CLOSED,DLrecused,FILE,JDrecused
U.S. District Court District of New Hampshire (Concord) CIVIL DOCKET FOR CASE #: 1:12-cv-00053-SM

Amanda D., et al v. NH Governor, et al Assigned to: Judge Steven J. McAuliffe Related Case: 1:18-cv-01039-JD Cause: 42:12101 Americans With Disabilities Act

Date Filed: 02/09/2012 Date Terminated: 02/19/2014 Jury Demand: None Nature of Suit: 446 Civil Rights: Americans with Disabilities - Other Jurisdiction: Federal Question

Plaintiff
Barry Ellsworth Guardian of Lynn E. TERMINATED: 02/07/2013 other Lynn E. TERMINATED: 02/07/2013

represented by Aaron Jesse Ginsberg Disabilities Rights Center Inc. 18 Low Ave Concord, NH 03301-4971 603-228-0432 Email: aarong@drcnh.org TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Catharine A. Mallinson Disability Rights Center 64 N Main St, Ste 2 Concord, NH 03301-4913 603 228-0432 Email: adriennem@drcnh.org TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Daniel E. Will NH Attorney General's Office 33 Capitol St Concord, NH 03301-6397 603 271-0110 Email: daniel.will@doj.nh.gov TERMINATED: 08/13/2018 LEAD ATTORNEY

Elaine M. Michaud

Devine Millimet & Branch PA (Manchester) 111 Amherst St Manchester, NH 03101 603 669-1000 Email: emichaud@devinemillimet.com TERMINATED: 05/31/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Joshua M. Wyatt Dover, City of Municipal Bldg 288 Central Ave Dover, NH 03820 603 516-6521 Email: j.wyatt@dover.nh.gov TERMINATED: 06/04/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Kristen Renae Blanchette Devine Millimet & Branch PA (Manchester) 111 Amherst St Manchester, NH 03101 603 669-1000 Email: kblanchette@devinemillimet.com TERMINATED: 11/08/2012 LEAD ATTORNEY
Amy Beth Messer Disability Rights Center 64 N Main St, Ste 2 Concord, NH 03301-4913 603 228-0432 Email: amym@drcnh.org TERMINATED: 06/02/2016 ATTORNEY TO BE NOTICED
Andrew Laurence Milne Disability Rights Center 64 N Main St, Ste 2 Concord, NH 03301-4913

603 228-0432 Email: andrewm@drcnh.org ATTORNEY TO BE NOTICED
Ira A. Burnim Judge David L. Bazelon Center for Mental Health Law 1101 Fifteenth St, NW Washington, DC 20005 202 467-5730 Email: irabster@gmail.com PRO HAC VICE ATTORNEY TO BE NOTICED
Jennifer Mathis Judge David L. Bazelon Center for Mental Health Law 1101 Fifteenth St, NW Washington, DC 20005 202 467-5730 Email: jenniferm@bazelon.org PRO HAC VICE ATTORNEY TO BE NOTICED
Jonathan A. Lax Devine Millimet & Branch PA 111 Amherst St Manchester, NH 03101 603 669 1000 Fax: 603 669 8547 Email: jlax@devinemillimet.com ATTORNEY TO BE NOTICED
Kathryn L. Rucker Center for Public Representation 246 Walnut Street Newton, MA 02460 617 965-0776 Email: krucker@cpr-ma.org PRO HAC VICE ATTORNEY TO BE NOTICED
Pamela E. Phelan Disability Rights Center 64 N Main St, Ste 2 Concord, NH 03301-4913

Plaintiff
Tri-County CAP, Inc../GS Guardian of Kenneth R. other Kenneth R.

603 228-0432 Email: pamelap@drcnh.org ATTORNEY TO BE NOTICED
Steven J. Schwartz Center for Public Representation 22 Green St Northampton, MA 01060 413 586-6024 Email: sschwartz@cpr-ma.org PRO HAC VICE ATTORNEY TO BE NOTICED
represented by Aaron Jesse Ginsberg (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Catharine A. Mallinson (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Daniel E. Will (See above for address) TERMINATED: 08/13/2018 LEAD ATTORNEY
Elaine M. Michaud (See above for address) TERMINATED: 05/31/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Kristen Renae Blanchette (See above for address) TERMINATED: 11/08/2012 LEAD ATTORNEY
Amy Beth Messer (See above for address) TERMINATED: 06/02/2016

Plaintiff
Office of Public Guardian, Inc. Guardian of Sharon B. other Sharon B.

Andrew Laurence Milne (See above for address) ATTORNEY TO BE NOTICED
Ira A. Burnim (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jennifer Mathis (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jonathan A. Lax (See above for address) ATTORNEY TO BE NOTICED
Kathryn L. Rucker (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Pamela E. Phelan (See above for address) ATTORNEY TO BE NOTICED
Steven J. Schwartz (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Joshua M. Wyatt (See above for address) ATTORNEY TO BE NOTICED
represented by Aaron Jesse Ginsberg (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Catharine A. Mallinson (See above for address) TERMINATED: 09/07/2018

LEAD ATTORNEY ATTORNEY TO BE NOTICED
Daniel E. Will (See above for address) TERMINATED: 08/13/2018 LEAD ATTORNEY
Elaine M. Michaud (See above for address) TERMINATED: 05/31/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Joshua M. Wyatt (See above for address) TERMINATED: 06/04/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Kristen Renae Blanchette (See above for address) TERMINATED: 11/08/2012 LEAD ATTORNEY
Amy Beth Messer (See above for address) TERMINATED: 06/02/2016
Andrew Laurence Milne (See above for address) ATTORNEY TO BE NOTICED
Ira A. Burnim (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jennifer Mathis (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jonathan A. Lax (See above for address) ATTORNEY TO BE NOTICED

Plaintiff Amanda D.

Kathryn L. Rucker (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Pamela E. Phelan (See above for address) ATTORNEY TO BE NOTICED
Steven J. Schwartz (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
represented by Aaron Jesse Ginsberg (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Catharine A. Mallinson (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Daniel E. Will (See above for address) TERMINATED: 08/13/2018 LEAD ATTORNEY
Elaine M. Michaud (See above for address) TERMINATED: 05/31/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Joshua M. Wyatt (See above for address) TERMINATED: 06/04/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Kristen Renae Blanchette

(See above for address) TERMINATED: 11/08/2012 LEAD ATTORNEY
Amy Beth Messer (See above for address) TERMINATED: 06/02/2016
Andrew Laurence Milne (See above for address) ATTORNEY TO BE NOTICED
Benjamin Sahl Disability Rights Center 64 N Main St, Ste 2 Concord, NH 03301-4913 603 228-0432 Email: BenS@drcnh.org TERMINATED: 09/07/2018 ATTORNEY TO BE NOTICED
Ira A. Burnim (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jennifer Mathis (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jonathan A. Lax (See above for address) ATTORNEY TO BE NOTICED
Kathryn L. Rucker (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Pamela E. Phelan (See above for address) ATTORNEY TO BE NOTICED
Steven J. Schwartz (See above for address)

Plaintiff
Office of Public Guardian, Inc. Guardian of Amanda E. other Amanda E.

PRO HAC VICE ATTORNEY TO BE NOTICED
represented by Aaron Jesse Ginsberg (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Catharine A. Mallinson (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Daniel E. Will (See above for address) TERMINATED: 08/13/2018 LEAD ATTORNEY
Elaine M. Michaud (See above for address) TERMINATED: 05/31/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Joshua M. Wyatt (See above for address) TERMINATED: 06/04/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Kristen Renae Blanchette (See above for address) TERMINATED: 11/08/2012 LEAD ATTORNEY
Amy Beth Messer (See above for address) TERMINATED: 06/02/2016
Andrew Laurence Milne (See above for address) ATTORNEY TO BE NOTICED

Plaintiff
Monique Doukas Guardian of Jeffrey D. other Jeffrey D.

Benjamin Sahl (See above for address) TERMINATED: 09/07/2018 ATTORNEY TO BE NOTICED
Ira A. Burnim (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jennifer Mathis (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jonathan A. Lax (See above for address) ATTORNEY TO BE NOTICED
Kathryn L. Rucker (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Pamela E. Phelan (See above for address) ATTORNEY TO BE NOTICED
Steven J. Schwartz (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
represented by Aaron Jesse Ginsberg (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Catharine A. Mallinson (See above for address) TERMINATED: 09/07/2018 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Elaine M. Michaud (See above for address) TERMINATED: 05/31/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Joshua M. Wyatt (See above for address) TERMINATED: 06/04/2019 LEAD ATTORNEY ATTORNEY TO BE NOTICED
Kristen Renae Blanchette (See above for address) TERMINATED: 11/08/2012 LEAD ATTORNEY
Amy Beth Messer (See above for address) TERMINATED: 06/02/2016
Andrew Laurence Milne (See above for address) ATTORNEY TO BE NOTICED
Benjamin Sahl (See above for address) TERMINATED: 09/07/2018 ATTORNEY TO BE NOTICED
Daniel E. Will (See above for address) TERMINATED: 08/13/2018
Ira A. Burnim (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jennifer Mathis (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Jonathan A. Lax (See above for address)

V. Intervenor Plaintiff United States of America

ATTORNEY TO BE NOTICED
Kathryn L. Rucker (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
Pamela E. Phelan (See above for address) ATTORNEY TO BE NOTICED
Steven J. Schwartz (See above for address) PRO HAC VICE ATTORNEY TO BE NOTICED
represented by Richard J Farano US Department of Justice (Civil Rights Division) 950 Pennsylvania Avenue NW PHB - Room 5020 Washington, DC 20530 202 307-3116 Email: richard.farano@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Alexandra Shandell US Department of Justice- Civil Rights Division (D) 601 D Street, NW Washington, DC 20579 202 307-6123 Email: alexandra.shandell@usdoj.gov ATTORNEY TO BE NOTICED
Deena S. Fox US Department of Justice (Civil Rights Division) 950 Pennsylvania Avenue NW PHB - Room 5020

V.
Defendant
NH Governor in his official capacity other John H. Lynch

Washington, DC 20530 202 305-1361 Email: deena.fox@usdoj.gov ATTORNEY TO BE NOTICED
Katherine Houston US Department of Justice- Civil Rights Division (D) 601 D Street, NW Washington, DC 20579 202 307-0652 Email: katherine.houston4@usdoj.gov ATTORNEY TO BE NOTICED
represented by Anne M. Edwards NH Attorney General's Office (DOJ) Department of Justice 33 Capitol St Concord, NH 03301 603 271-1231 Email: anne.m.edwards@doj.nh.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Rebecca Woodard Ross NH Attorney General's Office (Civil) Civil Bureau 33 Capitol St Concord, NH 03301-6397 603 271-1268 Email: rebecca.ross@doj.nh.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED
Brian David Thomas Sheehan Phinney Bass & Green 1000 Elm St, 17th Flr PO Box 3701 Manchester, NH 03105-3701 603 627-8136

Defendant
NH Department of Health and Human Services, Commissioner in his official capacity other Nicholas A. Toumpas

Email: bthomas@sheehan.com ATTORNEY TO BE NOTICED
David W. McGrath Sheehan Phinney Bass & Green (Manchester) 1000 Elm St PO Box 3701 Manchester, NH 03105-3701 603 668-0300 Email: dmcgrath@sheehan.com ATTORNEY TO BE NOTICED
James Q. Shirley Sheehan Phinney Bass & Green (Manchester) 1000 Elm St PO Box 3701 Manchester, NH 03105-3701 603 668-0300 Email: jshirley@sheehan.com ATTORNEY TO BE NOTICED
John-Mark Turner Sheehan Phinney Bass & Green (Manchester) 1000 Elm St PO Box 3701 Manchester, NH 03105-3701 603 627-8150 Email: jturner@sheehan.com TERMINATED: 03/07/2017
represented by Anne M. Edwards (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Rebecca Woodard Ross (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Brian David Thomas (See above for address)

Defendant NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner in her official capacity other Nancy L. Rollins
Defendant NH Department of Health and Human Services, Direct Programs/Operations

ATTORNEY TO BE NOTICED
David W. McGrath (See above for address) ATTORNEY TO BE NOTICED
James Q. Shirley (See above for address) ATTORNEY TO BE NOTICED
John-Mark Turner (See above for address) TERMINATED: 03/07/2017
represented by Anne M. Edwards (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Rebecca Woodard Ross (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Brian David Thomas (See above for address) ATTORNEY TO BE NOTICED
David W. McGrath (See above for address) ATTORNEY TO BE NOTICED
James Q. Shirley (See above for address) ATTORNEY TO BE NOTICED
John-Mark Turner (See above for address) TERMINATED: 03/07/2017
represented by Anne M. Edwards (See above for address) LEAD ATTORNEY

in her official capacity other Mary Ann Cooney
Defendant NH Bureau of Behavioral Health, Administrator in his official capacity other Erik G. Riera

ATTORNEY TO BE NOTICED
Rebecca Woodard Ross (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Brian David Thomas (See above for address) ATTORNEY TO BE NOTICED
David W. McGrath (See above for address) ATTORNEY TO BE NOTICED
James Q. Shirley (See above for address) ATTORNEY TO BE NOTICED
John-Mark Turner (See above for address) TERMINATED: 03/07/2017
represented by Anne M. Edwards (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Rebecca Woodard Ross (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Brian David Thomas (See above for address) ATTORNEY TO BE NOTICED
David W. McGrath (See above for address) ATTORNEY TO BE NOTICED
James Q. Shirley (See above for address) ATTORNEY TO BE NOTICED

John-Mark Turner (See above for address) TERMINATED: 03/07/2017

Date Filed 02/09/2012
02/10/2012 02/10/2012 02/10/2012
02/10/2012

#

Docket Text

1 NEW CASE/REDACTED COMPLAINT. Filing fee $ 350, receipt number 0102-838915 filed by Jeffrey D.; Sharon B., by her guardian, Office of Public Guardian, Inc.; Kenneth R., by his guardian, Tri-County CAP, Inc./GS;, Amanda D., by her guardian, Louise Dube; Lynn E., by her guardian, Barry Ellsworth; Amanda E., by her guardian, Office of Public Guardian, Inc. (Attachments: # 1 Civil Cover Sheet, Notice of Conventional Filing-Civil Cover Sheet, # 2 Summons - Waiver Notice of Conventional FilingSummons for John H. Lynch, # 3 Summons - Waiver Notice of Conventional Filing-Summons for Nicholas A. Toumpas, # 4 Summons - Waiver Notice of Conventional Filing-Summons for Nancy L. Rollins, # 5 Summons - Waiver Notice of Conventional Filing-Summons for Mary Ann Cooney, # 6 Summons - Waiver Notice of Conventional Filing-Summons for Erik G. Riera)(Will, Daniel) (Entered: 02/09/2012)

Case assigned to Magistrate Judge Landya B. McCafferty. The case designation is: 1:12-cv-53-LM. Please show this number with the judge designation on all future pleadings. (jeb) (Entered: 02/10/2012)

6 NOTICE of Assignment to U.S. Magistrate Judge sent to plaintiff(s) for service on all parties.(jeb) (Entered: 02/10/2012)

NOTICE. This case has been designated for Electronic Case Filing. All further submissions shall be filed in compliance with the Administrative Procedures for Electronic Case Filing. Pro se litigants are not required to file electronically and may continue to file documents in paper format. Persons filing electronically are strongly encouraged to complete the interactive training modules available on the courts website. To access these modules, click HERE.(jeb) (Entered: 02/10/2012)

Summonses issued by Mail as to NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. Notice ECF (USDCNH-91)

02/13/2012 02/13/2012 02/13/2012 02/14/2012 02/14/2012
02/14/2012

and NOTICE of Assignment to Magistrate Judge (USDCNH54) attached to the summonses. (jeb) (Entered: 02/10/2012)
7 NOTICE of Attorney Appearance by Elaine M. Michaud on behalf of Jeffrey D., Office of Public Guardian, Inc. o/b/o Sharon B., TriCounty CAP, Inc../GS, Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E. (Michaud, Elaine) (Entered: 02/13/2012)
8 NOTICE of Attorney Appearance by Kristen Renae Blanchette on behalf of Jeffrey D., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS, Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E. (Blanchette, Kristen) (Entered: 02/13/2012)
9 NOTICE of Attorney Appearance by Joshua M. Wyatt on behalf of Jeffrey D., Office of Public Guardian, Inc. o/b/o Sharon B., TriCounty CAP, Inc../GS, Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E. (Wyatt, Joshua) (Entered: 02/13/2012)
10 NOTICE of Attorney Appearance by Aaron Jesse Ginsberg on behalf of Jeffrey D., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS, Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E. Appearance A. Ginsberg (Ginsberg, Aaron) (Entered: 02/14/2012)
11 FILED IN ERROR. REPLACED BY DOCUMENT NO. 12. NOTICE of Attorney Appearance by Aaron Jesse Ginsberg on behalf of Jeffrey D., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS, Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E. Appearance A. Mallinson (Ginsberg, Aaron) Modified on 2/15/2012 to add: "FILED IN ERROR. REPLACED BY DOCUMENT NO. 12. (kad). (Entered: 02/14/2012)
NOTICE of ECF Filing Error re: 11 Notice of Attorney Appearance (A. Mallinson), filed by Jeffrey D., Office of Public Guardian, Inc. o/b/o Amanda E., Barry Ellsworth, Tri-County CAP, Inc./GS, Office of Public Guardian, Inc. o/b/o Sharon B., Louise Dube. A filing user may not file for a non-filing user. Login/password used must equal the /s/ signature on the filed document. Attorney's admitted to the bar of this court and in good standing who intend to appear in an ECF case in this judicial district shall register as Filing Users of the court's ECF system by completing an on-line registration form on the court's website at www.nhd.uscourts.gov. Refer to AP 2.7, 6.1 and 6.2. If the filing

02/15/2012 02/28/2012 03/02/2012 03/02/2012 03/02/2012 03/02/2012

party has any questions concerning this notice, please contact the judge's case manager at 603-225-1423. Notice of Compliance Deadline set for 2/24/2012.(kad) (Entered: 02/14/2012)
12 NOTICE of Attorney Appearance by Catharine A. Mallinson on behalf of Jeffrey D., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS, Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E. Mallinson Appearance (Mallinson, Catharine) (Entered: 02/15/2012)
13 WAIVER OF SERVICE Returned Executed as to All Defendants by All Plaintiffs. Served/Mailed on 2/24/2012. Answer Follow Up on 4/30/2012.(Blanchette, Kristen) (Entered: 02/28/2012)
14 MOTION for Steven J. Schwartz to Appear Pro Hac Vice (Filing fee $ 100, Receipt # 0102-846301.) filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., TriCounty CAP, Inc../GS. Follow up on Objection on 3/19/2012. (Attachments: # 1 Exhibit (Affidavit) Steven J. Schwartz Affidavit)(Blanchette, Kristen) (Entered: 03/02/2012)
15 MOTION for Kathryn L. Rucker to Appear Pro Hac Vice (Filing fee $ 100, Receipt # 0102-846303.) filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., TriCounty CAP, Inc../GS. Follow up on Objection on 3/19/2012. (Attachments: # 1 Exhibit (Affidavit) Kathryn L. Rucker Affidavit)(Blanchette, Kristen) (Entered: 03/02/2012)
16 MOTION for Ira A. Burnim to Appear Pro Hac Vice (Filing fee $ 100, Receipt # 0102-846310.) filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. Follow up on Objection on 3/19/2012. (Attachments: # 1 Exhibit (Affidavit) Ira A. Burnim Affidavit)(Blanchette, Kristen) (Entered: 03/02/2012)
17 MOTION for Jennifer Mathis to Appear Pro Hac Vice (Filing fee $ 100, Receipt # 0102-846312.) filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. Follow up on Objection on 3/19/2012. (Attachments: # 1 Exhibit (Affidavit) Jennifer Mathis Affidavit)(Blanchette, Kristen) (Entered: 03/02/2012)

03/15/2012 03/15/2012 03/15/2012 03/15/2012 03/23/2012

ENDORSED ORDER granting 14 Motion for Steven J. Schwartz to Appear Pro Hac Vice. Text of Order: Granted on the condition that Steven J. Schwartz complete an online ECF Registration Form within 10 days. So Ordered by Magistrate Judge Landya B. McCafferty. ECF Registration Deadline set for 3/29/2012.To access the online registration form, click HERE. Persons filing electronically are strongly encouraged to complete the interactive training modules available on the courts website. To access these modules, click HERE.(gla) (Entered: 03/15/2012)
ENDORSED ORDER granting 15 Motion for Kathryn L. Rucker to Appear Pro Hac Vice. Text of Order: Granted on the condition that Kathryn L. Rucker complete an online ECF Registration Form within 10 days. So Ordered by Magistrate Judge Landya B. McCafferty. ECF Registration Deadline set for 3/29/2012.To access the online registration form, click HERE. Persons filing electronically are strongly encouraged to complete the interactive training modules available on the courts website. To access these modules, click HERE.(gla) (Entered: 03/15/2012)
ENDORSED ORDER granting 16 Motion for Ira A. Burnim to Appear Pro Hac Vice. Text of Order: Granted on the condition that Ira A. Burnim complete an online ECF Registration Form within 10 days. So Ordered by Magistrate Judge Landya B. McCafferty. ECF Registration Deadline set for 3/29/2012.To access the online registration form, click HERE. Persons filing electronically are strongly encouraged to complete the interactive training modules available on the courts website. To access these modules, click HERE.(gla) (Entered: 03/15/2012)
ENDORSED ORDER granting 17 Motion for Jennifer Mathis to Appear Pro Hac Vice. Text of Order: Granted on the condition that Jennifer Mathis complete an online ECF Registration Form within 10 days. So Ordered by Magistrate Judge Landya B. McCafferty. ECF Registration Deadline set for 3/29/2012.To access the online registration form, click HERE. Persons filing electronically are strongly encouraged to complete the interactive training modules available on the courts website. To access these modules, click HERE.(gla) (Entered: 03/15/2012)
18 Assented to MOTION to Exceed Page Limits filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc.

03/23/2012
03/27/2012 03/27/2012 04/04/2012 04/04/2012 04/05/2012 04/05/2012

o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS.(Messer, Amy) (Entered: 03/23/2012)

19 MOTION to Certify Class filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. Follow up on Objection on 4/9/2012. (Attachments: # 1 Memorandum of Law, # 2 Exhibit Ex. 1, US DOJ Findings Ltr, # 3 Exhibit Ex. 2, Restoration I, # 4 Exhibit Ex. 3, Fulfilling the Promise, # 5 Exhibit Ex. 4, NOMS Data, # 6 Exhibit Ex. 5, NHH Annual Rpt, # 7 Exhibit Ex. 6, Listening Sessions, # 8 Exhibit (Affidavit) Ex. 7, Affidavit of C. A. Mallinson, # 9 Attachment to Exhibit Ex.7A, Glencliff Census Data, # 10 Exhibit Ex. 8, ADA Class Cert Cases, # 11 Exhibit Ex. 9, Institutional Placement Class Action Cases)(Messer, Amy) (Entered: 03/23/2012)

ENDORSED ORDER granting 18 Motion to Exceed Page Limits. Text of Order: Granted. So Ordered by Magistrate Judge Landya B. McCafferty.(gla) (Entered: 03/27/2012)

20 Assented to MOTION to Intervene as Plaintiff filed by United States of America. (Attachments: # 1 Memorandum of Law, # 2 Proposed Order, # 3 Exhibit One)(Farano, Richard) (Entered: 03/27/2012)

ENDORSED ORDER granting 20 Motion to Intervene. Text of Order: Granted. For all the reasons outlined in the United States' memorandum, the court finds that intervention is appropriate under Rule 24 as of right, Fed. R. Civ. P. 24(a)(2), and/or by permission, Fed. R. Civ. P. 24(b)(1)(B). So Ordered by Magistrate Judge Landya B. McCafferty.(gla) (Entered: 04/04/2012)

Intervenor COMPLAINT filed by United States of

21

America.(Farano, Richard) (Entered: 04/04/2012)

22 NOTICE of Attorney Appearance by Anne M. Edwards on behalf of NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor (Edwards, Anne) (Entered: 04/05/2012)

23 NOTICE of Attorney Appearance by Rebecca L. Woodard on behalf of NH Bureau of Behavioral Health, Administrator, NH

04/06/2012
04/06/2012 04/09/2012 04/10/2012 04/17/2012 04/17/2012

Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor (Woodard, Rebecca) (Entered: 04/05/2012)
24 MOTION to Strike 19 Motion to Certify Class,,, filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. Follow up on Objection on 4/23/2012. (Attachments: # 1 Memorandum of Law Memorandum of Law in Support of Motion to Strike)(Edwards, Anne) (Entered: 04/06/2012)
25 OBJECTION to 19 MOTION to Certify Class filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. (Edwards, Anne) (Entered: 04/06/2012)
26 Notice of Intent to Reply to Objection to 19 MOTION to Certify Class. Follow up on Reply on 4/26/2012.(Messer, Amy) (Entered: 04/09/2012)
27 NOTICE of Attorney Appearance by Deena S. Fox on behalf of United States of America (Fox, Deena) (Entered: 04/10/2012)
28 NOTICE of Attorney Appearance by David W. McGrath on behalf of NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor (McGrath, David) (Entered: 04/17/2012)
29 NOTICE of Attorney Appearance by John-Mark Turner on behalf of NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor, United States of America (Turner, John-Mark) (Entered: 04/17/2012)

04/17/2012 04/17/2012 04/17/2012 04/20/2012 04/20/2012 04/20/2012 04/20/2012

30 NOTICE of Attorney Appearance by Brian David Thomas on behalf of NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor (Thomas, Brian) (Entered: 04/17/2012)

31 NOTICE of Attorney Appearance by James Q. Shirley on behalf of NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor (Shirley, James) (Entered: 04/17/2012)

ANSWER to 1 Complaint - New Case,,, filed by NH Bureau of

32

Behavioral Health, Administrator, NH Department of Health and

Human Services, Commissioner, NH Department of Health and

Human Services, Community Based Care Services, Associate

Commissioner, NH Department of Health and Human Services,

Direct Programs/Operations, NH Governor.(Turner, John-Mark)

(Entered: 04/17/2012)

NOTICE OF PRETRIAL CONFERENCE. Pretrial Conference set for 5/22/2012 10:00 AM before Magistrate Judge Landya B. McCafferty. Follow up on Discovery Plan 5/16/2012.(kad) (Entered: 04/20/2012)

33 MEMORANDUM in Support re 19 MOTION to Certify Class filed by United States of America. (Fox, Deena) (Entered: 04/20/2012)

34 Assented to MOTION for Leave to File Reply filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Attachments: # 1 Exhibit Reply to Obj to Class Cert, # 2 Attachment to Exhibit Affidavit in Support of Reply, # 3 Attachment to Exhibit Affidavit in Support of Reply)(Messer, Amy) (Entered: 04/20/2012)

35 Assented to MOTION to Exceed Page Limit filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS.(Messer, Amy) (Entered: 04/20/2012)

04/20/2012 04/23/2012
04/23/2012 04/23/2012 04/23/2012

36 OBJECTION to 24 MOTION to Strike 19 Motion to Certify Class,,, filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Messer, Amy) (Entered: 04/20/2012)
NOTICE of ECF Filing Error re: 34 Assented to MOTION for Leave to File Reply filed by Jeffrey D., Office of Public Guardian, Inc. o/b/o Amanda E., Barry Ellsworth, Tri-County CAP, Inc./GS, Office of Public Guardian, Inc. o/b/o Sharon B., Louise Dube. Consistent with Supplemental Rules of Electronic Case Filing, affidavits prepared in the context of the litigation shall be filed in electronically converted PDF format and shall contain a /s/ signature for both the signator and the notary/jurat. NO ACTION REQUIRED - FOR INFORMATIONAL PURPOSES ONLY AND MERELY INTENDED TO EDUCATE ALL PARTIES IN THE CASE. If the filing party has any questions concerning this notice, please contact the judge's case manager at 603-2251423.(kad) (Entered: 04/23/2012)
NOTICE of ECF Filing Error re: 36 Objection to Motion, filed by Jeffrey D., Office of Public Guardian, Inc. o/b/o Amanda E., Barry Ellsworth, Tri-County CAP, Inc./GS, Office of Public Guardian, Inc. o/b/o Sharon B., Louise Dube. No certificate of service. Filer shall file a certificate of service using the Certificate of Service event and link the filing back to originally filed document. If the filing party has any questions concerning this notice, please contact the judge's case manager at 603-225-1423. Notice of Compliance Deadline set for 5/3/2012.(kad) (Entered: 04/23/2012)
37 CERTIFICATE OF SERVICE by Jeffrey D., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS, Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E. re: 36 Objection to Motion, (Ginsberg, Aaron) (Entered: 04/23/2012)
38 NOTICE of Intent to Move for Leave to File Reply to Plaintiffs' Objection to Motion to Strike by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(Turner, John-Mark) (Entered: 04/23/2012)

04/23/2012
04/24/2012 04/24/2012 04/24/2012 04/24/2012 04/25/2012 05/01/2012

39 NOTICE of Intent to Move for Leave to File Surreply to Plaintiffs' Reply to Defendants' Objection to Class Certification Motion by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(Turner, John-Mark) (Entered: 04/23/2012)
ENDORSED ORDER granting 34 Motion for Leave to File Reply. Text of Order: Granted. Within 48 hours counsel shall electronically refile the pleading attached to the Motion for Leave to File using the appropriate event in CMECF. So Ordered by Magistrate Judge Landya B. McCafferty.(gla) (Entered: 04/24/2012)
ENDORSED ORDER granting 35 Motion to Exceed Page Limit. Text of Order: Granted. So Ordered by Magistrate Judge Landya B. McCafferty.(gla) (Entered: 04/24/2012)
40 REPLY to Objection to Motion re 19 MOTION to Certify Class filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Attachments: # 1 Exhibit (Affidavit), # 2 Exhibit (Affidavit))(Messer, Amy) (Entered: 04/24/2012)
NOTICE OF PRETRIAL CONFERENCE. Pretrial Conference set for 5/24/2012 10:30 AM before Magistrate Judge Landya B. McCafferty. Follow up on Discovery Plan 5/17/2012.(kad) (Entered: 04/24/2012)
Deadlines terminated re: 4/24/2012 Notice of Pretrial Conference NOTICE FILED IN ERROR - PLEASE DISREGARD. PRETRIAL CONFERENCE is already set for 5/22/2012 10:00 AM before Magistrate Judge Landya B. McCafferty. Follow up on Discovery Plan 5/16/2012.(kad) (kad) (Entered: 04/25/2012)
41 NO CONSENT to Jurisdiction by U.S. Magistrate Judge. Because not all parties to the case consent to the assignment of a United States Magistrate Judge for all purposes including trial, pursuant to Fed. R. Civ. P. 73, 28 U.S.C. sec. 636(c), and Local Rule 73.1(b)(2), the case will be assigned to a United States District Judge. Clerk James R. Starr. (Blanchette, Kristen) (Entered: 05/01/2012)

05/01/2012 05/02/2012
05/02/2012 05/03/2012
05/04/2012 05/08/2012 05/08/2012

Case reassigned to Judge Steven J. McAuliffe. Reason for Reassignment: not all parties to the case consent to the assignment of a United States Magistrate Judge. The new case designation is: 12-cv-53-SM. Please show this number with the correct judge designation on all further pleadings.(kad) (Entered: 05/02/2012)
NOTICE of ECF Filing Error re: 41 Magistrate Judge Assignment-Consent/Objection, filed by Jeffrey D., Office of Public Guardian, Inc. o/b/o Amanda E., Barry Ellsworth, Tri-County CAP, Inc../GS, Office of Public Guardian, Inc. o/b/o Sharon B., Louise Dube. No certificate of service. Filer shall file a certificate of service using the Certificate of Service event and link the filing back to originally filed document. If the filing party has any questions concerning this notice, please contact the judge's case manager at 603-225-1423. Notice of Compliance Deadline set for 5/14/2012.(kad) (Entered: 05/02/2012)
42 CERTIFICATE OF SERVICE by Jeffrey D., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS, Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E. re: 41 Magistrate Judge Assignment-Consent/Objection, (Wyatt, Joshua) (Entered: 05/02/2012)
43 Assented to MOTION to Extend Time to File Motion for Leave to File Reply filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(Turner, John-Mark) (Entered: 05/03/2012)
ENDORSED ORDER granting 43 Motion to Extend Time to file. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 05/04/2012)
44 WAIVER OF SERVICE Returned Executed as to NH Governor and State of New Hampshire by United States of America. Served/Mailed on 4/4/2012. Answer Follow Up on 6/11/2012.(Farano, Richard) (Entered: 05/08/2012)
45 AMENDED ANSWER to 1 Complaint - New Case,,, by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human

05/10/2012 05/14/2012 05/14/2012
05/15/2012 05/15/2012 05/15/2012

Services, Direct Programs/Operations, NH Governor.(Turner, John-Mark) (Entered: 05/08/2012)
46 MOTION for Hearing re 24 MOTION to Strike 19 Motion to Certify Class,,,, 19 MOTION to Certify Class filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. Follow up on Objection on 5/29/2012.(Messer, Amy) (Entered: 05/10/2012)
47 Assented to MOTION to Exceed Page Limit filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(Shirley, James) (Entered: 05/14/2012)
48 Assented to MOTION for Leave to File Reply to Plaintiffs' Objection to Defendants' Motion to Strike Motion for Class Certification filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. (Attachments: # 1 Exhibit 1Reply)(Shirley, James) (Entered: 05/14/2012)
49 Proposed Discovery Plan filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Attachments: # 1 Exhibit Scheduling Plan Table)(Messer, Amy) (Entered: 05/15/2012)
ENDORSED ORDER granting 47 Motion to Exceed page limit; and granting 48 Motion for Leave to File reply. Text of Order: Granted So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 05/15/2012)
50 Proposed Discovery Plan filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. (Attachments: # 1 Attachment A - Scheduling Plan Table)(McGrath, David) (Entered: 05/15/2012)

05/16/2012
05/17/2012
05/17/2012 05/18/2012 05/18/2012 06/04/2012
06/11/2012

51 OBJECTION to 46 MOTION for Hearing re 24 MOTION to Strike 19 Motion to Certify Class,,,, 19 MOTION to Certify Class filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. (McGrath, David) (Entered: 05/16/2012)
52 REPLY to Objection to Motion re 24 MOTION to Strike 19 Motion to Certify Class,,, filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. (Shirley, James) (Entered: 05/17/2012)
Pretrial Conference set for 5/22/2012 10:00 AM before Magistrate Judge Landya B. McCafferty is cancelled; will be rescheduled before Judge Steven J McAuliffe at a later date. (jab) (Entered: 05/17/2012)
ENDORSED ORDER granting 46 Motion for Hearing. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 05/18/2012)
NOTICE re: 24 MOTION to Strike 19 Motion to Certify Class; 19 MOTION to Certify Class. Motion Hearing set for 6/11/2012 10:00 AM before Judge Steven J. McAuliffe.(jab) (Entered: 05/18/2012)
53 ANSWER to 21 Intervenor Complaint filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(McGrath, David) (Entered: 06/04/2012)
Minute Order for proceedings held before Judge Steven J. McAuliffe: MOTION HEARING held on 6/11/2012 re: 24 MOTION to Strike 19 Motion to Certify Class and 19 MOTION to Certify Class. Oral argument heard. Court denies, without prejudice to refiling after certification discovery period, plaintiffs' 19 Motion to Certify Class; denies 24 Motion to

06/13/2012
07/20/2012 07/20/2012 07/20/2012 08/14/2012 08/16/2012

Strike 19 Motion to Certify Class. Court allows merit-based discovery to proceed for six months. Parties will try and submit a joint proposed discovery plan; if unable to agree, each party will submit its own proposed discovery plan. (Court Reporter: Susan Bateman) (Pltfs Atty: Amy Messer, Daniel Will, Catharine Mallinson, Steven Schwartz) (Intervenor Pltfs Atty: Richard Faranto, Deena Fox) (Defts Atty: Anne Edwards, James Shirley, David McGrath, John-Mark Turner)(Total Hearing Time: 2 hrs and 9 minutes) (jab) (Entered: 06/11/2012)
ENDORSED ORDER mooting 49 Plaintiffs' Proposed Discovery Plan; mooting 50 Defendants' Proposed Discovery Plan. Text of Order: Moot. As stipulated at the hearing on June 11, 2012, counsel will endeavor to reconcile differences in the proposed scheduling orders and file an agreed-upon plan, if possible. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 06/13/2012)
54 Assented to MOTION for Protective Order filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Attachments: # 1 Exhibit Protective Order, # 2 Attachment to Exhibit Protective Order Agreement)(Ginsberg, Aaron) (Entered: 07/20/2012)
ENDORSED ORDER granting 54 Motion for Protective Order. Text of Order: Granted; the proposed order is adopted as an order of the court. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 07/23/2012)
55 PROTECTIVE ORDER. So Ordered by Judge Steven J. McAuliffe. (Attachments: # 1 Exhibit A - Protective Order Agreement)(jab) (Entered: 07/23/2012)
56 Proposed Discovery Plan Parties' Joint filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., TriCounty CAP, Inc../GS. (Attachments: # 1 Exhibit Att.A Scheduling Plan Table)(Messer, Amy) (Entered: 08/14/2012)
ENDORSED ORDER approving 56 Parties' Joint Discovery Plan. Length of Trial 20 days. Case Track: Complex. There will be no PRETRIAL CONFERENCE. Text of Order: Approved and adopted as a pretrial scheduling order. Trial: 6/17/2014 (Bench Trial) So Ordered by Judge Steven J. McAuliffe. Ready for Trial on 6/17/2014. Summary Judgment Motions due by 2/18/2014. Class Discovery deadline 1/15/2013.

08/16/2012 11/07/2012 11/08/2012 11/08/2012 01/10/2013

Motion to Certify Class Deadline set for 1/29/2013.(jab) (Entered: 08/16/2012)
TRIAL NOTICE: Pretrial Statements due 5/19/2014. LR 16.2(d) Objections due 6/2/2014. Final Pretrial Conference set for 6/6/2014 02:00 PM before Judge Steven J. McAuliffe. Bench Trial set for the two-week period beginning 6/17/2014 09:00 AM before Judge Steven J. McAuliffe. (jab) (Entered: 08/16/2012)
57 NOTICE of Attorney Withdrawal by Kristen Renae Blanchette on behalf of Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS(Blanchette, Kristen) (Entered: 11/07/2012)
58 Assented to MOTION for Kristen R. Blanchette to Withdraw as Attorney filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS.(Blanchette, Kristen) (Entered: 11/08/2012)
ENDORSED ORDER granting 58 Assented to Motion For Kristen Blanchette to Withdraw as Attorney. Text of Order: Granted. So Ordered by Magistrate Judge Landya B. McCafferty.(jab) (Entered: 11/08/2012)
59 TRANSCRIPT of Proceedings for Motion Hearing held on June 11, 2012. Court Reporter: Susan Bateman, Telephone # 603 2251453. Transcript is available for public inspection, but may not be copied or otherwise reproduced, at the Clerk's Office for a period of 90 days. Additionally, only attorneys of record and pro se parties with an ECF login and password who purchase a transcript from the court reporter will have access to the transcript through PACER during this 90-day period. If you would like to order a copy, please contact the court reporter at the above listed phone number.
NOTICE: Any party who requests an original transcript has 21 days from service of this notice to determine whether it is necessary to redact any personal identifiers and, if so, to electronically file a Redaction Request.
Redaction Request Follow Up 2/4/2013. Redacted Transcript Follow Up 2/14/2013. Release of Transcript Restriction set for 4/11/2013.(jab) (Entered: 01/10/2013)

01/15/2013
01/15/2013 01/17/2013 01/18/2013 01/18/2013

60 MOTION to Extend Time to Complete Class Discovery and Briefing Deadlines filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. Follow up on Objection on 2/1/2013. (Attachments: # 1 Memorandum of Law in Support of Motion to Extend Class Discovery and Briefing Deadlines, # 2 Exhibit A - 07-11-2012 Plaintiffs' Second Requests for Production)(Turner, John-Mark) (Additional attachment added on 1/15/2013: # 3 Memorandum of Law (text searchable format)) (jab). (Entered: 01/15/2013)
NOTICE of ECF Filing Error re: 60 MOTION to Extend Time to Complete Class Discovery and Briefing Deadlines filed by Defendants - the memorandum of law is not text searchable. Documents must be provided in an electronically converted PDF text searchable format in accordance with A.P. 2.3(a). Filer shall e-mail a PDF text searchable copy of the memorandum to the case manager to be attached to the docket entry rather than refiling the entire document. If the filing party has any questions concerning this notice, please contact the judge's case manager at 603-2251587. Notice of Compliance Deadline set for 1/25/2013.(jab) (Entered: 01/15/2013)
61 OBJECTION to 60 MOTION to Extend Time to Complete Class Discovery and Briefing Deadlines filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., TriCounty CAP, Inc../GS. (Messer, Amy) (Entered: 01/17/2013)
62 [Filed in error - wrong event used. See corrected notice, document no. 63.] NOTICE of Intent to File Motion for Leave to File Reply Memorandum by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(Turner, John-Mark) Modified on 1/18/2013 to add text in brackets. (jab). (Entered: 01/18/2013)
NOTICE of ECF Filing Error re: 62 Notice (Other), filed by Defendants. Filer used wrong event. Filer shall refile using the Notices/Notice of Intent to Reply event and enter in docket text: Replaces document no. 62. By utilizing this event, a deadline

01/18/2013 01/18/2013 01/18/2013
01/19/2013 01/22/2013 01/24/2013
01/24/2013

will be set to file the motion for leave to file reply. If the filing party has any questions concerning this notice, please contact the judge's case manager at 603-225-1587. Notice of Compliance Deadline set for 1/28/2013.(jab) (Entered: 01/18/2013)

63 Notice of Intent to Reply to Objection to 60 MOTION to Extend Time to Complete Class Discovery and Briefing Deadlines [Replaces document no. 62]. Follow up on Reply on 2/4/2013.(Turner, John-Mark) (Entered: 01/18/2013)

64 RESPONSE re 63 Notice of Intent to Reply and Request for Expedited Ruling filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Mallinson, Catharine) (Entered: 01/18/2013)

65 RESPONSE re 64 Response (not to Motion), Limited Objection to Request for Expedited Ruling filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. (Turner, John-Mark) (Entered: 01/18/2013)

66 RESPONSE to Motion re 60 MOTION to Extend Time to Complete Class Discovery and Briefing Deadlines filed by United States of America. (Farano, Richard) (Entered: 01/19/2013)

ORDER re 63 Notice of Intent to File Motion for Leave to file

67

Reply Memorandum: If defendants wish to file a reply

memorandum, they may do so on or before 4:00 p.m. on

Thursday, January 24, 2013. ( Follow up on Reply on

1/24/2013.) So Ordered by Judge Steven J.

McAuliffe.(jab) (Entered: 01/22/2013)

68 MOTION to Exceed Page Limits filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. Follow up on Objection on 2/11/2013.(Turner, John-Mark) (Entered: 01/24/2013)

69 REPLY to Objection to Motion re 60 MOTION to Extend Time to Complete Class Discovery and Briefing Deadlines filed by NH

01/24/2013
01/28/2013 01/28/2013 01/29/2013 01/29/2013

Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. (Attachments: # 1 Exhibit A - Monique D. Answer to Interrogatory No. 21, # 2 Exhibit B - Jeffrey D. 12/14/12 Response to Requests)(Turner, John-Mark) (Entered: 01/24/2013)

70 OBJECTION to 68 MOTION to Exceed Page Limits filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Messer, Amy) (Entered: 01/24/2013)

ENDORSED ORDER granting 68 Motion to Exceed page limits. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 01/28/2013)

ORDER denying 60 Motion to Extend Time. So Ordered by

71

Judge Steven J. McAuliffe.(lat) (Entered: 01/28/2013)

72 Assented to MOTION to Exceed Page Limit filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS.(Messer, Amy) (Entered: 01/29/2013)

73 MOTION to Certify Class filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. Follow up on Objection on 2/15/2013. (Attachments: # 1 Memorandum of Law Memo of Law Class Certification, # 2 Exhibit Ex. 1, US Investigation Letter, # 3 Exhibit Ex. 2, Addressing Critical Needs, # 4 Exhibit Ex. 3, Fulfilling the Promise, # 5 Exhibit Ex. 4, SAMHSA Data, # 6 Exhibit Ex. 5, NHH Annual Report, # 7 Exhibit Ex. 6, Listening Sessions, # 8 Exhibit (Affidavit) Ex. 7, Mallinson Affidavit, # 9 Attachment to Exhibit Att. 7A, Glencliff Data, # 10 Exhibit Ex. 8, CBHA Plan Progress, # 11 Exhibit (Affidavit) Ex. 9, SImpatico Affidavit, # 12 Attachment to Exhibit Att. 9A, Simpatico CV, # 13 Exhibit (Affidavit) Ex. 10, Boardman Affidavit, # 14 Attachment to Exhibit Att. 10A, Boardman CV, # 15 Exhibit (Affidavit) Ex. 11, Curran Affidavit, # 16 Attachment to Exhibit Att. 11A, Curran CV, # 17 Attachment to Exhibit Att. 11B, Byrne CV, # 18 Exhibit (Affidavit) Ex. 12, Rogers Affidavit, # 19 Attachment to Exhibit Att. 12A, Rogers CV, # 20 Exhibit (Affidavit) Ex. 13, Sudders

01/29/2013 02/06/2013 02/07/2013 02/19/2013
02/21/2013 03/07/2013
03/07/2013

Affidavit, # 21 Attachment to Exhibit Att. 13A, Sudders CV, # 22 Attachment to Exhibit Att. 13B, Sudders Doc. Index, # 23 Exhibit Ex. 14, ADA Case List, # 24 Exhibit Ex. 15, Institutional Case List)(Messer, Amy) (Entered: 01/29/2013)
ENDORSED ORDER granting 72 Motion to Exceed page limits. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 01/29/2013)
74 Assented to MOTION to Substitute Party filed by Jeffrey D., Louise Dube, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS.(Messer, Amy) (Entered: 02/06/2013)
ENDORSED ORDER granting 74 Assented-To Motion to Substitute Parties. Barry Ellsworth (Guardian of Lynn E.) terminated. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 02/07/2013)
75 Assented to MOTION to Extend Time to Submit an Objection to the renewed certification motion filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(Turner, John-Mark) (Entered: 02/19/2013)
ENDORSED ORDER granting 75 assented to Motion to Extend Time to object. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 02/21/2013)
76 Assented to MOTION to Exceed Page Limits filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(Turner, John-Mark) (Entered: 03/07/2013)
77 OBJECTION to 73 MOTION to Certify Class filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. Certain exhibit(s) maintained conventionally in Clerks Office. (Attachments:

03/07/2013 03/08/2013 03/11/2013 03/11/2013 03/21/2013 03/21/2013

# 1 Notice of Conventional Filing re Memorandum of Law, # 2 Exhibit (Affidavit) of Erik G. Riera, # 3 Exhibit 1 to Erik G. Riera Affidavit, # 4 Exhibit (Affidavit) Notice of Conventional Filing re Exhibit B, # 5 Exhibit (Affidavit) of Robert J. MacLeod, # 6 Exhibit A to Robert J. MacLeod Affidavit, # 7 Exhibit US Response to Interrogatory 14, # 8 Exhibit (Affidavit) of Megan C. Hertler, # 9 Exhibit Notice of Conventional Filing re Exh 1 to Hertler Affidavit, # 10 Exhibit Notice of Conventional Filing re Exh 2 to Hertler Affidavit, # 11 Exhibit Notice of Conventional Filing re Exh 3 to Hertler Affidavit, # 12 Exhibit Notice of Conventional Filing re Exh 4 to Hertler Affidavit, # 13 Exhibit Notice of Conventional Filing re Exh 5 to Hertler Affidavit, # 14 Exhibit 6 to Hertler Affidavit, # 15 Exhibit 7 to Hertler Affidavit, # 16 Exhibit (Affidavit) Notice of Conventional Filing re Bickford Affidavit, # 17 Exhibit (Affidavit) of Leonard Flynn, # 18 Exhibit 1 to Flynn Affidavit, # 19 Exhibit Plaintiffs' Answers to Defendants Int 35 and USA Ans to Def Int 6)(Turner, JohnMark) (Entered: 03/07/2013)
80 Assented to MOTION to Seal Certain Documents re: 77 Objection to Motion for Class Certification at Level I filed by Defendants(jab) (Entered: 03/13/2013)
ENDORSED ORDER granting 76 Motion to Exceed Page Limit for Memorandum of Law in support of Objection to Motion to Certify Class. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 03/08/2013)
78 Notice of Intent to Reply to Objection to 73 MOTION to Certify Class . Follow up on Reply on 3/28/2013.(Ginsberg, Aaron) (Entered: 03/11/2013)
79 Notice of Intent to Reply to Objection to 73 MOTION to Certify Class . Follow up on Reply on 3/28/2013.(Farano, Richard) (Entered: 03/11/2013)
81 Assented to MOTION to Exceed Page Limit filed by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS.(Messer, Amy) (Entered: 03/21/2013)
82 REPLY to Objection to Motion re 73 MOTION to Certify Class filed by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Attachments: # 1 Exhibit (Affidavit) Exhibit 1, Affidavit of Simpatico, # 2 Exhibit (Affidavit) Exhibit 2, Affidavit of Rogers,

03/21/2013 03/21/2013 03/22/2013 03/25/2013
03/25/2013
03/29/2013 04/04/2013

# 3 Exhibit (Affidavit) Exhibit 3, Affidavit of Chudzicki, # 4 Exhibit (Affidavit) Exhibit 4, Affidavit of McCabe, # 5 Exhibit (Affidavit) Exhibit 5, Affidavit of Amanda D., # 6 Exhibit (Affidavit) Exhbit 6, Affidavit of Doukas, # 7 Exhibit (Affidavit) Exhibit 7, Affidavit of Andrews-Peters)(Messer, Amy) (Entered: 03/21/2013)
83 Assented to MOTION to Exceed page limit filed by United States of America.(Fox, Deena) (Entered: 03/21/2013)
84 REPLY to Objection to Motion re 73 MOTION to Certify Class filed by United States of America. (Fox, Deena) (Entered: 03/21/2013)
85 Notice of Intent to Surreply to Reply to Objection to Renewed Motion for Class Certification. Surreply Follow Up on 4/8/2013.(McGrath, David) (Entered: 03/22/2013)
ENDORSED ORDER granting Plaintiff intervenor's 83 Assented to Motion to Exceed page limit re REPLY to Objection to 73 MOTION to Certify Class. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) Modified on 3/25/2013 to add document description. (jab). (Entered: 03/25/2013)
ENDORSED ORDER granting Plaintiffs' 81 Assented to Motion to Exceed page limit re: Reply in Support of Renewed Motion for Class Certification. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) Modified on 3/25/2013 to add document description. (jab). (Entered: 03/25/2013)
86 Addendum/ to 82 Reply to Objection to Motion,, Corrected Affidavit, Exhibit 6 by Amanda D., Monique Doukas, Office of Public Guardian, Inc. o/b/o Amanda E., Office of Public Guardian, Inc. o/b/o Sharon B., Tri-County CAP, Inc../GS. (Ginsberg, Aaron) (Entered: 03/29/2013)
87 Assented to MOTION to Exceed Page Limits filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor.(Turner, John-Mark) (Entered: 04/04/2013)

04/04/2013
04/05/2013 04/09/2013 04/11/2013 05/16/2013
07/09/2013

88 SURREPLY to Reply to 73 MOTION to Certify Class filed by NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor. (Turner, John-Mark) (Entered: 04/04/2013)
ENDORSED ORDER granting 87 Motion to Exceed page limits. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 04/05/2013)
NOTICE re: 73 MOTION to Certify Class Oral Argument set for 5/16/2013 09:30 AM before Judge Steven J. McAuliffe.(jab) (Entered: 04/09/2013)
CORRECTED RESCHEDULING NOTICE of Hearing. Final Pretrial Conference rescheduled for Thursday, 6/5/2014 at 02:00 PM before Judge Steven J. McAuliffe. (jab) (Modified to correct the year to 2014.) (Entered: 04/11/2013)
Minute Entry for proceedings held before Judge Steven J. McAuliffe. ORAL ARGUMENT held on 5/16/2013 re: Plaintiffs' Motion for Class Certification. Oral argument heard. Matter taken under advisement. (Court Reporter: Pam Carle, Avicore Reporting) (Pltfs Atty: Steven Schwartz, Amy Messer, Daniel Will, Richard Farano) (Defts Atty: John-Mark Turner, James Shirley, Anne Edwards, Rebecca Woodard, David McGrath)(Total Hearing Time: 2 hrs 9 minutes) (jab) (Entered: 05/16/2013)
89 TRANSCRIPT of Proceedings for Oral Argument held on 5/16/2013. Court Reporter: Pam Carle, Transcript is available for public inspection, but may not be copied or otherwise reproduced, at the Clerk's Office for a period of 90 days. Additionally, only attorneys of record and pro se parties with an ECF login and password who purchase a transcript from the court reporter will have access to the transcript through PACER during this 90-day period. If you would like to order a copy, please contact the court reporter at the above listed phone number.
NOTICE: Any party who requests an original transcript has 21 days from service of this notice to determine whether it is necessary to redact any personal identifiers and, if so, to electronically file a Redaction Request.

09/17/2013 10/10/2013
10/24/2013 10/25/2013 10/25/2013 11/01/2013
11/06/2013 12/19/2013

Redaction Request Follow Up 8/2/2013. Redacted Transcript Follow Up 8/12/2013. Release of Transcript Restriction set for 10/7/2013.(vln) (Entered: 07/10/2013)

///ORDER granting in part and denying in part 73 Plaintiffs'

90

Motion for Class Certification. So Ordered by Judge Steven J.

