Case 1:11-cv-00591-LPS Document 6 Filed 07/18/11 Page 1 of 2 PageID #: 49 Case 1:11-cv-00591-LPS Document 4-1 Filed 07/06/11 Page 1 of 2 PagelD #: 15

IN THE UNITED STATES DISTRICT COURT 
 FOR THE DISTRICT OF DELAWARE 


UNITED STATES OF AMERICA, Plaintiff,
v.
STATE OF DELAWARE, Defendant.

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CIVIL ACTION NO: II - 5' ~ I - LPj

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ORDER ENTERING SETTLEMENT AGREEMENT
The United States and the State of Delaware have determined that entering into a Settlement Agreement concerning the rights ofindividuals in Delaware with serious and persistent mental illnesses to be served in the most integrated settings appropriate to their needs, rather than contested litigation, is the best way to resolve the United States' claim in this matter.
After reviewing the Settlement Agreement, and in consideration of the parties' Joint Motion for Entry of Settlement Agreement, the Court hereby
ORDERS that the parties' Joint Motion is GRANTED; and the Court further ORDERS that the Settlement Agreement shall be entered as an order of the Court; and the Court further ORDERS that the Court shall retain jurisdiction over this case to enforce the terms of the Settlement Agreement until this case is dismissed; and the Court further
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ORDERS that the Court shall have the power to enforce the Settlement Agreement through all remedies that the law permits.
IT IS SO ORDERED. ,2011. UNITED STATES DISTRICT DGE
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 Consent Decree: United States of America v. State of Delaware

http://www.ada.gov/delaware.htm

Press Release | Fact Sheet

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE

UNITED STATES OF AMERICA, Plaintiff,
v. STATE OF DELAWARE,
Defendants

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CIVIL ACTION NO:

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SETTLEMENT AGREEMENT

I. Introduction
A. The State of Delaware ("the State") and the United States (together, "the Parties") are committed to full compliance with Title II of the Americans with Disabilities Act ("the ADA"), 42 U.S.C. § 12101 and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794. This agreement is intended to ensure the State's compliance with the ADA, the Rehabilitation Act, and implementing regulations at 28 C.F.R. Part 35, and 45 C.F.R. Part 84 ("Section 504"), which require, among other provisions, that, to the extent the State offers services to individuals with disabilities, such services shall be provided in the most integrated setting appropriate to meet their needs. Accordingly, throughout this document, the Parties intend that the principles of self-determination and choice are honored and that the goals of community integration, appropriate planning, and services to support individuals at risk of institutionalization are achieved.
B. The United States Department of Justice ("United States") initiated an investigation of Delaware Psychiatric Center ("DPC"), the State's psychiatric hospital, in November 2007 and completed on-site inspections of the facility and community services in May 2008 and August 2010. Following the completion of its investigation, the United States issued a ﬁndings letter notifying the State of its conclusions on November 9, 2010.
C. The State engaged with the United States in open dialogue about the allegations and worked with the United States to resolve the alleged violations of federal statutory rights arising out of the State's operation of DPC and provision of community services for individuals with mental illness.

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D. In order to resolve all issues pending between the Parties without the expense, risks, delays, and uncertainties of litigation, the United States and the State agree to the terms of this Settlement Agreement as stated below. This agreement resolves the United States' investigation of DPC, as well as its ADA investigation.
E. By entering into this Settlement Agreement, Delaware does not admit to the truth or validity of any claim made against it by the United States.
F. The Parties acknowledge that the Court has jurisdiction over this case and authority to enter this Settlement Agreement and to enforce its terms as set forth herein.
G. No person or entity is intended to be a third-party beneﬁciary of the provisions of this Settlement Agreement for purposes of any other civil, criminal, or administrative action, and accordingly, no person or entity may assert any claim or right as a beneﬁciary or protected class under this Settlement Agreement in any separate action. This Settlement Agreement is not intended to impair or expand the right of any person or organization to seek relief against the State or their ofﬁcials, employees, or agents.
H. The Court has jurisdiction over this action pursuant to 28 U.S.C. § 1331; 28 U.S.C. § 1345; and 42 U.S.C. §§ 12131-12132. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b).
II. Substantive Provisions
A. In order to comply with this agreement, the State must prevent unnecessary institutionalization by offering the community-based services described in this Section (II) to individuals in the target population. The services must be developed and provided according to the implementation timeline described in Section III. The services may be provided directly by the State or through a contract managed by the State.
B. Target Population
1. The target population for the community services described in this section is the subset of the individuals who have serious and persistent mental illness (SPMI) who are at the highest risk of unnecessary institutionalization. SPMI is a diagnosable mental, behavioral, or emotional disorder of sufﬁcient duration to meet diagnostic criteria and has been manifest in the last year, has resulted in functional impairment which substantially interferes with or limits one or more major life activities, and has episodic, recurrent, or persistent features.
2. Priority for receipt of services will be given to the following individuals within the target population due to their high risk of unnecessary institutionalization:
a. People who are currently at Delaware Psychiatric Center, including those on forensic status for whom the relevant court approves community placement;

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b. People who have been discharged from Delaware Psychiatric Center within the last two years and who meet any of the criteria below;
c. People who are, or have been, admitted to private institutions for mental disease ("IMDs") in the last two years;
d. People with SPMI who have had an emergency room visit in the last year, due to mental illness or substance abuse;
e. People with SPMI who have been arrested, incarcerated, or had other encounters with the criminal justice system in the last year due to conduct related to their serious mental illness; or
f. People with SPMI who have been homeless for one full year or have had four or more episodes of homelessness in the last three years;
g. People in the State who have SPMI may request services described in Section II of this agreement or may be referred for such services by a provider, family member, advocate, or State agency staff. Once the State receives a request or referral, the person with SPMI will be placed on the State's Target Population List.
h. Priority for receipt of services among those on the Target Population List will go to people who meet one of the criteria listed in II.B.2.a-f.
C. Crisis Services
1. The State shall develop a statewide crisis system. The crisis system shall:
a. Provide timely and accessible support to individuals with mental illness experiencing a behavioral health crisis, including a crisis due to substance abuse;
b. Stabilize individuals as quickly as possible and assist them in returning to their pre-crisis level of functioning;
c. Provide solution-focused and recovery-consistent interventions that are intended to be diversionary in nature and avoid unnecessary hospitalizations, incarceration, or placement in a crisis stabilization program;
d. Serve as an entry point to the mental health system. This shall include developing and implementing a pre-screening function that includes appropriate diversions and ensures that the State has a central role in determining whether an individual is involuntarily admitted to a psychiatric hospital (DPC or IMDs); and
e. Assess the individual's needs, identify the supports and services that are

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necessary to meet those needs, and connect the individual to those services.
2. Crisis System Components
a. Crisis Hotline
i. The crisis hotline is a toll-free statewide telephone system that people can use to access information about and referrals to local resources.
ii. The crisis hotline will be staffed 24 hours per day, 7 days per week with licensed clinical professionals who are able to assess the crisis by phone and assist the caller in identifying and connecting with local services. Where necessary, the crisis hotline will dispatch a mobile crisis team.
b. Mobile Crisis Teams
i. Mobile crisis teams respond to people at their homes and in other community settings and offer services, support and treatment to de-escalate the crisis without removing the individual from the community. Crisis teams include clinicians trained to provide emergency services, clinicians trained to provide substance abuse services and peer specialists.
ii. Mobile crisis teams work with trained law enforcement personnel to respond to people in mental health crisis who come into contact with law enforcement.
iii. Mobile crisis teams are available 24 hours per day, 7 days per week and respond to crises within one hour.
c. Crisis Walk-In Centers
i. Crisis walk-in centers provide community-based psychiatric and counseling services to people experiencing a mental health crisis. Staff assess, treat, and refer individuals experiencing a crisis without removing them from their homes and community.
ii. Where an individual who comes into contact with law enforcement personnel is in need of mental health services, law enforcement ofﬁcers can refer or bring individuals to the local crisis walk-in center.
iii. The walk-in centers will be staffed 24 hours per day, 7 days per week with licensed clinical professionals.
d. Crisis Stabilization Services

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i. Crisis stabilization services are short-term acute inpatient care intended to stabilize an individual and avoid long-term psychiatric hospitalization. Lengths of stay shall be limited to no longer than 14 days.
ii. Prior to admitting an individual for crisis stabilization services, the State shall, to the extent permitted by law, determine that such services are required and that admission of the individual could not be avoided through the use of other services.
iii. When an individual is admitted for acute care, intensive support service providers will engage with the individual within 24 hours of admission in order to facilitate a quick return to the community with necessary supports.
iv. The discharge of any individual receiving state-funded crisis stabilization services will be completed in accordance with the requirements in Section IV.
e. Crisis Apartments
i. Crisis apartments are apartments where individuals experiencing a psychiatric crisis can stay for up to seven days to receive support and stabilization services in the community before returning home. These apartments serve as an alternative to hospitalization and the clinical and peer staff assists individuals in de-escalating crises without leaving the community.
ii. Each crisis apartment will have peer staff on-site 24 hours per day, 7 days per week and will have licensed clinical staff on-call 24 hours per day, 7 days per week.
D. Intensive Support Services
1. The State shall develop a continuum of support services intended to meet the varying needs of individuals with mental illness. The support system shall:
a. Be ﬂexible and individualized to meet the needs of the individual;
b. Promote successful community living, including the retention of housing;
c. Help individuals to increase individuals' abilities to recognize and deal with situations that may otherwise result in crises; and
d. Increase and improve individuals' networks of community and natural supports, as well as their use of these supports for crisis prevention.
2. Support System Components

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a. Assertive Community Treatment (ACT)
i. ACT teams deliver comprehensive, individualized, and ﬂexible support, services, and rehabilitation to individuals in their homes and communities. An ACT team is a multidisciplinary group of professionals including a psychiatrist, a nurse, a psychologist, a social worker, a substance abuse specialist, a vocational rehabilitation specialist and a peer specialist. Services are customized to an individual's needs and vary over time as needs change. Among the services that may be offered to a client at a given time are: case management, initial and ongoing assessments, psychiatric services, assistance with employment and housing, family support and education, substance abuse services, crisis services, and other services and supports critical to allow the individual to live independently in the community.
ii. ACT Team services are available 24 hours per day, 7 days per week.
iii. Each ACT team, comprised of between 7-10 members, will serve no more than 10 people per ACT team member.
iv. ACT teams will operate with ﬁdelity to the Dartmouth Assertive Community Treatment model.
b. Intensive Case Management (ICM)
i. Intensive Case Management teams provide coordination of treatment and support services. The teams are supervised by licensed, master's level clinical mental health professionals who supervise case managers and offer direct support to individuals as needed. Case managers work with individuals to help them identify and access community supports and services, including needed medical, social, educational, housing, and other services.
ii. ICM teams will serve no more than 20 people per team member and each supervisor will manage no more than 10 case managers.
c. Case Management (CM)
i. Case Management providers coordinate treatment and support services. Case managers work with individuals to help them identify and access community supports and services, including needed medical, social, educational, housing and other services.
ii. Case managers will each serve no more than 35 individuals and each supervisor will manage no more than 15 case managers.

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E. Housing
1. The State will support individuals in the target population living in their own homes. The housing services will:
a. Ensure that people with SPMI can live like the rest of Delawareans, in their own homes, including leased apartments, houses, or living with their family;
b. Offer people choice regarding where they live and with whom;
c. Provide an array of supportive services that vary according to people's changing needs and promote housing stability.
2. Supported Housing
i. Supported housing is permanent housing with tenancy rights and support services that enables people to attain and maintain integrated affordable housing. Support services offered to people living in supported housing are ﬂexible and are available as needed and desired, but are not mandated as a condition of tenancy.
ii. The State will fund rental subsidies or vouchers to ensure that supported housing apartments are affordable to individuals with limited incomes, including those receiving SSI beneﬁts. The State will also provide additional bridge funding to cover deposits and other household necessities that individuals require as they procure and set up a new apartment.
iii. Supported housing provided under this agreement may be in the form of assistance from the Division of Substance Abuse and Mental Health, the Delaware State Housing Authority, the federal Department of Housing and Urban Development, and from any other governmental or private source. Nothing in this agreement shall require the State to forgo federal funding or federal programs to provide housing for individuals in the target population. To count as supported housing for purposes of meeting the State's obligations under Part III.I., however, all new housing created under this agreement must satisfy the requirements of Part II.E.
iv. All new housing created under this agreement will be scattered site supported housing, with no more than 20% of the units in any building to be occupied by individuals with a disability known to the State.
v. All new supported housing created under this agreement will have no more than two people in a given apartment, with a private bedroom for each person. If two people are living together in an apartment, the individuals must be able to select their own roommates.

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vi. Supported housing providers cannot reject individuals for placement due to medical needs or substance abuse history.
F. Supported Employment and Rehabilitation Services
1. The State shall develop options for people to work or access education and rehabilitation services. The supported employment and rehabilitation services shall:
a. Offer integrated opportunities for people to earn a living or to develop academic or functional skills; and
b. Provide individuals with opportunities to make connections in the community.
2. Supported Employment and Rehabilitation Services Components
a. Supported Employment
i. Supported employment is a service through which individuals receive assistance in preparing for, identifying, attaining, and maintaining integrated, paid, competitive employment. Among the services that a provider may offer is job coaching, transportation, assistive technology, specialized job training, and individually tailored supervision.
ii. Supportive employment providers will adhere to an evidence-based model for supporting people in their pursuit of and maintenance of work opportunities.
b. Rehabilitation Services
i. Rehabilitation services include education, substance abuse treatment, volunteer work, and recreational activities, and other opportunities to develop and enhance social, functional and academic skills in integrated settings. With respect to the State's application for Medicaid funding for such services, the deﬁnition at 42 CFR 440.130 shall take precedence over the deﬁnition listed herein and the explanation of Rehabilitation Services herein is for the purposes of enforcement of this Settlement Agreement only.
G. Family and Peer Supports
1. Family Supports
a. Family supports are designed to teach families skills and strategies for better supporting their family members' treatment and recovery in the community. Supports include training on identifying a crisis and connecting people in crisis to services as well as education about mental illness and

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about available ongoing community-based services.
b. Family supports can be provided in individual and group settings.
2. Peer Supports
a. Peer supports are services delivered by trained individuals who have personal experience with mental illness and recovery to help people develop skills in managing and coping with symptoms of illness, self-advocacy, identifying and using natural supports.
b. Peer supports can be provided in individual and group settings, in person or by phone.
H. The State shall ensure that providers of services listed in this Section (II) have linguistic and cultural competence to serve all individuals in the target population.
III. Implementation Timeline
A. Crisis Hotline
1. By January 1, 2012 the State will develop and make available a crisis line for use 24 hours per day, 7 days per week.
2. By July 1, 2012 the State will provide publicity materials and training about the crisis hotline services in every hospital, police department, homeless shelter, and department of corrections facility in the State. The training will be developed in consultation with the Monitor.
B. Mobile Crisis Services
1. By July 1, 2012 the State will make operational a sufﬁcient number of mobile crisis teams such that a team responds to a person in crisis anywhere in the state within one hour.
2. By July 1, 2013 the State will train all state and local law enforcement personnel about the availability and purpose of the mobile crisis teams and on the protocol for calling on the team.
C. Crisis Walk-in Centers
1. In addition to the crisis walk-in center in New Castle County serving the northern region of the State, by July 1, 2012, the State will make best efforts to make operational one crisis walk-in center in Ellendale to serve the southern region of the State. The crisis center in Ellendale shall be operational no later than September 1, 2012.

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2. By July 1, 2013 the State will train all state and local law enforcement personnel about the availability and purpose of the crisis walk-in centers and on the protocol for referring and transferring individuals to walk-in centers.
D. Crisis Stabilization Services
1. By July 1, 2012 the State will ensure that an intensive services provider meets with every individual receiving acute inpatient crisis stabilization services within 24 hours of admission in order to facilitate return to the community with the necessary supports and that all transition planning is completed in accordance with Section IV.
2. By July 1, 2013 the State will train all provider staff and law enforcement personnel to bring people experiencing mental health crises to crisis walk-in centers for assessment, rather than to local emergency rooms or IMDs.
3. By July 1, 2014 the number of annual State-funded patient days in acute inpatient settings in the State will be reduced by 30% from the State's baseline on the Effective Date of the Settlement Agreement as determined by the Monitor and the Parties.
4. By July 1, 2016 the number of annual State-funded patient days in acute inpatient settings in the State will be reduced by 50% from the State's baseline on the Effective Date of the Settlement Agreement as determined by the Monitor and the Parties.
E. Crisis Apartments
1. By July 1, 2012 the State will make operational two crisis apartments.
2. By July 1, 2013 the State will make operational a minimum of two additional crisis apartments, ensuring that the four apartments total are spread throughout the State.
F. Assertive Community Treatment
1. By July 1, 2012 the State will expand its 8 ACT teams to bring them into ﬁdelity with the Dartmouth model.
2. By September 1, 2013 the State will add 1 additional ACT teams that are in ﬁdelity with the Dartmouth model.
3. By September 1, 2014 the State will add 1 additional ACT team that is in ﬁdelity with the Dartmouth model.
4. By September 1, 2015 the State will add 1 additional ACT team that is in ﬁdelity with the Dartmouth model.
G. Intensive Case Management

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1. By July 1, 2012 the State will develop and begin to utilize 3 ICM teams.
2. By January 1, 2013 the State will develop and begin to utilize 1 additional ICM team.
H. Case Management
1. By July 1, 2012 the State will train and begin to utilize 15 case managers.
2. By September 1, 2013 the State will train and begin to utilize 3 additional case managers.
3. By September 1, 2014 the State will train and begin to utilize 3 additional case managers.
4. By September 1, 2015 the State will train and begin to utilize 4 additional case managers.
I. Supported Housing
1. By July 11, 2011, the State will provide housing vouchers or subsidies and bridge funding to 150 individuals. Pursuant to Part II.E.2.d., this housing shall be exempt from the scattered-site requirement.
2. By July 1, 2012 the State will provide housing vouchers or subsidies and bridge funding to a total of 250 individuals.
3. By July 1, 2013 the State will provide housing vouchers or subsidies and bridge funding to a total of 450 individuals.
4. By July 1, 2014 the State will provide housing vouchers or subsidies and bridge funding to a total of 550 individuals.
5. By July 1, 2015 the State will provide housing vouchers or subsidies and bridge funding to a total of 650 individuals.
6. By July 1, 2016 the State will provide housing vouchers or subsidies and bridge funding to anyone in the target population who needs such support. For purposes of this provision, the determination of the number of vouchers or subsidies and bridge funding to be provided shall be based on: the number of individuals in the target population who are on the State's waiting list for supported housing; the number of homeless individuals who have a serious persistent mental illness as determined by the 2016 Delaware Homeless Planning Council Point in Time count; and the number of individuals at DPC or IMDs for whom the lack of a stable living situation is a barrier to discharge. In making this determination, there should be due consideration given to (1) whether such community-based services are appropriate, (2) the individuals being provided such services do not oppose community-based treatment, and (3) the resources available to the State and the needs of other persons with

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disabilities. Olmstead v. L.C., 527 U.S. 581 at 607 (1999).
J. Supported Employment
1. By July 1, 2012 the State will provide supported employment to 100 individuals per year.
2. By July 1, 2013 the State will provide supported employment to 300 additional individuals per year.
3. By July 1, 2014 the State will provide supported employment to an additional 300 individuals per year.
4. By July 1, 2015 the State will provide supported employment to an additional 400 individuals per year.
5. In addition, by January 1, 2012 all individuals receiving ACT services will receive support from employment specialists on their ACT teams.
K. Rehabilitation Services
1. By July 1, 2012 the State will provide rehabilitation services to 100 individuals per year.
2. By July 1, 2013 the State will provide rehabilitation services to 500 additional individuals per year.
3. By July 1, 2014 the State will provide rehabilitation services to an additional 500 individuals per year.
L. Family and Peer Supports
1. By July 1, 2012 the State will provide family or peer supports to 250 individuals per year.
2. By July 1, 2013 the State will provide family or peer supports to 250 additional individuals per year.
3. By July 1, 2014 the State will provide family or peer supports to an additional 250 individuals per year.
4. By July 1, 2015 the State will provide family or peer supports to an additional 250 individuals per year.
IV. Transition Planning
A. Assessment and Placement of People Currently in Institutional Settings

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1. Each individual, now in or being admitted to DPC or an IMD, shall have a transition team including clinical staff and a representative of a community-based mental health provider.
a. Discharge planning shall begin upon admission.
b. Discharge assessments shall begin with the presumption that with sufﬁcient supports and services, individuals can live in an integrated community setting.
c. Discharge planning shall be developed and implemented through a personcentered planning process, in which the individual has a primary role, and based on principles of self-determination. Discharge planning teams shall have the linguistic and cultural competence to serve all individuals. The goal of discharge planning is to assist the individual in developing a plan to achieve outcomes that promote the individual's growth, well being, and independence, based on the individual's strengths, needs, goals, and preferences, in the most integrated settings in all domains of the individual's life (including community living, activities, employment, education, recreation, healthcare, and relationships).
d. The team will meet within ﬁve days of admission to identify needed services and supports that would allow the individual to return to the community, regardless of whether currently available.
e. The community provider must meet with the individual before the initial team meeting and then at least once every month while services are being planned and developed.
f. The team should engage a peer specialist who has utilized supports similar to those recommended for the individual to help prepare the individual for the transition to the community.
2. A re-assessment will commence for all individuals currently in DPC or an IMD within 30 days after this agreement is signed.
3. In the event that a treatment team makes a recommendation to maintain the institutional care or to place an individual in a less integrated setting (e.g., congregate care, nursing home), the treatment team shall identify the barriers to placement in a more integrated setting, describe steps the team will take to address the barriers, and begin engaging the specialized transition team.
4. The State will create a central specialized transition team to assist treatment teams in addressing identiﬁed barriers to discharge for individuals whose teams recommend remaining in DPC or an IMD or recommend discharge to a less integrated setting (i.e., congregate care, nursing home) for whom the teams cannot agree on a plan, and for individuals who have intensive behavioral or medical needs.

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5. Where the specialized team is unable to identify an appropriate community placement, the case will be referred to the Monitor for review.
6. Individuals who remain in DPC or an IMD after the assessment process will be assessed for transition to more integrated settings at least once every month and more frequently upon request or when there is a change in condition.
7. For individuals on forensic status for whom the treatment team or specialized team recommends community placement, the State shall educate judges about the recommended placement and services and participate where appropriate in judicial proceedings on behalf of those individuals.
B. Implementation of Transition Assessments and Placement
1. Within 30 days of the signing of the agreement the State will re-assess all individuals currently in institutional settings.
2. Within 60 days of the signing of the agreement the State will make operational transition teams including community provider and peer representatives.
3. Within 60 days of the signing of the agreement the State will make operational a central specialized transition team including community provider and peer representatives.
4. The State shall have as its goal that where a transition team determines that a community placement is the most integrated setting appropriate for an individual currently in DPC or an IMD, that individual will be discharged to the community with necessary supports within 30 days. Between July 1, 2014 and July 1, 2015, the State shall meet this goal for at least 75% of people transitioning from DPC or an IMD. Between July 1, 2015 and July 1, 2016, the State shall meet this goal for at least 95% of people transitioning from DPC or an IMD.
5. By July 1, 2012, the State shall develop a program to educate judges and law enforcement about community supports and services for individuals with mental illness on forensic status.
V. Quality Assurance and Performance Improvement
A. The goal of the State's Quality Assurance and Performance Improvement System shall be to ensure that all mental health services funded by the State are of good quality and are sufﬁcient to help individuals achieve positive outcomes, including increased integration and independence, and self-determination in all life domains (e.g., community living, employment, education, recreation, healthcare, and relationships); stable community living, avoidance of harms, and decreased hospitalization and institutionalization.
B. Risk Management

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1. The State will require that DPC, IMDs, and community providers develop transition and service plans that proactively identify and address risks of harm to individuals receiving services. Harm includes any physical or emotional injury, whether caused by abuse, neglect, or accidental causes.
2. When a risk of harm is identiﬁed, preventive measures will be developed and implemented.
3. All providers of services will be trained on common harm prevention measures. Staff working with individuals with identiﬁed risks must be competent to implement their plans, including the individualized preventive measures.
4. If harm occurs despite these measures, the responsible State, IMD or community provider will complete a root cause analysis within 10 days.
5. Using the results of the root cause analysis, the State, IMD or community provider will develop and implement a corrective action to prevent future harm.
6. The State, IMD or community provider will assess the effectiveness of all corrective actions. If the corrective action does not effectively address the identiﬁed harm, a specialized team from the State's Performance Improvement Section will be notiﬁed and will assist in developing and implementing a modiﬁed corrective action plan. The State specialists will remain involved in the case until the harm is effectively addressed.
7. Each identiﬁed harm and the responsive corrective action will be reported to the State's Performance Improvement Section.
8. If the State, IMD, or community provider refuses to report harms, implement corrective actions, or comply with the Performance Improvement Section specialists' recommendations, the State, in consultation with the Monitor, will take appropriate action.
9. The State will develop a detailed process for collecting and utilizing data on risk management at DPC, IMDs, and community providers incorporating the steps listed in V.B.1-8. The process is intended to identify patterns and trends in the quality of care and ensure a continuous loop of performance evaluation and improvement.
10. The Monitor must review and approve the State's risk management process.
C. Contracting
1. Contracts with community service providers will speciﬁcally describe expectations for services provided as well as for outcomes to be achieved.
2. Contracts with community service providers will be performance -based.
D. Quality Service Reviews

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1. The State will use Quality Service Reviews (QSRs) to evaluate the quality of services at an individual, provider and system-wide level. QSRs collect information through a sample of face-to-face interviews of the consumer, relevant professional staff, and other people involved in the consumer's life and through review of individual treatment plans. QSRs evaluate, among other things, whether individuals' needs are being identiﬁed, whether supports and services are meeting individuals' needs, and whether supports and services are designed around individuals' strengths and meeting individuals' goals.
2. The State shall design a process for implementing QSRs in conjunction with the Monitor, with input from the United States.
3. The State will conduct QSRs annually, with each community provider providing services under this agreement to be reviewed at least once every two years. Each new provider will be reviewed in the ﬁrst year it offers services under this agreement.
4. The State will use data from the QSRs to identify strengths and areas for improvement at the individual, provider, and system-wide levels.
E. Use of Data
1. The State shall collect and analyze data from assessments of the most integrated setting appropriate, including data about barriers to service, in order to reﬁne Olmstead planning and determine whether additional specialized services are needed.
2. The State shall ensure that every community provider assesses the adequacy of the individualized supports and services provided to persons in the target population by collecting and analyzing data, including, but not limited to:
a. Number of incidents of harm;
b. Number of repeat admissions to DPC, an IMD, or other inpatient psychiatric facilities;
c. Use of crisis beds and community hospital admissions;
d. Repeat emergency room visits;
e. Number of arrests and incarceration;
f. Time spent in congregate day programming;
g. Number of people employed, attending school, or engaged in community life;
h. Acquisition of life skills; and

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i. Maintenance of a chosen living arrangement.
3. Each year the State will aggregate and analyze the data collected by the State and by individual providers on the indicators listed in Section V.E.1,2.
4. If data collected under this section shows that the agreement's intended outcomes of increased integration, stable housing, and decreased hospitalization and institutionalization are not occurring, the State will convene a team including the Monitor and representatives of the U.S. Department of Justice, to consider modiﬁcations to community services.
F. Reporting
1. The State will publish an annual report identifying the number of people served in each type of service described in this agreement.
2. The State will publish an annual report of unmet needs using data gathered during admissions assessments, discharge planning processes, and community provider reports.
3. The State will publish an annual report on the quality of services provided by the State and community providers using data collected through the risk management system, the contracting process, the QSRs, and the outcome data.
VII. Monitor and Monitoring
A. Selection and Replacement of the Monitor
1. The Parties agree that Robert Bernstein shall be the Monitor.
2. In the event the Monitor resigns or the Parties agree to replace the Monitor, the Parties shall meet and confer within 30 days of the resignation or their agreement, select a replacement, and notify the Court. If they are unable to agree on the replacement Monitor at the meet and confer, the United States and the State shall each, within 21 days of the meet and confer, nominate up to two individuals with expertise in the provision of community services to persons with mental illness. The Court will select the Monitor from among those nominated.
B. Monitor Powers and Responsibilities
1. The Monitor is an ofﬁcer of the Court. The Monitor will review and report on the State's compliance with the agreement. The Parties will cooperate fully with the Monitor. The Monitor will pursue a problem-solving approach so that disagreements can be amicably resolved when possible and the Parties' energies can be devoted to achieving compliance.
2. The Monitor shall have the authority and responsibility to complete the following

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actions:
a. Independently observe and assess the State's compliance with the Agreement.
b. At least twice a year draft and submit to the Parties and the Court a comprehensive public report on the State's compliance including recommendations, if any, to facilitate or sustain compliance.
c. Review the adequacy and quality of the individualized supports and services provided to persons (a) discharged from the State hospital or (b) at risk of institutionalization, including those living with families.
d. Review and make recommendations regarding transition plans where the individual's team and the specialized transition team have been unable to identify an appropriate community placement.
e. Notify the Parties if the Monitor determines that a life-threatening situation or other emergency exists. This does not relieve the State of its obligation to report and notify the Monitor and the United States of the death or serious physical injury of any individual in DPC or any individuals receiving services in the community pursuant to the Settlement Agreement as speciﬁed in Section VI.D.
f. Independently determine that the speciﬁc scope, quantity, or implementation timeline relating to any demanded service be decreased or delayed when it appears that the State's resources might be better utilized to serve the target population.
g. Mediate any dispute arising out of a Party's position regarding the construction or implementation of this agreement.
h. Provide the State technical assistance relating to any aspect of this agreement or its stated purposes.
3. In completing the responsibilities listed in VI.B.2. the Monitor may:
a. Hire staff and consultants as necessary to assist in carrying out the Monitor's duties and responsibilities.
b. Require written reports from the State concerning compliance.
c. Enter, with or without advance notice, any part of DPC or any other facility or program providing services to persons covered by this agreement and may interview, on a conﬁdential basis or otherwise, persons affected by the Settlement Agreement. Staff and consultants of the Monitor shall also have such authority.

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d. Access residents, persons, employees, residences, facilities, buildings, programs, services, documents, records, and materials as necessary to assess the State's compliance with and/or implementation of this Settlement Agreement.
e. Communicate ex parte with the Court or with a Party as well as counsel, agents or staff of a Party or anyone else the Monitor deems necessary for completing his or her responsibilities. The monitor shall have the authority to convene meetings as appropriate.
f. Testify in this case regarding any matter relating to the implementation, enforcement, or dissolution of the Settlement Agreement, including, but not limited to, the Monitor's observations, ﬁndings, and recommendations in this matter.
g. Determine, using criteria set forth herein, whether the State is in substantial compliance, partial compliance, or non- compliance with its obligations under this Settlement Agreement. The Monitor shall utilize the following criteria when assessing the State's level of compliance with each of the terms of the Settlement Agreement:
i. Substantial Compliance. The term "substantial compliance" shall mean that the State has satisﬁed the requirements of all components of the assessed paragraph. This Settlement Agreement will terminate when the State has achieved substantial compliance with all paragraphs of the agreement and has maintained that substantial compliance for a period of one year. The USDOJ will determine whether the State has, in fact, maintained substantial compliance for the one year period. Non-compliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of sustained non-compliance shall not constitute substantial compliance.
ii. Partial Compliance. The term "partial compliance" shall mean that the State has achieved less than substantial compliance with all of the components of a rated paragraph of the agreement, but has made some progress toward substantial compliance on most of the key components of the rated paragraph. A partial compliance rating encompasses a wide range of performance by the State. Speciﬁcally, a partial compliance rating can signify that that the State is nearly in substantial compliance, or it can mean that the State is only slightly above a non-compliance rating.
iii. Noncompliance. The term "non-compliance" shall mean that the

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State has made negligible or no progress toward compliance with all of the components of the Settlement Agreement paragraphs being assessed.
C. Limits on Monitor Liability and Discovery
1. Neither the Monitor nor any staff or consultants retained by the Monitor, shall be:
a. Liable for any claim, lawsuit, or demand arising out of their activities under this agreement. This paragraph does not apply to any proceeding for payment under contracts into which they have entered in connection with their work under the Settlement Agreement; any such proceeding shall take place solely before this Court.
b. Subject to formal discovery, including, but not limited to, deposition(s), request(s) for documents, request(s) for admissions, interrogatories, or other disclosures In contested litigation, the Parties are not entitled to access the records or communications of the Monitor or any staff or consultants (person or entity) retained by the Monitor. However, the Monitor may provide copies of records or communications at the Monitor's discretion but must disclose to all parties those shared materials. The Court may review the Monitor's records at the Court's discretion.
D. The State promptly shall notify the Monitor and the United States of the death or serious physical injury of any individual in DPC. The State shall notify the Monitor and the United States of the death or serious physical injury of any individuals receiving services in the community pursuant to the Settlement Agreement when such information is known to the State. The State shall, via email, forward to the United States and the Monitor, electronic copies of all completed incident reports and ﬁnal reports of investigations related to such incidents as well as autopsies and death summaries when such information is known to the State. The submission of any such incident reports, investigative reports, autopsies and death summaries is not intended, and shall not be construed, as a waiver, in litigation with third parties, of any applicable statutory or common law privilege associated with such information. Other than to carry out the express functions as set forth herein, both the United States and the Monitor shall hold such information in strict conﬁdence to the greatest extent permitted by any applicable law or regulation.
E. The State shall collect data with respect to each element of required performance under the terms of the Settlement Agreement and make it available on a timely basis to the Monitor. The submission of any such data element is not intended, and shall not be construed, as a waiver, in litigation with third parties, of any applicable statutory or common law privilege associated with such information. Other than to carry out the express functions as set forth herein, both the United States and the Monitor shall hold such information in strict conﬁdence to the greatest extent permitted by any applicable law or regulation.
F. Budget of the Monitor

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1. Within 45 days of his/her appointment, the Monitor shall submit to the Court for the Court's approval a proposed budget for the ﬁrst twelve months of operations.
2. The Monitor will provide the Parties a draft of the proposed budget at least ﬁfteen days in advance of its submission to the Court. The Parties shall raise with the Monitor any objections they may have to the draft of the proposed budget within ten days of its receipt. If the objection is not resolved before the Monitor's submission of a proposed budget to the Court, a Party may ﬁle the objection with the Court within ten days of the submission of the proposed budget to the Court. The Court will consider such objections and make any adjustments the Court deems appropriate prior to approving the budget.
3. Thereafter, the Monitor shall submit annually a proposed budget for the Court's approval in accordance with the process set forth above.
4. At any time, the Monitor may submit to the Court for approval a proposed revision to the approved budget, along with any explanation of the reason for the proposed revision. Budget revisions will be effective upon approval by the Court.
G. Reimbursement and Payment Provisions
1. The cost of the Monitor, including the cost of any staff or consultants to the Monitor, shall be borne by the State in this action, but the Monitor and the Monitor's staff or consultants are not agents of the State. All reasonable expenses incurred by the Monitor or any of the Monitor's staff in the course of the performance of the duties of the Monitor, shall be reimbursed by the State. The Court retains the authority to resolve any dispute that may arise regarding the reasonableness of fees and costs charged by the Monitor.
2. The State shall deposit $100,000.00 into the Registry of the Court as interim payment of costs incurred by the Monitor. This deposit and all other deposits pursuant to this Order shall be held in the Court Registry Investment System and shall be subject to the standard registry fee imposed on depositors.
3. The Monitor shall submit monthly statements to the Court, with copies to the Parties, detailing all expenses the Monitor incurred during the prior month. The Court shall order the clerk to make payments to the Monitor. The clerk shall make those payments within 10 days of the entry of the Order directing payment. Within 45 days of the entry of each Order directing payment, the State shall replenish the fund with the full amount paid by the clerk in order to restore the fund's total to $100,000.00.
4. The Monitor shall not enter into any contract with the State while serving as the Monitor. If the Monitor resigns from his or her position as Monitor, the former Monitor may not enter any contract with the State on a matter related to this Settlement Agreement without the written consent of the United States while this Settlement Agreement remains in effect.

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VII. Construction and Termination
A. The Parties agree jointly to ﬁle this agreement with the United States District Court for the District of Delaware. The joint motion shall request that the Court enter the Settlement Agreement as an order of the Court.
1. The Parties anticipate that the State will have substantially complied with all provisions of the Settlement Agreement by July 1, 2016. Substantial compliance is achieved where the State has implemented all of the provisions of the agreement. Any violations of the agreement that are minor or occasional and are not systemic shall not be deemed non-compliance.
2. The Court shall retain jurisdiction of this action for all purposes until the State has substantially complied with all provisions of this Settlement Agreement and maintained substantial compliance with all provisions for one year. The Parties may agree to ask the Court to terminate the Settlement Agreement before the end of the anticipated ﬁve-year term, provided the State has substantially complied with all provisions of the Settlement Agreement and maintained substantial compliance with all provisions for one year. If the case has not yet been dismissed, the Parties agree to ask the Court for a non-evidentiary hearing on the status of compliance on or near July 1, 2016. If the Parties agree that there is non-compliance, or if there is a dispute about compliance, the Parties will so inform the Court, and the Court may set additional hearing dates as appropriate. If the State asserts that it is in compliance and the United States disputes the claim, the State shall bear the burden of demonstrating that it is in substantial compliance. The Parties may agree jointly at any time to allow for additional time to resolve compliance issues.
B. This Settlement Agreement may terminate prior to July 1, 2016 if the United States certiﬁes that the State has substantially complied with each of the provisions of the agreement and has maintained substantial compliance for at least one year. The burden shall be on the State to demonstrate this level of compliance.
C. With the exception of conditions or practices that pose an immediate and serious threat to the life, health, or safety of individuals covered by this agreement, if the United States believes that the State has failed to fulﬁll any obligation under this Settlement Agreement, the United States shall, prior to initiating any court proceeding to remedy such failure, give written notice to the State which, with speciﬁcity, sets forth the details of the alleged noncompliance.
1. With the exception of conditions or practices that pose an immediate and serious threat to the life, health, or safety of individuals covered by this agreement, the State shall have forty-ﬁve (45) days from the date of such written notice to respond to the United States in writing by denying that substantial noncompliance has occurred, or by accepting (without necessarily admitting) the allegation of noncompliance and proposing steps that the State will take, and by when, to cure the alleged noncompliance.

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2. If the State fails to respond within 45 days or denies that substantial noncompliance has occurred, the United States may seek an appropriate judicial remedy.
D. If the State timely responds by proposing curative action by a speciﬁed deadline, the United States may accept the State's proposal or offer a counterproposal for a different curative action or deadline, but in no event shall the United States seek an appropriate judicial remedy for the alleged noncompliance until at least 30 days after the State has responded under VII.C.2. above and until the Parties have conferred in good faith to resolve any outstanding differences.
1. The Parties may extend by mutual agreement the time period speciﬁed in this paragraph. If the Parties reach an agreement that varies from the provisions of this Settlement Agreement, the new agreement shall be reduced to writing, signed, and ﬁled with the Court for approval.
2. If the Parties fail to reach agreement on a plan for curative action, the United States may seek an appropriate judicial remedy.
E. If the United States believes that conditions or practices pose an immediate and serious threat to the life, health, or safety of individuals in DPC or receiving the community services required under this agreement, the United States may, without further notice, initiate a court proceeding to remedy those conditions or practices.
F. The Parties agree to work collaboratively to achieve the ultimate goal of achieving full compliance with the requirements of the law relating to the provision of adequate mental health services to the target population in the most integrated setting. In the event of any dispute over the language or construction of this agreement, its requirements, or its congruence with the requirements of the law, the Parties agree to meet and confer in an effort to achieve a mutually agreeable resolution. If after meeting and conferring, the Parties fail to agree, the Parties may submit the matter to the District Court for a determination and opinion as to the language or construction of this agreement.
G. A party may seek relief from the terms of this agreement by establishing that a signiﬁcant change in facts or law warrants revision of the agreement and that the proposed modiﬁcation is suitably tailored to the changed factual or legal circumstances. In the event that a party seeks such relief, it is hereby agreed that Fed. R. Civ. P. 60(b)(4-6) provides legally appropriate bases for such relief.
H. Nothing in this agreement is intended to require the State to force services required by this agreement upon individuals within the target population or override their right to make choices, including their right to refuse treatment or services consistent with state and federal law. For this reason, the Parties agree that the State's level of compliance with the terms of this Settlement Agreement shall not be affected by the refusal of any individual to accept or utilize any of the services set forth herein.
I. The Parties intend to allow the State to leverage the funding of the services listed herein to the fullest extent permitted by available federal, State, and private funding. Nothing in this

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Settlement Agreement shall preclude the State from seeking authority from the Center for Medicare and Medicaid Services at the United States Department of Health and Human Services for approval of coverage of Medicaid services under a different name than that used in this Settlement Agreement provided the State can demonstrate that the coverage for such services is otherwise legally permitted. In the event that the deﬁnitions and terms used in this Settlement Agreement create any difﬁculty in the State's utilization of funding from any federal, State, or private source, the Parties agree to work collaboratively to maximize the State's ability to access such funding.
J. This Settlement Agreement shall constitute the entire integrated Settlement Agreement of the Parties.
K. Any modiﬁcation of this Settlement Agreement shall be executed in writing by the Parties, shall be ﬁled with the Court, and shall not be effective until the Court enters the modiﬁed agreement and retains jurisdiction to enforce it.
L. The Settlement Agreement shall be applicable to, and binding upon, all Parties, their employees, assigns, and their successors in ofﬁce. If the State contracts with an outside provider for any of the services provided in Sections II-V of this agreement, the agreement shall be binding on any contracted parties, including agents and assigns.
M. The State shall ensure that all appropriate State agencies take any actions necessary for the State to comply with provisions of this Settlement Agreement.
N. By entering into this Settlement Agreement, the State parties do not admit the truth or validity of any claim made against them by the United States. The State does not speak for the Delaware General Assembly, which has the power under the Delaware Constitution and laws to determine the appropriations for, and to amend the laws respecting, the State of Delaware's programs for mental health. However, the State parties acting under their existing authority agree that it will be a condition of their conduct of the programs covered by this agreement to comply with the Settlement Agreement.
O. If the State fails to attain necessary appropriations to comply with this Settlement Agreement, the United States has the right to withdraw its consent to this agreement and revive any claims otherwise barred by operation of this Settlement Agreement.
P. The United States and the State shall bear the cost of their fees and expenses incurred in connection with this case.
VIII. General Provisions
A. The Settlement Agreement is binding on all successors, assignees, employees, agents, contractors, and all others working for or on behalf of the State to implement the terms of this Settlement Agreement.
B. The State agrees that it shall not retaliate against any person because that person has ﬁled or may ﬁle a complaint, provided assistance or information, or participated in any other manner

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in the United States' investigation or the Monitor's activities related to this agreement. The State agrees that it shall timely and thoroughly investigate any allegations of retaliation in violation of this agreement and take any necessary corrective actions identiﬁed through such investigations.
C. If an unforeseen circumstance occurs that causes a failure to timely fulﬁll any requirements of this agreement, the State shall notify the United States and the Monitor in writing within 20 calendar days after the State becomes aware of the unforeseen circumstance and its impact on the State's ability to perform under the agreement. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. The State shall take all reasonable measures to avoid or minimize any such failure.
D. Failure by any Party to enforce this entire agreement or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver, including of its right to enforce other deadlines and provisions of this agreement.
E. The Parties shall promptly notify each other of any court or administrative challenge to this agreement or any portion thereof, and shall defend against any challenge to the agreement.
F. The Parties represent and acknowledge this Settlement Agreement is the result of extensive, thorough and good faith negotiations. The Parties further represent and acknowledge that the terms of this Settlement Agreement have been voluntarily accepted, after consultation with counsel, for the purpose of making a full and ﬁnal compromise and settlement of any and all claims and for the express purpose of precluding any further or additional claims arising out of the allegations set forth in the complaints and pleadings in these Actions. Each Party to this Settlement Agreement represents and warrants that the person who has signed this Settlement Agreement on behalf of his or her entity is duly authorized to enter into this Settlement Agreement and to bind that Party to the terms and conditions of this Settlement Agreement.
G. Nothing in this Settlement Agreement shall be construed as an acknowledgement, an admission, or evidence of liability of the State under the Constitution of the United States, federal or state law, and this agreement may not be used as evidence of liability in this or any other civil or criminal proceeding.
H. This Settlement Agreement may be executed in counterparts, each of which shall be deemed an original, and the counterparts shall together constitute one and the same agreement, notwithstanding that each party is not a signatory to the original or the same counterpart.
IX. Implementation of the Agreement
A. The implementation of this Settlement Agreement shall begin immediately upon the Effective Date, which shall be the date on which this Settlement Agreement is approved and entered as an order of the Court.
B. Within one month from the effective Date of this Settlement Agreement, the State shall

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appoint a Settlement Agreement Coordinator to oversee compliance with this Settlement Agreement and to serve as a point of contact for the United States and the Monitor.
C. The State shall maintain sufﬁcient records to document that the requirements of this Settlement agreement are being properly implemented and shall make such records available to the Monitor and the United States for inspection and copying on a reasonable basis. Such action is not intended, and shall not be construed, as a waiver, in litigation with third parties, of any applicable statutory or common law privilege associated with such information. Other than to carry out the express functions as set forth herein, both the United States and the Monitor shall hold such information in strict conﬁdence to the greatest extent permitted by any applicable law or regulation.
D. The State shall work collaboratively with the Monitor, and, where appropriate, with the United States, in developing its implementation plans. In order to determine compliance with this Settlement Agreement, and to the extent they are within the State's custody or control, the Monitor and the United States shall have full access to persons, employees, residences, facilities, buildings, programs, services, documents, records, and materials that are necessary to assess the State's compliance and/or implementation efforts with this Settlement Agreement. Such access shall include departmental and/or individual medical and other records. The Monitor and the United States shall provide reasonable notice of any visit or inspection. The Parties agree in cases where there is an emergency situation that presents an immediate threat to life, health or safety of individuals, neither the United States nor the Monitor will be required to provide the State notice of such visit or inspection. Such access shall continue until this case is dismissed. Such access as set forth herein is not intended, and shall not be construed, as a waiver, in litigation with third parties, of any applicable statutory or common law privilege associated with such information. Other than to carry out the express functions as set forth herein, both the United States and the Monitor shall hold such information in strict conﬁdence to the greatest extent permitted by any applicable law or regulation.
X. "Notice" under this agreement shall be provided by overnight courier to the
following or their successors:
Chief of the Special Litigation Section United States Department of Justice Civil Rights Division 601 D St., NW Washington, D.C. 20004
Attorney General Delaware Department of Justice New Castle County 820 North French St. Wilmington, DE 19801

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Secretary of DHSS 1901 North DuPont Highway Administration Building, 1st Floor New Castle, DE 19720

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FOR THE UNITED STATES:
FOR THE STATE OF DELAWARE:
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___________________________ THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
___________________________ SAMUEL R. BAGENSTOS Principal Deputy Assistant Attorney General Civil Rights Division
___________________________ JONATHAN SMITH Chief Special Litigation Section
___________________________ JUDY C. PRESTON Deputy Chief Special Litigation Section
___________________________ ALISON N. BARKOFF Special Counsel for Olmstead Enforcement Civil Rights Division
___________________________ DAVID DEUTSCH DEENA FOX Senior Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section

___________________________ RITA M. LANDGRAF Secretary

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Delaware Department of Health and Social Services
___________________________ LAWRENCE W. LEWIS Delaware State Solicitor
___________________________ ILONA KIRSHON Deputy Attorney General
___________________________ AARON R. GOLDSTEIN Deputy Attorney General
___________________________ RALPH K. DURSTEIN Deputy Attorney General

SO ORDERED this _________ day of _________, 2011
UNITED STATES DISTRICT JUDGE

Case 1:11-cv-00591-LPS Document 4-1 Filed 07/06/11 Page 1 of 2 PagelD #: 15

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE

UNITED STATES OF AMERICA, Plaintiff,
v. STATE OF DELAWARE,
Defendants

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CIVIL ACTION NO: 11-591-LPS

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ORDER ENTERING SETTLEMENT AGREEMENT
The United States and the State of Delaware have determined that entering into a Settlement Agreement concerning the rights oﬁndividuals in Delaware with serious and persistent mental illnesses to be served in the most integrated settings appropriate to their needs, rather than contested litigation, is the best way to resolve the United States' claim in this matter.
After reviewing the Settlement Agreement, and in consideration of the parties' Joint Motion for Entry of Settlement Agreement, the Court hereby
ORDERS that the parties' Joint Motion is GRANTED; and the Court further
ORDERS that the Settlement Agreement shall be entered as an order of the Court; and the Court further
ORDERS that the Court shall retain jurisdiction over this case to enforce the terms of the Settlement Agreement until this case is dismissed; and the Court further
ORDERS that the Court shall have the power to enforce the Settlement Agreement through all remedies that the law permits.
IT IS SO ORDERED
Dated this 15th day of July, 2011
_________________________ UNITED STATES DISTRICT JUDGE
PDF version of signed Order Entering Consent Decree

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Last updated July 28, 2011

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 ·

FILED· ..

IN THE UNITED STATES DISTRI<:Y:P.fAOI!'HS"t'r;n$1-ed1)-t'6OTf"RDICELTA.CWOAURERT

FOR THE DISTRICT OF DELAWARE

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2011 JUL-6 AM 8: 55

UNITED STATES OF AMERICA, Plaintiff,
v. STATE OF DELAWARE,
Defendant.

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CIVIL ACTION NO: 1 1 - 5 9 "

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COMPLAINT FOR VIOLATIONS

) ,.. OF THE AMERICANS WITH

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DISABILITIES ACT

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42 U.S.C. §§ 12131-12134

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COMPLAINT

The State of Delaware ("State") discriminates against persons with disabilities in violation of Titl~ II of the Americans with Disabilities Act of 1990 ("ADA"), 42 U.S.C.

§§ 12131-12134, and its implementing regulations by segregating individuals with mental

illnesses in institutions that are not the most integrated setting appropriate to their needs, placing

individuals at risk of unnecessary institutionalization, and failing to provide adequate community

supports and services to individuals who are discharged from institutions.

JURISDICTION AND VENUE 1. This Court has jurisdiction over this action under Title II ofthe ADA, 42 U.S.C. §§ 12131-12132, and 28 U,S.C. §§ 1331 & 1345. This Court may grant the relief sought in this action pursuant to 28 U.S.C. §§ 2201-2202.

-2­ 2. Venue is proper in this district pursuant to 28 U.S.C. § 1391, as a substantial portion
of the acts and omissions giving rise to this action occurred in the District of Delaware. 28 U.S.C. § 1391(b).
pARTIES 3. Plaintiff is the United States of America. 4. Defendant is the State of Delaware. The State is sued as a "public entity" within the
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meaning of the ADA, 42 U.S.C. § 12131(1); 28 C.F.R. § 35.104, and is subject to Title II of the ADA, 42 U.S.C. § 12131 et seq., and its implementing regulations, 28 C.F.R. Part 35.
FACTS 
 The State's Mental Health System 
 5. The State of Delaware delivers services for its citizens with mental illnesses primarily through Department of Health and Social Services ("DHSS"), which is the umbrella agency supervising the Department of Substance Abuse and Mental Health ("DSAMH") and Delaware Psychiatric Center ("DPC"). 6. DHSS is responsible for the overall coordination of services for people with developmental disabilities, mental illnesses, addictive diseases, and other disabilities in the State of Delaware. This includes administering the State's mental health system, planning the services and the settings in which mental health services are provided, ensuring quality of care and consumer safety across settings, and allocating within the mental health service system all funds appropriated from federal, state, and other sources. 7. DHSS offers a range of treatment and support services to help persons with mental illnesses, addictive diseases, and developmerital disabilities integrate into, successfully live in,

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and contribute to, the community. Among the mental health services that DHSS provides or contracts for are: crisis services, Assertive CommunitY Treatment ("ACT"), case management, housing supports, employment supports, peer supports, rehabilitative services, and other community support services. 8. DHSS licenses and inspects mental health service providers, including DPC. DPC is an. institutional setting in which people receive residential care and treatment services. DHSS also coordinates, provides or purchases additional in-patient services for individuals with mental illnesses at private institutions throughout the State of Delaware. 9. The State receives Medicaid funding from the United States Department of Health and Human Services for the operation of its mental health system.
Individuals Are Unnecessarily Institutionalized 10. DPC is a congregate adult mental health facility managed an~ staffed by the State of Delaware for people with diagnoses of mental illness. Each of these individuals is substantially limited in major life activities by his or her mental illness. Each person is a qualified individual with a disability, as defined in the ADA. 11. DPC is an institution that segregates individuals with mental illness from their non-disabled peers in the community and provides limited, if any, access to community activities and interactions with people without disabilities. 12. Most, if not all, of the individuals at DPC, can benefit from community settings with community-based services and supports and do not object to receiving services in a more integrated setting. The State's own clinicians have determined that approximately half of the individuals at DPC no longer meet acute care criteria for continued admission in an institution and

-4­
are therefore, appropriate for community placement. Yet they remain confined in DPC due to the lack of appropriate community services and supports. 13. Many more individuals at DPC are likely appropriate for and do not oppose placement in more integrated settings. These individuals remain unnecessarily institutionalized due to the· State's failure to conduct individualized, person-centered assessments identifying the housing and support services that are necessary for a successful transition to the community. 14. Additional individuals with mental illness are institutionalized in private in-patient facilities that are funded by, and are part of the mental health system administered by, the State of Delaware. Many of these individuals are unnecessarily institutionalized due to the lack of adequate community-based supports and services.
Individuals At Risk ofUnnecessary Institutionalization 15. Approximately 17,709 people in Delaware have a severe and persistent mental illness.· Many of these individuals require community-based services and supports in order to avoid unnecessary institutional placements. Without such services, they are at risk of unnecessary institutionalization. 16. Many individuals are admitted or re-admitted to DPC or other institutional settings because of a lack of sufficient supports and services in the community. With intensive community based services - such as crisis services, ACT, case management, and housing supports - these individuals would not require long-term hospitalization. 17. Serving individuals in community placements instead of in institutional settings is a more cost effective option for the State. Intensive support in the community typically costs less than one quarter of the cost of institutional placement in Delaware.

-5­
VIOLATIONS OF THE AMERICANS WITH DISABILITIES ACT 18. The allegations of Paragraphs 1 through 17 are hereby re-alleged and incorporated by reference. 19. Defendant discriminate against "qucilified individual[s] with a disability," within the meaning of the ADA, by administering the State's mental disability service system in a manner that denies thousands of people with mental illness the opportunity to receive services in the most integrated setting appropriate to their needs. These individuals are qualified to receive services in a more integrated setting and do not oppose receiving services in a more integratep setting. 20. The State's actions as alleged herein constitute discrimination in violation of Title II of the ADA, 42 U.S.C. § 12132, and its implementing regulations.
PRAYER FOR RELIEF WHEREFORE, the United States of America prays that the Court: 21. Enjoin Defendant from administering mental disability services in settings that unnecessarily isolate and segregate individuals with disabilities from the community; 22. Require :pefendant to administer disability services in the most integrated settings appropriate to the needs of the individuals with disabilities; and 23. Order such other appropriate relief as the interests ofjustice require..

FOR THE UNITED STATES: 


-6­
Respectfully submitted, 

THOMAS E. PEREZ Assistant Attorney General Civil Rights Division
LXA iL==-.
SAMUEL R. BAGENSTOS Principal Deputy Assistant Attorney General Civil Rights Di ision

Special Litigation Section
~VL
JUD"Y:PRESTON 
 Deputy Chief 
 Special Litigation Section 

~~-~t:

ALISON N. BARKOFF Special Counsel for Olmstead Enforcement Civil Rights Division
DAVID DEUTSCH 
 DEENA FOX 
 Trial Attorneys 
 U.S. Department of Justice 
 Civil Rights Division 
 Special Litigation· Section 


-7­
950 Pennsylvania Ave, NW Washington, D.C. 20530 (202) '514-6255. daviddeutsch@usdoi.gov David Deutsch (DC Bar # 248120) Deena Fox (NY Bar # 4709655)
7 


 
 Case 1:11-cv-00591-LPS Document 25 Filed 01/30/12 Page 1 of 25 PageID #: 113

1

FIRST REPORT OF THE COURT MONITOR

2

ON PROGRESS TOWARD COMPLIANCE

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WITH THE

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SETTLEMENT AGREEMENT: U.S. v. STATE OF DELAWARE

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U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS

6

7

January 30, 2012

8

9 I. Introduction

10 This is the first report by the Court Monitor (“Monitor”) on the implementation of the Settlement 11 Agreement between the U.S. Department of Justice (“DOJ”) and the State of Delaware (“the 12 State”). The Settlement Agreement concerns the civil rights of individuals with serious and 13 persistent mental illnesses (“SPMI”) who are served in Delaware’s public programs. The report 14 presents the Monitor’s findings and recommendations relating to the State’s progress toward 15 compliance during the six-month period from the date the Settlement Agreement took effect, 16 July 15, 2011.

17 The Settlement Agreement has tremendous importance for Delaware residents who have mental 18 illnesses, their families, and their communities. When fully implemented, it will result in a 19 significant expansion of community-based services and supports that are crucial to people with 20 SPMI. These services are designed to prevent or diminish the crises that are now routine among 21 this population and that result in avoidable emergency room use, police involvement, court 22 intervention, and hospital admissions. Consistent with the principles of the Americans with 23 Disabilities Act (“ADA”) and the U.S. Supreme Court’s Olmstead decision, the Settlement 24 Agreement will enable Delawareans with SPMI to participate as full members of their 25 communities and to overcome the needless segregation, dependency and social isolation that are 26 too prevalent today. Accompanying such important human impact, proper implementation of the 27 Settlement Agreement will result in vastly more effective use of public funds that are now 28 heavily invested in responding to mental health crises—including emergency room care and 29 reliance on local police—and in various forms of unnecessary institutional care.

30 These positive outcomes are more than just aspirations. Delaware is fortunate in that it already 31 has in place many of the components that are required by the Settlement Agreement, and 32 individuals with SPMI who are receiving an appropriate complement of services are now 33 thriving in their communities. The essential problem confronting the State is that these services 34 are not readily available on a scale or with the timeliness that allows a full realization of their 35 benefits. Furthermore, critical services for Delawareans with SPMI have been provided within a 36 bureaucratic context that can fairly be described as challenging and convoluted. The State’s

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37 current service framework reflects an accumulation of decades of bureaucratic “fixes,” and 38 programs that are more structured around reimbursement than effective service delivery. The 39 system is plagued by complex, shifting and sometimes redundant administrative responsibilities 40 that are spread across various departments, divisions and organizations, making it prone to 41 unintended harmful and wasteful consequences. Dispersed oversight responsibilities, combined 42 with the State’s siloed data systems challenge attempts at reforms. Furthermore, processes that 43 were designed to address psychiatric emergencies that present an immediate danger to the 44 individual with SPMI or others are often misused, resulting in needless court intervention and 45 institutional confinement of people with SPMI who pose no evident threat. Taken as a whole, 46 these factors not only waste limited public resources, but also have profound civil rights 47 implications; they result in people with SPMI being needlessly segregated in institutions and to 48 being traumatized and degraded, for instance, when handcuffed, taken into custody and 49 transported by police when less intrusive interventions are appropriate. During this initial 50 implementation period, the Monitor has found both a broad awareness that the system is 51 problem-prone and a strong commitment by the State and other stakeholders to achieve the goals 52 of the Settlement Agreement in a meaningful and sustainable way.
53 It is obviously too soon to predict the ultimate success of this endeavor. Stakeholders frequently 54 remind the Monitor that they have witnessed a succession of prior investigations, failed reform 55 efforts, short-sighted decisions and unfulfilled promises relating to Delaware’s mental health 56 system. They express genuine interest in the wellbeing of citizens with SPMI, tempered by some 57 skepticism—perhaps, well-founded, given these experiences—as to the ultimate meaning of this 58 newest “fix”. Overwhelmingly, their concern is not so much about whether the positive 59 outcomes required by the Settlement Agreement are achievable, but rather whether the effort will 60 be sustained, whether innovation will be encouraged, whether bureaucratic loopholes and 61 challenges will be corrected, and whether the resources needed to allow individuals with SPMI 62 to live and thrive in integrated community settings will remain available over time.
63 This report reflects the State’s initial corrective measures in what is envisioned as a five-year 64 process to achieve full compliance. The Settlement Agreement includes few provisions that 65 require completion during this initial six-month period and, as would be expected, Delaware is 66 not yet in full compliance with any of its major requirements. This is not to say that the State is 67 not already making some important strides. The Monitor has found that the leadership of the 68 Department of Health and Social Services (“DHSS”) and the Division of Substance Abuse and 69 Mental Health (“DSAMH”) have approached implementation with a clear recognition of its 70 importance. They have begun to educate and engage citizens with SPMI, multiple levels of 71 DSAMH staff, providers, advocates and other state agencies with the goal that fulfillment of the 72 ADA—the essential framework of the Settlement Agreement—will become the natural product 73 of the service system.
74 Many of the State’s important and innovative activities during this reporting period are critical to 75 addressing these barriers and creating a foundation for lasting improvements, yet they do not
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76 appear as defined milestones in the Settlement Agreement. The Monitor believes that it is 77 important for the Court, the parties, and the general public to be aware of DHSS’s and 78 DSAMH’s start-up efforts to build infrastructure, examine and correct systemic flaws and to 79 ensure that Delawareans are afforded the Settlement Agreement’s full intended benefits. For this 80 reason, this report begins with a discussion of progress on some of these “foundational” issues 81 and then summarizes the status of work with regard to specific provisions. Throughout the 82 report, as applicable, the Monitor makes specific recommendations for immediate action by the 83 State.
84 The Monitor makes special note of the fact that this Settlement Agreement is being implemented 85 at a time of particular strain on state systems, in Delaware and nationwide. The achievement of 86 compliance requires not just actions on the part of DSAMH, but also of other divisions within 87 DHSS and other departments of State government. Being fully aware that implementation of 88 multiple and far-reaching system reforms is inherently stressful for states—and certainly even 89 more so today—the Monitor acknowledges DHSS Secretary Rita Landgraf ‘s success in bridging 90 the various governmental divisions that are affected, and in creating an atmosphere that fosters a 91 unified State effort to achieve the goals of the Settlement Agreement. The Monitor commends 92 Secretary Rita Landgraf, Director Kevin Ann Huckshorn, other officials and staff members 93 within Delaware government, as well as to other stakeholders for their insights and assistance, 94 and for their collaborative approach that has enabled the State to make significant progress 95 during this reporting period.
96
97 II. Sources of Information
98 The findings presented here are based upon a broad set of sources. These include site visits by 99 the Monitor to: Delaware Psychiatric Center (“DPC”), each of the State’s Community 100 Continuum of Care Programs (“CCCP”s), each of the three freestanding psychiatric hospitals 101 providing voluntary and involuntary care to people with SPMI (locally and in this report, these 102 are referred to as “IMDs”—Institutions for Mental Diseases), a Crisis and Psychiatric 103 Emergency Service (“CAPES”) site, various specialized housing programs for people with 104 SPMI, civil commitment hearings, and advocacy organizations concerned with public mental 105 health services in the State. The Monitor has met with many of the State officials relevant to 106 implementation, and participated in numerous meetings and committees. Examples include 107 meetings with: DSAMH’s central community transition team (“Barrier Busters”); leadership of 108 the State’s Medicaid office and Medicaid Managed Care Organizations (“MCOs”); the 109 Governor’s Mental Health Advisory Committee; DSAMH staff responsible for Quality 110 Assurance, Performance Improvement, and its Eligibility and Enrollment Unit (“EEU”); and 111 workgroups concerned with legislative reforms, data, training, and system reconfiguration. The 112 Monitor has reviewed numerous reports, policies, minutes, inpatient and outpatient case records, 113 data sets and other material relating to implementation. Finally, the Monitor has had regular
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114 formal and informal contact with DHSS Secretary Landgraf, DSAMH Director Huckshorn, 115 DSAMH Deputy Director Smith, other senior Division staff, and representatives from the Office 116 of the Delaware Attorney General. Without exception, the State has provided the Monitor with 117 requested information, facilitated access to any individual with whom the Monitor sought 118 contact, and otherwise offered full and helpful assistance in carrying out the monitoring 119 functions delineated in the Settlement Agreement.

120

121 III. Infrastructure and System Configuration

122 Before reviewing the State’s progress with regard to provisions that are linked to specific 123 achievement dates, this report includes discussion of two critical foundational issues:

124

• Stakeholders’ understanding of measures required by the Settlement Agreement and of

125

the ADA and the Olmstead decision which underlie these requirements; and

126

• Reconfiguration of public systems to comport with the Settlement Agreement, including

127

centralized oversight to ensure that services are least restrictive, most integrating, and

128

meeting the needs of people with SPMI who are served in public programs.

129 130 A. Stakeholders’ Understanding of the Settlement Agreement
131 132 The Settlement Agreement is explicit in its intent to fulfill the goals of the ADA and related 133 federal laws for Delawareans with SPMI, requiring that public services for people with SPMI be 134 provided in the “most integrating setting appropriate” and that “the principles of self135 determination and choice are honored and that the goals of community integration, appropriate 136 planning, and services to support individuals at risk of institutionalization are achieved.” (Section 137 I.A) Consistent with this, the Settlement Agreement specifies that “Discharge assessments shall 138 begin with the presumption that with sufficient supports and services, individuals can live in an 139 integrated community setting.” (IV.A.1.b) The practical meaning of such integration is plainly 140 expressed: “…people with SPMI can live like the rest of Delawareans, in their own homes, 141 including leased apartments, houses, or living with their family.” (II.E.1.a)
142 143 Most stakeholders with whom the Monitor has interacted (with the notable exception of mental 144 health consumers, themselves) have indicated that they have read the Settlement Agreement, and 145 many had participated in related local trainings by DSAMH. While this agreement has been 146 promulgated only in the past six months, the federal laws that are its basis have been around for 147 far longer; the ADA was enacted over twenty years ago, and the Olmstead decision was rendered 148 over a dozen years ago. Despite the fact that these federal laws have enormous implications for 149 people with SPMI and for how public mental healthcare is delivered, and notwithstanding 150 numerous trainings by DSAMH over the years, the Monitor found a widespread lack of 151 knowledge about the principles of the ADA, their crucial implications for people with SPMI, and 152 how they relate to public services. Senior staff members of DHSS, DSAMH, and the CCCPs 153 have an understanding of the Settlement Agreement and underlying civil rights laws. However, 154 just a step or two below leadership positions, it is apparent that there is often only a passing

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155 familiarity with the ADA, the Settlement Agreement, and their requirements. In DPC, the IMDs,

156 and even within civil commitment hearings, the Monitor found practices that do not even

157 minimally reflect ADA considerations. This is particularly significant because it is in these

158 settings, rather than in the offices of management, that decisions about services and interventions

159 for specific individuals are made. Perhaps most poignant is that interactions the Monitor has had

160 with consumers suggest that they are unaware of their own civil rights under the ADA, let alone

161 the fact that the State has effected an agreement with DOJ.

162

163 It is obvious that individuals who are charged with implementing the Settlement Agreement and

164 those who are intended beneficiaries should be well versed in its requirements. It is also

165 important that for the Settlement Agreement to represent something beyond a laundry list of

166 prescribed actions, stakeholders need an appreciation of the underlying values. It is the Monitor’s

167 impression that a lack of basic knowledge about the ADA and Olmstead has sustained providers,

168 courts and others in unquestioningly making decisions that perpetuate segregation, undermine

169 self-sufficiency, and even result in coercive practices.

170

171 Recommendation: To effectively implement the Settlement Agreement and to promote actions

172 that represent the spirit—as well as the specifics—of its provisions, the Monitor recommends

173 that the State immediately launch a multi-pronged training program to ensure that:

174

175

1. The workforce serving individuals with SPMI in publicly funded systems understands

176

and can demonstrate competence in the requirements of the Settlement Agreement and

177

the underlying principles of the ADA and Olmstead, and how these relate to daily

178

practice;

179

2. Consumers of services receive training and informational materials that allow them to

180

understand their rights under the ADA and related law and to have current information

181

about the Settlement Agreement, its implementation, and its implications for their lives

182

and life goals; and

183

3. Courts, attorneys, advocates and other parties involved in rights protection and the civil

184

commitment process have a working knowledge of the ADA, Olmstead and the goals and

185

requirements of the Settlement Agreement.

186

187 B. System Reconfiguration

188 Compliance with the Settlement Agreement will require that the State quickly address structural 189 factors that have sustained unwarranted institutional segregation, confounded proper oversight, 190 and complicated the provision of effective community services and supports. Two key aspects 191 are discussed here; the involuntary commitment statute and oversight of the use of institutional 192 care. Following discussion of these issues are a presentation of measures the State has initiated 193 during this initial implementation period and recommendations by the Monitor for immediate 194 action.

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195 1. Civil Commitment:

196 Delaware’s civil commitment process does not provide adequate protections, leaving individuals 197 with SPMI vulnerable to unwarranted institutional segregation, coercion, and trauma. Mrs. L, 198 who came to the attention of the Monitor by chance during an impromptu visit to civil 199 commitment hearings, illustrates the scope of this problem. She is particularly interesting 200 because this individual is not what one would consider to be an “outlier.” From a clinical 201 perspective, Mrs. L has problems attendant to SPMI that are routinely encountered in public 202 mental health settings. From a service perspective, Mrs. L has not done anything that would 203 generate any sort of special attention, and she is unlikely to do so in the future. In this sense, she 204 is entirely representative of individuals served by Delaware’s public mental health system and 205 who are the intended beneficiaries of the Settlement Agreement. Her recent experiences illustrate 206 the manifold problems embedded in the system as currently constructed and that challenge 207 meaningful implementation of the Settlement Agreement.

208

Mrs. L has a long history of psychiatric problems, multiple psychiatric hospitalizations,

209

and service within outpatient mental health settings. She has never harmed herself or

210

anyone else, but has persistent paranoid delusions, for instance, that she is being

211

poisoned. Mrs. L had been living in supportive housing, taking her medications as

212

prescribed and was actively and voluntarily engaged in services at a CCCP. Her

213

outpatient record there indicates that a psychiatrist, nurse and case manager were working

214

closely with Mrs. L, attempting to help her control delusional thoughts and, ultimately, to

215

fulfill her goal of getting a job. Her record shows no significant issues relating to her

216

involvement or compliance with treatment. After appearing uninvited at a relative’s

217

house, Mrs. L was brought by police to a hospital emergency department (standard

218

procedure is to transport such individuals in handcuffs), where she was noted to be

219

“sobbing” and expressing strange thoughts. Evidently without consulting her CCCP, she

220

was soon transported—again, by police and handcuffed—to an IMD on a 24-hour hold

221

for involuntary emergency care.

222

Upon admission, the IMD carried out an assessment of Mrs. L. As would be expected,

223

the clinical team found her to be at “Low Risk” of danger to herself and to others.

224

Nevertheless, on the very same sheet that these findings were recorded, Mrs. L’s hospital

225

record includes the recommendation for involuntary inpatient psychiatric care, based on

226

her being “psychotic- danger to self and others.” She was placed on suicide precautions

227

and monitored by staff at 15-minute intervals around the clock for several days thereafter.

228

At her civil commitment hearing (attended by the Monitor), no evidence was presented

229

indicating that Mrs. L was actually dangerous, nor was there any reference to the fact that

230

she had been actively engaged in voluntary community treatment. The IMD doctor

231

testifying at the hearing recommended that she remain hospitalized for a few more days.

232

Although Mrs. L stated that she would be agreeable to this plan, she was not offered an

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233

opportunity to continue her hospital care on a voluntary basis. Instead, she was civilly

234

committed to the IMD. Furthermore, the court ordered that her discharge from the IMD

235

be followed by a period of involuntary outpatient treatment. Upon completion of the

236

hearing, the Monitor inquired as to the rationale and legal basis for ordering involuntary

237

treatment. Neither the attorneys nor the presiding commissioner were able to offer a

238

definitive answer. Mrs. L remained in the hospital for several days thereafter and was

239

referred back the CCCP where she had been treated previously. She was given

240

medications and a copy of her discharge plan, which is perplexing both in its lack of

241

detail and its relevance to Mrs. L’s history: “comply with treatment.”

242 Certainly, most involuntary psychiatric hospital admissions in Delaware occur in response to 243 situations where there is an immediate danger and where no known viable alternative is available 244 to the crisis responders. As implementation of the Settlement Agreement unfolds, there will be a 245 significantly increased capacity to prevent, intervene early, and avert hospitalization through 246 newly available community alternatives. Nevertheless, Mrs. L’s encounters with the emergency 247 system, the police, the court, and the IMD reflect a deeper issue in Delaware. Mrs. L was not 248 dangerous to herself or others and was already receiving a high level of apparently good 249 community services via the CCCP. She was taken into custody, handcuffed and involuntarily 250 committed as an inpatient—and then as an outpatient—not because services were absent, but 251 because factors endemic in Delaware’s public systems make involuntary hospitalizations, police 252 transports, and court-ordered outpatient treatment all too common. These actions also did not 253 occur in the absence of oversight; Mrs. L’s care in the emergency department and in the IMD 254 was paid for with Medicaid funds that are controlled by a Managed Care Organization (“MCO”) 255 operating under contract with the State’s Medicaid office. (In the section that follows, the 256 Monitor discusses such oversight in detail, including the differences in outcomes when hospital 257 care is managed by DSAMH.)

258 Many informants have reported to the Monitor that 24-hour emergency psychiatric holds afford a 259 convenient, expedient, reimbursable and poorly-regulated path to removing people with SPMI 260 from where they are not wanted. Busy hospital emergency department evidently use this 261 mechanism not only with people such as Mrs. L, who pose no real threat and whose need for 262 hospital care is dubious, but also for people who actually have substance abuse problems and 263 who express only vague psychiatric complaints. There are few incentives in place that are 264 designed to encourage thoughtful differential diagnosis, to consult with providers currently 265 engaged with an individual or to take the time necessary to construct an appropriate service plan. 266 Instead, a 24-hour emergency psychiatric hold is a simple and readily available alternative, albeit 267 one with serious civil rights implications.

268 The other issue is outpatient commitment following discharge from a hospital. Individuals for 269 whom outpatient treatment is court-ordered are highly vulnerable to re-institutionalization, even 270 for reasons that do not meet civil commitment criteria. They may be returned to a psychiatric 271 hospital by police upon completion of a brief, one-page “Certificate of Non-Amenability,” which

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272 does not even require a face-to-face examination. Although outpatient commitment is 273 infrequently sought for people being discharged from DPC, people are often released from IMDs 274 with continuing orders for involuntary outpatient treatment. Senior staff members at DSAMH’s 275 CCCPs (i.e., the outpatient mental health treatment providers) have indicated that they almost 276 never initiate such court intervention, and that they frequently see instances where there is 277 neither an apparent logic nor a benefit to the use of these intrusive orders. Such outpatient 278 commitment orders conflict with the Settlement Agreement when they are not the least279 restrictive, most integrating service appropriate to the individual. To better understand the scale 280 of this issue, the Monitor examined data relating to the prevalence of court-ordered outpatient 281 treatment in Delaware. Neighboring states either do not have statutory provisions for outpatient 282 commitment or use this path only rarely, with individuals who are at particularly high risk. New 283 York is a state where outpatient commitment is used with some regularity and has been intensely 284 studied. Corrected for population, Delaware uses court-ordered outpatient treatment at a rate that 285 is about ten times higher than New York.
286 The Settlement Agreement requires that publicly funded mental health services in Delaware be 287 provided in the most integrated, least restrictive manner appropriate to the needs of the 288 individual, and also that services be oriented toward recovery. There are concerns that the State’s 289 mental health statute does not appropriately promote these requirements, that hearings relating to 290 involuntary hospitalization and treatment are often perfunctory, and that neither the law nor 291 current practices afford adequate protections against unnecessary institutional segregation. 292 Furthermore, there is a concern that the State’s existing civil commitment statute is being used 293 for purposes that were not intended.
294
295 2. Oversight of Psychiatric Hospitalizations:
296 The State’s overly-complex arrangements for managing services to people with SPMI poses 297 significant problems in assuring that appropriate interventions are provided, that rights are 298 protected, and that public resources are utilized efficiently. The summary that follows aptly 299 captures the complicated nature of the system that is now in place in Delaware:
300 Inpatient and outpatient mental health treatment for people with SPMI may be funded and 301 regulated by an MCO working under contract with the State’s Division of Medicaid and Medical 302 Assistance, by DSAMH’s utilization review program (i.e., the EEU), or by both. And based upon 303 whether the individual is eligible for Medicaid benefits, has exhausted those annual benefits, or 304 is determined to have a higher or lower clinical need, the source of payment, the entity with 305 primary oversight responsibility and even the community provider serving the individual may 306 shift. In the latter scenario, individuals in treatment for SPMI are sometimes required to change 307 service providers midstream due to reimbursement, rather than clinical interests. For individuals
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308 admitted to IMDs whose Medicaid benefit has been exhausted, DSAMH underwrites the cost of 309 inpatient care, but only if the care is provided on an involuntary basis.
310 This bewildering framework not only challenges consumers and the providers, but it also 311 conflicts with essential civil rights, including those reflected in the Settlement Agreement. For 312 instance, the policy limiting DSAMH funding to civilly committed individuals without insurance 313 was installed to limit the Division’s financial liability for inpatient care in IMDs. However, this 314 policy has had the unintended consequence of encouraging involuntary care as a means of 315 guaranteeing payment. Not only is there thus a disincentive for voluntary care, but as is 316 described in the previous section, there are few meaningful protections against misuse of 317 involuntary treatment orders. Furthermore, when there is an involuntary commitment, secure 318 transportation to the hospital by police—that is, in the back of a police car and in handcuffs— 319 presents no reimbursement issues and is readily available whether or not the individual presents a 320 danger and whether or not such physical restraint is detrimental to the individual’s overall health. 321 (As an aside, the Monitor notes that the unnecessary reliance on police for transporting people 322 with SPMI also diverts officers from legitimate criminal justice and public safety activities 323 within their communities). DSAMH is aware of this issue and is working to bring about changes 324 that encourage voluntary treatment whenever it is appropriate.
325 In sum, as things now stand, Delaware’s protections against unwarranted hospitalization are 326 weak and its complicated funding mechanisms inadvertently incentivize hospital admissions on 327 an involuntary basis. There are additional complications, as well. The State’s mental health 328 authority, DSAMH, does not have consistent control over publicly funded services to people 329 with SPMI who are currently eligible for Medicaid benefits. In fact, currently DSAMH may 330 know very little, if anything, about inpatient or outpatient services provided to individuals with 331 SPMI under the Medicaid program.
332 For certain publicly funded individuals who are involuntarily admitted to psychiatric hospitals, 333 DSAMH’s EEU plays an important and informative role. When an inpatient episode is being 334 paid for with DSAMH funds—that is, when individuals have no insurance or when Medicaid or 335 other insurance coverage is exhausted—DSAMH’s EEU determines the need for inpatient 336 services and oversees reimbursement for hospital care accordingly. When individuals have 337 Medicaid coverage for care in an IMD (as was the case with Mrs. L), an MCO that is under 338 contract with the Division of Medicaid and Medical Assistance manages the care instead; the 339 EEU plays a limited role in ensuring that the legal filings are in order and, as needed, in referring 340 the individual to an inpatient facility. In short, DSAMH currently has no meaningful authority to 341 control inpatient admissions to IMDs for people with SPMI who are covered by Medicaid.
342 Clinically, there is no reason to expect that the populations with and without active Medicaid 343 coverage are different in any way. Furthermore, referrals to the three IMDs are made on the basis 344 of bed availability and other factors that would not differentiate them in terms of clinical issues 345 or distinguish them from the population receiving acute care at DPC. Yet, the Monitor’s review
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346 of data relating to over 3,000 involuntary admissions (covering the period 7-1-10 through 10-31347 11) and a sample of case records shows some striking trends:

348

• The average length of hospital stay in IMDs was 15% longer when care was managed

349

by an MCO, as compared with care managed by DSAMH.

350

• Longer average lengths of stay under Medicaid MCO management occurred in each of

351

the IMDs, as compared with DSAMH management, whether or not co-occurring

352

substance abuse disorders were identified.

353

• There are a number of admissions to DPC—and as one would expect, also to the

354

IMDs—of individuals who have primary problems of substance abuse and sometimes

355

only vague symptoms that would justify court-ordered psychiatric hospitalization.

356

Within DPC, these admissions are generally converted to voluntary status and

357

individuals are discharged soon thereafter. Some of these individuals are released to

358

detox centers. Others want to be immediately released, and go to shelters because

359

appropriate housing cannot be arranged on short notice. In many instances, the

360

likelihood of readmission is very high. For instance, in the six months since the

361

Settlement Agreement has been in effect, one individual reviewed by the Monitor

362

accumulated six hospital admissions, four to DPC and two to IMDs

363

• Co-occurring substance abuse is diagnosed in roughly half of the admissions to DPC

364

and in two of the IMDs. The third IMD identifies substance abuse issues in only 12% of

365

its admissions. At a minimum, this suggests that diagnostic practices afforded people

366

with SPMI in public programs are not standard. Some informants have reported to the

367

Monitor that co-existing substance abuse diagnoses might raise questions as to the

368

appropriateness of a psychiatric admission, legally and in terms of reimbursement. To

369

the extent that this is true, this might affect the accuracy or completeness of diagnoses

370

that are recorded in the hospital record.

371

• Without question, psychiatric inpatient stays should be as brief as possible. Yet,

372

involuntary hospitalizations (i.e., admissions that ostensibly involve an immediate

373

danger to self or others) lasting one or two days raise questions as to whether the

374

admission was appropriate in the first place. On DPC’s acute care unit (K-3), these

375

occurred in about 12% of the admissions, sometimes in regard to individuals who

376

actually have substance abuse problems, rather than SPMI, and who nevertheless were

377

admitted on 24-hour psychiatric holds. In the IMDs, these discharges occur far less

378

frequently, in only 5% of the admissions. Possibly accounting for part of this difference

379

is the reported latitude afforded by Medicaid MCOs in routinely approving five-day

380

admissions to IMDs. There is presently no system in place to flag instances where

381

admissions appear to be questionable, to identify the systemic factors that culminated in

382

inappropriate admissions, or to account for these and other differences in publicly

383

funded involuntary hospital care. Further, the Monitor could access no hard data on the

384

cost to the public system relating to these problematic hospitalizations.

385 The essential issues raised by this review of the data are whether involuntary psychiatric 386 hospitalization is appropriate in the first place, whether 24-hour holds are being misused, and 387 whether core service needs are being appropriately addressed.

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388 The Monitor found no evident clinical explanation for these variations among the IMDs, between 389 the IMDs and DPC’s acute care unit, and between hospital care that is reimbursed through 390 Medicaid as opposed to DSAMH funding. These differences, which have important implications 391 for the civil rights of individuals with SPMI and for the State’s compliance with the Settlement 392 Agreement, are attributable to the currently convoluted bureaucratic structure though which 393 services are managed and to gaps in essential legal protections. There are also obvious fiscal 394 implications associated with questionable hospital stays.
395
396 3. Measures Being Taken by the State:

397 The Monitor has found broad agreement that issues relating to civil commitment and the 398 oversight of publicly funded inpatient care of individuals with SPMI need to be addressed in 399 order to achieve compliance with the Settlement Agreement and to ensure that the expansion of 400 services has its intended impact. During the initial six months of implementation, DSAMH and 401 the Monitor have been working closely on several measures:

402

• DSAMH has completed an excellent root-cause analysis of the diverse factors

403

contributing to the questionable hospital admissions of individuals such as Mrs. L, and

404

has identified aspects of the mental health statute and the healthcare delivery system that

405

contribute to this problem. Based in part on these findings, the State is currently

406

evaluating how protections against unwarranted institutional confinement can be

407

strengthened and how the full benefits of pre-screening and diversion programs (for

408

example, the Mobile Crisis Services and case management discussed later in this report)

409

can be realized through refinements in the legal and regulatory framework.

410

• A group of senior DSAMH staff members is working on a system map that lays out how

411

public mental health services might be simplified and better aligned to ensure the

412

requirements of the Settlement Agreement. An important overarching goal is establishing

413

more consistent oversight so that appropriate publicly funded services are available to all

414

individuals with SPMI—regardless of insurance status, legal status, or place of residence

415

within Delaware. Furthermore, the system map being developed is intended to make far

416

better use of data to ensure quality and efficiency, and to drive improvements in the

417

public system. Without question, the group’s current ideas about reconfiguration will

418

come to be refined over the implementation period and beyond. But this effort is pivotal

419

in that, from the outset, it is encouraging implementation measures to proceed within the

420

context of a bigger picture, one that is more coherent than the status quo.

421

• DSAMH has provided the Monitor with some preliminary data that may begin to identify

422

instances where individuals with substance abuse disorders and other issues not

423

specifically related to SPMI are being inappropriately admitted to psychiatric beds. The

424

intent is to explore the reasons for this occurring and to identify needed improvements in

425

oversight and community based alternatives to hospital care.

426

DHSS Secretary Landgraf and DSAMH Director Huckshorn have been actively engaged in

427

evaluating these systemic problems, which appear to be the culmination of decades of narrow

11

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428

or shortsighted policymaking. Moving forward, their plan is to promote some critically

429

needed changes in the structure of services for people with SPMI, the oversight of these

430

services, and processes to safeguard the rights of individuals served in public mental health

431

programs.

432
433 Recommendations:
434 These efforts by the State are commendable because, in the Monitor’s opinion, they contribute to 435 the establishment of a solid foundation for sustainable reforms and continuous improvement 436 during and beyond the Settlement Agreement. Instead of attempting to embed the Settlement 437 Agreement requirements within current practices, they reflect an openness by DHSS and 438 DSAMH to attacking what have been some longstanding operational challenges. As of this 439 writing, these initiatives represent works in progress, but there are some actions that the Monitor 440 strongly recommends be pursued in the immediate term:

441

1. The State should move as quickly as possible to introduce a comprehensive set of

442

reforms—programmatic, administrative and legal—that will reduce the unwarranted

443

institutionalization of Delawareans with SPMI and will make far better use of public

444

resources that are now invested in late-stage interventions and preventable hospital care.

445

There is an urgent need to introduce these reforms, above all to uphold the essential civil

446

rights of individuals with SPMI who are served by public systems. Beyond this, it is also

447

critical that the new and expanded programs that are being phased in per the Settlement

448

Agreement are embedded in a coherent, accountable system that is clearly oriented

449

toward recovery and community integration.

450

2. As is feasible within the context of the existing mental health statute, the State should

451

immediately provide guidance to the Courts, attorneys representing the State in

452

commitment actions, and other advocates requiring that petitions for civil commitment—

453

whether inpatient or outpatient—and 24-hour holds be supported by specific information

454

relating to the presence of a serious mental illness, imminent danger to self or others, and

455

the absence of less restrictive alternatives.

456

3. The EEU should be expanded and established as the statewide vehicle for managing

457

publicly funded inpatient and outpatient services for all Delawareans with SPMI, and

458

regardless of whether services are funded through DSAMH, Medicaid or another public

459

program. Centralizing oversight in this way will:

460

a. Allow a straightforward, understandable, consistent and accountable process for

461

ensuring that the full array of services and supports is available to all individuals

462

with SPMI according to individual needs;

463

b. Allow creation of a central data base to track the utilization, effectiveness and

464

changing needs relating to the services and supports that will fulfill the

465

requirements of the Settlement Agreement;

466

c. Position the State to make far more informed projections as to future service

467

needs, particularly with regard to housing, emergency services and early

468

intervention;

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469

d. Improve management of the various public resources allocated for services to

470

Delawareans with SPMI by reducing expenditures for unnecessary

471

hospitalizations and other high-end services and enabling a better understanding

472

of the impact of investments in timely, effective community services; and

473

e. Significantly improve monitoring to ensure that individuals with SPMI are being

474

served in the least-restrictive, most integrated settings appropriate to their needs.

475

4. When hospital treatment is indicated, DSAMH should encourage that this be carried out

476

on a voluntary basis and should no longer restrict payment only to involuntary

477

admissions. This measure should be accompanied by enhanced oversight by the EEU to

478

ensure that hospital admissions are appropriate and that lengths-of-stays are clinically

479

justified.

480

5. The State should immediately fund DSAMH’s needs to staff positions within the EEU.

481

As the EEU assumes broader responsibilities in utilization management, the need for

482

further expansion of the EEU to fulfill the requirements of the Settlement Agreement

483

should be examined periodically. The State’s most recent report to the Monitor on this

484

issue is the same as it has been for some time already, that approval of these positions is

485

“in process.” For all of the reasons detailed above, the Monitor strongly recommends

486

that needed EEU positions be filled without delay.

487

6. The State should immediately expand the EEU’s oversight to include ongoing on-site

488

reviews at DPC and the IMDs. Not only will such oversight further the State’s

489

compliance with the Settlement Agreement, but it will also better ensure that unnecessary

490

inpatient expenses are not incurred. Although this may require further expansions in the

491

level of EEU staffing, it is probable that the efficiencies achieved through improved

492

monitoring will substantially offset additional costs.

493

7. In collaboration with the Monitor, the State should immediately begin analyses of

494

inappropriate admissions to DPC and the IMDs. To further this effort, DSAMH should

495

instruct hospitals to flag admissions where the need for inpatient psychiatric care is

496

questionable.

497

8. In collaboration with the Monitor, the State should initiate a study of hospital emergency

498

departments and how they deal with individuals who have substance abuse disorders and

499

who do not have justifiable co-existing diagnoses of SPMI. The focus should be on

500

developing a system of care that appropriately addresses their needs and that rectifies the

501

current misuse of public psychiatric beds.

502

9. The State should quickly expand its mobile crisis capacity statewide and make this

503

service available to hospital emergency departments to provide assessments and referrals

504

as an alternative to the 24-hour emergency holds resulting in psychiatric inpatient

505

admissions. DSAMH recently informed the Monitor that additional positions for mobile

506

crisis services have been approved. The Division should make it a priority to fill these

507

positions and expand this critically important service.

508

509

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510 IV. Progress On Specific Provisions

511 A. Explanation of Ratings

512 In this section, the Monitor presents brief summaries of the State’s progress to fulfill specific 513 provisions of the Settlement Agreement, particularly those with defined target dates. While few 514 of the Settlement Agreement’s target dates actually fall within the start-up period covered by this 515 report, there are many instances where the State has begun phase-ins or is otherwise taking 516 preparatory measures in anticipation of meeting goals that are set for the year 2012.

517 For each goal with a target date that falls within this reporting period, the Monitor has made a 518 determination as to whether the State is in “Substantial Compliance,” “Partial Compliance,” or 519 “Noncompliance” (Section VI.B.3.g defines these ratings.). Four of the provisions discussed in 520 this report (III.I.1, IV.B1, IV.B.2 & IV.B.3) relate to discrete, one-time activities to be completed 521 within this period and that have the potential for achieving “Substantial Compliance.” Other 522 activities reflect what will be ongoing processes or interim steps toward long-range goals. For 523 these, a rating of “Substantial Compliance” cannot yet be achieved; a rating of “Partial 524 Compliance” may indicate that the State is making the progress that is attainable at this stage.

525

526 B. Evaluations of Compliance

527

528 1. Provisions with Target Dates in This Reporting Period:

529 The following four provisions have target dates for activities that were to be accomplished within 530 the initial six-month implantation period:

531

532 III.A.1 Crisis Hotline: By January 1, 2012 the State will develop and make available a crisis

533

line for use 24 hours per day, 7 days per week.

534 Substantial Compliance. The Crisis Hotline is in place and is operational around the clock. The 535 Monitor has tested the Hotline on several occasions at different times of day; the call was 536 promptly answered each time.

537

538 IV.B.1 Implementation of Transition Assessments and Placement: Within 30 days of the

539

signing of the agreement the State will re-assess all individuals currently in

540

institutional settings.

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541 Partial Compliance. During this reporting period, the State has concentrated on the 542 approximately 75 individuals in DPC—most of whom with long institutional histories—who 543 have been identified as appropriate for discharge to community settings. These individuals tend 544 to have complex psychiatric and medical issues that have heretofore been seen as barriers to 545 discharge. Virtually all of them are in need of housing and ongoing intensive supports. These 546 individuals have been reassessed by DPC and community providers, consistent with the 547 Settlement Agreement and with consideration of how enhanced community services can promote 548 integration. Progress and barriers relating to the discharge of these individuals, and deliberations 549 about how integrated living arrangements can be achieved, are occurring through the central 550 specialized transition team, “Barrier Busters.” (see IV.B.3).

551 The Monitor has also found that assessments and discharges of other clients at DPC, including 552 individuals being treated on the acute care units, are not adequately reflective of the requirements 553 of the Settlement Agreement. Based on a review of records, discharge data and meetings with 554 staff members, practices appear to be pretty much “business as usual” and do not include the 555 analyses discussed above. A surprising number of individuals have continued to be identified as 556 appropriate for group homes or even shelters without an evident evaluation of what services and 557 supports could make more stable, integrated living arrangements viable.

558 Similarly, assessments of individuals with SPMI who are in IMDs are apparently occurring as 559 they had been, without obvious changes attendant to the requirements of the Settlement 560 Agreement. Presently, DSAMH has little oversight responsibility in these settings. If the State is 561 to ensure that all individuals with SPMI served in IMDs receive appropriate assessments and 562 benefits per the Settlement Agreement, it will be necessary for the State to centralize 563 responsibility, as is discussed above in Section II.

564 Two important factors justify a finding of “Partial Compliance:”

565

• Assessments that are consistent with the requirements of the Settlement Agreement

566

constitute a significant culture change among hospital staff and community providers.

567

Members of the “Barrier Busters” transition teams are demonstrating palpable changes in

568

the right direction. Community providers are working closely with individuals who are

569

receiving long-term care at DPC, and at Barrier Busters meetings hospital staff and

570

community providers engage in regular—sometimes spirited—discussions of assessed

571

needs and how challenges to integrated community living can be overcome. Though still

572

evolving, these teams represent a significant positive accomplishment in evaluating

573

individuals with SPMI and devising plans for community living.

574

• There is no standard instrument that the State can turn to as a protocol for assessing

575

individuals with SPMI that (as required by the Settlement Agreement) is grounded in

576

assumption that individuals can live in integrated settings if sufficient supports and

577

services are made available. Most existing models are clinically-oriented or do not

578

culminate in a specific list of services and supports that can promote integration. In the

579

Monitor’s early discussions of this issue with DSAMH leadership, it became apparent

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580

that such an assessment tool could structure thinking by hospital and community

581

providers and help cultivate the new approaches to evaluation and services that are

582

required to achieve compliance. Furthermore, such an assessment tool could be designed

583

to facilitate appraisals of the impact of services, quality monitoring and an understanding

584

of unmet service needs on individual and aggregate levels. DSAMH has moved forward

585

with this idea, engaging consumers and community providers to draft the “Delaware

586

Uniform Assessment.” Consistent with the requirements of the Settlement Agreement,

587

this tool is person-centered and seeks to identify the specific day-to-day supports—

588

conventional and otherwise—that will enable the individual to live in an integrated

589

setting of his/her choice. Tentatively, DSAMH intends is to pilot this instrument within

590

DPC early in 2012 and, with refinements, to roll it out to other settings.

591

The Monitor considers these to be very important accomplishments.

592 Recommendations:

593

1. In consultation with the Monitor, DSAMH should immediately develop a process

594

whereby any individual who is hospitalized in DPC and whose team recommends

595

a discharge disposition other than supported housing (as defined in the Settlement

596

Agreement) or independent living undergoes an administrative review. This

597

process should be implemented immediately upon being finalized.

598

2. Within 60 days of implanting the above recommendation, the State should

599

implement a parallel process, whereby it reviews all instances where inpatients of

600

IMDs with public funding are being considered for discharge to a non-integrated

601

setting.

602

3. DSAMH should proceed as planned to pilot its assessment protocol within DPC,

603

and should develop a timetable to evaluate the utility of this instrument and to

604

apply it system-wide.

605

606 IV.B.2. Within 60 days of the signing of the agreement the State will make operational

607

transition teams including community provider and peer representatives.

608 Partial Compliance. As is discussed immediately above, transition teams are operational with 609 regard to the population targeted by Barrier Busters. Elsewhere in DPC, there is at least a 610 nominal assignment of a community representative for each individual, in some instances a 611 Targeted Case Manager (“TCM”). As things now stand, there is a lack of appropriate oversight 612 to ensure that all individuals are assigned a community representative in a timely way or that the 613 community representative participates in team meetings. In some instances, clients at DPC have 614 co-occurring developmental or intellectual disabilities. The Monitor has learned that 615 participation in transition planning by representatives of the State’s Division of Developmental 616 Disability Services (“DDDS”) has been a chronic problem for such individuals. Furthermore, 617 depending upon where an individual lives in the state, the assigned TCM may, or may not, be 618 involved in the provision of services post-discharge. As TCM is brought to scale statewide, it is 619 anticipated that the latter issue will be addressed.

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620 In IMDs, there is sometimes involvement by a community provider in discharge planning, 621 depending upon whether an individual is active with a CCCP and whether efforts are made to 622 include the provider in treatment planning. Implementation of DSAMH’s plans for statewide 623 TCM should bring about improvements, but currently there is no mechanism for oversight. 624 Further, there are other issues that speak to the need for the centralized management process and 625 oversight by DSAMH’s EEU, discussed above (e.g., as things now stand, DSAMH does not even 626 know of voluntary admissions to IMDs that are being covered by Medicaid).

627 Recommendation: DSAMH should immediately begin random reviews of individuals within 628 DPC and the IMDs to assure that transition teams are operational per the requirements of the 629 Settlement Agreement. Data from these reviews should inform training needs and the 630 development of a single oversight process relating to all publicly funded admissions.

631

632 IV.B.3. Within 60 days of the signing of the agreement the State will make operational a

633

central specialized transition team including community provider and peer

634

representatives.

635 Partial Compliance. As is discussed above, Barrier Busters is the centralized transition team. 636 Meetings occur weekly, alternating between providers in the northern and southern areas of the 637 state. Participants include representatives from the CCCPs, DPC administrative and clinical staff, 638 and consumers.

639

640

641 2. Provisions With Upcoming Target Dates or Without Fixed Target Dates:

642 The provisions discussed below either have target dates for achievement during the coming six643 month review period (generally, July 1, 2012) or else reflect requirements that are not associated 644 with fixed target dates, but that have significant activities to be reported. Where a compliance 645 rating is applicable, the highest possible rating that can be attained at this point is “Partial 646 Compliance.”

647 II.B.1-2 648
649 650 651 652 653

Target Population: The Settlement Agreement requires the development of a “Target Population List,” as follows:
1. The target population for the community services described in this section is the subset of the individuals who have serious and persistent mental illness (SPMI) who are at the highest risk of unnecessary institutionalization. SPMI is a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria and has been manifest in the last year, has resulted in

17

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654

functional impairment which substantially interferes with or limits one or more

655

major life activities, and has episodic, recurrent, or persistent features.

656

2. Priority for receipt of services will be given to the following individuals

657

within the target population due to their high risk of unnecessary

658

institutionalization:

659

a. People who are currently at Delaware Psychiatric Center, including those on

660

forensic status for whom the relevant court approves community placement;

661

b. People who have been discharged from Delaware Psychiatric Center within

662

the last two years and who meet any of the criteria below;

663

c. People who are, or have been, admitted to private institutions for mental

664

disease ("IMDs") in the last two years;

665

d. People with SPMI who have had an emergency room visit in the last year, due

666

to mental illness or substance abuse;

667

e. People with SPMI who have been arrested, incarcerated, or had other

668

encounters with the criminal justice system in the last year due to conduct

669

related to their serious mental illness; or

670

f. People with SPMI who have been homeless for one full year or have had four

671

or more episodes of homelessness in the last three years

672 Partial Compliance. Key to meaningfully implementing virtually all of the provisions of the 673 Settlement Agreement is information based on the size, composition and needs of the Target 674 Population. DSAMH has some significant challenges associated with its internal data systems, 675 but through its EEU and other vehicles, it has ready access to information about individuals 676 within or discharged from DPC (II.B.2.a-b) and the subset of individuals treated in IMDs with 677 DSAMH funding if they were admitted involuntarily (II.B.2.c). Information relating to 678 individuals with SPMI who were admitted to IMDs on a voluntarily basis and whose care was 679 covered by Medicaid or Medicare has not been regularly accessible by DSAMH. Likewise, 680 information relating to people with SPMI seen in emergency rooms (II.B.2.d), involved with 681 criminal justice (II.B.2.e), or who are homeless (II.B.2.f) has not generally been available to 682 DSAMH unless there has been a specific referral for services.

683 As is the case nationwide, electronic information within Delaware’s various public systems is 684 siloed and not formatted in a way that permits interdepartmental sharing or easy consolidation 685 into the Targeted Population List required in the Settlement Agreement. The State has launched a 686 cross-department information sharing initiative relating to reentry from criminal justice (“I687 ADAPT”), which may ultimately provide a format for monitoring service plans across systems. 688 To meet the immediate requirements of the Settlement Agreement, DSAMH has had to find 689 innovative means of accessing information from other state systems while at the same time 690 preserving the confidentiality of the people it serves. This has been a bureaucratically daunting 691 task, but the Division’s success during its first six months of implementing this Settlement 692 Agreement is impressive, and may be instructive for Olmstead activities in other localities.

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693 DSAMH has negotiated access to the State’s homelessness data base, the Homelessness 694 Management Information System (“HMIS”) and to the Delaware Criminal Justice Information 695 System (“DELJIS”), which has timely data relating to arrest and incarceration. In both instances, 696 the Division is positioning itself to be able to gather information about individuals known to 697 have serious mental illnesses by providers in other State’s bureaucracies. Further, DSAMH will 698 be able to determine if individuals it is already serving meet additional criteria for prioritization 699 under the Settlement Agreement under paragraphs II.B.2.e or II.B.2.f. To secure information 700 about voluntary publicly funded admissions to IMDs and emergency room visits, DSAMH has 701 been working with the State’s Medicaid agency to run relevant encounter data against a listing of 702 diagnostic codes reflecting SPMI.

703 While the elements of Target Population List are not yet fully in place, during this initial 704 implementation period DSAMH has done a commendable job of navigating bureaucratic hurdles 705 to create an integrated database that will meet the requirements of the Settlement Agreement and 706 guide service delivery and planning. As was referenced in the Introduction section, DSAMH and 707 DHSS have achieved this during a period when state systems as a whole are already under stress 708 and when requests for new information and participation in additional meetings (relating to the 709 Settlement Agreement) may be particularly challenging. Nevertheless, as of this writing, the 710 State’s concerted effort has resulted in the identification of approximately 5,000 Delawareans 711 who meet priority criteria. This information has been consolidated into a single database of 712 unduplicated names. To test the validity of the list, the Monitor gathered names of individuals 713 that providers knew to be homeless or treated in hospital emergency rooms for mental health 714 crises. The Monitor spot-checked a subset against the State’s Targeted Population List; in all 715 instances examined, these names appeared on the State’s list.

716

717 III.B.1 Mobile Crisis Services: By July 1, 2012 the State will make operational a sufficient

718

number of mobile crisis teams such that a team responds to a person in crisis

719

anywhere in the state within one hour.

720 Partial Compliance. Mobile Crisis Services are now operational in the northern part of 721 Delaware and are working effectively, given current capacities. DSAMH has defined additional 722 staffing and personnel changes that will be required to achieve compliance with this provision 723 and is preparing to extend these services statewide. DSAMH is planning to establish data 724 protocols that will enable it to monitor whether the response time of Mobile Crisis Services is 725 consistent with the one-hour standard and, as may be applicable, to make program adjustments 726 accordingly. Within the coming six months, DSAMH will need to ensure that there is a one-hour 727 maximum Mobile Crisis response statewide.

728 Recommendation: The Monitor believes that DSAMH has the capacity to rapidly bring its 729 Mobile Crisis Services to scale once staffing positions are approved. These services are not only

19

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730 critical to address mental health emergencies, but as is discussed elsewhere in this report, can 731 also play a key and urgently needed role in preadmission screening and diversion within hospital 732 emergency departments. For these reasons, the Monitor strongly recommends that the State 733 accelerate measures to implement this provision.

734

735 III.C.1 Crisis Walk-in Centers: In addition to the crisis walk-in center in New Castle County

736

serving the northern region of the State, by July 1, 2012, the State will make best

737

efforts to make operational one crisis walk-in center in Ellendale to serve the southern

738

region of the State. The crisis center in Ellendale shall be operational no later than

739

September 1, 2012.

740 Partial Compliance. The Monitor has had an opportunity to visit the one operational Crisis 741 Walk-in Center, “CAPES” in New Castle County, to interview several informants about the 742 nature and effectiveness of this program, and to review data and case records that are reflective 743 of their impact. By all accounts, this is an effective service model and an important community 744 resource that represents collaboration in direct services by DSAMH staff with private providers 745 that operate under contract with the Division. Based on the State’s activities with respect to this 746 provision, it is anticipated that the required expansion to the southern regions of Delaware will 747 be met by the target date. Renovations of the Ellendale facility are underway and expected to be 748 completed by June, 2012. DSAMH is now in the process of developing a Request for Proposals 749 (“RFP”) that will allow this additional crisis walk-in center to be operational by September. 750 Efforts to develop a crisis center in the southern part of the State appear to be moving along well.

751

752 III.D.1 Crisis Stabilization Services By July 1, 2012 the State will ensure that an intensive

753

services provider meets with every individual receiving acute inpatient crisis

754

stabilization services within 24 hours of admission in order to facilitate return to the

755

community with the necessary supports and that all transition planning is completed in

756

accordance with Section IV.

757 Partial Compliance. The system reconfigurations that are now being formulated by DSAMH 758 are contemplating this requirement, in part, by immediately assigning individuals a Targeted 759 Case Manager (“TCM”) upon entry into the crisis system, regardless of diagnosis. When 760 individuals in crisis are already receiving services, the provider will be immediately contacted 761 and expected to make timely face-to-face contact. Also planned is periodic and consistent 762 oversight by the EEU for individuals whose care is managed by DSAMH; for other individuals 763 with SPMI who are eligible for public services (e.g., via Medicaid), the expanded role of the 764 EEU that is discussed above would provide linkages to needed services, including the expanded 765 services required by the Settlement Agreement. In the immediate term, DSAMH is focusing on 766 DPC, working to ensure that individuals who are admitted to the facility for acute care are linked

20

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767 to either a TCM or, as applicable, a representative of their CCCP. There are several 768 administrative challenges to achieving this goal within DPC, and the DSAMH Director is 769 currently working with the facility’s new CEO to address these. Because of the complexities of 770 the existing service structure, compliance with this provision and appropriate monitoring will be 771 far more difficult in the IMDs unless, as recommended above, DSAMH assumes the overall 772 management of all individuals with SPMI receiving publicly-funded services. This is an interim 773 evaluation of progress with respect to this provision; the Monitor will evaluate the State’s status 774 more completely in the one-year report, at which point the Settlement Agreement requires 775 system-wide compliance.

776 Recommendation: To achieve compliance with this provision and to address other issues raised 777 in this report, it is essential that the State consolidate its management of publicly funded 778 psychiatric hospital care, as recommended in Section III of this report

779

780 III.E.1 Crisis Apartments: By July 1, 2012 the State will make operational two crisis

781

apartments.

782 Partial Compliance. Two crisis apartments are already operational in New Castle County. The 783 Monitor plans to visit and evaluate this program during the next review period, at which point 784 the implementation target date will have been reached.

785

786 III.F.1 Assertive Community Treatment: By July 1, 2012 the State will expand its 8 ACT

787

teams to bring them into fidelity with the Dartmouth model.

788 Partial Compliance. In December, 2011, DSAMH issued an RFP for Assertive Community 789 Treatment (“ACT”) and Intensive Case Management Services. Contracts awarded in response to 790 this RFP will replace agreements currently in effect with CCCPs and will enhance staffing ratios 791 to comport with the Dartmouth model. The RFP envisions that DSAMH will award contracts for 792 ACT in March, 2012, with projects beginning operations during the period April 1 to July 1, 793 2012.

794

795 Comment: The timely issuance of this and other RFPs referenced in this report is critical to 796 fulfilling the specific requirements of the Settlement Agreement and achieving its important 797 objectives. The Monitor notes that crafting and vetting RFPs for public mental health services is 798 generally a very arduous, protracted endeavor. The quality of the RFPs that have been 799 developed, as well as DHSS’s success in expediting bureaucratic processes, affirm the State’s 800 commitment to developing an effective community system to support Delawareans with SPMI.

