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Community Mental Health Plan

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Mid Shore Behavioral Health

on 31 December 2014

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Transcript of Community Mental Health Plan

…to continually improve the provision of mental health services for residents of Caroline, Dorchester, Kent, Queen Anne’s and Talbot Counties through effective coordination of services in collaboration with consumers, family members, providers and community leaders.
…to develop a model rural mental health delivery system with a continuum of mental health services that are culturally diverse. These services ensure consumer empowerment, have a community focus, are cost effective for the system and are integrated to serve the community as a whole, private and public sector, regardless of cultural or ethnic background.
Goal 1

Increase public knowledge and support for enhanced health and wellness.

Goal 2
Promote behavioral health through a system of integrated care where prevention, screening, and intervention are common practice across the lifespan.

Goal 3

Enhance prevention, screening, and intervention for the special needs population to increase outcomes.

Goal 4
Provide a coordinated approach to increase education, training, and employment to develop and sustain an effective behavioral health workforce and provider network.

Goal 5

Build partnerships to reduce transportation barriers to accessing services and increase the provision of affordable housing to decrease the episodes of homelessness.

Goal 6
Utilize data and health information technology to evaluate, monitor, and improve quality of Public Behavioral Health System services and outcomes.
MSMHS Community Mental Health Plan Goals FY15
State Priorities FY14

Mid-Shore Mental Health Systems, Inc.

Community Mental Health Plan

Presented by:
Holly R. Ireland, LCSW-C
Executive Director

CoC Roundtable on Homelessness
Integration Workgroup
Regional Focus Areas FY15

Defeating Stigma

SAMHSA's 2015-2018
6 Proposed Strategic Initiatives

This Strategic Initiative focuses on the prevention of substance abuse and mental illness
by maximizing opportunities to create environments where individuals, families, communities, and systems are motivated and empowered to manage their overall emotional, behavioral, and physical health.
This SI will include a focus on several
populations of high risk
, including
college students and transition age youth
, especially those at risk of first episodes of mental illness or substance abuse; American Indian/Alaska Natives;
ethnic minorities experiencing health and behavioral health disparities; military families; and lesbian, gay, bisexual, and transgender individuals

This Strategic Initiative focuses on health care and integration
across systems
including systems
of particular importance
for persons with behavioral health needs such as
community health promotion, health care delivery, specialty behavioral health care, and community living needs
. Integration efforts will seek to increase access to appropriate
high quality
prevention, treatment, recovery and wellness services and supports;
reduce disparities
between the availability of services for mental illness (including serious 4 mental illness) and substance use disorders compared with the availability of services for other medical conditions; and
support coordinated care and services
across systems.

This Strategic Initiative focuses on trauma and justice by integrating a
trauma-informed approach throughout health, behavioral health, human services, and related systems
in order to
reduce the harmful effects of trauma and violence
on individuals, families and communities. This SI also will support the utilization of
innovative strategies to reduce
the involvement of individuals with trauma and behavioral health issues in the
criminal and juvenile justice systems.

This Strategic Initiative will
promote partnering with people in recovery
from mental and substance use disorders and their family members to guide the behavioral health system and promote
individual, program, and system-level
approaches that
foster health and resilience
(including helping individuals with behavioral health needs be well, manage symptoms, and achieve and maintain abstinence);
increase housing to support recovery; reduce barriers to employment, education, and other life goals; and secure necessary social supports in their chosen community

This Strategic Initiative will ensure that the behavioral health system – including states, community providers, patients, peers, and prevention specialists – fully participate with the general healthcare delivery system in the
adoption of health information technology (Health IT)
, including
interoperable electronic health records (EHRs)
and the use of other electronic training, assessment, treatment, monitoring, and recovery support tools, to
ensure high-quality integrated health care
, appropriate specialty care, improved patient/consumer engagement, and effective prevention and wellness strategies.

This Strategic Initiative will support active strategies to
strengthen the behavioral health workforce
. Through technical assistance, training and focused programs, the initiative will promote an
integrated, aligned, competent
workforce that
enhances the availability of prevention and treatment
for substance abuse and mental illness,
strengthens the capabilities
of behavioral health professionals, and
promotes the infrastructure of health systems
to deliver competent, organized behavioral health services. This initiative will
continually monitor and assess the needs of peers, communities, and health professionals in meeting behavioral health needs in America
’s transformed health promotion and health care delivery systems.