McAuliffe.(lat) (Entered: 09/17/2013)

ENDORSED ORDER granting 80 Motion to Seal Certain Documents re: 77 Objection to Motion for Class Certification at Level I. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe. Sealed Document Review deadline 10/15/2014.(jab) (Entered: 10/10/2013)

91 NOTICE of Attorney Appearance by Katherine Houston on behalf of United States of America Attorney Katherine Houston added to party United States of America(pty:intvp).(Houston, Katherine) (Entered: 10/24/2013)

92 NOTICE of Attorney Appearance by Alexandra Shandell on behalf of United States of America Attorney Alexandra Shandell added to party United States of America(pty:intvp).(Shandell, Alexandra) (Entered: 10/25/2013)

93 Mediation Statement: Joint Statement on Mediation (Rucker, Kathryn) (Entered: 10/25/2013)

94 Joint Assented to MOTION to Stay Proceedings filed by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS. (Attachments: # 1 Exhibit Revised Proposed Discovery Table)(Messer, Amy) (Entered: 11/01/2013)

ENDORSED ORDER granting 94 joint assented-to Motion to Stay proceedings. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 11/06/2013)

95 Joint Assented to MOTION Preliminary Approval of Class Action Settlement filed by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), TriCounty CAP, Inc../GS. (Attachments: # 1 Exhibit Att.A Proposed Class Action Settlement, # 2 Exhibit Att. B. Proposed Class Notice, # 3 Exhibit Att.C Proposed Class Action Notice Order)(Messer, Amy) (Entered: 12/19/2013)

01/03/2014 01/03/2014 01/03/2014 01/07/2014 01/08/2014 01/17/2014 01/17/2014
01/17/2014

ENDORSED ORDER granting 95 Joint Assented to MOTION for Preliminary Approval of Class Action Settlement. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 01/03/2014)
96 [FILED IN ERROR. Wrong Document filed. See Corrected Filing, doc. no. 97.]] Proposed Class Action Settlement Agreement. So Ordered by Judge Steven J. McAuliffe.(jab) Modified on 1/3/2014 to add text in brackets. (jab). (Entered: 01/03/2014)
97 Class Notice Order. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 01/06/2014)
98 Assented to MOTION to Extend Time to File Motion for Attorneys' Fees and Costs filed by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS.(Messer, Amy) (Entered: 01/07/2014)
ENDORSED ORDER granting 98 assented-to Motion to Extend Time to file motion for attorneys' fees. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 01/08/2014)
99 Assented to MOTION to Exceed Page Limit filed by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS.(Ginsberg, Aaron) (Entered: 01/17/2014)
100 Joint Assented to MOTION Final Approval of Proposed Class Action Settlement filed by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS. (Attachments: # 1 Proposed Order Att. A, Proposed Order)(Messer, Amy) (Entered: 01/17/2014)
101 Assented to MOTION for Attorney Fees and Costs Pursuant to Settlement Agreement filed by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS. (Attachments: # 1 Memorandum of Law in Support of Motion for Attorney Fees, # 2 Exhibit Fees and Costs Chart, # 3 Exhibit Declaration of Messer, # 4 Exhibit Declaration of Schwartz, # 5 Exhibit Declaration of Burnim, # 6 Exhibit Declaration of Will, # 7 Exhibit (Affidavit) Affidavit of MacDonald)(Messer, Amy) (Entered: 01/17/2014)

01/21/2014 01/29/2014 02/07/2014 02/07/2014
02/10/2014 02/12/2014

ENDORSED ORDER granting 99 Assented to Motion to Exceed Page Limit (of Memorandum of Law to be filed in support of Motion for Attorneys' Fees and Costs). Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 01/21/2014)
NOTICE re: 100 Joint Assented to MOTION Final Approval of Proposed Class Action Settlement Motion Hearing set for 2/12/2014 02:00 PM before Judge Steven J. McAuliffe.(jab) (Entered: 01/29/2014)
102 Assented to MOTION to Exceed Page Limit filed by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS, United States of America.(Messer, Amy) (Entered: 02/07/2014)
103 MEMORANDUM in Support re 100 Joint Assented to MOTION Final Approval of Proposed Class Action Settlement filed by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS. (Attachments: # 1 Exhibit Exh. 1, Settlement Agreement, # 2 Exhibit (Affidavit) Exh. 2, Affidavit of Dube, # 3 Exhibit (Affidavit) Exh. 3, Affidavit of Mallon, # 4 Exhibit (Affidavit) Exh. 4, Affidavit of McCabe, # 5 Exhibit (Affidavit) Exh. 5, Affidavit of Norton, # 6 Exhibit (Affidavit) Exh. 6, Affidavit of Shumway, # 7 Exhibit (Affidavit) Exh. 7, Affidavit of Drake)(Messer, Amy) (Entered: 02/07/2014)
ENDORSED ORDER granting 102 assented-to Motion to Exceed page limit. Text of Order: Granted. So Ordered by Judge Steven J. McAuliffe.(lat) (Entered: 02/10/2014)
Minute Entry for proceedings held before Judge Steven J. McAuliffe. MOTION HEARING held on 2/12/2014 re: 100 Joint Assented to MOTION for Final Approval of the Proposed Class Action Settlement and 101 Assented to MOTION for Attorney Fees and Costs Pursuant to Settlement Agreement. Attys Messer, Edwards and Farano address the court re: proposed settlement agreement; court's questions to counsel re: proposed settlement agreement. Court approves Settlement Agreement and enters is as an order of the court for the reasons set forth on the record. Court approved the assented to motion for attorney fees and costs. (Court Reporter: Diane Churas) (Pltfs Atty: Amy Messer, Steven Schwartz, Daniel Will, Kathryn Rucker; Plaintiff-Intervenor:

Richard Farano) (Defts Atty: Anne Edwards, James Shirley, JohnMark Turner, Rebecca Woodard)(Total Hearing Time: 1 hr 6 min) (jab) (Entered: 02/12/2014)

02/12/2014

104 ORDER FOR FINAL APPROVAL OF PROPOSED SETTLEMENT AND ENTRY OF JUDGMENT; granting 100 Joint Motion for Final Approval of Proposed Settlement; granting 101 Assented to Motion for Attorneys' Fees and Costs. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 02/12/2014)

02/12/2014 105

Class Action Settlement Agreement. (jab) (Entered: 02/12/2014)

02/19/2014

Civil Case Terminated - statistically closed per Judge McAuliffe. (jab) (Entered: 02/19/2014)

02/28/2014

106 TRANSCRIPT of Proceedings for Motion Hearing held on February 12, 2014. Court Reporter: Diane Churas, Telephone # 603 225-1442. Transcript is available for public inspection, but may not be copied or otherwise reproduced, at the Clerk's Office for a period of 90 days. Additionally, only attorneys of record and pro se parties with an ECF login and password who purchase a transcript from the court reporter will have access to the transcript through PACER during this 90-day period. If you would like to order a copy, please contact the court reporter at the above listed phone number.

NOTICE: Any party who requests an original transcript has 21 days from service of this notice to determine whether it is necessary to redact any personal identifiers and, if so, to electronically file a Redaction Request.

Redaction Request Follow Up 3/24/2014. Redacted Transcript Follow Up 4/3/2014. Release of Transcript Restriction set for 5/30/2014.(jab) (Entered: 02/28/2014)

03/14/2014 03/20/2014

107 CCA Judgment - this case [appea] is voluntarily dismissed upon petitioners' Assented to Motion for Dismissal.(jab) (Entered: 03/17/2014)
108 STATUS REPORT by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS (Messer, Amy) (Entered: 03/20/2014)

03/20/2014 05/15/2014 05/19/2014 12/29/2014 01/01/2015 07/02/2015
01/05/2016
06/01/2016 06/02/2016

ENDORSED ORDER re: 108 Status Report. Text of Order: Reviewed. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 03/20/2014)
109 STATUS REPORT by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS (Attachments: # 1 Exhibit Curriculm Vitae of Stephen L. Day)(Messer, Amy) (Entered: 05/15/2014)
ENDORSED ORDER re: 109 JOINT STATUS REPORT ON SELECTION OF THE EXPERT REVIEWER. Text of Order: Reviewed. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 05/19/2014)
110 STATUS REPORT by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS (Attachments: # 1 Exhibit Expert Reviewer Report 1)(Messer, Amy) (Entered: 12/29/2014)
ENDORSED ORDER re: 110 Status Report. Text of Order: Reviewed. So Ordered by Judge Steven J. McAuliffe.(jab) (Entered: 01/01/2015)
112 STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), TriCounty CAP, Inc../GS, United States of America : Second Report of Expert Reviewer (Attachments: # 1 Exhibit Expert Reviewer Report)(Mallinson, Catharine) (Entered: 07/02/2015)
113 STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), TriCounty CAP, Inc../GS (Attachments: # 1 Exhibit Attachment A Expert Reviewer's Third Report)(Messer, Amy) (Entered: 01/05/2016)
114 NOTICE of Attorney Withdrawal by Amy Beth Messer on behalf of Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Amanda E.)(Messer, Amy) (Entered: 06/01/2016)
115 NOTICE of Attorney Appearance by Andrew Laurence Milne on behalf of Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Amanda E.) Attorney Andrew Laurence Milne added to party Amanda D.(pty:pla), Attorney

07/06/2016
01/09/2017 01/19/2017 03/07/2017
07/12/2017 07/20/2017
01/12/2018

Andrew Laurence Milne added to party Monique Doukas(pty:pla), Attorney Andrew Laurence Milne added to party Office of Public Guardian, Inc.(pty:pla).(Milne, Andrew) (Entered: 06/02/2016)
116 STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-
County CAP, Inc../GS : JOINT (Attachments: # 1 Exhibit Fourth Expert Reviewer Report)(Ginsberg, Aaron) (Entered: 07/06/2016)
117 STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), TriCounty CAP, Inc../GS : JOINT (Attachments: # 1 Exhibit Fifth Expert Reviewer Report)(Ginsberg, Aaron) (Entered: 01/09/2017)
ENDORSED ORDER RE: 117 Status Report. Text of Order: Reviewed. So Ordered by Judge Steven J. McAuliffe.(jbw) (Entered: 01/20/2017)
118 NOTICE of Attorney Withdrawal by John-Mark Turner on behalf of NH Bureau of Behavioral Health, Administrator, NH Department of Health and Human Services, Commissioner, NH Department of Health and Human Services, Community Based Care Services, Associate Commissioner, NH Department of Health and Human Services, Direct Programs/Operations, NH Governor(Turner, John-Mark) (Entered: 03/07/2017)
119 STATUS REPORT by Amanda D. : Sixth expert reviewer report completed (Attachments: # 1 Exhibit Sixth Expert Reviewer Report)(Milne, Andrew) (Entered: 07/12/2017)
120 NOTICE of Attorney Appearance by Benjamin Sahl on behalf of Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Amanda E.) Attorney Benjamin Sahl added to party Amanda D.(pty:pla), Attorney Benjamin Sahl added to party Monique Doukas(pty:pla), Attorney Benjamin Sahl added to party Office of Public Guardian, Inc.(pty:pla).(Sahl, Benjamin) (Entered: 07/20/2017)
121 STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), TriCounty CAP, Inc../GS Attorney Andrew Laurence Milne added to party Barry Ellsworth(pty:pla), Attorney Andrew Laurence Milne

02/05/2018 07/30/2018 08/10/2018 09/05/2018
09/05/2018 09/07/2018 09/07/2018

added to party Office of Public Guardian, Inc.(pty:pla), Attorney Andrew Laurence Milne added to party Tri-County CAP, Inc../GS(pty:pla). (Attachments: # 1 Appendix Expert Reviewer Report No. 7)(Milne, Andrew) (Entered: 01/12/2018)
File located at National Archives and Records Administration (NARA), Waltham, MA. ARCIS Transfer # PT-021-2018-0055, Box No. 1. (lml) (Entered: 04/05/2018)
122 STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), TriCounty CAP, Inc../GS (Attachments: # 1 Exhibit Eighth Expert Reviewer Report)(Milne, Andrew) (Entered: 07/30/2018)
123 NOTICE of Attorney Withdrawal by Daniel E. Will on behalf of Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS(Will, Daniel) (Entered: 08/10/2018)
124 NOTICE of Attorney Appearance by Pamela E. Phelan on behalf of Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS Attorney Pamela E. Phelan added to party Amanda D.(pty:pla), Attorney Pamela E. Phelan added to party Monique Doukas(pty:pla), Attorney Pamela E. Phelan added to party Office of Public Guardian, Inc.(pty:pla), Attorney Pamela E. Phelan added to party Office of Public Guardian, Inc.(pty:pla), Attorney Pamela E. Phelan added to party Tri-County CAP, Inc../GS(pty:pla).(Phelan, Pamela) (Entered: 09/05/2018)
NOTICE of Hearing re: 122 Status Report. Status Conference set for 10/10/2018 10:00 AM before Judge Steven J. McAuliffe.(jbw) (Entered: 09/05/2018)
125 Assented to MOTION Terminate Attorneys Sahl, Ginsberg and Mallinson as counsel for plaintiffs filed by Amanda D., Monique Doukas, Office of Public Guardian, Inc.(Guardian of Sharon B.), Tri-County CAP, Inc../GS.(Phelan, Pamela) (Entered: 09/07/2018)
ENDORSED ORDER granting 125 Assented to Motion to Terminate Attorneys Sahl, Ginsberg and Mallinson as counsel for plaintiffs. Text of Order: Granted. So Ordered by Magistrate Judge Andrea K. Johnstone. (lml) (Entered: 09/07/2018)

09/19/2018 10/29/2018 11/21/2018
01/23/2019 05/31/2019

RESCHEDULING NOTICE of Hearing re: 122 Status Report. Status Conference set for 10/29/2018 02:00 PM before Judge Steven J. McAuliffe.(lml) (Entered: 09/19/2018)
Minute Entry for proceedings held before Judge Steven J. McAuliffe. STATUS CONFERENCE held on 10/29/2018. Mr. Day updated the court as to the progess being made. Attorneys Rucker, Farano and Edwards also addressed the court. Court advises Mr. Day that any time he wishes to have a status conference to notify the deputy clerk. (Court Reporter: Susan Bateman) (Pltfs Atty: Andrew Milne, Pamela Phelan, Kathryn Rucker, Elaine M. Michaud, Richard Farano) (Defts Atty: Anne Edwards, Rebecca Ross. Expert Reviewer Steven Day.)(Total Hearing Time: 35 min) (lml) Modified on 11/7/2018 to correct attorney name (lml). (Entered: 10/29/2018)
126 TRANSCRIPT of Proceedings for Status Conference held on October 29, 2018. Court Reporter: Susan Bateman, Telephone # 603 225-1453. Transcript is available for public inspection, but may not be copied or otherwise reproduced, at the Clerk's Office for a period of 90 days. Additionally, only attorneys of record and pro se parties with an ECF login and password who purchase a transcript from the court reporter will have access to the transcript through PACER during this 90-day period. If you would like to order a copy, please contact the court reporter at the above listed phone number.
NOTICE: Any party who requests an original transcript has 21 days from service of this notice to determine whether it is necessary to redact any personal identifiers and, if so, to electronically file a Redaction Request.
Redaction Request Follow Up 12/12/2018. Redacted Transcript Follow Up 12/24/2018. Release of Transcript Restriction set for 2/19/2019. (jbw) (Entered: 11/21/2018)
127 STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), TriCounty CAP, Inc../GS (Attachments: # 1 Exhibit Ninth Expert Reviewer Report)(Milne, Andrew) (Entered: 01/23/2019)
128 NOTICE of Attorney Withdrawal by Elaine M. Michaud on behalf of Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public

Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS(Michaud, Elaine) (Entered: 05/31/2019)

06/04/2019

129 NOTICE of Attorney Withdrawal by Joshua M. Wyatt on behalf of Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS(Wyatt, Joshua) (Entered: 06/04/2019)

06/04/2019

130 NOTICE of Attorney Appearance by Jonathan A. Lax on behalf of Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), Tri-County CAP, Inc../GS Attorney Jonathan A. Lax added to party Amanda D.(pty:pla), Attorney Jonathan A. Lax added to party Monique Doukas(pty:pla), Attorney Jonathan A. Lax added to party Barry Ellsworth(pty:pla), Attorney Jonathan A. Lax added to party Office of Public Guardian, Inc.(pty:pla), Attorney Jonathan A. Lax added to party Office of Public Guardian, Inc.(pty:pla), Attorney Jonathan A. Lax added to party Tri-County CAP, Inc../GS(pty:pla).(Lax, Jonathan) (Entered: 06/04/2019)

07/16/2019

131 NOTICE of Regarding Expert Reviewer's Tenth Report by Amanda D..(Phelan, Pamela) (Entered: 07/16/2019)

09/12/2019

132 NOTICE of Expert Reviewer Report Number 10 by Amanda D.. (Attachments: # 1 Exhibit Expert Reviewer Report Number 10)(Phelan, Pamela) (Entered: 09/12/2019)

02/03/2020

133 NOTICE of Expert Reviewer Report Number 11 by Amanda D.. (Attachments: # 1 Exhibit A Expert Reviewer Report Number 11)(Phelan, Pamela) (Entered: 02/03/2020)

08/21/2020

134 STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth, Office of Public Guardian, Inc.(Guardian of Sharon B.), Office of Public Guardian, Inc.(Guardian of Amanda E.), TriCounty CAP, Inc../GS, United States of America : Expert Reviewer Report Filed Attorney Pamela E. Phelan added to party Barry Ellsworth(pty:pla). (Attachments: # 1 Exhibit (A) Expert Reviewer's 12th Report)(Phelan, Pamela) (Entered: 08/21/2020)

02/01/2021 135

STATUS REPORT by Amanda D., Monique Doukas, Barry Ellsworth : Joint Report on Expert Reviewer's Thirteenth Report

(Attachments: # 1 Exhibit A Expert Reviewer's Thirteenth Report)(Phelan, Pamela) (Entered: 02/01/2021)

02/15/2021

ENDORSED ORDER 135 Status Report. Text of Order: Reviewed. So Ordered by Judge Steven J. McAuliffe.(lw) (Entered: 02/16/2021)

PACER Service Center Transaction Receipt

04/01/2021 20:33:14

PACER Login:

CRClearinghouse Client Code: Simeck

Description:

Docket Report

Search Criteria:

1:12-cv-00053SM

Billable Pages: 30

Cost:

3.00

Exempt flag: Not Exempt

Exempt reason: Not Exempt

 
 Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 1 of 16

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF NEW HAMPSHIRE

_______________________________________________

LYNN E., et al.

)

)

Plaintiffs,

)

)

v.

)

)

JOHN H. LYNCH, et al.,

)

)

Defendants.

)

_______________________________________________ )

1:12-CV-53-LM

THE UNITED STATES OF AMERICA,

)

)

Plaintiff-Intervenor,

)

)

v.

)

)

THE STATE OF NEW HAMPSHIRE,

)

)

Defendant.

)

_______________________________________________ )

UNITED STATES’ MEMORANDUM IN SUPPORT OF PLAINTIFFS’ MOTION FOR CLASS CERTIFICATION
On February 9, 2012, this case was initiated by plaintiffs Lynn E., Kenneth R., Sharon B., Amanda D., Amanda E., and Jeff D., (collectively the “named plaintiffs”) to vindicate the rights of people with disabilities who are subjected to or at risk of needless and prolonged institutionalization in State facilities like the New Hampshire Hospital (“NHH”) and the Glencliff Home (“Glencliff’). They allege that the State is unnecessarily institutionalizing individuals with serious mental illness and seek an injunction requiring the State to develop community-based services sufficient to avoid class members’ unnecessary institutionalization.
After conducting an investigation, issuing a letter identifying violations of the Americans with Disabilities Act (“ADA”), 42 U.S.C. §§ 12101 et seq., by the State of New Hampshire, and engaging in months of negotiations attempting to resolve those findings, the United States filed a

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 2 of 16
motion to intervene in this action. On April 4, 2012, the Court granted this motion to intervene. Like the plaintiffs, the United States alleges that the State is violating the ADA in its administration of its mental health system and that this results in the unnecessary institutionalization of individuals with serious mental illness. The United States’ complaint-inintervention seeks systemic injunctive relief on behalf of all people in New Hampshire with serious mental illness who are unnecessarily institutionalized or at risk of institutionalization at NHH and Glencliff.
After filing their complaint, plaintiffs filed a motion for class certification, along with a memorandum supported by numerous exhibits. They identified the State’s overinvestment in institutional care and failure to develop an array of community services as the common cause of plaintiffs’ injuries and alleged that defendants had acted on grounds generally applicable to a class of individuals such that injunctive relief is appropriate. In support, they presented evidence – including defendants’ own reports and data – that the discriminatory segregation that the putative plaintiffs suffer results from the State’s administration of its resources, which favors institutional care over more effective, integrated services in the community. The State’s funding policy and its failure to provide critical community supports affect both putative class members who are currently in the State’s facilities and those who are at serious risk of entering the institutions. In response, the defendants filed a motion to strike plaintiffs’ class certification motion, or in the alternative, to grant additional time to object, and also filed an objection to the class certification motion. Their primary argument in their motion to strike is that extensive discovery is needed before the Court can determine whether plaintiffs meet the requirements for class certification, particularly after the Supreme Court’s recent decision in Wal-Mart v. Dukes, 131 S.Ct. 2541 (2011).
2

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 3 of 16
The United States files this memorandum to assist the Court in addressing the pending motions related to plaintiffs’ request for class certification.1 The United States urges the Court to deny defendants’ motion to strike and grant plaintiffs’ motion for class certification because: 1) class actions are an efficient, effective, and appropriate means for resolving civil rights matters, especially those, like this one, that seek to vindicate the rights of persons with disabilities pursuant to the integration mandate of the ADA, and the Supreme Court’s opinion in Olmstead v. L.C., 527 U.S. 581 (1999); and 2) the plaintiffs have met the requirements for class certification set forth in Rule 23 of the Federal Rules of Civil Procedure as recently interpreted by the Supreme Court in Wal-Mart. The United States agrees with plaintiffs that class certification in this case does not require further discovery given that defendants have in their own custody the documents and records central to this case, and the information plaintiffs have already placed before the Court.
ARGUMENT I. Class Certification Allows for Efficient, Effective Resolution of Civil Rights Cases,
Especially Olmstead Cases Class certification is appropriate in civil rights cases seeking injunctive relief, like this one, and remains appropriate after Wal-Mart. In Wal-Mart, the Supreme Court discussed the standard for establishing the commonality and cohesiveness elements of Rule 23 in the context of employment discrimination cases. Wal-Mart was a case that involved claims for money –
1 The Unites States has a vested interest in the enforcement of the ADA and has the authority to seek systemic relief for violations of the law in this and other cases. However, the United States cannot be a party to all ADA litigation across the nation. The United States presents this memorandum to offer its understanding of Wal-Mart, namely that class actions remain an appropriate and essential mechanism for private plaintiffs to employ when seeking to remedy systemic violations under the ADA.
3

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 4 of 16
back pay and punitive damages – and so did not fit within the scope of more traditional civil rights cases, like the instant suit, that merely seek declaratory and injunctive relief. In Wal-Mart, while only a plurality underlined the need for close scrutiny of class certification petitions in employment cases for money, a unanimous Supreme Court took great pains later in the WalMart opinion to recognize the important role that class actions play in remedying civil rights violations outside the limited and very different facts before the Court in Wal-Mart. The unanimous Court concluded: “As we observed in Amchem, ‘[c]ivil rights cases against parties charged with unlawful, class-based discrimination are prime examples’ of what [Rule 23](b)(2) is meant to capture.” Wal-Mart, 131 S.Ct. at 2557-58. The Court did not, therefore, disturb well-established class certification parameters in more traditional civil rights cases, such as the case at bar. Indeed, the advisory notes to Rule 23 explain that civil rights cases are illustrative of the type of cases appropriately brought under section (b)(2) of the rule, the section at issue in this case. Advisory notes to Fed. R. Civ. P. 23 (“Illustrative [of cases brought under 23(b)(2)] are various actions in the civil-rights field where a party is charged with discriminating unlawfully against a class, usually one whose members are incapable of specific enumeration.”).
Class actions are particularly appropriate in Olmstead cases brought under Title II of the ADA. Indeed, the Olmstead case itself illustrates the pitfalls of proceeding as a civil rights action involving only the needs of a few plaintiffs, rather than as a class action. Olmstead was filed on behalf of two individuals, L.C. and E.W., who were unnecessarily institutionalized in Georgia’s state psychiatric hospitals. Olmstead, 527 U.S. at 593. Plaintiffs prevailed in that case, and L.C. and E.W. obtained relief. See id. at 607. However, the hundreds of other individuals who were also unnecessarily institutionalized in Georgia’s institutions obtained no relief until more than a decade later. It was not until the United States filed an Olmstead case on
4

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 5 of 16
behalf of all of the individuals in Georgia’s mental health system who were unnecessarily institutionalized or at risk of unnecessary institutionalization, that Georgia changed its funding policy which had favored institutions over services in the community. See United States v. Georgia, No. 1:10- 249 (N.D. Ga. Oct. 29, 2010) (order granting settlement affording systemic relief to remedy ADA violations). That is the relief that plaintiffs are seeking here. While it would be a step in the right direction to protect the civil rights of the named plaintiffs, systemic relief cannot be ordered if this case proceeds as an action by six individuals.
The Olmstead Court recognized that community supports for people with disabilities should not be provided to one person who commenced legal action under the ADA while others who have been seeking the same services are pushed down the list. 527 U.S. at 606. It is difficult to see how a district court can ensure that institutionalized individuals for whom community care is appropriate, and who are not opposed to it, will all be treated fairly if they are not all before the court. Moreover, when Olmstead cases are brought as class actions, the court can order comprehensive relief where appropriate. On the other hand, in Olmstead cases brought by individuals, a state may simply provide community-based care for the individual plaintiffs without comprehensively addressing its broader Olmstead obligations.
Since the Supreme Court’s decision in Wal-Mart, other courts have continued to certify classes of plaintiffs in cases brought under Title II of the ADA and other civil rights laws. See, e.g., McReynolds v. Merrill Lynch, Pierce, Fenner & Smith, Inc., 672 F.3d 482, 489 (7th Cir. 2012) (reversing denial of class certification to African American financial advisors alleging racial discrimination under Title VII); Ross v. RBS Citizens, N.A., 667 F.3d 900, 910 (7th Cir. 2012) (upholding class certification for a group of employees alleging violations of the Fair Labor Standards Act); Chen-Oster v. Goldman, Sachs & Co., No. 10-6950, 2012 U.S. Dist.
5

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 6 of 16
LEXIS 12961 (S.D.N.Y. Jan. 19, 2012) (denying defendants’ motion to strike class allegations where class of women alleged discrimination under Title VII); Pashby v. Cansler, No. 5:11- 273, 2011 WL 6130819 (E.D.N.C. Dec. 8, 2011) (certifying class of all current or future North Carolina Medicaid recipients age 21 or older who have, or will have, coverage of personal care denied, delayed, interrupted, terminated, or reduced as a result of new eligibility requirements); D.L. v. District of Columbia, 277 F.R.D. 38, 45-6 (D.D.C. 2011) (denying defendants’ motion to decertify a class of children alleging denial of free appropriate public educations under the Individuals with Disabilities Education Act); Connor B. v. Patrick, 278 F.R.D. 30, 33 (D. Mass 2012) (denying defendants’ motion to decertify a class of children in foster harm alleging harm due to systemic deficiencies in the foster care system); Youngblood v. Family-Dollar Stores, Inc., No. 09-376, 2011 WL 4597555 (S.D.N.Y. Oct. 4, 2011) (certifying class of store managers alleging violations of the New York Labor Law); Bouaphakeo v. Tyson Foods, Inc., No. 5:0704009, 2011 WL 3793962 (N.D. Iowa Aug. 25, 2011) (denying defendants’ motion to decertify a class of employees alleging violations of the Fair Labor Standards Act). Class actions are an efficient tool for resolution of these claims, which warrant systemic reform. See American Pipe & Const. Co. v. Utah, 414 U.S. 538, 553 (1974) (finding class actions promote “the efficiency and economy of litigation”). Courts around the country continue to recognize the benefit and appropriateness of certifying classes in civil rights matters.
II. Plaintiffs Have Met the Requirements of Fed. R. Civ. P. 23 as Recently Interpreted by the Supreme Court in Wal-Mart v. Dukes
The standard for certifying class actions is set out in Rule 23 of the Federal Rules of Civil Procedure. Rule 23(a) requires that all classes meet four criteria: “(1) the class is so numerous that joinder of all members is impracticable; (2) there are questions of law or fact common to the
6

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 7 of 16
class; (3) the claims or defenses of the representative parties are typical of the claims or defenses of the class; and (4) the representative parties will fairly and adequately protect the interests of the class.” Fed. R. Civ. P. 23(a)(1)-(4). Class actions also must satisfy one of the categories of class actions listed in Rule 23(b). In this case, plaintiffs’ motion seeks certification under 23(b)(2), which requires that “the party opposing the class has acted or refused to act on grounds that apply generally to the class so that final injunctive relief or corresponding declaratory relief is appropriate respecting the class as a whole.” Fed. R. Civ. P. 23(b). Pls.’ Mot. Class Cert. at 23
a. New Hampshire’s funding policy results in a common injury Wal-Mart is legally distinguishable from this case. The violations of law alleged here are the result of government funding polices that privilege institutional care over community services, leading to insufficient community supports. In Wal-Mart, the Supreme Court noted that the plaintiffs challenged the broad discretion afforded to low-level supervisors at stores across the country and attempted to cast this discretion as a unified “policy.” 131 S.Ct. at 2549, 2554. Plaintiffs in that case failed to demonstrate “significant proof that Wal–Mart operated under a general policy of discrimination.” Id. at 2554 (citations omitted). Here, plaintiffs point to a pattern of State decisions made by high-level officials favoring institutional care over community-based services, and those decisions are causing a common injury. Here, the fatal flaw identified by the Court in Wal-Mart does not exist. Wal-Mart explains that “[c]ommonality requires the plaintiff to demonstrate that the class members ‘have suffered the same injury.’” Id. at 2551. In that case, the plaintiffs could not demonstrate that more than a million employees across thousands of stores nationwide experienced the same harms, for the same reasons. Id. at 2555. Here, however, plaintiffs allege that they all suffer the same specific harm – unjustified segregation, now or in the future – as a
7

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 8 of 16
result of their disabilities. This harm is recognized by the Supreme Court as a violation of the ADA. Olmstead, 527 U.S. at 600 (“Congress explicitly identified unjustified ‘segregation’ of persons with disabilities as a ‘for[m] of discrimination.’”). See also M.R. v. Dreyfus, 663 F.3d 1100, 1116-17 (9th Cir. 2011) (“An ADA plaintiff need not show that institutionalization is ‘inevitable’ or that she has ‘no choice’ but to submit to institutional care in order to state a violation of the integration mandate. Rather, a plaintiff need only show that the challenged state action creates a serious risk of institutionalization.”). Where, as here, all class members can show that they suffer a common harm due to a single policy, a class action remains appropriate under the Wal-Mart analysis. See, e.g., McReynolds, 672 F.3d at 489 (finding question regarding impact of employer’s “teaming policy” was common to class and appropriate for class-wide determination); Ross, 667 F.3d at 910 (finding policy of intentional failure to pay overtime a common claim); Connor B., 278 F.R.D. at 33 (finding specific deficiencies in the foster care system give rise to common claims appropriate for class-wide analysis); D.L., 277 F.R.D. at 4546 (finding plaintiffs provided sufficient “glue” to bind the class members claims in form of systemic deficiencies in special education system).
Courts applying Wal-Mart’s analysis continue to find class certification appropriate, even in cases where the injuries are more broadly defined and result from policies that are not as clear as that identified in this case. For example, in McReynolds v. Merrill Lynch, Judge Posner wrote for a Seventh Circuit panel that distinguished Wal-Mart in a Title VII case and found that class certification was appropriate for a class of African American financial advisors alleging racial discrimination and requesting both declaratory relief and damages. McReynolds, 672 F.3d 482. The court there explained that the class in Wal-Mart failed because “the incidents of discrimination complained of do not present a common issue that could be resolved efficiently in
8

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 9 of 16
a single proceeding” due to the size of the class, the discretion afforded to the individual supervisors, and the absence of a uniform policy set by top management. Id. at 488. The class in McReynolds was certified, however, due to the presence of company-wide policies that allegedly exacerbated discrimination. Id. Judge Posner concluded that resolution of the claims for injunctive and declaratory relief should go forward on a class-wide basis in the interest of efficiency, even though any individual monetary relief for class members would be determined in separate proceedings, with the benefit of the court’s decision. Id. at 490-91. Similarly, a district court in Massachusetts recently found that its previous certification of a class of children in foster care who were exposed to harms due to deficiencies in the foster care system remained appropriate after Wal-Mart. The court explained that, “[c]ontrary to Defendants' contention, the Wal–Mart decision did not change the law for all class action certifications. Instead, it provided guidance on how existing law should be applied to expansive, nationwide class actions that are very different from the case currently before the court.” Connor B., 278 F.R.D. at 33. Though the violations alleged in that case were quite diverse, the deficiencies in care offered by a single state agency “are the alleged causes of the class members’ injuries” and meet the requirement of commonality. Id. at 34. Courts recognize that even after Wal-Mart, it is appropriate to grant class certification where, as here, a common question and injury affect a class of plaintiffs.2
2 Of course, as was the case prior to the Supreme Court’s decision in Wal-Mart, some civil rights suits fail to pass the test for class certification post-Wal-Mart. For example, prior to deciding the McReynolds case described above, the Seventh Circuit found that a case under the Individuals with Disabilities Education Act was not appropriate for class treatment where resolving each individual class member’s claim would require a particularized inquiry. Jamie S. v. Milwaukee Pub. Schs., 668 F.3d 481, 498 (7th Cir. 2012). Unlike that case, the statutory framework that is the basis for this action does not require that individualized inquiry. The Fifth Circuit also recently found class certification was not appropriate in M.D. v. Perry, because a variety of constitutional claims asserted by the class members did not meet the standard of a common
9

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 10 of 16
b. Classwide resolution of the plaintiffs’ injuries is possible and appropriate under Rule 23(b)(2).
In addition to requiring that plaintiffs seeking class certification suffer the same harms and share a “common question,” Wal-Mart, 131 S.Ct. at 2556, the Court also noted that this question “must be of such a nature that it is capable of classwide resolution—which means that determination of its truth or falsity will resolve an issue that is central to the validity of each one of the claims in one stroke.” Id. at 2551. In Wal-Mart, each class member who was seeking individual relief would need the court to determine the scope of the individual remedy if liability was established, such that the court could not simply resolve the case with a single injunction. Id. at 2561. In contrast, class certification is appropriate where the “classwide proceeding [will] generate common answers apt to drive resolution of the litigation.” Wal-Mart, 131 S.Ct. at 2551. That is the case here.
As explained above, Olmstead cases are best adjudicated on a systemic level, with comprehensive injunctive relief as is required by Rule 23(b)(2) and Wal-Mart. In this case, the plaintiffs seek only injunctive relief requiring the defendants to develop an array of communitybased services sufficient to avoid class members’ unnecessary institutionalization. An order requiring defendants to take this action would resolve the plaintiffs’ complaint. There will be no need to require specific assessments of individuals’ needs and preferences and the development of plans for unique services. Plaintiffs do not request this. Rather, plaintiffs request that the Court require defendants to fund and make available the array and mix of services that New Hampshire has acknowledged are necessary to meet plaintiffs’ needs and avoid unnecessary institutionalization. See Ex. 2 to Pls.’ Mem. in Support of Mot. for Class Cert. (stating that “policy.” No. 11-40789, 2012 U.S. App. LEXIS 6061, *7-8 (5th Cir. Mar. 23, 2012). This case is also inapposite as there is a common funding policy at issue here.
10

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 11 of 16
admissions and census at NHH rose due to insufficient community services including supported housing and Assertive Community Treatment “ACT”). The exact amount and array of services necessary to meet the needs of the class will be determined at the remedy phase of proceedings, if the Court finds the defendants in violation of the law.
Each individual member of the plaintiff class need not share the exact same qualities, disabilities, needs, and circumstances in order for class relief to be appropriate. See Connor B., 278 F.R.D. at 33-34. If the Court were to accept the defendants’ contention that all distinctions between individual class members’ diagnoses, providers, and treatment histories make class certification improper, then no class actions would be possible under the ADA. People, by their natures, are unique. However, as decades of successful class action lawsuits on behalf of people with disabilities demonstrate, it is possible to remedy discrimination against a diverse group of individuals through comprehensive injunctive relief. See, e.g., Miranda B. v. Kulongoski, No. 00-01753 (D. Or. Dec. 13, 2004); Consumer Advisory Bd. v. Glover, 151 F.R.D. 490 (D. Mass. 1993); Halderman v. Pennhurst State Sch. and Hosp., 610 F. Supp. 1221 (E.D. Pa. 1985); Horacek v. Exon, 357 F.Supp. 71 (D. Neb. 1973). Many cases listed above were brought by the private bar on behalf of classes of people with disabilities; if this were no longer possible, only the United States would be left to litigate all systemic reform under the ADA.
Plaintiffs’ requested remedy is the appropriate remedy for a case under Rule 23(b)(2) which “applies only when a single injunction or declaratory judgment would provide relief to each member of the class.” Wal-Mart, 131 S.Ct. at 2557. It is not only possible to issue an injunction that resolves the plaintiffs claim by creating the array of services that will enable them to live in integrated settings and avoid unnecessary institutionalization, it is the efficient approach to litigating this claim.
11

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 12 of 16
III. Discovery Is Not Necessary Prior to Class Certification In This Case a. Sufficient facts are already before the Court to make an appropriate assessment regarding class certification
Plaintiffs have already presented to this Court substantial evidence supporting class certification. While “[r]eviewing the complaint alone is not normally a suitable method for determining whether a class eventually can be certified,” Coll. of Dental Surgeons of Puerto Rico v. Connecticut Gen. Life Ins. Co., 585 F.3d 33 (1st Cir. 2009), the Court may review facts before it – including exhibits and declarations like those submitted by plaintiffs here – and make decisions about class certification even outside the formal discovery process. Gooch v. Life Investors Ins. Co. of America, 672 F.3d 402, 418 (6th Cir. 2012) (finding court’s review of affidavits and exhibits a sufficient basis for its certification of a class).
Plaintiffs’ exhibits support their motion for class certification by providing the required evidence that they meet the conditions for class certification. Plaintiffs demonstrate the numerosity of their proposed class through the New Hampshire 2010 Mental Health Outcome Measures and the New Hampshire Hospital Annual Report. Exs. 4 and 5 to Pls.’ Mem. in Support of Mot. for Class Cert. New Hampshire Hospital admitted over 1,800 adults in 2010 and 35% of those admitted were readmitted within 180 days. The number of people who are residents at Glencliff, demonstrated through the census data from the Glencliff Home, adds to the size of the class. Ex. 7A to Pls.’ Mem. in Support of Mot. for Class Cert. The individuals who are currently at Glencliff or NHH, or are cycling in and out of those institutions and are at serious risk of readmission are so numerous that joinder is not appropriate.
Similarly, the plaintiffs have shown that they meet the commonality, typicality, and cohesiveness requirements through the defendants’ own reports including, Addressing the Critical Mental Health Needs of NH’s Citizens: A Strategy for Restoration; Fulfilling the
12

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 13 of 16
Promise: Transforming New Hampshire’s Mental Health System volumes I and II; and Addressing the Critical Mental Health Needs of NH’s Citizens: A Strategy for Restoration, Report of the Listening Sessions. Exs. 2, 3, and 5 to Pls.’ Mem. in Support of Mot. for Class Cert. These documents support plaintiffs’ claim that they have suffered a common injury that is susceptible to remedy through injunctive relief. State documents included as exhibits with plaintiffs’ motion affirm that the insufficiency of community-based services for people with intensive needs for supports resulted in unnecessary reliance on New Hampshire Hospital. See, e.g., Ex. 3 at 4, 14. The documents also support the assertion that an injunction requiring New Hampshire to develop an array of community supports, including services such as supported housing, supported employment, and ACT, would resolve the plaintiffs’ claims and be appropriate to serve a range of individual needs. See, e.g., Ex. 2 at 9-14; Ex. 3 at 11-12, 14, 18; Ex. 6 at 6.
The evidence before the Court is sufficient to support plaintiffs’ motion for class certification. Should defendants wish to place other facts before the Court prior to its decision regarding class certification, it is in a position to do so without discovery, as the State funds and operates the institutions and services that are at issue in this case. For example, the State has access to and control over records of those served in State institutions, state policy and budget documents, and regulations regarding community care. The State does not need discovery to marshal its own facts.
b. Wal-Mart preserves courts’ autonomy to determine the extent of inquiry necessary prior to class certification
While Wal-Mart reminds courts and litigants that “[a] party seeking class certification must affirmatively demonstrate his compliance with the Rule—that is, he must be prepared to prove that there are in fact sufficiently numerous parties, common questions of law or fact, etc.,”
13

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 14 of 16
131 S.Ct. at 2551, this is not a new requirement. “Rigorous analysis” of the basis for petitions for class certification has been required for decades. Id. (quoting Gen. Tel. Co. of Sw. v. Falcon, 457 U.S. 147, 160 (1982).) As in the past, the scope of evidence required by a court prior to certification will vary depending on the specific circumstances. See Connor B., 278 F.R.D. at 33 (“The court remains convinced that, while a preliminary evidentiary hearing may be required before certifying some class actions, it is not required in this case.”). As the First Circuit explained in In re New Motor Vehicles Canadian Exp. Antitrust Litig., it is clear that some level of inquiry into the merits of the claims is permissible and appropriate where class criteria and merits overlap, but the extent of the inquiry that is required is fact dependent and relates to the types of claims at issue. 522 F.3d 6, 24-26 (1st Cir. 2008). Where, unlike here, there is a “novel theory of legally cognizable injury,” the inquiry into the facts prior to class certification will be “searching.” Id. at 25. In contrast, here, where the claim is not novel,3 the Court may certify the class after determining that plaintiffs have proved the necessary elements of Fed. R. Civ. P. 23(a).
3 Cases around the country have vindicated plaintiffs’ rights to support in the community under Olmstead. See, e.g., Fisher v. Oklahoma Health Care Auth., 335 F.3d 1175 (10th Cir. 2003); Benjamin v. Dep’t of Pub. Welfare, 768 F. Supp. 2d 747 (M.D. Pa. 2011), aff’d, 432 Fed.Appx. 94 (3rd Cir. 2011); Long v. Benson, 2008 WL 4571903 (N.D. Fla. Oct. 14, 2008), aff’d, 383 Fed.Appx. (11th Cir. 2010); Messier v. Southbury Training Sch., 562 F. Supp. 2d 294 (D. Conn. 2008).
14

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 15 of 16

CONCLUSION For the foregoing reasons, the Court should deny defendants’ motion to strike and grant the plaintiffs motion for class certification.

Dated: April 20, 2012

Respectfully submitted,

JOHN P. KACAVAS

THOMAS

E. PEREZ

United States Attorney

Assistant Attorney General

District of New Hampshire

EVE L. HILL

JOHN FARLEY

Senior

Counselor to the Assistant Attorney General

Assistant United States Attorney

District of New Hampshire

ALISON

BARKOFF

U.S. Attorney’s Office

Special Counsel for Olmstead Enforcement

53 Pleasant Street

Civil

Rights Division

Concord, NH 03301

(603) 225-1552

/s/ Deena S. Fox

John.Farley@usdoj.gov

JONAT

HAN M. SMITH, Section Chief

JUDITH

C. PRESTON, Deputy Chief

RICHARD J. FARANO, Senior Trial Attorney

District

of Columbia Bar No. 424225

DEENA

S. FOX, Trial Attorney

New

York Bar Registration No. 4709655

U.S. Department of Justice

950 Pennsylvania Avenue, NW – PHB

Washington, DC 20530

Telephone: 202-305-1361

deena.fox@usdoj.gov

Counsel for Plaintiff-Intervenor, United States of America

15

Case 1:12-cv-00053-SM Document 33 Filed 04/20/12 Page 16 of 16
CERTIFICATE OF SERVICE I hereby certify that on April 20, 2012, I electronically filed the United States’ Memorandum in Support of Plaintiffs Motion for Class Certification, with the Clerk of the Court using the CM/ECF system which will automatically send email notification of such filing to the attorneys of record.

DEENA New Special

/s/ Deena Fox S. FOX, Trial Attorney York Bar Registration No. 4709655 Litigation Section
Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-305-1361 deena.fox@usdoj.gov
Counsel for Plaintiff-Intervenor, United States of America

16

 
 Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 1 of 36

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

____________________________________

)

Lynn E., by her guardian,

)

Barry Ellsworth; Kenneth R.,

)

by his guardian, Tri-County CAP, Inc./GS; )

Sharon B., by her guardian, Office of

)

Public Guardian, Inc.; Amanda D., by

)

her guardian, Louise Dube; Amanda E., )

by her guardian, Office of Public

)

Guardian, Inc.; and Jeffrey D.,

)

on behalf of themselves and all

)

others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

John H.

)

Lynch, Governor of the State of New

)

Hampshire; Nicholas A. Toumpas,

)

Commissioner, New Hampshire

)

Department of Health and Human

)

Services; Nancy L. Rollins,

)

Associate Commissioner, New Hampshire )

Department of Health and Human Services, )

Community Based Care Services;

)

Mary Ann Cooney,

)

Deputy Commissioner, New Hampshire )

Department of Health and Human Services, )

Direct Programs/Operations; Erik G. Riera, )

Administrator, New Hampshire Bureau of )

Behavioral Health,

)

)

Defendants.

)

____________________________________)

Civ. No. ___________

CLASS ACTION COMPLAINT

1

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 2 of 36
I. INTRODUCTION 1. This action challenges the needless institutionalization of adults with serious
mental illness at the New Hampshire Hospital (“NHH”) and the Glencliff Home (“Glencliff”) in violation of the Americans with Disabilities Act (“ADA”), 42 U.S.C. §§ 12101 et seq., Section 504 of the Rehabilitation Act of 1973 (“Rehabilitation Act”), 29 U.S.C. §§ 794 et seq., and the Nursing Home Reform Act (“NHRA”), 42 U.S.C. §§ 1396r et seq. New Hampshire Hospital is a state-operated psychiatric hospital and Glencliff is a state-operated nursing facility primarily for individuals with mental illness.
2. Plaintiffs Lynn E., Kenneth R., Sharon B., Amanda D., Amanda E., and Jeffrey D. are individuals with serious mental illness. These individuals and the class they seek to represent (“plaintiff class” or “class members”) are currently institutionalized at NHH or Glencliff or are at serious risk of being institutionalized at one of these state-operated facilities. Although plaintiffs and the plaintiff class are qualified to receive mental health services in more integrated community settings, New Hampshire (the “State”) has failed to provide the community services they need to leave NHH and Glencliff or to avert their needless institutionalization in these facilities.
3. Plaintiffs and the plaintiff class have been injured by their prolonged or repeated institutionalization. They have been isolated from families, and have lost opportunities to work and participate in community life. When institutionalized, they forfeit nearly all the freedoms that others take for granted. They cannot choose where they live or sleep, what they will do during the day, or even what they will eat. They cannot pursue chosen education or jobs, and have little opportunity to participate in community events or recreational activities. They have virtually no contact with their non-disabled peers, except for paid institutional staff.
2

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 3 of 36
4. There are numerous individuals, like plaintiffs Lynn E., Kenneth R., and Sharon B., who are unnecessarily institutionalized at NHH and at Glencliff because they lack access to community services. Many, like plaintiffs Amanda D., Amanda E., and Jeffrey D., are at serious risk of being institutionalized because they lack access to needed community services. Without such services, many class members are repeatedly and needlessly readmitted to NHH, or forced into other inappropriate settings, such as hospital emergency rooms, homeless shelters, and jails. Frequent visits or admissions to these inappropriate and institutional settings make it difficult for class members to maintain apartments, jobs, and relationships.
5. New Hampshire knows how to successfully serve the plaintiffs and the plaintiff class in integrated community settings. New Hampshire’s community mental health system has demonstrated its ability to serve individuals with the most severe forms of mental illness in their own homes and communities. However, the State has limited the community services available to plaintiffs and the plaintiff class, thereby perpetuating their needless institutionalization at NHH and/or Glencliff.
6. The State has long known that New Hampshire’s mental health system is, in the State's own words, “failing” with “the consequence … being realized across the community.” NH Dep’t of Health and Human Servs., Bureau of Behavioral Health, NH Cmty. Behavioral Health Ass’n, NH Mental Health Council, and Nat’l Alliance on Mental Illness-NH, Addressing the Critical Mental Health Needs of NH’s Citizens: A Strategy for Restoration, Report of the Listening Sessions 1 (April 2009) (“A Strategy for Restoration II”). Not only are individuals with serious mental illness suffering, so are their families and communities. The State’s broken system has contributed to homelessness and, as acknowledged by the State, put “stress … on local law enforcement, hospital emergency rooms, the court system and county jails.” Id.
3

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 4 of 36
7. Although long aware of these problems, the State has failed to correct them. The fundamental problem is that the State has elected to continue to fund an excessive amount of institutional care at NHH and Glencliff, and to underfund community services -- an “imbalance” that has been repeatedly brought to the State’s attention. See, e.g., Governor’s Study Comm. on Mental and Developmental Disabilities, Report (1982) (“Wheelock-Nardi Report”); Dep’t of Health and Human Servs., NHH Census: A Task Force Report (Draft Proposal) (2004) (“Task Force Report”); NH Dep’t of Health and Human Servs., New Hampshire Hosp., Bureau of Behavioral Health, and The Cmty. Behavioral Health Ass’n, Addressing the Critical Mental Health Needs of NH’s Citizens: A Strategy for Restoration (August 2008) (“A Strategy for Restoration I”). By correcting this imbalance, the State could avoid needlessly institutionalizing plaintiffs and the plaintiff class, while providing them with better and more cost-effective care.
8. The needless institutionalization of plaintiffs and the plaintiff class at NHH and Glencliff is not only a human tragedy, it is also a violation of their rights under federal law. The ADA and the Rehabilitation Act mandate an end to discrimination against persons with disabilities, which includes unnecessary segregation in institutions like NHH and Glencliff. The NHRA requires the State, before admitting an individual with mental illness to a nursing facility like Glencliff, to determine whether the individual’s needs could be met in an alternative community setting.
9. Through this action, plaintiffs and the plaintiff class seek declaratory and injunctive relief against the State’s ongoing violation of the ADA, the Rehabilitation Act, and the NHRA. They seek an order from this Court directing the State to expand community services as required to avoid their needless institutionalization at NHH and Glencliff.
4

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 5 of 36
II. JURISDICTION AND VENUE 10. This civil action is brought pursuant to the ADA, 42 U.S.C. §§ 12101 et seq., the
Rehabilitation Act, 29 U.S.C. § 794, and 42 U.S.C. § 1983, to vindicate the civil rights of and safeguard the privileges guaranteed to persons with disabilities under federal law.
11. This Court has jurisdiction over the claims brought under the ADA pursuant to 42 U.S.C. § 12133, the Rehabilitation Act pursuant to 29 U.S.C. § 794a, and the NHRA pursuant to 42 U.S.C. § 1396r and 42 U.S.C. § 1983. This court also has jurisdiction over these claims pursuant to 28 U.S.C. § 1331 and 28 U.S.C. § 1343.
12. Venue is proper in the District of New Hampshire pursuant to 28 U.S.C. § 1391(b). III. THE PARTIES
A. The Individual Plaintiffs 13. Plaintiff Lynn E. is a 54-year-old woman from Danville, New Hampshire who is confined to NHH. She brings this action through her husband and guardian, Barry Ellsworth, who lives in Danville, NH. 14. Plaintiff Kenneth R. is a 65-year-old man who resides at Glencliff. He brings this action himself, and through his guardian, Tri-County CAP, Inc./GS, 34 Jefferson Road, Whitefield, NH 03598. 15. Plaintiff Sharon B. is a 55-year-old woman who resides at Glencliff. She brings this action through her guardian, Office of Public Guardian, 2 Pillsbury Street, Suite 400, Concord, NH 03301. 16. Plaintiff Amanda D. is a 22-year-old woman who lives in Newport, NH. She brings this action through her guardian, Louise Dube, who lives in Newport, NH.
5

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 6 of 36
17. Plaintiff Amanda E. is a 30-year-old woman who lives in Manchester, New Hampshire. She brings this action through her guardian, Office of Public Guardian, 2 Pillsbury Street, Concord, NH, 03301.
18. Plaintiff Jeffrey D. is a 45-year-old man. He lives in Rochester, NH. B. The Defendants 19. Governor John H. Lynch is the chief executive officer of the State of New Hampshire. He is responsible for directing, supervising, and controlling the executive departments of state government, as well as for seeking and expending funds from the legislature to implement the programs and deliver the services of those executive agencies. Defendant Lynch appoints the Commissioner of the New Hampshire Department of Health and Human Services (“DHHS”). He is sued in his official capacity. 20. Nicholas A. Toumpas is the Commissioner of DHHS. DHHS is New Hampshire's single state Medicaid agency responsible for receiving federal funding under the Medicaid Act and complying with all provisions of the Act. As Commissioner, Defendant Toumpas oversees all DHHS programs, including its program of mental health services and its Medicaid program. His responsibilities include, among other things, overseeing NHH and Glencliff, as well as designing and delivering a comprehensive and coordinated system of community services for individuals with serious mental illness. DHHS’s program of community services for individuals with serious mental illness is administered largely through 10 non-profit community mental health centers (“CMHC”). Each CMHC has a contract with DHHS to provide an array of mental health services to individuals with serious mental illness. Defendant Toumpas is sued in his official capacity.
6

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 7 of 36
21. Nancy L. Rollins is Associate Commissioner of the Community Based Care Services office within DHHS. She has direct oversight over, among other things, the operations of the Bureaus of Behavioral Health, Drug & Alcohol Services, Homeless & Housing Services, Elderly & Adult Services, and NHH. The Bureau of Behavioral Health ("BBH”) is charged with delivering community mental health services and ensuring that each CMHC is meeting its contractual obligations to provide an appropriate array of services to persons with disabilities, including those with serious mental illness. Ms. Rollins is also charged with overseeing the State’s compliance with the Preadmission Screening and Resident Review (“PASRR”) requirements of the NHRA. Her responsibilities include ensuring that persons seeking admission to Glencliff are properly screened, assessed, and evaluated for alternative placement. Defendant Rollins is sued in her official capacity.
22. Mary Ann Cooney is Deputy Commissioner of Direct Programs/Operations at DHHS. She has direct oversight over, among other things, Glencliff. Ms. Cooney has supervisory responsibility for Glencliff operations and management, including being responsible in part for the provision of ongoing PASRR reviews and determinations of the need for continued institutionalization at Glencliff. Defendant Cooney is sued in her official capacity.
23. Erik G. Riera is the Administrator of BBH. BBH is New Hampshire’s designated State Mental Health Authority. As the State Mental Health Authority, BBH funds and oversees each of the 10 CMHCs. As Administrator of BBH, Mr. Riera is charged with ensuring the effective and efficient delivery of services to adults with serious mental illness, and ensuring that the CMHCs meet their contractual obligations to the State. Defendant Riera is sued in his official capacity.
7

