Category1ProjectNarrative

BluebonnetTrailsCommunityServices‐126844305.1.2

ProjectArea, OptionandTitle:1.13.1 – Developand implementcrisis stabilization servicesto address theidentifiedgapsin thecurrentcrisis system

RHPProjectIdentificationNumber:126844305.1.2

Performing ProviderName:Bluebonnet TrailsCommunity Mental Health and Mental

RetardationCenterdba/Bluebonnet TrailsCommunity Services

Performing ProviderTPI#:126844305

ProjectSummary:

  • ProviderDescription:BluebonnetTrailsCommunity Services(BTCS) is theLocal Mental Health Authority for Burnetand Williamson Countiesin RHP8and for sixadjacent Counties in threeotherRHPs.Theycomprise 25%of theland mass but54%ofthe population. Williamson County has nearly50%of thepopulation at422,679.BTCS is the public provider of behavioral health servicesfor thepoor, under and uninsuredin Williamson County.
  • Intervention:BTCS proposestocreate,certifyand provide foran involuntary emergency detention unit for thepurpose of providing crisis stabilization.A48‐HourObservation Unit will beestablished in Georgetown,Texastoprovide foremergencyand crisis stabilization servicesin a secureand protected,clinicallystaffed,psychiatrically supervisedtreatmentenvironment.This48‐HourObservation Unit will provide assessmentand activeintensive treatmentfor adults.
  • ProjectStatus:This is anewproject,nofacility orservicenowexists in any of the Counties servedby BTCS that acceptsand evaluatesadults on emergencydetention orders.Weexpecttoserveabout 300people ayearwhentheprojectmatures.
  • ProjectNeed:No48Hour Observation Units exist in BTCS’sarea.ThisaddressesRHP8 CommunityNeedsAssessmentneeds:CN.2.1‐ Limitedaccesstobehavioralhealthservicestorural,poorandunderuninsuredpopulations(meds,casemanagement,counseling,diagnoses)inWilliamsonCounty;CN.2.2–LimitedaccessforseriousmentallyilladultstocrisisservicesinWilliamsonCounty;and CN.2.13—LimitedaccesstoadultbehavioralhealthservicesinWilliamsonCounty.
  • TargetPopulation:Thetargetpopulation is adults presentinga significant threattothe safetyof self orothersand exhibitingbehaviorsconsistent with acutepsychiatricdisorder. Of adults servedby BTCS in FY2012,an averageof 43%wereMedicaid‐eligible; 73%of BTCS clientsarebelow thefederalpovertylevel.Weestimateapproximately 70%of those benefitting fromthisprojectwill bepoor, under oruninsured.Weexpecttoserve 250people in DY4and300in DY5.
  • Category1or 2ExpectedProjectBenefitfor Patients:The projecthelpspatients by providing accesstocarelocally and proactivelysothat theyarenot takenout of County and hospitalized.Quick local assessmentsupports local stabilization and reducesthe number of short inpatient stayswhich result fromusing thehospital as an assessment location. Theprojectseekstoprovide assessmentand stabilization servicesto250people in DY4and300people inDY5.
  • Category3Outcomes:IT‐3.14:Our goal istoreducethe behavioral health/substance abuse 30-day readmission ratetohospital by a percentageTBD based on baseline establishedDY3.What theachievementof thisgoalmeansis toprovideservices tothetargetpopulationofpeoplewhohavebeenhospitalizedor experiencedacrisis eventand/orhavebeen intheCrisisRespitefacilityandto assistthem toregain functioningandself‐managetheirwellness.Improvementin functioning and self‐managementof symptomsand wellness arecriticalpatientoutcomes.Whenthegoals areachieved,programparticipants shouldexperiencea reduction in symptomsand a reduction in crisis events.Weexpecttoserve250people in thiscommunity based crisis alternativein DY4and300people inDY5.Our goal is to servepeople in thecommunity. Thisnotonly representsa substantial savings overusing hospital and ED, but more importantlyimprovesthelives of those who otherwisewould havegoto hospital outof County orspend wastedtimein inappropriate ED settings.Currentlyhospital and EDs are theonly options.
  • Collaboration:TexasA&MHealth Science Center(TAMHSC)had a Pass1allocation it could not use,since TAMHSC did not haveproviders in RHP8.TAMHSC allowed its allocation to beusedby local healthdepartmentsand local mental health authorities (public entities)which had muchsmaller provider allocationsin Pass1,so theseentities could havemorebroad, transformative andregionalprojects.TAMHSC hasnot playeda role in theseprojects,otherthan therole of anchor. Therearenoimpermissible provider‐ relateddonationsinvolved.This usageof theTAMHSC allocation ensured theseproviders, whocould self‐fund therequired IGT,could participate in thewaiver.This projectis transformativein that it createsan alternativeforthose in behavioral health crisis that is local, reduceshospital admissionsand use of EMS and EDs.Therearenocommunity- based crisis stabilization alternativesexcepthospitals and EDs.