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801

802 III.G.1 Intensive Case Management: By July 1, 2012 the State will develop and begin to

803

utilize 3 ICM teams.

804 Partial Compliance. The RFP referenced in regard to III.F.1 includes the development of three 805 fidelity-based Intensive Case Management teams, with the same schedule for implementation. 806 Intensive case management will reflect a new service model in the State and may reflect new 807 providers. The Monitor’s one-year review will report on the operations of the ICM teams.

808

809 III.H.1 Case Management: By July 1, 2012 the State will train and begin to utilize 15 case

810

managers.

811 Partial Compliance. DSAMH has developed parameters for a new statewide TCM program that 812 is intended to fulfill the requirements of this provision. To ensure that TCM embodies the 813 independence needed to effectively monitor and advocate on behalf of its clients, DSAMH is 814 limiting applicants for this initiative to organizations that do not provide direct client services 815 under other contracts with the Division. The RFP for TCM is expected to be issued by February 816 10, 2012 with implementation to begin in May, 2012. The Monitor will provide a more 817 complete report on the State’s progress with respect to this provision in the one-year report.

818

819 III.I.1 820 821

Supported Housing: By July 11, 2011, the State will provide housing vouchers or subsidies and bridge funding to 150 individuals. Pursuant to Part II.E.2.d., this housing shall be exempt from the scattered-site requirement

822 Partial Compliance. DSAMH has provided the Monitor with a list of 150 individuals who are 823 currently living in supported housing funded through housing vouchers or DSAMH. Individuals 824 living in these settings receive clinical and other needed community services through CCCPs. 825 The Monitor randomly selected and visited 9 individuals from this list, who are living in three 826 different supported housing venues in New Castle County. These individuals all have SPMI, 827 some with co-occurring disabilities (e.g., one individual is blind and another has an intellectual 828 disability). Two of the sites are what would be considered “ordinary” living arrangements, that 829 is, garden apartment complexes with most units occupied by average individuals and their 830 families. In these sites, supported housing units for people with SPMI are mostly clustered 831 together, with each apartment generally housing two individuals who have their own bedrooms. 832 Housemates are assigned by the CCCP, which has an office on the premises. The third site is a 833 newly remodeled building that was converted specifically to provide supported housing. It has 834 single occupancy units. Many of the residences visited by the Monitor—particularly in the 835 garden apartments—were personalized and the occupants’ hobbies and interests were

22

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836 immediately evident. Most individuals cook their own meals (some admitted to occasionally 837 getting carryout food).

838 In summary, the supported housing visited by the Monitor affirms that there already are 839 programs in Delaware enabling individuals with significant psychiatric disabilities to live in 840 semi-integrated housing and often to assume substantial responsibility for tasks of daily living. 841 These site visits affirmed for the Monitor that the development of the more fully integrated 842 housing required by Settlement Agreement should be readily achievable.

843

844 III.I.2. By July 1, 2012 the State will provide housing vouchers or subsidies and bridge

845

funding to a total of 250 individuals.

846 Partial Compliance. This provision requires the development of new scattered-site supported 847 housing for 100 additional individuals with SPMI by the target date. At this point, DSAMH has 848 funding that will support development of integrated housing for 25 individuals, plus housing 849 vouchers have been earmarked for an additional 25 individuals. The State will need to make 850 funding available for an additional 50 individuals to meet this provision’s requirements. 851 Supported housing that comports with the Settlement Agreement is beginning to be developed, 852 particularly for individuals now at DPC. As it happened, one such individual who had been an 853 inpatient at DPC is now living with supports from the CCCP in her own apartment in one of the 854 complexes discussed in the above section. She lives in a different building within this sprawling 855 development and CCCP staff was very mindful of the fact that this was in compliance with the 856 Settlement Agreement’s definition of what constitutes scattered-site, integrated housing 857 (II.E.2.g). The Monitor noted good news on two fronts regarding this individual and the State’s 858 start-up efforts relating to this provision: she was reported to be doing “beautifully” in her own 859 apartment, and the Monitor was not be able to meet with her because she was out visiting her 860 family. Ostensibly, she is leading the “ordinary” life envisioned by the Settlement Agreement for 861 Delawareans with SPMI.

862 Recommendation: The State will need to secure funding for housing an additional 50 863 individuals by July 1, 2012, and will need to make longer-range provisions to assure 864 achievement of the incremental goals throughout the life of the Settlement Agreement.

865

866 III.J.1 By July 1, 2012 the State will provide supported employment to 100 individuals per

867

year.

868 Not Rated. Supported employment is a part of CCCP contracts, but the Monitor has not yet 869 reviewed the State’s compliance with this provision. Compliance with this provision will be 870 evaluated in the next report.

23

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871

872 III.K.1 By July 1, 2012 the State will provide rehabilitation services to 100 individuals per

873

year.

874 Not Rated. The Monitor has not yet reviewed the State’s compliance with this provision; the 875 next report will address this provision.

876

877 III.L.1 By July 1, 2012 the State will provide family or peer supports to 250 individuals per

878

year.

879 Not Rated. The Monitor has not yet reviewed the State’s compliance with this provision; it will 880 be addressed in the next report.

881

882 IV.B.5 By July 1, 2012 the State shall develop a program to educate judges and law

883

enforcement about community supports and services for individuals with mental

884

illness on forensic status.

885 Not Rated. The Monitor has not yet reviewed the State’s compliance with this provision.

886

887 V.B.4-5 Quality Assurance and Performance Improvement: If harm occurs despite these

888

measures, the responsible State, IMD or community provider will complete a root

889

cause analysis within 10 days. Using the results of the root cause analysis, the State,

890

IMD or community provider will develop and implement a corrective action to prevent

891

future harm.

892 Partial Compliance. One Sentinel Event occurred at DPC during this period. DSAMH complied 893 with these and other relevant provisions of the Settlement Agreement, conducting a very 894 thorough root cause analysis. This analysis revealed some areas for improvement (now being 895 pursued—for example, relating to staff training—but no evidence of widespread systemic 896 departures from professional practice. Although the incident involved the death of an individual, 897 by all accounts the DPC staff’s emergency response was exemplary.

898 One additional event, a patient-on-patient assault at DPC resulting in serious injuries that are not 899 life-threatening, occurred as this report was being finalized. DSAMH’s root cause analysis and 900 other information pertinent to an assessment of this incident and how it was handled will not be 901 available until the next reporting period. The Monitor’s next report will include such an 902 assessment.

24

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903 904 V. Summary 905 The Monitor is pleased to report that Delaware has made significant advances toward 906 compliance with the Settlement Agreement during this initial six-month implementation period. 907 The State is working effectively to meet the requirements of its specific provisions, including 908 those that were scheduled for achievement during this reporting period and those that require 909 preparatory actions in order to meet upcoming target dates. Of equal importance, the State is 910 taking some very important steps to correct longstanding structural matters that now compromise 911 the civil rights of individuals with SPMI, and obstruct the effective provision and management of 912 the services afforded them through public programs. The Monitor commends the effectiveness of 913 DHSS Secretary Rita Landgraf and DSAMH Director Kevin Ann Huckshorn in creating a 914 climate for collaboration toward meaningful change, and applauds the stakeholders at all levels 915 whose dedication and innovation can make the important goals of the Settlement Agreement a 916 reality. 917 918 Respectfully Submitted,
919 920 Robert Bernstein, Ph.D. 921 Court Monitor
25

 
 1

SECOND REPORT OF THE COURT MONITOR

2

ON PROGRESS TOWARD COMPLIANCE

3

WITH THE

4

SETTLEMENT AGREEMENT: U.S. v. STATE OF DELAWARE

5

U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS

6

7

September 5, 2012

8

9

I. Introduction

10

This is the second report by the Court Monitor (“Monitor”) on the implementation of the

11

Settlement Agreement between the U.S. Department of Justice (“DOJ”) and the State of

12

Delaware (“the State”), covering the six-month period January 15, 2012 through July 15,

13

2012. As was discussed in the Monitor’s initial report, the State has responded to the

14

requirements of the Settlement Agreement not only with the intent of meeting the

15

numeric targets, but also with the goal of restructuring systems so that the its public

16

programs produce outcomes that are consistent with the Americans with Disabilities Act

17

(“ADA”) and the U.S. Supreme Court’s Olmstead decision. The Settlement Agreement

18

targets a specific population of Delawareans with disabilities, those with Serious and

19

Persistent Mental Illnesses (“SPMI”). As such, the State’s Division of Substance Abuse

20

and Mental Health (“DSAMH”) within the Department of Health and Social Services

21

(“DHSS”) has been at the center of implementation activities. Kevin Ann Huckshorn, in

22

her capacity as Director of DSAMH, has had a primary role in providing assistance and

23

working through issues with the Monitor, and in effecting the innovative reforms in

24

programs and service culture described in this report. At the same time, from Governor

25

Jack Markell through DHSS Cabinet Secretary Rita Landgraf, there has been a clear

26

recognition that the fulfillment of the ADA for citizens with SPMI requires the alignment

27

of programs across state departments and on the county and local levels. Accordingly,

28

the findings presented below include specific instances where the State is working across

29

traditional bureaucratic boundaries to achieve not only the letter, but the spirit of the

30

Settlement Agreement.

31

Furthermore, leadership within the State has an understanding that the opportunities and

32

the lessons of reform efforts pursuant to the Settlement Agreement have critical meaning

33

for people with SPMI, and for other populations with disabilities, as well. For this

34

reason, in its implementation efforts DHSS is increasingly including representatives of

35

programs working on behalf of individuals with physical or intellectual/developmental

36

disabilities. Such efforts are not at all superfluous to the Settlement Agreement. They

37

clearly support the State in meeting its broader obligations under the ADA, and to the

38

extent that the changes in culture and practice brought about through the Settlement

1

39

Agreement are infused in public programs statewide for all individuals with disabilities,

40

the sustainability of the reforms that are discussed in this report is heightened.

41

As is detailed below, the State is largely meeting its benchmarks and it is making

42

significant, sometimes ground-breaking, progress in retooling its systems in fulfillment of

43

the ADA. This has not been a simple, linear process. The Settlement Agreement

44

required that in this first year, a multitude of new services and procedures be launched

45

simultaneously, inevitably causing some disruptions, uncertainty and unanticipated

46

challenges. In some instances, these concurrent changes affected the State’s ability to

47

meet its implementation target dates, for instance, in recruiting mobile crisis staff in an

48

environment of newly heightened competition for mental health professionals (due to

49

other expansions required by the Agreement). In addition, as is referenced repeatedly

50

below, DSAMH is seriously challenged by fragmented, outmoded and ineffective data

51

systems that are critical to its management of services and future planning.

52

53

Still, at this juncture, things are finally settling into a new—and better—“normal,”

54

whereby longstanding gaps in services (particularly in the southern counties) are being

55

addressed and new initiatives supporting integrated community living are being put in

56

place. Most significantly, the State’s reform efforts are translating into real, palpable

57

changes for individuals with SPMI. The Monitor has had an opportunity to meet with

58

several beneficiaries of the Settlement Agreement—all of whom with long histories of

59

institutional segregation, multiple psychiatric crises, homelessness or involvement with

60

criminal justice systems. They are now living in ordinary, scattered-site housing,

61

receiving flexible community-based services and supports. Their days are spent in such

62

mundane activities as shopping, cooking, housekeeping, or working. Given that just a

63

year ago, these individuals would likely be living in hospitals, correctional settings or

64

congregate facilities, this is a remarkable achievement. As contemplated by the

65

Settlement Agreement and, more broadly, the ADA, these individuals are living “like the

66

rest of Delawareans.”1

67

68

II. Sources of Information

69

The findings presented here are based upon a broad set of information sources. They

70

include regular meetings with the leadership of DHSS, DSAMH, various state agencies

71

and providers; peer advocates; local chapters of organizations such as Mental Health

72

America and NAMI; the Delaware Psychiatric Center (“DPC”) and other psychiatric

73

inpatient providers; and individual consumers of public mental health services in the

74

state. In addition, the Monitor has convened or participated in a number of work groups

75

dealing, for instance, with issues such as legislative reform, risk management, discharge

76

planning, housing, and data systems. The Monitor has also reviewed numerous reports,

1 Settlement Agreement, Section II.E.1.a
2

77

policies, minutes, inpatient and outpatient case records, data sets and other material

78

relating to implementation. Without exception, the State has continued to provide the

79

Monitor with requested information, facilitated access to any individual or group with

80

whom the Monitor sought contact, and otherwise offered full and helpful assistance in

81

carrying out the monitoring functions delineated in the Settlement Agreement.

82

83

III. Infrastructure and System Configuration

84

The Monitor’s January 30, 2012 report on implementation during the initial six months

85

referenced two areas not specifically delineated within the Settlement Agreement as

86

requirements, but nonetheless critical to meaningful implementation:

87

Stakeholders’ understanding of measures required by the Settlement Agreement and

88

of the ADA and the Olmstead decision which underlie these requirements; and

89

Reconfiguration of public systems to comport with the Settlement Agreement,

90

including centralized oversight to ensure that services are least restrictive, most

91

integrating, and meeting the needs of people with SPMI who are served in public

92

programs.

93

The State has made significant progress in each area.

94

95

96

A. Stakeholders’ Understanding of the Settlement Agreement

97

98

In the initial report, the Monitor found that, notwithstanding the fact that the ADA was

99

enacted over twenty years ago, a meaningful understanding of this pivotal legislation and

100

its implications for practice tended to be limited to managerial staff system-wide. On a

101

direct service level, staff knowledge about the ADA was often superficial, with little

102

evident impact on their interventions with individuals. As a consequence, longstanding

103

practices that are at odds with the ADA and Olmstead continued without question.

104

Further, people being served by DSAMH’s programs often had at best a vague

105

understanding of their own civil rights. Accordingly, the Monitor recommended training

106

on the ADA, the Olmstead decision and the Settlement Agreement with the goal of

107

increasing stakeholders’ understanding of the underlying principles and their practical

108

meaning.

109

In the ensuing months, DSAMH has provided relevant training—sometimes involving

110

the Monitor—within DPC (e.g, with Recovery Academy staff, social work staff and

111

medical staff) and externally (e.g., with professional organizations such as the Delaware

112

Organization of Nurse Leaders, police chiefs, judges, the Sussex Mental Health Task

113

Force, the Sussex Interagency Council, and the Delaware Rural Health Initiative). These

3

114

trainings continue on an ongoing basis. A number of town hall meetings have been held

115

across the state, including representatives from DHSS, NAMI, the Mental Health

116

Association in Delaware (“MHA”), the Delaware protection and advocacy agency,

117

leaders in consumer-run coalitions, consumers, families and other concerned citizens.

118

Furthering these formal training efforts, the local news media has been actively covering

119

the Settlement Agreement’s implementation and related reform efforts (such as the new

120

mental health legislation discussed below), thus increasing awareness of the ADA and its

121

meaning among the general public. Notably, the Summer, 2012 newsletter of MHA

122

included an extensive interview with the Monitor relating to the ADA and the Settlement

123

Agreement; this publication was promulgated as an insert with the state’s major local

124

newspaper, thus getting very wide circulation.

125

126

B. System Reconfiguration

127

The Monitor’s initial six-month report cited two structural aspects of Delaware’s public

128

mental health system that were in conflict with the requirements of the Settlement

129

Agreement in that they have promoted unnecessary institutional segregation, confounded

130

appropriate oversight, and complicated effective community services. These were the

131

poorly controlled use of civil commitment and DHSS’s oversight of psychiatric inpatient

132

care.

133

134

A. Civil Commitment

135

The Monitor’s last report referenced various gaps in legal protections against the

136

unwarranted detainment, hospital confinement and continuing court oversight of

137

individuals with SPMI. As a consequence, individuals on the Targeted Population List

138

were at unnecessary risk of involuntary hospitalization and the attendant trauma, as well

139

as questionable legal coercion via outpatient commitment orders. As a case in point, the

140

Monitor’s report presented the story of Mrs. L, an individual with SPMI who was

141

actively engaged in community-based treatment. Although not dangerous to herself or

142

others, Mrs. L came to be transported in handcuffs by police from an emergency room

143

(where she had come on her own with delusional physical complaints) to a psychiatric

144

hospital. Notwithstanding the fact that she was not a danger, she was subsequently

145

civilly committed on the basis of dangerousness. The outpatient team that had been

146

providing Mrs. L with comprehensive community based services was not consulted about

147

these actions. There is good news relating to Mrs. L. She is no longer subjected to court-

148

ordered treatment and, in fact, as a beneficiary of the Settlement Agreement, she is now

149

successfully living in her own apartment with continuing community supports.

150

There is also good news to report on a systemic level. The Delaware legislature recently

151

enacted House Bill 311 and House Joint Resolution 17, both signed into law by Governor

4

152

Markell on July 24, 2012. House Bill 311 rectifies an issue that directly affected Mrs. L;

153

it requires an assessment by a qualified mental health screener before an individual is

154

detained on a 24-hour psychiatric hold, thereby helping to ensure that detainment and

155

hospitalization only occur when it is clinically necessary and that the individual is

156

afforded appropriate access to the less-restrictive alternatives being developed across the

157

state. This legislation also updates the mental health law that had been in effect in

158

Delaware for many decades, incorporating language about community integration,

159

requiring that care be provided on a voluntary basis whenever it is feasible, and removing

160

an unintended incentive for civil commitment whereby in certain circumstances, the State

161

would only underwrite involuntary hospital care.

162

Having thus remedied some immediate critical problems, the companion legislation,

163

House Joint Resolution 17, creates a study group to evaluate the State’s mental health law

164

in its entirety and to make recommendations for further reforms. Governor Markell,

165

Cabinet Secretary Landgraf, members of the legislature—in particular, Representative

166

Barbieri—merit great credit for engaging a broad array of stakeholders with very diverse

167

perspectives and quickly moving these important bills to enactment. As the provisions of

168

House Bill 311 become effective, significant “front door” issues that have culminated in

169

unwarranted hospitalization and legal coercion should be rectified. Furthermore, the

170

statewide processes for responding to psychiatric emergencies should become much more

171

aligned with the State’s obligations under the Settlement Agreement. The study group

172

that will be formed under House Joint Resolution 17 will have an opportunity to further

173

these gains.

174

The Monitor’s initial report also referenced the frequent use of continuing outpatient

175

commitment orders following involuntary hospital care. In conflict with Olmstead, these

176

outpatient commitment orders place significant numbers of individuals within the Target

177

Population under questionable legal coercion and at heightened risk of unwarranted

178

rehospitalization. Based upon a review of records and discussion with informants (both

179

within the initial six-months and more recently), the Monitor has found that these orders

180

for continuing court supervision are issued routinely, sometimes in the absence of an

181

explicit clinical rationale and, commonly, without a record of why this is the least

182

restrictive measure appropriate to the individual’s circumstances. Furthermore, these

183

court orders can be remarkably vague, not only failing to specify the community provider

184

that is responsible for delivering the court-ordered services, but also failing to specify

185

what these services are. Notwithstanding such ambiguity, these court orders indicate that

186

individuals who are outpatient committed can be re-hospitalized if they are not

187

“amenable” to such treatment.

188

Delaware remains very much an outlier in its use of outpatient commitment, not only in

189

comparison with neighboring states (where such orders are rarely, if ever, used) but also

190

in comparison to New York, where outpatient commitment is used and well studied. As

5

191

at least a blunt measure of the overuse of court-ordered services in Delaware, following

192

recent discussions with the Monitor, one major community provider determined that it

193

was appropriate to terminate court supervision of about 40% of its clients who had active

194

outpatient commitment orders.

195

196

Recommendations:

197

1. Although recent legislative reforms will not come to be fully in effect for another

198

year, pursuant to the Settlement Agreement the State launched a number of service

199

improvements which should have a more immediate impact in reducing

200

questionable hospital admissions and the attendant involvement of the judicial

201

system. As a means of evaluating and improving the impact of these reforms, the

202

Monitor recommends that the State track changes in the following measures:

203

a. Involuntary Hospitalizations

204

b. Voluntary Hospitalizations

205

c. Outpatient Commitment Orders

206

The Monitor recommends that these measures be evaluated not only with respect to

207

the State’s own baselines (perhaps using data from the past year or two) but also, to

208

the extent that information is available, population-adjusted data from neighboring

209

states. Such information is not only useful for Performance Improvement purposes,

210

but can also provide stakeholders with an indication of the State’s progress towards

211

a more Olmstead-oriented service model.

212

Although these measures are fairly basic, the State’s ability to collect and analyze

213

such data is currently challenged by its inadequate electronic information systems.

214

A fuller explanation of this problem and the need for immediate remedies is

215

presented in a later portion of this report.

216

2. The State has begun to examine how, within the legislative and policy structures

217

now in effect, it can improve documentation that is presented to Mental Health

218

Commissioners (who issue orders for involuntary psychiatric treatment) so that the

219

basis for court-ordered treatment—whether inpatient or outpatient—is more

220

specific and includes clear information as to why less-restrictive measures are not

221

seen as viable. The Monitor recommends that the State quickly move forward in

222

this initiative, certainly because of its obvious legal implications, but also because

223

requiring more explicit documentation can have the effect of reinforcing Olmstead-

224

oriented decision making among the parties involved.2 Furthermore, piloting

2 The Monitor notes that changes in documentation requirements are having a similar effect in reorienting the system towards housing and service models that promote integration see discussion relating to Section IV.B.1.
6

225

improved documentation may inform the work of the study group’s review of

226

Delaware’s mental health laws, pursuant to House Joint Resolution 17.

227

3. In examining the Delaware’s decades-old mental health laws, the study group that

228

was created through House Joint Resolution 17 will have the opportunity to make

229

recommendations that build on House Bill 311 in further embedding the values and

230

requirements of the ADA in practices within the State. The Monitor recommends

231

that the diverse stakeholders the study group comprises give careful consideration

232

to how further revisions in Delaware’s law can solidify the gains that are now being

233

made pursuant to the Settlement Agreement.

234

235

236

2. Oversight of Psychiatric Hospitalizations:

237

The Monitor’s initial report noted that the State’s overly-complex arrangements for

238

managing services to people with SPMI posed significant problems in assuring that

239

appropriate interventions are provided, that rights are protected, and that public resources

240

are utilized efficiently. Part of the problem is that there has not been a single point of

241

accountability for public services to people with SPMI; instead, oversight is within

242

DSAMH, within the State’s Medicaid program, within both, or shifting between the two

243

entities. The consequences of this arrangement have been evident in a number of ways,

244

including questionable use of hospital emergency departments and inpatient psychiatric

245

beds, poor coordination of outpatient and inpatient services, and inpatient psychiatric

246

admissions of individuals whose fundamental problems are substance abuse. The

247

Monitor found that these problems in managing services not only compromised the rights

248

of individuals on the Target Population List, but also had the effect of drawing on public

249

resources for high-end services (such as hospital care) that are either preventable or

250

unneeded. To a significant degree, the processes that sustain these inefficiencies appear

251

to represent an accumulation of decades of policies and practices, rather than an overall

252

plan to provide effective mental health services in accordance with the ADA and related

253

laws.

254

During the past six months, the Monitor has regularly met with leadership in DHSS and

255

DSAMH to discuss ways of enhancing the management of services and service-dollars.

256

Several of the Monitor’s recommendations from the initial report have been addressed,

257

for instance, House Bill 311 addresses financial incentives favoring involuntary

258

treatment.

259

In addition, the State has expanded its staffing of the Eligibility and Enrollment Unit

260

(“EEU”) by six staff members. Many of these positions have been filled and recruitment

261

efforts are underway to bring the EEU to full staffing. The expansion in the EEU will

262

allow this unit to apply eligibility and placement criteria to a broader range of services

263

and to begin to perform Utilization Reviews in different service settings. Included will

7

264

be services to the over 1,300 individuals who were successfully transitioned from

265

existing community programs into the new Assertive Community Treatment (“ACT”)

266

and Intensive Case Management (“ICM”) programs that have been developed pursuant to

267

the Settlement Agreement (they are discussed elsewhere in this report). Finally, with

268

passage of House Bill 311, the EEU will have responsibility for tracking and managing

269

all inpatient psychiatric care and community services for publicly-funded individuals

270

with SPMI.

271

272

Two issues of great importance to meaningful compliance with the Settlement Agreement

273

are currently under discussion with DHSS and DSAMH:

274

The most appropriate format for DSAMH’s system-wide Quality Assurance

275

(“QA”) and Performance Improvement (“PI”) programs. QA and PI are related

276

functions, but with distinct methods and goals; simply stated, QA looks back at

277

services rendered and works to ensure conformity with standards, while PI draws

278

on QA data and other sources with the aim of enhancing outcomes and efficiency.

279

These functions are currently consolidated in a single DSAMH program. Given

280

the new program expansions, changes in service structure, needs for refinement of

281

policies and procedures, and demands for future planning, DSAMH is examining

282

how to most effectively carry out these functions.

283

Establishing a coordinated process for care management. Presently, responsibility

284

for the oversight of services and reimbursement to individuals with SPMI is

285

dispersed among DSAMH, Medicaid and Medicaid Managed Care Organizations.

286

This not only presents problems in monitoring the flow of services and related

287

expenditures, but also in assuring that all individuals on the Target Population

288

List are appropriately afforded access to the array of services that are developed

289

per the Settlement Agreement.

290

As discussions proceed and planning around these issues is solidified, the State will need

291

to address an issue that is frequently referenced in this report: the data systems that are

292

critical to effectively carrying out QA/PI and care management are not in place, and there

293

are apparently bureaucratic hurdles to be overcome if appropriate IT systems are to be

294

established.

295

296

Recommendations Carried Forward from the Initial Report:

297

1. In collaboration with the Monitor, the State should begin analyses of inappropriate

298

admissions to DPC and the private psychiatric hospitals (“IMDs”). To further the

299

expanded oversight by the EEU and to provide a basis for root-cause analyses,

300

DSAMH should instruct DPC and IMDs to flag admissions of publicly-funded

301

individuals where the need for inpatient psychiatric care is questionable.

8

302

2. In collaboration with the Monitor, the State should initiate a study of hospital

303

emergency departments and how they deal with individuals who have substance

304

abuse disorders and who do not have justifiable co-existing diagnoses of SPMI. The

305

focus should be on developing a system of care that appropriately addresses their

306

needs and that rectifies the current misuse of public psychiatric beds.

307

308

New Recommendations:

309

1. In the coming months, the Monitor plans to engage an expert consultant to evaluate

310

the needs of DSAMH with respect to system-wide Performance Improvement and to

311

make recommendations relating to the scope, key tasks and infrastructure needs.

312

313

314

IV. Progress On Specific Provisions

315

316

A. Explanation of Ratings

317

In this section, the Monitor presents brief summaries of the State’s progress in fulfilling

318

specific provisions of the Settlement Agreement, particularly those with defined target

319

dates. In accordance with the Settlement Agreement, for each goal the Monitor has made

320

a determination as to whether the State is in “Substantial Compliance,” “Partial

321

Compliance,” or “Noncompliance” (Section VI.B.3.g defines these ratings). Many of the

322

provisions relate to what will be ongoing processes or interim steps toward long-range

323

goals over the five years of implementation. The ratings presented below represent the

324

State’s levels of compliance with each provision during the period July 15, 2011 through

325

July 15, 2012.

326

327

B. Evaluations of Compliance

328

329 II.B.1-2 330

The Settlement Agreement requires the development of a “Target Population List,” as follows:

331

1. The target population for the community services described in this section

332

is the subset of the individuals who have serious and persistent mental illness

333

(SPMI) who are at the highest risk of unnecessary institutionalization. SPMI is a

334

diagnosable mental, behavioral, or emotional disorder of sufficient duration to

335

meet diagnostic criteria and has been manifest in the last year, has resulted in

9

336

functional impairment which substantially interferes with or limits one or more

337

major life activities, and has episodic, recurrent, or persistent features.

338

2. Priority for receipt of services will be given to the following individuals

339

within the target population due to their high risk of unnecessary

340

institutionalization:

341

a. People who are currently at Delaware Psychiatric Center, including those on

342

forensic status for whom the relevant court approves community placement;

343

b. People who have been discharged from Delaware Psychiatric Center within the

344

last two years and who meet any of the criteria below;

345

c. People who are, or have been, admitted to private institutions for mental

346

disease ("IMDs") in the last two years;

347

d. People with SPMI who have had an emergency room visit in the last year, due

348

to mental illness or substance abuse;

349

e. People with SPMI who have been arrested, incarcerated, or had other

350

encounters with the criminal justice system in the last year due to conduct

351

related to their serious mental illness; or

352

f. People with SPMI who have been homeless for one full year or have had four

353

or more episodes of homelessness in the last three years

354

355

Partial Compliance.

356

The Monitor’s prior report referenced that, the importance of the Target Population List

357

notwithstanding, constructing and maintaining this list has been a daunting task. As in

358

other states, Delaware’s public systems do not have data systems that were designed to

359

communicate with each other. Many rely on outdated software and inefficient modes of

360

data submission. This is the case not only across state departments, but also within DHSS

361

and its various bureaucratic sections.

362

As was verified by an expert consultant hired by the Monitor to assist the State, DSAMH

363

is using information technology that is not only insufficient to address the basic

364

requirements of constructing a Target Population List, but it also lacks a capacity to

365

access timely and accurate data that are essential to the overall monitoring and

366

management of services that are referenced throughout the Settlement Agreement.

367

Among other findings, the consultant noted that DSAMH collects important data that it

368

cannot easily or meaningfully extract for routine oversight or long range planning. Data

369

submission relating to services provided through its programs is a hodgepodge of

370

electronic and paper transmissions, none of it in real time and much of it requiring

371

manual entry and tedious error correction. Lacking an overall unified system, key

372

information (for instance with regard to the disposition of hospital discharges and

373

housing created pursuant to the Settlement Agreement) is maintained in spreadsheets

10

374

improvised by various staff members. DPC does not yet have a system for electronic

375

medical records and DSAMH confronts bureaucratic barriers to introduce much needed

376

improvements.

377

Based on the report of the Monitor’s expert consultant, DSAMH will need help to

378

expedite the procurement and implementation of an electronic health record and redesign

379

of a database that can more appropriately provide data on individuals affected by the

380

Settlement Agreement. The Monitor has learned that the State’s restrictive IT security

381

standards complicate the procurement of software products (among them, Electronic

382

Health Records) that can vastly improve the efficiencies of service delivery and

383

oversight.

384

That said, and acknowledging the significant effort required of DSAMH’s IT staff, the

385

State’s Target Population List includes 6,373 unduplicated names as of May 31, 2012.

386

The list includes individuals with SPMI who are receiving state-funded inpatient

387

psychiatric care or who were admitted to such care during the two-year period prior to the

388

date the Settlement Agreement took effect (representing about 3,000 admissions). For

389

this same period, it includes 990 individuals with SPMI who have been homeless.

390

Drawing from Medicaid claims data, it also includes information about 1,638 individuals

391

who were admitted to emergency departments of general hospitals, apparently for

392

treatment of issues attendant to SPMI (this required some inference based on diagnostic

393

information, since there is apparently no distinct coding that would flag psychiatric

394

emergency care in these settings). Although individuals who have received treatment at

395

DPC under forensic orders are included on the Target Population List, DSAMH has not

396

yet established mechanisms to access data relating to criminal justice involvement by

397

individuals with SPMI. This is a significant gap in the database. And again, the status of

398

DSAMH’s IT systems is such that generating the critically important information to

399

maintain and utilize the Target Population List is a labor-intensive enterprise, using

400

information that is not consistently current.

401

402

Recommendations:

403

Because issues relating to information technology are central to this provision of the

404

Settlement Agreement and are also intertwined with other provisions, the following

405

recommendations have bearing on the State’s fulfillment of other sections, as well.

406

DHSS is aware that its IT systems are antiquated and siloed. A Department-wide

407

overhaul of IT systems is already underway, with the goals of vastly improving access to

408

information needed for oversight and decision making, and integrating information across

409

DHSS’s various Divisions. Because of the complexity of this process, the planned

410

creation of a State Data Hub and other IT elements needed to fully achieve the

411

Department’s goals will not be immediate. At the same time, fulfillment of the

11

412

Settlement Agreement requires that some data issues be immediately addressed, likely

413

through temporary measures as the State’s longer-range IT improvements proceed.

414

1. DHSS should quickly move forward in resolving restrictions to accessing data from

415

other state agencies, particularly the State’s Department of Justice and Department

416

of Corrections. Not only is this essential to fully meeting requirements relating to

417

the Target Population List, but real-time criminal justice data about individuals on

418

that list can enable mental health providers to intervene to prevent arrests and

419

further involvement with the legal system. The Monitor is aware of electronic

420

systems that are able to carry out this function while protecting the confidentiality

421

of individuals receiving mental health services.

422

2. DHSS should consider the recommendations of the consultant engaged by the

423

Monitor as it continues to refine plans for an upgrade of IT systems within DSAMH

424

and other related Divisions.

425

3. Within the next few months, DHSS and DSAMH, in collaboration with the

426

Monitor, should establish a working blueprint for addressing data requirements

427

presented by the Settlement Agreement, including issues to be addressed in the

428

long-range rebuild of the State’s data systems and interim measures that will

429

address the immediate IT needs.

430

431 III.A.1 Crisis Hotline: By January 1, 2012 the State will develop and make available a crisis

432

line for use 24 hours per day, 7 days per week.

433

434

Substantial Compliance.

435

The Crisis Hotline is in place and is operational around the clock, as evidenced by

436

random quality checks. DSAMH has promulgated information about the Crisis Hotline

437

by distributing postcards through its peer-specialist and provider networks, and through

438

advertising panels at major shopping malls in the state.

439

440 III.B.1 441 442

Mobile Crisis Services: By July 1, 2012 the State will make operational a sufficient number of mobile crisis teams such that a team responds to a person in crisis anywhere in the state within one hour.

443

444

Partial Compliance.

445

During the initial four months of this calendar year, mobile crisis teams responded to a

446

monthly average of 40.5 emergencies statewide, 70% of which occurred in New Castle

447

County with the remainder roughly equally divided between the two southern counties.

448

The State has not been tracking the specific time it takes for mobile crisis staff to

12

449

physically arrive to intervene in emergencies, but it reports that staff members are

450

deployed on average within 13 minutes of the a request for assistance and they return to

451

base on average within about two hours. Assuming that a face-to-face intervention lasts

452

around one hour, and considering the State’s small geographic size, it is possible that the

453

state is meeting the one-hour requirement specified in the Settlement Agreement.

454

Looking forward, the State should directly measure compliance with this provision.

455

The Monitor notes that there are as many as seven vacancies for related positions within

456

the Kent and Sussex Counties, in large part as a result of the competition for qualified

457

mental health staff associated with the new programming that is being developed there

458

under the Settlement Agreement and the reality that such positions are hard to fill due to

459

the level of education and experience required. It is unclear how these vacancies are

460

affecting the mobile crisis response in those counties, where requests now average only

461

slightly more than one per week, and how demand may change as the Ellendale facility

462

(discussed immediately below) reaches its full impact in the region.

463

Recommendations:

464

1. As referenced in the above section, the State needs to improve its capacity for data

465

collection and management, including its ability to capture data reflecting the time

466

between receipt of a request for crisis intervention and the arrival of staff on the

467

scene.

468

2. In order to ensure that resources are appropriately in place statewide, data relating

469

to response times should be tracked on a county-by-county basis, including day,

470

time of day, and specific responders.

471

472 III.C.1 473 474 475 476

Crisis Walk-in Centers: In addition to the crisis walk-in center in New Castle County serving the northern region of the State, by July 1, 2012, the State will make best efforts to make operational one crisis walk-in center in Ellendale to serve the southern region of the State. The crisis center in Ellendale shall be operational no later than September 1, 2012.

477

478

Substantial Compliance.

479

Renovations to the Ellendale Crisis and Psychiatric Assessment Center (“CAPAC”) were

480

completed on June 25, 2012. The State contract for the program was awarded to

481

Recovery Innovations and, as of the time of this report, that new provider is training staff.

482

In keeping with the timeline in the Settlement Agreement, CAPAC will be fully

483

operational by September 1, 2012. The Ellendale site is now providing at least limited

484

crisis services on a 24-hour basis, 7 days per week to Delaware’s southern counties, in

485

partnership with the State’s Mobile Crisis Intervention Team.

486

13

487 III.D.1 488 489 490 491

Crisis Stabilization Services By July 1, 2012 the State will ensure that an intensive services provider meets with every individual receiving acute inpatient crisis stabilization services within 24 hours of admission in order to facilitate return to the community with the necessary supports and that all transition planning is completed in accordance with Section IV.

492

493

Substantial Compliance.

494

Currently, crisis stabilization services occur within Crisis and Psychiatric Emergency

495

Services (“CAPES”), the psychiatric crisis center serving northern Delaware that is

496

located within Wilmington Hospital-Christiana Care. As is discussed above, in

497

September, 2012, a crisis center serving the lower counties will open in Ellendale.

498

CAPES presently has a bed capacity of 5 beds, and CAPAC will have 6 beds.

499

Approximately 75% of individuals who are admitted to CAPES stay less than eight

500

hours. When individuals are being served by community programs, staff at CAPES

501

consults with the providers as a part of the assessment process and the determination of

502

an appropriate disposition. Based on the Monitor’s review, individuals are receiving

503

appropriate transition planning. The Monitor will review practices at CAPAC when that

504

facility is operational.

505

506 III.E.1 Crisis Apartments: By July 1, 2012 the State will make operational two crisis

507

apartments.

508

509

Substantial Compliance.

510

As of this report, community providers statewide have a capacity to access up to six crisis

511

apartments and to provide associated short-term services, thereby exceeding the capacity

512

required by the Settlement Agreement. As new services come to be fully operational (for

513

instance, statewide mobile crisis) and new and existing providers assume roles in the

514

reorganized system, the Monitor will evaluate how these crisis beds are being used.

515

516 III.F.1 517

Assertive Community Treatment: By July 1, 2012 the State will expand its 8 ACT teams to bring them into fidelity with the Dartmouth model.

518

519

Substantial Compliance.

520

The State is exceeding the requirements of this provision, having awarded contracts for

521

ten ACT teams statewide, all under contract and fully operational as of this report. The

522

parties to the Settlement have agreed that in place of the Dartmouth operational

14

523

standards, these teams will demonstrate program fidelity through the Tool for

524

Measurement of Assertive Community Treatment (“TMACT”), a newer assessment

525

instrument with enhanced requirements for person-centered services and recovery

526

planning. During the coming year, the Monitor will evaluate the performance of the new

527

ACT teams, some of which represent new providers in the state.

528

529 III.G.1 Intensive Case Management: By July 1, 2012 the State will develop and begin to utilize

530

3 ICM teams.

531

532

Substantial Compliance.

533

The State has surpassed this target. As of mid-May, contracts for five Intensive Case

534

Management teams had been awarded. As of this report, these teams are fully functional

535

in New Castle County and have begun operations in Kent and Sussex Counties. During

536

the coming year, the Monitor will be evaluating their performance.

537

538 III.H.1 Case Management: By July 1, 2012 the State will train and begin to utilize 15 case

539

managers.

540

541

Partial Compliance.

542

In late 2011, the State issued a Request for Proposals (“RFP”) for Targeted Care

543

Management (“TCM”) in fulfillment of this provision, but received only one response.

544

In March, it reissued an RFP with revised specifications, and a contract with a provider is

545

currently being finalized to provide for 11 case managers with caseloads to be at a level

546

of 1:25. These caseloads are much lower than had been anticipated, but they reflect

547

DSAMH’s assessment of the complex needs of the individuals being served. As a result

548

of contracting issue, there has been an understandable delay in fully implementing TCM

549

statewide—not attributable to the State’s lack of effort—until the beginning of

550

September, 2012. At the same time, 4.5 TCMs are active on the acute care units of DPC,

551

serving as liaisons to the community for approximately 90 individuals at any point in

552

time. In addition to these 15.5 TCM positions, DSAMH’s contracts with ACT providers

553

include a requirement for peer specialists (one per team), whose work complements that

554

of the case managers.

555

556 III.I.1 557 558

Supported Housing: By July 11, 2011, the State will provide housing vouchers or subsidies and bridge funding to 150 individuals. Pursuant to Part II.E.2.d., this housing shall be exempt from the scattered-site requirement

15

559 III.I.2. By July 1, 2012 the State will provide housing vouchers or subsidies and bridge funding

560

to a total of 250 individuals.

561

562

Substantial Compliance.

563

As was reported in the prior report, the State has identified 150 individuals who live in

564

semi-integrated housing and it continues to provide supports allowing these individuals to

565

live successfully in these settings. In some instances, individuals in this group have been

566

able to move to more integrated supported housing.

567

The Settlement Agreement requires that as of July 1, 2012, the State fund integrated

568

housing for an additional 100 individuals. As of this report, the State has exceeded this

569

goal. Funding for an additional 151vouchers has been approved for individuals on the

570

Target Population List through a combination of programs through HUD, DSAMH, and

571

the Delaware State Rental Assistance Program (“SRAP”). These vouchers have enabled

572

91 individuals to move into integrated housing, and the additional 60 individuals are in

573

various stages of transition. The Targeted Population List provides some information as

574

to which priority subpopulations (defined above in relation to Section II.B.2) have

575

benefited from these housing expansions (Individuals may be reflected in more than one

576

category):3

577

DPC .......................................................21.9%

578

IMD .......................................................23.8%

579

Emergency Department Treatment .......19.2%

580

Homeless ...............................................25.2%

581

Inpatient History + Inappropriately

582

Housed per Community Program .........33.8%

583

The Monitor’s visits to several such individuals in New Castle County have affirmed that

584

housing and related supports are, indeed, consistent with the requirements of the

585

Settlement Agreement. Individuals with SPMI who would otherwise be living in

586

institutions or congregate settings that segregate them from the community mainstream

587

are now living in nice, scattered-site apartments in ordinary apartment complexes with

588

the flexible array of community supports that is helping them meet their personal goals.

589

It is evident that these individuals (and the providers who assist them) rightly feel a sense

590

of pride in making the goals of the ADA something beyond mere aspirations and

591

demonstrating the true capacities of these Delawareans. During the coming year, the

592

Monitor will continue to assess the State’s progress with respect to this pivotally

3 As discussed elsewhere, criminal justice information is not yet incorporated in the Target Population List
16

593

important provision, particularly in the southern counties where housing and supports

594

have historically been a special challenge.

595

Comment:

596

It is noteworthy that the DHSS and DSAMH have not only been working to fulfill the

597

quantitative requirements of the Settlement Agreement relating to integrated housing, but

598

they have also taken a leadership role in ensuring that relevant policies and practices are

599

aligned across State departments. For example, Cabinet Secretary Landgraf and

600

Delaware State Housing Authority (“DSHA”) Director Anas Ben Addi successfully

601

negotiated changes in the SRAP program to remove barriers that particularly

602

disadvantaged individuals on the Target Population List in qualifying for housing

603

vouchers.

604

605

Furthermore, Secretary Landgraf and Director Huckshorn have been instrumental in

606

launching an initiative to examine existing congregate housing in order to identify

607

opportunities to “retool” this housing stock to comport with the ADA’s integration

608

requirements. The development of much of this housing either pre-dated the ADA or was

609

based on funding programs that were not structured around the ADA. Because federal

610

disability protections apply to a larger population of Delawareans than is the focus of the

611

Settlement Agreement, the State has broadened discussions about housing

612

reconfiguration to include individuals with developmental, intellectual and physical

613

disabilities, as well as stakeholders concerned with older adults and homeless individuals.

614

DHSS has engaged leadership from DSHA and the federal Department of Housing and

615

Urban Development in this initiative. The goal is to develop an ADA-consistent master

616

plan for integrated housing that spells out actions that can be taken long-range and in the

617

more immediate term to expand opportunities for ordinary mainstream housing.

618

619

These two initiatives have great significance. The changes in SRAP policy reflect the

620

goals of the Governor, the Cabinet Secretary and other leadership in the State to not only

621

fulfill the State’s specific obligations under the Settlement Agreement, but to also ensure

622

that public programs in Delaware comply with the ADA’s wider requirements. The

623

development of an Olmstead-oriented master plan for housing individuals with

624

disabilities speaks to the enduring commitment of the State to promote meaningful

625

integration of its citizens with disabilities well beyond the expected five-year period of

626

implementing this Settlement Agreement. Leadership within Delaware should be

627

commended for these measures.

628

17

629 III.J.1 630

By July 1, 2012 the State will provide supported employment to 100 individuals per year.

631

632

Substantial Compliance.

633

The State is surpassing this requirement. Because DSAMH’s contracts with Community

634

Continuum of Care Programs (“CCCPs”), included supported employment as a part of

635

the service package, a majority of the 1,300 individuals they served received these

636

services. Pursuant to the Settlement Agreement, these programs reformulated as ACT

637

teams, with supported employment services remaining a contractual element. The

638

Delaware Department of Labor, Division of Vocational Rehabilitation has contracted

639

with each of the ACT teams to strengthen the supported employment services provided.

640

It is noted that supported employment is included among the services offered to the 151

641

individuals for whom new integrated housing was funded (see discussion of Section

642

III.I.1-2).

643

The success of these programs is evidenced in the number of individuals currently in

644

competitive employment. As of July 1, 2012, 49 individuals on the Target Population

645

List have been in supported employment for 90 days, and an additional 79 individuals

646

have been in supported employment for at least 10 days. Although on their face, these

647

numbers may appear small, unemployment among people with SPMI is astronomically

648

high nationwide and the State is building on an admirable record of making vocational

649

services and employment opportunities available to this population. There is an

650

expectation that DSAMH’s data collection regarding supported employment will improve

651

in the coming year as a function of the reporting requirements of the new ACT and

652

Community Re-Integration Project (“CRISP;” discussed in Section IV.A) programs. The

653

Monitor plans to conduct interviews with a sample of individuals in supported

654

employment during the coming months.

655

656 III.K.1 By July 1, 2012 the State will provide rehabilitation services to 100 individuals per

657

year.

658

659

Substantial Compliance.

660

As is the case with regard to supported employment, DSAMH’s core database relating to

661

rehabilitation services is derived from reports of providers working under the old CCCP

662

contracts. These generic reports show that 1,395 individuals with SPMI received some

663

level of community-based rehabilitation services. Unlike supported employment, where

664

the impact of services can be measured at least bluntly in the number individuals in

665

gainful employment, the existing data capacities with respect to rehabilitation services are

18

666

very limited. Information regarding the provision of rehabilitation services and service

667

outcomes should improve through reporting by the new ACT teams (which replaced the

668

CCCPs) and CRISP, particularly if the State makes the much needed improvements in its

669

IT systems that are referenced throughout this report. Although information about the

670

provision of rehabilitation services over the past year is general, the State has met is

671

numeric targets. The Monitor plans to conduct more targeted assessments of this service

672

requirement during the coming months.

673

674 III.L.1 675

By July 1, 2012 the State will provide family or peer supports to 250 individuals per year.

676

677

Substantial Compliance.

678

The State is exceeding its targets with respect to family and peer supports. Between the

679

July 1, 2011 and the date of this report, a total in excess of 416 individuals have received

680

or are receiving such services. These include: 30 inpatients at DPC and served by the

681

hospital’s peer program; 49 individuals receiving the services of Bridge Peers, who assist

682

in transition to community living; 250 peers served at the peer-operated Rick VanStory

683

Center in Wilmington; 57 peers served at the Open Door Peer Support Center in

684

Wilmington; 30 individuals receiving supports through the Sussex Drop-in Centers; and

685

an additional number of individuals (unavailable as of this report) who receive supports

686

through the drop-in center located in Dover.

687

During the past six months, the Monitor has had an opportunity to visit the Rick

688

VanStory Center and to meet with its director, to hear first-hand from individuals now

689

living in integrated housing about the benefits of Bridge Peers, and to meet fairly

690

regularly with the Peer Specialists at DPC. The State has made considerable strides in

691

expanding the role of peers in these settings, as well as in its new ACT teams.

692

The Peer Specialists at DPC have been active advocates, not only in individualized work

693

with people who are hospitalized, but also in identifying systemic issues, such as those

694

relating to questionably restrictive practices and poor coordination in implementing

695

arrangements for discharge. Under the leadership of Gayle Bluebird, the DPC Peer

696

Services Director (who is nationally known for her work), they also are doing impressive

697

work in the area of trauma, producing a plain-language booklet illustrated with works by

698

peer artists, entitled “What You Need to Know About Trauma.”

699

19

700 IV.A Assessment and Placement of People Currently in Institutional Settings

701

702

Not Rated. (Ratings of provisions in Section IV with specific implementation milestones

703

appear below.)

704

This section of the Settlement Agreement lays out processes for evaluating the

705

capabilities and needs of individuals who are institutionalized, with the goal of moving

706

people who do not require an institutional level of care into community settings that

707

maximize integration. During the initial six months of implementation, DSAMH’s

708

“Barrier Busters” committees—comprising DPC staff, community providers and peers—

709

focused on individuals who are on the hospital’s long-term care units. Typically, these

710

individuals have very longstanding problems attendant to SPMI, often with co-occurring

711

physical health issues, substance abuse and legal challenges. Consistent with the

712

Settlement Agreement, Barrier Busters was highly successful in not only problem-

713

solving, but also reorienting transition planning for this population towards a strength-

714

based model of community integration. The Barrier Busters committees (one for New

715

Castle and one for the two southern counties) strengthened the collaboration between

716

hospital staff, community providers and peer specialists and laid the groundwork for the

717

mindset that is now gaining traction system-wide, whereby an individual is presumed

718

appropriate for integrated supported housing unless otherwise demonstrated.

719

Understanding the sometimes unique needs of the long-term care population that was the

720

focus of Barrier Busters—reflecting not only clinical complexities, but also dependencies

721

that are encouraged by protracted institutionalization—the State developed a new

722

program model for the community integration of these individuals, issuing contracts to

723

two providers. The Community Re-Integration Project (“CRISP”) is a capitated, shared-

724

risk initiative which allows these community providers great flexibility in delivering

725

traditional and innovative services and supports in integrated settings. Part of the CRISP

726

contracts, which were modeled after another state’s successful initiative, hold the

727

involved providers financially responsible for any post-discharge visits to emergency

728

rooms or admission to inpatient psychiatric care. CRISP will become fully operational

729

during the coming months, with each program serving 50 individuals. It is anticipated

730

that the program will result in at least 50 additional discharges from DPC’s long term

731

care units. CRISP will also support other individuals with SPMI who may be in the

732

community, but who are high risk for hospitalization at DPC because they have had

733

difficulties engaging in recovery services. As is discussed below, the introduction of

734

CRISP, as well as new processes attendant to transition planning has resulted in DSAMH

735

restructuring how if carries out the centralized special transition functions that had been

736

the focus of Barrier Busters.

737

20

738 IV.B.1 739 740

Implementation of Transition Assessments and Placement: Within 30 days of the signing of the agreement the State will re-assess all individuals currently in institutional settings.

741

742

Substantial Compliance.

743

The provisions of the Settlement Agreement relating to transition planning are

744

particularly significant to the State’s efforts to reorient its systems in support of the

745

community integration required by the ADA. In Delaware (and elsewhere), longstanding

746

practices relating to service planning were built around a “levels of care” framework

747

whereby an individual with SPMI would be matched to the setting regarded as most

748

consistent with his or her needs—for instance, group homes, nursing homes, or

749

supervised apartments. At least in theory, the individual would move through the

750

established levels of care as needs changed. The Settlement Agreement reflects the

751

recognition that this outdated service model tends to perpetuate institutional segregation,

752

in part because service planning is constructed around settings that were state-of-the-art

753

well before the ADA was enacted and when the principal goal was downsizing massive

754

state hospitals.

755

Consistent with the ADA’s goal of ending segregation based on disability, the Settlement

756

Agreement specifies a very different model, requiring that “…assessment shall begin

757

with the presumption that with sufficient supports and services, individuals can live in an

758

integrated community setting.”4 The Settlement Agreement clearly describes an

759

integrated setting as one where “…people with SPMI can live like the rest of

760

Delawareans, in their own homes, including leased apartments, homes or living with

761

family”5 and includes specific parameters to prevent the new development of settings

762

where people with SPMI are intentionally clustered with other individuals who have

763

disabilities. These requirements are a departure from many of the housing, service and

764

assessment models that have been utilized in Delaware and nationwide over the past

765

decades.

766

Pursuant to the Settlement Agreement, the State has developed an innovative protocol for

767

assessing individuals based first on a presumption of integrated living and, when this is

768

not feasible (e.g., in light of the intensity of an individual’s needs) or consistent with the

769

individual’s informed choice, for analyzing and reviewing alternative plans. The

770

consequence has been a dramatic, laudable shift in how service planning is being

771

conducted; this is evidenced in the growing number of individuals with SPMI moving

772

from segregated settings to integrated supported housing (see discussion below relating to

773

Sections III.I.1-2).

4 Settlement Agreement, Section IV.A.1.b 5 Settlement Agreement, Section II.E.1.a
21

774

This change in culture and practice can be fairly described as cutting-edge. It has

775

required creative thought, input from a variety of stakeholders, and flexibility to change

776

approaches midstream. While the State’s efforts relating to assessment and transition

777

planning properly remain a work in progress, the traditional “defaults,” whereby

778

individuals with SPMI were routinely placed into segregated specialized settings clearly

779

have been supplanted by planning that is oriented towards integration.

780

At the same time, implementation of the Settlement Agreement over the past year has

781

revealed a need to clarify how some provisions will be addressed if the shift toward

782

integrated living is to be fully realized. DPC serves two different populations:

783

individuals with SPMI who are on long-term care units and have sometimes been

784

hospitalized for years, and individuals who are admitted for short-term acute care.6 The

785

IMDs, which account for the largest number of hospital admissions in the state,

786

essentially serve the latter population. Individuals in these settings are in acute mental

787

health crises and have lengths of stay of approximately 5-7 days.

788

The Monitor has found that the protocol for integrated transition planning that was

789

developed at DPC is working well, particularly on its long-term care units. There is an

790

increasingly collaborative (and well documented) partnership of DPC staff, community

791

providers and the person being served to construct and implement supported housing

792

plans. As the State’s new CRISP program, which targets this population, ramps up, it is

793

anticipated that larger numbers of individuals on the long-term care units will be moving

794

to settings that maximize community integration.

795

Piloting this model within acute care settings (both at DPC and in the IMDs) has worked

796

less well. The Monitor conducted random reviews of clinical records of individuals

797

recently admitted to DPC for acute inpatient care. In 100% of the cases, the new protocol

798

for transition plans based on a presumption of integrated living was completed with

799

participation by the individual being served and the community provider. At the same

800

time, individuals are in these settings only briefly and, given that they are in immediate

801

psychiatric crises, they may not be in a position to meaningfully participate in person-

802

centered planning regarding their preferred integrated setting. Although many may be

803

desirous of and appropriate for integrated supported housing, their immediate concern is

804

likely to be getting back home, even if that home is a non-integrated setting.

805

Considering all of the above, the Parties agree that requirements of the Settlement

806

Agreement relating to transition planning and access to supported housing can be

807

meaningfully achieved if operationalized as follows:

808

a. The assessment and transition planning for individuals on DPC’s long term care

809

units will continue as is.

6 DPC also serves a forensic population, which is not being considered here.
22

810

b. For individuals receiving publicly funded acute inpatient care in DPC or an IMD,

811

the designated community provider will take on greater responsibility for

812

conducting and implementing a person-centered assessment, including an

813

integrated housing assessment that is consistent with the protocol in use on DPC’s

814

long-term care units. Depending upon an individual’s circumstances, this

815

assessment may occur while the individual is hospitalized or subsequently, but in

816

all instances the hospital record will show how, by whom and when the transition

817

planning is to be conducted.

818

c. For individuals who are receiving publicly funded acute inpatient care and who

819

lack appropriate housing upon discharge, the designated community provider will

820

assure access to alternatives [such as “Haven Housing” (transient housing in

821

unused group home beds) or crisis apartments] where they can live while

822

integrated housing needs are assessed and plans are implemented.

823

824

Recommendation:

825

1. Through its system-wide Quality Assurance (“QA”) program, DSAMH should

826

carefully monitor transition planning and implementation, particularly in instances

827

where such planning occurs in the community following discharge from acute

828

inpatient care. In all instances, the hospital record should either include a transition

829

assessment consistent with what is being successfully utilized at DPC, or else a

830

specific plan for carrying out such an assessment shortly following discharge.

831

2. Through its system-wide QA, DSAMH should monitor discharge arrangements

832

from acute inpatient care (both at DPC and the IMDs) to ensure that individuals are

833

not being discharged to homelessness, shelters or unstable housing situations and

834

that Haven Housing, crisis apartments and other arrangements are being

835

appropriately used while permanent housing needs are evaluated and addressed.

836

3. Data from the QA monitoring of the use of such temporary housing arrangements

837

should be used to inform DSAMH about the adequacy of its current capacity to

838

prevent discharges to homelessness, shelters or other unstable living arrangements

839

and whether additional development is needed.

840

4. Given the positive impact of the new transition planning protocols at DPC, both in

841

individual service planning and in supporting a shift in culture towards an Olmstead

842

orientation, DSAMH should promote the routine use of these assessments (or a

843

variation thereof) within the community programs it funds.

844

23

845 IV.B.2. Within 60 days of the signing of the agreement the State will make operational

846

transition teams including community provider and peer representatives.

847

848

Partial Compliance.

849

The Monitor’s review of records within DPC and discussions with Peer Specialists and

850

other informants confirm that transition teams are operating with participation by

851

community providers and peer representatives. DSAMH currently monitors

852

hospitalizations for individuals who are admitted to DPC or involuntarily admitted to

853

IMDs. In the coming year, its oversight will be expanded to all publicly-funded

854

individuals with SPMI who are admitted to these facilities.

855

856

Recommendation:

857

1. As a part of its system-wide QA, DSAMH should expand its monitoring to ensure that

858

transition teams in IMDs appropriately include community providers and peer

859

representatives for all publicly-funded hospitalizations for individuals with SPMI.

860

861 IV.B.3. Within 60 days of the signing of the agreement the State will make operational a

862

central specialized transition team including community provider and peer

863

representatives.

864

865

Substantial Compliance.

866

As was discussed in regard to Section IV.A, Barrier Busters was phased out as the central

867

specialized transition team. DSAMH meets regularly with the ACT and CRISP providers

868

to resolve problems in care. In addition, it is building on an effective model that it has

869

devised at DPC to ensure that individuals who present challenges in discharge to an

870

integrated setting are identified, that additional consultation is provided as needed, and

871

that discharges to living arrangements that are not integrated are appropriately reviewed.

872

Other than for individuals who are returning to their congregate living arrangement

873

following brief hospitalization, DPC has initiated a special addendum to its transition

874

planning packet (discussed above, and including participation by the individual being

875

served and the community provider) in instances where a disposition of a non-integrated

876

setting is being recommended. This form, in combination with other information relating

877

to discharge planning, is the basis for reviewing either problems in implementing an

878

appropriate plan or a proposed discharge to a setting such as a group home. It documents

879

the types of community living arrangements that were discussed with and offered to the

880

individual, and the reasons (including the individual’s informed choice) that integrated

881

housing is not being pursued. It specifically requires information relating to “serious

24

882

medical physical illness that requires consistent monitoring including, but not limited to:

883

inability to ambulate, problems with other bodily functions, chronic orthostatic

884

hypotension, brittle diabetes, wounds requiring frequent care, dementia...” that might

885

justify a special living arrangement. The form is reviewed by a Peer, a Peer Supervisor,

886

the Director of Professional Services and the Director of DPC before it is forwarded to

887

the DSAMH Director and the Court Monitor. At any point, when further information or

888

discussion is required a meeting of relevant parties can be convened. The Monitor has

889

found that this overall process not only affords appropriate protections against the

890

inappropriate reliance on segregated living arrangements for individuals on the long term

891

care units of DPC, but it has also had the additional advantage of encouraging staff and

892

other stakeholders to critically examine what had been engrained practices that are in

893

conflict with the ADA.

894

As is discussed in regard to Section IV.B.1, this process will now be extended to

895

individuals with SPMI receiving publicly-funded inpatient services at IMDs, with the

896

designated community providers taking a prominent role.

897

898

Recommendations:

899

1. DSAMH should expand its QA functions to assure that transition planning in all

900

inpatient settings occurs in compliance with the Settlement Agreement and that

901

reviews and assistance by the centralized transition team are occurring system wide.

902

2. DSAMH should improve its electronic data systems to ensure that it is capturing real-

903

time information relevant to transition planning, including such factors as individuals’

904

living arrangements at the time of hospital admission, whether the discharge is to an

905

integrated setting and whether reviews of discharges to non-integrated settings are

906

taking place appropriately.

907

908 IV.B.5 909 910

By July 1, 2012 the State shall develop a program to educate judges and law enforcement about community supports and services for individuals with mental illness on forensic status.

911

912

Substantial Compliance.

913

DSAMH leadership met with all of the superior court judges and commissioners who are

914

routinely involved with DSAMH clients at their annual retreat in April, 2012, presenting

915

information on the ADA, the Settlement Agreement and changes underway in the service

916

system. In June, Superior Court Judge Jan Jurden, who oversees the mental health court,

917

hosted a meeting including the Monitor, leadership from DSAMH, legal advocates and

918

court personnel. The intent was to review the implementation of the Settlement

919

Agreement and its implications for the probation and diversion cases that come before

25

920

Judge Jurden’s court. The meeting served as a beginning to what is expected to be an

921

ongoing a dialogue around the factors that bring individuals with SPMI—and many with

922

co-occurring substance abuse—into contact with the criminal justice system and how

923

mental health programs might improve their effectiveness in averting this outcome.

924

925 V.B.4-5 Quality Assurance and Performance Improvement: If harm occurs despite these

926

measures, the responsible State, IMD or community provider will complete a root

927

cause analysis within 10 days. Using the results of the root cause analysis, the State,

928

IMD or community provider will develop and implement a corrective action to prevent

929

future harm.

930

931

Substantial Compliance.

932

At the time the Monitor’s initial six-month report was being finalized, a serious event

933

occurred at DPC, involving a patient-on-patient assault that did not result in life-

934

threatening injuries. DSAMH had not yet completed its root cause analysis at the time

935

the report was issued. This analysis, which was provided to the Monitor shortly

936

thereafter, was thorough and well done. It did not identify an underlying systemic

937

problem at DPC, and staff on the unit evidently responded quickly and competently to the

938

resultant medical emergency.

939

No other significant incidents of harm have been since reported at DPC or the IMDs.

940

During the review period, DSAMH received a total of 7 reports of possible abuse, neglect

941

or harm in community programs through the State’s “PM-46” process. Three of the

942

associated investigations determined the allegations to be unsubstantiated; the remaining

943

four remain under investigation. All occurred in group home settings, and none involved

944

issues of serious harm.

945

946

V. Summary

947

As is clearly evidenced in this report, the State of Delaware has made impressive gains

948

over the past year, not only in achieving the specific intermediate targets required by the

949

Settlement Agreement, but also in taking steps to establish enduring ADA-oriented

950

practices in its service systems. Although this Settlement Agreement focuses specifically

951

on individuals who have serious mental illnesses, the State’s increasing actions to engage

952

in implementation efforts other populations covered by the ADA (e.g., individuals with

953

physical, developmental or intellectual disabilities) and relevant divisions of state

954

government beyond DHSS and DSAMH demonstrates an appreciation of the importance

955

of the ADA among Delaware’s leadership.

26

956

Because of the scope of new programming and other organizational changes required in

957

the first year of implementation, this has been a challenging period. The coming years

958

require far less in terms of launching new types of programs, and much more in regard to

959

refining the State’s new array of services and bringing these services to full fruition.

960

Important to this undertaking will be a continuation of the ingenuity and effort that

961

Delaware’s stakeholders have shown during the past year.

962

963

Respectfully Submitted,

964

965

Robert Bernstein, Ph.D.

966

Court Monitor

27

 
 1

THIRD REPORT OF THE COURT MONITOR

2

ON PROGRESS TOWARD COMPLIANCE

3

WITH THE

4

AGREEMENT: U.S. v. STATE OF DELAWARE

5

U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS

6

7

March 8, 2013

8

9

10

I. Introduction

11

This is the third report of the Court Monitor (“Monitor”) on the implementation of the

12

above-referenced Settlement Agreement (“Agreement”) between the United States,

13

through the U.S. Department of Justice (“DOJ”), and the State of Delaware (“the State”).

14

This report roughly covers the six-month period July 15, 2012 through January 15, 2013.

15

The State has continued to make important ongoing progress in implementing many

16

elements of the Agreement since the Monitor’s last report in September, 2012. For this

17

reporting period, the Agreement specifies only one new benchmark to be achieved.

18

Accordingly, this mid-year report rates the State’s compliance with respect to that

19

provision and then provides comments on the State’s interim progress in some of the

20

Agreement’s other key areas. The next report, to be issued in the summer of 2013, will

21

discuss a large number of new benchmarks that are to be met by the two-year anniversary

22

of the Agreement.

23

As is summarized below, the State has been working diligently to not only meet the strict

24

language of the Agreement, but also to embed practices in its systems that embody the

25

spirit of the Americans with Disabilities Act (ADA) and the U.S. Supreme Court’s

26

Olmstead decision. This is no small feat. In Delaware (as elsewhere) many public

27

systems that are key to people with disabilities moving from the social sidelines to the

28

mainstream of their communities rely on practices that pre-date the ADA and that do not

29

necessarily prioritize the ADA’s goals. From the outset, the State’s approach to this

30

Agreement has been to examine and to realign processes within its Department of Health

31

and Social Services (DHSS), the Division of Substance Abuse and Mental Health

32

(DSAMH), and other public agencies to make ADA outcomes the natural work products

33

for the populations covered. Furthermore, while this Agreement relates specifically to

34

Delawareans who have Serious and Persistent Mental Illnesses (SPMI), the State is

35

appropriately considering how the reforms occurring on behalf of this population

36

translate to all of its citizens who are covered by the ADA. For all of the above reasons,

37

the progress that the State is making has required innovation and a capacity to critically

1

38

examine some longstanding practices. Not surprisingly, there have been—and, no doubt,

39

will continue to be—bumps in the road, some of which are noted in this report.

40

Furthermore, the broad scope and complexity of changes and new programs required by

41

the Agreement have meant that, on a practical level, every new challenge could not be

42

addressed at once. Nevertheless, the Monitor is pleased to report to the Court, to the

43

DOJ, and to the citizens of Delaware that the State is making admirable progress toward

44

meaningful compliance with the provisions of the Agreement. From the Governor’s

45

office, to the State agencies, and through various collaborations involving individuals

46

with SPMI, providers and other stakeholders, the Monitor has found widespread

47

dedication to fulfillment of the ADA for citizens with SPMI or other disabilities.

48

49

50

II. Ratings of Compliance with the Agreement

51

Only one provision of the Agreement has a target date falling within the period covered

52

by this report:

53

III.G Intensive Case Management

54

I.

By July 1, 2012 the State will develop and begin to utilize 3 ICM

55

teams.

56

II. By January 1, 2013, the State will develop and begin to utilize 1

57

additional ICM team.

58

59

Substantial Compliance.

60

The State has exceeded the requirements of this provision in that there are

61

currently 5 Intensive Care Management (ICM) teams statewide. These teams are

62

designed to serve individuals with SPMI who have significant needs, but who do

63

not require ongoing services on the level provided by Assertive Community

64

Treatment (ACT) programs. Because ICM is a new service that was launched

65

concurrently with new ACT teams and other community programs, it has taken

66

some time to sort through who can be most effectively served in what elements of

67

the evolving community service array. Partly as a consequence and partly as a

68

result of population density, in the southern parts of the state ICM teams are not

69

yet being fully utilized. DSAMH is working with providers to bring the use of

70

these programs to full scale. As of December, 2012, about 500 individuals were

71

receiving active intensive care management through these teams.

72

73

2

74

III. Progress on Other Provisions of the Agreement

75

The following discussion concerns provisions of the Agreement that do not have

76

benchmarks to be achieved during the period covered here and do not require new ratings

77

of compliance, but where there is work of particular significance to be reported. Unless

78

otherwise noted, the findings, ratings and recommendations from the Monitor’s

79

September, 2012 report continue to apply to the State’s efforts with respect to all

80

provisions of the Agreement, including those not discussed below.

81

82

A. Data Systems

83

84

Previous reports of the Monitor have noted that Delaware is hampered by very much

85

outmoded data systems, many of which operate in isolation from each other and which

86

capture data that are not timely. As a result, DSAMH has had to expend considerable

87

staff time in manually compiling basic information that is needed for routine quality

88

control and planning, and for reporting compliance with respect to many aspects of the

89

Agreement. A much needed comprehensive overhaul of the DHSS’s electronic data

90

systems is underway; this should vastly improve the quality and timeliness of data both

91

within and across governmental divisions. It also entails initiation of electronic medical

92

records, which will dramatically improve access to information that is critical to service

93

provision and quality management.

94

The scope of this modernization effort is such that, realistically, a fully functional

95

integrated data system is years off. However, to address some of the key data

96

requirements that are immediate, the Monitor has been working with the State to devise

97

some interim work-arounds. The Target Priority Population List, discussed below, is one

98

such example.

99

Recommendation: The plans that are under way appear to be moving DHSS in the

100

direction of having a much more coherent and efficient flow of important information. It

101

is safe to say that the past 18 months of implementation of the Agreement have

102

reinforced an appreciation for analytic capacity within DSAMH, particularly the need for

103

an individual who is not only fluent with information technology, but also with the

104

complexities of service delivery systems affecting individuals with SPMI. Staff members

105

of DSAMH certainly are knowledgeable about mental health services and related

106

supports, but they have been working in an environment where today’s information

107

technology has not been meaningfully embedded. Critical information is still being

108

conveyed in ways that don’t lend themselves to aggregate analysis, such as through email

109

or fax. As an example, up until recently, determining whether or not individuals were

110

being discharged from DPC into integrated settings consistent with the Agreement

111

required tedious searching through paper hospital records, checking what type of housing

3

112

exists at specific street addresses, manually entering this information into a spreadsheet,

113

and then reformatting this information so it could be incorporated in the Target Priority

114

Population List (see below). That issue is now largely resolved, but the resolution is part

115

of a number of piecemeal fixes in response to a very broad array of routine data needs.

116

Fully integrating information technology in DSAMH’s operations and ensuring that the

117

Division derives maximal benefits for service delivery, cost effectiveness. and quality

118

oversight will require expertise that can drive a much needed change in culture and re-

119

education of the workforce. As the Monitor has noted in past reports, service delivery to

120

Delawareans with SPMI occurs within an incredibly complex service system.

121

Accordingly, both to address immediate needs and to ensure that the larger retooling of

122

DHSS’s data systems delivers to full advantage, it is very important that DSAMH have

123

the analytic expertise to integrate both the information and the service delivery elements.

124

The recommendations from earlier reports to bring the staffing capacity to DSAMH to

125

allow for such analytic expertise not only remain, but are strongly suggested for action in

126

the near future.

127

128

B. Target Priority Population List

129

130

Section II.B of the Agreement requires the State to develop a Target Population List that

131

reflects several criteria placing individuals with SPMI at heightened risk of

132

institutionalization and other poor outcomes. These criteria include current or recent

133

psychiatric inpatient care through public programs, homelessness, emergency room use

134

related to mental health or substance abuse issues, and arrests or incarceration. At the

135

outset of the Agreement, Delaware’s mental health system was in a position typical of

136

state mental health departments nationwide with respect to data about these factors.

137

DSAMH had fairly good information about individuals being served at Delaware

138

Psychiatric Center (DPC) and people being served on an involuntary basis in the three

139

private psychiatric hospitals (Institutions for Mental Disease, or “IMDs”) with which it

140

contracts. But the Division had very limited information about people with SPMI—

141

including those individuals it already serves—who meet the Agreement’s criteria for

142

homelessness, emergency room use, or criminal justice involvement.

143

Such information is not only essential to ensure that individuals covered by the

144

Agreement are appropriately prioritized for services and supports, but is also critical to

145

planning public services. Furthermore, unaddressed issues among individuals with SPMI

146

result in avoidable public costs within mental health (e.g., preventable hospitalizations)

147

and other systems (e.g., emergency room use, police involvement, and incarceration). In

148

order to demonstrate the true social and fiscal impact of the reforms entailed in the

149

Agreement, the State needs good measures of how these various factors change over the

150

course of implementation.

4

151

During the past six months, the State has redoubled its efforts to establish a

152

comprehensive and accurate Target Population Priority List (TPPL). This has required

153

working across systems to capture data on homelessness, emergency room encounters,

154

and criminal justice (through the Delaware Criminal Justice Information System, or

155

“DELJIS”). The data are not yet entirely in sync. For instance, while DSAMH is able to

156

get daily data about arrests of individuals who are already on the TPPL, it is still working

157

to get information on current inmates within the correctional system who have SPMI and

158

will be re-entering their communities. DSAMH’s information relating to emergency

159

room use is based on Medicaid claims, which sometimes have time lags of several

160

months. And data about psychiatric care in IMDs that is voluntary and is paid for

161

through Medicaid is still cumbersome to retrieve on a timely basis.

162

Still, in a single spreadsheet, DSAMH now has information about over 7,000 individuals

163

with SPMI who are prioritized for services under the Agreement. This represents about

164

700 additional individuals since the last report, many of whom had been served through

165

the state’s Medicaid or homeless services programs. Although the data will undoubtedly

166

come to be further refined over time, a breakdown of the target population as of January

167

31, 2013 already demonstrates the far-reaching implications the reforms required by the

168

Agreement can have. In keeping with its provisions, the following is a breakdown of

169

individuals on the TPPL (individuals may be represented in more than one category):

170

171

Inpatient Care in DPC ........................................... 9.2%

172

Inpatient Care in IMD ........................................... 51.3%

173

Intensive Community Services (e.g. ACT)........... 18.7%

174

Emergency Room use related to

175

Mental Health or Substance Abuse Issues ............ 27.9%

176

Homelessness ........................................................ 28.5%

177

Criminal Justice Involvement1.............................. 3.8%

178

179

The State is taking some noteworthy steps to better understand the factors that cause

180

individuals to fall into these high-risk categories. For instance, DHSS has partnered with

181

the State’s Department of Public Health and the University of Delaware to review

182

emergency room utilization statewide by people with SPMI, whether primarily for

1 Criminal Justice Involvement data are understated. The percentage shown reflects arrest data of people who are otherwise on the TPPL during a period beginning two years before the agreement plus 81 individuals who were treated on DPC’s forensic unit (Mitchell) during this same time frame. Not represented are individuals who were arrested or incarcerated, but not already appearing in at least one of the other categories. DHHS is working to resolve this issue.
5

183

physical health or for psychiatric issues. The goal is to discover factors that trigger

184

emergency room contact and, ultimately, to provide interventions that reduce that risk.

185

This project can yield invaluable information about breaking the cycle of crises that are

186

all too common disruptions in the lives of people with SPMI and, again, reflects the

187

State’s laudable efforts to secure meaningful systemic reforms.

188

189

Recommendations:

190

1. DSAMH already has plans to utilize DELJIS arrest data to alert providers so that they

191

can intervene on behalf of individuals being served and, for Quality Improvement

192

purposes, to examine patterns of police encounters with people on the TPPL. For a

193

variety of reasons—among them the reality that arrests are the “front-door” for

194

incarcerations that are widespread among people with SPMI—it is recommended that

195

DSAMH quickly move forward with these plans. Ideally, every arrest of a person on

196

the TPPL should trigger a root-cause analysis to inform service refinements on

197

individual and aggregate levels.

198

2. As a part of the analytics referenced above in Section A, DSAMH should extract data

199

relating to hospitalization, emergency room use, homelessness and arrests in order to

200

identify trends attributable to the expanded array of community services and

201

improved procedures for pre-admission evaluations.

202

203

C. Crisis Walk-In Centers

204

205

Section III.C of the Agreement required the State to establish a crisis walk-in center

206

serving the southern areas of Delaware by September 1, 2012, and this program was

207

launched just as the last Monitor’s report was issued. Since that time, the Ellendale

208

Recovery Resource Center (RRC) has become fully operational. The Monitor’s visit to

209

the program affirmed that RRC is not only designed to address a longstanding unmet

210

need in the southern part of the state, but that it is doing so with a model of service and in

211

a physical setting that are designed to reinforce individuals’ ability to recover. In contrast

212

to the often frenetic clinical environment of hospital emergency rooms, individuals

213

served at RRC find what is much more like a calm living room where they can talk to

214

trained staff and peers over a cup of coffee and, if desired, move to a private quiet space.

215

The program, which is operated through a contract with Recovery Innovations, is still

216

evolving within the local service system. As of this report, about 650 individuals in

217

mental health crisis have been seen at RRC since the program was initiated.

218

As a related matter, the Agreement requires training of law enforcement personnel about

219

the availability and purpose of crisis walk-in centers by July 1, 2013 (Section III.C.2).

220

Another requirement (Section III.D.2) has the same target date and also applies to all

6

221

provider staff; its goal is to reduce the use of hospital emergency departments. With

222

regard to both provisions, such training has been ongoing and is planned to continue so.

223

Furthermore, information relating to emergency room use that is now being routinely

224

collected for the Targeted Priority Population List (see Section B above) will allow the

225

State to generate trend data indicating whether reductions in emergency room use are

226

occurring as anticipated. Taken as a whole, the RRC, these training activities, and other

227

new initiatives (some of which are discussed in this report) are moving the system

228

towards significant improvements in how mental health crises are responded to within the

229

State.

230

231

D. Civil Commitment

232

233

Both of the past reports of the Monitor have noted the State’s extraordinarily high

234

reliance on court-ordered treatment for people with SPMI served in its public systems.

235

Court-ordered mental health treatment is properly used as an emergency measure, and it

236

should prompt individual and systemic analyses of how earlier voluntary interventions

237

might have averted the need (or perceived need) to turn to the courts. Over-reliance on

238

court-ordered treatment is generally a signal of problems in service, including problems

239

in accessing timely help or the use of legal coercion to offset staffing shortages that limit

240

consumer engagement.

241

Particularly in light of the community service enhancements that have occurred in

242

relation to this Agreement, neither of these issues should be at play at this point.

243

However, in the past several factors that are non-clinical have inadvertently encouraged

244

providers to involve the courts in mental health service delivery. These factors include a

245

policy whereby DSAMH would underwrite the cost of inpatient psychiatric care only

246

when it was provided on an involuntary basis, the convenience of using police to

247

transport individuals when they are under court order, practices whereby involuntary

248

treatment—particularly on an outpatient basis—would be sought and ordered in the

249

absence of specific criteria, and the apparent perception that hospital discharges of

250

individuals under continuing court orders shield providers from liability. As has been

251

discussed in the Monitor’s previous reports, all of these factors have contributed to a

252

climate that is in conflict with the ADA (and perhaps other laws) and that is inconsistent

253

with the recovery-oriented service system toward which the State is moving.

254

Delaware is making some important progress to promote less-restrictive services and to

255

reduce the unwarranted involvement of the courts in services for people with SPMI. As

256

was noted in the last Monitor’s report, enactment of House Bill 311 and House Joint

257

Resolution 17 were important accomplishment in that this legislation requires pre-

258

detention screening by a qualified mental health examiner, efforts to encourage voluntary

259

treatment (including payment for voluntary hospital care when warranted), and the

260

establishment of a study group to make recommendations about reforms in Delaware’s

7

261

overall mental health laws. Because House Bill 311 doesn’t fully go into effect until

262

2014, the State has not yet realized all of its benefits. However, DSAMH is already

263

ramping up its programs for crisis intervention (e.g., mobile crisis services and the crisis

264

walk-in centers) in ways that will accommodate the upcoming legal requirements.

265

Furthermore, DSAMH is now reviewing for payment on case-by-case basis individuals

266

who meet civil commitment standards for hospitalization, but who are willing to be

267

admitted voluntarily.

268

Nevertheless, problems in court-ordered treatment persist in the State. For instance, the

269

Monitor has met with several mental health peers who recently observed the civil

270

commitment process on random days. They presented a consistent story of hearings that

271

last approximately five minutes, often relying on testimony from a doctor who has not

272

treated the individual, and where often the defense attorney concedes to whatever that

273

doctor recommends. On its face, if the individual, through his or her attorney, concedes

274

to what the doctor is recommending, one would expect that treatment would occur on a

275

voluntary basis. Yet, the peer advocates’ observations are that virtually every case

276

culminates in an order for involuntary treatment order for hospital care, typically also

277

including court-ordered outpatient treatment. These reports are consistent with data on

278

the disposition of civil commitment cases maintained by DSAMH and regularly made

279

available to the Monitor.

280

In addition, peers who themselves have been subject to civil commitment in the State

281

report that they are not made aware of their rights or what was transpiring. They

282

indicated that in some instances, involuntary commitment occurred even though they had

283

indicated a willingness to accept treatment voluntarily, and that they were denied

284

opportunities for family members to be present at their hearings.

285

As has been noted in each of the Monitor’s prior reports and is detailed in Attachment-1

286

to this report, Delaware remains very much an outlier among states in its use of outpatient

287

commitment. Based on the Monitor’s analysis of data from December, 2012, there has

288

actually been a 28% increase in the number of individuals with outpatient commitment

289

orders, as compared with May, 2012. Furthermore, Delaware’s neighboring states

290

(consistent with practices nationwide) use outpatient commitment only very rarely and

291

only with regard to individuals who have demonstrated histories of recurrent

292

hospitalizations and arrests despite intensive community supports. New York is a state

293

with a much-studied outpatient commitment program. The chart in Attachment-1 shows

294

that, adjusted for population, Delaware uses outpatient commitment at a rate that is over

295

six times higher than that of New York State, and even higher as compared to its

296

neighboring states.

297

In New York and elsewhere where it is used, outpatient commitment is a legal

298

intervention that is triggered by high rates of recidivism. Given its unusually widespread

299

use of such commitments, one might expect that readmissions to inpatient psychiatric

8

300

care are unusually high in the Delaware. In fact, they are not. Within the Delaware,

301

readmissions to psychiatric hospitals within 30 days of discharge actually occur at a rate

302

that is only 60% of the national average, and the State’s rate for 180-day readmissions is

303

only 61% of national norms.2 If anything, then, the pool of individuals who seemingly

304

meet the customary criteria for outpatient commitment (high recidivism) would likely be

305

lower in Delaware than in most states, and if these criteria are carefully applied, relatively

306

small numbers of individuals would be considered. However, based on the Monitor’s

307

reviews of clinical and legal records of individuals placed under outpatient commitment,

308

orders continue to be issued based on extraordinarily vague facts. In addition, as has

309

been noted in the Monitor’s prior reports, often what the individual is required to do to

310

comply with an outpatient commitment order—other than to be “amenable” to

311

treatment—is not specified.

312

Pursuant to House Joint Resolution 17, there is a study group now examining the issue of

313

outpatient commitment. Furthermore, under current law, DSAMH is taking measures to

314

dramatically improve the consistency and specificity of information that is brought before

315

mental health commissioners when an outpatient commitment order is being sought. The

316

study group’s findings, as well as the impact of procedural changes that can be initiated

317

in the immediate term can inform the state legislature of broader mental health reforms

318

that might be taken up.

319

Recommendations: Based on all of the above, the Monitor again strongly recommends

320

actions contained in the September, 2012 report, including:

321

1. Production of monthly trending data relating to:

322

a. Involuntary Hospitalizations,

323

b. Voluntary Hospitalizations, and

324

c. Outpatient Commitment Orders;

325

2. Immediate implementation of measures that can be taken within current law, such

326

as clearer formats and standards for seeking outpatient commitment orders, and

327

discussion of system improvements with providers and commissioners; and

328

3. Consideration by the study group of how further reforms in Delaware’s law can

329

solidify the gains that are now being made pursuant to the Agreement.

2 Delaware’s 30-day readmission rate is 5.6%, compared with 9.3% nationally; the State’s 180-day readmission rate is 12.9%, compared with 21.0% nationally. U.S. Department of Health and Human Services, Center for Mental Health Services, Mental Health National Outcome Measures: 2011 Uniform Reporting System, http://www.samhsa.gov/dataoutcomes/urs/2011/Delaware.pdf
9

330

In addition, the Monitor now recommends:

331

4. Immediate measures to inform individuals of their rights when subject to court-

332

ordered treatment (whether inpatient and outpatient), including plain-language

333

written material and opportunities to have questions answered;

334

5. Measures that make civil commitment a more transparent process, such as

335

formalizing the role of peer advocates as court observers;

336

6. Consistent system-wide practices that encourage voluntary treatment when it is

337

needed either on an inpatient or outpatient basis; and

338

7. Promotion of instruments such as healthcare advance directives to allow substitute

339

decision-makers of an individual’s choice—rather than the courts—to provide

340

needed assistance during periods of incapacity.

341

342

E. Inpatient Psychiatric Care

343

344

Section III.D.3 of the Agreement requires that within the next 17 months (by July 1,

345

2014) the State reduce patient days in publicly-funded psychiatric inpatient settings by

346

30%. This is achievable through a combination of mechanisms, including:

347

• The array of new community-based mental health services (such as Assertive

348

Community Treatment, Peer Supports, Mobile Crisis, and Crisis Apartments);

349

• New housing that can markedly reduce the vulnerabilities of people with SPMI,

350

including those who have been at heightened risk due to homelessness;

351

• Improvement in the State’s substance abuse system (the inappropriate psychiatric

352

hospitalization of individuals who actually have acute substance abuse issues has

353

been a longstanding problem);

354

• The new Ellendale crisis walk-in center;

355

• Pre-admission screening (which is a part of new legislation enacted by the State);

356

and

357

• Improved Utilization Review.

358

359

The State has taken positive action on each of these components, but at this juncture they

360

remain in varying stages of implementation. Collectively, significant reductions in

361

inpatient use have not yet materialized, but based on the State’s ongoing actions and if

362

the Recommendation that follows is acted upon, there is reason to expect that the

363

requirements for reduced inpatient use will be achieved. Comparing the most recent data

364

available (for the month of December, 2012) with the average for the baseline fiscal year

365

of 2010-11, total inpatient days are only about 3% lower today (4,834 vs. 4,710).

366

However, there has been a shift in where inpatient care is being provided. At the outset

10

367

of the Agreement, DPC accounted for 68% of the publicly funded inpatient days, and the

368

IMDs (private psychiatric hospitals) provided 32% of the days of care. As of December,

369

2012, DPC accounted for 63% of the inpatient days and the IMDs provided 37%.

370

Looked at in other terms, there has been a 9% reduction in the use of DPC and a similar

371

increase in the use of private settings, where Medicaid dollars sometimes offset the cost

372

of treatment.

373

There has also been a significant change in the length of stay at DPC. Reflecting a

374

concerted effort to provide the long-term care population at this hospital with appropriate

375

community alternatives (scattered-site supported housing among them), the State has

376

achieved a 28% reduction in the number of individuals with long-term stays at DPC since

377

the date the Agreement was signed. Thus, in addition to a reduction in the overall use of

378

DPC, there has been a notable shift in the type of care being provided, whereby today at

379

least half of the care being provided is short-term acute treatment.

380

Furthermore, the Monitor has engaged a consultant to work with the State to improve the

381

quality of nursing and direct care services provided at DPC and to further progress

382

towards recovery-oriented services. By all accounts, such consultation, which is planned

383

to continue during the coming six months, has proved invaluable in light of DPC’s

384

reorientation towards acute care and several administrative changes recently instituted

385

within the facility.

386

Recommendation:

387

Measures that can reduce the State’s reliance on inpatient psychiatric care, including

388

those listed above, continue to be challenged by the states’ overly complex structure for

389

managing hospital care. As has been referenced in prior reports of the Monitor,

390

depending upon an individual’s legal status and public payer source (i.e., Medicaid or

391

state mental health funds), hospital care may be overseen by DSAMH, a Medicaid

392

managed care entity, or both. And for a single individual, the payer and the responsibility

393

for oversight may shift from hospital admission to hospital admission within a single

394

year. This service structure is not only challenging for individuals who are receiving

395

publicly funded mental health services, but it undermines accountability for the

396

management of inpatient care in the IMDs to the point that oversight is piecemeal, at

397

best. Taken together with the concerns about basic legal protections, discussed above,

398

there is an urgent need to for the State to initiate meaningful controls over hospital use.

399

While a number of management models could prove effective, it is strongly

400

recommended that the State establish a single—and unshifting—point of accountability

401

for oversight, monitoring, and maintenance of information relating to psychiatric

402

hospitalizations on individual and aggregate levels. Establishing such accountability is

403

critical to the State if it is to meet the requirement of the Agreement that inpatient days be

404

reduced by 30% by July 1, 2014.

11

405

406

F. Mobile Crisis Teams

407

408

Section III.B of the Agreement requires the State to develop statewide mobile crisis

409

services. The September, 2012 Monitor’s report noted that while the state was making

410

progress in extending mobile crisis services to the southern counties, it was encountering

411

difficulties in filling positions and bringing this program to scale in all areas. Obviously,

412

mobile crisis services are pivotally important, both as an emergency response and to

413

ensure that individuals are afforded interventions in the least restrictive manner

414

appropriate. In many instances, mobile crisis services can divert individuals from

415

hospital care when crisis apartments or some other community-based intervention can

416

serve as alternatives. The nature of mobile crisis work requires specialized, carefully

417

trained staff and it often presents challenges in terms of recruitment and retention.

418

Problems in maintaining full staffing of mobile crisis have persisted during the six-month

419

period of this report. Notwithstanding staffing issues, recent data show that the State has

420

been able to meet the one-hour face-to-face response time required by the Agreement for

421

95% of the referrals received. As mobile crisis becomes more integrated into the service

422

system statewide, the demand for this service will certainly increase, thereby intensifying

423

the need for full and stable staffing.

424

425

Recommendation: Because of the unique and critical role of Mobile Crisis services, it is

426

critical that the State address factors that challenge the recruitment and retention of an

427

effective workforce, including a compensation package that is commensurate with the

428

specific nature of this work.

429

430

G. Transition Planning

431

432

Section IV of the Agreement requires the State to establish Olmstead-compliant transition

433

planning for individuals treated in DPC or one of the IMDs. Among the requirements

434

are: an assessment process beginning with the presumption that an individual can live in

435

an integrated community setting if sufficient supports are offered, timely involvement of

436

a responsible community provider in discharge planning, and processes to ensure that

437

individuals are not placed into less-than-integrated settings without appropriate review.

438

As was noted in the Monitor’s last report, these measures have been successfully

439

implemented at DPC, both for individuals receiving long-term care services and for those

440

receiving short-term acute care. Extension of these processes to the IMDs has been

441

slower and less consistent, complicated in part by the dual responsibilities of DSAMH

442

and Medicaid’s managed care entities in those settings. Recently, DSAMH has taken

443

some positive steps to assure that individuals over whose care it has direct oversight are

444

afforded appropriate assessments for integrated community services (including housing)

12

445

and engagement by community service providers. These measures are consistent with

446

recommendations made in the Monitor’s September, 2012 report. The development of

447

processes to address the needs of individuals whose inpatient care is managed by

448

Medicaid, including the care coordination provided by that system, has proceeded much

449

more slowly. Meetings to discuss this issue with leadership from the State’s Division of

450

Medicaid and Medical Assistance are scheduled in the near future.

451

452

Recommendation: The State should move quickly to ensure that the requirements of the

453

Agreement relating to Transition Planning are extended to all individuals with SPMI who

454

are admitted to an IMD under publicly funded programs, including Medicaid. Thus far,

455

this has not occurred.

456

457

H. Substance Abuse

458

459

A substantial population of individuals with SPMI and co-occurring substance abuse is

460

covered by the Agreement. Furthermore, as has been noted in previous reports of the

461

Monitor, individuals who have primarily substance abuse disorders (sometime without

462

evident mental illnesses) have tended to drift into psychiatric hospitals because

463

appropriate alternatives are often difficult to access. When this occurs (and the Monitor’s

464

first report suggested that such admissions are not infrequent), resources that are intended

465

for mental healthcare are diverted. For these reasons, and because DSAMH has authority

466

over both mental health and substance abuse services in the state, the availability of

467

appropriate community based substance abuse services affects the State’s compliance

468

with the Agreement. DSAMH recently engaged a consultant to evaluate the capacity and

469

structure of the state’s substance abuse system, and the Monitor has met with the

470

consultant to discuss the impact of his findings and the potential for better integrating

471

substance abuse and mental health services. Furthermore, the State’s recently expanded

472

capacity to conduct reviews of hospital admissions at DPC and the IMDs should provide

473

further information about the trajectory leading to the psychiatric hospitalization of

474

individuals whose immediate problems primarily relate to substance abuse. In the past,

475

the Monitor has recommended that hospital staff play an active role in flagging cases

476

where psychiatric inpatient admissions are found to be attributable to substance abuse.

477

Such a process would further facilitate DSAMH gaining an understanding of the scope of

478

unaddressed substance abuse issues and meaningful remedies.

479

Recommendation: The Monitor strongly suggests that DSAMH continue to utilize its

480

national consultant to assist in the reorganization of substance abuse services, including

481

factors that place individuals with substance abuse problems and those with co-occurring

482

disorders at heightened risk of institutionalization.

483

13

484

I. Impact of Delaware’s Olmstead Reforms

485

The Agreement delineates numerous quantitative benchmarks—some of which are

486

discussed above—to be met in the implementation process. These benchmarks are

487

important to ensure that there is a common understanding of some of the key actions the

488

State will take and how these actions will unfold over the five-year period covered.

489

Furthermore, they are consistent with the State’s efforts to ensure quality in services and

490

to prudently manage its resources through data-driven decision making.

491

A critically important goal embedded in the Agreement is that “people with SPMI can

492

live like the rest of Delawareans” (Section II.E.1.a). This goal reflects the essence of the

493

ADA, yet is not easily captured in numeric data or even by the existence of a new

494

program. For this reason, in addition to reviewing data, the Monitor spends a good deal

495

of time interacting with stakeholders to get a sense of the on-the-ground meaning of the

496

recent improvements in services. These interactions regularly include parties who are

497

positioned to see what is actually occurring: individual consumers of public mental health

498

services; representatives of the vibrant and insightful peer movement that has taken hold

499

in the State; advocates including NAMI, the Mental Health Association; individual

500

providers; and provider associations such as DelARF (the Delaware Association of

501

Rehabilitation Facilities). If the opinions of these diverse stakeholders over the18 months

502

of implementation can be encapsulated, it would be that skepticism based on a history of

503

broken promises is giving way to a sense of optimism. Certainly, the transition process

504

continues to present some real challenges, but there is an increasingly unified view that

505

things are heading in a good direction, and a sense of pride at what has been

506

accomplished thus far.

507

Two elements have garnered particular enthusiasm: the development of integrated

508

supported housing options that allow individuals with SPMI to live in ordinary settings,

509

and the State’s efforts to assist individuals in obtaining mainstream employment. In

510

contrast to the important benchmarks reflecting the development of a new service (e.g.,

511

the number of ICM teams), in a very real sense, stable mainstream housing and

512

employment are the fruits of the State’s new service array. Thus, while Delaware is

513

meeting—and in some instances surpassing—most of the numeric targets of the

514

Agreement, its accomplishments with respect to these two factors demonstrate that it is

515

also succeeding in the more qualitative goals of the ADA.

516

517

J. Integrated Supported Housing

518

519

One key provision of the Agreement (Section III.I) requires the creation of new scattered-

520

site supported housing for people with SPMI. By July 1, 2013, the State is required to

521

support a total of 450 individuals in integrated housing. This includes 150 individuals in

522

pre-existing supervised apartments that are grandfathered into this requirement.

14

523

Accordingly, the State is required to provide an additional 300 individuals housing

524

vouchers, subsidies, and bridge funding in fully integrated scattered-site housing to meet

525

the July 1, 2013 benchmark.

526

The State appears well positioned to more than meet the upcoming benchmark relating to

527

housing. Between housing funded through various HUD programs, Delaware’s State

528

Rental Assistance Program (SRAP), DSAMH funds, and housing costs that are covered

529

by its new Community Reintegration Support Program (CRISP), the State expects to

530

provide scattered-site supported housing to at least 444 individuals by July 1, 2013.

531

Added to the 150 individuals who are living in pre-existing semi-integrated housing, a

532

total of 594 individuals will be supported. This far exceeds the target of 450 individuals

533

for this year and is a testament to the State’s earnest efforts with regard to this key

534

indicator of integration.

535

The Monitor’s random visits with individuals living in supported housing developed

536

pursuant to the Agreement confirm that they are truly integrated—that is, they are

537

residing in ordinary apartment complexes interspersed with people who do not have

538

disabilities. The supportive services that are being provided reflect movement within the

539

system toward an orientation that promotes recovery. These individuals proudly point to

540

how they have personalized their apartments; several, for the first time in decades, are

541

now living in what they rightly call homes of their own.

542

Aggregate data from the State show that the Agreement is having the intended effect of

543

rebalancing the housing available to people with SPMI so that they have real choice in

544

terms of where they live. At the outset of the agreement, only 7% of the housing

545

generally available to this population was fully integrated (as defined in the Agreement);

546

the remainder was in congregate settings or settings where people with disabilities were

547

clustered in a single building. By the end of July of 2013, 32% of the housing available

548

to people with SPMI through this Agreement is expected to be in fully integrated settings.

549

The State is doing an impressive job in not only expanding new integrated housing

550

opportunities for individuals with SPMI, but in ensuring that this housing meets the

551

standards of the Agreement. And, as is referenced above, the State’s achievements in this

552

regard are notable not only because where one lives is an essential indicator of ADA

553

compliance, but also because this success reflects the convergence of other services and

554

supports contained in the Agreement.

555

556

K. Supported Employment

557

558

Governor Jack Markell, both in his Delaware role and as Chair of the National

559

Governor’s Association, has launched initiatives to promote the employment of people

560

with disabilities. Employment, like integrated housing, is an important indicator of

561

whether the goals of the ADA are being meaningfully achieved, and this is particularly so

15

562

for adults with SPMI. Nationwide, people with SPMI have extraordinarily high levels of

563

unemployment, even prior to today’s economy where employment is a challenge for

564

individuals whether or not they have disabilities.

565

566

Since the last report, the Monitor has had an opportunity to meet with the leadership of

567

the State’s Division of Vocational Rehabilitation (DVR), which has a close and

568

productive working relationship with DSAMH. The value of this relationship is

569

evidenced in recent data showing that the State is far exceeding the requirements of the

570

Agreement. Under Section III.J of the Agreement, the State was slated to provide

571

supportive employment to 100 individuals per year by July 1, 2012 and to an additional

572

300 individuals per year by July 1, 2013. As of January, 2013, a total of 1,049

573

individuals with SPMI have received active supported employment services (for instance,

574

job preparation and training) since the Agreement was signed, and of these people, 206

575

were employed in mainstream work settings. This is a very important and commendable

576

achievement.

577

578

Recommendation: In consultation with DVR and DSAMH, it is evident that further gains

579

in the employment of people with SPMI can be realized if an expectation of work is

580

better embedded in the service orientation of providers. Building on lessons learned from

581

the State’s effective (and ongoing) efforts to prompt a culture change relating to

582

supported housing, meetings with DVR have suggested that a similar path might be taken

583

with respect to supported employment. In the coming months, the Monitor is planning a

584

series of additional meetings with DSAMH and DVR to chart out a course towards an

585

“employment first” model.

586

587

588

589

III. Summary

590

591

During the past six months, the State has continued to make significant progress towards

592

fulfillment of the Agreement on behalf of individuals with SPMI. Since the Agreement

593

was executed about 18 months ago, the State has restructured its mental health service

594

system and launched an array of new programs to allow individuals to participate in the

595

mainstream of their communities, living in ordinary housing with supportive services

596

and—slowly, but increasingly—entering in the workforce. At the same time, the State

597

has dramatically shifted away from relying on hospitals to provide long term psychiatric

598

care; the bulk of publicly funded psychiatric hospitalization is now for short-term acute

599

services and most people who had been on DPC’s long-term care units are now living in

600

far more integrated community settings. Because this report is being issued at a time

601

when only one new benchmark was slated to be reached under the Agreement (the State

16

602

was found to be in substantial compliance with this benchmark relating to Intensive Case

603

Management), this report focuses on provisions of the Agreement where the State is

604

making particularly notable progress (for instance, with regard to integrated housing and

605

supported employment) and on some areas where it is working to overcome some

606

longstanding challenges (for instance, around its data systems and the over-reliance on

607

court-ordered treatment). Assuming that the State maintains its efforts and appropriately

608

addresses structural issues such as those discussed in this report, it is well positioned to

609

meet the requirements of the Agreement during the coming years. The Monitor

610

commends the continuing commitment of the leadership of the State to the ADA, on

611

which the Agreement is substantially based, as well as the State’s solid achievements

612

over six months covered by this report.

613

614

Respectfully Submitted,

615

616

Robert Bernstein, Ph.D.

617

Court Monitor

17

618 619 620 621 622 623
0.60

Attachment 1 Comparison of Delaware, New York, Pennsylvania & Maryland
PER CAPITA NUMBER OF INDIVIDUALS WITH ACTIVE OUTPATIENT COMMITMENT ORDERS
May & December, 2012
0.56

0.50 0.43
0.40

OUTPATIENT COMMITMENT ORDERS PER 1,000 POPULATION

DELAWARE 0.30
NEW YORK
MARYLAND 0.20
PENNSYLVANIA

0.10

0.09

0.09

0.00
624
625

0.00 0.00
5/23/12

0.00 0.00
12/4/12

18

 
 1

CORRECTED FOURTH REPORT OF THE COURT MONITOR

2

ON PROGRESS TOWARD COMPLIANCE

3

WITH THE AGREEMENT:

4

U.S. v. STATE OF DELAWARE

5

U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS

6

7

September 24, 2013

8

(Originally filed September 16, 2013)

9

10

11

12

I. Introduction

13

This is the fourth report of the Court Monitor (“Monitor”) on the implementation of the

14

above-referenced Settlement Agreement (“Agreement”) between the United States,

15

through the U.S. Department of Justice (“DOJ”), and the State of Delaware (“the State”).

16

This report covers the six-month period January 15, 2013 through July 15, 2013 and it

17

reflects the State’s two full years of progress.

18

Whereas the last report covered a period in which the Agreement specified only one new

19

requirement (relating to Intensive Care Management), the current report coincides with

20

requirements relating to numerous new benchmarks that cover a range of program areas.

21

As is detailed below, Delaware has met—and often surpassed—each of the targets

22

scheduled to be achieved in this review period.

23

Furthermore, the State is making progress in addressing what might be called structural

24

issues, factors that cut across specific provisions, but that have been cited in prior reports

25

by the Monitor as being critical to achieving the immediate and long-term requirements

26

of the Agreement. These structural issues include the use of data, the reliance on court-

27

ordered treatment, and the State’s complex arrangements for the management of inpatient

28

and outpatient services.

29

Because each of these issues has implications for multiple measures of compliance with

30

the Agreement, this report begins with a discussion of progress in these structural areas,

31

followed by an evaluation of compliance with specific provisions of the Agreement. In

32

several instances, explanations of the State’s compliance with individual requirements of

33

the Agreement refer back to the broader measures the State is taking to address

34

underlying structural issues.

35

1

36

II. Progress on Structural Improvements

37

38

A. Use of Data

39

In keeping with recommendations in the Monitor’s past reports, the State has been

40

working to improve its capacities for capturing good data and using this information to

41

monitor service quality and guide decision making. This is happening on two tracks.

42

While Delaware is proceeding with a program of broad, long-term upgrades to its

43

information technology (“IT”) systems, it is also moving forward on some more

44

immediate, and much-needed, expansions of capacities within DSAMH that are essential

45

to its meeting the requirements of the Agreement. These short-term measures are still

46

incomplete, but they are already offering a glimpse of how a fully functional information

47

system can vastly increase the State's abilities to monitor the quality, impact and

48

efficiency of DSAMH's services to individuals with SPMI. As an example, four new IT

49

positions are being requested by DSAMH. These will address a critical need for data

50

analytics that are specifically tailored to people with SPMI and the multiple systems that

51

serve them. Further progress is being made with the imminent adoption of electronic

52

medical records at Delaware Psychiatric Center (“DPC”); this should vastly improve

53

access to clinical information and related quality assurance.

54

As has been noted in previous reports, in many respects DSAMH has been accustomed to

55

functioning in the absence of timely and reliable data, and this has hampered its abilities

56

to maximize outcomes and efficiencies. During the past six months, the Monitor has

57

been working very closely with leadership in the Division to systematically incorporate

58

data in its tracking of compliance with the Settlement Agreement. DSAMH has created a

59

“dashboard” that reflects its current status with regard to each of the Settlement’s key

60

elements and that supplies data essential to compliance monitoring (both internally and

61

by the Monitor). In addition, it has begun to produce trending data relating to these

62

elements and other performance indicators.

63

The State’s significant progress in this area since the last report is evidenced throughout

64

this report, which incorporates several of the trending charts that are beginning to be used

65

on an routine basis to evaluate services and their impact. Again, while acknowledging

66

the State’s significant advances during the last six months, the data set reflected in this

67

report should properly be regarded as a work in progress.

68

69

Targeted Priority Population List:

70

One early challenge confronting the State with respect to data concerned the

71

establishment of a Targeted Priority Population List (“TPPL”), in keeping with Section

72

II.B of the Agreement. The construction and maintenance of this list have required the

2

73

State to integrate disparate data across departmental divisions, among them mental

74

health, corrections, Medicaid and housing. This has been an enormous, but worthwhile

75

undertaking. While the TPPL continues to be refined over time, it provides an

76

increasingly clear picture of the population with Serious and Persistent Mental Illness

77

(SPMI) that is served by Delaware’s public systems. This information—much of which

78

was simply nonexistent in a usable format when the Agreement was formulated—now

79

provides essential information about strategies for compliance and for future planning.

80

The TPPL currently includes 8,254 individuals, whose historical or current characteristics

81

are as follows (an individual may be represented in more than one category):

82

 Treatment at DPC ........................................ 8.25%

83

 Treatment in an IMD ................................. 53.76%

84

 Criminal justice contact ............................. 31.11%

85

 Homeless ................................................... 27.67%

86

 Emergency room use for mental health..... 25.64%

87

These data not only show the levels of clinical and social disability of the targeted

88

population, but also the impact that improved outcomes (such as those that are being

89

realized through implementation of the Agreement) can have on multiple State systems.

90

91

Evaluation of Individuals Discharged From DPC Following Long Hospitalizations:

92

DSAMH is beginning to apply its improving data capacities to generate studies that focus

93

on specific service issues. A recently completed evaluation in collaboration with the

94

Monitor demonstrates the Division’s growing ability to evaluate the impact of new

95

programs created in accordance with the Agreement, as well as changes it is making in

96

practices to reduce its reliance on court-ordered treatment. A summary of this evaluation

97

and its important findings is presented below.

98

Description of the Population-

99

The evaluation focused on a high-risk, high-expense population of individuals who were

100

discharged from DPC between July 1, 2012 and June 30, 2013, following at least 60 days

101

of continuous inpatient care. The 105 individuals who met these criteria have extensive

102

inpatient histories, averaging 1147.1 days (about 3 years) at DPC, with a median length

103

of stay of 140 days (about 4.6 months).1 Some of the individuals who were discharged

104

into more integrated community settings had been at DPC since the 1960s.

1 The median is the number of days of continuous inpatient care received by half of this group. The divergence of the mean (i.e., the average) days of care and the median days of care reflects the inclusion of some individuals who had extremely long durations of hospitalization.
3

105

The community services to which these individuals were referred were as follows:

106

 72 of these individuals (68.6%) were referred to the high-end community

107

services created pursuant to the Settlement: Assertive Community

108

Treatment (ACT), Intensive Care Management (ICM), or the Community

109

Reintegration Support Program (CRISP).

110

 11 (10.5%) received Targeted Care Management (TCM) that was created

111

pursuant to the Settlement.

112

 The remaining individuals were referred to state-operated community

113

clinics or other programs.

114

The living arrangements to which the vast majority of these individuals were referred—

115

80.9%—affirm that, even for this high-need population, integrated community living is a

116

viable option. The specific breakdown of were living arrangements is follows:

117

 23 individuals (21.9%) received SRAP vouchers to enable them to live in

118

scattered-site supported housing.

119

 38 (36.2%) received needed housing supports (in scattered-sites, unless

120

otherwise approved following DSAMH’s review process) through the

121

CRISP program.

122

 24 (22.8%) returned to their family homes with needed supports.

123

 3 (2.9%) were referred to group homes.