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 8 of 36
24. All defendants are responsible for ensuring that persons with serious mental illness are served in accordance with federal law, including the ADA, the Rehabilitation Act, and the NHRA. IV. CLASS ACTION ALLEGATIONS
25. Pursuant to Rule 23(a) and (b)(2) of the Federal Rules of Civil Procedure, the plaintiffs bring this action on behalf of themselves and other individuals with serious mental illness institutionalized at NHH or Glencliff or at serious risk of being institutionalized in these facilities. Plaintiffs seek declaratory and injunctive relief individually and on behalf of the class to remedy and prevent their needless institutionalization at NHH and Glencliff.
26. The plaintiff class is so numerous that joinder of all members is impracticable. The class consists of hundreds of individuals. Approximately 125 individuals are confined at NHH at any one time, most of whom could be served and desire to be served in community settings. Approximately 120 individuals reside at Glencliff, most of whom are individuals with serious mental illness who could be served and would prefer to be served in the community. On any given day, scores of additional individuals with serious mental illness are at serious risk of institutionalization at NHH because they lack access to needed community services, as evidenced by the large number of individuals with previous, and sometimes repeated, needless hospitalizations.
27. Every year hundreds of individuals with serious mental illness cycle in and out of NHH or are forced to seek services at other State-supported psychiatric units across New Hampshire. They often struggle to return to and remain in integrated settings due to Stateimposed limitations on needed community-based services. For many individuals, these
8

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 9 of 36
institutional admissions/hospitalizations result from the inability of existing community programs to meet their service needs and prevent their unnecessary institutionalization.
28. There are questions of law and fact common to the plaintiff class including, inter alia:
a. Whether defendants are violating the ADA and the Rehabilitation Act by failing to serve plaintiffs and the plaintiff class in the most integrated setting appropriate to their needs;
b. Whether defendants are violating the ADA and the Rehabilitation Act by failing to provide plaintiffs and the plaintiff class community mental health services needed to avoid their unnecessary institutionalization at NHH or Glencliff;
c. Whether defendants are violating the ADA and the Rehabilitation Act by administering their mental health system in a way that discriminates against plaintiffs and the plaintiff class;
d. Whether defendants have a comprehensive and effectively working plan for serving plaintiffs and the plaintiff class in the community instead of in institutional settings; and
e. Whether defendants are violating the PASRR requirements of the NHRA by failing to properly determine whether individuals referred to Glencliff could be served in a more integrated setting. 29. The named plaintiffs’ claims are typical of the plaintiff class, allowing the named plaintiffs to adequately and fairly represent the interests of the class members. The named plaintiffs will fully and vigorously prosecute this action and are represented by attorneys experienced in federal class action litigation and disability law. Individual members of the class
9

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 10 of 36
would have difficulty pursuing their own claims or remedying systematic violations on their own.
30. New Hampshire has administered its mental health system in a way that discriminates against persons with serious mental illness by failing to provide the communitybased services required to prevent the unnecessary institutionalization, including needlessly prolonged or repeated institutionalization, of plaintiffs and the plaintiff class. Therefore, the defendants have acted or refused to act on grounds that apply generally to the class, making injunctive and/or corresponding declaratory relief appropriate with respect to the class as a whole. As a result, and consistent with similar civil rights actions, the plaintiffs seek certification pursuant to Fed. R. Civ. P. 23(b)(2). V. STATEMENT OF FACTS
A. Statutory Framework (a) The Requirements of the Americans with Disabilities Act and the Rehabilitation Act
31. On July 12, 1990, Congress enacted the ADA, 42 U.S.C. § 12101 et seq., to create “a clear and comprehensive national mandate” for the elimination of discrimination against individuals with disabilities. 42 U.S.C. § 12101(b)(1).
32. In enacting the ADA, Congress recognized that “historically, society has tended to isolate and segregate individuals with disabilities, and, despite some improvements, such forms of discrimination against individuals with disabilities continue to be a serious and pervasive social problem.” 42 U.S.C. § 12101(a)(2).
33. Among the forms of “discrimination” recognized by Congress and prohibited in the ADA is the needless segregation of persons with disabilities in institutions. 42 U.S.C. § 12101(a)(3) (“discrimination against individuals with disabilities persists in . . . institutional-
10

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 11 of 36
ization”); Olmstead v. L.C. ex rel. Zimring, 527 U.S. 581, 598-601 (1999) (needless segregation in an institution constitutes “discrimination” under the ADA).
34. In promulgating regulations to implement the ADA, the Attorney General has required that New Hampshire and other states “administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.” 28 C.F.R. § 35.130(d). According to the Attorney General, the hallmark of an “integrated setting” is that it “enables individuals with disabilities to interact with nondisabled persons to the fullest extent possible . . . .” 28 C.F.R. Pt. 35, App. B.
35. In addition to requiring services in the “most integrated setting,” the Attorney General’s regulations also prohibit states from utilizing “criteria or methods of administration” that have the effect of subjecting individuals with disabilities to any form of discrimination prohibited by the ADA, including segregation. 28 C.F.R. § 35.130(b)(3).
36. The regulations also require states to make reasonable modifications in policies, practices, or procedures when the modifications are necessary to avoid discrimination on the basis of disability, including segregation, unless the state can demonstrate that making the modifications would fundamentally alter the nature of the service program or activity. 28 C.F.R. § 35.130(b)(7).
37. The Rehabilitation Act similarly prohibits discrimination on the basis of disability, 29 U.S.C. § 794(a) and 28 C.F.R. § 41.51(a), requires the provision of services in the most integrated setting, 28 C.F.R. § 41.51(d), and makes it a violation of the Act to use methods of administration that subject individuals to discrimination, 28 C.F.R. § 41.51(b)(3), 45 C.F.R. § 84.4(b)(4).
11

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 12 of 36
(b) The Requirements of the Preadmission Screening and Resident Review (PASRR) Provisions of the Nursing Home Reform Act
38. Congress enacted the PASRR provisions of the NHRA to prevent and remedy the unnecessary admission and confinement of people with mental illness in nursing facilities. 42 U.S.C. §§ 1396r(b)(3)(F) and 1396r(e)(7).
39. All persons with mental illness for whom an admission to Glencliff is sought, must be screened by the State to determine if they have a mental illness and satisfy the State's nursing facility level of care criteria ("Level I screen"). The State must then evaluate and determine whether their needs could be met in the community through the provision of appropriate services, and whether they could benefit from the provision of specialized services to maximize their ability for self-determination and independence. This more in-depth evaluation is named a “Level II” PASRR review. 42 C.F.R. §§ 483.128 et seq.
40. The State is required in its Level II review to conduct a functional assessment of the individual’s ability to engage in activities of daily living and must document the level of support that would be needed to assist the individual to perform these activities while living in the community. 42 C.F.R. § 483.134(b)(5). The Level II review must determine whether it would be possible to meet the individual's needs through the provision of services in the community, as an alternative to institutionalization at Glencliff.
B. Effective Services for Individuals with Mental Illness 41. Many individuals will suffer from mental illness at some point in their lives. While some may have a mental illness that is mild and short in duration, others will experience more serious mental illness as a disabling condition requiring intensive services. 42. People with serious mental illnesses -- such as schizophrenia, severe depression, and bipolar disorder -- can have successful and fulfilling lives. Without access to appropriate
12

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 13 of 36
services, however, living in one’s own home, maintaining relationships with family and friends, or finding and keeping a job can be challenging or even impossible.
43. Experience and research has produced a consensus on the services individuals with serious mental illness need to succeed in the community, including mobile crisis services, Assertive Community Treatment, supportive housing, and supported employment. See The President’s New Freedom Comm’n on Mental Health, Achieving the Promise: Transforming Mental Health Care in America (2003). These services enable individuals to access a coordinated array of psychiatric, rehabilitation, and medical supports in the community. Individuals with serious mental illness with access to such services are able to live in their own homes, obtain employment, and contribute to their communities. See U.S. Dep’t of Health and Human Servs., Substance Abuse and Mental Health Servs. Admin., Ctr. for Mental Health Servs., Nat’l Inst. of Health, Nat’l Inst. of Mental Health, Mental Health: A Report of the Surgeon General – Chapter 4 (1999). Without access to such services though, individuals instead can spend years of their lives institutionalized, revolving in and out of institutions, hospitals, nursing homes, emergency rooms, homeless shelters, and jails.
a) Mobile Crisis Services 44. Mobile crisis service is a short-term intervention that prevents unnecessary admissions to psychiatric hospitals, nursing facilities, emergency rooms, homeless shelters, and jails. The intensity and duration of the service is based on need. Mobile crisis services are available to individuals in their homes and in the community around the clock on a 24/7 basis. Appropriate care is to be provided when and where it is needed, including access to overnight respite, detoxification services, and short-term crisis stabilization beds.
13

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 14 of 36
b) Assertive Community Treatment 45. Assertive Community Treatment (“ACT”) is a long-term intervention, often provided to individuals with serious mental illness for a period of years. ACT is delivered by a multidisciplinary team of professionals. The team is available around the clock and provides a wide range of flexible services, including outreach, intensive case management, medication management, and psychosocial rehabilitation. ACT teams are mobile, providing services in individuals’ homes and in other community settings in which individuals spend their time. ACT is a proven method of preventing psychiatric hospitalizations and nursing home stays, as well as needless visits and admissions to emergency rooms, homeless shelters, and jails.
c) Supportive Housing 46. Supportive housing is a treatment intervention. In supportive housing, individuals are provided with their own apartment along with the services they need to be successful tenants and members of the community. Individuals in supportive housing have access to an array of services, including social skills training, medication management, and medical treatment. Supportive housing services have proven to be very successful at helping persons with serious mental illness manage their mental illness while continuing to live in the community.
d) Supported Employment 47. Supported employment enables individuals with serious mental illness to find and maintain competitive employment at job sites in the community, where they are integrated with their non-disabled peers. In supported employment, individuals with serious mental illness receive both individualized placement and ongoing support services. In addition to being therapeutic and reducing the risk of institutionalization, supported employment enables individuals to earn money to support a household and their participation in community activities.
14

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 15 of 36
C. New Hampshire Fails to Provide Services in Integrated Settings a) New Hampshire’s Initial Commitment to Provide Mental Health Services in the Community
48. New Hampshire was once a leader in the delivery of community services to individuals with disabilities. State policy and practice strongly favored serving people with serious mental illness in the community rather than in institutions. A New Hampshire Study Committee on Mental and Developmental Disabilities reported to the Governor in 1982:
The heart of any statewide mental health system is the community. Experience in New Hampshire has shown that when community services are in place, admissions to the state hospital are greatly reduced. Wheelock-Nardi Report at 12. 49. The Study Committee’s report declared that “the traditional concept of the ‘State Hospital’ is obsolete” and recognized that “the development of community-based services have made it possible for people with chronic or severe mental illness to receive care near their homes.” The report called for the closure of the Laconia State School, an institution for people with intellectual disabilities, the downsizing of NHH, the State’s sole state-operated psychiatric facility, and the development of community services, including treatment, case management, residential, and vocational services. 50. Consistent with the Wheelock-Nardi Report, the New Hampshire Legislature in 1986 passed the Mental Health Services System law, N.H. Rev. Stat. Ann. 135-C, making it the policy of the State to provide mental health care that is within each person’s own community, is directed at promoting independence, and is the “[l]east restrictive to” the person’s freedom and participation in the community. N.H. Rev. Stat. Ann. 135-C:1, 15. Regulations implementing the statute require that services must “[p]romote[] community integration and participation.” N.H. Code Admin. R. Ann. He-M 401.10(h). Other regulations mandate that CMHCs, the entities with
15

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 16 of 36
which the State contracts to provide most community services, “strive to provide all services … in each consumer’s own community, and in a manner which promotes the personal selfsufficiency, dignity, and maximum community participation of each consumer,” N.H. Code Admin. R. Ann. He-M 403.06(j), and that individuals receiving mental health services have a right to services that promote full participation in community living. N.H. Code Admin. R. Ann. He-M 309.06(a)(3); He-M 311.06(a)(6).
51. The State initially made good progress in implementing the recommendations of the Wheelock-Nardi Report by expanding community treatment and residential services. By the late 1980s, New Hampshire was recognized by the National Institute of Mental Health for its leadership in providing services in community settings.
b) New Hampshire Reneges on Its Commitment to Provide Mental Health Services in the Community
52. The State’s commitment and leadership, however, were short-lived. The availability of community services began to decrease and institutionalization began to rise. From 1989 to 2010, the number of annual admissions to NHH increased from approximately 900 to about 2,300 -- a 150 percent increase.
53. In 2004, DHHS, recognizing there were significant “imbalances in the mental health system of New Hampshire that cause many consumers to receive care at NHH rather than community alternatives,” convened another expert panel comprised of mental health professionals, administrators, and stakeholders. Task Force Report at 2. The panel was asked “to assess … causes and remedies.” Id. The panel concluded that “many people are admitted to and remain at NHH because of a lack of … alternatives.” Id. at 12.
54. According to the panel, the underlying causes were a decline in crisis and other intensive community mental health services and the fact that there had been “virtually no
16

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 17 of 36
investment or development” in community residential services. Id. at 6. The panel reported that many individuals remained institutionalized at NHH due to the unavailability of adequate residential services in the community. Some persons with mental illness in crisis ended up in the emergency rooms of general hospitals, from which they were “discharged … in unsafe condition.” Id. at 12. Others found themselves in community hospitals ill-equipped to serve them or “were held … in jails.” Id.
55. Three years later, in 2007, a legislative commission issued a report echoing the findings of DHHS’s 2004 expert panel. Comm’n to Develop a Comprehensive State Mental Health Plan, Fulfilling the Promise: Transforming New Hampshire’s Mental Health System (2007). The report decried the “shrinking community resources” for individuals with serious mental illness, id. at 2, and highlighted the need for the State to expand supportive housing and other evidenced-based services, such as ACT and supported employment. Id. at 18.
56. By 2008, growing concern led to yet another report. A panel of knowledgeable mental health professionals was convened, with the support of DHHS, to assess the status of mental health services and make recommendations for meeting the critical needs of New Hampshire citizens. Its report, Addressing the Critical Mental Health Needs of NH’s Citizens, A Strategy for Restoration, August 2008 (“A Strategy for Restoration I”), portrayed a system in crisis, marked by an ever-increasing number of admissions to NHH and the continued unavailability of community services. Both problems, the panel concluded, were leading to needless institutionalization. As the panel explained, “many individuals are admitted to New Hampshire Hospital because they have not been able to access sufficient [community] services in a timely manner (a “front door problem”) and remain there, unable to be discharged, because of a lack of viable community-based alternatives (a “back door problem”).” A Strategy for
17

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 18 of 36
Restoration I at 4. The report called for, among other things, additional crisis services, ACT teams, and residential services, including supportive housing.
57. Commenting on the report, defendant DHHS Commissioner Toumpas acknowledged that “NH’s mental health care system is failing and the consequence of these failures is being realized across the community. The impacts of the broken system are seen in the stress it is putting on local law enforcement, hospital emergency rooms, the court system and county jails, and, most importantly, in the harm under-treated mental health conditions cause NH citizens and their families.” A Strategy for Restoration II at 1 (April 2009).
c) New Hampshire’s Discriminatory Administration of Its Service System 58. As the State has acknowledged, its mental health service system is failing, subjecting plaintiffs and the plaintiff class to needless institutionalization. Plaintiffs and the plaintiff class are being deprived of services they require to live in their own homes and communities. 59. In New Hampshire, there are ten regional CMHCs charged with providing community services to individuals with serious mental illness. However, as a direct result of the State's actions and inactions, these CMHCs are limited in their ability to provide the kinds of services and supports required to prevent the unnecessary institutionalization of plaintiffs and the plaintiff class. The State offers a very limited amount of residential services, such as supportive housing, to individuals with serious mental illness. The State has severely limited mobile crisis services, ACT, and supported employment services, which are uniquely effective in preventing the prolonged or repeated institutionalization of individuals with serious mental illness, including those with the most complex needs.
18

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 19 of 36
60. The plaintiffs and the plaintiff class are unnecessarily institutionalized or at serious risk of unnecessary institutionalization because the State has chosen to limit the availability of mobile crisis, ACT, supportive housing, and supported employment services. Currently, half of New Hampshire’s CMHC regions have no ACT teams, and others do not have a sufficient number of ACT teams. Similarly, mobile crisis services, supportive housing, and supported employment are available in such limited quantity that the need far exceeds existing State capacity. If these services were sufficiently available to plaintiffs and the plaintiff class, they would not be needlessly segregated in the State’s institutions. Instead, they would experience far fewer hospitalizations at NHH and other state-supported psychiatric units, and their hospitalizations would not be inappropriately prolonged.
61. In addition to being needlessly institutionalized at NHH or Glencliff, plaintiffs and the plaintiff class are at times forced to seek care in homeless shelters or emergency rooms, or are confined in jail, because the State has chosen to limit the availability of mobile crisis, ACT, supportive housing, and supportive employment services. This is both expensive and damaging to the individuals forced into these settings. If mobile crisis, ACT, supportive housing, and supported employment services were available to plaintiff and the plaintiff class, the number and duration of inappropriate admissions to homeless shelters, emergency rooms, and jails would be significantly reduced.
62. Many people are institutionalized at NHH for prolonged periods of time. New Hampshire’s 2011 data reflects that approximately 45 percent of individuals in NHH had been there for longer than 30 days. 16 percent of individuals at NHH have been there over a year. For most of these individuals, NHH provides little more than custodial care. They suffer a loss of autonomy and choice. They have no contact with their non-disabled peers, except for paid staff,
19

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 20 of 36
and lack privacy in their living and sleeping arrangements. Their most basic rights are curtailed. If adequate mobile crisis, ACT, supportive housing, and supported employment services were available to them, nearly all the long-term patients at NHH could be served instead in their own homes and communities, and would prefer to be served in an integrated community setting rather than in an institution.
63. There were over 1,800 adult admissions to NHH in 2010, nearly 800 of which were readmissions of individuals who had been at NHH within the previous 180 days. Over 17 percent of adults discharged from NHH in 2010 were readmitted within 30 days of discharge, and 35 percent were readmitted within 180 days of discharge. Individuals discharged from psychiatric hospitals often struggle to successfully remain in integrated settings due to State limitations on community-based services. New Hampshire’s staggeringly high readmission rates highlight the State’s failure to provide sufficient services to enable individuals with mental illness to remain in their communities.
64. Prolonged institutionalization at Glencliff is also a severe problem. Glencliff is a state-operated, 120-bed nursing facility, located in an isolated area of northern New Hampshire. Persons institutionalized there experience most of the same deprivations, conditions, and rights restrictions as class members at NHH. In addition, individuals placed at Glencliff are far from family and friends; the facility’s remote location makes it difficult for many family members or friends to visit their loved ones.
65. Moreover, few individuals ever return to the community from Glencliff. Between 2005 and 2010, there were a total of 13 discharges from Glencliff. Of those discharges, 11 were to NHH or other facilities, while only two people returned to their homes. In recent years, more people have died at Glencliff than have returned to the community.
20

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 21 of 36
66. Sadly, younger and younger individuals are being placed in this remote facility. In 2010, 28 percent of the individuals at Glencliff were in their 40’s or 50’s. Glencliff residents would prefer to be served in a community setting, near family and friends, rather than spend the rest of their lives in an institution.
67. Many Glencliff residents were transferred directly from NHH. The State has relied on transfers to Glencliff to help relieve the “front-door” problem of increasing admissions to NHH and the “backdoor” problem of prolonged stays at NHH. See A Strategy for Restoration I at 4. However, the State’s strategy has actually solidified the “imbalances in the mental health system of New Hampshire that cause many consumers to receive care at NHH rather than community alternatives.” Task Force Report at 2. Money that could be spent on expanding mobile crisis, ACT, supportive housing, and supported employment services is spent instead on largely unnecessary and costly institutional care at Glencliff.
68. Many of the individuals transferred from NHH to Glencliff do not have physical health problems that require care in a nursing home. Others have physical health problems, ranging from chronic obstructive pulmonary disease to diabetes, that regularly are treated in the community. These individuals would need access to medical and personal care services that the State already provides to individuals with similar health conditions living in the community.
69. Some of Glencliff’s residents are transferred from other nursing facilities, and a few are admitted directly from the community. These individuals usually are admitted to Glencliff because of behaviors related to their mental illness. Their physical and mental health needs could be successfully met in community settings with appropriate support services. They would prefer to receive services in an integrated community setting, closer to their families and/or home communities, rather than in an isolated institutional setting like Glencliff.
21

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 22 of 36
d) Findings of Legal Violations by U.S. Department of Justice 70. The U.S. Department of Justice recently found that New Hampshire is violating the ADA for the very same reasons asserted in this Complaint. On April 7, 2011, the United States issued detailed findings, concluding that New Hampshire is violating the ADA and Olmstead by failing to provide services to individuals with serious mental illness, like plaintiffs and the plaintiff class, in the most integrated setting appropriate to their needs. The United States found that this failure “has led to the needless and prolonged institutionalization of individuals with disabilities…” and that the “systemic failures in the State’s system place qualified individuals with disabilities at risk of unnecessary institutionalization now and going forward.” U.S. Dep’t of Justice, United States’ Investigation of the New Hampshire Mental Health System Pursuant to the Americans with Disabilities Act 2 (April 7, 2011), http://www.justice.gov/crt/about/spl/documents/New_Hampshire_MH_findlet_04-07-11.pdf.
e) New Hampshire Is Violating the PASRR Requirements of the NHRA 71. States like New Hampshire that choose to participate in the Medicaid program must ensure compliance with the PASRR requirements of the NHRA. 42 U.S.C. § 1396r (b)(3)(F); 42 U.S.C. § 1396r(e); 42 C.F.R. §§ 483.100 et seq. 72. The State is obliged to comply with PASRR in operating Glencliff, since Glencliff is certified by the State as a nursing facility and receives funding through the Medicaid program. 42 U.S.C. § 1396r(e)(7); 42 C.F.R. §§ 483.100 et seq. 73. The State's PASRR program does not appropriately assess the needs of each individual with mental illness who is referred to Glencliff and determine whether the individual can be served in the community prior to admission to Glencliff, or upon a change in condition, as
22

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 23 of 36
required by federal law. Instead, it assumes that an individual with both serious mental illness and any medical needs should be institutionalized at Glencliff.
74. The State’s PASRR program does not appropriately assess whether an individual needs specialized services and, if so, what specific services are needed. As a consequence, the State does not provide necessary specialized services at Glencliff.
75. If the State were properly performing PASRR reviews, it would have determined that most individuals admitted to Glencliff could be served instead in community settings. It also would have determined that most Glencliff residents could be transitioned to the community with appropriate supports, including mobile crisis, ACT, supportive housing, and supported employment services.
f) The Impact on the Named Plaintiffs
(1) Lynn E. 76. Lynn E. is a 54-year-old woman who currently is at NHH. Lynn’s home is in Danville, New Hampshire with her husband and two of her children. She brings this action through her guardian and husband, Barry Ellsworth. 77. Lynn was born and raised in Cambridge, Massachusetts, the second of four children. She graduated from high school and completed two years of college. Lynn has three children, ages 30, 25, and 15. Lynn was trained as a Licensed Nursing Assistant (LNA). Prior to the onset of her mental illness, she worked for a number of nursing homes and agencies as an LNA. 78. Lynn has a serious mental illness. She has varying diagnoses of schizophrenia and bipolar disorder with psychosis. Her symptoms began after the birth of her first child, when Lynn was 26 years old. Since that time, she has been institutionalized on numerous occasions, both at
23

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 24 of 36
NHH and in community hospitals in New Hampshire and Massachusetts. Her current admission to NHH began on April 5, 2011, when she was transferred from the Emergency Room at Parkland Medical Center in Derry, NH. She has remained at NHH for almost 10 months.
79. Since 2007, Lynn has received community-based mental health services from the Center for Life Management in Derry, New Hampshire. Her main goal is to stay out of the hospital; being hospitalized is her worst fear. Lynn would very much like to work. Her mental health clinician believes that working would add structure to her daily routine and bolster her self esteem. Unfortunately, the only services Lynn was receiving in the community were psychotherapy once a month and medication monitoring every two months. These services were insufficient to prevent her first hospitalization at NHH in 2008 and have not effectively addressed her ongoing risk of institutionalization.
80. Lynn needs, but has not received, mobile crisis intervention, assertive community treatment, and supported employment. If these services were available to her in sufficient intensity and duration, she would make gains towards recovery, be better able to assist her family, and be able to avoid repeated, costly hospitalizations.
(2) Kenneth R. 81. Kenneth (Ken) R. is a 65-year-old man who resides at Glencliff. Ken brings this action on his own behalf and through and with the support of his guardian, Tri-County CAP, of Whitefield, New Hampshire. 82. Ken was born in Massachusetts, but has spent most of his adult life in New Hampshire. He has four siblings and five children. Ken is very social and enjoys interacting with many people. He is compassionate, routinely engaged with other Glencliff residents, and often
24

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 25 of 36
tries to help them with their problems. He likes gardening and weightlifting and spends time in the game room listening to music.
83. Ken has a diagnosis of depression and mood disorder. As a result of a motor vehicle accident over twenty-five years ago, Ken also has paraplegia and a brain injury. For most of the time since his accident, Ken lived successfully and independently in the community. He received some support services from West Central Behavioral Health in Claremont, New Hampshire.
84. At one time, Ken was an avid wheelchair racer and is proud of his participation in this sport. Because he is now confined in an isolated nursing institution, he is unable to participate in this activity which had had once brought him so much joy and satisfaction.
85. Ken has a long history of psychiatric admissions to community hospitals. In 2004, he had his first admission to NHH and two months after his discharge he returned to NHH where he then remained for the next six months. Ken was then transferred from NHH to Glencliff in May of 2005 when NHH and West Central Behavioral Health failed to identify an appropriate housing alternative for him. He never wanted to be in Glencliff, and only agreed to move there as a temporary residence. Ken has now been stuck at Glencliff for seven years.
86. More than anything, Ken wants to return to the community and to live in his own apartment. Ken’s public guardian, appointed after his admission to Glencliff, supports his desire to return to the community with appropriate services. Ken needs assistance transferring in and out of his chair. One of his goals is to gain the skills to become more independent and transfer by himself. The State has not provided Ken with sufficient community home health, mental health, and support services that he needs to live in the community. If these services were available in sufficient intensity and duration, Ken would not have to remain institutionalized in Glencliff.
25

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 26 of 36
Ken needs, but has never received, supportive housing, supported employment, and mobile crisis intervention services. As a result of the lack of these services, Ken is now faced with the likelihood of spending the rest of his life at Glencliff.
(3) Sharon B. 87. Sharon B. is a 55-year-old woman who resides at the Glencliff Home. Sharon brings this action through her guardian, the Office of Public Guardian in Concord, New Hampshire. 88. Sharon was born in Dover, New Hampshire and has spent almost her whole life here. Sharon is divorced and has two grown boys and three grandchildren. She enjoys reading, listening to the radio, art, and gardening. 89. Sharon has a diagnosis of schizoaffective disorder, bipolar type, and posttraumatic stress disorder. She has spent most of the last 5 years at either NHH or Glencliff. She had her first psychiatric hospitalization at age 20 and has endured 5 separate hospitalizations at NHH since that time. Sharon was institutionalized at NHH from July 2009 to February 2010, and then transferred to Glencliff where she remains today. Sharon rarely gets to see the people that are important to her, including her mother, siblings, children and grandchildren. Her family lives a significant distance away and is unable to visit Sharon as often as they and Sharon would like. Sharon’s prolonged isolation from her family and community is an ongoing source of pain and loss. 90. When she lived in the community, Sharon was a client of Riverbend Mental Health Center in Concord, New Hampshire. Sharon lived in apartments on her own; however, without adequate support services, she struggled. She was transferred to other residential settings, including Riverbend’s Mill House and Miller House, as well the Transitional Housing
26

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 27 of 36
Program on the grounds of NHH. Ultimately, Sharon left each of these programs, in one instance because the program closed, in the others because the programs could not meet her needs.
91. Although the defendants have offered Sharon care in multiple congregate care settings, they have not provided the community home health and mental health services that she needs to live successfully in her own apartment. Sharon needs, but has never received, supportive housing, ACT, mobile crisis intervention, and supported employment. Sharon’s medical needs could be managed with appropriate community health services. If community health and mental health services were available in sufficient intensity and duration, Sharon would not have to remain institutionalized, nor would she be faced with the prospect of spending the rest of her life in the Glencliff Home.
(4) Amanda D. 92. Amanda D. (Mandy) is a 22-year-old woman who lives in her mother’s home in Newport, New Hampshire. She brings this action through her mother and guardian, Louise Dube. 93. Mandy is an intelligent young woman who obtained her high school diploma despite spending many years, and much of her childhood, in hospitals and residential placements. She loves animals, and cares for her companion cat and her yellow Labrador that she is training to become a psychiatric service dog. She is an award-winning poet and loves music. 94. Mandy has been diagnosed at various times with bipolar disorder, post-traumatic stress disorder, and borderline personality disorder. She requires services to manage her symptoms and is working to improve her independent living skills. 95. Mandy was only 12 years old when she experienced her first hospitalization at the Anna Philbrick Center, the former children’s psychiatric hospital on the grounds of the NHH. This was the beginning of a cycle of repeated hospital admissions, robbing Mandy of the normal
27

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 28 of 36
educational and social experiences of adolescence. Over the past 10 years, Mandy has had 20 psychiatric hospitalizations at NHH. She also endured dozens of additional psychiatric hospitalizations at Dartmouth-Hitchcock Medical Center, Cheshire Hospital, Valley Regional Hospital and the Springfield Hospital, in large part because she did not receive adequate community-based mental health services. Mandy continues to be at serious risk of institutionalization at NHH.
96. Mandy has lived in various residential settings, including Connecticut Valley House in Claremont, New Hampshire. In August 2010, when this house closed, Mandy moved into her mother’s basement. Due to the lack of appropriate services, she suffered repeated admissions to various emergency rooms and psychiatric wards. For a brief period, Mandy went to live in her own apartment, but because adequate services were not available, her mother was forced to stay with her, sleeping on Mandy’s floor. When it became clear that Mandy needed intensive services that the defendants did not offer, Mandy ended up back in the hospital.
97. Mandy currently receives services from West Central Behavioral Health, the community mental health center in Claremont, New Hampshire. She has access to limited case management, counseling, and medication monitoring, but not to the community mental health services, including supportive housing, mobile crisis intervention, ACT and supported employment, that would address her ongoing and serious risk of unnecessary institutionalization.
98. Mandy’s greatest wish is to live in her own apartment as her peers do. However, the lack of community-based services prevents her from doing this. Instead, her life is marked by constant disruption as she cycles in and out of various psychiatric units and hospitals.
99. With services such as supportive housing, mobile crisis intervention, supported employment and ACT, Mandy could avoid needless hospitalizations in the future and create
28

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 29 of 36
more stability for herself in the community, as well as move closer to her goal of a job working with animals.
(5) Amanda E. 100. Amanda E. is a 30-year-old woman who lives in Manchester, New Hampshire. Amanda brings this action through her guardian, the Office of Public Guardian in Concord, New Hampshire. 101. Amanda was born in Fitchburg, Massachusetts, and shortly thereafter was abandoned by her biological mother. She experienced abusive conditions in foster care placements before being placed with her adoptive parents, who raised her in Hudson, New Hampshire. Amanda received special education services for emotional disabilities. She attended an out-of-district day school placement, where she liked to play basketball. As a child, she had multiple hospitalizations in Massachusetts for suicidal ideation. 102. Amanda has been diagnosed with post-traumatic stress disorder, schizoaffective disorder, poly-substance abuse, borderline personality disorder, and seizures. She has experienced more than 30 hospitalizations at NHH. She also has a lengthy history of emergency room visits and psychiatric hospitalizations in community hospitals. Amanda has not had access to the community-based mental health services needed to prevent her repeated institutionalization. Her marriage ended and she lost custody of her only daughter. 103. Amanda has lived in a variety of settings in Nashua and Manchester, NH, including a group home, an apartment, and a homeless shelter. She currently resides in a rooming house in Manchester. During the day, Amanda attends the peer support center in Manchester. She enjoys reading, going for walks, creative writing, and listening to music, and she hopes to get her GED and go to college. She receives some community mental health services from The
29

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 30 of 36
Mental Health Center of Greater Manchester, including case management, therapy, and functional support. These services have been insufficient to prevent her repeated hospitalizations, and she remains at serious risk of institutionalization. In the last three months alone, Amanda has spent multiple days at the Cypress Center, an acute psychiatric residential treatment center, the emergency room at Elliott Hospital, and NHH.
104. Amanda has the strength and courage to live successfully in the community, but she needs mobile crisis intervention, occasional access to a crisis respite bed, ACT, supported employment, and especially supportive housing. Without these services, she will continue to suffer repeated, unnecessary hospitalizations.
(6) Jeffrey D. 105. Jeffrey (Jeff) D. is a 45-year-old man who resides in Rochester, New Hampshire. 106. Jeff was born and raised in Connecticut, the third of four children. He obtained his high school diploma and moved with his wife to the Seacoast region of New Hampshire in 1985. Jeff and his wife have three daughters. 107. Jeff is a skilled carpenter and loves the outdoors. He has a variety of hobbies, including fishing and woodworking. With the proper services, Jeff can be successful and independent in the community. 108. Jeff has a diagnosis of bi-polar disorder with psychosis. He has been admitted to NHH five times, with four of these hospitalizations occurring within the past four years. Jeff was confined to NHH from September 2009 through August 2011. Since his discharge in August 2011, he has returned to NHH once for a brief stay. 109. Jeff is at serious risk of re-institutionalization. He went to the emergency room at Frisbie Hospital in Rochester three times in January 2012 to obtain treatment for his psychiatric
30

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 31 of 36
condition; when discharged home, he did not receive the community mental health services he needs.
110. While Jeff languished at NHH, his wife was forced to sell their home. Jeff now lives in an apartment with his wife and youngest daughter. Because of his lengthy institutionalization, Jeff has severe difficulty with social interaction. Jeff has been unable to access the community mental health services he needs, including mobile crisis intervention and ACT to prevent periodic crises from turning into unnecessary, prolonged periods of institutionalization. He currently receives only medication management and case management, and is on a waitlist for psychotherapy.
111. If Jeff were to receive mobile crisis intervention, and ACT in sufficient intensity and duration, his condition would improve, he would become more independent and productive, and he would be able to avoid repeated hospitalizations. However, in the absence of these services, Jeff remains at serious risk of institutionalization. VI. LEGAL CLAIMS
112. In their capacities as state officials and under color of law, the defendants have subjected the plaintiffs to unnecessary institutionalization and segregation in violation of the ADA, the Rehabilitation Act, and the NHRA.
COUNT I Violation of the Americans with Disabilities Act 113. The plaintiffs reallege paragraphs 1 through 112 as though fully set forth herein. 114. The named plaintiffs and the members of the plaintiff class, due to their mental illnesses, are individuals with disabilities within the meaning of the ADA. 42 U.S.C. § 12131(2).
31

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 32 of 36
115. Defendants, acting in their official capacities, are public entities within the meaning of the ADA.
116. The named plaintiffs and the plaintiff class are qualified to participate in New Hampshire’s system of community services for individuals with serious mental illness.
117. Defendants violate the ADA when they needlessly institutionalize individuals with serious mental illness at NHH and Glencliff, instead of providing them the services they need to remain in their own homes and communities.
118. Defendants are failing to administer services, programs, and activities in “the most integrated setting” appropriate to the needs of plaintiffs and the plaintiff class. 28 C.F.R. § 35.130(d).
119. Defendants are using methods of administering New Hampshire’s mental health system that subject the plaintiffs and the plaintiff class to unjustified institutionalization and segregation. 28 C.F.R. § 35.130(b)(3).
120. It would not fundamentally alter the defendants’ programs, services, or activities to provide plaintiffs and the plaintiff class the community services they need to avoid needless institutionalization and segregation at NHH and Glencliff.
121. Defendants lack a comprehensive and effectively working plan for serving people with serious mental illness in community rather than institutional settings.
COUNT II Violation of Section 504 of the Rehabilitation Act 122. The plaintiffs reallege paragraphs 1 through 121 as though fully set forth herein.
123. The named plaintiffs and the members of the plaintiff class are qualified individuals with disabilities under Section 504 of the Rehabilitation Act. 29 U.S.C. § 794(a).
32

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 33 of 36
124. DHHS, a state agency, receives federal financial assistance for its programs and activities.
125. DHHS violates Section 504 when they needlessly institutionalize individuals with serious mental illness at NHH and Glencliff, instead of providing them the services they need to remain in their own homes and communities.
126. Defendants have failed to administer services, programs, and activities “in the most integrated setting” appropriate to the needs of plaintiffs and the plaintiff class. 28 C.F.R. § 41.51(d).
127. Defendants are using methods of administering New Hampshire’s mental health system that subject the plaintiffs and the plaintiff class to unjustified institutionalization and segregation. 28 C.F.R. § 41.51(b)(3).
128. It would not fundamentally alter the defendants’ programs, services, or activities to provide plaintiffs and the plaintiff class the community services they need to avoid needless institutionalization and segregation at NHH and Glencliff.
129. Defendants lack a comprehensive and effectively working plan for serving people with serious mental illness in the community rather than institutional settings.
COUNT III Violation of the Nursing Home Reform Act The plaintiffs reallege paragraphs 1 through 129 as though fully set forth herein. 130. Defendants have failed to develop and implement a PASRR program as required by the NHRA that appropriately determines whether the needs of applicants to and residents of Glencliff could be met in an alternative, more integrated setting than Glencliff; and advises the
33

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 34 of 36
individuals of the available alternatives to Glencliff, in violation of 42 U.S.C. §§ 1396r(b)(3)(F)(i), 1396r(e)(7)(A) & (B), and 42 C.F.R. §§ 483.130, 483.132, 483.134.
131. Defendants’ failure to appropriately assess all applicants with mental illness and determine whether the needs of these individuals could be met in a more integrated communitybased setting has resulted in the inappropriate placement and retention individuals with serious mental illness in Glencliff, in violation of 42 U.S.C. §§ 1396r(e)(7)(B)(ii) & (C) and 42 C.F.R. § 483.132(a). VII. PRAYERS FOR RELIEF
WHEREFORE, the plaintiffs and the plaintiff class respectfully request that this Court: 1. Certify this case a class action pursuant to Fed. R. Civ. P. 23. 2. Issue a declaratory judgment that:
(a) Defendants are violating the ADA and the Rehabilitation Act by failing to provide the plaintiffs and the plaintiff class with services in the most integrated setting and by needlessly institutionalizing them at NHH and Glencliff; and (b) Defendants are violating the PASRR requirements of the NHRA by failing to properly assess class members’ ability to be served in a more integrated setting than Glencliff and to determine if the individual should be served in an alternative setting to Glencliff. 3. Grant permanent injunctive relief to remedy Defendants' violations of the ADA, the Rehabilitation Act, and the NHRA, including requiring Defendants: (a) To expand community services that plaintiffs and plaintiff class members need to avoid unnecessary institutionalization at NHH and Glencliff, including
34

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 35 of 36

especially mobile crisis intervention, ACT, supportive housing, and supported employment services (b) To conduct proper PASRR assessments to determine whether Glencliff residents and individuals referred to Glencliff could be served in a more integrated setting. 4. Award the plaintiffs costs of this litigation and their reasonable attorneys’ fees pursuant to 29 U.S.C. § 794(b), 42 U.S.C. §§ 1988 and 12133, and any other applicable provision of law; and 5. Grant such further and other relief as may be just and proper.

Dated: February 9, 2012
Pro Hac Vice Applications to be Submitted: Steven Schwartz (MA BBO 448440) Kathryn Rucker (MA BBO 644697) CENTER FOR PUBLIC REPRESENTATION 22 Green Street Northampton, MA 01060 (413) 586-6024 SSchwartz@cpr-ma.org KRucker@cpr-ma.org

Respectfully submitted,
Lynn E., by her guardian, Barry Ellsworth; Kenneth R., by his guardian, Tri-County CAP, Inc./GS; Sharon B., by her guardian, Office of Public Guardian, Inc.; Amanda D., by her guardian, Louise Dube; Amanda E., by her guardian, Office of Public Guardian, Inc.; and Jeffrey D.,
By their attorneys:
DISABILITIES RIGHTS CENTER
By: /s/ Amy B. Messer Amy B. Messer (NH Bar 8815) Adrienne Mallinson (NH Bar 17126) Aaron Ginsberg (NH Bar 18705) 18 Low Avenue Concord NH 03301 (603 228-0432 amym@drcnh.org adriennem@drcnh.org aarong@drcnh.org
35

Case 1:12-cv-00053-LM Document 1 Filed 02/09/12 Page 36 of 36

Ira Burnim (D.C. Bar 406154) Jennifer Mathis (D.C. Bar 444510) JUDGE DAVID L. BAZELON CENTER FOR MENTAL HEALTH LAW 1101 15th Street, NW, Suite 1212 Washington, D.C. 20005 (202) 467-5730 irab@bazelon.org jenniferm@bazelon.org

DEVINE, MILLIMET & BRANCH PROFESSIONAL ASSOCIATION
By: /s/ Daniel E. Will__________ Elaine M. Michaud (NH Bar 10030) Daniel E. Will (NH Bar 12176) Kristen R. Blanchette (NH Bar 19616) Joshua M. Wyatt (NH Bar 18603) 111 Amherst Street Manchester, NH 03101 (603) 669-1000 emichaud@devinemillimet.com dwill@devinemillimet.com kblanchette@devinemillimet.com jwyatt@devinemillimet.com

36

 
 Case 1:12-cv-00053-SM Document 19 Filed 03/23/12 Page 1 of 5

UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSIRE

)

Lynn E., by her guardian,

)

Barry Ellsworth; Kenneth R.,

)

by his guardian, Tri-County CAP, Inc./GS; )

Sharon B., by her guardian, Office of

)

Public Guardian, Inc.; Amanda D., by

)

her guardian, Louise Dube; Amanda E., )

by her guardian, Office of Public

)

Guardian, Inc.; and Jeffrey D.,

)

on behalf of themselves and all

)

others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

John H. Lynch,

)

Governor of the State of New

)

Hampshire; Nicholas A. Toumpas,

)

Commissioner, New Hampshire

)

Department of Health and Human

)

Services; Nancy L. Rollins,

)

Associate Commissioner, New Hampshire )

Department of Health and Human Services, )

Community Based Care Services;

)

Mary Ann Cooney,

)

Deputy Commissioner, New Hampshire )

Department of Health and Human Services, )

Direct Programs/Operations; Erik G. Riera, )

Administrator, New Hampshire Bureau of )

Behavioral Health,

)

)

Defendants.

)

____________________________________)

Civ. No. 1:12-cv-53-LM

PLAINTIFFS’ MOTION FOR CLASS CERTIFICATION Plaintiffs Lynn E., Kenneth R., Sharon B., Amanda D., Amanda E., and Jeff D. (collectively the “named plaintiffs”), respectfully move this Court to certify the above-captioned

1

Case 1:12-cv-00053-SM Document 19 Filed 03/23/12 Page 2 of 5
case as a class action pursuant to Fed. R. Civ. P. 23(a) and 23(b)(2). In support of their motion, the plaintiffs state as follows:
1. The named plaintiffs are adults with serious mental illness who currently are institutionalized at New Hampshire Hospital (NHH) or the Glencliff Home (Glencliff) or at serious risk of institutionalization in these facilities. They bring the instant class action on behalf of themselves and at least several hundred similarly situated individuals.
2. This case seeks to end the suffering and harm experienced by the named plaintiffs and plaintiff class members by providing integrated, community services to avoid their needless institutionalization.
3. The Complaint requests that the Court certify a class comprised of: all persons with serious mental illness who are institutionalized at New Hampshire Hospital or the Glencliff Home or at serious risk of institutionalization in these facilities.
4. The named plaintiffs, and the class they seek to represent, all have disabilities that substantially limit major life activities and require ongoing services and support. They are qualified to receive mental health services in integrated community settings, yet New Hampshire (the “State”) has failed to provide the community services they need to avoid their unnecessary institutionalization.
5. In order to remedy these systemic legal violations, the named plaintiffs and the plaintiff class seek declaratory and injunctive relief under Title II of the Americans with Disabilities Act (ADA) 42 U.S.C. §§ 12101 et seq., Section 504 of the Rehabilitation Act, 29 U.S.C. §§794 et seq., and the Nursing Home Reform Amendments (NHRA) to the Medicaid Act, 42 U.S.C. §§1396 et seq., and an order directing the State to provide the community services
2

Case 1:12-cv-00053-SM Document 19 Filed 03/23/12 Page 3 of 5
required to avoid class members’ needless institutionalization, including mobile crisis, Assertive Community Treatment (ACT), supportive housing, and supported employment.
6. As more fully described in the attached Memorandum, and as supported by the evidence attached as exhibits 1-9, the proposed class satisfies the numerosity, commonality, typicality, and adequacy of representation requirements of Rule 23(a) of the Federal Rules of Civil Procedure.
7. The defendants have administered the State mental health system in a way that discriminates against persons with serious mental illness by failing to provide the community-based services required to avoid their unnecessary institutionalization. Thus, the defendants have acted or refused to act on grounds generally applicable to the class, making injunctive and declaratory relief appropriate for the class as a whole. As a result, the proposed class satisfies the standards of Rule 23(b)(2) of the Federal Rules of Civil Procedure.
8. The named plaintiffs are jointly represented by the Disabilities Rights Center, Devine Millimet & Branch, the Bazelon Center for Mental Health Law and the Center for Public Representation. Co-counsel have extensive experience in complex litigation and the prosecution of class actions, including class actions on behalf of persons with disabilities. They have the skills and resources to adequately represent the plaintiff class in this case.
9. Because this is a Rule 23 (b)(2) class action, notice to the class is not required. Fed. R. Civ. P. 23(c)(2)(A).
10. Pursuant to Local Rule 7.1(c), the plaintiffs certify that a good faith attempt has been made to obtain concurrence in the relief sought and defendant has responded that they do not assent at this time.
3

Case 1:12-cv-00053-SM Document 19 Filed 03/23/12 Page 4 of 5

WHEREFORE, the plaintiffs respectfully request that, pursuant to Fed. R. Civ. P. 23(c), the

Court certify a class consisting of:

all persons with serious mental illness who are institutionalized at New Hampshire

Hospital or the Glencliff Home or at serious risk of institutionalization in these facilities.

Plaintiffs further request that the Court appoint the Disabilities Rights Center, Devine Millimet &

Branch, the Bazelon Center for Mental Health Law and the Center for Public Representation as co-

counsel for the class pursuant to Fed. R. Civ. P. 23(g). The plaintiffs have filed a Memorandum

in support of this Motion for Class Certification.

Dated: March 23, 2012

Respectfully submitted,

Lynn E., by her guardian, Barry Ellsworth; Kenneth R., by his guardian, Tri-County CAP, Inc./GS; Sharon B., by her guardian, Office of Public Guardian, Inc.; Amanda D., by her guardian, Louise Dube; Amanda E., by her guardian, Office of Public Guardian, Inc.; and Jeffrey D.,

By their attorneys:

Pro Hac Vice admission granted:
Steven Schwartz (MA BBO 448440) Kathryn Rucker (MA BBO 644697) CENTER FOR PUBLIC REPRESENTATION 22 Green Street Northampton, MA 01060 (413) 586-6024 SSchwartz@cpr-ma.org KRucker@cpr-ma.org

DISABILITIES RIGHTS CENTER
By: /s/ Amy B. Messer Amy B. Messer (NH Bar 8815) Adrienne Mallinson (NH Bar 17126) Aaron Ginsberg (NH Bar 18705) 18 Low Avenue Concord NH 03301 amym@drcnh.org adriennem@drcnh.org aarong@drcnh.org

4

Case 1:12-cv-00053-SM Document 19 Filed 03/23/12 Page 5 of 5

Ira Burnim (D.C. Bar 406154) Jennifer Mathis (D.C. Bar 444510) JUDGE DAVID L. BAZELON CENTER FOR MENTAL HEALTH LAW 1101 15th Street, NW, Suite 1212 Washington, D.C. 20005 (202) 467-5730 irab@bazelon.org jenniferm@bazelon.org

DEVINE, MILLIMET & BRANCH PROFESSIONAL ASSOCIATION
By: /s/ _Daniel Will__________ Elaine M. Michaud (NH Bar 10030) Daniel E. Will (NH Bar 12176) Kristen R. Blanchette (NH Bar 19616) Joshua M. Wyatt (NH Bar 18603) 111 Amherst Street Manchester, NH 03101 (603) 669-1000 emichaud@devinemillimet.com dwill@devinemillimet.com kblanchette@devinemillimet.com jwyatt@devinemillimet.com

CERTIFICATE OF SERVICE
I hereby certify that a copy of the foregoing document was filed electronically on this 23rd day of March, 2012 and hand delivered to counsel for defendant, Michael Brown, Esq., Senior Assistant Attorney General, 33 Capitol Street, Concord, NH 03301.
/s/ ___Amy Messer__________________________ March 23, 2012

5

 
 Case 1:12-cv-00053-SM Document 20 Filed 03/27/12 Page 1 of 5

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF NEW HAMPSHIRE

_______________________________________________

LYNN E., by her guardian, Barry Ellsworth;

)

KENNETH R., by his guardian, Tri-County CAP,

)

Inc./GS; SHARON B., by her guardian, Office of

)

Public Guardian, Inc.; AMANDA D., by her guardian, )

Louise Dube; AMANDA E., by her guardian, Office of )

Public Guardian, Inc.; and JEFFREY D., on behalf of )

themselves and all others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

JOHN H. LYNCH, Governor of the State of New

)

Hampshire; NICHOLAS A. TOUMPAS, Commissioner )

New Hampshire Department of Health and Human

)

Services; NANCY L. ROLLINS, Associate

)

Commissioner, New Hampshire Department of Health )

and Human Services, Community Based Care Services; )

MARY ANN COONEY, Deputy Commissioner, New )

Hampshire Department of Health and Human Services, )

Direct Programs/Operations; ERIK G. RIERA,

)

Administrator, New Hampshire Bureau of

)

Behavioral Health,

)

)

Defendants.

)

1:12-CV-53-LM

)

_______________________________________________ ) UNITED STATES’

THE UNITED STATES OF AMERICA,

) ASSENTED-TO

) MOTION TO INTERVENE

Plaintiff-Intervenor,

)

)

v.

)

)

THE STATE OF NEW HAMPSHIRE,

)

)

Defendant.

)

_______________________________________________ )

Case 1:12-cv-00053-SM Document 20 Filed 03/27/12 Page 2 of 5
ASSENTED-TO MOTION TO INTERVENE BY THE UNITED STATES OF AMERICA The United States respectfully requests that this Court grant its intervention as a plaintiff in this action as a matter of right, pursuant to Federal Rule of Civil Procedure 24(a)(2), or, alternatively, through permissive intervention pursuant to Federal Rule of Civil Procedure 24(b). The existing parties have assented to the United States’ intervention in this case. As further grounds in support thereof, the United States states as follows: 1. The United States’ motion to intervene is timely because the litigation is in its early stages. The Plaintiffs just filed their complaint several weeks ago, on February 9, 2012, and the Defendants have yet to file an answer. As a result, the United States’ intervention will not create any delay and it will not prejudice the existing parties. 2. The United States satisfies the requirements for intervention as of right under Fed. R. Civ. P. 24(a)(2). The United States has substantial legal interest in the subject matter of the action because it involves claims asserted under Title II of the Americans with Disabilities Act (“ADA”), 42 U.S.C. §§ 12131-12134, and Section 504 of the Rehabilitation Act of 1973 (“Rehabilitation Act”), 29 U.S.C. § 794. The United States Department of Justice is the federal agency with primary regulatory and enforcement responsibilities under Title II of the ADA, and, as such, plays a unique role in enforcing and interpreting the statute and its implementing regulations on behalf of the broad public interest. It also has significant interest in enforcing the Supreme Court’s decision in Olmstead v. L.C., 527 U.S. 581 (1999), where the Supreme Court held that the unnecessary institutionalization of individuals with disabilities is unlawful discrimination and violates Title II of the ADA and its integration mandate, 28 C.F.R. § 35.130(d).
2

Case 1:12-cv-00053-SM Document 20 Filed 03/27/12 Page 3 of 5
3. Disposition of this action without the United States’ participation may impede its enforcement and regulatory interests. Because there are not many cases interpreting Olmstead, the outcome of this case implicates stare decisis concerns that warrant the United States’ intervention.
4. The United States’ interests are not adequately protected by the existing parties to the litigation. Because the United States represents the public interest on a national scale, its interests differ from those represented by private Plaintiffs.
5. The United States satisfies the requirements for permissive intervention because the United States’ claims against the State of New Hampshire share common questions of law and fact with the claims of the private Plaintiffs and because this action involves the interpretation of statutes that the Attorney General is entrusted by Congress to administer. See Fed. R. Civ. P. 24(b)(2).
6. Pursuant to civil Local Rule 7.1(c), counsel for the United States conferred in good faith with counsel for the parties to see if there was concurrence with regard to the United States intervening in the instant action. Counsel for the Plaintiffs and counsel for the Defendants assented to the United States’ request/motion to intervene.
7. As further support for its motion, the United States respectfully directs the Court to its accompanying memorandum in support, which is attached hereto and incorporated herein by reference.
3

Case 1:12-cv-00053-SM Document 20 Filed 03/27/12 Page 4 of 5

Dated: March 27, 2012
JOHN P. KACAVAS United States Attorney District of New Hampshire
JOHN J. FARLEY Assistant United States Attorney
New Hampshire Bar No. 16934 District of New Hampshire U.S. Attorney’s Office 53 Pleasant Street Concord, NH 03301 (603) 225-1552 John.Farley@usdoj.gov

Respectfully submitted,
THOMAS E. PEREZ Assistant Attorney General
EVE L. HILL Senior Counselor to the Assistant Attorney General
ALISON BARKOFF Special Counsel for Olmstead Enforcement Civil Rights Division
/s/ Richard J. Farano JONATHAN M. SMITH, Section Chief JUDITH C. PRESTON, Deputy Chief RICHARD J. FARANO, Senior Trial Attorney
District of Columbia Bar No. 424225 DEENA S. FOX, Trial Attorney
New York Bar Registration No. 4709655 Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-307-3116 Facsimile: 202-514-0212 richard.farano@usdoj.gov
Counsel for Plaintiff-Intervenor, United States of America

4

Case 1:12-cv-00053-SM Document 20 Filed 03/27/12 Page 5 of 5
CERTIFICATE OF SERVICE I hereby certify that on March 27, 2012, I electronically filed the United States’ Assented-To Motion to Intervene, a Memorandum in Support, and the United States’ proposed Complaint-in-Intervention, with the Clerk of the Court using the CM/ECF system which will automatically send email notification of such filing to the attorneys of record; I also certify that on March 27, 2012, I sent these documents by FedEx and email to counsel for Defendants, Michael Brown, Esq., Senior Assistant Attorney General for the State of New Hampshire, 33 Capitol Street, Concord, NH 03301.
/s/ Richard J. Farano RICHARD J. FARANO, Senior Trial Attorney
District of Columbia Bar No. 424225 Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-307-3116 Facsimile: 202-514-0212 richard.farano@usdoj.gov Counsel for Plaintiff-Intervenor, United States of America
5

 
 Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 1 of 28

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF NEW HAMPSHIRE

_______________________________________________

LYNN E., by her guardian, Barry Ellsworth;

)

KENNETH R., by his guardian, Tri-County CAP,

)

Inc./GS; SHARON B., by her guardian, Office of

)

Public Guardian, Inc.; AMANDA D., by her guardian, )

Louise Dube; AMANDA E., by her guardian, Office of )

Public Guardian, Inc.; and JEFFREY D., on behalf of )

themselves and all others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

JOHN H. LYNCH, Governor of the State of New

)

Hampshire; NICHOLAS A. TOUMPAS, Commissioner )

New Hampshire Department of Health and Human

)

Services; NANCY L. ROLLINS, Associate

)

Commissioner, New Hampshire Department of Health )

and Human Services, Community Based Care Services; )

MARY ANN COONEY, Deputy Commissioner, New )

Hampshire Department of Health and Human Services, )

Direct Programs/Operations; ERIK G. RIERA,

)

Administrator, New Hampshire Bureau of

)

Behavioral Health,

)

)

Defendants.