ProjectDescription:

CrisisStabilizationforPersonsinBehavioralHealthCrisis

BTCS is theLMHA for Burnetand Williamson Countiesin RHP8and for sixadjacent Countiesin threeotherRHPs.BTCSproposestocreate,certifyand provide for an involuntary emergency detention unit for thepurpose of providing crisis stabilization.Todoso,a 48‐HourObservation Unit will becreatedtoprovide for emergencyand crisis stabilization servicesprovidedto individualsin a secureand protected,clinicallystaffed,psychiatrically supervisedtreatment environmentwith immediate accesstourgentoremergentmedical evaluationand treatment. This48‐HourObservation Unit will provideactiveintensive treatmentfor adults in needof acute inpatient psychiatric service;with suicidal indication; persons presenting a significant threattothesafetyof self orothers;and persons exhibiting behaviorsconsistent with acute psychiatric disorder which mayinclude significantmental statuschanges.

The 48‐HourObservation Unit will befully compliant with all regulations and health and safety standards. Thisoptionwill beaccomplishedbymodifying our currentvoluntaryCrisis Respite facility in Georgetown.Aphysical separationwill becreatedbetweenanareacomprising two roomsand theremainderof thesixteenbed facility in ordertoestablisha lockedunit that is suitable for patients in crisis tobesecurelyand safelydetainedfor up to 48hours.Duringthe 48hours, theindividual in crisis will beassessed;will receivemedication and intensive psychiatric treatmentmeetingtheirneeds;andwill beprovidedshort termcare,step down respitecareand assistedtransition intooutpatient servicesand community resources.The facility will provide accesstoemergencycareatall timesand will safelyand appropriately manageindividualswiththemost severepsychiatric symptoms.Itis designedtoprovide a safe and secureenvironmentfor short‐termstabilization of behavioral healthsymptomsthat mayor maynot requirea continued stayin an acutecarefacility.Extended observation andtreatment can takeplace for up to 48hours.Individuals whocannot be stabilizedwithinthat timeframe would belinked totheappropriate levelof care(inpatient hospitalunit).

Thisinvoluntary behavioralhealth facility has thepotential to servean additional 300people a year.The proposal builds on thecurrentcrisis systemestablished by theLMHA and the relationships with local law enforcementagencies.Toaccomplish thiswepropose tomake necessarybuilding modifications, increaseprofessionalstaff forthefacility tomeetstandards requiring 24hour nursingcoverage,MD assessmentwithin one hour and transfercapability to another inpatient facility if appropriate.Establishing thecapacity toacceptpersonswhoare under EmergencyDetentionand hold themfor assessmentand short termstabilization will reducetheunnecessaryutilization of EmergencyDepartments(EDs), psychiatric inpatient facilitiesand jail.This projectreducespreventable readmissions to hospitalby providing a communityalternativefor rapid stabilization and referraltoappropriateresidentialoptions. Since theserviceis locatedin thesamebuilding as voluntary Crisis Respite,those whocan achievesufficient stability can transfertothevoluntary programtocompletetreatment.For persons requiring higher levelsof medicalexpertise,and to ensureeasyaccesstomedical services,theclinic will belinked by telemedicinetoour locations with additional physicians.