124

 The remaining 17 individuals (16.2%), following DSAMH’s review

125

process, went to other settings consistent with their needs.

126

The information presented above demonstrates the State’s effectiveness in moving from

127

an institutional model of services to far more integrated settings.

128

This group’s level of need is not only reflected in its protracted stays at DPC—together,

129

members of the group consumed 120,447 hospital days during their last admissions—but

130

they also have very significant functional deficits. The Global Assessment of Functioning

131

scale (GAF) is a measure from 0 to 100 that is commonly used in mental health to assess

132

an individual’s status. At the point of their discharge from DPC, the average GAF for

133

this group was 28.1, which indicates:

134

Behavior is considerably influenced by delusions or hallucinations OR

135

serious impairment in communication or judgment (e.g., sometimes

136

incoherent, acts grossly inappropriately, suicidal preoccupation) OR

137

inability to function in almost all areas (e.g., stays in bed all day; no

138

job, home, or friends).2

2 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.) (p.34). Washington, DC: Author.

4

139

140

Legal Status-

141

As is discussed in the next section, the State has been making significant efforts to move

142

away from court-ordered treatment (both inpatient and outpatient) and towards a system

143

that is much more oriented towards voluntary services. During the period covered by this

144

study, DSAMH took some important measures to reduce referrals for outpatient

145

commitment, and rates of these court orders have declined accordingly. Given the

146

histories of most of the individuals included in this study (multiple hospitalizations,

147

criminal justice involvement, emergency room use, very significant levels of disability

148

and so on), this is the population that is often considered as appropriate for court

149

supervision following discharge.

150

151

The study had some surprising (and positive) findings in terms of how individuals fared

152

with or without court-ordered treatment. Of the 105 individuals, 26 (24.8%) were

153

discharged with a continuing order for outpatient commitment; 79 (75.2%) were not

154

under a court order. The mean GAF score for individuals who were discharged on

155

outpatient commitment 26.8 and the median was 25. The mean GAF score for

156

individuals who were discharged without a court order was 28.6, with a median of 30.

157

For both groups, the similarity of the mean and the median suggests a normal (“bell-

158

shaped”) distribution that is not skewed by outlier GAF scores.

159

160

Further analysis of these data yielded an important finding; contrary to what one might

161

have expected, the group of individuals who were outpatient committed was not more

162

impaired than the group with no court order. In other words, both groups comprise

163

individuals with severe functional disabilities, and the GAF scores of those with court-

164

ordered treatment in the community were not significantly different from those who were

165

not subject to continuing court supervision.3 Accordingly, whether there were

166

differences in how these individuals fared in the community can be helpful to the State as

167

it continues to roll out processes aimed at increasing voluntary services and as it studies

168

potential changes in its mental health laws.

169

170

Readmission Rates-

171

The chart below presents the 30- and 180-day readmission rates of these 105 individuals

172

who were discharged in the past year, following 60 days or more of continuous inpatient

173

care at DPC. For comparison are the most recently published national readmission rates

174

and those for the state of Delaware.

3 In a one-tail t-Test, t=-0.926, P=0.178, ns.
5

30-DAY READMISSION
RATE

180-DAY READMISSION
RATE

Post-Discharge DPC Population of 105 Individuals:

Readmission Rates 4

4.7%

13.2%

Comparison Rates:

U.S. Rates (SAMHSA, 2011)

9.3%

21.0%

Delaware Rates (2013)

9.6%

23.1%

175

176

Fourteen (14) members of this group (13.2%) were re-hospitalized within 180 days of

177

their discharge from DPC, 5 of whom (4.7%) were readmitted within thirty days.

178

Notwithstanding the histories and functional levels of these individuals that place these

179

individuals at very high risk of failure in the community, these readmission rates are at

180

least 45% lower than the national rates for 180-day and 30-day readmissions (21.0% and

181

9.3%, respectively5) and the Delaware’s overall psychiatric readmission rates (which are

182

very consistent with these national norms). Most importantly, These significant findings

183

highlight that, even for this at-risk group, the intensive services and integrated housing

184

opportunities that the State has created pursuant to the Settlement Agreement are being

185

successful in maintaining people with serious and persistent mental illnesses within the

186

community. In fact, these individuals actually have lower rates of psychiatric

187

rehospitalization than does the general population of individuals with serious mental

188

illness.

189

190

Fiscal Impact-

191

It is worth noting that, based on an estimated cost of care within DPC of $800 per day,

192

the median length of stay of 140 days would mean hospital costs of about $112,000 per

193

person. Applying the average length of stay of this group of 1,147.1 days, a rough

194

estimate of the cost incurred for their hospital care is a remarkable $917,680 per person.

195

A meaningful cost estimate would be somewhere between these figures but, no doubt,

196

would be substantial.

197

In any event, given that care within DPC is generally not reimbursable through Medicaid

198

or other insurance, these costs have largely been borne by the state of Delaware. In

4 Readmission rates are calculated as a percentage of the 105 individuals who were discharged from DPC in fiscal year 2013 following 60+ days of hospital care and who were re-hospitalized for psychiatric care.
5 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Outcomes Measures, 2011.

6

199

contrast, many of the services being provided to these individuals within the community

200

are not only lower cost, but they draw in federal dollars through Medicaid or other

201

programs. The average annual total cost of supporting an individual in the community

202

with Assertive Community Treatment (ACT) services is $23,500 ($15,000 for ACT

203

services + $8,500 for SRAP housing supports). Taking into account that ACT services

204

are reimbursable through Medicaid and draw federal dollars, the costs to the State are

205

even lower, approximately $16,000 ($7,500 state Medicaid match for ACT + $8,500 for

206

SRAP housing supports). In other words, applying the more conservative median cost of

207

hospitalization at DPC of $112,000 per person, the community supports to these

208

individuals pursuant to the Agreement represent savings to the state of about 86%. The

209

table below summarizes annualized projections (since the mean length of stay for this

210

group was greater than one year, full year costs are presented instead):

211

Cost Comparison of Evaluation Group:

DPC vs. Intensive Community Services

Annual Cost Basis

Total Annual Cost

Federal Medicaid

Net State Cost

Median Full Year

DPC

Hospital Days:

140

365

Median 140

Full Year 365

Inpatient care @$800 $112,000 $292,000

$0 $112,000 $292,000

Community

ACT @$15,000 + SRAP Housing @$8,500

$23,500

Range of Annual Savings/Person: $88,500 to $268,500

$7,500

$16,000

$96,000 to $276,000

212

213

214

Readmissions and Legal Status-

215

Finally, this evaluation yielded some very interesting information regarding outpatient

216

commitment and its impact. Generally, proponents of outpatient commitment assert that

217

for people with serious mental illness and significant impairments—both of which

218

characterize this group—court intervention improves outcomes and results in fewer

219

hospitalizations. In contrast to outpatient commitment programs in some other states, in

220

Delaware outpatient commitment does not entitle individuals to an enhanced package of

221

services, nor does it improve one’s access to services.6

222

All of the individuals in this group had access to services in accordance with their

223

discharge plans and needs, and their post-discharge legal status presented neither an

6 For example, in some states outpatient commitment is regarded as a means of jumping the queue and reducing time on a waiting list of services.

7

224

advantage nor a disadvantage in receiving these services. For example, as referenced

225

above, 24.8% of the group was discharged on outpatient commitment status, but 68.6%

226

received high-end services such as ACT. The individuals who were outpatient

227

committed received the same level of service and access to housing as those who were

228

not. That being said, and considering that the functional status of these two groups was

229

essentially the same, it was interesting to find that individuals who were outpatient

230

committed were much more—not less—likely to be re-hospitalized than those who were

231

receiving community services voluntarily.

232

The chart below summarizes the striking differences between these groups. Of the 79

233

individuals who were discharged without an outpatient commitment order, only 6 (7.6%)

234

were readmitted. Individuals who had outpatient commitment orders were about four

235

times more likely to be readmitted than were those who were receiving the same services

236

voluntarily.

237

238

Recommendations:

239

This evaluation demonstrates movement within DSAMH towards much more

240

data-driven oversight of services and their impact, as well as the potential for

241

information technology to inform planning and policy decisions. As evidenced by

242

this evaluation and data presented throughout this report, the State has made

243

palpable progress in this area. Nevertheless, the data presented here are best

244

regarded as a preview. DSAMH remains significantly limited in its abilities to

8

245

produce and appropriately analyze data in ways that will maximize its

246

performance. It is important that it quickly move forward on its plans to expand

247

its IT capacities with individuals who are versed in data analysis, as well as the

248

array of services and systems affecting the population covered by this Agreement.

249

250

B. Reliance on Court-Ordered Treatment

251

Prior reports by the Monitor have discussed a long tradition in the State’s mental health

252

system of relying on court-ordered inpatient and outpatient treatment. In some instances,

253

involuntary treatment was occurring in the absence of clear clinical or legal bases.

254

Furthermore, the policy of DSAMH underwriting the cost of inpatient care in a private

255

psychiatric hospital (“IMD”) only when under court order created the unintended

256

incentive of encouraging involuntary admissions to ensure payment.

257

Judicial involvement in mental healthcare should be a last-resort, emergency measure.

258

When it becomes necessary to turn to the courts, an assessment should be triggered to

259

determine how earlier-on voluntary services might have averted the involvement coercive

260

treatment. Unwarranted involuntary treatment—including court-ordered treatment to

261

reduce providers’ perceived liability, assure payment, or as a substitute for good

262

consumer engagement—is not the “least-restrictive” approach consistent individuals’

263

rights under the ADA and other state and federal laws. Furthermore, absent a specific

264

and carefully considered individual need, coerced treatment is inconsistent with the

265

recovery orientation that DSAMH is pursuing system wide.

266

The State continues to take significant steps to move to a much more voluntary system of

267

services. On a case-by-case basis, DSAMH will now reimburse IMDs for the cost of

268

needed inpatient care in the absence of a court order. Further, both the Division and

269

representatives of the State Attorney General’s office have been working with providers

270

and the courts to ensure that orders relating to outpatient commitment are based on

271

specific, well justified, and demonstrably least-restrictive requests, with clarity as to what

272

is required of the individual to demonstrate compliance.

273

The chart below presents the State’s continuing, dramatic progress in reducing its

274

reliance on court-ordered treatment for both inpatient and outpatient services. The chart

275

shows the number of individuals who were under active civil commitment orders each

276

month by type of order, as well as the monthly average for the year prior to

277

implementation of the Agreement (i.e., June 15, 2010-July 15, 2011). Overall it shows

278

about a 34% decrease in both inpatient and outpatient commitments relative to that base

279

year.

9

280

281

These trend data not only allow the State to evaluate its progress, but also are informative

282

about the impact of its interventions. For example, revisions in the Delaware’s law with

283

respect to outpatient commitment are currently under discussion by a legislatively

284

mandated study group and the State is about to issue new guidance with more specific

285

requirements for how providers may petition for outpatient commitment. Neither of

286

these efforts was completed at the time the above chart was generated. Yet, the graph

287

shows a dramatic decrease between February and May of 2013—about 27% —in the

288

number of people with outpatient commitments. These occurred as DSAMH began

289

apprising stakeholders of the impending changes in the process for seeking outpatient

290

commitments.

291

It is reasonable to expect that Delaware will continue its trajectory of reducing its reliance

292

on court ordered services, particularly as the planned procedural changes in the outpatient

293

commitment process go into effect, the impact of crisis and diversion services (discussed

294

below) continues to expand, and further refinements are made in the legal and policy

295

framework in which services are delivered. As is evidenced in the data presented in this

296

and the prior sections, DSAMH is rapidly expanding its capacities to capture and analyze

297

data relating to the reliance on court-ordered treatment and how individuals are faring in

298

a system more oriented towards voluntary services.

299

300

C. Management of Clinical Services

301

Past Monitor reports have called attention to the State’s overly complex systems for

302

managing the care of individuals receiving public mental health services. Essentially,

10

303

depending upon an individual’s status with regard to Medicaid, during the course of a

304

year an individual’s care may be overseen by DSAMH; or the Division of Medicaid and

305

Medical Assistance (“DMMA”), via a managed care organization (“MCO”); or a

306

combination of the two. This arrangement has built-in inefficiencies and inconsistencies

307

in addressing the needs of people with serious and persistent mental illness.

308

Matters are further complicated as the Affordable Care Act comes into effect, as many

309

individuals with SPMI who have heretofore been supported with State dollars through

310

DSAMH will be newly eligible for Medicaid or have access to insurance via the

311

marketplace. Furthermore, the State is pursuing changes in its Medicaid plan which will

312

expand coverage for services such as supported employment and care management. In

313

all instances, it is important that individuals be afforded appropriate access to services

314

and monitoring to ensure that these services are necessary and having their intended

315

benefits.

316

Each of the Monitor’s prior reports has discussed how the current care management

317

arrangement, with its shifting responsibilities, is problematic. This is particularly the

318

case with respect to the State’s obligations under the Agreement to reduce its psychiatric

319

inpatient bed-days (See discussion of Crisis Stabilization Services below).

320

Notwithstanding the Monitor’s prior recommendations, the State’s disjointed

321

arrangements for managing inpatient and other services to individuals with SPMI persist

322

to this day, and the State still does not have a specific plan to improve this critical

323

oversight function.

324

The discussion of Crisis Stabilization Services includes a chart entitled “Inpatient Days

325

by Provider Type by Month.” This chart shows that, over time, DPC is accounting for a

326

significantly decreasing proportion of inpatient bed-days, that bed-day use in the IMDs

327

has been fairly constant when managed by DSAMH, and that it is trending upward when

328

managed by DMMA via the MCOs. Fulfilling the requirements of the Agreement will

329

require not only a continuation of bed-reduction efforts at DPC, but a much more

330

concerted approach to manage inpatient utilization within the IMDs.

331

 Inpatient Care Management by DSAMH

332

Individuals’ inpatient care in IMDs is managed by DSAMH’s Eligibility and

333

Enrollment Unit (“EEU”) when they are uninsured, when they have been carved

334

out for high-end services (such as Assertive Community Treatment), or when

335

individuals who have Medicaid coverage have exhausted their benefits under the

336

capitated managed care contracts DMMA holds with MCOs.

337

The EEU is not staffed to review and approve admissions before they occur.

338

However, when an individual is admitted with DSAMH as the payor, that

339

individual has gone through one or more gatekeepers within the mental health

340

system (e.g., a Crisis Walk-In Center, Mobile Crisis), and a determination has

11

341

been made that alternatives to inpatient care (such as Crisis Apartments) are not

342

viable. DSAMH has recently expanded its capacity to conduct on-site Utilization

343

Review at the IMDs. Typically, approval for inpatient care is given in 24-hour

344

increments.

345

 Inpatient Care Management by DMMA

346

Inpatient care is managed by DMMA when an individual is Medicaid eligible and

347

has not expended a 30-day annual inpatient benefit that is a part of the State’s

348

capitated managed care contracts with two privately-operated MCOs.

349

The general premise behind such capitated MCO arrangements with states is that

350

these organizations are allotted fixed (“capitated”) healthcare budgets based on

351

the number of individuals insured and their needs, and that the financial

352

incentives to contain costs and to reduce the risk of being financial liable for

353

overspending the capitated rate will improve efficiencies. The problem with the

354

psychiatric inpatient arrangement with the MCOs in Delaware is that these

355

organizations are not at full risk. Instead of the MCO being liable for the full cost

356

of an insured individual’s inpatient psychiatric care, once the Medicaid benefit is

357

used up, DSAMH picks up any further inpatient psychiatric costs. In other words,

358

the degree of the MCO’s risk—ostensibly a significant driver of cost-efficient

359

care in the managed care world—is limited by the 30-day annual benefit.

360

As is the case with DSAMH, most inpatient care is approved after an individual

361

has already been admitted to an IMD and reviews take place during regular

362

weekday business hours. IMDs have up to 48 hours following admission to

363

submit documentation to MCOs for a determination of whether hospital care is

364

needed (although the admission has already occurred). Per DMMA, denials of

365

admission by MCOs are estimated to occur less than 10% of the time. On average,

366

the approval is granted for 6.4 days.

367

People with SPMI whose hospital admissions are managed by the MCOs may—

368

or may not—have passed through DSAMH’s gatekeeping and diversion

369

processes. This is particularly problematic because, MCOs’ decision making has

370

not been well integrated with the full array of alternatives available through

371

DSAMH (many of these alternatives, such as Crisis Apartments and Targeted

372

Care Management, were developed pursuant to this Agreement).

373

Finally, it is important to note that although DMMA contracts with these private

374

entities (similarly, DSAMH contracts with private providers for mental health

375

services), the responsibility for fulfillment of this Agreement and the

376

requirements of the ADA rests with the State. DMMA will need to make this a

377

priority and to work much more closely with the MCOs to assure that Medicaid-

12

378

funded services to individuals with serious mental illness are in accordance with

379

the ADA and the Agreement.

380

381

During the past year, the Monitor has been working closely with leadership in DHSS,

382

DSAMH and DMMA to craft a plan for services management that will further the State’s

383

compliance with this Agreement, streamline its oversight of services and outcomes for

384

people with serious mental illness, and ensure that public dollars are being utilized in

385

ways that reduce costly hospitalizations. This work is ongoing and reflects collaboration

386

across Divisions. However, two years into implementation of the Agreement, there is

387

still no basic framework for how this critical oversight will occur.

388

With respect to the State’s obligations under the Agreement, a more coherent and unified

389

process for services management has critical and very time-sensitive implications. For

390

example, as is discussed later in this report, the Agreement includes an important

391

requirement that inpatient bed-days be reduced by 30% in about a year. Achievement of

392

this goal will reflect the culmination of most of the program reforms required by the

393

Agreement (for instance, Mobile Crisis, ACT, and Crisis Apartments), but it cannot rely

394

on those alone. It will also require careful control over hospitalizations. Care

395

management must integrate each of these elements, and it must consider (and produce)

396

timely and consistent data. Finally, as the Monitor has repeatedly recommended in the

397

past, there should be a single, centralized point of accountability for management of

398

hospital admissions, regardless of the public payor. The discussion below relating to

399

hospital bed-day reduction further reinforces the importance of quickly moving ahead in

400

resolving this issue.

401

Recommendations:

402

1. The Monitor is actively working with DSAMH and DMMA to bring about

403

some immediate measures to reduce acute care bed-days in the IMDs and

404

DPC. These include expansions in on-site Utilization Review by DSAMH

405

and plans for intensive meetings (beginning on a weekly basis) between the

406

DHSS Secretary’s office, leadership at DMMA and the MCOs. The two

407

divisions are now working on a work plan with timelines for implementing

408

various immediate-term activities aimed at the achievement of the bed-day

409

reductions required in the Agreement. A long-range plan is still lacking and

410

needs to be developed concurrently.

411

Apropos of the above discussion of data systems, these actions are tied to

412

regular statistical reports on how the State is faring in terms of meeting its

413

bed-use requirements and how various interventions by this collaboration are

414

furthering efforts to meet the benchmarks included in the Agreement. Not

415

only in fulfillment of the Agreement, but because of pending changes in the

13

416

State’s Medicaid plan and the new Medicaid expansions under the Affordable

417

Care Act, it is very strongly recommended that the parties aggressively move

418

to craft an immediate and longer-range management strategy.

419

2. Regardless of payor, the State’s arrangements for managing services to

420

individuals with serious mental illness need to improve, unifying oversight of

421

inpatient utilization and ensuring that individuals at risk of hospital admission

422

are appropriately evaluated for less restrictive, less expensive alternatives.

423

What is urgently needed is a single point of accountability.

424

3. The clinical criteria applied to determine the need for inpatient psychiatric

425

care and whether less intrusive alternatives are appropriate should be the

426

same, whether DMMA or DSAMH is paying for the cost of hospitalization.

427

4. Because it is much harder to implement alternatives to unnecessary hospital

428

care—and much more disruptive for the individual—when these

429

determinations are made after an admission has taken place, DHSS, DSAMH

430

and DMMA should assure that certification of the need for admission occurs

431

prior to an individual’s transfer to an IMD. Pre-certification reviews should

432

not be limited to regular business hours, but should be available on a 7-

433

day/24-hour basis, as needed.

434

5. Continuing stay reviews for individuals deemed in need of hospital care

435

should take place on weekends, as well as during the work week. This is

436

particularly critical for individuals with SPMI who may be hospitalized on an

437

involuntary basis.

438

6. The Monitor supports DMMA’s plan to significantly intensify its oversight of

439

the MCOs with respect to the achievement of all relevant requirements of the

440

Agreement.

441

7. DMMA and DSAMH should immediately establish mechanisms for sharing

442

and consolidating timely information about inpatient utilization, unmet needs

443

in the community, and other key benchmarks of compliance with this

444

Agreement. Status reports should be provided to the Monitor at least on a

445

monthly basis.

446

447

14

448

III. Ratings of Compliance with the Agreement

449

The three structural issues discussed in the previous section have very important

450

implications for all of the programs required through the specific provisions of the

451

Agreement, which are discussed below. Appropriate monitoring of the utilization and

452

impact of these programs requires a workable system of care management that is guided

453

by complete and meaningful data. Furthermore, the ubiquitous goal of providing services

454

that are recovery-oriented requires that they be provided on a voluntary basis, and that

455

coercive court-ordered services occur only as a last resort.

456

At this juncture, the State is in Substantial Compliance with each of the benchmarks of

457

the Agreement that are now required. In order to sustain its current success, it is essential

458

for the State to continue progress with respect to these structural matters.

459

460

A. Mobile Crisis Services

461

Substantial Compliance.

462

Section III.B.2 requires the State to train state and local law enforcement personnel about

463

the availability, purpose, and procedure for accessing mobile crisis teams. The State is in

464

compliance with this provision; it has an ongoing program of training and consultation

465

with law enforcement personnel across Delaware.

466

Furthermore, as required in Section III.B.1, the State is continuing to meet the

467

requirement of a one-hour response time to mobile crisis calls. The chart above

468

demonstrates DSAMH’s monthly monitoring of this provision for the teams stationed in

15

469

New Castle County and Kent/Sussex Counties.

470

471

B. Crisis Walk-in Centers

472

Substantial Compliance.

473

Section III.C.2 of the Agreement requires the State to train all state and local law

474

enforcement personnel about the availability and purpose of the crisis walk-in centers and

475

the protocol for referring and transferring individuals to walk-in centers. The State is

476

providing ongoing training to state and local law enforcement in this regard.

477

In compliance with Section III.C.1, the State launched the Recovery Response Center

478

(RRC) in Ellendale about a year ago and it has been collecting data regarding its impact

479

and utilization. As is presented in the chart below, in May, 2013, RRC diverted from

480

hospitalization 73% of people evaluated. By way of comparison, the hospital-based

481

CAPES program, which serves the northern part of the state and utilizes a more

482

traditional model, diverted from hospitalization 48%% of the people assessed that month.

483

The following chart presents a comparison of the diversion rates for these two screening

484

centers during January through May of 2013. RRC estimates that substantial additional

485

individuals can be diverted from hospital care if it had a capacity for voluntary overnight

16

486

crisis stabilization.

487

When the walk-in center in Ellendale was being planned, there was a clear understanding

488

of the need for such a program in the southern part of the state, but a much less precise

489

understanding of what the demand for its services would be. RRC is already in the

490

position where it routinely has to delay or deny transfers in from hospital emergency

491

departments because it is at capacity. This information is being tracked by month, day,

492

and time of day so needed adjustments in the program’s capacity can be designed

493

accordingly. Furthermore, RRC is collecting data on individuals who are being referred

494

elsewhere because their immediate need is for detox services. DSAMH is using this

495

information as it moves forward with some major improvements in its substance use

496

service network.

497

498

Recommendations:

499

1. The State should carefully examine whether the capacities of RRC reflect the

500

needs of the southern part of the Delaware in order to assure that there is ready

501

access to its services and that individuals appropriate for transfer to RRC do not

502

become backed up in emergency departments. Based on available data, it appears

503

that a good case can be made for expanding the program’s capacities.

504

2. Not only for purposes of complying with the Agreement (e.g., with regard to the

505

hospital bed-day reductions discussed elsewhere), but also to improve cost

506

efficiencies, the State should evaluate an expansion of the Ellendale program to

507

include voluntary overnight crisis services.

508

3. Given the demonstrated success of RRC in diverting high percentages of

509

individuals assessed from hospital care, the State should develop a crisis walk-in

510

center applying its model for New Castle County.

511

512

C. Crisis Stabilization Services

513

Substantial Compliance.

514

Section III.D.2 of the Agreement requires that the State train all provider staff and law

515

enforcement personnel regarding the use of crisis walk-in centers rather than IMDs or

516

hospital emergency departments for individuals who are experiencing mental health

517

crises. The State is in Substantial Compliance with this requirement; it is providing

518

ongoing training to law enforcement, providers and other stakeholders statewide with

519

regard to the use of crisis walk-in centers.

520

17

521

Not only is the RRC relatively new and its program model non-traditional, but as

522

discussed above this walk-in center was launched in a part of the state that had lacked

523

alternatives to hospital emergency departments and that had become accustomed to

524

relying heavily on them. There is good reason to conclude that the RRC is having its

525

intended impact. Beebe Medical Center, one of the major hospitals serving the southern

526

part of the state, has reported a notable decrease in the number of psychiatric patients

527

being seen in its emergency department.

528

529

Reduction in Inpatient Bed Days:

530

Section III.D.3 of the Agreement requires that by about one year from now—July 1,

531

2014—the State will need to reduce its publicly funded inpatient bed days by 30% of its

532

baseline. While compliance with this provision is not yet required, this is a very

533

important requirement because it reflects the State’s success in moving from an

534

institutional model of services to one that promotes individuals with serious mental

535

illness living successfully in integrated community settings. Achievement of this

536

benchmark will represent the combined effects of a number of program and policy

537

elements required by the Agreement, among them, screening and diversion activities by

538

Mobile Crisis services, Crisis Walk-in Centers and House Bill 311; the impact of ACT,

539

CRISP and ICM; availability of Crisis Apartments; and careful management of clinical

540

services.

541

Furthermore, it reflects the State’s capacity to move from high-cost hospital care—the

542

evaluation presented above in the section relating to the Use of Data references (albeit in

543

very rough terms) the levels of savings that are potentially available—to more ADA

544

compliance and less costly community services. Accordingly, the State and the Monitor

545

have been carefully tracking trends in the use of bed days by the targeted population.

546

Again, DSAMH’s evolving capacities for data analytics is proving invaluable in

547

identifying progress and challenges in meeting this requirement.

548

For purposes of evaluation, the parties have agreed that the baseline to be used for

549

measuring compliance with this provision will be the number of publicly funded bed days

550

in DPC and the IMDs during the fiscal year preceding the effective date of the

551

Agreement (June 30, 2010 to July 1, 2011). During that period, people with serious

552

mental illness accounted for 62,931 bed-days. A 30% reduction from this baseline, to be

553

achieved by next July, is 44,052 bed days. The 50% reduction to be achieved by July,

554

2016 is 31,465. As is presented in the chart below, the State has made some progress

555

during the two years of implementing the Agreement (FY12 and FY13 in the chart), but

556

this has resulted in only a 6% decrease thus far.

557

18

558

559

The following charts further demonstrate how DSAMH is using data analytics to evaluate

560

its status with respect to this important benchmark and to target its interventions

561

562

accordingly. The first chart shows a running total of accumulated bed-days during the

563

past year and the relative contributions to the accumulated bed-days from DPC, from

564

inpatient care in the IMDs that is controlled by Medicaid managed care (“MA Funded”),

19

565

and from inpatient care in IMDs that is managed by DSAMH (“DSAMH Funded”). This

566

analysis shows that around March of the year, the State had already reached its annual

567

target (i.e., the line for Total days intersects the 30% reduction line around March). In

568

the subsequent months, the State was exceeding targeted limit. The greatest contributor

569

to bed-days was DPC—in part, because it includes some individuals with much longer

570

term hospital stays—followed by Medicaid managed acute care clients and then DSAMH

571

managed acute care clients.

572

The second chart clarifies where DSAMH has been successful in achieving reductions in

573

bed-days and where there are challenges that need special focus. It tracks the total bed

574

days utilized each month (as opposed to the month-to-month running total in the first

575

chart) by provider type over the past three years. The dotted line with the Totals shows

576

the monthly use of bed-days and the slight drop that has occurred over time. The DPC

577

578 579

580

line shows that, primarily through community discharges from long-term care, there has

581

actually been a significant decrease in monthly bed-days, from 3,426 in July of 2010 to

582

around 2,131 in June of 2013; that is a 38% reduction. In fact, DPC was able to close a

583

long term care unit, bringing its civil beds down from 120 to 80. The bed-days associated

584

with DSAMH-funded care in the IMDs have remained relatively unchanged over time,

585

with a slight reduction. But the monthly bed-days under Medicaid managed care have

586

actually increased, from 1,228 in July of 2010 to 1,373 in June of 2013—a growth of

587

12%.

20

588

Based on these and other analyses, as well as the urging of DOJ, DSAMH has undertaken

589

several measures to meet the challenging targets for bed-use reduction. These include the

590

initiation of on-site utilization review by DSAMH for the individuals it funds within the

591

IMDs. DSAMH is receiving ongoing consultation by an expert contracted through the

592

Monitor to maximize the effectiveness of this new initiative. As is referenced in an

593

earlier section of this report, navigating the complicated interface with Medicaid

594

managed care is complicated for a number of technical reasons. The Director of DMMA

595

is fully—and positively—engaged in crafting a plan to help move the State to compliance

596

with this provision, and to do so in ways that maximize efficiencies and outcomes that are

597

consistent with the ADA.

598

Finally, it is worth reiterating that, though it may be difficult for the State to meet this

599

impending benchmark, its improving capacities to access and analyze data put it in a

600

wholly different position from prior years. The multiple charts are included in this report

601

to demonstrate how DSAMH is now able to evaluate performance and to target remedies

602

accordingly. The evaluation of individuals discharged from DPC (presented above)

603

demonstrates that a population that had accounted for very high numbers of hospital bed-

604

days can be successfully discharged with ACT, supported housing and other evidence-

605

based community services. Further referrals from DPC and the IMDs with the levels of

606

intensive support available through ACT, ICM and CRISP may result in additional

607

reductions and present a similarly positive return on an investment in integrating

608

community services.

609

Recommendations:

610

The recommendations (discussed elsewhere in this report) relating to the expansion in

611

the number of ACT teams, the development of an RRC-style Crisis Walk-in Center to

612

serve the northern part of the state, and reforms in how clinical services are managed

613

are essential for fulfilling this important requirement.

614

615

D. Crisis Apartments

616

Substantial Compliance.

617

Section III.E.2 of the Agreement requires the state to make 2 additional crisis apartments

618

available by July1, 2013, bringing the total number of crisis apartments to 4. These

619

apartments are required to be situated so that individuals throughout the state in need of

620

this service can have access. The State has surpassed this requirement. There are now 9

621

crisis apartments situated throughout the state. DSAMH is monitoring their occupancy

622

patterns and is taking measures to ensure that Mobile Crisis Teams and other providers

623

are aware of the availability of beds. The typical length of stay in these crisis beds is

624

about three to seven days.

625

21

626

E. Assertive Community Treatment

627

Substantial Compliance.

628

Section III.F.2 requires that the State establish 1 additional ACT team—bringing the total

629

to 9 ACT teams—by September 1, 2013. The State has already surpassed that target.

630

There are presently 11 ACT teams statewide. Nevertheless, there are now waiting lists of

631

individuals in need of ACT services in New Castle County because the teams there are

632

largely at capacity.

633

DSAMH is routinely assessing the fidelity of all 11 teams with the TMAC model, which

634

the parties have agreed to as a more recovery-oriented standard than the Dartmouth

635

model referenced in the Agreement. The teams are in various stages of development and

636

are receiving consultation and support, as needed, from DSAMH. During the past year,

637

one of the ACT providers discontinued services in the state, but DSAMH engaged

638

alternate providers without significant or sustained interruptions in services.

639

The Monitor recently had an opportunity to meet with a Sussex County ACT Team,

640

which was specifically selected because the southern part of the state has historically

641

been underserved. Individually and collectively the members of the team were

642

impressive in their knowledge of the status and needs of the individuals being served,

643

their focus on how individuals were navigating the various day-to-day demands of

644

community living, and their consideration of medication-related issues without allowing

645

these to become the dominant interest. One telltale quality of a well-functioning ACT

646

team was very much in evidence: The Monitor entered the team’s meeting while it was

647

already underway and, to avoid being disruptive, introductions of various members were

648

made after the fact. During the discussions taking place prior to these introductions, it

649

was very difficult to discern who was the doctor, the nurse, the case manager, the peer

650

specialist, and so on. All were very active participants and there was clearly an interest in

651

what every member had to contribute. Each member appeared to have a working

652

knowledge of not only the individual’s clinical needs, but what was going on in that

653

individual’s life. This small observation is an important measure of a good ACT team,

654

where professional roles (and associated hierarchies) are intended to be blurred and

655

where there is a collaborative effort to assist the individual in meeting his or her needs..

656

On a more global level, DSAMH has data that demonstrate the effectiveness of the ACT

657

model and other community programs. The chart below shows that individuals being

658

served by ACT, Intensive Care Management (discussed in the next section) and CRISP

659

account for very few involuntary hospitalizations. This occurs even though these

660

programs serve individuals who have significant disabilities, generally with long histories

661

of recurrent hospital admissions. In contrast, the great majority of hospital admissions

662

involve individuals who are new to the system or those being served by private

663

practitioners, many of whom are being served through MCO care management—a

664

population that tends to be higher functioning.

22

665 666

667

These data, as well as the individuals’ stories presented below in regard to supported

668

housing and employment, affirm that the State’s ACT programs are serving an essential

669

role in achieving the requirements of the Agreement.

670

Recommendations:

671

Based on the waiting list for ACT in New Castle County, as well as the

672

effectiveness of the State’s ACT programs in assisting individuals who have

673

significant needs and who have required high-end, high-cost services, the Monitor

674

has recommended that the State further expand the number of ACT teams by two.

675

The ACT teams (and CRISP) have been pivotal in reducing the long-term care

676

population at DPC; this population (which accounts for considerable inpatient

677

bed-days), can further reduced with additional ACT capacity.

678

In addition, through exchanges with DSAMH, as well as stakeholders in the

679

corrections and judicial systems, it is clear that there is a need for ACT services

680

among people with serious mental illness who have become caught up in the

681

criminal justice system. Finally, as has been discussed in prior reports,

682

individuals with serious mental illness and co-occurring substance use problems

683

require specialized services, and ACT can be effective in reducing their frequent

684

use of emergency services and psychiatric inpatient beds. For all of the above

685

reasons, the State should work to further expand the number of ACT teams.

686

23

687

F. Intensive Care Management

688

Substantial Compliance.

689

Section III.G.2 of the Agreement required the State to have a total of 4 Intensive Care

690

Management (“ICM”) teams operational by January 1, 2013. As was described in the last

691

report, Delaware has surpassed this target, having 5 ICM teams operational statewide.

692

These teams are currently serving 590 individuals, an increase of 18% over what was

693

reported six months ago. As was discussed in the previous section with reference to

694

ACT, individuals receiving ICM services are, by definition, at elevated risk of mental

695

health crises, including rehospitalization. Nevertheless, they do not account for a

696

significant proportion of psychiatric hospital admissions.

697

698

G. Case Management

699

Substantial Compliance.

700

Section III.H.2 requires that by September 1, 2013, the State will train and begin to

701

utilize 3 additional care managers—termed Targeted Care Managers (“TCM”) within the

702

DSAMH system--bringing the total to 18. The State has already met and surpassed this

703

target, having 21 TCMs working in the community and, increasingly, participating in

704

discharge planning at DPC and the IMDs. DSAMH’s longer-range plan is to utilize

705

TCMs as a part of the “front door” for individuals entering public mental health services,

706

with their involvement continuing as needed by the individual.

707

708

H. Supported Housing

709

Substantial Compliance.

710

Section III.I.3 requires the State to increase housing vouchers, subsidies and bridge

711

funding so that 450 individuals are served as of July 1, 2013. The State continues to do

712

an exemplary job in responding to this provision. The chart below presents data

713

demonstrating that the State is surpassing its target. During the past year, it has created

714

new integrated supported housing for 221 individuals. Of these individuals, 186 received

715

housing supports through state funded programs (SRAP or CRISP). The total number of

716

individuals receiving supported housing in integrated settings (or in semi-integrated

717

supervised apartments, in the case of the 150 individuals who were grandfathered in

718

under the Agreement) is 522. In other words, the State is well on its way to achieving its

719

target for July 1, 2014 of 550 individuals.

720

24

721

722

Delaware’s success in its supported housing program goes well beyond its achievement

723

of the numerical targets of the Agreement. Access to integrated housing with needed

724

supports is fundamental to the ADA’s vision of eliminating the social and institutional

725

segregation that have been common among people with serious mental illness.

726

727

The Monitor recently had an opportunity to meet William and Steve, who are served

728

by the Sussex County ACT team and have chosen to share an apartment together.

729

Again, it is worth noting that this area of the State has traditionally been underserved,

730

and thus the availability of ACT and supported housing in the southern counties is an

731

important measure of success. William has a serious mental illness and a history of

732

involvement with the criminal justice system. Steve also has a serious mental illness,

733

in addition to a co-occurring problem with alcohol abuse. He has been in the criminal

734

justice system and has been homeless, sometimes sleeping in shelters.

735

Both William and Steve have disabilities and histories that in the past would have

736

made it very likely that they would be relegated to institutions. These individuals

737

now live in a pleasant, modern—and, in keeping with the vision of the ADA—

738

ordinary apartment complex. They are visited by members of their ACT team 2-3

739

times per week. They have their own bedrooms and share responsibilities in relation

740

to cooking and shopping.

741

William and Steve are not yet at their point in recovery where they are fully engaged

742

in outside social activities or employment, but they are doing well living quietly in

743

their own home. Given their histories, that, in itself, is an enormous accomplishment.

744

But there is more to this story that is telling about their success and the success of this

25

745

DSAMH initiative. Several months back, Steve’s prior roommate left and he was

746

having some problems managing things. Not only was he receiving support from his

747

ACT team, but reportedly neighbors looked in on him to encourage him and ensure

748

that he was doing okay. That interaction with neighbors is mundane, and it is also a

749

testament to how longstanding social barriers affecting people with serious mental

750

illness are beginning to break down.

751

752

I. Supported Employment

753

Substantial Compliance.

754

Section III.J.2 of the Agreement requires the state to provide supported employment

755

services to an addition 300 individuals, bringing the total to 400 individuals. There are

756

several levels of employment services provided through the State’s Department of

757

Vocational Rehabilitation (“DVR”). For purposes of evaluating compliance with this

758

provision, supported employment services to individuals with serious and persistent

759

mental illness were counted if an individual had progressed through the DVR system to

760

the point that there was an active plan for vocational rehabilitation or, of course, if the

761

individual was being employed at some level and receiving needed supports. During the

762

past year, a total of 569 individuals met these criteria, thus surpassing the Agreement’s

763

requirements. Of this group, 67 were actively employed at some point during the year.

764

Individuals who are a part of the population targeted by the Agreement commonly have

765

unstable work histories—if they have work histories at all—and their entry into the

766

workforce may be challenged by their levels of impairment, criminal justice histories, and

767

where they stand with respect to their individual recoveries. A substantial number of the

768

individuals receiving supported employment services (99) had a substance abuse issue

769

co-occurring with serious mental illness, presenting an additional set of challenges to

770

employment.

771

Individuals with SPMI who have obtained gainful employment are carrying out critical

772

functions as peer counselors who are employed by the State or by providers (Peer

773

services are discussed below). Others work in mainstream work environments with

774

needed supports. The stories below describe some of the individuals who are

775

beneficiaries of the State’s employment initiatives and the range of their work.

776

777

Jayne lives in her own home with her husband and daughter. She has a long history of

778

treatment for bipolar disorder with psychotic features and has been hospitalized

779

several times. She works as a research assistant for the State, in part, in conjunction

780

with the University of Pennsylvania which is evaluating DSAMH’s CRISP program.

781

In that capacity, she is being certified in human subject research, following the

782

protocol that the university uses for all such research assistants. She sees this as an

26

783

important addition to her resume. Her CRISP research focuses on consumers’

784

experiences in that program. In addition, Jayne carries out peer satisfaction

785

interviews as a part of DSAMH’s quality assurance program. In both instances, she

786

has leant her first-hand experience as a consumer to assist in the design of the

787

questionnaires being utilized. She finds her work highly rewarding, indicating that

788

“these studies will improve people’s lives in the community.”

789

790

Sandra has been in and out of psychiatric hospitals due to schizophrenia and bipolar

791

disorder. She is served by an ACT team that supports her in living in her own

792

apartment. Sandra describes her life as having been “out of control,” but now works

793

in mainstream employment in a variety of tasks, including assembly work. She

794

reports “I’ve been able to stay out of the hospital for a long time now...and I’m able to

795

go to work.” She regards her current work as transitional, noting “I’m not where I

796

want to be, but I’m not where I was.”

797

798

Todd is a middle-aged man who has hospitalized multiple times for treatment of

799

schizophrenia. For about a year, he has been working in food services at the

800

University of Delaware. He reports that he is often complimented about his work and

801

he takes great pride in leading a productive life. “I am treated like everybody else,”

802

he says, which is an apt description of what the Agreement—and the ADA—intend to

803

achieve for people with disabilities.

804

805

Recommendation:

806

807

1. Each of the providers with ACT teams has been able to fund one employment

808

specialist for the agency. DSAMH’s plan has been to focus on bringing these

809

new ACT teams into fidelity with the TMAC model and, as the basic structure

810

and operations become established (which they now are), to ramp up their

811

capacities for supported employment by having one dedicated employment

812

counselor for each team. This is a sensible approach. It is recommended that

813

these positions be established this year.

814

2. DSAMH also plans to create a new leadership position within the Division to

815

coordinate employment services throughout its programs. This is a very

816

worthwhile measure and should help the State achieve the significant

817

increases in the number of individuals receiving supported employment

818

services that are required per the Agreement in the coming years.

819

27

820

J. Rehabilitation Services

821

Substantial Compliance.

822

Section III.K.2 of the Agreement requires the State to provide rehabilitation services to

823

an additional 500 individuals by July 1, 2013, bringing the total requirement to 600.

824

Rehabilitation services comprise an array of activities, such as education, substance abuse

825

treatment, and recreational activities. Some of these components are not well defined in

826

the State’s data systems. Furthermore, without sufficient intensity of a rehabilitative

827

service, the meaning is dubious (for instance, crediting a single recreational encounter

828

with an individual towards the goal of 600). For purposes of evaluating the State’s

829

compliance with this provision, an individual was counted if:

830

(a) Psychosocial Rehabilitative Services, Psychosocial Group Services, or Family

831

Psychosocial Education was provided at least twice per month for at least 6

832

months. 439 individuals met this criterion;

833

(b) Some level of substance abuse service for a co-occurring disorder was

834

provided during the year. 929 individuals met this criterion; or

835

(c) There was ongoing participation as a peer volunteer. 10 individuals met this

836

criterion.

837

The State is surpassing its requirements with respect to Rehabilitation Services.

838

839

K. Family and Peer Supports

840

Substantial Compliance.

841

Section III.L.2 of the Agreement requires the State to provide family or peer supports to

842

an additional 250 individuals, bringing the total number receiving this service to 500. As

843

has been noted in previous reports, an impressive peer movement has evolved in the

844

State, whereby individuals who, themselves, have mental illness provide vital services to

845

members of the population covered by the Agreement. These services range from

846

supports to inpatient at DPC (where peers meet with individuals and provide “Hope”

847

bags containing information and essentials upon admission and discharge), to

848

socialization and support in consumer advocacy, to participation on ACT teams. The

849

State has surpassed its requirements with respect to this provision, providing Family and

850

Peer Supports to approximately 600 individuals.

851

28

852

L. Transition Planning

853

Substantial Compliance.

854

Section IV.A sets forth requirements for person-centered recovery-oriented discharge

855

planning, including the requirement that individuals be assessed from the perspective

856

that, with sufficient supports and services, they can live in integrated community settings.

857

Fulfillment of this provision requires not only procedural changes, but significant

858

changes in how the needs of individuals are conceptualized and how their preferences are

859

accommodated.

860

Delaware continues to make important advances in achieving these reforms. For

861

example, the person-centered Community Living Questionnaire that was developed at

862

DPC to meet these requirements is now being used in the IMDs, as well, with

863

collaboration by community providers. Furthermore, DSAMH continues to require

864

special review of individuals who (generally for physical healthcare reasons) are not

865

being recommended for fully integrated housing upon discharge. In these small number

866

of instances—perhaps a dozen during the course of the past year—the hospital or

867

community provider compiles a detailed analysis explaining why a fully integrated living

868

arrangement is not feasible. These analyses are then reviewed by DSAMH and by the

869

Monitor, sometimes culminating in a time-limited approval for an alternative setting

870

while physical healthcare issues stabilize. This system is working well.

871

872

IV. Summary

873

Delaware continues to make significant progress toward fulfillment of its obligations

874

under the Agreement. As is delineated above, it has met or surpassed the benchmarks

875

contained in the Agreement for each of the measures that have come due. The State

876

continues to move forward on measures to address the structural issues—data,

877

involvement of the court system, and care management—that are necessary for it to

878

sustain its accomplishments through the duration of the Agreement and beyond. The

879

leadership in the State, at DHSS, and DSAMH merit praise for their efforts to advance

880

the opportunities for Delawareans with SPMI and other disabilities.

881

882

883

Robert Bernstein, Ph.D.

884

Court Monitor

29

 
 1

FIFTH REPORT OF THE COURT MONITOR 


2

ON PROGRESS TOWARD COMPLIANCE 


3

WITH THE AGREEMENT: 


4

U.S. v. STATE OF DELAWARE 


5

U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS 


6

May 19,2014

7

8

9

10

I. Introduction

11

This is the fifth report of the Court Monitor (Monitor) on the implementation ofthe

12

above-referenced Settlement Agreement (Agreement) between the United States, through

13

the U.S. Department of Justice (DOJ), and the State of Delaware (the State). This report

14

covers the six-month period July 15,2013 through January 15,2014; it also reflects the

15

State's overall progress in fulfilling its requirements under the Agreement during the past

16

2 ~ years.

17

The Agreement lays out specific corrective actions with respect to public programs

18

serving Delawareans with Serious and Persistent Mental Illnesses (SPMI). As has been

19

noted in past reports, the State is not only working to meet the targets delineated in the

20

Agreement, but is attempting to do so in ways that will result in sustainable

21

improvements in its service systems. This is not a simple task. At the outset of

22

implementation, Delaware's public systems relevant to the Agreement reflected a

23

patchwork of disconnected requirements, funding opportunities and expedient reforms

24

within and across bureaucratic divisions. The resultant policies were often incoherent,

25

poorly coordinated, or directed towards conflicting priorities. The State's fulfillment of

26

its requirements under the Americans with Disabilities Act (ADA}-around which much

27

of the Agreement is framed-was not an organizing value. This was essentially the state

28

of affairs in Delaware (as it remains in many states nationwide) when the Agreement took

29

effect in 2011.

30

In its 2 ~ years of implementing the Agreement, the State has made an admirably strong

31

effort to remedy these inefficiencies and to realign its strategies. This has required it to

32

focus not only on the quantitative requirements of the Agreement, but also to look at the

33

structures and systems-many of them embodying longstanding, ingrained practices­

34

that underlie the provision and management of services. While it is making good

35

progress in this complicated endeavor, these system refinements are ongoing; as is

36

discussed in this report, the State's fulfillment of some requirements of the Agreement

37

remain hampered by practices that are not well aligned. Nevertheless, from the

1

38

Governor's office on down, there is a commitment to serve people with SPMI, as well as

39

other disabilities, in ways that promote their full participation in community life. This is

40

the principle underlying the Agreement and the ADA.

41

As last time, this report begins with a discussion of the State's progress with respect to

42

some essential improvements in the structure of services and services management.

43

Several of these cut across departments, divisions and relationships with private

44

providers. These reforms challenge-and, sometimes, are challenged by-persistent

45

bureaucratic silos.

46

The report then presents findings with respect to the Agreement's measurable targets. As

47

is discussed below, the State is in Substantial Compliance with the Agreement, having

48

met or exceeded its requirements, with only two exceptions, where it is in Partial

49

Compliance: the Discharge Planning provisions relating to Crisis Stabilization Services,

50

and the requirements for Risk Reduction. The State is taking appropriate steps to achieve

51

Substantial Compliance with respect to these requirements and, appears to be well­

52

positioned to meet additional new requirements that go into effect in July, 2014.

53

The July targets include a challenging new benchmark with regard to reducing

54

psychiatric inpatient bed-use. As things are currently configured, oversight of psychiatric

55

bed-use straddles two divisions within DHSS. As a result, achieving the necessary

56

reductions has been an unusually vexing issue for the State. Nevertheless, as is discussed

57

in the following section, the State is now taking some immediate-term measures and it

58

has developed longer-term plans to address this important requirement.

59

In summary, Delaware continues to make impressive progress in implementing the

60

Agreement. With a sustained focus on both the Agreement's Implementation Timeline

61

(Section III) and the structural factors discussed below, there is good reason to expect

62

that it will successfully meet its obligations within the five-year period that the parties

63

projected. Much ofthe success in implementing the Agreement can be attributed to the

64

uniquely collegial relationship between the State, DOJ, and the Monitor, whereby issues

65

that need attention are identified early on and the parties collaborate around strategies for

66

tackling them. This relationship is exemplified in the inpatient bed-use reduction plan

67

which is discussed herein.

68

69

II. Proe;ress on Structural Improvements

70

The State's achievement of Substantial Compliance with virtually all of its targets has

71

required flexibility, a willingness to critically evaluate longstanding practices, and

72

openness to trying new approaches. For example, the Agreement reflects the challenging

73

goal of reducing the State's reliance on hospital care and moving towards a much more

74

preventive, voluntary, and recovery-oriented model. Meaningful accomplishment of this

75

goal is not simply a matter of creating the new community programs that are delineated

2 


76

in the Agreement. It also requires a careful understanding of the pathways that lead

77

people to adverse outcomes such as mental health crises, hospital admissions, and

78

involvement of the police or courts. Such analyses allow the State to test new

79

administrative or service approaches that may--or may not-ultimately prove to work as

80

expected. All of these elements have made it necessary for the State to develop new

81

capabilities to capture timely data (often across bureaucratic divisions) and to evaluate

82

the impact of services and the context within which they are provided.

83

84

A. Use of Data

85

Delaware continues to move forward in an overhaul of its information systems, with the

86

broad goals of unifying data, allowing proper and timely data access across (and within)

87

divisions, and promoting better and more efficient outcomes in its public programs. This

88

important endeavor entails a concerted effort over several years. At the same time, the

89

Agreement is envisioned to be carried out within a five-year window, with evaluations of

90

progress about every six months. Notwithstanding the State's longer-range efforts, the

91

Agreement presents an immediate need for data that has required the State to devise some

92

interim measures. A large share of the data presented in this report is generated by these

93

means.

94

As Delaware's larger refinement of its information technology systems goes into effect,

95

some of the interim measures may come to be replaced and better integrated with larger,

96

and in some ways more sophisticated, data sets. Even if that is the case, the interim

97

approaches are already changing how staff at DHSS utilize data to inform their work.

98

Whereas staff had been accustomed to relying upon outdated information that was

99

compiled manually and on an impromptu basis, they are now increasingly incorporating

100

into routine practice data systems that consolidate information across and within

101

bureaucratic divisions, and trending charts with various measures of programs'

102

performance over time. Many of these are presented in this report. This reflects an

103

important, positive change in the culture of services management that is not particularly

104

explicit in the Agreement, but that nonetheless positions the State to provide effective,

105

efficient services in accordance with its ADA obligations, through the implementation

106

period and beyond.

107

Data improvements (or at least those relevant to the Agreement) have been most dramatic

108

within DHSS's Division of Substance Abuse and Mental Health (DSAMH). At the

109

outset of implementation, DSAMH relied heavily on an array of inefficient and

110

incomplete data sources, including paper or faxed reports, idiosyncratic spreadsheets

111

constructed by individual staff members, extraction of information buried in clinical

112

records, and a good deal of manual counting and sorting. While still very much a work in

113

progress, today DSAMH's data systems are a far cry from what they were 2 Y2 years ago.

114

The Division has created a unified data scorecard that includes measures relevant to each

3 


115

of the major provisions of the Agreement. These measures are updated monthly and

116

trended over time, thereby facilitating the State's (and the Monitor's) oversight of

117

compliance and the identification of successes or problems in services. Some data sets,

118

such as the number of individuals served through Assertive Community Treatment

119

(ACT), can readily provide an overall picture of where the State stands, or they easily can

120

be drilled down to the status of a particular agency or clinical team. This is an impressive

121

accomplishment.

122

The Division's evolving data capacities are also being applied to evaluate the impact of

123

new initiatives. For example, data relating to the mental health screening that is required

124

under recent legislation allow DSAMH to assess outcomes such as whether an individual

125

who was screened was ultimately admitted to a hospital, who had conducted the

126

screening, and other key factors. Such information is allowing Delaware to evaluate how

127

the State's new law is working and to take appropriate steps to improve outcomes and

128

align them with its broader system reforms.

129

For a variety of reasons, the Division of Medicaid and Medical Assistance (DMMA) has

130

found the collection and analysis of data relevant to the Agreement to be more difficult.

131

At this juncture, DMMA is far less advanced in this regard, but it is recently making

132

some progress. DSAMH has direct responsibility for services relevant to the majority of

133

individuals with SPMI in the state, but DMMA manages care to a significant population

134

of individuals who are diagnosed with serious mental illnesses, including some who meet

135

the Agreement's criteria for SPMI (i.e., serious and persistent mental illness). They are

136

served through Medicaid programs that are administered by private Managed Care

137

Organizations (MCO) operating under contract with the State.

138

In contrast to DSAMH, most individuals served through MCOs have primarily physical

139

healthcare needs; those with serious mental illnesses represent only a small portion of the

140

covered population and those with SPMI are an even smaller subpopulation. DMMA's

141

data systems were not designed to easily capture the sort of information that is critical to

142

the Agreement and that is more routine within DSAMH. In fact, even the basic task of

143

identifying the MCO population of individuals diagnosed with serious mental illness, and

144

then extracting the sub-population of this group that meets the criteria for SPMI (i.e., the

145

persistence and intensity of disability and associated adverse outcomes specified in

146

Section II.B) has been challenging for DMMA and remains so.

147

Moreover, although the State contracts with MCOs to provide active care management

148

during the course of an individual's psychiatric hospitalization-that is, the MCO's

149

monitor an individual's inpatient care from admission through discharge-DMMA

150

maintains that it is unable to get accurate "real-time" information about hospital

151

utilization. Instead, it asserts that accurate bed-day data are only available many months

152

after hospital discharge, when Medicaid claims have been reconciled. In evaluating the

153

State's status with regard to reductions in hospital use, this causes obvious problems.

4 


154

Furthermore, such long delays in access to what are ostensibly straightforward data (i.e.,

155

the number of days spent in psychiatric hospitals) present significant problems in

156

evaluating the impact of measures intended to reduce hospital use.

157

On one level or another, the data issues discussed above have been impediments to

158

monitoring compliance with the Agreement that have been referenced in each of the prior

159

Monitor reports.

160

Recently, there have been some promising collaborative efforts by DMMA and DSAMH,

161

and between these Divisions and the Monitor, to devise some immediate and longer­

162

range remedies. These are presented in the section of the report relating to Crisis

163

Stabilization Services. As things now stand, DSAMH's data are reasonably reliable and

164

timely; DMMA's data are less so. The data sets from DMMA that were incorporated in

165

the Monitor's past reports were considered by all parties to be accurate, per se, but highly

166

unreliable with respect to the requirements of the Agreement. Largely, this is because

167

diagnostic information that would trigger an individual's inclusion in the Targeted

168

Priority Population List (TPPL}--and the monitoring of such factors as inpatient

169

psychiatric bed-day use-was based on what appeared on Medicaid billings. These

170

ranged from diagnoses rendered by emergency room physicians who are not psychiatrists

171

to diagnoses by psychiatrists in IMDs that were potentially incentivized by the scarcity of

172

beds for substance abuse treatment or misperceptions about MCOs' decision-making

173

relating to payment for inpatient services. Accordingly, these data are problematic for

174

purposes of evaluating compliance, in that they may include substantial numbers of

175

individuals whose mental health issues are misdiagnosed or overstated.

176

While the number of individuals included in the TPPL, in itself, is not a factor that

177

generates a rating with respect to the State's implementation of the Agreement, the TPPL

178

is important because it provides an overall picture of the population covered by the

179

Agreement and this group's experiences with adverse outcomes such as emergency room

180

use, homelessness and police encounters. Furthermore, as is discussed later (in the

181

section relating to Crisis Stabilization Services), the use of psychiatric inpatient beds by

182

individuals on the TPPL is an important compliance measure that is tracked and rated.

183

For these reasons, it is essential that the State has accurate data about people with SPMI

184

who are served through its public systems.

185

Most of the measures of compliance presented in this report concern DSAMH-managed

186

programs, such as Assertive Community Treatment (ACT), supported housing, and

187

intensive case management. These are not affected by issues with DMMA's data that

188

affect implementation monitoring and, at least for now, do not materially affect the

189

State's standing with regard to compliance with the Agreement. However, in preparing

190

this report, an initial analysis of the State's data strongly suggested that some measures of

191

compliance could be significantly distorted if adjustments were not made in how

192

individuals with SPMI were identified within the MCO group. For example, when

5

193

applying the same data protocols for TPPL inclusion to DMMA as are used with respect

194

to DSAMH (these are the same protocols that have been used since implementation

195

monitoring began), the DMMA data for this fiscal year showed over a 59% increase in

196

bed-days within acute psychiatric hospitals for individuals managed by MCOs relative to

197

the "base year" of2011. Most of these reflect first, and only, admissions. That increase

198

did occur-at significant expense to the State-but clinical incidence rates and other

199

considerations would suggest that such an increase in the number of Delawareans with

200

SPMI and their use of hospital care would be far, far lower. Much more likely is that the

201

diagnostic data from the private psychiatric hospitals that are available to DMMA

202

through Medicaid claims, represent greatly overstated numbers of people with SPMI.

203

As the Monitor's discussions of available inpatient bed-use data with DMMA and

204

DSAMH moved forward in recent months, it became clear that in order to extract the

205

most accurate information about individuals prioritized in the Agreement whose care is

206

managed by an MCO, an alternative strategy would need to be developed. Accordingly,

207

the Monitor is working closely with these Divisions to establish a methodology to

208

determine which MCO-managed individuals with diagnoses of serious mental illnesses

209

should be included on the TPPL based upon their admissions to a private psychiatric

210

hospital (in the Agreement's federal parlance, these facilities are known as "Institutions

211

for Mental Disease," or "IMDs"). As of this report, the Monitor and the State have

212

established at least an interim methodology, which is reflected in several sections that

213

follow. This protocol includes all MCO-managed hospital admissions for individuals

214

diagnosed with schizophrenia, as well as individuals diagnosed with certain serious

215

mental illnesses who have had at least one prior psychiatric hospital admission within a

216

two-year period. The diagnoses that appear to be most prone to misapplication by

217

Medicaid providers are not included in these interim numbers. Figures for DSAMH­

218

managed services are not affected since their data are usable as-is for monitoring

219

purposes.

220

The Monitor plans to work with the State in the coming months to assure that the process

221

ofDMMA data extraction is further refined by the time some of the critically important

222

targets (e.g., hospital bed-days) are evaluated in July, 2014. The data presented in this

223

report reflect the best current estimates as to where the State stands with respect to

224

compliance. Because of changes in methodology, figures that have appeared in prior

225

Monitor reports relating to the base year (2011) have been revised accordingly. The

226

numbers reported here may be further revised in the next report.

227

To present the status of compliance as accurately as possible in light of these issues, as

228

applicable in this report, measures that are reliant on DMMA's data are not only

229

presented as a single "State" figure, but also break-out DSAMH and DMMA

230

components.

6 


231

Recommendations:

232

1. It is strongly recommended that the State redouble its efforts to make immediate

233

improvements in its data capacities, particularly with respect to individuals with

234

SPMI whose care is managed via DMMA. It is essential that the State has timely

235

and accurate information about the numbers of individuals with SPMI who are

236

served through its public programs. The Monitor will continue to closely work

237

with the State in this regard.

238

239

2. It is strongly recommended that DHSS ensure that DMMA appropriately

240

prioritizes compliance with the Agreement and associated monitoring

241

requirements.

242

243

244

B. Targeted Priority Population List:

245

Section II.B of the Settlement Agreement defines the populations of people with SPMI

246

who are prioritized for the required service expansions. These include individuals who

247

have been psychiatrically hospitalized, who have been treated in an emergency room or

248

had criminal justice contact for issues attendant to SPMI, or who have been homeless. It

249

is not uncommon that a single individual has experienced several of these adverse

250

outcomes and, therefore, is represented in more than one of the statistics presented below.

251

Because of the status of the State's data systems and the need to gather information

252

across Divisions and Departments, creating the Targeted Priority Population List (TPPL)

253

was initially quite challenging. The State is continuing to greatly refine its capacities to

254

provide information about Delawareans with SPMI who are served by its public systems.

255

Based on currently available data, and applying the revised methodology with regard to

256

DMMA, the TPPL now includes a total of 11,131 individuals. By way of comparison,

257

the Monitor's last report (in September, 2013) indicated that there were 8,254 on this list.

258

The table below presents a breakdown ofthe characteristics of individuals on the TPPL,

259

including the proportion whose care is managed by DSAMH and the proportion managed

260

by DMMA. DMMA data are not included in the statistics related to the adverse

261

outcomes of criminal justice contact or homelessness. Emergency room treatment for

262

issues relating to serious mental illness is based upon Medicaid claims data and includes

263

both populations. Again, an individual may be represented in more than one category of

264

adverse outcomes.

7

265

Overall Composition of the TPPL

266

• Services managed by DSAMH (approx.).............. 58.8% 


267

• Services managed by DMMA (approx.) ............... 40.1 % 


268 


269

Adverse Outcomes Experienced by Individuals on the TPPL 


270

• Treatment at DPC 1 (DSAMH-managed) .............. 10.9% 


271

• Treatment in an IMD ............................................. 33.4% 


272

o DSAMH-managed ...................................... 15.7% 


273

o DMMA-managed........................................ 17.7% 


274

• Criminal justice contact (DSAMH) ...................... 16.2% 


275

• Homeless (DSAMH) ............................................. 18.2% 


276

• ER use for mental health (DSAMH+DMMA) ...... 50.0% 


277

The TPPL identifies Delawareans with SPMI who may be at high risk for adverse events 


278

and who are prioritized for specialized services and supports. In itself, inclusion on the 


279

TPPL need not indicate that an individual is in need of the full complement of intensive 


280

services offered by the programs developed in accordance with the Agreement; it simply 


281

suggests that there may be an elevated risk for one or more specialized mental health 


282

servIces. 


283

284

C. Delaware Psychiatric Center:

285

Over the past decades, state-operated psychiatric facilities nationwide have undergone

286

significant changes, shifting from massive self-contained facilities that warehoused

287

people for years on end to much smaller hospitals that provide active specialty treatment

288

directed towards successful community living. Prior to the development of this

289

Agreement, Delaware Psychiatric Center (DPC) had already embarked on reducing its

290

number of beds, although a sizable population of individuals remained on its long-term

291

care units because ofthe absence of appropriate community alternatives. The expansions

292

in housing and community services that have taken place in accordance with the

293

Agreement have allowed a substantial number of these individuals-some of whom were

294

hospitalized for decades-to return to their communities and to realize the opportunities

295

that are afforded them under the ADA. Their discharge to community settings

296

accelerated a shift in the function ofDPC that was already underway, from mainly

297

providing long-term care to more acute stabilization and recovery-oriented services.

298

I Forensic patients at the Mitchell building are not included in these numbers, since the criminal courts, rather than the State's human service programs, have control over them.

8 


299

Evaluation 0/Individuals Discharged Following Long Hospitalizations:

300

The Monitor's last report included data demonstrating the positive outcomes for

301

individuals who were discharged from DPC following extended continuous

302

hospitalizations, defined as 60-days or longer. As a brief update, in calendar year 2013,

303

102 such individuals were discharged to community settings, generally with ACT and

304

other high-intensity services discussed later in this report. The re-admission rates for

305

these individuals, following 30- and 180-days in the community are presented in the table

306

below. For comparison are the most recently published national readmission rates and

307

those for the state of Delaware.

30-DAY READMISSION
RATE
Post-Discharge DPC Population of 102 Individuals:

lSO-DAY READMISSION
RATE

Readmission Rates*

5.9%

13.7%

Comparison Rates:

U.S. Rates (SAMHSA, 2012)**

9.1%

20.1%

Delaware Rates (2013)

9.6%

23.1%

*The above numbers are based upon all clients discharged from DPe within FY13

following stays of 60+ days

u.s. **

Department of Health and Human Services, Substance Abuse and Mental

Health Services Administration, National Outcomes Measures, 2012.

308

309

As is reflected in their histories of protracted inpatient psychiatric treatment, members of

310

this population have significant levels of disability, often complicated by physical health

311

issues, addictions, and dependencies bred by long-term institutionalization. Nevertheless,

312

their readmission rates one-month and six-months following discharge from DPC remain

313

significantly better than the comparison populations with serious mental illness. These

314

data are a blunt-but very positive-measure of the impact of Delaware's investment in

315

alternative community based mental health programs. The low readmission rates for

316

individuals discharged from long-term care during this period are consistent with those

317

reported in the Monitor's September, 2013 report, for the prior year.

318

319

Facility Downsizing& Repurposing:

320

The successful discharge of individuals from DPC following long-term care has resulted

321

in significant reductions in bed-days at the hospital (see discussion below relating to

9 


322 


Section III.D.3) and to a reconfiguration of the facility towards more intermediate-term

323 


and acute care. These discharges have also enabled significant reductions in the

324 


hospital's average daily census. As is reflected in the table that follows, DPC's current

325 


average daily census of 115 is about 50% lower than it was in the State's 2008 fiscal

326 


year, and 30% lower than in 2011, the "base year" prior to the Agreement that is used as

327 


a comparison point for implementation monitoring.

Average Daily Census Delaware Psychiatric Center
250 ...,~,,··"9·~·"'··..···~..····~····..··-···· ........_... SEY 2Q,Qa.:.-SfY_2.014,. . ... "-"'-"_"_' __' 


200 
 150 
 100 

so
o

328 
 329 


*The Average Daily Census is based off the census for the Kent and Sussex Units.

330 


DPC can be regarded as providing three levels of non-forensic care: Long-Term Care

331 


(defined as 180 days+), specialized Intermediate-Term Care (defined as 15-179 days),

332 


and Acute Care (defined in the Agreement as 14 days or fewer). The following table

333 


shows how the proportions ofDPC's inpatient population are shifting from

334 


predominantly Long-Term Care and towards Intermediate-Term Care and Acute Care.

335 


336 


The Long-Term Care population at DPC includes individuals with SPMI with ongoing

337 


needs for intensive mental health services, often accompanied by physical health issues.

338 


While this group is defined here as individuals who have had 180 days of continuous

339 


hospitalization or longer, some have been in the hospital much longer, even for decades.

340 


The Intermediate-Term population includes individuals with SPMI with intensive mental

341 


health needs, most of whom were transferred from Acute Care from one of the IMDs

342 


because significant psychiatric issues could not be resolved within 14 days. DPC's

343 


Acute-Care population includes new admissions, mostly of people who either are

344 


uninsured or who have been carved-out of Medicaid Managed Care for DSAMH's

345 


intensive community programs; in either instance, DSAMH assumes the responsibility

346 


for the cost and management of inpatient psychiatric care.

10 


Long-Term, Intermediate-Term &

Acute Care in OPC

100%

B~se_JE!ar (2011) compared to 2014

80%

60%

40%

20%

0% DPC BASE YEAR (Avg 162 Beds)

DPC PROJECTED SFY 14 (Avg 115 Beds)

= • DPC ACUTE ::;. DSAMH-INTERMEDIATE DSAMH-LONG TERM CARE

347

348

349

To assist DSAMH in its ongoing efforts to improve the quality of care at DPC and to

350

assist DPC in its transition towards a more acute-care orientation, the Monitor has

351

facilitated expert technical assistance relating to nursing services and the hospital's

352

Utilization Review program. This technical assistance will be continuing during the

353

remainder of the year and, likely, beyond.

354

355

356

D. Reliance on Court-Ordered Treatment

357

358

Prior reports by the Monitor have referenced Delaware's long history of over-reliance on

359

court-ordered treatment and the disjuncture between this tradition and the reforms that

360

DSAMH is pursuing. Properly used, judicial involvement in mental healthcare is a last­

361

resort, emergency measure; its overuse signals problems in services earlier on.

362

Furthermore, unwarranted involuntary treatment-including court-ordered treatment to

363

reduce providers' perceived liability, assure payment, facilitate transports by police, or as

11

364

a substitute for good consumer engagement-is not the "least-restrictive" approach

365

consistent individuals' rights under the ADA and other laws.

Involuntary Inpatient and Outpatient
By Month Compared with Base Year Average (SFYll)

350
III
'iV 300
::I "lJ
:~ 250 "clJ - 200
'0...
.CaII 150
§ 100
Z 50

-- _-_ _._._-_.­ - - ..,..- .. ..... ..... ...,...-..,...~." ..~.....~.....~-,.....~~..,...-.....~.....~,.......,.~.~...- - .........,.,.... ..... .. ............ 3

...... ,..............-..... ....... ..........-_...- ........."..........- ...._......... ....202--·..--·__·....- ..- - ....

._.. e...... ...... ...........
.. .... .... 
 •"}:.9.b.,••. ...- ..- ..--.-.. .. ~.---

•• •• ~ ! ~ . ' ...~-~-!....- .. ..................'i ._· ......................._..................- .....- ......._ ..- . .... 


" ••,_ .•,••• 1' .. ......_ ..... .... ...__••_ .......... ......................... ._ •• _._......_ ••_ ••••__.._ _._••_ .. ....,......._. ,••__.................. .... .. ... .... . . .. . , ' ..' .

..._ ......, 

•• 80

.... _- .- .--..- ...- - - -........................- ........................................"...............,......"................._ ..._-.....- .........."_.........,,._..........- ....' 


o +--.---,--.--.,--.--,--.,--.-,---. -- .--,---.--.--,---.­
Base Yr Sep-ll Dec-ll Mar-12 Jun-12 Sep-12 Dec-12 Mar-13 Jun-13 Sep-13 Dec-13 Avg

-

TOTAL INVOL OUTPATIENTS ••••• TOTAL INVOL INPATIENTS

*Based on data provided to DSAMH's Eligibility and Enrollment Unit (EEU)

366

The State continues to make significant progress in extracting the court system from

367

routine care for individuals with SPMI and in moving towards a much more voluntary

368

approach to services. The chart above quantifies the State's dramatic progress in

369

reducing its reliance on court-ordered treatment for both inpatient and outpatient services.

370

It presents the number of individuals who were under active civil commitment orders

371

each month by type of order, as well as the monthly average for the base year prior to

372

implementation of the Agreement (i.e., July, 2010 to July, 2011).

373

The State has achieved about a 60% reduction in its use of outpatient commitments,

374

dropping from an average of 328 active orders in the base year to just 132 in February,

375

2014. This reduction is particularly significant since the number of people being served

376

in outpatient programs has increased during this period, including (as discussed above) a

377

sizable population of individuals with high levels of disability who had been served on

378

DPC's long-term care units.

379

In terms of inpatient treatment, there has been about a 50% reduction in reliance upon

380

involuntary treatment orders, with 162 as the average in the base year and only 80

381

inpatient orders in February, 2014.

382

The impressive progress that the State is making reflects an array of measures to change

12

383

practices and a service culture that saw involvement of the courts and police in mental

384

health services as unremarkable and routine. Some corrective measures taken by the

385

State have been major, such as the recent change in law requiring an evaluation by a

386

qualified screener (discussed immediately below) before a person is placed under an

387

involuntary hold. Other measures, such as expanding alternatives to police transports, are

388

less obvious but have important implications for everyday practice. Building upon its

389

success, the State is continuing its refinement in services to avert crises and to provide

390

alternatives to hospital care, and it is moving forward in examining ways to modernize its

391

mental health laws. These efforts can play an important role in furthering its

392

transformation of services systems towards least-restrictive care, voluntary engagement,

393

and a recovery orientation.

394

395

E. Mental Health Screeners

396

In July, 2012, Governor Markell signed into law a bill requiring that an assessment be

397

conducted by a certified mental health screener prior to an individual being detained on a

398

24-hour hold, which is the first step in the State's civil commitment process. Among

399

other things, the screener is qualified to certify that the individual indeed appears to have

400

a serious mental illness (as defined by law) and the screener must also certify that

401

voluntary treatment options were considered and appropriately offered. Following the

402

development of processes for screeners' certification and training by DHSS, mental

403

health screenings were implemented statewide on July 1,2013.

404

Based upon reviews by the Monitor and a consultant, the mental health screening process

405

appears to be off to a good start. A random sample of recent admissions to IMDs,

406

including individuals whose care is managed by DSAMH or DMMA, found that 100% of

407

the hospital charts examined had the required screening forms. Reflecting its new data

408

capacities, DSAMH is now in the position where it can evaluate the impact of mental

409

health screenings and their quality. For example, for people who were detained on 24­

410

hour holds, DSAMH is able to produce reports identifying the specific screener, the

411

facility in which the individual was screened (e.g., a particular hospital emergency room),

412

where the individual was hospitalized, and whether a screener's recommendation for

413

involuntary hospitalization actually resulted in that outcome. With regard to the latter,

414

DSAMH has already identified a surprisingly large number of instances whereby (after

415

offering an opportunity for voluntary services) screeners have authorized police transfers

416

and 24-hour holds; within a matter of hours, following transport to the hospital, the

417

individual then agrees to a voluntary admission. In the past, it was frequently reported to

418

the Monitor that, notwithstanding legal protections guaranteeing that individuals would

419

be afforded "least restrictive" measures, involuntary holds were a convenience to

420

emergency room personnel because the police (at great expense to Delaware's taxpayers,

421

the Monitor has learned) provide ready transportation to a psychiatric facility. Whether

13

422

the numerous instances of quick conversions of 24-hour holds to voluntary care reflect

423

the overall newness of the mental health screening process, inadequate screening

424

approaches, a lingering dependence upon convenient police transports, or individuals

425

changing their minds about accepting voluntary services are all unknowns. What is

426

important-and laudable-is that DSAMH is in a position to monitor how mental health

427

screenings are working, to develop some performance scorecards that can provide

428

screeners with feedback, and to make necessary refinements as things move forward.

429

F. Management of Clinical Services

430

The table below presents, in a somewhat simplified form, how responsibility for

431

management of public services to people with SPMI is assigned. Each of the Monitor's

432

four prior reports has cited how the State's bifurcated approach to serving people with

433

SPMI-some within DSAMH, and others within DMMA--creates fundamental

434

problems in managing services, ensuring good outcomes, using public resources

435

efficiently, and complying with some of the key requirements of the Agreement. Despite

436

repeated recommendations by the Monitor for the State to restructure things in ways that

437

clarify and consolidate accountability, develop consistent service standards, and establish

438

a unified information system to provide appropriate oversight, to this day the

439

management structure affecting citizens with SPMI remains largely unchanged. As is

440

discussed later in this report (in the section concerning Crisis Stabilization Services),

441

Delaware is taking measures to alter its Medicaid State Plan and restructure its contracts

442

with MCOs that may ultimately address many of these concerns.

443

DMMA

DSAMH

• Community-based services for individuals in Medicaid Managed Care
• Acute Inpatient Care at an IMD for individuals in Medicaid Managed Care

• Community-based services for individuals carved out of Medicaid Managed Care for much more extensive speCialized DSAMH services

• Inpatient Care at an IMD or DPC for individuals who are carved out of Medicaid Managed Care

• Inpatient Care and Community­ based services for individuals who are otherwise uninsured

• Inpatient Care at DPC for individuals in Medicaid Managed Care who are transferred from IMDs for intermediate- or long-term care.

444

14 


445

Currently, people with SPMI who are served through an MCO under contract with

446

DMMA have access to a much more limited menu of services and supports than do

447

people who are "carved-out" for DSAMH services. The more limited array of services

448

available through MCOs may appropriately meet the needs of some individuals with

449

SPMI, but the State lacks a clear mechanism to evaluate individual cases to determine

450

whether this is, indeed, the case. If people with SPMI were consistently referred to

451

DSAMH-at least for review, if not for direct services-there would then be a vehicle to

452

ensure that they are given an opportunity to access the broader range of services and

453

supports (many of them described below) that are not generally available through

454

Medicaid's managed care programs.

455

Based upon the State's data, as well as the Monitor's recent review of documentation by

456

the mental health screeners, there appears to be a sizable population of individuals with

457

SPMI and very serious levels of disability whose care is being managed by DMMA.

458

Unless these individuals are referred to DSAMH for carve-out, they do not get such

459

services as ACT, Supported Housing, Supported Employment, Respite, Transitional

460

Housing, or Intensive or Targeted Care Management. As is discussed throughout this

461

report, entry into the DSAMH system not only vastly expands the array of services

462

available, but also access to a system that is increasingly attuned to identifying the needs

463

of individuals with SPMI, measuring clinical outcomes, and ensuring quality.

464

To encourage greater numbers of referrals ofDMMA-managed individuals with SPMI,

465

several months ago DSAMH streamlined the process through which these individuals can

466

be assessed for carve-out. Unfortunately, this has not prompted any evident surge in new

467

referrals, in part, because it is unclear what entities within DMMA's domain have

468

responsibility for identifying candidates for carve-out or making an actual referral.

469

Furthermore, oversight of this important function-to the extent that it exists-is

470

embedded within the individual MCOs' practices and is not appropriately aligned with an

471

overall State standard.

472

As is discussed below, in the section on Crisis Stabilization Services, there are some

473

measures that are being planned to improve service coordination within DMMA and

474

between DMMA and DSAMH. Some of these measures will not be initiated until the

475

year 2015. At the present time, though, information about the number of individuals

476

under DMMA's management who have SPMI, what their needs are, and how well these

477

needs are being addressed remains unclear.

478

15 


479

III. Ratings of Compliance with the Agreement

480

The issues discussed above have implications that cut across the programs required in the

481

provisions of the Agreement that are discussed in this section. For instance, information

482

systems that produce timely and meaningful data are important not only for

483

demonstrating compliance with the Agreement's numerical targets, but also for

484

monitoring the impact, access and quality of services being provided and identifying

485

unmet needs. Furthermore, the unnecessary use of coercion through the courts, reliance

486

on police, or in provider interactions with individuals being served is inconsistent with

487

fulfilling both the State's legal requirements and its goal of recovery-oriented mental

488

health services.

489

For the period covered by this report, the State is in Substantial Compliance with each of

490

the targets that are required under the Agreement, except for Crisis Stabilization

491

(Sections II.C.2.d.iii and iv) and Risk Reduction (Section V.B); the State is in Partial

492

Compliance with these two provisions.

493

494

A. Crisis Hotline

495

Substantial Compliance.

496

Section IILA of the Agreement requires the State to establish a crisis hotline, allowing

497

individuals 24-hour access to assistance and referral information. Delaware remains in

498

substantial compliance with this provision in that it operates a fully functional hotline.

499

The table below presents its tracking of calls during this fiscal year. As would be

500

expected, the majority of calls are being received from New Castle County (NCC), where

501

most of the state's population is situated.

502

Total Crisis Hotline Calls
SFY14
3000 , .._-_..._-.-..- ...--...- - - - -..- _..-.....- ....­ _......_........._.....................................................-......................_.........._--..__.

2500

2000

1500

1000

500

o

Jul-13

Aug-13

Sep-13 Oct-13 Nov-13 • NCC • Kent/Sussex

Oec-13

Jan-14

503

*Crisis Hotline Calls are based upon monthly reported data provided by Mobile Crisis Intervention

16 


504

B. Mobile Crisis Services

505

Substantial Compliance.

506

Mobile Crisis programs are a critical element of the State's emergency response system

507

for people with SPMI in that they allow an opportunity for on-site evaluation and, ideally,

508

de-escalation of a crisis, as well as the referral of the individual to the most appropriate

509

service needed. As is required in Section III.B.1, the State has created mobile crisis

510

programs throughout Delaware. Furthermore, it is continuing to meet the important

511

target of a one-hour response time for mobile crisis calls. The chart below presents the

512

State's monthly monitoring of this provision for the teams stationed in New Castle

513

County and Kent/Sussex Counties. It demonstrates that the statewide program is well

Average Mobile Crisis Response Time by County SFY14

1:04
0:57 ••••••••••••••••••••••••••••••
0:50 0:43 0:36 0:28 0:21 0:14 0:07 0:00 +-----.-----r-----r--------.----,-----.------.
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

-

NCC -

K/S - - Overall • • • • Target

514

515

within its response-time requirements, even in the downstate counties of Kent and Sussex

516

(KlS), which are more rural and where travel tends to be more challenging. Response

517

times are recorded from the time a call is completed until the point at which a face-to­

518

face contact occurs. In reporting to the State, the mobile crisis programs provide

519

information when specific calls result in longer response times, for example, in situations

520

when callers request that the mobile crisis responder come at a particular time of day;

521

these are not included in the chart above.

522

Section III.B.2 requires the State to train state and local law enforcement personnel about

523

the availability, purpose, and procedure for accessing mobile crisis teams (Section III.C.2

524

has a similar requirement with regard to Crisis Walk-In Centers. Because these programs

525

and related training are interwoven, they have been consolidated for monitoring

17

526

purposes). The State remains in substantial compliance with these provisions. The table

527

below presents trainings that have occurred this fiscal year.

528

Number of Provider Staff & Law Enforcement Officers

Trained

160 ... . . .... .

­ S,..F...Y,....1...4." ........\.......'.....,'......." ..............,.~...................................

140 120 100

80

60

40

20
o
JUI-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

529

Training is coordinated and/or facilitated by DSAMH staff

530

531

C. Crisis Walk-in Centers

532

Substantial Compliance.

533

Crisis Walk-In Centers are an important element of the Agreement in that they provide

534

alternatives to hospital emergency rooms. They allow the evaluation of individuals who

535

are experiencing psychiatric crises in settings that are attuned to their clinical needs, as

536

opposed to physical health emergencies. Section III.C of the Agreement requires the

537

State to develop a Crisis Walk-In Center to serve downstate residents, where no such

538

service had existed. The Recovery Response Center (RCC), located in Ellendale, was

539

developed in fulfillment of this provision.

540

As is indicated in the following chart, between the State's single hospital-based service in

541

New Castle County (CAPES) and RRC, about 60% of individuals seen are able to be

542

diverted from hospital care. Whereas CAPES is hospital-based and operates more along

543

the lines of a traditional psychiatric crisis center, RRC's program is structured more

544

around the "National Living Room" model where, in addition to a multidisciplinary

545

clinical team, peer support is a central factor and the physical environment is much more

546

reflective of a comforting home than it is of a hospital. The figures presented in the chart

547

for this fiscal year are consistent with-and even an improvement upon-those reported

548

in the last Monitor's report. RRC consistently diverts a much greater percentages of

549

individuals from hospital care than CAPES.

18

RRC and CAPES Hospital Referral Rate 

SFV14 

70% ,,,,,,.,,,,,,,.,,,,.,,,,,,,.,,,,.,,,,,,,,,...,,.,-,...,-,,,.,-,..,,-,,,,,- , - - - ' "'---'''--'- ''- ''--'''-'''''-'''''-'''''-'''''''''''' '''''''-'''"-'''''- '''''''''''--'

Jul-13

Aug·13

Sep-13

Oct-13

Nov-13

Oec-13

• % Referred to Inpt Hospital (RRC) ~ % Referred to Inpt Hospital (CAPES) 8 Overall

550

·CAPES data for November and December are incomplete, but the reported rate is correct

551

Recognizing the success ofthe RRC program, and in concert with the state policy to do a

552

formal RFP every five years, the State is pursuing measures to develop a similar program

553

in New Castle County (this action was among the recommendations in the last Monitor's

554

report). A request for funds to support such a program has been made to the legislature

555

and is already in the Governor's approved budget.

556

557

D. Crisis Stabilization Services

558

1. Reduction in Inpatient Bed Days:

559

Trending Towards at Least Partial Compliance.

560

Section III.D.3 of the Agreement requires that by July 1,2014 the State will need to

561

reduce the number of inpatient bed days by 30% of its baseline, which is defined as the

562

inpatient bed use in the year prior to implementation of the Agreement (the State's Fiscal

563

Year 2011). This is an important provision of the Agreement in that it reflects the

564

combined effects of such factors as the State's new programs that are oriented towards

565

recovery and early intervention; the shift in its public system's practices and culture

566

towards voluntary, least-restrictive services; the impact of recently enacted legislative

567

reforms; and improved management capacities through better use of data. Furthermore,

568

the Supreme Court's decision in Olmstead specifically referenced unwarranted

569

institutionalization as a form of discrimination that is illegal under the ADA.

570

In addition to reforms in programs and practices, fulfillment of this requirement will also

571

reflect the State's success in restructuring its current convoluted division of

19

572

responsibilities for services to members of the TPPL. In the absence of clear, unified

573

mechanisms for evaluation, oversight, planning and accountability, it is difficult for the

574

State to control bed use in the private psychiatric hospitals. Likewise, it is difficult for

575

the State to demonstrate that actual bed use (notwithstanding the reduction targets within

576

the Agreement) is justified by the identified needs of the individuals affected.

577

To date, the State's success in regard to this provision has been uneven, but it is

578

increasingly moving towards compliance with the July, 2014 target. As is discussed

579

later, the State has recently developed a plan for reducing inpatient bed days for

580

individuals whose care it manages. It includes strategies such as 23-hour observation

581

beds, better access to detox for individuals with substance abuse problems, and more

582

integrated Utilization Review. Most components of the plan are not yet in effect, though.

583

At this time, bed days for individuals managed by DSAMH have been significantly

584

reduced for the long-term care population at DPC, largely because of new supportive

585

housing and intensive community services such as ACT, Intensive Care Management

586

(ICM), and the Community Reintegration Project (CRISP). In addition, the State has

587

achieved some more modest reductions in acute inpatient bed use among people managed

588

by DSAMH who are served at DPC or one of the IMDs. This accomplishment is

589

attributable to at-risk individuals' access to these high-end community programs, but also

590

to service approaches that are increasingly well-integrated with other resources DSAMH

591

has developed pursuant to the Agreement. Finally, the State's dramatic and continuing

592

improvements in its use of information systems for the management and oversight are

593

enabling the DSAMH to monitor quality and to adjust service approaches in ways that

594

had not been available in the past.

595

DSAMH has expanded its Utilization Review (UR) program for the inpatient populations

596

it manages and has sought technical assistance through an expert engaged by the Monitor.

597

The expert has been working with DSAMH around a number of refinements in its UR

598

system, including improved supervision of the UR nurses and more standardized

599

protocols for determining the need for inpatient psychiatric care. In reviewing records in

600

the IMDs, the expert found several factors that substantiated the urgency in improving

601

UR functions-and these apply to both the Utilization Review Processes provided by

602

DSAMH and UR provided for DMMA-managed individuals through the MCOs

603

(discussed below). Her concerns regarding the local private hospital (IMD) chart reviews

604

included such factors as:

605

• Admissions for preventable reasons or matters for which community alternatives

606

exist (an example cited is that of an individual ran out of medications while the

607

physician was on vacation);

608

• Vague treatment focus with poorly specified objectives and discharge criteria;

609

• Treatment that does not flow from the clinical assessments; and

20

610

• Assessments and plans that do not appropriately address recidivism.

611

Again, these fundamental problems in documentation within the IMDs not only have

612

implications for monitoring the effectiveness of hospital treatment that is being provided

613

to individuals with SPMI through use of State funds (DSAMH or Medicaid), but they

614

also challenge efforts to evaluate whether hospitalization is necessary or whether a less­

615

restrictive mode of intervention is more appropriate. This is a critically important

616

determination, in terms of compliance with the ADA and other laws, and also in ensuring

617

that public resources are not needlessly spent on expensive hospital services.

618

DMMA has responsibility for a sizable population of individuals who have been

619

diagnosed with serious mental illness. In theory, at least, individuals with SPMI who

620

require the higher intensity or scope of services provided by DSAMH are carved-out of

621

DMMA's Medicaid managed care programs and enrolled with DSAMH for their mental

622

healthcare (MCOs continue to manage physical healthcare for these individuals).

623

However, how within DMMA's system the State ensures that such individuals are

624

identified and appropriately referred, who has responsibility for carrying out these

625

essential functions, and how this overall process is monitored remains surprisingly vague,

626

even 2 lh years into implementation of the Agreement.

627

Furthermore, for those individuals with SPMI who, for whatever reason, are not referred

628

for carve-out, it remains unclear how such functions as crisis intervention, hospital

629

discharge planning or assessment of housing needs are occurring in accordance with the

630

requirements of the Agreement and where within DMMA's system oversight

631

responsibility rests. Data presented in the next section give a glimpse of the differences

632

between DSAMH- and DMMA-managed individuals with respect to discharge planning

633

in the IMDs.

634

These issues, which are pivotal with regard to fulfilling the requirements with regard to

635

bed-use reductions, are long standing. They have been referenced in prior reports by the

636

Monitor and, as noted earlier, are now beginning to be addressed. Because the important

637

target to reduce hospital bed use is impending, it is very important that the State

638

demonstrate a focused effort to improve the timeliness and reliability ofDMMA's data

639

with respect to the requirements of the Agreement and that it be able to present a reliable

640

consolidated State figure with regard to its level of compliance.

641

The table below presents projections as to bed-day use for this fiscal year, applying the

642

revised methodology-as it now stands-for DMMA-managed care. As was noted

643

earlier, the Monitor's continuing discussions with the State around DMMA's data may

644

result in additional revisions (either up or down) by the time the July target date is

645

reached. As such, these are tentative projections. They assume that current patterns of

646

bed use will continue through July, 2014. However, efforts now under way to further

647

reduce bed use-particularly among individuals with SPMI who are covered through

648

Medicaid Managed Care-may ultimately result in better outcomes than are shown. At

21

649

this juncture, the State's overall reduction in bed-days is projected to be 26.9%, largely as

650

a result of discharges from long-term care at DPC. Between long- and intermediate-term

651

care, DPC realized about a 34% reduction in bed days compared with 2011. Since the

60000
S()()()()

INPATIENT BED-DAY USE (REVISED METHODOLOGY) BASE YEAR AND FV 2014 PROJECTION

4()()()() 1 - - ­

30% REDUCTION

30000 20000 10000

PROJECTED CHANGE
OVERAU
-26.'"

o

,

BASE YEAR FY 2011

PROJECTED 2014

652

• DSAMH-LONG TERM CARE . DSAMH-INTERMEDIATE • DSAMH- ACUTE • DMMA-ACUTE

653

overall population ofDPC is reducing, particularly with respect to long-term care, the

654

State will find it difficult to achieve the further bed-day reductions that are required in the

655

Agreement ifit remains heavily reliant on practices in that facility.

656

Sections III.D.3-4 specifically reference reduction in acute care bed use. The chart below

657

presents projected change in the State's use of inpatient psychiatric beds for acute care,

658

defined in the Agreement as 14 days or fewer.

14000

CHANGES IN ACUTE BED-DAY USE 
 FOR INDIVIDUALS 

MANAGED BY DSAMH & DMMA 

(Revised Methodology)

12000

10000

8000

659

6000 4000 2000
o

OVERALL PROJECTED
CHANGE
-2.6%

FY 2011

PROJECTED 2014

• DSAMH - Acute • DMMA - Acute

22

660

As was described earlier, DMMA has oversight responsibility for acute inpatient care­

661

14 days or fewer-within IMDs for individuals whose behavioral health is covered

662

through Medicaid Managed Care. DSAMH manages acute care in IMDs or DPC for

663

individuals who have been carved-out from these programs based upon a need for the

664

more intensive services that it offers through its system, as well as for individuals who

665

are uninsured. Individuals whose behavior health is covered by Medicaid managed care

666

generally are not admitted to DPC unless they require intermediate- or long-term care

667

servIces.

668

The above chart compares acute inpatient bed-days in the base year (as managed by

669

DSAMH and DMMA) with what is projected for this year, based on current patterns of

670

hospital use. The projections indicate that, while DSAMH-managed acute care has been

671

reduced by about 19%, acute care under DMMA has increased by almost 8%. The latter

672

figure, which reflects the tentatively revised methodology for identifying individuals with

673

SPMI whose behavioral healthcare is managed through DMMA, is dramatically lower

674

than what would have resulted had the criteria used in prior Monitor reports been applied.

675

Generally, in accordance with the longstanding "IMD Exclusion" in federal law,

676

Medicaid programs do not pay for care in an IMD. However, Delaware is one ofa small

677

number of states where IMD services are reimbursed, through an arrangement with the

678

federal Centers for Medicare and Medicaid regarding its Medicaid managed care

679

program. This is essentially the reason that management of care in these facilities is

680

bifurcated in the State, with DSAMH having responsibility for state funded care (as is the

681

case in most other states with regard to IMD care) and DMMA having the unusual

682

responsibility for managing IMD care because it is reimbursed through Medicaid for

683

those who are not carved out of its managed care programs.

684

As was referenced earlier and in previous reports, this bifurcated arrangement presents

685

significant problems in terms ofthe State's oversight and management of inpatient

686

psychiatric bed use. Furthermore, to the extent that the State's ability to capture federal

687

reimbursement incentivizes IMD care (e.g., by relieving the State of the cost burden for

688

hospitalizations), it reduces pressure on the system to carefully evaluate the need for

689

admission and to develop appropriate alternatives. The clinical populations managed by

690

DSAMH and DMMA that are represented in the above chart are not all that different,

691

particularly given the new methodology that is being used. The differences in outcomes

692

are much more likely reflective ofDSAMH's stronger focus on diversion and utilization

693

review and the reality that the State is financially at risk for hospital services for the

694

population it manages. In contrast, this risk is mitigated by federal Medicaid

695

reimbursements with the DMMA-managed population.

696

In any event, if further refinements in the methodology for extracting DMMA data do not

697

significantly change things, the State will likely achieve---or come close to achieving­

698

compliance with the Agreement's important bed-reduction target in July, 2014. Whether

23

699

or not this turns out to be the case, it is important that the State demonstrates its best

700

efforts to identify individuals who are covered by the Agreement and to ensure that

701

hospitalizations-voluntary or involuntary-occur only when clinically justified and

702

when less restrictive alternatives are not appropriate.

703

DSAMH has launched on-site Utilization Reviews to evaluate whether or not hospital

704

care is appropriate for individuals whose mental healthcare it manages. In most

705

instances, but certainly not all, individuals being admitted for hospital care under

706

DSAMH management are already being served by a community provider, and there has

707

been a determination that hospitalization is, indeed, appropriate. In addition, when the

708

admission is on an involuntary basis, the State's evolving program of mental health

709

screening (discussed earlier) makes a similar determination.

710

When individuals managed through DMMA are admitted for psychiatric inpatient care on

711

an involuntary basis, mental health screeners are involved, as well. These individuals

712

may also be evaluated through Mobile Crisis or one ofthe Crisis Walk-In Centers if they

713

happen to appear there for services. However, individuals with SPMI whose mental

714

healthcare is managed through DMMA currently do not have access to the same array of

715

early interventions or alternatives to hospitalization that DSAMH provides (Crisis

716

Respite is one example). Moreover, the State maintains that its current contracts with

717

MCOs do not enable it to require that these contractors provide early mental health

718

intervention and diversion, whereby they would offer alternatives to hospitalization for

719

consideration by hospital emergency physicians. Similarly, MCOs' current level of

720

involvement in managing inpatient care within IMDs through their UR programs appears

721

to be significantly more limited than is the case with respect to DSAMH-managed care.

722

Possibly for these reasons, hospital days continue to rise for the DMMA-managed

723

population.

724

To address these issues, the Monitor requested that the State develop a specific blueprint

725

for bed-use reduction for all people with SPMI whose care it manages. Through a

726

collaboration between DSAMH and DMMA, the State has recently crafted some specific

727

measures aimed at ensuring that inpatient care occurs only when appropriate for people

728

with SPMI. These include:

729

• A State Plan to Reduce Inpatient Bed Use, with such elements as:

730

o the creation of 23-hour observation beds and crisis respite beds for MCO­

731

covered individuals to provide better opportunities to evaluate the need for

732

hospital care and make alternative referrals accordingly;

733

o refinements in DMMA's contracts with the MCOs to better integrate the

734

requirements of the Agreement (these were included in the recent Request for

735

Proposals issued by DMMA);

736

o expanded access to detox and substance abuse services;

24

737

o the creation of Quality Improvement scorecards with data relating to services

738

in eachIMD;

739

o pending modifications in the State's Medicaid Plan, through which DSAMH

740

will have expanded responsibilities for coordinating a broad array of new

741

services, including case management, through its "PROMISE" program;

742

o the potential for DSAMH to expand its Utilization Reviews within IMDs to

743

include DMMA-managed individuals, and

744

o the collection of data relating to the impact and quality of newly required

745

mental health screening prior to the issuance of involuntary holds and hospital

746

admissions.

747

• A streamlined process for referring individuals with SPMI who are in DMMA's

748

Medicaid managed care program for carved-out mental healthcare through DSAMH

749

(albeit with the limitations discussed earlier).

750

751

Not all of the these initiatives will have an immediate impact on inpatient bed use-the

752

new MCO contracts, for example, will not go into effect until 20 IS-but they are

753

certainly positive steps.

754

755

Recommendations:

756

1. As these measures go into effect, it is critical that the State has unified data

757

systems in place (i.e., with the capacity to integrate timely information about

758

bed use from DSAMH and DMMA) to allow for meaningful DR, ongoing

759

program monitoring and refinement, and to demonstrate these measures'

760

impact on bed use. This information is important in itself, and, in light of the

761

challenges of meeting this requirement, can also help demonstrate that the

762

State is making its best efforts to achieve compliance.

763

2. It is ,strongly recommended that the State immediately implement measures to

764

ensure that all individuals putatively having SPMI and meeting the criteria for

765

inclusion in the TPPL be evaluated for carve-out and access to the more

766

intensive services and supports that are available through DSAMH.

767 


768

2. Discharge Planning: 


769

Partial Compliance.

770

Sections II.C2.d.iii & iv of the Agreement require the involvement of a community

771

provider within 24 hours of the admission of an individual with SPMI for acute care in an

772

IMD or DPC. Based upon the Monitor's reviews, this appears to be generally occurring

773

within DPC. Either a community provider or, if no provider already has been assigned, a

25

774

Targeted Care Manager (TCM) meets with the individual and the treatment team,

775

beginning shortly after admission. In discussions with DSAMH, the practical goal was to

776

assure that these encounters take place within one business day.

777

To facilitate monitoring ofthis provision, DSAMH has developed a form to be completed

778

by community providers to record discharge planning and coordination activities for DPC

779

inpatients. The plan is to expand the use of this form to IMDs, both for individuals

780

whose care is managed by DSAMH and ultimately for those managed through DMMA,

781

as well. These measures will significantly improve data available to DSAMH for

782

monitoring the involvement of community providers and their role in effecting

783

appropriate discharge plans.

784

When a DSAMH-managed individual is admitted to an IMD, the Division's Enrollment

785

and Eligibility Unit (EEU) notifies the assigned community provider directly and also

786

identifies the provider to the IMD in order to facilitate care coordination and discharge

787

planning. No clear parallel system exists for DMMA-managed care.

788

In part to evaluate compliance with the Agreement's discharge planning requirements, a

789

consultant engaged by the Monitor reviewed a sample of charts in each of the three IMDs

790

relating to recently discharged individuals. The sample included both individuals whose

791

care is managed through DMMA and those managed through DSAMH. She reported

792

great inconsistencies in the engagement of community providers. She found poorest

793

compliance with the requirement for involvement by a community provider in two of the

794

IMDs, and in all settings, for individuals whose care is managed via DMMA. Monitoring

795

compliance with this provision was difficult because of inconsistent or conflicting

796

documentation within the IMD records, an issue that is further troubling because input

797

from a community provider should be so central to treatment and discharge planning for

798

individuals with SPMI. The table below summarizes her findings:

799

COMMUNITY PROVIDER INVOLVEMENT IN IMDs

(ope not included)

DSAMH-

DMMA-

Managed

Managed

Overall Rates

Community Provider contact w/in 24 hrs.

50%

12%

29%

Additional Community

Provider contact during

43%

0%

19%

remainder of hospital stay

800

801

Recommendations:

802

803

Engagement of a community provider in discharge planning for hospitalized

804

individuals is critically important to ensure that an appropriate array of services is in

26

805

place upon return to the community and that there is continuity in services and service

806

approaches. While there is a need for improvement both for individuals whose care is

807

managed by DSAMH and for those managed via DMMA, compliance with this

808

provision of the Agreement is particularly troubling for DMMA-managed individuals,

809

who account for the bulk of inpatient days within IMDs. Accordingly, it is strongly

810

recommended that the State:

811

1. Quickly move to establish a consistent system-wide process for documenting

812

the involvement by community providers within the IMDs and DPC, for

813

both DSAMH and DMMA-managed individuals;

814

2. Include monitoring of compliance with this requirement on the State's

815

monthly dashboard; and

816

3. Continue to avail itself of the technical assistance that the Monitor has

817

facilitated with regard to this, and other quality monitoring requirements

818

with respect to the targeted population within the IMDs and DPC.

819

820

E. Crisis Apartments

821

Substantial Compliance.

822

Section III.E.2 of the Agreement requires the State to develop a total of 4 crisis apartment

823

beds to provide temporary respite to individuals whose needs are not at a level requiring

824

hospital care. The typical length of stay in these crisis beds is designed to be about three

825

to seven days. The State has surpassed this requirement. It not only developed two crisis

826

apartments--one in the northern part of the state and the other in the southern part-each

827

with 2 beds, but it also made available an additional 4 respite beds, bringing the total to 8.

828

In addition, DSAMH has established 10 "Resource Beds" in the community that can be

829

flexibly used, including for crisis respite. Unlike the Crisis Apartments, these are not

830

staffed by peers overnight.

831

The table below presents trend data relating to the occupancy of the four crisis apartment

832

beds. Because the program is still fairly new, it is not yet being used to capacity. To

833

make better use ofthis resource, the Mobile Crisis Team has begun circulating updates

834

about vacancies in Crisis Apartments three times per day (once per shift) among team

835

responders and to DSAMH's Emollment Eligibility Unit. Furthermore, use ofthe crisis

836

beds is being monitored by DSAMH as a part of its monthly compliance scorecard.

27 


Percent of Crisis Apartment Bed Days Used

100% 
 _,..............,_............,_..".... ,_,..,_'_,.,_ "'.~,~,,~.f..Y.,~4 _ ..,~ '" '" _. '"


90% 
 - , ... -,...,-,...,-.....~.-....-....--.-

- -- 80%

-- .. • - '" ..,-,.,-,..,..-.-....-~,...,.......,~..... ... .....,~....•.~.....,-'....,_,....".,..... ' ,. _,.. .•,., ....".....
-~

. 70%
... _'-_ ___.-_ __ .. ....,- -' 60%

_..... ..... -.. -,..-~-..,...- ......- ... ...........- ......- .....,.....,....- .....~...-~.....-,..,..--,....,-,....,-....~-,-....~.-,-~-.,-._.,...,, ! .. _ ....._...­

.....,..,--~.,-..,-,-... ,...""" ,-",..........._,_... ... .... ... .. ._,-".......,..._....._,_ ,_

.~.. ---"
 •

50% 
 40% 

~.-'~:=~'i~~~~ ~'~:'i.~~~L~.~.::~~::.~...:::=::_~:~-~:.:~: :~:~~~.::~=:~ 30%
. - . 20% .__....._.._ ....._.....__.,_...__...._ ............"...._....._."..,,,.......,,...... ,..,...".......__.._~" .. .,i!!....._,.."........_,.........,'_
. ... .. ---­ 10% ......................"'...........,--.....-....--.....-...-..,...~..."...- ........-,.....-..".....,...._..~,•·..·....···1•.",.~......-......._..__....._......._ ...­

0% +-----~------~-----r----~r-----,-----~----~

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Oec-13 Jan-14

-

% Total Used (NCe) ••••• % Total Used (K/S) - - Combined % Bed Days Used

837

838

In both the northern and southern sites, the landlords of the crisis apartments have

839

expressed concerns about leasing units that will be used by unidentified tenants (i.e.,

840

individuals not known to them who come to be in crisis). As a result, in March, 2014,

841

DSAMH moved these crisis programs to free-standing houses, each with four beds. One

842

is located in New Castle County and the other is near the border between Kent and

843

Sussex Counties.

844

845

F. Assertive Community Treatment

846

Substantial Compliance.

847

ACT is a critically important service for people with SPMI who have intensive service

848

needs in the community. It is a well-established, evidence-based practice whereby

849

individuals received flexible, mobile services to promote their recovery and to help them

850

navigate the demands of community life. Section III.F.2 requires that the State have 9

851

ACT teams operational by September 1, 2013. The State has established 11 ACT teams

852

and is essentially already in compliance with requirements that go into effect in

853

September 2014 and 2015 (Sections III.F.2-3). The teams-7 in New Castle County and

854

4 in the southern counties-are in various states of development and emollment. The

855

table below summarizes the average numbers of clients active in teams within each

856

county. Full ACT teams can accommodate between 100 and 120 individuals. ACT teams

857

in the southern rural counties can accommodate somewhat fewer.

28 


Clients Per ACT Team
-- _ SFV14
120 ........................... ........ ....._ .--..,_.....................................,....." ................... _--.-.. .........__......-......_...,.......................--............... 


100 80

•••_ ...... ............ ... ..ft.•" •••, •••f...'-.Jt..~. ... ....._...A ......_

................._ •••••••_ .................................................._ ........... .._ ................_ . _ 


=-...-..-..;.-.....----.. ---._--...-..-.'..-...--._..-_..­.....-_........-.........•....... .....-...-
 .............

,~~ ~

~

- "';i;i;;i;i;.-iititiIJ,•••~__- . ....
.-

•.......... . - .•••.•••••••.••• 


60 . .................._.....""",................._.............................................",'..,....,...'"" .....",...,............................._.....................-......_-_.... 


20 ..,......."...... ................"...........,.....,....," '.',.......... ,_......_ .._'...............,...................,....,...........,...._......._....._..._......._ ..._......,..


o +------.-----.------.------.-----.------.-----~
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Oec-13 Jan-14

• • • • • NCC Clients/Team

- • • Kent Clients/Team

- - Sussex Clients/Team

-

Overall

858

859

DSAMH has an active program of surveying each ACT team for program fidelity (as is

860

required in Section ILD.2.a) and providing needed consultation. The survey process

861

includes written appraisals of each team's adherence to the program model and, as

862

indicated, corrective action plans. In addition to fidelity surveys, DSAMH monitors

863

various quality measures relating to its ACT and Intensive Care Management programs,

864

examples of which are presented in the charts below.

865

The first chart (which reflects responses to Question 1 on DSAMH's Quality survey

866

instrument) presents the number of ACT members who were homeless for any night

867

during the month reported. Overwhelmingly, the reported instances of homelessness do

868

not represent individuals who are receiving ongoing services; instead, they reflect the

869

housing status of new members who are being enrolled in services. For instance, the NHS

870

team, which showed a 5% homeless rate in December, is actually a new ACT team that

871

was just recently launched. Nevertheless, access to this information allows DSAMH to

872

monitor this adverse outcome and, as applicable, to take appropriate corrective actions.

873

29

ACT/ICM Providers 


Question 1 


Percentage of Consumers Homeless for Any Night 


6% ................................._........................d....u....r...i..n....g......t...h.....e......M.......o.....n....t...h....:.....
.._................._....__....._ ......_.............

4%

: .,......... .. ' . .......n··..·······..···,,·_ · ·...·rr......••..·_···_···········•••••••~.......................................................- _ ••!....._....._ .._....It....~••: •••.. _ •••.'•.• 


::' '

........ 

....

2% .................................. ..................- ..................- ..........,.~..- ................"'........!..l ......................................~............. 