)

1:12-CV-53-LM

)

_______________________________________________ )

UNITED STATES’

THE UNITED STATES OF AMERICA,

)

COMPLAINT-IN-

)

INTERVENTION

Plaintiff-Intervenor,

)

)

v.

)

)

THE STATE OF NEW HAMPSHIRE,

)

)

Defendant.

)

_______________________________________________ )

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 2 of 28
UNITED STATES’ COMPLAINT-IN-INTERVENTION 1. Because of the manner in which the State of New Hampshire (the “State”) plans,
structures, and administers its mental health service system, scores of people with mental illness in New Hampshire are unjustifiably forced to obtain needed mental health services in segregated residential institutions like the State’s psychiatric hospital, New Hampshire Hospital (“NHH”), and the State’s nursing facility for persons with mental illness, the Glencliff Home (“Glencliff”), and/or are placed at serious risk of institutionalization, even though they could be appropriately served in communitybased settings. The State’s failures have led to the needless and prolonged institutionalization of individuals with disabilities who could be served in more integrated settings in the community with adequate services and supports. 2. The State discriminates against individuals with mental illness by unnecessarily institutionalizing them in segregated, restrictive settings such as NHH and Glencliff, and by creating a serious risk of institutionalization for individuals with mental illness due to the State’s failure to provide them with sufficient community services. As a result, the State is in violation of Title II of the Americans with Disabilities Act of 1990 (“ADA”), 42 U.S.C. §§ 12131-12134, and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794 (“Rehabilitation Act”). 3. Title II of the ADA prohibits the unjustified isolation of persons with disabilities, see 42 U.S.C. § 12132 and Olmstead v. L.C., 527 U.S. 581, 597 (1999), and requires states and other public entities to “administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.” 28
2

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 3 of 28
C.F.R. § 35.130(d); accord 29 U.S.C. § 794(a); 28 C.F.R. § 41.51(d) (Rehabilitation Act). 4. Integrated and appropriate alternatives for persons with mental illness already exist within New Hampshire’s mental health service system. These alternatives include supportive housing and an array of mental health services to support people with mental illness living in the community, including Assertive Community Treatment (“ACT”), mobile crisis services, and supported employment. If administered appropriately, these community-based services would be both cost-effective and capable of meeting the needs of people with mental illness. 5. Nonetheless, because of the manner in which the State has administered its service system, people with mental illness in institutions, and many of those at serious risk of institutionalization, have not been afforded meaningful access to adequate and effective community-based alternatives. Because adequate and effective community-based alternatives are not available in sufficient supply in the State’s system, people with mental illness are often given no choice but to enter an institution to receive needed mental health services from the State, many are forced to be readmitted multiple times, and many remain institutionalized for unnecessarily prolonged periods. 6. Gaps and weaknesses in the State’s mental health system too often subject individuals with mental illness to needless trauma, especially during a crisis. Individuals with mental illness who experience a crisis in New Hampshire often spend days in local hospital emergency rooms that are ill-equipped to address their needs, before ultimately being transported to the State’s psychiatric facility, sometimes by the police. This needlessly traumatic process, rife with delayed treatment and undue restrictions, is
3

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 4 of 28
costly and not therapeutic, especially when compared to proven and effective community alternatives. 7. The State has been candid about the many limitations, shortcomings, and deficiencies in its mental health system. Addressing the Critical Mental Health Needs of NH’s Citizens, A Strategy for Restoration (hereinafter “State Ten-Year Plan”), Aug. 2008; Addressing the Critical Mental Health Needs of NH’s Citizens, A Strategy for Restoration, Report of the Listening Sessions (hereinafter, “State Report”), Apr. 2009. The State has characterized its mental health system as “failing,” “broken,” and “in crisis,” and has recognized that people with mental illness are not receiving the care they need in the system. State Report at 1, 17. The State has concluded that the lack of adequate community capacity in its system is unnecessarily forcing these individuals into institutional settings to obtain needed services for their mental illness, and too often prompting unwanted contact with local law enforcement, hospital emergency rooms, the court system, and county jails. Id. 8. Although the State has drafted a remedial plan to address acknowledged deficiencies in its mental health system, the State has failed to sufficiently implement its plan or to put in place needed reforms to meet the needs of persons with mental illness. See N.H. Cmty. Beh. Health Ass’n (“CBHA”), N.H. Ten-Year Mental Health Plan Progress, Four Years Out, Mar. 5, 2012; and Two Years Out, Sept. 24, 2010 (both reports concluding that the State had failed to implement critical elements of its plan, most notably in the areas of housing and crisis services). 9. On February 9, 2012, six individually-named Plaintiffs filed this class action on behalf of themselves and other individuals with serious mental illness at NHH or Glencliff or
4

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 5 of 28
at serious risk of being institutionalized in these facilities. The suit alleges violations of federal law, including the ADA and the Rehabilitation Act, and seeks declaratory and injunctive relief. 10. Plaintiffs and the members of the plaintiff class, who receive services in, or are at serious risk of entry into an institutional setting, are individuals with mental illness that substantially limits one or more major life activities, such as personal care, working, concentrating, thinking, and/or sleeping. They are, therefore, qualified persons with a disability for the purposes of the ADA and Rehabilitation Act. 11. On April 7, 2011, the United States issued an extensive findings letter to New Hampshire Attorney General Michael A. Delaney, notifying the State that it was failing to comply with federal law by unnecessarily segregating individuals with mental illness in institutional settings and by placing individuals with mental illness living in the community at serious risk of placement into institutional settings. The letter reported in detail the findings of the United States’ investigation, provided the State notice of its failure to comply with the ADA and the Rehabilitation Act, and outlined the steps necessary for the State to meet its obligations pursuant to federal law. 12. The United States’ letter identified numerous remedial measures the State could take to comply with federal law, and further advised the State that, in the event that a resolution could not be reached voluntarily, the Attorney General may initiate a lawsuit pursuant to the ADA. 13. In the latter half of 2011, the United States met with State officials, including the New Hampshire Attorney General, on several occasions, both in person in Concord, New Hampshire, and by telephone, and exchanged several written proposals in an attempt to
5

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 6 of 28
reach agreement on remedial measures to address the deficiencies identified in the United States’ letter. Despite these good faith efforts, the United States has determined that voluntary compliance cannot be reached at this time. Judicial action is, therefore, necessary to remedy the violations of law identified in the United States’ letter and to vindicate the rights of the persons with mental illness in or at serious risk of being admitted to an institutional setting like NHH or Glencliff. 14. On March 27, 2012, the United States filed an assented-to motion to intervene in this case. On April 4, 2012, the Court granted the United States’ motion “for all the reasons outlined in the United States’ memorandum.” Endorsed Order, Apr. 4, 2012 (Doc. 20). Through this intervention, the United States seeks to vindicate the rights of people with mental illness in New Hampshire’s institutions, and those at serious risk of entry into these institutions, to receive services in the most integrated setting appropriate to their needs.
JURISDICTION AND VENUE 15. This Court has jurisdiction of this action under Title II of the ADA, 42 U.S.C. § 12133,
Section 504 of the Rehabilitation Act, 29 U.S.C. § 794a, and 28 U.S.C. §§ 1331, 1345. The Court may grant the relief sought in this action pursuant to 28 U.S.C. §§ 22012202. 16. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b).
PARTIES 17. Plaintiff-Intervenor is the United States of America.
6

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 7 of 28
18. Defendant, State of New Hampshire, is a “public entity” within the meaning of the ADA, 42 U.S.C. § 12131(1), and is therefore subject to Title II of the ADA, 42 U.S.C. § 12131 et seq., and its implementing regulations, 28 C.F.R. pt. 35.
19. At all times relevant to this action, the State of New Hampshire has been a “recipient” of “federal financial assistance,” including Medicaid funds, and is therefore subject to the Rehabilitation Act, 29 U.S.C. § 794.
20. The Plaintiffs bring this action on behalf of “themselves and other individuals with serious mental illness institutionalized at NHH or Glencliff or at serious risk of being institutionalized in these facilities.” Complaint ¶ 25, Feb. 9, 2012.
21. Each individually-named Plaintiff is a qualified individual with a disability, as defined by the ADA and the Rehabilitation Act. Each has one or more impairments that substantially limit one or more major life activities. According to their complaint, Plaintiff Lynn E. has schizophrenia and bipolar disorder with psychosis; Plaintiff Kenneth R. has depression and a mood disorder, a brain injury from a motor vehicle accident, and paraplegia; Plaintiff Sharon B. has a schizoaffective disorder, bipolar type, and post-traumatic stress disorder; Plaintiff Amanda D. has bipolar disorder, posttraumatic stress disorder, and borderline personality disorder; Amanda E. has schizoaffective disorder, post-traumatic disorder, and borderline personality disorder; and Plaintiff Jeffrey D. has bi-polar disorder with psychosis. These individuals bring their action on behalf of themselves and other qualified individuals with a disability.
7

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 8 of 28
STATUTORY AND REGULATORY BACKGROUND A. The Americans with Disabilities Act and the Rehabilitation Act 22. 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)(1). It found that “historically, society has tended to isolate and segregate individuals with disabilities, and, despite some improvements, such forms of discrimination against individuals with disabilities continue to be a serious and pervasive social problem.” 42 U.S.C. § 12101(a)(2). 23. For those reasons, Congress prohibited discrimination against 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. 24. Title II of the ADA prohibits discrimination on the basis of disability by public entities. This encompasses the State of New Hampshire, its agencies, and its mental health system, because a “public entity” includes any state or local government, as well as any department, agency, or other instrumentality of a state or local government, and it applies to all services, programs, and activities provided or made available by public entities, such as through contractual, licensing, or other arrangements. 42 U.S.C. § 12131(1). 25. Congress directed the Attorney General to issue regulations implementing Title II of the ADA. 42 U.S.C. § 12134. The Title II regulations require public entities to “administer services, programs, and activities in the most integrated setting appropriate
8

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 9 of 28
to the needs of qualified individuals with disabilities.” 28 C.F.R. § 35.130(d). The preamble discussion of this “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.F.R. pt. 35, App. B at 673 (2011). 26. Regulations implementing Title II of the ADA further prohibit public entities from utilizing “criteria or methods of administration” that have the effect of subjecting qualified individuals with disabilities to discrimination or “[t]hat have the purpose or effect of defeating or substantially impairing accomplishment of the objectives of the public entity’s program with respect to individuals with disabilities[.]” 28 C.F.R. § 35.130(b)(3); accord 45 C.F.R. § 84.4(b)(4) (Rehabilitation Act). 27. In Olmstead v. L.C., 527 U.S. 581, 597 (1999), the Supreme Court held that Title II prohibits the unjustified segregation of individuals with disabilities. The Court explained that its holding “reflects two evident judgments.” Id. at 600. “First, 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. “Second, 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. 28. Under Olmstead, public entities are required to provide community-based services when (a) such services are appropriate, (b) the affected persons do not oppose community-based treatment, and (c) community-based services can be reasonably
9

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 10 of 28
accommodated, taking into account the resources available to the entity and the needs of other persons with disabilities. Id. at 607. 29. Discrimination on the basis of disability is also prohibited by Section 504 of the Rehabilitation Act, 29 U.S.C. § 794(a):
No otherwise qualified individual with a disability in the United States … shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance or under any program or activity[.] 30. The Rehabilitation Act’s implementing regulations provide that recipients of federal funds “shall administer programs and activities in the most integrated setting appropriate to the needs of qualified handicapped persons.” 28 C.F.R. § 41.51(d); see also 45 C.F.R. § 84.4. 31. Similarly, New Hampshire has numerous statutes and regulations that strongly favor integrated community services and supports. See the “Mental Health Services System” law, N.H. RSA 135-C, making it the policy of the State to provide mental health care that is within each person’s own community, is directed to promoting independence, and is the “[l]east restrictive to” the person’s freedom and participation in the community. N.H. RSA 135-C:1, 15. Regulations implementing the statute require that services must “promote community integration and participation.” He-M 401.10. Other regulations mandate that Community Mental Health Centers (“CMHCs”), the entities with which the State contracts to provide most community services, “strive to provide all services … in each consumer’s own community, and in a manner which promotes the personal self-sufficiency, dignity and maximum community participation of each consumer,” He-M 403.06, and that individuals receiving mental health services
10

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 11 of 28
have a right to services that promote full participation in community living. He-M 309.06; He-M 311.06. B. The Nursing Home Reform Amendments to the Medicaid Act 32. The federal Nursing Home Reform Act requires that states develop and implement a Preadmission Screening and Resident Review (“PASRR”) program for all Medicaidcertified nursing facilities. 42 U.S.C. § 1396r(e)(7); 42 C.F.R. §§ 483.100 to 483.138. 33. Pursuant to PASRR, the State must identify all individuals seeking admission to a nursing facility who are suspected of having mental illness; this is known as a Level I PASRR review. 42 C.F.R. § 483.128(a). Then the State must assess these persons to determine, inter alia, whether the “individual’s total needs are such that his or her needs can be met in an appropriate community setting” (42 C.F.R. § 483.132(a)(1)), and “[i]f specialized services are recommended, [the evaluation must] identif[y] the specific … mental health services required to meet the evaluated individual’s needs[.]” 42 C.F.R. § 483.128(i)(5); see also 42 C.F.R. § 483.134. This evaluation is referred to as the Level II PASRR review. 42 C.F.R. § 483.128(a). 34. For individuals with mental illness in nursing facilities, “specialized services” means the services specified by the state which, combined with services provided by the nursing facility, results in the “continuous and aggressive implementation” of an individualized plan of care that is developed and supervised by an interdisciplinary team, and which, among other things, is “directed toward diagnosing and reducing the resident’s behavioral symptoms that necessitated institutionalization, improving his or her level of independent functioning, and achieving a functioning level that permits
11

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 12 of 28
reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time.” See 42 C.F.R. § 483.120(a)(1). 35. If an individual in a nursing facility requires specialized services, then “[t]he State must provide or arrange for the provision of the specialized services needed by the individual while he or she resides in the [nursing facility].” 42 C.F.R. § 483.116(b)(2); see also 42 C.F.R. § 483.126. 36. The nursing facility must provide mental health services which are of a lesser intensity than specialized services to all residents who need such services. 42 C.F.R. § 483.120(c).
FACTUAL ALLEGATIONS A. New Hampshire’s Mental Health System 37. New Hampshire has a mental health service system through which it delivers services,
programs, and activities (hereinafter, “services”) to persons with mental illness. The State determines what mental health services to provide, who will provide them, in what settings to provide them, and how to allocate funds among various services and settings. 38. The New Hampshire Department of Health and Human Services (“DHHS”) is the State agency responsible for providing and administering mental health services for persons with mental illness, including setting strategic goals and determining how state, local, and federal resources will be deployed. The Commissioner of DHHS is responsible for the overall management of DHHS, which includes setting mental health policy for DHHS, overseeing the implementation of services for persons with mental illness, and providing the leadership and direction necessary to ensure the design and delivery of a
12

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 13 of 28
comprehensive and coordinated system of mental health services. Within DHHS, the Division of Community Based Services (“DCBS”) manages the State’s mental health system. Also within DHHS, the State’s Office of Medicaid Business and Policy is responsible for the management of the State’s Medicaid program, which includes coverage of mental health, developmental disabilities, substance abuse, and other services to Medicaid-eligible individuals in institutional and other settings. DHHS is the single state Medicaid agency. 39. As part of its mental health system, New Hampshire, through DHHS, delivers publiclysubsidized inpatient psychiatric and other mental health services in institutional settings – at NHH and at Glencliff. 40. NHH is a State-operated psychiatric facility. NHH provides acute treatment services for persons with severe mental illness. The State operates NHH under the administrative management of DCBS. 41. Glencliff is a State-operated Medicaid-certified nursing facility that provides long-term care for persons with severe mental illness and/or developmental disabilities. The State operates Glencliff directly through DHHS. 42. Both NHH and Glencliff are segregated, institutional settings. Physically, both NHH and Glencliff are isolated from the general community. They provide little opportunity for individuals with disabilities to interact with individuals without disabilities outside the institution. Institutionalized individuals live in close quarters, primarily with other persons with disabilities. Most aspects of their daily lives are regimented and limited by rigid rules and inflexible practices which segregate individuals from the community and impede interactions with people without disabilities. These rules and practices
13

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 14 of 28
include rights restrictions, involuntary searches, imposed quiet times, structured meal and medication times, limits on the ability to have visitors, and limits on travel outside the facilities. As a result, most aspects of their daily lives are controlled by the institutions, and they have limited autonomy, privacy, or meaningful opportunities to participate in the community. 43. Within DCBS, its Bureau of Behavioral Health (“BBH”) is responsible for planning, coordinating services, allocating public funds, contracting, enforcing policies and regulations, and monitoring New Hampshire’s system of public mental health services. BBH is the State Mental Health Authority, obligated to ensure the provision of effective services to persons with severe mental, emotional, and behavioral impairments. 44. The State offers some community mental health support and residential services. BBH has designated ten community mental health regions throughout New Hampshire. BBH contracts with a CMHC to provide mental health services in each of the ten geographic regions. The CMHC’s are to offer a variety of mental health programs, including psychiatric services, individual and group therapy, symptom management, as well as more intensive services, such as ACT. Residential services include supportive housing and group homes. 45. BBH maintains responsibility for the services offered in the community through its provider network. BBH conducts various reviews of CMHC operations and requires financial and performance reporting. BBH also approves community service programs for each CMHC, provides staff training, and details what services are to be provided,
14

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 15 of 28
how clinical records are to be maintained, and oversees other aspects of CMHC operations. B. Individuals with Mental Illness Residing in NHH or Glencliff Are Qualified to
Receive Services in More Integrated Settings 46. Upon information and belief, the vast majority of persons with mental illness who are
or become institutionalized at NHH or Glencliff, including the individually-named Plaintiffs and the members of the proposed plaintiff class, are qualified to receive mental health services, and can be served, in more integrated community settings. 47. People who are or become institutionalized at NHH or Glencliff are similar to people with mental illness who receive services in the community. They have similar diagnoses and needs as people who live successfully in more independent settings, with the types of supports and services that currently exist in the State’s community mental health system. 48. The State already offers an array of community-based services to individuals with mental illness, including supportive housing, crisis services, ACT, and supported employment which, if expanded to meet the needs of the plaintiff class, would enable them to live in the community. 49. Numerous individuals have expressed their desire to leave NHH or Glencliff and become members of their communities once again. Upon information and belief, persons with mental illness in NHH and Glencliff would not oppose moving to integrated settings if appropriate community services were available and they had a fully-informed choice and a realistic opportunity to do so.
15

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 16 of 28
C. The State Discriminates Against Qualified Individuals with Mental Illness by Unnecessarily Institutionalizing Them in Segregated, Restrictive Settings
50. New Hampshire unnecessarily segregates qualified individuals with mental illness in institutions and/or places them at serious risk of institutionalization. The State’s planning, structuring, and funding of its system of mental health care has isolated qualified persons with mental illness, including individually-named Plaintiffs and members of the proposed plaintiff class, and has unnecessarily forced them to obtain needed mental health services in institutional settings like NHH and Glencliff, even though they could be appropriately served in more integrated community-based settings. Systemic failures in the State’s system place certain other qualified individuals with disabilities, including individually-named Plaintiffs and members of the proposed plaintiff class, at serious risk of unnecessary institutionalization now and going forward.
51. The State of New Hampshire has recognized that its mental health system is failing, broken, and in crisis. In a public State report, the Commissioner of DHHS concluded: “NH’s mental health system is failing, and the consequence of these failures is being realized across the community. The impacts of the broken system are seen in the stress it is putting on local law enforcement, hospital emergency rooms, the court system and county jails, and, most importantly, in the harm under-treated mental health conditions cause NH citizens and their families.” State Report at 1.
52. Community capacity in New Hampshire has declined in recent years, and this has led to unnecessary institutionalization, unnecessarily prolonged institutionalization, and a heightened risk of institutionalization. Although the State offers an array of community-based services, scores of qualified individuals with mental illness in the
16

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 17 of 28
community are at serious risk of being institutionalized because needed mental health services are in insufficient supply in the State’s community system. 53. The State has acknowledged that some people with mental illness “are not receiving the care that they need.” Id. at 2. The State has concluded that, in recent years, “[a]s community capacity to serve more people declined, access to critical services became more difficult to get. More individuals found themselves in a system that could no longer meet their needs, some ending up in settings not designed to provide mental health care, such as the state corrections system and county jails.” Id. at 17. 54. The State has recognized that it has not been spending its money on services for persons with mental illness effectively, and that this has had a negative impact on community services and on the health and welfare of persons with mental illness in need of such services. Id. at 8. 55. In 2008, the State developed and publicized a ten-year plan purportedly to resolve the plainly-evident deficiencies in its mental health system. The State recognized the need to expand existing community capacity to meet outstanding needs in areas including, but not limited to: supportive housing, bridge subsidies for community housing, crisis services, ACT, and more intensive services and supports for persons with more complex health and/or mental health needs. State Ten-Year Plan at 9-15. 56. In spite of this, the State has thus far taken insufficient measures to implement its plan, especially in foundational bedrock areas needed to promote and achieve positive outcomes for persons with mental illness who are in need of residential, crisis, and other key community services.
17

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 18 of 28
57. In September of 2010, at about the two-year anniversary of the State’s publication of its plan, the New Hampshire Community Behavioral Health Association, the association of the State’s CMHC community contractors, issued a report on whether the State had met deadlines and accomplished what had been set forth in the plan. The CBHA concluded that the State had taken little or no action in a host of important areas. CBHA Progress Rep., Sept. 24, 2010, at 2-3. The CBHA very recently issued an updated report, once again finding that the State had failed to meet important benchmarks within its ten-year plan, including in such areas as supportive housing, crisis services, intensive services like ACT, and services for persons with developmental disabilities. CBHA Progress Rep., Mar. 5, 2012, at 1-2. In separate correspondence, the CBHA recently informed a fellow federal agency that the situation in New Hampshire has deteriorated in recent years: “We regret to inform you that our community system has less capacity in January of 2012 than it had in August of 2008 when the “Ten-Year Plan” called for additional investment.” Letter from Roland P. Lamy, Exec. Dir., CBHA, to Kathleen Sebelius, Sec’y, U.S. Dep’t of Health & Human Svcs., Feb. 29, 2012, at 1.
58. With reasonable modifications, the types of services that already exist in New Hampshire’s community mental health system would be able to meet the needs of people with mental illness in institutions or at serious risk of being institutionalized. These services include but are not limited to, supportive housing, crisis services, ACT, integrated supported employment, and other intensive community supports.
59. Supportive housing is a program that is designed to meet the needs of persons with mental illness in the community. The State has acknowledged that supportive housing
18

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 19 of 28
is an effective service for persons with serious mental illness and achieves positive outcomes in terms of housing and health stability and improvement in quality of life for persons with mental illness. State Ten-Year Plan at 3, 8-9. In the alternative, the State has recognized that “[u]nstable housing and homelessness leads to greater levels of impairment, more difficulty in accessing services and supports, and a loss of stability, which leads to hospitalization or in some cases incarceration and then difficulties with discharge from the hospital or other institutional settings.” Id. at 6. 60. Nonetheless, there is an insufficient amount of safe, affordable, and stable community housing, including supportive housing, for persons with mental illness in New Hampshire. The State has recognized that sufficient supportive housing is not available to meet the needs of persons with mental illness in New Hampshire, concluding that formal supportive housing “is not available to most NH residents with a mental illness disability,” in part, because “home-based services need to be further developed to meet the current need.” Id. at 8. 61. There are insufficient crisis, intensive, and other services and supports in the State’s community system, which cause unnecessary institutionalization and increase the risk of unnecessary institutionalization. The State has acknowledged that “care in the middle and at the higher intensity end of the spectrum of treatment … is not easily available to many individuals with severe mental illness, resulting in an overburden on [NHH] and poor outcomes for individuals who are unable to access sufficient treatment choices to remain in the community or to be discharged from the hospital when ready.” Id. at 4.
19

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 20 of 28
62. The State recognizes, and has seen first-hand, the benefits of intensive/crisis services like ACT in terms of promoting positive outcomes among persons with mental illness. Id. at 13. The State has concluded that ACT “has been shown to be effective at helping individuals with serious mental illness manage their illnesses while living independently in the community. When applied to homeless individuals with serious mental illness, ACT reduces homelessness. … When applied to individuals with frequent hospitalizations, ACT reduces their hospital use and enhances their ability to maintain employment and personal satisfaction.” Id.
63. In spite of this, the State has no ACT program in at least half of its ten geographic regions statewide, leaving thousands of persons in need without the ability to even access ACT. Not only does the State recognize that ACT can produce positive outcomes, it acknowledges that ACT is “cost-effective,” especially for frequentlyinstitutionalized individuals. Id. at 14.
64. In recent years, hundreds of persons with mental illness have been admitted or readmitted to NHH each year to address acute symptoms and/or crisis situations that could have been, but were not, addressed satisfactorily outside the confines of an institutional setting. Many individuals cycle through NHH because community capacity in the State’s system is not adequate. Admission and readmission rates to NHH are high and reveal that there are inadequacies in the State’s system that force people with mental illness to obtain needed services at an institutional facility, even though these services generally could be provided effectively and cost-effectively in integrated community settings. The State reported that the “primary finding” of its plan taskforce was that many individuals have been admitted to NHH because they have not
20

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 21 of 28
been able to access sufficient community services in a timely manner (a “front door problem”), and remain there, unable to be discharged, because of a lack of viable community-based alternatives (a “back door problem”). Id. at 6. 65. Individuals with mental illness are often admitted to Glencliff without being appropriately assessed for whether they can be served in the community. The State’s PASRR program also does not adequately or appropriately assess whether an individual with mental illness needs specialized services. Moreover, the State fails to provide necessary specialized services at Glencliff. The failure of the State’s PASRR program results in the unnecessary institutionalization of persons with mental illness. 66. Individuals at NHH and Glencliff are relegated to unnecessarily prolonged stays because discharge and transition planning and implementation efforts are insufficient and because housing and other critical services and supports are available in too limited supply in the community. Many individuals admitted to NHH and Glencliff, especially those with more complex physical and/or mental health needs, remain there longer than necessary simply because community-based alternatives with adequate and appropriate intensive services and supports are not available in sufficient supply in the community. The State has acknowledged that, once admitted to NHH, almost a third of the individuals remain “longer than necessary.” Id. at 6. The State has recognized that some individuals with complex mental health issues have lived at NHH for “prolonged periods of time” because adequate community housing and treatment alternatives are “not available.” Id. The State has concluded that the “scarcity of high intensity community resources, including supervised residences and intensive community treatment” is one of several “barriers to discharge.” Id. At Glencliff, the average
21

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 22 of 28
length of stay is measured not in days or weeks, but in years, with some individuals having been at Glencliff for decades. In recent years, only a handful of individuals have been discharged to integrated community settings; in fact, more individuals have died at Glencliff than have been placed into community settings in any given year. 67. The State’s failure to develop sufficient community capacity and services is a barrier to the discharge of individuals from NHH and Glencliff who could be served in more integrated community settings with adequate and appropriate services and supports. 68. Individuals with mental illness and a dual diagnosis of a developmental disability or an acquired brain disorder have remained unnecessarily institutionalized, often for prolonged periods, in the State’s mental health system because of a lack of community alternatives with proper supports. Id. at 14-15. The State has acknowledged that about half of the persons with developmental disabilities at NHH remained there “longer than required” to provide acute evaluation and stabilization of their presenting psychiatric symptoms.” Id. at 14. C. The State Can Provide Services in Integrated Settings By Reasonably Modifying
its Mental Health Services System 69. The State can provide services in integrated community settings to institutionalized
persons with mental illness and to persons with mental illness at serious risk of entry to an institution through reasonable modifications to its mental health services system. 70. The types of services needed to support people with mental illness in community-based settings already exist in New Hampshire’s community-based mental health service system, including but not limited to ACT teams, case management services, peer support services, supported employment services, psychosocial rehabilitation services, and crisis services. However, none of the services are provided in sufficient supply and
22

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 23 of 28
geographic location to meet the needs of persons who are unnecessarily institutionalized. Supportive housing also exists in the State’s mental health system, but on a scale that is inadequate to meet the needs of persons who are unnecessarily institutionalized. 71. Much of the remedial action needed in New Hampshire could be achieved through redirection of resources. The State could redirect the ample funds it currently spends on services in institutions and use them to better support persons with mental illness in more integrated community settings. 72. In spite of a challenging fiscal environment, the State has continued to fund costly institutional care at NHH and Glencliff, even though cost-effective and therapeutic alternatives could be developed in integrated community settings. Total expenditures for operations at NHH have risen steadily in recent years. It cost nearly ten million dollars more to run NHH in FY 2010 than it did in FY 2006. Virtually all of these costs are paid for with State-only dollars, as the federal government does not provide Medicaid matching funds for most services provided in psychiatric hospitals. State fund expenditures for operations at Glencliff have also risen steadily in recent years, rising about two million dollars from FY 2006 to FY 2010.
COUNT I VIOLATION OF TITLE II OF THE AMERICANS WITH DISABILITIES ACT
42 U.S.C. §§ 12131 et seq. 73. The allegations of Paragraphs 1 through 72 of this Complaint-in-Intervention are
hereby realleged and incorporated by reference.
23

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 24 of 28
74. Defendant, State of New Hampshire, is considered a public entity subject to Title II of the ADA, 42 U.S.C. § 12131(1).
75. Plaintiffs and the members of the proposed plaintiff class are persons with a disability covered by Title II of the ADA, and they are qualified to receive mental health services, programs, or activities from defendants. 42 U.S.C. §§ 12102, 12131(2).
76. Defendants violate the ADA by administering the State’s mental health service system in a manner that denies qualified individuals with a disability the benefits of the State’s mental health services, programs, or activities in the most integrated setting appropriate to their needs and by failing to reasonably modify the State’s mental health services system to avoid discrimination against, and unnecessary segregation of, plaintiffs. 42 U.S.C. § 12132.
77. The State’s actions constitute discrimination in violation of Title II of the ADA, 42 U.S.C. § 12132, and its implementing regulations at 28 C.F.R. pt. 35. COUNT II VIOLATION OF SECTION 504 OF THE REHABILITATION ACT 29 U.S.C. § 794
78. The allegations of Paragraphs 1 through 72 of this Complaint-in-Intervention are hereby realleged and incorporated by reference.
79. The State of New Hampshire, as a recipient of federal financial assistance, is subject to the Rehabilitation Act. 29 U.S.C. § 794.
80. Plaintiffs and the members of the proposed plaintiff class are persons with a disability covered by the Rehabilitation Act and they are qualified to receive mental health services, programs, or activities from the State.
24

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 25 of 28
81. The State violates the Rehabilitation Act by discriminating against qualified individuals with a disability within the meaning of the Rehabilitation Act by administering mental health programs and activities receiving federal financial assistance in a manner that denies these individuals the benefits of such programs or activities in the most integrated setting appropriate to their needs and by failing to reasonably modify the State’s mental health services system to avoid discrimination against, and unnecessary segregation of, plaintiffs. 29 U.S.C. § 794(a).
82. The State’s actions constitute discrimination in violation of Section 504 of the Rehabilitation Act, 29 U.S.C. § 794, and its implementing regulations at 28 C.F.R. § 41.51(d); see also 45 C.F.R. § 84.4.
PRAYER FOR RELIEF WHEREFORE, the United States of America prays that the Court: A. Grant judgment in favor of the United States on its Complaint-in-Intervention and declare that the Defendant has violated Title II of the ADA, 42 U.S.C. §§ 12131 et seq., and Section 504 of the Rehabilitation Act, 29 U.S.C. § 794; B. Enjoin Defendant from: 1. failing to provide appropriate, integrated community services, programs, or activities
for Plaintiffs and the members of the plaintiff class, consistent with their individual needs; 2. discriminating against Plaintiffs and the members of the plaintiff class by failing to provide services, programs or activities in the most integrated setting appropriate to their needs; C. Issue a declaratory judgment declaring that:
25

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 26 of 28
1. Defendant has violated Title II of the ADA and Section 504 of the Rehabilitation Act by failing to make reasonable modifications to services, programs, or activities for persons with mental illness to enable Plaintiffs and the members of the plaintiff class to obtain the services, programs, and activities they require to reside in the most integrated setting appropriate to their needs; and
D. Order such other appropriate relief as the interests of justice may require. / / / / / / / / / / /
26

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 27 of 28

Dated: April 4, 2012

Respectfully submitted,

JOHN P. KACAVAS United States Attorney District of New Hampshire
JOHN J. FARLEY Assistant United States Attorney
New Hampshire Bar No. 16934 District of New Hampshire U.S. Attorney’s Office 53 Pleasant Street Concord, NH 03301 (603) 225-1552 John.Farley@usdoj.gov

/s/ Thomas E. Perez THOMAS E. PEREZ Assistant Attorney General
EVE L. HILL Senior Counselor to the Assistant Attorney General
ALISON BARKOFF Special Counsel for Olmstead Enforcement Civil Rights Division
/s/ Richard J. Farano JONATHAN M. SMITH, Section Chief JUDITH C. PRESTON, Deputy Chief RICHARD J. FARANO, Senior Trial Attorney
District of Columbia Bar No. 424225 DEENA S. FOX, Trial Attorney
New York Bar Registration No. 4709655 Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-307-3116 Facsimile: 202-514-0212 richard.farano@usdoj.gov
Counsel for Plaintiff-Intervenor, United States of America

27

Case 1:12-cv-00053-SM Document 21 Filed 04/04/12 Page 28 of 28
CERTIFICATE OF SERVICE I hereby certify that on April 4, 2012, I electronically filed the United States’ Complaintin-Intervention with the Clerk of the Court using the CM/ECF system which will automatically send email notification of such filing to the attorneys of record. I also certify that on April 4, 2012, I sent the Complaint-in-Intervention, along with a completed Notice of a Lawsuit and Request to Waive Service of a Summons form (AO 398), and two copies of the accompanying Waiver of the Service of Summons form (AO 399), by FedEx and email to counsel for Defendants, Michael Brown, Esq., Senior Assistant Attorney General for the State of New Hampshire, 33 Capitol Street, Concord, NH 03301. I included in the FedEx shipment a stamped, self-addressed envelope for returning one signed copy of the Waiver form.
/s/ Richard J. Farano RICHARD J. FARANO, Senior Trial Attorney
District of Columbia Bar No. 424225 Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-307-3116 Facsimile: 202-514-0212 richard.farano@usdoj.gov Counsel for Plaintiff-Intervenor, United States of America
28

 
 Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 1 of 9

UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSIRE

Lynn E., et al.

)

others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

Margaret W. Hassan, Governor, et al.

)

)

Defendants.

)

____________________________________)

The United States of America

)

)

Plaintiff-Intervenor

)

)

v.

)

)

The State of New Hampshire

)

)

Defendant

)

____________________________________)

Civ. No. 1:12-cv-53-SM

PLAINTIFFS’  RENEWED MOTION FOR CLASS CERTIFICATION

Plaintiffs Lynn E., Kenneth R., Sharon B., Amanda D., Amanda E., and Jeff D.

(collectively  the  “named  plaintiffs”),  respectfully   move this Court to certify the above-captioned

case as a class action pursuant to Fed. R. Civ. P. 23(a) and 23(b)(2). In support of their renewed

motion the plaintiffs state as follows:

1. The named plaintiffs are adults with serious mental illness who currently are

institutionalized at New Hampshire Hospital (NHH) or the Glencliff Home (Glencliff) or at serious

risk of institutionalization in these facilities. They bring the instant class action on behalf of

themselves and at least several hundred similarly situated individuals.

1

Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 2 of 9
2. This case seeks to end the suffering and harm experienced by the named plaintiffs and plaintiff class members by providing integrated, community services to avoid their needless institutionalization.
3. The Complaint requests that the Court certify a class comprised of: all persons with serious mental illness who are institutionalized at New Hampshire Hospital or the Glencliff Home or at serious risk of institutionalization in these facilities.
4. The named plaintiffs, and the class they seek to represent, all have disabilities that substantially limit major life activities and require ongoing services and support. They are qualified to receive mental health services in integrated community settings, yet New Hampshire (the  “State”)  has failed to provide the community services they need to avoid their unnecessary institutionalization.
5. In order to remedy these systemic legal violations, the named plaintiffs and the plaintiff class seek declaratory and injunctive relief under Title II of the Americans with Disabilities Act (ADA) 42 U.S.C. §§ 12101 et seq., Section 504 of the Rehabilitation Act, 29 U.S.C. §§794 et seq., and the Nursing Home Reform Amendments (NHRA) to the Medicaid Act, 42 U.S.C. §§1396 et seq., and an order directing the State to provide the community services required  to  avoid  class  members’  needless  institutionalization,  including  mobile  crisis,  Assertive   Community Treatment (ACT), supportive housing, and supported employment.
6. On March 23, 2012, the plaintiffs filed their Motion and Memorandum in Support of Class Certification (Doc. 19), together with seven exhibits that described key aspects of the New Hampshire mental health system, the numbers of persons institutionalized in NHH and Glencliff, and a Findings Letter from the Department of Justice which determined that the defendants were
2

Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 3 of 9
operating their service system in a discriminatory manner by unnecessarily institutionalizing persons with serious mental illness at NHH and Glencliff.
7. Subsequently, the Court received multiple briefs regarding the appropriateness and timing of class certification, including Defendants’ Objection (Doc. 25) and Motion to Strike Class Certification (Doc. 24), Plaintiffs’ Reply to Defendants’ Motion to Strike (Doc. 36), Defendants’   Reply to Plaintiffs’ Objection to Motion to Strike (Doc. 48-1), and the   Department   of   Justice’s   Statement of Interest in Support of Class Certification (Doc. 33).
8. On June 11, 2012, the Court denied the plaintiffs’   motion   without   prejudice, ordering class-based discovery and granting leave to file a renewed motion for class certification.
9. Consistent with the court-approved scheduling order, the plaintiffs now file their Renewed Motion for Class Certification. In addition to the original exhibits 1-7, attached hereto, the plaintiffs now file in conjunction with this Renewed Motion five affidavits from mental health professionals, as well as supporting facts and documentation further evidencing that the proposed class satisfies the numerosity, commonality, typicality and adequacy of representation requirements of Rule 23(a) of the Federal Rules of Civil Procedure.
10. These professionals conducted a client review based upon a random sample of class members admitted to NHH or Glencliff, and the six named plaintiffs in this case. See Exhibits 9-11. As described in the attached affidavits, virtually all of the 47 sample participants: 1) very likely experienced avoidable institutionalization; 2) very likely would have spent less time institutionalized or could be discharged to the community with a combination of remedial and existing services; and 3) very likely would choose community living if appropriate services were available.
3

Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 4 of 9
11. A former mental health director and commissioner in New Hampshire and Massachusetts also conducted a systems review of the community mental health services operated, administered, and funded by the defendants. See Exhibit 13. As described in her affidavit, glaring deficiencies in that system, and specifically the lack of particular community services result in the needless institutionalization of hundreds, if not thousands, of individuals with serious mental illness to NHH and Glencliff. These deficiencies have been repeatedly acknowledged by the defendants, and are commonly identified by various stakeholders including class members, families, mental health professionals, providers and university experts.
12. Together these findings demonstrate that the proposed class is sufficiently numerous to satisfy standards for Rule 23(a)(1). The fluidity of the class, and the presence of future unidentified class members, are further evidenced by findings regarding review participants at serious risk of institutionalization. The size and nature of the proposed class, the isolation and disability experienced by class members, and their location across the state all make joinder in this case impractical, if not impossible.
13. Whether currently institutionalized in NHH or Glencliff, or at serious risk of institutionalization in these facilities, the plaintiff class is suffering as a result of a common course of conduct by the defendants, from which arises a set of common claims and contentions satisfying Rule 23(a)(2). The plaintiff class has established commonality precisely because they identify both a common contention -- that existing community mental health services are insufficient to avoid unnecessary institutionalization -- as well as a common injury -- discriminatory segregation.
14. There are multiple questions of law common to the class, all of which admit of a common answer that would resolve the claims  of  the  plaintiff  class  “in  a  single stroke”  including:    
4

Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 5 of 9
(a) Whether defendants are violating the ADA and Section 504 of the Rehabilitation Act by failing to provide community mental health services needed to avoid unnecessary institutionalization at NHH and Glencliff; (b) Whether defendants are violating the ADA and Section 504 of the Rehabilitation Act by administering their mental health system in a way that discriminates against the plaintiff class; (c) Whether defendants are violating the ADA and Section 504 of the Rehabilitation Act by failing to serve plaintiffs and the plaintiff class in the most integrated setting appropriate to their needs; (d) Whether the defendants have developed a comprehensive and effectively working plan for serving plaintiffs and the plaintiff class in the community instead of institutional settings; and (e) Whether the defendants are violating PASRR provisions of the Nursing Home Reform Act by failing to properly determine whether individuals referred to Glencliff could be served in more integrated settings. 15. Similarly, there are multiple factual contentions common to the class and that admit of a common answer  which  would  resolve  all  of  the  claims  of  the  class  “in  a  single  stroke”   including: (a) The defendants’  policies, procedures and practices concerning the administration and funding of their community services system deny the plaintiff class the opportunity to receive services in the most integrated setting. Specifically, the defendants fail to provide an adequate array of community services to accommodate the needs of persons
5

Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 6 of 9
with serious mental illness institutionalized in NHH or Glencliff, or at serious risk of such institutionalization; (b) As a result of the defendants’  policies,  procedures and practices that deny persons with serious mental illness professional assessments for, reasonable access to, and a sufficient amount of community services, the members of the plaintiff class are unnecessarily segregated in institutions; (c) The defendants fail to administer their community service system for persons with serious mental illness in a manner that accommodates the needs of members of the plaintiff class, and (d) The defendants fail to develop and implement a PASRR program that timely and appropriately assesses whether the needs of persons with serious mental illness seeking admission to Glencliff could be met in a more integrated, community-based setting. 16) As demonstrated  by  the  plaintiffs’  client  and  system  reviews,  defendants’ actions and   inactions   are   the   common   cause   of   class   members’   injuries, constitute the basis for their common legal claims, and therefore present a common contention capable of class wide resolution. 17. The named plaintiffs are typical of the plaintiff class and have a personal interest in this litigation. They are aggrieved by the same limitations in the community mental health service system, and raise claims based on the same legal theories regarding the discriminatory administration of the state mental health system. The plaintiffs seek the same relief as the class, which is reasonably related to the harm experienced by all class members. 18. Class-based discovery further illustrates how the interests of the named plaintiffs and those of the plaintiff class coincide – with both seeking to avoid unnecessary institutionalization and
6

Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 7 of 9
to receive services in the community. There are no meaningful differences among the plaintiff class on   these   fundamental   issues.      The   named   plaintiffs’   ability   and   intent   to   vindicate   the   legal   rights   shared by the proposed class make them adequate representatives pursuant to Rule 23(a)(4).
19. The defendants have administered the State mental health system in a way that discriminates against persons with serious mental illness by failing to provide the community-based services required to avoid their unnecessary institutionalization. As described in Exhibit 13, the plaintiffs’  system review provides further evidence of the inadequacy of existing community mental health services, especially when compared to the level of unmet need among the proposed class. The defendants’ policies, practices and operation of its mental health system impact the plaintiff class in a similar manner by denying them the opportunity to live in the community. These findings demonstrate that the defendants have acted or refused to act on grounds generally applicable to the class, making injunctive and declaratory relief appropriate. An injunction requiring the defendants to develop community-based  services  sufficient  to  avoid  class  members’  unnecessary   institutionalization is capable of redressing these legal violations and would benefit the class as a whole. As a result, the proposed class satisfies the standards of Rule 23(b)(2) of the Federal Rules of Civil Procedure.
20. The named plaintiffs are jointly represented by the Disabilities Rights Center, Devine Millimet & Branch, the Bazelon Center for Mental Health Law and the Center for Public Representation. Co-counsel have extensive experience in complex litigation and the prosecution of class actions, including class actions on behalf of persons with disabilities. They have the skills and resources to adequately represent the plaintiff class in this case.
21. Because this is a Rule 23 (b)(2) class action, notice to the class is not required. Fed. R. Civ. P. 23(c)(2)(A).
7

Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 8 of 9

22. Pursuant to Local Rule 7.1(c), the plaintiffs certify that a good faith attempt has been made to obtain concurrence in the relief sought and defendant has responded that they do not assent at this time.

WHEREFORE, the plaintiffs respectfully request that, pursuant to Fed. R. Civ. P. 23(c), the

Court certify a class consisting of:

all persons with serious mental illness who are institutionalized at New Hampshire

Hospital or the Glencliff Home or at serious risk of institutionalization in these facilities.

Plaintiffs further request that the Court appoint the Disabilities Rights Center, Devine Millimet &

Branch, the Bazelon Center for Mental Health Law and the Center for Public Representation as co-

counsel for the class pursuant to Fed. R. Civ. P. 23(g). The plaintiffs have filed a Memorandum

in support of this Motion for Class Certification.

Dated: January 29, 2013

Respectfully submitted,

Lynn E., by her guardian, Barry Ellsworth; Kenneth R., by his guardian, Tri-County CAP, Inc./GS; Sharon B., by her guardian, Office of Public Guardian, Inc.; Amanda D., by her guardian, Louise Dube; Amanda E., by her guardian, Office of Public Guardian, Inc.; and Jeffrey D.,

Pro Hac Vice admission granted:
Steven Schwartz (MA BBO 448440) Kathryn Rucker (MA BBO 644697) CENTER FOR PUBLIC REPRESENTATION 22 Green Street Northampton, MA 01060 (413) 586-6024 SSchwartz@cpr-ma.org KRucker@cpr-ma.org

By their attorneys:
DISABILITIES RIGHTS CENTER
By: /s/ Amy B. Messer Amy B. Messer (NH Bar 8815) Adrienne Mallinson (NH Bar 17126) Aaron Ginsberg (NH Bar 18705) 18 Low Avenue Concord NH 03301 amym@drcnh.org adriennem@drcnh.org aarong@drcnh.org

8

Case 1:12-cv-00053-SM Document 73 Filed 01/29/13 Page 9 of 9

Ira Burnim (D.C. Bar 406154) Jennifer Mathis (D.C. Bar 444510) JUDGE DAVID L. BAZELON CENTER FOR MENTAL HEALTH LAW 1101 15th Street, NW, Suite 1212 Washington, D.C. 20005 (202) 467-5730 irab@bazelon.org jenniferm@bazelon.org

DEVINE, MILLIMET & BRANCH PROFESSIONAL ASSOCIATION
By: /s/ _Daniel Will__________ Elaine M. Michaud (NH Bar 10030) Daniel E. Will (NH Bar 12176) Joshua M. Wyatt (NH Bar 18603) 111 Amherst Street Manchester, NH 03101 (603) 669-1000 emichaud@devinemillimet.com dwill@devinemillimet.com jwyatt@devinemillimet.com

CERTIFICATE OF SERVICE
I hereby certify that on January 29, 2013 the foregoing document was filed electronically with the Clerk of the Court using the CM/ECF system, which sends notification of such filing to all counsel of record.
/s/ ___Amy Messer__________________________
January 29, 2013

9

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 1 of 50

UNITED STATES DISTRICT COURT DISTRICT OF NEW HAMPSIRE

Lynn E., et al.

)

others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

Margaret W. Hassan, Governor, et al.

)

)

Defendants.

)

____________________________________)

The United States of America

)

)

Plaintiff-Intervenor

)

)

v.

)

)

The State of New Hampshire

)

)

Defendant

)

____________________________________)

Civ. No. 1:12-cv-53-SM

PLAINTIFFS’  MEMORANDUM  IN  SUPPORT  OF  THEIR RENEWED MOTION FOR CLASS CERTIFICATION

I. Introduction

On February 9, 2012, Plaintiffs Lynn E., Kenneth R., Sharon B., Amanda D.,

Amanda E., and Jeff D. (collectively the “named   plaintiffs”),   filed   a class action

Complaint on behalf of themselves and all persons with serious mental illness who are

institutionalized in New Hampshire Hospital (NHH) or the Glencliff Home (Glencliff) or at serious risk of institutionalization in these facilities.1 Both NHH and Glencliff are

large, public institutions operated by the State of New Hampshire that segregate persons

1 Amanda  D.,  Amanda  E.,  and  Jeff  D.  were  in  the  community  “at  serious  risk  of  institutionalization”  when   the case was filed in February 2012. All three of these individuals have been hospitalized at least once since the filing of the case.