BTCS revieweddata relatedtoadmissionstotheStateHospital and tothevoluntary Crisis Respite facility.Wefound a largepercentageof the218yeartodateadmissionsto theState Hospital‐‐17%accounting for 37of the218admissions‐‐weremadewithout prior screeningand authorization by BTCS, theLMHA.In meetingswith stakeholdersin Williamson County,we learned thatthose admissionsarebeing takendirectlytothehospital by law enforcement officersbecausetheyhavenolocal crisis alternativeand havebeenrequestedtotake individualsfromED’s orhavetakenthemupon their own screeningand assessment.They transport for directadmission to theStateHospital whenin their judgment theindividual needs an involuntaryfacility evenfor a short period oftime.Nosuch facility existsin Williamson County orany otherCounty servedby BTCS.Analysis of those StateHospital admissionsreveals a substantial number withveryshort lengths ofstay,indicating that theywereinappropriately admitted and might bepreventedwitha community alternativefor crisis stabilization.The number of individualswith lengths of stayless than 3daysreflectsthat 61persons mayhave beeninappropriately admitted year‐to‐date.Whenwereviewedtheadmission data for the voluntary CrisisRespite facility, it revealedthat therewere252admissions in FY 2012and 95% of those werefromWilliamson County.Of those admissions,13%werefromEDs and local Hospitals;8%werefromtheStateHospital; and 13%werefromjail.Clearly,all of these individualswerecandidates for crisis stabilization as a first option ratherthan hospitalization— expending valuable timeand resourcesin thewrongsetting.Thisprojectdirectlyaddressesthe problem of inappropriate admission by creatingthe2beds for the48‐HourObservation Unit as an option for law enforcementin lieu of jail, ED orStateHospital.Wewill ensurethat qualified assessmentstaff will beavailable atall timessothat whenan individualis brought tothefacility he/she canbeassessedand disposition madeas quickly as possible,therebyallowingthelaw enforcementofficer toreturntoregularduties.Social Servicestaff will provide for follow up to refertheindividual tootherlevelsof careupon stabilization ortoprepareand process legal mental health commitment as needed.

GoalsandRelationshiptoRegionalGoals:

ProjectGoals:

  • Establish an involuntary crisis stabilization servicein Williamson Countythrough a 48‐HourObservation Unit
  • Develop a professional teamon site and supportedby telemedicine
  • Providethiscrisis servicein a safeand secureenvironmentthat allowsforthose in custody and under detention ordertobedetainedand assessed
  • Reduceoreliminate theinappropriate utilization by thementallyill of ED’s,jails, private hospitals and theStateHospital forshort stays

ThisProjectmeetsthefollowingRegionalGoals:

  • Increasing coordinationof prevention and carefor residents,including those with behavioral ormental health needs
  • Reducing inappropriateutilization ofservices

Weareproposing thisprojectin Williamson County because it is thelargestcounty intheBTCS catchmentarea,with 55%of thepopulation.Additionally,data aboveindicates that 95%of the admissionsforcrisis residential servicescamefromWilliamson County.Williamson County also has a well‐developed mentalhealthdeputy programand providestheopportunity for expansion and refinementof that program.This location is agoodstrategicchoice becausethe County sharesa borderwith 3of theother8Counties weserve.Astheprogrammatures,the number of beds can beexpanded easilytoservehalf of thecatchmentareaif needed.