4 ~. , .... ' ,

.1. ... . "

0%

Jul..13 Aug..13 Sep..13 Oct..13 Nov-13 Dec-13 Jan-14

· Conn -

HH - - - RHO ...... NHS

874

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

875

The following trending charts present additional quality measures being monitored by

876

DSAMH The first shows the percentages of ACT clients who were arrested each

877

month-rather low figures given the level of disability of these individuals and the

878

frequency of co-occurring substance use problems. The next presents the number of

879

individuals hospitalized for psychiatric inpatient care. Again, with respect to this

880

measure, some of the hospitalizations reflect individuals being enrolled in the ACT

881

program and their hospital status at the point of enrollment.

ACT/ICM Providers Question 2
3.0% ...__....._.............__......P-er.c.entage..Qf.CQns.u.m.er.~.Ar.re.ste.d.~......................................................

2.5% 2.0% 1.5%

.........................................., ........._.................................._.-......................................................................,..........,...................... 

I
...........,....._..........." .............\.._...._ .........................................................._...- ..............- ............_ _.._.._..._............... 

\

1.0%

0.5%

0.0%

Jul-13 Aug..13 Sep-13 Oct-13 Nov..13 Oec-13 Jan..14

· Conn -

HH - - RHO ...... NHS

882

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

30 


ACT/ICM Providers 
 Question 3 

Percentage of Consumers Hospitalized In Psychiatric Hospital 

10% ........................................................................._.................._..._ ...._ ..._................................................................_ ...._.._.. 


8% .................. .....__.._....._..........._.............................................................................................................................._........- ..

6%
4%
2%
0%

-. -. , __ _ _ ............................................... .................. -..................._......... ... ......... ................................................................. 

.. .-' - - -- .. . ,.... ....__.....-._..-..._-._--_..-..._~_..~......~..............~......-.....:...:..-..........~ .................._........................._-...._-......-......-...--....-........~......~...-..............­
.. . .'. ' .' '

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

- • · Conn -

HH

- - - RHD

•••••• NHS

883

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

884

885

The table below presents the percentages of ACT clients who used a hospital emergency

886

room during each month. These encounters could reflect either physical health issues, or

887

behavioral issues.

- --------,
ACT/ICM Providers 


Question 5 


Percentage of Clients with Emergency Department Visits: 


12% 10%
8% 6%
4%
2% 0%

..................................._..._ ........................_.................................................................................................................................. 


" " - - _ ___ _ _ ..............................................~................... ............................. ....._............... ......... ... ... ............ .............

" , _. - ­ , ~ -
..............- ........- ...................,............, ......................:iiI"....~...<f'!!'::....._ .............\ ...._...................... .......................- .. 

, . , ;'
.... .... . "., . ' . ,
 ......................~..............-.............-.--\...- -,;'-- ......- .....- .....- ...--__.._....._.....__..............._ ...._ ...<f!....__..

. ..'

.. . ' ." ..' . '........,'............... .......... 
 ..~... .............. ........... .. ...............:••••,.." ......I ...... ,.,•••'••''' ......." •••••'''...... . ,•• ••••;:.~II..~

~

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan..14

- • · Conn

-

HH

- - RHD

•••••• NHS

888

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

889

Finally, the table below presents the percentage of ACT clients who are employed each

890

month, in terms of the number of hours per week that were worked.

31 


ACT/ICM

Employed Clients as Percentage of Overall Census

FY14 through January

12%

- - _...._....._ ...._...... ...... ...,.............,..._................................................................_............................


10% ,....- ........__......_,..,........"--",.....",....."",,......_.., _....,-'...,--....., "....-"...'--.-,_...- ..'.-....- ....."...,-.._,,_.-­

8% 


6% 


4% 


2% 


0% 


13-Jul Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

.<10 Hrs/Wk

1110-20 Hrs/Wk

• >20 Hrs/Wk

891 892

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

893

As has been discussed throughout this report, DSAMH is making significant progress in

894

its capacities to capture timely data and to do trend analyses of key indicators of quality.

895

The tables above evidence this commendable progress and reflect the State's success in

896

meeting its obligations around Quality Assurance and Performance Improvement

897

(Section V of the Agreement).

898

899

G. Intensive Care Management

900

Substantial Compliance.

901

Section III.G.2 of the Agreement requires the State to have a total of 4 Intensive Care

902

Management (ICM) teams operational by January 1,2013. The State is surpassing this

903

requirement in that it has a total of 5 ICM teams. The Agreement requires that each staff

904

member on a team have responsibility for no greater than 20 clients and that the

905

supervision of staff be no less intense than a one-to-ten ration. ICM teams vary in their

906

levels of staffing and in the numbers of individuals served. Based upon a staffing review

907

of some of the teams, it appears that the State is appropriately meeting the requirements

908

for staffing ratios. The table below presents the number of clients per ICM team and an

909

overall trend towards these numbers increasing as new clients are added to each team.

32 


,--­

Clients Per ICM Team
SFY14
160

140

.-.... .., ...

120 100
80 60

- - ..----.... -- -- . . .-.­ . .. ... .. ...... .. . ...... . ... .. . .. .. .. . ... .. . •••• •..v. ;>
--.---- ----­ ~

...

40

20

0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

910

- . •••••• NCC Clients/Team • Sussex Clients/Team

- - - Kent Clients/Team

-

Overall

911

It is also worth noting that, given the level of need demonstrated by clients assigned to

912

ICM, the State is now reconfiguring its teams to allow for more intensive levels of

913

staffing. It plans to enhance staffing levels on four of the ICM teams to that of ACT

914

teams; it will maintain one ICM team at its current staffing levels because it appears that

915

an increase in staff intensity is not clinically warranted. The numbers of individuals

916

served are not expected to be affected by these changes. These changes result in

917

enhancements in staffing levels over and above what is required in the Agreement for

918

ICM and, as such, do not change the State's Substantial Compliance with this provision.

919

920

H. Case Management

921

Substantial Compliance.

922

Section IILH.2 required the State to have a total of 18 Targeted Care Managers (TCM)

923

available to assist individuals in identifying and accessing needed community services

924

and supports. The State continues to surpass the requirements of this provision, having a

925

total of 25 TCMs available statewide. The Agreement requires that each care manager

926

serve no greater than 35 individuals at a time. The chart below demonstrates that the

927

State is well within this guideline.

928

Both within hospital and in the community, TCMs playa critical role in linking

929

individuals who have SPMI to needed services. For many such individuals, they are the

930

"front door" the State's mental health service system. Depending upon the specific needs

931

of the individual, TCM may be a brief service, or one that extends in time.

33 


Average Case Load Per Case Manager 

SFY14 


18

16

14 12 10 8

- ­ - -­ .- - .. .............

-­

"
. ....

. . ..... -.~

. .

6 -

4

2

0

Jul-13

Aug-13 Sep-13

Oct-13

Nov-13 Dec-13

Jan-14

932 933

•••••• State State - Avg Clients/CM

- - - RI - NCC RI NCC - Avg Clients/CM

- • • RI - Ellendale RI Ellendale - Avg Clients/CM

-

Totals Overall- Avg Clients/CM

934

935

I. Supported Housing

936

Substantial Compliance.

937

938

Housing is a critical need for many individuals with SPMI. The Agreement seeks not

939

only to address this need, but to do so by creating housing for individuals that reflects the

940

vision of the ADA that people with disabilities-including SPMI-can live like ordinary

941

citizens. Accordingly, the Agreement includes requirements that the State develop new

942

housing that is integrated in the community (as opposed to congregate housing or

943

clustered developments that are limited to people with disabilities) and that they develop

944

individualized supports to allow people to live successfully as neighbors and tenants.

945

946

Section III.I.4 of the Agreement will require the State to fund a total of 550 supported

947

housing vouchers or subsidies by July 1, 2014. The State is already in compliance with

948

this provision in that it has funded at this level. As would be expected, there has been

949

some movement and vacancies among individuals who had secured supported housing

950

vouchers in past years- for instance, some have had difficulty finding an apartment to

951

their liking, and some had problems adjusting to this housing (generally due to co­

952

occurring medical needs). Furthermore, due to changes in how some of the HUD

953

vouchers that had been utilized in past years were administrated (by parties other than the

954

State), there has been a need to replace some of the housing slots that were counted in

955

past years. As a result, there has been some "back-filling" of housing slots that were

956

created and, prior to this fiscal yearend, counted with respect to past evaluations of

34

957

compliance. The following chart demonstrates how DSAMH is tracking the utilization of

958

Supported Housing vouchers, including individuals with vouchers who are in the process

959

of seeking housing and the number of additional vouchers available. As has been noted in

960

prior reports, DSAMH has been diligent in monitoring both the quality of housing and

961

compliance with respect to the requirements for integration that are delineated in the

962

Agreement.

963

Supported Housing Status FY14
600 ~------------------------------------------------

500

400

300

200

100

o
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

= • FYll-FY13 Total

SRAP W/Voucher looking III Remaining FY14

964

965

966

Making arrangements for permanent supported housing can take several months-­

967

securing an apartment of an individual's choice, getting furnishings, putting benefits in

968

order, and so on. To enable individuals to leave hospital settings while these

969

arrangements are being made, DSAMH has established 17 transitional beds. In addition,

970

the Division has created 10 Resource Beds in the community that can be flexibly used for

971

housing transition purposes or for respite, according to the immediate need.

972

In summary, the State is creating integrated supported housing opportunities for

973

individuals with SPMI who, in the past, would remain institutionalized or whose options

974

would be largely limited to congregate settings. The supported housing efforts the State

975

has made pursuant to the Agreement represent a distinct change in culture and practice, in

976

accordance with the ADA. This was an early focus in its implementation efforts that was

977

commendable early on, and that remains so to this day.

978

35 


979 980 981 982 983 984 985 986 987
988 989 990 991 992 993 994 995 996 997 998 999 1000 1001 1002 1003

J. Supported Employment
Substantial Compliance.
Section III.J.2 of the Agreement requires the state to provide supported employment services to a total of 400 individuals. As has been noted in earlier reports, there are several levels of employment services provided through the State's Division of Vocational Rehabilitation (DVR). For purposes of evaluating compliance with this provision, only individuals who have at least progressed to the point of having an active vocational plan are being counted. The Monitor's last report found a total of 569 individuals who met these criteria, thus surpassing the Agreement's requirements in

New Clients Receiving Supported Employment (Running Total)
400 ~........--...­ .....--..............­ ..................~,~.•.~~...........,...................- ............. ..--..----. 350 +.......-._-.........­ ...................-....................................... .......................................- ... - ­ 300 -1-_.....__._...._-............_ ...­ ...._ ......... 250 .,_......._.....__....................­ ..-_.......................... ....

200 150 .,............_....._..._..._ .....­ ........................... .......

100

50
o -I­-

'--r­

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

*Supportive Employment numbers are based upon from the Division of

effect. Given the current rates, DSAMH estimates that approximately 600 individuals on the TPPL will receive supported employment services this fiscal year, thereby again exceeding the requirements of the Agreement.
It has been noted in previous reports that there is an unusually positive working relationship between DVR, which is situated within the State's Department of Labor, and DSAMH, which is a division ofDHSS. Accordingly, a large percentage of the individuals receiving services through DVR have SPMI. This very much benefits the State's fulfillment of the requirements of the Agreement. Nationwide, unemployment among individuals with SPMI is shamefully high. As is the case with where one lives (e.g., in integrated supported housing, as opposed to a specialized facility), whether an adult with disabilities such as SPMI is in the mainstream workforce is an important "bottom line" indication of the impact of the ADA. The State is making admirable progress in this regard.
36 


1004

K. Rehabilitation Services

1005

Substantial Compliance.

1006

Section III.K.2 of the Agreement requires the State to provide rehabilitation services to a

1007

total of 600 individuals. As was discussed in the last report, rehabilitation services

1008

comprise an array of activities, such as education, substance abuse treatment, and

1009

recreational activities. Some of these components are not well defined in the State's data

1010

systems. Furthermore, without sufficient intensity the meaning of the service is

1011

questionable. Applying the criteria used in the last report, figures are as follows:

1012

• Psychosocial Rehabilitative Services, Psychosocial

1013

Group Services, or Family Psychosocial Education was

1014

provided at least twice per month for at least 6 months ............ 259 individuals

1015

• Some level of substance abuse service for a co-occurring

1016

disorder was provided during the year....................................... 978individuals

1017

• Total Unduplicated Count.............................................. .. ....... 1,222 individuals 


1018

The State is surpassing its requirements with respect to Rehabilitation Services and has

1019

already met the July, 2014 target of 1,100.

1020

1021

L. Family and Peer Supports

1022

Substantial Compliance.

1023

Family and peer supports are incredibly important means of enhancing individual's

1024

natural social connections. Peer supports in particular allow individuals to connect with

1025

people who have "lived experience" with mental illness and the various systems that

1026

provide services to them; they are a crucial element in promoting recovery. Section III.L

1027

of the Agreement required the State to provide Family and Peer Supports to a total of 500

1028

individuals by July of2013, and will require services to an additional 250 individuals by

1029

July 1,2014. The State's data system makes it difficult to extract an unduplicated count

1030

of peers and families being served, but the numbers of contacts-2,500 in January, 2014

1031

alone-strongly suggest that it is meeting, if not exceeding this requirement. Past reports

1032

have recognized the State's successful promotion of very robust peer programs at DPC

1033

and in the community. The chart below demonstrates the degree to which peer supports

1034

have become a routine and important part of the various elements ofDSAMH's system.

1035

37 


1036
1037
1038
1039
1040 1041 1042 1043 1044 1045
1046 1047 1048 1049 1050 1051 1052 1053 1054 1055 1056 1057 1058

Peer Total Contacts

3000

' " ,,,...,,",,.,,"'F,,..Y.,,'"1""4"".."""""""..................................,,.....,,.......,,....................."...."·..·..·..·,,....1

2500 ........"..""......"."....""_.......-,......._,,....._.,,..-.,,-- -_.".._..".-...._."....'_.,.............".""......"....",...."""......",,·......·__,,·....·1

2000 1500 1000 500

Jul..13 Aug-13 UIJ DPC Peer Contacts

Sep-13

Oct-13 Nov-13 Dec..13 I:JI Trauma Peer Contacts

8 ACT/ICM Combined Census

• CRISP Census

*Peer Contacts represent both engagement and intensive contacts

Jan-14

M. Quality Assurance and Performance Improvement
Substantial Compliance.
Section V of the Agreement requires the State to develop systems to ensure the quality of services offered and to improve service outcomes. Aided by its improving data capacities, DSAMH is increasingly enhancing its Quality Assurance (QA) and Performance Improvement (PI) efforts. In addition, the Monitor has arranged for ongoing technical assistance with respect to these important functions. Evidence of measures taken by DSAMH in this regard appears throughout this report.
In addition, DSAMH has contracted with the University of Pennsylvania to provide quality of service research with regard to service outcomes for individuals on the TPPL and for the CRISP program (a program providing flexible, intensive services and supports primarily to former long-term inpatients ofDPC). UPenn's research with regard to the TPPL is comprehensive, allowing longitudinal evaluations of cohorts of individuals appearing on the list. In plain language, this means that the researchers are examining outcomes for individuals who were placed on the TPPL during the initial year of implementation, and that they will be able to track how these individuals fare in the following year, the year following that, etc., with regard to such factors as hospitalizations and emergency room use. The researchers will be able to conduct similar assessments for people placed on the TPPL in year 2 of implementation, and so on. This study is ongoing. It should be able to provide invaluable information about service outcomes for individuals with SPMI and how these outcomes change as the various new
38

1059 1060
1061 1062 1063 1064 1065 1066
1067 1068 1069
1070 1071 1072 1073 1074 1075 1076
1077 1078 1079 1080 1081
1082
1083
1084 1085 1086 1087 1088 1089 1090 1091 1092 1093 1094 1095 1096

programs that have been launched mature. This is important not only for Delawareans, but for other states that are pursuing reforms in their systems in fulfilment of the ADA.
The CRISP research includes periodic clinical and functional assessments of individuals in the program, as well as interviews with clients and staff about their perceptions of the program and its impact. The UPenn research relating to the TPPL includes individuals whose care is managed by DSAMH and by DMMA. The research relating to CRISP, which is a program administered by DSAMH, includes only individuals whose care is managed by that entity.
UPenn's longitudinal studies are in relatively early phases. As significant findings come to be generated, they will be incorporated in DSAMH's QA and PI processes and, no doubt will be included in monitoring reports.
At this juncture, the State is in Substantial Compliance with the provisions of the Agreement relating to Quality Assurance and Performance Improvement. This rating does not mean that the relevant systems are all in place, and properly and fully functioning, but it does reflect the finding that DSAMH is taking appropriate steps to develop comprehensive and meaningful programs to fulfill these requirements. Meeting the Agreement's requirements for QA and PI requires a long-term, ongoing endeavor which will likely extend through the term of its implementation.
Although QA and PI efforts are far less clear with respect to individuals managed via DMMA, overall the State is where it should be with respect to the requirements of Section V and, for this reason, is in Substantial Compliance. Maintaining this rating, of course, will require a continuing effort and more focused consideration of individuals whose behavioral health care is coordinated through Medicaid managed care.
N. Risk Management
Partial Compliance.
Section V.B ofthe Agreement requires the State to have risk management systems in place that address adverse outcomes for individuals in DPC, IMDs or community programs. There are currently multiple systems at multiple levels within DHSS, DSAMH, DPC, the IMDs, and community programs that are intended to capture information about adverse events, including abuse, neglect, injury and death, and to ensure appropriate corrective action. The multitude and idiosyncratic nature of these processes significantly dissipates the overall impact of any system-wide risk-reduction efforts. What entity reports an adverse event affecting an individual covered by the Agreement, to whom the report is made, and with what consequences may depend largely upon where the incident happened to occur. For instance, an event in a State-operated setting (such as DPC or a group home) may trigger a "PM-46" report that ultimately
39 


1097 1098 1099 1100 1101 1102 1103
1104 1105 1106 1107 1108 1109 1110 1111 1112 1113 1114 1115 1116
1117 1118 1119 1120 1121 1122 1123
1124
1125 1126 1127 1128 1129 1130 1131 1132
1133

lands in the Division of Long Term Care. The same event happening in an IMD or in a community program may be subject to reporting and, as indicated, investigation by DSAMH. Similarly, DHSS has a Mortality Review Committee that examines deaths and, as indicated, their root causes, but only within programs operated by the State. In summary, there is no single system-wide repository for reports of adverse events and there is no single system-wide authority that conducts investigations, for oversees corrective actions, and implements risk reduction measures.
As a concrete example, there was an adverse event in DPC that involved an individual on the TPPL choking on food that was a not a part ofthe individual's prescribed diet. Just by happenstance, the Monitor learned of a very similar event that occurred with another individual who was living in a community setting. These events were reported according to the required protocols, investigated, and corrective action plans were developed. Yet, the reporting, investigations, and corrective measures taken occurred in isolated bureaucratic streams. There is no mechanism for capturing information about the frequency of choking episodes within the overall service system-both those that result in injury and those that are "near-misses" as a result of timely staff intervention. Likewise, there is no mechanism whereby DHSS might use these data as a basis for taking some system-wide preventive measures, such as issuing an alert about appropriate procedures to prevent choking. Without question, there are similar instances relating to other adverse events that are not being captured.
The State's various parallel, disconnected systems of incident reporting and risk reduction are very difficult to understand, either individually or collectively. Properly configured, risk-reduction measures should be straightforward, transparent, and accountable. The systems that are currently in place appear to be largely an accumulation of measures that have been taken over the years, either in response to an adverse event or to comply with some specific certification or regulatory requirements. What is sorely lacking is an overall blueprint for risk reduction.
Recommendation:
It is strongly recommended that DHSS establish a unified, system-wide process for reporting adverse events, conducting investigations and root cause analyses, ensuring corrective actions, and broadly implementing preventive measures. Embedded in the various processes now in place may well be some model practices or promising approaches; an initial first step might be to map out current systems and to explore the feasibility of making them universal. Critical to any reconfiguration is that there be data systems in place that provide timely and usable information.
40 


1134
1135 1136 1137 1138 1139 1140 1141 1142
1143
1144 1145

IV. Summary This report documents that the State continues to make impressive progress towards fulfilling the multiple requirements ofthe Agreement. This progress is being demonstrated not only in meeting the quantitative targets contained in the Agreement, but also in moving Delaware's public systems increasingly in the direction of supporting the recovery of people with SPMI and their inclusion in their communities-factors that are less easily reduced to numbers. The collaborative relationship between the State, DOJ, and the Monitor, no doubt, has created an environment that promotes the success that is being realized.
\v Court Monitor

41 


 
 1

SIXTH REPORT OF THE COURT MONITOR

2

ON PROGRESS TOWARD COMPLIANCE

3

WITH THE AGREEMENT:

4

U.S. v. STATE OF DELAWARE

5

U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS

6

December 29, 2014

7

8

9

I. Introduction

10

This is the sixth report of the Court Monitor (Monitor) on the implementation of the above-

11

referenced Settlement Agreement (Agreement) between the United States, through the U.S.

12

Department of Justice (DOJ), and the State of Delaware (the State). This report presents

13

compliance data and ratings covering the six-month period January 16, 2014 through July15,

14

2014, and it also includes more recent findings with respect to certain aspects of the State’s

15

implementation efforts.

16

At this juncture, the Agreement has been in effect for well over three years. The State

17

continues to make admirable progress in achieving most of the benchmarks delineated in the

18

Agreement, and also systemic reforms that will help ensure that these reforms are sustainable

19

and well aligned with broader practices affecting individuals with Serious and Persistent

20

Mental Illnesses (SPMI). As has been noted in prior Monitor reports, Delaware has had

21

special challenges in assuring that all individuals in the population targeted by the Agreement

22

benefit from the full array of services and supports required in its provisions. To a large

23

degree, this is because the State has a bifurcated system, whereby a significant population

24

with SPMI receives specialty mental health services under management by the Division of

25

Substance Abuse and Mental Health (DSAMH) and another significant population with

26

SPMI receives services through Managed Care Organizations (MCOs) that operate as agents

27

of the Division of Medicaid and Medical Assistance (DMMA). Both DSAMH and DMMA

28

are divisions of the Department of Health and Social Services (DHSS). Theoretically, at

29

least, those individuals with SPMI who are at high risk of adverse outcomes and who require

30

intensive mental health services are referred from DMMA to DSAMH for specialty care.

31

Although the system managed through DSAMH is still evolving, individuals’ needs are

32

routinely assessed and Assertive Community Treatment (ACT), supportive housing, and

33

other services critical to achieving the Agreement’s goal of community integration are

34

largely in place and subject to ongoing efforts to improve performance and quality. As is

35

discussed later in this report, however, the State still has not demonstrated a similar

36

understanding of the needs of the significant SPMI population whose care is managed

37

through DMMA, nor does it have an effective means of ensuring that these needs are being

1

38

addressed in keeping with the requirements of the Agreement. In many important respects,

39

during the past 3 ½ years, the State’s approach to managing services to the relevant DMMA

40

population has not palpably changed, and things have remained pretty much as they were

41

prior to the Agreement.

42

As with any complex public system serving high-need individuals who often have multiple

43

clinical, social and legal challenges, the State routinely confronts problems in service

44

provision and unanticipated adverse outcomes for some individuals. An important difference

45

between the State’s two service structures is that, under the leadership of the DSAMH

46

Director Huckshorn (who recently resigned from her position), DSAMH has in place systems

47

and data sets to track the quality of care provided, service outcomes, and risk factors. These

48

are functions required by the Agreement (e.g., Section V), but have been essentially absent in

49

any comprehensive form for individuals served through DMMA for whom the Agreement

50

also applies. As a consequence, although the State is largely in compliance with the

51

Agreement with respect to services and outcomes provided through DSAMH,

52

notwithstanding some recent efforts to improve the referral process for specialty mental

53

health services, it is very difficult to ascertain its status with respect to those whose services

54

are managed through DMMA.

55

What is clear is that individuals who are at high risk and who, ostensibly, are in need of

56

specialized services have remained under DMMA’s management. Based upon a small

57

random sample that was not even constructed to identify people who may require specialty

58

mental healthcare through DSAMH,1 the following scenarios emerged with respect to

59

individuals served through MCOs who were being involuntarily re-hospitalized in a private

60

psychiatric hospital (an “Institution for Mental Disease,” or “IMD”):

61

 Mr. A is a young man with a long history of substance abuse, a co-occurring mood

62

disorder (possibly schizoaffective disorder), and history of suicide attempts, for

63

instance, attempting to hang himself while in jail. He was hospitalized after slicing

64

his neck with a knife.

65

 Ms. B is a middle-age woman who has been homeless for about 9 years, has a history

66

of bipolar disorder and co-occurring substance use and psychiatric hospitalizations.

67

She was re-hospitalized after she stopped eating, discontinued her medication in an

68

attempt to trigger a diabetic coma, and threatened to shoot herself.

69

 Ms. C is a young woman who was homeless and living in a hotel. She is reported to

70

have a long history of violence and is diagnosed with Bipolar Disorder and co-

71

occurring substance use. Ms. C has had multiple admissions to psychiatric hospitals

72

and was complaining of depression at the time of this hospital admission. At some

1 The sample comprised individuals—both with care managed through DSAMH and DMMA—who were admitted to an IMD in southern Delaware under 24-hour psychiatric detentions in January, 2014.
2

73

point after her discharge from this hospitalization, she was referred to DSAMH for

74

services.2 But by the time the referral was made (evidently several weeks later), she

75

could not be located. Had discharge planning occurred in compliance with Section

76

II.C.2.d.iii of the Agreement, there would have been a seamless transition to

77

community services (including housing), and it is unlikely that this outcome would

78

have occurred.

79

As is characterized in these examples (which, again, were not sampled by the Monitor with

80

the intent of identifying individuals appropriate for DSAMH’s services), people known to

81

have SPMI and who are clearly not doing well in the community have not been successfully

82

referred for specialty mental health services through DSAMH.3 Furthermore, there is no

83

evidence to suggest that DMMA has in place a working system to appropriately identify such

84

ostensibly high-risk individuals and to assure that the State is meeting its obligations to them

85

under the Agreement and the ADA.

86

As is described later in this report, the State has only recently launched an initiative whereby

87

DMMA has begun to systematically refer at least some of the individuals with the most

88

obvious need for specialized services (as evidenced by multiple admissions to psychiatric

89

hospitals) to DSAMH for services4. Up until now, not only has there been no such concerted

90

effort, but even the entity responsible for making such referrals—an MCO, DMMA, or an

91

IMD—has remained vague. For the State to meet its obligations under the Agreement, it will

92

need to aggressively move forward on initiatives such as this to ensure that individuals are

93

appropriately referred for specialized services and that those whose care remains managed

94

through DMMA are also afforded access to needed services.

95

In summary, while the State continues to evidence admirable progress in serving one

96

subgroup of individuals with SPMI, there remain significant “unknowns” with respect to

97

other individuals covered by the Agreement. To what extent addressing the unmet needs of

98

the DMMA population may affect the capacities of DSAMH’s programs (e.g., with the

2 Such referrals were apparently not made with respect to the other individuals described here.
3 In the summer of 2014, the Monitor notified the leadership of DHSS and DMMA that he was finding what looked to be a pattern of high-risk individuals who are covered by the Agreement and who were not being referred for DSAMH’s specialty services (including ACT and housing).
4 This initiative includes a backlog of referrals accumulated over the 3 ½ years the Agreement has been in effect, whereby transition plans for DSAMH services were not made as part of hospital discharge planning. The time lag between these individuals’ hospitalizations and DMMA’s recent referrals has been problematic in that many individuals’ whereabouts are now unknown. As of November, 2014, the State’s data show that of 116 highest-risk individuals referred by DMMA for DSAMH services, 21.6% had incorrect or no contact information and a phone message could not be left for an additional 18.1%. In two months of implementing this initiative, referrals were completed or actively in progress for only 6 individuals. (TCM Outreach Status Breakdown data, Priority Groups 1a and 1b, November 13, 2014)
3

99

prospect of large numbers of new referrals for ACT or supported housing services) remains

100

an open question. Likewise, although the State is currently negotiating contracts with the

101

MCOs that should better align with the requirements of the Agreement, it has not yet

102

clarified how it intends to operationalize these contracts, to meet its obligations to Medicaid-

103

covered individuals with SPMI who are not referred for specialty services or whose referrals

104

are pending,5 or to monitor the quality or services provided. DSAMH has established what

105

appear to be sustainable and solid programs to provide these specialty services under the

106

leadership of Dr. Huckshorn, who is a nationally known expert in public mental health, and

107

continuity of such leadership is of obvious importance to the Agreement. As of this writing,

108

the State has not yet named a permanent replacement for the Division Director. Resolution

109

of these and other factors discussed in the body of this report are essential to the State’s

110

ability to demonstrate continuing progress and ultimate fulfillment of the Agreement’s

111

requirements.

112

113

II. Progress on Structural Improvements

114

115

A. Targeted Priority Population List:

116

The Agreement’s Targeted Priority Population List (TPPL) is defined in Section II.B as

117

individuals with SPMI who have been psychiatrically hospitalized, treated in an emergency

118

room or had criminal justice contact for issues attendant to mental illness, or who have been

119

homeless. A single individual may fall into more than one of these categories.

120

As of the end of the 2014 fiscal year, the State’s TPPL included 12,125 individuals, an

121

increase of 994 from data available at the time of the Monitor’s May report. About half of

122

the new members of this group were added as a consequence of admissions to IMDs. The

123

histories of individuals on the TPPL are summarized as follows:

124

 Treatment at DPC .................................................... 9.1%

125

 Treatment in an IMD ............................................. 59.3%

126

 Criminal justice contact ......................................... 18.0%

127

 Homeless .............................................................. 11.1%

128

 Emergency Room use for mental health ............... 33.6%

129

In comparison to the May, 2014 data, the proportion of individuals on the TPPL who were

130

admitted to IMDs has increased significantly—from 33.4% to 59.3%—highlighting the

5 Based upon the DSAMH’s capacity to process these new referrals, working through the initial group of about 460 high-risk individuals may take six months or longer to complete.
4

131

importance of the State’s plans to reduce inpatient bed use in these settings (discussed below

132

in regard to Crisis Stabilization Services).

133

In itself, inclusion on the TPPL need not indicate that an individual is in need of the full

134

complement of intensive services offered by the programs developed in accordance with the

135

Agreement; it simply suggests that there may be an elevated risk and a need for one or more

136

specialized mental health services.

137

138

B. Delaware Psychiatric Center:

139

Evaluation of Individuals Discharged Following Long Hospitalizations:

140

The Monitor’s prior reports presented data relating to the positive outcomes for individuals

141

who were discharged from Delaware Psychiatric Center (DPC) following extended

142

continuous hospitalizations, defined as 60-days or longer. As is evidenced by their

143

protracted hospitalizations—in some instances, decades-long—such individuals tend to

Figure-1: Readmission Rates for Individuals Discharged from DPC Following Long-Term Care (FY 2014)

30-DAY READMISSION
RATE

180-DAY READMISSION
RATE

Post-Discharge DPC Population of 102 Individuals:

Readmission Rates*

8.8%

15.7%

Comparison Rates:

U.S. Rates (SAMHSA, 2013)**

8.6%

20.3%

DPC Rates (2013)**

16.0%

32.0%

* Based upon all clients discharged within FY14 from DPC following lengths of stay of 60+ days ** U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Outcomes Measures, 2013.

144

145

present special service challenges. Thus, how they fare is an important indicator of the

146

effectiveness of community alternatives to inpatient care. Figure-1 presents an update on this

5

147

population for Fiscal Year 20146 with respect to 102 such individuals. The vast majority of

148

them receive ACT or other intensive mental health services within the community.

149

The year’s readmission rates for 30 and 180 days following discharge (8.8% and 15.7%,

150

respectively) represent increases over those reported in the Monitor’s May report (5.9% and

151

13.7%, respectively). In part, this is an artifact of the small size of the group; in a population

152

of 102 individuals, one readmission represents a change of about 1%. That factor, as well as

153

the clinical complexity of the group, suggests DSAMH’s community programs are doing

154

well in that the sample’s readmission rates approximate the 30-day national average of 8.6%,

155

and that they are significantly below the 180-day State and national comparisons of 32.0%

156

and 20.3%, respectively.

157

The much higher percentages of readmissions reflected in DPC’s overall recidivism rates—

158

16.0% within 30 days and 32.0% within 180 days—represent individuals who had been

159

hospitalized for much shorter durations. While some of these individuals were served by

160

ACT teams, as is described later in this report (e.g. Figures 18 and 19), hospital admissions

161

among clients of ACT occur relatively infrequently. The State is currently in the process of

162

analyzing the factors underlying readmissions to DPC, including the fact that they are much

163

higher than the national norms, with the goal of making adjustments in hospital and

164

community providers’ practices accordingly.

165

166

Facility Downsizing & Repurposing:

167

Past monitoring reports have presented data showing the State’s success in reducing the

168

census of DPC, particularly on its long-term care units. Figure-2 updates these data for the

169

State’s full 2014 fiscal year, showing a modest, but continuing downward trend relative to

170

figures reported in May, 2014. These discharges have significantly furthered the State’s

171

efforts to reduce bed-use days (see discussion relating to III.D.3) and, although a need for

172

long-term services will likely remain for a small group of individuals, to reorient the

173

hospital’s services more towards acute care. DPC’s current average daily census remains

174

about half of what it was in 2008, and is about a third smaller than it was in the Agreement's

175

“base year” of 2011.

176

This is obviously a positive achievement for the State, and even more so because of the

177

ongoing improvements in care provided in this once troubled facility that have occurred

178

during the period the Agreement has been in effect.

6 Delaware’s fiscal year is from July 1 to June 30.
6

250

232

Figure-2: Average Daily Census Delaware Psychiatric Center SFY 2008 - SFY 2014

204

200

200

162

150

146 136

111

100

Number of Inpatients

50

0 SFY 2008 SFY 2009 SFY 2010 SFY 2011 SFY 2012 SFY 2013 SFY 2014
*The Average Daily Census is based off the census for the Kent and Sussex Units. SFY 2014 represents a 52.2% reduction from SFY 2008
179
180

181

C. Reliance on Court-Ordered Treatment

182

Court-ordered treatment is sometimes required to address the needs of individuals who are

183

imminently at risk of harming themselves or others as a result of mental illness. However,

184

situations demanding courts’ intervention do not exist in isolation. Programs that provide

185

early intervention, peer supports, effective individualized crisis plans, and other services can

186

significantly reduce the number of scenarios culminating in involuntary treatment.

187

Furthermore, Delaware’s reliance upon involuntary psychiatric detention has reflected other

188

factors, for instance, being used as a means of facilitating ready transport from an emergency

189

room or overcoming wait lists for substance abuse treatment. Both of these scenarios had

190

been widely reported to the Monitor; they are clearly inappropriate uses of the State’s civil

191

commitment law.

192

Over the past few years, the State has taken a number of measures to reduce its over-reliance

193

on involuntary treatment and to move towards the recovery-oriented model of services

194

promoted by the Agreement. It has made major refinements in its laws governing civil

195

commitment, including a requirement that psychiatric detentions—the first step towards

196

involuntary hospitalization—be pre-approved by certified mental health screeners who are

197

versed in the alternatives to hospital care that are available through the States’ mental health

198

service system, as well as the legal requirements for least restrictive interventions, including

199

those underpinning the Agreement.

7

200

The State has been tracking civil commitments, both for inpatient care in psychiatric

201

hospitals and court-ordered outpatient treatment. Figure-3 presents its impressive success in

202

reducing the number of such court-orders. Monthly tracking data for hospital care show a

203

reduction by 41.4% and for outpatient treatment by 54.3%—both relative to the base year

204

(2011) immediately preceding the Agreement.

205

Figure-3: Involuntary Inpatient and Outpatient Commitment
By Month Compared with Base Year Average (FY11)
400

350 300 328

Number of Individuals

250

200 162

150

121

100 110
50

0

206

Average Invol. Outpatients

Average Invol. Inpatients

*Based on information provided to the Eligibility and Enrollment Unit (EEU) during Commitment hearings **FY14 represents a 54.3% reduction in Outpatient and 41.4% reduction in inpatient commitments from the base year FY11

207

Figure-4 presents these data in a slightly different format, showing the average number of

208

inpatient and outpatient commitments for each fiscal year since 2011.

209

The revision in Delaware’s law requiring pre-detention evaluations by mental health

210

screeners, became effective in fiscal year 2013. Based upon the Monitor’s spot checks,

211

evidence of these screenings is consistently appearing in hospital records, both within DPC

212

and the IMDs. DSAMH has established a database to track and begin to oversee the quality

213

of these pre-detention screenings, by client, by screener, and by referring facility (e.g., a

214

general hospital’s emergency department). While this process is still evolving, it is already

215

revealing some trends that merit further investigation, for instance, patterns whereby

216

individuals are identified as appropriate for involuntary detention—based both upon clinical

217

need and a refusal of voluntary treatment—and within hours of transport to a hospital agree

218

to voluntary care. While some individuals certainly may change their decision and be more

219

open to voluntary treatment once they arrive at a hospital, the frequent occurrence of this

220

scenario (based upon DSAMH’s tracking data, for some screeners, it exceeds 80% of the

8

221

individuals identified as requiring involuntary care) raises questions as to whether voluntary

222

care is being appropriately presented as an option by the screener, or whether practices still

223

persist whereby involuntary transfers by police are used for their convenience. In any event,

224

it appears that the State is taking appropriate actions to monitor and, as may be indicated, to

225

take corrective actions to improve the effectiveness of the overall process.

Number of Individuals

Figure-4: Involuntary Inpatient and Outpatient
By Fiscal Year Average

400

354

350

328

299

300

250

200

162

150

140

136

150

95

100

50

0

226 227

Average Invol. Outpatients

Average Invol. Inpatients

*Based on information provided to the Eligibility and Enrollment Unit (EEU) during Commitment hearings **FY14 represents a 54.3% reduction in Outpatient and 41.4% reduction in inpatient commitments from the base year FY11

228

Overall, the data on court interventions and oversight of mental health screenings reflect very

229

positively on the State’s efforts to serve people with SPMI in ways that promote recovery,

230

reduce stigma, and emphasize that crises associated with mental illness are primarily aspects

231

of healthcare, rather than police or court matters.

232

233

234

III. Ratings of Compliance with Specific Provisions of the Agreement

235

The following sections present ratings of the State’s compliance with respect to provisions

236

comprised by Sections II-V of the Agreement, including those with specific numerical

237

targets. As of July, 2014 and based upon available information (i.e., given the limitations in

238

information about people served through DMMA, which were referenced at the beginning of

239

this report), the State was in Substantial Compliance with each of these, except for Crisis

240

Stabilization (Sections II.C.2.d.iii and iv), Assertive Community Treatment (Section III.F)

241

and Risk Reduction (Section V.B); the State is in Partial Compliance with these provisions.

242

9

243

A. Crisis Services

244

Substantial Compliance.

245

Section III.A of the Agreement requires the State to establish a crisis hotline, allowing

246

individuals 24-hour access to assistance and referral information. The State remains in

247

substantial compliance with this provision. Figure-5 presents relevant monthly trending data

248

for New Castle County (NCC), which includes Wilmington, and for Kent and Sussex

249

Counties (KS) for the State’s 2014 fiscal year. Each month’s statistics are broken down by

250

whether the calls represented problems not primarily associated with substance use (Non-

251

SUD) and calls related to substance use (SUD calls). In addition, monthly statistics include

252

the number of calls that resulted in a face-to-face contact by the Mobile Crisis Programs

253

(FTF-Call Resp.), as well as face-to-face contacts that were not crisis in nature, for instance,

254

wellness checks that may occur following an initial crisis intervention (Other FTF Cont.).

255

As would be expected based upon the population distribution in Delaware, the bulk of the

256

calls come from New Castle County, where the State’s residents are most concentrated.

257

However, staff reports indicate that calls emanating from Kent and Sussex Counties, which

258

are more rural, tend to be more acute in nature; thus, the proportion of calls resulting in face-

259

to-face interventions by Mobile Crisis is higher in these counties than in New Castle.

260

Figure-5: MCIS Monthly Activity Report (FY14)
2500 2000 1500 1000
500 0

NCC KS
NCC KS
NCC KS
NCC KS
NCC KS
NCC KS
NCC KS
NCC KS
NCC KS
NCC KS
NCC KS
NCC KS

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

Non SUD Calls

FTF Call Resp.

SUD Calls

Other FTF Cont.

*Crisis Hotline Calls are based upon monthly reported data provided by Mobile Crisis Intervention Services

261

262

Delaware’s Mobile Crisis programs (required by Section III.B of the Agreement) provide

263

essential face-to-face services to individuals with SPMI who are experiencing psychiatric

264

emergencies. Their goal is to quickly assess the nature of the crisis, taking into account

265

environmental issues that can be assessed in the individual’s natural living setting; to provide

10

266

emergency interventions, including services directed toward de-escalating the crisis; and to

267

make referrals or connections with individuals’ providers accordingly. Although face-to-face

268

Mobile Crisis contacts are made when an individual is in an acute emergency and ostensibly

269

at very high risk of hospitalization, anecdotal information from responders indicates that a

270

high percentage of these encounters actually result in an alternative to hospital care—

271

immediate de-escalation, referrals or coordination with current providers, or use of crisis

272

apartments or walk-in services.

273

Figure-6 presents data demonstrating that the State is in compliance with Section III.B.1 of

274

the Agreement, which requires a response time for face-to-face interventions of one hour or

275

less. Although Delaware is small in size, fulfilling the one-hour requirement can be

276

challenging, especially in Kent and Sussex Counties where there are no freeways and local

277

roads seasonally get clogged with beach traffic.

278

Figure-6: Average Crisis Response Time (Calls Only) FY14
1:40

1:26

1:12

Hours:Minutes

0:57

0:43

0:28

0:14

0:00

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

NCC

K/S

Overall

Target

279

280

The State’s Mobile Crisis program is not limited to one-time emergency interventions.

281

Mobile Crisis responders routinely reconnect with at-risk individuals, either in person or by

282

telephone, for follow up activities such as wellness checks or to deliver medication. In

283

addition, the program is well integrated with other services, such as Targeted Care

284

Management (generally for individuals not currently receiving services) and the Crisis Walk-

285

In Centers (for individuals who may need further assessment or immediate, short-term

286

respite).

287

Mobile Crisis, along with its seamless connections with the Targeted Care Management

288

program, also serves as an alternative to the police for transporting individuals who need

289

additional assessment. For instance, Mobile Crisis transported Ms. D from home to the

11

290

Recovery Response Center (“RRC,” the Crisis Walk-In Center in Ellendale) to address

291

thoughts of suicide and Mr. E, who was under a 24-Hour Detention to and from a medical

292

consultation that had been requested by the RRC. These functions are not only far less costly

293

to the State, but also are likely far less traumatizing and demeaning than being handcuffed

294

and transported in a police car, as had once been routine practice.

295

Section III.B.2 requires the State to train law enforcement personnel about the functions and

296

means of accessing Mobile Crisis (Section III.C.2 has a similar requirement with regard to

297

Crisis Walk-In Centers, which are inter-related to Mobile Crisis). The State remains in

298

Substantial Compliance with these provisions. The following two figures present monthly

299

tracking of trainings by county, and the cumulative number of trainings conducted during the

Number of Individuals Trained

Figure-7: Number of Provider Staff and Law Enforcement Officers Trained by County FY14
160
140
120
100
80
60
40
20
0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 NCC Kent/Sussex State Police
300

301

fiscal year for local and state police officers. Figure-7 presents the number of trainings by

302

county for each month of the fiscal year. Figure-8 presents these data as cumulative totals

303

during this period. Almost 700 trainings took place, including trainings with State police and

304

in small towns that have very small numbers of officers. The audiences for the trainings are

305

not evenly distributed in size or location across the fiscal year, but are determined by the

306

availability of participants and specific requests for assistance.

307

These trainings are incredibly important as a means of familiarizing officers with the array of

308

services—including Mobile Crisis services—that can be utilized in responding to individuals

309

who are having problems apparently associated with mental illness. Ultimately, they should

310

also assist the State in reducing the routine involvement of the police as first responders in

311

situations that do not represent immediate threats of danger to self or others—a goal that is

312

very much welcomed by the police officials with whom the Monitor has had contact.

12

Figure-8: Cumulative Totals of Provider Staff and Law Enforcement Trained FY14
800

700

Number of Individuals Trained

600

500

400

300

200

100

0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
NCC Kent/Sussex State Police
313
314

315

B. Crisis Walk-in Centers

316

Substantial Compliance.

317

Crisis Walk-In Centers are another critical element of the State’s service system. Their goal

318

is to provide intensive, short-term assessments of individuals who are in crisis and whose

319

issues cannot be resolved at home (e.g., through Mobile Crisis), and to implement

320

intervention plans that represent the most integrated, least-restrictive approaches to address

321

them. Figure-9 presents the rates at which the State’s two Crisis Walk-In programs have

322

been able to divert individuals who are in psychiatric crises from admission to a psychiatric

323

hospital.

324

The two Crisis Walk-In programs—CAPES in New Castle County, and the RRC serving

325

Kent and Sussex Counties—reflect different models of service. CAPES is located within a

326

large general hospital; it represents the traditional, hospital-based approach of essentially

327

creating a special emergency department for individuals in psychiatric crisis. The RRC

328

reflects a recovery orientation along the lines of what is referred to as the “living room”

329

model. Rather than assessing individuals within the sometimes daunting environment of an

330

emergency room, the atmosphere and approaches at RRC are much more directed towards

331

encouraging the individual to feel comfortable in a home-like setting where he or she is

332

treated more as a “guest” than a “patient.” While the RRC has essentially the same

333

complement of mental health professionals as a traditional crisis center, trained peers play a

13

334

very significant role in helping to understand what the individual is going through and in

335

establishing recovery-oriented interventions accordingly, with the individual as a partner.

336

As is depicted in Figure-9, the RRC has demonstrated high rates of diverting individuals

337

from hospitalization—higher than those achieved by the hospital-based program. In light of

338

the success of this program, the State has funded a counterpart to be established in New

339

Castle County. This program is slated to be implemented in 2015.

340

Figure-9: RRC and CAPES Hospital Diversion Rates
FY14
100%

Percent of Screened Individuals Diverted

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

% Diverted (RRC) % Diverted (CAPES) Overall

341

CAPES data not reported for May and June, 2014

342

Beyond the benefits seen in the RRC’s diversion rates and the alignment of this program with

343

a recovery orientation, the establishment of this model for Crisis Walk-In services statewide

344

has an additional important and positive implication. As a part of its efforts to reduce

345

hospitalizations (see discussion of Section III.D.4 below), the State is wisely moving to carry

346

out assessments of individuals who are detained under 24-hour holds (the first step towards

347

civil inpatient commitment) outside of hospital settings and, instead, within Crisis Walk-In

348

Centers. Simply stated, the purpose of 24-hour psychiatric holds is to determine whether an

349

individual has a mental illness, whether hospitalization is the least restrictive approach to

350

address the individuals’ immediate clinical issues, and whether the individual meets the legal

351

criteria for involuntary treatment in the event that he or she refuses voluntary care. In the

352

past, these detention assessments have sometimes occurred within Crisis Walk-In Centers,

353

but they more routinely occurred within psychiatric hospitals. When these assessments occur

354

in hospitals, the individual has already been admitted as a patient, and the diversion rate—

14

355

i.e., the number of individuals found inappropriate for hospitalization and referred elsewhere

356

within 24-hours—is virtually zero.7

357

The State’s plan, which is already partially implemented, is to make the Crisis Walk-In

358

Centers the default locale for assessment of individuals under 24-hour detentions, unless

359

there is some overriding reason to admit the individual directly to a hospital (e.g., in

360

circumstances where there is an immediate and unremitting threat of harm to self or others—

361

a circumstance that is not as routinely encountered as might be expected). Given the State’s

362

success in diverting admissions when people are evaluated through the Crisis Walk-In

363

Centers, this approach may well significantly reduce the number of hospitalizations. As is

364

referenced later in this report, there are already some preliminary data suggesting that this

365

may be the case.

366

Recommendation-

367

1. Use of the Crisis Walk-In Centers to assess individuals who are under 24-hour

368

psychiatric detentions is a very important, positive measure. It is recommended

369

that the State develop monthly “dashboard” measures to track the impact of this

370

initiative and, as may be indicated, to further refine or expand capacities within

371

the Crisis Walk-In Centers.

372

373

C. Crisis Stabilization Services

374

1. Reduction in Inpatient Bed Days:

375

Partial Compliance.

376

Issues in Measuring Compliance

377

Section III.D.3 requires that by July 1, 2014, Delaware reduce State-funded hospital bed-days

378

for the population covered by the Agreement by 30%, relative to the base year; Section

379

III.D.4 requires further reductions—to 50%—by July 1, 2016. These represent very

380

important and seemingly straightforward measures. For hospital care that is managed

381

through DSAMH—that is, for individuals receiving its specialty mental health services, for

382

individuals treated at DPC, and for other individuals who are hospitalized but who don’t have

383

either Medicaid MCO or commercial coverage—monitoring of this provision has, in fact,

384

been straightforward.

385

For individuals whose care is managed through DMMA, monitoring has been quite

386

challenging. For well over a year, the State had asserted that it could not get accurate data

387

from MCOs about hospital stays until several months after the fact because bed-use days are

7 This is evidenced in IMDs’ lengths of stay data, which do not show any significant number of instances where a length of hospital stay is less than 24 hours, as would occur when an individual is diverted from hospitalization during the initial detention period.

15

388

a “moving target” until all claims have been paid out. The State vigorously maintained and

389

that “paid bed-days”—that is, data generated only after a hospital billing for care had actually

390

been paid by the State—represent the only appropriate metric for this provision of the

391

Agreement. Because hospitals are allowed a 90-day period following an individual’s

392

discharge to bill for services, at least a three-month delay was required in order to capture

393

useful data. The State further maintained that such a delay in data is not problematic in terms

394

of its oversight of services to the population covered by the Agreement (this, notwithstanding

395

increases in bed-day use discussed below), nor should it be problematic for the Monitor’s

396

purposes of evaluating ongoing implementation of the Agreement.

397

Paid bed-day information, of course, is one accurate measure of hospital use, but the

398

magnitude of delay that the State represented as unavoidable is impractical for monitoring

399

purposes. It would mean that the State would not be able to demonstrate compliance with the

400

requirements of the Agreement until more than three months after the fact. Further, it would

401

undermine both the State’s and the Monitor’s oversight of how Delaware’s plan to reduce

402

bed use (discussed later) was proceeding and whether it was having any impact. For

403

instance, the impact of the State’s initiative to use Crisis Walk-In Centers to conduct

404

assessments pursuant to 24-hour psychiatric detentions could not begin to be evaluated until

405

three months afterward and the effects of any efforts to improve upon this process could not

406

be evaluated for another three months. This is simply not good management of a critical

407

(and expensive) service that relates to an adverse event—a psychiatric crisis necessitating

408

hospitalization—nor does it allow appropriate monitoring of a provision that is critical to the

409

Agreement.

410

Beyond this matter, in response to the State’s data showing increases in IMD bed-day use

411

among people whose care is managed through MCOs, DHSS and DMMA strongly argued

412

that they now considered the diagnostic list that the State and the Monitor had been relying

413

upon to identify individuals covered by the Agreement since implementation began over

414

three years ago to be inappropriate because it might include people with Serious Mental

415

Illness (SMI) who may not have Serious and Persistent Mental Illness.

416

In an attempt to accommodate the State’s assertions with regard to its inability to provide

417

timely data and these diagnostic issues, the Monitor worked with the State for probably a

418

year or more to devise alternate approaches to extracting information needed from DMMA’s

419

data sets.8 This became an arduous, sometimes contentious and, in many ways, time-wasting

420

enterprise in which discussions of the service needs of individuals were set aside as various

421

ways of capturing DMMA data were explored. In effect, the State had made a decision to

422

defer improvements in DMMA-managed services to people covered by the Agreement

423

because (at that point, more than two years into implementation of the Agreement) it now

8 This was described in the Monitor’s last report.
16

424

had questions as to whether the TPPL was over-inclusive.9 In addition, it chose to defer

425

immediate action because it anticipated major revisions in its MCO contracts beginning in

426

January, 2015. Neither the Monitor nor DOJ were consulted about or concurred with this

427

approach. In fact, the Monitor repeatedly requested that, notwithstanding definitional issues

428

or future MCO contractual refinements, the State demonstrate that, in keeping with the

429

Agreement, it was taking measures to address the immediate needs of individuals being

430

hospitalized in IMDs. The Monitor believes that since the Agreement took effect, the State

431

could (and should) have taken several actions on behalf of people whose care is managed

432

through DMMA to improve outcomes and to demonstrate its efforts to appropriately meet its

433

obligations. It could have done so without fundamentally altering its programs.10

434

Ultimately, in October, 2014, with intervention by DOJ and Delaware’s Attorney General’s

435

office, a meeting with DMMA and an MCO readily (i.e., reportedly within one hour)

436

resolved the issue of timely data. They determined that largely accurate paid bed-day data

437

could, in fact, be provided shortly after the end of each month through a database that is

438

routinely used in the managed care industry.11 The reason that DMMA had not addressed this

439

issue well over a year prior remains unclear; had it done so, significant time and effort

440

dedicated to a data “workaround” could have been avoided and, instead, issues relating to

441

individuals’ service needs could have been the focus of attention.

442

Later in October, the State agreed to set aside its challenges to the diagnostic criteria used to

443

identify the population being monitored and to revert to the original approach. Accordingly,

444

IMD bed-days would once again be counted for individuals whose care is managed through

445

DMMA when one or more of their discharge diagnoses appear on a diagnostic list that the

446

Monitor constructed in 2011 in collaboration with DSAMH, DMMA, and the MCOs. These

447

data are presented in Figure-10.12 As has been the case throughout the Agreement, all

9 Whether public services to individuals who have disabilities are ultimately “credited” under the Agreement should not affect referrals to address unmet needs. The State is aware that the Agreement and the TPPL cover only a portion of the population for whom it has obligations under the ADA and other laws. Moreover, as has been referenced in past reports by the Monitor, the DHSS Cabinet Secretary has articulated the State’s commitment to appropriately serve all Delawareans, regardless of their status with respect to the Agreement.
10 One example would be to systematically refer homeless individuals to DSAMH upon their hospitalization in an IMD so that they might access supportive housing and other alternatives not available through DMMA.
11 The MCO explained that hospitals have up to 90-days to bill for care, but that claims are overwhelmingly settled much sooner, within 30 days.
12 The data presented in the Monitor’s May 19, 2014 report incorporated revisions in calculating bed-days for individuals whose care is managed through DMMA that were made to accommodate the State’s assertion that it could not provide timely data and that the available diagnostic data were insufficient to determine that individuals had SPMI. As is explained in the current report, these factors are no longer relevant and the data presented here reflect the
17

448

individuals managed through DSAMH are presumed to have SPMI, and their bed use is

449

counted accordingly.

450

Bed-Use Data

451

Figure-10 indicates that the State has not reached the 30% reduction in bed-use that is

452

required by July 1, 2014, per the Agreement. Its overall rate of bed-use reduction was

453

22.6%, largely achieved as a consequence of significant reductions at DPC —31.9% —in

454

long- and intermediate- term care. This reduction, while unquestionably a positive

455

achievement for the State, will not continue to carry the State to compliance with the 2016

456

benchmark of a 50% reduction (Section III.D.4), in large part, because DPC’s long-term care

457

population is now only about ¼ of what it was in 2011. Further reductions will need to be

458

seen in bed use for acute care, both within DPC and in the IMDs. As of July 1, 2014, bed-

459

use in IMDs by the population covered in the Agreement was essentially flat relative to the

460

base year, showing only a 0.4% reduction.

60,000 50,000 40,000

Figure-10: Inpatient Bed Day Reduction Base Year (FY11) vs. FY14
30% TARGET

22.6% Reduction

30,000

31.9% Reduction

Days of Hospital Care

20,000

0.4% Reduction

10,000

0

DPC

IMD

Overall

461

FY11 FY14

462

Because of its relevance to the Agreement and the ADA, with concurrence of the parties, the

463

Monitor has been including the long-term care population at DPC in calculations of hospital

methodology that had been originally used in implementation monitoring. As such, comparisons of bed-use data presented here with those presented in the last report are not meaningful.
18

464

bed-use. Technically, though, the language of Sections III.D.3 and 4 refers to requirements

465

only for reductions in “acute” (i.e., not long-term) inpatient settings, which would represent

466

stays of 14 days or fewer in the IMDs and the acute-care units of DPC. Although the State’s

467

overall acute-care bed use is essentially unchanged from 2011, further analysis of the data

468

shows important differences in acute care bed-days in IMDs based upon what entity is

469

managing the inpatient care and, likely as well, what processes exist to divert individuals

470

from hospital admissions.

471

Figure-11 presents data about the first of these factors, demonstrating that there are

472

significant differences in bed-use managed through DSAMH, compared with that managed

473

through DMMA. Clinically, these populations are similar. And to the extent that differences

474

do exist, DSAMH is managing hospital care for a generally more complex group of

475

individuals (e.g., people who have been referred for its specialized services or DMMA-

476

managed individuals whose needs are such that they had exhausted their Medicaid inpatient

477

benefit13). As is depicted in Figure-11, relative to the base year, DSAMH-managed acute

478

hospital days have decreased by 8.8%—a divergence from the 30% target of 21.2%—while

479

DMMA-managed hospital days have increased by 2.1%—a divergence from the July target

480

by 32.1%.

14,000 12,000

Figure-11: Inpatient Bed Day Reduction Base Year (FY11) vs. FY14
2.1% Increase

10,000

Days of Hospital Care

8,000

6,000 4,000 2,000

8.8% Reduction

0

481

DSAMH IMD FY11 FY14

Medicaid IMD

13 Medicaid coverage of inpatient psychiatric care is no longer limited in this way.
19

482

This difference may be attributable to a number of factors. During the past two years,

483

DSAMH has been ramping up its Utilization Review program, in part through technical

484

assistance secured through the Monitor. Data over the past year or more have indicated that

485

this effort is resulting in reductions in bed-use for the acute care it manages within the IMDs.

486

Although it is currently renegotiating its contracts with MCOs, DMMA has not provided

487

specific information about how the MCOs conduct their Utilization Review, nor has it sought

488

technical assistance in regard to fulfilling related provisions of the Agreement.14 Past

489

Monitor reports have shown bed-use among the DMMA-managed population to be trending

490

upward and anecdotal reports suggest that five- to seven-day authorizations by MCOs for

491

hospital care have been routine.15

492

Another potential factor, which is suggested by the individual stories presented at the

493

beginning of this report, is that hospital use is increasing among the population managed

494

through DMMA because it includes a significant number of individuals who are not being

495

referred to DSAMH for the specialized services or housing they need and, thus, in conflict

496

with the goals of the Agreement, they remain at elevated risk of hospitalization. If DMMA

497

pursues its recent efforts to more systematically monitor the referral of ostensibly high-need

498

individuals to DSAMH, their more ready access to intensive community based mental health

499

services, as well as the closer linkages to community providers before, during, and after

500

episodes of hospitalization may ultimately reduce the reliance on hospital care, or at least

501

shorten stays.

502

Finally, as was discussed earlier, the RRC in Ellendale is showing impressive progress in

503

diverting individuals from hospitalization in the first place, including those being evaluated

504

under 24-hour detentions. Significantly, bed-day use among individuals whose care is

505

managed through DMMA has dropped in the IMD that is located in southern Delaware,

506

which is served by the RRC—in fact, by a factor of almost 26% relative to the base year. In

507

contrast, bed-day use managed through DMMA in hospitals in the northern part of the state,

508

where the RRC is far less likely to be involved in pre-admission interventions and where 24-

509

hour detention evaluations tend to occur within the IMDs themselves, has increased by over

510

15% during the same period. These data suggest that the pending launch of an RRC to serve

511

New Castle County may be pivotal in reversing the increases in bed use by individuals whose

512

care is managed through MCOs and furthering the reductions in bed use that have been

513

achieved through DSAMH’s Utilization Review process.

14 The State is not, of course, required to seek technical assistance, but such assistance might have been helpful in improving its performance with respect to this and related provisions of the Agreement. 15 The State has not provided data refuting this anecdotal information.
20

514

Delaware’s Plan to Reduce Days of Hospitalization

515

UR that carefully considers the State’s community alternatives to hospitalization, referral of

516

high-risk individuals to DSAMH, and use of the Crisis Walk-In Centers for psychiatric

517

detention assessments collectively lay a foundation for achieving the reductions in acute care

518

bed use that are required in the Agreement. The State has incorporated these and other

519

elements in an overall plan to reduce the use of acute psychiatric hospital beds which was

520

developed collaboratively by DMMA and DSAMH. The plan also includes measures to

521

create better linkages to substance use services and enhanced reimbursement for essential

522

mental health services through “PROMISE,” an amendment to a State Medicaid waiver.

523

PROMISE is an important and positive initiative that the State has presented as a centerpiece

524

of its plans to reduce bed-use and to assure that individuals with SPMI who are served

525

through DMMA have access to a broad array of needed mental health services. In reality,

526

most of the services comprised by the PROMISE program are already available to

527

individuals served through DSAMH, but they are provided at State expense. PROMISE will

528

allow the State to capture Medicaid reimbursement that is not currently offered for these

529

services. Individuals whose care is managed through DMMA and who need the types of

530

services that will be covered by PROMISE can now, and have been able to, receive them

531

through DSAMH. An essential problem is that access to these specialty mental health

532

services—and, indeed, access to PROMISE—requires that such individuals first be referred

533

to DSAMH. As is explained elsewhere in this report, the State has not been managing this

534

referral process in ways that fulfill its obligations under the Agreement.16

535

At the suggestion of the Monitor, the State is now beginning to explore specific “triggers” for

536

referrals, but when these triggers will go into effect, what entity will have responsibility for

537

actually making the referrals to DSAMH, and how the State will monitor the process to

538

ensure that the requirements of the Agreement are met have not yet been determined.

539

Furthermore, the referral initiative now underway (which relates to an initial group of about

540

460 very high-risk individuals) is working well, but as noted earlier, the time lag in initiating

541

referrals has resulted in the State being unable to now locate many of these individuals, and

542

DSAMH has indicated a capacity to process only about 60 referrals per month. There may

543

be a much larger backlog of people with significant unmet needs. Based upon the TPPL, the

544

pool of individuals with SPMI who are now served through DMMA and who may be

545

appropriate for PROMISE (the State has not compiled good data about what these

546

individuals’ service needs actually are) might be as large as 6,000 or more. How the State

547

plans to assess their needs and assure their timely access to needed services remains

548

unknown.

16 As was described in the Monitor’s May 16, 2014 report, the State has streamlined its referral process for DSAMH services, but it has not had—and does not now have—a system to ensure that referrals of individuals with SPMI whose care is managed through DMMA are appropriately being made.
21

549

Another aspect of the State’s bed-use reduction plan requires consultation between MCOs

550

and DSAMH with regard to individuals managed through MCOs who have SPMI. As of this

551

writing, and although these changes are slated to go into effect in less than one month, the

552

specific nature of this consultation has not yet been worked out, including plans for a

553

collaborative approach to Utilization Review of individuals who are hospitalized in IMDs.

554

This issue is of particular importance because when the PROMISE program is implemented,

555

DSAMH will no longer independently conduct Utilization Reviews in IMDs for individuals

556

it serves if they are covered by Medicaid.

557

It is critical that the State give high priority to its bed-use reduction plan, closely tracking its

558

impact and making adjustments accordingly. The plan, which was finalized in June of this

559

year, would correct some of the problems described in the Introduction section of this report

560

relating to the referral of individuals by DMMA to DSAMH for specialized services,

561

housing, and other supports not otherwise readily available to them. Given recent

562

developments—namely, the resolution of problems with DMMA in timeliness of data and

563

the diagnostic disputes discussed above—the State should now be in a position to

564

aggressively move forward on its bed-use reduction plan and, as urged in the Monitor’s May

565

report, to appropriately prioritize other efforts to ensure that the needs of individuals whose

566

care is managed through MCOs are being met in compliance with the Agreement. The

567

following recommendations from the May report are being reiterated:

568

Recommendations:

569

1. It is strongly recommended that DHSS ensure that DMMA appropriately

570

prioritizes compliance with the Agreement and associated monitoring

571

requirements.

572

2. As these measures go into effect, it is critical that the State has unified data

573

systems in place (i.e., with the capacity to integrate timely information

574

about bed use from DSAMH and DMMA) to allow for meaningful UR,

575

ongoing program monitoring and refinement, and to demonstrate these

576

measures’ impact on bed use. This information is important in itself, and,

577

in light of the challenges of meeting this requirement, can also help

578

demonstrate that the State is making its best efforts to achieve compliance.

579

3. It is strongly recommended that the State immediately implement measures

580

to ensure that all individuals putatively having SPMI and meeting the

581

criteria for inclusion in the TPPL be evaluated for carve-out and access to

582

the more intensive services and supports that are available through

583

DSAMH.

584

22

585

2. Discharge Planning:

586

Partial Compliance.

587

Sections II.C.2.d.iii-iv of the Agreement require the timely involvement of a community

588

provider to assist in discharge planning when an individual is admitted to DPC or an IMD for

589

acute care. The Monitor’s last report found that this requirement was being inconsistently

590

met with regard to individuals whose care is managed through DSAMH and that the

591

requirement was essentially not being met at all with regard to those whose care is managed

592

through DMMA.

593

With regard to DSAMH clients, the State has since taken measures to ensure that

594

involvement by community providers is uniformly documented across providers and across

595

hospitals so that the timeliness and extent of participation by the community program can be

596

readily monitored. Community providers are notified at the time of an individual’s hospital

597

admission both by DSAMH’s Eligibility Enrollment Unit (EEU) and the hospital itself.

598

DSAMH’s contracts with ACT and Intensive Care Management (ICM) providers now

599

require their direct involvement when a client is psychiatrically hospitalized, at the time of

600

admission, at least three times per week during the course of inpatient care, and at the time of

601

discharge. Documentation of providers’ involvement is an additional requirement. DSAMH

602

is presently monitoring adherence to these requirements and is reviewing options to not only

603

improve performance with respect to the requirements of the Agreement, but to also assure

604

that involvement by community providers is meaningfully contributing to the services

605

afforded the individual.

606

As of this writing, the State is negotiating improved collaboration in discharge planning

607

between DMMA, the MCOs, and DSAMH, but it has reported no concrete measures actually

608

taken over the past 3 ½ years with regard to implementing this provision for the population

609

managed through DMMA. This is a serious matter, given that in excess of 75% of acute care

610

bed days associated with the population covered by the Agreement occur with regard to

611

individuals whose care is managed through DMMA.17

612

613

D. Crisis Apartments

614

Substantial Compliance.

615

Section III.E.2 of the Agreement requires that the State develop 4 crisis beds to serve as an

616

alternative for individuals who are experiencing mental health crises, but do not need hospital

617

care. Although referred to as “Crisis Apartments,” these are no longer actual apartments.

17 For Fiscal Year 2014-5, the State reported 3,497 IMD acute care bed days managed by DSAMH and 13,045 managed by DMMA.
23

618

Landlords that had been leasing units to house this program became concerned about their

619

use by transient residents who were not only unknown to them but, by program design, were

620

experiencing psychiatric emergencies. Accordingly, during the 2014 fiscal year, the State

621

relocated its crisis apartment programs serving New Castle and the southern counties to

622

freestanding houses. These provide a total of 8 beds, which significantly exceeds the

623

required number. These beds are augmented by additional community “Resource Beds,”

624

which DSAMH accesses for a variety of purposes on an as-needed basis.

625

As a result of the newness of the Crisis Apartment program, and some confusion about which

626

consumers were eligible to use these beds (all individuals covered by the Agreement are

627

eligible, whether clients of DSAMH or with care managed through MCOs), use of the crisis

628

beds has been limited at some points, and there were some periods when they were

629

essentially empty. Responding to the tracking data which is presented in Figure-12, DSAMH

630

initiated measures to better assure that key referral sources—for instance Mobile Crisis

631

responders—were aware of vacancies. As is reflected in this trend chart, use of these crisis

632

beds has steadily increased, and by June the use for both counties had exceeded 80% of the

633

potential bed-days.

Bed Days Used

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Figure-12 : Percent of Crisis Apartment Bed Days Used FY14
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

% Total Used (NCC)

% Total Used (K/S)

Combined % Bed Days Used

634

635

The Agreement contemplates that the length of stay in Crisis Apartments will be up to seven

636

days. As is depicted in the Figure-13, individuals have tended on average to stay longer than

637

that, with New Castle showing a mean of 17 days in June, 2014 and Kent/Sussex showing

638

10.5 days for the same period. The State is closely monitoring use of these beds, and is

639

working to improve the involvement of ACT teams when one of their clients is occupying a

640

crisis bed. For some individuals, the length of stay surpasses expectations because other

641

issues, such as the inability of the person to return to his or her previous living arrangement,

24

642

delay things. The essential issue, of course, is not strict adherence to the length of stay

643

contemplated by the Agreement, but whether, given clinical and social needs of the

644

individuals being served, the crisis beds are being used effectively to fulfill the goals

645

community integration. Overall, the State is appropriately monitoring and making

646

increasingly good use of this resource.

647

Figure-13: Crisis Apartments: Average Length of Stay FY14

35

30

30 31

25

26

Days

20

17 15
13.42

10

10.3

5

10 6.83
3.1 3.5

10.5 7.75

0
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

648

Avg LOS (NCC)

Avg LOS (Kent/Sussex)

649

650

651

E. Assertive Community Treatment

652

Partial Compliance.

653

ACT is an essential service for people with SPMI who have intensive service needs in the

654

community. This service model provides flexible, mobile services to such individuals

655

through teams including mental health professionals, peers, and case managers. Section

656

III.F.2 of the Agreement required that the State have 9 ACT teams operational by September

657

1, 2013. The State has established 11 ACT teams and is essentially already in compliance

658

with requirements that go into effect in September 2014 and 2015 (Sections III.F.2-3).

659

By agreement of the parties, the State is measuring fidelity of its ACT programs not through

660

the Dartmouth model referenced in the Agreement, but through the TMACT model, which is

661

more heavily oriented towards a recovery model of service. The TMACT fidelity instrument

662

comprises 47 indicators of quality that are rated according to 5-point scales. These measures

663

produce six subscale measures and an overall composite score. Figure-14 presents ratings for

664

nine of the ACT teams, including their Overall Scores and ratings on five specific items that

25

665

are among those having particular relevance to the Agreement: Adherence to the Supported

666

Housing Model, the Role of the Peer Specialist on the Team, the team’s Responsibility for

667

Crisis Services, Consumers’ Self-Determination, and Engagement of Natural Supports that

668

are important to the individual’s recovery.

669

The State has a system in place to conduct preliminary TMACT assessments as the ACT

670

teams become fully operational, and then to conduct formal reviews annually thereafter.

671

Figure-14 presents data from formal reviews that were available at the time this report was

672

being written.18 Assessments of teams’ fidelity include specific recommendations about

673

improving the quality of services; as indicated, technical assistance or more focused

674

monitoring may occur as these recommendations are implemented.

TMACT Score

Figure-14: ACT TEAM Fidelity Measures
5

4

3

2

1

0

TMACT OVERALL SUPPORTED

SCORE

HOUSING

MODEL

ROLE OF PEER RESP FOR CRISIS CONSMR SELF-

SPECIALIST

SERVICES

DETERM

TMACT FACTOR

ENGAGE NATURAL SUPPORTS

RHD Delaware

CONNECTIONS II

CONNECTIONS III

HORIZON HOUSE Alliance

HORIZON HOUSE Hope

HORIZON HOUSE Vision

RHD Dover

675

.

CONNECTIONS Dover

CONNECTIONS I

676

The average Overall Score for the teams surveyed is 3.6 out of 5. Average scores for the

677

other selected measures are as follows: Supported Housing Model 3.8, Role of Peer

678

Specialists 3.8, Responsibility for Crisis Services 3.9, Consumer Self-Determination 3.8, and

679

Engagement of Natural Supports 2.6. While the State is moving to improve performance

680

across the board, teams’ engagement with natural supports, i.e., family members, friends,

681

employers, and others who are not a part of the formal service network is one area that has

682

been in particular need of improvement. As a general matter, fidelity and quality

683

improvement of ACT teams is an ongoing processes, and—particularly with relatively new

684

teams such as these—not some sort of absolute, fixed status. What is important is that the

18 Two of the teams had not yet reached the point where a formal review is conducted. A number of teams were about to have their annual reviews, so more current data are forthcoming.
26

685

State has in place a working system aimed at monitoring fidelity and promoting continuous

686

improvement. The next round of data will give a clearer picture as to how the State is faring

687

in bringing all of its ACT teams into fidelity with TMACT standards, in keeping with Section

688

II.D.2.a of the Agreement. At this juncture, it is in Partial Compliance with this provision.

689

As has been discussed in past reports, DSAMH is making significant improvements in its

690

capacities to capture timely data and to conduct trend analyses of key indicators of quality.

691

The figures that follow evidence this commendable progress and reflect the State’s success in

692

meeting its obligations around Quality Assurance and Performance Improvement (Section V

693

of the Agreement).

694

Figure-15 presents the average number of clients per ACT team in each county across the

695

fiscal year. In general, teams are designed to serve about 100 individuals; some of the

696

numbers reflected below are lower than this because new teams are still adding clients—a

697

process that, by design, occurs at a limited pace.

698

Figure-15 : Clients Per ACT Team FY14
120

100

Average Number of Clients

80

60

40

20

0

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

NCC Clients/Team

Kent Clients/Team

Sussex Clients/Team

Overall

699

*As of June 1, 2014, all New Castle and Kent County ICM teams have been transitioned into ACT teams

700

701

Figures 16-21 reflect a number of outcome indicators that the State tracks to evaluate the

702

performance of its ACT teams. Figure-16 presents the average number of individuals who

703

were homeless for any night during the month. This situation may reflect an individual who

704

is served by ACT and who loses his or her housing during the month, but much more

705

commonly, it reflects the housing status of individuals who are just entering an ACT program

706

and with whom the team is working to secure permanent housing.

27

707

Figure-16 : ACT/ICM Providers
Average homeless for any night during the month by provider agency
10%

Average Percent Homeless

8%

6%

4%

2%

0% Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-13 May-14 Jun-14

Conn

HH

RHD

NHS

708

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

709

Figure-17 presents the State’s tracking of the number of ACT clients who were arrested

710

each month, a risk factor specifically referenced in the Agreement. A substantial number

711

of individuals served by ACT have histories of contact with the criminal justice system,

Figure-17: ACT/ICM Providers
Average of Consumers arrested

Average Percent of Clients Arrested

10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-13 May-14 Jun-14

Conn

HH

RHD

NHS

712

*Data provided via ACT/ICM Monthly Qualitative Reporting

28

713

often associated with co-occurring substance use. There are no national standards against

714

which these data can be compared, but the number of individuals arrested—generally,

715

about 1% or fewer each month—appears to be low, given the population being served.

716

Figure-18 presents the State’s tracking of the percent of ACT clients who are hospitalized

717

for psychiatric care each month. These data do not show the duration of time in the

718

community (for instance, as is reflected in the 30- and 180-day readmission rates to DPC

719

discussed above), nor do they show whether some individuals are being repeatedly

720

readmitted due to special challenges in care. Again, in the absence of national norms,

721

and based upon anecdotal information about ACT teams elsewhere, the admission rates

722

appear to be consistent with what would be expected for this population.

723

Figure-18: ACT/ICM Providers
Average of Consumers hospitalized in Psychiatric Hospital

Percentage of Clients Hospitalized

10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-13 May-14 Jun-14

Conn

HH

RHD

NHS

724

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

725

726

Figure-19 presents data on the average number of days individuals being served by ACT

727

spent in psychiatric inpatient care for each month of the fiscal year. Interestingly, NHS,

728

which showed relatively high rates of hospitalization in Figure-18, showed low numbers

729

of days clients spent in the hospital; in other words, the data suggest a high number of

730

brief admissions. On the other hand, Horizon House (HH), which has remained average

731

in the number of hospital admissions, has shown long lengths of stay for its hospitalized

732

clients, suggesting that one or more of the individuals being served has particularly

733

complex needs.

29

Figure-19: ACT/ICM Providers
The average number of Psychiatric Hospital Patient Days per month

40

35

Days of Hospital Care

30

25 20

15

10

5
0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-13 May-14 Jun-14

Conn

HH

RHD

NHS

734

*Data provided via ACT/ICM Monthly Qualitative

735

Figure-20 shows the average percentages of ACT clients who utilized emergency rooms of

736

general hospitals each month, another risk indicator that is specifically referenced in the

737

Agreement. Although clients may go to emergency rooms for a variety of reasons, as the

738

State accumulates more performance data, it might wish to see if there is a relationship

Figure-20 : ACT/ICM Providers
Average of Emergency Department Visits:

15%

Average Number of Clients using EDs

12%

9%

6%

3%

0% Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-13 May-14 Jun-14

Conn

HH

RHD

NHS

739

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

30

740

between the use of emergency departments and how specific ACT teams perform on

741

TMACT measures relating to teams’ crisis response capabilities. At this juncture, the State is

742

using these data more for purposes of monitoring whether ACT teams are consistently

743

showing up as outliers on measures such as these.

744

Finally, Figure-21 presents a positive outcome that the State is monitoring with respect to

745

ACT and Intensive Care Management (ICM) clients (discussed immediately below); the

746

percentage employed, broken out by the average number of hours worked per week. The

747

numbers reflect work in mainstream employment, not sheltered workshops or other settings

748

that segregate individuals with disabilities.

749

Figure-21: ACT/ICM
Employed Clients as Percentage of Overall Census
FY14
16%

14%

Percentage of Clients Employed

12%

10%

8%

6%

4%

2%

0% Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

<10 Hrs/Week 10-20 Hrs/Week 20+ Hrs/Week

750

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

751

752

F. Intensive Care Management

753

Substantial Compliance.

754

Section III.G.2 of the Agreement required the State to have a total of 4 Intensive Care

755

Management (ICM) teams operational by January 1, 2013. As was reported in the May

756

report, the State surpassed this requirement by establishing a total of 5 ICM teams with

757

staffing ratios consistent with the requirements of the Agreement. In monitoring the

758

performance of these teams, DSAMH determined that the level of need characterizing the

759

individuals being referred for ICM was generally indistinguishable from that characterizing

31

760

people being served by ACT teams. In consultation with the Monitor, DOJ supported the

761

State’s plan to convert all but one of its ICM teams to ACT, serving the same number of

762

individuals, but having the capacity to provide supports that exceed what could be provided

763

through ICM. Accordingly, as of June 1, 2014, the ICM teams serving New Castle and Kent

764

Counties converted to ACT19 and there is now one ICM team in the State that serves Sussex

765

County (DSAMH has indicated that it will convert that team to ACT, as well, if warranted).

766

Figure-22 presents the number of clients served through ICM in each of the counties, as well

767

as the overall State average of individuals served. The numbers in April and May were

768

affected by the conversion process. Looking forward, the relevant data relate to the Sussex

769

team, which was serving about 200 individuals as of June, 2014.

770

Figure-22: Clients Per ICM Team FY14
250

Number of Clients Served

200

150

100

50

0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

NCC Clients/Team

Kent Clients/Team

Sussex Clients/Team

Overall

*As of June 1, 2014, all New Castle and Kent County ICM teams have been transitioned into ACT teams
771

772

The State is rated as being in Substantial Compliance with Section III.G.2 of the Agreement

773

in that it developed—and even surpassed—the number of ICM teams required and then, with

774

the concurrence of the parties, is now providing services that exceed this requirement in

775

keeping with the needs of the individuals being served.

776

19 Because these ACT teams are new, they are not included in the data presented in the previous section, including the data relating to fidelity. They will be incorporated in these measures in the 2015 fiscal year.
32

777

G. Case Management

778

Substantial Compliance.

779

Section III.H.2 requires a total of 18 Targeted Care Managers (TCM), who play a key role in

780

connecting individuals—generally those not currently being served through DSAMH—with

781

the community-based services and supports they need. The State continues to exceed this

782

requirement in that it has a total of 25 TCMs serving such individuals statewide. Over 6% of

783

the individuals on the TPPL have received, or are receiving, TCM services, generally during

784

a period of transition until there is a hand-off to a service provider for ongoing services. The

785

Agreement requires that each care manager serve no greater than 35 individuals at a time;

786

Figure-23 shows that the State is well within this guideline.

787

Figure-23 : Average Case Load Per TCM Case Manager
FY14
18

16

Average Number of Clients

14

12

10

8

6

4

2

0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

State Avg Clients/CM

RI - NCC Avg Clients/CM

788

RI - Ellendale Avg Clients/CM

Totals Avg Clients/CM

789

790

H. Supported Housing

791

Substantial Compliance.

792

Since the inception of the Agreement, Delaware has made the requirements for integrated

793

supported housing a priority. This has required an internal culture change within DSAMH

794

away from pre-classifying individuals for various congregate living arrangements (as has

795

been the practice in public mental health systems nationwide) and towards an orientation that

796

considers individuals’ preferences and the wrap-around services needed to support an

797

individual in an ordinary living environment. It has also required collaboration with other

798

governmental divisions, such as the State’s housing authority. While, of course, not

799

everybody being served is now in his or her preferred living situation, the State has made

33

800

palpable moves to increase access to scattered-site supported housing (as defined in the

801

Agreement). Only about 2% of individuals on the TPPL live in state-funded group homes,

802

increasingly due to medical care needs that co-occur with SPMI.

803

Developing supported housing in keeping with the requirements of the Agreement is a

804

complicated endeavor. It requires a comprehensive assessment of individual’s preferences

805

and needs—sometimes not an easy task to accomplish given that many do not have histories

806

of stable housing and have difficulties making informed choices. Furthermore, their abilities

807

to address day-to-day living requirements in their own homes are not always easy to predict

808

from what is known about them while living in an institution or in the community without the

809

supports that are now available. Securing housing is also challenging in finding landlords

810

willing to accept housing vouchers (either through HUD or the State’s housing program for

811

the target population, “SRAP”) or tenants who, as many in the target group do, have histories

812

of criminal justice contact. Finally, once housing arrangements are made, many individuals

813

thrive, but some move away on their own, are re-hospitalized, or are unsuccessful tenants.

814

As such, while the State funds new vouchers per the Agreement, it is also backfilling

815

vacancies relating to vouchers previously issued.20 Thus, while counting the number of

816

vouchers made available pursuant to the Agreement is straightforward, tracking their

817

utilization is somewhat dynamic because the number of unused vouchers fluctuates and

818

individuals are in various stages of securing housing of their choice.

819

Section III.I.4 of the Agreement required that, by July 1, 2014, the State fund a total of 550

820

supported housing vouchers or rental subsidies for the targeted population. As is represented

821

in Figure-24, it has exceeded that number, funding 651 vouchers. This chart shows the

822

number of units funded for each year of the Agreement, differentiated by funding source. It

823

also presents the cumulative total as of July, 2014, which demonstrates that the State has

824

surpassed the requirements of the Agreement.

825

Figure-25 presents the State’s monthly tracking data relating to that portion of the housing

826

vouchers that are processed through DSAMH in collaboration with the Delaware State

827

Housing Authority; it does not include information with regard to the “grandfathered” semi-

828

integrated housing referenced in Section III.I.1. Its intent is to provide snapshot information

829

about the proportion of individuals in integrated supported housing and the proportion in

830

various phases of transition in to supported housing. In September, 2014, for instance, 284

831

individuals were using vouchers to support them in their own apartments. An additional 115

832

individuals had vouchers and were actively looking for an apartment. Applications for

20 The Monitor has learned that these circumstances also exist in other states that are creating new supported housing for people with SPMI.
34

Figure-24 : Settlement Agreement
Housing Targets by Fiscal Year
800

Integrated Housing Units Funded

700

600

500

400

300

200

100

0 FY11
Grandfathered

FY12 SRAP

FY13

HUD

CRISP

FY14

4 Year Totals

Connections

PATH

833

GRANDFATHERED refers to Section III.I.1 of the Agreement SRAP is a State-funded rental assistance program HUD refers to various rental vouchers through this federal program CRISP is DSAMH's capitated program for high-risk individuals CONNECTIONS is a community provider PATH is a federal program to assist individuals with SMI in transitioning from homelessness

Figure-25 : Total Applications Breakdown July, 2012 to Sept, 2014
50%

40%

30%

20%

10%

0% FY 14 Yr End

Jul-14

Aug-14

Sep-14

Total Units Leased

Total Withdrawn

Total Voucher Looking

Total Expired Voucher

Total Apps in Process

Total Terminated

834

Total Trans to Perm/ Subs. Hsg/ Aged Out/ Prog. Exp.

835

housing vouchers were being processed for an additional 39 individuals. The percentages

836

shown in the chart relate to the total number of applications that have been received (709) for

837

the 651 vouchers the State has made available. Thus, for instance, the 284 figure is 40% of

838

this 709.

35

839

With respect to the specifics of the Agreement, the State was required to fund 550 housing

840

units by July 1, 2014, 150 of which were grandfathered in, leaving a total of 400 scattered-

841

site supported housing units to be funded. Applying the housing data to what is required in

842

the Agreement (rather than the larger number of vouchers that the State is actually funding),

843

Figure-26 shows the State’s standing. As was referenced in the May report, some vouchers

844

that had been counted in previous years are no longer available to fulfill the State’s

845

requirements under the Agreement. This, as well as individuals relocating out of state,

846

moving in with family, and other factors mentioned above, contribute to the number of

847

individuals now in transition to supported housing.

848

Figure-26: Status of Housing Vouchers as of September, 2014

Vouchers Percent

Supported Housing Units Required (Target)

400

of Target

Vouchers Issued: Units Rented

284 71.0%

Vouchers Issued: Housing Being Arranged

115 28.8%

Applications Submitted: Vouchers Pending

39

9.8%

Total Vouchers Issued and Pending

438 109.5%

849

850

I. Supported Employment

851

Substantial Compliance.

852

Section III.J.2 of the Agreement requires the state to provide supported employment services

853

to a total of 400 individuals. DSAMH continues to have a strong partnership with the State’s

854

Division of Vocational Rehabilitation, which places strong emphasis upon people with SPMI

855

entering the mainstream workforce. Furthermore, DSAMH has an admirable record of

856

employing individuals who have been diagnosed with SMI in positions as peer supporters,

857

research assistants and other important roles. Figure-27 presents cumulative data on the

858

number of individuals covered by the Agreement who are receiving supported employment

859

services, at a minimum with active employment plans in effect. As of the end of the fiscal

860

year, 663 individuals were being served, thereby surpassing the requirements of the

861

Agreement.

862

Figure-28 summarizes the status of these individuals. The data presented below represent the

863

status of the 663 individuals served last fiscal year in the supported employment

36

Figure-27: Cumulative Number of Clients Receiving Supported Employment FY14

700

Number of Individuals with SPMI Served

600

500

400

300

200

100

0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14
*Supportive Employment numbers are based upon data from the Division of Vocational Rehabilitation within
864

Figure-28: Employment Support Categorical Breakdown of the 663 Individuals Served in FY14

3.8% 19.8%

Individual Plan for Employment (IPE) Counseling and Guidance
Restoration

5.3% 1.8%
1.5%

67.9%

Training Ready to Work

In Employment

*Supportive Employment numbers are based upon data from the Division of Vocational Rehabilitation wihtin

865

the State Department of Labor

866

process; although the numbers are not large, other individuals in the targeted group have

867

received supported employment in earlier years and are no longer counted in this data set.

37

868

Less than 4% of the group served is employed; almost 20% are considered job-ready and are

869

actively seeking work.

870

871

Recommendations:

872

1. It is recommended that the State focus intensely on securing employment for the

873

substantial population of individuals who are categorized as “Ready to Work.”

874

2. The Monitor plans to make technical assistance available to the State in support of

875

this effort.

876

877

J. Rehabilitation Services

878

Substantial Compliance.

879

Section III.K.3 of the Agreement requires that the State provide rehabilitation services to a

880

total of 1,100 individuals by July 1, 2014. These services include activities such as education,

881

substance abuse treatment, and recreational activities. As has been explained in past reports,

882

the State’s data systems do not readily capture meaningful information about the provision of

883

these services. For this reason, the Monitor and the State have agreed upon measures that

884

could be used to demonstrate compliance with this provision. The State was unable to

885

provide an update to its May, 2014 data with respect to Rehabilitation Services, but the data

886

available at the time of that report demonstrated that it had already surpassed the

887

requirements of the Agreement for the fiscal year. Those data are re-presented below:

888

 Psychosocial Rehabilitative Services, Psychosocial Group

889

Services, or Family Psychosocial Education at least twice

890

per month for at least 6 months.................................................. 259 individuals

891

 Some level of substance abuse treatment for a co-occurring

892

disorder ...................................................................................... 978 individuals

893

 Total Unduplicated Count....................................................... 1,222 individuals

894

895

The State is in Substantial Compliance with this provision.

896

897

K. Family and Peer Supports

898

Substantial Compliance.

899

Section III.L.3 of the Agreement requires the State to provide family or peer supports to a

900

total of 750 individuals by July 1, 2014. As has been described in past Monitor reports,

901

Delaware has developed a robust and innovative program of peer supports, whereby

902

individuals who have “lived experience” with mental illness provide an array of services to

38

903

peers who are hospitalized or living in the community. Beyond their work with individuals,

904

peers in Delaware have actively participated in such systemic work as the recent reforms in

905

the State’s mental health laws, and representatives periodically meet with the Monitor to

906

provide information about aspects of services around which they are seeking improvements.

907

Peers have been trained as research assistants and carry out quality of service interviews in

908

an initiative being conducted through the University of Pennsylvania. From not only a

909

numerical perspective, but qualitatively, as well, the State is in Substantial Compliance with

910

the requirements of the Agreement relating to peer services. DSAMH should be commended

911

for the ways in which it has incorporated these services in its operations and the

912

encouragement the Division has offered peers in helping to shape innovative solutions to

913

service challenges.

914

Figure-29: Peer Total Contacts FY14
3000

2500

Number of Monthly Contacts

2000

1500

1000

500

0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14

915

DPC Peer Contacts Trauma Peer Contacts ACT/ICM Combined Census CRISP Census

916

Figure-29 presents only a portion of the picture of the role of peer services in DSAMH

917

programs. It shows the number of peer contacts with individuals who are hospitalized at

918

DPC, as well as those served through ACT Teams or DSAMH’s CRISP program, which

919

focuses mostly on individuals with histories of protracted care at DPC and special challenges

920

to living in the community. In addition, it presents data relating to a special peer-initiated

921

program to provide supports to individuals who have histories of trauma, an issue which is

922

widespread among people with SPMI and which is gaining increasing traction nationwide

923

within public mental health systems. Each month anywhere from about 1,900 to over 2,500

924

peer contacts occur. Because of the nature of services being provided and differences among

39

925

the various peer programs, it is difficult to ascertain a specific unduplicated count of the

926

number of individuals receiving these services, but based upon the Monitor’s interviews with

927

peer leaders and DSAMH staff, the number far exceeds the 750 required in the Agreement.

928

The State is in Substantial Compliance with this provision.

929

930

L. Quality Assurance and Performance Improvement

931

Substantial Compliance.

932

The State remains in Substantial Compliance with Section V of the Agreement—at least with

933

respect to DSAMH—which requires that it develop Quality Assurance (QA) and

934

Performance Improvement (PI) programs to ensure the services are appropriate to achieving

935

the goals of the Agreement. Although the State is now negotiating new contracts with the

936

MCOs, it has not provided information indicating how, if at all, it has fulfilled this

937

requirement in the period being reviewed here with respect to individuals served through

938

DMMA, nor has it sought assistance in this regard from the Monitor.21

939

Within DSAMH, QA and PI functions reflect an array of efforts, including those relating to

940

services within DPC; the ACT fidelity and qualitative reviews presented earlier; and a

941

number of ongoing studies conducted through the University of Pennsylvania that examine

942

clinical and subjective outcomes associated with the CRISP program, as well as longitudinal

943

service outcomes relating to cohorts of individuals newly appearing on the TPPL.

944

The charts presented throughout this report evidence how the State has moved to the point

945

where it can trend critical performance indicators over time, identify successes or problems

946

in services, and make adjustments accordingly. The creation of an RRC to serve the northern

947

part of the State, adjustments to the ICM program (transitioning all but one to ACT teams),

948

dramatic reductions in court-ordered treatment, and better use of Crisis Apartments are all

949

palpable examples of the ways DSAMH is using these data to improve quality and

950

performance. As with any well-functioning QA/PI program, these initiatives are always a

951

work in progress; new items for inclusion in the monthly data dashboard are continually

952

being identified (the referral of high-risk individuals from DMMA to DSAMH is one

953

example) for monitoring and program improvement.

954

955

M. Risk Management

956

Partial Compliance.

957

Section V.B requires that the State develop a Risk Management program that reduces the risk

958

of harm to individuals covered by the Agreement both within hospital settings and within the

21 Such technical assistance, of course, is not required by the Agreement.
40

959

community. As was described in the Monitor’s May, 2014 report, Delaware had been

960

carrying out essential risk management functions through a set of idiosyncratic, parallel

961

systems of reporting and oversight that varied considerably depending upon where an event

962

possibly representing abuse, neglect, or injury occurred. Furthermore, these various data sets

963

remained largely segregated from each other and were not consolidated before any single risk

964

management entity. As a result, the State has not been in a position to compile information

965

across systems and settings to identify patterns of risks and adverse events. Corrective

966

actions, when they were required, thus remained specific to the setting in which an adverse

967

event occurred, and the State had no mechanism to alert the field to the need for related

968

preventive measures.

969

At least with respect to DSAMH programs, the State has since taken important steps to

970

overhaul its risk management system. It is now developing decision trees for consistent,

971

system-wide actions to be taken and reporting of adverse events. The resultant data will feed

972

into a central committee that is responsible for oversight and corrective measures—both for

973

individual events and systemic. Because this reflects a major restructuring of risk

974

management functions, involving a multitude of players within and outside of State

975

government, this is a complex and labor-intensive endeavor. Nevertheless, the State has

976

made significant progress since the May report. It expects its new risk management system

977

to become operational early in 2015.

978

979

IV. Summary

980

As is explained in this this report, 3 ½ into its implementation of the Agreement, the State of

981

Delaware presents a mixed picture.

982

With respect to the population of people with SPMI that is served through DSAMH, the State

983

is either in Substantial Compliance with the provisions of the Agreement or is on track to

984

achieve compliance. DSAMH’s service system has evolved dramatically since 2011. The

985

Division has expanded services and developed data systems that allow it to increasingly

986

understand the needs of individuals being served, to track critical aspects of services intended

987

to promote their community integration, and to capture information allowing it to engage in

988

ongoing improvements in its programs.

989

At this juncture, there is far less known about the significant population covered by the

990

Agreement whose services are managed through DMMA, including such essentials as what

991

individuals’ needs are, whether they are appropriately housed, and how this population’s

992

increased hospital use may be reversed. With few exceptions, the State has largely continued

993

to serve the DMMA-managed population as it had prior to the Agreement. Although there

994

are measures the State might have taken thus far to serve these individuals in keeping with

995

the Agreement’s requirements and without fundamentally changing its programs, it instead

996

elected to defer action until new MCO contracts and the Medicaid PROMISE program go

41

997

into effect on January 1, 2015. These initiatives are positive steps but, setting aside the

998

human impact of the State’s foregoing interim measures to comply with the Agreement with

999

regard to the DMMA-managed population, these programs will likely be fully operational for

1000

only a little over one year at the point the State is aiming to be able to demonstrate full

1001

compliance with the Agreement, in July of 2016. Accordingly, it is critical that the State

1002

redouble its efforts to ensure that all populations covered by the Agreement are appropriately

1003

served and that it be able to provide meaningful, comprehensive, and timely data to

1004

document that this is the case. The Monitor remains available to assist the State in this effort.

1005

1006

1007

1008

Robert Bernstein, Ph.D.

1009

Court Monitor

42

 
 1

SEVENTH REPORT OF THE COURT MONITOR

2

ON PROGRESS TOWARD COMPLIANCE

3

WITH THE AGREEMENT:

4

U.S. v. STATE OF DELAWARE

5

U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS

6

June 11, 2015

7

8

9 I. Introduction:

10 This is the seventh report of the Court Monitor (Monitor) on the implementation by the State of 11 Delaware (State) of the above-referenced Settlement Agreement (Agreement).1 Prior reports of 12 the Monitor have reviewed the State’s progress with regard to each element of the Agreement, as 13 well as related reforms it is making to support the Agreement’s goals. With the concurrence of 14 the parties, this is an abbreviated report. It focuses upon those provisions of the Agreement for 15 which the Monitor has concluded that the State was not in Substantial Compliance per the 16 Monitor’s sixth report.2 These provisions relate to:

17

a. Reducing the number of State-funded psychiatric inpatient bed-days used by the

18

population of people with Serious and Persistent Mental Illness (SPMI) that the

19

Agreement targets (Section III.D.3 of the Agreement),

20

b. Discharge planning for individuals who are hospitalized in Delaware Psychiatric

21

Center (DPC) or one of the private psychiatric hospitals (IMDs3) that serve members

22

of the target population through State funding (Section IV),

23

c. The State’s Assertive Community Treatment programs (ACT) and their fidelity to the

24

TMACT program standards (Section III.F4), and

1 This report generally covers the period from July 1, 2014 through February 28, 2015.
2 Section VI.B.3.g presents criteria by which the Monitor is responsible for evaluating the State’s performance with regard to the Agreement’s provisions, through ratings of: Substantial Compliance, Partial Compliance, and Noncompliance. For the period ending July 15, 2014, the Monitor found the State to be in Substantial Compliance with the relevant provisions of the Agreement that are not discussed in this report. Although not reviewed here, the State is required to maintain Substantial Compliance for these provisions. Based upon the Monitor’s ongoing evaluations, including the “dashboard” data provided by the State on a monthly basis, Delaware is, indeed, fulfilling its responsibility to sustain compliance with these provisions.
3 IMD refers to the federal classification of such facilities under Medicaid as “Institutions for Mental Diseases.” Three privately operated IMDs serve members of the target population.
4 In 2012, the Monitor and the parties agreed that the TMACT model of fidelity would be substituted for the Dartmouth model, which is specified in the Agreement.
1

25

d. The State’s risk management program, which is intended to reduce the risk of harm to

26

individuals covered by the Agreement (Section V.B).

27 In addition to these four provisions, this report also presents an update on the State’s efforts to 28 increase the number of individuals who receive supported employment services (per Section 29 III.J) and who ultimately secure jobs in the mainstream workforce. The State has been in 30 Substantial Compliance with respect to providing the supported employment services required 31 by this provision of the Agreement, however, the Agreement has no specific targets for the actual 32 employment outcomes of these services. As was referenced in prior reports of the Monitor, the 33 Governor has made employment of Delawareans with disabilities a priority of his administration. 34 Furthermore, employment of people with disabilities in the mainstream of their communities is 35 one essential goal of the Americans with Disabilities Act (ADA), upon which the Agreement is 36 substantially based. For these reasons, an update on the State’s success in securing jobs for 37 members of the target population is included in this report.

38

39

40 II. Review of Delaware’s Status with Respect to Specific Provisions of the Agreement:

41

42

A. Annual Inpatient Bed-Days Used & Discharge Planning

43 Reducing psychiatric hospitalizations among the target population is an important benchmark 44 contained in the Agreement in that it reflects the collective impact of the various community45 based services and supports that the Agreement requires. At the time the last Monitor’s report 46 was written, the State had not demonstrated the overall reduction in annual state-funded bed-days 47 as is required in Section III.D.3; it was found to be in Partial Compliance with this provision. 48 Based upon data provided by the State at that time, Delaware had achieved significant reductions 49 in bed-days for individuals receiving long-term care services at DPC, and more modest 50 reductions in acute inpatient care—which is what this provision of the Agreement specifically 51 references—for those individuals whose services were managed by the Division of Substance 52 Abuse and Mental Health (DSAMH). However, for those individuals whose care was under 53 management of the Division of Medicaid and Medical Assistance (DMMA)5 and the private 54 Managed Care Organizations (MCOs) with which it contracts, the number of acute bed-days 55 used had actually increased, relative to the “base year” of 2011.6

56 Figure-1 presents updates on the cumulative number of state-funded hospital bed-days used by
57 the target population this fiscal year with respect to the 30% and 50% reduction targets [relative 58 to the baseline of the State’s fiscal year (FY) 2011] required by the Agreement.7 The data

5 Both DSAMH and DMMA are divisions of the State’s Department of Health and Social Services (DHSS). 6 It is noted that the State has improved its monthly reporting of Medicaid-funded bed-days since the Monitor’s last report. The State’s Bed-Day Reporting Memorandum, dated February 3, 2015, describes its corrective actions. 7 Agreement, Sections III.D.3-4.
2

59 represent the period from July, 2014 through February, 2015, and the reduction targets represent 60 where the State’s overall bed-days are required to be as of June 30 in 2014 and 2016. Figure-1 61 includes the State’s total bed-day use for the target population (“Overall”), as well as cumulative 62 data for the three components that are comprised by the overall total. The DPC total reflects 63 bed-days for acute, intermediate, and long-term hospital care within that State-operated facility. 64 The IMD data for DSAMH and Medicaid are only for acute-care that is provided within those 65 privately-operated settings.
66 Relative to the base year, the State projects an overall reduction in hospital bed-days of 21.0% at 67 the end of this fiscal year (this projection is represented by the dashed portion of the “Overall” 68 line in the graph). In other words, its expected bed use for this fiscal year will exceed the 2014 69 reduction goal (Section III.D.3). This projection contemplates continued lower numbers of long70 term care days at DPC, as well as reductions in acute care managed through DSAMH at DPC 71 and the IMDs.
72

60,000 50,000

Figure-1 Cumulative Inpatient Bed Days
for the Target Population
FY15 (as of 3/31/2015)

BASELINE (FY 2011)

State-Funded Bed-Days

40,000 30,000 20,000

30% REDUCTION (FY 2014 GOAL) 50% REDUCTION (FY 2016 GOAL)

10,000

0 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

DPC - Total

IMD - DSAMH Funded

Medicaid Funded

Overall

73

74

75 Figure-2 presents the State’s projections of bed-day use for acute-care this fiscal year, based 76 upon current trends.8 As is reflected in these data, overwhelmingly, the acute inpatient care
77 provided to the target population is managed through DMMA; the State projects a 25.9%

8 Sections III.D.3-4 of the Agreement specifically reference acute inpatient settings.
3

78 increase in hospital bed days for this group relative to FY 2011, which is clearly inconsistent 79 with the Agreement’s targets.
80 In interpreting this projection, however, there are some important additional factors to consider. 81 The data presented in Figure-2 from July through December, 2014 essentially represent 82 management of inpatient care as it has taken place since the Agreement took effect. Beginning 83 in January, 2015 some significant changes began to occur. Inpatient psychiatric care for 84 DSAMH clients who have Medicaid coverage was no longer “carved out” of the State’s 85 Medicaid managed care program and subject to approval (and reimbursement) through DSAMH. 86 Instead, it came to be managed as for other Medicaid recipients, by DMMA through the 87 contracted MCOs. For the Medicaid population of people with SPMI not served through 88 DSAMH, there were changes as well; annual limits on psychiatric hospital care were no longer 89 applied to these individuals.9 And other changes in the State’s Medicaid program will shift 90 further responsibility for the management of acute inpatient psychiatric care from DSAMH to 91 DMMA.10
92
Figure-2 Cumulative State-Funded Bed-Days for Acute Care

DSAMH DMMA

Jul14
142 1645

Aug14
254 3374

Sep14
412 4886

Oct14
650 6268

Nov14
984 7686

Dec14
1254 9172

Jan15
1439 10,700

FY Projected
Total
2336 16,086

Change Relative to Base Year
40.7% Red. 25.9% Inc.

93
94 These developments do not mean that management of inpatient psychiatric care for the 95 Agreement’s target population became the sole responsibility of DMMA and the MCOs. As is 96 explained in the next section, the State is in the process of implementing some significant 97 reforms in how Medicaid-funded services for individuals with SPMI are managed. These 98 measures should result in more consistent involvement of DSAMH in the coordination of care to 99 individuals whose care is managed through DMMA, and they should improve the process for 100 ensuring that individuals in need of specialized services and housing—both of which can reduce 101 the risk of hospitalization—are appropriately referred to DSAMH. As a consequence of these 102 multiple changes, there will likely be significant revisions in the number of bed-days used for 103 acute care by the end of this fiscal year.

9 Prior to this, DSAMH assumed responsibility for managing inpatient care when individuals’ annual Medicaid benefits for psychiatric hospitalization were exhausted. 10 For instance, greater numbers of heretofore uninsured individuals will qualify for Medicaid and DSAMH will no longer be the funder and manager of their inpatient psychiatric care.
4

104

105

1. The State’s Measures to Reduce Inpatient Psychiatric Bed Days

106 As a general matter, the parties agree that the bed-day reduction targets contained in the 107 Agreement were intended as a proxy measure of the impact of the newly created array of 108 community services upon the target population, particularly with respect to these individuals 109 successfully living stably, integrated within their communities and outside of institutions. These 110 goals are in keeping with the requirements of the ADA. Such a reduction may indicate that 111 members of the target population are being appropriately served in the community in accordance 112 with the ADA. Also important with regard to this provision are individuals’ access to 113 specialized services and supportive housing that allow them to live successfully in their 114 communities, and the interrelated issue of discharge planning which should be a pivotal point in 115 connecting people to these services (e.g., Section IV). The Monitor had in the past found that, 116 for individuals whose care is managed through DMMA, the overall process of referring 117 individuals for DSAMH’s specialized services has been vague and not closely overseen by the 118 State. In addition, discharge planning in the IMDs was found to be poorly coordinated with 119 community providers.

120 As was referenced in the last Monitor’s report, DSAMH and DMMA have collaboratively 121 developed a bed-day reduction plan that is intended to not only continue the trend toward 122 decreased numbers of long-term care bed-days at DPC, but also impact the acute-care bed-days 123 used. This plan incorporates a variety of approaches, including such elements as: PROMISE, an 124 amendment to State’s Medicaid waiver;11 new collaborative agreements involving, variously, 125 DMMA, DSAMH, the MCOs, and the IMDs; Medicaid funding for detoxification services in 126 IMDs for individuals whose acute needs relate to substance use; and replication of the successful 127 Recovery Resource Center (a crisis walk-in center serving southern Delaware) in New Castle 128 County.

129 Since the last report, progress has continued in this overall effort. The State has provided 130 additional information about the new collaborative agreements, which include measures intended 131 to address many of the problems cited in past Monitor reports that may underlie the increasing 132 rates of hospital use. These measures should improve coordination among these entities prior to 133 and following hospital admissions and improve discharge planning. In addition, they should 134 help ensure that all members of the target population—particularly the sizable population of 135 people with SPMI who are not served through DSAMH—are appropriately afforded access to 136 the housing and specialized services that were created pursuant to the Agreement. This has been 137 referenced in several previous Monitor reports. Some of the State’s corrective measures have 138 been implemented only recently, and others are still pending. Thus, their effects would not be 139 expected to be fully seen in the bed-use data reported above. But, if implemented as planned, the

11 Through PROMISE, Medicaid now covers an array of new services relevant to the Agreement and its target population, including: Care Management, Individual Employment Supports, Short-Term Small Group Supported Employment, Financial Coaching, Benefits Counseling, Peer support, Non-Medical Transportation, Psychosocial Rehabilitation, Respite, Independent Activities of Daily Living/Chore Services, Personal Care, and Community Transition Services.
5

140 new agreements and revisions in operational protocols should have a favorable impact in 141 reducing the annual bed-day numbers.

