Crisis Best Practices Workgroup July 21, 2017

Today’s Agenda Welcome Content Overview: The Safety Net Review Survey Results/Discussion Review Project Plan and Timeline Adjourn Housekeeping: Using Skype for questions—please mute us, but don’t put our call on hold Purpose: To develop a comprehensive Best Practice Toolkit for Crisis Residential Services, informed by Crisis Residential providers across the country.

Crisis Best Practices Workgroup TBD Solutions is proud to sponsor the Crisis Best Practices Workgroup. Crisis Program Development Quality & Process Improvement Metrics Development Integrated Care Coordination Middle Management Training Research & Analysis Interactive Data Visualization Software Procurement Consulting www.TBDSolutions.com

Workgroup Participants 115 participants from 37 states Plus England and Costa Rica Approximately 350 crisis homes exist nationwide Welcome new participants from HI, OK, VA

Content Review: The Safety Net December 2016: Staffing January 2017: Scope & Function February: Metrics & Outcomes March: Taxonomy & Community Relations April: Treatment Philosophy & Approach May: Intake June: Funding July: The Safety Net

The Safety Net Crisis Services and the Safety Net: A Dynamic Tension Walter Peck

Safety Net Survey Results: Scope of Care “We used to provide detox but had to stop due to a lack of nursing resources in our area.” n=27

Safety Net Survey Results: Scope of Care “We only admit indigent, under- insured or uninsured individuals. Our county funds more of the program, and it was specifically established to serve this grossly underserved part of our population.” n=27

Safety Net Survey Results: Appropriate Referrals In what situations are you not comfortable accepting a referral? “When the core service agency asks that a client who is psychiatrically stable be held for several weeks or months.” “At times in Kansas, there are no appropriate options. For example, there is a moratorium with our state hospital and we have multiple people in the community waiting to get admitted.” n=27

Safety Net Survey Results: Appropriate Referrals In what situations are you not comfortable accepting a referral? Very violent or aggressive clients Medically complex individuals Homelessness Anyone requiring 1:1 monitoring n=27

Safety Net Survey Results “They believe we do case management and will find people housing.” “Often the local Emergency Departments send us clients that are not in crisis but need housing options or similar non-emergent issues.” “There is a lot of misunderstanding about length of stay. Clients are only authorized to stay 3-7 days.” n=27

Safety Net Survey Results: Compromising Program Standards “Asked to provide medical detox services when the unit may not be licensed to do so or have adequate staffing.” “Allowing clients to stay for 4 months due to housing at the request of the county.” “Recently we have assisted an IDD adult that is transitioning from home placement to a IDD group home and has experienced a MH crisis.” n=27

Safety Net Survey Results: Compromising Program Standards “Our Program Director has no input on who is accepted into our crisis house; the determination for admission rests solely on the Crisis Worker’s assessment of the client and who, at most times, are not QMHPs.” At times, hospitals refer clients when they have nowhere else to send them and it can be a stretch to meet our level of medical criteria.” n=27

Safety Net Survey Results: Maintaining Program Integrity Have you dealt with any consequences for denying admissions from any of your referral sources? “Fewer referrals” “Hospital doctors angry and calling Executive Director to get his way. (It didn’t work.)” “Experiencing pushback from the local EDs as they would like us to maintain involuntary and/or aggressive folks here” “We do not deny admissions, we can almost always come to a creative solution to serve them.” “There are times our community partners do not understand why we cannot simply increase our medical staffing to accommodate high-acuity medical clients.”

Safety Net Survey Results How do you balance your desire to be a helpful provider in your community's care continuum with maintaining the functional integrity of your program, ensuring that people meet criteria to receive services for the duration of their stay at your program? “We enjoy growing the program to be able to competently serve as many as we can. We enjoy filling in gaps and thinking outside the box. But we will not do what we cannot do and we will not take on something that is above the risk we can manage” “We are revaluating our program scope to make sure it meets the needs of the community. For example the opiate epidemic means we must adapt to these patients.” “We have frequent treatment team meetings (minimum once weekly) with all facets of the program (clinicians/management/etc.) to include varying perspectives to evaluate each client. This helps balance varying priorities (program integrity vs. yielding to client needs)”

Safety Net Survey Results Do you ever experience internal conflict in your organization over accepting a referral? If so, how is that managed?  “Often our front line staff feel that our licensed clinicians and/or management staff are accepting referrals that are not a good fit.” “There is some internal conflict. We continue to provide education on our admission criteria and the definition of medical necessity. I have met with different groups in our agency to discuss and explain.” “All questionable referrals are forwarded through management and vetted with more experienced staff members. We are fortunate enough to be a very large agency and have a countless team members to rely upon for informed decisions and staff training to align less experienced employees with the leaders.”

Safety Net Survey Results What is your perception of how a crisis program like yours complements the continuum of services in your community? “Crisis Units are just that—for people in a behavioral health crisis including when their environment becomes unstable. “Person centered treatment involves treating the whole person.” “All of those needs are frequent issues at our Crisis Center--our staff are well versed in community resources and we have on site support with SOAR, Homeless team, and on site sobering, detox and referrals for SUD treatment.” “Our crisis program is a "catch-all" for the community. We are in a great position to help and cannot adequately do so if we cannot be flexible enough to bend to the unique needs of the individuals we serve. We cannot do everything, but we do everything within our power to change lives for the better.”

Safety Net Survey Results “At our Crisis Stabilization Unit, we take clients who are waiting for detox bed. These are short stays for individuals who don’t participate in groups. Our productivity is down because of this.” n=27

Safety Net Survey Results How has your Crisis Program adapted over the years in its function as part of the Safety Net?  “The units have adapted to take stepdowns from acute care hospital units, state hospital discharges and to be more flexible with admissions to support individuals receiving the best care in the least restrictive environment.” “We can continue to add staff and provide support to the community in this age of the State Hospital moratorium.” “Our alumni program is one of the very few "safety nets" serving the population of indigent, seriously mentally ill individuals in the community. Individuals who become alumni are able to have a safe place to spend time seven days per week; take showers; attend group and receive individual therapy and case management assistance as needed. Many alumni spend holidays with us when they would otherwise have no place to go. Alumni also have an opportunity to give back by providing assistance to the unit and to our current residents by helping them navigate a complex healthcare system.” “In the past 10 years, we have gone from 16 beds in a crisis residential program (the Inn) to 79 beds by adding a Crisis Expansion Respite facility (Next Step) and an 1115- waiver-funded facility. These additions helped to meet the community safety net need, but our city continues to grow and so does the need.”

Safety Net Survey Results “Shorter length of stay” “Limited funding requires us to reduce lengths of stay or limit services (such as case management)” n=24

Upcoming Webinar Training: SAMHSA 4th Monday of each month April-September Monday July 24th 3pm EST/12pm PST https://tinyurl.com/mezytde

Next Steps Next Conference Calls: Wednesday, August 23rd @ 2pm EDT/11am PDT (Topic TBA) Friday, September 15th @ 1pm EDT/10am PDT Group Listserv: CrisisResidentialNetwork@TBDSolutions.com Website: www.CrisisResidentialNetwork.com (Meeting Slides stored here) Questions: TravisA@TBDSolutions.com