1

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 2 of 50
with serious mental illness. This case seeks to redress the common injuries suffered by class members who are unnecessarily institutionalized at NHH and Glencliff, or at serious risk of institutionalization in these facilities, due to a lack of community services. Complaint, ¶¶ 2-4.
The named plaintiffs and the plaintiff class are qualified to receive mental health services in integrated  community  settings,  yet  New  Hampshire  (the  “State”)  has  failed  to   provide the community services they need to leave NHH and Glencliff and to avoid their unnecessary institutionalization in these facilities. The plaintiffs therefore seek declaratory and injunctive relief under Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. §§ 12101 et seq., Section 504 of the Rehabilitation Act, 29 U.S.C. §§ 794 et seq., and the Nursing Home Reform Amendments (NHRA) to the Medicaid Act, 42 U.S.C. §§ 1396r et seq., as well as an order directing the State to provide community services  required  to  avoid  class  members’  needless  institutionalization.
After conferring with the defendants in early March, the plaintiffs filed their Motion for Class Certification (Doc. 19) and Memorandum (Doc. 19-1) with supporting exhibits on March 23, 2012. Without conferring with the plaintiffs, or seeking an extension of time to respond, the defendants filed an Objection to Plaintiffs’  Motion to Certify (Doc. 25) and a Motion to Strike (Doc. 24) with supporting Memorandum (Doc. 24-1). In these filings, the defendants objected to the proposed class, and requested that the Court deny the plaintiffs’   Motion,   or   indefinitely   delay   defendants’ time for responding to the Motion. After further briefing,2 on June 11, 2012, the Court heard oral arguments from all parties on the various motions concerning class certification, ultimately concluding that both merits
2 See Plaintiffs’   Objection   to   Defendants’   Motion   to   Strike,   (Doc.   36),   the   United   States’   Memorandum   in   Support  of  Plaintiffs’  Motion  for  Class  Certification  (Doc.  33),  and  the  Defendants’  Reply  (Doc.  48-1).
2

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 3 of 50
and class based discovery should be allowed to proceed simultaneously. (Minute Order of June 11, 2012). As a result, the Court dismissed the plaintiffs’  pending  Motion  for  Class   Certification without prejudice to refiling after class discovery was completed.
Consistent with the court-ordered discovery schedule,3 the plaintiffs now submit their Renewed Motion for Class Certification. The plaintiffs seek relief that would require the defendants to remedy systemic deficiencies in the State mental health system that deny class members their rights under Title II of the ADA, §504 of the Rehabilitation Act, and the NHRA. In particular, the plaintiffs seek an expansion of mobile crisis services, Assertive Community Treatment (ACT), supportive housing and supported employment. An injunction requiring the defendants to develop these services in an amount sufficient   to   avoid   class   members’   unnecessary   institutionalization   would, in a single stroke, redress all of these legal violations and would benefit the class as a whole.
In their Renewed Motion, the plaintiffs are requesting that this Court certify a class consisting of:
all persons with serious mental illness who are institutionalized in New Hampshire Hospital or Glencliff or at serious risk of institutionalization in these facilities. This Memorandum is submitted in support of the plaintiffs' Renewed Motion.
3 The   Court   approved   the   parties’   Joint   Discovery   Plan on August 16, 2012. Pursuant to the schedule incorporated   into   the   Plan,   the   plaintiffs’   renewed   class   motion   is   to   be   filed   by January 29, 2013, the defendants’   objection,   by   February   28,   2013,   the   plaintiffs’   reply   by   March   14,   2013,   and   the   defend ants’   sur-reply, if any, by March 28, 2013.
3

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 4 of 50
II. Statement of Facts As described in detail below, all relevant provisions of Fed. R. Civ. P. 23 are
satisfied, and certification is appropriate to resolve the common contentions presented by the plaintiff class and  to  systemically  redress  the  common  injury  caused  by  defendants’   discriminatory conduct.
A. Common Injuries, Common Contentions and the Appropriateness of a Single, Injunctive Remedy for the Plaintiff Class.
The named plaintiffs bring the instant class action on behalf of themselves and all similarly-situated individuals with serious mental illness. All of the named plaintiffs and members of the plaintiff class have disabilities that substantially limit major life activities, including self-care, and that require ongoing services and support. Complaint, ¶¶ 2-4, 76-111. They are eligible to receive community-based mental health services and desire to receive services in integrated settings. Id.
The named plaintiffs and the plaintiff class suffer significant harm when needlessly institutionalized. Id. In NHH and Glencliff, they must relinquish most, if not all, of their personal liberty, freedom of association, and meaningful access to community life. Id., ¶¶ 3-4, 62, 64. Their institutionalization in NHH or Glencliff, or their serious risk   of   institutionalization   in   these   facilities,   is   due   to   the   defendants’   failure   to   provide   sufficient mental health services in the community. Id., ¶¶ 52-57, 70, 76-111.
In   administering   the   State’s   mental   health   system,   the   defendants   have   excessively relied on institutional care and failed to develop an adequate array of community services. Id., ¶¶ 6-7. As noted by the U.S. Department of Justice, these “systemic  failures  in  the  State’s  system  place  qualified  individuals  with  disabilities  at  risk  
4

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 5 of 50
of  unnecessary  institutionalization  now  and  going  forward.”   United  States’  Investigation   of the New Hampshire Mental Health System (April 7, 2011), attached as Exhibit 1.
As   evidenced   by   the   defendants’   own   documents   and   data,   as   well   as   by   expert   reviews of class members at NHH and Glencliff and of the community service system, the lack of community services constitutes a common practice that is the common cause of  class  members’  injuries. Complaint, ¶¶ 8, 115-133. A single injunction that requires the State to comply with the ADA, the Rehabilitation Act, and the NHRA by expanding specific   community   services   could   remedy   these   violations   “in   a   single   stroke.” WalMart Stores, Inc. v. Dukes, 131 S. Ct. 2441, 2551 (2011).
B. The   Defendants’   Own   Data and Reports Demonstrate That Their Planning, Administration and Operation of the Mental Health System Result in Unnecessary Institutionalization.
Much of the evidence upon which the plaintiffs rely is contained in the defendants’  own  data and reports. The defendants have repeatedly acknowledged that they are failing to provide sufficient community services to the plaintiff class, thereby perpetuating their needless institutionalization at NHH and Glencliff. See, e.g., NH  Dep’t   of Health and Human Servs., New Hampshire Hosp., Bureau of Behavioral Health, and The Cmty. Behavioral  Health  Ass’n,  Addressing the Critical Mental Health Needs of NH’s  Citizens:  A  Strategy  for  Restoration (August  2008)(“Restoration  I”),  attached  as   Exhibit 2;4 Commission to Develop a Comprehensive State Mental Health Plan, Fulfilling the Promise: Transforming  New  Hampshire’s  Mental  Health  System   (2007)(“Fulfilling  the  Promise,  Vol.  I.”);;  Fulfilling  the  Promise:  Transforming  New  
4 The 2008 report, Addressing   the   Critical   Mental   Health   Needs   of   NH’s   Citizens:   A   Strategy   for   Restoration is the product of the NH Department of Health and Human Services taskforce convened to assess the status of publicly funded mental health services and supports critical to meeting the needs of New   Hampshire’s   citizens.       The   report  is   commonly   referred   to   as  “ The   10-Year   Plan” .   
5

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 6 of 50
Hampshire’s  Mental  Health  System  (2008)(“Fulfilling  the  Promise  Vol.  II),  attached as Exhibit 3 (“Unmet needs and critical gaps are largely summed up in the primary finding of the taskforce: ‘…that  many  individuals  are  admitted  to  New  Hampshire  Hospital   because  they  have  not  been  able  to  access  sufficient  services  in  a  timely  manner  (a  “front   door  problem”)  and  remain  there,  unable to be discharged, because of a lack of viable community based alternatives (a  “backdoor”  problem)’”); Complaint, ¶¶ 5-7, 48-69, 70.
Patterns of repeated hospitalization underscore the significant limitations in the defendants' community-based service system, and illustrate the extent to which individuals with serious mental illness are not provided the services required to prevent their unnecessary institutionalization. More than 120 adults with mental illness are confined to NHH at any given time, and many of these persons experience prolonged or repeated institutionalization. See Exhibit 2, Restoration I at 4, 6. Of the more than 1,800 adult admissions to NHH in 2010, nearly 800 were for persons who already had been at NHH at least once in the previous 180 days. See New Hampshire 2010 Mental Health National  Outcome  Measures  (NOMs),  CMHS,  Uniform  Reporting  System  (“2010  NOMs   data”),  attached  as  Exhibit  4;;  New  Hampshire  Hospital  Annual  Report,  Fiscal  Year  2011,   attached as Exhibit 5. One in six adults discharged from NHH in 2010 were readmitted within just 30 days. See 2010 NOMs data; Restoration I (August 2008); Addressing the Critical  Mental  Health  Needs  of  NH’s  Citizens:  A  Strategy  for  Restoration,  Report  of  the   Listening Sessions, (April 2009) (“Restoration   II”),   attached   as   Exhibit   6.5 See e.g. Complaint, ¶¶ 26, 52-59, 62-64.
5 The Report of Listening Sessions, issued in 2009, is the product of five listening sessions organized by the New Hampshire Community Behavioral Health Association in partnership with the NH Department of Health and Human Services, the NH Mental Health Council, and the National Alliance on Mental Illness. The purpose of the listening sessions was to take the 10-Year  Plan  “into  NH  communities  in  an   effort  to  hear  directly  from  those  who  are  living  with  the  crisis”.    Id. at 1.
6

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 7 of 50
In  addition,  the  limitations  in  the  defendants’  community  service  system result in lengthy, often life-long, institutionalization at Glencliff.6 Once admitted to Glencliff, few residents ever leave. Between 2005 and 2010, only 13 individuals were discharged from Glencliff, 11 of whom went to NHH or other institutions. See Census Data from the Glencliff Home, attached as Exhibit 7A to Affidavit of C. Adrienne Mallinson, Exhibit 7. See also Complaint, ¶¶ 64-65.
Despite the defendants’  knowledge  of  the  severity  of  the  problem  of  unnecessary   institutionalization of individuals with mental illness, the defendants have implemented virtually none of the recommendations in the Ten-Year Plan. N.H. Cmty. Behavioral Health   Ass’n,   N.H. Ten-Year Mental Health Plan Progress, Four Years Out, (Mar. 5, 2012) (attached as Exhibit 8).
C. Expert Reviews of Class Members and the Community Mental Health System Demonstrate that Hundreds, if Not Thousands of Persons Are Unnecessarily Institutionalized.
To supplement the   defendants’   own   evidence   regarding   systemic deficiencies in New   Hampshire’s   community   service   system,   presented   in   conjunction   with   the   plaintiffs’   initial   Motion   for   Class   Certification, the plaintiffs asked experts to evaluate class   members   at   NHH   and   Glencliff,   as   well   as   the   State’s   community   mental   health   system. See Affidavit of Dr. Thomas Simpatico, attached as Exhibit. 9; Affidavit of Judith Boardman, attached as Exhibit 10; Affidavit of Susan Curran, attached as Exhibit 11; Affidavit of Dr. Sally Rogers, attached as Exhibit 12; Affidavit of Marylou Sudders, attached as Exhibit 13. The experts’   findings demonstrate that the proposed class
6 Glencliff is a 120 bed nursing facility, located in an isolated area of northern New Hampshire. Complaint, ¶¶ 26, 64. Most Glencliff residents have serious mental illness, and many were transferred from NHH. Id., ¶¶ 67, 69.
7

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 8 of 50
contains hundreds, if not thousands of individuals with serious mental illness scattered throughout the State of New Hampshire, and that these individuals share common injuries that can be remedied by a single injunction. See Rogers Aff., ¶14; Simpatico Aff., ¶¶ 13-21; Boardman Aff., 19-27; Curran Aff., ¶¶ 18-25. As the reviews collectively demonstrate, the  defendants’  administration,  planning  and  operation  of  the  mental  health   service system needlessly segregates persons with serious mental illness, thereby establishing the appropriateness of, and the need for, a class wide remedy in this case. See Sudders Aff., ¶¶ 17-26. The conduct, outcomes and implications of each review is discussed in detail below.
1. The Client Review The plaintiffs asked a team of mental health professionals to review a random sample of class members in order to determine whether they were institutionalized as a result  of  common  deficiencies  in  New  Hampshire’s  mental  health  service  system.    Susan Curran and Daniel Byrne reviewed a sample of persons admitted to NHH for 30 days or more (either cumulatively or consecutively) during the period between July 1, 2011 and June 30, 2012.7 Judith Boardman reviewed a cohort of persons residing at Glencliff as of June 30, 2012.8 Dr. Thomas Simpatico, M.D., provided clinical consultation and oversight for both facility reviews, and rendered independent clinical determinations
7 Both of these mental health professionals have extensive experience in evaluating persons with serious mental illness in public institutions and community programs, including conducting similar reviews for federal judges in Florida and the District of Columbia. See Curran Aff., ¶¶ 4-5, FN1. A detailed description  of  the  NHH  component  of  the  client  review  is  set  forth  in  Ms.  Curran’s  affidavit.     Id., ¶¶ 7-8, 11-16. 8 Ms. Boardman is a nurse with many years of experience evaluating and serving persons with mental illness, including those who have medical or nursing needs. Boardman Aff., ¶¶3-7. A detailed description of  the  Glencliff  component  of  the  client  review  is  set  forth  in  Ms.  Boardman’s  affidavit.     Id., ¶¶ 9-10, 1318.
8

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 9 of 50
about each individual in the sample.9 Dr. Sally Rogers, a noted researcher and the assistant director of the Boston University Center for Psychosocial Rehabilitation, developed   the   review’s   sampling   protocol   and   randomly   selected   the   cohort   of   persons   who were approached to participate in the review. Six named plaintiffs – four with admissions to NHH and two currently admitted to Glencliff - also were included in the review.10
The NHH and Glencliff experts reviewed approximately two years of facility and community mental health records, conducted in-person meetings and observations with review participants, and interviewed guardians and mental health providers. See Boardman Aff., ¶¶ 11-12, 14-16; Curran Aff., ¶¶ 9-10, 13-14. Following the collection, presentation and discussion of all of this information, the experts answered three central questions: 1) whether the individuals in the sample would have avoided admission to NHH or Glencliff if they had access to the services sought in this case, along with other existing services; 2) whether these individuals would have spent less time at NHH or Glencliff, or could be discharged to the community, if they had access to the services sought in this case, along with other existing services; and 3) whether these individuals would choose, or their guardians would choose for them, to live in the community if they
9 Dr. Simpatico teaches at the University of Vermont, College of Medicine, was a former medical director at the Vermont State Hospital, and is the medical director of several community mental health programs in Vermont, including those that rely upon supportive housing and ACT teams to provide community care to persons with serious mental illness. Simpatico Aff., ¶¶ 2-3. A  fuller  description  of  Dr.  Simpatico’s  role  in   both components of the client review is described in his affidavit. Id., ¶¶ 5-6, 8-11. 10 Dr. Rogers has designed similar client reviews for federal courts in Florida and Massachusetts. A detailed description of the population included in the client review, the statistical methodology for selecting the sample, and the reliability and validity   of   the   sampling   process   is   set   forth   in   Dr.   Rogers’   affidavit. Rogers Aff., ¶¶ 10-13. Based upon her experience and the methodology employed by Dr. Rogers, the reviewers’  findings  for  the  NHH and Glencliff cohorts can accurately be extrapolated to the population of residents at both facilities for the specified time period, including those persons who are repeatedly admitted to NHH. Id., ¶ 14.
9

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 10 of 50
were fully informed of, and had access to, the services sought in this case along with other existing services. See Simpatico Aff., ¶¶ 6,12; Boardman Aff., ¶¶ 10, 19; Curran Aff., ¶¶ 8, 17.
The experts noted the high degree of commonality across the individuals in the sample and, therefore, all individuals in the population, concluding that the vast majority has experienced avoidable, prolonged and unnecessary institutionalization. See Simpatico Aff., ¶¶ 13-17; Boardman Aff., ¶¶ 19-24; Curran Aff., ¶¶ 18-22. A common cause behind this unnecessary institutionalization was the absence of appropriate community mental health services, and specifically the services sought in this case. See Simpatico Aff., ¶¶ 13-16; Boardman Aff., ¶¶ 19-20, 22, 25; Curran Aff., ¶¶ 18-19, 21-22. Similarly, the reviewers concluded that the vast majority of participants could be discharged to the community if the requested remedial services were available, and that virtually all participants and their guardians would choose community living, if they were fully informed of and had access to these service options. See Simpatico Aff., ¶¶ 13-14, 21; Boardman Aff., ¶¶ 19, 22; Curran Aff., ¶ 18.
Specifically, the NHH reviewers concluded that 96% of the individuals in the NHH sample very likely could have avoided admission to NHH if they had access to the services sought in this case, along with other existing services. Curran Aff., ¶ 18. They further concluded that 96% very likely would have spent less time at NHH or could be discharged to the community if they had access to the services sought in this case, along with other existing services. Id. Finally, they found that 96% of persons would very likely choose, or their guardians would choose for them, to live in the community if they
10

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 11 of 50
were fully informed of, and had access to the services sought in this case, along with other existing services. Id.
The Glencliff reviewer found that 22 of the 22 individuals in the Glencliff sample, or 100%, very likely could have avoided admission to Glencliff if they had access to the services sought in this case, along with other existing services. Boardman Aff., ¶ 19. She concluded that 17 of the 22, or 80%, very likely would have spent less time at Glencliff or could be discharged to the community if they had access to the services sought in this case, along with other existing services. Id. Finally, Ms. Boardman found that 17 out of 22, or 80% of persons very likely would choose, or their guardians would choose for them, to live in the community if they were fully informed of, and had access to the services sought in this case, along with other existing services. Boardman Aff., ¶ 19.
These conclusions were almost universally affirmed by Dr. Simpatico, whose participation in and clinical oversight over the entire review led him to conclude that: (1) at NHH, 88% of persons very likely would have avoided admission, 88% very likely would have spent less time hospitalized or could be discharged, and 88% very likely would choose to live in the community if they were fully informed of and had access to the services sought in this case, along with other existing services; and (2) at Glencliff, 91% of persons very likely would have avoided admission, 91% very likely would have spent less time hospitalized or could be discharged, and 91% very likely would choose to live in the community if they were fully informed of and had access to the services sought in this case, along with other existing services. Simpatico Aff., ¶¶ 13.
11

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 12 of 50
These findings strongly support the contention that a class of individuals with serious mental illness is experiencing unnecessary institutionalization as a result of the defendants’   administration, planning and operation of the State’s mental health system. The experts also concurred that individuals with serious mental illness can be identified as being "at risk of institutionalization" where they have multiple, repeated, or prolonged hospitalizations, are frequent users of crisis or emergency services for psychiatric reasons, have criminal justice involvement as a result of their mental illness, or lack adequate community-based mental health services. See Sudders Aff., ¶10-11 (list of factors that indicate serious risk of institutionalization); Simpatico Aff., ¶15. These review findings make clear that the legal claims of the class could be resolved though a single injunction requiring the State to develop the requested mental health services.
2. The System Review The plaintiffs asked former Deputy Director and Acting Director of the Division of Mental Health and Developmental Services for the State of New Hampshire, and former Commissioner of Mental Health for the Commonwealth of Massachusetts, Marylou Sudders, to conduct a review of New   Hampshire’s   community   mental   health   system, and specifically whether persons with serious mental illness were being needlessly institutionalized, or placed at serious risk of such institutionalization, due to a lack of community mental health services. Ms. Sudders reviewed documents and materials concerning the structure, capacity and operation of the community mental health system, data on admissions and discharges at NHH and Glencliff, and the utilization of community hospitals and emergency departments for psychiatric emergencies. See Sudders Aff., ¶¶ 5-8. She also met with and interviewed
12

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 13 of 50
knowledgeable individuals and representatives of key entities   within   New   Hampshire’s   mental health system, including providers of community mental health services and supportive housing, individuals involved with the criminal justice system and university– based experts in community mental health services. Id., ¶ 9.
The system review,   like   the   defendants’   own   reports, found that New Hampshire’s  community  mental  health  system lacks mobile crisis services, ACT teams, supportive housing, and supported employment programs needed to avoid segregation in NHH and Glencliff and that these systemic deficiencies directly contribute to the unnecessary and repeated institutionalization of class members, including those who remain at serious risk of institutionalization. Id., ¶¶ 14-17. New  Hampshire’s  historical   recognition of the importance of integrated community mental health services is in stark contrast to its more recent neglect of identified, but unmet, needs of adults with serious mental illness. Id., ¶¶ 13, 26. Despite the  State’s  recognition of the need for precisely the kind of remedial services sought in this case, the system review concludes that the defendants’   planning and administration of their mental health system has led to the unavailability of these needed community mental health services. Id., ¶¶ 14-17. The result has been devastating for class members, leading to lengthy and repeated NHH hospitalizations, high readmission rates, discharges to inappropriate locations, homelessness, criminal justice involvement, and repeated admissions to emergency rooms that are ill-equipped to handle individuals in psychiatric crises. Id., ¶¶ 18-21.
As   documented   in   the   defendants’   own   reports   and   these expert reviews, the unnecessary institutionalization of the named plaintiffs and plaintiff class members has a
13

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 14 of 50
common cause – the lack of community services – which can and would be remedied by the requested injunctive relief in this case. III. The Proposed Class Meets the Standards for Class Certification Under Rule
23(a) of the Federal Rules of Civil Procedure. A. The Requirements of Fed. R. Civ. P. 23(a). The party moving for class certification must satisfy all of the requirements of Rule 23(a) of the Federal Rules of Civil Procedure as well as at least one of the subdivisions of Rule 23(b). Smilow v. Sw. Bell Mobile Sys., Inc., 323 F.3d 32, 38 (1st Cir. 2003). Rule 23(a) has four distinct criteria: (1) the class must be so numerous that joinder of all members is impracticable; (2) the members of the class must share common questions of law or fact; (3) the claims or defenses of the named representatives must be typical of those of the class; and (4) the persons representing the class must be able to fairly and adequately represent the interests of the class. Fed. R. Civ. P. 23(a)(1)-(4); see also, Griffin v. Burns, 570 F.2d 1065, 1072 (1st Cir. 1978). Rule 23(a) has always required a rigorous analysis of whether the prerequisites of Rule 23(a) have been met. Wal-Mart, 131 S. Ct. at 2551, quoting, Gen. Tel. Co. of S.W. v. Falcon, 457 U.S. 147, 161 (1982)); M.D., 675 F.3d at 837. Wal-Mart did not alter Falcon’s well-established standard for certifying a class,11 nor the rigor of the analysis that the court must conduct to assess compliance with that standard. Further, neither Falcon nor Wal-Mart suggests that information set forth in the Complaint is irrelevant or inadequate. Rather, the Supreme Court affirmed Falcon's understanding that "sometimes it may be necessary for the court to probe behind the pleadings before coming to rest on
11 As discussed in more detail in Section III(E), the Court reaffirmed that only where there are no common questions of fact or law should certification be denied. (“We  quite  agree  that  for  purposes  of  Rule  23(a)(2)   ‘[e]ven  a  single  [common]  question  will  do”)  (citations  omitted).    Id. at 2541, 2557.
14

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 15 of 50
the certification question."12 Id. (quoting Falcon, 457 U.S. at 160 (emphasis added)).
After Wal-Mart, the district court must analyze whether there are common contentions which  exist  “whose  resolution  will  resolve  an  issue  that  is  central  to  the  validity  of  each   one  of  the  class  members  claims  in  one  stroke.” 13 Wal-Mart, 131 S. Ct. at 2551.
B. The Proposed Class The proposed class consists of “all   persons   with   serious   mental   illness   who   are  
institutionalized in New Hampshire Hospital or Glencliff or at serious risk of
institutionalization  in  these  facilities.”    Plaintiffs’  Renewed Motion for Class Certification at
9. It   is   routine   for   courts   to   certify   classes   in   cases   challenging   government   officials’  
noncompliance with Title II of the ADA. See List of Selected ADA Class Action Cases, attached as Exhibit 14. This  is  particularly  true  in  cases  seeking  compliance  with  Title  II’s  
requirement that services be provided in the most integrated setting appropriate to
individuals’   needs.      Additionally,   courts   have   routinely   certified   classes   of   persons   with  
mental disabilities in cases challenging a failure to provide appropriate services in a state or
private facility. See List of Selected Institutional Placement Class Actions, attached as
Exhibit 15. This long line of decisions granting class certification in cases challenging
12 Wal-Mart arguably did enhance the evidence that must be provided by the plaintiffs and require trial courts to identify a link between that evidence and common contentions capable of common answers. 131 S. Ct. at 2551-52. 13 Wal-Mart involved an unprecedented nationwide  class  action,  where  it  found  “nothing  to  unite  all  of  the   plaintiffs’  claims,”  no  evidence  that  the  same  discriminatory  employment  practices  “touched  and  concerned   all  members  of  the  class,”  and  members  whose  potential  entitlement  to  monetary  damages required an individualized analysis to determine liability. Id. at 2557. Wal-Mart’s  conclusion does not preclude class certification here, because of the claims asserted (the existence of a common discriminatory policy or practice), the relief sought (a single injunction), and, most importantly, the fact that in this case, unlike Wal-Mart, the claims of all class members can be resolved "in a single stroke" through the provision of the requested community services that are critical to avoiding unnecessary institutionalization. See Connor B., 2011 WL 5513233 at *3, 5 (While Wal-Mart provides  “…guidance  on  how  existing  law  should  be  applied  to   expansive,  nationwide  class  actions,”  it  does  not  preclude  injunctive  relief  designed  to  remedy  overarching   deficiencies in a state service system).
15

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 16 of 50
needless institutionalization and/or the denial of appropriate community services argues strongly for class certification here.
A similar class was certified in a case raising similar claims under the ADA and NHRA, and affirmed by the First Circuit. See Rolland v. Cellucci, 1999 WL 34815562 (D. Mass. Feb. 2, 1999);14 Rolland v. Patrick, 2008 WL 410488 (D. Mass. Aug. 19, 2008) (refusing to decertify the class based upon alleged differences in the needs and conditions of persons in nursing facilities); Voss v. Rolland, 592 F. 3d (1st Cir. 2010) (refusing to consider a challenge to class certification in an ADA case involving persons with intellectual disabilities in nursing facilities); Hutchinson v. Patrick, No. 07-30084-MAP (D. Mass. Oct, 4, 2007), approved 636 F.3d 1 (1st Cir. 2011) (affirming fee award for class based upon district court's approval of settlement agreement under Fed. R. Civ. P. 23(e)).
Courts have certified similar classes in other ADA Title II cases brought on behalf of institutionalized persons with disabilities. See Van Meter v. Harvey, 272 F.R.D. 274 (D. Me. 2011); Connecticut Office of Protection and Advocacy, 706 F. Supp. 2d 266 (D. Conn. 2010); Long v. Benson, No. 08-cv-26 (N.D. Fla. Oct. 14, 2008); Colbert v. Blagojevich, 2008 WL 4442597 (N.D. Ill. Sept. 29, 2008); Chambers v. San Francisco, No. 06-cv-6346 (N.D. Cal. July 12, 2007); Williams v. Quinn, 2006 WL 3332844 * 5 (N.D. Ill. Nov. 13, 2006).
ADA Title II integration cases customarily focus on the standardized conduct of the defendants and do not depend on individualized determinations of either liability or remedy. Thus, courts frequently, and barely without exception, have little difficulty certifying ADA classes, precisely because the Title II claims focus on the defendants'
14 Discretionary review was denied pursuant to Fed. R. Civ. P. 23(f) by the United States Court of Appeals for the First Circuit, Docket 99-8089 (March 2, 1999).
16

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 17 of 50
systemic practices, not the individual plaintiffs' conditions.15 See Ex. 14. Significantly, there is not a single decision where a court has declined to certify an ADA Title II case or which has applied Wal-Mart to an ADA Title II case and concluded that class certification is inappropriate. To the contrary, in several ADA or Rehabilitation Act postWal-Mart cases, courts have certified classes, re-certified classes, or refused to decertify classes. Lane v. Kitzhaber, 283 F.R.D. 587 (D. Or. 2012) (certifying a class of persons with developmental disabilities in segregated workshops, where the plaintiffs challenge the   defendants’   planning,   funding,   and   administering   of   their   employment   services   system and not individual placement decisions;;  court  rejects  defendants’  claims  that  class   members’  different  abilities,  skills,  needs,  and  preferences  preclude  certification);;  Gray v. Golden  Gate  Nat’l  Recreation  Area, 279 F.R.D. 501 (N.D. Cal. 2011) (certifying a class of individuals with mobility and/or vision disabilities challenging barriers at a national recreational area and concluding that commonality was met by general policies and practices of defendants that failed to address access barriers despite differing types and levels of disabilities of the class members); Oster v. Lightbourne, 2012 WL 685808 at *5 (N.D. Cal. March 2, 2012) (class certification granted where cuts to in-home support services affected named plaintiffs and class members in different ways.); Pashby v. Cansler, 279 F.R.D. 347, 353 (E.D.N.C. 2011) (a determination that the policy or rule in question is valid or invalid on its face would resolve the claims of all potential plaintiffs,
15 A  critical  factor  in  the  Court’s  conclusion  was that the claim in Wal-Mart, unlike the one here, required proof of discriminatory intent, which, by its very nature and particularly when applied by thousands of employment supervisors to millions of employees, is almost impossible to prove, absent a common policy or practice. And it is precisely the presence of such a common practice or policy in most ADA integration cases that distinguishes them from Wal-Mart, since  the  Court’s  conclusion  depended heavily on the absence of such a policy or practice.
17

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 18 of 50
regardless of their particular factual circumstances); D.L. v. District of Columbia, 277 F.R.D. 38 (D. D.C. 2011).16
ADA Title II classes routinely have been certified precisely because they raise a
common question susceptible to a common solution through a single injunction: the
modification of the public entity's program to provide services in the most integrated
setting. Like those cases, the Complaint here seeks a single injunction that would require
the defendants to make reasonable modifications to their community service system, in
order to ensure that all class members have access to community services in the most
integrated setting. Thus, in Wal-Mart terms, the Court can, "in a single stroke," ensure
that class members avoid needless institutionalization at NHH and Glencliff and have the opportunity to live in the community.17 Thus, there is a virtually unbroken line of
decisions granting class certification in Title II cases challenging systemic practices of
institutionalizing persons with disabilities in violation of federal statutory and constitutional
16 Courts have also continued to certify classes in a variety of other contexts, and refused to de-certify existing class after Wal-Mart. See Ault v. Walt Disney World Co., 2011 WL 1460181(M.D. Fla, April 4, 2011), aff'd 692 F.3d 1212 (11th Cir. 2012) (certifying ADA Title III class); Connor B. ex. Rel. Vigurs v. Patrick, 278 F.R.D. 30 (D. Mass. Nov, 2011) (following the Wal-Mart decision, court declined to de-certify class  of  foster  children  harmed  by  systemic  deficiencies  in  state’s  foster  care  system);;   Johnson v. General Mills, 276 F.R.D. 519 (C.D. Cal. 2011) (unlike Wal-Mart, injury results from a common core of salient facts); In re Ferrero Litigation, 2011 WL 5557407 (S.D. Cal. Nov. 15, 2011) (plaintiffs need not prove a common class-wide injury at class certification stage; rather, they need only to demonstrate that there is a common contention that is capable of class wide resolution); Martinez v. Gerber Childrenswear, LLC, 2011 WL 6757875 (C.D. Cal. Dec. 15, 2011) (unlike Dukes, there is common control over the challenged practice); Parkinson v. Freedom Fidelity Management, Inc., 2012 WL 72820 (E.D. Wash. Jan. 10, 2012) (certifying class for violations of state Consumer Protection Act and Debt Adjusting Statute, although plaintiffs suffered different statutory violations in different ways by different debt collectors); Arthur v. Sallie Mae, Inc., 2012 WL 90101 * 7 (W.D. Wash. Jan. 10, 2012) (commonality only requires a single question of law or fact). 17 As discussed in Section III(E), infra, individualized decisions concerning which persons want to leave NHH or Glencliff and what community services they need to leave have nothing to do with class certification, since this process is not part of the federal court proceedings. Instead, these determinations are properly made in an individualized service planning process, similar in many respects to the treatment planning process currently used by the defendants.
18

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 19 of 50
provisions. Those conclusions and the reasoning of those cases are equally applicable here, and should weigh heavily in the Court's analysis regarding certification of the plaintiff class.
C. The Plaintiffs Have Presented Sufficient Evidence to Support Their Motion.
In addition to the information set forth in their Complaint, which includes substantial details about the named plaintiffs and numerous references to documents, reports, data, and findings by the Department of Justice and others concerning systemic deficiencies   in   New   Hampshire’s   mental   health   system,   the plaintiffs have further supported their Renewed Motion with the affidavits of five experienced mental health professionals. See Exs. 1-8; Affidavits of Dr. Thomas Simpatico, Judith Boardman, Susan Curran, Dr. Sally Rogers, and Marylou Sudders (Exs. 9-13). As discussed in Section II, infra, this evidence is more than sufficient to allow the Court to conduct the requisite analysis of the class certification question.18
D. The Class Is So Numerous That Joinder of All Members Is Impractical. Rule 23(a)(1) has two components: the number of class members and the practicality of joining them individually in the case. Fed. R. Civ. P. 23(a)(1). The first presents a relatively   “low   threshold”   for   plaintiffs,   and   does   not   impose   a   precise   numerical   requirement for purposes of certification. Conner B. v. Patrick, 272 F.R.D. 288, 292 (D. Mass. 2011) (quoting Garcia-Rubiera v. Calderon, 570 F. 3d 443, 460 (1st Cir. 2009); see also, DeRosa v. Mass. Bay Commuter Rail Co., 694 F. Supp. 2d 87, 98 (D. Mass. 2010) (certifying a class of approximately 110 members); Tyrell v. Toumpas, No. 09-CV-243-JD, 2010 WL 174287 at * 4 (D.N.H. Jan.  14,  2010)  (“Unless the  class  is  very  small,  ‘numbers  
18 This evidence also directly addresses, and more than completely responds to, the defendants’  concerns   that in the original motion the plaintiffs had not provided sufficient information about the types of services needed by class members, their unnecessary institutionalization at the NHH and Glencliff, and their interest in living in the community. See Defs’  Mem.  in  Support  of  Motion  to  Strike  at  6  (Doc.  24-1).
19

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 20 of 50
alone   are   usually   not   determinative….’”)(quoting   Andrews v. Bechtel Power Corp., 780 F.2d 124,131-32 (1st Cir. 1985).
Here the proposed class consists of at least several hundred members, and probably many more, given the   defendants’   own   reports   about   the   number   of   persons   actually   institutionalized in the NHH each year. See Ex. 5. See also, Sudders Aff., ¶ 18. It is clearly sufficient to satisfy the numerosity requirement. Typically, classes consisting of only a fraction of this number are certified under Rule 23(a)(1). See, e.g., Griffin v. Burns, 570 F.2d 1065, 1072-73 (1st Cir. 1978) (123 voters are sufficient to satisfy Rule 23(a)(1)); Korn v. Franchard Corp., 456 F.2d 1206, 1209 (2nd Cir. 1972) (class consisting of at least 70, and possibly 212 members, sufficient); George Lussier Enterprises, Inc. v. Subaru of New England Inc., No. Civ. 99-109-B, 2001 WL 920060 at *3 (D.N.H. Aug. 3, 2001) (class of approximately seventy-five present and former Subaru dealers satisfies the numerosity requirements); Grace v. Perception Tech. Corp., 128 F.R.D. 165, 167 (D. Mass. 1989) (class consisting of between 300 and 1300 shareholders is sufficient).
The plaintiffs need not establish the precise number or identity of proposed class members, particularly in Rule 23(b)(2) classes. Yaffe v. Powers, 454 F.2d 1362, 1366 (1st Cir. 1972) (in civil   rights   actions   members   of   the   class   are   often   “incapable   of   specific   enumeration.")   (quoting   Committee's   Notes   to   Revised   Rule   23,   3B   Moore’s   Federal   Practice 23.0 [10-2](2d ed. 1969); see also, Doe v. Charleston Area Med. Ctr., Inc., 529 F.2d 638, 645 (4th Cir. 1975) (size of class can be speculative where only injunctive or equitable relief is requested); Carpenter v. Davis, 424 F.2d 257, 260 (5th Cir. 1970); Westcott v. Califano, 460 F. Supp. 737, 744 (D. Mass. 1978); Jane B. v. New York City
20

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 21 of 50
Dept. of Social Servs., 117 F.R.D. 64, 70 (S.D.N.Y. 1987) (precise determination of proposed class not a prerequisite to maintenance of a class action).
In  fact,  a  proposed  class  is  “more  likely  to  satisfy  the  numerosity  requirement  if  it  is   difficult to identify potential  class  members.”    In re Tyco International, LDT., No. MD-021335-PB, 2006 WL 2349338 at *1 (D.N.H. Aug. 15, 2006) (citing Andrews, 780 F.2d at 132); see also, Advertising  Special  Nat.  Ass’n  v.  Federal  Trade  Comm’n, 238 F.2d 108, 119 (1st Cir. 1956) (impracticability of joinder strengthened by fact that class membership is not fixed but number changes from year to year). This is particularly true where only declaratory and injunctive relief is sought. In such matters, district courts may draw reasonable inferences from the facts presented to find the requisite numerosity and proceed on a reasonable estimate of the proposed class size. See Doe v. Flowers, 364 F. Supp. 953, 954 (N.D. W.Va. 1973), aff’d. mem., 416 U.S. 922 (1974); see also, 7 Newberg on Class Actions §23:2 (4th ed. 2011) ("Courts generally have not required detailed proof of class numerousness in government benefit class actions when challenged statutes or regulations are of general applicability to a class of recipients, because those classes are often inherently very large.").
In addition to considering the number of persons within a proposed class, courts also examine the practicability of joining all the plaintiffs. In this analysis, significant weight is given to factors such as the   plaintiffs’   ability   to   bring   their   own   separate   actions,   their   geographical diversity and the likely presence of unidentified, future class members. Van Meter, 272 F.R.D. at 282 (class contained present and future nursing home residents whose chronic disabilities and segregation made the maintenance of separate actions impractical); Rolland, 1999 WL 3415562 at *3-5; Jordan v. Los Angeles, 669 F.2d 1311, 1319 (9th Cir.
21

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 22 of 50
1982)   (“The   joinder   of   unknown   individuals is inherently impractical”),   vacated on other grounds, 459 U.S. 810 (1982); National Ass'n. of Radiation Survivors v. Walters, 111 F.R.D. 595, 599 (N.D. Cal. 1986).
These factors weigh strongly in favor of class certification here. The named plaintiffs are individuals with serious mental illness who are institutionalized at NHH or Glencliff or at serious risk of institutionalization in these facilities because of the defendants’ failure to provide community services that are critical to class members being able to live in an integrated setting. See Simpatico Aff., ¶¶ 13-16; Boardman Aff., ¶¶ 1922, 27; Curran Aff., ¶¶ 18-21; and Sudders Aff., ¶¶ 13-16, 18, 26. They request injunctive and declaratory relief on behalf of themselves and all persons in New Hampshire with serious mental illness who are similarly situated. They seek to represent the interests of at least several hundred class members, all of whom have serious mental illness and are institutionalized at NHH or Glencliff or are at serious risk of institutionalization in these facilities because  of  the  defendants’  failure  to  provide  community  services.
The disability, geographic diversity, segregation, and size of the class make joinder of all members impracticable. See, e.g., Armstead v. Pingree, 629 F. Supp. 273, 279 (M.D. Fla. 1986) (“Considering   plaintiffs'   confinement,   their   economic   resources,   and   their   mental handicaps, it is highly unlikely that separate actions would follow if class treatment were denied”). As was true of the plaintiffs in Armstead, it would be extremely difficult, and thus impracticable, for the members of the proposed class to maintain individual suits against the defendants, particularly given the persistent nature of their disabilities, their limited financial resources, and their segregation in hospital or nursing facilities. Therefore, it is highly unlikely that individual class members could institute
22

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 23 of 50
separate suits for declaratory and injunctive relief in this case in the event class certification is denied. See, e.g., Van Meter, 272 F.R.D. at 282; Raymond v. Rowland, 220 F.R.D. 173, 179 (D. Conn. 2004) (multiple factors indicate that disabled and impoverished nursing home residents unlikely to maintain individual actions for relief).
Moreover, the proposed class members, individuals with a serious mental illness comprise "precisely the type of group which class treatment was designed to protect." Armstead, 629 F. Supp. at 279. Under these circumstances  “the  difficulty  or  inconvenience   of joining all members makes class litigation desirable." Koster v. Perales, 108 F.R.D. 46, 49 (E.D.N.Y. 1985) (quoting Northwestern National Bank of Minneapolis v. Fox & Co., 102 F.R.D. 507, 511 (S.D.N.Y. 1984)); Risinger v. Concannon, 201 F.R.D. 16, 19 (D. Me. 2001) (difficulties associated with identifying and formally joining a geographically dispersed group of more than 391 disabled children and families made joinder impractical).
Furthermore, joinder is impracticable in the instant case because the class includes not only currently institutionalized individuals, but also individuals who are at serious risk of institutionalization in the future.19 Where “[t]he alleged class also includes unnamed, unknown future” class members who will allegedly be harmed by the defendants’ conduct and policies, courts have held that joinder is “certainly impracticable.” Jack v. Am. Linen Supply Co., 498 F.2d 122, 124 (5th Cir. 1974); see also Phillips v. Joint Legislative Comm., 637 F.2d 1014, 1022 (“the requirement of Rule
19 In their earlier Motion to Strike, the defendants did not challenge the sufficiency of the numbers of class members but argued that the hundreds or thousands of persons with mental illness in New Hampshire somehow could be practically joined because they all lived in the same state and were easily identifiable. This claim is simply not credible. Prosecuting hundreds of separate lawsuits on behalf of hundreds of individuals presented a serious concern to the Supreme Court in determining how States should accommodate the competing needs of institutionalized persons. See Olmstead v. L.C., 527 U.S. 581, 602 (1999).
23

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 24 of 50
23(a)(1) is clearly met, for joinder of unknown individuals is certainly impracticable”) (internal quotations omitted))
Therefore, in light of its size and the circumstances of those persons who compose it, the proposed class satisfies the requirements of Rule 23(a)(1).
E. Members of the Class Share Common Questions of Law and Fact. Rule 23(a)(2) requires that the claims of a proposed class share common questions of law or fact. As many courts have noted, "[t]he threshold of 'commonality' is not high." Jenkins v. Raymark Indus., Inc., 782 F.2d 468, 472 (5th Cir. 1986); Newton v. Merrill Lynch, Pierce, Fenner & Smith, Inc., 259 F.3d 154, 181-83 (3rd Cir. 2001); Faherty v. CVS Pharmacy Inc., 2011 WL 81078 at *2 (D. Mass. Mar. 9, 2011) (commonality rule aimed in part   at   “determining   whether   there   is   a   need   for   combined   treatment   and   a   benefit   to   be   derived  there  from”)  (quoting  Jenkins, 782 F.2d at 472). Rule 23(a)(2) requires only one common factual or legal issue, the resolution of which will affect all or a significant number of putative class members. See Lightbourn v. County of El Paso, 118 F.3d 421, 426 (5th Cir. 1997) (commonality found when class of individuals with different disabilities and accommodation needs were impacted by the same governmental inaction); see also, Mulligan v. Choice Mortgage Corp. USA, No. Civ. 96596-B, 1998 WL 544431 at *3 (D.N.H. Aug. 11, 1998) ("Because the class need share only a single legal or factual issue at this stage of the analysis, the commonality prerequisite ordinarily is easily established"); Conner B. v. Patrick, 272 F.R.D. 288, 293 (D. Mass. 2011) (“Commonality  is  easily  satisfied  in  part  because  ‘there  need  be  only  a  single issue common to  all  members  of  the  class.’”)  (quoting  Natchitoches  Parish  Hosp.  Serv.  Dist.  V.  Tyco  Int’l,   Ltd., 247 F.R.D. 253, 263-64 (D. Mass. 2008); 1 Newberg on Class Actions § 3:20 (5th ed.
24

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 25 of 50
2011). While Wal-Mart held that the class members’ claims must depend on a common issue  of  law  or  fact  capable  of  being  resolved  “in  a  single  stroke,”  Wal-Mart re-affirmed that not every issue of law or fact need be common to the entire class, since “even a single common question will do. Wal-Mart, 131 S. Ct. at 2556 (citations and internal quotations omitted).20
Courts have easily identified commonality in class actions that seek injunctive and declaratory relief. See, e.g., Baby Neal ex rel. Kanter v. Casey, 43 F.3d 48, 57 (3d Cir. 1994) (“Injunctive  actions  ‘by  their  very  nature  often  present  common  questions satisfying Rule 23(a)(2)"); Anderson   v.   Dep’t   of   Public   Welfare,   1 F. Supp. 2d 456, 461 (E.D. Pa. 1998)   (“Commonality   is   easily   established   in cases seeking injunctive relief”).   This is particularly the case with respect to classes such as in this action, which challenge governmental policies and practices that discriminate under federal law in a manner common to the class. See, e.g., Califano v. Yamasaki, 442 U.S. 682, 700-703 (1979) (affirming   class   treatment   where   relief   sought   involved   members’   entitlement   to   request   a   hearing prior to recoupment of Social Security benefits); Van Meter, 272 F.R.D. at 282 (finding commonality where the state agency’s   “course   of   conduct”   presents   questions   common to all class members, implicates a common set of federal statutes, and the class seeks relief from systemic barriers to proper treatment); Colon v. Wagner, 462 F. Supp. 2d 162, 174 (D. Mass. 2006) (certifying class of shelter benefit recipients alleging the constitutional inadequacy of statewide termination notices); Ass'n for Disabled Americans v. Amoco Oil Co., 211  F.R.D.  457,  463  (S.D.  Fla.  2002)  (“Plaintiffs’  allegations  of  common  
20 Federal decisional law post-Wal-Mart recognizes that while Wal-Mart provides   “…guidance   on   how   existing  law   should  be  applied  to  expansive,  nationwide  class  actions,”  it  does  not  preclude  injunctive  relief   designed to remedy systemic deficiencies in a state service system. Connor B., 2011 WL 5513233 at * 3, 5.
25

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 26 of 50
discriminatory practices of ADA noncompliance, as a matter of law, satisfy the requirement that the representative plaintiffs share at least one question of fact or law with the grievances of  the  putative  class.”)  (citations  omitted).  
Commonality may exist even where class members are not identically situated, or where their injury does not arise in exactly the same way. See Milonas v. Williams, 691 F.2d 931, 938 (10th Cir. 1982) (“factual differences in the claims of the class members should not result in a denial of class  certification  where  common  questions  of  law  exist”)   (citations omitted). Moreover, where there are common discriminatory practices alleged, “…the   actions   of   the   defendant   need   not   affect   each   member   of   the   class   in   the   same   manner.”    Arnold v. United Artists Theatre Circuit, Inc., 158 F.R.D. 439, 448-49 (N.D. Cal. 1994) (quoting Walthall v. Blue Shield of Calif., 1977 WL 34 (N.D. Cal. 1977); see also, Curtis v. Commissioner, Maine Dep’t. of Human Servs., 159 F.R.D. 339, 341 (D. Me. 1994) (“Where a question of law refers to standardized conduct of the defendant towards members of the proposed class,  commonality  is  usually  met”);;  Marisol A. v. Giuliani, 126 F.3d 372, 376-7 (2nd Cir. 1997) (affirming district court's certification of class of children in foster care system despite varying reasons for placement and varying injuries among class members); Christina A. ex rel. Jennifer A. v. Bloomberg, 197 F.R.D. 664, 667-68 (D. S.D. 2000) (the  fact  that  prison  conditions,  policies  and  procedures  “affect  plaintiffs differently does not defeat the commonality of their claims.”);; Boulet v. Cellucci, 107 F. Supp. 2d 61, 81 (D. Mass. 2000) (class of persons with intellectual disabilities waiting for community support services shared a common legal theory despite differences in medical and support needs of each individual); Rolland, 1999 WL at *7 (same).
26

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 27 of 50
Wal-Mart does not require that every class member must be affected in an identical way by the defendants’   conduct.      Indeed, circuit courts, district courts in the First Circuit, and other courts considering systemic deficiencies have continued to certify classes post-Wal-Mart,  where  the  focus  is  on  the  defendant’s  conduct,  as  evidenced  by  its   policies or practices, even when challenged practices do not have the identical effect on all named plaintiffs and class members. See e.g. Ross v. RBS Citizens, N.A., 667 F.3d 900, 909 (7th Cir. 2012) (unlike Wal-Mart, there is no need for proof of discriminatory intent and no need for individualized determinations of damages, even though there may be   differences   in   how   the   defendants’   practices   affected   individual   class   members);;   McReynolds v. Merrill Lynch, Pierce, Fenner & Smith, 672 F.3d 482 (7th Cir. 2012) (reversing denial of class certification in disparate impact case where common questions exist regarding company policies and their contributory effect on alleged employment discrimination, even if individual employee decisions may also be a factor); Rodriguez v. Countrywide Home Loans, __ F.3d __, 2012 WL 4041448 (5th Cir. Sept. 14, 2012) (certification affirmed in case seeking injunctive relief based upon challenge to defendant’s   debt collection practices); Sullivan v. D.B. Investments, 667 F.3d 273, 300 (3d Cir. 2011) (class certification upheld since there were common questions that generate   common   answers,   including   “answers   to   questions   about   [defendants’]   alleged   misconduct  and  the  harm  it  caused”  class  members); Connor B., 272 F.R.D. at 296 (that harms suffered by unnamed class members differs from that experienced by named plaintiffs does not undermine commonality or typicality); George   v.   Nat’l   Water   Main   Cleaning Co., 2012 WL 4468768 (D. Mass. Sept. 27, 2012) (court certifies class based upon  defendants’  practice  of  compensating  employees  at  lower  than  the  prevailing  wage  
27

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 28 of 50
because a common injury – unlawful compensation – flows from a common source, despite differences in worker classification, pay scales, type of work, type of contract, location, and hours worked); Glass Dimensions, Inc. v. State Street Bank & Trust Co., 2012 WL 5416443 (D. Mass. Aug. 22, 2012) (court certifies ERISA class based upon common questions despite differences in the type of investment funds and rates of return); Lyons v. Citizen Financial Group, 2012 WL 5499878 (D. Mass. Nov. 9, 2012) (class certified in wage case since evidence is common to most, even if not all, branch managers, despite differences in wages paid or employment duties); LaRocque v. TRS Recovery Services, 2012 WL 2921191 (D. Me. July 17, 2012) (court certifies several damage classes in federal debt collection case based upon common overdraft procedure, despite differences among consumers and transactions); D.L. v. District of Columbia, 277 F.R.D.   38,   46   (D.D.C.   2011)   (“The   reasons   for   [the]   common   injury   do   not   also   have   to   be  common  to  all  members  of  the  class.”);; Churchill v. Cigna Corp., 2011 WL 3563489 (E.D. Pa. Aug. 12, 2011) (plaintiff class denied the benefit of treatment for Autism Spectrum  Disorder  stated  common  claims   as  well  as  “'common  answer   apt   to   drive  the   resolution  of  the  litigation’”  regardless  of  their  different  conditions,  treatment  needs,  and   abilities to benefit from ABA therapy. Id. at *3 (citing Wal-Mart); In re Rail Freight Fuel Surcharge Antitrust Litigation, 2012 WL 2870207 (D.D.C. June 21, 2012) (“[P]laintiffs’  burden  at  the  class  certification  stage  is  to  demonstrate  that  the  elements  of   their   claim   are   ‘capable   of   proof   at   trial   through   evidence that is common to the class rather  than  individual  to  its  members’”).
Courts also continue to certify classes in ADA cases post-Wal-Mart, finding that commonality may exist even where class members are not identically situated. See, e.g.,
28

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 29 of 50
Oster, 2012 WL 685808 at * 5 (rejecting defendants' challenge under Wal-Mart that class members do not meet the commonality because they suffer different service reductions); Lane, 283 F.R.D. at 598 )“As  in  other  cases  certifying  class  actions  under  the  ADA  and   Rehabilitation Act, commonality exists even where class members are not identically situated.”);;  Henderson v. Thomas, 2012 WL 3777146 (M.D. Ala. Aug. 30, 2102) (class certification granted where class of prisoners with HIV alleged that the Alabama Department   of   Corrections’   policy   of   segregating   inmates   with   HIV   from   the   general   prison population violated Title II of the ADA).
In a case that shares many similarities with this lawsuit, the district court in Oregon certified a class asserting claims under the integration mandate of Title II of the ADA and the Rehabilitation Act. Lane, 283 F.R.D. at 595. The Lane court recognized that  “commonality  only  requires  a  single  common  question  of  law   or fact and held that there was both a common question of law and fact. Lane, 283 F.R.D. at 598 (emphasis in original). After carefully analyzing the evidence, the common contentions, and the enhanced requirements imposed by Wal-Mart, the court held that a common question of law   was   “whether   the   defendants   have   failed   to   plan,   administer,   operate   and   fund   a   system that provides employment services that allow individuals with disabilities to work in   the   most   integrated   setting.” Id. The common question of fact was whether the plaintiffs were denied supported employment services in integrated settings for which they are qualified. Id.
The court in Lane held  that  the  defendants’  standardized  conduct  was  the  proper   frame for considering whether commonality was met, regardless of whether some plaintiffs may need more or different employment services than others. Id. The court
29

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 30 of 50
recognized that even post-Wal-Mart:     “[a]s  in   other  cases  certifying  class   actions  under   the ADA and Rehabilitation Act, commonality exists even where class members are not identically  situated.”    Id. The Lane court  specifically  rejected  the  defendants’  argument   that it was necessary at the class certification stage for the named plaintiffs to prove that they and all putative class members are unnecessarily segregated and would benefit from employment services. Id.      The   court   explained   “[t]hat   is,   in   effect,   the answer to the common question and not the common question of whether they are being denied supported  employment  services  for  which  they  are  qualified.”    Id. (emphasis added).
The  court  was  particularly  troubled  by  the  defendants’  argument  that  “differences   with respect to the needs and preferences of persons with disabilities would always preclude  the  certification  of  a  class  in   virtually  all   ADA  Title   II  cases.”     Id. The court went on to conclude that the case could be resolved, as required by Wal-Mart,   “in   one   stroke”  with  an  injunction  that  requires  the  defendants to provide supported employment services to all qualified class members, consistent with their individual needs. Id. at 602. The court noted that rather than engage in an analysis of individual class member’s circumstances, the type of relief sought by plaintiffs  “focuses  on  the  defendants’ conduct, not on the treatment needs of each class member. It is aimed at providing class wide alternatives to segregated employment, regardless of a person’s individualized support needs, by modifying the way defendants fund, plan and administer the existing employment  service  system.”    Id.
The parallels between Lane and this case are significant. As in Lane, the plaintiffs here are challenging the defendants’   discriminatory   planning,   administration,   operation and funding of a service system that contributes to the institutionalization and
30

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 31 of 50
segregation of individuals with serious mental illness. This is exactly the same common contention that the Lane court found satisfied commonality. In addition, while there may be, and inevitably will be, differences among Lynn E. class members, such differences are not germane to commonality where there are, as there were in Lane, common questions of fact, common legal claims, common contentions, and common answers. Just as Lane recognized   that   the   court   did   not   need   to   determine   each   class   member’s   individual needs, the Court in this case does not need to determine what services each class member needs to live in an integrated setting.
Viewed in that context, this proposed class meets the commonality threshold as a result of multiple questions of law common to the class, all of which admit of a common answer  that  would  resolve  the  claims  of  the  plaintiff  class  “in  one  stroke”  including:  
(a) Whether defendants are violating the ADA and Section 504 of the Rehabilitation Act by failing to provide community mental health services needed to avoid unnecessary institutionalization at NHH and Glencliff; (b) Whether defendants are violating the ADA and Section 504 of the Rehabilitation Act by administering their mental health system in a way that discriminates against the plaintiff class; (c) Whether defendants are violating the ADA and Section 504 of the Rehabilitation Act by failing to serve plaintiffs and the plaintiff class in the most integrated setting appropriate to their needs;
31

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 32 of 50
(d) Whether the defendants have developed a comprehensive and effectively working plan for serving plaintiffs and the plaintiff class in the community instead of institutional settings;21 and (e) Whether the defendants are violating PASRR provisions of the Nursing Home Reform Act by failing to properly determine whether individuals referred to Glencliff could be served in more integrated settings. Similarly, there are multiple, common contentions of fact that admit of a common answer  which  would  resolve  all  of  the  claims  of  the  class  “in  a  single  stroke”  including: (a) Whether the defendants’  policies,  procedures,  and  practices  concerning  the   administration and funding of their community services system deny the plaintiff class the opportunity to receive services in the most integrated setting. There is ample evidence that the defendants fail to provide an adequate array of community services to accommodate the needs of persons with serious mental illness institutionalized in NHH or Glencliff, or at serious risk of such institutionalization. See Sudders Aff., ¶¶ 13-17; Simpatico Aff., ¶¶ 13-16, 18-21; Boardman Aff., ¶¶ 19-22, 24-25; and Curran Aff., ¶¶ 18-24; (b) Whether, as a result of the defendants’  policies,  procedures,  and  practices   that deny persons with serious mental illness reasonable access to, and a sufficient amount of community services, the members of the plaintiff class are unnecessarily segregated in institutions. See Simpatico Aff., ¶¶ 13-16, 19-21;
21 This common question arises if defendants assert affirmative defenses under Olmstead v. L.C. ex.rel. Zimring, 527 U.S. 581(1999). The existence of a common question of law, which can include a common defense, makes class certification appropriate. Smilow v. Southwestern Bell Mobile Systems, Inc., 323 F.3d 32, 39 (1st Cir.  2003)  (“[Both  the  factual  basis  for  and  the  legal  defense  of  waiver  present  common  issues  for  all   class  members”)  (citation  omitted).
32

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 33 of 50
Boardman Aff., ¶¶ 19-22, 24, 27; Curran Aff., ¶¶ 18-20, 22, 25; and Sudders Aff., ¶¶ 17-20, 23-26; (c) Whether the defendants fail to administer their community service system for persons with serious mental illness in a manner that accommodates the needs of members of the plaintiff class. See Simpatico Aff., ¶¶ 13, 17-21; Boardman Aff., ¶¶ 19, 24-27; Curran Aff., ¶¶ 18, 22-25; and Sudders Aff., ¶¶ 24-26; and (d) Whether the defendants fail to develop and implement a PASRR program that timely and appropriately assesses whether the needs of persons with serious mental illness seeking admission to Glencliff could be met in a more integrated community-based setting. See Simpatico Aff., ¶¶ 13, 16, 19-21; Boardman Aff., ¶¶ 19-20, 23-27. These common contentions (the defendants’  failure  to  administer  a  system  which   denies institutionalized persons or those at serious risk of institutionalization the opportunity to receive services in integrated settings) raise common facts, based upon a common   legal   claim   (the   ADA’s   Title   II   integration   mandate),   applicable   to   all   class   members. They are susceptible to common answers, based upon common proof about the defendants’  conduct, as evidenced by the defendants’  policies,  procedures,  and,  most   importantly,   their   practices.      These   contentions   are   “capable   of   class wide   resolution”,   since  a  “determination  of  its  truth  or  falsity  will  resolve  an  issue”  (whether  the  defendants fail   to   provide   a   sufficient   supply   of   community   services)   “that   is   central   to   each   one   of   the  claims  in  one  stroke.”    Wal-Mart, 131 S. Ct. at 2551. The common thread or "glue" which unites their common factual and legal claims is the fact that members of the plaintiff class are subject to, or at serious risk of, unnecessary institutionalization and segregation as a
33