142 The new contracts and collaborative agreements with the MCOs and with the IMDs provide a 143 structure to significantly improve matters. For instance:

144

Contracts between the State and the IMDs:

145

 Embed principles of community integration, mainstream employment, informed

146

personal choice, and involvement of peer supports—all of which reflect the

147

requirements of the ADA and the Agreement.12

148

 Specifically reference the Agreement13 and require IMDs to comply with its

149

requirements relating to timely involvement by a community provider upon

150

hospital admission (Section IV of the Agreement).14

151

Contracts between the State and the MCOs:

152

 Require a collaborative protocol involving the MCO and DSAMH to ensure that

153

individuals are being appropriately referred to PROMISE (The PROMISE

154

program comprises the array of specialized services provided through DSAMH,

155

most of which are directly or indirectly required under the Agreement.).15

156

 Require that, with respect to involuntary inpatient or outpatient treatment,

157

comprehensive discharge and crisis plans are developed including, as appropriate,

158

referrals for PROMISE services.16

159

 Require MCOs to actively assist in discharge planning for individuals receiving

160

institutional care.17

161

 Indicate that DSAMH has primary responsibility for developing and monitoring

162

care provided under the PROMISE program and that MCOs have responsibility

163

for service coordination,18 and require DSAMH and the MCOs to devise protocols

164

for collaboration to effectively carry out these functions.19

165

 Require MCOs to work with DSAMH to devise collaborative strategies to achieve

166

the bed-use reductions required in the Agreement,20 including in the process of

12 Contract for Involuntary Patient Psychiatric Services between DHSS/DSAMH and IMDs, Appendix A-1 (e.g., Contract #j 021508). 13 Ibid., Appendix B-4, p.1. 14 Ibid., Appendix B, p.2. 15 MCO Final Contract, 2015, Section 3.8.4.1. 16 Ibid., Section 3.4.6.9.4. 17 Ibid., Section 3.8.4.2.3. 18 Ibid., Section 3.8.9.10.1.1. 19 Ibid., Section 3.8.9.10.3. 20 Ibid., Section 3.12.4.1.
6

167

admission to an IMD, in utilization review during the hospital stay, and in

168

discharge planning.21

169 At this juncture, the State’s contracts with the IMDs are in effect and operational. DSAMH, 170 DMMA and the MCOs are having regular meetings to discuss implementation of the State’s 171 contracts with the MCOs, and DSAMH and DMMA are having regular interdivisional 172 agreements to discuss related matters. The State is finalizing the specifics about procedures 173 relating the new agreements, how it will oversee these processes, and how it will report progress 174 relevant to the Agreement as a part of the Monitor’s monthly dashboard. As was explained 175 earlier, elements such as these are critical in augmenting the inpatient bed-use numbers to 176 demonstrate the State’s status with respect to Section III.D and other provisions of the 177 Agreement.

178

179

2. Referrals for Specialized Mental Health Services & Supported Housing

180 As was referenced earlier, the Monitor has found significant problems in the State’s processes to 181 ensure that individuals covered by the Agreement are being appropriately referred to DSAMH 182 for the specialized services and housing that are not otherwise available to them.22 While such 183 referrals may be made at any time, they are particularly relevant as a part of discharge planning 184 following an acute hospitalization, and they should be part of a seamless transition from the 185 hospital to the community service system. The Monitor’s last report noted that the State has 186 identified 454 individuals whose care is managed through DMMA and who, based upon their 187 psychiatric diagnoses and a history of repeated hospitalizations in IMDs, likely should have been 188 referred for intensive services such as ACT, Peer Services, and Supported Housing. Because 189 these referrals were not made in a timely way (i.e., at the point of hospital discharge), beginning 190 in September, 2014, the State launched an intensive effort to connect with these individuals and 191 to work through this backlog of referrals. Unfortunately, due to the time that elapsed between the 192 hospitalizations and this referral initiative, significant numbers of these individuals cannot now 193 be located. As of the beginning of March 2015, the State attempted to connect—by phone or in 194 person—to 185 people on the list of 454, beginning with those who ostensibly have the greatest 195 need.23 Notwithstanding DSAMH’s intensive outreach efforts, the State has not been able to 196 locate 44.3% of this group due to inaccurate contact information. An additional 13% refused the 197 offer of services. And only 22 of the 185 (11.8%) are being successfully engaged in services.

198 In order to get a sense of the individuals who were not being successfully engaged, the Monitor 199 reviewed records at one of the IMDs of 11 individuals whom the State had not been able to 200 locate. Each these individuals had in excess of 3 psychiatric hospitalizations during a two-year 201 period ending in July, 2014. All told, they accounted for at least 45 admissions to this one

21 Ibid., Section 3.12.4.1.4, Section 3.10.2.1.58. 22 Most of these services, other than housing, will be covered through the new PROMISE program, which also entails referral to DSAMH. 23 Based upon the number of recent hospitalizations.
7

202 hospital alone during this period. Their records indicated significant problems that strongly 203 suggest a need for ACT or other intensive services provided through DSAMH. Most were 204 repeatedly admitted due to suicidality. At least 6 of the 11 individuals were repeatedly admitted 205 and identified as homeless, without being referred for the supported housing available through 206 DSAMH. At least one individual was repeatedly admitted and discharged back to a living 207 arrangement that was reported to be exploitive.
208 As the State continues its efforts to reconnect with such high-risk individuals, moving forward, 209 its new collaborative arrangements involving the MCOs, DSAMH, and the IMDs should ensure 210 a much more systematic approach to referring at-risk individuals with SPMI to ACT, supportive 211 housing, and other specialized services. Nevertheless, the intensity of the issues identified in the 212 records review speaks to the importance of the State vigorously continuing its efforts to 213 reconnect with them and offer needed services. DMMA has indicated that, by the end of April, it 214 will provide the MCOs with the names of their beneficiaries who are among the 454 prioritized 215 for review by DSAMH.24
216 The State is now working with the Monitor to establish monthly dashboard measures relating to 217 the new agreements discussed above, including their impact in ensuring that individuals are 218 appropriately connected with the services and housing required by the Agreement. One such 219 measure will be the number of individuals newly referred to DSAMH for services (this number 220 will ultimately include referrals for the new PROMISE program). To this end, the State has 221 compiled baseline data reflecting new referrals to DSAMH’s Eligibility and Enrollment Unit 222 (EEU) since January, 2014; these data can be compared with referral patterns after the new 223 initiatives are operational. For the calendar year 2014, the monthly average number of such 224 referrals was 19.1. January, 2015, when several new components of the State’s collaborative 225 agreements began to go into effect, already showed an increase, with 29 new referrals for that 226 month. The State will continue to provide monthly data relating to EEU referrals, as well as 227 other new dashboard indicators in order to monitor progress relating to this important measure 228 and to help detect problems in implementation as they may arise.
229 In addition, to better identify members of the target population who are homeless or are living in 230 unstable or inappropriate housing, the State is now requiring that IMDs complete a housing 231 assessment form for all admitted Medicaid clients with SPMI; heretofore, this form had been 232 used only for DSAMH-funded clients and there was no systematic means of evaluating the 233 housing status of other members of the target population.25 This measure should significantly 234 assist the State in capturing housing information relevant to members of the target population 235 served through MCOs who, as exemplified in the cases referenced above, may be appropriate for 236 the supported housing created pursuant to the Agreement. The State is taking additional steps to
24 This process was delayed somewhat because, as of January 1, 2015, there were changes among the MCOs working under contract with the State and not all individuals affected had yet expressed their choices as to which MCO they preferred to manage their Medicaid benefit.
25 This form was developed to facilitate the State’s compliance with Sections II.B.2.f, II.E, and III.I.
8

237 identify members of the target population who are homeless through consultation with 238 Delaware’s Homeless Planning Council.

239

Recommendation:

240

 The State’s list of individuals whose care is managed through MCOs and who are

241

considered to be at elevated risk of hospitalization or other adverse outcomes has

242

not been updated since July, 2014. Although there are measures in various phases

243

of implementation that should improve the referral of such individuals to

244

DSAMH (or the new PROMISE program), it is recommended that the State

245

update this list and include newly identified individuals in its outreach efforts

246

until the improved processes for collaboration and coordination are fully

247

functional.

248

249

250

B. Assertive Community Treatment

251 ACT is an essential community-based service for many individuals who have SPMI— 252 particularly those who have histories of adverse outcomes such as repeated hospitalizations, 253 criminal justice contact, and homelessness. Properly implemented, ACT programs provide 254 flexible clinical and psychosocial services outside of office settings and, instead, in the home, 255 work, and other community environments where individuals spend their days. In this way, ACT 256 teams gain a first-hand understanding of the individual’s success and challenges in meeting the 257 demands of community life, and when issues arise, they can tailor interventions accordingly.

258 Section III.F of the Agreement requires the State to have a total of 11 ACT teams operational by 259 September 1, 2015. As has been discussed in prior reports by the Monitor, the State has 260 exceeded the number of ACT teams required and, in fact, at the end of 2013 it had already met 261 its 2015 goal. It also upgraded most of its Intensive Case Management teams (ICM)26 to the 262 ACT model in order to more appropriately meet the needs of the individuals who were being 263 served through those teams. The parties have recognized that the conversion of ICM teams to 264 ACT teams actually represents more intensive community services than are required by Section 265 III.G for ICM clients. Thus they agreed that, as long as the number of individuals being served 266 was not reduced as a result of this upgrade and as long as the ACT fidelity standards were met, 267 the State’s compliance with the Agreement’s requirements regarding ICM teams would not be 268 negatively affected.

269 Figure-3 reconciles the numbers of teams and individuals being served before the conversion 270 (December, 2013) with current data from March, 2015 (following the conversion). It shows that 271 the State continues to exceed the upcoming September, 2015 requirements and that the total

26 ICM teams are required in Section III.G of the Agreement.
9

272 number of individuals served by ACT and ICM following the conversion has increased by about 273 10%.27
Figure-3 ACT and ICM Services Prior-To and Following ICM Conversions

Dec, 2013

Sep, 2015 Mar, 2015

Required

Actual

Required

Actual

ACT Teams

928

11

1129

16

ICM Teams

430

5

431

1

Total Clients

1,587

1,751

274

275 The Agreement specifically requires the State to operate its ACT programs in conformance to 276 standardized fidelity measures. Figure-4 presents comparisons of ten of the ACT teams’ overall 277 scores according to the TMACT model which the State uses.32 The remaining teams which are 278 not represented in Figure-4 are in various stages of preliminary assessment, so scores were not 279 yet available. Following a start-up period when preliminary assessments and consultations by 280 the State’s experts are provided, ACT teams are evaluated at least annually. For teams that have 281 been operational long enough to have more than annual assessment, trending of their 282 performance according to TMACT is included in Figure-4.

283 When teams are evaluated, DSAMH generates detailed reports of findings, including 284 recommendations for improvement or requirements for corrective action plans. It subsequently 285 monitors teams’ efforts to comply with such plans and, as indicated, provides technical 286 assistance in furtherance of these efforts. As is reflected in the above chart, some ACT teams 287 have improved in their scores over time, others have scored more poorly, and some have stayed 288 fairly consistent. Such variance is common within State systems, influenced in part by factors 289 including staff turnover, vacancies, level of experience and provider management. 290 Notwithstanding the State’s assistance, some teams have not performed adequately during the 291 course of the Agreement’s implementation; there have been instances where DSAMH has 292 terminated ACT contracts and reformulated teams under the auspices of different provider 293 organizations. While such events are unfortunate (and certainly not reflective of most ACT 294 teams that were developed pursuant to the Agreement), they do demonstrate that DSAMH is 295 actively monitoring and holding providers accountable for the quality of services being provided.

27 It is standard that ACT teams each serve about 100 individuals, so the required 11 teams should serve a total of 1,100 people. There are no such general standards for ICM; the Agreement specifies minimum staff-to-client ratios for ICM, but not a specific number of clients to be served.
28 Agreement, Section III.F.3 29 Agreement, Section III.F.4 30 Agreement, Section III.G.2 31 Ibid. 32 The maximum score that can be achieved is 5.
10

296 As the State compiles TMACT data on the ACT teams that are not included in Figure-4, it is 297 expected that it will able to demonstrate Substantial Compliance with the Agreement’s Sections 298 III.F-G.

299

Figure-4

300
301 Complementing the above fidelity data, prior reports by the Monitor have presented the 302 impressive array of trending data that the State collects to measure positive outcomes (such as 303 employment) and adverse events (such as hospitalizations) among individuals served by ACT 304 teams. In addition, in concert with the University of Pennsylvania, the State is carrying out 305 ongoing comprehensive qualitative assessments of how ACT clients are faring.33 The State 306 regularly presents these data and consults with the Monitor about its quality control and 307 performance improvement measures relating to ACT.

308

309

C. Risk Management

310

311 The State continues to make progress in its efforts to reduce the risk of harm to members of the

312 target population, both within institutional settings and within the community programs that are

313 required under the Agreement. As has been described in prior reports of the Monitor, the relevant

314 risk management systems within DHSS had been disjointed and significantly defined by where

315 an incident involving harm occurred (for instance, a state-operated facility as opposed to a

316 community setting). It did not promote the identification and remediation of issues that cut

317 across various settings and bureaucratic divisions. The State is moving forward with a major

318 restructuring of its system, with the goals of unifying its reporting and investigations, individual

319 and aggregate reviews of adverse events, and corrective actions—both on a case-level and

33 This quality of care research also includes the State’s CRISP program, which provides ACT-like services through a capitated funding mechanism designed to encourage flexible use of resources to address clients’ needs.
11

320 systemically. Based upon these plans, the State has been evaluated as being in Partial 321 Compliance with respect to the requirements of Section V.B of the Agreement.

322 Revision of the risk-reduction processes affecting the target population is a complex endeavor, 323 involving multiple levels of staff and provider entities. As such, system redesign, training, and 324 the development of data systems are involving a significant staff effort. This body of work is 325 proceeding according to timeframes established last year; the State is anticipating rolling out 326 major changes in risk management this spring. DSAMH is already conducting intensive 327 training, both internally and with its contractual providers, relating to its refined risk-reduction 328 program. This training includes comprehensive sections on the identification of adverse 329 incidents (such as abuse, neglect, and inappropriate restraint practices); mandatory reporting 330 requirements for state employees and employees of contractual providers; uniform protocols for 331 reporting and investigations; staff background checks; and the State’s structures for oversight 332 and review. The risk-reduction requirements covered by the training apply not only to services 333 currently managed by DSAMH, but to the new PROMISE program, as well.

334 If this effort continues as anticipated, the State is positioned to vastly improve its risk 335 management of services to the target population. In the interim, the State is providing the 336 Monitor with monthly updates, as well as critical incident reports and investigations.

337

338

D. Supported Employment

339 The requirements of the Agreement harmonize with Governor Markell’s priority to promote the 340 employment of Delawareans who have disabilities. This priority has been embraced by DHSS 341 and the State’s Department of Labor (DOL). As has been previously reported by the Monitor, 342 the State has consistently met or surpassed its annual numeric goals for supported employment, 343 per Section III.J of the Agreement. These goals relate to the number of individuals within the 344 target population who receive supported employment services.

345 DOL’s Division of Vocational Rehabilitation (DVR) has a longstanding, close working 346 relationship with DSAMH. It maintains detailed data about services provided to its clients— 347 including the substantial proportion who are members of the target population. Because 348 supported employment entails several levels of service (from application through actual 349 engagement on a job), for purposes of evaluating the State’s compliance with Section III.J, the 350 parties have agreed to count only those members of the target population who are at least at the 351 point of having active individualized employment plans in place. The Monitor’s last report 352 noted that the State was meeting its requirements under the Agreement with respect to the 353 number of people receiving such services, but that about 20% of these individuals were job354 ready but unemployed, and only about 4% were actually employed. Figure-5 presents an update 355 for the current fiscal year. Whereas the proportion of people served who are considered job356 ready has remained about the same (21.2%) there has been an approximate 400% increase in the 357 proportion of individuals who are now employed (3.9% in FY 14, as compared with 13.4% in 358 FY 15).

12

359

Figure-5

360

Status of Members of the Target Population

361

Who Are Receiving Supported Employment Services

362

FY 14 and FY 15 (YTD)

363

364 365

366 To further understand the employment status of members of the target population, DSAMH has 367 developed a detailed spreadsheet through which its contractual providers will report such factors 368 as where individuals are employed, at what hourly rate, and for what duration. These data will 369 be incorporated in its monthly dashboard of compliance indicators.

370 In addition, the State has been receiving expert technical assistance and the Monitor has 371 discussed providing additional technical assistance resources should the State request them.

372

373

Recommendation:

374

 As is reflected above, the State is making some significant improvement in

375

moving people with SPMI through the supported employment process and into

376

jobs in the mainstream workforce. While the job market remains competitive, the

377

State has indicated that it could likely achieve even further improvements if

378

additional trained employment specialists were available to work with the targeted

379

population and prospective employers. While the State is in Substantial

380

Compliance with the numerical requirements relating to supported employment

381

servicers, mainstream employment (like mainstream housing) is an outcome that

382

goes to the core of the Agreement’s intent. Accordingly, and consistent with the

383

State’s priority of promoting the employment of Delawareans who have

13

384 385 386 387 III.

disabilities, it is recommended that the State carefully consider an expansion in the number of trained employment specialists working with the target population.
Summary:

388 This abbreviated report documents that Delaware is making progress in addressing issues raised 389 in prior Monitor’s reports and toward fulfilling its requirements under the Agreement. As has 390 been explained above, several key measures have not yet been fully implemented, but systems 391 and processes that support the goals of the Agreement are now being developed. Data over the 392 coming months should begin to demonstrate the impact of the State’s new processes and, as has 393 been reflected in the State’s approach throughout implementation of the Agreement, should 394 inform further ongoing system refinements.

395
396 Robert Bernstein, Ph.D. 397 Court Monitor

14

 
 EIGHTH REPORT OF THE COURT MONITOR ON PROGRESS TOWARD COMPLIANCE WITH THE AGREEMENT: U.S. v. STATE OF DELAWARE
U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS 12/26/2015

1 I. Introduction:

2

This is the eighth report of the Court Monitor (Monitor) on the implementation by the

3 State of Delaware (State) of the above-referenced Settlement Agreement (Agreement). Unless

4 noted otherwise, it is based on compliance data through the State’s 2015 fiscal year1 and is

5 reflective of four years of implementation efforts by the State.

6

As is detailed below, the State continues to demonstrate progress in meeting the

7 requirements of the Agreement. In those areas where it has not yet demonstrated Substantial

8 Compliance,2 for the most part the State has put in place active plans toward achieving

9 Substantial Compliance. Some of these plans entail extensive changes in how the State’s systems

10 operate in serving individuals with Serious and Persistent Mental Illness (SPMI), but they are not

11 yet fully operational. As a consequence, data relevant to such provisions as inpatient bed-day

12 reductions (Section III.D), Quality Assurance and Performance Improvement (Section V.A), and

13 Risk Management (Section V.B) are either incomplete or not fully reflective of the impact of the

14 State’s plans.

15

In those areas where the State has been demonstrating Substantial Compliance, a core

16 issue at this juncture is whether these reforms, which are directed to promote successful

17 community integration among the targeted population, will be sustained beyond the Agreement’s

18 term. Several factors are working in the State’s favor. First of all, the Americans with Disabilities

19 Act (ADA) and the U.S. Supreme Court’s decision in Olmstead3 —laws that are central to the

20 intent of the Agreement—required the State to make some fundamental changes in its service

21 system relating to the targeted population and in how these services are delivered. Provisions of

22 the Agreement relating to supported housing that is integrated within the larger community

23 (Section II.E), comprehensive crisis services (Section II.C), and peer supports (Section II.G.2)

24 are examples of areas where the State actively worked (and continues to do so) to reorient its

25 workforce and the people it serves to promote person-centered services, personal responsibility,

26 and community integration. The sustainability of these changes is bolstered not only by various

1 Delaware’s 2015 fiscal year runs from July 1, 2014 through June 30, 2015. 2 Section VI.B.3.g of the Agreement defines the criteria on which the Monitor evaluates the State’s level of compliance as “Substantial Compliance,” “Partial Compliance,” or “Non-Compliance.” 3 Olmstead v. L.C., 527 U.S. 581 (1999)
1

27 ongoing trainings and the emergence of a vibrant peer movement in Delaware, but also by the 28 fact that the State has embedded the principles of the Agreement in its funding structures. 29 Delaware’s SRAP program, which provides rental subsidies for integrated housing to people 30 with disabilities, and the modification of its Medicaid program through PROMISE, which 31 captures federal funds for a wide array of services relevant to the Agreement are examples of 32 funding streams that promote the requirements of the Agreement and that cut across bureaucratic 33 boundaries.4

34

PROMISE, which is a modification of the Delaware’s Medicaid waiver, received federal

35 approval in late 2014, and the State began implementation of this program in January 2015. It

36 has broad implications that cut across many provisions of the Agreement that are discussed in the

37 next section. To briefly summarize what is a complicated endeavor, Medicaid’s PROMISE

38 program vastly expanded the array of covered services that are essential to people with SPMI

39 living in the community in accordance with the goals of the Agreement—peer services, chore

40 and personal support services, employment supports, and respite services are among them.

41 PROMISE has not only affected funding for services, but it has also required the State to make 42 significant changes in how DSAMH, DMMA, the MCOs,5 and contracted providers interact with

43 regard to services being provided to members of the target population, notably (but not solely)

44 when these individuals are psychiatrically hospitalized. In developing PROMISE procedures, the

45 State sought to address many of the issues of cross-bureaucracy accountability and responsibility

46 that had plagued its prior service arrangements. Although these changes technically went into

47 effect at the beginning of this calendar year, their potential impact is not yet being fully realized.6

48 At this juncture, contracts for new or expanded community services are still being rolled out, and

49 while DSAMH, DMMA, and the MCOs are meeting regularly, they are still working through the

50 specific processes for collaboration and improving outcomes. As such, PROMISE was an

51 important, long overdue, step towards creating a more coherent service system for the target

52 population, but it is still a work in progress.

53

The following section presents the State’s status with respect to fulfilling the

54 requirements of the Agreement.

4 In these instances, the Division of Substance Abuse and Mental Health (DSAMH), the Division of Medicaid and Medical Assistance (DMMA), and the Delaware State Housing Authority (DSHA). 5 MCOs are Managed Care Organizations that, through contracts with DMMA, manage individuals’ Medicaid benefits. 6 For instance, bed-use for acute psychiatric hospitalization continues to rise, in conflict with the requirements of the Agreement. This is discussed further in the Crisis Stabilization section of this report.
2

55 II. Ratings of Compliance with Specific Provisions of the Agreement

56

Summary of Compliance Ratings

Factor

Reference in the Agreement Compliance Rating

Crisis Hotline

III.A

Substantial Compliance

Mobile Crisis Services

III.B.1

Substantial Compliance

Crisis Walk-In Centers

III.C

Substantial Compliance

Crisis Stabilization Services

III.D.3-4

Partial Compliance

Crisis Diversion Training

III.A.2, III.B.2, III.C.2, III.D.2 Substantial Compliance

Crisis Apartments

III.E

Substantial Compliance

Assertive Community Treatment III.F

Substantial Compliance

Intensive Case Management

II.D.2.b, III.G.1-2

Substantial Compliance

Case Management

II.D.2.c.ii, III.H

Substantial Compliance

Supported Housing

III.I.5

Substantial Compliance

Supported Employment

III.J.1-4

Substantial Compliance

Rehabilitation Services

III.K.4

Substantial Compliance

Family & Peer Supports

III.L.1-4

Substantial Compliance

Discharge Planning

III.C.2.d.iii-iv

Partial Compliance

Quality Assurance

V.A

Partial Compliance

Risk Management

V.B.1-10

Partial Compliance

57

58

59 A. Crisis Hotline

60

Substantial Compliance.

61

In keeping with the requirements of Section III.A of the Agreement, the State has

62 established and maintained 24-hour crisis hotlines that provide counseling services and, as may

63 be indicated, enable timely access to face-to-face help for individuals who are experiencing

64 mental health emergencies. The Crisis Hotlines are a resource for individuals who are already

65 receiving some level of mental healthcare, and they are also an important point of service entry

66 for individuals with mental health needs who are new to the system.

67

Figure-1 presents the State’s monthly tracking of calls to the Crisis Hotlines from

68 individuals in New Castle County (“NC”), where the bulk of the State’s population resides, and

69 for the southern counties of Kent and Sussex (“KS”), which are more rural. The hotlines are

70 well integrated with Mobile Crisis Services, particularly so, because these programs are co-

3

71 located. As is indicated in this chart, the majority of the calls are received from individuals who 72 have SPMI and who do not express problems relating to co-occurring substance use (“NON73 SUD Calls”). Nevertheless, the State’s analysis of Crisis Hotline data over time has revealed 74 significant numbers of callers who are seeking help for substance use (“SUD Calls”) and it is 75 now promoting the hotlines for use by individuals who have mental health and/or substance 76 abuse issues.
77
FIGURE-1:
MCIS Monthly Activity Report
2500
(Fiscal Year 2015)
2000

1500

1000

500

0 NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS
FY14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Avg

Non SUD Calls FTF Call Resp. SUD Calls Other FTF *Crisis Hotline Calls are based upon monthly reported data provided by Mobile Crisis Intervention Services (MCIS)

78

79

The State remains in Substantial Compliance with Section III.A of the Agreement.

80

81 B. Mobile Crisis Services

82

Substantial Compliance.

83

The State’s Mobile Crisis Service programs provide rapid face-to-face responses to

84 people who are in acute mental health crises. The State operates two such programs, one for New

85 Castle County and one for Kent and Sussex Counties. Generally, calls for this service are

86 received through the Crisis Hotlines, which provide preliminary screening, data-gathering and, as

87 indicated, immediate phone counseling while the Mobile Crisis staff is en route. As is reflected

88 in Figure-1, a substantial number of the calls received through the Hotlines are addressed

4

89 through interventions by phone; those that are determined to require a face-to-face response 90 (“FTF Call Resp”) present a need for rapid in-person intervention by a mental health 91 professional.
92

FIGURE-2:

Mobile Crisis Crisis Response Time

Average Face-to-Face Response Time in Minutes

1:04

Fiscal Year 2015

0:57

0:50

0:43

0:36

0:28

0:21

0:14

0:07

0:00

FY14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Avg

NCC

K/S

Overall

Target

93

94

In keeping with the urgent nature of such interventions, Section III.B.1 of the Agreement

95 sets a standard that Mobile Crisis programs provide in-person services statewide within one hour

96 of referral. The State maintains detailed data relating to this requirement. In the past, it has been

97 able to meet the Agreement’s standard and, as is reflected in Figure-2, it continues to maintain

98 compliance. Often, the involvement of Mobile Crisis staff does not entail just a single encounter,

99 but also a short-term, continuing role in resolving the emergency situation and ensuring a

100 seamless transition to ongoing services. Depending upon specific circumstances, such

101 involvement by Mobile Crisis may be carried out by phone or by additional face-to-face visits

102 (“Other FTF” in Figure-1).

103

The State remains in Substantial Compliance with respect to the Agreement’s

104 requirements for Mobile Crisis Services.

105

106 C. Crisis Walk-In Centers

107

Substantial Compliance.

108

Section III.C of the Agreement requires the State to operate at least two 24-hour Crisis

109 Walk-In Centers that provide assessment and short-term treatment services to individuals who

110 are experiencing psychiatric emergencies. The term “walk-in center” may be a bit of a misnomer

5

111 in that it can suggest a program geared to people who have relatively low levels of need and who 112 come in on their own for help. Indeed, there are such individuals being served through this 113 program, but more typically, the State’s Crisis Walk-In Centers serve people in acute crisis who 114 are at very high risk of admission to a psychiatric hospital and whose needs are urgent. They 115 commonly are transferred from the emergency rooms of general hospitals and are often brought 116 to the Centers by police.

117

Delaware’s mental health law includes provisions for the emergency detention of

118 individuals at a designated psychiatric facility when, as a result of mental illness, there is a

119 substantial risk of danger to self or others.7 The purpose of such 24-hour detentions is to

120 determine if the individual meets the legal criteria for involuntary hospitalization and whether

121 such hospitalization is the least restrictive and most appropriate intervention to address the

122 presenting issues. Historically, these evaluations have occurred at IMDs8 where the detentions

123 almost invariably result in hospitalization (either involuntary or voluntary). Recognizing this

124 outcome and that the purpose of the 24-hour detention is to determine the need for

125 hospitalization rather than to be an aspect of hospitalization, the State has taken measures to

126 better differentiate these functions. Accordingly, in the southern counties, DSAMH’s Enrollment

127 and Eligibility Unit (EEU) directs the individuals subject to 24-hour detentions to the Recovery

128 Resource Center (RRC)9 unless there is a compelling reason to do otherwise.10

129

FIGURE-4:

Hospital Diversion Rates

RRC, CAPES,* and Mobile Crisis

100%

Fiscal Year 2015

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

FY14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Avg

% Diverted (RRC) % Diverted (CAPES) % Diverted (MCIS) Overall

*CAPES did not submit data for FY 2015

7 16 Del.C § 5004. 8 IMDs (Institutions for Mental Diseases, in Medicaid parlance) are freestanding psychiatric hospitals. Delaware has three such facilities: Rockford, MeadowWood, and Dover Behavioral Health. 9 Prior reports of the Monitor have described this successful Crisis Walk-In program in Ellendale, Delaware. 10 Examples of such reasons are that the RRC is full or that the individual presents an urgent danger of harm.
6

130

As is presented in Figure-4, RRC has demonstrated impressively high rates of diverting

131 individuals from hospitalization, including those being evaluated under 24-hour detention orders.

132 As has been discussed in previous Monitor reports, the State is developing a new Crisis Walk-In

133 Center, patterned after the RRC and its “living room” model, to serve New Castle County. That

134 facility is currently under construction. Once it is operational, EEU will direct individuals under

135 24-Hour Detention orders to that facility as it currently does in the State’s southern counties.

136 Until the new facility opens (likely early in 2016), CAPES—the Crisis Walk-In Center located in

137 a general hospital—continues to provide services to the northern part of the state, including 24-

138 Hour Detention evaluations for some individuals and a significant number of individuals

139 continue to be evaluated at an IMD.

140

The State is in Substantial Compliance with the Agreement’s requirements with respect

141 to Crisis Walk-In Centers.

142

143 D. Crisis Stabilization Services

144

Partial Compliance.

145

Section III.D.3 and III.D.4 of the Agreement delineate requirements for the State to

146 reduce its acute inpatient bed days in the IMDs and in DPC11 by 30% and 50%, respectively,

147 relative to the base year of 2011. Prior reports of the Monitor have included extensive

148 discussions of these provisions and the State’s difficulties in meeting these targets. To briefly

149 summarize the issue, the State’s arrangements for oversight of acute psychiatric hospital care for

150 people with SPMI had been quite complicated, with accountability dispersed among DSAMH,

151 DMMA, and the MCOs operating under contract with DMMA. The entity or entities responsible

152 for monitoring the quality and appropriateness of an individual’s hospital care could shift, based

153 upon limitations in Medicaid coverage or referral for more intensive specialized services

154 including those required by the Agreement. Furthermore, the responsibility for ensuring that

155 individuals were appropriately referred for such critically needed intensive services was vague,

156 at best.

157

Inpatient psychiatric care is sometimes warranted, but it is also intrusive, it can be

158 coercive or traumatic, and it is an expensive service that drains resources that could be used

159 otherwise. The Agreement anticipates that the array of community program alternatives required

160 in its provisions, once fully operational, will significantly reduce the State’s reliance upon

161 hospital care by the percentages referenced above. As such, the number of inpatient days used by

162 the target population reflects the culmination of these new programs. For all of these reasons, the

163 Crisis Stabilization provisions of the Agreement are particularly important in demonstrating the

164 State’s alignment with the requirements of the ADA and Olmstead, around which it was

165 substantially crafted.

11 Delaware Psychiatric Center (DPC) is the state-operated psychiatric hospital located in New Castle, Delaware.
7

166

Data presented in prior reports of the Monitor showed that the State has been successful

167 in reducing inpatient days dedicated to long-term care at DPC,12 but the State was not only

168 failing to decrease the acute inpatient days referenced in Section III.D, these bed-days were

169 increasing.

170

Figure-5 presents the State’s monthly totals for acute-care psychiatric hospital bed days

171 used by the target population.13 The monthly average number of acute-care bed days in the base

172 year (2011) preceding the agreement was 1,393 (indicated by a dotted line). As is indicated in

173 this chart, acute-care bed days for each of the months since July 2014—including the months

174 since PROMISE was implemented in January 2015—have exceeded this level, sometimes

175 significantly. Likewise, the trend line (the dashed line in the chart) shows a general upward

176 trajectory with respect to acute care bed-day use.

177

FIGURE-5:
MONTHLY ACUTE-CARE BED DAYS
Monthly Average for Base Year (2011) & July 2014 - August 2015
2,500

2,000 1,500 1,000

1393

1787

1841

1670

1620

1752

1774

2204

1947

2267

2117

1484

2134 1522

500

0

BASE AVG Jul-14
Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15

178

179

The increases in acute care bed-days are essentially attributable to hospital stays at the

180 IMDs. 87% of the bed-days categorized by the State as acute care occurred in the IMDs14 and

12 Provisions in Section III.D relating to bed day reductions refer to acute care bed use only. The Agreement does not include specific numerical targets for long-term psychiatric hospitalization, but it does incorporate provisions to reduce unwarranted long-term care (e.g., Section IV.A-B). 13 In the past, these data have been broken out by the State division responsible for oversight (DSAMH and DMMA); given the changes since January 1, 2015, this differentiation is no longer relevant. 14 It is noted that the State is now analyzing data with respect to individuals transferred to DPC from IMDs (e.g., because they could not be stabilized within a short period in those settings), and those moving from acute-care
8

181 were managed through DMMA (15,510 out of 17,771). As is explained later (and detailed in 182 prior Monitor reports), at least a part of these increases may have been due to the State’s lack of 183 appropriate controls over the process by which individuals whose behavioral healthcare was 184 managed through MCOs were referred to DSAMH for the specialized services and housing 185 required by the Agreement that can reduce the vulnerability for hospitalization. The protocols for 186 such referrals and lines of accountability have been significantly improved since January 1, 187 2015. However, acute bed-days have continued to rise this calendar year. Given this pattern of 188 increasing hospital use, plans that are now being discussed to further expand hospital capacity by 189 building a new IMD in southern Delaware15 raise additional questions as to whether the State 190 will be able to curtail hospital rates for the target population.

191

Figure-6 presents the data contained in Figure-5 on a cumulative basis, that is, not as

192 monthly totals, but as running totals for the fiscal year. This presentation allows ready analysis

193 of bed use against the 30% and 50% reductions (from the base year) that are specified in the

194 Agreement.

195

FIGURE-6:

CUMULATIVE BED-DAYS FOR ACUTE PSYCHIATRIC CARE

BASE YEAR AND FISCAL YEAR 2015

25,000

21985

20,000 15,000

16714 Total Acute 11700 30% REDUCTION TARGET

10,000

8357 50% REDUCTION TARGET

5,000

0

Total Acute 30% REDUCTION TARGET 50% REDUCTION TARGET

status to intermediate-status in DPC to ensure that the above data correctly reflect the entire duration of an individual’s hospitalization episode. 15 The proposal that has been shared with the Monitor calls for a 90-bed hospital. Although the full plan for this facility has not yet been completed, it is noted that conditions for approval include requirements to prevent the unnecessary admission of individuals and to collaborate with DSAMH and its network of community providers to ensure least-restrictive treatment and service continuity.
9

196

This chart shows that last fiscal year the State’s total overall bed-day use met and

197 exceeded the 50% reduction level (which is to be met by July 1, 2016 per Section III.D.4 of the

198 Agreement) in November 2014, with seven months still remaining in the fiscal year. By January

199 2015—with five months remaining in the fiscal year—it had already exceeded the 30% reduction

200 level which was to have been met in July 2014 (Section III.D.3). And in March 2015 it had

201 almost reached the point of utilizing the full Baseline bed-use from which these reduction targets

202 are calculated. By the end of the 2015 fiscal year, the State reported 21,985 acute care bed days,

203 which is greater than a 30% increase in acute care bed use by the target population, relative to

204 the Baseline year. These increases not only run counter to the requirements of the Agreement,

205 but they raise systemic issues of quality and performance. As is discussed in the section of this

206 report relating to Quality Assurance and Performance Improvement, the State is not taking

207 appropriate advantage of data that could clarify the characteristics of the population responsible

208 for bed-use increases, as well as their utilization of services earlier on that could reduce their

209 hospitalization rates.

210

211

Additional Factors

212

In assessing the State’s performance with regard to Crisis Stabilization provisions of the

213 Agreement, there are some additional factors worth noting.

214

215 Reductions in Longer-Term Care at DPC

216

FIGURE-7:
Reductions in Longer Term Care at DPC
Relative to Base Year in Total Bed Days

35,000

30,000

25,000

20,000

15,000

10,000

5,000

0

BASE YEAR FY11 30 % Reduction 50% Reduction

FY14

Target

Target

FY 15

DPC - Intermediate DPC - Long Term

217

10

218

Figure-7 presents data demonstrating the State’s success in reducing reliance on long

219 term care at DPC. Applying the 30% and 50% reduction targets which the Agreement contains

220 with respect to acute care to longer term care at DPC, the State is performing much better.16 The

221 State defines “acute care” as hospitalization lasting 14 days or fewer. “Intermediate” term care at

222 DPC is defined as lasting 15 to 179 days and “long term” hospital care is defined as longer than

223 179 days. As is reflected in this chart, the State has dramatically reduced bed-days in long term

224 care, meeting a 50% reduction target in both fiscal years 2014 and 2015. These rates have

225 remained stable for some time. Whereas DPC used approximately 40,000 bed days for

226 intermediate- and long-term care in the base year, as of fiscal year 2015 the combined total for

227 these categories of care was only about 25,000 bed days—a reduction of about 38%.

228

229 Referrals for Specialized Mental Health Services

230

Prior Monitor reports have described significant problems in the State ensuring that

231 members of the Agreement’s target population whose behavioral healthcare was managed

232 through DMMA were being appropriately referred to DSAMH for the specialized services and

233 housing required in the Agreement. The arrangements that had been in place for years were

234 wholly unclear not only as to what entity was responsible for making such referrals—the IMD,

235 the MCO, or DMMA—but even what criteria would be applied for determining that such

236 referrals were necessary.

237

As was discussed in the Monitor’s last report, the State identified a group of 454

238 individuals with SPMI who had not been referred for specialized services even though they were

239 obviously not doing well in the community, as evidenced by multiple re-hospitalizations in IMDs

240 in a short period of time. That report described an initiative by the State that was launched in

241 March 2015 to reach out to these ostensibly very high-risk individuals, including through phone

242 contact and in-person visits, to ascertain their wellbeing and to make specialized services

243 available to them. For reasons that are not at all clear, the State delayed action on this initiative,

244 thereby further lengthening the time between individuals’ hospital discharge and the outreach to

245 offer specialized services. Accordingly, it was unable to make contact with a large proportion of

246 this group of 454 (had referrals been made routinely as a part of discharge planning at the IMDs,

247 this would not have been an issue). Once the initiative got underway, however, the State made a

248 good-faith effort using Targeted Care Managers (TCM) to attempt to connect with each of these

249 individuals.

250

Figure-8 summarizes the outcomes of this effort, as well as the detailed data the State

251 maintained to track its progress. Notwithstanding their intensive efforts, the TCM staff were able

252 to make contact with only about 23% of the group; they were unable make contact with about

253 77% of this group. With respect to those actually contacted, about 13% of the group of 454

254 declined the offer of services and just under10% were brought to some level of either receiving

255 services or enrollment in services. For those individuals not among those on track to be served

256 (and who are still in the State’s Medicaid program), the applicable MCOs have been notified of

16 Such targets for long-term care, however, are not a part of the Agreement.
11

257 their high-risk status so they can pursue referrals should opportunities present themselves in the 258 future.

259

FIGURE-8:
TCM Outreach Status to High-Risk Individuals Whose

MH Care Is Managed Through MCOs*

as of November 10, 2015

Interested in TCM Services, 1.4% Referred to EEU, 1.2%

Out of State, 0.5% Declined EEU Services, 0.5%

Other Provider, 1.7%

No Reason Given, 0.2%

Agreed to or Already In TCM Services,

Incarcerated, 0.2%

4.8%

Unable to Locate or Contact (Closed), 10.1%
Declined TCM and EEU Services, 12.8%

Problems Locating (Phone/Address Issues),
47.2%

Left Message, 16.6%

Priority groups 1a to 2d; individuals with prior TCM contact were not included.

260

261

In addition, as a part of the new collaboration agreements that went into effect this

262 calendar year, DSAMH, DMMA and the MCOs now have specific criteria—for instance,

263 hospital readmission—that trigger a referral for specialized services. The State has created a

264 tracking dashboard with such measures as the number of monthly hospital admissions, the status

265 of these individual relative to PROMISE/DSAMH, and the number of individuals not receiving

266 specialized services who are referred. While the numbers are still preliminary, there has already

267 been a significant increase in referrals of individuals with SPMI who had not been receiving

268 these services. It is too soon to say whether this effort will have the effect of reducing the

269 number of inpatient days used by the target population.

270

12

271 Referrals of Homeless Individuals for Housing

272

Among the problems relating to referrals for specialized services was the finding,

273 discussed in past Monitor reports, that individuals were being admitted to IMDs from

274 homelessness or from unstable housing situations, and that they were being discharged to the

275 same situations—often without even a plan to secure housing.17 In some instances, individuals

276 were discharged to shelters, which are inherently problematic for people with SPMI. Aside from

277 the issues of accountability in the referral process discussed earlier, it had been difficult to

278 ascertain which individuals had issues relating to housing because this information, when it

279 appeared at all, tended to be buried within progress notes or psychosocial assessments in the

280 IMD charts. From the perspective of the bed-day reduction provisions of the Agreement,

281 homelessness or instability in housing is a known risk factor for untoward outcomes such as re-

282 hospitalization.

283

The State has taken affirmative measures to correct this problem. It now requires IMDs to

284 complete a Housing Assessment form upon admission of all members of the target population.

285 This form, which is submitted to DSAMH, clearly identifies which individuals are homeless or

286 unstably housed, and whether a referral was made to TCM to link them to housing and other

287

FIGURE-9:
Outcomes of Housing Assessments by IMDs
March-April 2015

Status of Homeless Individuals

Housing

Referred

Active w/ Referred

Assessmts Have a

to Referred Service Living in

IMD

Month Completed Home Homeless EEU/TCM to TCM Provider Shelter

Rockford March

53

40

13

4

5

4

Dover BH March

11

8

3

2

1

MeadoWd March

14

10

4

3

1

Rockford

April

38

31

7

1

4

2

Dover BH April

40

37

3

3

MeadoWd April

15

14

1

1

Totals

171

140

31

5

12

6

8

288

17 The Monitor had not found this to be an issue at DPC.
13

289 needed services. The State has also developed a decision tree that delineates the appropriate 290 measures to be taken, based upon stability of an individual’s housing and that the individual’s 291 existing linkages to services.

292

Figure-9 presents early data from this initiative. Although it covers only two months,

293 March and April of 2015, the chart shows the sizable proportion of individuals among the target

294 population who were admitted to IMDs and identified as being homeless, as well as referrals

295 now being made to TCM to address this issue. Out of 171 housing assessments completed by

296 IMDs on individuals with SPMI who were admitted to their facilities during this two-month

297 period, almost one in five were homeless. As is reflected in the data presented here, the State has

298 begun to address this longstanding problem by referring individuals for services and housing in a

299 much more systematic way than had been the case in the past. As is discussed later in this

300 report, such findings relating to homeless individuals may affect the State’s status with respect to

301 Section III.I.6 of the Agreement. Furthermore, they may highlight a need to further explore the

302 underutilization of Crisis Apartment beds, which is discussed later.

303

###

304

305

In summary, with respect to the Agreement’s requirements relating to Crisis Stabilization

306 Services, the State has not met the bed-use reduction targets of Section III.D.3 of the Agreement

307 and it is very unlikely that it will meet the further reductions specified in Section III.D.4 to be in

308 effect by July 1, 2016. It has made—and maintained—its progress in reducing long-term care at

309 DPC, where some individuals had been consigned for decades. Particularly since the beginning

310 of this calendar year, the State has begun to take important steps in linking individuals who are at

311 elevated risk of hospitalization to the services and housing they need to be successful in the

312 community. As is discussed in the Quality Assurance and Performance Improvement section of

313 this report, there are steps that the State can take to better understand factors underlying the

314 increasing number of bed-days used by the target population and to devise interventions

315 accordingly.

316

The State is in Partial Compliance with the Agreement’s Crisis Stabilization

317 requirements.

318

319 E. Training Relating To Crisis Diversion Services

320

Substantial Compliance.

321

Sections IIIA.2, III.B.2, III.C.2, and III.D.2 of the Agreement require that the State train

322 providers and law enforcement personnel in regard to its various diversion programs: its Crisis

323 Hotlines, Mobile Crisis, Crisis Walk-In Centers, and Crisis Stabilization Services, respectively.

324 Such training remains ongoing since implementation of the Agreement began, and DSAMH

325 provides monthly data regarding the number of individuals trained and the counties where the

326 trainings occur. During Fiscal Year 2015, approximately 600 individuals received training in

14

327 crisis alternatives, a very substantial number of whom were from state and local police 328 departments.

329

The State is in Substantial Compliance with regard to the staff and law enforcement

330 training provisions of the Agreement referenced above.

331

332 E. Crisis Apartments

333

Substantial Compliance.

334

Crisis Apartments represent a critically important component of the State’s mental health

335 service system; they provide respite housing for individuals who are in crisis, cannot resolve

336 their crisis within their current living situation, and do not present an immediate danger to

337 themselves or to others. The apartments—which are, in actuality freestanding houses—are

338 staffed by peers; clinical services and TCM are provided through the responsible community

339 programs. Section III.E of the Agreement requires that the State make operational at least four

340 Crisis Apartments to provide statewide coverage. The State continues to exceed this requirement

341 in that, in addition to the four apartments required (the State fulfills this through the Princeton

342 and Harrington Restart programs in New Castle and Kent Counties, respectively), it also operates

343 an additional four respite beds and ten “resource beds” that can be used flexibly as needed.

344

FIGURE-10:
Crisis Apartment Utilization
Percent of Total Available Bed Days Used
Avg Use in FY 2014 and Monthly Use in FY 2015
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

% Total Used (NCC)

% Total Used (K/S)

Combined % Bed Days Used

% Total Used (CRISP)

*The State began receiving data on the crisis apartments utilized by the State's CRISP population in April

345

15

346

Prior Monitor reports have described how the use of these beds has been variable,

347 particularly in the southern counties, as well as the State’s efforts to better integrate these

348 resources with day-to-day service operations (for instance, by frequently sharing vacancy

349 information through its Mobile Crisis programs). Figure-10 presents the State’s tracking of bed

350 use in the four crisis apartments required by the Agreement. Although there is variation month-

351 to-month, this chart shows that the very low utilization rates in years past are no longer in

352 evidence and that Crisis Apartment are, indeed, becoming integrated within service plans for

353 individuals experiencing psychiatric emergencies. Utilization rates remain lower in the southern

354 counties, where for seven months of the fiscal year, more than half of the beds were empty, on

355 average. Also included, beginning in April 2015 is information from the CRISP program.18

356

FIGURE-11:
Average Days of Stay in Crisis Apartments
Monthly Avg in Fiscal Years 2014 and 2015
20 18 16 14 12 10
8 6 4 2 0

Avg LOS (NCC)"

Avg LOS (Kent/Sussex)

Avg LOS (CRISP)

357

358

The Agreement contemplated that the Crisis Apartments would be used for up to seven

359 days and that, thereafter, the individual would return home,19 however, the State has found that

360 this is not how they have come to be used in practice. Often, individuals who use this program

361 have mental health crises that cannot be resolved with in-home services because their living

362 arrangements are unstable or incompatible with their needs. Accordingly—particularly in New

363 Castle County—average lengths of stays in Crisis Apartment have been double this time frame

364 or even longer as arrangements are made to secure stable housing. Figure-11 presents the

365 average lengths of stay in Crisis Apartments by county, and Figure-12 presents the same data,

18 CRISP has been described in detail in prior Monitor reports; it is an ACT-like program that serves high-need individuals and that enables providers to flexibly use capitated funds to address their clients’ needs, including for crisis apartments. 19 Agreement, Section II.C.2.e
16

366 but as total numbers of bed-days used each month. While not always the case, considering that 367 the individuals occupying the Crisis Apartment beds have not only acute mental health issues, 368 but also often housing issues as well, their risk of hospital admission would likely be very high 369 would this program not be available.
370

FIGURE-12:

Total Bed Days Used Monthly in Crisis Apartments

Average Monthly Fiscal Year 2014

120

and Monthly for Fiscal Year 2015

100

80

60

40

20

0

# of Bed Days (NCC)

# of Bed Days (Kent/Sussex)

# of Bed Days (CRISP)

371

372

The State is in Substantial Compliance with respect to the requirements for Crisis

373 Apartments.

374

375 F. Assertive Community Treatment

376

Substantial Compliance.

377

Assertive Community Treatment (ACT) is a critically important service for people with

378 SPMI, particularly those with complex clinical issues in combination with trauma histories,

379 repeated episodes of institutionalization, criminal justice involvement, and/or co-occurring

380 substance use problems. Section III.F of the Agreement requires the State to have eleven ACT

381 teams in conformance with evidence-based TMACT standards.20 There are now fifteen ACT

382 programs serving the target population,21 plus the CRISP program which, while not held to

20 The Agreement calls for fidelity with the Dartmouth model, but early in the implementation process, the parties agreed that the TMACT model would be used. 21 One team, Connections ACT-IV, is new and has not yet had its full TMACT evaluation.
17

383 TMACT standards, provides similarly intense mobile services to individuals who have service 384 needs that are at least as significant as those served through ACT.22

385

The State provides monthly data with regard to the number of clients served by each

386 ACT team, which generally approximate 100 clients per team except in the southern counties

387 where logistics have required smaller caseloads, of around 80.

388

TMACT fidelity is one means of evaluating the quality of ACT services being provided

389 in Delaware. As in any system, there is variation among the ACT teams in the fidelity scores

390 achieved, and notwithstanding efforts to improve a specific team’s score, performance may drop

391 due to such factors as staff turnover. The State continues its rigorous program of conducting

392 TMACT assessments of each team at least annually and, as indicated, assisting teams in fulfilling

393 resultant corrective action plans through consultation by very experienced experts.

394

During the past year, the State has also identified patterns of issues in ACT services that

395 cut across teams. For instance, its own assessments and those of the Monitor revealed that the

396 living environments of some individuals being served in supported housing were not adequate,

397 sometimes not only as a result of clinical issues presented by the clients, but landlord

398 responsiveness to maintenance needs, as well. As a consequence, the State has taken action to

399 more intensively evaluate the quality of individuals’ living environments, whether care plans are

400 appropriately addressing these issues, and whether ACT is the appropriate service for these

401 individuals. In at least one instance, the State concluded that an apartment complex was not

402 providing adequate repair and maintenance services, and alternative apartments are being

403 secured as a result. In addition, recognizing the level of need presented by some clients of ACT

404 programs, the State has made arrangements for new personal care and chore services covered

405 through the PROMISE program to supplement ACT services on a case-by-case basis. This has

406 not yet gone into effect, though.

407

Figure-13 presents TMACT “overall” scores for the State’s ACT teams, reflecting

408 evaluations conducted in Fiscal Year 2015 and, where they exist, comparative evaluations for

409 Fiscal Year 2014.23,24 These overall scores are composite measures reflecting six subscales that

410 comprise 47 measures. Some teams’ overall scores reflect consistency among the subscales,

411 while in other instances, there may be considerable internal variance. As is indicated in this

412 chart, eleven out of the fourteen ACT teams that were scored obtained overall TMACT scores of

413 3.0 or higher; even within these teams, there may be deficiencies identified through the subscales

414 for which the State is requiring corrective measures. The three ACT teams with overall scores

22 Reconciling the State’s compliance with the numerical targets of Section III.F (ACT) and III.G (Intensive Case Management, or ICM) has been a bit challenging because, with the concurrence of the parties and the Monitor, the State converted some of its ICM teams to ACT. Furthermore, the CRISP program represents additional capacity (approximately 100 clients) for ACT-like services. This was explained more fully in the Monitor’s Seventh Report. All factors considered, the Monitor has determined that the State is exceeding the combined numerical requirements for ACT and ICM. 23 Full evaluations are only conducted after one year to eighteen months of start-up and preliminary evaluations, so newly formed teams may not have evaluations from FY 2014. 24 It is noted that Figure-4 in the Monitor’s Seventh Report (May 1, 2015) incorrectly presented the TMACT scores obtained by the Connections I ACT team. The scores presented here, in Figure 13, are correct.
18

415 below 3.0 [NHS ACT-I, NHS ACT-III, and Horizon House (HH) ACT-Pathways] all have 416 corrective action plans, although in some instances they may already be performing well on 417 specific subscales. The State has shown that it takes action when TMACT evaluations are poor 418 and those teams’ responsiveness to corrective action plans are inadequate. Accordingly, the RHD 419 ACT-I team, whose overall score declined to 2.0, was closed by the DSAMH; in its place, a new 420 ICM team is now being operated by Horizon House. Another team, NHS ACT-II was closed by 421 the State before a full evaluation occurred because of poor performance at the preliminary stages; 422 The Connections ACT-IV team is its replacement.
423

RHD ACT-ENRICHMT RHD ACT-I DOVER RHD ACT-RECOVER
RHD ACT-I (CLOSED) NHS ACT-III
NHS ACT-II (CLOSED) NHS ACT-I
HH ACT-NAVIGATOR HH ACT-HOPE
HH ACT-VISIONS HH ACT-PATHWAYS
HH ACT-ALLIANCE CONN ACT-DOVER CONN ACT-IV (NEW)
CONN ACT-III CONN ACT-II CONN ACT-I

FIGURE-13:
TMACT Fidelity Overall Scores
Fiscal Years 2014 and 2015

0

1

2

3

4

5

TMACT Overall Score

FOR EACH ACT TEAM, THE TOP BAR (BLUE) IS THE MOST RECENT EVALUATION SCORE AND THE GRAY

BAR(S) PRESENT EARLIER EVALUATIONS

424

425

In addition to TMACT measures, which heavily focus on process, the State conducts

426 assessments of a number of outcome indicators reflecting the success of ACT teams (and ICM,

427 as well) in achieving the goals of the Agreement. A sample of these measures is presented below

428 as aggregate data for teams operated by each provider. The State’s data system allows it to not

19

429 only evaluate performance on this level, but to drill down to a specific ACT/ICM team or even 430 individual clients.

431

Figure-14 summarizes the number of homeless individual served by these programs each

432 month. Although some clients lose their housing while being served by ACT (an example is a

433 tenant with co-occurring substance abuse who engages in unacceptable behaviors), more

434

FIGURE 14:
Percent of ACT/ICM Clients Homeless

for Any Night During the Month

16%

By Provider, Fiscal Year 2015

14%

12%

10%

8%

6%

4%

2%

0% Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Conn

HH

RHD

NHS

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

435

436 typically, homelessness among ACT clients occurs upon entry to the program while housing 437 arrangements are still being worked out; as such, this issue is particularly applicable to newer 438 ACT teams which do not yet have their full complement of clients. As is indicated Figure-14, 439 NHS shows the highest levels of homelessness among its clients, the State is working with this 440 provider to address this issue.

441

Figure-15 presents the percentages of clients arrested each month by ACT/ICM provider.

442 The arrest rates have remained fairly stable and low—generally hovering at around 1%. This is a

443 significant outcome indicator in that arrests are among the target population’s risk factors

444 referenced in the Agreement (Section II.B.2.e). The individuals served by ACT and ICM are at

445 elevated risk of encounters with police, not only because of the intensity of mental health issues

446 that qualify them for these levels of service, but also because co-occurring substance use is

447 common among them. The large majority of these individuals are now living independently in

448 integrated supported housing (i.e., per Section III.I of the Agreement), that is, outside of the daily

449 “structure” that characterizes the institutions in which they once lived.

20

450
FIGURE-15:
Percent of ACT/ICM Clients Arrested
By Provider, Fiscal Year 2015

10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Conn

HH

RHD

NHS

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool
451

452

FIGURE-16:
Percent of ACT/ICM Clients Psychiatrically Hospitalized
By Provider, Fiscal Year 2015
25%

20%

15%

10%

5%

0% Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Conn

HH

RHD

NHS

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

21

453

Figures -16 and -17 present the monthly psychiatric re-hospitalization rates and

454 emergency room use, respectively, for clients of ACT and ICM. For the same reasons specified

455 for Figure-15, these are also an important measures of performance with respect to the high-risk

456 population being served.

457

FIGURE-17:
Percent of ACT/ICM Clients with Emergency Room Visits
By Provider, Fiscal Year 2015
14%

12%

10%

8%

6%

4%

2%

0% Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Conn

HH

RHD

NHS

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

458

459

As is explained later (with regard to Quality Assurance and Performance Improvement),

460 an ongoing study through the University of Pennsylvania is looking at how different cohorts of

461 the target population are faring as new services and refinements in processes roll out through the

462 course of the Agreement’s implementation. This research is showing that, while the likelihood of

463 an individual being re-hospitalized is declining somewhat for successive cohorts (e.g., members

464 of the target population who entered service during the first year of the Agreement’s

465 implementation, as compared to those entering service during the second year), there is a high

466 use of emergency rooms by individuals who are not hospitalized.25 This research includes not

467 only individuals served through ACT/ICM as represented in Figure-17, but also a sizable number

468 whose care is managed through DMMA and MCOs. Relevant here, such findings point to the

469 importance of looking “upstream” from hospital admissions to see where earlier opportunities for

470 intervention may be appropriate.

471

In contrast to the negative outcomes reflected in the tracking on the above four measures,

472 the State’s quality measurements for ACT and ICM also include positive outcomes. Figure-18

473 presents data relating to the employment status of clients served through these programs.

25 It is not clear whether these emergency room visits reflect behavioral health crises or issues reflective of a need to better address physical health needs.
22

474 Employment is an extremely important outcome with respect to the goals of the Agreement. It is 475 also a difficult outcome to achieve. Typically, the individuals being served through ACT and 476 ICM do not have stable work histories; they are challenged by a lack of marketable skills, the 477 harms attendant to recurrent or protracted institutionalization, and often by criminal justice 478 histories, as well. As is explained further, with regard to Section III.J, the State has been working 479 aggressively to promote mainstream employment for members of the population targeted by the 480 Agreement (and for all Delawareans with disabilities, as well, per an initiative of the Governor). 481 Figure-18 reflects the slow, but important, progress the State is making with respect to the target 482 population, not only in the percentage of ACT/ICM clients who are employed in regular jobs in 483 their communities, but in the proportion that are working 20 hours per week or more.

484

FIGURE-18:

Percent of ACT/ICM Client Employed

16%

All Teams, By Hours per Week; Fiscal Year 2015

14%

12%

10%

8%

6%

4%

2%

0% Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15
<10 Hrs/Week 10-20 Hrs/Week 20+ Hrs/Week

*Data provided via ACT/ICM Monthly Qualitative Reporting Tool

485

486

Taking into consideration all of the factors discussed in this section, the State is rated as

487 being in Substantial Compliance with the Agreement’s requirements with respect to Assertive

488 Community Treatment.

489

490 G. Intensive Case Management

491

Substantial Compliance.

492

Intensive Case Management (ICM) is a program designed to serve individuals with SPMI

493 who do not require the very high level of services associated with ACT, but who nevertheless,

494 need ongoing and mobile support to live successfully in the community. As has been explained

23

495 in prior reports of the Monitor, the State initially developed four ICM teams per the requirements 496 of Sections III.G.1 and III.G.2 of the Agreement. Once operationalized, however, it found that 497 these teams were not able to provide the level of support needed by the individuals being served 498 and, with the concurrence of the Monitor and DOJ, DSAMH upgraded some of its ICM teams to 499 conform to ACT requirements (these additional ACT teams are included in the TMACT surveys 500 discussed above). The State now operates two ICM teams.

501

While there are no standardized fidelity measures for ICM, the State is including its ICM

502 teams in the quality outcome monitoring discussed above and summarized in Figures-14 through

503 18. It is maintaining ICM staffing ratios in keeping with Section II.D.2.b of the Agreement.

504

The State remains in Substantial Compliance with the Intensive Case Management

505 requirements of the Agreement.

506

507 H. Case Management

508

Substantial Compliance.

509

Case Management, which the State refers to as Targeted Care Management (TCM), is a

510 program that provides time-limited services to individuals who require linkage to mental health,

511 housing, employment, or other programs. For many individuals, TCM is the front door to

512 community services, including those offered through the PROMISE program. Accordingly,

513 TCM is intimately connected with the State’s Mobile Crisis programs, its Crisis Walk-In

514 programs, and (increasingly with routineness) discharge processes at the IMDs. Targeted Care

515 Managers also play a pivotal role in the in-person and telephone outreach to high-risk individuals

516 that was discussed above in the section “Referrals for Specialized Mental Health Services.”

517

The Agreement requires that TCM staff be responsible for no more than 35 individuals

518 (Section II.D.2.c.ii), however, the State has found that in practice this staffing ratio is not

519 sufficiently intensive. Instead, its TCMs tend to maintain caseloads of about 10-14 individuals.

520 By its nature, there is considerable turnover among individuals served; some may only require

521 (or agree to) a single visit, while others (particularly those who require housing) may require

522 multiple visits and sustained involvement over a period of months. Provisions included in

523 Section III.H of the Agreement require that the State utilize 25 case managers. DSAMH’s TCM

524 program includes a total of 25 case managers between sites in New Castle County, a site in

525 southern Delaware that is co-located in the Ellendale Walk-In Center, and a state-operated

526 program. On average, about 286 individuals were served through Delaware’s TCM program

527 each month in fiscal year 2015.

528

The State is in Substantial Compliance with the Agreement’s provisions relating to Case

529 Management.

530

24

531 I. Supported Housing

532

Substantial Compliance.

533

The Supported Housing provisions of the Agreement are among the pivotal indicators of

534 the State’s success in complying with Olmstead, including the goal of enabling individuals who

535 have SPMI to live “like the rest of Delawareans, in their own homes...”26 A substantial number of

536 the individuals targeted by the Agreement have long histories of residing in segregated facilities,

537 including psychiatric hospitals, group homes, and other congregate settings that set them apart

538 from the community mainstream. Recognizing the importance of creating integrated housing

539 alternatives, supported housing was an early priority in DSAMH’s implementation efforts, and it

540 remains an area where the State has achieved success.

541

FIGURE-19:
Compliance with Supported Housing Targets
By Fiscal Year and Source of Funding

5 Year Totals
FY15

FY 2015 TARGET: 650

FY14

FY13

FY12

FY11

0

100

200

300

400

500

600

700

800

Grandfathered SRAP-Budgeted SRAP-Additional CRISP CoC HUD Section 811

542

543

Section III.I.5 of the Agreement requires the State to provide vouchers or subsidies for

544 scattered-site integrated supported housing to a total of 650 individuals. The State has

545 consistently exceeded this target, relying on a combination of opportunities through its SRAP

546 program, HUD programs, and DSAMH funds (e.g., CRISP). As is represented in Figure-19, it

547 continues to exceed the Agreement’s requirements, in fact, substantially so.

548

Section III.I.6 of the Agreement commits the State, with certain considerations, to

549 provide bridge funding and housing subsidies to anyone in the target population who needs such

26 Agreement, Section II.2.E1.a
25

550 support. Particularly relevant here will be whether or not existing resources are sufficient to 551 address the ongoing and already known housing needs of the target population, as well as those 552 of homeless individuals with SPMI who are identified when admitted to an IMD (this was 553 discussed above in the section “Referrals of Homeless Individuals for Housing”) and newly 554 identified individuals arising from DSAMH’s interactions with the State’s Homeless Planning 555 Council.27

556

The State is in Substantial Compliance with the Agreement’s requirements with respect

557 to Supported Housing.

558

559 J. Supported Employment

560

Substantial Compliance.

561

As is the case with respect to integrated supported housing, supported employment that

562 enables members of the target population to hold ordinary jobs in their communities is a very

563 significant “bottom line” measure of whether the array of new services required by the

564 Agreement is actually working to achieve the goals of the ADA and Olmstead.

565

Past reports of the Monitor have referenced the positive working relationship between

566 DSAMH and the Division of Vocational Rehabilitation (DVR) of the Delaware Department of

567 Labor. People with SPMI represent a large portion of the population served by DVR, and DVR

568 has allocated resources to enhance the capacity of DSAMH’s ACT programs to assist their

569 clients in entering the mainstream workforce. Figure-18, discussed earlier, reflects the products

570 of this interagency collaboration.

571

Sections III.J.1-4 of the Agreement require that the State provide supported employment

572 services to a total of 1,100 individuals as of July 1, 2015. As is presented in Figure-20, the State

573 is surpassing this requirement in that 1,326 members of the target population were receiving

574 Supported Employment Services in the fiscal year by that date.

575

There are some factors in the federal program that is administered by DVR that present

576 challenges to individuals with SPMI. Generally, DVR supported employment services terminate

577 after an individual is employed in a job for 90 days, a federal limitation that was not designed

578 with a mind to the needs of individuals with psychiatric disabilities. Given the combination of

579 clinical, educational, and social factors confronting many members of the Agreement’s target

580 population, however, the State has recognized that these individuals may have a need for more

581 extended supported employment services if their job success is to be sustained and enhanced.

582 Accordingly, the PROMISE program includes coverage of individual and small-group

583 employment supports that, as appropriate, may extend services well beyond federal limitations in

584 DVR programs. The State is finalizing contracts with providers that will be certified to offer

585 supported employment services through PROMISE to individuals who are not served by ACT or

586 ICM; these are expected to go into effect in mid-December 2015. In addition, PROMISE

587 includes other services that may directly assist members of the target population who are

27 The 2016 Delaware Homeless Planning Council Point in Time count is specifically referenced in Section III.I.6.
26

588 participating in the mainstream workforce, including non-medical transportation, financial 589 coaching and benefits counseling.
590

FIGURE-20:

Clients Receiving Supported Employment

1,400

Total Clients for Fiscal Year 2014 & Cumulative Totals for Fiscal Year 2015
1326

1,200 1,000

ANNUAL TARGET: 1100

800

600

400

200

0

FY14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

FY14 Carryover

Year-to-Date Count

*Supportive Employment numbers are based upon data from the Division of Vocational Rehabilitation within the State Department of Labor **The FY14 Carryover number is based on 90% of the overall total from FY14. Overall, the percentage of clients "In Service" and "Job Ready" combined equaled 96.1% of the overall total. The State then took a conservative estimate of 90% to calculate a number of 597 clients still active going into FY15.

591

592

Figure-21 shows the State’s progress in moving individuals through the Active Service

593 Planning phase28 and into Job Readiness and mainstream Employment. Each of the fiscal years

594 presented represents a cohort of about 700 individuals, so a comparison based upon the

595 percentages of individuals in each category can be easily made. In both years, about 20% of the

596 target population receiving supported employment services was categorized as “Job Ready,”

597 meaning that they were at the point of actively seeking employment. In 2015, the State made

598 dramatic gains in the proportion actually employed, increasing from 3.8% in 2014 to 11.9% —

599 more than a threefold increase. Based upon the Monitor’s consultation with vocational experts in

600 the State, the primary barrier to even further improving this outcome has been limitations in the

601 number of employment counselors. Although the effect will not be immediate, the new contracts

602 for supported employment services through PROMISE should significantly address this

603 limitation.

28 As has been the case through monitoring of this provision, individuals are only counted toward compliance if they have an active service plan in effect or have move into stages of service beyond this, i.e., job readiness or actual employment.
27

604

Employed, 3.8%

FIGURE-21:
SUPPORTED EMPLOYMENT CATEGORIAL BREAKDOWN OF CLIENT STATUS
Employed, 11.9%

Job Ready 20.4%

Job Ready 19.7%

Fiscal Year 2014

Active Service
Plan 76.4%

Fiscal Year 2015

Active Service
Plan 67.6%

Supportive Employment numbers are based upon data from the Division of Vocational Rehabilitation within the State Department of Labor

605

606

The State is in Substantial Compliance with the Agreement’s provisions relative to

607 Supported Employment.

608

609 K. Rehabilitation Services

610

Substantial Compliance.

611

Rehabilitation Services comprise a diverse array of supports that enable the individual to

612 advance social, functional, or educational skills within integrated settings. They include various

613 training, substance abuse treatment and recreational activities. Section III.K.4 of the Agreement

614 requires that the State provide Rehabilitation Services to at least 1,100 members of the target

615 population. Replicating measures that have been used in past reports of the Monitor, DSAMH

616 was providing services as follows to the targeted population during Fiscal Year 2015:

617

Psychosocial Rehab Services, Psychosocial Group Services, or Family Psychosocial

618

Education —at least twice/month for at least 6 months ............................517 individuals

619

Some level of Substance Abuse Treatment for a

620

co-occurring disorder................................................................................1,593 individuals

621

622

Total............................................................................................................. 2,110 individuals29

29 There may be some duplication among individuals receiving the two categories of Psychosocial Services, however, the Substance Abuse Treatment category, alone, fulfills the requirements of Section III.L.4.
28

623

The State is in Substantial Compliance with the requirements of the Agreement relating

624 to Psychosocial Services.

625

626 L. Family and Peer Supports

627

Substantial Compliance.

628

Sections III.L.1-4 of the Agreement require that, by July 1, 2015 the State provide 1,000

629 individuals with family or peer supports. The State’s data systems are best able to track the

630 provision of peer supports and, on this aspect alone, it has met its requirements. As is presented

631 in Figure-22, about 2,000 individuals received peer services each month. This number represents

632 a reduction from past months because a federal grant supporting an important peer-operated

633 trauma program ended March 1, 2015. Nevertheless, the State is exceeding the requirements of

634 the Agreement.

635

Past reports of the Monitor have referenced the impressive growth in DSAMH’s peer

636 network, whereby individuals who have “lived experience” with SPMI provide a variety of

637 support services to members of the target population, including innovative approaches to

638 individuals at the point of admission to or discharge from DPC; engagement with individuals

639 who have received long term services within the hospital; participation as members of ACT,

640 ICM, and some TCM teams; on-site staffing of Crisis Apartments; and operation of peer-run

641 centers such as the Rick VanStory Center and the Creative Vision Factory in Wilmington (which

3,000

FIGURE-22:
Peers Served
By Contact Type, Average Monthly Contacts for Fiscal Year 2014 & Monthly Contacts for Fiscal Year 2015

2,500

2,000

1,500

1,000

500

0

FY14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

Avg DPC Peer Contacts

Trauma Peer Contacts

MH Court Peers

ACT/ICM Combined Census

CRISP Census

642

29

643 have been referenced in past reports). During the past several months, the Monitor had an 644 opportunity to visit another peer-run program serving individuals in southern Delaware, the ACE 645 (Acceptance, Change, and Empowerment) Peer Resource Center in Seaford. The ACE Center, 646 which is funded by DSAMH, serves over 200 individuals. It is a vibrant program that welcomes 647 individuals with SPMI who typically are confronting multiple challenges, such as substance use, 648 homelessness, unemployment, and histories of trauma or incarceration. The Center works closely 649 with other community programs, including the Crisis Walk-In Center in Ellendale and the 650 southern Delaware Mobile Crisis program. It demonstrates an approach that is present in other 651 peer programs the Monitor has visited in the state that is characterized by acceptance, fellowship, 652 mutual support, and sharing. Members of the ACE Center with whom the Monitor met are 653 rightfully proud of their accomplishments and eager to expand their program through extending 654 its hours of operations and overcoming transportation challenges that are inherent to its rural 655 service area.

656

The State is in Substantial Compliance with respect to the Agreement’s requirements

657 relating to Family and Peer Supports.

658

659 M. Community Involvement in Discharge Planning

660

Partial Compliance.

661

Sections II.C.2.d.iii-iv of the Agreement require the timely involvement of a community

662 provider to assist in discharge planning when an individual is admitted to DPC or an IMD for

663 acute care.30 In the past, the Monitor had found that this requirement was being inconsistently

664 met with regard to individuals whose care is managed through DSAMH and that the requirement

665 was essentially not being met at all with regard to those whose care is managed through DMMA.

666 At the time of the Monitor’s last report, the State was implementing significant new changes in

667 processes and oversight relating, directly or indirectly, to its compliance with these requirements.

668 Because it had not yet begun reporting data on the impact of these changes with respect to timely

669 provider involvement in discharge planning, this aspect of discharge planning was not evaluated

670 in the Monitor’s last report. These data are now available and, as is discussed below, the State is

671 beginning to show progress.

672

To briefly summarize these requirements and related discussions, the Agreement

673 specifies that community providers become involved with an individual within 24 hours of

674 admission to an IMD or DPC for acute care, with the goal of coordinating treatment and ensuring

675 timely and seamless discharge. For a number of reasons, this proved to be challenging to the

676 State. For instance, a substantial number of individuals whose care was managed through

677 DMMA and the MCOs had no community provider with whom to coordinate. Furthermore, the

678 State raised the reasonable point that critically important communication upon admission was

30 A related provision of the Agreement is Section IV.B.4, which sets standards for the timeliness of community placement for discharge-ready individuals. This provision is mostly relevant to people at DPC who are receiving intermediate- or long-term care. The Monitor’s next report will include an evaluation of the State’s compliance with this provision.
30

679 often not so much with a community case manager (who would be tasked with making face-to680 face contact), but between the hospital psychiatrist and the individual’s community psychiatrist 681 (where one exists). This could most readily take place via phone. With concurrence of the 682 Monitor, the State has moved forward with requiring such doctor-to-doctor consultations and 683 with initiating mechanisms to track the timeliness of community involvement, whether on the 684 physician level or otherwise. Figure-23 presents the State’s data showing the first contact—either 685 between physicians or social workers. While one IMD (Dover Behavioral Health) is an outlier, 686 the overall trend has been toward more timely involvement. The State did not provide current 687 data with regard to the timeliness of community involvement at DPC, however, the last reported 688 period was very much out of compliance with the Agreement’s requirements. It is noted, though, 689 that DPC has greatly improved its processes for notifying providers and inviting their 690 participation when one of their clients is admitted.
691

FIGURE-23:
Average Provider Response Time (in Days) Following Clients' Hospital Admission
Fiscal Year 2015
6

5

4

3

2

1

0 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15

DPC

Dover

MeadowWood

Rockford

Total

692

693

For Medicaid-covered individuals who are not served through DSAMH or the PROMISE

694 program and who do not have a community provider, there have been procedural improvements,

695 as well. The State’s agreements between DMMA and DSAMH, as well as its new contracts with

696 MCOs, encourage collaborative communication upon an individual’s hospital admission,

697 including timely involvement of TCM to link these individuals with the community services they

698 need.

31

699

Overall, the State remains in Partial Compliance with these provisions concerning

700 discharge planning, but it is making progress. Data reports by DPC that align with those being

701 provided by the IMDs, as well as data relating to the involvement of TCM with individuals who

702 do not have a community provider can further document the impact of the service improvements

703 referenced.

704

705 N. Quality Assurance and Performance Improvement

706

Partial Compliance.

707

Section V.A of the Agreement requires the State to maintain a system of Quality

708 Assurance and Performance Improvement (QA/PI) to ensure that services are of appropriate

709 quality to achieve the Agreement’s goals and to promote ongoing improvements. The Agreement

710 covers services within hospitals, those of community providers, those provided or managed

711 through DHSS divisions (DSAMH and DMMA), and those of other State Departments (e.g.,

712 DVR and the Delaware Housing Authority). Accordingly, QA/PI activities are quite diverse,

713 sometimes entailing formal research protocols and sometimes simply entailing the use of data to

714 monitor outcomes and drive system improvements. With regard to the latter, a number of QA/PI

715 initiatives have already been referenced in this report. These include the State’s actions to

716 evaluate the adequacy of ACT services with respect to clients appropriately maintaining their

717 living environments; resultant measures include more intensive ongoing monitoring, termination

718 of relationships with problematic landlords, and plans to use PROMISE services to bolster the

719 capacities of ACT teams to address personal care and chore service needs. A second example is

720 the State’s effort to address the underuse of the Crisis Apartments; the identification of this

721 problem, as well as the State’s progress in remedying it, are reflected in the Figure-10’s trending

722 data. Finally, TMACT and the numerous ACT/ICM outcomes measures (Figures-13 through -

723 18) demonstrate the State’s QA/PI efforts with respect to these important programs. As was

724 discussed in the relevant section of this report, these data drive corrective action plans of the

725 various teams and, in some instances, have resulted in termination of poorly performing

726 programs.

727

There are additional, more formal QA/PI efforts that the State carries out in collaboration

728 with the University of Pennsylvania’s Perelman School of Medicine (UPenn). These include a

729 QA/PI initiative entailing Quality Process Reviews of ACT/ICM services. This research

730 incorporates consumer interviews and chart reviews with regard to such issues as: the perceived

731 impact of services on housing, employment, one’s sense of autonomy, and physical and mental

732 health; where services are being provided; and how services could be improved. The State is

733 pursuing practical application of its findings by reviewing them with providers and requiring that

734 they formulate plans to improve services accordingly.

735

Another initiative being carried out through UPenn that has great significance to its

736 QA/PI requirements is a comprehensive study (referenced earlier) of cohorts of the target

737 population that enter services for each year of the Agreement’s implementation. The overarching

738 goal of this research is to examine how each of these groups is served as Delaware’s community

739 system expands in scope and capacity, in keeping with the Agreement’s requirements. This

32

740 initiative provides a rich data set characterizing patterns of care that, when more fully used by 741 the State, can define and drive important system improvements. This is particularly relevant to 742 the challenges the State is facing with regard to reducing the number hospital bed-days.31 Among 743 the pivotal QA/PI issues that the State might examine and incorporate in service practices are the 744 characteristics of the individuals that account for the increases in hospital bed use, including their 745 diagnoses and patterns of service utilization prior to admission. Such information could be 746 helpful in identifying gaps in the access to, scope of, or timeliness of services prior to admission. 747 For individuals who have already had episodes of inpatient psychiatric care, the data set can help 748 identify the clinical profiles and patterns of service use that define heightened vulnerability to re749 hospitalization or, in the alternative, factors that appear to insulate individuals from hospital 750 admission. One significant finding arising from UPenn’s data is that individuals who have not 751 been hospitalized during the duration of the study may still be experiencing crises; they have 752 high use of emergency rooms.32 Relevant to this finding, the State might examine the more 753 specific predictors of emergency room episodes and what “upstream” services might avert the 754 underlying crises. Unfortunately, as things now stand, the State appears to do little beyond 755 receiving the data from the researchers relating to its cohort analyses of service patterns.33

756

In summary, the State is collecting very good data relating to quality measures and, in

757 some instances, is using this information to drive system improvements. But there are also many

758 instances where important data remain just that; sets of statistics where there is no evident

759 analysis or application of findings. Past evaluations by the Monitor have found the State to be in

760 Substantial Compliance with respect to QA/PI, however, in consultation with the State, the

761 Monitor has strongly encouraged that it move forward in incorporating relevant data into service

762 refinements.34 The Agreement requires that the State maintain a “Quality Assurance and

763 Performance Improvement System,”35 and at this point in implementation, such a program should

764 be operational. Unfortunately, QA/PI functions remain much more piecemeal than systemic.

765 DSAMH has recently presented plans to better unify, align, and evaluate the various QA/PI

766 efforts affecting the target population, a move that may well address what is currently lacking,

767 particularly if it includes members of the target population who are served through DMMA and

768 are not receiving specialized services. At this juncture, the State is in Partial Compliance with the

769 Agreement’s requirements relative to Quality Assurance and Performance Improvement.

770

31 This was discussed in the section of this report relating to Crisis Stabilization. 32 Of 752 individuals in the study’s Cohort 2 who were not hospitalized between 2010 and 2014, 64.2% had an emergency room visit. Of the 47 individuals who were very high users of hospital care, in that they were hospitalized in each of these 4 years, emergency room use was 80.9%. 33 The State has noted that its work pursuant to the State Innovation Model is relevant to averting intensive services through earlier intervention, but it has provided the Monitor with no data demonstrating how this initiative has bearing on the Agreement and the population it targets, or how service utilization patterns identified through UPenn’s analyses integrate with this initiative. 34 One example is in reference with UPenn’s cohort analysis, where the State has repeatedly cited declining rates of readmission between successive cohorts, but (as discussed above) has not taken any evident measures beyond citing these statistics. 35 Agreement, Section V.A. Emphasis added.
33

771 O. Risk Management

772

Partial Compliance.

773

Previous reports of the Monitor have described how, mostly as a result of an

774 accumulation of bureaucratic requirements over the years, Risk Management functions affecting

775 the target population have been dispersed over various offices and divisions within DHSS. The

776 Monitor’s past reports discussed a major restructuring of these functions that is underway and

777 that should greatly consolidate information and position the State to take measures to reduce the

778 risk of harm to service recipients.

779

At the same time, it is essential that the State fulfill its obligations relative to Risk

780 Management as these improvements are being rolled out. The State is conducting mortality

781 reviews, in some instances, including detailed analyses of individuals’ clinical records and

782 meetings with providers. Other actions to identify and address risks of harm, which the

783 Agreement defines as “any physical or emotional injury, whether caused by abuse, neglect, or

784 accidental causes,”36 are being carried out in a much less systematic way. The State has been

785 providing the Monitor with incident reports relating to those members of the target population

786 that are being served by community providers operating under contract by DSAMH. It has not

787 been providing data relating to Risk Management at DPC, although it certainly has access to

788 such information. Furthermore, it has provided no data relating to IMDs and it is unclear whether

789 the State is even receiving such information, in conformance with Sections V.B.8. It is noted

790 that the IMDs provide care to the vast majority of individuals among the target population who

791 are being hospitalized. As such, it is critical that the State’s Risk Management program

792 incorporate these facilities, as well.

793

A spreadsheet provided by the State summarizing its actions relating to abuse and neglect

794 allegations shows that only nine investigations were carried out during the 2015 fiscal year. In

795 none of these instances was a root-cause analysis carried out, per Section V.B.4-5, although

796 some level of corrective action was recorded for each. There is no evidence that the State is

797 taking measures to ensure the effectiveness of these corrective actions (Section V.B.6).

798 Furthermore, there is no evidence that the State is evaluating patterns of risk of harm and making

799 related systemic improvements (Section V.B.9). None of these investigations related to

800 treatment in DPC or the IMDs, and none related to members of the target population whose care

801 is managed via DMMA.

802

In summary, the State has been moving forward with comprehensive improvements to its

803 Risk Management program for about one year now,37 but these reforms are not yet fully

804 implemented and there remain very significant immediate gaps in meeting the requirements of

805 Section V.B.1-9. Not only do these require immediate attention because risk reduction is

806 inherently a serious matter, but to achieve Substantial Compliance with regard to Risk

807 Management the State will need to produce comprehensive, timely, and consistent data

808 demonstrating that it is meeting its requirements within the framework of the new processes it is

36 Agreement, Section V.B.1. 37 See “Sixth Report of the Monitor,” December 29, 2014, p. 41.
34

809 putting in place. The State is rated as being in Partial Compliance with regard to the provisions
810 contained in Section V.B, although in some important respects it is only “slightly above a non811 compliance rating.”38

812

813 III. Conclusion

814

As is detailed above, for the most part, the State is maintaining its progress in those areas

815 of the Agreement where it has been in Substantial Compliance, but there are some other areas

816 where it needs to accelerate its implementation of plans for improvements if it is to demonstrate

817 that it has fulfilled the Agreement’s requirements. Its greatest challenge relates to the hospital-

818 use reductions that appear in Section III.D; these are important in themselves, but they are also

819 closely intertwined with the effectiveness of the broad array of services and supports that are

820 required in provisions throughout the Agreement. The State’s long overdue action to insert some

821 coherence and accountability into the process of referring Medicaid-covered members of the

822 target population for these specialized services was an important step forward with regard to

823 reducing hospitalizations, but this process was only implemented mid-way into the fiscal year

824 covered by this report and, furthermore, some elements of the PROMISE program are still being

825 launched. Properly applied, data discussed with regard to Quality Assurance/Performance

826 Improvement (notably, data arising through the UPenn cohort research) can further drive system

827 improvements and document a concerted effort by the State (both through DSAMH and DMMA)

828 to address the root causes behind hospital admissions. There are significant and longstanding

829 gaps in its Risk Management system and it has yet to be seen whether the improvements now

830 being initiated will address them. In summary, in many respect Delaware has responded to the

831 requirements of the Agreement in admirable—even exemplary—ways. For those areas still

832 needing improvements, it has the tools required to achieve Substantial Compliance and with a

833 focused effort, it can do so.

834

835
836 Robert Bernstein, Ph.D. 837 Court Monitor

38 “A partial compliance rating encompasses a wide range of performance by the State. Specifically, a partial compliance rating can signify that the State is nearly in substantial compliance, or it can mean that the State is only slightly above a non-compliance rating.” Agreement, Section VI.B.3.g.ii.
35

 
 NINTH REPORT OF THE COURT MONITOR ON PROGRESS TOWARD COMPLIANCE WITH THE AGREEMENT: U.S. v. STATE OF DELAWARE
U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS 5/26/2016

1 I. Introduction:

2 This is the ninth report of the Court Monitor (Monitor) on the implementation by the State of 3 Delaware (State) of the above-referenced Settlement Agreement (Agreement). This is an interim 4 report that focuses on those provisions of the Agreement that the Monitor found the State to be in 5 less than Substantial Compliance1 in the eighth report to the Court.2 These provisions relate to:

6

a. Crisis Stabilization Services

7

b. Discharge Planning

8

c. Quality Assurance and Performance Improvement

9

d. Risk Management

10 The eighth report found the State to be in Substantial Compliance with the remaining provisions 11 of the Agreement, and it remains so at this time.

12 With regard to the four provisions being reviewed here, the State had been found to be in Partial 13 Compliance, and it has been working closely with the Monitor to achieve Substantial 14 Compliance with them, as well. The findings in this report are based upon discussions with State 15 officials, providers, and individuals who have Serious and Persistent Mental Illness (SPMI) who 16 are the intended primary beneficiaries of the Agreement; document and clinical record reviews; 17 site visits; and compliance data that the State has generated since the last report.

18 As is reflected in the discussion that follows, the State has either achieved Substantial 19 Compliance or is approaching Substantial Compliance with regard to each of the provisions 20 discussed here. As such, the State is on track to fulfill its overall obligations under the 21 Agreement. During the coming months, the State needs to demonstrate that it is continuing its 22 implementation efforts with regard to all of the provisions of the Agreement and that it will 23 sustain the programs and services for Delawareans with SPMI in accordance with the Americans 24 with Disabilities Act (ADA).

1 Section VI.B.3.g of the Agreement defines the criteria on which the Monitor evaluates the State’s level of compliance as “Substantial Compliance,” “Partial Compliance,” or “Non-Compliance.” 2 The Eighth report of the Court Monitor was filed on 12/26/15.
1

25

26 II. Ratings of Compliance

27

28 A. Crisis Stabilization Services

29

Moving Towards Substantial Compliance

30

As has been discussed in prior Monitor reports, the Agreement required the State to have

31

reduced by July 1, 2014 the annual State-funded acute-care3 hospital bed-days used by

32

people with SPMI by 30% of what it was in the year prior to the Agreement taking effect4

33

(Section III.D.3). It did not meet that benchmark. In fact, as was described in the Monitor’s

34

sixth report,5 the acute care bed-days at that point were essentially unchanged relative to the

35

base year.6 They have since increased markedly. Section III.D.4 of the Agreement requires

36

that the State achieve further reductions by July 1, 2016 by 50% of the base year level. As

37

of the Monitor’s eighth report, State-funded acute bed-days used by people with SPMI—

38

particularly in Delaware’s three private psychiatric hospitals (IMDs7)—had continued to

39

increase8 and that trend continues as of today. It is clear that the State will not meet either

40

of the acute bed-day reduction targets in the foreseeable future.

41

The provisions for reduced hospital use were not conceived to be requirements that exist

42

independently of other elements of the Agreement. In including them in the Agreement, the

43

underlying assumption was that the array of community services that was to be developed

44

pursuant to other provisions—mobile crisis services, crisis apartments, Assertive

45

Community Treatment, peer services, supported housing, and so on—would have the effect

46

of reducing the need for acute psychiatric hospitalization. Thus, reductions in hospital bed-

47

use would be a natural outcome. The State has developed these services in accordance with

48

the Agreement (and in some instances, beyond what the Agreement requires), and still bed-

49

days for acute care have risen. However, as is reflected in the data presented below, people

50

being served through the community programs required by the Agreement account for only

51

a very small proportion of the psychiatric acute bed days being used. This is notable

52

because, as is evidenced by their referral for specialized mental health services, these

53

individuals have very significant and often complex psychiatric disabilities.

3 The Agreement defines “acute care” as hospitalizations lasting 14 days or fewer. Section II.C.2.d.i 4 The Agreement’s “base year” from which this is calculated is the fiscal year ending June 30, 2011. 5 The Monitor’s sixth report was filed with the Court on December 29, 2014. 6 The Monitor’s sixth report found that overall bed days in IMDs, where most of the acute care was being provided showed a reduction of 0.4% as of July, 2014 relative to the base year, and bed-days managed through DMMA showed an increase of 2.1%. 7 These hospitals—Rockford Center, MeadowWood Behavioral Health, and Dover Behavioral Health—are commonly referred to, in federal terminology, as “IMDs” or Institutions of Mental Diseases. 8 Delaware Psychiatric Center (DPC), the State-operated psychiatric hospital, has also increased its acute care beddays relative to the base year, but this reflects an intentional transition of the facility from primarily being a longterm care setting to one providing acute psychiatric care. DPC’s total number of civil beds (i.e, non-forensic) has actually been reduced during the course of the Agreement.
2

54

Thus, the reasons for the increased bed-day trend are complicated, and not necessarily a

55

reflection of the quality of the community alternatives the State has created in fulfillment of

56

the Agreement. Among the factors that have likely contributed to increases in State-funded

57

acute psychiatric care for people diagnosed with SPMI are: an epidemic of substance use

58

whereby individuals with drug-related crises are admitted to psychiatric beds and given a

59

discharge diagnosis of SPMI;9 a convoluted bureaucratic structure—vastly improved over

60

the past 18 months—whereby inpatient psychiatric care had been poorly coordinated, and

61

managed variously through the State’s Division of Substance Abuse and Mental Health

62

(DSAMH), its Division of Medicaid and Medical Assistance (DMMA), or both; and market

63

forces attendant to the fact that Delaware has been among a small number of states whereby

64

Medicaid has reimbursed for care in an IMD.10

65

In consultation with the Monitor, in May, 2014, the State developed a plan to address the

66

requirements of sections III.D.3-4 that significantly relied upon PROMISE, an expansion of

67

services covered by Medicaid for people with SPMI with improved coordination and

68

accountability within the community and IMDs. As has been referenced in prior Monitor

69

reports, PROMISE went into effect in January 2015. Given its complexity, it is taking time

70

for the program to reach its full capacity and to show its full impact with respect to hospital

71

bed-use. If properly implemented, PROMISE should address many of these systemic issues

72

that underpin the increases in acute hospitalizations by the target population.

73

In light of these factors, the parties agreed to explore an alternative strategy to measure the

74

State’s compliance with the intent of the Crisis Stabilization section. This approach would

75

include, but not rely solely upon, the numerical bed-use requirements specified in sections

76

III.D.3-4. Following extensive meetings and discussions, in February, 2016, the State, the

77

U.S. Department of Justice, and the Monitor agreed that the State’s compliance with

78

provisions III.D.3-4 of the Agreement will also be evaluated in terms of a broader set of

79

Quality Assurance and Performance Improvement (QA) data that includes several additional

80

measures of the State’s efforts to reduce hospital use to drive system improvements, and

81

link individuals who are covered by the Agreement with needed community services and

82

housing.

83

Table-1 presents an overview of the data dashboard that the State has developed pursuant to

84

this agreement of the parties. Generally, these data are generated, analyzed, and provided to

85

the Monitor on a monthly basis.

9 Early in the process of implementing the Agreement, the State and the Monitor agreed on a set of diagnoses that are indicative of SPMI and would be used in identifying members of the Agreement’s priority population. 10 In most instances, under the federal “IMD exclusion,” states have been responsible for covering the cost of care in IMDs for Medicaid-covered individuals between the ages of 21 and 64. This has been, and remains the case, for such individuals who are hospitalized in DPC. In the three privately owned IMDs, federal dollars cover the majority of costs for adults who have Medicaid. Over the course of implementation, many informants have apprised the Monitor of fiscal incentives as a driver of hospital care in Delaware’s IMDs.
3

86
Table-1 Revised Measures of Compliance with Crisis Stabilization Provisions III.D.3-411
Bed Days 1a Monthly Bed-Day Reports 1b FY16 DPC Admissions from an IMD, by IMD and the Total LOS 1c Mean, median, mode, and range of Days for 1b who have been discharged 1d Clients whose lengths of stay have exceeded 14 days 1e Direct admissions to DPC (i.e. not via an IMD) 1f Mean, median, mode, and range of Days for 1e who have been discharged 1g Clients whose lengths of stay have exceeded 14 days 1h ALOS at DPC by LOS Type: 0-14, 15-49, 50-179, 180+ days 1i Number of persons & length of time for each person on DPC ready to discharge list
Crisis Walk-In Centers 2a Number of individuals evaluated at RRC 2b Diversion from hospitalization by RRC 2c IMD admissions (from 1a) via Crisis Walk-In Centers 2d IMD admissions (from 1a) not evaluated via Crisis Walk-In Centers
Engagement in Community Services Comprised by the Settlement Agreement 3a Hospital admissions of people who are actively served by DSAMH/PROMISE 3b DSAMH community provider participation in discharge planning of 3a at IMDs & DPC 3c Hospital admissions relating to people NOT being served by DSAMH/PROMISE 3d 3c who were referred for specialized services 3e 3c approved for specialized services 3f 3c found ineligible for specialized services 3g 3c approved, but refusing specialized services 3h 3c actively receiving specialized services 3i Breakdown of 3h by types of services (e.g. ACT) 3j Timely engagement of community provider/TCM in discharge planning of 3c individuals 3k State’s progress on addressing the 454 high-risk consumers identified in 2014
Co-Occurring Substance Abuse 4a IMD admissions with substance abuse as one of the discharge diagnosis 4b 4a receiving mental health services via DSAMH/PROMISE prior to admission
11 As agreed to by the parties on February 16, 2016.
4

Homelessness 5a 3a who are homeless 5b 5a who have been referred for housing (newly referred + already active) 5c 3c who are homeless 5d 5c who have been referred for housing 5e 3a who were discharged from hospital to shelters 5f 3c who were discharged from hospital to shelters
Hospital Readmissions 6a Persons discharged from DPC and each IMD in FY15 6b 30-, 90-, 180-, and 365-day Readmission Rates by LOS type 6c 1, 2, 3, or 3+ readmits to an IMD/DPC during a Fiscal Year
Reliance Upon Court-Ordered Treatment 7a Involuntary Outpatient Commitments FY11 to FY15 7b Involuntary Inpatient Commitments FY11 to FY15
DPC Average Daily Census Report (Civil Units Only) 87

88

In addition to these quantitative measures, the parties agreed that the State will work with

89

the Monitor to establish QA initiatives that target significant issues identified by the above

90

data, as well as additional factors relating to increased hospital bed use by people with

91

SPMI. The quantitative data and these QA initiatives will be considered by the Monitor in

92

evaluating the State’s compliance with III.D.3-4 for this fiscal year.12

93

It has been about 2½ months since the parties agreed to these revised measures. As is

94

evidenced by the data below, during this time the State has made an earnest and effective

95

effort to produce the required data dashboard. It has also begun to analyze this information

96

to improve outcomes for the Agreement’s target population.

97

The following section explains the rationale for changes in data reporting and highlights

98

some of the data provided by the State in accordance with this new process.

99

100 Quantitative Measures:

101

102

A. Bed Days-

103

The State is continuing to report State-funded hospital bed-days used by the target

104

population on a monthly basis with some refinements that were agreed upon by the

105

parties:

12 The 2016 fiscal year runs from July 1, 2015 through June 30, 2016.
5

106

a. Sections III.D.3-4 relate specifically to reductions in “acute inpatient settings”

107

which, as described above, were expected to be achieved through the

108

establishment of the community alternatives that are required elsewhere in the

109

Agreement. While these reductions are certainly central to the overall goals

110

of the Agreement, so too are reductions in longer term hospitalizations,

111

including for individuals who have had protracted stays at DPC. Past Monitor

112

reports have included data about the State’s success in reducing the number of

113

days of long-term care at DPC and in shifting the facility’s focus toward more

114

acute care services. Yet, there is no section of the Agreement that specifically

115

requires such reductions. Recognizing that the State’s efforts to reduce long

116

term hospitalizations is consistent with the ADA’s requirements, the parties

117

agreed that such data should be included in the revised measurement process.

118

b. Previously, data on hospitalizations had been reported in terms of Acute Care,

119

which the Agreement defines as having a duration of 14 days or fewer;

120

Intermediate Care, defined as 15-180 days; and Long Term Care, defined as

121

180 days or longer. Individuals receiving Long Term Care have complex

122

clinical issues, and sometimes attendant legal barriers to discharge (e.g.,

123

sexual offenses). However, those in the Intermediate Care category reflect an

124

array of issues, ranging from those who remain in the hospital slightly beyond

125

14 days as housing arrangements are made, to those who stay hospitalized for

126

several months due to complicated clinical factors. For this reason, the parties

127

agreed to a revised reporting structure to better differentiate among people

128

with intermediate hospital stays. The State now categorizes stays in terms of

129

Intermediate-I, which includes hospitalizations of 15-49 days, and

130

Intermediate-II, which includes hospitalizations of 50-179 days. Acute and

131

Long Term hospitalizations remain unchanged in terms of definitions.

132

c. Admissions to DPC include some individuals coming directly from the

133

community or hospital emergency departments, and some individuals who

134

were admitted to an IMD and could not be stabilized through the acute care

135

that those facilities provide. When individuals are transferred from IMDs to

136

DPC for continuing care, the State now calculates the duration of the

137

hospitalization as a single—or “blended”—episode that reflects the combined

138

number of bed-days in the two facilities. Calculating bed days in this way

139

more accurately reflects the duration of inpatient care for crises falling into

140

this category.

141

Figure-1 summarizes annual State-funded bed days for fiscal years 2011 through 2015,13

142

including the blended admissions to DPC from an IMD. The total number of bed days

143

declined from 2011 through 2014, and then began to tick upwards. Relative to the year

144

2011, 2015 represented an overall reduction in bed-day use by 12.6%. The chart shows

145

that the driver of these reductions is bed use at DPC, which declined by 37.9% relative to

13 The State is reporting 2016 data but, because the fiscal year is not yet complete, this information does not appear on this chart.
6

146

the 2011 base year. The rise in total bed use by the target population, including the

147

increase between 2014 and 2015, is attributable to the IMDs. Relative to the base year,

148

IMD bed-days have increased by 48.4%.

149

“Blended” bed days increased by 8.2% relative to the base year. However, other data

150

now being reported by the State show that, notwithstanding this increase, the number of

151

individuals transferred from IMDs to DPC for continuing hospital care has dropped by

152

32.5% during this period, and the average length of blended hospitalizations (IMD plus

153

DPC) has increased by 60.3% to 86.9 days. Collectively, these figures suggest that

154

transfers for continuing hospitalization, while occurring less frequently, may be for

Figure-1 Inpatient Paid Bed Days by Facility Type
FY11-FY15 (Recalculated LOS Data)

60,000

50,000

Paid Bed Days

40,000

30,000

20,000

10,000

0

FY11

FY12

FY13

FY14

FY15

DPC-Total

IMD-Total

Blended-Total

Total

155

156

individuals with complicated clinical issues and who require extended hospital stays—a

157

finding that is consistent with the intended purpose of such transfers. The State should

158

undertake a QA study to clarify whether this is, in fact, the case or whether other factors

159

are at play; such a study could easily be conducted, given that only 27 transfers from

160

IMDs to DPC occurred in fiscal year 2015.

161

Figure-2 presents the State’s bed-day utilization data for the target population in terms of

162

the new method of categorizing lengths of stay, that is, by more precisely differentiating

163

intermediate lengths of stay. It shows that the most dramatic decreases in inpatient bed

164

days occurred among individuals receiving long-term inpatient care at DPC, some of

165

whom had been hospitalized for decades before being discharged to much more

166

integrated community settings, such as supported housing. These individuals have

167

significant service needs, generally with complex behavioral issues co-occurring with

168

major physical health and social issues. (i.e., they often lack close connections with the

7

169

social networks within the community, have become dependent upon institutional

170

services for addressing routine daily needs, and may have ongoing legal problems).

171

Documenting the State’s success in shifting from institutional to community services for

172

this population, there was a 47% reduction in bed days for long term care at DPC in

173

2015, relative to the 2011 base year. Furthermore, the average length of stay for people

174

receiving long term care at DPC has been reduced during this period by 16.3% (from

175

270.7 days in 2011 to 226.7 days in 2015), and the number of individuals discharged

176

following long term hospitalizations has declined from 120 in 2011 to 55 in 2015 (a

177

36.7% reduction). Again, all of these factors point to the State’s success in shifting

178

services for people with SPMI who have complex needs to integrated community

179

settings—a core requirement of the ADA.

60,000

Figure-2 Inpatient Paid Bed Days by LOS Type FY11-FY15
(Recalculated Reporting Method)

50,000

Paid Bed Days

40,000

30,000

20,000

10,000

180

0 FY11

FY12

FY13

FY14

Acute (DPC, IMD, Blended) 0-14 Days

Intermediate I (DPC, IMD, Blended) 15-49 Days

Intermediate II (DPC, IMD, Blended) 50-179 Days

Long-Term (DPC, Blended) 180+ Days

Total

FY15

181

Figure-3 summarizes the State’s success over the past decade in downsizing DPC. Since

182

2014, the average daily census for “civil” (i.e., non-forensic) patients has been less than

183

80 patients. This represents about a 35% reduction of the facility’s census from when

184

implementation of the Agreement began at the beginning of fiscal year 2011.

185

The State’s new method of reporting intermediate length hospital care gives further

186

clarity to trends occurring in the system concurrent with the implementation of the

187

Agreement. Bed days in both categories of intermediate care increased since 2011, but

188

short-term intermediate stays (Intermediate-I) increased at more than double the rate of

189

longer intermediate stays (Intermediate-II); 49.5% versus 21.6%, respectively.

190

Furthermore, in 2015 the number of episodes of Intermediate-I (334) were almost five

191

times that of Intermediate-II (67). The average lengths of stay in Intermediate-I have

8

192

been fairly consistent over time, reported as 21.6 days in 2015; this figure is at the low

193

end of the range comprised by Intermediate-I (15-49 days), indicating that these

194

individuals are not staying much beyond the acute care period. The average lengths of

195

stay for individuals whose hospitalizations are categorized as Intermediate-II has also

196

been fairly consistent over time, reported as 74.9 days in 2015. Again, the data suggest

197

that Intermediate-II hospitalizations tend not to be at the high end of this category (179

198

days is the upper limit). Overall, these data suggest that while shorter-term intermediate

199

care (of about 21 days) is increasing, the increases are generally among individuals who

200

are hospitalized only slightly longer than the 14 days that constitute acute care. In fact,

201

stays of 50 days or more have decreased dramatically (by about 40%) since the base year

202

of 2011. In other words, it does not appear that intermediate care is becoming a pathway

203

into long term care.

Figure-3

Average DPC Daily Census

(Non-Forensic Inpatient Care)

FY 2006-2016
200

180

160

AGREEMENT IMPLEMENTED

140

Number of Inpatients

120

100

80

60

40

20

0 SFY 2006 SFY 2007 SFY 2008 SFY 2009 SFY 2010 SFY 2011 SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016
204

205

Tables 2, 3 and 4 present detailed information about these trends, including partial year

206

data for 2016.

207

In addition to data aggregating facilities, the State maintains and reports information

208

specific to each of the three private psychiatric hospitals and DPC, and thus it is able to

209

evaluate trends underlying bed use and to target interventions accordingly to reduce

210

hospitalizations. Because of the volume of these statistics, the full data sets are not

211

included in this report. In general, they show that the mean and median length of stay for

212

acute care in IMDs is around seven days. Only a small proportion of admissions to IMDs

213

exceed fourteen days, but because DPC has more complex admission and discharge

214

processes than the IMDs, 76.4% of the direct admissions to DPC (i.e., those not

215

representing transfers from IMDs) extend into intermediate care. As was noted above, on

216

average these admissions last a week or so beyond the acute care period.

217

9

Stay Type
Acute (DPC, IMD, Blended) 014 Days Intermediate-I (DPC, IMD, Blended) 15-49 Days Intermediate-II (DPC, IMD, Blended) 50-179 Days Long-Term (DPC, Blended) 180+ Days Total

Table-2 Bed Days by Stay Type
FY 2011-2016 (Recalculated Report Method)

FY11

FY12

FY13

FY14

14,346 14,657 16,616 16,291

4,825 4,169 5,128 6,718

4,125 3,287 7,103 7,072

32,489 28,748 21,417 14,190

55,785 50,861 50,264 44,271

FY15 19,317

FY16 % Change
(Part Year) (FY15-FY11)
8,581 34.7% Inc.

7,215 3,089 49.5% Inc.

5,015 1,772 21.6% Inc.

17,230 7,854 47.0% Red.

48,777 21,296 12.6% Red.

Stay Type
Acute (DPC, IMD, Blended) 014 Days Intermediate-I (DPC, IMD, Blended) 15-49 Days Intermediate-II (DPC, IMD, Blended) 50-179 Days Long-Term (DPC, Blended) 180+ Days Total

Table-3 Number of Episodes by Stay Type
FY 2011-2016 (Recalculated Reporting Method)

FY11

FY12

FY13

FY14

2,367 2,307 2,479 2,462

FY15 2,790

FY16 % Change
(Part Year) (FY15-FY11)
1,342 17.9% Inc.

195

196

247

287

334

140 71.3% Inc.

55

45

90

101

67

28 21.8% Inc.

120

105

88

66

76

55 36.7% Red.

2,737 2,653 2,904 2,916 3,267 1,565 19.4% Inc.

Stay Type
Acute (DPC, IMD, Blended) 014 Days Intermediate-I (DPC, IMD, Blended) 15-49 Days Intermediate-II (DPC, IMD, Blended) 50-179 Days Long-Term (DPC, Blended) 180+ Days

Table-4 Average Length of Stay by Stay Type
FY 2011-2016 (Recalculated Report Method)

FY11

FY12

FY13

FY14

6.1

6.4

6.7

6.6

24.7

21.3

20.8

23.4

75.0

73.0

78.9

70.0

270.7 273.8 243.4 215.0

FY15 6.9

FY16 % Change (Part Year) (FY15-FY11)
6.4 14.2% Inc.

21.6

22.1 12.7% Red.

74.9

63.3 0.2% Red.

226.7 142.8 16.3% Red.

Total

20.4

19.2

17.3

15.2

14.9

13.6 26.7% Red.

218

10

219

All things considered, the State might be able to further streamline discharges from DPC,

220

but a far more critical issue—both programmatically and fiscally—relates to the high

221

number of brief admissions to IMDs and whether the presenting issues could be

222

addressed through a service other than inpatient psychiatric care. These issues are

223

discussed later in this report; an analysis of individuals in DPC who are ready for

224

discharge but whose discharge is delayed, and two new QA initiatives relating to

225

individuals with one-time admissions to IMDs and those with multiple admissions to

226

IMDs, whose needs might have been better addressed through other avenues.

227

228

B. Timeliness of Discharge-

229

Section IV.B.4 of the Agreement requires that by July 1, 2015, the State will discharge at

230

least 75% of hospitalized individuals to the community with necessary supports within 30

231

days of a determination that hospital care is no longer needed, and that by July 1, 2016,

232

the State shall meet this target for 95% of discharge-ready individuals. While this

233

provision is not one of the four that are the specific focus of this report, clearly discharges

234

that are unnecessarily delayed would contribute to the overall bed-day use and could

235

signal a larger systemic issue about the capacity of community programs to meet the

236

needs of the target population. For this reason, this factor has been included among the

237

new measures relating to sections III.D.3-4 and the State has incorporated detailed data

238

relating to discharge readiness it in its monthly data dashboard.

239

The requirement for discharge within 30 days of readiness is not relevant to acute care,

240

which by definition reflects stays of fourteen days or fewer. Only a small number of

241

discharges from IMDs relate to stays in excess of fourteen days; in 2015, only 188 (or

242

6%) of IMD hospitalizations lasted longer than fourteen days, and only one of these

243

lasted beyond the 49-day period that is categorized as Intermediate-I.14 Setting that one

244

exception aside, the mean length of stay for individuals who were hospitalized in IMDs

245

beyond fourteen days was 19.4 days. In fact, within the IMDs, 99.7% of discharges

246

occurred within 30 days of a determination of discharge readiness. As such, the

247

requirements of IV.B.4 overwhelmingly relate to discharge practices at DPC, which (in

248

part, by design) has a much larger population whose clinical needs are such that

249

hospitalizations may last in excess of 30 days.

250

At this juncture, the State is in Substantial Compliance with the requirements of IV.B.4.

