Senate Democratic Policy Committee Hearing

April 3, 2008

 

Written testimony provided by Allegheny County Department of Human Services

Patricia L. Valentine, Deputy Director for Behavioral Health

 

 

Thank you for inviting the Allegheny County Department of Human Services to provide testimony regarding potential effects that the closure of Mayview State Hospital may have on the region.  The Department of Human Services consists of five program offices, including the Area Agency on Aging, the Offices of Children, Youth, and Families, Mental Retardation/ Developmental Disabilities, Community Services and Behavioral Health, which is the office that is responsible for mental health and drug & alcohol services.  In addition, four support offices provide administrative, communications, information technology and data analysis services.  The Department of Human Services serves over 200,000 Allegheny County citizens each year, many of whom receive multiple services.

 

This Committee has asked for testimony regarding the potential effects, specifically the health, welfare and economic impact, the closure of Mayview State Hospital may have on the region. I would like to testify about the effects upon Behavioral Health services and supports available to individuals being discharged from Mayview, individuals being diverted from Mayview, and all of the more than 15,000 individuals with serious and persistent mental illness and co-occurring substance use disorders being served by the public behavioral health system in Allegheny County.  

 

Most people, regardless of their status in terms of health or illness, or level of ability or disability, want to live with as much freedom and self-determination as possible.  Most people want to live in a neighborhood that is compatible and affordable, and engage in productive work or other meaningful activity, as well as pleasurable social and recreational activity.  Furthermore, our governments, at the federal and commonwealth levels, have determined that people should be able to live in the least restrictive environment in which they are able to live successfully, with the supports that they need.  This is reflected in court decisions such as the Supreme Court Olmstead decision, as well as through Commonwealth efforts to assist senior citizens and people with serious physically disabling conditions to live in their own homes rather than in nursing homes, in efforts to assist people with intellectual disabilities to live in the community rather than in State Centers, and in the efforts that we are discussing today, to assist people with serious mental illness, who have historically lived in Mayview State Hospital for various periods of time, to live with us in the community.


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First, it’s important to note that people have always returned to the Allegheny County community from Mayview.  In State Fiscal Year 2007, there were 126 discharges from Mayview State Hospital.  In State Fiscal Year 2006, there were 134, and in State Fiscal Year 2005, there were 142.  It’s also important to note that we have always diverted people from the need for State Hospitalization.

 

The vast majority of people are able to live successfully in the community following discharge from Mayview.  However, some people, in the past, have had to return to Mayview after discharge.  Our current development of services is specifically designed to assure service availability for people at all levels of ability and need in the community, and to respond to people’s differing preferences regarding how they can best use services. 

 

Obviously, housing is essential to people’s ability to live successfully in the community.  For people with serious and persistent mental illness who are currently residing at Mayview, are hospitalized in a community psychiatric inpatient unit, or are living in a behavioral health funded residential facility, and who don’t need staff support 24 hours per day, we are offering permanent supported housing.  In permanent supported housing, people choose their own apartment in the neighborhood in which they want to live.  The only requirement for selection of the housing is that it must conform to HUD standards, and the landlord must be willing to accept a Section 8 voucher when such vouchers are again available.  This requirement is intended to promote long-term affordability of the housing through a Section 8 subsidy.  Individuals referred to Permanent Supported Housing receive tenant-related services from a Housing Support Team, and behavioral health services through community behavioral health providers as needed and desired.  As of February 29, 2008, 68 individuals had moved into apartments through this initiative and 66 additional people have been referred and accepted, and are in the process of finding housing.  Apartments for the 68 people currently living in Permanent Supported Housing are located throughout Allegheny County in the following communities:  Bridgeville, Duquesne, East Liberty, Etna, Greenfield, Homestead, Squirrel Hill, Monroeville, Mt. Oliver, North Side, Shadyside, South Side and Wilkinsburg.  

 

Some people, though, either can’t or don’t want to live in an apartment alone or with someone else.  For people who need or want more intensive supports, including 24 per day on-site staff, there are many other options.  We are currently serving people from Mayview and/or from the community in each of these housing options, and are in the process of developing additional options based upon identified needs.    

 

For people who need personal care services along with specialized mental health services in their home, we have Comprehensive Mental Health Personal Care Homes (CMHPCH’s), which are licensed personal care homes staffed with specialized mental health staff.  We currently have 5 CMHPCH’s in operation in South Side, Munhall, West Mifflin and McKeesport, and are in various stages of development of three additional ones, at least one of which will be located in the Russellton area. 


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We also have two, and are developing two additional, small specialized homes for individuals for whom smaller home environments are more appropriate.  These houses, staffed according to the needs of the people who live there, become home for 3 or 4 people who live as a family.  Our two existing homes are located in Pleasant Hills and South Park, and it is likely that the two homes being developed will be located in the Bellevue area.  The fifth and sixth small specialized homes, yet to be developed, will be operated by State employees who are currently working at Mayview, and will be available to Mayview residents from any of the five counties that currently have people being served at Mayview.

