeless and our veterans and a coordination of somatic and behavioral health care. Outwardly overwhelming, the Anne Arundel County Mental Health Agency has seized this as an opportunity to use its existing programs, supplemented by a complete restructuring of its Crisis Response Grant, to refurbish the current behavioral health delivery system in Anne Arundel County. Key to the success of this overhaul is access to data, Memorandums of Understanding with various community stakeholders, flexibility in funding options, and at a minimum, the current level of Local, State and Federal support.
For convenience, the system is envisioned in the insert Community Mental Health System (see following pages). The term chosen for this arrangement is “No Wrong Door”. An Operation Center, funded by the Core Service Agency, could become asingle point of coordination for people in crisis with behavioral health issues in Anne Arundel County. A concept of concentric circles indicates levels of care or support. The most intense services exist in the Crisis system, followed by the Routine Care system, and finally supplemented with Community Supports. The system proposed is truly integrated and those entering the system will be effectively directed to the level of care deemed necessary for the situation. In addition, the system is heavily reliant on prevention. This is apparent by the comprehensiveness of the outer ring detailing the Community supports. For example, elements include housing, health education including proper diet, exercise and smoking cessation, cultural competency and specialized resources such as those needed for Justice System involvement.
In late FY12 the CSA began by issuing a RFP (Request for Proposal) for services. Beginning in FY13 the CSA began the process of making the changes needed to successfully implement this vision.
There are three main areas of clinical treatment concern, in addition to the routine and crisis requests for services. Based on the demographics of Anne Arundel County, they will continue to pose a challenge for continued treatment. These are: persons with substance abuse and mental health issues (co-occurring), the aging population, and the increased number of persons with traumatic brain injury. These groups are responsible for a large portion of the increased need for services. Therefore, coordinating care for
these people is vital in order to control costs. Because of their disability, the people in these three groups are also the least likely to benefit from any changes in the health care delivery system without intervention and assistance from the CSA.
In all three areas, education is the most important prerequisite for providing the appropriate level and type of care. The Anne Arundel County CSA has been instrumental in taking the lead for providing quality trainings in these, as well as other health care related areas. The CSA provides Continuing Education Units (CEU) to certain licensed health care personnel.
Another critical component for successful care is the integration of somatic and behavioral care. Unresolved medical care issues often result in high cost Emergency Room visits, and/or the need for emergency petitions. In many of these cases the psychotic behavior is a direct result of a serious somatic issue that has not been remedied, including severe urinary tract infections, dehydration, dangerously high glucose levels secondary to diabetes, alcohol poisoning, and kidney involvement requiring dialysis. It is important that the somatic issue is quickly addressed and the person is directed to Medical Urgent Care as opposed to an intensive Behavioral Health evaluation. The person must also be linked to needed follow up care and education.
This system has become possible by redesigning the elements of the current Crisis Response System. As funding has remained static, key elements of the program have been divided into unique cost centers and rebid. This has resulted in a more efficient delivery of services. For example, rather than funding an Urgent Care facility during business hours, patients are referred to Outpatient Mental Health Clinics (OMHCs). The need for the Urgent Care facility remains during off hours and funds have been provided for this purpose. However, because of the increased demand and the need to maintain services 24/7, 365 days a year, the current staff is struggling to meet these needs. The CSA would like to improve this system by funding one licensed mental health clinician, one data person, and two line staff. Where possible, all available resources are utilized, reserving the high-cost services for severe cases, or using grant services as a bridge until more traditional services are available.
Finally, thesystem is dependent on a robust data infrastructure. The CSA has also partnered with the Department of Social Services (DSS) to co-fund a DSS worker specializing in entitlements coordination. The CSA has also been supportive of the local Partnership for Children, Youth and Families effort to pilot a system for residents that provides information regarding all of the benefits which they are entitled to receive.
Describe efforts that improve communication and support the implementation of health reform and coordination of care in the delivery of services to individuals with mental illness in your jurisdiction. Include discussions or efforts to address the anticipated growth in the system and the need for increased capacity and access to prevention, treatment, and recovery support services, particularly in the realm of behavioral health.
The Anne Arundel County Mental Health Agency continually works with Providers and local communities to assure quality mental health care for our residents. The Agency has held community-wide programs on Health Care Reform issues as well as trainings to update and inform service providers on new/changed initiatives. Quarterly Provider meetings provide a forum for open discussion on issues that directly affect the mental health community. The CSA will continue to hold forums and education events regarding Health Care Reform. In addition, the Agency will send representatives to State meetings and planning forums regarding Health Care Reform issues in Maryland as budgets allow.
As economic conditions remain uncertain and funding levels for behavioral health decrease, our ability to maintain the current level of mental health services plus meet the increased demand for assistance is stressed beyond our capacity. We continually work with community leaders and providers to find innovative and creative ways to serve the mental health population throughout the county. However, the current societal stresses are limiting the number of individuals who can be helped and priorities are being established, i.e., Veterans, discharges from state hospitals, homeless, severely mentally ill, etc.
The Director meets regularly with the Anne Arundel County Department of Health regarding services to our citizens with co-occurring illness and the most effective way to deliver behavioral health services.
Describe special initiatives between the CSA and the state-operated psychiatric hospital, local general hospital(s), emergency rooms, activities related to discharge planning and to reduce hospitalization, and hospital diversion efforts, as applicable.
Through the Crownsville Hospital Initiative the Anne Arundel County CSA partners with all the State hospitals in order to successfully transition consumers out of the state hospitals and into the community. The Anne Arundel County CSA also contracts with other CSAsand private vendors in order to implement highly individualized plans of care when needed.