251

In July, 2015, at which point the Agreement requires 75% compliance with the 30-day

252

target, the State met this target for 81.8% of individuals at DPC. In calculating this

253

figure, the State takes the date on which an individual is determined by the clinical team

254

to be ready for discharge and subtracts this from the date of actual discharge to the

255

community. It has compiled data that go beyond the sheer numerical targets of the

14 That hospitalization lasted 59 days, which is at the low end of the Intermediate-II category.
11

256

Agreement and that allow it to conduct analyses of why discharges sometimes are not

257

occurring within 30 days of readiness.

258

Figure-4 presents data on individuals who were admitted to DPC, were determined to be

259

appropriate for discharge during the acute care phase of treatment (i.e., 14 days or fewer),

260

but remained hospitalized beyond 30 days of this determination. This scenario occurred

261

with respect to 131 discharges in 2015, which represent 8% of the total number of

262

hospitalizations where the clinical teams determined that the individual was discharge-

263

ready within the acute care period. Because this is a new initiative, the State does not

264

always have complete retrospective data on the reasons that discharge did not occur in a

265

timely way (thus, the “Reason not Available” category in this chart). In at least ten of the

266

instances where individuals who were determined to be discharge-ready from DPC

267

during the acute care period, delays were attributed to waiting lists for Assertive

268

Community Treatment (ACT) or CRISP, the State’s program of providing intensive and

269

flexible community services through a capitated case rate.15

Figure-4 DPC Reasons for Discharge Beyond 30 Days
Stabilization during Acute Care FY16

Within 30 Days 92%

Not within 30 Days 8%

Reason Not Availalble

ACT/CRISP Waiting List 10 Admits

270

271

Figure-5 presents similar data for individuals at DPC who were determined to be

272

discharge ready during the Intermediate-I period. Of the 19% of these discharges that did

273

not occur within 30 days, eleven individuals were awaiting ACT or CRISP services, and

274

one individual was awaiting a bed in a group home.

275

15 ACT and CRISP have been described more fully in past Monitor reports.
12

Figure-5 DPC Reasons for Discharge beyond 30 Days
Stablization during Intermediate-I FY16

ACT/CRISP Waiting List
11 Admits

Within 30 Days 81%

Not Within 30 Days 19%

Group Home Waiting List
1 Admit

276

277

Figure-6 presents the data for individuals at DPC who were determined to be discharge-

278

ready during the Intermediate-II period. Although the proportion of Intermediate-II

279

discharges is large, the actual number of individuals included in this group is small—12

280

people. The issues delaying their discharges remain access to ACT or CRISP services

281

and, less frequently, the availability of beds in group homes.

Figure-6 DPC Reasons for Discharge Beyond 30 Days
Stablization during Intermediate-II FY16

ACT/CRISP Waiting List

Within 30 Days
35%

Not within 30 days 65%

Group Home Waiting List 2 Admits
282

283

Figure-7 presents data on individuals whose readiness for discharge was determined

284

during periods of long-term care, that is, hospitalizations lasting 180 days or longer.Thus

285

far this fiscal year, five individuals fell into this category. In addition to ACT/CRISP and

286

group home availability being factors delaying their discharges following long term care,

287

one of these individuals had medical issues requiring nursing home care and another had

13

288

issues relating to inappropriate sexual conduct that presented challenges in making

289

arrangements for discharge.

Figure-7 DPC Reasons for Discharge Beyond 30 Days
Stabilization during Long-Term Care FY16
Not within 30 Days 71%

Group Home Waiting List 2 Admits

Within 30 Days 29%
290

ACT/CRISP Waiting List
1 Admit
Sex Offender/Behavior 1 Admit

Nursing Home Waiting List 1 Admit

291

The State has only recently begun compiling these discharge-readiness data, and overall,

292

the number of individuals whose discharges exceed the 30-day standard specified in the

293

Agreement is relatively small. Nevertheless, the analyses that can now be conducted

294

position the State to further improve how the hospitals and the community programs

295

interact to ensure that individuals do not remain institutionalized significantly beyond the

296

point where inpatient care is no longer needed. Ostensibly, an initial issue to be explored

297

is whether the State has appropriate capacity in its ACT or CRISP programs, or whether

298

individuals are moving through those programs appropriately so that others in need of

299

those services can access them in a timely way.

300

301

C. Crisis Walk-In Centers

302

As has been discussed in past reports, the Crisis Walk-In Center in the southern part of

303

the state is playing an important role in applying a recovery model to evaluating and

304

assisting individuals with SPMI who are at imminent risk of admission to a psychiatric

305

hospital. The program, the Recovery Resource Center (RRC), is located in Ellendale. It

306

works seamlessly with southern Delaware’s mobile crisis and targeted care management

307

programs. The Ellendale RRC’s success motivated the State to replicate it in the northern

308

part of Delaware. However, delays mostly associated with physical plant construction

309

have thus far delayed its opening. It is anticipated that the new Crisis Walk-In Center,

310

which will be located in Newark, will begin operations sometime this spring. Because

311

Crisis Walk-In Centers play a major role in diverting people from hospital admissions,

312

data relating to their operations were incorporated among the new measures relating to

313

sections III.D.3-4. Table-5 presents the Ellendale RRC outcome data for fiscal years

14

314

2014 and 2015. The State has included Crisis Walk-In Center data in its monthly

315

dashboard, and will be including data relating to the new center once it becomes

316

operational.

317

Table-5 RRC Crisis Walk-In Center Referral and Diversion Breakdown
(All figures relate to individuals with SPMI who are a part of the Agreement’s Target Population)
FY 2014-2015

FY14 FY15

Number of Individuals Evaluated at RRC (Total)

1760 2183

Number Diverted from Hospitalizations

1386 1627

% Diverted

78.75% 74.53%

Number Admitted to IMD [Dover Behavioral Health (DBH)]

476

658

Number of DBH Admissions Evaluated by RRC

374

556

% of DBH Admissions Evaluated by RRC

78.57% 84.50%

Number of DBH Admissions Not Evaluated by RRC

102

102

% of DBH Admissions Not Evaluated by RRC

21.43% 15.50%

318

319

The data show that between 2014 and 2015, the number of individuals evaluated at RRC

320

increased by 24%. Although the program’s hospital diversion rate dropped somewhat in

321

2015, about three-quarters of the people who are evaluated at the RRC are diverted from

322

inpatient treatment. Given that the majority of the people seen at the center are brought

323

by police, referred by Mobile Crisis, or transferred from general hospital emergency

324

departments, it is reasonable to conclude that the population served includes significant

325

numbers of individuals who are experiencing serious mental health crises and are at high

326

risk of hospitalization. Thus, this diversion rate is impressive. During the past year,

327

DSAMH has made a concerted effort to ensure that members of the target population

328

who may require inpatient psychiatric care at Dover Behavioral Health (DBH), the IMD

329

that serves southern Delaware, are first evaluated at the RRC unless there is some

330

compelling reason (e.g., an immediate danger to self or others) to authorize a direct

331

admission to the hospital. As is reflected in Table-5, the State is having some success in

332

that 78.57% of the relevant admissions to DBH were pre-evaluated at the RRC in 2014,

333

and this increased to 84.50% in 2015.

334

Because of the delays in launching the Crisis Walk-In Center to serve northern Delaware,

335

it is not yet known what impact the new program will have in terms of reducing hospital

336

use. Most of the State’s IMD admissions come from the northern part of the State, which

337

is more heavily populated. And if the new program can replicate the successes of the

338

RRC, it is possible that the overall bed use numbers for the State can be reduced

339

substantially.

340

15

341

D. Engagement in Community Services Comprised by the Agreement

342

As was discussed earlier, one premise underlying the bed-use reductions contained in

343

sections III.D.3-4 was that the demand for hospital use would decline as the community

344

services required elsewhere in the Agreement ramped up. Past Monitor reports have

345

explained how, notwithstanding the State’s success in creating these programs, the

346

disjointed structure of service management was a barrier for members of the target

347

population in accessing putatively needed specialized mental health services. The

348

responsibility for oversight of hospitalized individuals had been disbursed between

349

DSAMH and DMMA, and the responsibility for referring individuals for the

350

Agreement’s specialized services was ambiguous, at best. PROMISE not only included a

351

structure for capturing federal reimbursement for a wide range of community services

352

relevant to the Agreement’s goals, but it also vastly improved coordination across

353

systems. Furthermore, over the past year and in collaboration with the Monitor, the State

354

devised protocols for systematically referring individuals who have SPMI and significant

355

service needs to DSAMH for its specialized services and supported housing. This was a

356

very important measure, and one directly related to III.D.3-4 in that, as a threshold

357

matter, Delaware’s specialized mental health services cannot have an impact on hospital

358

use if at-risk individuals are not referred for such services. Accordingly, a number of

359

indices relating to referrals to PROMISE16 were included in the new approach to

360

measuring the State’s compliance with these provisions.

361

Table-6 presents data on hospital admissions among individuals who are, or are not,

362

receiving PROMISE services. It does not present information relating to a full fiscal year

363

because the program went into effect in January, 2015 (6 months into FY 2015) and 6-

364

month data for FY 2016 (July through December, 2015).17 These statistics provide

365

important information about who is being admitted to hospitals and what community

366

services they were receiving at the time of admission. In FY 2015 and FY 2016, the

367

available data show that only 13.5% and 11.4%, respectively, of hospital admissions

368

related to individuals who were receiving DSAMH/PROMISE services—in other words,

369

the specialized services required by the Agreement. Over 85% of acute admissions,

370

whether considered in absolute numbers or as unduplicated counts, related to individuals

371

diagnosed with SPMI upon discharge who were not receiving specialized mental health

372

services. The full implications of this are not clear cut. For instance, it is likely that a

373

large number of these admissions, particularly the “one-and-done” admissions that are

374

discussed later in this report, relate to individuals who actually do not have SPMI

375

(notwithstanding their hospital discharge diagnoses) and who primarily require treatment

376

for substance use, rather than mental illness. DSAMH has a QA initiative, which is

377

discussed later, that may help clarify whether this is, in fact, the case. Nevertheless, the

378

low representation of people who are receiving DSAMH or PROMISE services among

16 Referrals to PROMISE are essentially referrals for DSAMH services. 17 Unless otherwise noted, all FY 2016 data referenced in this report is for the 6-month period July through December, 2015.
16

379
Table-6 Breakdown of Psychiatric Hospitalizations by PROMISE Status
FY 2015-2016 (partial data for both years)

FY15 (Jan thru Jun) FY16 (Jul thru Dec)

Number %

Number

%

Total Hospital Admissions

1813

1661

DSAMH/PROMISE Clients*

245 13.5%

189 11.4%

Others w/ SPMI and Medicaid Coverage

1568 86.5%

1472 88.6%

Unduplicated Hospital Admissions

1369

1243

DSAMH/PROMISE Clients

161 11.8%

130 10.5%

Others w/ SPMI and Medicaid Coverage

1199 87.6%

1109 89.2%

Admissions of the same individual with and without PROMISE

9 0.7%

4 0.3%

*These individuals have been presumptively determined to be eligible for PROMISE because they are being served

by ACT, Intensive Care Management, or in a group home.

380

381

those admitted to psychiatric hospitals does lend credence to the hypothesis underlying

382

the bed-use reduction targets in III.D.3-4 that intensive community services reduce the

383

risk of hospitalization—particularly so, because these individuals have been determined

384

through the DSAMH/PROMISE eligibility processes to have SPMI and significant

385

service needs.

386

Table-7 presents data on the State’s progress in referring new individuals for specialized

387

mental health services, to reiterate, a process that had been very poorly coordinated and

388

managed prior to PROMISE. Since PROMISE went into effect in January, 2015, the

389

State has streamlined the application process for specialty mental health services and has

390

been working closely with the Managed Care Organizations (MCOs)18 to ensure that

391

people with SPMI are systematically referred when they meet certain triggers (such as

392

repeated hospitalizations). Between January, 2015 and May 1, 2016, 2,877 individuals

393

were referred to PROMISE. Of these, 843 individuals had been diagnosed with SPMI,

394

but had not been receiving specialized mental health services. In other words, one in

395

three referrals to PROMISE relate to individuals who had not been receiving ACT,

396

Intensive Care Management (ICM), CRISP, or supported housing. Of this group, 541

397

referrals were made by the MCOs. The data presented in Table-7 are new, and the State

398

plans to present more detailed information in the future (for instance with regard to

399

determination of ineligibility, client refusal, the number of individuals receiving the

400

various services covered by PROMISE, and so on), but for purposes here, they do

401

demonstrate that the State has made a significant effort to enroll members of the target

18 Two MCOs operate under contract with DMMA as part of the administration of the State’s Medicaid program.
17

402

population in PROMISE, thereby affording them access to the array of services required

403

by the Agreement as well as other community supports.

404

Table-7

PROMISE Referral Breakdown

1-1-15 through 4/30/16

Sources of Referrals

Number of referrals for PROMISE services

2877

Active DSAMH clients (ACT. CRISP, ICM, etc.)

2024

New referrals

853

via direct MCO referral

541

via other referral sources

312

Determination Status

Number of referrals for PROMISE services

2877

Approved

1808

Pending

356

Closed (Ineligible, Moved, Refused, etc.)

713

405

406

407

E. Co-Occurring Substance Use

408

Based upon consultation with a number of parties active in monitoring or implementing

409

inpatient psychiatric admissions (among them, the two MCOs) and IMD chart reviews, it

410

is likely that a sizable number of the acute care psychiatric admissions to the IMDs

411

associated with SPMI diagnoses actually relate primarily to problems attendant to

412

substance use. To the extent that this is the case, these admissions may artificially inflate

413

the count of bed-days that the State is reporting by relying upon Medicaid claims data. To

414

further understand this issue, as well as the degree to which substance use problems are

415

being appropriately addressed for the target population, as a part of the new process for

416

evaluating sections III.D.3-4 the State is now reporting data relating to co-occurring

417

substance use among people diagnosed with SPMI who are admitted for acute psychiatric

418

care.

419

Figure-8 summarizes this information for all inpatient admissions (IMDs and DPC) from

420

fiscal year 2011 through the first six months of fiscal year 2016. Overall, substance use

421

diagnoses co-occur with diagnoses of SPMI in about 30-35% of the acute care

422

admissions during the period reported. While this proportion has remained relatively

423

stable since the base year, since the number of hospital admissions has risen, the absolute

424

numbers of admissions and bed-days represented by people with substance use diagnoses

425

has increased as well. The State has data relating to individuals in PROMISE only from

426

January 1, 2015 forward, and these early statistics show that somewhere in the

18

427

Figure-8 Inpatient Admissions of People Diagnosed with SPMI by Co-
Occurring Substance Use FY 2011-2016
100%

Percent of Admissions

80%

60%

40%

20%

0%

FY11

FY12

with SUD Dx served by PROMISE

FY13

FY14

FY15

FY16

with SUD Dx but not With Promise

with no SUD Dx served by PROMISE

with no SUD Dx but not With Promise

428

429

neighborhood of 5% of total admissions related to individuals who have been reviewed

430

by DSAMH and determined eligible for PROMISE services (and thus, with a fairly high

431

degree of certainty, have SPMI). A total of 1,650 individuals who were admitted for

432

acute psychiatric care during fiscal year 2015 and the first six months of 2016 who had

433

both SPMI and substance use diagnoses. Of them, only 85—or 5%—related to

434

individuals in PROMISE (most of whom received specialized mental health services

435

through DSAMH). The remaining 95% of these admissions (1,565) who were not in

436

PROMISE and may include the individuals referenced above whose needs are primarily

437

for substance use treatment. In other words, based on the diagnoses of record upon their

438

hospital discharge, about one-third of the hospital admissions related to people with co-

439

occurring substance use and SPMI, but only 5% of them were determined to need

440

specialized serves funded by the State to address the needs of individuals who have

441

SPMI.

442

443

F. Homelessness

444

The Agreement identifies homelessness as a factor that places members of the target

445

population at elevated risk of unnecessary institutionalization (section II.B.2.f).

446

Particularly in light of past reporting by the Monitor that found that IMDs were

447

sometimes discharging homeless individuals back to unstable living environments, the

448

measures relating to the State’s efforts to address this issue were included among the new

449

measures of compliance with III.D.3-4. As was described in the Monitor’s Eighth report,

450

beginning in March, 2015, the State launched a new initiative to ensure that members of

19

451

the target population were not being discharged from hospitals back into cycles of

452

homelessness.

453

Table-8 Target Population IMD Homelessness Initiative Outcomes
March, 2015 Through November, 2015

FY15
(Mar thru Jun)

Number

%

FY16
(Jul thru Nov)

Number

%

Total State-Funded IMD Admissions

966

1,248

Homeless

47

4.87%

81

6.49%

Receiving DSAMH Services

9 19.15%

11 13.58%

Referred for EEU/TCM

11 23.40%

21 25.93%

Referred for TCM Only

19 40.43%

40 49.38%

Discharged to shelters

8 17.02%

10 12.35%

Dover

1 12.50%

9 90.00%

MeadowWood

1 12.50%

1 10.00%

Rockford

6 75.00%

0

0.00%

454

455

Table-8 presents data from the inception of this initiative through November of 2015

456

reflecting the identification of homelessness among hospitalized members of the target

457

population and actions taken.19 The table shows that for the portion of fiscal years 2015

458

and 2016 that are reported, 4.87% and 6.49%, respectively, of IMD admissions of the

459

target population were identified as being homeless. A minority of these homeless

460

individuals—19.15% in 2015 and 13.58% in 2016—were receiving some level of

461

DSAMH services at the time of admission. The remainder were either referred for

462

specialized services (via DSAMH’s Eligibility and Enrollment Unit, or “EEU”) or to

463

Targeted Care Management (“TCM”) through which they can be linked to other services,

464

including substance use services. All of the individuals identified with SPMI who were

465

not already referred for housing services were referred for such services through this

466

important initiative. Table-8 also includes data relating to discharges from specific IMDs

467

to homeless shelters.20 Although the numbers are small and preliminary, it is notable that

19 It is noted that these data reflect only those homeless individuals who were admitted for psychiatric inpatient care. Homeless individuals touching the mental health system at other points are also referred for housing services as indicated, but they are not included in this initiative. 20 The data in this table relate to the three IMDs only, not to DPC. Except in extraordinary circumstances, DPC does not discharge individuals to shelters, and referrals for housing have been a routine component of DPC’s discharge process for some time.
20

468

in fiscal year 2016, 90% of the shelter discharges were from Dover Behavioral Health

469

IMD, which serves the southern part of the State were resources have been historically

470

scarcer than in northern Delaware.

471

472

G. Readmissions

473

Representing another measure of the State’s effectiveness in linking members of the

474

target population with needed services and reducing unnecessary hospitalizations, the

475

State is now reporting readmission rates associated with each of the categories reflecting

476

the duration of hospitalizations. Table-9 present readmission data for individuals who

477

were hospitalized in fiscal year 2014, the most recent year for which it compiled data in

Table-9 Hospital Readmission Rates by Duration of Hospitalization
for Individuals Discharged in FY 2014

1-30 Days

31-90 Days

91-180 Days 181-365 Days

Duration of Number of Hospitalization Discharges

n

%

n

%

n

%

n

%

Acute Care

2042 349 17.09% 231 11.31% 204 9.99% 236 11.56%

Intermediate-I

238 44 18.49% 25 10.50% 20 8.40% 31 13.03%

Intermediate-II

90 8 8.89% 6 6.67% 5 5.56% 8 8.89%

Long Term

27 0 0.00% 0 0.00% 0 0.00% 0 0.00%

Total 478

2397 401 16.73% 262 10.93% 229 9.55% 275 11.47%

479

reporting this new measure. The Acute Care data relate to individuals with hospital

480

episodes lasting 14 days or fewer; most of these were in the IMDs, but some also

481

occurred among individuals treated at DPC. In the Intermediate categories and in Long

482

Term care, overwhelmingly, the discharges relate to individuals who were treated at

483

DPC. From a clinical perspective, as the hospitalization classifications proceed from

484

Acute Care to Long Term care, individuals are presenting increasingly complex issues

485

that necessitate extended inpatient stays. Nevertheless, with only a couple of exceptions,

486

the readmission rates are successively lower as the clinical complexity increases, to the

487

point that none of the 27 individuals who were discharged to the community following

488

long-term stays at DPC were readmitted within a year.

489

490

H. Quality Assurance Initiatives relating to Inpatient Bed Use

491

In addition to the measures highlighted above, the parties agreed that the State would

492

initiate and report on QA activities that are specifically directed to factors identified

21

493

through the data dashboard (Table-1) that appear to underlie the increases in acute-care

494

bed use. Some of these initiatives were ongoing within DSAMH and others were

495

planned in collaboration with the Monitor. Among the QA actions the State has taken in

496

this regard are:

497

1. A study of high-end users (at DPC and/or an IMD), as defined by: four or

498

more hospitalizations, 30 days of inpatient care within a one-year period, or

499

three hospital admissions within any 90-day period. A scan of various data

500

sources revealed that 41 individuals met one or more of these criteria within

501

the 2015 calendar year. DSAMH established a High-End User Review

502

Committee which is monitoring the status of and treatment afforded to these

503

individuals, and is guiding actions to reduce their use of inpatient care.

504

2. A study of homeless individuals being admitted to IMDs, aimed at identifying

505

this population and ensuring referrals to supportive housing or other housing

506

services. This initiative, which is ongoing, produced the data presented in

507

Table-8.

508

3. A study of Single-Episode Hospital Utilization, now underway, which is

509

examining case records of a sample of individuals who have diagnoses of

510

SPMI upon discharge from an IMD, but who have no further encounters with

511

the system for extended periods of time, thus raising questions about their

512

diagnoses and possibly skewing data relating to inpatient bed use of the target

513

population. This study was referenced above in Section D.

514

These QA studies are in various stages of implementation, but the State should be able to

515

demonstrate how they are being used to drive refinements in practices aimed at reducing

516

psychiatric hospital use among the target population. Further information about the

517

State’s QA processes is presented later in this report.

518

519

Summary

520

The qualified rating with regard to Crisis Stabilization Services, “Moving Towards

521

Substantial Compliance,” is not based on any single measure, but on the totality of

522

quantitative measures and QA activities that are summarized above. The State has made a

523

significant effort to generate the required data and to move forward with QA measures

524

pursuant to the agreed upon plan for evaluating hospital use by the target population.

525

Given that the agreement of the parties about how compliance with sections III.D.3-4

526

would be evaluated occurred only about three months ago, the State’s ability to create a

527

new data dashboard, to compile underlying data, and to begin analyses is, without

528

question, impressive.

529

Further, the data show areas where the State is being successful in addressing issues

530

closely related to sections III.D.3-4, for instance:

22

531

a. It has significantly reduced the census at DPC, particularly with respect to long-

532

term institutionalization.

533

b. While acute psychiatric hospitalizations have increased, these are of short

534

duration (averaging 6.4 days).

535

c. Only a small number of hospitalizations exceed the acute care period of 14 days;

536

out of 3,267 admissions in fiscal year 2015, 2,790—or 85%—lasted 14 days or

537

fewer and only 15% exceeded 14 days.

538

d. Of those hospitalizations extending beyond 14 days, 70% (334 admissions out of

539

477 in fiscal year 2015) were classified as Intermediate-I, with an average length

540

of stay of 21.6 days.

541

e. Only a small number of people who remain hospitalized longer than 14 days are

542

not discharged within 30 days of a determination that they no longer need

543

hospital care. The State is examining systemic barriers to their timely discharge,

544

for instance, whether ACT teams and other high-end services are appropriately

545

moving clients through their programs, thereby creating vacancies to

546

accommodate hospitalized individuals.

547

f. People who are receiving the services required under the Agreement account for

548

only 10.5% of hospital admissions.

549

g. The State is actively enrolling individuals in PROMISE services.

550

h. The State has working plan in place to identify homeless individuals and to link

551

them with housing and other services.

552

553

Not surprisingly, the data also show some areas that require further investigation and

554

action to address what may well be unnecessary psychiatric hospitalizations (e.g., single

555

episode hospitalizations by individuals who may actually have primary needs for

556

substance use treatment) or repeated hospitalizations (e.g., high-end users). In these

557

instances, the State has launched efforts to further understand underlying factors so that it

558

can implement interventions accordingly. Largely as a result of the recency of the

559

parties’ agreement about these measures, there is not yet sufficient evidence of the State’s

560

use of these data or of the impact of its related QA activities. For this reason, it is being

561

rated as “Moving Towards Substantial Compliance” at this time with regard to these

562

important Crisis Stabilization provisions.

563

To demonstrate that it is fully meeting and sustaining the agreed upon requirements, the

564

State will need to:

565

1. Continue its collection of data, as delineated in Table-1;

566

2. Provide the Monitor with findings, action steps, and outcome measures

567

associated with QA activities, including those referenced above;

23

568

3. Evaluate and address the factors that are creating delays in discharging

569

individuals from DPC when they need ACT or CRISP services, including

570

whether individuals currently served through those programs could be

571

more appropriately served elsewhere in the system, thereby creating

572

vacancies for people at DPC; and

573

4. Provide the Monitor with documentation of how the agreed upon data sets

574

and QA findings are being used to better understand hospital use by the

575

Agreement’s targeted priority population and to drive activities aimed at

576

reducing hospitalizations among this group.

577

578 B. Discharge Planning

579

Substantial Compliance

580

The Monitor’s eighth report found that the State was making progress with respect to the

581

Agreement’s discharge planning provisions II.C.2.d.iii-iv, but that additional documentation

582

was required to demonstrate that it is meeting its obligations. Notably, it was missing

583

tracking data relating to the timely engagement of community providers at DPC. It has

584

since provided the necessary data to demonstrate Substantial Compliance.

585

Figure-9 Average Provider Response Time (Days) to Inpatient Admission
FY 2016 by Month, Compared with FY 2015 Average

3.50

Average Days until First Contact

3.00

2.50

2.00 1.61
1.50 1.26
1.00

0.50

0.00

FY15 Avg

Jul

Aug

Sep

Oct

Nov

Dec

DPC

Dover

MeadowWood

Rockford

Total

586

24

587

Figure-9 presents response time tracking for community providers in each inpatient

588

setting. This information is a part of the State’s monthly data dashboard and trends are

589

being monitored accordingly. Figure-9 also shows that the average length of time

590

between an individual’s hospital admission and contact from the individual’s community

591

provider was 1.61 days in fiscal year 2015, but that figure dropped to 1.26 days as of

592

December, 2015. As has been described in earlier Monitor reports, many of these

593

encounters are doctor-to-doctor, which are important interactions to facilitate

594

coordination of care.

595

596 C. Quality Assurance and Performance Improvement

597

Substantial Compliance

598

The last Monitor’s report noted that the State has been conducting Quality Assurance and

599

Performance Improvement (QA) activities and that sometimes these drive system

600

improvements, but that too often these activities existed in isolation and were not part of the

601

system wide QA program required by the Agreement in section V.A. Since that report, the

602

DSAMH has reconfigured its QA system and formed a Quality Control Steering Committee

603

as the hub of its QA activities. This committee, which is advisory to the DSAMH Director,

604

the DSAMH Medical Director, and the Secretary of Health and Social Services, coordinates

605

QA activities, data analyses, and corrective actions. Its scope includes inpatient mental

606

health settings (including DPC and the IMDs), mental health community programs, and

607

DSAMH’s substance use programs. In addition to the three QA initiatives referenced earlier

608

with regard to Crisis Stabilization Services, the QA program includes a number of initiatives

609

relevant to the requirements of the Agreement, including:

610

1. A Quality Process Review of Assertive Community Treatment (ACT) and Intensive

611

Care Management (ICM)21 that has been ongoing since 2015.

612

2. An investigation of how homelessness affected lengths of stay among members of

613

the target population who were hospitalized at DPC, which was initiated in 2015.

614

3. A study of rates of court commitment for inpatient or outpatient treatment (initiated

615

in 2014 and referenced in past Monitor reports), which shows the systems impressive

616

move toward voluntary treatment.22

617

4. Monthly QA meetings between DSAMH and the IMDs to resolve problems in care,

618

including coordination and information sharing between hospital and community

619

providers; this initiative was launched early in 2016.

620

5. An initiative to incorporate into practice data from the evaluation of DSAMH’s

621

CRISP program that has been a product of the ongoing partnership between the State

21 ACT and ICM are programs required by the Agreement. 22 The State’s new data dashboard includes related data (see Table-1, items 7a and 7b).
25

622

and the University of Pennsylvania (this research has been noted in past Monitor

623

reports).

624

6. An investigation of the needs of individuals living in community housing who have

625

complex challenges, particularly with respect to addressing Activities of Daily

626

Living. This program was initiated in 2015.

627

7. A Client Death Review investigation focusing on deaths occurring outside of

628

hospital settings. This study is a component of DSAMH’s risk management

629

activities, which are discussed below.

630

631

In summary, DSAMH has made palpable progress in not only expanding its program of

632

Quality Assurance and Performance Improvement, but in reconfiguring it to effectively

633

provide system-wide monitoring and refinement. It is now in Substantial Compliance with

634

the requirements of the Agreement contained in section V.A.

635

636 D. Risk Management

637

Partial Compliance

638

The last report of the Monitor referenced the State’s disjointed risk management system that

639

largely represented an accumulation of various isolated measures over many years. That

640

report also noted that measures were underway to restructure and streamline the reporting of

641

adverse events system-wide and to create a centralized process for investigating these

642

events, implementing corrective actions, and identifying and addressing patterns of elevated

643

risk. While these reforms are still being phased in, the State has reached the point where a

644

functional risk management system is now operational, but not completely so.

645

The Monitor’s December, 2015, report noted a key, longstanding issue with respect to

646

evaluating the State’s compliance with the Agreement:23 “[the State] has provided no data

647

relating to IMDs and it is unclear whether the State is even receiving such information in

648

conformance with Sections V.B.8.”24 An effective Risk Management program that includes

649

the IMDs is highly relevant to the Agreement. As a general matter, Risk Management deals

650

with abuse, neglect and serious issues up to and including deaths, so it plays a very

651

important role with respect to reducing the possibility of physical and psychological harm.

652

Secondly, the IMDs play a very significant role in serving the target population; in 2015,

653

they accounted for 89% of the hospitalizations covered by the Agreement (2,926 out of a

654

total of 3,267 admissions). Thirdly, by virtue of the fact that these admissions involve

655

individuals in acute mental health crises—including situations where there is an immediate

656

danger to self or others—and sometimes involuntary treatment orders, IMD hospitalizations

657

may entail an elevated risk of adverse events, allegations of abuse, and so on. Finally, IMDs

23 The risk management provisions of the Agreement pertain to individuals with SPMI who receive mental health services (whether in the community, DCP or IMDs) paid for by the State (i.e., DSAMH or DMMA). 24 Monitor’s Eighth Report, line 788.
26

658

are specifically referenced in the Risk Management provisions of the Agreement (sections

659

V.B.1, 4, 5, 6, 8, and 9). For all of these reasons, it is critical that IMDs be fully integrated

660

into Risk Management activities relevant to the Agreement for the State to demonstrate

661

Substantial Compliance.

662

A key barrier to such integration is that reporting and investigations of adverse events in

663

IMDs do not automatically go to DSAMH, but instead to other state agencies within the

664

Department of Health and Social Services. In May, 2016, the State drafted a Memorandum

665

of Understanding (MOU) between DSAMH, the Division of Long Term Care Residents

666

Protection, and the Division of Public Health that is intended to remedy this disjointed

667

reporting arrangement, but it may not go far enough. It would allow a sharing of

668

information relating to reports of abuse, neglect, mistreatment, financial exploitation, and

669

deaths occurring due to the use of seclusion or restraints in IMDs. The draft MOU does not

670

specifically address serious injuries or deaths that may occur in situations not involving the

671

use of seclusion or restraints in IMDs, and therefore, may limit the reach of the risk

672

management process discussed below (see Figure-10). The MOU calls for regular

673

collaborative meetings among the Divisions affected, as well as joint risk management

674

activities, including oversight of needed corrective actions within the IMDs. As of this

675

writing, the MOU has not yet been executed.

676

In response to a request for examples of recent investigations in IMDs, the State provided

677

documents that do not allow a meaningful assessment of how risk management processes

678

now being carried out through other DHSS divisions align with the requirements of the

679

Agreement. These examples of recent investigations—some of which were conducted by

680

the federal Centers for Medicare and Medicaid Services and others by the State—were

681

redacted so that any patient-level information was missing (even though numeric patient

682

identifiers, rather than names were apparently used). Thus, essential information relating to

683

the specific nature of the complaints and investigatory findings was deleted. While there

684

were some instances where corrective actions by the IMDs were referenced, whether they

685

were appropriately responsive to the presenting complaint and how they connect to any

686

larger risk management endeavor were not at all apparent. Furthermore, the State provided

687

no aggregate information as to the overall number of investigations, the nature of complaints

688

being received, actions taken by the responsible state agency, and so on.

689

Within DSAMH programs, including DPC and community providers relevant to the

690

Agreement, the situation is quite different. The State has made improvements in its Risk

691

Management system, including the reporting of adverse events, the investigation process,

692

and tracking of corrective measures. DSAMH provided several examples of investigations

693

of critical incidents, including its new process for reporting incidents that includes reviews

694

of relevant clinical documentation by a registered nurse and final reviews by the DSAMH

695

medical director. As a part of the medical director’s review, there is a determination as to

696

whether a root cause analysis (RCA) is indicated. DSAMH also provided documentation

697

showing that when RCAs are conducted, as has been noted in past Monitor reports, they are

698

thorough and are used as opportunities to identify areas for program improvement.

27

699

Figure-10 presents an overview of how DSAMH’s risk management system functions,

700

including how information relating to incidents in the IMDs (i.e., information to be shared

701

via the inter-divisional MOU) will be incorporated into the process. As is depicted in this

702

flow chart, the medical director plays a direct and key role in ensuring that appropriate

703

actions are taken in response to sentinel events25 or other critical incidents. In addition, the

704

medical director reviews trending data, performance improvement data, and other

705

information collected by the DSAMH Quality Control staff. Ultimately, information

706

relating to risk management is integrated with the Division’s overall QA functions through

707

the Quality Control Steering Committee which is referenced in the previous section.

Figure-10

708

709

For instance, the ongoing QA initiative that is analyzing deaths occurring outside of hospital

710

settings has very important implications in terms of risk management.

711

In summary, the State continues to make progress in its Risk Management system, as

712

required by the Agreement, but such progress with respect to the IMDs is notably lagging

713

behind. Largely for this reason, the State is evaluated as being in Partial Compliance with

714

respect to sections V.B.1-9.

25 A Sentinel Event is a term used by The Joint Commission, a healthcare accrediting body, to refer to any unanticipated event resulting in death or serious physical or psychological injury to a patient.
28

715

For the State to demonstrate Substantial Compliance with the Agreement’s Risk

716

Management provisions, it is recommended that it:

717

1. Continue its progress in improving Risk Management for events occurring at

718

DPC or in community programs operating under contract with DSAMH;

719

2. Meaningfully integrate reporting, investigations, and corrective actions

720

associated with events occurring within IMDs relating to the target

721

population, including all events relating to serious injury or deaths in IMDs

722

involving members of the target population;

723

3. Provide documentation to the Monitor on how events relating to care in IMDs

724

are reported, including legal or regulatory requirements for such reporting;

725

how consumers or other stakeholders can file complaints and how they are

726

apprised of this process; and what actions ensue once a report of an incident is

727

received;

728

4. Collect and analyze monthly information relating to the number of incidents,

729

categories of incidents (e.g., death, serious injury, abuse), actions taken

730

(investigations, root cause analyses, corrective plans), and resolutions with

731

respect to members of the target population, beginning in fiscal year 2015;

732

5. Provide to the Monitor unredacted documentation relating to each incident of

733

death or serious injury occurring in an IMD (including any incidents of death

734

or serious injury proximate to care an IMD) with respect to members of the

735

target population, beginning in fiscal year 2013 forward, including

736

investigations and all actions taken;

737

6. Provide to the Monitor documentation of how events and findings associated

738

with the care of the target population in IMDs is incorporated in the Quality

739

Control Steering Committee; and

740

7. Otherwise demonstrate that the system is fully in conformance with each of

741

the provisions of section V.B

742

743 III. Summary:

744 As is described above, the State has achieved Substantial Compliance for two of the four 745 provisions found to be in Partial Compliance in the Monitor’s December, 2015 report; it is rated 746 as Moving Towards Substantial Compliance for a third provision (Crisis Stabilization); and it 747 remains in Partial Compliance with respect to Risk Management. With regard to the latter two 748 provisions, this report details specific measures that it should take to demonstrate that it has 749 achieved Substantial Compliance in accordance with the Agreement’s requirements. The 750 Agreement includes one additional provision relating to Supported Housing (III.I.6) which has a 751 target date of July, 1, 2016 and, thus, has not yet been evaluated. Assuming that the State meets 752 the requirement of that provision, takes the steps detailed above relating to sections III.D and

29

753 V.B in a complete and timely way, and demonstrates that it will sustain its efforts with respect to 754 other provisions (as documented in the Monitor’s eighth report), it appears to well positioned to 755 establish that it is fully meeting its obligations under the Agreement. 756 757 758 Robert Bernstein, Ph.D. 759 Court Monitor
30

 
 TENTH REPORT OF THE COURT MONITOR ON PROGRESS TOWARDS COMPLIANCE WITH THE AGREEMENT: U.S. v. STATE OF DELAWARE
U.S. District Court for the District of Delaware, Civil Action No: 11-591-LPS 9/19/2016

1

Karen1 describes her life as a journey through hell and back. As a child, when she entered

2

Delaware’s mental health system, she was shy to the point that she wouldn’t speak. She

3

mostly kept her head down and stared at her feet, but would sometimes throw tantrums for

4

no apparent reason. As an adult, she had a history of repeatedly overdosing. Within the

5

Delaware Psychiatric Center, where Karen reports she was admitted around 30 times, she

6

would bang her head against the brick wall. “It was torture,” she said, “Like a prison. You

7

have no freedom. I remember looking out the window and thinking ‘When is it going to

8

end?’” Karen now describes with pride how, with the assistance of the CRISP program, she

9

has taken control of her own recovery. “I’m doing so much better now than I’ve ever been

10

in my life. I get upset and I bounce right back.” She lives in her own apartment in an

11

ordinary apartment complex. She cooks and cleans and has plans to help others, perhaps as

12

a peer specialist. “Life is wonderful now.”

13

###

14

Jerry had been working as an emergency responder, but after becoming seriously injured in

15

an accident and followed by the breakup of his marriage, his life seemed to fall apart. He

16

estimates that he tried to harm himself—through overdosing on pills or stabbing himself—

17

about 20 times. He started drinking heavily to soothe his depression, but became a “fall

18

down drunk.” He was admitted to the Delaware Psychiatric Center several times and was

19

diagnosed with bipolar disorder. He is now receiving outpatient mental health services and

20

alcohol treatment and has been clean for six months. Jerry lives in his own apartment, which

1 To protect their privacy, peers’ names used in this report have been changed.
1

21

he describes as nice, and finds his treatment team to be very supportive of his recovery. He

22

is thinking about job prospects and, while he admits to being “a little scared every day,”

23

describes himself as now optimistic. He reads a lot, stays in touch with his family, and

24

attends to grocery shopping and other household chores.

25

###

26

Susan has had a very difficult life. Beginning as a teenager, she was the victim of abuse

27

and molestation. She has been diagnosed as having paranoid schizophrenia and guesses

28

that she was psychiatrically hospitalized 15 or 20 times. When outside of a hospital, much

29

of Susan’s adult life was spent in homelessness. She described living in shelters, sleeping

30

on park benches, or huddled with other homeless people; “It was scary and dangerous, but

31

you just keep on going. Never stay in one place too long.” She reported the many indignities

32

of being homeless: trying to find a private place to relieve herself because she was denied

33

access to restrooms; police harassing her—shooing her away, telling her to go down the

34

street or to another city, and threatening to arrest her for vagrancy; and being looked down

35

upon by passersby. “Try living on the streets without food and rest for days on end. Tell

36

me how strong you’re going to be,” she said. And hers was a lonely life, “Most people are

37

unable to understand me or they don’t take the time to get to know me. I would hang out in

38

bars because I didn’t have any friends.” Susan’s life is vastly different now. For more than

39

a year and a half, she has received supported housing services, living in her own apartment

40

in what she describes as a “decent neighborhood, safe.” This is the longest period of time

41

that Susan has had a stable home in her adult life. Susan describes her apartment as

42

spacious, with a washer and dryer, a garbage disposal, and dishwasher. “I have a lovely

43

apartment; I love it.” In sharp contrast to being concerned about survival on the streets, she

44

now describes her efforts to live within her budget (she doesn’t use the dishwasher to help

45

keep her electric bill low), and she reminded herself to pick up some carpet cleaner because

46

she had spilled something on her rug. Susan feels that her treatment team affords her dignity

47

and respect, and describes her very close relationship with an individual providing her with

48

peer supports. “My life is a miracle,” she says.

49

###

50 2

51 This is the tenth report of the Court Monitor (Monitor) on the implementation by the State of Delaware 52 (State) of its Settlement Agreement (Agreement) with the U.S. Department of Justice (DOJ) relating to 53 its services for individuals with Serious and Persistent Mental Illness (SPMI). The Agreement, which 54 went into effect on July 15, 2011, requires the State to comply with the Americans with Disabilities Act 55 (ADA), the Supreme Court’s decision in Olmstead v. L.C. (Olmstead), and other laws that require public 56 systems to support individuals with SPMI to live successfully in their communities without being 57 subjected to unwarranted institutional segregation. In slightly longer than five years of implementing 58 the Agreement, the State has made dramatic improvements in its services to Delawareans with SPMI. 59 While this report presents substantial aggregate data in support of the Monitor’s finding that the State is 60 now in Substantial Compliance with the requirements of the Agreement, the stories above speak to its 61 individual human outcomes. They reflect individuals who have struggled against incredible 62 challenges—clinically and otherwise—and who are pursing recovery that might have been unthinkable 63 not so long ago. Today, these individuals’ lives are not dramatic; remembering to pick up some rug 64 cleaner is a mundane matter. Yet, for these and other members of the Agreement’s target population, 65 that life could become so mundane is dramatic. It is also what is at the heart of the ADA, Olmstead, and 66 the Agreement: affording individuals who had been relegated to the margins of society the services and 67 opportunities they need to live ordinary lives in the community mainstream.
68 This report presents a detailed analysis of Delaware’s success in complying with the Agreement and in 69 achieving the kind of outcomes reported by these three individuals when they were interviewed by the 70 Monitor in July, 2016. These individuals have made substantial progress and are now on pathways 71 towards further improving their lives. Likewise, Delaware’s service systems affecting these and other 72 people with SPMI have made substantial progress and are on a trajectory to achieve further progress. 73 These systems are not perfect, but they are increasingly aligned to promote recovery, self-determination, 74 and community integration.
75 This report begins with information about the population of individuals targeted as the prime 76 beneficiaries of the Agreement, followed by information about some cross-cutting systemic changes that 77 have broadly affected implementation of the Agreement, and then a discussion of the State’s compliance 78 with regard to specific provisions of the Agreement. The State is now in Substantial Compliance with 79 each of these provisions.
3

80 A. Target Population

81 Section II.B of the Agreement defines the population to be served, as well as specific sub-populations 82 that are prioritized based upon their elevated risk of institutional segregation:

83

1. The target population for the community services described in this section is the subset

84

of the individuals who have serious and persistent mental illness (SPMI) who are at the

85

highest risk of unnecessary institutionalization. SPMI is a diagnosable mental,

86

behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria and

87

has been manifest in the last year, has resulted in functional impairment which

88

substantially interferes with or limits one or more major life activities, and has episodic,

89

recurrent, or persistent features.

90

2. Priority for receipt of services will be given to the following individuals within the target

91

population due to their high risk of unnecessary institutionalization:

92

a. People who are currently at Delaware Psychiatric Center, including those on

93

forensic status for whom the relevant court approves community placement;

94

b. People who have been discharged from Delaware Psychiatric Center within the last

95

two years and who meet any of the criteria below;

96

c. People who are, or have been, admitted to private institutions for mental disease

97

("IMDs") in the last two years;2

98

d. People with SPMI who have had an emergency room visit in the last year, due to

99

mental illness or substance use;

100

e. People with SPMI who have been arrested, incarcerated, or had other encounters

101

with the criminal justice system in the last year due to conduct related to their

102

serious mental illness; or

2 IMDs are privately owned psychiatric hospitals. The IMDs currently serving the target population are Dover Behavioral Health, MeadowWood Behavioral Health, and Rockford Center. A fourth IMD is being developed in Sussex County, but is not yet operational.
4

103

f. People with SPMI who have been homeless for one full year or have had four or

104

more episodes of homelessness in the last three years.

105 To construct the required Target Population Priority List (TPPL), in the first year of implementation the 106 Monitor and the State agreed on a list of psychiatric diagnoses that are indicative of SPMI. This list is 107 included in Appendix-A. In addition, the Monitor and the State devised a set of strategies to identify an 108 initial population for inclusion on the TPPL (e.g., individuals served through the Division of Substance 109 Abuse and Mental Health’s (DSAMH) specialized mental health programs) and for adding new 110 individuals to the list (e.g., psychiatric hospitalization of individuals within the Medicaid program where 111 the discharge diagnoses included one or more of those indicative of SPMI). The TPPL list grew 112 quickly. As of December, 2016, 12,826 individuals had been identified in accordance with the agreed 113 upon criteria.

114 In order get a sense of the population being served and the reach of the Agreement in terms of the high115 risk categories delineated above and other factors, the State has maintained data about the service 116 histories of members of the TPPL. Table-1 presents the numbers of individuals within each high-risk

117

Table- 1

Breakdown of TPPL Risk or Inclusion Factors

12,826 Individuals

December, 2016

Risk or Inclusion Factor

Number of Individuals

Hospitalization or History of Hospitalization at Delaware

1,096

Psychiatric Center (DPC)

Hospitalization or History of Hospitalization at a private

7,070

psychiatric hospital (IMD)

Emergency Room Use due to Mental Illness or Substance

4,116

Use

Criminal Justice Contact related to Mental Illness

2,764

Homelessness

905

Crisis Walk-In Center Use

1,058

Target Care Management Use

3,086

Group Home

254

Intensive Community Mental Health Service Programs

2,937

Generic Community Mental Health Programs

2,590

Percent of Total TPPL
8.5%
55.1%
32.1%
21.5% 7.1% 8.2% 24.1% 2.0% 22.9% 20.2%

5

118 category, as well as their representation as a proportion of the total TPPL. A single individual may be 119 represented in more than one risk category.

120 Working in collaboration with experts from the University of Pennsylvania (UPenn)3 the State has 121 access to analyses of overall trends relating to the target population4 and changes that have occurred 122 through the course of the Agreement’s implementation. As a general matter, the Agreement seeks to 123 reduce the State’s reliance on institutions such as hospitals in serving individuals with SPMI and, as is 124 discussed in detail later in this report, it requires the development of a comprehensive array of 125 community-based mental health programs. UPenn’s analysis of Medicaid claims and other data finds 126 that, indeed, outpatient mental health service use has increased significantly, as compared with use prior 127 to and at the outset of implementation. Figure-1 shows that between Fiscal Year 20105—the year 128 preceding implementation of the Agreement—and Fiscal Year 2015, outpatient mental health service 129 utilization (of any type) by people with SPMI almost doubled.

130

Number of clients

9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000
0
FY10

Figure- 1: Use of Any Outpatient Service by Target Population

Any Outpatient

FY11

FY12

FY13

FY14

FY15

3 Center for Mental Health Policy and Services Research, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania. 4 It is noted that the University of Pennsylvania employs methodology for including individuals in its analyses that slightly differs from the State’s, but this difference is unlikely to significantly affect the overall trends reported. 5 Fiscal Year (FY) 2010 runs from July 1, 2009 through June 30, 2010 and other FYs are defined accordingly.
6

131 At the same time, the State was able to reduce its civil beds at the Delaware Psychiatric Center (DPC) by 132 42%.6 Figure-2 summarizes use of psychiatric hospitals by the target population during the same time 133 period. It shows that admissions to DPC or an IMD declined when Fiscal Year 2010 is compared with 134 Fiscal Year 2015, although inpatient use increased in some of the intervening years.

Number of clients

Figure- 2: Psychiatric Inpatient Use

by the Target Population

3000

(cumulative)

2500

2000

1500

1000

500

0 Any Inpatient
FY10 FY11 FY12 FY13 FY14 FY15

135

136 On the other hand, Figure-3 shows that emergency department use rates by the target population have 137 increased dramatically. As is discussed throughout this report, the State uses such data to drive system 138 improvements. Based in part upon its monitoring of this trend, the State is taking actions to shift crisis 139 evaluations from hospital emergency departments to it Crisis Walk-In Centers.7

6 The bed reduction at DPC is discussed further in Section XIII of this report, which concerns Quality Assurance and Performance Improvement. 7 It is noted that the number of individuals identified by physicians in emergency departments as having SPMI is likely inflated because of problems in differentiating mental illness from substance use in those settings. This diagnostic issue is discussed further in this report in the section, Provisions Relating to Reductions in Acute Care Bed Days.
7

Number of Clients

Figure- 3: Emergency Department Use

6000

by the Target Population

5000

4000

3000

2000

1000

0 AnyED
FY10 FY11 FY12 FY13 FY14 FY15

140 Information provided in this report includes details of the use and outcomes of specific community 141 services. As a general matter, these data relating to the TPPL show that the Agreement appears to have 142 spurred a significant growth in outpatient mental health service use by the high-risk target population; in 143 some respects, a decrease in the use of psychiatric hospitals (although the picture is more complex, as is 144 discussed later); and a shift to emergency departments and other settings where diversion from further 145 hospitalization may occur.

146

147 B. Structural Changes with Broad Impact

148 In implementing the Agreement, the State made several broad structural changes in its systems affecting 149 the target population. Their impact cuts across specific provisions of the Agreement and they provide 150 context for many of the State’s accomplishments that are detailed later in this report. They are also 151 important because they represent significant changes in law, policy, and decision making that have now 152 become embedded in Delaware’s service systems. As such, they enhance the strong likelihood that the 153 reforms made pursuant to the Agreement will continue beyond its resolution.

8

154

1. Mental Health Laws-

155 At the outset of the Agreement, Delaware’s mental health system was guided by a very antiquated set of 156 laws that were written decades ago and that reflected an era when DPC and its Superintendent were the 157 hub of the State’s mental health system. Since the Agreement went into effect, the State has made 158 several important legislative changes that not only update its mental health laws, but also align them 159 with the requirements of the ADA, Olmstead and, more particularly, the Agreement. This legislation 160 includes:

161

a. House Bill 311, which was signed into law in July, 2012. Among its provisions, this law

162

required that, prior to an individual being detained for 24-observation to determine if involuntary

163

hospitalization is indicated, that individual first be evaluated by a credentialed screener to

164

determine that the individual likely has a serious mental illness and whether less restrictive

165

measures can be put into effect. This law specifically references its intent to further the State’s

166

efforts to comply with the Agreement.

167

b. House Joint Resolution 17, which was passed in June, 2013, established a study group to

168

evaluate Delaware’s civil mental health laws and to make recommendations for their

169

improvement. This study group included a broad range of stakeholders, including providers,

170

legal and policy experts, and individuals who have lived experience with serious mental illness.

171

The Group issued its final report in April, 2014.

172

c. The study group’s recommendations culminated in House Bill 346, which was signed into law in

173

October, 2014. This law significantly modernized the State’s mental health code by clarifying

174

criteria for commitment to either a hospital or outpatient treatment, ensuring that individuals are

175

first afforded an opportunity to be served on a voluntary basis, and improving the timeliness of

176

legal hearings.

177

d. Senate Bill 245, which was passed by both chambers in June, 2016. This law establishes a

178

Behavioral and Mental Health Commission that includes a Peer Review Subcommittee charged

179

with overseeing services to individuals with SPMI, including in matters relating to adverse

180

events and related root cause analyses. The law focuses on the Agreement’s target population,

9

181

essentially adopting the prioritization criteria discussed above, and it specifically references the

182

requirements of the ADA with respect to individuals who have SPMI.

183 These laws include important protections for individuals with SPMI who receive services and they help 184 to assure that preventing their hospitalization—whether on a voluntary or involuntary basis—remains a 185 State priority.

186

187

2. Funding Services that Promote Community Integration-

188 Having successfully navigated the process for obtaining federal approval, in January, 2015, the State put 189 into place very important changes with regard to Medicaid-covered services that enable people with 190 SPMI to live successfully in their communities. The PROMISE program (Promoting Optimal Mental 191 Health for Individuals through Supports and Empowerment) vastly expanded Medicaid coverage of 192 community services for the target population that, when they were available before PROMISE, had been 193 totally funded with State dollars. By including these community-based and recovery-oriented services 194 in the State’s Medicaid program, Delaware is able to draw federal dollars to pay a significant portion of 195 their costs. PROMISE comprises a comprehensive array of services, many of which are required by the 196 Agreement, and all of which align with the Agreement’s goals:

197

 Care management

198

 Benefits counseling

199

 Community psychiatric support and treatment

200

 Community-based residential supports, excluding assisted living

201

 Financial coaching

202

 Independent activities of daily living/chore services

203

 Individual employment supports

204

 Non-medical transportation

205

 Nursing

10

206

 Peer support

207

 Personal care

208

 Psychosocial rehabilitation

209

 Respite

210

 Short-term small group supported employment

211

 Community transition services

212 In addition to vastly expanding opportunities for capturing federal dollars in support of the Agreement’s 213 requirements, PROMISE brought two other very important benefits. Several earlier Monitor reports 214 described the State’s convoluted and uncoordinated processes within and between DSAMH and the 215 Division of Medicaid and Medical Assistance (DMMA). The responsibility for managing hospital care 216 for a member of the target population could shift back-and-forth between these bureaucracies, and there 217 was no clear-cut accountability around such critical functions as averting psychiatric hospitalization for 218 Medicaid-covered individuals with SPMI who were not served by DSAMH or referring them for 219 DSAMH’s housing or specialized mental health services. These problems significantly affected the 220 State’s ability to meet some requirements of the Agreement, particularly with respect to hospital use.8 221 As a part of meeting the requirements of the federal Centers for Medicare and Medicaid Services (CMS) 222 to implement PROMISE, this situation has significantly changed. Through collaborative agreements 223 and new processes variously involving DMMA, DSAMH, the IMDs, and the MCOs,9 there is now a 224 much more systematic sharing of information and coordination of care. While these new interactions 225 are still evolving, without question, they are much improved and will likely continue on this course.

226 A second benefit of PROMISE is less tangible, but perhaps equally important. The process of applying 227 for and securing federal authorization of changes in states’ Medicaid programs, such as PROMISE, is 228 long, complex, and arduous. Partly for this reason, services covered by states’ Medicaid programs tend 229 to remain stable and do not dramatically change in short order. In interacting with a broad range of

8 This is discussed in detail later in this report, in the section relating to Crisis Stabilization Services and Quality Assurance/Performance Improvement. 9 MCOs are Managed Care Organizations that, under contract with DMMA, manage mental health and other healthcare benefits for the Medicaid population.
11

230 stakeholders—including peers, family members, providers, and others—the most consistent concern 231 heard by the Monitor is not so much that there are problems in services, but far more often that 232 stakeholders worry that the array of services introduced through the Agreement will go away once the 233 Agreement is resolved and the State is no longer subject to a court order. In this regard, and in addition 234 to the likely impact of the laws discussed in the prior section, PROMISE affords some assurance that the 235 State’s existing comprehensive menu of covered services will continue as elements of the Delaware’s 236 mental health service system. For all of these reasons, PROMISE has broad importance to the State’s 237 fulfillment of the requirement of the Agreement and of the ADA with regard to Delawareans with SPMI.

238

239

3. Data Systems-

240 Early Monitor reports referenced the fact that, as in states nationwide, Delaware’s data systems relating 241 to services for individuals with SPMI were antiquated, disjointed, idiosyncratic, and improvised. While 242 the State had been pursuing a major overhaul of its data systems that will likely take many years to 243 accomplish, the Agreement required a much more immediate and flexible approach. Commendably, 244 DSAMH tapped into the talent and innovation of a data team whose achievements are evidenced in the 245 tables and graphs that make up much of this report. The State has moved from arrangements whereby 246 client information would be faxed between buildings on the Holloway Campus (where DPC, DSAMH, 247 DMMA and the Health and Social Services Cabinet Secretary’s offices are located) and manually 248 tallied, to electronic information systems that can trend aggregate data over time, evaluate patterns, and 249 drill down to the performance of specific providers. Such information has informed the parties and the 250 Monitor about how to most effectively meet the goals of the Agreement (for instance, as is discussed 251 later, with respect to the allocation of Assertive Community Treatment and Intensive Case Management 252 teams). Likewise, DSAMH’s decision to replicate its Ellendale Crisis Walk-In Center in the northern 253 part of the state was based upon analyses of data regarding that program’s performance and impact in 254 reducing hospital use. As is the case with the other accomplishments discussed in this section, the State 255 has made impressive improvements in its access to and use of data, as well as in its ability to respond to 256 emerging data needs.

12

257 C. Ratings of Compliance with Specific Provisions of the Agreement

Table- 2: Ratings of Compliance
P=Partial Compliance S=Substantial Compliance

Requirement

I.

II.

III.

IV.

V.

VI. VII. VIII. IX.

X.

Provision 1/30/12 9/5/12 3/8/132 9/24/13 5/19/14 12/29/14 6/16/153 12/26/15 5/26/164 9/19/16

Crisis Hotline

III.A

S S -- -- S S -- S -- S

Mobile Crisis Services III.B

P P -- S S S -- S -- S

Crisis Walk-In Centers III.C

P S -- S S S -- S -- S

Crisis Stabilization Svs. III.D

P

S

--

S

P

P

--

P MTS5 S

Crisis Apartments

III.E

P S -- S S S -- S -- S

Assertive Com. Treatmt. III.F

P S -- S S S -- S -- S

Intensive Case Mgmt. III.G

P S S S S S -- S -- S

Case Management

III.H

P P -- S S S -- S -- S

Supported Housing

III.I

P S -- S S S -- S -- S

Supported Employment III.J

-- S -- S S S -- S -- S

Rehabilitation Services III.K

-- S -- S S S -- S -- S

Family/Peer Supports III.L

-- S -- S S S -- S -- S

Discharge Planning

II.C.2;IV.B -- P/S1 -- S P P -- P S S

Quality Assurance

V.A

P S -- -- S S -- P S S

Risk Management

V.B

-- -- -- -- P P -- P P S

1. The Monitor’s Second Report found some provisions relating to Quality Assurance to be in Partial Compliance and others to be in Substantial Compliance.

2. The Monitor’s Third Report included a compliance rating for only one provision; the Agreement specified no other new implementation targets for the time period covered.

3. The Monitor’s Seventh Report focused on four areas in which the State had failed to achieve Substantial Compliance per the Sixth Report; it did not include compliance ratings of any provisions.

4. The Monitor’s Ninth Report focused upon four areas in which the State had failed to achieve Substantial Compliance per the Eighth Report; it only included compliance ratings for these provisions.

5. The State was rated as being “Moving Towards Substantial Compliance” with regard to newly established criteria.

258 Section VI.B.3.g of the Agreement requires that the Monitor evaluate the State’s success in meeting its 259 requirements in terms of ratings of Substantial Compliance, Partial Compliance, or Noncompliance. 260 Table-2 presents these ratings with reference to key provisions of the Agreement based upon nine 261 previous reports, and this—the tenth—Monitor’s report. As is detailed below, this report finds the State 262 to be in Substantial Compliance with each of these key provisions.

13

263 The following sections review these provisions in detail and explain the basis for the State being rated as 264 being in Substantial Compliance with them. Many of these discussions begin with aggregate 265 information about the State’s performance across several years, followed by more detailed current 266 information that demonstrates how the State is able to trend performance month-to-month and to 267 monitor key performance measures for purposes of quality control and improvement.

268

269 I. Crisis Hotline

270

Substantial Compliance.

271

Section III.A of the Agreement includes the following provisions:

272

1. By January 1, 2012, the State will develop and make available a crisis line for use 24

273

hours per day, 7 days per week.

274

2. By July 1, 2012, the State will provide publicity materials and training about the crisis

275

hotline services in every hospital, police department, homeless shelter, and department of

276

corrections facility in the State. The training will be developed in consultation with the

277

Monitor.

278 The Crisis Hotline is a critically important element of services for people with SPMI. It provides 279 immediate consultation and phone counseling for individuals who are in crisis and, as applicable, it can 280 trigger intervention by Mobile Crisis10 or other emergency services. It can also be a gateway for 281 services for individuals who have other, less urgent service needs, and those with substance use 282 problems that may or may not co-occur with mental illness.

283 The State has been found to be in Substantial Compliance with the provisions relating to the Crisis 284 Hotline in each of the Monitor’s reports for which it was rated, dating back to the first Monitor’s Report 285 in January, 2012. It remains in Substantial Compliance. Table-3 presents the average number of

10 Mobile Crisis teams, which are discussed in the next section, provide rapid-response, face-to-face interventions by mental health professionals.
14

286 monthly calls received by the Crisis Hotline in New Castle County (NC), where the largest number of 287 the State’s residents live, and in Kent and Sussex Counties (KS), which are in the southern part of the 288 State and are more rural. The overall number of calls has decreased somewhat since Fiscal Year 2014, 289 but the number of calls from Kent and Sussex have proportionally increased. In absolute numbers, a 290 total of 28,262 calls were received in Fiscal Year 2016.

291
Table-3: Average Monthly Calls to Crisis Hotline by Fiscal Year and County

Totals

FY14

NC

KS

1,956.0 550.0

FY15

FY16

NC

KS

NC

KS

1804.9 513.5 1,629.6 725.6

2506.0

2318.4

2355.2

292 Figure-4 presents a breakdown of these calls in terms of whether or not they represented issues relating 293 to substance use (SUD); whether they were primarily related to mental health issues (Non-SUD);

Avg. Monthly Calls

Figure-4: Average Monthly Calls to Crisis Hotline by Presenting Issue & Response
2500

2000

1500

1000

500

0

NC

KS

NC

KS

NC

KS

FY14 Avg Non SUD Calls

FY15 Avg SUD Calls FTF Call Resp.

FY16 Avg Other FTF

294 whether they triggered an emergency face-to-face response (FTF Call Resp.); or whether they entail 295 another type of face-to-face response (Other FTF), such as a wellness check.

15

296 Figure-5 demonstrates the State’s capacity to more closely monitor trends on a month-to-month basis. It 297 breaks down the above data for Fiscal Year 2016 and shows the flow of service demand in the northern 298 and southern portions of the State.

299
2000

Figure- 5: MCIS Monthly Activity by County FY16

1750 1500

Number of Calls

1250 1000

750 500

250

0 NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS NC KS

FY14 FY15 Jul-15 Aug-15Sep-15 Oct-15 Nov- Dec-15 Jan-16 Feb-16 Mar- Apr-16 May- Jun-16

Avg Avg

15

16

16

Non SUD Calls FTF Call Resp. SUD Calls Other FTF

300

301 Overall, the State’s Crisis Hotline is functioning well, is integrated with Mobile Crisis and other critical 302 elements of the mental health service structure, and is an important element of the service system 303 addressing the needs of Delawareans who have SPMI.

304 II. Mobile Crisis Services

305

Substantial Compliance.

306 Section III.B of the Agreement relates to Mobile Crisis Service. It includes two elements: 16

307

1. By July 1, 2012 the State will make operational a sufficient number of mobile crisis

308

teams such that a team responds to a person in crisis anywhere in the state within one

309

hour.

310

2. By July 1, 2013 the State will train all state and local law enforcement personnel

311

about the availability and purpose of the mobile crisis teams and on the protocol for

312

calling on the team.

313 The State has been rated as being in Substantial Compliance with the requirements of the Agreement 314 relating to Mobile Crisis since September of 2013. In the two assessments by the Monitor prior to that, 315 it had been rated as being in Partial Compliance because the program was still being phased in.

316 Mobile Crisis is an extremely important service for people with SPMI in that it provides timely face-to317 face interventions by trained mental health professionals and follow-up for individuals who are at very 318 high risk of hospitalization. At its best, it assumes a role that too often used to fall to the police and that 319 tended to result in either transport to a hospital or entry into the criminal justice system. Delaware’s 320 Mobile Crisis program is closely integrated not only with the Crisis Hotline, but also with the Crisis 321 Walk-In Centers and with the Targeted Care Management program. The program has been an essential 322 element of the State’s overall system aimed at resolving mental health crises in ways that promote 323 recovery and avoid unnecessary hospitalizations.

324 As is represented in Figure-6, the State has consistently met the requirements of Section III.B.1 that the 325 Mobile Crisis be able to provide face-to-face interventions statewide within one hour. The State collects 326 its data by calculating the time from when a Crisis Hotline call is completed to the time that the Mobile 327 Crisis team meets with the individual. The average statewide response time is now about 40 minutes.

328

17

Face-to-Face Arrival

Figure-6: Average Face-to-Face Response Time

to Crisis Calls

1:04

FY12 to FY16

0:57

0:56

0:50

0:48

0:43 0:36

0:41

0:39

0:40

0:28

0:21

0:14

0:07

0:00

FY12

FY13

FY14

FY15

FY16

State

Target

329

330 Figure-7 demonstrates the State’s capacity to carefully monitor the flow and timeliness of Mobile Crisis 331 Services on a month-to-month basis and to track the performance of the New Castle and the Kent/Sussex 332 teams in meeting the requirements of the Agreement. Although the State is meeting the one-hour

Figure-7: Average Face-to-Face Response Time to Crisis Calls by County FY16
1:12 0:57 0:43 0:28 0:14 0:00

Face-to-Face Arrival (Hour:Minutes)

NCC

K/S

Overall

Target

18

333 requirement across the board, not surprisingly it takes slightly longer to reach individuals in the southern 334 counties, which have rural roads and seasonal traffic.

335 The Agreement recognizes the importance of Mobile Crisis becoming a resource to, and a part of, other 336 emergency service systems in the State. Accordingly, Section III.B.2 requires that state and local law 337 enforcement be trained in the availability of this service and the protocol for accessing it. Figure-8 338 presents the total number of such trainings from Fiscal Year 2014 through Fiscal Year 2016. During this 339 3-year period, 1,714 individuals were trained in the use of Mobile Crisis and other resources to address 340 mental health emergencies.

Number of Personnel Trained

Figure-8: Number of Court and Law Enforcement Personnel Trained FY14 to FY16

800

700

600

500

400

300

200

100

0

FY14

FY15

FY16

341

342 These trainings range in size from single consultations with rural police departments to trainings for 343 hundreds of participants in New Castle County. In addition to law enforcement, the State’s training 344 relating to Mobile Crisis also includes mental health providers, judges and court staff, paramedics, fire 345 departments, and even representatives from the Department of Natural Resources and Environmental 346 Control (which oversees State parks), and members of the military from the Dover Airforce Base. 347 Figure-9 presents a breakdown of the audiences for these trainings in Fiscal Year 2016.

19

348

Figure-9: FY16 Trainings

By Agency Type

Military, 3 DNREC, 8

DSAMH, 2

Courts - Judges, 30

Fire Departments, 1

Paramedics, 99

Police Departments,
188

Courts - Staff, 127

349

350 III. Crisis Walk-in Centers

351

Substantial Compliance.

352 Section III.C of the Agreement includes provisions relating to Crisis Walk-In Centers:

353

1. In addition to the crisis walk-in center in New Castle County serving the northern region

354

of the State, by July 1, 2012, the State will make best efforts to make operational one

355

crisis walk-in center in Ellendale to serve the southern region of the State. The crisis

356

center in Ellendale shall be operational no later than September 1, 2012.

357

2. By July 1, 2013 the State will train all state and local law enforcement personnel about

358

the availability and purpose of the crisis walk-in centers and on the protocol for referring

359

and transferring individuals to walk-in centers.

360 The State has been found to be in Substantial Compliance with these provisions of the Agreement since 361 September of 2012.

20

362 At the outset of the Agreement, the State had been operating only one Crisis Walk-In Center, which was 363 located in New Castle County. That program, “CAPES,” operated in accordance with a model that has 364 been used for decades nationwide, whereby a part of a general hospital’s emergency department 365 provides mental health assessments and is associated with a small inpatient psychiatric unit. No such 366 service was available in Kent and Sussex Counties. In fulfilling Sections III.C.1, in August of 2012, 367 DSAMH opened a second crisis walk-in center in the city of Ellendale to serve the southern part of the 368 State.
369 This program, called the Recovery Response Center (RRC), differed significantly from the CAPES 370 hospital-based model. While similarly staffed with mental health professionals, the RRC also has a 371 heavy emphasis on employing trained mental health peers—that is, individuals who themselves have 372 lived experience with serious mental illness and, often, psychiatric hospitalizations and other traumatic 373 events that are common among the members of the target population. Furthermore, unlike operations 374 typical within hospital settings, the RRC follows what is called the “living room model,” which offers a 375 relaxing environment (with sofas and recliners, rather than gurneys) and, while not foregoing clinical 376 diagnoses and treatment, encourages individuals to tell their own stories about what is happening to 377 them. The RRC is intended to promote individuals’ recovery plans and to avert hospital admissions 378 whenever possible. It does not have an inpatient unit. With a capacity for 10 individuals, people can 379 stay at the RRC up to 23 hours and, if hospitalization is not required, they can return home or go to 380 another integrated crisis program (such as Crisis Apartments, discussed later).
381 The RRC provides DSAMH with detailed monthly statistics that allow tracking of its utilization and 382 outcomes. The program has performed impressively—so much so, that the State decided to replace its 383 New Castle Crisis Walk-In Center (CAPES) with a Recovery Resource Center to serve the northern part 384 of the State. After significant construction-related delays, the new RRC opened in the city of Newark in 385 July, 2016, and has a capacity to serve up to 16 individuals at a time.
386 Figure-10 presents the rates of diversion from hospitalization of people served through the Ellendale 387 RRC11 and the statewide Mobile Crisis program. It includes annual averages for Fiscal Years 2014 and 388 2015, and monthly data for Fiscal Year 2016. Diversion rates for Mobile Crisis have been consistently
11 The Newark RRC has not been operating long enough to produce meaningful data.
21

Rate of Diversion from Hospitalization

Figure-10: Ellendale RRC and MCIS Hospital

Diversion Rate

FY2014 -2016
100%

86.8%

90%

90.4%

80%

70% 78.7%

60%

74.5%

50%

40%

30%

% Diverted (RRC)

% Diverted (MCIS)

389

390 very high, tending to be in the high 80% to low 90% range. Diversion rates from the Ellendale RRC 391 have tended to be in the mid- to high-70% range, but have been dropping significantly during the 2016 392 Fiscal Year, an outcome that the State and the provider are now carefully examining. The availability 393 of performance data has not only allowed the State and the provider to become aware of changes in the 394 program’s diversion rate, but will also enable them to track the impact of corrective actions that are now 395 underway.

396 Mobile Crisis and Crisis Walk-In Center Services are available to anyone, regardless of whether they 397 have commercial insurance, are covered by Medicaid, or have no insurance and are funded via DSAMH. 398 The State’s Medicaid program covers services provided at its Crisis Walk-In Centers and the RRC is in 399 the process of becoming approved for such reimbursement. Figure-11 presents the State’s tracking of 400 the Medicaid status of individuals being served at the RRC. Although trending lower this fiscal year, 401 about 45-46% of individuals served in the past two fiscal years have been covered by Medicaid. Over 402 50% of people seen in those years have either commercial insurance or are uninsured, and this group is 403 increasing in Fiscal Year 2016.

22

Percent of Clients Served

Figure-11: RRC Clients Served by Funding Source FY16
80%

70%

53.7%

54.9% 60%

50%

40% 45.1%

30%

46.3%

20%

% Medicaid

% Non-Medicaid

404

405 The RRC maintains detailed data about service utilization. Table-4 provides an example of some of the 406 data it captures, presenting the source of referrals received during June, 2016. The overwhelming 407 number of referrals—74.2% —come from general hospital emergency rooms, a finding that is consistent 408 with the UPenn data presented earlier. Ideally, individuals in mental health crises would come directly

409

Table-4: Referral Sources Ellendale RRC June, 2016

Referral Source General Hospital Emergency Room Law Enforcement Self or no referral Mobile Crisis Team Emergency Medical Services (EMS) Outpatient community mental health provider Family/friend Case Management (not Recovery Innovations) Residential Facility (less than 24 hour)
Total:

Count 121 14 10 8 3 3 2 1 1 163

Percent 74.2% 8.6% 6.1% 4.9% 1.8% 1.8% 1.2% 0.6% 0.6%

23

410 to a Crisis Walk-In Center and would not go to a hospital emergency department. On the one hand, this 411 is a positive finding important because direct transfers from hospital emergency rooms to IMDs—where 412 stays are lengthier and considerably more expensive—used to be the norm and there had been little 413 opportunity for diversion from psychiatric hospitalization. The State is encouraging direct utilization of 414 the Crisis Walk-In Centers by emergency responders (e.g., via the trainings referenced above). Again, 415 its access to data such as this (and Figure-3, which shows increasing emergency room use by the target 416 population) enables the State to monitor the impact of these trainings and other efforts to reduce 417 unnecessary use of hospital emergency departments for individuals in mental health crises.
418 As has been discussed in prior Monitor reports, the State has taken important measures to differentiate 419 evaluations occurring pursuant to 24-hour mental health holds (a part of the civil commitment process) 420 from actual hospital admission and treatment. The RRC reported that in the month of June, 2016, 119 421 (about 66% of those referred) were on such involuntary status when they came to the program. The RRC 422 carried out this function outside of a hospital where, as was noted in past Monitor reports, inpatient 423 admission has been a virtual certainty. 50.4% of these individuals were ultimately hospitalized 424 involuntarily in June, 2016 (as presented in Figure-10, the diversion rate has historically been higher, 425 and the hospitalization rate has been lower). RRC’s data submission does not clearly show how many— 426 if any—of the remaining individuals were hospitalized on a voluntary basis. As this practice continues 427 in southern Delaware and becomes routine in the new northern Delaware RRC, it may show a 428 significant impact in reducing hospital use by people with SPMI.
429 The RRC maintains data relating to 30-day recidivism to its program. The rate reported in June, 2016 430 was 11.46% (18 readmissions).
431 Without question, the Ellendale RRC has become a significant resource to Kent and Sussex Counties 432 and, as its “living room” model becomes operational statewide12 with the recently opened New Castle 433 County program, Delaware will have access to important data about the impact of this model—both 434 from the quantitative perspective of reducing hospital use by people with SPMI, and also qualitatively in 435 terms of its non-traumatizing, recovery-oriented focus. Such information can drive further
12 While living room model walk-in centers exist in some other localities in other states, Delaware is apparently the first state where this service is statewide.
24

436 programmatic and systemic refinements and should be incorporated into the State’s ongoing Quality 437 Assurance/Performance Improvement efforts.

438

439 IV. Crisis Stabilization Services

440

Substantial Compliance.

441 Section III.D of the Agreement includes targets with respect to Crisis Stabilization Services:

442

1. By July 1, 2012 the State will ensure that an intensive services provider meets with every

443

individual receiving acute inpatient crisis stabilization services within 24 hours of

444

admission in order to facilitate return to the community with the necessary supports and

445

that all transition planning is completed in accordance with Section IV.

446

2. By July 1, 2013 the State will train all provider staff and law enforcement personnel to

447

bring people experiencing mental health crises to crisis walk-in centers for assessment,

448

rather than to local emergency rooms or IMDs.

449

3. By July 1, 2014 the number of annual State-funded patient days in acute inpatient settings

450

in the State will be reduced by 30% from the State's baseline on the Effective Date of the

451

Settlement Agreement as determined by the Monitor and the Parties.

452

4. By July 1, 2016 the number of annual State-funded patient days in acute inpatient settings

453

in the State will be reduced by 50% from the State's baseline on the Effective Date of the

454

Settlement Agreement as determined by the Monitor and the Parties.

455 The Agreement defines Crisis Stabilization Services as acute inpatient psychiatric care lasting 14 days or 456 fewer that is directed towards resolving mental health crises and preventing long-term psychiatric 457 hospitalization. The State faced significant procedural and administrative obstacles in coming into 458 compliance with the Crisis Stabilization and acute bed use provisions. In response, the parties 459 negotiated revised measures with respect to the targets for reductions in inpatient bed days (Sections

25

460 III.D.3-4). Delaware has made significant improvements, particularly over the past year, and in the 461 May, 2015, Monitor’s report, it was rated as “Moving Towards Substantial Compliance”—as is 462 explained later, mostly because revised measurement strategies that were agreed to by the parties were 463 not yet sufficiently in place. At this time, the State has made progress to the point that it can now be 464 rated as being in Substantial Compliance with the Agreement’s Crisis Stabilization requirements.
465 A. Community Provider Involvement
466 Section III.D.1 requires that by July 1, 2012, an “intensive services provider” meet with an individual 467 within 24 hours of admission to a psychiatric hospital in order to facilitate a timely return to the 468 community. Section II.D.2 defines “intensive support services” as Assertive Community Treatment 469 (ACT), Intensive Case Management (ICM), and Case Management (which the State refers to as 470 Targeted Care Management, or “TCM”). To briefly summarize the course of implementing this 471 provision, early on the State required that service providers operating under contract with DSAMH (i.e., 472 the programs providing ACT, ICM, and TCM) meet with individuals whom they were serving and that 473 TCM be available to meet with newly referred individuals, both at DPC and in the IMDs. One problem 474 was that, particularly in the IMDs, very large numbers of individuals who were diagnosed with SPMI 475 upon admission and were covered by Medicaid (and were therefore, putative members of the target 476 population) did not have intensive service providers affiliated with them and, furthermore, might not be 477 determined upon discharge to have SPMI.13 Ultimately this issue was resolved when the State adopted 478 specific triggers for referring individuals for intensive support services.14
479 In addition, in evaluating the impact of involvement by community providers, the State recommended 480 that for hospitalized individuals who were already receiving community services, far more urgent than 481 contact with a case manager from an intensive support service provider was communication between the 482 community psychiatrist and the hospital psychiatrist (which could take place via telephone). 483 Accordingly, DSAMH required that such communications occur and they were adopted as a part of 484 measuring compliance with III.D.1. Figure-12 presents data on the statewide averages for timeliness of 485 community provider consultations—including doctor-to-doctor communications—when an individual is
13 This was not the case with people already being served by DSAMH, who had well-established SPMI diagnoses. 14 This is discussed later in the section “Provisions Relating to Reductions in Acute Care Bed Days,” specifically the subsection “Engagement in Community Services.”
26

486 hospitalized. Incorporating clearer processes for addressing individuals who do not have community 487 providers (e.g., applying triggers for referral to specialized services) and doctor-to-doctor consultations, 488 the State has not only improved the quality of these contacts, but it has dramatically improved their 489 timeliness.

490

Figure-12: Average Provider Response Time

to Inpatient Hospitalization

3.5

FY14 to FY16

3.30

3.0

Days following Admission

2.5

2.0 1.61
1.5 1.28
1.0

0.5

0.0

FY14

FY15

FY16

Target

State

491

492 The State’s data system allows it to analyze differences in the timeliness of provider involvement at each 493 of the IMDs and at DPC, which can reflect not only the responsiveness of the community providers, but 494 also the diligence of hospital staff in seeking their consultation. Figure-13 presents these data. Most 495 significantly, consultations tend to be less timely at Dover Behavioral Health, which serves the southern 496 counties. The State is closely monitoring the issue and has tentatively determined that at least a part of 497 this trend reflects the fact that there are far fewer community psychiatrists in Southern Delaware, and 498 their availability for consultation may be more limited than in other parts of the state. In any event, as is 499 reflected in Figure-12, the trajectory for the State’s overall compliance with the requirements of III.D.1 500 is favorable to the point that it can be considered to be in Substantial Compliance with this provision.

27

Days following Admission

Figure-13: Average Provider Response Time to Hospitalization by Facility FY16
5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0

DPC

Dover

MeadowWood

Rockford

Total

501

502

503 B. Stakeholder Training

504 Section III.D.2 requires that the State train providers and law enforcement staff in the utilization of the 505 Crisis Walk-In Centers for assessment. Its compliance with this provision is incorporated in training 506 that occurs pursuant to Section III.B.2, which was discussed above. The State is in Substantial 507 Compliance with provision III.D.2.

508

509 C. Provisions Relating to Reductions in Acute Care Bed Days-

510 Sections III.D.3-4 of the Agreement require reductions in the number of inpatient bed-days used by the 511 target population and paid for in whole or part with State funds. These provisions are important; their 512 essential intent was to measure the collective impact of the array of community services and reforms 513 resulting from the State’s efforts to meet its Olmstead obligations to people with SPMI in not only 514 diverting them from unnecessary hospital admissions, but also averting crises that put them at risk of

28

515 institutionalization. In other words, the rationale was that if the State systems serving people with SPMI 516 were working in accordance with the Agreement, greater numbers of these individuals would be living 517 stably within the community and the demand for acute care would drop accordingly. For a number of 518 reasons, the State has not been able to achieve this goal, at least when measured in terms of the criteria 519 contained in Sections III.D.3-4. Previous Monitor reports covering the past five years have described in 520 detail the various factors and developments that have affected the State’s failure to meet the targets 521 contained in the Agreement, as originally constructed. The most significant among them are 522 summarized as follows:

523

 For most of the Agreement’s implementation period, responsibility for oversight and monitoring

524

psychiatric hospitalizations of the target population was convoluted and diffuse, spread across

525

DSAMH, DMMA, and the MCOs. The State had shown progress in reducing acute

526

hospitalizations among individuals receiving specialized mental health services via DSAMH and

527

when DSAMH managed their inpatient care. In general, however, bed-days relating to acute

528

psychiatric hospitalizations among individuals diagnosed with SPMI whose care had been

529

managed through DMMA and the MCOs tended to increase, rather than decrease.

530

 PROMISE not only expanded Medicaid coverage for community services critical to the target

531

population, but also entailed collaborative agreements and new processes intended to address

532

gaps and inefficiencies that had affected hospital use by the target population. While the State

533

has been moving aggressively to implement PROMISE since it was authorized by the federal

534

Centers for Medicare and Medicaid Services, this is a complex initiative and the full array of

535

covered services is not yet fully available. As such, while it is very likely that PROMISE—once

536

fully operational—can and will reduce psychiatric hospital use by the target population (and

537

have other important benefits relating to Olmstead compliance, as well), realistically it will be

538

some time before its impact is demonstrated in hospital bed-use decreases.

539

 Multiple informants from several stakeholder groups (including providers and MCOs, and also

540

substantiated by the Monitor’s clinical record reviews) have suggested that, due to limited

541

information at the time of an individual’s hospital admission or perceptions by IMD providers

542

that authorization for Medicaid reimbursement would be more certain, individuals who likely did

543

not have SPMI when entering the IMDs were nevertheless given SPMI diagnoses. Accordingly,

29

544

perhaps a significant number of individuals who were hospitalized, so diagnosed, and included

545

on the TPPL, have inflated the true numbers of hospital bed-days affecting the population to

546

which the Agreement is actually directed.

547

 The number of individuals prone to such misdiagnosis increased due to an epidemic of substance

548

use in Delaware (and elsewhere). In addition, perceptions about Medicaid coverage and

549

reimbursement rates for substance use treatment, and a shortage of substance use treatment beds

550

further contributed to a climate whereby individuals were questionably diagnosed with SPMI,

551

psychiatrically hospitalized, and counted with respect to Sections III.D.3-4 compliance.

552 In light of these and other factors, it became clear to the Monitor and the parties that, notwithstanding 553 the State’s success in meeting—and, in some instances, surpassing the requirements of the Agreement 554 with regard to developing comprehensive community services, as well as its efforts (e.g., via PROMISE) 555 to address some of the structural issues affecting hospital bed use by the target population, realistically it 556 would not be able to meet the targets contained in Sections III.D.3-4 any time soon. Accordingly, the 557 Monitor, DOJ and the State held a series of discussions to explore how—without compromising the 558 underlying intent of the Agreement’s bed-day measurements—alternative approaches might be 559 established to document the State’s efforts to reduce psychiatric hospital bed use by people with SPMI. 560 In February, 2016, the parties agreed that the State’s compliance with Sections III.D.3-4 would be 561 evaluated not only with regard to acute hospital bed-day counts, but also with regard to a comprehensive 562 set of additional measures reflecting hospital use, hospital diversion activities, and measures to address 563 critical risk factors.

564 The State is in Substantial Compliance with Sections III.D.3-4, based upon this expanded set of 565 measures. Because they are now incorporated in the State’s Quality Assurance and Performance 566 Improvement (QA/PI) program, detailed discussion of the State’s findings and actions relating to the 567 revised set of measures is presented in the QA/PI section of this report (Section XIII).

568

30

569 V. Crisis Apartments

570

Substantial Compliance.

571 Section III.E of the Agreement includes provisions relating to crisis apartments:

572

1. By July 1, 2012 the State will make operational two crisis apartments. 15

573

2. By July 1, 2013 the State will make operational a minimum of two additional crisis

574

apartments, ensuring that the four apartments total are spread throughout the State.

575 Crisis apartments are an important community alternative for individuals with SPMI who are at risk of 576 hospitalization. They are staffed by trained mental health peers; clinical and other services are provided 577 by ACT teams, TCM, and other providers. The State has been found to be in Substantial Compliance 578 with the Agreement’s requirements relating to Crisis Apartments since September, 2012, and it remains 579 so today. In fact, it has consistently—and significantly—exceeded the targets contained in the 580 Agreement. In Fiscal Year 2016, the State operated in 7 Crisis Apartment units, which exceeds the 581 requirements of Section III.E.2 by 75%. As is represented in Figure-14, in Fiscal Year 2016, DSAMH’s

Crisis Apartment Beds

Figure-14: Number of Crisis Apartment Beds FY12 to FY16
25

20

15

10

5

0

FY12

FY13

FY14

FY15

FY16

15 The Agreement does not define the number of beds required in each Crisis Apartment, nor does it include a standard for occupancy rates.
31

582 Crisis Apartment program has 21 beds available statewide. The program includes Restart Respite 583 Apartments, which are operated by Recovery Innovations (the provider that also operates the RRC 584 Crisis Walk-In Centers), with locations in both the northern and southern parts of the state. It also 585 includes 4 beds that are affiliated with the CRISP program (discussed in the section relating to Assertive 586 Community Treatment) and 9 beds associated with the Targeted Care Management program.
587 The Agreement contemplates that individuals will stay in Crisis Apartments for up to seven days, but in 588 practice many people utilizing these beds have unstable housing; they remain longer than that as 589 permanent living arrangements are put into place.
590 The State has been monitoring utilization of Crisis Apartment beds because they represented a new 591 resource for the system and it was unclear what the demand and needed capacity would be. Initially, the 592 Crisis Apartments had significant vacancy rates, but the State took measures to better integrate the 593 program with its community service structure—for instance, notifying Mobile Crisis Teams of bed 594 availability—and utilization has been trending upward. Figure-15 presents the State’s detailed trending 595 of bed utilization by program, with annual averages for Fiscal Years 2014 and 2015, and monthly 596 trending for Fiscal Year 2016. CRISP and TCM Crisis Apartments were not counted until 2015.
597 In summary, the State has exceeded the requirements of the Agreement with respect to Crisis 598 Apartments. The program is well integrated with its larger crisis system (e.g., Mobile Crisis and the 599 Crisis Walk-In Centers), and the beds affiliated with Targeted Care Management allow ready access for 600 individuals who are just becoming linked to specialized mental health services and who may be living in
601 very unstable living environments. It is monitoring this program and its relationship to other services to 602 ensure that it is being appropriately utilized and that capacities align with service needs. The program is 603 in Substantial Compliance with Section III.E.
32

Occupancy Rates

Figure-15: Occupancy Rates in Crisis Apartments

2014-FY16
100%

90%

80% 60.22% 70%

60%

50%

53.58%

40% 30% 47.48%

20%

10%

0%

% Total Used (NCC)

% Total Used (K/S)

Combined % Bed Days Used

% Total Used (CRISP)

% Total Used (TCM)

604

Note- There is a disjuncture in reporting of CRISP bed use in December, 2015

605

606 VI. Assertive Community Treatment & Intensive Case Management

607

Substantial Compliance.

608 Assertive Community Treatment (ACT) and Intensive Case Management (ICM) are among the elements 609 of the Intensive Support Services that are defined in Section II.D of the Agreement. Sections III.F and 610 III.G lay out specific targets in terms of the number of teams required for ACT and ICM, respectively.

611

Section III.F

612

1. By July 1, 2012 the State will expand its 8 ACT teams to bring them into fidelity with

613

the Dartmouth model.

614

2. By September 1, 2013 the State will add 1 additional ACT team that is in fidelity with

615

the Dartmouth model.

33

616

3. By September 1, 2014 the State will add 1 additional ACT team that is in fidelity with

617

the Dartmouth model.

618

4. By September 1, 2015 the State will add 1 additional ACT team that is in fidelity with

619

the Dartmouth model.

620

Section III.G

621

1. By July 1, 2012 the State will develop and begin to utilize 3 ICM teams.

622

2. By January 1, 2013 the State will develop and begin to utilize 1 additional ICM team.

623 The State has been in Substantial Compliance with both ACT and ICM requirements consistently since 624 September, 2012. As has been discussed in prior Monitor reports, though, some modifications of these 625 provisions have been proposed and agreed to by the parties. First of all, early on the State requested that 626 in place of the Dartmouth fidelity standards, the Tool for Measurement of Assertive Community 627 Treatment (TMACT) be used because it more closely aligns with the recovery orientation that DSAMH 628 is promoting in its programs. TMACT fidelity monitoring has taken place throughout the 629 implementation period.

630 Secondly, the State has met and sometimes surpassed the requirements of the Agreement with respect to 631 ACT, but it has also found that ICM—which is a less intensively staffed level of service—was not 632 always meeting the needs of the individuals actually assigned to the program. Accordingly, with 633 agreement by the Monitor and DOJ, it upgraded some of its ICM teams to ACT levels, essentially 634 providing services to some of the ICM population at an intensity beyond what Section III.G requires. It 635 has since made further adjustments—to higher and lower levels of service—based upon the assessed 636 needs of individuals being served.

637 Finally, although not required by the Agreement, in 2012 the State initiated the CRISP program 638 (Community Reintegration Support Project), which was directed at individuals with levels of need 639 beyond what was available through ACT. Many such individuals were clinically stable, but remained in 640 DPC because no program could provide the needed services. CRISP programs are reimbursed on a 641 capitated basis, which allows providers to use funds innovatively to meet the needs of the people served, 642 including clinical and other services, rental costs, transportation, and other expenses. CRISP programs

34

643 are also liable for inpatient psychiatric expenses, and are thus incentivized to create alternatives (such as 644 the CRISP Crisis Apartments). They operate similarly to ACT programs and are an important part of 645 DSAMH’s service array.

646 In summary, ACT, ICM, and CRISP are all intensive programs that are directed at individuals who have 647 SPMI and the highest levels of disability. These programs provide mobile, out-of-office services and 648 are available on a 24-hour basis. Each of them enables members of the target population to live in 649 ordinary housing and to pursue mainstream employment. Sections III.F and III.G differentiate ACT 650 from ICM; they do not address CRISP even though it entails similar levels of service. Furthermore, the 651 shifts between ACT and ICM and the additional resources that the State has dedicated to these intensive 652 services have made it extraordinarily complicated to reconcile the services being provided with the 653 Agreement’s numerical targets. For all of these reasons, and with agreement by the parties, the 654 evaluation of compliance with Sections III.G and III.F is being consolidated and CRISP services are 655 being incorporated in consideration of the State’s fulfillment of these provisions’ requirements.

656 Figure-16 presents the number and configuration of ACT, ICM, and CRISP teams from Fiscal Year 657 2012 through Fiscal Year 2016. For comparison, it also includes the number of intensive service teams 658 (called CCCP) that were operating in Fiscal Year 2011, at the outset of implementation. The dashed line

Treatment Teams

Figure-16: Number of CCCP, ACT, ICM, and CRISP Teams FY11 to FY16
20

15

10

5

0

FY11

FY12

FY13

FY14

FY15

FY16

n of CCCP Teams n of CRISP Teams

n of ACT Teams Target (ACT/ICM)

n of ICM Teams

659 35

660 labelled as “Target” indicates the combined number of treatment teams per sections III.F and III.G that 661 were required for each year the Agreement has been in effect. As is reflected in this Figure, the State 662 has consistently exceeded the Agreement’s requirements. In Fiscal Year 2016, it had operational 15 663 ACT teams, 2 ICM teams, and 2 CRISP teams.16
664 ACT services have been heavily utilized and vacancies are relatively rare. The State monitors the 665 number of clients served by teams in the three counties, as is presented in Figure-17. Teams are 666 designed to serve approximately 100 individuals, although in Sussex County the State has configured 667 teams to serve fewer individuals to accommodate the realities of travel for out-of-office services in that 668 rural area.

Figure-17: Average Number of Individuals Served by ACT Team by County FY 14-16
Overall

Sussex Clients/Team

Kent Clients/Team

NCC Clients/Team 0

20 FY16 Avg

40

60

80

Individuals Served

FY15 Avg FY14 Avg

100

120

669

670 In Fiscal Year 2016, the State operated two ICM teams, a team in Sussex County serving on average 177 671 individuals and a team in New Castle County that is building in size; during the year, it averaged 90 672 clients, but in June, 2016 it had increased to 134 clients.

16 The CRISP teams had been operated by two providers, but they have since been consolidated under one provider, serving the same number of individuals.
36

673 In terms of the fidelity of ACT teams to program standards, the State conducts preliminary evaluations 674 of new teams; these are not scored, but are intended to assist them in developing proficiency in the 675 service model. Thereafter, teams are evaluated and scored on TMACT at least annually. As indicated, 676 they establish corrective action plans which are monitored by the DSAMH and may entail outside 677 consultation and training. During the period the Agreement has been in effect, there have been some 678 circumstances in which the State determined that an ACT team was not appropriately meeting fidelity 679 standards, even with corrective actions. In these instances, DSAMH closed the team and transferred 680 responsibility to another provider. While this is unfortunate, it does reflect the State’s seriousness in 681 ensuring quality and using data to drive decision-making.
682 Figure-18 presents TMACT scores for the State’s ACT teams from Fiscal Year 2014 through 2016. In 683 some instances, reviews are not reported for Fiscal Year 2016 because they were still in process at the 684 time of the State’s final data submission for this report. In addition to the TMACT fidelity measures, 685 which focus heavily on the mechanics of ACT teams, DSAMH also carries out extensive outcome 686 measures of its ACT and ICM programs. These measures are a part of the State’s Quality Assurance 687 and Performance Improvement program, which is discussed later in this report, but they are included in 688 this section because they are elements of DSAMH’s performance monitoring of its ACT and ICM 689 teams.
690 Figures 19 to 31, which follow, will not be discussed in terms of their specific implications, but they are 691 presented here as evidence of the scope of the State’s efforts to assure that these critically important 692 services are producing outcomes that are consistent with the requirements of the Agreement and 693 Olmstead. It is notable that one provider (NHS) not only performed poorly in terms of fidelity 694 measures, but as is evident in the following figures, also tended to score high on negative performance 695 indicators (e.g., homelessness) and low on positive indicators (e.g., employment). Based upon these 696 data, the State ended that program.
697
698
37

Figure-18: ACT Team TMACT Fidelity Scores FY14 to FY16

RHD ACT NCC - Recover

RHD ACT I Kent

RHD ACT 2 Kent-Enrichment

RHD ACT 1 NCC

PROGRAM DISCONTINUED

RHD ACT 1 Kent

NHS ACT 3 NCC NHS ACT 1 NCC HH ACT Vision

PROGRAM DISCONTINUED PROGRAM DISCONTINUED

HH ACT Pathways

HH ACT Navigator

HH ACT Hope

HH ACT Alliance

Conn. ACT III NCC

Conn. ACT II NCC

Conn. ACT I NCC

Conn. ACT I Dover

0.00

1.00

2.00

3.00

4.00

5.00

TMACT Total Score

FY14 FY15 FY16

699

38

Figure-19: ACT/ICM Providers Average homeless for any night during the month

4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0%

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

700

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Conn 0.75% 0.24% 0.00% 0.22% 0.22% 0.20% 0.21% 0.00% 0.21% 0.20% 0.00% 0.20% HH 2.18% 1.58% 1.78% 2.44% 2.23% 1.85% 2.05% 1.86% 2.16% 1.63% 2.53% 1.89% RHD 0.76% 1.01% 2.18% 2.07% 1.55% 1.04% 1.33% 1.79% 2.84% 2.05% 2.25% 2.11% NHS 2.26% 3.65% 4.22% 4.23%
17

Figure-20: ACT/ICM Providers Average Consumers who spent at least one night in a motel
during the month

5.0%

4.0%

3.0%

2.0%

1.0%

701

0.0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

Jul-15 Conn 0.89% HH 0.82% RHD 0.51% NHS 4.57%

Aug-15 1.45% 0.78% 1.01% 3.65%

Sep-15 1.02% 0.79% 0.65% 4.22%

Oct-15 1.45% 2.07% 0.78% 4.23%

Nov-15 Dec-15 1.25% 1.62% 1.19% 1.61% 0.78% 0.00%

Jan-16 1.20% 1.85% 1.05%

Feb-16 Mar-16 Apr-16 May-16 1.00% 0.60% 0.61% 0.20% 2.04% 1.81% 1.98% 2.02% 0.51% 2.04% 0.76% 0.89%

Jun-16 1.37% 0.83% 1.63%

17 In this, and in the following 12 charts, NHS data is presented through October, 2015, at which point the program was discontinued and clients were transferred to other providers.
39

Figure-21: ACT/ICM Providers Average of Consumers arrested

702

3.5%

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16May-16 Jun-16

Conn HH RHD NHS

Jul-15 1.28% 1.04% 1.42% 0.88%

Aug-15 0.43% 3.10% 0.51% 1.83%

Sep-15 0.82% 0.90% 0.26% 0.00%

Oct-15 0.65% 1.51% 0.00% 1.39%

Nov-15 0.20% 0.69% 0.54%

Dec-15 1.43% 0.70% 0.26%

Jan-16 0.80% 0.34% 0.40%

Feb-16 0.80% 0.85% 0.25%

Mar-16 1.00% 0.36% 0.00%

Apr-16 May-16 0.40% 0.79% 0.68% 1.65% 0.74% 0.63%

Jun-16 0.39% 1.64% 0.64%

Figure-22: ACT/ICM Providers Average of Consumers hospitalized in Psychiatric Hospital
35%

30%

25%

20%

15%

10%

5%

0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16May-16 Jun-16

703

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Conn 3.39% 1.85% 2.92% 2.69% 2.06% 3.04% 2.40% 2.56% 2.97% 2.75% 3.17% 2.57% HH 13.21% 14.13% 13.08% 31.91% 25.79% 27.64% 18.59% 7.74% 4.74% 23.70% 28.17% 22.36% RHD 2.83% 3.20% 4.42% 4.08% 4.05% 1.83% 1.71% 4.72% 2.94% 4.89% 4.78% 3.09% NHS 3.69% 5.46% 4.70% 6.14%

40

Figure-23: ACT/ICM Providers Average number of Psychiatric Hospital Patient Days per
month:

30

25

20

15

10

5

0 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

704

Conn HH RHD NHS

Jul-15 9.41 8.92 14.03 3.08

Aug-15 16.90 12.63 8.57 5.17

Sep-15 7.62 11.66 10.06 5.00

Oct-15 6.93 13.21 8.96 12.02

Nov-15 8.30 20.53 11.19

Dec-15 6.20 22.19 9.54

Jan-16 6.50 26.52 10.58

Feb-16 8.50 19.79 9.24

Mar-16 6.00 6.56 7.25

Apr-16 8.68 22.50 11.17

May-16 8.09 20.88 8.33

Jun-16 7.67 12.84 14.13

Figure-24: ACT/ICM Providers Average of Emergency Department Visits
6%

5%

4%

3%

2%

1%

0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

705

Conn HH RHD NHS

Jul-15 4.57% 2.16% 1.17% 0.91%

Aug-15 2.67% 2.33% 2.79% 4.12%

Sep-15 2.29% 3.18% 2.48% 4.70%

Oct-15 2.04% 2.76% 3.50% 1.41%

Nov-15 Dec-15 1.84% 2.60% 2.14% 2.56% 3.73% 3.10%

Jan-16 1.60% 1.69% 4.39%

Feb-16 Mar-16 Apr-16 May-16 Jun-16 1.99% 1.99% 2.38% 1.77% 1.38% 1.00% 1.45% 1.72% 1.84% 1.83% 3.47% 2.42% 5.20% 2.15% 2.75%

41

Figure-25: ACT/ICM Providers Average Consumers admitted to a general hospital

7%

6%

5%

4%

3%

2%

1%

0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

706

Conn HH RHD NHS

Jul-15 0.58% 1.15% 0.78% 0.00%

Aug-15 0.82% 1.31% 1.02% 6.46%

Sep-15 0.86% 1.92% 1.57% 0.93%

Oct-15 0.42% 1.53% 1.71% 0.95%

Nov-15 0.80% 0.86% 1.42%

Dec-15 2.41% 0.87% 2.32%

Jan-16 0.81% 0.85% 2.01%

Feb-16 0.97% 0.53% 1.40%

Mar-16 1.59% 1.29% 0.65%

Apr-16 May-16 Jun-16 1.20% 1.38% 1.18% 1.38% 1.05% 0.67% 2.10% 2.36% 0.64%

Figure-26: ACT/ICM Providers Average Consumers unemployed for any period during the
month

90% 80% 70% 60% 50% 40% 30% 20% 10%
0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

707

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Conn 71.53% 69.96% 70.22% 70.46% 69.17% 67.62% 67.15% 64.92% 63.43% 61.69% 60.60% 60.85% HH 73.30% 58.90% 73.30% 71.09% 72.96% 72.89% 73.44% 61.71% 62.60% 62.28% 62.59% 62.02% RHD 45.23% 45.22% 45.39% 45.63% 44.85% 45.26% 44.70% 46.40% 68.05% 67.88% 67.17% 66.31% NHS 76.61% 76.99% 78.42% 78.82%

42

Figure-27: ACT/ICM Providers Average Consumers competitively employed <10
hrs./week:
25%

20%

15%

10%

5%

708

0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

Conn HH RHD NHS

Jul-15 5.39% 3.44% 1.32% 1.82%

Aug-15 5.75% 19.78% 1.53% 1.83%

Sep-15 5.65% 7.11% 1.56% 1.86%

Oct-15 5.88% 6.84% 1.59% 1.87%

Nov-15 Dec-15 6.05% 6.71% 6.11% 5.24% 1.59% 1.58%

Jan-16 6.66% 5.82% 1.56%

Feb-16 Mar-16 6.30% 6.67% 5.59% 3.36% 1.26% 1.02%

Apr-16 May-16 7.64% 8.45% 3.13% 3.28% 1.26% 1.47%

Jun-16 8.32% 3.49% 1.24%

Figure-28: ACT/ICM Providers Average Consumers competitively employed 10-20
hrs./week

12%

10%

8%

6%

4%

2%

709

0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

Conn HH RHD NHS

Jul-15 6.52% 3.94% 5.49% 2.70%

Aug-15 Sep-15 6.86% 6.91% 6.84% 6.41% 5.67% 5.75% 2.72% 2.77%

Oct-15 Nov-15 Dec-15 7.14% 7.09% 6.52% 5.96% 3.61% 7.73% 6.04% 6.59% 6.65% 2.79%

Jan-16 7.08% 6.13% 6.40%

Feb-16 Mar-16 Apr-16 May-16 Jun-16 9.31% 10.12% 10.54% 10.59% 10.11% 8.46% 4.24% 5.33% 5.11% 9.20% 5.82% 6.36% 6.83% 7.00% 7.14%

43

Figure-29: ACT/ICM Providers Average of Consumers competitively employed 20+
hrs./week

14%

12%

10%

8%

6%

4%

2%

0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

710

Conn HH RHD NHS

Jul-15 6.22% 5.55% 4.68% 3.69%

Aug-15 6.40% 8.35% 4.70% 3.70%

Sep-15 6.86% 8.60% 4.78% 3.77%

Oct-15 6.70% 8.08% 4.81% 3.77%

Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 6.66% 6.34% 6.50% 7.02% 7.02% 7.23% 7.48% 8.51% 5.97% 10.49% 11.53% 8.02% 6.86% 6.03% 5.97% 9.32% 5.06% 4.82% 4.97% 4.63% 4.88% 5.21% 4.95% 4.67%

Figure-30: ACT/ICM Providers Percentage of Consumers on an Outpatient Commitment
during the month

711

7%

6%

5%

4%

3%

2%

1%

0% Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

Conn HH RHD NHS

Jul-15 1.22% 2.89% 1.03% 4.16%

Aug-15 1.22% 2.41% 0.77% 3.68%

Sep-15 1.63% 2.65% 0.78% 6.60%

Oct-15 1.46% 2.79% 0.54% 5.25%

Nov-15 Dec-15 1.42% 1.60% 2.55% 2.53% 0.53% 0.53%

Jan-16 1.01% 1.99% 0.52%

Feb-16 Mar-16 1.02% 0.81% 1.81% 1.68% 0.76% 0.76%

Apr-16 May-16 0.80% 0.80% 1.41% 1.24% 0.98% 0.97%

Jun-16 0.59% 0.87% 0.50%

44

712

Figure-31: ACT/ICM Providers Percentage of Services provided in the community
(outside the provider's offices)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16

713

Conn HH RHD NHS

Jul-15 83% 56% 59% 79%

Aug-15 85% 58% 58% 80%

Sep-15 85% 58% 59% 76%

Oct-15 84% 57% 60% 80%

Nov-15 86% 54% 61%

Dec-15 85% 50% 60%

Jan-16 85% 51% 63%

Feb-16 83% 55% 63%

Mar-16 83% 56% 66%

Apr-16 84% 53% 67%

May-16 83% 52% 65%

Jun-16 85% 50% 67%

714 In summary, the State’s ACT, ICM, and CRISP programs are important elements of the community 715 service system that enables people with SPM to live in and participate in their communities. In the 716 aggregate, the State is exceeding the Agreement’s requirements for the number of such teams and it has 717 in place rigorous and comprehensive systems to monitor and improve performance. It remains in 718 Substantial Compliance with relevant provisions of the Agreement.

719

720 VII. Case Management

721

Substantial Compliance.

722 Section III.H of the Agreement sets requirements of case management services, which the State refers to 723 as Targeted Care Management (TCM).

45

724

1. By July 1, 2012 the State will train and begin to utilize 15 case managers.

725

2. By September 1, 2013 the State will train and begin to utilize 3 additional case managers.

726

3. By September 1, 2014 the State will train and begin to utilize 3 additional case managers.

727

4. By September 1, 2015 the State will train and begin to utilize 4 additional case managers.

728 The State has been in Substantial Compliance with these provisions since September, 2013. There are 729 three TCM teams. Two are operated by Recovery Innovations, which also operates the Crisis Walk-In 730 Centers and some of the Crisis Apartment sites. A third team is operated by the State, and has special 731 responsibilities for individuals who are hospitalized at DPC and are not yet engaged with community 732 providers. TCM is a very important service that assists individuals in accessing essential community 733 services. TCM works closely with Mobile Crisis Services in providing follow-up and linkage to 734 ongoing assistance following a mental health emergency. As is referenced elsewhere in this report, 735 TCM assists individuals who have been admitted to IMDs in qualifying for PROMISE services. And 736 TCM plays an important role in assisting individuals who have been identified as homeless via the 737 initiative at the IMDs discussed earlier and in helping them to secure appropriate housing and other

Number of Case Managers

Figure-32: Case Managers FY12 to FY16
30

25

20

15

10

5

0

FY12

FY13

FY14

FY15

FY16

State

Target

46

738 supports. Figure-32 presents the State’s history of meeting (and in some years, exceeding) the targets 739 delineated in the Agreement.

740 Section II.D.2.c.ii limits the number of individuals served by case managers to no more than 35, 741 however, the State has found that the level of need of individuals being served requires more intensive 742 involvement than this would allow. Table-5 presents data on the number of case managers, the average 743 number of individuals served at any point in time, as well as the average clients per case manager.

744

Table-5: Targeted Care Managers and Point-in-Time

Averages of Individuals Served

FY 14-16

FY14 Avg FY15 Avg FY16 Avg

# of Clients

61.1

58.8

93.3

State TCM # of CMs

5

5

5

Clients/CM

12.2

11.8

18.7

# of Clients

123.5

107.5

111.4

RI - NCC # of CMs

9

9

9

Clients/CM

13.7

11.9

12.4

# of Clients

104.7

119.6

106.7

RI - Ellendale # of CMs

11

11

11

Clients/CM

9.5

10.9

9.7

# of Clients

289.3

285.9

311.4

Totals

# of CMs

25

25

25

Clients/CM

11.6

11.4

12.5

745 The State continues to be in Substantial Compliance with respect to Case Management services.

746

747 VIII. Supported Housing

748

Substantial Compliance.