We also have a treatment housing option called Long Term Structured Residences (LTSR’s).  We currently have 4 LTSR’s, and will be developing 2 more, in addition to the LTSR that will be operated by State employees. Our existing LTSR’s are located in Carrick, East Liberty, Rochester and Carnegie.  The two LTSR’s that are yet to be developed will be small LTSR’s, for 6-8 people each, and will be available for people who are currently living at Mayview. 

As I indicated earlier, we know that we need to provide services and supports to meet needs of varying types and intensities.  The most intensive service available in the community is inpatient psychiatric hospitalization.  Most people who need inpatient psychiatric hospitalization improve within a few days or weeks, and are then able to return to resume their lives in the community.  Some people, however, may need this level of support for a longer period of time.  For people who need intensive services in a treatment environment for a longer period of time, we currently have two options, and will be developing a third option.  Currently, we have extended acute psychiatric hospitalization services available at Western Psychiatric Institute and Clinic, in the Transitional Recovery Unit (TRU).  The Transitional Recovery Unit provides 30 people at any given time with extended treatment in a recovery-promoting environment that is focused on community reintegration.  In addition, we have available a Residential Treatment Facility for Adults, operated by Mercy Behavioral Health, which also meets the need for extended intensive treatment for up to 16 people at any given time.    Finally, we are in the process of drafting a Request for Proposal for a non-hospital extended acute unit, able to serve 12-16 people at any given point in time, which will provide temporary treatment housing for people who might otherwise have been referred to Mayview. 

I’ve focused so far on residential and intensive treatment services.  However, we have available many non-residential services that provide individualized, recovery-focused services that support people in their goal of community living.  One of these services is called a Community Treatment Team.  A Community Treatment Team (CTT) is a multi-disciplinary team, generally composed of approximately 10 staff including psychiatrists, psychiatric nurses, therapists, case managers, peer support staff and vocational staff.  Each CTT supports up to 100 people with serious and persistent mental illness, many of whom have co-occurring substance use disorders, to successfully achieve their goals of living and working in the community.  Prior to the decision to close Mayview, Allegheny County had 5 Community Treatment Teams, including one that specializes in serving transition-age youth and young adults.  We currently


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have 6 CTT’s, and will be developing a seventh team in the coming months.  These teams will be joined by a State-Operated Services CTT.

Rather than outlining all of the individual services that have been, and are being developed in the community to support people who are leaving Mayview, as well as others with serious and persistent mental illness, I would like to offer to meet with any Committee member who would like to have a complete list of services and explanation of each.  However, there are three more services that deserve special mention. 

The first is a service called Mobile Medication services.  Many people with serious and persistent mental illness are on complicated medication regimens.  Many have to take multiple medications per day for psychiatric and physical illnesses.  Remembering what medication to take at what time, under what circumstances (e.g., with or without food), can be a challenge for anyone who relies on multiple medications.  Mobile Medication Services provide on-site assistance to people who need assistance with medication management, as well as training and organizational assistance to help people to be able to successfully manage their medication regimens. 

The second is a service called Single Point of Accountability.  Individuals with serious and persistent mental illness and sometimes, co-occurring substance use disorders, may be involved with many services within the behavioral health system, as well as with many other systems and people.  These include but are not limited to Social Security, Department of Public Welfare, Office of Vocational Rehabilitation, a Primary Care Physician, Physical Health Managed Care Organization, Behavioral Health Managed Care Organization, Medicare Special Needs Unit, employers, landlords, and many others.  It can be very difficult for people to know which of these systems or people to approach with a particular question or concern.  Who can help with a Rent Rebate application?  Who can help with Social Security redetermination?  What are these papers that I am getting from my managed care organization?  It can also be very difficult for consumers to “negotiate” when those systems and people might not be coordinating their efforts and activities very well.  The purpose of a Single Point of Accountability is to provide each consumer with a single person or team that the consumer can go to with any question or concern.  The role of the Single Point of Accountability is to make sure that that question or concern is addressed by the right person or system, to make sure that the consumer has access to what he or she needs and wants, and to make sure that the efforts and activities of all of the systems with which the consumer is involved are coordinated. 

The third is a variety of services that fall under the category of Peer Support.  Whether the support being provided is that of a peer mentor, a Certified Peer Specialist, a Recovery Support specialist, peer staff in a housing program, in a drop-in center, through the Warmline, or other kinds of peer support, it is clear that one of the most helpful, affirming and recovery-promoting options that we can offer to people is the opportunity to participate in a helping relationship with someone who has walked in their shoes, and who knows first-hand the challenges and triumphs of recovery. 

 

 

 

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Before closing, I would like to address a couple concerns that I have recently heard about the community behavioral health system. 