Challenges:

The primarychallenge for thisprojectis toachievewidespread use of the48‐HourObservation Unit as a first option by law enforcement.Thereareestablished law enforcementpatternsof detention and disposition for mental health casesin Williamson County—as well as Burnet County.Justproviding anewoptionwill not automatically lead toacceptanceand utilization. Weplan tocommunicatetolaw enforcementleadershipin thecounty and tothefrontline officers.Wecurrentlyprovide training and haveroutine communication with themajor law enforcementagencies,Williamson County Sheriff’s Office,BurnetCounty Sheriff’sOfficeand thepolice departmentsof Round Rock,Georgetown,Burnetand MarbleFalls.Weplan to continue theseactivities and add additional communication and education meetingsfor the first yearof theprojecttofosteracceptanceanduse of theservices.

5‐YearExpectedOutcome for ProviderandPatients:

Overthenext 5years,weexpecttheoutcomestoinclude reduction of hospitalizations for persons whoarecurrentlyadmittedfor veryshort stays,reductionof EDutilization by law enforcementthat havebehavioral health clientsin custody,and reduction in incarceration of thementallyill.

StartingPoint/Baseline:

Currently,noinvoluntarycrisis stabilization serviceexistsin Williamson County; therefore,the baseline is 0in DY2.Wedonothavethedata to estimatethenumber of people whowere admitted tojail inappropriately,whowereadmittedtoprivatepsychiatricfacilities inadjacent Counties orwhoweredetainedin EDs.Amajoreffortis neededduringDY2toidentifythe extentof theresourcesneededandensurethattheinterventionis appropriate and adequate. Wewill use thenumber of admissions intotheStateHospital Systemand PsychiatricInpatient Units duringFY 2012 asour baselinefor theperformanceindicators.

Rationale:

CommunityNeedAddressed:

  • CommunityNeedArea:CN.2– Limited accesstoprimarycare
  • SpecificCommunity Need:

oCN.2.1– Limited accesstobehavioral health servicestorural,poor and under &un‐ uninsuredpopulations(meds,casemanagement,counseling, diagnoses)in Williamson County

oCN.2.2– Limited accessfor serious mentally ill adults tocrisisservicesinWilliamson

County

oCN.2.13– Limited accesstoadult behavioralhealth servicesin Williamson County

Asecureand safecommunity based crisis stabilization alternativewill givelaw enforcement officersand crisis responder’snewopportunitiestohelp people.Someone experiencinga mental health crisis is assessedtodetermineif he/she is ‘adangertoself orothers’.Itis that standardin thelaw that must bemetin orderto detain someone,transport themto a safe place,conduct a thorough evaluation and determinethemost appropriatecourseof action to assist theindividual.Alaw enforcementofficer,whohas someonein custody under this circumstance,has little recourseotherthan totransport theperson tothenearestsafeand securefacility for evaluation.Jail, EDs and psychiatric hospitals aresecureoptions and generallysafeoptions. But as referencedin theRHPPlanning Protocol– Category1,page141, BehavioralHealth NewsVol. 7Issue3reportedthat “Community‐based crisis alternativescan effectivelyreduceexpensiveand undesirable outcomes,suchas preventableinpatient stays. For example,statepsychiatric hospital recidivismtrendeddownwardcoincident with implementationof crisisoutpatient servicesin someTexascommunities.The percentof persons readmittedtoa Texasstatepsychiatric hospital within 30daysdecreasedfrom8.0%in SFY2008(beforeimplementation ofalternatives)to6.9%in SFY2011.”A projecttoimprove stabilization servicesand add a missing partof thecontinuum of care,thecapacitytoassess and treatpeople whoareon emergencydetention orders,is neededinWilliamson County. BTCS participatesin theMental Health Task forcefor Williamson County and thisgroup of leadersandhealth careprofessionals reportthat mentally illpeople aretakeninappropriately toEDs, jail and theStateHospital.Otherthan thedata reportedaboverelatedtoadmissionsto thevoluntary Crisis Respitefacility,thecommunity needbeing expressedis, toa certainextent, anecdotal.Howeverit is clearthatweneedtobegin offering a community based crisis stabilization option evenas weaddress thecorecomponents of thisProjectOption.