749 Section III.I of the Agreement includes provisions with respect to Supported Housing for members of 750 the target population:
47

751

1. By July 11, 2011, the State will provide housing vouchers or subsidies and bridge

752

funding to 150 individuals. Pursuant to Part II.E.2.d., this housing shall be exempt from

753

the scattered-site requirement.

754

2. By July 1, 2012 the State will provide housing vouchers or subsidies and bridge funding

755

to a total of 250 individuals.

756

3. By July 1, 2013 the State will provide housing vouchers or subsidies and bridge funding

757

to a total of 450 individuals.

758

4. By July 1, 2014 the State will provide housing vouchers or subsidies and bridge funding

759

to a total of 550 individuals.

760

5. By July 1, 2015 the State will provide housing vouchers or subsidies and bridge funding

761

to a total of 650 individuals.

762

6. By July 1, 2016 the State will provide housing vouchers or subsidies and bridge funding

763

to anyone in the target population who needs such support. For purposes of this

764

provision, the determination of the number of vouchers or subsidies and bridge funding to

765

be provided shall be based on: the number of individuals in the target population who are

766

on the State's waiting list for supported housing; the number of homeless individuals who

767

have a serious persistent mental illness as determined by the 2016 Delaware Homeless

768

Planning Council Point in Time count; and the number of individuals at DPC or IMDs for

769

whom the lack of a stable living situation is a barrier to discharge. In making this

770

determination, there should be due consideration given to (1) whether such community-

771

based services are appropriate, (2) the individuals being provided such services do not

772

oppose community-based treatment, and (3) the resources available to the State and the

773

needs of other persons with disabilities. Olmstead v. L.C., 527 U.S. 581 at 607 (1999).

774 Supported Housing is an extremely important service for individuals with SPMI, who often have 775 extensive histories of institutionalization in hospitals, criminal justice settings, or congregate mental 776 health residential facilities. In addition, a substantial number of these individuals have histories of

48

777 homelessness. Supported Housing is directed at not only providing individuals with stable living 778 environments, but also at promoting the community integration that the ADA and Olmstead require. 779 Because people with SPMI have a long history of being relegated to living situations such as nursing 780 facilities, group homes, or apartment buildings restricted to residents with disabilities—settings that may 781 be physically located in the community, but that actually perpetuate the segregation of people with 782 SPMI from the community mainstream—the Agreement includes specific standards for new Supported 783 Housing that is truly integrated into the community. Section II.E requires the State to support members 784 of the target population living in their own homes with services that will:

785

a. Ensure that people with SPMI can live like the rest of Delawareans, in their own homes,

786

including leased apartments, houses or living with their family;

787

b. Offer people choice regarding where they live and with whom;

788

c. Provide an array of supportive services that vary according to people’s changing needs and

789

promote housing stability.

790 Section II.E.2.d and 2.e define minimum standards for integration in terms of what has come to be 791 known in Delaware as the “20%/2-Person Rule;” housing created pursuant to the Agreement is required 792 to be scattered-site—meaning that no greater than 20% of the units in an apartment building may be 793 occupied by people known by the State to have a disability, and no greater than two individuals may 794 occupy an apartment and each must have a private bedroom.

795 Needless to say, the Agreement’s Supported Housing standards represent a sea change from mental 796 health systems (in Delaware and nationwide) whereby individuals with SPMI were routinely assigned to 797 placement “slots” based upon the determination of clinical staff. The placements were mostly in settings 798 where residents’ daily interactions were generally limited to staff and other individuals with SPMI, 799 where individuals were assigned roommates and reassigned to different bedrooms per the decisions of 800 staff, and were people were offered no choice around such basic issues as when and what to eat and 801 what time to go to bed.

802 From the outset of Agreement, the State recognized the significance of Supported Housing in terms of 803 the aims and requirements of the ADA and Olmstead, and this has been a very strong element of its 804 implementation efforts. The vignettes presented at the beginning of this report document some of the
49

805 dramatic life changes that have occurred as a result of the State’s Supported Housing work. Not every 806 story has been a success; Supported Housing is a relatively new service in public mental health and 807 many members of the target population have significant and longstanding challenges associated with 808 mental illness, co-occurring substance use, criminal justice involvement, and other social issues. 809 Furthermore, many such individuals have little or no histories in fulfilling the responsibilities of tenancy, 810 and years of institutional care have bred unnecessary dependence in such areas as food preparation and 811 housekeeping. Notwithstanding these challenges, the State has worked diligently and innovatively to 812 develop a successful Supported Housing program that essentially did not exist prior to the Agreement.

813 The development of its Supported Housing program required more than simply funding rental subsidies 814 and an assortment of in-home community services. It entailed changing the culture of how mental 815 health professionals assess the housing needs of individuals and incorporate those individuals’ personal 816 preferences in their service approaches. Section IV.A.1.b (relating to transition planning from hospitals 817 to the community) delineates an important requirement that gets to the heart of this culture change:

818

Discharge assessments shall begin with the presumption that with sufficient supports and

819

services, individuals can live in an integrated community setting.

820 In Delaware and nationwide, individuals with SPMI were routinely evaluated in terms of “levels of 821 care”—essentially assigning them to housing based on a menu of predetermined segregated housing 822 options that vary in the intensity of services they provide, for instance from several levels of specialized 823 group homes to nursing facility care. Commonly, acceptance of the services provided was a prerequisite 824 for entering community housing. The Agreement requires something different; that assessments be 825 based on the individuals’ personal goals, and that the services, supports, and specific housing 826 arrangements be designed accordingly. Furthermore, rather than being regarded as occupying 827 “placement slots,” the Agreement requires that individuals have tenancy rights and that, with needed 828 support services, they assume the responsibility of being good tenants.

829 To promote assessments that meet these requirements, in the first year of implementation the State 830 developed the Community Living Questionnaire to structure interviews with individuals about their 831 housing preferences and their perceptions about what services and supports they will need to live

50

832 successfully in their preferred living arrangements, and to reconcile these with staff perceptions of the 833 individual’s service needs. This was helpful in reorienting both staff and consumers, both groups having 834 been accustomed to the level-of-care model. The Community Living Questionnaire is included in 835 Appendix-B.
836 In an important effort to make integrated housing the “default” consideration, DSAMH also required 837 that treatment teams prepare written justification when they recommend housing for an individual in a 838 non-integrated setting, i.e., a setting that does not meet the requirements of the “20%/2-Person Rule.” 839 These detailed analyses encourage treatment teams to think carefully and critically about utilizing non840 integrated housing. Such requests are reviewed by DSAMH to ensure that individuals are being 841 appropriately afforded opportunities to live in Supported Housing. In some instances, teams have 842 requested approval of living arrangements as alternatives for nursing home placements, for instance, 843 approval for three individuals with medical care needs to occupy a first floor apartment with an on-site 844 staff apartment.
845 For many members of the target population, the Delaware State Housing Authority’s (DSHA) State 846 Rental Assistance Program (SRAP) pays rental costs in Supported Housing. SRAP funding for these 847 individuals is administered through a close coordination between the Housing Authority and DSAMH. 848 For hospitalized individuals (and others in special circumstances) with pending SRAP applications, 849 DSAMH has the capacity to provide immediate bridge funding for rent and other costs so that 850 movement into Supported Housing can proceed without delay.
851 Prior to individuals moving into Supported Housing, DSAMH conducts an inspection to ensure that it 852 meets basic quality standards and it also completes a DSAMH Integrated Community Certification to 853 affirm that the scattered-site requirements of the Agreement are met or, if not, that a waiver of this 854 requirement has been approved, as discussed above. Such certifications are also used by DSAMH to 855 maintain data about apartment complexes that have reached the 20% limit of tenants known to have 856 disabilities, as well as those that are available to members of the target population without a need for 857 special approval based upon this limit not having been reached. In addition, to help broaden the choices 858 available when providers and clients are exploring housing options, DSAMH housing staff reaches out
51

859 to landlords to inform them about the SRAP program and the scope of services that are available to 860 assist individuals to be successful tenants.

861 DSAMH and DSHA have conducted several landlord outreach meetings, including reaching out to state 862 and local landlord associations. In addition, DSAMH developed a brochure on housing supports for case 863 managers to share with their clients and potential landlords. The State has in place programs to train key 864 stakeholders in the availability of SRAP supports and how to access this resources. These programs 865 have included group trainings by DSAMH and DSHA staff, as well as more individualized consultations 866 with peer specialists, ACT teams, and other providers.

867 Figure-33 presents data on the number of rental supports (through SRAP and other sources) that the 868 State has funded for the target population for Fiscal Years 2012 through 2016, as well as the targets 869 required per the provisions of Section III.J. The Figure shows that, with the exception of Fiscal Year 870 2012, the State has exceeded the requirements of the Agreement for each year of implementation 871 (targets are shown in italics; the number of rental supports funded is shown in bold).

Rental Supports Funded

Figure-33: Supportive Housing Funded for the Target

Population

FY12 to FY16

900

781

812

800

700

650

600

650

650

500

462 550

400

450

300

241

200

250

100

0

FY12

FY13

FY14

FY15

FY16

State

Cumulative Target

872

873 Figure-34 presents the breakdown of how these housing supports were funded for each fiscal year, and 874 for the 5-year overall total. The “Grandfathered” figure relates to Section III.I.1, while the remaining

52

875 funding sources reflect a combination of State funds (e.g., SRAP and CRISP) and federal dollars (e.g., 876 HUD).

877

Figure-34: Sources of Funding for Integrated Housing FY11 to FY16

5 Year Totals FY16 FY15 FY14 FY13 FY12 FY11

0

100

Grandfathered

200

300

400

Additional SAP

500

600

SRAP-Budgeted

700

800

900

SRAP-Additional

CRISP
878

CoC HUD

Section 811

HUD 1 & 3

879 In Fiscal Year 2016, the State had funding available for 812 individuals. But in practice, the number of 880 housing supports funded for a year does not equal the number of individuals in Supported Housing at 881 any point in time. For instance, most individuals in the Supported Housing program are successful, but 882 some do not succeed as tenants (most often due to substance use and attendant issues). Others leave 883 their apartments for other living arrangements. There are also instances where individuals with rental 884 vouchers through SRAP transfer to federally funded voucher programs. Vouchers that become unused 885 in these ways are “backfilled.” And to ensure that vouchers are available throughout the fiscal year 886 (particularly for individuals being discharged from hospitals), the State intentionally does not release all 887 vouchers at the beginning of the year. For all of these—and other—reasons, voucher use is complex and 888 fluid. As of July 1, 2016, for instance, the State had funded up to 528 SRAP vouchers and 461 had been 889 issued. 40 individuals with vouchers were actively looking for apartments and 15 SRAP applications 890 were in process.

53

Table-6: SRAP Applications and Prioritization of the Waiting List

Group
1 2 3 4
5 6 7 TOTAL

Definition
HIGHEST PRIORITY

Total Applications Received
9/2011 – 5/2016

On Waiting List
as of 5/31/16

Percent of Total on Waiting
List

Clients exiting DPC, IMD’s and DSAMH’s

Supervised Apartment Program (clients living in

SAP housing who can move to more independent

259

0

housing are included in this category) and who

have a diagnosis of SPMI

Clients who have been hospitalized within the last

two years (24 mos.) and are eligible for or receiving services from an ACT/ICM team and

164

have a diagnosis of SPMI

Clients from IMDs, ACT/ICM teams (and/or

receiving State-funded services such as Medicaid) that meet the federal definition of chronically

183

homeless and have a diagnosis of SPMI.

7 27.8%
4

Clients receiving services from a DSAMH-funded

community mental health program (who are not

enrolled in ACT or ICM services and who meet the

94

44

definition of chronic homeless and have a

diagnosis of SPMI).

MEDIUM PRIORITY

Clients receiving services from a DSAMH-funded

community mental health program such as (TASC, ACT and CMHCs) and who have a diagnosis of

444

SPMI

110

55.6%

LOWER PRIORITY

Clients receiving services from a community

mental health provider that is not receiving funds

46

from DSAMH.

Clients from a Community Service Provider that is not receiving funds from DSAMH

22

20 16.7%
13

Remains on Waiting List

1212

198

16.3%

891 54

892 Table-6 presents the State’s approach to prioritizing members of the target population for rental 893 supports, as well as the number of applications received from September, 2011, through the end of May, 894 2016, and the number of individuals on a waiting list for housing supports as of the end of May, 2016. 895 Highest priority is afforded individuals in DPC, an IMD, or the Supervised Apartment Program (the 896 intent with regard to Supervised Apartments is to free up those beds for other high-risk individuals), for 897 those recently hospitalized and in need on intensive services (i.e., ACT/ICM), and those who are 898 homeless. These individuals account for 27.8% of the housing waiting list and they tend to remain on 899 the waiting list only briefly. Among them, no individuals exiting hospitals or the supervised apartments 900 (Group 1) were on the waiting list as of the date shown. Other individuals in the highest priority 901 categories are homeless or are living in unstable housing. Individuals in Groups 5-7 account for 72.2% 902 of the individuals on the waiting list. They are assigned lower levels of priority because they have stable 903 housing and are not in hospitals, but their housing may not be integrated.
904 Section III.I.6 of the Agreement is lengthy, but it essentially requires the State to be able to demonstrate 905 that its Supported Housing program not only meets the targets established in Sections III.I.1-5, but also 906 that it makes reasonable efforts to expand its housing program to accommodate the needs of the target 907 population, particularly hospitalized or homeless individuals. Table-7 summarizes the State’s data with 908 respect to subgroups of the target population that are referenced in this Section. As many as 232 909 individuals who may be covered by the Agreement meet one or more of the factors identified in Section 910 III.I.6. The largest group—132 individuals counted in the Delaware Homeless Planning Council in its 911 Point in Time study—is based upon a one-night snapshot of individuals in shelters, those who are 912 unsheltered, and other sources. This study does not collect individuals’ names, so it is unknown if some 913 of the individuals counted are already being served by DSAMH, and it is possible that they may be 914 counted in other categories within this table. Furthermore, their mental health status is based upon self915 report and whether they meet criteria for SPMI is not known. As such, this category is a very blunt 916 measure of need with respect to the Agreement. As is discussed elsewhere in this report, though, if 917 these individuals come to be psychiatrically hospitalized, or if they come into contact with DSAMH 918 programs, they will be referred for housing evaluations. With respect to the other categories presented 919 in the table, the discussion above describes the State’s prioritization of high-risk individuals for housing
55

920 supports. And individuals awaiting discharge from DPC because of housing issues18 are not awaiting 921 supported housing, but rather have special needs (particularly medical needs).

Table-7: Estimates of Housing Needs per Section III.I.6 of the Agreement

(Individuals counted by the Homeless Planning Council may be duplicated in other categories)

The number of individuals in the target population who are on the State's waiting list for supportive

housing as of 5.31.16

48

The number of homeless individuals with severe mental illness as determined by the 2016

Delaware Homeless Planning Council in the Point in Time count

132

Total number of individuals at DPC or IMD's whom for the lack of a stable living situation is a barrier

to discharge, as of 6.15.16

52

Awaiting Supported Housing or Supervised Apartment

0

Awaiting ACT or CRISP services

16

Awaiting Group Home or Nursing Facility

26

Awaiting resolution of legal issues

6

Discharge imminent

4

Total

232

922

923 Figure-35 presents data on the length of tenancy of the target population in Supported Housing and how 924 the distribution of tenancy has changed between Fiscal Year 2014 and 2016. In 2014, individuals had 925 been tenants in Supported Housing from one month to 36 months, with the highest category of tenancy 926 being from 13-18 months (27%). By 2016, the distribution had changed significantly; tenancy ranged 927 from one month to five years (60 months), and the category into which individuals most frequently fell 928 into was longer (19-24 months). In other words, notwithstanding the “churning” referenced above, 929 whereby some individuals are unsuccessful as tenants or otherwise leave supported housing, the overall 930 profile of the State’s Supported Housing program is that individuals are remaining permanently housed

18 The number of such individuals at IMDs is small, if any. They would either be referred to TCM or, if clinically unstable, transferred to DPC.
56

931 for longer periods of time. Whereas in 2014, 11.2% of the target population receiving SRAP support 932 had lived in their apartments for two years or longer, by 2016, that proportion had increased to 41.6%.

Percentage of Clients in Supported Housing with SRAP

Figure-35: Housing Stability in SRAP Supported Housing FY14-16
30%

25%

20%

15%

10%

5%

0% 1 2-6

FY 14 Year End 7-12 13-18 19-24

FY 15 Year End Time Leased (Months) 25-30 31-36 37-42

FY 16 Year End 43-48 49-54 55-60

933

934 Monitor reports have rated the State to be in Substantial Compliance with the Agreement’s Supported 935 Housing requirements since September, 2012, and it remains so. The State has developed an impressive 936 program that has not only met the annual targets of the Agreement’s provisions,19 but it has also changed 937 the service culture for individuals who have SPMI and with respect to the requirements of Olmstead.

938 In regard to needs beyond what is required in Section III.I.1-5 (i.e., the requirements of Section III.I.6), 939 the State has already significantly exceeded the Agreement’s numerical targets for housing vouchers. 940 Furthermore, it has in place effective mechanisms to connect members of the target population with 941 housing, for instance for homeless individuals who are hospitalized at DPC or an IMD. As is discussed 942 in this, as well as prior Monitor reports, Supported Housing is a critical factor in achieving community 943 integration for individuals who have SPMI and it is among the strongest elements of the State’s 944 implementation efforts.

19 2012 showed a minor deviation from that year’s target.
57

945 IX. Supported Employment

946

Substantial Compliance.

947 Section III.J of the Agreement includes provisions relating to Supported Employment services to the 948 target population.

949

1. By July 1, 2012 the State will provide supported employment to 100 individuals per year.

950

2. By July 1, 2013 the State will provide supported employment to 300 additional

951

individuals per year.

952

3. By July 1, 2014 the State will provide supported employment to an additional 300

953

individuals per year.

954

4. By July 1, 2015 the State will provide supported employment to an additional 400

955

individuals per year.

956

5. In addition, by January 1, 2012 all individuals receiving ACT services will receive

957

support from employment specialists on their ACT teams.

958 Like Supported Housing, Supported Employment is a critically important service with respect to 959 Olmstead compliance in that it is specifically directed at enabling individuals with SPMI to participate 960 in the community mainstream. Employment is not only a means of achieving self-sufficiency, but it is 961 also an important aspect of an adult’s social identity and role in the community. Historically, people 962 with SPMI have been excluded from the workforce or relegated to “sheltered” work programs that 963 segregate people with disabilities. Following hospitalization, many such individuals were assigned the 964 identity of “former mental patient” by the community. Supported Employment changes that. It allows 965 people with SPMI to pursue their personal employment goals and to hold competitive, ordinary jobs 966 alongside people who do not have disabilities.

967 The State’s Division of Vocational Rehabilitation (DVR) has a long history of close collaboration with 968 DSAMH to promote mainstream employment for people with SPMI. A part of this collaboration has 969 been to support ACT teams in assisting the individuals they serve in entering the workforce. 970 Nationwide, vocational rehabilitation services that receive federal funding (as does DVR) have 971 limitations in providing ongoing services to individuals once they secure employment. Recognizing that

58

972 individuals with SPMI often require employment services that extend beyond these limits, the State’s 973 PROMISE program includes Medicaid coverage of Short-Term Small Group Supported Employment 974 and ongoing Individual Employment Supports. As PROMISE becomes more fully operational, these 975 employment services have the potential to significantly increase the number of individuals in the target 976 population entering the mainstream workforce, as well as the number that approach or reach full-time 977 employment.

978 The State has been rated as being in Substantial Compliance with the Agreement’s Supported 979 Employment requirements since September, 2012 and it remains so. Figure-36 presents the number of 980 individuals within the target population who are receiving Supported Employment services, meaning 981 that they have active employment plans or are at some level of service beyond this, including to the 982 point of holding a job. As Figure-36 indicates, the State has exceeded the Agreement’s numerical 983 targets for each year of implementation.

984 The target population has special challenges in entering the mainstream workforce. Beyond the 985 employment discrimination that the ADA and other laws seek to overcome, many individuals lack work 986 skills and histories of stable employment. Anecdotally, several individuals who are living in their own 987 apartments following long histories of institutionalization have expressed the feeling to the Monitor that

Individuals Served

Figure-36: Members of the Target Population Receiving
Supported Employment Services
FY12 to FY16
3500

3000

2500

2000

1500

1000

500

0

FY12

FY13

FY14

FY15

FY16

State

Target

59

988 they are not yet ready to pursue employment and that they need to concentrate upon fulfilling the daily 989 demands of maintaining their homes, shopping, and so on. Figure-37 presents data on the movement of 990 members of the target population who are receiving Supported Employment services from initial work 991 on employment plans (such as basic work skills) to job readiness (seeking employment) to actual 992 employment. It shows that there has been a significant increase in the proportion of people who actively 993 employed—about a fourfold increase since Fiscal Year 2014. Furthermore, because the population of 994 individuals receiving supported employment is increasing yearly (per Figure-36), the absolute numbers 995 of individuals represented by these proportions is increasing as well.
996
Figure-37: Supported Employment Categorical Breakdown FY14 to FY16
76.4% 67.7% 67.1%

Percent of Individuals Receiving Supported Employment per the Agreement

Service

19.7% 20.4% 17.4%

FY14 %

Job Ready FY15 % FY16 %

11.9% 15.5% 3.8%
Employed

997

998 X. Rehabilitation Services

999

Substantial Compliance.

1000 Section III.K of the Agreement includes requirements for Rehabilitation Services:

1001

1. By July 1, 2012 the State will provide rehabilitation services to 100 individuals per year.

60

1002

2. By July 1, 2013 the State will provide rehabilitation services to 500 additional individuals

1003

per year.

1004

3. By July 1, 2014 the State will provide rehabilitation services to an additional 500

1005

individuals per year.

1006 Rehabilitation Services include a broad array of activities, such as education, substance use disorder 1007 treatment, recreation, training in functional skills, and other activities that promote community 1008 integration. Because they are embedded in so many of the services provided under the Agreement, early 1009 in the Agreement the parties agreed that Rehabilitation Services would be quantified for purposes of 1010 evaluating the State’s compliance by counting:

1011

1) Any ACT or ICM client receiving one of the services below at least twice a month in any six

1012

months of the fiscal year:

1013

a) Psycho-Social Rehabilitative Services

1014

b) Psycho-Social Group Services

1015

c) Family Psycho-Social Education

1016

2) Any individual on the Target Population Priority List who also appears on DSAMH's

1017

substance use treatment database and is thus receiving services for co-occurring substance use

1018

problems.

1019

Figure-38: Members of the Target Population Receiving

Rehabilitation Services

2500

FY12 to FY15

Individuals Served

2000

1500

1000

500

1020

0

FY12

FY13

FY14

FY15

Totals

Targets

61

1021 The State has been in Substantial Compliance with the Agreement’s Rehabilitation Service requirements 1022 since September, 2012 and, as is indicated in Figure-38, it continues to exceed the numerical targets 1023 contained in Section III.K.

1024

1025 XI. Family and Peer Supports

1026

Substantial Compliance.

1027 Section III.L of the Agreement includes provisions relating to Family and Peer Supports.

1028

1. By July 1, 2012 the State will provide family or peer supports to 250 individuals per year.

1029

2. By July 1, 2013 the State will provide family or peer supports to 250 additional

1030

individuals per year.

1031

3. By July 1, 2014 the State will provide family or peer supports to an additional 250

1032

individuals per year.

1033

4. By July 1, 2015 the State will provide family or peer supports to an additional 250

1034

individuals per year.

1035 Family Supports entail training and consultation that enable family members to play an active role in 1036 individuals’ recovery process. Peer Supports are services provided by individuals who, themselves, 1037 have mental illness and who have direct experience in recovery and in addressing many of the 1038 challenges confronting members of the target population.

1039 The State provides both Family Supports and Peer Supports to the target population, but it maintains the 1040 best data with regard to Peer Supports; these data have been included in Monitor reports throughout 1041 implementation. Peer services have flourished through the course of the implementation period to the 1042 point that what was once a narrow aspect of DSAMH services has now become ubiquitous. Trained 1043 peers are embedded as critically important elements of services in ACT, ICM, Crisis Apartments, Crisis 1044 Walk-In Centers, and other programs. They play a very significant role in handling consumer 1045 complaints. Peers orient individuals upon their admission to DPC, assist them during the course of their 1046 hospitalization, and provide tote bags with toiletries and other essentials upon discharge to the

62

1047 community. Peers operate drop-in centers in the northern and southern parts of the State (the Rick 1048 VanStory Center and the ACE Center, respectively), as well as an art gallery (the Creative Vision 1049 Factory) in downtown Wilmington featuring the artwork of people with SPMI. Recently, peers helped 1050 to create a monument as a part of the restoration of a graveyard that had been used over the decades for 1051 patients of DPC. Peers played an important, substantive role in reforming Delaware’s mental health 1052 laws and will be members of the oversight subcommittee established through Senate Bill 245. Peers 1053 have been trained as research assistants who helped to construct and implement the quality reviews of 1054 ICM and CRISP services discussed later. Peers conduct certification trainings that enable the services of 1055 peer specialists to be reimbursable under the PROMISE program. And, finally, throughout the course of 1056 implementation, peer specialists and the people they assist have been invaluable sources of information 1057 and education for the Monitor.

1058

Figure-39: Members of the Target Population

Utilizing Peer Services

3,000

FY12 to FY16

2,500

2,000

Peers Served

1,500

1,000

500

1059

0

FY12

FY13

FY14

FY15

FY16

State Monthly Avg.

Target

1060 In short, Peer Support services and the larger peer movement in Delaware have become a vibrant 1061 component of the service system for people with SPMI, and in multiple ways—beyond the requirements 1062 of Section III.L, they have helped move the State towards compliance with the Agreement and

63

Peers Served

Figure-40: Types of Peer Contacts Point-in Time Averages for FY 2014-2016
3000

2500

2000

1500

1000

500

0 FY14 Avg

FY15 Avg

FY16 Avg

1063

DPC Peer Contacts

Trauma Peer Contacts

ACT/ICM Combined Census CRISP Census

MH Court Peers

1064 Olmstead. Figure-39 demonstrates that, for each year of implementation, the number of individuals 1065 receiving Peer Supports has exceeded—and, for the last three years, far exceeded—the Agreement’s 1066 requirements.

1067 Figure-40 presents a breakdown of the types of peer contacts occurring during the past three years. In 1068 2016, federal funding for an important peer program addressing trauma ended. In 2015, peers began 1069 providing mentoring services in the New Castle County mental health court.

1070 In summary, the promotion, systemic integration, and meaningful utilization of peer services is another 1071 important accomplishment of the State in implementing the Agreement.

1072

1073 XII. Transition Planning

1074 Section IV.B of the Agreement includes requirements with respect to Transition Planning for members 1075 of the target population in DPC or an IMD. The subsection that is currently relevant is as follows:

64

1076

4. The State shall have as its goal that where a transition team determines that a

1077

community placement is the most integrated setting appropriate for an individual

1078

currently in DPC or an IMD, that individual will be discharged to the community

1079

with necessary supports within 30 days. Between July 1, 2014 and July 1, 2015, the

1080

State shall meet this goal for at least 75% of people transitioning from DPC or an

1081

IMD. Between July 1, 2015 and July 1, 2016, the State shall meet this goal for at least

1082

95% of people transitioning from DPC or an IMD.

1083 The intent of this provision is that once an individual who is hospitalized has been determined to be 1084 ready for discharge, transition arrangements should proceed in a timely way and that individual should 1085 be released in less than 30 days with appropriate community services and supports. While this is a 1086 straightforward requirement, its meaningful application is less so. As has been discussed earlier, the 1087 overwhelming majority of hospitalizations among the target population occur within IMDs, where the 1088 length of inpatient care averages fewer than seven days and only about 5% of the discharges exceed 14 1089 days of hospitalization. Thus, for the population receiving Acute Care in IMDs (which, by definition 1090 lasts 14 days or fewer) and where MCOs’ approvals of benefits tend to be for 6-7 days of hospital care, a 1091 standard requiring that once an individual has become clinically stable, discharge occur within 30 days 1092 is not very meaningful.

1093 In DPC, it is somewhat of a different story. DPC admits individuals directly from the community for 1094 acute care and, while their lengths of stay are a bit longer than in the IMDs, by definition, their 1095 discharges occur within 14 days. DPC also accepts transfers from the IMDs of individuals who have 1096 complex needs and cannot be stabilized within the Acute Care period; the hospitalizations of these 1097 “blended” admissions tend to extend into the Intermediate Care categories, which may last up to 179 1098 days. Other individuals are directly readmitted to DPC when in need of hospital care because they have 1099 extensive psychiatric histories; they are known to the facility and tend to require extended inpatient care. 1100 Finally, although the State’s success in linking this group with intensive community services has 1101 reduced their hospitalization rates dramatically, there are still individuals at DPC receiving Long Term 1102 Care, which can extend from 180 days to decades. With the exception of the Acute Care group, it is 1103 possible that transition arrangements for other patients at DPC (i.e., those receiving Intermediate or

65

1104 Long Term Care) could have exceeded 30 days beyond a determination that hospital care is no longer 1105 needed, and it is for this group that the requirements of Section IV.B.4 are most meaningful.

1106

Table-8: Inpatient 30-Day Post-Stabilization Breakdown

FY15

FY16

DPC

IMD Total DPC IMD Total

Total Number of Discharges (Acute, Intermediate, and Long Term)
Number of Discharges within 30 Days of Psychiatric Stabilization

154

2,815 2,969 375 2,554 2,929

126

2,807 2,933 303 2,546 2,849

% of Discharges within 30 Days of Psychiatric Stabilization

81.8%

99.7% 98.8% 80.8% 99.7% 97.3%

1107 Table-8 presents data from Fiscal Years 2015 and 2016 on the timeliness of discharge following a 1108 determination that hospitalization is no longer needed in DPC, in the IMDs, and in the aggregate. It 1109 shows that the State’s overall success in these years in discharging individuals within 30 days is 98.8% 1110 and 97.3%, respectively.
1111 In DPC, the success rate with respect to the 30-day standard is lower; 81.8% in Fiscal Year 2015 and 1112 80.8% in Fiscal Year 2016. Table-9 provides a snapshot of individuals at DPC awaiting discharge at 1113 three points in time. These figures reflect both individuals whose discharges exceed 30 days beyond 1114 stabilization and individuals whose discharges are proceeding within this time frame, but they give a 1115 sense of the factors that impede transition from the hospital. First of all, the number of individuals 1116 reflected in each of the discharge barriers listed is small, fewer than 20. The barriers most frequently 1117 occurring relate to Group Home or Nursing Facility waiting lists (these individuals tend to have complex 1118 medical issues and would have been exempted from Supported Housing in the process discussed 1119 earlier), and to waiting for an opening in ACT or CRISP services. With regard to the latter, DSAMH is 1120 aware that this has become a factor delaying discharge from DPC and it is now examining whether 1121 individuals are appropriately moving through these programs when they no longer require such intense 1122 services. It is working with providers in this regard. DSAMH believes that addressing this issue could 1123 significantly help in freeing up services for individuals who remain hospitalized.

66

1124

Table-9: Point-in-Time Breakdown of Discharge Barriers at DPC

FY15 (6/30/15)

FY16 (12/31/15)

FY16 (6/30/16)

n

%

n

%

n

%

Number of Clients Ready for Discharge

56

45

52

Provider Active/Currently Discharging

16 28.6% 11 24.4%

4 7.7%

Group Home List

12 21.4%

8 17.8% 19 36.5%

Nursing Home/DDDS List

8 14.3%

5 11.1%

7 13.5%

Legal Barriers

4 7.1%

3 6.7%

2 3.8%

ACT/CRISP List

2 3.6%

3 6.7% 16 30.8%

Other (Medicaid pending, Level of Care determination, etc.)

14 25.0%

15 33.3%

4 7.7%

1125 In addition to the information presented above, the State maintains extensive additional data that it uses 1126 to monitor the timeliness of discharge and the factors that impede individuals’ timely return to the 1127 community. Although the timeliness measures at DPC do not meet the standard established in Section 1128 IV.B.4, relatively small number of individuals—many of whom require medical care services—are 1129 affected. Furthermore, the State is taking appropriate actions to address delays that relate to openings in 1130 programs such as ACT and CRISP. Finally, when all hospitalizations are considered, including stays at 1131 the IMDs that are, by design, of very short duration and very rarely extend to anything near 30 days, the 1132 State is meeting the plain language of this provision. For all of these reasons, the State is rated as being 1133 in Substantial Compliance with Section IV.B.4.

1134

1135 XIII. Quality Assurance and Performance Improvement

1136

Substantial Compliance.

1137 Section V.A of the Agreement requires that the State have in place a Quality Assurance and 1138 Performance Improvement (QA/PI) system that ensures that services are of appropriate quality and that 1139 they are achieving the goals of community integration, independence, and self-determination that the
67

1140 Agreement requires. The extensive data on which this report is based is evidence that the State, indeed, 1141 has such a system in place. Furthermore, as was discussed with respect to the State’s establishment of a 1142 new Crisis Walk-In Center or the discontinuation of some ACT teams, the State uses performance data 1143 to make decisions about expanding programs and program contracting. Figures-19 through -31 1144 document that the State monitors the quality of its intensive service programs in terms of such important 1145 dimensions as arrest rates, emergency room use, and hours of competitive employment and that it can 1146 analyze such outcomes either in the aggregate or on a program or team level.

1147 The Monitor’s ninth report, which was issued recently (on 5/26/16) described how the State has greatly 1148 increased the coordination of its QA/PI activities, in part by establishing the Quality Control Steering 1149 Committee to serve as the hub of analysis and identification of new initiatives. That report summarized 1150 an array of ongoing QA/PI activities that are relevant to the Agreement:

1151

1152

1. A Quality Process Review of ACT and ICM that has been ongoing since 2015 (Figures-19

1153

through -31).

1154

2. An investigation, which was initiated in 2015, of how homelessness affected lengths of stay

1155

among members of the target population who were hospitalized at DPC.

1156

3. A study of rates of court commitment for inpatient or outpatient treatment, which shows the

1157

systems impressive move towards voluntary treatment (Discussed below, see Figure-48).

1158

4. Monthly QA meetings between DSAMH and the IMDs to resolve problems in care,

1159

including coordination and information sharing between hospital and community providers

1160

5. An investigation of the needs of individuals living in community housing who have complex

1161

challenges, particularly with respect to addressing Activities of Daily Living. This program

1162

was initiated in 2015.

1163

6. A Client Death Review investigation focusing on deaths occurring outside of hospital

1164

settings. This study is a component of DSAMH’s risk management activities.

68

1165

7. An initiative to incorporate into practice data from the evaluation of DSAMH’s CRISP

1166

program that reflects the ongoing partnership between the State and the University of

1167

Pennsylvania.

1168 Some of the initiatives cited above will be discussed more fully in the section below relating to QA/PI 1169 activities relating to the new Crisis Stabilization measures. As an example of a QA/PI initiative that 1170 does not relate to these measures, the CRISP initiative (#7 above) is a longitudinal project that is now at 1171 the point where the State can analyze data on individuals with SPMI who had been hospitalized at DPC 1172 for protracted periods of time and who are now living in integrated settings with support services 1173 pursuant to the Agreement. As a part of this multifaceted study, peers were trained as research assistants 1174 in interviewing consumers annually to gather information about their functioning and perceptions about 1175 their lives. The interview protocol, which was designed with the input of peers, is included in 1176 Appendix-C. Table-10 summarizes some of the data from these interviews. The table shows the 1177 percentages and raw numbers of individuals who report positive outcomes relating to community living 1178 during an initial (Baseline) interview and a follow-up interview one year later. The final two columns 1179 indicate for each factor the percentage and number of individuals whose reports indicate positive change 1180 over the year and those indicating no change. The greatest gains were found with regard to consumers 1181 reporting that they have treatment goals that they direct (27.5%), that they feel control over their life 1182 (18%), that they are abstaining from tobacco use (15.9%), and that they have positive feelings of self1183 worth (15%). These outcomes reflect well on the system’s overall efforts to promote recovery.

1184 It is notable that the CRISP population includes individuals with significant challenges. In fact, referrals 1185 were made to the CRISP program in part based upon a finding that ACT services would not be sufficient 1186 to support them in the community. The University of Pennsylvania study found that inpatient use 1187 among the CRISP population was minimal, and that all individuals were able to remain in community 1188 settings. Also interesting was the finding that, based upon a widely used measure of psychiatric 1189 functioning,20 individuals’ symptoms actually increased over the year (on average, by 16%), but this 1190 evidently did not have an impact on their ability to live in integrated settings, nor did it affect the 1191 positive self-reports summarized in the table below. All in all, the ongoing CRISP study is further

20 The Brief Psychiatric Rating Scale was used.
69

1192 evidence from the State’s extensive dataset that community services do work to the benefit of 1193 individuals with SPMI, including those with very significant challenges.

1194

1195

Table-10 CRISP Consumer Self-Report Data

DOMAIN

Baseline % +

12. mo. % +

% + change

% no change

Health Status Baseline (n = 46); 12 mo. (n = 45)
Control of Life Baseline (n = 48); 12 mo. (n = 44)
Satisfactory Housing Baseline (n = 48); 12 mo. (n = 43)
Feelings of self-worth Baseline (n = 46); 12 mo. (n = 43)
Abstinence from tobacco Baseline (n = 49); 12 mo. (n = 44)

80.4% (37) 79.2% (38) 87.5% (42) 73.9% (34) 42.9% (21)

Staff believe in consumer growth and recovery Baseline (n = 48); 12 mo. (n = 44)

91.7% (44)

71.1% (32) 11.1% (5) 79.5% (35) 18.2% (8) 83.7% (36) 11.6% (5) 69.8% (30) 15% (6) 38.6% (17) 15.9% (7) 77.3% (34) 9% (4)

73.3% (33) 63.6% (28) 72.1% (31) 65% (26) 63.6% (28) 68.2% (30)

Consumer directed treatment goals Baseline (n = 46); 12 mo. (n = 43)
Happy with friendships Baseline (n = 49); 12 mo. (n = 44) Feeling a part of the community Baseline (n = 49); 12 mo. (n = 44)

73.9% (34) 81.4% (35) 27.5% (11) 55% (22)

83.7% (41) 81.6% (40)

79.5% (35) 13.6% (6) 81.8% (36) 13.6% (6)

68.2% (30) 68.2% (30)

1196 QA/PI Activities Relating to Crisis Stabilization
1197 As was referenced in Section IV, the parties negotiated a set of QA/PI measures to provide a fuller 1198 picture of the State’s efforts to reduce hospital use by members of the target population than was 1199 required in provisions III.D.3-4 of the Agreement. These measures represent the basis for important 1200 QA/PI activities—some ongoing and some to be launched in the future—and, for this reason, they are 1201 discussed here. The new measures are presented in Table-11. In addition to these, the parties agreed

70

1202 that the State would also focus some of its Quality Assurance activities on understanding and better 1203 addressing factors that may obscure its measurement of services, outcomes, and needs of people with 1204 SPMI who are served through State-funded programs, for instance, questionable diagnosing within the 1205 IMDs of individuals who may not have SPMI. Presented below are detailed data relating to the revised 1206 measures of compliance (Table-11), followed by a discussion of the State’s progress relating to these 1207 diagnostic challenges.

1208

Bed Days

Table-11
Revised Measures of Compliance with Crisis Stabilization Provisions III.D.3-421

1a Monthly Bed-Day Reports

1b FY16 DPC Admissions from an IMD, by IMD and the Total LOS

1c Mean, median, mode, and range of Days for 1b who have been discharged

1d Clients whose lengths of stay have exceeded 14 days

1e Direct admissions to DPC (i.e. not via an IMD)

1f Mean, median, mode, and range of Days for 1e who have been discharged

1g Removed22

1h ALOS at DPC by LOS Type: 0-14, 15-49, 50-179, 180+ days

1i Number of persons & length of time for each person on DPC ready to discharge list

Crisis Walk-In Centers

2a Number of individuals evaluated at RRC

2b Diversion from hospitalization by RRC

2c IMD admissions (from 1a) via Crisis Walk-In Centers

2d IMD admissions (from 1a) not evaluated via Crisis Walk-In Centers

Engagement in Community Services Comprised by the Settlement Agreement

21 As agreed to by the parties on February 16, 2016. With minor differences, this table was included in the Monitor’s Ninth Report (Table-1). 22 With the agreement of the parties, item 1g has been removed because it was duplicative of item 1d.
71

3a Hospital admissions of people who are actively served by DSAMH/PROMISE 3b DSAMH community provider participation in discharge planning of 3a at IMDs & DPC 3c Hospital admissions relating to people NOT being served by DSAMH/PROMISE 3d 3c who were referred for specialized services 3e 3c approved for specialized services 3f 3c found ineligible for specialized services 3g 3c approved, but refusing specialized services 3h Removed23 3i Removed 3j Timely engagement of community provider/TCM in discharge planning of 3c individuals 3k State’s progress on addressing the 454 high-risk consumers identified in 201424 Co-Occurring Substance use 4a IMD admissions with substance use as one of the discharge diagnosis 4b 4a receiving mental health services via DSAMH/PROMISE prior to admission Homelessness 5a 3a who are homeless 5b 5a who have been referred for housing (newly referred + already active) 5c 3c who are homeless and referred for DSAMH services 5d 5c who have been referred for housing 5e 3a who were discharged from hospital to shelters 5f 3c who were discharged from hospital to shelters Hospital Readmissions 6a Persons discharged from DPC and each IMD in FY15 6b 30-, 90-, 180-, and 365-day Readmission Rates by LOS type
23 Measures 3h and 3i related to participation in new PROMISE services. These measures have been removed because these services are still being developed. The State intends to incorporate monitoring of the use and impact of new PROMISE services in its Quality Assurance and Performance Improvement program once they are fully operational. 24 The parties have agreed that Measure 3k will not be used in assessing the State’s compliance because it has been subsumed by other actions the State is taking to engage high-risk individuals in services. Discussion of this measure is included for purposes of providing an update on the State’s progress in addressing this issue, which was cited in previous Monitor reports.
72

6c 1, 2, 3, or 3+ readmits to an IMD/DPC during a Fiscal Year Reliance Upon Court-Ordered Treatment
7a Involuntary Outpatient Commitments FY11 to FY15 7b Involuntary Inpatient Commitments FY11 to FY15 DPC Average Daily Census Report 8 Data on Civil Units only

1209 As of the Monitor’s Ninth Report, the new approach to measuring the bed-day reduction provisions of 1210 Crisis Stabilization Services had been in effect for only 2 ½ months. Although some of the measures 1211 included in the above table had been a part of the State’s ongoing data collection, others were new. 1212 Based upon the State’s substantial efforts to move forward on the quantitative and qualitative 1213 components of the revised approach, the Ninth Report rated the State as “Moving Towards Substantial 1214 Compliance” with respect to Crisis Stabilization. As is documented below, the State is now in 1215 Substantial Compliance with the Agreement’s Crisis Stabilization provisions, as well as with provisions 1216 relating to QA/PI. The tables and figures that follow detail the State’s status with respect to each 1217 measure included in Table-11.

1218

1. Bed Day Measures

1219 The first set of measures relates to individuals with SPMI who have been hospitalized in DPC or one of 1220 the IMDs with State funding, their lengths of stay, and timeliness of discharge. The State has been 1221 monitoring total bed days used by the target population since the Agreement went into effect in Fiscal 1222 Year 2011. Figure-41 presents the bed days used for each of the five years of implementation for DPC 1223 and, combined, for the three IMDs. It also includes a small number of “Blended” hospitalizations, 1224 relating to individuals who were admitted to an IMD and who were subsequently transferred to DPC for 1225 continuing inpatient care because they were not stabilized within the relatively short treatment periods to 1226 which IMD care is directed. The bed-day figures include individuals categorized as receiving Long 1227 Term Care (in excess of 180 days), Intermediate-II Care (50-179 days), Intermediate-I Care (15-49 1228 days), and Acute Care (14 days or fewer). DPC serves individuals falling into each of these categories. 1229 Bed use in the IMDs overwhelmingly falls within the Acute Care category; very few hospitalizations 1230 extend into either of the Intermediate Care categories, and none extend into Long Term Care. As is
73

1231 depicted in Figure-41, comparing FY 2011 with FY 2016, DPC has reduced the number of bed days25 1232 used by the target population by 47.2%, from 38,415 to 20,302. These reductions have mostly occurred 1233 with regard to Long Term Care (a 55.3% reduction from FY 2011), but were also realized in 1234 Intermediate Care-I and -II and Acute Care (8.7%, 4.4%, and 4.5% reductions, respectively). Care 1235 within the IMDs, which is mostly for 14 days or fewer, increased significantly between 2011 and 2015. 1236 Possibly reflecting some of the early effects of PROMISE and other improvements that the State has 1237 made in coordinating services between DSAMH, DMMA, the MCOs, and the IMDs, the number of bed 1238 days used by the target population in the IMDs dropped during the past year, from 22,179 in FY 2015 to 1239 18,131 in FY 2016. This is the first time this figure has declined in five years of the Agreement’s 1240 implementation.

Bed Days

60,000 50,000 40,000 30,000 20,000 10,000
0

Figure-41: Inpatient Paid Bed Days by Facility Type

FY11-FY16

55,785

50,861

50,264

44,254

48,397

38,415

41,515

15,201

2,169

FY11

FY12

Blended Total

FY13 DPC-Total

FY14 IMD-Total

FY15 Total

20,302
18,131 3,082
FY16

1241

1242 Nevertheless, as of the end of FY 2016, IMD bed days were 19.3% higher than they were in FY 2011. 1243 Moving forward, it will be important for the State to closely monitor whether, in fact, FY 2016 showed 1244 the beginning of a new downward trajectory and, with the prospect of a new IMD opening in Sussex

25 Only non-forensic bed-days are counted.
74

1245 County, whether it can continue to reduce acute care hospitalizations for people with SPMI. Figure-41 1246 shows the so-called Blended hospitalizations, which reflect the total of initial hospital days in an IMD 1247 followed by hospital days in DPC, as being relatively flat over the course of implementation. All told, 1248 the bed days from DPC, the IMDs, and Blended hospitalizations that entail both DPC and an IMD have 1249 dropped from 55,785 in Fiscal Year 2011 to 41,515 in Fiscal Year 2016, a 25.6% reduction.

1250 Figure-42 combines hospitalizations among all facilities and presents aggregate data based upon length 1251 of stay for each year of implementation. It shows that Long Term hospitalizations dropped significantly 1252 between Fiscal Year 2011 and Fiscal Year 2014, a period during which the State was developing its 1253 array of intensive community services (such as Assertive Community Treatment) and Supported 1254 Housing. Since 2014, Long Term Care has pretty much leveled off. Both categories of Intermediate 1255 Care have remained relatively stable during the implementation period. Acute Care in the IMDs and 1256 DPC has increased and, consistent with the discussion above, appears to begin to drop in Fiscal Year 1257 2016.

1258

Bed Days

Figure-42: Inpatient Paid Bed Days by LOS Type

60,000

FY11-FY16

50,000

40,000

30,000

20,000

10,000

0

FY11

FY12

FY13

Acute (DPC, IMD, Blended) 0-14 Days

Intermediate II (DPC, IMD, Blended) 50-179 Days

Total

FY14

FY15

FY16

Intermediate I (DPC, IMD, Blended) 15-49 Days

Long-Term (DPC, Blended) 180+ Days

1259

75

1260 Table-12 provides additional information about the episodes of hospitalization for people transferred to 1261 DPC from an IMD; it responds to Measure 1c in Table-11. Table-12 shows DPC discharges during 1262 Fiscal Year 2016, including from blended hospitalizations where IMD transfers may have occurred 1263 during that year or earlier. Twenty-two such discharges following a blended hospitalization took place, 1264 with combined IMD and DPC hospital episodes ranging from 9 days to a high of 966 days. The Mean 1265 and Median data for these hospitalizations show that these extremes are, in fact, outliers. On average, 1266 blended hospitalizations lasted 134.9 days and the median number of days—that is, the number of days 1267 that 11 of these 22 individuals were hospitalized—is 59.0. By either measure, these are long 1268 hospitalizations, an outcome that is consistent with the premise that individuals who are transferred from 1269 IMDs to DPC have complex clinical issues that are not amenable to being resolved within the Acute 1270 Care periods to which IMD services are oriented.

1271

Table-12: DPC Lengths of Stay by Admission Type

FY16

Admission Type

n of Discharges

Mean Bed Days

Median Bed Days

Direct DPC

199

132.1

25.0

IMD Transfers Total

22

134.9

59.0

From Dover

10

236.3

66.0

From MeadowWood

3

160.3

57.0

From Rockford

9

114.3

61.0

Total

221

132.4

27.0

Range of Bed Days
2 - 6,470 9 - 966 9 - 966 37 - 387 23 - 413
2 - 6,470

1272 Table-13 concerns Measure 1d in Table-11, which relates to Blended hospital stays in which an 1273 individual is transferred from an IMD for longer term inpatient treatment a DPC. It shows that during 1274 Fiscal Year 2016, sixteen such individuals were transferred to DPC. The State calculates their lengths of 1275 stay as a single episode and, not surprisingly, virtually all of them (93.8%) remained hospitalized 1276 beyond the Acute Care period of fourteen days.

1277 Tables-12 and -13 include the data required in Measure 1b in Table-11, that is, the total number of 1278 individuals who were admitted to DPC from an IMD by IMD during Fiscal Year 2016 (16 individuals) 1279 and lengths of stay (which can only be determined once they are discharged—i.e., Table-12).

76

1280

Table-13: Lengths of Stay beyond 15 Days

for Direct DPC Admissions vs. IMD transfers

FY16

Admission Type

n of Admissions

n of Total LOS % of Total LOS

>=15 Days

>=15 Days

Direct DPC

193

128

66.3%

IMD Transfers Total

16

15

93.8%

From Dover

6

5

83.3%

From MeadowWood

3

3

100.0%

From Rockford

7

7

100.0%

Total

209

143

68.4%

1281 Table-14 presents data on how Blended hospital stays have trended during the course of the Agreement. 1282 Because the numbers are so small, calculations of changes from Fiscal Year 2011 to Fiscal Year 2016 1283 are not very meaningful for individual length-of-stay categories, but it is notable that there has been a 1284 27.5% reduction in the overall number of Blended hospitalizations during this period.

1285
Table-14: Number of Blended Hospitalization Episodes by Length-of-Stay Category FY11- FY16

Stay Type

FY11 FY12 FY13 FY14 FY15 FY16

Blended-Acute (0-14 Days) Blended-Intermediate I (15-49 Days) Blended-Intermediate II (50-179 Days) Blended-Long Term (180+ Days)
Blended-Total

3

3

0

2

1

22

7

13

26

7

1 % Change

(FY11-

8

FY16)

13

5

16

13

10

12

2

2

4

4

9

8

27.5%

40

17

33

45

27

29

Red.

1286 With respect to Measure 1e in Table-11, and as is presented above in Table-13, DPC reported a total of 1287 193 direct admissions during Fiscal Year 2016. These included individuals with complex needs and 1288 long histories of treatment at DPC who need additional hospital treatment, as well as individuals in need

77

1289 of Acute Care –particularly those who lack Medicaid or other insurance that would cover hospitalization 1290 at an IMD.

1291 Table-15 presents data that responds to Measures 1f and 1h in Table-11, that is, statistics relating to 1292 individuals who were directly admitted to DPC. Although the State maintains such data for other 1293 periods as well, this table includes information for Fiscal Year 2016 only. 30.2% of individuals 1294 discharged had durations of hospitalization that fell within the category of Acute Care (i.e., 14 days or 1295 fewer). 42.7% had Intermediate-I lengths of stay (15-49 days), 14.1% had Intermediate-II lengths of 1296 stay (defined as 50-179 days, but with a range of 51-170 days for these 28 individuals), and the 1297 remainder had hospital stays in excess of 180 days.

1298

Table-15: Discharges from DPC by Length of Stay Category

(Direct Admissions Only)

Fiscal Year 2016

Admission Type

Number of Discharges

Mean Bed Days

Median Bed Days

Range of Bed Days

Acute

60

9.2

9.0

2 - 14

Intermediate I

85

27.5

26.0

15 - 49

Intermediate II

28

86.3

70.5

51 - 170

Long Term

26

807.2

299.5

185 - 6,470

Total

199

132.1

25.0

2 - 6,470

1299 Figures-43, -44, and -45 clarify the meaning of these data. They present the distributions for lengths of 1300 hospitalizations in DPC and the IMDs within the categories of Acute Care, Intermediate-I, and 1301 Intermediate-II, respectively.26 In each figure, the horizontal lines (sometimes called the “whiskers”) 1302 show the range of bed days used during Fiscal Year 2016. The box represents the second and third 1303 quartiles within this range, and the vertical line indicates the median (the length of stay reflecting 50% 1304 of the individuals in the group). The mean, indicated by a diamond, is the average length of stay for the 1305 group. As is shown in Figure-43, the mean and median for Acute Care discharges from DPC are about 9 1306 days, or slightly longer than tends to be the case in the IMDs. It is likely that this difference is

26 Long Term Care discharges were not included because there is no defined upper limit to this category.
78

1307 attributable to the fact that the admission and discharge processes at DPC, which entail multidisciplinary 1308 assessments and formal team meetings, are more involved than those utilized within the IMDs.
Figure-43: Inpatient Bed Use Distribution Acute LOS Type, FY 16
IMD - Acute
DPC - Acute
-1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Hospital Days Mean
1309 1310 Individuals with Intermediate-I lengths of stay represent only a small fraction of hospital discharges 1311 from the IMDs. The number of discharges from IMDs in Fiscal Year 2016—2,554—is almost thirteen 1312 times larger than those from DPC (199), and virtually all of the hospitalizations in IMDs (95%) were for
Figure-44: Inpatient Bed Use Distribution Intermediate-I LOS Type, FY 16
IMD - Intermediate I

DPC - Intermediate I

10

20

30

40

50

60

Hospital Days

Mean

79

1313 Acute Care. Only about 5% of IMD discharges followed Intermediate-I lengths of stay. As is indicated 1314 in Figure-44, they tend to last only a few days longer than Acute Care. Figure-44 shows that within 1315 DPC, Intermediate-I hospitalizations tend to be around 26 or 27 days, and that three-fourths of the 1316 hospitalizations in this category (the right-hand side of the box represents three quartiles) are between 15 1317 and 35 days (49 days is the upper limit for this category).

1318 Intermediate-II lengths of stay (defined as from 50 to 179 days) are extremely rare in the IMDs. Only 2 1319 such instances occurred in Fiscal Year 2016.27 Figure-45 shows that three-quarters of the individuals 1320 whose inpatient stays fell into the Intermediate-II category were discharged within 110 days.

1321
Figure-45: Inpatient Bed Use Distribution Intermediate-II LOS Type, FY16
DPC - Intermediate II

1322

40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 Hospital Days
Mean

1323 Tables-16 and -17 present length-of-stay data for the IMDs similar to what was discussed above with 1324 respect to DPC, and which is included in Figures-43 and -44. Notable in Table-17 is that the number of 1325 hospitalizations extending beyond Acute Care is small, and that the Mean and Median of these 1326 hospitalizations (19.6 and 18.0, respectively) are only a few days beyond what would be considered 1327 Acute Care. Intermediate-II lengths of stay (beyond 49 days) is a rarity, reflecting only 0.1% of 1328 discharges.

1329

27 Because the number of Intermediate-II hospitalizations in IMDs is so small, their inclusion in the related distribution chart would not be meaningful.
80

1330

Table-16: IMD Length-of-Stay Statistics by Facility FY16

Admission Location

n of Discharges Mean Bed Days Median Bed Days

Range of Bed Days

IMD

2,554

7.2

6.0

0 - 69

Dover

626

8.3

7.0

0 - 69

MeadowWood

911

6.1

5.0

1 - 37

Rockford

723

7.8

7.0

0 - 54

IMD not identified

294

7.3

7.0

2-36

1331

1332

Table-17: IMD Statistics by LOS Type FY16

1333

Admission Type
Acute Intermediate I Intermediate II Total

n of Discharges
2,426 126
2
2,554

Percent of Discharges
95.0% 4.9%
0.1%
100.0%

Mean Bed Days 6.6 19.6
61.5
7.2

Median Bed Days 6.0 18.0
61.5
6.0

Range of Bed Days
0 - 14 15 - 47
54 - 69
0 - 69

1334

1335

2. Crisis Walk-In Centers

1336 The second set of measures relating to Crisis Stabilization concern the impact of the Crisis Walk-In 1337 Centers in evaluating individuals who are at immediate risk of hospitalization, providing crisis

1338 intervention and, as appropriate, diverting them from inpatient care. As is discussed in the section of 1339 this report dealing with provisions of the Agreement about Crisis Walk-In Centers, the State has an

1340 effective program operating in southern Delaware through the “living room model” of services, and it 1341 has just recently replaced its hospital-based walk-in center in northern Delaware with a parallel program.

1342 Because of the newness of the northern Delaware program, the State does not yet have data on its 1343 operations, but it does maintain and review comprehensive information about the Recovery Resource

81

1344 Center (RRC), which operates in Ellendale. Table-18 presents the State’s data relating to Measures 2a, 1345 2b, 2c, and 2d in Table-11 for Fiscal Years 2014 and 2015 (it has not yet analyzed data for Fiscal Year 1346 2016). It shows the increasing utilization of the RRC between these years, from 1,760 evaluations in 1347 Fiscal Year 2014 to 2,183 in Fiscal Year 2015. For both years, the rate of diversion from hospitalization 1348 has exceeded 70%.
1349 Dover Behavioral Health is the IMD serving southern Delaware. In past years, this and the other two 1350 IMDs have had substantial numbers of direct admissions for State-funded care of individuals with SPMI 1351 without prior screening and evaluation by a Crisis Walk-In Center. In some instances, such admissions 1352 have been approved by DSAMH, for instance when an individual is at an immediate and serious risk of 1353 self-harm that clearly cannot be addressed outside of a hospital. In other instances, individuals present 1354 themselves at IMDs for admission or various emergency entities (such as police or emergency 1355 departments of general hospitals) have initiated direct transfers. During the past year or so, the State has 1356 taken steps to ensure that, unless circumstances dictate otherwise, individuals are afforded RRC 1357 assessments before hospitalization occurs—particularly when such assessments are part of the civil 1358 commitment process.
1359 As was discussed earlier, Delaware’s mental health law provides for a 24-hour hold to determine 1360 whether an individual who is in crisis is in need of involuntary hospitalization and whether less 1361 restrictive measures are appropriate. In the past, such 24-hour assessments have occurred within IMDs 1362 where, for a variety of reasons, they virtually always culminated in hospitalization. By assigning this 1363 function to the RRC, the State has appropriately sought to distinguish a 24-hour assessment period from 1364 hospitalization itself, which increases opportunities for diversion. For this reason, Measures 2c and 2d 1365 in Table-11 examine IMD admission with and without prior evaluation at the RRC. As is reflected in 1366 Table-18, over 75% of IMD admissions in southern Delaware relating to members of the target 1367 population were first evaluated and approved by the RRC. Of those hospital admissions not pre1368 screened in this way, some direct admissions by IMDs were at DSAMH’s direction due to a risk of 1369 imminent harm. These are important measures of performance that the State plans to extend to the new 1370 RRC serving the northern part of the Delaware in that they provide opportunities to ensure that 1371 individuals are afforded the least restrictive care appropriate (in keeping with State and federal laws) and 1372 to drive further improvements in the system’s programs for early intervention and crisis prevention.
1373
82

Table-18: Southern Delaware Referral and Diversion Breakdown

FY14 FY15

Number of Individuals Evaluated at RRC Crisis Walk-In Center

1760 2183

Number Diverted from Hospitalizations

1386 1627

% Diverted

78.75% 74.53%

Number of Dover Behavioral Health IMD Admissions

476 730

Number of IMD Admissions Evaluated by RRC

374 556

% of IMD Admissions Evaluated by RRC

78.57% 76.16%

Number of IMD Admissions Not Evaluated by RRC

102 174

% of IMD Admissions Not Evaluated by RRC

21.43% 23.84%

1374

1375

1376

3. Engagement in Community Services

1377 The third set of new measures relating to Crisis Stabilization reflects the State’s efforts to reduce the risk 1378 of crises leading to hospitalization by engaging members of the target population in the network of 1379 community services comprised by the Agreement. Table-19 presents data on hospitalizations among the 1380 target population to an IMD or DPC during Fiscal Years 2015 and 2016 based upon individuals’ 1381 engagement in specialized community mental health services (through either PROMISE or DSAMH) at 1382 the time of hospital admission. The top half of the table presents data on all such hospital admissions 1383 during these periods; the lower half of the table reflects unduplicated data—that is, it takes into account 1384 that some individuals had more than one admission during a year. From either perspective, the findings 1385 of this analysis are striking. Individuals who are receiving specialized services have dramatically lower 1386 rates of admission than do those who are not receiving services such as ACT, Intensive Care 1387 Management, Supported Housing, and other services required by the Agreement. For instance, the 1388 unduplicated figures for Fiscal Year 2016 show that only 9.9% of hospitalizations involved individuals 1389 receiving specialized community services, 89.5% were not receiving these services, and a small number

1390

83

Table-19: Hospitalizations of Individuals Based on

Engagement with Specialized Mental Health Services

FY15 (Jan to FY16 (Jul to

Jun)

May)

n

%

n

%

Hospital Admissions

1775

2696

Hospital Admissions Relating to DSAMH/PROMISE Clients

247 13.9% 301 11.2%

Hospital Admissions Not Relating to DSAMH/PROMISE Clients

1528 86.1% 2395 88.8%

Clients Admitted to Hospitals (Unduplicated)

1339

1913

PROMISE Clients Admitted to Hospitals

159 11.9% 189 9.9%

Non-PROMISE Clients Admitted to Hospitals

1173 87.6% 1712 89.5%

Individuals Admitted to Hospitals both as nonPROMISE and PROMISE Clients

7 0.5% 12 0.6%

1391

1392 (0.6%) were enrolled in specialized services during the course of the year.28 Enrollment in PROMISE 1393 (or DSAMH) services entails a careful review by DSAMH of individuals’ clinical diagnoses and service 1394 needs. In other words, provider records of these individuals have been reviewed by DSAMH’s 1395 Eligibility and Enrollment Unit (EEU) to determine that, in fact, they have SPMI and that they have 1396 functional impairments that necessitate specialized services. That individuals with such documented 1397 levels of impairment represent such small numbers of hospital admissions—only 189 in Fiscal Year 1398 2016—reflects very positively on the overall effectiveness of Delaware’s programs to address the needs 1399 of inherently high-risk individuals, in keeping with the requirements and intent of the Agreement.

1400 Individuals not enrolled in PROMISE have been given diagnoses of SPMI (generally by IMDs), but 1401 either they have not been referred for PROMISE or the EEU has determined that they do not have SPMI 1402 or a need for specialized services. Monitor reports from past years noted that the State’s referral 1403 processes for specialized services was poorly coordinated and, in many respects, arbitrary. During the 1404 past two years, the State has made important improvements by creating clear triggers for referral, 1405 streamlining procedures for making referrals, and monitoring related quality indicators. Table-20

28 Most likely, their hospitalizations triggered referrals for PROMISE services.
84

1406 presents the cumulative number of referrals for specialized mental health services since PROMISE was 1407 launched in January, 2015, totaling 3,059 as of the end of the 2016 fiscal year. As the State’s enrollment 1408 processes became fully operational, the number of referred individuals awaiting PROMISE 1409 determinations dropped from 36.6% in December of 2015 to only 1% in June of 2016. Cases closed, 1410 including reviews determining that individuals are ineligible, have increased to almost 30%.

1411

Table-20: Breakdown of New PROMISE Referrals

1412

Cumulative Referrals

Clients Referred for Specialized Mental Health Services Clients Approved for Specialized Services Clients Closed (Ineligible, Refused, Moved, etc.) Clients Waiting Determination

As of 12/31/15

As of 4/30/16

As of 6/30/16

n

%

n

%

n

%

2137

2877

3059

873 40.9% 1808 62.8% 2117 69.2%

481 22.5% 713 24.8% 912 29.8%

783 36.6% 356 12.4% 30 1.0%

1413 Taken as a whole, Tables-19 and -20 document that the State is making significant progress in engaging 1414 individuals with SPMI with the intensive services they need to live in the community. These services 1415 for people determined to have significant disabilities appear to be effective in preventing their 1416 hospitalization. And, perhaps reflecting diagnostic practices in IMDs discussed earlier in this report, 1417 about 9 out of 10 hospitalizations occur with respect to people not receiving specialized services. While 1418 these individuals have been given SPMI diagnoses, either their diagnoses and service needs were not 1419 validated in EEU reviews, services were not implemented because of other factors (e.g., client refusal), 1420 or they were not referred. Because non-PROMISE clients account for about 90% of the State-funded 1421 hospital admissions (representing very significant public expenditures), and given the evident 1422 effectiveness of PROMISE services in preventing hospitalizations of individuals with SPMI, the State 1423 should redouble its efforts to understand why these admissions are occurring in such high numbers.

85

1424 Measure 3j in Table-11 concerns the timeliness of provider contact with members of the target 1425 population who are hospitalized. This issue was discussed above in the section “Community Provider 1426 Involvement,” and related statistics were presented in Figures-12 and 13.

1427 Measure 3k in Table-11 relates to the State’s progress in referring for specialized mental health services 1428 454 high-risk individuals, who were identified in 2014. As has been discussed in earlier Monitor 1429 reports, these individuals, who had multiple psychiatric hospitalizations, appeared to have clear needs 1430 for specialized mental health services but were not referred via the IMDs, MCOs, or another entity under 1431 the arrangements that were in effect at the time of their hospitalizations. In response (and also as 1432 discussed in past Monitor reports), the State launched an aggressive program of outreach and 1433 engagement, although due to the time lag since the hospitalizations occurred, it had only mixed results. 1434 As was discussed above, the State has since significantly improved its system for referring individuals 1435 with SPMI for specialized services and, for instance, if they come to be hospitalized, a referral for 1436 PROMISE is now assured. Furthermore, it has notified the MCOs of beneficiaries who were members 1437 of this high-risk group so that engagement efforts can occur even absent hospital admission. In light of 1438 these factors, Measure 3k in Table-11 is essentially subsumed by the other monitoring efforts discussed 1439 in this section.

1440

1441

4. Co-Occurring Substance Use Disorders

1442 As was referenced earlier, many informants have indicated that individuals who primarily have 1443 substance use disorders (SUD) were being admitted to IMDs and diagnosed with SPMI. While these 1444 individuals may have a need for intensive services, psychiatric hospitalization may not be the most 1445 appropriate course of treatment. Furthermore, for purposes of monitoring the Agreement’s provisions 1446 with respect to psychiatric hospital bed use by the target population, such admissions may artificially 1447 inflate inpatient numbers attributed to people with SPMI. With the intent of better positioning the State 1448 to address this issue, measurements were included to reflect the determination (upon hospital discharge) 1449 that individuals diagnosed with SPMI also have substance use issues. Figure-46 presents data from 1450 Fiscal Year 2011 through Fiscal Year 2016 reflecting the breakdown of hospital discharges of the target 1451 population with—and without—SUD diagnoses in addition to SPMI diagnoses. For Fiscal Years 2015 1452 and 2016, Figure-46 also includes information on whether or not individuals were receiving specialized

86

1453 mental health services (via PROMISE).29 It shows that SUD diagnoses represent increasing proportions 1454 of discharges between individuals with and without PROMISE, accounting for 37.7% of discharges in 1455 2015 (32.6% + 5.1%) and 39.2% (34.1% + 5.1%) in 2016. Furthermore, and in keeping with data 1456 discussed earlier, whether or not individuals have been diagnosed with SUD, individuals receiving 1457 PROMISE services account for only a small proportion of hospitalizations. In fact, for each of these 1458 fiscal years, only 5.1% of the hospital discharges related to individuals with SPMI (as vetted via the 1459 PROMISE eligibility process) and who also had SUD.
Figure-46: Hospital Discharges of People with SPMI based upon Co-occurring SUD Diagnosis and PROMISE Status

Proportion of Annual Hospital Discharges

65.2%

70.7%

69.0%

66.6%

59.5%

54.8%

6.15%

9.35%

1460

34.8%
FY11 SUD + PROMISE

29.3%

31.0%

33.4%

32.6% 5.12%

34.1% 5.07%

FY12

FY13

SUD + No PROMISE

FY14 No SUD + PROMISE

FY15

FY16

No SUD + No PROMISE

1461

1462

5. Homelessness

1463 Homelessness is an important risk factor for hospitalization, and is specifically referenced in the 1464 Agreement in defining priority populations for community services.30 The Target Priority Population 1465 List identifies 905 individuals who have histories of homelessness. While they represent 7.1% of the 1466 total number of individuals on the list, because these numbers may well be inflated by individuals who 1467 do not have SPMI (e.g., due to the diagnostic practices referenced earlier), they likely represent a larger 1468 proportion of the population to which the Agreement is directed. For instance, the Monitor’s regular

29 Enrollment information in DSAMH services predating PROMISE was not available. 30 Section II.B.2.f
87

1469 meetings with members of the target population find that self-reports of prior homelessness are very 1470 commonplace. As was discussed earlier with respect to the Agreement’s Supported Housing provisions, 1471 the State has consistently met or surpassed its requirements for funding integrated mainstream housing 1472 that prioritizes homeless individuals. Furthermore, DPC has been diligent in ensuring that homeless 1473 individuals are linked with housing, and it is now extremely rare and indicative of special circumstances 1474 when homeless individuals are discharged to shelters.

1475 In part because of the past diffuse oversight of referrals of Medicaid-covered individuals for specialized 1476 mental health services, homelessness was not being appropriately addressed for many individuals 1477 diagnosed with SPMI who were not served through DSAMH. Past reports of the Monitor described 1478 numerous instances in which such individuals were repeatedly admitted to IMDs, identified as homeless, 1479 and discharged back into homelessness. The State has since moved to aggressively remedy this situation 1480 and, with oversight by DSAMH and the MCOs, homeless individuals with SPMI are now regularly

1481

Table-21: IMD Housing Assessment Homelessness Breakdown

FY15 (Mar, Apr, Jun)

FY16 (Jul to Dec, Feb to Jun)

n

%

n

%

Hospital Admissions for State Funded Clients 947

2,524

Homeless

47 4.96%

160

6.34%

Receiving DSAMH Services

9 19.15%

20

12.50%

Referred for EEU/TCM

11 23.40%

57

35.63%

Referred for TCM Only

19 40.43%

68

42.50%

Discharged to shelters

8 17.02%

14

8.75%

Dover

1 12.50%

13

92.86%

MeadowWood

1 12.50%

1

7.14%

Rockford

6 75.00%

0

0.00%

1482

1483 identified by the IMDs and referred for services, either via PROMISE or Targeted Care Managers. 1484 Because of the significant linkage between homelessness and the risk of hospitalization, a set of

88

1485 indicators relating to the identification of homeless individuals and their referral for housing and other 1486 services was included in the revised format for measuring progress in reducing hospital bed use. Table1487 21 presents data relating to Measures 5a through 5f,31 as delineated in Table-11. With regard to the 1488 individuals discharged from IMDs to shelters, all were offered alternative services, but declined those 1489 services.

1490

1491

6. Hospital Readmissions

1492 In defining the priority service population, Section II.B of the Agreement identifies people with SPMI 1493 and histories of psychiatric hospitalization as at high risk of unnecessary institutionalization. Measure 1494 6a in Table-11 is the number of individuals within the target population who were discharged from DPC 1495 or an IMD during Fiscal Year 2015, Measure 6b concerns their rates of re-hospitalization, and Measure 1496 6c identifies the number of single and multiple readmissions during the year.

1497 Tables-22, -23 and -24 present the State’s analyses of discharges and readmission rates (i.e., Measures 1498 6a and 6b) for the Fiscal Years 2011, 2014, and 2015, respectively.32 The readmission rates are 1499 differentiated by the categories of lengths of hospitalization (i.e., Acute Care, Intermediate, etc.), as well 1500 as by the time periods since an individual’s date of discharge—1-30 days, 31-90 days, 91-180 days, and 1501 181-365 days. The readmission rates are calculated based upon an individual’s re-hospitalization in any 1502 facility, not necessarily the same facility in which earlier hospital care had been provided.33

1503 From year to year, there has been considerable variation in readmission patterns. In each year, 1504 readmission rates of people who were hospitalized for 14 days or fewer were highest during the first 1505 thirty days following discharge. Also notable, is that in every year the readmission rates of individuals 1506 who receive Long Term Care are low. In fact, in 2014, there were no readmissions of individuals who

31 As is indicated, data for some months is missing because of incomplete submissions by the IMDs. 32 Data for Fiscal Year 2016 was incomplete as of the time of this report. 33 Delaware’s data includes both its state-operated facility (DPC) and private psychiatric hospitals (IMDs). The most widely used national norms are compiled by the Substance use and Mental Health Services Administration of the Department of Health and Human Services, but they relate to state hospitals only. The 2015 SAMHSA national adult readmission rates for 30 days following discharge from a state hospital were 8.4%, and for 180 days were 18.9%. Reporting on DPC only, Delaware’s rates as reported to SAMHSA were lower than the national norms, at 7.7% and 10.7%, respectively. But unlike the data presented in this report, which include hospitalizations and readmissions (with state funding) to any facility, SAMHSA’s data reflects discharges from, and readmissions to, state hospitals only. The Monitor is not aware of any national norms that are comparable to the data presented here.
89

1507 had been hospitalized for 181 days or longer. Among people discharged in Fiscal Year 2015, two 1508 individuals were readmitted within 30 days of discharge following Long Term Care at DPC,34 and an 1509 additional readmission occurred between 31 and 90 days following discharge from DPC. No individuals 1510 who had received Long Term Care at DPC were readmitted that year following 91 days or beyond in the

Table-22: Inpatient Readmissions FY11

1-30 Days

31-90 Days 91-180 Days

181-365 Days

Number of

Discharges n

%

n

%

n

%

n

%

(FY11)

Acute

2334 308 13.20% 222 9.51% 175 7.50% 200 8.57%

Intermediate I

187 31 16.58% 14 7.49% 17 9.09% 9 4.81%

Intermediate II

51 4 7.84% 6 11.76% 2 3.92% 7 13.73%

Long Term

37 0 0.00% 0 0.00% 2 5.41% 1 2.70%

Total

2609 343 13.15% 242 9.28% 196 7.51% 217 8.32%

1511

Table-23: Inpatient Readmissions FY14

1512

1-30 Days 31-90 Days 91-180 Days 181-365 Days

Number of

Discharges n

%

n

(FY14)

%

n

%

n

%

Acute

2042 349 17.09% 231 11.31% 204 9.99% 236 11.56%

Intermediate I

238 44 18.49% 25 10.50% 20 8.40% 31 13.03%

Intermediate II

90 8 8.89% 6 6.67% 5 5.56% 8 8.89%

Long Term

27 0 0.00% 0 0.00% 0 0.00% 0 0.00%

Total

2397 401 16.73% 262 10.93% 229 9.55% 275 11.47%

34 As was indicated earlier, the IMDs do not provide Long Term Care so, although these tables do not identify the hospital, individuals readmitted following Long Term Care would have received that care at DPC.
90

Table-24: Inpatient Readmission FY15

1-30 Days 31-90 Days 91-180 Days 181-365 Days

Number of

Discharges n

%

n

%

n

%

(FY15)

n

%

Acute Intermediate I

2695 442 16.40% 312 11.58% 244 9.05% 203 7.53% 308 33 10.71% 42 13.64% 34 11.04% 25 8.12%

Intermediate II

56 9 16.07% 3 5.36% 3 5.36%

6 10.71%

Long Term

22 2 9.09% 1 4.55% 0 0.00%

0 0.00%

Total

3081 486 15.77% 358 11.62% 281 9.12% 234 7.59%

1513

1514 community. As was referenced earlier, this is an important accomplishment because of the clinical and 1515 social challenges affecting individual who require extended hospitalizations. Figure-47 provides a 1516 graphic representation of the readmission inpatient patterns following each category of hospitalization 1517 where discharges occurred during Fiscal Year 2015.

1518

% of Discharges following Rehospitalization

Figure-47: Rehospitalization Length-of-Stay Breakdown
FY15
20%

15%

10%

5%

1519 1520 1521 1522

0% 1-30 Days

31-90 Days

Acute

Intermediate I

91-180 Days Intermediate II

181-365 Days Long Term

Table-25 responds to Measure 6c in Table-11, presenting the number of single and multiple readmissions in Fiscal Years 2011, 2014, and 2015. DSAMH has a Quality Assurance initiative relating to individuals who have multiple readmissions, including those represented in this table. This study
91

1523 focuses on high-end users (at DPC and/or an IMD) with four or more hospitalizations, 30 days of 1524 inpatient care within a one-year period, or three hospital admissions within any 90-day period. The 1525 State’s scan of various data sources revealed that 41 individuals met one or more of these criteria within 1526 the 2015 calendar year (it regularly updates its list). DSAMH established a High-End User Review 1527 Committee that is monitoring the status of and treatment afforded to these individuals, and is guiding 1528 actions to reduce their use of inpatient care. The Committee, which meets monthly, has been evaluating 1529 aggregate data and solicited providers’ input as to strategies to mitigate the risk of readmissions. It will 1530 present its findings and recommendations to the DSAMH Steering Committee in September, 2016.
1531
Table-25: Readmission Counts (All Hospitals)

1532

Number of Readmissions
1 2 3 3+

FY11 Count
330 137 67 58

FY14 Count
381 169 74 71

FY15 Count
392 185 71 104

1533

7. Reliance Upon Court-Ordered Treatment

1534 Early reports of the Monitor described an over-reliance on court-ordered treatment, both for hospital 1535 care and on an outpatient basis. Individuals were regularly committed to outpatient treatment in the 1536 absence of clear legal criteria and with court orders that were not specific with respect to what they were 1537 actually required to do. Nevertheless, if a mental health professional determined that such individuals 1538 were not being “amenable” to treatment, a warrant could be issued for them to be taken into custody and 1539 hospitalized—apparently, even if civil commitment criteria were not met.

1540 Even before the long-overdue revisions in the State’s mental health laws were finalized, the State took 1541 affirmative measures to correct such practices to ensure that the individuals who have SPMI that it 1542 serves are afforded treatment through the least restrictive means appropriate and that involuntary 1543 treatment was no longer used as a matter of routine or convenience, or to leverage access to services.

92

1544 Figure-48 documents the State’s significant progress in reducing its reliance on involuntary inpatient 1545 and outpatient services for people with SPMI. Between Fiscal Year 2011 (when implementation of the 1546 Agreement began) and Fiscal Year 2016, the number of individuals subject to involuntary outpatient 1547 commitment decreased by 63.3% (from 328 to 121). Aside from the striking percentage change, this 1548 finding is important on several levels. First of all, these decreases occurred without apparent adverse 1549 consequences and coincided with the State making significant expansions and improvements in its 1550 community-based services for people with SPMI. Secondly, as is discussed in the next section, during 1551 this period the State dramatically increased its community placement of individuals receiving long-term 1552 care at DPC—that is, individuals who tended to remain hospitalized because of the significant levels of 1553 their disability, their clinical complexity, their intense service needs, and often their persistent 1554 problematic behavior. Finally, the absolute numbers of people receiving court-ordered outpatient 1555 treatment reduced as the overall number of people being served in the public system increased, from 1556 5,469 individuals receiving some sort of DSAMH service in Fiscal Year 11 to 7,892 individuals 1557 receiving such services in Fiscal Year 2015—a 44% increase.35 Thus, reductions in outpatient 1558 commitments as a percentage of individuals with SPMI being served is even more significant than is 1559 represented in Figure-48.

1560

Number of Individuals

Figure-48: Involuntary Inpatient and Outpatient

Commitments

Point-in-Time Averages By Fiscal Year

400

350

300

250

200

150

100

50

0

FY11 (Base

FY12

FY13

FY14

FY15

FY16

Year)

Average Involuntary Outpatients

Average Involuntary Inpatients

35 University of Pennsylvania Service Use Rates
93

1561 Involuntary hospitalizations have reduced, as well, but not as consistently or dramatically as the 1562 outpatient commitment rates. In Fiscal Year 2014, court ordered hospitalizations dropped by 41% 1563 relative to the year 2011, but the rate has since ticked up again and, as of Fiscal Year 2016, there is only 1564 a 6.1% reduction relative to the base year. The reasons for this are unclear, and given the State’s interest 1565 in moving towards a more recovery-oriented, voluntary model of services, court-ordered hospitalization 1566 rates should warrant further analysis and action. Overall, however, the State has made significant 1567 progress in reducing its reliance on coercive treatment since implementation of the Agreement began.

1568

1569

8. DPC Census

1570 The final quantitative measure relating to hospital bed-days used by the target population concerns the 1571 census at DPC. Figure-49 presents the average daily census for non-forensic patients at that facility for 1572 Fiscal Years 2006 through 2016. In Fiscal Year 2016, the average daily census for these individuals was 1573 76, which represent a 55.6% reduction from 2006 and a 42% reduction since 2010, just prior to 1574 implementation of the Agreement.

1575

Number of Inpatients

Figure-49: Average Daily Census DPC (Kent and Sussex Units)

200

180

IMPLEMENTATION OF AGREEMENT

160

BEGINS

140

120

100

80

60

40

20

0 SFY 2006 SFY 2007 SFY 2008 SFY 2009 SFY 2010 SFY 2011 SFY 2012 SFY 2013 SFY 2014 SFY 2015 SFY 2016

1576 The Agreement does not specifically require reductions in civil beds used at DPC, however, per the 1577 ADA, Olmstead, and other laws, it does require that individuals not be segregated in hospitals when they

94

1578 can be served in the community instead. The State’s reduction in its Long Term Care bed use at DPC, 1579 as well as its downsizing the number of civil beds reflect its own determination of hospital bed needs in 1580 light of the array of community services that it has developed in accordance with the Agreement.

1581

1582

9. Addressing Diagnostic Issues

1583 While individuals with SPMI can do well in the community (as is evidenced throughout this report), 1584 they generally require an array of community services and supports and, even with these supports, some 1585 may require brief re-hospitalizations. Recent data analyses from the University of Pennsylvania 1586 researchers show a surprising number of individuals who have been diagnosed with SPMI (often in 1587 association with hospitalization at an IMD), but then receive no subsequent treatment. Thus, although 1588 receiving hospital care ostensibly for SPMI, they are not referred for specialized mental health services 1589 through DSAMH, are not re-hospitalized, and do not receive generic mental health treatment through 1590 Medicaid providers. As was discussed earlier, several sources have suggested that there may be a 1591 significant population of individuals who are admitted to IMDs and misdiagnosed with SPMI when they 1592 actually have issues attendant to SUD. They may not be receiving appropriate services and, both for 1593 purposes of monitoring the Agreement and for the State’s QA/PI activities that will extend beyond the 1594 Agreement, these individuals may be distorting important data relating to the needs and outcomes of 1595 individuals who do, in fact, have SPMI. Accordingly, the State initiated a study of single-episode 1596 hospital utilization, which is examining case records of a sample of individuals who have diagnoses of 1597 SPMI upon discharge from an IMD, but who have no further encounters with the system for extended 1598 periods of time.

1599 The researchers report that about 24% of individuals diagnosed with SPMI and included on the TPPL 1600 have no treatment—inpatient, outpatient, or in an emergency department—in the two years following 1601 their initial identification. Furthermore, as is presented in Figure-50, over five years, these individuals 1602 account for almost 40% of the TPPL.36

36 As was referenced earlier, the University of Pennsylvania and the State’s criteria for inclusion on the TPPL vary somewhat.
95

1603

Number of clients

Figure-50: Members of the TPPL Receiving No Inpatient,

Outpatient, or ED Services

2009-10

8000

(n=5630)

7000 6000 5000 4000 3000

2010-11 (n=7876)
2011-12 (n=10210)
2012-13 (n=12662)

2000

2013-14

1000

(n=15018)

0

2014-15

(n=16830)

1604 Because these findings are not consistent with what would be expected for individuals who have SPMI, 1605 they are being used by the State to better understand how these individuals come to be admitted to IMDs 1606 and so diagnosed, and whether their service needs would be more appropriately addressed in other ways. 1607 A preliminary analysis of some individuals who were included on the TPPL in Fiscal Year 2011 (i.e., 1608 2010-11 in the Figure above) and who had further treatment in the subsequent four years found that, co1609 occurring with SPMI diagnoses, 16.7% had primary discharge diagnoses of substance or alcohol use, 1610 40% had these as secondary diagnoses, and 33.3% had these as a third discharge diagnoses. All of these 1611 factors support the importance of the State continuing to evaluate whether in fact these individuals are 1612 being appropriately diagnosed and served and the degree to which they are distorting hospitalization 1613 rates (and costs) and other outcomes that are being attributed to individuals with SPMI. The State’s 1614 initial approach was to identify a sample of these individuals and to conduct thorough reviews of their 1615 clinical records within IMDs and, as may be applicable, with other service providers involved in their 1616 hospitalization. The intent was to clarify the trajectory leading individuals to hospital care and to begin 1617 to identify opportunities for diversion accordingly. Unfortunately, the State encountered difficulties in 1618 accessing the sample’s clinical records; it is now exploring alternative strategies for this important 1619 effort. 1620

96

1621 As has been presented in this section, the State is carrying out extensive QA/PI activities and it is now 1622 doing so in a comprehensive way, using the Quality Control Steering Committee as its coordinating 1623 body. It is in Substantial Compliance with Section V.A of the Agreement (relating to a Quality 1624 Assurance and Performance Improvement System), as well as with Contracting (Section V.C), Quality 1625 Service Reviews (V.D), and Use of Data (V.E), which are closely related.
1626

1627 XIV. Risk Management

1628

Substantial Compliance.

1629 The ninth Monitor’s report found the State to be in Partial Compliance with regard to Risk Management, 1630 but noted that it was taking steps to meet the requirements of the Agreement, as delineated in Section 1631 V.B. The State’s essential problem was not so much that it lacks risk reduction programs, but that these 1632 functions are spread across various agencies and have not had a clear mechanism for integrated analysis. 1633 With respect to the Agreement, this has been a particular problem in the IMDs, where most of the 1634 hospital admissions of the target population occur. Reporting of complaints and adverse events in IMDs 1635 depends upon which agency has jurisdiction:

1636

1637

a. DSAMH receives reports for incidents which occur within an IMD for all individuals

1638

who receive services through DSAMH, as required by its contracts with community

1639

providers.

1640

b. DMMA, via its contracted MCOs, receives reports for incidents which occur within an

1641

IMD for all individuals whose care is paid for by DMMA, as required by DMMA’s

1642

contracts with the MCOs. DMMA also requires IMDs to provide incident reports

1643

directly to the Division for those individuals receiving Medicaid on a fee-for-service

1644

basis.

1645

c. The Division of Long Term Care Residents Protection (DLTCRP) receives reports from

1646

IMDs related to incidents of abuse, neglect, mistreatment, or financial exploitation.

97

1647

Delaware law requires IMDs to report such incidents to the DLTCRP, and dictates the

1648

DLTCRP’s response.

1649

d. The Department of Public Health (DPH) conducts hospital surveys on behalf of the

1650

federal Centers for Medicare and Medicaid Services and receives reports from IMDs

1651

when deaths occur due to the use of seclusion or restraint.

1652 What the State lacked was a central clearinghouse where analyses of risks and adverse events affecting 1653 the target population could occur with the collective involvement of all responsible agencies and through 1654 which patterns of risk could be identified and addressed systemically. As was discussed in the 1655 Monitor’s ninth report, in the Spring of 2016, the State put into effect memoranda of understanding 1656 affecting DSAMH, DMMA, DLTCRP, and DPH to ensure information-sharing relating to risk 1657 management. Furthermore, it is now convening Incident Review Meetings and Quality Control Steering 1658 Committee Meetings where risk management information relating to the target population is being 1659 consolidated and discussed with multi-agency input. The State has provided information and otherwise 1660 taken appropriate action in accordance with the recommendations regarding risk management that were 1661 included in the ninth Monitor’s report. Finally, the Peer Review Subcommittee relating to Senate Bill 1662 245, referenced early in this report, is charged with examining critical incident reports and root cause 1663 analyses relating to the target population.
1664 In summary, the State has taken significant measures to unify its risk management processes relating to 1665 the target population and, given that oversight of these functions by the Peer Review Subcommittee is 1666 now enshrined in law, the improvements it has put into place are likely to continue. The State is rated as 1667 being in Substantial Compliance with the Agreement’s Risk Management requirements.
1668
1669 D. Conclusion
1670 This report has detailed the State of Delaware’s successful efforts to meet the requirements of the 1671 Settlement Agreement it entered into with the U.S. Department of Justice in 2011 with the goal of 1672 promoting recovery and community integration of individuals with Serious and Persistent Mental Illness 1673 whom the State serves. The Monitor’s finding that the State is in Substantial Compliance with the
98

1674 Agreement is based not only upon the extensive data presented here, but also upon the self-reports of 1675 individuals served by the Delaware’s public mental health system, such as those presented at the 1676 beginning of this report.

1677 The Monitor’s first report, issued January 30, 2012, included the following observation with regard to 1678 implementation of the Agreement:

1679

1680

It is obviously too soon to predict the ultimate success of this endeavor. Stakeholders

1681

frequently remind the Monitor that they have witnessed a succession of prior

1682

investigations, failed reform efforts, short-sighted decisions and unfulfilled promises

1683

relating to Delaware’s mental health system. They express genuine interest in the

1684

wellbeing of citizens with SPMI, tempered by some skepticism—perhaps, well-founded,

1685

given these experiences—as to the ultimate meaning of this newest “fix”.

1686

Overwhelmingly, their concern is not so much about whether the positive outcomes

1687

required by the Settlement Agreement are achievable, but rather whether the effort will be

1688

sustained, whether innovation will be encouraged, whether bureaucratic loopholes and

1689

challenges will be corrected, and whether the resources needed to allow individuals with

1690

SPMI to live and thrive in integrated community settings will remain available over time.37

1691

1692 As is discussed throughout this report, there is ample evidence that, over these five years, the positive 1693 outcomes required by the Agreement (and the Americans with Disabilities Act, the Olmstead decision, 1694 and other laws on which the Agreement is based) have been significantly achieved for people with 1695 SPMI. Furthermore, the sustainability of these outcomes is supported by changes in the State’s laws, 1696 administrative structures, reimbursement mechanisms, and service culture. It is also supported by a 1697 large, engaged, and vocal constituency including individuals with SPMI who are served by the system, 1698 their families and friends, Delaware’s peer movement, providers, and other stakeholders. The State’s 1699 now impressive data systems allow these constituents to examine service outcomes, to hold public 1700 programs accountable, and to recognize innovation and success. The State’s services for people with

37 Page 2.
99

1701 SPMI are not flawless, but there is increasing unity and momentum regarding the goal of enabling these 1702 individuals to move from the social margins and to live as ordinary Delawareans as full members of 1703 their communities. 1704 1705 1706 Robert Bernstein, Ph.D. 1707 Court Monitor
100

APPENDICES 101

P-Dx Cde Formal
F20.81 F20.9 F20.90 F21 F21.0 F21.00 F22 F22.0 F22.00 F25 F25.0 F25.00 F25.1 F25.10 F29 F29.0 F29.00 F31 F31.0 F31.00 F31.11 F31.12 F31.13 F31.2 F31.20 F31.31 F31.32 F31.4 F31.40 F31.5 F31.50 F31.73 F31.74 F31.75 F31.76 F31.81

Appendix-A
Diagnoses Indicative of Serious and Persistent Mental Illness
used in Constructing the Target Priority Population List
P-Dx Literal
Schizophreniform disorder Schizophrenia Schizophrenia Schizotypal personality disorder Schizotypal personality disorder Schizotypal personality disorder Delusional disorder Delusional disorder Delusional disorder Schizoaffective disorder, Bipolar type Schizoaffective disorder, Bipolar type Schizoaffective disorder, Bipolar type Schizoaffective disorder, Depressive type Schizoaffective disorder, Depressive type Unspecified schizophrenia spectrum and other psychotic disorder Unspecified schizophrenia spectrum and other psychotic disorder Unspecified schizophrenia spectrum and other psychotic disorder Bipolar I disorder, Current or most recent episode hypomanic Bipolar I disorder, Current or most recent episode hypomanic Bipolar I disorder, Current or most recent episode hypomanic Bipolar I disorder, Current or most recent episode manic, Mild Bipolar I disorder, Current or most recent episode manic, Moderate Bipolar I disorder, Current or most recent episode manic, Severe Bipolar I disorder, Current or most recent episode manic, With psychotic features Bipolar I disorder, Current or most recent episode manic, With psychotic features Bipolar I disorder, Current or most recent episode depressed, Mild Bipolar I disorder, Current or most recent episode depressed, Moderate Bipolar I disorder, Current or most recent episode depressed, Severe Bipolar I disorder, Current or most recent episode depressed, Severe Bipolar I disorder, Current or most recent episode depressed, With psychotic features Bipolar I disorder, Current or most recent episode depressed, With psychotic features Bipolar I disorder, Current or most recent episode manic, In partial remission Bipolar I disorder, Current or most recent episode manic, In full remission Bipolar I disorder, Current or most recent episode depressed, In partial remission Bipolar I disorder, Current or most recent episode depressed, In full remission Bipolar II disorder

102

F31.89 F31.9 F31.9 F31.9 F31.9 F31.9 F31.90 F33.1 F33.10 F33.2 F33.20 F33.3 F33.30 F33.41 F33.42 F33.9 F33.90 F60 F60.0 F60.00 F60.1 F60.10 F60.3 F60.30

Other specified bipolar and related disorder Bipolar I disorder, Current or most recent episode hypomanic, Unspecified Bipolar I disorder, Current or most recent episode manic, Unspecified Bipolar I disorder, Current or most recent episode depressed, Unspecified Bipolar I disorder, Current or most recent episode unspecified Unspecified bipolar and related disorder Bipolar disorder Major depressive disorder, Recurrent episode, Moderate Major depressive disorder, Recurrent episode, Moderate Major depressive disorder, Recurrent episode, Severe Major depressive disorder, Recurrent episode, Severe Major depressive disorder, Recurrent episode, With psychotic features Major depressive disorder, Recurrent episode, With psychotic features Major depressive disorder, Recurrent episode, In partial remission Major depressive disorder, Recurrent episode, In full remission Major depressive disorder, Recurrent episode, Unspecified Major depressive disorder, Recurrent episode, Unspecified Paranoid personality disorder Paranoid personality disorder Paranoid personality disorder Schizoid personality disorder Schizoid personality disorder Borderline personality disorder Borderline personality disorder

103

Appendix-B Community Living Questionnaire
104

105

106

107

108

109

110

111

112

Appendix-C CRISP Interview
113

114

115

116

117

118

119

120

121

122

123

 
 Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 1 of 24 PageID #: 680

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE

UNITED STATES OF AMERICA, :

:

Plaintiff,

:

:

v.

:

:

STATE OF DELAWARE,

:

:

Defendant.

:

Civil Action No. 11-591-LPS

JOINT BRIEF IN SUPPORT OF THE PARTIES’ JOINT MOTION TO DISMISS
The parties jointly move the Court to enter an order to dismiss this case with prejudice because the State has substantially complied with the terms of the remedial Settlement Agreement, as described below, entered as an order of the Court on July 18, 2011. D.I. 7.
The State has implemented reforms that have transformed its service-delivery system for people with serious and persistent mental illness (“SPMI”), greatly expanded and enhanced capacity to deliver community-based services, minimized reliance on segregated institutional services, and generally improved outcomes for people with SPMI in Delaware. The State is now on a trajectory to achieve even further progress within its service system to enable people with SPMI to continue to live successfully in their homes and not subject them to unnecessary institutional segregation. To ensure sustainability of its efforts, the State recently enacted legislation that ensures the reform efforts will continue without court oversight. The independent court monitor found the State in compliance with all provisions of the Settlement Agreement, as detailed more fully in the attached Tenth Report of the Court Monitor, D.I. 182. This case is a success story.

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 2 of 24 PageID #: 681
I. BACKGROUND AND PROCEDURAL HISTORY A. Court-Ordered Settlement Agreement
On November 9, 2010, the United States sent a Letter of Findings to Governor Jack Markell detailing systemic conditions and practices that it found violated the constitutional and statutory rights of individuals with mental illness in the State’s mental health system. The United States found that the State’s mental health system failed to provide services to individuals with mental illness in the most integrated setting appropriate to their needs, as required by the Americans with Disabilities Act (“ADA”) and Olmstead v. L.C., 527 U.S. 581 (1999), which resulted in needless prolonged institutionalization of many individuals with disabilities in the Delaware Psychiatric Center (“DPC”) who could be served in the community, and also identified numerous other deficient practices at DPC in violation of the U.S. Constitution.
The parties agreed that the ADA and Olmstead require the delivery of public services in the most integrated setting appropriate to individuals served by the State’s mental health system and recognized that any remedy that focused solely on the conditions at DPC could divert resources away from building the necessary community capacity to serve Delaware citizens with mental health disabilities without unnecessary institutionalization. Therefore, the parties reached a settlement agreement (“Agreement”) that focused on building community capacity and required the State to significantly expand and enhance community-based mental health services to ensure positive individual outcomes in integrated settings. D.I. 7. The Agreement emphasized the need to transition institutionalized people to the community and prevent people at risk of institutionalization from entering institutions. Id.
The Agreement specified a target date of five years for Delaware to fully implement all requirements and specified that the Court was to retain jurisdiction until the State implemented all Agreement provisions and demonstrated sustained compliance of those provisions for one

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year. D.I. 7 at Section VII.A.2. On July 18, 2011, the Court entered the Agreement as an order of the Court. D.I. 7.
B. Independent Court Monitor The Agreement provides for independent oversight and compliance reporting by a court monitor. Id. at Section VI. Robert Bernstein, Ph.D., has served in this role since the inception of the Agreement. Dr. Bernstein has conducted regular in-depth reviews of the State’s mental health system, including onsite reviews at DPC, private institutions for mental disease (“IMDs”),1 and various community providers. He has issued compliance reports twice annually, which detail the State’s progress on complying with the Agreement. In his latest report, Dr. Bernstein reviewed the State’s history of compliance, highlighting many areas where the State exceeded the standards set forth in the Agreement. D.I. 182, Tenth Report of the Court Monitor (“Tenth Report”). He concluded that the State has achieved substantial compliance with all provisions in the Agreement and has demonstrated a year’s sustained compliance for nearly all provisions in the Agreement. Id. at ln. 257, 261-62. For the few provisions where the State has not achieved a full year of sustained compliance, Dr. Bernstein identified other assurances which demonstrate that the State’s compliance will be sustained.2 II. INTEGRATED COMMUNITY SERVICES The principal requirement of the Agreement is to achieve the goals of the ADA and Olmstead: to ensure that people with mental health disabilities in Delaware can live at home in their communities and avoid unnecessary segregation in institutions like DPC. The Agreement
1 The IMDs currently serving the target population are Dover Behavioral Health, MeadowWood Behavioral Health, and Rockford Center. 2 The State has only recently come into compliance with two provisions relating to crisis stabilization and risk management, although it earlier reached and sustained compliance with the majority of provisions related to these critical elements.

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 4 of 24 PageID #: 683
requires the State to prevent unnecessary institutionalization of individuals with SPMI by offering intensive community-based services to those individuals.3 D.I. 7 at Section II.A. Since entry of the Agreement, the State has put in place sufficient and appropriate community-based mental health services to assist individuals with SPMI to live successfully in the community without unnecessary hospitalization at DPC. The State also has demonstrated the ability to collect relevant data, recognize key trends from the data, and respond to those trends with targeted resources. When a breakdown occurs in the State’s system—an inevitability in any multifaceted organization—the State is able to quickly and appropriately respond. As a result, individuals with SPMI in Delaware are now able to live in their homes without unnecessarily entering segregated institutions, reflecting the key tenets of the ADA and Olmstead.
These systemic reforms have resulted in dramatic improvements in the lives of many individuals with SPMI. One Delawarean with SPMI, who was chronically homeless for decades, hospitalized dozens of times and diagnosed with paranoid schizophrenia, and who now lives in a supported apartment subsidized by the State, recently wrote to the United States and Dr. Bernstein:
This letter is being typed to you to tell you how much I appreciate what you all have done to make it possible for me to live in a safe neighborhood and have my own home! . . . In my spare time I can do pretty much what I want to. . . . I don’t have to worry about threats from outside sources. It is pretty quiet here, and people don’t bother you. I have even chatted with the children who live at this development. They are polite and willing to communicate. . . . Well, I don’t know what else to say; but I just had to thank you all from the bottom of my heart for your mercy and help. Another Delawarean with SPMI, who grew up in the foster care system and became involved in gang activities at an early age, reported to the United States that she used to be depressed and 3 Section II.B of the Agreement defines the population to be served, as well as specific subpopulations who are prioritized based on their elevated risk of institutional segregation. D.I. 7.

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 5 of 24 PageID #: 684
suicidal. Beginning in fifth grade, she tried to kill herself on multiple occasions and was admitted to DPC. She now receives intensive community-based mental health services from the State and especially relies on her peer support specialist to help her through difficult times. She described being “afraid of life for a long time,” but now she “really believes in the State [of Delaware] and before I didn’t.” These individuals have made substantial progress and are now on the path to recovery.
These positive outcomes are reflected in the State’s data as well. Since entry of the Agreement, the State has significantly reduced its reliance on institutional care, particularly at the state-run DPC. For instance, it has reduced the number of bed days used by the target population in DPC by 47.2% since entry of the Agreement in 2011. D.I. 182 at ln. 1230-32. These reductions have mostly occurred with regard to long-term stays (a 55.3% reduction from FY 2011), but were realized for shorter stays as well. Id. at ln. 1232-34. Additionally, the overall bed days at DPC and the private IMDs have dropped by about 26% since entry of the Agreement. Id. at ln. 1247-49. The average daily census at DPC for the target population in Fiscal Year 2016 was 76, reflecting a 42% reduction since 2010, just prior to implementation of the Agreement. Id. at ln. 1572-74. For the most part, individuals who were hospitalized in DPC at the start of the Agreement are now living successfully in the community; indeed, individuals who are receiving services under the Agreement through the State’s Division of Substance Abuse and Mental Health have dramatically lower rates of hospital admissions than those who are not receiving those services. Only 9.9% of hospitalizations in Fiscal Year 2016 involved individuals receiving services under the Agreement. Id. at ln. 1387-89. Finally, the State reports that the number of Medicaid-eligible Delawareans receiving community-based services has increased by 92% since the United States began its investigation.
Despite these successes, not all of the State’s data reflects perfection nor is that an

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expectation of the Agreement. What makes the State’s system work, however, is that the State tracks data, analyzes the data, and uses the data to drive programmatic and systemic decisionmaking. For instance, when the State identified increased emergency department utilization rates among people with SPMI and also saw that the overwhelming number of referrals to its mental health crisis walk-in centers (74.2%) come from emergency departments, it changed its training for emergency responders. Id. at ln. 406-17. Emergency responders are now trained to bypass emergency rooms, when appropriate, and take an individual in a mental health crisis directly to a crisis walk-in center (designed for individuals whose crisis does not require hospitalization). The State’s commitment to using data to drive its decision-making strongly suggests that it is on a trajectory to sustain the progress it has made and achieve further success.
A. Delaware has a well-functioning robust crisis system The Agreement requires the State to develop a robust mental health crisis system to respond to individuals in a mental health crisis, which the State has successfully implemented and maintained for years: it now has a crisis line for use 24 hours per day, 7 days per week; two mobile crisis teams (one in New Castle and one in Kent and Sussex Counties) that respond to a person in a mental health crisis within one hour of a call; two “living room model” crisis walk-in centers (one in New Castle and the other in Sussex County); 21 crisis apartment beds; and 3 targeted care management teams. Id. at ln. 283-85, 313-14, 431-33, 580-82, 728-29. The State’s crisis system has achieved notable success. The mobile crisis teams typically divert 80% to 90% of people they encounter from hospitalization and criminal justice interaction. Id. at ln. 388-90. The crisis walk-in center in Sussex County, which has an average length of stay of less than 23 hours, usually diverts about 70% of people from further hospitalization or criminal justice interaction. Id. at ln. 379, 390-91. The walk-in centers report that it takes law enforcement officers on average less than 10 minutes to drop-off an individual in a mental health

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 7 of 24 PageID #: 686
crisis, which motivates officers to divert individuals to a walk-in center rather than take them to an emergency room or jail, where booking is a much lengthier process.
Another important part of Delaware’s crisis system is its ability to immediately link individuals who are not service connected to critical services within hours of a mental health crisis. The State has developed 3 targeted care management teams to connect individuals, many of whom are homeless, to housing, community-based mental health services, and other critical resources upon discharge from a crisis walk-in center, DPC, or IMD. Id. at ln. 728-29. To encourage a seamless transition, targeted care management teams are co-located at the crisis walk-in centers and DPC.
Despite these impressive achievements, as discussed further in Section III below, the State has not successfully reduced the number of acute in-patient bed days at the IMDs, as required by Sections III.D.3-4 of the Agreement. D.I. 7; see also D.I. 182 at ln. 517-519. As the court monitor indicated in his Tenth Report, “notwithstanding the State’s success in meeting— and, in some instances, surpassing the requirements of the Agreement with regard to developing comprehensive community services, as well as its efforts . . . to address some of the structural issues affecting hospital bed use by the target population[—]realistically it would not be able to meet the targets contained in Section III.D.3-4 any time soon.” D.I. 182 at ln. 552-56. It is clear from the data, court monitor’s qualitative reviews, and successful outcomes for individuals, however, that the State has put in place a system that addresses the needs of people with SPMI; indeed, people with SPMI are no longer unnecessarily institutionalized in the state-run psychiatric hospital. Recognizing the overall quality of the State’s service system and in reliance on the independent court monitor’s recommendation that alternative measures could document the State’s efforts to reduce unnecessary psychiatric hospital bed use without compromising the intent of the Agreement, the parties agreed on additional measures of compliance. Id. at ln. 560-

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 8 of 24 PageID #: 687
63, 1208. The State is now undertaking an aggressive quality assurance and improvement initiative to better understand and address factors that are contributing to the short-term psychiatric hospitalizations of people with SPMI. Id. at ln. 565-66, 1197-1201. The initial review has raised questions about whether the increased utilization even includes people with SPMI; the preliminary review showed a considerable number of misdiagnoses as SPMI when, in fact, individuals had other conditions. The State’s action to address the issue, as discussed more fully below in Section III, demonstrates its continuing commitment to improving its system to further the goals of Olmstead and the ADA.
B. Delaware has exceeded the Agreement’s requirements related to Assertive Community Treatment and Intensive Case Management
The Agreement required the State to create 11 Assertive Community Treatment (“ACT”) teams that operate with fidelity to an evidence-based practice model, the Tool for Measurement of Assertive Community Treatment (“TMACT”),4 and 4 intensive case management (“ICM”) teams. D.I. 7 at Sections III.F, III.G. The State has exceeded and sustained compliance with these provisions of the Agreement.
In Fiscal Year 2016, the State had operational 15 ACT teams and 2 ICM teams,5 thus exceeding the number and intensity-level of teams required by the Agreement. D.I. 182 at ln. 662-63. Collectively, these teams serve about 1,700 individuals at any given time. The ACT teams are evaluated and scored at least annually on the TMACT. Id. at ln. 675. When teams are unable to meet the TMACT requirements, the State has taken corrective actions, including, when
4 The Agreement specifies use of the “Dartmouth Model,” but early on the parties agreed that the State could use the Tool for Measurement of Assertive Community Treatment instead. D.I. 182 at ln. 625-29. 5 With the consent of the Monitor and United States, the State converted 2 ICM teams to ACT teams in order to provide a more intensive level of service. Id. at ln. 632-34.