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 34 of 50
result   of   the   defendants’   conduct   – specifically,   the   defendants’   failure   to   provide  
community services necessary to avoid the institutionalization of persons with serious
mental illness. Whether currently institutionalized in NHH or Glencliff, or at serious risk of
institutionalization in these facilities, the plaintiff class is suffering as a result of a common
course of conduct by defendants, from which arises a set of common legal claims and factual contentions.22 See Simpatico Aff., ¶¶ 13-21; Boardman Aff., ¶¶ 19-27; Curran
Aff., ¶¶ 18-25; and Sudders Aff., ¶¶ 18-20, 24-26.
1. Neither M.D. v. Perry nor Jamie S. v. Milwaukee Public Schools Preclude Class Certification in This Case.
In their Reply Memorandum in Support of their Motion to Strike (Doc. 48-1), the
defendants relied heavily on two recent court of appeal decisions, M.D. v. Perry, 675
F.3d 832 (5th Cir. 2012), and Jamie S. v. Milwaukee Public Schools, 668 F.3d 481 (7th
Cir. 2012), neither of which undermine this analysis nor alter this conclusion. In M.D.,
the Fifth Circuit concluded that the district court failed to explain how systemic
deficiencies in Texas's child welfare system that arose from three separate and unrelated
legal claims allowed a common solution that would address the claims of all class members.23 At the same time, the Fifth Circuit identified a number of practices that
22 See Statement of the Department of Justice on Enforcement of the Integration Mandate of Title II of the Americans with Disabilities Act and Olmstead v. L.C., at http://www.ada.gov/olmstead/q&a_olmstead.htm (“[T]he ADA and the Olmstead decision extend to persons at serious risk of institutionalization or segregation and are not limited to individuals currently in institutional or other segregated settings. Individuals need not wait until the harm of institutionalization   or   segregation   occurs   or   is   imminent…   a   plaintiff could show sufficient risk of institutionalization to make out an Olmstead violation if a public entity’s   failure   to   provide   community   services   or   its   cut   to   such   services   will   likely   cause a decline in health,  safety,  or  welfare  that  would  lead  to  the  individual’s  eventual  placement  in  an  institution.”). 23 Moreover, the appeals court was understandably troubled by the lack of coherence between three quite different claims under three quite different constitutional provisions, particularly since the substantive due process one appeared to require an individualized inquiry of harm. Id. at 843. It suggested that the district court should consider the possibility of subclasses for each claim, since each presented a quite different contention, and different answer to the contention. Id. at 848. Here, of course, there are really only two claims, one involving segregation in NHH and Glencliff under two related statutes, the ADA and the Rehabilitation Act, and the other involving the failure to properly screen and divert admissions to Glencliff
34

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 35 of 50
would satisfy commonality requirement, such as the lack of sufficient staffing or a structural deficiency in the system. As the Fifth Circuit explained:
Rather, the class claims could conceivably be based upon an allegation that the State engages in a pattern or practice of agency action or inaction – including a failure  to  correct  a  structural  deficiency  within  the  agency….     M.D., 675 F.3d at 847. Here, unlike M.D., the plaintiffs’  Complaint  focuses  on  a  structural  deficiency   – the lack of specific community services required to avoid needless institutionalization at NHH   and   Glencliff   that   directly   result   from   the   defendants’   planning   and   administration of their community services system. This deficiency can be remedied by an injunction to provide those services, which would, in a single stroke, address the claims and harms of each class member. Similarly, Jamie S. is even less relevant. The Seventh Circuit was understandably troubled by the combination of two factors that simply are not present here. First, the Individuals with Disabilities Education Act (IDEA) requires, on its face, individualized determinations of each child's education needs and precludes judicial relief without the exhaustion of all administrative remedies. The class action case in Jamie S. sought to circumvent that requirement by challenging a systemic deficiency in Milwaukee's child find practices. The Seventh Circuit found that the class definition was fatally flawed and could not be invoked to accomplish such circumvention. Jamie S., 668 F.3d. at 493-96. Neither the ADA nor the Rehabilitation Act impose such exhaustion limitations nor demand such individualized determinations.
as required by the Nursing Home Reform Amendments (NHRA) to the Medicaid Act. In no sense do the common questions in this case involve the type of "super-claim" that the Fifth Circuit found so troubling in M.D.
35

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 36 of 50
Second, and perhaps more importantly, the remedy ordered by the district court
established an individualized child review process that substituted for the city's child find
process and resulted in the issuance of separate injunctive orders for each child. The
Seventh Circuit concluded that these separate injunctions demonstrated that the remedial
order did not generate a common answer and a single injunction that applied to the class as a whole.24 Id. at 498-99. Here, the Court is not involved in an inquiry into individualized relief. 25 Instead, it only will determine whether it is appropriate to issue a
single injunction requiring the defendants to develop additional community services that
would avoid class members’   needless   segregation in NHH and Glencliff and, instead,
allow these individuals to live in the most integrated setting.
In short, the plaintiff class has established commonality precisely because they have
identified both a common contention -- that existing community mental health services are
insufficient to avoid unnecessary institutionalization -- as well as a common injury --
discriminatory segregation. See Simpatico Aff., ¶¶ 13-21; Boardman Aff., ¶¶ 19-27;
Curran Aff., ¶¶ 18-25; and Sudders Aff., ¶¶ 13-26. The common contention, moreover, is
“of  such  a  nature  that  it  is  capable  of  class  wide  resolution...”    Wal-Mart, 131 S. Ct. at 2551. The modifications that the plaintiffs  seek  to  the  State’s  community  mental  health  system  can  
24 That there is nothing in Jamie S. which precludes a finding of commonality or precludes class certification here is underscored by a subsequent decision of the same court of appeals that, post-Wal-Mart, certified a class of African-American employees who alleged racial discrimination in employment promotion and compensation practices. McReynolds v. Merrill Lynch, Pierce, Fenner, and Smith, Inc., 672 F.3d 482 (7th Cir. 2012) (certifying a class for liability purposes because this phase of an employment discrimination case, as opposed to the damage claims, can be resolved by a single injunction and does not require individualized remedial orders). 25 As more fully discussed in Section IV, infra, neither an assessment of commonality for the purposes of class certification, nor even a determination of liability under federal law, requires this Court to evaluate the individual clinical conditions, support needs, or the residential preferences of each one of the hundreds of persons in New Hampshire who are in, or at risk being admitted to, NHH or Glencliff. Rather, this Court can determine that a violation of federal law has occurred, and remedy that common legal violation, without the type of individualized liability determinations at issue in Wal-Mart or M.D.
36

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 37 of 50
be achieved through a single injunction providing relief to the class as a whole. Id. at 2560. The class injuries can be redressed by the development of additional community-based services such that they may avoid being subjected to unnecessary segregation. Therefore, the plaintiffs  have  presented  both  the  common  questions  and  the  “common  answers  apt  to   drive  the  resolution  of  the  litigation.”   Id. at 2551. Consistent with long standing precedent in class actions alleging systemic civil rights violations, the Court should find there are questions of law and fact common to the class.
F. The Claims or Defenses of the Named Representatives Are Typical of the Class.
The third component of Rule 23(a) requires that the representatives' claims for relief be typical of the claims of the absent class members. Fed. R. Civ. P. 23(a)(3). The typicality requirement does not demand a showing of complete identity between the legal claims of a representative and each class member, but only "...a showing of sufficient interrelationship between the claims of the representative and those of the class so that adjudication of the individual claims will necessarily involve the decision of common questions affecting the class." 1 Newberg on Class Actions, §3:29 (5th ed. Nov. 2011); see also, McLaughlin v. Liberty Mut. Ins. Co., 224 F.R.D. 304, 310 (D. Mass. 2004) (in determining typicality, the central inquiry is whether class representatives’  claims  “have  the   same essential characteristics as the claims of other members of the plaintiff class.”)(citations   omitted).      For   this   reason,   typicality   is   achieved   when   the   class   representatives generally "possess the same interest and suffer the same injury" as unnamed class members. Gen. Tel. Co. of Sw. v. Falcon, 457 U.S. 147, 156 (1982) (quoting East Texas Motor Freight Sys. v. Rodriguez, 431 U.S. 395, 403 (1977); Jones v. Shalala, 64 F.3d 510, 514 (9th Cir. 1995); California Rural Legal Assistance Inc. v. Legal Services Co., 917
37

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 38 of 50
F.2d 1171, 1175 (9th Cir. 1990), modified, 937 F.2d 465 (9th Cir. 1991). “[T]he critical inquiry is whether the class representative’s claims have the same essential characteristics of those of the putative class. If the claims arise from a similar course of conduct and share the same legal theory, factual differences will not defeat typicality.” James v. City of Dallas, 254 F.3d 551, 571 (5th Cir. 2001) (quoting 5 Moore’s Federal Practice ¶ 23.24[4] (3d ed. 2000)).
Applying these principles, courts in this Circuit have held that the typicality requirement   is   met   when   the   plaintiffs’   claims   “arise   from   the   same   event   or   practice   or   course  of  conduct  that  gives  rise  to  the  claims  of  other  class  members”  and  are  “based  on  the   same  legal  theory.”    Tyrell, 2010 WL 174287 at *5 (quoting Garcia-Rubiera, 570 F.3d at 460); In re Tyco International, Ldt.,  2006  WL  2349338  at  *6  (“Because  the  proposed class representatives and the members of the class are aggrieved by the same conduct and rely on the same legal theories, there is substantial identity between their claims with respect to most of the relevant issues. This is sufficient to support a   finding   of   typicality.”);;   Griffin v. Burns, 570 F.2d 1065, 1073 (1st Cir. 1978) (typicality does not require court to recreate the probable actions of each class member when all members experienced the same deprivation of a fundamental right); Rolland, 1999 WL 34815562 at *7 (certification is appropriate where the plaintiffs’ claims  are  “broadly  typical”  of  the  class  of  nursing  home   residents who have not been provided appropriate services or placement in the community); Guckenberger v. Boston Univ., 957 F. Supp. 306, 326 (D. Mass. 1997) (despite different disabilities and accommodation needs, plaintiffs are typical of a class of students with learning disabilities because they are subject to the same allegedly discriminatory policy and practice); Curtis v. Commissioner, Maine Dep’t. of Human Servs., 159 F.R.D. 339, 341 (D.
38

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 39 of 50
Me. 1994) ("The typicality requirement is satisfied because . . . the representative Plaintiff is subject to the same statute and policy as the class members."); Neff v. VIA Metropolitan Transit Authority, 179 F.R.D. 185, 194 (W.D. Tex. 1998) (typicality standard satisfied in ADA case where named representatives are adversely affected by the same facilities, policies and practices as absent class members, regardless of the manner in which they have been injured).
As considered determinative by the district court in Lane, 283 F.R.D. at 598-99, the named plaintiffs satisfy the typicality requirement of Rule 23(a)(3) because they share numerous interests and characteristics with putative class members in that: (1) they all have serious mental illness; (2) they all are segregated, or at risk of segregation in an institution (either NHH or Glencliff); (3) they all are entitled to have their needs met in an appropriate community setting; and (4) it is very likely the vast majority of them could be discharged to the community with the specific services sought in this case; and 5) it is very likely that, if adequately informed, and given access to remedial services, they would choose community placement. See Simpatico Aff., ¶¶ 13-21; Boardman Aff., ¶¶ 19-27; and Curran Aff., ¶¶ 18-25.
Here,   the   named   plaintiffs   and   the   plaintiff   class’s   claims   arise   from   the   same   policies and practices of the defendants and are based on the same legal theory. The named plaintiffs suffer injuries that stem from legal violations that are typical of those experienced by the plaintiff class. See Simpatico Aff., ¶¶ 13-16; Boardman Aff., ¶¶ 19-22; Curran Aff., ¶¶ 18-22; and Sudders Aff., ¶¶ 16-21. The defendants, through their actions and inactions, are needlessly institutionalizing the named plaintiffs or placing them at serious
39

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 40 of 50
risk of institutionalization due to a lack of appropriate community-based services. See Sudders Aff., ¶¶ 25-26.
Like classes certified in other ADA cases, see Ault v. Walt Disney World Co., 692 F.3d 1212, 1216 (11th Cir. 2012)(difference  in   class  member’s  disability   or  needs  does   not undermine typicality) and Exhibit 14, that the named plaintiffs and plaintiff class may have varying conditions, enter the mental health system in different ways, or require different combinations of the services sought in the Complaint does not defeat a finding of typicality. The fact that class members may have different medical conditions or that they may require a slightly different service array does not justify denying class certification. See Rolland, 2008 WL 4104488 at *5. Instead, the requisite typicality exists because the defendants are needlessly institutionalizing class members in violation of Title II of the ADA and the NHRA. See Curtis, 159 F.R.D. at 341 (typicality is met because “the representative Plaintiff is subject to the same statute and policy as the class members.”); D.G. ex. Rel. Stricklin v. Devaughn, 594 F.3d 1188, 1199 (10th Cir.   2010)   (“[T]ypicality   exists where, as here, all class members are at risk of being subjected to the same harmful practices,  regardless  of  any  class  member’s  individual  circumstances”).
Typicality is established precisely because the named plaintiffs and the plaintiff class are aggrieved by the same limitations in community services, and their claims are based on the same legal theories regarding the discriminatory administration of the state mental health system. See Connor B., 272   F.R.D.   at   297   (“Because   Plaintiffs   have   identified   specific   systemic failures that expose the entire Plaintiff class to an unreasonable risk of harm, the typicality  requirement  is  satisfied.”)    
40

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 41 of 50
Finally, the named class members have a personal interest in this litigation and seek the same relief as the class, which is reasonably related to the harm experienced by all class members. Risinger, 201 F.R.D. at 22 (finding typicality where plaintiffs invoke the same legal provisions, allege the same system deficiencies and seek the same relief). Since the named  plaintiffs’  legal  theories  arise  from  the  same  course  of  conduct, and their common claims are broadly typical of the claims of the unnamed class, the requirements for typicality under Rule 23(a)(3) are satisfied.
G. The Class Representatives Fairly and Adequately Represent the Interest of the Class.
Rule 23(a)(4) requires that the representative plaintiffs in a class action fairly and adequately represent the interests of the entire class. In order to satisfy this requirement, two criteria must be met: (1) the attorneys representing the class must be qualified and competent; and (2) the class representatives must not have antagonistic or conflicting interests with the unnamed members of the class. See, e.g., Andrews v. Bechtel Power Corp., 780 F.2d 124, 130 (1st Cir. 1985); Lerwill v. Inflight Motion Pictures, Inc., 582 F.2d 507, 512 (9th Cir. 1978); Rodriguez v. Carlson, 166 F.R.D. 465 at 473 (E.D. Wash. 1996); In re Bank of Boston Corp. Securities Litigation, 762 F. Supp. 1525, 1534 (D. Mass. 1991). Both elements of Rule 23(a)(4) are met in this case.
1. Adequacy of Counsel Factors considered in determining the adequacy of the counsel in class actions include the attorneys' professional skills, experience, and resources. See, e.g., Andrews, 780 F.2d at 130 (counsel should be qualified, experienced and able to vigorously conduct the proposed litigation)(citations omitted); North American Acceptance Corp. Securities Cases v. Arnall, Golden & Gregory, 593 F.2d 642, 644 (5th Cir. 1979).
41

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 42 of 50
The Disabilities Rights Center (DRC) is the federally-designated protection and advocacy organization for the state of New Hampshire and is charged with protecting the rights of individuals with disabilities throughout the State. It brings to this case more than three decades of experience litigating on behalf of individuals with disabilities, both individually and in class action cases, as well as an extensive knowledge of, and experience working  within,  New  Hampshire’s mental health service system. It also is in direct contact with the Named Plaintiffs and numerous other class members through its ongoing outreach and intake processes.
Devine Millimet & Branch (Devine Millimet) is one of the leading private law firms in New Hampshire with a practice that includes complex state and federal litigation. Devine Millimet adds expertise in the area of complex litigation and trial skills, and provides extensive litigation support capabilities. The Center for Public Representation (CPR) has been involved in complex class action litigation on behalf of institutionalized persons with disabilities for over thirty-five years and has been lead counsel in numerous class action lawsuits throughout the country. The Judge David L. Bazelon Center for Mental Health Law (Bazelon Center) is nationally recognized for its expertise in disability law, including the rights of adults with mental disabilities to live in integrated settings. Since its founding in 1972, it has served as co-counsel in many similar class action cases around the country, including playing a significant role in the Olmstead v. L.C. case.
The plaintiffs' resources are adequate to represent the class competently and they have no other professional commitments which are antagonistic to, or which would detract from, their efforts to seek a favorable decision for the class in this case.
2. Adequacy of the Named Representatives
42

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 43 of 50
In order for the named representatives to be adequate to represent the class, their interests must coincide with those of the unnamed class members. See generally, Gen. Tel. Co. of Sw. v. Falcon, 457 U.S. 147 (1982). Additionally, the interests of the named plaintiffs must not be antagonistic to the unnamed class members. Andrews, 780 F.2d at 130. In the present case, the interests of the named plaintiffs and those of the plaintiff class coincide. They seek to avoid unnecessary institutionalization and to receive services in the community. See Complaint, ¶ 78-113. As the experts found, when provided adequate information and appropriate community alternatives, the vast majority of persons reviewed also would very likely choose to receive services in the community and avoid institutionalization if they were fully informed of, and provided access to, the services sought in this case. See Simpatico Aff., ¶¶ 13, 21; Boardman Aff., ¶¶ 19; Curran Aff., ¶¶ 18. As noted above, this conclusion can be confidently generalized to the larger population of individuals who are institutionalized or at risk of institutionalization at NHH and Glencliff. See Rogers Aff., ¶¶ 11,14. Therefore, there are no meaningful differences among the plaintiff class on these fundamental issues. See Simpatico Aff., ¶¶ 10, 13, 21; Boardman Aff., ¶¶ 14, 19; and Curran Aff., ¶¶ 12, 18. The named plaintiffs do not have interests antagonistic to other class members. Rather, they seek to vindicate legal rights shared by all members of the putative class. IV. The Defendants Have Acted or Refused to Act on Grounds Generally
Applicable to the Class, Making Final Injunctive or Declaratory Relief Appropriate. A class may be certified under Rule 23 (b)(2) when the prerequisites of Rule 23(a) are  met  and  “the  party  opposing  the  class  has  acted  or  refused  to  act  on  grounds  generally  
43

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 44 of 50
applicable to the class, thereby making appropriate final injunctive relief or corresponding declaratory  relief  with  respect  to  the  class  as  a  whole.”    Fed.  R.  Civ.  P.  23(b)(2).
Courts have long recognized that certification under subsection (b)(2) of Rule 23 is particularly important in, and an appropriate vehicle for, civil rights actions. See, e.g., Yaffe, 454  F.2d  at  1366  (“[t]he  conduct  complained  of  is  the  benchmark  for  determining  whether  a   subdivision (b)(2) class exists, making it uniquely suited to civil rights  actions….");;  Coley v. Clinton, 635 F.2d 1364, 1378 (8th Cir.  1980)  (“[A]  class  action  may  be  maintained  under   Fed.R.Civ.  P.  23(b)(2),  which  is  an  especially  appropriate  vehicle  for  civil  rights  actions.”);;   Hawkins ex  rel    v.  Comm’r of the New Hampshire Dept. of Health and Human Services, No. Civ. 99-143-JD,  2004  WL  166722  *  4  (D.N.H.,  Jan  23,  2004)  (“Classes  certified  under  Rule   23(b)(2)  ‘frequently  serve  as  the  vehicle  for  civil  rights  actions  and  other  institutional  reform   cases,’  including  cases  alleging deficiencies in government administered programs such as Medicaid.”)  (quoting  Baby Neal, 43 F.3d at 58-9) (other citations omitted).
Here the elements of Rule 23(b)(2) are satisfied, and class certification is appropriate, because plaintiffs allege systemic civil rights violations and seek declaratory and injunctive relief to benefit the class as a whole. This is exactly the type of litigation that the Federal Rules Advisory Committee anticipated would proceed under Rule 23(b)(2). See Fed. Rule Civ. P. 23(b)(2), Advisory Committee Notes, 1966 amendments (“Illustrative  are   various actions in the civil-rights field where a party is charged with discriminating unlawfully against a class, usually one whose members are incapable of specific enumeration.”).
In  New  Hampshire,  the  defendants  have  administered  the  State’s  system  of  services   for individuals with mental illness in a discriminatory manner by failing to provide the
44

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 45 of 50
community-based services required to avoid their unnecessary institutionalization. See Simpatico Aff., ¶¶ 13, 15-18; Boardman Aff., ¶¶ 19, 24-27; Curran Aff., ¶¶ 18, 21-25; and Sudders Aff., ¶¶ 24-26. The defendants are acting or refusing to act in a manner that equally affects and is generally applicable to the entire class. Id. Injunctive and declaratory relief  is  appropriate  precisely  because  it  will  resolve  the  legality  of  the  defendants’  conduct   towards the class and provide a remedy to the class as a whole. Id.
The Complaint seeks an injunction to alter that conduct and to compel compliance with federal law,  by  reasonably  modifying  New  Hampshire’s  community service system for persons with serious mental illness, so that the State offers services in integrated settings.      The   focus   on   the   defendants’ conduct in operating their community services system, and the resulting systemic claims of unnecessary segregation, are what have led virtually every court that has considered class certification in ADA, Rehabilitation Act, and Medicaid Act cases to certify a class, despite the obvious difference in the abilities, disabilities, and needs of class members. At the proper level of analysis for class certification purposes, the focus is, and should be, on the adequacy of the defendants’ actions and inactions in providing services in the most integrated setting for qualified persons with serious mental illness.
Differences concerning an  individual’s disability do not preclude certification in cases where those class members have suffered a common injury and where that injury can be redressed by a single injunction requiring the defendants to fund and operate their community service system consistent with federal law. Unlike M.D., 675 F.3d at 846, and Jamie S., 668 F.3d at 499-500, which explicitly sought or resulted in a judicial process that used court-created expert panels or a hybrid IEP system to determine for
45

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 46 of 50
each class member whether a separate injunctive order should issue, no individualized remedy is sought or needed here. Thus, the determinative factor that led both appeals courts to decline certification is absent in this case. Rather, because the Complaint seeks, and the ADA and Rehabilitation violations can be remedied by, a single injunction, certification of the proposed class is appropriate under Rule 23(b)(2).
Courts in this circuit have recognized several additional reasons why class certification is necessary and compelling in the context of civil rights actions such as this. In cases seeking only equitable relief, class certification is necessary to make sure that mandatory relief runs to benefit all of the members of the class. See Rolland, 1999 WL 34815562 at *9. In fact, the First Circuit explicitly rejected the requirement of demonstrating necessity for class certification where a defendant governmental agency claims it will extend equal benefits to all putative class members, even if only an individual injunction is issued. Dionne v. Bouley, 757 F.2d 1344, 1356 (1st Cir. 1985). Instead, the Court of Appeals has held that if injunctive or declaratory relief is appropriate with respect to the whole class, certification is proper. Id. Additionally, relief for the named plaintiffs will not automatically translate into appropriate and timely relief for class members. Id.; see also, Van Meter, 272 F.R.D. at 283-84; Rolland, 1999 WL 34815562 * 9. Even if adequate services were directed to the named plaintiffs, it would not follow that class members would be afforded similar relief, and certainly not with the level of immediacy their circumstances require.
The  defendants’  failure  to  establish  community-based services sufficient to avoid unnecessary institutionalization is precisely the kind of conduct Rule 23(b)(2) class
46

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 47 of 50
actions were designed to address. Certification is both appropriate and necessary in order to remedy the system-wide legal violations alleged in this case. V. Class Counsel Should Be Appointed Pursuant to Rule 23(g).
The named plaintiffs are jointly represented by the DRC, Devine Millimet, the Bazelon Center and the CPR, each of which brings unique resources, experience and skills to this case. The organizational qualifications of class counsel are described above at Section IV, D(1). Together, these four law firms request appointment as class co-counsel pursuant to Rule 23(g).
Amy Messer, the lead DRC attorney on this case, has over 20 years of experience representing individuals in state and federal court, including 12 years litigating cases exclusively on behalf of individuals with disabilities. Her practice has included class action litigation in the U.S. District Court and the First Circuit Court of Appeals, as well as individual representation at all levels of the state courts in New Hampshire. Attorney Messer is supported in this case by two DRC staff attorneys experienced in the representation of individuals with serious mental illness.
Attorney Elaine Michaud is a shareholder at the law firm of Devine Millimet and serves   as   Chair   of   the   firm’s   Litigation Department and Healthcare Practice Group Department. Attorney Michaud has 19 years of experience litigating cases involving complex healthcare issues. Attorney Daniel Will is also a shareholder at the law firm of Devine Millimet and specializes in complex litigation. Attorney Will has 18 years of state and federal litigation experience, including two years of clerking at the United States District Court and United States Court of Appeals prior to commencing practice. Attorneys Michaud and Will are supported in this case by several experienced associates.
47

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 48 of 50
Devine Millimet adds expertise in the area of complex litigation and trial skills, and provides extensive litigation support capabilities
Bazelon Center attorney Ira Burnim is a nationally-recognized expert concerning the rights of individuals with disabilities and has over 30 years of experience in the field of disability law. Mr. Burnim has served as lead counsel in numerous class actions involving the Americans with Disabilities Act, the Medicaid Act, Section 504 of the Rehabilitation Act, and the Due Process and Equal Protection Clauses of the Fourteenth Amendment. Attorney Jennifer Mathis has over 16 years of experience practicing disability law and has served as co-counsel in numerous class actions and individual cases involving Americans with Disabilities Act and Section 504 of the Rehabilitation Act.
CPR attorney Steven Schwartz has served as lead counsel in numerous class actions. Mr. Schwartz is a nationally-recognized expert concerning the rights of institutionalized individuals and has over 30 years of experience representing individuals with psychiatric and intellectual disabilities. Attorney Kathryn Rucker is co-counsel in two Massachusettsbased class action cases and has over 13 years of experience representing individuals with disabilities.
There is no conflict among counsel. Pursuant to Rule 23(g), plaintiffs request that this Court appoint DRC, Devine Millimet, the Bazelon Center and CPR as co-class counsel in this action. Hamilton v. First Am. Title Ins. Co., 266 F.R.D. 153, 173 (N.D. Tex. 2010) (appointing co-class counsel); Garcia v. Tyson Foods, Inc., 255 F.R.D. 678, 692 (D. Kan. 2009) (same).
48

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 49 of 50

VI. Conclusion and Request For Relief

For all the reasons set forth above, the named plaintiffs respectfully request that the

Court certify a plaintiff class consisting of:

all persons with serious mental illness who are institutionalized in New

Hampshire Hospital or Glencliff or at serious risk of institutionalization in these

facilities.

In addition, named plaintiffs respectfully request that this Court appoint the DRC, Devine

Millimet, the Bazelon Center and the CPR as co-class counsel in this action pursuant to Rule

23(g).

Dated: January 29, 2013

Respectfully submitted,

Lynn E., by her guardian, Barry Ellsworth; Kenneth R., by his guardian, Tri-County CAP, Inc./GS; Sharon B., by her guardian, Office of Public Guardian, Inc.; Amanda D., by her guardian, Louise Dube; Amanda E., by her guardian, Office of Public Guardian, Inc.; and Jeffrey D.,

Pro Hac Vice admission granted:
Steven Schwartz (MA BBO 448440) Kathryn Rucker (MA BBO 644697) CENTER FOR PUBLIC REPRESENTATION 22 Green Street Northampton, MA 01060 (413) 586-6024 SSchwartz@cpr-ma.org KRucker@cpr-ma.org

By their attorneys:
DISABILITIES RIGHTS CENTER
By: /s/ Amy B. Messer Amy B. Messer (NH Bar 8815) Adrienne Mallinson (NH Bar 17126) Aaron Ginsberg (NH Bar 18705) 18 Low Avenue Concord NH 03301 amym@drcnh.org adriennem@drcnh.org aarong@drcnh.org

Ira Burnim (D.C. Bar 406154) Jennifer Mathis (D.C. Bar 444510) JUDGE DAVID L. BAZELON CENTER FOR MENTAL HEALTH LAW

DEVINE, MILLIMET & BRANCH PROFESSIONAL ASSOCIATION
By: /s/ _Daniel Will__________

49

Case 1:12-cv-00053-SM Document 73-1 Filed 01/29/13 Page 50 of 50

1101 15th Street, NW, Suite 1212 Washington, D.C. 20005 (202) 467-5730 irab@bazelon.org jenniferm@bazelon.org

Elaine M. Michaud (NH Bar 10030) Daniel E. Will (NH Bar 12176) Joshua M. Wyatt (NH Bar 18603) 111 Amherst Street Manchester, NH 03101 (603) 669-1000 emichaud@devinemillimet.com dwill@devinemillimet.com jwyatt@devinemillimet.com

CERTIFICATE OF SERVICE
I hereby certify that on January 29, 2013 the foregoing document was filed electronically with the Clerk of the Court using the CM/ECF system, which sends notification of such filing to all counsel of record.
/s/ ___Amy Messer_______
January 29, 2013

50

 
 Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 1 of 32

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

U.S. DISTRICT COURT
DISTRICT OF NEWHOUPSHIRE
r[n 12 tm
FILED

Amanda D., et al., and others similarly situated,

Plaintiffs,

v.

Margaret W. Hassan, Governor, et al.,

Defendants. United States of America,

Civ. No. l:12-cv-53-SM

Plaintiff-Intervener,

v. State of New Hampshire,
Defendant.

CLASS ACTION SETTLEMENT AGREEMENT
I. Background and Introduction
A. This case involves the services, programs, and activities offered to thousands of persons with serious mental illness ("SMI") in the State of New Hampshire's mental health system. The State's mental health system includes the New Hampshire Hospital ("NHH") in Concord, NH, the Glencliff Home ("Glencliff) in Benton, NH, and services, programs, and activities at other sites, including but not limited to those offered by the community mental health programs and providers across the state.
B. In 2010 and 2011, the United States investigated the State of New Hampshire's mental health system to assess compliance with Title II of the Americans with Disabilities Act ("ADA"), 42 U.S.C. §§ 12101 et seq., and its implementing regulations, 28 C.F.R. pt. 35, and Section 504 of the Rehabilitation Act of 1973 ("Rehabilitation Act"), 29 U.S.C. §§ 794 et seq.
C. On April 7, 2011, the United States issued its findings and conclusions in a letter sent to the State of New Hampshire.

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 2 of 32
D. The New Hampshire Disabilities Rights Center, Inc. ("DRC") had earlier conducted an investigation of the State's mental health system and sent its own findings letter to the State on November 2, 2010.
E. On February 9, 2012, six individuals filed a class action Complaint on behalf of themselves and others similarly situated (collectively, "Plaintiffs"), in the United States District Court for the District of New Hampshire, alleging New Hampshire's administration of its mental health system violates the rights of individuals with SMI under the ADA, 42 U.S.C. §§ 12101 et seq., and the Rehabilitation Act, 29 U.S.C. §§ 794 et seq. In addition, the Plaintiffs alleged that the State and the other Defendant officials (collectively "the State" or "Defendants") have failed to comply with the requirements of the Nursing Home Reform Act ("NHRA"), 42 U.S.C. §§ 1396r et seq.
F. On March 27, 2012, the United States moved to intervene in the matter as PlaintiffIntervenor, and on April 4, 2012, the Court granted its motion to intervene.
G. The State denies all violations alleged by the Plaintiffs and the United States. By entering into this Settlement Agreement, the State does not admit to the truth or validity of any claim or allegation made against it by Plaintiffs or the United States. Nothing in this Settlement Agreement shall be constmed as an acknowledgement, an admission, or evidence of liability of the State under the ADA, the Rehabilitation Act, or the NHRA, or any federal or state law. This Settlement Agreement may not be used as evidence of Defendants' liability in any civil or criminal proceeding, except proceedings to enforce or implement this Settlement Agreement.
H. On September 17, 2013, the United States District Court certified a class comprised of:
All persons with serious mental illness who are unnecessarily institutionalized in New Hampshire Hospital or Glencliff or who are at serious risk of unnecessary institutionalization in these facilities.
At risk of institutionalization means persons who, within a two year period: (1) had multiple hospitalizations; (2) used crisis or emergency room services for psychiatric reasons; (3) had criminal justice involvement as a result of their mental illness; or (4) were unable to access needed community services.
I. The Joint Motion referenced in Section III will request that the certified class include all claims brought pursuant to the ADA, the Rehabilitation Act, and the NHRA.
J. In order to resolve ongoing issues between the Parties without the expense, risks, delays, and uncertainties of litigation, the Parties, have agreed to settle this matter on the terms and conditions set forth below in this Settlement Agreement. The puipose of this Settlement Agreement is to make a full and final compromise and settlement of any and all claims or allegations of the Plaintiffs and the United States set forth in the instant lawsuit.
2

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 3 of 32

II.

Definitions

A. "Community mental health program or provider" or "CMHP" means an entity or its subcontractor that provides community mental health semces to any individual with SMI in New Hampshire, pursuant to a contract with the State.

B. "Persons with serious mental illness" means individuals 18 years of age or older whom the State defines as having either severe mental illness or severe and persistent mental illness ("SPM1") pursuant to N.H. Code Admin. R. He-M 401, and those whom the State defines as "severely mentally disabled" pursuant to N.H. Rev. Stat. Ann. 135-C:2, XV.

III. Legal Foundation

A. The Parties agree to file this Settlement Agreement with the United States District Court for the District of New Hampshire along with a joint motion (the "Joint Motion") requesting that the Court enter the Settlement Agreement as an order of the Court. The Joint Motion will also request that the Court retain jurisdiction to enforce the Settlement Agreement, in accordance with Section X. The Parties will cooperate in drafting the Joint Motion and agree to provide their best efforts to support the Joint Motion at any hearing or argument.

B. The Parties acknowledge that the Court has jurisdiction over this case and authority to enter this Settlement Agreement and to enforce its terms in accordance with Section X.

C. 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.

D. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b).

E. This Settlement Agreement constitutes the entire, exclusive, integrated agreement of the Parties. It supersedes any previous understandings and agreements between the Parties concerning the subject matter of the instant lawsuit other than the Parties' Joint Stipulation Regarding Discovery and the Court-ordered Protective Order (Doc. 55).

F. The Parties represent and acknowledge that this Settlement Agreement is the result of extensive, thorough, and good faith negotiations. The Parties represent and acknowledge that the terms of this Settlement Agreement have been voluntarily accepted, after consultation with counsel.

G. Once entered by the Court, this Settlement Agreement is legally binding upon and judicially enforceable by the Parties, and it shall be applicable to and binding upon all of the Parties, including their officers, employees, successors, assigns, and agents, as well as the guardians of the class members (and their representatives, estates, next of kin, administrators, executors, and any other individual that has the authority to bring a claim or suit on their behalf regarding the claims and allegations raised in this lawsuit). Notwithstanding the foregoing, and any suggestion to the contrary, if any, in this Settlement Agreement, Defendants do not and cannot bind the New Hampshire General Court, which has the authority under the New

3

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 4 of 32
Hampshire Constitution and New Hampshire statutes to appropriate funds for the State's mental health system and to pass laws concerning the State's mental health system. Should the New Hampshire General Court enact laws or direct appropriations that limit the State's performance of any of its obligations under this Settlement Agreement, the provisions of Section X.F. shall apply.
H. Should the Court deny the Joint Motion, the Parties agree to work cooperatively and in good faith to modify any terms of this Settlement Agreement the Court may find objectionable and resubmit a Joint Motion and revised Settlement Agreement. If the Parties are unable to reach agreement on the issues raised by the Court through negotiation, the Parties agree to enter into mediation upon the request of any Party. If, after mediation, a modified Settlement Agreement is not reached and/or the Parties are unable to obtain the approval of the Settlement Agreement by the Court, this and any modified Settlement Agreement shall become null and void and the litigation shall proceed. This provision of the Settlement Agreement is binding and effective immediately upon all Parties signing this Agreement.
IV. Intent of the Parties
A. The Parties are committed to compliance with the ADA, 42 U.S.C. §§ 12101 et seq., the Rehabilitation Act, 29 U.S.C. §§ 794 et seq., the NHRA, 42 U.S.C. §§ 1396r et seq., and related laws.
B. According to the United States Department of Justice's regulations, 28 C.F.R. § 35.130(d) in particular, the ADA requires, among other provisions, that, to the extent the State offers services, programs, and activities to qualified individuals with disabilities, such services, programs, and activities will be provided in the most integrated setting appropriate to meet their needs.
C. The Parties recognize and support the puiposes of the ADA to assure equality of opportunity, full participation, independent living, and economic self-sufficiency for individuals with disabilities. 42 U.S.C. § 12101(a)(7).
D. The general observations and statements of intent in this Section IV are made without prejudice to the right of any Party to assert either their support for or alternative interpretations of the relevant laws in the event the Settlement Agreement is vacated and/or this matter is reinstated on the Court's trial docket. The Parties also reserve their right to offer alternative interpretations of the relevant laws in any other matter, and none of the statements in this Section IV may be used as evidence in any other matter.
V. Substantive Provisions
A. In order to comply with this Settlement Agreement, the State shall develop and implement the services set forth below in this Settlement Agreement. The services may be provided directly by the State or through contracts with CMHPs.
4

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 5 of 32
Target Population
1. The Target Population for the community services described in this Agreement is the subset of adults within the State who have SMI, and who are institutionalized or at serious risk of institutionalization at NHH or Glencliff (collectively, hereinafter "individuals"). SMI, as used herein, includes individuals whom the State defines as having either SMI or SPMI pursuant to N.H. Code Admin. R. He-M 401, and those whom the State defines as "severely mentally disabled" pursuant to N.H. Rev. Stat. Ann. 135-C:2, XV.
2. The first priority for receipt of sei'vices and supports will be given to individuals who reside at NHH or Glencliff.
3. The second priority for receipt of sei'vices and supports will be given to the following individuals within the target population due to their serious risk of institutionalization:
(a) individuals who have been admitted two or more times to NHH within the last two years;
(b) individuals who have used crisis or emergency services for psychiatric reasons within the last two years;
(c) individuals who have had criminal justice involvement as a result of their mental illness in the last two years;
(d) individuals who were unable to access needed community services within the last two years; and
(e) individuals who reside at the Transitional Housing Sei'vices programs ("THS") or who have resided at THS within the last two years.
4. The State will allocate sei'vices and supports under this Agreement consistent with these priorities.
Crisis Service System
1. The State will develop a crisis system that:
(a) is available 24 hours per day, seven days per week;
(b) provides timely and accessible services and supports to individuals with mental illness (including those with co-occurring substance abuse disorders) who are experiencing a mental health crisis;
5

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 6 of 32
(c) stabilizes individuals as quickly as practicable and assists them in returning to their pre-crisis level of functioning;
(d) provides interventions to avoid unnecessary hospitalization, incarceration, and/or Designated Receiving Facility, Acute Psychiatric Residential Treatment Program, emergency room, or nursing home admission;
(e) provides services and supports at the site of the crisis, including at the individual's residence; and
(f) promptly assesses individual needs, identifies the services and supports that are necessary to meet those needs, and connects the individual to those services and supports in a timely manner.
2. Crisis System Components
(a) Mobile Crisis Teams
i. The State will develop and implement measures to ensure that mobile crisis teams:
a. are available 24 hours per day, seven days per week;
b. are composed of clinicians trained to provide behavioral health emergency services and crisis intervention sei'vices, and also include at least one peer specialist and one on-call psychiatrist;
c. are able to respond to individuals 24 hours per day, seven days per week onsite in their homes and in other natural environments and community settings where crises arise, including in crisis apartments described more fully below;
d. are able to offer services and supports via telephone and, whenever necessary, consistent with legitimate safety concerns, meet face-to-face to de-escalate crises without removing the individuals from their homes and/or community programs;
e. are able to provide services and supports until the crisis subsides, up to seven days following the onset of the crisis;
f. may provide, in their discretion, services and supports to individuals beyond the immediate crisis; and
g. are able to work with law enforcement personnel to respond to individuals in mental health crisis who come into contact with law enforcement.
6

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 7 of 32
ii. For individuals served by an Assertive Community Treatment ("ACT") team, described more fully below, the ACT team shall serve as their mobile crisis team.
iii. The State's network will have three mobile crisis teams that are able to respond onsite to any individual crisis within one hour from the time of contact within three Mental Health Regions, including Region 4 (Concord), Region 7 (Manchester), and Region 6 (Nashua). In all other regions, the State shall, at a minimum, maintain its current crisis system, including existing crisis beds or implement mobile crisis teams.
iv. By the time each mobile crisis team becomes operational consistent with the requirements of this section and the implementation timelines in section V.C.3 below, each team will have available to it at least four community crisis apartment beds, with no more than two beds per crisis apartment.
(b) Community Crisis Apartments
i. Consistent with its Ten-Year Plan, the State will develop and implement the measures set forth below to expand short-term community crisis beds and to involve peers in providing crisis sei'vices and supports. These measures are in addition to crisis apartments that already have been established, which will be maintained by the State.
ii. As an alternative to hospitalization and/or institutionalization, the State will expand its community network of crisis apartments in the regions served by the mobile crisis teams described above, where individuals can stay for a limited time to receive crisis services and interventions in the community before returning home. In all other regions, the State shall, at a minimum, maintain its current crisis system, including existing crisis beds, or implement mobile crisis teams.
iii. Crisis apartments will be operated with sufficient clinical support and oversight, and peer staffing, as is reasonably necessary to prevent unnecessary institutionalization. Each crisis apartment will have peer staff and clinical staff available to be onsite, 24 hours per day, seven days per week, whenever necessary, to meet individualized needs.
iv. Individual stays at a crisis apartment will be limited to seven days.
v. The crisis apartments will have sufficient dedicated staff capacity to meet the needs of the individuals served at each apartment.
vi. Each crisis apartment will provide transportation for individuals from the site of the crisis to the apartment, and to their home or other residential setting after stabilization has occurred.
7

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 8 of 32
3. Implementation of Crisis Service System
(a) By June 30, 2015, the State will add mobile crisis capacity and crisis apartments in Mental Health Region 4 (Concord) that meet the standards set forth above in Section V.C.2.
(b) By June 30, 2016, the State will add mobile crisis capacity and crisis apartments in Mental Health Region 7 (Manchester) that meet the standards set forth above in Section V.C.2.
(c) By June 30, 2017, the State will add mobile crisis capacity and crisis apartments in Mental Health Region 6 (Nashua) that meet the standards set forth above in Section V.C.2.
(d) The State shall maintain its current crisis services, or implement mobile crisis teams, in all other regions.
D. Assertive Community Treatment ("ACT")
1. Consistent with its Ten-Year Plan, the State will develop and implement the measures set forth below to expand ACT.
2. ACT Team Components
The State will develop and implement measures to ensure that ACT teams:
(a) are available 24 hours per day, seven days per week, with on-call availability from midnight to 8:00am, consistent with Section V.D.2(b);
(b) are able to deliver comprehensive, individualized, and flexible services, supports, treatment, and rehabilitation to people 24 hours per day, seven days per week in a timely manner as needed, onsite in their homes and in other natural environments and community settings, or alternatively, via telephone where appropriate to meet the needs of the individual;
(c) offer services, supports, treatment, and rehabilitation that are customized to an individual's needs and vary over time as needs change; these may include case management, initial and ongoing assessments, psychiatric sei'vices, assistance with employment and housing, family support and education, substance abuse services, crisis sei'vices, and other services, supports, treatment, and rehabilitation critical to allow the individual a reasonable opportunity to live independently in the community;
(d) are composed of a multi-disciplinary group of between 7 and 10 professionals, including, at a minimum, a psychiatrist, a nurse, a Masters-level clinician (or functional equivalent therapist), functional support worker, and a
8

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 9 of 32
peer specialist; the teams also will have members who have been trained and are competent to provide substance abuse support services, housing assistance, and supported employment; to accommodate geographic concerns in Regions 1, 2, and 5, teams may employ up to 12 members per ACT Team;
(e) ordinarily serve no more than 10 people per ACT team member (excluding the psychiatrist); if circumstances unique to New Hampshire require a team to serve more than 12 people per ACT team member, the State will create an additional ACT team to meet the need for services within six months, provided the team in question is, at that time, still serving more than 12 people per ACT team member; no more than 70 people will be served per 0.5 FTE psychiatrist;
(f) consistent with legitimate safety concerns, are able to offer services, supports, treatment, and rehabilitation face-to-face in a timely manner to deescalate crises, until the crises subside, without removing the individuals from their homes and/or community programs; and
(g) are able to work with law enforcement personnel to respond to people in mental health crisis who come into contact with law enforcement.
3. Implementation of Assertive Community Treatment
(a) By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth above in Section V.D.2.
(b) By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team.
(c) By June 30, 2015, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2, with the capacity to serve at least 1,300 individuals in the Target Population at any given time.
(d) By June 30, 2016, the State will provide ACT team sei'vices consistent with the standards set forth above in Section V.D.2, for an additional 200 people, with the capacity to serve at least 1,500 individuals in the Target Population at any given time.
(e) By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but unavailable, specifying the Mental Health Region in which the individuals reside, and, to the extent it has not already done so, develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.
9

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 10 of 32
E. Housing
1. Supported Housing
Consistent with its Ten-Year Plan, the State will develop and implement the measures below to ensure that supported housing meets individuals' needs:
(a) supported housing will be permanent housing with tenancy rights, where obtaining tenancy rights is not conditioned on individuals' participation in treatment or compliance with mandatory programmatic criteria; supported housing includes support sei'vices to enable individuals to attain and maintain integrated affordable housing, and includes support sei'vices that are flexible and available as needed and desired;
(b) all new supported housing created pursuant to this Settlement Agreement will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population;
(c) all new supported housing created pursuant to this Settlement Agreement will be single occupancy or single family housing unless the individual prefers to live with a roommate; if the individual chooses to live with a roommate, there will be a private bedroom for each person; the individual will be able to select his or her roommate;
(d) "supported housing," as used in this Settlement Agreement, includes housing supported by subsidies from any source, including State-funded rental subsidies through the State's Bridge Subsidy Program or funding from the U.S. Department of Housing and Urban Development ("HUD"), coupled with other ongoing mental health and tenancy support sei'vices provided by ACT, case management, and/or a housing specialist.
2. Community Residences
(a) Notwithstanding the provisions regarding supported housing set forth above, the State may prospectively transition individuals with mental illness and complex health care needs, who could not be cost-effectively served in supported housing, into a community setting serving up to four persons with complex health care needs where the community home provides or coordinates the delivery of needed health care services, supports, and treatments. Such community settings may include enhanced family care, supported roommate, or non-congregate community residences. Consistent with the provisions of subparagraph V.E.2(b) below, the cost of these community settings shall not exceed an annual budget of
10

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 11 of 32
$100,000 per person or $400,000 per community setting.1 This paragraph does not require the State to remove individuals currently in community residences that house more than four persons. Utilizing the resources and expertise within the State Bureau of Elderly and Adult Services and/or any other appropriate agency, the State will develop and implement, consistent with the individual's or guardian's desires, individual transition plans, as set forth in this Settlement Agreement, for any individual placed in a community setting.
(b) The implementation of community residences for medically complex individuals described in subparagraph V.E.2(a) above and Sections V.E.3(g) - (j) below, may be accomplished through openings in or expansion of existing community service capacity or by a vendor selected after issuing a Request for Proposals ("RFP") in 2014. The service provider or RFP vendor shall have a budget cap of $100,000 per person served or $400,000 per community setting. If existing programs or acceptable vendors are not located through the 2014 RFP process, the State will, subject to the budget cap, continue its efforts to transition medically complex individuals to community settings through openings in or expansion of existing programs and will issue a second RFP in 2015. If, after the completion of the second RFP process, the State remains unable to develop the capacity to serve at least four individuals with SMI and complex health care needs by January 1, 2016, the State shall reallocate the General Fund share of the funding described above to fund additional supported housing, supported employment, mobile crisis, and/or ACT. The reallocation of funds shall be the General Fund amount of $50,000 for each of the 16 community settings described in Sections V.E.3(g)-(i) below, or the prorated share thereof, if some, but not all, of the community capacity is developed or utilized.
3. Implementation of Housing
(a) By June 30, 2014, the State will have 240 supported housing units that meet the standards set forth above in Section V.E. 1.
(b) By December 31, 2014, the State will create an additional 50 supported housing units that meet the standards set forth above in Section V.E.I, for a total of 290 supported housing units.
(c) By June 30, 2015, the State will create an additional 50 supported housing units that meet the standards set forth above in Section V.E.I, for a total of 340 supported housing units.
(d) By June 30, 2016, the State will create an additional 110 supported housing units that meet the standards set forth above in Section V.E.I, for a total of 450 supported housing units.
1 "Community setting" costs do not include routine medical, mental health, or waiver services provided under the State Medicaid program.
11

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 12 of 32
(e) By June 30, 2017, the State will make all reasonajple efforts to apply for and obtain HUD funding for an additional 150 supported housing units for a total of 600 supported housing units.
(f) By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.
(g) By June 30, 2015, the State will have the capacity to serve in the community four individuals with mental illness and complex health care needs residing at Glencliff who cannot be cost-effectively served in supported housing, consistent with the provisions set forth above in Section V.E.2.
(h) By June 30, 2016, the State will have the capacity to serve in the community six additional individuals with mental illness and complex health care needs residing at Glencliff who cannot be cost-effectively served in supported housing, consistent with the provisions set forth above in Section V.E.2.
(i) By June 30, 2017, the State will have the capacity to serve in the community six additional individuals with mental illness and complex health care needs residing at Glencliff who cannot be cost-effectively served in supported housing consistent with the provisions set forth above in Section V.E.2.
(j) By June 30, 2017, the State will identify and maintain a list of all individuals with mental illness and complex health care needs residing at Glencliff who cannot be cost-effectively served in supported housing and, to the extent it has not done so already, develop an effective plan for providing sufficient community-based residential supports for such individuals in the future.
F. Supported Employment
1. The State will, through its community mental health providers, deliver supported employment services in accordance with the Dartmouth evidence-based model. Supported employment services include providing individualized assistance in identifying, obtaining, and maintaining integrated, paid, competitive employment. Consistent with the Dartmouth model, supported employment services should be provided in the amount, duration and intensity to allow the opportunity for individuals to work the maximum number of hours in integrated community settings consistent with their individual treatment plans. Services offered should include job development, job finding, job carving, job customization, co-worker and peer supports, self-employment supports, re-employment supports, time management training, benefits counseling, job coaching, transportation, workplace
12

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 13 of 32
accommodations, assistive technology assistance, specialized on-the-job training, and, if not already provided, individually-tailored case management and supervision.
2. Implementation of Supported Employment
(a) By October 1, 2014, all individuals receiving ACT services will have access to supported employment services from employment specialists on their ACT teams.
(b) By June 30, 2014, the State will increase its penetration rate of individuals with SMI receiving supported employment services by two percent over the 2012 penetration rate of 12.1 percent reported to the Substance Abuse and Mental Health Services Administration (SAMHSA), to 14.1 percent of eligible individuals with SMI.
(c) By June 30, 2015, the State will increase its penetration rate of individuals with SMI receiving supported employment sei'vices by an additional two percent, to 16.1 percent of eligible individuals with SMI.
(d) By June 30, 2016, the State will increase its penetration rate of individuals with SMI receiving supported employment services by an additional two percent, to 18.1 percent of eligible individuals with SMI.
(e) By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment sei'vices by an additional 0.5 percent, to 18.6 percent of eligible individuals with SMI.
(f) By June 30, 2017, the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable, and, to the extent it has not already done so, develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.
G. Family and Peer Supports
1. The State will have an effective family support program to meet the needs of families of individuals throughout the State. The family support program will teach families skills and strategies for better supporting their family members' treatment and recovery in the community. The family support program will include training on identifying a crisis and connecting individuals in crisis to services and supports, as well as education about mental illness and available ongoing community-based services and supports. Family supports can be provided in individual and group settings.
13

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 14 of 32
2. The State will have an effective peer support program to help individuals develop skills in managing and coping with symptoms of illness, in self-advocacy, and in identifying and using natural supports. The peer support program will train peers who have personal experience with mental illness and recovery to deliver the peer services and supports. Peer supports can be provided in individual and group settings, in person, or by phone.
3. Implementation of Family and Peer Supports
(a) By June 30, 2014, the State will maintain family support sei'vices statewide consistent with the provisions set forth in Section V.G.I. Notwithstanding anything to the contrary in this Agreement, the State's current contract with its vendor for the provision of family support sei'vices (or a substantially similar agreement with another entity offering similar services) satisfies the requirements of this subsection.
(b) By June 30, 2014, the State will have a system of peer support services, which are offered through peer support centers, open a minimum of eight hours per day, five-and-a-half days per week, or the hourly equivalent thereof, in each Mental Health Region in the State, consistent with the provisions set forth above in Section V.G.2.
Transition Process
Transition Planning and Transition Plans for People in Facilities
1. The State, through its community mental health providers and/or other relevant community providers, will provide each individual in NHH and Glencliff with effective transition planning and a written transition plan as set forth below. The written transition plan may be incorporated into the individual's discharge summary and paperwork from NHH or Glencliff.
2. Transition planning will:
(a) begin with the presumption that with sufficient sei'vices and supports, individuals can live in an integrated community setting;
(b) be developed and implemented through a person-centered planning process in which the individual has a primary role and is based on the principle of self-determination;
(c) include persons who have the linguistic and cultural competence to serve the individuals;
(d) be based on each individual's needs and not on the availability, perceived or actual, of current community resources and capacity; and
14

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 15 of 32
(e) not exclude any individual from consideration for community living based solely on his or her level of disability.
3. The transition planning process will result in an effective written transition plan that:
(a) sets forth in reasonable detail the particular sei'vices and supports, including their scope, frequency, and duration, that each individual needs in order to successfully transition to and live in an integrated community setting, whether or not a suitable community setting is currently available; such services and supports may include housing, transportation, staffing, mental health care, health care, and other professional services;
(b) sets forth which persons and/or organizations have responsibility for delivering needed services and supports before, during, and after the transition;
(c) sets forth the date the transition should occur, as well as the timeframes for completion of needed steps to effect the transition;
(d) sets forth any barriers to transition to an integrated community setting and how to overcome them, if possible; and
(e) sets forth a post-transition schedule of monitoring visits by community mental health providers to the new community setting to assess whether the needs of the individual are being met.
4. In developing the transition plans, the State will make all reasonable efforts to avoid placing individuals into nursing homes or other institutional settings. Before adopting a transition plan that places an individual in a nursing home or other institutional setting, the State must consider all possible alternatives and describe the steps it took to implement the alternatives. If the final transition plan results in placement of the individual in a nursing home or other institutional setting, the plan shall be used to identify the bamers to placement in a more integrated setting and describe steps the State will take to address the barriers.
5. Similarly, the State will make all reasonable efforts to avoid admitting persons with developmental disabilities to NHH, except where individuals' acute psychiatric needs cannot be addressed in a more integrated service or treatment setting. If such individuals are admitted, the State will document the basis for their admission and immediately begin transition planning on their behalf, consistent with the requirements of Section VI.
6. The State will create a central team to assist in addressing and overcoming any of the barriers to discharge identified during transition planning and/or set forth in the transition plans. The central team will include personnel with experience and expertise in how to successfully resolve barriers to discharge including ACT team
15