SAMHSA's 2015-2018
6 Proposed Strategic Initiatives

Total System

• Recovery Supports
• Public Awareness and Education
• Tobacco/Smoking Cessation
• Behavioral health workforce development efforts
• Suicide prevention
• Efforts to address co-occurring disorders/dual diagnosis capability training
• Access to services across the lifespan
• Evidence-based practices
• Health disparities/cultural competency
• Diversion efforts
• Outcomes/quality
(as identified in the Implementation Report for the
FY13 State Mental Health Plan)
State Mental Health Plan Goals FY15
Regional Behavioral Health
Advisory Committee

Pursuant to the Annotated Code of Maryland, Health General, Title 10, Mental Hygiene Law, Subtitle 3, Caroline, Dorchester, Kent, Queen Anne’s and Talbot Counties has established a Regional Behavioral Health Advisory Committee, for the purpose of advising County and State officials on the needs of citizens with mental illnesses in these jurisdictions and ways in which these needs can be met.
Meeting Structure

Consumer Council
The Roundtable on Homelessness serves as the local Continuum of Care (CoC) for Caroline, Dorchester, Kent, Queen Anne’s and Talbot Counties. A CoC is a group of local stakeholders, decision makers, organizations, consumers, etc. that serve to unite all agencies and organizations that serve homeless and or at risk individuals/families in order to coordinate services and reduce episodes of homelessness. The group strives to address the complex issues of homelessness in our rural region.

To improve the availability and delivery of both housing and supportive services to homeless persons and families within the Mid-Shore Region.

a) To collaborate among member organizations to improve service delivery to homeless clients.
b) To identify needs and fill gaps in services and programs for homeless persons and families.
c) To do long and short range planning, including resource development, to accomplish the mission.
Behavioral Health Services Network
A standing committee consisting solely of primary consumers of publicly funded mental health services to provide ongoing input to the Board and Executive Director of MSMHS.

Stays current on what’s happening in the PMHS at large and provides guidance on what's needed locally from a consumer experience and perspective.

Promotes advocacy and education about resources within the public mental health system to local area consumers.

Meets monthly at Chesapeake Voyagers, Inc. - Wellness and Recovery Center

What Works
Action Plan
Defeating Stigma Coalition
What Works
Action Plan
Child and Adolescent Workgroup
What Works
Action Plan
Long Term Care Workgroup
What Works
Action Plan
Crisis Response Workgroup
What Works
Action Plan
Behavioral Health Integration in the mid-shore region. All regional behavioral health providers will minimally be Dual-Diagnosis capable. Persons suffering with co-occurring disorders will be able to access and receive services to treat both disorders in one setting or, if the provider/agency is not co-occurring enhanced, to appropriately refer as needed.

Bi-Directional Integration with behavioral health and somatic care. All providers will be administering screening for behavioral health and somatic issues, providing treatment and/or making appropriate referrals based on screening results.

Serving MSMHS Community Mental Health Plan Goal #2
Serving MSMHS Community Mental Health Plan Goal #1
Serving MSMHS Community Mental Health Plan Goals # 2 and #3
Serving MSMHS Community Mental Health Plan Goals #2 and #3
Serving MSMHS Community Mental Health Plan Goals #2, #3, #5, and #6
National Data:
9.2 million persons have co-occurring disorders; that is, they have both a mental health and substance use disorder.
7.4 % of individuals receive treatment for both conditions with 55.8% receiving no treatment at all.

Local Data:
48% of consumers participating in pilot project tested positive for co-occurring illness.
70% of census at Warwick Manor have a co-occurring disorder as of January, 2014.
Crisis Services funded through MSMHS have the following breakdown of co-occurring disorders thru the 4th qtr. of FY14:
Call Center: 32%
Mobile Crisis Services: 18% increase over FY13
Urgent Care Appts: 22%

Co-morbidity of physical health problems and co-occurring disorders
68% of individuals with a mental disorder also had one or more medical conditions
Medical conditions may lead to mental disorders, or mental disorders may lead to medical conditions.