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 9 of 24 PageID #: 688
necessary, closing a team and transferring responsibility to another provider. Id. at ln. 675-81. The State also conducts its own quality reviews of the ACT and ICM programs, including measuring and tracking outcomes such as the average number of individuals receiving ACT or ICM services who (1) spent at least one night in a motel; (2) who were arrested; and (3) who were hospitalized in a given month. Id. at ln. 690-713.
Apart from the Agreement, Delaware also implemented the Community Reintegration Support Project (“CRISP”) to provide community-based mental health services to individuals with the most difficult and complicated needs. Id. at ln. 637-40. CRISP serves 100 high-need individuals, many of whom had been long term residents or frequently readmitted to DPC, and is designed to give providers the flexibility to offer creative and individualized community mental health supports based upon the individualized needs of each individual. CRISP provider contracts are structured to incentivize positive outcomes for individuals in the community, and contain a financial incentive to avoid unnecessary hospitalization. Id. at ln. 640-45. Individuals in the CRISP program report increased satisfaction and community integration. One individual stated, “The case [managers] I have, they treat me with respect, which is something no one’s ever done before.” Another individual reports “doing more independent things like going to the store by myself, shopping on my own, doing grocery shopping on my own. Things like that.” And others note that they are no longer in “the hospital anymore, which is a good thing” or “not in prison anymore. It helped me stay out of prison.” Given that individuals receiving CRISP services, many of whom were institutionalized for years, require the highest level of care, this is truly a remarkable transformation.
Delaware engaged a team of researchers from the University of Pennsylvania, Center for Mental Health Policy and Services Research (“UPenn”) to review the CRISP program. The research confirmed that “[o]verall, CRISP individuals have transitioned successfully to

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 10 of 24 PageID #: 689
community living and feel that they are part of their community.” They found that individuals in the CRISP program showed increasingly positive outcomes in the community, including in domains of “control over one’s life,” “feelings of self-worth,” and “social connectedness.” DOJ Br. Number 3: CRISP, Ex. 1, at 2.
The positive results of community services created under the Agreement are felt by the individuals who receive them every day. Individuals who spent much of their lives segregated in institutional settings due to a mental health disability now report that they live at home and are sufficiently supported by their service provider. For example, one individual who lives in southern Delaware and grew up in the foster care system, described being physically abused by his father and removed from his family home when he was four years old. He has been hospitalized multiple times throughout his life for a mental health condition, spent 11 months in jail for a DUI, and periodically experienced homelessness. After the Agreement went into effect, he began to receive intensive services from a community service provider he describes as “excellent” and “focus[ed] on individuals’ real needs.” This Delawarean now lives in his own home, is sober, and has become involved in a peer-run drop-in center funded by the State. This is but one of many success stories made possible by Delaware’s implementation of the Agreement.
C. The State has a strong permanent supported housing program Supported housing is an important service for individuals with SPMI, who often have extensive histories of institutionalization in hospitals, criminal justice settings, or congregate mental health residential facilities and is essential to realizing the goals of the ADA and Olmstead by supporting individuals with SPMI in their own homes. Under the Agreement, the State is required to provide housing vouchers or subsidies and bridge funding to anyone in the target population who needs such support. D.I. 7 at Section II.E.2.b. The State has developed

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“an impressive program that has not only met the annual targets of the Agreement’s provisions, but it has also changed the service culture for individuals who have SPMI and with respect to the requirements of Olmstead.” D.I. 182 at ln. 935-37. Delaware has created a system that makes integrated housing the “default.” The State prioritizes individuals’ housing preferences and preferred living arrangements, rather than simply “slotting” them into an available spot. As a result, housing stability has increased year-over-year since implementation of the Agreement such that individuals are remaining permanently housed for longer periods of time. Id. at ln. 929-32. Further, the State funded 812 permanent supportive housing vouchers in Fiscal Year 2016, exceeding the Agreement’s targets. Id. at ln. 879. While there are some individuals on the waitlist for housing, the State has appropriately identified individuals in need of housing and its waitlist is moving at a reasonable pace, consistent with the requirements of Olmstead. Id. at ln. 898-903.
D. Delaware has a growing workforce of individuals in the target population The State has provided supported employment services to thousands of individuals with SPMI in the target population, meeting the requirements of the Agreement. D.I. 7 at Section III.J; D.I. 182 at 978-79. Although the percentage of people in the target population who are employed is 15%, the State continues to expand work opportunities for people with disabilities. Id. at ln. 996. The number of people in the target population who are employed has increased four-fold since Fiscal Year 2014, suggesting that the State’s efforts and prioritization of supported employment are paying off. Id. at ln. 992-93. Additionally, the State actively funds and supports other meaningful day activities for individuals with SPMI, including through the Creative Vision Factory in downtown Wilmington, a peer-run art studio that supports recovery through the arts, and the ACE Center in Seaford, a peer-run drop-in center that focuses on fellowship and well-being. Id. at ln. 1047-49.

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E. The State provides family and peer supports to the target population The Agreement requires Delaware to provide family or peer supports to a total of 1,000 individuals. D.I. 7 at Section III.L. Delaware has exceeded this target in more ways than one. Delaware reports 2,383 average monthly peer contacts in Fiscal Year 2016. D.I. 182 at ln. 1063. The majority of those contacts occur within ICM or ACT teams, not including other contacts individuals may have at peer-run drop-in centers like the Creative Vision Factory or ACE Center. Id. at ln. 1063. Even more importantly, however, Delaware has fully integrated peers into its delivery of mental health services, both inpatient and in the community: peers orient individuals upon their admission to DPC, assist them during the course of their hospitalization, and provide personal care items upon discharge to the community; operate drop-in centers;6 conduct quality reviews of ICM and CRISP services; and are essential members of ACT, ICM, CRISP, crisis apartment, and crisis walk-in center teams. Id. at ln. 1042-49. Delaware also has a peer program that specifically serves individuals with SPMI or co-occurring disorders in the State’s Mental Health Court. Id. at ln. 1068-69. Mental Health Court Peers provide support to individuals as they proceed through diversion or probation and assist peer defendants to access resources in the community such as housing and transportation. In June 2016, there were 52 Mental Health Court peer contacts. What is difficult to measure, but nevertheless apparent, is Delaware’s achievement in creating a mental health system in which peers feel welcomed and supported in their work. Delaware embedded these values into every aspect of its system, including provider contracts.
6 The State funds the ACE Center in Seaford, the Creative Vision Factory in Wilmington, and the Rick Van Story Center in Wilmington. These peer-run organizations are essential components of Delaware’s mental health system. The State has made a commitment to ensuring that these programs are appropriately funded and supported long after the Agreement.

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For example, the CRISP contract states that peers “shall be received and treated as a meaningful
addition to the agency’s workforce and integrated into the philosophy and service system for
their unique and valuable strengths and perspective.” App. A-1 Division Requirements for
Behavioral Health Service Providers, Ex. 2, at Section E.i. It also specifies that “[p]eers are not
to be used as ‘add-on’ staff, substitute staff, or volunteer labor except in time limited and very
goal oriented projects.” Id. The State has worked to ensure that peers are critical members of
mental health service delivery in Delaware. Peer inclusion is a major shift in the way Delaware
has supported community integration in the wake of the Agreement and Delaware has taken
important steps to ensure that peer supports outlast the Agreement. See Infra., Section V.
III. QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT
Prompted by the Agreement, Delaware established a robust quality assurance and
performance improvement system (“QA/PI”). D.I. 182 at ln. 1137-41. The QA/PI system is
intended to ensure that services are of appropriate quality and are achieving the goals of the
ADA and Olmstead: community integration, independence, and self-determination. As part of
the QA/PI system, the State created a “Quality Control Steering Committee” that is charged with
monitoring compliance related to the provision of mental health treatment and wraparound
services:
The Committee is responsible for analyzing, interpreting, and acting on data related to specific performance measures in an effort to identify where systems: experience failures or weaknesses, demonstrate opportunities for improvement and/or require corrective action. The use of data to drive [the State’s] quality control initiatives is part of Delaware’s Olmstead plan to ensure that individuals with disabilities are not unnecessarily hospitalized for mental health treatment when community-based services would be appropriate. The State believes strongly in the rights of Delawareans with disabilities to live independently and to exercise meaningful self-determination and choice in their treatment as well as all aspects of their lives. [The State] will use data to inform its decision making regarding utilization of services, quality of care, and overall functioning of Delaware’s public mental health system to sustain evidence-based decision making that is consistent with the requirements of Olmstead.

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DSAMH Steering Committee: Quality Control Initiatives, Ex. 3, at 1. Currently, the Steering
Committee is charged with addressing the increased utilization of acute in-patient hospital beds,
among several other initiatives. The State has been collecting and analyzing a comprehensive set
of measures that reflect hospital use, diversion activities, and measures to address critical risk
factors for hospitalization. D.I. 182 at ln. 1208. By examining this data, the State is seeking to
better understand and address factors that contribute to the acute psychiatric hospitalization of
the target population, as well as factors that obscure its measurement of services, outcomes, and
needs of people with SPMI (such as misdiagnosis). This effort has culminated in several on-
going quality assurance activities:
1. Establishing a High-end User Review Committee that will identify clients who are frequently admitted to inpatient facilities and will ensure that those clients identified as high-end users are linked with the appropriate level of services. Ex. 3, at 4-5.
2. Identifying clients who are homeless at the time of admission to an IMD to ensure that all clients who present as homeless at the time of admission are referred for housing placement. Ex. 3, at 9.
3. Investigating how homelessness affects lengths of stay among members of the target population who were hospitalized at DPC. Ex. 3, at 11.
4. Holding monthly QA/PI meetings between DSAMH and the IMDs to resolve problems in care, including coordination and information sharing between hospital and community providers. Ex. 3, at 16.
5. Conducting an investigation with the University of Pennsylvania of the needs of individuals living in community housing who have complex challenges, particularly with respect to addressing Activities of Daily Living. Ex. 3, at 18-19.
6. Ensuring that a collaborative process is in place to assess the housing needs of all clients who are transitioning to a community setting. Ex. 3, at 25.
The State has also identified several other quality assurance activities that will support its
continuing efforts to improve its system: 1. Ensuring that the Quality Process Review (“QPR”) function7 is fully integrated into the
7 Through the Quality Process Review, an average of 330 recipients of ACT and ICM services are interviewed each year.

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DSAMH Quality Control processes and that the QPR analytical data reports are included in the formal reports submitted to the DSAMH Steering Committee. Ex. 3, at 6. 2. Studying the rates of court commitment for inpatient or outpatient treatment. Ex. 3, at 13. 3. Ensuring that client death review investigation occur for deaths of clients receiving the most intensive services: ACT, ICM, and CRISP. Ex. 3, at 20. 4. Conducting an initiative to incorporate into practice data from the evaluation of the CRISP program that reflects the ongoing partnership between the State and the University of Pennsylvania. Ex. 3, at 18. The sophistication of the State’s QA/PI process improved substantially in the last rating period, but the State has demonstrated throughout the course of the Agreement a commitment to using data to inform its decision-making: when ICM was ineffective for some members of the target population, the State converted 2 ICM teams to ACT teams; when the rates of emergency department utilization increased, the State trained its emergency responders on the availability of crisis walk-in centers; when the crisis center in New Castle County was less effective than the center in Sussex County, the State built a new center in New Castle County that is modeled after the Sussex County one. D.I. 182 at ln. 136-39, 382-84, 632-34. Further, as described below in Section V, the State has taken several other important steps to ensure that QA/PI remains an essential component of its mental health system. IV. RISK MANAGEMENT The Agreement requires the State to establish a risk management system that provides a clear mechanism for integrated analysis of risk. Recently, the State established “a central clearinghouse where analyses of risks and adverse events affecting the target population [can] occur with the collective involvement of all responsible agencies and through which patterns of risk could be identified and addressed systematically.” D.I. 182 at ln. 1652-54. Through memoranda of understanding, the State now ensures that the Division of Medicaid & Medical Assistance, Division of Long Term Care Residents Protection, Division of Substance Abuse and

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 16 of 24 PageID #: 695
Mental Health, and Department of Public Health share information about risk management. Id. at ln. 1655-57. The State is also convening incident review meetings where risk management information relating to the target population is being consolidated and discussed with multiagency input. Id. at ln. 1657-59. Although this is a new system and the State has not demonstrated substantial compliance for a full year, as Dr. Bernstein concluded, the State has ensured long-term sustainability of the program by embedding risk management into recently enacted legislation. See Infra., Section V.
V. SUSTAINABILITY OF REFORMS Delaware’s commitment to the principles of Olmstead and sustaining the reforms that it
has made to its mental health system is further exemplified by passage of key legislation, implementation of a new Medicaid program, and creation of a peer-directed grievance process.
A. Legislation Delaware achieved three separate legislative reforms of its mental health system within the five-year period of the Agreement. In the most recent legislative session, the Delaware General Assembly passed SB 245 to establish an independent oversight commission to monitor Delaware’s public mental health system. Id. at ln. 177-82. The Commission will be appointed by the Governor and include a variety of stakeholders, from doctors to peers, and will be supported by the Delaware Department of Justice. It ensures that a community of stakeholders has access to Delaware’s critical incident reports and will hold the State accountable for the mental health services it provides and systems it oversees. The conduct and records of a specialized Peer Review Subcommittee, established within the Commission, are subject to Delaware’s peer review privilege to ensure the Commission’s ability to engage in critical analysis of State and provider operations and outcomes in an open, frank, and robust manner. The Peer Review Subcommittee is required to have at least two public meetings per year as well

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 17 of 24 PageID #: 696
as provide an annual report to the General Assembly. This report guarantees that the Commission’s work and recommendations are made public for further review and consideration.
Recognizing that civil commitment is often the entry point to hospitalization, Delaware has twice modified its statute governing civil commitment to provide for greater procedural protections and to imbue the process with the tenets of Olmstead’s integration mandate. In 2012, the General Assembly passed HB 311, which restructured the initial 24-hour emergency detention period, the first step in the civil commitment process in Delaware. Id. at ln. 161-66. HB 311 dictated that a 24-hour emergency detention could no longer occur in an emergency department, and instead had to take place in a specialized mental health crisis center or psychiatric hospital. HB 311 also created a new crisis screening position designed to address the overuse of emergency detentions by those who lack specialized crisis training or knowledge of available community resources. The goal of HB 311 was to reduce reliance on civil commitment as a way to “clear” emergency departments and compel providers to seek the least restrictive means to assist a person in crisis.
HB 311 was followed two years later by HB 346, which addressed the parts of the civil commitment process that occur after the initial 24-hour emergency detention. Id. at ln. 172-76. HB 346 revised the criteria for both probable cause hearings and civil commitment hearings to require proof of a direct link between a mental health condition and an imminent threat of dangerousness, as well as showing that inpatient hospitalization is the least restrictive placement for an individual. The law also reduced various timeframes in the civil commitment process and created a number of new procedural requirements designed to protect individuals agreeing to voluntary treatment who might not otherwise fully understand the implications of a voluntary admission. HB 346 established for the first time in Delaware specific and distinct criteria for outpatient commitment.

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 18 of 24 PageID #: 697
As a result of HB 311 and HB 346, Delaware has realized reductions in both inpatient and outpatient commitments. Between Fiscal Year 2011 and Fiscal Year 2016, inpatient commitments decreased by 6.1%8 and outpatient commitments decreased by 63.3%. Id. at ln. 1545-47, 1563-64.
B. Medicaid Promoting Optimal Mental Health for Individuals through Supports and Empowerment (“PROMISE”) Program
In addition to legislative changes, Delaware has also significantly enhanced the availability and delivery of community mental health services in the State since the implementation of the Agreement by making structural changes to its Medicaid program. By capitalizing on the federal-state Medicaid partnership, Delaware is now able to provide services in a way that is financially sustainable for the State.
In 2014, the State received approval from the Centers for Medicare and Medicaid Services to create the PROMISE program to serve individuals with SPMI who are the target population of the Agreement. PROMISE provides benefits counseling; case management; community-based residential alternative supports that exclude assisted living; community transition services; community psychiatric supportive treatment and other services by nonlicensed clinical staff including evidence-based practices, such as ACT and ICM; financial coaching; non-medical transportation; nursing; peer supports; personal care; respite; skillbuilding for individual activities of daily living/chore; and supported employment. Id. at ln. 195211. As of August 2016, the majority of the contracts necessary for full enactment of PROMISE
8 Between Fiscal Year 2011 and Fiscal Year 2014, inpatient commitment decreased by 41%; however, there was a notable uptick in inpatient commitments between Fiscal Year 2015 and Fiscal Year 2016. DSAMH is currently reviewing possible reasons for the increase inpatient commitments. Id. at ln. 1562-66.

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 19 of 24 PageID #: 698
benefits have been completed and implementation is underway.9 To date, the State reports that there are approximately 2,175 individuals receiving services through PROMISE. Of those, 1,381 are Medicaid beneficiaries and 794 have their services paid for solely by the State. Notably, only about 10% of individuals receiving PROMISE services were hospitalized in Fiscal Years 2015 and 2016 and those individuals reflected only 10% of total hospital admissions for those years. Id. at ln. 1391. The PROMISE program has dramatically expanded the reach of community mental health services in Delaware to low-income individuals with SPMI. It is an important sustainability effort that allows Delaware to leverage federal dollars through Medicaid to provide an expanded array of community mental health services and supports that previously were either unavailable or solely state-funded.
C. Community Grievance Process The Agreement does not require the availability of a grievance process for individuals receiving mental health services in the community; however, for the past several years, Delaware has been working closely with advocacy groups and peers to enhance its community grievance process. This effort has resulted in the creation of a toll-free hotline, and most recently, a dedicated email account. Individuals also have the option to file a grievance directly with the DSAMH Director or Director of Community Services at any time. A full time employee with DSAMH’s Quality Assurance Unit receives and responds to incoming grievances. These are then documented, allowing DSAMH to analyze complaints and grievances by provider, program, and county. After the initial communication from the individual reporting the grievance, the employee emails the individual’s provider using a standardized correspondence template with a summary of the individual’s concerns. DSAMH
9 The only outstanding contracts are for nursing services, personal care services, and financial counseling.

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 20 of 24 PageID #: 699
asks for the provider’s input as well as for information on whether and how the concerns have been previously addressed. DSAMH also gives the provider a deadline for responding that is tailored to the severity of the grievance and consistent with applicable federal and state regulations. This email is copied to the PROMISE Clinical Services Administrator for the county in which the individual resides. The relevant parties create and implement a personcentered, recovery-oriented resolution, with the individual at the helm of the process. The resolution process includes confirming with the individual that the matter had been resolved from their point of view and that the relevant parties followed through on the deliverables for resolution. Once the grievance is resolved to the individual’s satisfaction, DSAMH sends the individual a standardized letter summarizing the reported grievance and the outcome.
Based on input from the peer community, DSAMH is in discussions to train peers in the community on the grievance process and how to help individuals file a grievance. Likewise, DSAMH is also exploring the use of PROMISE case managers to assist with grievances as well. The hope is that peer support will empower individuals to raise concerns about their care directly to DSAMH by further facilitating a grievance process that is distinct from an individual’s provider.
DSAMH has fostered a more proactive and comprehensive community grievance process because it is an important tool for individuals to advocate for themselves and it also facilitates direct communication between individuals and the State about the services provided. Delaware has transformed its mental healthcare system into a person-centered model that encourages individuals to advocate for themselves, point out perceived problems, and demand accountability.
VI. CONCLUSION As detailed in this brief and in the Monitor’s Tenth Report, D.I. 182, the State has

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 21 of 24 PageID #: 700
achieved substantial compliance with the terms of the remedial Settlement Agreement entered as an order of the Court. D.I. 7. Accordingly, the Parties respectfully urge the Court to dismiss this case with prejudice, and to cancel the scheduled October 13, 2016, oral argument.

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 22 of 24 PageID #: 701

Date: October 6, 2016

Respectfully submitted,
FOR THE UNITED STATES PLAINTIFF:
VANITA GUPTA Principal Deputy Assistant Attorney General
EVE L. HILL Deputy Assistant Attorney General
STEVEN H. ROSENBAUM Chief Special Litigation Section
MARY R. BOHAN Deputy Chief Special Litigation Section
/s/ Elizabeth C. Kelley Elizabeth C. Kelley [VA Bar #80255] Trial Attorney United States Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, N.W. Patrick Henry Building, Room 5427-B Washington, DC 20530 Telephone: (202) 514-0460 Fax: (202) 514-0210 Beth.Kelley@usdoj.gov

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 23 of 24 PageID #: 702
FOR THE STATE OF DELAWARE DEFENDANTS: STATE OF DELAWARE DEPARTMENT OF JUSTICE

DATE: October 6, 2016 DATE: October 6, 2016

/s/ Aaron R. Goldstein Aaron R. Goldstein (#3735) State Solicitor Carvel State Office Building, 6th Fl. 820 North French Street Wilmington, Delaware 19801 (302) 577-8400
/s/ Sarah Fishman Goncher Sarah Fishman Goncher (# 5481) Deputy Attorney General Health Law Unit, Unit Head Carvel State Office Building, 6th Fl. 820 North French Street Wilmington, Delaware 19801 (302) 577-8188

Case 1:11-cv-00591-LPS Document 185 Filed 10/06/16 Page 24 of 24 PageID #: 703
CERTIFICATE OF SERVICE
The undersigned certifies that on October 6, 2016, she caused the attached Joint Brief in
Support of the Parties’ Joint Motion to Dismiss to be filed with the Court via CM/ECF and
served electronically to the following:
Aaron R. Goldstein Sarah Fishman Goncher Delaware Department of Justice Carvel State Office Building, 6th Fl. 820 North French Street Wilmington, Delaware 19801
UNITED STATES DEPARTMENT OF JUSTICE
/s/ Elizabeth C. Kelley Elizabeth C. Kelley (VA Bar #80255)

 
 Case 1:11-cv-00591-LPS Document 186 Filed 10/11/16 Page 1 of 1 PageID #: 755 Case 1:11-cv-00591-LPS Document 184-1 Filed 10/06/16 Page 11 ooff11 PagelD #: 679

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE

UNITED STATES OF AMERICA,

Plaintiff,

v.

Civil Action No. 11-591

STATE OF DELAWARE,

Defendant.

~jI>RRoPD(jE~RDRER TO DISMISS WITH PREJUDICE

The United States and the State of Delaware, relying on the findings of the independent court monitor, seek ternmnination of the Settlement Agreement in this matter, as fully described in the Parties' Joint Motion and Brief in Support.
Upon review of the court monitor's Tenth Report, D.1I. 182, and in consideration of the parties' Joint Motion to Dismiss and Brief in Support, the Court hereby
ORDERS the parties' Joint Motion is GRANTED; and the Court further ORDERS that this case is dismissed with prejudice; and the Court further ORDERS that the oral argument scheduled for October 13,,2016, is canceled and will be removed from the Court's calendar.

1lLL 6~ nn ('}.~ IT IS SO ORD~ ERED.
DATED this day of'

. /
\\JJ1'\1(
:rro16.

 
 DELAWARE SETTLEMENT AGREEMENT DISMISSAL FACT SHEET
The U.S. District Court for the District of Delaware terminated the remedial settlement agreement governing the state of Delaware’s service system for people with serious and persistent mental illness. The court agreed with the joint motion of the state and the Department of Justice that Delaware has fully complied with the terms of the 2011 agreement, based on the assessment of an independent court monitor.
This is the first successful conclusion of a systemic reform case brought by the department under the Americans with Disabilities Act (ADA) and the Supreme Court’s Olmstead decision.
The agreement has:
 Expanded community-based services. Since entry of the agreement, Delaware has significantly reduced its reliance on institutional care, particularly at the state-run Delaware Psychiatric Center (DPC). o It has reduced the number of DPC bed days used by people in the target population by 47.2 percent. The average daily census in DPC for the target population in FY2016 was 76. o The number of Medicaid-eligible Delawareans receiving community-based services has increased by 92 percent since the United States began its investigation. o Individuals who receive services under the agreement through the state’s Division of Substance Abuse and Mental Health have dramatically lower rates of hospital admissions than those who are not receiving those services: only 9.9 percent of hospitalizations in FY2016 involved individuals receiving services under the agreement. o Delaware now operates 15 Assertive Community Treatment (ACT) teams and two intensive case management (ICM) teams. Collectively, these teams serve about 1,700 people at any given time. o The state also created the Community Reintegration Support Project (CRISP) that provides community-based mental health services to 100 people with the most difficult and complicated needs, many of whom were institutionalized for decades. o Delaware provided funding for 812 permanent supportive housing units in FY2016, exceeding the agreement’s targets. Importantly, the state has created a system that makes integrated housing the default option.
 Expanded crisis and diversion services. The state has successfully implemented a mental health crisis system. o Delaware now has a 24/7 crisis line; two mobile crisis teams that respond within one hour of a call; two “living room model” crisis walk-in centers; 21 crisis apartment beds; and 3 targeted care management teams. o Mobile crisis teams in Delaware typically divert 80 to 90 percent of people they encounter from hospitalization or criminal justice interaction.

o The state’s crisis walk-in center in Sussex County diverts about 70 percent of people from further hospitalization or criminal justice interaction. It takes law enforcement officers less than 10 minutes on average to drop-off an individual in a mental health crisis.
 Ensured on-going quality assurance and performance improvement. o To ensure sustainability of its reforms, Delaware created a “Quality Control Steering Committee” to analyze, interpret and act on data related to specific performance measures in order to improve mental health care in the state. o These efforts will be sustained by recently passed legislation that established an independent oversight commission to monitor Delaware’s public mental health system. The commission will be appointed by the governor and includes a variety of stakeholders, from doctors to peers.
 Dramatically improved the lives of individuals with mental illness. o One Delawarean was 16 years old when she was first admitted to DPC. She repeatedly attempted suicide because she “just wanted to die” and “couldn’t stand life anymore.” After each attempt, she would be brought back to the hospital, where she remembers smashing her head against a brick wall over and over and being held in four-point restraints. She describes that time of her life as going “through hell and back.” Following the department agreement with Delaware, her life changed because she started to receive the intensive supports she needed to remain stable in the community. She has a therapist who helps her write affirmations, which she repeats in the mirror every day, and a peer support specialist who regularly meets with her and has inspired her to become a peer support specialist. She also has her own apartment through the state’s permanent supported housing program. She lives with a roommate whom she met at the hospital and who has become her best friend.  She said that she “takes it slow every day; I don’t think about suicide anymore.” She is thankful for the time she can spend with her daughter and describes herself as “doing tremendously better now.” o A second Delawarean with mental illness who grew up in the foster care system and became involved in gang activities at an early age said that she used to be depressed and suicidal. Beginning in fifth grade, she tried to kill herself multiple times and was admitted to DPC. She now receives intensive community-based mental health services from the state and especially relies on her peer support specialist to help her through difficult times. She described being “afraid of life for a long time,” but now she “really believes in the State [of Delaware] and before I didn’t.”

 
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Home » Briefing Room » Justice News

Department of Justice

FOR IMMEDIATE RELEASE

Office of Public Affairs

Wednesday, July 6, 2011

Justice Department Obtains Comprehensive Agreement Regarding the State of Delaware's Mental Health System
WASHINGTON - The Justice Department today announced that it has entered into a comprehensive agreement with the state of Delaware that will transform Delaware’s mental health system and resolve violations of the Americans with Disabilities Act (ADA). The ADA and the Supreme Court’s landmark decision in Olmstead v. L.C.afford individuals with disabilities the right to receive services in the most integrated settings appropriate to their needs, and today’s agreement will ensure individuals in Delaware can exercise that right.

The Justice Department in 2008 began its investigation of Delaware’s state hospital, and modified the scope of the investigation in 2010 to focus on violations of the ADA throughout the mental health system. The state worked cooperatively with the Justice Department to negotiate an agreement resolving alleged violations of the ADA.

“Across the country we are enforcing the rights of people with disabilities, affirmed by the Supreme Court more than a decade ago, to live and receive services in their communities,” said Thomas E. Perez, Assistant Attorney General for Civil Rights. “The services that the state of Delaware has agreed to provide under this agreement will enable people with mental illnesses living in Delaware to reside successfully in their homes and communities, rather than entering costly segregated facilities. As states around the country work to breathe life into the rights promised by the ADA and Olmstead, this agreement demonstrates Governor Markell and Attorney General Biden’s vision and leadership.”

The agreement expands community mental health services so that Delaware can serve people with severe and persistent mental illness in the most integrated settings appropriate to those individuals’ needs. Over the next five years, Delaware will prevent unnecessary hospitalization by expanding and deepening its crisis services, including a hotline, crisis walk-in centers, mobile crisis teams, crisis apartments and short term crisis stabilization programs. Delaware will also provide assertive community treatment teams, intensive case management, and targeted case management to individuals living in the community who need support to remain stable. In addition, the state will offer scattered-site supported housing to everyone in the agreement’s target population who needs that housing support. Finally, Delaware will offer supports for daily life, including supported employment, rehabilitation services and peer and family supports.

The Civil Rights Division enforces the ADA, which authorizes the attorney general to investigate whether a state is serving individuals in the most integrated settings appropriate to their needs. Visit www.justice.gov/crtto learn more about the Olmsteaddecision, the ADA and other laws enforced by the Justice Department’s Civil Rights Division.

The agreement in this case protecting the rights of individuals with mental illness in Delaware are due to the efforts of the following Special Litigation Section attorneys: Jonathan Smith, Chief; Judy Preston, Deputy Chief; Alison Barkoff, Special Counsel for Olmstead Enforcement; David Deutsch and Deena Fox, Trial Attorneys. In

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addition, the division received support and assistance from Shannon Hanson, Assistant U.S. Attorney for the District of Delaware.

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Civil Rights Division

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 U.S. Department of Justice Civil Rights Division

Office of the Assistant Attorney General

Washington, D.C. 20530
NOV - 9 Z010

The Honorable Jack Markell Governor of Delaware Tatnall Building Dover, DE 19901
RE: Investigation of the Delaware Psychiatric Center
Dear Governor Markell:
We write to report the findings of the Civil Rights Division's investigation of conditions and practices in the Delaware Psychiatric Center ("DPC") pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, and the State of Delaware's ("State") - compliance with Title II of the Americans withDisabilities Act ("ADA"),42 U.S.C. § 12132, as interpreted in Olmstead v. L.C., 527 U.S. 581 (1999), with respect to the services the State provides to persons with mental illness at DPCand other settings across the State.
CRIPA gives the Department of Justice authority to seek a remedy for a pattern and practice of conduct that violates the constitutional or federal statutory rights (including those under the ADA) of individuals with mental illness or developmental disabilities who are in public institutions. The Department also has authority to seek a remedy for violations of Title II of the ADA. 42 U.S.C § 12133.
We notified then-Governor Ruth Ann Minner in November 2007 that we were initiating an investigation of conditions and practices atDPC pursuant to CRIPA. We conducted an on site inspection ofDPC on April28-May 2, 2008, with the assistance of expert consultants in the fields of psychiatry, psychology, psychiatric nursing, and fire safety. On July 29,2010, we notified Delaware's Deputy Attorney General that we were also focusing our investigation on community integration issues in the State. On August 4-6, 2010, we toured DPC and the community to examine whether the State is serving individuals confined to DPC and statewide in the most integrated setting appropriate to their needs.
While on site, we interviewed persons in statewide leadership positions, hospital administrative staff, community providers of mental health services, and individuals confined to DPC, and examined the physical plant conditions throughout the facility. We also reviewed a wide variety of documents, including policies and procedures, incident reports, and medical and mental health records. Our most recent tour included interviews with leadership from DPC and

-2-
the Delaware Department of Health and Social Services ("DDHSS") and a review of hospital clinical records and administrative documents, as well as substantial interviews with providers who are responsible for community-based mental health services to individuals discharged from DPC or at risk of admission. In addition, we had an opportunity to interview consumers who are currently served by the community system. Consistent with our commitment to provide technical assistance and conduct a transparent investigation, we concluded our tours with an extensive debriefing at which our consultants conveyed their initial impressions and concerns about the DPC to counsel, administrators, staff, and State officials.
Before discussing our findings, we wish to express our appreciation for the hospitality, cooperation, and professionalism of the statewide leadership and hospital staff and administrators throughout our investigation. We hope to continue to work with Delaware officials and the staff at DPC in the same cooperative manner going forward.
In accordance with our statutory requirements under CRIPA, we now write to advise you formally of the findings of our investigation, the facts supporting them, and the minimum steps necessary to remedy the deficiencies set forth below. 42 U:S.C. § 1997b(a). This letter also serves to provide you notice of your failure to comply with the ADA and of the steps you should take to voluntarily comply with the law.. 42 U.S.C. § 2000d-l (incorporated by 42
U.S.C. § 12133).
Specifically,w~haveco11cludedtl1at the State's curre11t mental].1ealth sy~tem fails to provide services to individuals with mental illness in the most integrated setting appropriate to their needs, as required by the ADA. This has resulted in needless prolonged institutionalization . of many individuals with disabilities in DPC who could be served in the community. It also has placed individuals currently in the community at risk of unnecessary institutionalization. Moreover, individuals confined to DPC not only are harmed by unnecessary and prolonged institutionalization itself, but they also suffer significant harm and risk of harm, in violation ofthe U;S. Constitution, due to numerous other deficient practices while at DPC, including: inadequate risk assessments; inadequate mental health treatment, especially the failure to provide appropriate behavioral interventions for individuals with identified risks; inadequate restraint and seclusion practices; inadequate investigations of serious incidents; and inadequate discharge planning/community integration to ensure individuals live in the most integrated setting. These deficiencies have contributed to the untimely deaths of individuals confined to DPC as well as led to other preventable illnesses, injuries, and harm from a variety of sources.
Delaware has been on notice of many ofthe findings we make in this letter. In November 2007- shortly after we notified Delaware of our CRIPA investigation- the Delaware Depmiment of Justice ("DDOJ") initiated its own investigation to determine whether DPC had violated individuals' statutory rights guaranteed by Delaware law. On March 7, 2008, the DDOJ issued its own findings citing significant deficiencies and concluded that numerous conditions, practices, acts, and failures to act by DPC administrators and staff resulted in systemic and pervasive violations of the state statutory civil rights of individuals confined to DPC, including: failure to develop appropriate treatment plans; failure to prepare adequate discharge plans; failure to ensure safety; physical and emotional abuse of individuals by staff; mistreatment of individuals

-3-

by staff through inappropriate use of medications, isolation, and physical and chemical restraints; neglect of individuals by staff; failure to protect individuals from assaults by other patients; and failure to protect individuals from self-inflicted abuse due to inadequate supervision and monitoring. In May 2008, the DPC entered into a memorandum of agreement with DDOJ to address these findings. The U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services ("CMS") has made similar findings.

Current Delaware leadership acknowledge and recognize that an effective remedy for

unconstitutional conditions at DPC is inseparable from an effective effort to place in community

settings all the individuals who are inappropriately institutionalized. Leadership from both DPC

and the DDHSS acknowledge that Olmstead requires the delivery of public services in the least

restrictive, most integrated settings appropriate to individuals served by the State's mental health

system and the freedom of these individuals from recognize that any remeaYlfiat focuses merely on

unwarranted institutional isolation. They tile cond.tttons-ar:E>Pe-wi-H-direct-resources,

-------

away from building the necessary community capacity and toward a focus on DPC- an inequity

that will only perpetuate the inappropriate and harmful institutionalization of Delaware citizens

with mental disabilities~

We are, accordingly, encouraged by our meetings with current Delaware leadership, both at DPC and DDHSS, who acknowledged the problems and indicated a strong desire and interest in working with the United States Department of Justice ("USDOJ") both in relation to our overall investigation and in working toward an amicable resolution.

We recognize that the current leadership of the DDHSS has been actively addressing many of the deficiencies at DPC since our initial2008 tour. Though still problematic, these efforts have resulted in improvements in treatment planning, in reducing the dependence on inappropriate interventions such as seclusion and restraint; and in creating a shift toward developing person-centered recovery plans that reflect individuals' personal goals. We are therefore encouraged that the DDHSS leadership both recognizes the continuing deficiencies at DPC and have a workable, and realistic vision, of the undertakings necessary to ensure than individuals are served in the most integrated setting while addressing the issues at DPC required to be keep individuals there safe.

I. BACKGROUND

Located in New Castle, Delaware, the DPC is the only public psychiatric hospital in Delaware for adults. The DPC is operated by the Delaware Division of Substance Abuse and Mental Health, and has a current capacity of 170 civil and 42 forensic beds. The hospital is divided into several separate units, based upon gender, diagnosis, age, and, in one unit,

-4-

involvement in the Delaware criminal justice system. 1 At the time of our most recent tour, DPC's civil census was 161.

II. FINDINGS

A. Delaware Is Violating the ADA By Failing to Serve Individuals with Mental Illness In The Most Integrated Setting

Congress enacted the ADA in 1990 "to provide a clear and comprehensive national

mandate for the elimination of discrimination against individuals with disabilities." 42 U.S. C.

§ 12101(b)(l). Congress found that "historically, society has tended to isolate and segregate

individuals with disabilities, and despite some improvements, such forms of discrimination

against 42 U.S.

individuals with disabilities continue C. § 12101 (a)(2)-:-For these reasons,

to be a serious and pervasive social problem." Congress pruh::i:bite-d-discrimination-a

gain

s

t:

----

----

-

individuals with disabilities by public entities:

[N]o qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.

42 U.S.C. § 12132.

One form of discrimination prohibited by Title II of the ADA is violation of the

"integration mandate." ADA, the regulations o

f

The integration mandate arises out of Congress's the Attorney General implementing Title II,2 and

explicit findings in the Supreme Com

the i's

1 The separate units at the DPC are: (1) Kent-3, a 32-bed extended care unit serving individuals with serious psychiatric diagnoses; (2) Kent-2, a 45-bed unit for male and female adults with behavior problems; (3) Sussex-3, a 43-bed unit for aggressive males; (4) Sussex-2, a 45-bed long-term unit for males and females with mental illness; (5) Sussex-1, a 35-bed unit for male and female geriatric patients; and (6) Jane Mitchell, a 42-bed forensic psychiatric unit for males and females involved in the Delaware criminal justice system, including people charged with crimes and awaiting psychiatric evaluation, prisoners serving sentences in the Delaware Department of Corrections facilities, and individuals adjudicated as criminally insane.
2 The regulations provide that "a public entity shall administer services, programs and activities in the most integrated setting appropriate to the needs of qualified persons with disabilities." 28 C.P.R.§ 35.130(d); see also 28 C.P.R.§ 41.51(d). The preamble discussion of the ADA "integration regulation" explains that "the most integrated setting" is one that "enables individuals with disabilities to interact with nondisabled persons to the fullest extent possible." 28 C.P.R.§ 35.130(d), App. A. at 571 (2009).

·--

. -

- ----····------- -

~~~~~---·--·-·-------··-------------~- - - - - -

-5-
decision in Olmstead, 527 U.S. at 586. In Olmstead, the Supreme Court held that public entities are required to provide community-based services to persons with disabilities when (a) such services are appropriate; (b) the affected persons do not oppose community-based treatment; and (c) community-based services can be reasonably accommodated, taking into account the resources available to the entity and the needs of other persons with disabilities. Id. at 607. In so holding, the Court explained that "institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life." Id. It also recognized the harm caused by unnecessary institutionalization: "confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment." Id. at 601. 3 As the Third Circuit Court of Appeals has made clear, the ADA "favor[s] integrated, community-based treatment over institutionalization." Frederick L. v. Dept. of f - - - - - -.P..,--.ubficWemrre,To4r-:-Ja~497~49T=-9T(3·fd-cir2004)1-.- - - - - - - - - - - - - - - - - -
1. Individuals Remain Unnecessarily and Inappropriately Institutionalized in DPC in Violation of the ADA
DPC is violating the ADA by unnecessarily institutionalizing individuals who are appropriate for community-based treatment. Olmstead, 527 U.S. at 607. Based on the information we reviewed during our tours of DPC, including our review of patient records and interviews with statewide leadership and hospital staff and administrators, it is clear that the vast majority of individuals confined to DPC could be-and have a right to be-living in community settings with appropriate services and supports. DPC staff has already determined that over 70 percent of the individuals being treated at DPC are clinically ready to leave the hospital and to be served in more integrated settings. The percentage of individuals ready for discharge likely is even higher, according to our experts, due to DPC's inappropriate discharge assessmeht process, as discussed below. In fact, during an interview, the State's Director of the Division of Substance Abuse and Mental Health Services ("DSAMHS") acknowledged that "pretty much everyone at DPC would be appropriate for community placement."
DPC maintains and keeps current a central roster, entitled "DPC Discharge Assessment," which lists all individuals in DPC and their status with respect to discharge. This list indicates which individuals are ready for release and summarizes barriers to discharge.
3 Olmstead therefore makes clear that the aim of the integration mandate is to eliminate unnecessary institutionalization and enable individuals with disabilities to participate in all aspects of community life. Accord Press Release, The White House, "President Obama Commemorates Anniversary of Olmstead and Announces New Initiatives to Assist Americans with Disabilities" (June 22, 2009) (in announcing the Year of Community Living Initiative, President Obama affirmed "one of the most fundamental rights of Americans with disabilities: Having the choice to live independently.").

-6-
At the time of our August 2010 visit, approximately 85 individuals were designated as clinically ready to leave the hospital-either immediately or within a short time span-and to be served in more integrated settings. The most significant barriers to their discharge reflect not their individual needs but rather, the level of DDHSS resources and categorical restrictions on these funds.
As the State acknowledges:
The average length of stay at DPC for civil units should run from 3-6 months but due to lack of community based placements the average length of stay is approximately 3 years As of February 2010, 71 individuals were ready to be discharged to supervised living in the community but were unable to be placed due to lack of funding for additional community based programs.
Delaware Memorandum of Agreement Compliance Committee Report, at 8 (February 2010).
These individuals, at minimum, remain institutionalized in the hospitals in violation of their rights under the ADAand Olmstead. A hospital, by definition, is a segregated setting, where individuals with mental illness are congregated together with little to no opportunity to interact with their non-disabled peers. 28 C.F.R. § 35.130(d), App. A. at 571 (an "integrated setting" "enables individuals with disabilities to interacted with nondisabled persons to the fullest extent possible"). Individuals in DPC are deprived of many of the personal freedoms that citizens in the community enjoy. They live a regimented life tied to the needs ofthe institution, such as waking up and going to sleep at set hours, not being able to choose with whom they associate and live, having set mealtimes with little to no choice of content, and having limited to no contact with the community outside the four walls of the facility. Accord DAI v. Patterson, 653 F. Supp.2d 184,200-207 (RD.N.Y. 2009) (describing characteristics of institutions to include regimented daily activities, lack of privacy, and few choices). Yet the State continues to provide services to far too many individuals with disabilities in the most segregated setting imaginable-the hospital.
Our investigation shows that DPC 's discharge plruming process is inadequate, causing individuals who could be served in the community to remain inappropriately and needlessly institutionalized and leading to individuals who are discharged being placed in more restrictive settings than appropriate to their needs in violation of the ADA.
DPC's treatment professionals inappropriately assess an individual's readiness for discharge in terms of"compliance" with a number of factors that are clearly hospital-focused and often irrelevant to community living, notably among them: unit routine, unit rules, privilege levels and participation in treatment mall activities/therapies. Tellingly with regard to the importance assigned to an individual's functioning as a patient, DPC's protocol for discharge readiness explicitly emphasizes "compliance," but does not reference whether treatment at DPC has resolved the specific issues that caused an individual to be hospitalized in the first place. In contrast, effective discharge assessments focus on the individual's specific capacities to function

-7-
in a more integrated setting and to meet the demands of community living. They also identify the supports and services necessary for the individual's successful community living.
DPC's inappropriate discharge assessment process has kept many individuals in DPC from receiving a treating professional's recommendation of community placement. Moreover, individuals who can show the level of hospital "compliance" required to be considered ready for discharge often continue to languish at DPC because their discharge planning process fails to identify the supports necessary to address barriers to discharge. The result is that individuals who could live in integrated community settings with appropriate supports remain at DPC because they have not received adequate assessments ofthe supports and services necessary to allow them to succeed in the community. Accord Frederick L. v. Dept. ofPublic Welfare, 157 F. Supp.2d 509, 540 (E.D. Pa. 2001) ("Olmstead does not allow States to avoid the integration mandate by failing to require professionals to make recommendations regarding the service needs of i-------institutionalized-inctiviauals with clisaoltlties. '')~D7ti-;o5"3-F-:--supp-:-2d-at-2S~-ts-ame)'-.- - - - - - - - -
DPC's discharge planning process also fails to ensure that individuals are discharged to the most integrated setting appropriate to their needs. DPC has no clear criteria for determining the most integrated setting appropriate for an individual, and discharge teams often recommend discharging individuals to more restrictive settings than necessary. Specifically, our expert found that the default recommendation of most discharge teams was to discharge the individual to a group home without first examining whether that person could be served in·a more integrated setting, like an apartment with supportive services. This problem is exacerbated by DPC discharge team's limited familiarity with community living options and services and their failure to engage community providers until after they have already made a decision about a placement for the individual being discharged.
2. Individuals in the Community are At Risk of Unnecessary Institutionalization in Violation of the ADA
The ADA's integration mandate not only applies to individuals who are currently institutionalized but also to individuals who are at risk of unnecessary institutionalization by the State's administration of its healthcare delivery system. See, Helen L. v. DiDario, 46 F.3d 325 (3d Cir. 1995) (holding that the ADA was offended where a person with disabilities was offered personal care services in an institutional setting but not at home); Accord Radaszewski v. Maram, 383 F.3d 599 (ih Cir. 2004) (ADA applied to individual at risk of entering a nursing home); Fisher v. Oklahoma Health Care Auth., 335 F.3d 1175 (lOth Cir. 2003) (same). We found that individuals in the community are at risk of unnecessary hospitalization and placement in other institutions, such as privately-operated Institutions for Mental Disease (IMDs), because of the State's failure to provide sufficient community-based services, particularly crisis services. Individuals in the community in crisis have no choice but to go to local emergency rooms, where they are directed to DPC or IMDs. Our expert estimates, based on conversations with state officials, DPC personnel and community providers, that the State could dramatically reduce unnecessary admissions to DPC and IMDs, perhaps by as much as 50%, by expanding crisis services such as mobile crisis and crisis stabilization programs. Not

-8-
only would an expansion of such crisis services avoid unnecessary institutionalization, but it would lead to a significant cost savings for the State.
3. Expansion of Services Would Not Require A Fundamental Alteration Of Delaware's Community Service System
A state's obligation to provide services in the most integrated setting may be excused only where a state can prove that the relief sought would result in a "fundamental alteration" of the state's service system. Olmstead, 527 U.S. at 603-4. Because it is not a fundamental alteration to expand existing community programs to include currently institutionalized individuals, see,~ DAI, 653 F. Supp.2d at 305, Delaware cannot meet its burden of proving the fundamental alteration defense.4
Witliii1.1lieir service array, Delaware's existing community-syste-m-1s-crtre~c:rdy-provi-dirr services such as Assertive Community Treatment programs ("ACT") and scattered site supported housing that are essential to achieving the requirements of Olmstead. Thus, in most respects, what is needed is not new to the system, but rather a phasing out of dated models to be consistent with appropriate practices and bringing to scale those community programs that are already · providing effective integrating services. Accordingly, providing community services individuals in or at risk of entering DPC would work only a "reasonable modification" of the State's program. Olmstead, at 603.
The State already provides to individuals in the community services of the type the individuals in or at risk of entering the hospitals would need to live successfully in the community. Funded services include supported housing, crisis stabilization, substance abuse treatment, supported employment, peer support, mental health mobile crisis, transportation, psycho-social rehabilitation and more. But those services are inadequate to meet the needs of those individuals. We found existing community services to be inadequate and not available in sufficient supply to enable individuals who are currently inappropriately segregated in DPC to be discharged from that setting into the community and provided appropriate services there. As a direct result of Delaware's actions and inactions, state-funded community health service providers fail to provide adequate community services necessary to avoid needless institutionalization. For example, case managers' case loads have risen dramatically, rendering this core service unable to provide needed attention to each client. ACT teams have been reduced or diluted. Currently, there are no ACT teams specializing in co-occurring disorders for mentally ill persons with specialized needs. In addition, we found an inadequate crisis system, with too few mobile crisis teams and crisis stabilization programs spread out geographically throughout the State. The result is that individuals in crisis are now seen in DPC and local
4 Moreover, general allegations of short-term costs or budgetary constraints alone are insufficient to establish the defense. Pa. Prot. and Advocacy, 402 F.3d at 380; Frederick L., 364 F.3d at 495.

-9-
·emergency rooms. There is also a shortage of residential services for individuals with mental illness, including an inadequate supply of integrated, permanent supported housing.
Other core community mental health programs are inadequate. Only some of the regional mental health centers operate residential programs and some of these have reduced services. Inadequate resources has limited mobile crisis and diversion programs. The result is that many individuals with severe mental illness are provided with insufficient supports to remain in the community and find themselves institutionalized or at risk of institutionalization.
Moreover, a state cannot prove this affirmative defense unless it can show that is has developed and is implementing a comprehensive and effective plan to move individuals with disabilities into the community, with any individuals waiting for services moving at a reasonable pace. Olmstead, 527 U.S. at 584; Frederick L. v. Dept. of Public Welfare, 422 F.3d +--------.15-COrct-cir.-2-o-o-5}("'TA] comprenensive worleing plan is a necessary componenn;f-a-su-c-c-es·sful-----'fundamental alteration' defense."); Pa. Prot. and Advocacy, Inc. v. Dept. of Public Welfare, 402 F.3d 374, 381 (3rd Cir. 2005) ("[T]he only sensible reading ofthe integration mandate consistent with the Court's Olmstead opinion allows for a fundamental alteration defense only if the accused agency has developed and implemented a plan to come into compliance with the ADA."). Delaware's own admission that individuals languish for years longer than necessary at DPC, Delaware Memorandum of Agreement Compliance committee Report at 8, is evidence that it is not implementing a working Olmstead plan, with a waiting list moving at a reasonable pace. Accord DAI, 563 F. Supp.2d at 302-305.
Both Delaware leadership and community providers report a positive cultural change within DPC and DDHSS, and a new emphasis on community integration that could move Delaware's public mental health system substantially toward compliance with ADA. However, notwithstanding this stated goal, the State has failed to provide sufficient community-based services to ensure that Delaware citizens with mental illness are served in the most integrated setting appropriate to their needs in violation of the ADA.
B. Prolonged Institutionalization Has Resulted in Unconstitutional Harms
Unnecessary segregation not only violates individuals' rights under the ADA but also causes irreparable harm:
[O]ne of the harms oflong-term institutionalization is that it instills 'learned helplessness,' making it difficult for some who have been institutionalized to move to more independent settings.
Disability Advocates, Inc., 598 F. Supp.2d at 320; Accord Marlo M. v. Cansler, 679 F. Supp.2d 638 (E.D.N.C. 2010) (finding unnecessary institutionalization leads to regressive consequences that cause irreparable harm; Long v. Benson, 2010 WL 2500349 (11th Cir. Jun 22, 2010) (affirming district court's granting of preliminary injunction based on irreparable injury of unnecessary institutionalization).

-10-
States also have a constitutional obligation to provide adequate care and keep individuals safe while they are confined in institutions. The Fourteenth Amendment's due process clause requires a state mental health care facility to provide "adequate food, shelter, clothing, and medical care," along with "conditions of reasonable care and safety, reasonably nonrestrictive confinement conditions, and such training as may be required by these interests." Youngberg v. Romeo, 457 U.S. 307,315,324 (1982). A state psychiatric hospital is constitutionally required to provide reasonable, adequate mental health treatment. See, Torisky v. Schweiker, 446 F.3d 43 8, 448 (3d Cir. 2006) (concluding that plaintiffs may be able to prove that they were deprived of their constitutional liberty interest and of Youngberg's duty of care and protection when they were transferred, against their will, to an institution inappropriate to serve their needs); Scott v. Plante, 691 F.2d 634, 636 (3d Cir. 1982) (affirming that individuals in state psychiatric hospitals have a right to adequate treatment, a right to reasonable care, and a right to be free from unreasonably restrictive confinement); Fournier v. Corzine,No. 07-1212,2007 WL 2159584, at *11 (D.N.J. 2007) ,------------"""~· (''Tlie Fourteenth AmenamenrDue Process Clause requires-state-oftJ.-ctats-to-provi-d-e·-------civilly committed persons ... with access to mental health treatment that gives them a realistic opportunity to be cured or to improve the mental condition for which they were confined."). Treatment is not adequate if it substantially departs from accepted professional judgment, practice, or standards. Youngberg, 457 U.S. at 320-23.
Unnecessary institutionalization, particularly when protracted, is itself an irreparable harm. It creates learned helplessness and reinforces institutional behaviors; and the congregate environment often exacerbates the very behaviors for which individuals were admitted in the first place. The harm of unnecessary institutionalization in DPC is compounded by-and contributes to-the unconstitutional and life-threatening conditions at the hospital.5 These conditions underscore the urgency of moving individuals with disabilities out of inappropriate institutional placements. The Constitution requires that Delaware provide reasonable care and safety to individuals in DPC. The State fails to meet this obligation.
1. DPC Fails to Provide Reasonable Safety in DPC in Violation of the Constitution
Individuals in DPC have the constitutional right to live in reasonably safe conditions. See, Youngberg, 457 U.S. at 315. DPC is failing to ensure that they are reasonably free from harm or unnecessary risk of harm.
Confinement in an institution leaves individuals vulnerable to harm and abuse. Unnecessary confinement of individuals who are ready for discharge diverts staff resources that should be focused on individuals with the most significant clinical needs and creates congregate conditions that increase risks of harm and can exacerbate maladaptive behaviors. On our most recent visit, we found several instances of individuals who were awaiting placement who had
5 As noted previously, there have been substantial improvements in the past year under new DPC leadership.

-11-
been victims ofpatient-on-patient abuse. While most ofthese incidents appeared to be a result of congregate life, where people with various levels of adjustment live in close quarters, many of the risk factors for the harms now occurring would dissolve if individuals were not left languishing in DPC while awaiting discharge to the community.
On our earlier visit, we found that DPC staff failed to identify and provide appropriate treatment and supervision for individuals engaged in the very behaviors which led to their admission to DPC, including suicide attempts, self-injury, and aggression. Initial suicide and · violence risk assessments often are not completed at all or, if they are completed, lack critical information. This is a violation of individuals' constitutional rights. Youngberg, 457 U.S. at 315. Reassessments are similarly inadequate and untimely. Even when risks are identified, treatment plans fail to include appropriate behavioral interventions to address those risks and DPC staff fail to appropriately supervise individuals at high risk ofharm, again in violation of the r--------Constituti~Ia-:-DPC'sfai1ure toidenfi-fy ana provitle-crppn:rpriate-interventiuns-arrd-supervision-----places individuals at risk of harming themselves or others, as illustrated by the serious injuries ·and deaths of individuals described below:
• On April6, 2009, C.X.6 collapsed in the hallway of her unit at DPC. She lay there for several minutes without moving while staff walked past her without checking on her. Even more troubling, a DPC staff member pointed out C.X. to a nurse, who replied that C.X. "always does that" and did not respond further. By the time staff did check on C.X., she was unresponsive, and attempts to revive her failed. 7 This utter failure to provide care amounts to deliberate indifference and is an egregious violation of C.X.' s constitutional rights.
• On January 31, 2009, N.T. committed suicide by hanging herself with a bedspread. She was found by the staff member assigned to check her every 15 minutes. Despite her documented history of suicidal ideation and multiple serious episodes of self -harm, there had been no significant change to her treatment plan. In fact, N.T. herself warned DPC staffthat its response to these incidents - placing N. T. temporarily on heightened observation - would not keep her safe. DPC's failure to provide appropriate treatment and supervision violated N.T.' s constitutional rights.
6 To protect individuals' identities, we use fictitious initials throughout this letter. We will separately transmit to counsel a schedule cross-referencing the fictitious initials with the individuals' names.
7 To its credit, DPC reported two nurses involved in this incident to the state nursing licensing board.

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• U.L. was assaulted by another individual on the unit while she was on 1:1 close observation status. After the assault, she attempted suicide by hanging herself. U.L. 's risk for self-injurious behavior and victimization was well-documented. Her treatment plan, however, contained only vague goals relating to her self-injurious behavior, for example, that she will "remain free of suicidal gestures, attempts or behaviors" and "will communicate thoughts of self-harm as experienced to others who can help" and contained no steps to help her avoid victimization. Indeed, even staff whose job was to keep U.L. safe from others failed to provide that protection. DPC's failure to provide appropriate treatment and protection from harm violated her constitutional
rights.

• On August 27, 2009, C.P. died after swallowing a half-gallon of cleaning fluid r-------------ctliat was leffin an unlocl<ea. supply closet. CP. was a151e to gain access to1h::-:;ec--------
cleaning fluid without being observed by staff. Despite his documented history of attempting to digest dangerous chemicals while at DPC, including chlorine bleach, there had been no significant change in his treatment plan to address this behavior and to keep him safe while confined at DPC. Again, DPC's failure to provide appropriate treatment and supervision violated C.P.'s constitutional rights and was a direct cause of his death.

Moreover, DPC's incident, risk, and quality management systems fail to manage the risks of abuse, neglect, physical harm, self-injurious behavior, and suicide, in violation of the Constitution. Youngberg, 457 U.S. at 315-16. Internal investigations into abuse, neglect, and suspicious injuries in the hospitals systematically fail to include information that is necessary to finding the root cause of an incident or to delve sufficiently into the possible origins of incidents. DPC fails to reliably and adequately analyze the data that they collect, rendering State and hospital officials incapable of recognizing adverse trends and correcting issues that directly lead to harm and death of individuals confined to DPC. And, for risks that they do identify, DPC fails to implement corrective and preventive actions in a timely manner, if at all, or to monitor those actions as necessary to reduce or eliminate the risk of harm.

DPC's failure to appropriately identify and manage these risks substantially increases the

chances that individuals, including those who are awaiting discharge and no longer should even

be in DPC, will be subjected to harm. In addition, DPC's failure to provide a reasonably safe

living environment compromises the other care and treatment provided to individuals, prolongs

the duration of hospitalizations, leads to frequent and unnecessary re-hospitalizations, and

delays the movement of individuals to more integrated settings, in violation ofboth the

constitution and Olmstead.

·

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2. DPC Improperly Restrains and Secludes Individuals in Violation of Their Constitutional Rights
The right to be free from undue body restraint is the core of the liberty interest protected from arbitrary governmental action by the Due Process Clause. Youngberg, 457 U.S. at 316. Seclusion and restraint are emergency responses to failures in treatment; they are not treatment interventions that address the underlying behaviors for which the individual was hospitalized. To rely routinely on seclusion and restraint rather than behavior techniques, such as social reinforcement, to control aggressive behavior, violates the Fourteenth Amendment. Kirsch v. Thompson, 717 F. Supp. 1077, 1080-1081 (E.D. Pa. 1988) (holding that plaintiffs Fourteenth Amendment rights were violated when he was restrained at a state hospital for approximately three years in four-point physical restraints). Seclusion and restraint should be used only as a last resort. Thomas S. v. Flaherty, 699 F. Supp. 1178, 1189 (W.D.N.C. 1988), affd, 902 F.2d ~---~2SOT4111Cir.-T990), ceft. deniect;-498-T:J-:-5-:-95_1_0_990);-Davis-v~r.Iubbard;-5-(]6-F-:-S-upp~9-I-5-;-943:-----­ (W.D. Ohio 1980) (holding that the Constitution minimally requires that alternatives be considered before putting an individual in restraints) ..
We found that DPC uses restraints too frequently, and keeps individuals in restraints for excessive periods oftime in violation of their constitutional rights.8 Youngberg, 457 U.S. at 316. Further, DPC uses inappropriate criteria to place individuals in restraints, inappropriate criteria to release individuals from restraints, and does not monitor individualss adequately while they remain in restraints. Finally, in some instances, DPC pre-planned the use of restraints. We believe that DPC's improper use of seclusion and restraint not only violates individuals' constitutional rights,-but also is a symptom of its inadequate assessment and treatment of risks, as described above.
Below are examples of individuals being subjected to undue bodily restraint:
• F.X. was placed in restraints at least 26 times and into seclusion at least 13 times over a 13-month period. A review of his record indicates DPC used, or threatened to use, restraint and seclusion as a form of punishment instead of exploring treatment interventions to address F.X.' s history of aggression.
• K.O. was placed in restraints over 40 times over a 13-monthperiod. Our review of her record indicated some instances where she was placed in restraints more than once in a single day. Her record indicated no attempt to explore less intrusive approaches.
8 As noted, we understand that there has been a reduction in appropriate usage of seclusion and restraint in the past year under new DPC leadership.

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3. DPC Unconstitutionally Abuses Individuals
Individuals' constitutional liberty interests in reasonable protection from harm in mental health hospitals includes protection from abuse by staff. United States v. Dise, 763 F.2d 586,589 (3d Cir. 1985). The very nature of institutional settings-that staff are in a position of authority with complete control over every aspect of people's lives and that institutionalized individuals are isolated from the outside world-creates a high risk for abuse and neglect. Individuals in DPC, including the vast majority of people who are awaiting discharge to the community, are subjected to this significant risk of abuse. In our review ofDPC documents and records, we noted numerous incidents in which staff abused individuals, either verbally or physically.9
Examples include:
• A DPC employee hit K.X. on his head with a set of keys, resulting in a laceration that required sutures and staples to close.
• A DPC employee assigned to care for K.Q. on 1:1 precautions hit him on the head.
• A DPC employee assigned to take care ofN.X. on 1:1 precautions sexually assaulted her.
4. DPC's Unconstitutional Conditions are Exacerbated By Its Inadequate Investigation of Serious Incidents
We found that DPC does not consistently investigate injuries to individuals confined there and, when it does investigations, critical features, such as witness interviews and medical documentation, are often lacking. We found no evidence that DPC uses the historical data from investigations to: (1) identify actual or potential risks ofharm; (2) develop timely and appropriate interventions designed to minimize or eliminate risks of harm; or (3) monitor the efficacy of interventions used and modify them as necessary in response to further data, as required by the constitution.
We reviewed 63 reports of injuries occurring while the individual was on 1:1 or 2:1 close observation during the fifteen-month time period between January 2007 and March 2008. The majority of those incidents were not properly or fully investigated. For example, there was only occasional evidence that staff were interviewed and that records were reviewed. In some reports, only the involved individuals were interviewed, and when they were, the results
9 The DDOJ report included additional examples of staff abuse, including multiple sexual assaults of a patient by a DPC worker for which the worker was arrested and prosecuted.

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ofthe interview were in some cases dismissed as umeliable due to the individual's mental status. Findings from patient interviews should not be wholly dismissed because of the individual's mental status; all staff and individuals with direct as well as indirect information
about the event should be interviewed; and records should be reviewed.

In addition, the reports reflected an inadequate and inconsistent investigative methodology that is ineffective to protect individuals' constitutional right to a safety, because the circumstances that caused harm to one or more individuals are not understood and remedied. For example, when nursing interventions were documented, the documentation typically reflected that the person willfully did something wrong despite "re-direction." There was no evidence in the records of interactions or activities implemented to prevent the circumstances that might have caused or contributed to the individual's behavior.
Tfie facnliat so many injuries were sustained-by :lndividuats-who~were~ptac-ed~on-I-:-1------­ close observation to keep them safe, makes DPC's failure to adequately investigate serious incidents more alarming. The failure of DPC to have a transparent and effective system for identifying, tracking, and correcting problems, adverse events, faulty treatment, and staff adherence to policies and procedures, increases the actual and potential harm due to prolonged institutionalization.

As indicated, the constitutional violations at DPC pose a serious threat to the life, health,

and safety of individuals who are confined there. They make more urgent the need to move

individuals in DPC out of inappropriate placements in the hospital to more appropriate

integrated settings in the community.

1

IV. RECOMMENDED REMEDIAL MEASURES

To remedy the deficiencies discussed above and protect the constitutional and federal statutory rights of both individuals in Delaware Psychiatric Hospital ("DPC") and those at risk of being institutionalized at DPC, the State should promptly implement the minimum remedial
measures set forth below:

A. Serving Individuals with Mental Illness in the Most Integrated Setting

In order to remedy its failure to serve individuals in the most integrated setting appropriate to their needs, consistent with the mandate of Title II ofthe ADA and its implementing regulation,
Delaware should take the following steps:

Delaware should ensure that, before an individual is admitted to DPC, the individual receives a professionally-based assessment to ensure that admission to DPC is necessary and that DPC is the most integrated setting appropriate to serve the needs of that individual. Expanding Delaware's community-based crisis system is essential to diverting unnecessary admissions to
DPC (and other institutions).

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For those individuals for whom DPC is determined to be the most integrated setting appropriate to their needs, the State should revise its treatment and discharge planning process to focus, from the time of admission, on the appropriate discharge of individuals residing at DPC. During the treatment planning process and in implementing individual treatment plans, DPC should ensure that barriers to discharge are identified and addressed, and for individuals with a history of re-admission, that factors that led to re-admission are also analyzed and addressed.
Discharge planning should begin at the time of an individual's admission to DPC. The State should revise its discharge assessment process to focus on individuals' capacities to function in a more integrated setting and meet the demands of community living-not their compliance with hospital regiments-and identify the services and supports necessary for successful community living. DPC's assessment teams should become knowledgeable about community living options and services and should engage community providers early in the -----__,iseliarge planning process. Discl:Iarge plans snoulclserforth-in-reasuna:bte-d~eta:il-a-written------­ transition plan specifying the particular supports and services that each individual will or may need in order to safely and successfully transition to and live in the community. The plan should include, at a minimum: the individual's (and where relevant, family's) preferences for care; a discussion of how the individual (and where relevant, family) will access and pay for such services; the names and positions of those responsible for the individual's care, making appropriate referrals when necessary; a plan on how to coordinate care among multiple providers, if applicable; identification of the individual's specific needs after discharge; a discussion of how the individual (and, where relevant, family) need to prepare for discharge; and corresponding time frames for completion of needed steps to effect transition.
In order to ensure an appropriate transition upon discharge, DPC should engage identified community providers in the discharge planning process as far in advance of discharge as possible, and develop and implement a system to follow up with individuals after discharge to identify gaps in care and address proactively any such gaps to reduce the risk of re-admission. DPC should also create, revise, and implement a quality assurance or utilization review process to oversee the discharge process. The quality assurance process should include, at a minimum: developing a system to review the quality and effectiveness of discharge plans; developing a system to track discharged individuals to determine if they receive care in the community as prescribed at discharge; and identifying and assessing gaps in community services identified through the tracking of discharge outcomes.
B. Serving Persons With Mental Illness In The Community
To prevent the unnecessary institutionalization of individuals with mental illness, the State should develop and arrange for sufficient supports and services to ensure that those individuals are served in the most integrated setting appropriate to their needs. This included, but is not limited to, defining the target population for community services to include all individuals who are in or at risk of entering DPC or other restrictive institutional settings. To promote the community integration of the target population, the State should increase community capacity by expanding the following services to the target population: assertive community

-17-
treatment ("ACT"), supported housing, supported employment, family and peer support services, community crisis services, and appropriate case management services.
The State should ensure that the ACT services deliver comprehensive, individualized, and flexible treatment, support, and rehabilitation to individuals where they live and work and operate with fidelity to the Dartmouth ACT model. The ACT services should be provided through a multidisciplinary team with services that are individualized and customized, and address the constantly changing needs of the individual over time. ACT teams should have the full array of staff on each their team, including at least one peer specialist, necessary to provide the following services: case management, initial and ongoing assessments, psychiatric services, assistance with employment and housing, family support and education, substance abuse services, crisis services, and other services and supports critical to an individual's ability to live successfully in the community. ACT teams should provide crisis services, including helping individuals t-------increase tneir aoifity-to recognize anacleal with: situations fnat may otnerwise result in.---~------­ hospitalization, increase and improve their network of community and natural supports, and increase and improve their use of those supports for crisis prevention. ACT teams should provide services to promote the successful retention of housing, including peer support and· services designed to improve daily living skills, socialization, and illness self-management. ACT teams that serve individuals with co-occurring substance abuse disorders should provide substance abuse treatment and referral services to those individuals. Such ACT teams should include on their staff a clinician with substance abuse expertise. ACT services should be available 24 hours per day, 7 days per week. Finally, the number of individuals served by an ACT team should be no more than 10 individuals per ACT team member.
The State should provide supported housing to the target population in the form of housing, housing subsidies, or housing vouchers. Supported housing provides individuals with their own leased apartments or home, where they can live alone or with a roommate of their choosing. The housing is permanent (e.g., not time-limited) and is not contingent upon participation in treatment. The supported housing provided by the State should be scattered~site, meaning in an apartment building or housing complex in which no more than ten percent of the units are occupied by individuals with a disability. Personal care homes, group homes, and community living homes do not constitute supported housing. The State should ensure that individuals in supportive housing have access to a comprehensive array of services and supports necessary to ensure successful tenancy and to supportthe person's recovery and engagement in community life, including through ACT services.
The State should provide supported employment services to the target population through supported employment programs, the access to which is facilitated by ACT teams. Supported employment services should .assist individuals in finding competitive employment in an integrated setting based on the individual's strengths and interests. Support employment programs assist individuals in identifying vocational interests and applying to jobs and should provide services to support the individual's successful employment, including social skills training, job coaching, benefits counseling, and transportation. Supported employment services are integrated with the individual's mental health treatment. Enrollment in congregate day programs should not constitute supported employment.

-18-
The State should provide family and peer support services. Family support services are designed to educate and train an individual's family to better support the individual's treatment and successful community living, including by educating family members about the individual's mental illness, and about strategies for assisting with treatment and recognizing and addressing crises. Peer support services are delivered by peers to improve an individual's community living skills, including their ability to cope with and manage symptoms and to develop and utilize existing community supports. Peer support services may be provided by face-to-face or telephone contact and include outreach, wellness training, and training in self-advocacy.
The State should develop a statewide crisis system that includes a crisis call center, mobile crisis services, regional crisis centers, crisis stabilization programs, and crisis apartments. The Crisis Call Center is staffed by skilled professionals 24 hours per day, 7 days per week, to assess, make referrals, and dispatch available mobile teams. The State should provide mobile crisis !--------services~to-respond-to-crises-anywhere-in-the-cummurrity-(e-:-g-:-;-nomes, schools, or hospital_ _ _ _ _ _ __ emergency rooms) 24 hours per day, 7 days per week. The services are provided by clinical staff members (including staff with substance abuse expertise) and by peers. The State should also develop regional walk-in crisis centers that are clinically staffed 24 hours per day, 7 days a week; to receive individuals in crisis and to assess and provide them services and support, including evaluation, observation, triage, and referrals. · The State should provide crisis stabilization programs that are community-based residential services operated by community providers that provide psychiatric stabilization and detoxification services as an alternative to psychiatric hospitalization. Finally, the State should provide crisis apartments in the community to serve as an alternative to crisis stabilization programs and to psychiatric hospitalization.
The State should require that community care programs and community providers assess the adequacy of the individualized supports and services provided to persons by such providers in the community. These assessments include, but str not limited to, whether the community service boards and community providers' efforts are: reducing repeated admissions to DPC and other institutional settings; increasing stability of community residence; increasing housing services to individuals who have serious mental illness and who are homeless; retaining employment and/or schooling; increasing supported housing; and increasing supported employment.
The State should provide appropriate oversight of Community Service Boards and/or Community Providers by: establishingthe responsibilities of community care programs and/or community providers; identifying qualified providers, including providers in geographically diverse areas of the State; performing a cost rate study of provider reimbursement rates to determine whether current provider reimbursement rates are adequate; requiring community care programs and/or community providers to develop written plans describing services to be provided, in consultation with community stakeholders; requiring and/or providing training to community service boards and/or community providers so that services can be maintained in a manner consistent with evidence-based standards and this Findings Letter; and monitoring the performance of the community care programs and/or community providers.

-19-
C. Safety in DPC While Transitioning Individuals to Community Placements
In order to protect the safety of individuals currently residing in DPC, the State should transition individuals who can be served in more integrated settings from DPC and should provide safety, treatment, and services for individuals in DPC that are consistent with generally accepted professional standards. Generally accepted professional standards require that facilities appropriately monitor, supervise, and provide treatment to individuals in order to ensure their reasonable safety.
At a minimum, DPC should, consistent with generally accepted professional standards, appropriately monitor and supervise individuals, especially those at risk. All persons will have an individualized treatment plan formulated by qualified mental health professionals consistent
r------~w"~itl1 generalty-a-c~c-epte~d-pmfessicmahtarrd~s-.-Irrdivi~duats-witl-he~provi-deu~tlre-de-gre-e-oJ--------
individualized treatment as will afford them a reasonable opportunity to improve in social, behavioral, and mental functioning, to diminish symptoms related to their psychiatric illness, and to function as independently as possible. The treatment team will review and follow-up on each individual's care and treatment at appropriate intervals, and whenever an individual's condition requires. Risks (e.g. suicide, self-injury, aggression, other behavioral problems) requiring special observations/precautions will be appropriately addressed consistent with generally accepted professional standards.
To ensure that each individual is being treated in the most integrated setting, discharge planning will be given high priority and will begin on admission. The State should revise its discharge assessment process to focus on the individual's specific capacities to function in a more integrated setting and to meet the demands of community living and to identify the supports and services necessary for the individual's successful community living. DPC discharge teams should become knowledgeable about community living options and services and should engage community providers in the discharge planning process as soon as is practicable. During the assessment and treatment planning phases, discharge criteria will be established, included in the treatment plan, and regularly reviewed by the treatment team. The individual's progress toward discharge criteria and any barriers to discharge will be monitored in treatment plan updates and progress notes. The role of each treatment team member in assisting the individual to meet discharge criteria and achieve the level of functioning necessary for a successful discharge will be delineated in the treatment plan. Treatment will be directed toward helping the individual achieve the level of functioning necessary to be ready for discharge and to live in a community setting.
The State should institute a risk management program to identify high risk situations that require corrective action in an appropriate and timely manner a).ld to develop and implement timely interventions that remedy the identified risks to prevent or minimize harm to the individuals in DPC. The risk management program will include, but not be limited to, the following processes: incident reporting, data collection, and data aggregation to capture information regarding high risk situations; identification of individuals at risk that require review by the appropriate clinical disciplines and the interdisciplinary team, as well as a hierarchy of

- - -~~

I

-20-
interventions that correspond to the level of risk; identification and analysis of trends in high risk situations; and the development and implementation of corrective action in response to trends.
DPC should review and analyze all mortalities and incidents of serious injuries to reduce the risk of harm to other individuals, and identify and correct causative and contributing factors to the mortality.
The State should institute a quality management system. · The system will collect information related to the adequacy of safety, treatment, and services provided by community providers and DPC.
V. CONCLUSION
+---------Ptease-note--thatthis-findings-I-etteds-a-pubti-c-d-crcumem-.-It wi:U-oe postea on tl:IeCi'vil Rights Division's website. Although we will provide a copy of this letter to any individual or entity upon request, as a matter of courtesy, we will not post this letter on the Civil Rights Division's website until ten calendar days from the date of this letter.
We hope to continue working with the State in an amicable and cooperative fashion to resolve our outstanding concerns with respect to the services the State provides to persons with mental illness at DPC and other settings across the State. Assuming that our cooperative relationship continues, we are willing to send our consultants' written evaluations --which are not public documents-- under separate cover. Although the consultants' reports do not necessarily reflect the official conclusions of the Department of Justice, the observations, analysis, and recommendations contained therein provide further elaboration of the issues discussed in this letter and offer practical technical assistance to help address them.
We hope that you will· give this information careful consideration and that it will assist in facilitating a dialogue swiftly addressing the areas that require attention.

-21-
We are obligated to advise you that, in the unexpected event that we are unable to reach a resolution regarding our concerns, the Attorney General may initiate a lawsuit pursuant to CRIPA to correct deficiencies of the kind identified in this letter 49 days after appropriate officials have been notified of them, 42 U.S.C. § 1997b(a)(l), and pursuant to the ADA once we have determined that we cannot secure compliance voluntarily, 42 U.S.C. § 2000d-1. We would prefer, however, to resolve this matter by working cooperatively with the State and are confident that we will be able to do so. The DOJ lawyer assigned to this investigation will be contacting the State's attorneys to discuss this matter in further detail. If you have any questions regarding this letter, please call Jonathan M. Smith, Chief of the Civil Rights Division's Special Litigation Section, at (202) 514~5393.
Sincerely,
Thomas E. Perez Assistant Attorney General
cc:
Beau Biden Attorney General State of Delaware
Rita Landgraf Secretary Delaware Department of Health and Social Services
Kevin Huckshorn Director Delaware Department of Substance Abuse and Mental Health Acting Director Delaware Psychiatric Center
The Honorable David Weiss United States Attorney District of Delaware
Roger M. Lukoff Certification Officer Centers for Medicare & Medicaid Services

 
 Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 1 of 11
U.S. District Court District of Delaware (Wilmington) CIVIL DOCKET FOR CASE #: 1:11−cv−00591−LPS

CLOSED

United States of America v. State of Delaware Assigned to: Judge Leonard P. Stark Cause: 42:12101 Americans with Disabilities Act
Plaintiff

Date Filed: 07/06/2011 Date Terminated: 10/11/2016 Jury Demand: None Nature of Suit: 446 Civil Rights: Americans with Disabilities − Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by Elizabeth C. Kelley U.S. Department of Justice Civil Rights Division 950 Pennsylvania Ave., N.W. PHB−5427−B Washington, DC 20530 (202) 514−0460 Fax: (202) 514−4883 Email: beth.kelley@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Ryan C. Wilson U.S. Department of Justice − Civil Rights Division 601 D. Street, NW Washington, DC 20002 202−305−9937 Fax: 202−514−0212 Email: ryan.wilson@usdoj.gov TERMINATED: 07/19/2016 LEAD ATTORNEY ATTORNEY TO BE NOTICED

David Deutsch U.S. Department of Justice − Civil Rights Division Special Litigation Section 601 D Street NW, Patrick Henry Building Washington, DC 20004 (202) 514−6270 Fax: (202) 514−6273 Email: david.deutsch@usdoj.gov TERMINATED: 05/15/2014 ATTORNEY TO BE NOTICED

Deena S. Fox U.S. Department of Justice − Civil Rights Division Special Litigation Section 601 D Street NW, Patrick Henry Building Washington, DC 20004 (202) 305−1361 Email: deena.fox@usdoj.gov TERMINATED: 07/19/2016 ATTORNEY TO BE NOTICED

V. Defendant

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 2 of 11

State of Delaware

represented by Aaron R. Goldstein Department of Justice 820 N. French Street, 6th Floor Wilmington, DE 19801 (302) 577−8400 Email: Aaron.Goldstein@state.de.us LEAD ATTORNEY ATTORNEY TO BE NOTICED

Sarah Fishman Goncher Department of Justice 820 N. French Street, 6th Floor Wilmington, DE 19801 302−577−8188 Fax: 302−575−0840 Email: sarah.goncher@state.de.us LEAD ATTORNEY ATTORNEY TO BE NOTICED

Ilona M. Kirshon Department of Justice 820 N. French Street, 6th Floor Wilmington, DE 19801 (302) 577−8400 Email: ilona.kirshon@state.de.us TERMINATED: 05/21/2014 ATTORNEY TO BE NOTICED

Lawrence W. Lewis Department of Justice 820 N. French St. Wilmington, DE 19801 (302) 577−8500 Email: lawrence.lewis@state.de.us ATTORNEY TO BE NOTICED

Meredith Stewart Tweedie Department of Justice 820 N. French St. Wilmington, DE 19801 302−577−8382 Email: meredith.stewart@state.de.us TERMINATED: 07/13/2015 ATTORNEY TO BE NOTICED

Ralph K. Durstein , III Department of Justice 820 N. French St. Wilmington, DE 19801 (302) 577−8400 Email: ralph.durstein@state.de.us TERMINATED: 05/21/2014 ATTORNEY TO BE NOTICED

Date Filed 07/06/2011
07/06/2011

# Docket Text
1 COMPLAINT filed against State of Delaware − Magistrate Consent Notice to Pltf. − filed by United States of America. (Attachments: # 1 Civil Cover Sheet)(dlk) (Entered: 07/06/2011)
2 Notice, Consent and Referral forms re: U.S. Magistrate Judge jurisdiction (Received at time of filing over the counter) (dlk) (Entered: 07/06/2011)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 3 of 11

07/06/2011 07/06/2011 07/06/2011 07/06/2011 07/13/2011 07/18/2011 07/18/2011 08/25/2011 08/29/2011
09/07/2011 09/08/2011 09/09/2011 10/06/2011 10/06/2011 10/26/2011 11/14/2011 11/15/2011 11/22/2011 12/20/2011 12/22/2011

3 ACKNOWLEDGMENT OF RECEIPT of Magistrate Consent Forms (dlk) (Entered: 07/06/2011)
4 Joint MOTION For Entry of Settlement Agreement − filed by United States of America. (Attachments: # 1 Text of Proposed Order)(dlk) (Entered: 07/06/2011)
5 (PROPOSED) SETTLEMENT AGREEMENT by State of Delaware, United States of America. (dlk) (Entered: 07/06/2011)
Summons Issued as to State of Delaware on 7/6/2011. (dlk) (Entered: 07/06/2011)
Case Assigned to Judge Leonard P. Stark. Please include the initials of the Judge (LPS) after the case number on all documents filed. (rjb) (Entered: 07/13/2011)
6 ORDER granting 4 Joint Motion for Entry of Settlement Agreement. Signed by Judge Leonard P. Stark on 7/15/11. (ntl) (Entered: 07/18/2011)
7 SO ORDERED re 5 Settlement Agreement filed by State of Delaware, United States of America. Signed by Judge Leonard P. Stark on 7/15/11. (ntl) (Entered: 07/18/2011)
8 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, DAG regarding Monitor's proposed budget − re 7 Order, 5 Settlement Agreement. (Attachments: # 1 Exhibit Exhibit A − Budget Proposal)(Goldstein, Aaron) (Entered: 08/25/2011)
9 ORAL ORDER: Having reviewed the letter submission of August 25, 2011 (D.I. 8 ), IT IS HEREBY ORDERED that the Monitor's proposed budget, contained in Exhibit A to the letter submission, is APPROVED. The State need not file any responsive pleading to the complaint. ORDERED by Judge Leonard P. Stark on 8/29/11. (ntl) (Entered: 08/29/2011)
10 MOTION to Deposit Funds − filed by State of Delaware. (Goldstein, Aaron) (Entered: 09/07/2011)
11 ORDER granting 10 Motion to Deposit Funds. Signed by Judge Leonard P. Stark on 9/7/11. (ntl) (Entered: 09/08/2011)
12 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of funds − re 11 Order on Motion to Deposit Funds. (Attachments: # 1 receipt of deposit)(Goldstein, Aaron) (Entered: 09/09/2011)
13 ORDER granting the July/August 2011 invoice for court monitor services of Robert Bernstein, Ph.D.. Signed by Judge Leonard P. Stark on 10/6/11. (ntl) (Entered: 10/06/2011)
14 ORDER granting the September 2011 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 10/6/11. (ntl) (Entered: 10/06/2011)
15 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of replenishment funds − re 11 Order on Motion to Deposit Funds. (Attachments: # 1 receipt of deposit)(Goldstein, Aaron) (Entered: 10/26/2011)
16 ORDER granting the October 2011 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 11/14/11. (ntl) (Entered: 11/14/2011)
17 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order 16 . (ntl) (Entered: 11/15/2011)
18 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding acknowledging the deposit of funds. (Goldstein, Aaron) (Entered: 11/22/2011)
19 ORDER Granting the 12/16/11 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 12/19/11. (ntl) (Entered: 12/20/2011)
20 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 19 . (ntl) (Entered: 12/22/2011)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 4 of 11

01/09/2012
01/10/2012 01/13/2012 01/20/2012
01/30/2012 02/10/2012 02/14/2012 03/19/2012 03/22/2012 03/23/2012
04/17/2012 04/18/2012 05/03/2012
05/16/2012 05/17/2012 06/19/2012
06/19/2012 06/20/2012 07/12/2012 07/17/2012 08/13/2012
08/21/2012

21 Letter to The Honorable Leonard P. Stark from Deputy Attorney General Aaron R. Goldstein regarding deposit of funds − re 11 Order on Motion to Deposit Funds. (Goldstein, Aaron) (Entered: 01/09/2012)
22 ORDER Granting the 1/9/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 1/10/12. (ntl) (Entered: 01/10/2012)
23 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 22 . (ntl) (Entered: 01/13/2012)
24 Letter to The Honorable Leonard P. Stark from Aaron r. Goldstein, Deputy Attorney General regarding deposit of additional funds − re 11 Order on Motion to Deposit Funds. (Goldstein, Aaron) (Entered: 01/20/2012)
25 First Report of the Court Monitor Robert Bernstein, Ph.D. (ntl) (Entered: 01/30/2012)
26 ORDER Granting the 2/8/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 2/9/12. (ntl) (Entered: 02/10/2012)
27 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 26 . (ntl) (Entered: 02/14/2012)
28 ORDER Granting the 3/5/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 3/19/12. (ntl) (Entered: 03/19/2012)
29 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 28 . (ntl) (Entered: 03/22/2012)
30 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 11 Order on Motion to Deposit Funds. (Goldstein, Aaron) (Entered: 03/23/2012)
31 ORDER Granting the 4/9/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 4/16/12. (ntl) (Entered: 04/17/2012)
32 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 31 . (ntl) (Entered: 04/19/2012)
33 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of additional funds − re 11 Order on Motion to Deposit Funds. (Goldstein, Aaron) (Entered: 05/03/2012)
34 ORDER Granting the 5/9/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 5/16/12. (ntl) (Entered: 05/16/2012)
35 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 34 . (ntl) (Entered: 05/17/2012)
36 Letter to The Honorable Leonard P. Stark from Ilona M. Kirshon regarding deposit of additional funds − re 11 Order on Motion to Deposit Funds. (Goldstein, Aaron) (Entered: 06/19/2012)
37 ORDER Granting the 6/6/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 6/19/12. (ntl) (Entered: 06/19/2012)
38 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 37 . (ntl) (Entered: 06/20/2012)
39 ORDER Granting the 7/5/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 7/12/12. (ntl) (Entered: 07/12/2012)
40 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 39 . (ntl) (Entered: 07/17/2012)
41 Letter to The Honorable Leonard P. Stark from Ilona M. Kirshon regarding depositi of additional funds − re 11 Order on Motion to Deposit Funds. (Kirshon, Ilona) (Entered: 08/13/2012)
42 ORDER Granting the 8/11/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 8/21/12.(ntl) (Entered: 08/21/2012)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 5 of 11

08/22/2012
08/22/2012 09/05/2012 09/18/2012 09/20/2012 10/18/2012
10/25/2012 10/31/2012 11/05/2012
11/16/2012 11/20/2012 12/03/2012
12/21/2012 01/03/2013 01/09/2013 01/10/2013 01/17/2013 01/30/2013 02/08/2013 02/13/2013
02/21/2013 03/14/2013

43 Letter to The Honorable Leonard P. Stark from Ilona M. Kirshon regarding deposit of funds − re 11 Order on Motion to Deposit Funds. (Kirshon, Ilona) (Entered: 08/22/2012)
44 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 42 . (ntl) (Entered: 08/23/2012)
45 Second Report of the Court Monitor Robert Bernstein, Ph.D. (ntl) (Entered: 09/05/2012)
46 ORDER Granting the 9/3/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 9/18/12. (ntl) (Entered: 09/18/2012)
47 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 46 . (ntl) (Entered: 09/20/2012)
48 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of additional funds − re 11 Order on Motion to Deposit Funds. (Goldstein, Aaron) (Entered: 10/18/2012)
49 ORDER Granting the 10/14/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 10/24/12. (ntl) (Entered: 10/25/2012)
50 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 49 . (ntl) (Entered: 10/31/2012)
51 Letter to The Honorable Leonard P. Stark from Deputy Attorney General Aaron R. Goldstein regarding deposit of additional funds − re 49 Order. (Goldstein, Aaron) (Entered: 11/05/2012)
52 ORDER Granting the 11/12/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 11/16/12. (ntl) (Entered: 11/16/2012)
53 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 52 . (ntl) (Entered: 11/20/2012)
54 Letter to The honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of Additional Funds − re 11 Order on Motion to Deposit Funds, 52 Order. (Goldstein, Aaron) (Entered: 12/03/2012)
55 ORDER Granting the 12/9/12 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 12/21/12. (ntl) (Entered: 12/21/2012)
56 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 55 . (ntl) (Entered: 01/04/2013)
57 ORDER Granting the 1/6/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 1/9/13. (ntl) (Entered: 01/09/2013)
58 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 55 Order. (Goldstein, Aaron) (Entered: 01/10/2013)
59 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 57 . (ntl) (Entered: 01/17/2013)
60 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, DAG regarding deposit of additional funds − re 57 Order. (Goldstein, Aaron) (Entered: 01/30/2013)
61 ORDER Granting the 2/2/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 2/7/13. (ntl) (Entered: 02/08/2013)
62 Remark: Pursuant to the Standing Order of the Court (attached) dated January 18, 2013, the registry funds on deposit in this matter have been transferred to the Court Registry Investment System (CRIS). (dms, ) (Entered: 02/20/2013)
63 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 61 . (ntl) (Entered: 02/21/2013)
64 Third Report of the Court Monitor Robert Bernstein, Ph.D. (ntl) (Entered: 03/14/2013)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 6 of 11

03/14/2013 03/15/2013 03/21/2013 04/10/2013
04/12/2013 04/18/2013 05/07/2013
05/16/2013 05/24/2013 06/12/2013 06/19/2013 06/27/2013 07/12/2013 07/23/2013
07/24/2013 07/26/2013 08/08/2013 08/20/2013 08/22/2013 09/06/2013 09/13/2013 09/17/2013

65 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 61 Order. (Goldstein, Aaron) (Entered: 03/14/2013)
66 ORDER Granting the 3/6/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 3/15/13. (ntl) (Entered: 03/15/2013)
67 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 66. (ntl) (Entered: 03/21/2013)
68 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of additional funds − re 66 Order. (Goldstein, Aaron) (Entered: 04/10/2013)
69 ORDER Granting the 4/1/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 4/12/13. (ntl) (Entered: 04/12/2013)
70 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 69. (ntl) (Entered: 04/18/2013)
71 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of additional funds − re 69 Order. (Goldstein, Aaron) (Entered: 05/07/2013)
72 ORDER Granting the 5/5/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 5/15/13. (ntl) (Entered: 05/16/2013)
73 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 72. (ntl) (Entered: 05/24/2013)
74 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 72 Order. (Goldstein, Aaron) (Entered: 06/12/2013)
75 ORDER Granting the 6/9/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 6/18/13. (ntl) (Entered: 06/19/2013)
76 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 75 . (ntl) (Entered: 06/27/2013)
77 ORDER Granting the 7/7/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 7/12/13. (ntl) (Entered: 07/12/2013)
78 Letter Letter to The Honorable Leonard P. Stark from Deputy Attorney General Meredith Stewart Tweedie regarding U.S. v. Delaware, C.A. No.: 11−00591−LPS Third Year Budget. (Attachments: # 1 Exhibit Third−Year Budget − July 8, 2013)(Tweedie, Meredith) (Entered: 07/23/2013)
79 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 75 Order. (Goldstein, Aaron) (Entered: 07/24/2013)
80 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 77 . (ntl) (Entered: 07/26/2013)
81 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 77 Order. (Goldstein, Aaron) (Entered: 08/08/2013)
82 ORDER Granting the 8/4/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 8/19/13. (ntl) (Entered: 08/20/2013)
83 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 82 . (ntl) (Entered: 08/22/2013)
84 ORDER Granting the 9/2/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 9/5/13. (ntl) (Entered: 09/06/2013)
85 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 84 . (ntl) (Entered: 09/13/2013)
86 FOURTH REPORT of the Court Monitor by Robert Bernstein, Ph.D. (ntl) (Entered: 09/17/2013)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 7 of 11

09/24/2013 10/10/2013 10/17/2013 11/19/2013 11/26/2013 12/09/2013
12/16/2013 12/19/2013 01/16/2014 01/17/2014 01/28/2014 02/11/2014 02/21/2014 02/27/2014 03/24/2014 03/27/2014 04/22/2014
04/30/2014 05/06/2014
05/07/2014
05/15/2014
05/19/2014

87 CORRECTED FOURTH REPORT of the Court Monitor by Robert Bernstein, Ph.D. (ntl) (Entered: 09/24/2013)
88 ORDER Granting the 10/6/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 10/9/13. (ntl) (Entered: 10/10/2013)
89 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 88 . (ntl) (Entered: 10/17/2013)
90 ORDER Granting the 11/9/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 11/18/13. (ntl) (Entered: 11/19/2013)
91 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 90 . (ntl) (Entered: 11/26/2013)
92 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 88 Order, 90 Order, 84 Order. (Goldstein, Aaron) (Entered: 12/09/2013)
93 ORDER Granting the 12/1/13 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 12/16/13. (ntl) (Entered: 12/16/2013)
94 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 93 . (ntl) (Entered: 12/19/2013)
95 ORDER Granting the 1/5/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 1/16/14. (ntl) (Entered: 01/16/2014)
96 Letter to The Honorable Leonard P. Stark from Meredith Stewart Tweedie regarding deposit of additional funds − re 93 Order. (Tweedie, Meredith) (Entered: 01/17/2014)
97 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 95 . (ntl) (Entered: 01/28/2014)
98 Letter to The Honorable Leonard P. Stark from Meredith Stewart Tweedie regarding deposit of additional funds − re 95 Order. (Tweedie, Meredith) (Entered: 02/11/2014)
99 ORDER Granting the 2/9/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 2/21/14. (ntl) (Entered: 02/21/2014)
100 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 99 . (ntl) (Entered: 02/27/2014)
101 ORDER Granting the 3/18/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 3/24/14. (ntl) (ntl). (Entered: 03/24/2014)
102 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 101 . (ntl) (Entered: 03/27/2014)
103 ORDER Granting the 3/1/14 through 3/31/2014 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 4/22/2014. (rpg) (Entered: 04/23/2014)
104 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 103 . (ntl) (Entered: 04/30/2014)
105 Letter to The Honorable Leonard P. Stark from Meredith Stewart Tweedie regarding deposit of additional funds − re 101 Order, 103 Order, 99 Order. (Tweedie, Meredith) (Entered: 05/06/2014)
106 MOTION to Substitute Attorney: Ryan Wilson to be substituted for David Deutsch − filed by United States of America. (Attachments: # 1 Text of Proposed Order Proposed Order)(Wilson, Ryan) (Entered: 05/07/2014)
SO ORDERED, re 106 MOTION to Substitute Counsel: Ryan Wilson to be substituted for David Deutsch filed by United States of America −− Attorney David Deutsch terminated. Signed by Judge Leonard P. Stark on 5/15/14. (ntl) (Entered: 05/15/2014)
107 FIFTH REPORT of the Court Monitor by Robert Bernstein, Ph.D. (ntl) (Entered: 05/19/2014)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 8 of 11

05/21/2014 05/21/2014
05/28/2014 06/09/2014 06/27/2014 07/07/2014 07/22/2014 07/23/2014 07/29/2014 08/07/2014 08/13/2014 09/16/2014 09/30/2014
10/14/2014 10/22/2014 10/29/2014 11/06/2014 11/25/2014 12/11/2014 12/16/2014 12/17/2014 12/23/2014 12/29/2014

108 ORDER Granting the 5/11/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 5/21/14. (ntl) (Entered: 05/21/2014)
109 NOTICE OF SUBSTITUTION OF COUNSEL re State of Delaware: Entry of appearance of attorney Meredith Stewart Tweedie. Attorney Ilona M. Kirshon and Ralph K. Durstein, III terminated. (Attachments: # 1 Certificate of Service)(Tweedie, Meredith) (Entered: 05/21/2014)
110 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 108 . (ntl) (Entered: 05/28/2014)
111 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 108 Order. (Goldstein, Aaron) (Entered: 06/09/2014)
112 ORDER Granting the 6/18/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 6/27/14. (ntl) (Entered: 06/27/2014)
113 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 112 . (ntl) (Entered: 07/07/2014)
114 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 112 Order. (Goldstein, Aaron) (Entered: 07/22/2014)
115 ORDER Granting the 7/13/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 7/23/14. (ntl) (Entered: 07/23/2014)
116 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 115 . (ntl) (Entered: 07/29/2014)
117 ORDER Granting the 8/4/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 8/7/14. (ntl) (Entered: 08/07/2014)
118 Remark: A registry interim payment was made to the Court Monitor in accordance with the Order at D.I. 117 . (ntl) (Entered: 08/13/2014)
119 ORDER Granting the 9/6/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 9/15/14. (ntl) (Entered: 09/16/2014)
120 Letter to The Honorable Leonard P. Stark from Meredith Stewart Tweedie regarding deposit of additional funds − re 117 Order, 119 Order. (Tweedie, Meredith) (Entered: 09/30/2014)
121 Remark: A registry interim payment was made to the Court Monitor on 10/10/14 in accordance with the Order at D.I. 119 . (ntl) (Entered: 10/14/2014)
122 ORDER Granting the 10/12/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 10/22/14. (ntl) (Entered: 10/22/2014)
123 Remark: A registry interim payment was made to the Court Monitor on 10/28/14 in accordance with the Order at D.I. 122 . (ntl) (Entered: 10/29/2014)
124 Letter to The Honorable Leonard P. Stark from Meredith Stewart Tweedie regarding deposit of additional funds − re 122 Order. (Tweedie, Meredith) (Entered: 11/06/2014)
125 ORDER Granting the 11/10/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 11/25/14. (ntl) (Entered: 11/25/2014)
126 Letter to The Honorable Leonard P. Stark from Meredith Stewart Tweedie regarding deposit of additional funds − re 125 Order. (Tweedie, Meredith) (Entered: 12/11/2014)
127 Remark: A registry interim payment was made to the Court Monitor on 12/16/14 in accordance with the Order at D.I. 125 . (ntl) (Entered: 12/17/2014)
128 ORDER Granting the 12/6/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 12/17/14. (ntl) (Entered: 12/17/2014)
129 Remark: A registry interim payment was made to the Court Monitor on 12/23/14 in accordance with the Order at D.I. 128 . (ntl) (Entered: 12/23/2014)
130 SIXTH REPORT of the Court Monitor by Robert Bernstein, Ph.D. (ntl) (Entered: 12/29/2014)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 9 of 11

01/16/2015 01/22/2015 02/03/2015 02/13/2015 02/18/2015
02/24/2015 03/04/2015 03/20/2015 03/24/2015 03/31/2015 04/01/2015 04/15/2015 04/21/2015 05/18/2015 05/29/2015 06/09/2015 06/11/2015 06/19/2015 06/26/2015 07/10/2015
07/13/2015 08/11/2015 08/19/2015

131 ORDER Granting the 12/1/14 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 1/16/2015. (rpg) (Entered: 01/16/2015)
132 Remark: A registry interim payment was made to the Court Monitor on 1/22/15 in accordance with the Order at D.I. 131 . (ntl) (Entered: 01/22/2015)
133 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 131 Order. (Goldstein, Aaron) (Entered: 02/03/2015)
134 ORDER Granting the 2/6/15 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 2/13/15. (ntl) (Entered: 02/13/2015)
135 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 128 Order, 115 Order. (Goldstein, Aaron) (Entered: 02/18/2015)
136 Remark: A registry interim payment was made to the Court Monitor on 2/24/15 in accordance with the Order at D.I. 134 . (ntl) (Entered: 02/24/2015)
137 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 134 Order. (Goldstein, Aaron) (Entered: 03/04/2015)
138 ORDER Granting the 3/14/15 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 3/19/15. (ntl) (ntl). (Entered: 03/20/2015)
139 Remark: A registry interim payment was made to the Court Monitor on 3/24/15 in accordance with the Order at D.I. 138 . (ntl) (Entered: 03/24/2015)
140 ORDER Granting the 3/30/15 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 3/31/15. (ntl) (Entered: 03/31/2015)
141 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 138 Order. (Goldstein, Aaron) (Entered: 04/01/2015)
142 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 140 Order. (Goldstein, Aaron) (Entered: 04/15/2015)
143 Remark: A registry interim payment was made to the Court Monitor on 4/21/15 in accordance with the Order at D.I. 140 . (ntl) (Entered: 04/21/2015)
144 ORDER Granting the 5/3/15 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 5/18/2015. (rpg) (Entered: 05/18/2015)
145 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein regarding deposit of additional funds − re 144 Order. (Goldstein, Aaron) (Entered: 05/29/2015)
146 Remark: A registry interim payment was made to the Court Monitor on 6/9/15 in accordance with the Order at D.I. 144 . (ntl) (Entered: 06/09/2015)
147 SEVENTH REPORT of the Court Monitor by Robert Bernstein, Ph.D. (ntl) (Entered: 06/11/2015)
148 ORDER Granting the 6/9/15 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 6/19/15. (ntl) (Entered: 06/19/2015)
149 Remark: A registry interim payment was made to the Court Monitor on 6/25/15 in accordance with the Order at D.I. 148 . (ntl) (Entered: 06/26/2015)
150 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of additional funds − re 148 Order. (Goldstein, Aaron) (Entered: 07/10/2015)
151 NOTICE of Withdrawal of Counsel by State of Delaware (Goldstein, Aaron) (Entered: 07/13/2015)
152 ORDER Granting the 7/31/15 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 8/11/15. (ntl) (Entered: 08/11/2015)
153 Remark: A registry interim payment was made to the Court Monitor on 8/18/15 in accordance with the Order at D.I. 152 . (ntl) (Entered: 08/19/2015)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 10 of 11

08/27/2015
09/18/2015 09/24/2015
10/13/2015
12/21/2015 01/04/2016 01/04/2016 01/05/2016 01/05/2016 02/08/2016 02/11/2016 02/29/2016 03/18/2016 03/29/2016 04/20/2016 05/17/2016 05/19/2016 05/31/2016 06/14/2016 06/15/2016 06/23/2016 06/30/2016

154 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of additional funds − re 152 Order. (Goldstein, Aaron) (Entered: 08/27/2015)
155 ORDER Granting the 9/7/15 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 9/18/15. (rpg) (Entered: 09/18/2015)
156 Remark: A registry interim payment was made to the Court Monitor on 9/24/15 in accordance with the Order at D.I. 155 . (ntl) Modified on 9/24/2015 (ntl). (Entered: 09/24/2015)
157 Letter to The Honorable Leonard P. Stark from Aaron R. Goldstein, Deputy Attorney General regarding deposit of additional funds − re 155 Order. (Goldstein, Aaron) (Entered: 10/13/2015)
158 ORDER Granting the 12/6/15 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 12/21/15. (ntl) (Entered: 12/21/2015)
159 Remark: A registry interim payment was made to the Court Monitor on 12/29/15 in accordance with the Order at D.I. 158 . (ntl) (Entered: 01/04/2016)
160 EIGHTH REPORT of the Court Monitor by Robert Bernstein, Ph.D. (ntl) (Entered: 01/04/2016)
161 NOTICE of Appearance by Sarah Fishman Goncher on behalf of State of Delaware (Goncher, Sarah) (Entered: 01/05/2016)
162 Letter to The Honorable Leonard P. Stark from Sarah Fishman Goncher regarding deposit of additional funds − re 158 Order. (Goncher, Sarah) (Entered: 01/05/2016)
163 ORDER Granting the 1/18/16 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 2/8/16. (ntl) (Entered: 02/08/2016)
164 Remark: A registry interim payment was made to the Court Monitor on 2/11/16 in accordance with the Order at D.I. 163 . (ntl) (Entered: 02/11/2016)
165 Letter to The Honorable Leonard P. Stark from Sarah Fishman Goncher regarding deposit of additional funds − re 163 Order. (Goncher, Sarah) (Entered: 02/29/2016)
166 ORDER Granting the 3/16/16 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 3/18/2016. (rpg) (Entered: 03/18/2016)
167 Remark: A registry interim payment was made to the Court Monitor on 3/29/16 in accordance with the Order at D.I. 166 . (ntl) (Entered: 03/29/2016)
168 Letter to The Honorable Leonard P. Stark from Sarah Fishman Goncher regarding deposit of additional funds − re 166 Order. (Goncher, Sarah) (Entered: 04/20/2016)
169 ORDER Granting the 5/7/16 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 5/17/16. (ntl) (Entered: 05/17/2016)
170 Remark: A registry interim payment was made to the Court Monitor on 5/19/16 in accordance with the Order at D.I. 169 . (ntl) (Entered: 05/19/2016)
171 NINTH REPORT of the Court Monitor by Robert Bernstein, Ph.D. (ntl) (Entered: 05/31/2016)
172 Letter to The Honorable Leonard P. Stark from Sarah Fishman Goncher regarding deposit of additional funds − re 169 Order. (Goncher, Sarah) (Entered: 06/14/2016)
173 ORDER Granting the 6/12/16 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 6/15/16. (ntl) (Entered: 06/15/2016)
174 Remark: A registry interim payment was made to the Court Monitor on 6/23/16 in accordance with the Order at D.I. 173 . (ntl) (Entered: 06/23/2016)
175 Letter to The Honorable Leonard P. Stark from Deputy Attorney General Sarah Fishman Goncher regarding deposit of additional funds − re 173 Order. (Goncher, Sarah) (Entered: 06/30/2016)

Case: 1:11-cv-591 As of: 11/05/2017 09:09 PM EST 11 of 11

07/19/2016
07/20/2016
08/18/2016 08/23/2016 08/29/2016
09/09/2016 09/19/2016 09/29/2016 10/06/2016 10/06/2016
10/11/2016
10/11/2016 10/18/2016 10/28/2016 01/31/2017 02/09/2017

176 NOTICE OF SUBSTITUTION OF COUNSEL re United States of America: Entry of appearance of attorney Elizabeth C. Kelley. Attorney Ryan Wilson terminated. (Kelley, Elizabeth) (Entered: 07/19/2016)
177 Letter to Chief Judge Leonard Stark from the parties regarding a joint request for a non−evidentiary hearing on the status of the State's compliance with the terms of the Settlement Agreement. (Goncher, Sarah) (Entered: 07/20/2016)
178 ORDER Granting the 8/7/16 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 8/17/16. (ntl) (Entered: 08/18/2016)
179 Remark: A registry interim payment was made to the Court Monitor on 8/23/16 in accordance with the Order at D.I. 178 . (ntl) (Entered: 08/23/2016)
180 ORAL ORDER: IT IS HEREBY ORDERED that the Court will hear oral argument on October 13, 2016 beginning at 2:00 p.m. Each side will be allocated up to one (1) hour to present its argument. ORDERED by Judge Leonard P. Stark on 8/29/16. (ntl) (Entered: 08/29/2016)
181 Letter to The Honorable Leonard P. Stark from Sarah Fishman Goncher regarding deposit of additional funds − re 178 Order. (Goncher, Sarah) (Entered: 09/09/2016)
182 TENTH REPORT of the Court Monitor by Robert Bernstein, Ph.D. (ntl) (Entered: 09/20/2016)
183 ORDER Granting the 9/19/16 invoice for court monitor services of Robert Bernstein, Ph.D. Signed by Judge Leonard P. Stark on 9/29/16. (ntl) (Entered: 09/29/2016)
184 Joint MOTION to Dismiss − filed by United States of America. (Attachments: # 1 Text of Proposed Order)(Kelley, Elizabeth) (Entered: 10/06/2016)
185 Joint OPENING BRIEF in Support re 184 Joint MOTION to Dismiss filed by United States of America.Answering Brief/Response due date per Local Rules is 10/24/2016. (Attachments: # 1 Exhibit 1, # 2 Exhibit 2, # 3 Exhibit 3)(Kelley, Elizabeth) (Entered: 10/06/2016)
186 ORDER TO DISMISS WITH PREJUDICE re 184 Joint MOTION to Dismiss filed by United States of America. Oral Argument scheduled for October 13 is CANCELLED. Signed by Judge Leonard P. Stark on 10/11/16. (ntl) (Entered: 10/11/2016)
CASE CLOSED (ntl) (Entered: 10/11/2016)
187 Remark: A registry interim payment was made to the Court Monitor on 10/18/16 in accordance with the Order at D.I. 183 . (ntl) (Entered: 10/18/2016)
188 Letter to The Honorable Leonard P. Stark from Sarah Fishman Goncher regarding deposit of additional funds − re 183 Order. (Goncher, Sarah) (Entered: 10/28/2016)
189 MOTION for Release of Funds − filed by State of Delaware. (Attachments: # 1 Text of Proposed Order, # 2 Certificate of Service)(Goncher, Sarah) (Entered: 01/31/2017)
190 ORDER for Return of State Funds re 189 MOTION for Return of State Funds filed by State of Delaware. Signed by Judge Leonard P. Stark on 2/8/17. (ntl) (Entered: 02/09/2017)