ProjectComponents:

Thisprojecttoprovide involuntary Crisis Respiteservicesfor adults will address all of the requiredcoreprojectcomponents:

a)Convenecommunitystakeholderswho can support thedevelopmentof crisisstabilization servicesto conduct a gap analysis ofthecurrentcommunitycrisis systemand developa specific action plan thatidentifiesspecificcrisis stabilizationservicesto address identified gaps.Wewill workwith health careand law enforcementstakeholders toidentify gaps that lead toinappropriate admission tojail, EDs and short termstaysin psychiatric hospitals. Wewill convenecommunity stakeholdersduring theremainderof FY2013to identify information neededtoassess thegap incrisis servicesand assessroot cause.

b)Analyze thecurrentsystemof crisisstabilizationservicesavailable in thecommunity including capacityof eachservice,currentutilization patterns,eligibilitycriteria and dischargecriteria for eachservice.Weknow that law enforcementis transporting toand fromEDs intheir own community and in Austin and one causeis limitedcrisisresponse servicesand/orconcern for thesafetyand securityof thepatient and thecommunity.We will identifytools and agreementsneededtoaccessand analyze todeterminecapacityfor service,currentutilization patterns and toidentify thekeycharacteristicsof thepeople to beserved.

c)Assessthebehavioral health needsof patients currentlyreceivingcrisis services.Determine thetypes and volumeofservicesneededto resolvecrises in community‐based settings. Then conducta gap analysis that will result in a data‐drivenplan to developspecific community‐based crisisstabilizationalternativesthat will meetthebehavioralhealthneedsof thepatients.Wewill use BTCS staff toassess admissionsand dispositions to voluntary CrisisRespiteand toall psychiatric facilitiesin thearea.Wewill focus on those detainedand transported during thelast year.

d)Explore potential crisis alternativeservicemodelsand determineacceptable and feasible models for implementation.Using theinformation fromstakeholders,fromcapacityand utilization tools and fromassessmentof those detained, wewill assess theintervention weareproviding todetermineif it is sufficient in bed capacityand scope of evaluation and treatmentoptionsavailable.Wewill use that information torecommendnext steps for RHP8.

e)Reviewtheintervention(s) impact onaccess to and qualityofbehavioralhealth crisis stabilizationservicesand identify“lessonslearned,”opportunities to scale all orpart of the intervention(s)to a broaderpatientpopulation,and identifykeychallengesassociatedwith expansion of theintervention(s),including special considerations for safety‐net populations.Wewill reviewtheimpactof involuntary CrisisRespite andidentify lessons learned andadjust themodel with respecttoarea,intensityand population.

ContinuousQualityImprovement:

BTCS is committed tocontinuous qualityimprovementand learning relatedtothisproject.Wewill establish quality improvementactivitiessuchas rapid cycleimprovementand will performotheractivitiessuchas “lessons learned” and identifying projectimpacts.In addition, weareparticipatingin a regional learning collaborativewhich sharesinformation suchas challenges,lessonslearnedandconsiderations for safetynet populations.

Howtheprojectrepresentsanewinitiativeorsignificantlyenhancesanexistingdeliverysystemreforminitiative:Thisprojectprovidescrisis servicestoenhance theinitiatives currently funded by theU.S.Departmentof Health andHuman Services(DHHS).BTCS receivesfunds to operatesubstance abuse OutreachScreening and ReferralservicesinWilliamson and several othercounties, and Mental Health block grantfunds for outpatient mentalhealth services. Those DHHS funds will notbeusedfordirectservicesin thisproject;however,thisproject enhancesand extends thecarecurrentlyprovidedwith Federal funds by a providing alocal option toaddress crisis needs. Webelievethiscrisisservicewill improvethehealthcare outcomesfor entirecommunity, relievepressureon law enforcementand ED’s andpromote stable community tenurefor our patients.