1. Individuals with substance abuse issues cannot access MH TX until they have a certain amount of sobriety. (Often, MH issues are an obstacle in recovery) (MH TX providers are not trained in SA issues) (SA providers are not trained in MH issues)

2. SA and MH providers don’t screen for both issues.

3. Limited MH resources for referral from SA providers.

4. Lack of integrated resources, education, and support for providers and persons in recovery and the community.

5. Primary Care Providers do not screen or have time to screen for behavioral health issues.

6. Access to care via insurance.
Mid-Shore Outpatient Mental Health and Addictions Providers
Mobile Crisis Teams
Community Hospitals (Emergency Rooms and Inpatient Units)
State Hospital
Crisis Beds
Inpatient Addictions Rehabilitation Facilities
Detention Centers
Residential Rehabilitation Programs
Psychiatric Rehabilitation Programs
Residential Treatment Centers (Acute and Inpatient)
Primary Care Providers
Medical Community At Large
Salisbury State University School of Social Work
B-HIPP Statewide and Local Coordinators
Eastern Shore Operations Center
Substance Abuse Recovery Community
Mental Health Recovery Community
Insurance Industry and the Community At Large
1. Universal screening tools that can be used in all behavioral health and somatic care treatment settings.

2. Education for persons who suffer with bi-directional disorders, providers, family members, and community agencies and resources.

3. Providers will be at a minimum, dual diagnosed capable and will be able to co-treat people with co-occurring disorders in one treatment setting.

4. Enhancing access to services and having no wrong door in which to access treatment for co-occurring disorders.

5. Education for reducing stigma throughout the mid-shore region.

To empower people to approach behavioral health issues openly and honestly, enabling those in need of treatment to access help without fear of judgment and/or discrimination.
Stigma associated with behavioral health issues/diagnoses often creates shame, embarrassment for the individual and their families, which prevents many from seeking treatment. Often when treatment is sought, healthcare professionals, teachers,
community members,
etc. pass judgment and
make assumptions that
may hinder treatment
and/or recovery.
Chesapeake Voyagers
Dri-Dock Recovery and Wellness Center
Mental Health Association of Talbot County
Local Educators
Community/Business Members
Personal interaction with individuals who have behavioral health diagnoses; education and honest discussion to allay fears and debunk myths.
All children and families will be safe and healthy in their communities, have access to quality behavioral health services and the opportunity to utilize supportive community resources.
See needs assessment completed August 2012 (draft):

DJS referrals from law enforcement decreased statewide;
Talbot County DSS numbers down for this year – CPS and in-home;
RTC referrals to ABH consistent at this time with average length of stay at about 7 months;
Respite through Children’s Choice has seen an increase in children referred for services; Dorchester County Channel Marker has a waiting list consistently
Kent County youth in particular are having a difficult time – drugs, alcohol, tobacco and drop-out rate, attendance at school was poor, MH issues. Transitional Age Youth –14 to 29 (TIP) or 16-24 y.o. youth.

Parents likely have similar issues; access to help is a barrier in rural areas; unemployment is high and many employers require high school diploma/GED.

Limited/lacking parenting skills.