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 16 of 32
members, supported housing providers, and peers who work for community providers.
7. The State will design and implement a system for in-reach activities. The in-reach system will include meetings between individuals in NHH and Glencliff and the community mental health program or provider from their respective regions to develop relationships of trust and to actively support these individuals in transitioning to the community. The in-reach system will also include opportunities for meetings with the State and to obtain the State's assistance in identifying and addressing barriers to community living. In conducting in-reach:
(a) the State, through the community mental health program or provider will, among other things:
i. explain fully the benefits of community living, including ACT, supported housing, and supported employment;
ii. facilitate visits to community settings and accompany residents of these facilities on these visits;
iii. explore and work to address the concerns of any individuals who decline the opportunity to move to a community setting or who are ambivalent about moving to a community setting;
iv. review with reasonable regularity (at least quarterly), these individuals' housing preferences and interest in community living; and
(b) the State will:
i. offer to meet with any individual and/or their guardian, if one has been appointed, that continues to express reservations about living in the community, to ensure that the individual and guardian fully understand the community living options; and
ii. propose individualized strategies to address the individual's or guardian's concerns, provide opportunities to visit community programs, and facilitate conversations with providers about the services that will be available in the community and with individuals who have successfully transitioned from institutional settings to living in the community.
8. If an individual and/or guardian is opposed to a community setting, the State will document the steps taken to fully inform them of the community options and document the particular concerns that the individual and/or guardian has with moving to the community. The State will develop individualized strategies to address the individual's or guardian's concerns, to be discussed at future meetings. The State will
16

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 17 of 32
establish a system for re-contacting these individuals and/or their guardians regularly, and at least annually, regarding their interest in community alternatives.
9. The State will identify individuals at NHH or Glencliff within the Target Population who have a dual diagnosis of developmental disability and mental illness and provide each individual with effective transition planning and a written transition plan as set forth in this section, using sei'vices and supports available from both the developmental disabilities and mental health services delivery systems to meet their needs.
10. Any individual referred to Glencliff, whether from the community, NHH, or any other facility or hospital, will be reviewed pursuant to Pre-Admission Screening and Resident Review (PASRR), to determine if the individual has a developmental disability and/or mental illness and whether that individual's needs could be met in the community with adequate and appropriate services and supports. These PASRR reviews will be conducted by qualified developmental disability and/or mental health professionals. If the PASRR review determines that the individuafs needs could be met in a community setting, the individual will be referred promptly to the appropriate Area Agency and/or Community Mental Health Center. Providers of developmental and mental health sei'vices will discuss and develop community options with the individual and will offer the individual appropriate sei'vices and supports in an integrated community setting.
B. Implementation of the Transition Planning Process
1. By February 1, 2014, the State will begin implementation of the provisions set forth above in Section VI.A., to be substantially completed by June 30, 2014.
VII. Quality Assurance and Performance Improvement
A. The State will develop and implement a quality assurance and performance improvement system, emphasizing the use of client-level outcome tools and measures, to ensure that existing community-based services described in the Agreement are offered in accordance with the individualized transition process set forth above, and that the individuals served are provided with the State's services and supports they need to ensure their health, safety, and welfare. The goal of the State's system will be to ensure that all mental health and other services and supports funded by the State are of good quality and are sufficient to provide reasonable opportunities to help individuals achieve increased independence, gain greater integration into the community, obtain and maintain stable housing, avoid harms, and decrease the incidence of hospital contacts and institutionalization.
2 This paragraph is intended by the Parties to address the needs of individuals with intelleclual and developmental disabilities and those with acquired brain injuries who also have SMI. Therefore, as used in this section, "developmental disabilities" means those individuals eligible for services under N.H. Rev. Stat. Ann. 171-A and 137-K, and their implementing regulations, N.H. Code Admin. R. He-M 503, 522.
17
{

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 18 of 32
Provider Network
1. The State will ensure an adequate network of qualified providers with the expertise and competency to effectively deliver the sei'vices and supports set forth in this Settlement Agreement.
2. Program specifications for the services and supports set forth above in this Settlement Agreement will be developed by the State with input from the Plaintiffs and the United States.
3. The State or Managed Care Organizations ("MCOs") will certify, and re-certify every two years, that providers of the community services set forth above are operating in compliance with all provider network requirements, and delivering services consistent with relevant program specifications. If a provider is not in compliance with these requirements, a corrective action plan will be developed, with timelines for implementation, oversight and monitoring by the responsible State agency.
4. The State will execute performance-based contracts with CMHPs, either directly or through its managed care agents, that specifically describe expectations with regard to the individual outcomes to be achieved and the services and supports to be provided to individuals consistent with the provisions of this Settlement Agreement.
Quality Assurance System
1. The State will develop and implement a quality assurance review system that will regularly collect, aggregate, and analyze data related to transition efforts, including but not limited to information related to both successful and unsuccessful transitions, as well as the problems or barriers to serving and/or keeping individuals in the most integrated setting. Such problems or barriers may include, but not be limited to insufficient or inadequate housing, community resources, mental health care, crisis services, and supported employment. The State will review this information and use it to develop plans to reduce the incidence of such problems or barriers and implement prompt and effective measures, utilizing the sei'vices developed through this Agreement and other existing services, to overcome, if possible, the problems and barriers identified.
2. The State will regularly review community providers and programs to identify gaps and weaknesses, as well as areas of highest demand, to provide infonnation for comprehensive planning, administration, resource-targeting, and implementing needed remedies. The State will develop and implement effective measures that work to address any gaps or weaknesses identified.
Quality Service Reviews
1. As part of the Quality Assurance System outlined in Section VII.C, the State will use Quality Service Reviews ("QSRs") to evaluate the quality of services and supports.
18

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 19 of 32
Through the QSR process, the State will collect information through a sample of faceto-face interviews of the individual, relevant professional staff, and other people involved in the individual's life, as well as through review of individual treatment plans. Through the QSR process, the State will evaluate, among other things, whether individuals' needs are being identified, whether services and supports are meeting individuals' needs, and whether services and supports are designed around individuals' strengths and meeting individuals' goals.
2. The State will work collaboratively with the Plaintiffs and the United States to design a process (or adapt an existing process) for implementing QSRs and reporting on QSR findings. The State will work in good faith to obtain and consider recommendations of the Plaintiffs and the United States, but will have final decisionmaking authority on the process to be adopted.
3. The State will conduct QSR reviews of sei'vices and supports provided under this Settlement Agreement at least annually. The QSR review process will ensure statewide review of each service provision during the term of this Agreement.
4. The State will collect and analyze data from the QSRs and then use it to identify strengths and areas for improvement at the individual, provider, and systemwide levels; this will include issues related to barriers to meeting individualized needs in integrated community settings. The State will use the data from the QSRs to identify gaps and weaknesses, as well as areas of highest demand, to provide information for comprehensive planning, administration, and resource-targeting, to consider whether any areas are in need of improvement including whether additional community-based services and supports are necessary. The State will further use this information to develop and implement prompt and effective measures to utilize the services and supports developed pursuant to this Agreement, and other existing services, to address any areas in need of improvement and to ensure individuals have the opportunity to receive services in the most integrated setting.
E. Reporting
1. The State will provide to the Expert Reviewer (described below in Section VIII) and the Parties, on an annual basis, infonnation:
(a) identifying the number of people served in each type of service described in this Settlement Agreement;
(b) detailing unmet needs using data gathered through the process set forth above in this section or the Slate's other quality assurance/improvement programs; and
(c) detailing the quality of services and supports provided by the Stale and its community providers using data collected through the State's quality
19

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 20 of 32
assurance/improvement systems, including any data gathered during the QSR process.
2. Nothing in Section VII.E.l is intended to expand the Expert Reviewer's functions as set forth in VIII.F. and VI1I.K.
3. The Expert Reviewer will periodically convene meetings with the Parties and members of the State's mental health services team at mutually convenient times and locations for discussions on implementation of the Agreement. Prior to the meetings, the State will provide the Expert Reviewer, Plaintiffs and the United States with data regarding implementation consistent with section VIII.I.
VIII. Expert Reviewer
A. The Parties will jointly agree on an Expert Reviewer within 90 days of the execution of this Settlement Agreement. The Expert Reviewer will be independent and no Party or any employee or agent of any Party shall have supervisory authority over the Expert Reviewer's activities, reports, and/or recommendations.
B. The Expert Reviewer will have three functions. The Expert Reviewer may provide technical assistance as requested by the State to implement the provisions of this Settlement Agreement and to improve the State's mental health care system. The Expert Reviewer will mediate disputes between the Parties in accordance with Section X.D. The Expert Reviewer will assess and issue a public report to the Parties on the State's implementation of and compliance with the provisions of this Settlement Agreement.
C. In the event the Expert Reviewer resigns, or the Parties agree to replace the Expert Reviewer, the Parties will: (a) confer within 30 days of the resignation or agreement by the Parties to replace the Expert Reviewer, and (b) select a replacement and notify the Court of their joint selection. If the Parties are unable to agree on a replacement Expert Reviewer, the Parties will each submit to the Court, within 14 days of the conference, the names and curricula vitac of up to four individuals (up to two from the State and two from the Plaintiffs and the United States) as candidates for the Expert Reviewer position. The Parties will request that the Court select the Expert Reviewer from among those nominated.
D. The Expert Reviewer will have the authority and responsibility to independently observe, assess, review, and issue public reports to the Parties on the State's implementation of and compliance with the provisions of this Settlement Agreement. The Expert Reviewer's assessments will provide the Parties with guidance on the State's efforts to implement the terms of this Settlement Agreement, ways to improve implementation, and other suggestions to enhance the State's mental health system. The Expert Reviewer's suggestions and assessments may not, however, modify any provision of this Settlement Agreement, absent an order of the Court. All Parties reserve their right to object to and contest any such order of the Court.
E. The Expert Reviewer will review the services and supports provided to individuals in the State's mental health system and will devote such time as is necessary to fulfill the duties and
20

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 21 of 32
responsibilities of the Expert Reviewer pursuant to this Settlement Agreement, consistent with the budget allocated for his or her services. The Expert Reviewer may retain consultants to assist in carrying out his or her duties and responsibilities, to the extent funds are available in the Expert Reviewer's budget. In no event will the State be obligated to reimburse the Expert Reviewer for any fees, costs, or expenses that exceed the amount of the Expert Reviewer's maximum budget, as defined in Section VIII.P., except that the Parties may jointly agree to an increase in the Expert Reviewer's budget. Upon the request of a Party, the Court may approve, in extraordinary circumstances, an increase in the budget if there is an issue related to noncompliance that requires an unanticipated degree of additional work by the Expert Reviewer, limitations on the availability of information from the State necessary for the Expert Reviewer to fulfill his/her duties and responsibilities for assessing compliance, or a request by the Court for additional assistance or information necessary to ensure compliance and enforcement of its orders. In the event that a request is made to the Court for an increase in the budget of the Expert Reviewer, any Party may object and request a hearing on the issue.
F. The Expert Reviewer will evaluate implementation of and compliance with the terms of the Settlement Agreement. These evaluations may include: onsite inspection of facilities and programs responsible for the delivery of services under the Agreement; interviews with staff, class members, guardians, and other stakeholders; data collection; and document and record review, including transition planning where the individual's team identified barriers to discharge or recommended placement in another institutional setting. The evaluations will include review and assessment of the status of individual transitions and the adequacy and quality of individualized services and supports.
G. The Expert Reviewer and consultants will have full access, with reasonable notice, to the people, places, and documents that are necessary to assess the State's compliance and/or implementation efforts with this Settlement Agreement, to the extent they are within the State's custody or control, including: (I) individuals receiving and/or offered services in the State's mental health system; (2) residences, facilities, buildings, services, programs, and activities in the State's mental health system, as well as the persons involved in providing services and supports at these locations; and (3) pertinent documents, records, and other materials, including departmental and/or individual residential medical and other records, associated with sei'vices, programs, and activities for individuals receiving and/or offered services in the State's mental health system. The Expert Reviewer shall exercise its access to State employees, facilities, and documents, in a reasonable manner in order to minimize disruption to State operations. The State has no obligation to require any individual or entity that is not a State employee, contractor, subcontractor, grantee, or provider of State-funded semces to speak with the Expert Reviewer and/or his or her staffer consultants.
H. The Expert Reviewer may communicate ex parte with the Court at its request, or with any of the Parties, including counsel, employees, agents, contractors, and all others working for or on behalf of the State to implement the terms of this Settlement Agreement, as well as anyone else the Expert Reviewer and any consultants deem necessary for completing the duties and responsibilities of the Expert Reviewer pursuant to this Settlement Agreement.
21

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 22 of 32
I. The State will maintain sufficient records and collect sufficient data to document that the requirements of each element of this Settlement Agreement are being properly implemented, including data on the location and point of contact for individuals in crisis. The State will provide such data and records to the Expert Reviewer in a timely manner upon the Expert Reviewer's request. The Expert Reviewer may make requests for additional information that are reasonable and not unduly burdensome for puiposes of evaluating compliance with the Settlement Agreement. All records and data shared with the Expert Reviewer will be provided by the State to the Plaintiffs and the United States in a timely manner.
J. The Expert Reviewer may confer regularly and informally with the Parties on matters relating to implementation efforts and compliance. The Expert Reviewer will have the authority to convene meetings at mutually agreeable times and places.
K. Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report on the State's implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
L. In accordance with Section X.D., the Expert Reviewer will mediate any dispute regarding the implementation or enforcement of, or compliance with, this Settlement Agreement.
M. The Expert Reviewer may testify in this case with regard to any matter relating to the implementation or enforcement of, or compliance with, the Settlement Agreement, including, but not limited to, the Expert Reviewer's observations, findings, and recommendations in this matter. Expert Reviewer testimony will be inadmissible in any other proceeding or matter, excluding any proceeding related to the implementation or enforcement of, or compliance with, this Settlement Agreement.
N. The Expert Reviewer shall not be subject to formal discovery, including but not limited to depositions, requests for documents, requests for admissions, interrogatories, or other disclosures.
O. Neither the Expert Reviewer nor any consultant shall be liable for any claim, lawsuit, or demand arising out of their activities under this Settlement Agreement. However, this paragraph does not apply to any proceeding for payment of contracts or subcontracts into which they have entered in connection with their work under this Settlement Agreement.
P. The Expert Reviewer's reasonable fees, costs, and expenses (including costs of consultants or subcontractors, if any) will be borne by the State, up to a maximum budget of $175,000 per calendar year. In the event the Expert Reviewer does not use all of the funds in a particular year, any unused funds may be applied in a future year. The Expert Reviewer will invoice the State monthly for his or her fees, costs, and expenses. The monthly statements shall include daily records of time spent and expenses incurred, and shall include copies of supporting documentation including receipts. Monthly statements shall be provided to all Parties. The State and the Expert Reviewer will agree in advance on the scope and cost of any technical assistance
22

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 23 of 32
that the State requests and the Expert Reviewer provides. Any objection to the monthly statement shall be submitted to the Court within 21 days of receipt of a monthly statement. The Court retains the authority to resolve any dispute that may arise regarding costs, fees, or expenses charged by the Expert Reviewer. The State shall make payment to the Expert Reviewer within 30 days of receipt of the invoice, or upon order of the Court in the event there is a dispute regarding the Expert Reviewer's fees, costs, or expenses.
Q. The Expert Reviewer shall not enter into or be offered any contract with the State, the Plaintiffs, the United States Department of Justice, or their counsel, in any litigation or investigation, while serving as the Expert Reviewer, unless agreed to by all Parties. If the Expert Reviewer resigns, the former Expert Reviewer may not enter into any contract with the State, or their counsel, in any litigation or investigation on a matter in New Hampshire during the pendency of this Settlement Agreement without the written consent of the Plaintiffs and the United States. Similarly, the former Expert Reviewer may not enter into any contract with the Plaintiffs, the United States Department of Justice, or their counsel, in any litigation or investigation on a matter in New Hampshire during the pendency of this Settlement Agreement without the written consent of the State.
IX. General Provisions
A. 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.
B. All individual Defendants are officers of the Executive Branch of the State of New Hampshire and are sued only in their official capacities.
C. The State has authority and responsibility for the operation of NHH, Glencliff, and the rest of its mental health system.
D. The Plaintiffs and the United States may make reasonable requests for documents or data not otherwise produced to the Expert Reviewer, provided the requests are not unduly burdensome to the State and are relevant to the implementation of this Settlement Agreement. Such requests will be made in the first instance to an individual identified by the State to serve as the point of contact for such requests. If that individual concludes such requests are relevant to the implementation of this Settlement Agreement and are not unduly burdensome, he or she will provide the documents or data in a timely manner. If that individual concludes the infonnation is not relevant or is unduly burdensome, the request may be referred to the Expert Reviewer who will make a recommendation after conferring with the Parties. Nothing in this paragraph is intended to apply to document requests by, or production to, the DRC in cases of individual representation of class members or investigations.
E. The Parties and the Expert Reviewer will be responsible for maintaining the confidentiality of records in their possession. Submissions to the Court that contain identifying
23

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 24 of 32
information of individuals (such as their full name, address, or social security number) shall be filed with the Court consistent with the Protective Order already entered in this matter.
F. When necessary to fulfill their ethical responsibilities and monitor the implementation of this Settlement Agreement, the Plaintiffs and the United States will have reasonable access to relevant people, places, and information necessary to assess the State's compliance and/or implementation efforts with this Settlement Agreement, including: (1) individuals receiving and/or offered services in the State's mental health system; and (2) residences, facilities, buildings, services, programs, and activities in the State's mental health system, as well as the persons involved in providing services at these locations. The Plaintiffs and the United States will provide reasonable advanced notice of any monitoring visit or inspection. The Defendants may elect to have counsel present at any such visit or inspection in which the Plaintiffs or the United States intend to interview State employees for puiposes of monitoring this Settlement Agreement. Where there is an emergency situation that presents an immediate threat to the life, health, or safety of individual(s), that is not being adequately handled by the State, the Plaintiffs and the United States will not be required to provide the State with notice of any such visit or inspection. Any request for documents or data under this Section not otherwise produced to the Expert Reviewer, shall comply with Section IX.D. Nothing in this Settlement Agreement shall limit access afforded to the DRC or the United States pursuant to any federal or state laws or other agreement(s).
G. The State agrees that it will 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 in the Plaintiffs' and the United States' investigations or in any monitoring activities related to this Settlement Agreement. The State agrees that it will timely and thoroughly investigate any allegations of retaliation in violation of this Settlement Agreement and, where necessary, take corrective actions for any retaliation identified through such investigations.
H. No person or entity is intended to be a third-party beneficiary of the provisions of this Settlement Agreement for puiposes of any other civil, criminal, or administrative action. 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 expand the right of any person or organization to seek relief against the State or their officials, employees, or agents.
I. The Court may modify this Settlement Agreement pursuant to Fed. R. Civ. P. 60, but all Parties reserve the right to object to any such modification. The Parties agree to first provide reasonable notice, meet and confer, and seek to reach agreement about any proposed modification. Any modification to this Settlement Agreement agreed to by the Parties 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.
J. Upon full execution of this Settlement Agreement, all Parties agree that it may be filed electronically with the United States District Court for the District of New Hampshire, in conjunction with the filing of a Joint Motion as outlined in Section III. A.
24

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 25 of 32
K. During the pendency of this Settlement Agreement, the United States and members of the Plaintiff Class are barred from bringing a new action in federal or state court against the Defendants under the ADA, the Rehabilitation Act, or the NHRA for any claim or allegation set forth in the lawsuit. Nothing in this provision is intended to preclude individual appeals on PASRR decisions.
L. The United States and the State will bear the cost of their own fees and expenses incurred in connection with this case. The State agrees to pay Plaintiffs a total of $2,426,800 for all attorneys' fees, costs and monitoring in this case, except as provided in paragraph X.E. The total amount shall be paid in yearly installments in accordance with the following schedule: the first installment of $1,113,400 shall be paid 90 days from the Effective Date of this Agreement; the second installment of $1,113,400 shall be paid no later than 12 months from the due date of the first installment; the third installment of $75,000 shall be paid no later than 24 months from the due date of the first installment; the fourth installment of $75,000 shall be paid no later than 36 months from the due date of the first installment; and the fifth installment of $50,000 shall be paid no later than 48 months from the due date of the first installment. The Plaintiffs will file an assented-to motion for fees and expenses consistent with this paragraph and pursuant to Fed. R. Civ. P. 23(h) and L.R. 23.1(b)(4), and will not file any additional request for attorneys' fees in this matter except as provided in X.E.
M. This Settlement Agreement will become effective upon signature of all Parties and approval by the Court ("Effective Date"), except as provided by Section III.H. of this Settlement Agreement.
N. Provision of any information to the Expert Reviewer, Plaintiffs, or the United States pursuant to this Settlement Agreement will not constitute a waiver of any privilege that would otherwise protect the information from disclosure to third parties. This paragraph is intended to confer the full protections offered by Fed. R. Evid. 502(d).
O. This Agreement may be executed in counterparts, each of which will be deemed an original, and the counterparts will together constitute one and the same agreement, notwithstanding that each Party is not a signatory to the original or the same counterpart.
X. Construction and Enforcement
A. Except where otherwise specified, the State will implement all provisions of this Settlement Agreement within 30 days of the Effective Date of this Settlement Agreement.
B. The Parties agree that insignificant or brief, temporary deviations from the requirements set forth in this Settlement Agreement do not constitute noncompliance with the Agreement.
C. Except as provided in Section X.F., and/or with the exception of a situation that poses an immediate and serious threat to the life, health, or safety of individuals covered by this Agreement to which the State is not adequately responding, if Plaintiffs or the United States believe that the State is failing or has failed to comply with any term(s) of this Settlement Agreement, the process contained in this Sections X.C.-E. constitutes the sole and exclusive
25

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 26 of 32
means to resolve disputes related to such claims of noncompliance with the tenns of the Settlement Agreement.
1. Should an issue regarding the implementation or tenns of this Settlement Agreement arise, the Party asserting the issue will confer with the other Parties and the Expert Reviewer in good faith in an effort to cure the issue. If informal resolution does not lead to complete and timely resolution, the Parties shall utilize the procedures set forth in Sections X.C.2-5.
2. A Party asserting a failure of the State to comply with this Settlement Agreement ("Complaining Party"), will give written notice ("Notice of Noncompliance") to the State that, with specificity, sets forth the details of the alleged noncompliance, including the specific provisions of this Settlement Agreement alleged to have been violated, and the reasons why the Complaining Party believes the provisions were violated.
3. Upon issuance of a written Notice of Noncompliance, the State will have 30 calendar days from the date of such written notice to respond, and to describe any steps that the State will take, if any, to cure the alleged noncompliance.
4. Following the State's response to the Notice of Noncompliance, the Complaining Party may either accept the State's response, or may request a conference to resolve the disagreement. A conference will be held within 14 calendar days of the request. At the conference, which may take place in person or, if any Party requests it, via telephone, the Parties agree to confer in good faith in an attempt to resolve their differences.
5. If these steps do not resolve the differences between the Parties, the Complaining Party may petition the Court to enforce the Settlement Agreement, in accordance with Section X.E.
D. With respect to any dispute or other matter regarding the implementation of the Settlement Agreement, any Party may request that the Expert Reviewer mediate this dispute or make a recommendation to address an implementation matter. The Parties agree that upon the request of any Party for mediation by the Expert Reviewer, all Parties will participate in mediation in good faith.
E. The Court shall have the power to enforce the Settlement Agreement and issue further orders as needed to ensure compliance. The Plaintiffs and the United States agree that they will not seek to enforce compliance with the tenns of this Settlement Agreement through a motion for contempt, nor seek damages or penalties, in the first instance for any particular instance of alleged noncompliance. Any attorneys' fees or costs requested by Plaintiffs in connection with a petition to enforce the settlement will be reasonable. Such fees or costs will not be automatically awarded, but only after a hearing as to the propriety of such an award and its reasonableness. Defendants retain their rights to object to any such request.
26

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 27 of 32
F. The Governor and the other individual Defendants agree to request from the New Hampshire General Court, and make their best efforts to secure, the funding they believe is necessary to implement the terms of the Settlement Agreement. In the event the New Hampshire General Court fails to appropriate the requested funds and precludes the Defendants from substantially complying with one or more provisions of the Agreement, the Plaintiffs and the United States may withdraw their consent to this Settlement Agreement, and revive any claims otherwise barred by operation of this Settlement Agreement. In the event of a failure to appropriate requested funds, nothing in this paragraph is intended to prohibit Plaintiffs or the United States from enforcing, consistent with this Agreement, those provisions, and only those provisions, of the Settlement Agreement that have been adequately funded by the General Court, but with which the Defendants are nevertheless not in compliance.
G. Within 30 days of the filing of this Settlement Agreement with the Court, the State will identify for Plaintiffs and the United States an individual within the State to serve as a point of contact for the Plaintiffs, the United States, and the Expert Reviewer for puiposes of implementation of this Settlement Agreement.
H. All provisions of this Settlement Agreement will have ongoing effect until the final dismissal of this action.
I. The Court shall retain jurisdiction of this action for all puiposes until the State has complied with all provisions of this Settlement Agreement and maintained compliance with all provisions for a period of one year. The Parties anticipate that the State will have complied with all provisions of the Settlement Agreement within six years of its Effective Date and that the case will be dismissed with prejudice if compliance is achieved, consistent with this paragraph. The Parties may agree to jointly ask the Court to terminate the Settlement Agreement and dismiss the case with prejudice prior to the end of the six-year term. If the State asserts that it is in compliance and the Plaintiffs and/or the United States disputes the claim, the State will bear the burden of demonstrating that it has complied with all provisions of this Settlement Agreement and maintained compliance with all provisions for one year. The Parties may agree jointly at any time to allow for additional time to resolve compliance issues. Upon a determination of the Court that the State has demonstrated compliance with all of the provisions of this Settlement Agreement, including the provisions in this paragraph, the case shall be dismissed with prejudice.
J. Failure by any Party to enforce this entire Settlement 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 Settlement Agreement.
K. The Parties will promptly notify each other of any court or administrative challenge to this Settlement Agreement or any portion thereof and shall defend against any challenge to the Settlement Agreement.
L. The Parties agree that, as of the date the Court enters an order granting the Joint Motion, for purposes of the Parties' preservation obligations pursuant to Fed. R. Civ. P. 26, state and federal law, and the litigation hold letter sent to the State on June 17, 2011, the Parties are no
27

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 28 of 32 longer required to maintain any litigation holds. The State's outside counsel will maintain the data already collected from the State, in the manner in which it currently exists, or archived, until this case is dismissed with prejudice. With regard to the data and documents produced by the State and held by the United States and Plaintiffs, the United States and the Plaintiffs will abide by Section 16.f. of the Joint Stipulation between the Parties concerning electronically stored information.
/
28

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 29 of 32

The undersigned AGREE to the form and

of this Settlement Agreement:

FOR THE UNITED STATES:

/s/ John P. Kacavas JOHN P. KACAVAS United States Attorney District of New Hampshire

/s/Jocelyn Samuels JOCELYN SAMUELS Acting Assistant Attorney General Civil Rights Division

/s/ John J. Farley JOHN J. FARLEY New Hampshire Bar No. 16934 Assistant United States Attorney United States Attorney's Office District of New Hampshire 53 Pleasant Street Concord, NH 03301 Telephone: (603)225-1552 John.farleyCajusdoi.,gov

/s/Eve L.Hill EVE L. HILL Deputy Assistant Attorney General Civil Rights Division
/s/ Jonathan M. Smith JONATHAN M. SMITH Chief Special Litigation Section
Is/ Judy C. Preston JUDY C. PRESTON Deputy Chief Special Litigation Section

/s/ Richard J. Farano RICHARD J. FARANO District of Columbia Bar No. 424225 DEENA S. FOX New York Bar Registration No. 4709655 KATHERINE V. HOUSTON California Bar No. 224682 ALEXANDRA L. SHANDELL District of Columbia Bar No. 992252 Trial Attorneys United States Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, NW Patrick Henry Building Washington, DC 20530 Telephone: (202)307-3116 richard. farano (ti)\\ sdo j. gov decna.foxf6fiusdoi.gov katherinc.houston(c^usdoi.aov alexandra.shandellfjfAisdoj.gov

29

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 30 of 32
/s/Amy B. Messer AMY B. MESSER New Hampshire Bar No. 8815 C. ADRIENNE MALL1NSON New Hampshire Bar No. 17126 AARON J. GINSBERG New Hampshire Bar No. 18705 Disabilities Rights Center, Inc. 18 Low Avenue Concord, NH 03301 Telephone: (603) 228-0432 amymfcfjdrcnh.ora adrienncmfftjdrcnh.org aaronRf^drcnh.org
/s/ Steven J. Schwartz STEVEN J. SCHWARTZ Massachusetts Bar No. 448440 KATHRYN L. RUCKER Massachusetts Bar No. 644697 Center for Public Representation 22 Green Street Northampton, MA 01060 Telephone: (413)586-6024 sschwartxfaiepr-ma.oru kruekcrfoiepr-ina.orsj
/s/ Ira A. Burnim IRA A. BURNIM District of Columbia Bar No. 406154 JENNIFER MATHIS District of Columbia Bar No. 444510 Judge David L. Bazelon Center for
Mental Health Law 1101 15th Street, NW, Suite 1212 Washington, DC 20005 Telephone: (202) 467-5730 i rahfoibazelon. org iennifcrmfajbazelon.org
30

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 31 of 32

FOR THE DEFENDANTS:

/s/Daniel E. Will DANIEL E. WILL New Hampshire Bar No. 12176 ELAINE M. MICHAUD New Hampshire Bar No. 10030 JOSHUA M. WYATT New Hampshire Bar No. 18603 Devine, Millimet & Branch, P.A. 111 Amherst Street Manchester, NH 03101 Telephone: (603)669-1000 dwillfcidevinemillimet.com emichaud(rtjdevincmillimct.coin iwyattfc/Mevinnemillimet.com
/s/ Joseph A. Foster JOSEPH A. FOSTER New Hampshire Attorney General
/s/Anne M. Edwards ANNE M. EDWARDS New Hampshire Bar No. 6826 REBECCA L. WOODARD New Hampshire Attorney General's Office New Hampshire Bar No. 17176 33 Capitol Street Concord, NH 03301-6397 Telephone: (603)271-3650 annc.cdwardsfaidoi.nh.aov rebccca.woodard^doi.nh.gov
/s/ John-Mark Turner JOHN-MARK TURNER New Hampshire Bar No. 15610 JAMES Q. SHIRLEY New Hampshire Bar No. 2332 DAVID W. MCGRATH New Hampshire Bar No. 9347 Sheehan Phinney Bass + Green. P.A. 1000 Elm Street, PO Box 3701 Manchester, NH 03105 Telephone: (603) 668-0300 j tumerfg] sheehan. com l'shirlev(ajshcchan.com
31

Case 1:12-cv-00053-SM Document 105 Filed 02/12/14 Page 32 of 32

WHEREFORE, the Parties to this action having agreed to the provisions in the Settlement Agreement set forth above, and the Court being advised in the premises, this Settlement Agreement is hereby entered as t $ Order and Judgment of this Court.

It is so ordered, this

ay of

20l/if«, at Concord, New Hampshire.

I STEVEN J. McAULI United States District Judge

32

 
 IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF NEW HAMPSHIRE

_______________________________________________

LYNN E., by her guardian, Barry Ellsworth;

)

KENNETH R., by his guardian, Tri-County CAP,

)

Inc./GS; SHARON B., by her guardian, Office of

)

Public Guardian, Inc.; AMANDA D., by her guardian, )

Louise Dube; AMANDA E., by her guardian, Office of )

Public Guardian, Inc.; and JEFFREY D., on behalf of )

themselves and all others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

JOHN H. LYNCH, Governor of the State of New

)

Hampshire; NICHOLAS A. TOUMPAS, Commissioner )

New Hampshire Department of Health and Human

)

Services; NANCY L. ROLLINS, Associate

)

Commissioner, New Hampshire Department of Health )

and Human Services, Community Based Care Services; )

MARY ANN COONEY, Deputy Commissioner, New )

Hampshire Department of Health and Human Services, )

Direct Programs/Operations; ERIK G. RIERA,

)

Administrator, New Hampshire Bureau of

)

Behavioral Health,

)

)

Defendants.

)

1:12-CV-53-LM

_______________________________________________ )

THE UNITED STATES OF AMERICA,

) UNITED STATES’

) MEMORANDUM

Plaintiff-Intervenor,

) IN SUPPORT OF ITS

) ASSENTED-TO

v.

) MOTION TO INTERVENE

)

THE STATE OF NEW HAMPSHIRE,

)

)

Defendant.

)

_______________________________________________ )

MEMORANDUM IN SUPPORT OF THE UNITED STATES’ ASSENTED-TO MOTION TO INTERVENE
The United States files this memorandum in support of its assented-to motion to
intervene in this matter to remedy the State of New Hampshire’s failure to comply with
obligations under Title II of the Americans with Disabilities Act (“ADA”), 42 U.S.C. §§ 12131-
12134, and Section 504 of the Rehabilitation Act of 1973 (“Rehabilitation Act”), 29 U.S.C. § 794.1
The United States’ proposed Complaint-in-Intervention alleges that the State of New
Hampshire discriminates against individuals with mental illness by unnecessarily
institutionalizing them in segregated, restrictive settings such as the State’s psychiatric hospital,
New Hampshire Hospital (“NHH”), and the State’s nursing facility for persons with mental
illness, the Glencliff Home (“Glencliff”), and by creating a serious risk of institutionalization for
individuals with mental illness due to the State’s failure to provide them with sufficient
community services. See United States’ proposed Complaint-in-Intervention, attached as Exhibit
1. The United States alleges, therefore, that the State fails to provide services in the most
integrated setting appropriate to the needs of persons with mental illness in violation of the ADA
and Section 504 of the Rehabilitation Act.
1 Title II of the ADA was modeled closely on Section 504 of the Rehabilitation Act, which prohibits discrimination on the basis of disability in federally-conducted programs and in all of the operations of certain entities, including public entities that receive federal financial assistance. In all ways relevant to this discussion, the ADA and Section 504 of the Rehabilitation Act are generally construed to impose the same requirements. See Lesley v. Hee Man Chie, 250 F.3d 47, 54 (1st Cir. 2001) (“Section 504 of the Rehabilitation Act ‘is interpreted substantially identically to the ADA’”) (quoting Katz v. City Metal Co., 87 F.3d 26, 31 n.4 (1st Cir. 1996)); accord Yeskey v. Commw. of Pa. Dep’t of Corr., 118 F.3d 168, 170 (3d Cir. 1997) (“”[A]ll the leading cases take up the statutes together, as will we.”), aff’d, 524 U.S. 206 (1998).
2

Congress enacted the ADA “to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities.” 42 U.S.C. § 12101(b)(1). It found that “historically, society has tended to isolate and segregate individuals with disabilities, and, despite some improvements, such forms of discrimination against individuals with disabilities continue to be a serious and pervasive social problem … [this includes discrimination in] such critical areas as employment, housing, public accommodations, education, transportation, communication, recreation, institutionalization, health services, voting, and access to public services.” 42 U.S.C. § 12101(a)(2) and (3).
For those reasons, Congress prohibited discrimination against 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.
The United States Department of Justice is the federal agency with primary regulatory and enforcement responsibilities under Title II of the ADA. As a result, the Department has a significant interest in enforcing and interpreting Title II and ensuring that the integration mandate, set forth by the Supreme Court in Olmstead v. L.C., 527 U.S. 581 (1999), is met. The United States also has a substantial interest in ensuring that recipients of federal financial assistance, such as the State of New Hampshire, do not violate Section 504 of the Rehabilitation Act’s similar prohibition of disability discrimination. The instant case directly implicates these interests.
As set forth below, the United States’ motion to intervene is timely, the United States has a substantial legal interest in the instant litigation, intervention is necessary to protect the United States’ interest, the United States’ interest is not adequately represented by the existing parties,
3

and the United States’ claims against the State of New Hampshire share common questions of
law and fact with the claims of the private Plaintiffs; as a result, the United States’ motion
satisfies the requirements for intervention in this matter, whether as a matter of right or through
permissive intervention, pursuant to Rule 24 of the Federal Rules of Civil Procedure. The
existing parties assent to the United States’ intervention in this case. Therefore, the United
States respectfully requests intervention as a plaintiff.
ARGUMENT Rule 24 of the Federal Rules of Civil Procedure provides for two means by which an
applicant may intervene in an action: intervention as a matter of right, governed by subsection
(a), and permissive intervention, governed by subsection (b). As discussed below, the United
States satisfies both standards.
A. Intervention of Right
Rule 24(a)(2) provides that, upon a timely motion, the court must permit anyone to
intervene who:
[C]laims an interest relating to the property or transaction that is the subject of the action, and is so situated that disposing of the action may as a practical matter impair or impede the movant’s ability to protect its interest, unless existing parties adequately represent that interest.
As construed by the First Circuit, an applicant for intervention is entitled to intervention as a
matter of right when:
(i) its motion is timely; (ii) it has an interest relating to the property or transaction that forms the foundation of the ongoing action; (iii) the disposition of the action threatens to impair or impede its ability to protect this interest; and (iv) no existing party adequately represents its interest. Ungar v. Arafat, 634 F.3d 46, 50 (1st Cir. 2011); B. Fernandez & Hnos., Inc. v. Kellogg USA, Inc., 440 F.3d 541, 544-45 (1st Cir. 2006). These requirements should be read “not discretely,
4

but together,” and the rule should be applied with “an eye toward the ‘commonsense view of the overall litigation.’” Ungar v. Arafat, 634 F.3d at 51; Pub. Serv. Co. of N.H. v. Patch, 136 F.3d 197, 204 (1st Cir. 1998). The United States’ intervention request satisfies the requirements of Rule 24(a)(2).
1. The United States’ Motion for Intervention Is Timely The First Circuit has identified several factors relevant to determining whether a request for intervention is timely: (i) the length of time that the putative intervenor knew or reasonably should have known that his interests were at risk before he moved to intervene; (ii) the prejudice to existing parties should intervention be allowed; (iii) the prejudice to the putative intervenor should intervention be denied; and (iv) any special circumstances militating for or against intervention. R & G Mortg. Corp. v. Fed. Home Loan Mortg., 584 F.3d 1, 7 (1st Cir. 2009); Banco Popular de P.R. v. Greenblatt, 964 F.2d 1227, 1231 (1st Cir. 1992). Timeliness is not based on an absolute measure. The Supreme Court has emphasized that “[t]imeliness is to be determined from all the circumstances.” NAACP v. New York, 413 U.S. 345, 366 (1973); see also R & G Mortg. Corp. v. Fed. Home Loan Mortg., 584 F.3d at 7 (“The timeliness inquiry is inherently fact-sensitive and depends on the totality of the circumstances.”). In conducting a timeliness analysis, the status of the litigation at the time of the request for intervention is “highly relevant.” R & G Mortg. Corp. v. Fed. Home Loan Mortg., 584 F.3d at 7. A motion to intervene is timely if it is filed promptly after a movant obtains actual or constructive notice that a pending case threatens to jeopardize his rights. Id. at 8. The more advanced the litigation though, the more searching the scrutiny the motion must withstand, as one of the core purposes of the timeliness requirement is to prevent disruptive, late-stage intervention that could have been avoided by the exercise of reasonable diligence. Banco
5

Popular de P.R. v. Greenblatt, 964 F.2d at 1231; R & G Mortg. Corp. v. Fed. Home Loan Mortg., 584 F.3d at 7, 9; see also R & G Mortg. Corp. v. Fed. Home Loan Mortg., 584 F.3d at 7 (motions to intervene that will have the effect of reopening settled cases are regarded with “particular skepticism”).
Applying these factors to the instant case, the United States’ application for intervention is timely. The proceedings are at a very early stage. The Plaintiffs just filed their complaint on February 9, 2012, and the Defendants have yet to file an answer. The Court has not yet entered a scheduling order, and, accordingly, discovery has not commenced. In addition, the United States’ proposed Complaint-in-Intervention does not expand the claims already pending in this litigation.2 As a result, the United States’ intervention will not cause any prejudice through delay of the proceedings.
While the existing parties to the litigation will not be prejudiced by the United States’ intervention, the United States will be prejudiced if its request for intervention is denied. Its interests in enforcing Title II of the ADA and the integration mandate of Olmstead will undoubtedly be impaired if it is not permitted to intervene in this action. Moreover, the Department’s extensive experience with the statutes at issue will benefit the existing parties in presenting facts and arguments that will help frame the issues. By avoiding multiple lawsuits and coordinating discovery, intervention will lend efficiency to the proceedings.
2 The United States’ proposed Complaint-in-Intervention names the State of New Hampshire as a Defendant in this case. The State of New Hampshire may be joined as a Defendant because the right to relief asserted against the State and the existing Defendants (State officials sued in their official capacities) is joint and several and contains common questions of law and fact in compliance with Rule 20(a)(2) of the Federal Rules of Civil Procedure.
6

2. The United States Has a Substantial Legal Interest in this Litigation A party seeking intervention of right must state a claim that bears a “sufficiently close relationship to the dispute between the original litigants,” and the claimed interest must be direct and “significantly protectable.” Ungar v. Arafat, 634 F.3d at 51; see also Pub. Serv. Co. of N.H. v. Patch, 136 F.3d at 205 (a putative intervenor must show at a bare minimum that it has a “significantly protectable interest” that is “direct, not contingent”). The United States has a direct, substantial, and legally protectable interest in this litigation. As the federal agency with primary regulatory and enforcement responsibilities under Title II of the ADA, the Department of Justice has significant interests in enforcing and interpreting Title II and ensuring that its integration mandate, 28 C.F.R. § 35.130(d), as interpreted by Olmstead, is met. Accordingly, the Department has recently initiated or intervened in Olmstead litigation in a number of different states. Through explicit designation to the United States Attorney General, Congress carved out a prominent role for the United States Department of Justice with regard to ADA matters. In enacting the ADA, Congress sought “clear, strong, consistent, enforceable standards addressing discrimination against individuals with disabilities,” 42 U.S.C. § 12101(b)(2), and so directed the Attorney General to issue regulations implementing Title II of the ADA, 42 U.S.C. § 12134. Thereafter, the Attorney General promulgated the ADA regulations as required by Congress. 28 C.F.R. pt. 35 (July 26, 1991). Among other things, the ADA regulations require public entities to “administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.” 28 C.F.R. § 35.103(d). Moreover, Congress explicitly stated that one of its purposes was “to ensure that the Federal Government plays a central role in enforcing the standards established in [the ADA] on
7

behalf of individuals with disabilities.” 42 U.S.C. § 12101(b)(3). The United States’ prominent enforcement role is reflected in the authorization given the Attorney General to commence a legal action when discrimination prohibited by the ADA takes place. 42 U.S.C. § 12133; 28 C.F.R. pt. 35, subpts. F, G.
The Department of Justice, therefore, has a unique role in enforcing and interpreting the ADA and its implementing regulations on behalf of the broad public interest. This case directly implicates the United States’ interest in enforcing Title II of the ADA, and the Department’s goal of ensuring that Title II’s integration mandate, 28 C.F.R. § 35.130(d), as interpreted by Olmstead, is met. Similarly, the Department has authority to coordinate the implementation and enforcement of Section 504 of the Rehabilitation Act. Exec. Order No. 12,250, Leadership and Coordination of Nondiscrimination Laws, 3 C.F.R. 298 (1980 Comp.), reprinted in 42 U.S.C. § 2000d-1, note.
The central issues of the instant case are critical to the Department’s efforts to advance national goals on community integration and to vindicate the civil rights of persons with disabilities. Thus, the United States’ interest in the pending litigation merits intervention of right.
3. Intervention Is Necessary to Protect the United States’ Interest The United States’ ability to protect its substantial legal interest would be impaired absent intervention. Because the ADA is a relatively young statute, federal decisions interpreting and applying the provisions of the ADA are an important enforcement tool. Further, because there has not been significant case law developed under the Supreme Court’s decision in Olmstead, an unfavorable disposition of this case may, as a practical matter, impair the United States’ ability to enforce the integration mandate. The outcome of this case, including the
8

potential for appeals by existing parties, implicates stare decisis concerns that warrant the United States’ intervention. See Daggett v. Comm’n on Gov’t Ethics and Election Practices, 172 F.3d 104, 110-11 (1st Cir. 1999) (impairment of intervenors’ interest includes adverse collateral impact of judicial decision); see also Sierra Club v. Espy, 18 F.3d 1202, 1207 (5th Cir. 1994) (impairment of an intervenor’s interest includes “the stare decisis effect of the district court’s judgment”). As such, intervention is necessary to protect the United States’ substantial interest in this litigation.
4. The United States’ Interest Is Inadequately Represented by Existing Parties The final requirement for intervention as a matter of right is that the interest is inadequately represented by the existing parties to the litigation. Although the applicant for intervention bears the burden of demonstrating inadequate representation, the burden is “minimal” and is satisfied if the applicant shows that representation of his interest may be inadequate. B. Fernandez & Hnos., Inc. v. Kellogg USA, Inc., 440 F.3d at 545. The putative intervenor need only offer “an adequate explanation as to why” it is not sufficiently represented by the named party. Id. at 546. Differences in interest in kind or degree, including asymmetry in the intensity of interest, can be enough to show inadequate representation. Id. See also Tell v. Trs. of Dartmouth Coll., 145 F.3d 417, 419 (1st Cir. 1998) (stating that “without a perfect identity of interests, a court must be very cautious in concluding that a litigant will serve as a proxy for an absent party”); Sw. Ctr. for Biological Diversity v. Berg, 268 F.3d 810, 824 (9th Cir. 2001) (“It is sufficient for Applicants to show that, because of the difference in interests, it is likely that Defendants will not advance the same arguments as Applicants.”). The existing parties to this litigation cannot adequately represent the United States’ interests. Only the Attorney General can attend to the interests of the United States. 28 U.S.C. §
9

517 (“[t]he Solicitor General, or any officer of the Department of Justice, may be sent by the Attorney General to any State or district in the United States to attend to the interests of the United States in a suit pending in a court of the United States, or in a court of a State, or to attend to any other interest of the United States.”)
In this case, the United States’ interest is in enforcing the ADA and Section 504 of the Rehabilitation Act to advance the public interest in eliminating discrimination in the form of unjustified institutionalization. The private Plaintiffs do not and cannot represent the United States’ views on the proper interpretation and application of Title II and Section 504 of the Rehabilitation Act. As the Ninth Circuit recognized in a case allowing private parties to intervene alongside government agency defendants, “[t]he interests of government and the private sector may diverge.” Sw. Ctr. for Biological Diversity v. Berg, 268 F.3d at 823 (9th Cir. 2001); see also San Juan County v. United States, 503 F.3d 1163, 1228 (10th Cir. 2007); Scotts Valley Band of Pomo Indians of the Sugar Bowl Rancheria v. United States, 921 F.2d 924, 92627 (9th Cir. 1990) (recognizing that city government’s interest could not be adequately represented by another entity).
B. Permissive Intervention Rule 24(b) of the Federal Rules of Civil Procedure provides an alternative basis for the United States’ intervention in this action. Rule 24(b)(1)(B) states, in relevant part: On timely motion, the court may permit anyone to intervene who … has a claim or defense that shares with the main action a common question of law or fact. The First Circuit has concluded that this is a “low threshold.” Mass. Food Ass’n v. Mass. Alcoholic Beverages Control Comm’n, 197 F.3d 560, 568 (1st Cir. 1999).
10

In addition, the Rule provides that a federal officer or agency may be permitted to intervene, upon timely motion, in an action if an existing party’s claim or defense is based upon “a statute or executive order administered by the officer or agency; or … any regulation, order, requirement, or agreement issued or made under the statute or executive order.” Fed. R. Civ. P. 24(b)(2). For all requests for permissive intervention, the “court must consider whether the intervention will unduly delay or prejudice the adjudication of the original parties’ rights.” Fed. R. Civ. P. 24(b)(3). The United States should be granted permissive intervention pursuant to Rule 24(b).
As discussed above in conjunction with the Rule 24(a) analysis, the United States’ application for intervention in this litigation is timely and the United States’ participation would neither unduly delay the proceedings nor prejudice the adjudication of the rights of the original parties. In addition, the United States’ claims against the State of New Hampshire – namely, that the State unnecessarily segregates persons with mental illness in institutions and places them at serious risk of placement therein – share common questions of law and fact with the private Plaintiffs’ claims.
In addition, Rule 24(b)(2) permits intervention by a government agency if a party’s claim is based on a statute administered by the agency. See Fed. R. Civ. P. 24 Advisory Committee Notes on the 1946 Amendments (explaining that subsection (b) was amended in 1946 to include explicit reference to governmental agencies and officers in order to avoid exclusionary construction of the rule, and citing with approval, cases in which governmental entities were permitted to intervene). As the agency tasked with enforcing Title II of the ADA, the Department’s intervention falls squarely within the language of Rule 24(b)(2). See, e.g., Disability Advocates, Inc. v. Paterson, No. 03-3209, 2009 WL 4506301, at *2 (E.D.N.Y. Nov.
11

23, 2009) (permitting intervention by the United States under Fed. R. Civ. P. 24(b)(2) in an action based on the ADA and the integration mandate). Accordingly, the United States meets the requirements for permissive intervention.
CONCLUSION For the foregoing reasons, the Court should grant the United States’ assented-to motion to intervene and order its intervention in this action (1) as a matter of right pursuant to Rule 24(a)(2) of the Federal Rules of Civil Procedure, or, in the alternative, (2) permissively pursuant to Rule 24(b) of the Federal Rules of Civil Procedure. A proposed order and proposed Complaint-in-Intervention accompany this motion and memorandum.
12

Dated: March 27, 2012
JOHN P. KACAVAS United States Attorney District of New Hampshire
JOHN J. FARLEY Assistant United States Attorney
New Hampshire Bar No. 16934 District of New Hampshire U.S. Attorney’s Office 53 Pleasant Street Concord, NH 03301 (603) 225-1552 John.Farley@usdoj.gov

Respectfully submitted,
THOMAS E. PEREZ Assistant Attorney General
EVE L. HILL Senior Counselor to the Assistant Attorney General
ALISON BARKOFF Special Counsel for Olmstead Enforcement Civil Rights Division
/s/ Richard J. Farano JONATHAN M. SMITH, Section Chief JUDITH C. PRESTON, Deputy Chief RICHARD J. FARANO, Senior Trial Attorney
District of Columbia Bar No. 424225 DEENA S. FOX, Trial Attorney
New York Bar Registration No. 4709655 Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-307-3116 Facsimile: 202-514-0212 richard.farano@usdoj.gov
Counsel for Plaintiff-Intervenor, United States of America

13

 
 IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF NEW HAMPSHIRE

_______________________________________________

LYNN E., by her guardian, Barry Ellsworth;

)

KENNETH R., by his guardian, Tri-County CAP,

)

Inc./GS; SHARON B., by her guardian, Office of

)

Public Guardian, Inc.; AMANDA D., by her guardian, )

Louise Dube; AMANDA E., by her guardian, Office of )

Public Guardian, Inc.; and JEFFREY D., on behalf of )

themselves and all others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

JOHN H. LYNCH, Governor of the State of New

)

Hampshire; NICHOLAS A. TOUMPAS, Commissioner )

New Hampshire Department of Health and Human

)

Services; NANCY L. ROLLINS, Associate

)

Commissioner, New Hampshire Department of Health )

and Human Services, Community Based Care Services; )

MARY ANN COONEY, Deputy Commissioner, New )

Hampshire Department of Health and Human Services, )

Direct Programs/Operations; ERIK G. RIERA,

)

Administrator, New Hampshire Bureau of

)

Behavioral Health,

)

)

Defendants.

)

1:12-CV-53-LM

_______________________________________________ )

)

ORDER

THE UNITED STATES OF AMERICA,

)

)

Plaintiff-Intervenor,

)

)

v.

)

)

THE STATE OF NEW HAMPSHIRE,

)

)

Defendant.

)

_______________________________________________ )

ORDER GRANTING THE UNITED STATES’ ASSENTED-TO MOTION TO INTERVENE Upon careful consideration of the United States’ Assented-To Motion to Intervene, the United States’ Memorandum in Support of the Motion, any response thereto, and the applicable law, this Court finds that, pursuant to Rule 24 of the Federal Rules of Civil Procedure, the United States shall be permitted to intervene and to file its proposed Complaint-in-Intervention. WHEREFORE, IT IS HEREBY ORDERED, ADJUDGED, and DECREED, this _____ day of ____________, 2012, at Concord, NH, that the United States’ Assented-To Motion to Intervene in this action is hereby GRANTED.
_________________________ LANDYA B. McCAFFERTY United States Magistrate Judge
2

 
 IN THE UNITED STATES DISTRICT COURT


FOR THE DISTRICT OF NEW HAMPSHIRE 


_______________________________________________

AMANDA D., et al.

)




)




Plaintiffs,

)




)




v.

)




)




MARGARET WOOD HASSAN, et al.,

) 


)


Defendants.

) 


_______________________________________________ ) 
 1:12-CV-53-SM 


THE UNITED STATES OF AMERICA,

) 


)


Plaintiff-Intervenor,

)




)




v.

)




)




THE STATE OF NEW HAMPSHIRE,

) 


)


Defendant.