RelatedCategory3Outcome Measure:

  • OD‐3Potentially PreventableRe‐Admissions‐30day Readmission Rates(PPRs)

oIT‐3.14Behavioral Health/Substance Abuse 30-day Readmission Rate

Reasons/rationaleforselectingtheoutcomemeasure:Readmissions topsychiatricfacilities aredrivenby a number of circumstancessurrounding the initial hospital stay.Those include inaccurateassessmentof acuity and earlyrelease,pooror hurrieddischarge planning, inadequate knowledgeof community resources,inadequate resourcestoaccommodatea soundcommunityplacement.Creatingtheoption toprovide involuntary detention and evaluation in thecommunity providestheopportunity toaddress severalof thesedrivers.Wecan provide timelyevaluationsand quick stabilization linked to communityfollow up. Weknow thecommunityresourcesincluding housing and treatment options.It alsogivesusthechancetointervenewith thosewhootherwisewould be readmittedratherthangettingcommunity help.Admissions toinpatient settings should be moreappropriate and readmissions reduced.

Baseline Information: The baselinerateestablished inDY3 was 6.04%. Our baseline measurement period established in DY3 was 09/01/2013-08/31/2014.

RelationshiptoOtherProjects:

Thisenhancesadditional projects that BTCS is pursuing relatedtoChild Crisis Respite (#126844305.1.2)and EmergencyServicesDiversion (#126844305.2.2)in that it providesaccess tocarefollowing thoseemergencyinterventions.Weexpecttheotherprojects will demonstrate improvedoutcomesdue toavailability of outpatient and aftercareservicesin the communities in which people live.Itboth supports and relieson theTransitionalHousing (#126844305.2.1)projects which provide a placefor people tocontinue recoveryin the communityafterstabilization is achieved.This option supports substance abuse treatmentas a back‐upfor relapseandcrisis events.Routine outpatient careis enhancedby thesafetynetof short termcrisisresolution.

Thisprojectalsosupportstheintensive outpatient crisis services(#126844305.1.4)projectto be implemented by theLMHA in BurnetCounty,in RHP8.Byproviding theinvoluntary crisis stabilization serviceinWilliamson County,theproviders in BurnetCounty (25‐45minutesfrom theproposed48‐HourObservation Unit) will besupported by a resourcepreviouslyunavailable for persons in crisis.

RelationshiptoOtherPerforming ProviderProjects andPlanfor LearningCollaborative:

BTCS will participatein all learning collaboratives organized orsponsored by TexasA&MHealth Science Centerthat arerelevanttoour projects.Webelieveit is important toimproving and adjusting thecareprovided.Wewill alsoparticipate with othercommunity centersand behavioral health careprovidersas wecontinuetodo through theTexasCouncil of Community Centers.Theexchangeof ideas through both developing and existing relationships will keep the line of communicationopenandwill help us adjust and refineour programsand approachestobehavioral health care.

ProjectValuation:

Weexpecttoserve250people in thiscommunity based crisis alternativein DY4and300people in DY5.Servingpeople in thecommunity is a substantial savings overusinghospitaland ED, which arenow theonlyoptions. Thevaluation calculatedfor thisprojectusedcost‐utility analysiswhich measuresprogramcost in dollars and thehealth consequencesin utility‐ weightedunits that wereapplied tothefactors existing in thisunderservedarea,including: limitedaccesstoprimarycareand tobehavioral health care,povertyand thelink between chronic health conditionsand chronic behavioralhealth conditions.Thevaluation study was preparedbyprofessors H.Shelton Brown,Ph.D.and A.Hasanat Alamgir,Ph.D. bothof theUT Houston Schoolof PublicHealth andThomasBohman, Ph.D. of theUTAustin Centerfor Social WorkResearchbased on a model that includedquality‐adjusted life‐years(QALYs) and an extensiveliteratureof similar interventions andcost savingsand health outcomesrelatedto those interventions. TheQALYindex incorporatescosts avertedwhenknown (e.g.,emergency room visitsthatareavoided).

Adescription of themethod used,titled ValuingTransformation Projects,has beenposted on theperforming provider websitewhich will belinkedto theMedicaid

1115Transformation Waivertab. A complete write‐upof theprojectwillbeavailableonline.