Multiple Points of Intervention
Family Preservation
Promotion/Preservation Programs
Elimination of labels for youth – “diagnosis” “sex offender”
Development of Community Centers
Education, both academic and personal (i.e. communication/parenting), would improve outcomes.
Transition to Independence Process (TIP) is shown to improve outcomes for TAY population.
To educate and work collaboratively with long term care facilities to accept placement of people diagnosed with chronic mental illness. Identify those providers willing to fill the need for housing and appropriate care of this population as they age and become unable to live independently, due to mental illness and somatic issues. Explore the needed workforce development to support these transitions.
There are limited options and long term care facilities for housing and care of this population. This is largely due to the population within the mid-shore region increasing in age and the caution about treatment of individuals with chronic mental illness within the confines of the established regional aging services umbrella.
Recent partnerships with a local care facility, Mallard Bay have been successful in transitions from state hospitals, private hospitals, and RRP placements. Both RRP providers in the MSMHS region are developing Health Homes. Channel Marker has been approved for provision of this service and began offering this program this month.
Effective partnerships with established providers in the MSMHS region has been most effective in reversing the culture and in successfully treating consumers with both chronic mental illness/aging somatic conditions. A continued dialogue of possible workforce development to assist in serving this population of consumers has also been helpful.
An effective crisis response system that meets the needs of consumers, their families, and the community at large which will result in the reduction of emergency department visits and acute inpatient stays as well as recidivism of ED and inpatient admissions. Increased knowledge of and access to community-based crisis response services by consumers, families, community agencies, and providers, are paramount to the effectiveness of this crisis response system.
Recidivism Rates:
Shore Regional Health ED:
7 days: Avg 3.49% (1/13-9/13)
14 days: Avg 6.06% (1/13-9/13)
30 days: Avg 8.56% (1/13-12/13)

Shore Regional Health BHU:
30 days: Avg 26.22% (1/13-12/13)

Clients, family members and community members aren’t aware of community-based services that could be used to intervene prior to crisis. Consumers don’t always follow-through with treatment plans.
Inpatient MDs
Nurses and Social Workers
Emergency Room Staff
Providers (linking consumers to crisis line instead of directly to ED)
Mobile Crisis and Mobile Treatment Services
Urgent Care Providers
Respite Services
Chesapeake Voyagers and Peer Specialists
Private and Public Behavioral Health and Addiction Services
Primary Care Physicians
Law Enforcement
Business Community
Transportation Providers
MD Choices
Consumers surveyed say talking with someone is one of the best methods to avert crisis. Peer to peer interaction also helps. Access to services and adequate supply of medication also is crucial. Consumers knowing what their resources are when they are in crisis and CVI working with the Crisis Planning Group on the inpatient Unit.
Suicide Prevention
Workforce Development
Crisis Services Advisory
Governor O’Malley allocated funding for communities across Maryland to implement
Crisis Intervention Teams (CIT)
in each jurisdiction.

Part of MSMHS’ mission is to enhance outcomes for
special needs populations
as well as to increase public knowledge and support for enhanced health and wellness. Aligns with Federal SI/State & Regional goals of
trauma and justice

Meets quarterly to review and provide advisement on the CIT Program, Eastern Shore Operations Center (ESOC), Forensic Mental Health Program, and the Mobile Crisis Team (MCT).

Comprised of members of law enforcement, emergency services, mental health and addictions providers, consumers and/or families, a health officer, advocacy community and corrections.
Mid-Shore Mental Health Systems, Inc.
Organizational Structure
Source: MHA and Crystal Reports MARF004 based upon claims paid through September 30, 2013; report run date 10/15/13.
Source: MHA based upon claims paid through September 30, 2013.
Source: MHA and Crystal Reports MARF004 based upon claims paid through September 30, 2013; report run date 10/15/13.
Source: MHA and Crystal Reports MARF004 based upon claims paid through September 30, 2013; report run date 10/15/13.
Source: MHA and Crystal Reports MARF004 based upon claims paid through September 30, 2013; report run date 10/15/13.
Child and Adolescent Data by Service Type
Data by Service Type

One in five people have a diagnosable behavioral health issues at some point in their lives yet many do not seek treatment.
As this population of consumers continues to age, there is a greater need for Health Homes residences that will support both aging somatic concerns, and treatment of chronic mental health issues. Development of supports in the current established housing is also needed.

Goal 1
Increase Public Awareness and Support for Improved Health and Wellness

Goal 2
Promote a System of Integrated Care Where Prevention of Substance Abuse and Mental Illness is Common Practice Across the Life Span

Goal 3
Work Collaboratively to Reduce the Impact of Violence and Trauma for Individuals with Serious Mental Illness and Other Special Needs

Goal 4
Provide a Coordinated Approach to Increase Employment and Promote Integration of Services and Training to Develop and Sustain an Effective Behavioral Health Workforce

Goal 5
Build Partnerships to Increase the Provision of Affordable Housing and Reduce Barriers to Access in Order to Prevent Homelessness for Individuals with Mental Illness