I have heard concerns that the closure of Mayview will result in less access to services and supports for other Allegheny County citizens with serious and persistent mental illness.  This is not accurate.  In fact, the substantial development that is occurring will make services and supports more available for all people who need them.  Every year, providers serve approximately 15,000 Allegheny County citizens with serious and persistent mental illness and co-occurring disorders in Allegheny County.  The expansion of resources has made, and will continue to make, housing, treatment, case management, rehabilitation, and peer services available to individuals based upon need and preference.

It is important to note that this does not mean that we are able to ensure that each person is able to access each service that he or she wants or needs at any given time.  Neither the community system nor Mayview State Hospital has been able to do that.  Do I envision that we will ever be able to ensure that each person is able to access each service that he or she wants or need at any given time?  Unfortunately, no.  Even if Mayview were not closing, the community and state hospital systems together cannot ensure that.  However, the resources that have been used in recent years to serve just a few hundred individuals in Mayview State Hospital are being, and will continue to be, used very effectively in the community to promote the safety, health and recovery of everyone with a serious and persistent mental illness. 

I have also heard concerns that more people will need to use community psychiatric inpatient services, and that the availability of community psychiatric inpatient services will be limited because individuals who left Mayview, or who would have gone to Mayview, will be using the inpatient beds.  There is nothing to substantiate this concern.  In fact, since the closure announcement, only 6 individuals discharged from Mayview during that time period have been hospitalized for psychiatric reasons, with an average length of stay of 9.3 days.  In addition, for HealthChoices members, who comprise the majority of the population with serious and persistent mental illness, both the number of psychiatric inpatient admissions and average length of stay when admitted have been reduced over the past 20 months.  In July of 2006, there were 539 HealthChoices admissions.  In August of 2006, there were 567 admissions.  In November and December of 2007, the most recent months for which we have reliable claims data, there were 435 and 461 admissions, respectively.  Taken together, that represents a 19% reduction in admissions.  In addition, Community Care Behavioral Health Organization, which manages the Behavioral Health Medical Assistance program in Allegheny County, has not had difficulty meeting people’s needs for inpatient services.  In addition, average length of stay has been reduced from 10.4 and 10.65 days in July and August of 2006, to 8.96 and 9.09 days, respectively in November and December of 2007.  That constitutes a 14% reduction.  Just as importantly, readmissions within 7, 30 and 90 days of discharge from a community psychiatric hospital are all significantly lower in March 2008 than in July, 2006. 

 

 

 

 

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I have also heard concerns expressed about a waiting list for the Transitional Recovery Unit.  There are 13 people waiting for TRU who, in the past, probably would have been referred to Mayview.  However, this is a vast improvement over the many times in the past, when the waiting list for Mayview could reach 50 or 60 people, and the wait times could approximate 90 days. 

Reinforcing the good quality of care that individuals who have been discharged from Mayview receive in the community is a report of nursing assessments of 55 people, 25 of whom were identified as medically fragile, completed by nurses from Mayview State Hospital between the dates of February 11, 2008 and March 14, 2008.  The team of nurses was impressed with the consistent follow-up in medical care that they have observed. Moreover, the report states, “Based upon the Mayview team’s assessments, they have determined that the majority of consumers have progressed significantly in their recovery process since their discharge from Mayview. 

In addition, the team of Mayview nurses was able and willing to provide information and consultation to community staff and consumers. 

 

It is important to make sure that you know of the commitment that Allegheny County is making, and will continue to make, to ensure that individuals in Allegheny County with serious and persistent mental illness receive the highest quality, most appropriate services and supports in the community.  This commitment is demonstrated through a number of initiatives and decisions, including but not limited to:

 

·        Use of evidence-based practices whenever possible and monitoring of fidelity to those practices

·        Development of standards to guide practice in areas in which there is, as yet, no evidence base. 

·        Evaluation of processes and outcomes to assure continuous improvement in areas of quality and cost-effectiveness

 

 

 

 

 

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·        Intensive monitoring of the services and supports in which people are participating and intensive monitoring of people’s status, including the commitment of Community Care Behavioral Health Organization to dedicate four high-risk care managers to work with Allegheny County, providers and case managers to assure that oversight and monitoring includes clinical expertise 24 hours per day, and to ensure coordination of physical health and behavioral health services for people who are discharged from Mayview State Hospital.

·        Ongoing evaluation of consumer and family satisfaction

·        Use of Early Warning indicators, along with the Incident Reporting System to alert us to and allow us to address system issues, as well as individual issues related to people who have been discharged from Mayview, in a timely manner.

·        Detailed use of data, facilitated by Allegheny HealthChoices, Inc to provide information on service trends and gaps, as well as other information that will be used to assure ongoing system responsiveness to the needs of individuals participating in services.

·        Ongoing opportunities for system staff to participate in training, coaching and evaluation to assure quality of services.

 

In closing, Allegheny County Department of Human Services strongly supports the decision of the Department of Public Welfare to close Mayview State Hospital.  Our experience has demonstrated our ability to provide successful community support to populations with significantly greater challenges as long as we have the financial resources on an ongoing basis to develop and modify services and supports to meet their changing needs.  

 

Thank you for your consideration.