Goal 6
Utilize Data and Health Information Technology to Evaluate, Monitor, and Improve Quality of Behavioral Health System of Care Services and Outcomes

#1: Prevention of Substance Abuse and Mental Illness
#2: Health Care and Health Systems Integration
#3: Trauma and Justice
#4: Recovery Support
#5: Health Information Technology
#6: Workforce Development
The State Priorities for FY15 will be listed in the Implentation Report for the FY14 State Mental Health Plan, expected to be released in/around November.
Source: MHA and Crystal Reports MARF004 based upon claims paid through September 30, 2013; report run date 10/15/13.
Healthy Families – pregnant and parenting teen programs
Case Management Entity (CME)
Law Enforcement Agencies
Parents, Youth, and Extended Families
Faith Community Leaders
Community Center (YMCA)
Mental Health Providers
Department of Juvenile Services/Courts/P&P
Local Management Board (LMB) and LCC
Parks and Recreation
Health Departments
Department of Social Services
Mobile Crisis Teams
PEACE (Talbot Co.)
What Works
Action Plan
Serving MSMHS Community Mental Health Plan Goal #5
When talking about the Roundtable on Homelessness, the Continuum of Care for the five Mid-Shore Counties, I often am met with a question, “Why do we need that? Homelessness is not a problem in the Mid-Shore.” The reason for this common occurrence is that homelessness in our largely rural area looks much different than it does in most peoples’ heads. We indeed do have those individuals and families that are living on the streets or in place not meant for human habitation but they are not usually concentrated to a single location like in the urban areas. The Roundtable strives to
expel those myths about
homelessness in our area and to
assist those in need by connecting
them to the best suited service.
Final 2014 PIT/HIC numbers were submitted to HUD. This year we are reporting our highest PIT in the last five years, finding

people that were literally homeless in the Mid-Shore on the night of January 29, 2014. While we are not happy to report there are more individuals and families that are homeless in the Mid-Shore this year, we

• Data/HMIS Subcommittee
Roundtable identified Goal for FY15 – update HMIS Policy Manual.

• Homeless Prevention and Housing Resource Subcommittee

Roundtable Identified Goal for FY15 – complete a housing resource guide with program eligibility requirements and landlord list. Arrange for presentations regarding mainstream resources.

• Community Coordination Subcommittee
Roundtable Identified Goal for FY15 – identify partners that are missing from the table and work to recruit them. Organize policies regarding discharges from agencies.

• Employment and Education Subcommittee
Roundtable Identified Goal for FY15 – arrange for a presentation on Supported Employment Services and available services at the Workforce Exchange Boards.

FY15 Subcommittee Goals:
Homeless Management Information System (HMIS) – Local homeless service providers use this online recorded keeping system in order to store client level data. This allows for better coordination of services with our limited resources.

PATH (Project for Assistance in Transitions from Homelessness) – this program provides case management to individuals and families that are literally homeless or in danger of being homeless who have mental health disabilities. The program provides street outreach and works to connect participants with housing opportunities.
Local Department of Social Services
Veterans Services
Mental Health Providers
Community Action Agencies
County Housing Departments
Year Round Homeless Shelters
Seasons Homeless Shelters
Transitional Housing Programs
Permanent Housing Programs
Faith Based Organizations
Food Pantries
The Behavioral Health Services Network (BHSN) meets quarterly to discuss trends, changes, and issues concerning behavioral health on the Eastern Shore.

The network comprises six (6) workgroups whose members include providers, consumers, and mental health professionals:

Integration Workgroup
Defeating Stigma Coalition
Child and Adolescent Workgroup
Long Term Care Workgroup
Crisis Response Workgroup
CoC Roundable on Homelessness

These groups meet at least six times annually to plan, strategize and implement improvements to the mental health system in this region.
Delmarva Community Action Center - November 2013
are happy to submit what is a more accurate picture of homelessness in our region. The Roundtable on Homelessness feels that this number is still lower than the actual number of homeless individuals and families. Through coordination and partnership the Roundtable is moving in the right directions in identifying the true issue of homelessness in the region.
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