)

_______________________________________________ )

UNITED STATES’ REPLY TO DEFENDANTS’ OPPOSITION TO AND IN SUPPORT OF PLAINTIFFS’ RENEWED MOTION FOR CLASS CERTIFICATION The United States submits this reply to Defendants’ Opposition and in support of
the Plaintiffs’ Renewed Motion for Class Certification. Plaintiffs filed this lawsuit because they have suffered unnecessary institutionalization due to the inadequacy of community supports in the operation of the state of New Hampshire’s mental health delivery system, a failure which has long been acknowledged by the State. The presence of the Department of Justice (“the Department”) as a Plaintiff-Intervenor in this case does not preclude certification.
The Court should certify a class in this matter because class actions are necessary and appropriate vehicles for achieving systemic reform in Olmstead cases and remain so after the Supreme Court’s decision in Wal-Mart v. Dukes. Extensive briefing and evidence on the

question of class certification support the finding that the Plaintiffs have met their burden under Rule 23 of the Federal Rules of Civil Procedure, and Plaintiffs need not fully prove the merits of their claims to meet the class certification threshold. Defendants’ attempts to paint a class of people with serious mental illness as individuals sharing no common interest in systemic mental health reform reveals a strained effort to see only trees in a forest. Under Defendants’ logic, no class of individuals with disabilities would ever be certified. Such a result would be contrary to the intent of the Supreme Court in Wal-Mart. For the reasons set forth below, the Department urges the Court to certify a class in this matter.
I. Introduction In lengthy papers currently before the Court, as well as initial briefing on this issue
submitted last spring, the Parties have presented their arguments on the question of whether it is appropriate to certify a class in this matter. Plaintiffs persuasively argue that the Court should certify a class because the claims of the named plaintiffs and members of the putative plaintiff class all share common questions of fact and law that are susceptible to a common answer, as required by Rule 23 and Wal-Mart v. Dukes, 131 S.Ct. 2541 (2011). Plaintiffs are all individuals with serious mental illness who are unnecessarily institutionalized or are at serious risk of institutionalization in New Hampshire Hospital or Glencliff due to the State’s failure to provide sufficient mental health services in the community. They assert, and the United States agrees, that an injunction requiring the State to provide mobile crisis services, Assertive Community Treatment (“ACT”), supported housing, and supported employment would resolve their claims in a single stroke. Defendants, meanwhile, shift the focus away from the State’s policies which lead to unnecessary institutionalization and argue that the Plaintiff class fails to meet the commonality, typicality, adequacy, and cohesiveness requirements of Rule 23 because of
2


differences between class members’ specific circumstances. Defendants also argue in their recent brief that the Court need not certify the class because the Department’s intervention makes a class superfluous. As explained below, Plaintiffs’ view of the law should prevail and the Department’s presence should not impede class certification.
II. The Presence of the Department Does Not Make a Class Unnecessary Defendants argue that the presence of the Department as an intervenor in this case makes
class certification unnecessary. This position is based on the assumption that the interests of the Department and the Plaintiff class are identical and that the relief the two parties will seek could not diverge. While the Department and Plaintiffs each brought claims under the Americans with Disabilities Act (“ADA”) and the Rehabilitation Act, they represent different interests. Furthermore, unlike the Plaintiffs, the Department did not bring a claim under the Pre-Admission Screening and Resident Review requirements of the Medicaid Act (“PASRR”).
Differences between the interests represented by the Parties also weigh heavily in favor of certification. The Department represents national interests when litigating matters under the ADA. Charged with developing a national enforcement program, the Department seeks to take a consistent approach in its cases across the nation, while tailoring claims and remedies to the specific circumstances of any jurisdiction. This role is a privilege bestowed on the Department, which is afforded deference in its understanding of the ADA as the agency empowered to draft and interpret its regulations. Olmstead v. L.C., 527 U.S. 581, 597-98 (1999). (“Because the Department is the agency directed by Congress to issue regulations implementing Title II, its views warrant respect.” (citation omitted); Pashby v. Delia, 2013 WL 7911829, at *10 (4th Cir. 2013) (“Because Congress instructed the DOJ to issue regulations regarding Title II, we are especially swayed by the DOJ's determination”); M.R. v. Dreyfus, 663 F.3d 1100, 1117 (9th Cir.
3


2011) (deferring to DOJ’s views regarding title II and its regulations, stating that “[a]n agency’s
interpretation of its own regulation is ‘controlling unless plainly erroneous or inconsistent with
the regulation.’”) (citations omitted). Of course, this great responsibility comes with some
constraints. For example, our Olmstead adult mental health practice is affected by the previous statements, positions, interpretations, and settlements entered by the Department in this area.1
With regard to litigation decisions, such as the choice of experts and desirability of settlement,
the Department is also required to use judgment directed toward serving national interests and
cannot forfeit that discretion in an effort to meet the specific needs of class members in a
particular case. The Plaintiffs, on the other hand, are unencumbered in their ability to pursue the
remedies needed and desired by the class, and, indeed, are ethically required to further the
interests of the class of individuals in any settlement or litigation. The distinctions between the
Parties’ interests and the Federal Rules both support class certification.
Regardless of these differences, the Court can and should enable the putative plaintiff
class to represent its own interests. Even where the Department is engaged in the case, plaintiffs
may represent a class unless, unlike here, Congress has explicitly precluded the claims from
going forward on a parallel basis. Recently, a New York district court held that “the existence of
1 In their brief, the Defendants imply that the United States has unfairly targeted New Hampshire for enforcement action. To support this claim they make a comparison between their current inpatient capacity and the 2006 inpatient capacity of other states in which the Department has conducted Olmstead enforcement. Defs.’ Opp. at 18. Even if New Hampshire had compared inpatient capacity from the same year across states, the State would be missing the point. The critical question is not how many beds a jurisdiction has, rather it is the balance of institutional and community spending and the extent to which a state supports community services that reduce the need for inpatient treatment. New Hampshire Hospital’s high readmission rates are evidence of the inadequacy of the needed community services. See New Hampshire 2010 Mental Health Outcome Measures, CMHS, Uniform Reporting System. Furthermore, New Hampshire’s comparison of its inpatient capacity to those of North Carolina and Virginia is completely irrelevant. The Department’s investigation of North Carolina focused on segregation of adults in adult care homes, not inpatient psychiatric hospitals. The Department’s investigation of Virginia focused exclusively on the state’s developmental disabilities system and had nothing to do with individuals with mental illness.
4


the parallel government action does not bar certification of the class under Rule 23(b)(3),” in the context of an action under the Employee Retirement Income Security Act (“ERISA”). In re Beacon Assocs. Litig., No. 09 Civ. 777, 2012 WL 1569827, at *13 (S.D.N.Y. May 3, 2012). The court was persuaded by the Department of Labor’s argument that a per se rule prohibiting class certification where a parallel government suit exists would interfere with and undermine the private enforcement mechanisms in the statute. Id. at *12-13; see also United States v. Local Union No. 3, Int'l Union of Operating Engineers, 1972 WL 194, at *5 (N.D. Cal. July 18, 1972) (“There is no statute which precludes private suits from proceeding – even as class actions – simultaneously with pattern and practice suits brought by the United States pursuant to 42 U.S.C. § 2000e-6. … given that the possibility of the two proceedings at the same time would have occurred to the drafters of Title VII, it is only reasonable to expect Congress to have prohibited such simultaneous proceedings if it wanted to.”). Like ERISA, the ADA provides for both government and private enforcement mechanisms which were carefully crafted by Congress. The Court should not interfere with this scheme. Only where the government had already obtained relief or class certification threatened to unravel a government settlement, neither of which is the case here, would certification of parallel suits be problematic. See Beacon, at *12­ 13. The putative plaintiff class and the Department represent distinct interests and the Court should certify the plaintiff class to ensure that both perspectives are represented, as allowed under the law and the Federal Rules.
Finally, even if the Parties did not represent different interests, the rights of the class to bring its claims under Rule 23 should not be undermined by the presence of the Department where, as here, all of the requirements of the Rule are met. The First Circuit has explained that “whether the action should be maintained as a class action depends on the appropriateness of
5


injunctive or corresponding declaratory relief with respect to the class as a whole.” Dionne v. Bouley, 757 F.2d 1344, 1356 (1st Cir. 1985) (emphasis in original). Even where injunctive relief can be obtained without certifying a class, the court recognized that “other considerations may render a denial of certification improper.” Id. One such situation described by the First Circuit is “where class certification does not impose any significant burden on the Court.” Id. Here, where the Department will be proceeding with the litigation, discovery will continue at the same scale and the Parties will be moving toward trial at the same rate, whether or not the Plaintiff class is certified. Accordingly, the Court will not experience any additional burdens as a result of class certification. In fact, the case would become more complicated to manage if the Plaintiff class were certified only as to its PASRR claim, a claim not raised in the Department’s Complaint. Under that scenario, the Department would proceed on two claims, the Plaintiff class would proceed on a third claim, and the named Plaintiffs would proceed on all three claims. Determinations regarding discovery and other litigation issues would be excessively complicated and time consuming. Class certification is appropriate under Rule 23 and it will result is a conservation of judicial resources during the remaining year of discovery.
III. Class Actions Are Appropriate under the ADA and Olmstead, and Remain So After Wal-Mart
Certification of a class ensures that those who are unnecessarily institutionalized or at risk of unnecessary institutionalization are before the court at the same time. Without the class action device, relief would only be afforded to individuals with the resources or wherewithal to retain private counsel, rather than to all those who are affected by the State policies at issue. Affording Olmstead relief on a piecemeal basis risks the distribution of one-time relief to those who have complained, in the order in which they complain. Moreover, piecemeal relief leaves in
6


place the very systemic deficiencies of a statewide service system that caused the unnecessary institutionalization in the first place, that are likely to be perpetuated in the future, and that violate the ADA.
Although the Olmstead case was not a class action, the Supreme Court’s opinion suggested that class actions are appropriate vehicles to resolve injuries to people with disabilities when public entities are not administering services and programs in the most integrated settings. In Olmstead, two women with disabilities sought to live in the most integrated setting appropriate to their needs, in conformity with the requirements of the ADA and its implementing regulations. See Olmstead v. L.C., 527 U.S. 581, 593 (1999). Only the named plaintiffs attained relief through their litigation and the Supreme Court intimated that class actions were the best private means of enforcing the right to be free from “unjustified institutionalization.” It was not until the United States filed an Olmstead case on behalf of all of the individuals in Georgia’s mental health system who were unnecessarily institutionalized or at risk of unnecessary institutionalization more than a decade later, that Georgia changed its funding policy which had favored institutions over services in the community. See United States v. Georgia, No. 1:10- 249 (N.D. Ga. Oct. 29, 2010) (order granting settlement affording systemic relief to remedy ADA violations). Recognizing that relief for those individuals who file complaints might not lead to a fair result for all those affected by a state policy, the Olmstead Court cautioned that courts should not “order displacement of persons at the top of the community-based treatment waiting list by individuals lower down who commenced civil actions.” Id. at 606.
The Olmstead Court also suggested that class actions were appropriate vehicles to resolve claims in the context of its discussion of the state’s affirmative defenses in an ADA integration case. There, the Court laid out a process by which a jurisdiction may raise a
7


fundamental alteration defense and argue that in the allocation of available resources, immediate relief for the plaintiffs would be inequitable, “given the responsibility the State has undertaken for the care and treatment of a large and diverse population of persons with mental disabilities.” 527 U.S. at 604. Accordingly, analysis of the fundamental alteration defense, if raised by the State here, would necessarily require looking beyond the individually-named Plaintiffs to the State’s overall system serving thousands of other individuals with mental illness. The Olmstead Court recognized that it is imperative to consider the system and resources for serving people with disabilities as a whole, rather than dividing the system into innumerable subgroups, each of which must be considered and addressed separately. The Court’s analysis supports the view that the members of the plaintiff class, despite the differences in their specific disabilities and current treatment needs (differences apparent in any class of people with disabilities), have a common contention susceptible to a single stroke resolution.
Where, as here, all class members can show that they suffer a common harm due to State policies, a class action remains appropriate under the Wal-Mart analysis. The Court in Wal-Mart instructed judges to carefully consider the question of commonality, particularly in a situation where a nationwide class sweeps in millions of plaintiffs whose claims are each based on the decisions of individual supervisors. 131 S.Ct. at 2555. However, this increased scrutiny was not intended to eliminate class actions. See id. at 2553-54 (providing example of circumstances in which class would be appropriate in employment discrimination case). Nor, as the Supreme Court recently clarified, was the intent to require that cases be fully proven at the class certification stage. Amgen v. Connecticut Retirement Board, 133 S. Ct. 1184, 1194-95 (2013) (“Rule 23 grants courts no license to engage in free-ranging merits inquiries at the certification stage.”). Thus the Court has now reaffirmed the longstanding guidance provided in Eisen v.
8


Carlisle & Jacquelin, that “[c]lass certification hearings should not be mini-trials on the merits of the class or individual claims.” 417 U.S. 156, 177-78 (1974); see Amgen, 133 S. Ct. at 1201.
Where plaintiffs share a common contention, Wal-Mart affirms that certification is appropriate, and courts have continued to certify classes like the one proposed here, including in Olmstead cases, since Wal-Mart. In Pashby v. Cansler, 279 F.R.D. 347 (E.D.N.C. 2011), aff’d Pashby v. Delia, 2013 WL 791829 (4th Cir. March 3, 2013), the court certified a class of plaintiffs with disabilities who challenged the State’s termination of in-home personal care services via implementation of more restrictive eligibility rules. Id. at 351, 354. The plaintiffs asserted that the reduction or termination of in-home services would place them at risk of institutionalization in violation of Olmstead and sought to block the termination of benefits. Id. at 350, 355. The court concluded that plaintiffs had shown a common contention that “will resolve the claims of all potential plaintiffs, irrespective of their particular factual circumstances.” Id. at 353.
As a court in the First Circuit recently explained when affirming class certification in a case involving children in the foster care system, Wal-Mart “provided guidance on how existing law should be applied to expansive, nationwide class actions that are very different from the case currently before the court.” Connor B. v. Patrick, 278 F.R.D. 30, 33 (D. Mass 2012) (denying defendants’ motion to decertify a class of children in foster care alleging harm due to diverse systemic deficiencies in the foster care system under the control of a single state agency). Here, like in Connor, Plaintiffs allege that the harm they suffer is caused by a failure in the administration of State services. Unlike the plaintiffs in Wal-Mart, Plaintiffs in this case share a common contention—that Defendants are not providing services in the most integrated setting
9


appropriate to class members’ needs as required by the ADA—and this contention is “central to the validity” of each class member’s ADA claim. Wal-Mart, 131 S. Ct. at 2551.
IV. Differences Between Ultimate Relief Afforded Olmstead Class Members Do Not Preclude Classes Defendants incorrectly argue that individuals in the putative plaintiff class are not
appropriate for inclusion in a class because their circumstances are not identical. Their arguments misunderstand the requirements of Rule 23 and the nature of mental illness. Plaintiffs have met their burden of showing, for example, that state policies are causing harm to putative class members who are currently institutionalized and others who are likely to be institutionalized in the future. Likewise, Plaintiffs have shown that a single injunction to expand the community services identified in their complaint will remedy the common harms, regardless of the specific mix of services each putative class member would need to avoid unnecessary institutionalization. If, as Defendants claim, any such distinctions inherently defeat class certification, then class actions involving people with disabilities under the ADA would be impermissible, a contention that has been rejected by multiple courts post-Wal-Mart.
Courts considering classes of individuals with disabilities must always face the question of whether inevitable differences between class members preclude certification. Having considered this very issue in post-Wal-Mart decisions, judges around the country have affirmed that the class requirements of commonality, typicality, and adequacy are not undermined by these unavoidable differences in classes involving people with disabilities. Most analogous to the case at hand is Lane v. Kitzhaber, 283 F.R.D. 587 (D. Or. 2012), a case in which plaintiffs sought class certification to challenge the defendants’ failure to “plan, administer, operate and fund a system that provides employment services that allow persons with disabilities to work in
10


the most integrated setting.” Id. at 595. The court rejected nearly identical arguments to those raised by Defendants here and found commonality even though the class members were not “identically situated.” Id. at 598. In the Lane case discussed above, the court explained that, “Under defendants' interpretation, differences with respect to the needs and preferences of persons with disabilities would always preclude the certification of a class in virtually all ADA Title II cases.” 283 F.R.D. at 598. As the Court in Lane made clear, after Wal-Mart, ADA cases may still proceed as class actions despite the inherent differences between individuals with disabilities. Id.
Lane is not the only post Wal-Mart case in which the court has certified a class of people with disabilities. For example, in Oster v. Lightbourne, 2012 WL 685808 (N.D. Cal. Mar. 2, 2012), the Court found commonality among the plaintiff class whose state in-home support services would be “limited, cut, or terminated” by 20 percent under a new state law, even though some individuals in the class may not actually be impacted by the reduction in services because of their ability to apply for supplemental hours. Id. at *1, *4-6. Similarly, an Indiana court recently found that the commonality prong was satisfied in a case related to prisoners with a range of mental illnesses who have been or will be held in segregation. Indiana Protection and Advocacy Servs. Comm’n v. Comm’r, Indiana Dep’t of Corr., 2012 WL 6738517, at *18 (S.D. Ind. Dec 31, 2012). A New York district court considering accommodations in emergency plans for people with a wide range of disabilities, from mobility impairments to mental illness, also found commonality. Brooklyn Ctr. for Independence of the Disabled v. Bloomberg, 287 F.R.D. 240, 249 (S.D.N.Y. 2012) (“In other words, “[a] court may find a common issue of law even though there exists some factual variation among class members' specific grievances.”).
11


Moreover, courts have found that classes of individuals with disabilities meet the typicality prong of Rule 23. For example, in a recent case regarding accommodations for people with a range of mobility needs, the court found that plaintiffs met the typicality requirement for certification despite differences between class members’ needs for mobility assistance. Ault v. Walt Disney World Co., 692 F.3d 1212 (11th Cir. 2012) (“’Class members’ claims need not be identical to satisfy the typicality requirement; rather, there need only exist ’a sufficient nexus ... between the legal claims of the named class representatives and those of individual class members to warrant class certification.’”) (citations omitted). Variation between class members’ disabilities and the reasonable accommodations needed did not preclude a finding of typicality in Gray v. Golden Gate Nat'l Recreation Area, 279 F.R.D. 501, 510 (N.D. Cal. 2011) (“Plaintiffs persuasively counter that classes of disabled individuals seeking reasonable accommodation have been certified without the need for individualized assessments of each alleged barrier, each class member's disability or the type of accommodation needed.”), reconsideration denied in part, 866 F. Supp. 2d 1129 (N.D. Cal. 2011). Contrary to Defendants’ contention, Wal-Mart has not been interpreted as requiring that plaintiffs be indistinguishable or need identical services or accommodations in order for a class to be certified.
Class members here seek a working system of community mental health services that will support their changing needs over time. Compl. ¶ 9. That is because mental illness is often characterized by periods of stability and periods during which more intensive services are necessary, occasionally including acute care. See Mental Health: A Report of the Surgeon General, 98-104 (1999). Thus, distinguishing between class members on the basis of their present, immediate needs fails to ensure that the appropriate relief is available to them over time. Because individual needs and circumstances change over time, courts have recognized that it is
12


appropriate to afford Olmstead relief not only to classes of individuals currently in institutions but also to classes of people who are at risk of being, but are not currently, institutionalized. See, e.g., Pashby v. Delia, 2013 WL 791829, at *9 (4th Cir. March 3, 2013); M.R. v. Dreyfus, 663 F.3d 1100, 1116-17 (9th Cir. 2011); Fisher v. Oklahoma Health Care Authority, 335 F.3d 1175, 1182 (10th Cir. 2003); see also Ligas v. Maram, 2006 WL 644474, at *5 (N.D. Ill. 2006).
Defendants fail to take into account this fundamental reality – the changing needs for services by a person over time. That is evident in Defendants’ attempts to divide the class, for example, based on one person’s current need for ACT and another’s need for supportive housing. Defs.’ Opp. at 34-44. Underlying this view of a divisible class is the assumption that mental illness is a static condition and an inappropriately inflexible vision of the mental health system. A system of supports that provides adequate mobile crisis, ACT, supported housing, and supported employment would meet the changing needs of people with serious mental illness in New Hampshire, whether they are individuals currently in NHH or Glencliff who need these services to transition to the community, or individuals in the community who need these services to avoid unnecessary institutionalization. See Sudders Aff. at ¶ 22-25.
Similarly, Defendants’ attempt to silo the Plaintiffs based on the severity of their symptoms and diagnoses is misplaced. Defs.’ Opp. at 20-27. Contrary to Defendants’ assertions, periods of severe symptoms or challenging diagnoses do not preclude an individual from benefitting from community-based supports. In fact, these assertions themselves are evidence of the bias toward institutional care that continues to pervade New Hampshire’s mental health system.2 Evidence-based practices such as ACT and supported housing have effectively
2 It is not surprising that the Defendants’ affiants, who are employed by the very facilities that are at issue in this case and made the treatment decisions contradicted by Plaintiffs’ experts, find fault with the Plaintiffs’ expert opinions. Dr. De Nesnera’s determination that for many individuals “NHH is the only appropriate form of treatment
13


been employed around the country to support individuals with serious mental illness, even those who had been hospitalized for decades and who have had severe symptoms. See, e.g., Substance Abuse and Mental Health Services Administration. Assertive Community Treatment: The Evidence (2008); Substance Abuse and Mental Health Services Administration. Permanent Supportive Housing: Building Your Program 5-7 (2010). In fact, the Defendants’ own Ten-Year Plan identified these services as critical to preventing hospitalization and enabling people to transition back to the community. See NH Dep’t of Health and Human Servs., Addressing the Critical Mental Health Needs of NH’s Citizens: A Strategy for Restoration 3-6 (Aug. 2008). It is ironic that Defendants assert that the presence of some individuals who have historically not succeeded in the community should destroy the class; Defendants’ inadequate community services have contributed to the lack of success. Individuals who have not succeeded in community placements in the past, without the benefit of adequate community-based services, often do succeed when they have the benefit of that support.
The need for acute inpatient care is reduced by the availability of resources in the community which can prevent the escalation of a crisis. See Mental Health: A Report of the Surgeon General, 285-95 (1999). Thus, Defendants’ argument that current emergency room use and wait times for admission to New Hampshire Hospital evidence a need for more hospital beds in New Hampshire assumes the continuing inadequacy of community supports. See Sudders Aff. at ¶ 13, 16. Defendants are merely pointing to the harms that have resulted from the exact failures at issue in this case. Defendants cannot use the negative effects of their own actions to oppose a class-based remedy to such failures.
– no matter what community-based services are available,” De Nesnera Aff. at ¶ 22, is a striking affirmation of the institutional bias that persists.
14

New Hampshire’s leaders, including newly-elected Governor Wood Hassan, have recognized the critical role that community services play in a functioning mental health system that does not resort to the unnecessary institutionalization of individuals with mental illness. The Governor recently acknowledged that the State mental health system is not meeting the needs for community-based services saying, “We can all agree that our mental health system is deeply strained… it is time to resume our efforts to repair our mental health system.” Budget Address of Gov. Margaret Wood Hassan, Feb. 14, 2013; see also Riera Aff. at ¶ 15, 33. These statements echo the finding from the State’s Ten-Year Plan that, “many individuals are admitted to New Hampshire Hospital because they have not been able to access sufficient services in a timely manner (a “front door problem”) and remain there, unable to be discharged, because of a lack of viable community based alternatives (a “back-door” problem).” NH Dep’t of Health and Human Servs., Addressing the Critical Mental Health Needs of NH’s Citizens: A Strategy for Restoration 6 (Aug. 2008).
But, instead of recognizing the impact that these services can have in enabling success in the community, the Defendants fill page after page describing the symptoms and challenges of named and potential class members, whose very lives are being adversely affected by the strains on New Hampshire’s mental health system. In particular, dissecting the medical records and psychotherapy notes3 of courageous named plaintiffs who have come forward to seek relief on behalf of all those who, like them, have experienced unnecessary institutionalization is distasteful, to say the least. To echo some of the Governor’s recent sentiments, New Hampshire is a better state than that. See Budget Address of Gov. Margaret Wood Hassan, Feb. 14, 2013.
3 Even where it is permitted under HIPAA, the use of psychotherapy notes in legal proceedings is ethically fraught. See Paul Mosher and Peter P. Swire, “The ethical and legal implications of Jaffee v. Redmond and the HIPAA medical privacy rule for psychotheraphy and general psychiatry,” Psychiatr. Clin. N. Amer. 25, 575-84 (2002); see also Mental Health: A Report of the Surgeon General, 438-49 (1999).
15


Having made a showing that there are questions common to the class that may be resolved through a single injunction, the Plaintiffs should be allowed to proceed as a class. See Wal-Mart, 131 S. Ct. at 2551; Amgen, 133 S. Ct. at 1191. The Court need not reach the merit of whether the Plaintiffs have proven their ADA claim. Plaintiffs have presented more than sufficient evidence to support a finding that they meet the requirements of Rule 23 and, therefore, a class is appropriate.
CONCLUSION For the foregoing reasons, the Court should grant Plaintiffs’ renewed motion for class certification.

Dated: March 21, 2013

Respectfully submitted,

JOHN P. KACAVAS United States Attorney District of New Hampshire
JOHN FARLEY Assistant United States Attorney District of New Hampshire U.S. Attorney’s Office 53 Pleasant Street Concord, NH 03301 (603) 225-1552 John.Farley@usdoj.gov

THOMAS E. PEREZ Assistant Attorney General
EVE L. HILL Senior Counselor to the Assistant Attorney General
ALISON BARKOFF Special Counsel for Olmstead Enforcement Civil Rights Division
/s/ Deena S. Fox JONATHAN M. SMITH, Section Chief JUDITH C. PRESTON, Deputy Chief RICHARD J. FARANO, Senior Trial Attorney District of Columbia Bar No. 424225 DEENA S. FOX, Trial Attorney New York Bar Registration No. 4709655 KATHERINE V. HOUSTON, Trial Attorney California Bar No. 224682
16


REGAN M. BAILEY, Trial Attorney Washington Bar No. 39142 ALEXANDRA L. SHANDELL, Trial Attorney District of Columbia Bar No. 992252 U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-305-1361 deena.fox@usdoj.gov Counsel for Plaintiff-Intervenor, United States of America
17


CERTIFICATE OF SERVICE

I hereby certify that on March 21, 2013, I electronically filed the United States’ Reply to Defendants’ Opposition to and in Support of Plaintiffs Motion for Class Certification, with the Clerk of the Court using the CM/ECF system which will automatically send email notification of such filing to the attorneys of record.
/s/ Deena Fox DEENA S. FOX, Trial Attorney
New York Bar Registration No. 4709655 Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-305-1361 deena.fox@usdoj.gov Counsel for Plaintiff-Intervenor, United States of America
18


 
 Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 1 of 46

UNITED STATES DISTRICT COURT
 DISTRICT OF NEW HAMPSHIRE


Kenneth R., by his Guardian Tri-County CAP, Inc./GS; Sharon B. and Amanda E., by Their Guardian the Office of Public Guardian, Inc.; Jeffrey D., by his Guardian Monique Doukas; and Amanda D.,
Plaintiffs
v.

Case No. 12-cv-53-SM Opinion No. 2013 DNH 123

Margaret W. Hassan, Governor
 of the State of New Hampshire;
 Nicholas A. Toumpas, Commissioner
 of the NH Department of Health
 and Human Services;
 Nancy L. Rollins, Associate
 Commissioner of the NH Department
 of Health and Human Services,
 Community Based Care Services;
 Mary A. Cooney, Deputy Commissioner,
 NH Department of Health and Human
 Services, Direct Programs/Operations;
 Erik G. Riera, Administrator,
 NH Bureau of Behavioral Health,

Defendants
 ________________________________

The United States of America,
 Plaintiff-Intervenor


v.


The State of New Hampshire,
 Defendant


O R D E R


The plaintiffs and intervenor claim that the State of New
 Hampshire unnecessarily institutionalizes people with serious


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 2 of 46
mental illnesses, in violation of the integration mandates of the
 Americans With Disabilities Act, 42 U.S.C. § 12131(2), and the
 Rehabilitation Act, 29 U.S.C. § 794. The named plaintiffs seek
 certification of an appropriate class, doc. no. 73, and class-
 based relief. The United States, as intervenor, supports the
 motion for class certification. Defendants object, however,
 arguing that the requirements for certification under Fed. R.
 Civ. P. 23(a) and 23(b)(2) are not met.

Background
 Title II of the Americans with Disabilities Act of 1990
 (“ADA”), 42 U.S.C. § 12132, provides that “no 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.” Id. at
 § 12131(2). A “public entity” includes State and local
 governments, and “any department, agency, special purpose
 district or other instrumentality of a State . . . or local
 government.” Id. at § 12131(1)(A) & (B).

The needless segregation of persons with disabilities — in
 institutions — is a form of “discrimination” prohibited by the
 ADA. Olmstead v. L.C. ex rel. Zimring, 527 U.S. 581, 587, 588

2


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 3 of 46
(1999) (relying, in part, on Congress’s finding “[i]n the opening
 provisions of the ADA,” that “discrimination against individuals
 with disabilities persists in . . . institutionalization”). To
 comply with the ADA’s “integration mandate” (i.e., the
 requirement that persons with disabilities be “integrated” in
 general society to the extent reasonably feasible), states must
 “provide community-based treatment for persons with mental
 disabilities” when

(1) the State’s treatment professionals have determined
 that community placement is appropriate,
 (2) the transfer from institutional care to a less
 restrictive setting is not opposed by the affected
 individual, and
 (3) “the placement can be reasonably accommodated,
 taking into account the resources available to the
 State and the needs of others with mental
 disabilities.”
 Id. at 607.

The Attorney General’s implementing regulations also contain
 an integration mandate, which requires public entities to
 administer programs “in the most integrated setting appropriate
 to the needs of qualified individuals with disabilities.” 
 28 C.F.R. § 35.130(d).1 The regulations, likewise, prohibit
 public entities from “utiliz[ing] criteria or methods of

1 An “integrated setting” is one that “enables individuals with
 disabilities to interact with nondisabled persons to the fullest
 extent possible . . . .” 28 C.F.R. Pt. 35, App. B.

3


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 4 of 46
administration . . . that have the effect of subjecting qualified
 individuals with disabilities to discrimination,” 28 C.F.R.
 § 35.130(b)(3), including needless segregation. See Day v.
 District of Columbia, 894 F. Supp. 2d 1, 22 (D.D.C. 2012) (To
 state a claim under the ADA, it is “sufficient to allege . . .
 that the [government] has utilized criteria or methods of
 administration that have caused plaintiffs to be confined
 unnecessarily in nursing facilities.”) (internal punctuation and
 quotation marks omitted).

Although a public entity must make “reasonable modifications
 in policies, practices, or procedures” to avoid unnecessarily
 segregating persons with disabilities, 28 C.F.R. § 35.130(b)(7),
 that obligation is not absolute. The regulations “allow[] States
 to resist modifications” to their policies, practices, and
 procedures that “entail a fundamental alteration” of their
 services and programs. Olmstead, 527 U.S. at 603 (internal
 punctuation omitted) (citing 28 C.F.R. § 35.130(b)(7)).

The Rehabilitation Act (“RA”) and its regulations similarly
 prohibit discrimination on the basis of disability, 29 U.S.C.
 § 794(a) and 28 C.F.R. § 41.51(a); require that services be
 provided in the most integrated setting, 28 C.F.R. §§ 41.51(d);
 and make it a violation of the Act to use methods of

4


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 5 of 46
administration that subject individuals to discrimination, 28
 C.F.R. § 41.51(b)(3), 45 C.F.R. § 84.4(b)(4). See Bryson v.
 Stephen, 2006 WL 2805238, at *3 (D.N.H. Sept. 29, 2006) (“The
 Rehabilitation Act contains . . . similar provision[s]” to the
 ADA).

The Nursing Home Reform Act (“NHRA”), 42 U.S.C.
 § 1396r(e)(7)(D)(ii), also addresses the unnecessary segregation
 of people with mental disabilities. The NHRA mandates a
 screening process “called a Preadmission Screening and Annual
 Resident Review (PASARR).” Voss v. Rolland, 592 F.3d 242, 246
 (1st Cir. 2010) (citing 42 U.S.C. § 1396r(e)(7)(B)(ii)). Under
 the PASARR provisions, applicants to Medicaid-certified nursing
 facilities must be evaluated to determine whether they have a
 mental illness and whether they meet level-of-care criteria. 
 Those that pass this initial screening are evaluated to determine
 the most appropriate setting for their needs, which may include a
 community setting. 42 C.F.R. § 483.128, et seq.

The named plaintiffs in this putative class action are
 people with serious mental illnesses who are institutionalized in
 one of the State’s institutional treatment facilities, New
 Hampshire Hospital (“NHH”) or the Glencliff Home (“Glencliff”),
 or who are alleged to be at serious risk of institutionalization

5


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 6 of 46
in those facilities. Seeking to represent a class of similarly
 situated persons, the named plaintiffs allege that the defendants
 – the Governor of New Hampshire, officials of the New Hampshire
 Department of Health and Human Services, and the Administrator of
 the New Hampshire Bureau of Behavioral Health (collectively, the
 “State”) – are violating the integration mandates of the ADA and
 the RA, in that they rely excessively on the provision of
 institutional care to treat mental illness, rather than
 appropriate community-based care programs, and, relatedly, have
 failed “to develop an adequate array” of community-based
 services. Complt., doc. no. 1, at ¶¶ 6-7, Pl. Br., doc. no. 73­ 1, at 4. Plaintiffs also allege that the State is violating the
 NHRA by failing “to develop and implement an [adequate] PASARR
 program” for Glencliff residents and applicants. Complt., doc.
 no. 1, at ¶ 130.

With regard to their integration mandate claims, plaintiffs
 assert two legal theories. They say that the State’s pattern and
 practice of under-funding community services and its over­ reliance on institutional treatment has created a systemic
 deficiency in the array of available community services, which,
 in turn, has 1) contributed to the unnecessary
 institutionalization of people with serious mental illnesses; and
 2) contributed to the placement of people with serious mental

6


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 7 of 46
illnesses at serious risk of unnecessary institutionalization.2
 The “at risk” theory is based on the Attorney General’s technical
 guidance interpreting its integration mandate regulation. See
 U.S. Dept. Of Justice, Statement of the Department of Justice on
 Enforcement of the Integration Mandate of Title II of the
 American with Disabilities Act and Olmstead v. L.C.,
 http://www.ada.gov.olmstead/g&a_olmstead.htm (last updated June
 22, 2011). As counsel for the United States explained at oral
 argument: “We clearly state [in our technical assistance guide]
 that the ADA and Olmstead do[] extend to people who are at
 serious risk of institutionalization, and you don’t have to wait
 until you suffer the harms of being institutionalized before
 being able to state a claim.” Hrg. Tr., doc. no. 89, at 119. 
 The appellate courts for the Fourth, Ninth, and Tenth Circuits
 agree. See Pashby v. Delia, 709 F.3d 307, 321-22 (4th Cir.
 2013); M.R. v. Dreyfuss, 663 F.3d 1100, 1116-17 (9th Cir. 2011),
 amended by 697 F.3d 706 (9th Cir. 2012); Fisher v. Okla. Health
 Care Auth., 335 F.3d 1175, 1181 (10th Cir. 2003). The court
 accepts the theory as viable.

2 The State suggests, without developed argument, that class
 members who are “at serious risk” of needless
 institutionalization do not have standing. The State did not
 brief the issue, but only mentioned it at oral argument, and it
 is, as presented, unpersuasive.

7


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 8 of 46
Plaintiffs seek a declaratory judgment, and injunctive
 relief requiring the State to develop and provide an adequate
 array of identified community-based treatment services: mobile
 crisis services, Assertive Community Treatment (“ACT”), supported
 housing, and supported employment. They do not seek
 individually-tailored injunctions regarding appropriate treatment
 for each class member.

The court denied, without prejudice, plaintiffs’ first
 motion for class certification and allowed limited discovery on
 the certification issue. See 6/11/12 Minute Order. That
 preliminary discovery period is now concluded. In support of
 their renewed motion for certification of a Rule 23(b)(2)
 injunctive class, plaintiffs have provided a body of evidence
 they say fully supports their request, because it shows that the
 State’s pattern or practices relating to the funding and
 provision of community-based services has had the effect of
 creating a system-wide deficiency in community services that
 adversely affects a large class of persons with serious mental
 illnesses.

Plaintiffs point first to the State’s own reports, in which
 the State has itself repeatedly identified a widespread, and
 problematic, deficiency in community services. In 2004, DHHS

8


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 9 of 46
convened a task force of experts comprised of mental health
 professionals, administrators, and stakeholders to study the
 causes of, and to suggest remedies for, the significant
 “imbalances in the mental health system of New Hampshire that
 cause many consumers to receive care at NHH rather than community
 alternatives.” Complt., doc no. 1, at ¶ 53. The task force
 concluded that “many people are admitted to and remain at NHH
 because of a lack of . . . alternatives.” Id. It found a
 problematic decline in crisis and other community mental health
 services, and it pointed out that there had been “virtually no
 investment or development” in community residential services. 
 Id. at ¶ 54.

In 2007, a legislative commission made similar findings and
 warned of “shrinking community resources.” It emphasized the
 need for the State to expand services such as ACT, supported
 employment, and supportive housing. Id. at ¶ 55. In 2008, with
 the support of DHHS, another panel of mental health professionals
 was convened to assess New Hampshire’s mental health services
 system and to make recommendations for meeting the critical needs
 of people with serious mental illnesses. In its report, entitled
 “Addressing the Critical Mental Health Needs of NH’s Citizens, A
 Strategy for Restoration,” the panel found that “many individuals
 are admitted to New Hampshire Hospital because they have not been

9


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 10 of 46
able to access sufficient [community] services in a timely manner
 (a ‘front door’ problem) and remain there, unable to be
 discharged, because of a lack of viable community-based
 alternatives (a ‘back door’ problem).” Id. at ¶ 56. The report
 called for, among other things, additional crisis services,
 supportive housing, and ACT teams. Id.

Plaintiffs also rely on evidence of statistical patterns of
 repeated hospitalizations at NHH and lengthy institutionalization
 at Glencliff suggesting a systemic deficiency in available
 community-based services that forces people to seek treatment in
 institutions and to remain institutionalized unnecessarily. In
 addition, they point to the findings of the United States. In
 its review of the State’s mental health system, the U.S. Dept. of
 Justice found that the State’s failure to provide services to
 individuals with serious mental illness in the most integrated
 setting appropriate to their needs “has led to the needless and
 prolonged institutionalization of individuals with disabilities,”
 and that the “systemic failures in the State’s system place
 qualified individuals with disabilities at risk of unnecessary
 institutionalization now and going forward.” Id. at ¶ 70,
 (quoting United States’ Investigation of the New Hampshire Mental
 Health System (April 7, 2011)).

10


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 11 of 46
Plaintiffs’ experts echo that finding. In their “System
 Review,” the experts found the same systemic deficiencies in
 community services that the State previously identified. Pl.
 Br., doc. no. 73-1, at 12-14. In a separate “Client Review,”
 plaintiffs’ experts also concluded that there exists a large
 class of persons with mental illnesses who are affected by the
 deficiency in available community-based services. For that
 study, the “NHH and Glencliff experts reviewed approximately two
 years of facility and community mental health records, conducted
 in-person meetings and observations with review participants, and
 interviewed guardians and mental health providers.” Pl. Br.,
 doc. no. 73-1, at 9. The experts concluded that 80-96% of review
 participants would have avoided institutionalization, would have
 spent less time hospitalized, or could be discharged, and would
 likely choose to live in the community, if they were fully
 informed of and had access to community-based treatment services. 
 One of plaintiffs’ experts, Dr. Sally Rogers, opined that these
 conclusions can be reliably generalized to the broader population
 of persons institutionalized in the named facilities. Rogers
 Aff., doc. no. 73-18, ¶¶ 11, 14. Glencliff is a 120-bed
 facility, and NHH experienced over 1800 adult admissions in 2010. 
 Extending those conclusions to the larger populations would yield
 a class size pertinent to the ADA and RA claims numbering in the
 hundreds.

11


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 12 of 46
The State argues that the experts’ client review should be
 excluded from consideration under Daubert v. Merrell Dow Pharm.,
 Inc., 509 U.S. 579 (1993), because the review’s design was not
 methodologically sound and its implementation was not reliable. 
 In support of its argument, the State submitted an affidavit from
 its expert, Dr. Leonard Flynn. Dr. Flynn has experience in
 conducting research studies and is Professor Emeritus at
 Framingham State University, where he has “taught courses at the
 graduate and undergraduate level through the Psychology and Math
 Departments since 1970,” including Statistics, Research Methods,
 and Experimental Psychology. Flynn Aff., doc. no. 77-17. Dr.
 Flynn avers that the client review suffers from several errors.

Although the State advanced its Daubert argument in its
 brief in opposition, it did not seek a Daubert hearing or press
 the issue at oral argument. Development of the issue, therefore,
 has been minimal. Nevertheless, the argument is unsupportable in
 light of the averments of plaintiffs’ expert, Dr. E. Sally
 Rogers, Research Associate Professor and Director of Research for
 the Center for Psychiatric Rehabilitation at Sargent College of
 Health and Rehabilitation Sciences, Boston University. See
 Rogers Aff., doc. no. 73-18; Rogers Supp. Aff., doc. no. 82-2. 
 Dr. Rogers cogently, directly, and persuasively rebuts Dr.

12


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 13 of 46
Flynn’s challenges to the client review. See Rogers Supp. Aff.,
 doc. no. 82-2.

Beyond its challenge to the client review, the State
 submitted evidence regarding the needs and preferences of persons
 institutionalized at Glencliff and NHH. The State’s experts –
 NHH’s Associate Medical Director and Glencliff’s Administrator –
 conducted reviews of patient histories and health records,
 concluding that a large percentage of patients were properly
 admitted to these institutions and continue to need institutional
 care “no matter what community-based services are available,” and
 that they prefer such treatment. Def. Br., doc. no. 77, at 20­ 27.

Discussion
 This case presents as a familiar Olmstead integration
 putative class action. The named plaintiffs “challenge[] a
 system-wide policy or practice that [allegedly] affects” a class
 of persons with disabilities, and they seek class treatment of
 the claims despite differences in class member disabilities,
 needs, and treatment preferences. Armstrong v. Davis, 275 F.3d
 849, 868 (9th Cir. 2001). Relying on a developed body of case
 law permitting class certification in cases similar to this one,
 and on intimations in Olmstead itself that class certification is

13


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 14 of 46
generally appropriate in integration mandate cases,3 plaintiffs

argue that class certification is warranted.

The State opposes class certification primarily on grounds

that individual differences in disabilities and treatment

preferences exist between and among putative class members, and

similar differences exist between and among putative class

members and the named plaintiffs. The crux of the State’s

objection is that, while courts in many Olmstead integration

cases have granted class certification, the Supreme Court’s

relatively recent decision in Wal-Mart Stores, Inc. v. Dukes, __

U.S. __, 131 S. Ct. 2541 (2011), has dramatically changed the

class action landscape, such that the individualized nature of

each putative class member’s particular circumstances necessarily

undermines plaintiffs’ ability to meet Rule 23(a)'s commonality,

3 As the United States points out, in defining rights and duties
 under the ADA’s integration mandate, the court in Olmstead, by
 negative implication, seemed to tie the class action procedural
 device to vindication of rights under the integration mandate. 
 See Olmstead, 527 U.S. at 606 (warning against “displacement of
 persons at the top of the community-based treatment waiting list
 by individuals lower down who commenced civil actions.”). Id. 
 That Olmstead claims may, as a general matter, be suited for
 class treatment is also suggested by the fact that the
 fundamental alteration defense involves an inquiry into the needs
 of all persons served by the state’s mental health system. Id. 
 Class treatment would avoid “repetitious resolution” of that
 inquiry. Gintis v. Bouchard Transp. Co., 596 F.3d 64, 67 (1st
 Cir. 2010) (“[M]ost or all cases, if individually litigated,
 would require repetitious resolution of an objection by
 [defendant] that is common to each one of them.”).

14


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 15 of 46
typicality, and adequacy of representation prerequisites, as well
 as Rule 23(b)(2)’s requirements. See Def. Surreply, doc. no. 88,
 at 2. The State also argues that class certification should be
 denied outright, because the involvement of the intervenor-
 plaintiff, the United States, makes class-based litigation
 unnecessary in this case.

I. The Involvement of the United States
 Under the “reasonably clear” language of Rule 23(b)(2),

“whether the action should be maintained as a class action
 depends on the appropriateness of injunctive or corresponding
 declaratory relief with respect to the class as a whole.” Dionne
 v. Bouley, 757 F.2d 1344, 1356 (1st Cir. 1985) (emphasis in
 original). One factor a court may consider in determining the
 appropriateness of class certification is the fact that “the same
 relief can be obtained without certifying a class . . . .” Id. 
 The State notes that the United States is seeking the same relief
 as are plaintiffs. So, it asserts, the court should exercise its
 discretion to deny class certification as unnecessary.

The court in Bouley, however, recognized that “[t]here may
 . . . be situations where a class certification under Rule
 23(b)(2) will arguably be unnecessary, but where other
 considerations may render a denial of certification improper.” 

15


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 16 of 46
Id. It offered, as one of several examples, a situation in which
 “class certification does not impose any significant burden on
 the court.” Id. That is the case here. As the United States
 points out, full discovery will be at the “same scale and the
 Parties will be moving toward trial at the same rate, whether or
 not the Plaintiff class is certified.” Intervenor Br., doc. no.
 84, at 6.

And, there is another reason why the United States’
 participation does not render class certification inappropriate. 
 Although the interests of the plaintiff class and the United
 States overlap significantly, those interests are not coextensive
 — and the differences can reasonably be expected to affect both
 litigation and settlement strategies. As the United States says,
 it is “[c]harged with developing a national enforcement program,”
 and it seeks consistency in its approach across all of its cases,
 without compromising its decision-making “to meet the specific
 needs of class members in a particular case.” Id. at 3-4. 
 Representative plaintiffs, on the other hand, are duty-bound to
 advocate for the best interests of the particular defined class,
 regardless of how decisions or outcomes in this litigation might
 influence governmental policy positions, or other cases in
 litigation, across the country.

16


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 17 of 46
For these reasons, class certification is not rendered
 “inappropriate” by virtue of the involvement of the United
 States.

II. Legal Standards for Class Certification
 The party seeking certification must establish “the elements

necessary for class certification: the four requirements of 23(a)
 and one of the several requirements of Rule 23(b).” In re
 Relafen Antitrust Litig., 218 F.R.D. 337, 341 (D. Mass. 2003)
 (citing Smillow v. Southwestern Bell Mobile Sys., 323 F.3d 32, 38
 (1st Cir. 2003)). Whether the movant has carried that burden is
 a question the district court must resolve through a “rigorous
 analysis” of Rule 23's requirements. Id. (citing General Tel.
 Co. of Southwest v. Falcon, 457 U.S. 147, 161 (1982)). That
 analysis “may ‘entail some overlap with the merits of the
 plaintiff’s underlying claim.’” Amgen Inc. v. Connecticut Ret.
 Plans and Trust Funds, ___ U.S. ___, 133 S. Ct. 1184, 1194 (2013)
 (quoting Wal-Mart, 131 S. Ct. at 2551). But the overlap must
 necessarily be limited, for “Rule 23 grants courts no license to
 engage in free-ranging merits inquiries at the certification
 stage.” Id. Instead, “[m]erits questions may be considered to
 the extent – but only to the extent – that they are relevant to
 determining whether the Rule 23 prerequisites for class
 certification are satisfied.” Id. at 1195. In short, “[b]y

17


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 18 of 46
sifting the abundant evidence through the sieve of the legal
 claims, [a] court [will] satisf[y] the requirement to perform a
 ‘rigorous analysis.’” Glazer v. Whirlpool Corp., __ F.3d __,
 2013 WL 3746205, at *9 (6th Cir. July 18, 2013) (quoting Wal-
 Mart, 131 S. Ct. at 2551)). 

In addition to the explicit requirements of Rule 23, courts
 generally recognize the “implicit requirement” that the class
 definition must be sufficiently definite to allow the court,
 parties, and putative class members to ascertain class
 membership. Shanley v. Cadle, 277 F.R.D. 63, 67-68 (D. Mass.
 2011).

III. Class Definition
 The level of precision, or “definiteness” required, varies

depending on the type of class sought to be certified under part
 (b) of Rule 23. See Newberg on Class Actions, § 3:7 (5th ed.
 June 2013). A high level of precision in defining class
 membership is necessary, for example, in (b)(3) classes, because
 all class members must be identified in order to notify each of
 his or her opt-out rights, and, later, to distribute monetary
 relief. See Yaffe v. Powers, 454 F.2d 1362, 1366 (1st Cir.
 1972). In contrast, where certification of a (b)(2) injunctive
 class is sought, “actual membership of the class need not . . .

18


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 19 of 46
be precisely delimited” because “notice to the members . . . is
 not required.” Id. See also Shook v. El Paso Cty., 386 F.3d
 963, 972 (10th Cir. 2004) (relying on Yaffe, and finding proposed
 class definition sufficiently definite, explaining that “Rule
 23(b)(2) [is] well suited for cases where the composition of a
 class is not easily ascertainable” due to the “shifting” nature
 of the population); McCuin v. Sec. of Health and Human Svcs., 817
 F.2d 161, 167 (1st Cir. 1987) (“[W]here only declaratory and
 injunctive relief is sought for a class, plaintiffs are not
 required to identify the class members once the existence of the
 class has been demonstrated.”).

The named plaintiffs in this case seek certification of a
 (b)(2) injunctive class. They propose the following class
 definition:

All persons with serious mental illness who are
 unnecessarily institutionalized in New Hampshire
 Hospital or Glencliff or are at serious risk of
 unnecessary institutionalization in these facilities.
 Hrg. Tr., doc. no. 89, at 60.

Plaintiffs originally proposed a definition that mirrored,
 and was as broad as, class definitions that have been routinely
 approved in previous ADA integration cases. That proposed class
 definition did not include the words “unnecessarily” and
 “unnecessary” before the words “institutionalized” and

19


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 20 of 46
“institutionalization,” respectively. Plaintiffs added those
 words at oral argument, however, in response to the court’s
 inquiries. Although Yaffe does not require that the proposed
 definition of the (b)(2) class in this case “precisely delimit[]”
 class membership, the modification is a decided improvement
 because it narrows the class to include only those who are
 allegedly harmed or affected by the State’s conduct. In short,
 the proposed class definition, as modified, accurately
 articulates “the general demarcations” of the class of
 individuals who are being harmed by the alleged deficiencies in
 the State’s provision of community services. Floyd v. City of
 New York, 283 F.R.D. 153, 172 (S.D.N.Y. 2012) (“[G]eneral class
 descriptions based on the harm allegedly suffered by plaintiffs
 are acceptable in class actions seeking only declaratory and
 injunctive relief under Rule 23(b)(2).”) (quotation omitted).

Contrary to the State’s assertion, nothing in Crosby v.
 Social Sec. Admin., 796 F.2d 576 (1st Cir. 1986), and Carrier v.
 Am. Bankers Life Assur. Co. of Florida, 2008 WL 312657, at *4
 (D.N.H. Feb. 1, 2008) (DiClerico, J.)) prohibits defining this
 (b)(2) class by reference to the harm allegedly suffered, that
 is, by general reference to the harm associated with (the merits
 of) each class member’s claim. See generally Newberg on Class
 Actions, Sec. 3:6 (describing a “fail-safe” class — which some

20


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 21 of 46
courts prohibit under some circumstances — as one that
 “require[s] a court to decide the merits of prospective
 individual class members’ claims to determine class
 membership.”). In both Crosby and Carrier, unlike here,
 notification to every class member would have been required, thus
 the class members had to be readily ascertainable, i.e.,
 ascertainable without “individualized fact-finding and
 litigation.” Crosby, 796 F.2d at 580 (plaintiffs sought
 certification of a (b)(2) class, but requested an injunction
 ordering the defendant to notify all class members of their
 rights under federal law; “Without an identifiable class of
 disability claimants, we cannot grant class-wide relief in this
 case either in the form of granting notices or compiling status
 reports.”); Carrier, 2008 WL 312657, at *2 (plaintiffs sought to
 certify a (b)(3) class, which requires notice). In the absence
 of any need to notify each class member, or distribute monetary
 relief, the proposed class here is appropriately defined in part
 by reference to the harms allegedly suffered by its members as a
 result of the violations asserted.

Plaintiffs also proposed in their reply brief (but did not
 formally include in their proposed class definition) additional
 definitional language in response to the State’s objection that
 the phrase “at serious risk” is impermissibly “contingent on a

21


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 22 of 46
particular state of mind,” and that this “imprecision [is] . . .
 compounded by the failure to include any sort of temporal
 limitation” on who is “at serious risk.” Def. Br., doc. no. 77,
 at 8-9. The proposed language reads:

At risk of institutionalization means persons who,
 within a two year period: (1) had multiple
 hospitalizations; (2) used crisis or emergency room
 services for psychiatric reasons; (3) had criminal
 justice involvement as a result of their mental
 illness; or (4) were unable to access needed community
 services.

Although it does not define who is at “serious” risk, the
 proffered language provides some objective and relevant limiting
 criteria, and serves to narrow the class as well by imposing a
 reasonable temporal limitation. The proposed limiting language,
 therefore, adequately addresses the State’s objection.

For these reasons, the court finds that the proposed class,
 as modified at oral argument and as supplemented by plaintiffs’
 proffered language defining those “at risk,” is sufficiently
 definite.

IV. Rule 23(a)
 Rule 23(a) sets forth four “requirements applicable to all

class actions”: numerosity, commonality, typicality, and adequacy

22


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 23 of 46
of representation. Amchem Prods., Inc. v. Windsor, 521 U.S. 591,
 613 (1997); Fed. R. Civ. P. 23(a).

A. Numerosity
 Under Rule 23(a)(1), the class must be “so numerous that
 joinder of all members is impracticable.” Fed. R. Civ. P.
 23(a)(1). The numerosity requirement “has two components, the
 number of class members and the practicability of joining them in
 a single case.” Rolland v. Cellucci, 1999 WL 34815562, at *3 (D.
 Mass. Feb. 2, 1999).

1. Number of Class Members
 The exact number of class members need not be established,
 “particularly where . . . only declaratory and injunctive relief
 is sought.” Rolland, 1999 WL 34815562, at *3. In deciding
 whether plaintiffs have met the numerosity requirement, the court
 “may draw a reasonable inference as to the size of the class
 given the facts before it.” Id. at *3.

Plaintiffs’ evidence, which includes the State’s own
 reports, the findings of the United States, and the opinions of
 plaintiffs’ experts, establishes that the proposed ADA and RA
 class is comprised of hundreds of persons. With regard to the
 PASARR claim, however, the number of class members has not been

23


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 24 of 46
even roughly established. Assuming that there are, as alleged,
 deficiencies in the State’s PASARR screening protocol at
 Glencliff, the proffered evidence does not support an adequate
 inference that the number of persons negatively affected by the
 asserted deficiencies is sufficiently large to warrant class
 treatment. Class certification, therefore, is denied as to the
 PASARR claim.

2. Impracticability of Joinder
 The requirement that joinder of the ADA and RA class be
 impracticable is easily met. The size of the class, the asserted
 disabilities of proposed class members, and geographic diversity,
 make it “highly unlikely that separate actions would follow if
 class treatment were denied.” Armstead v. Pingree, 629 F. Supp.
 273, 279 (M.D. Fla. 1986). See also Rolland, 1999 WL 34815562,
 at *3 (finding joinder impracticable in light of “the inability
 of nursing home residents with mental retardation and
 developmental disabilities to initiate actions on their own
 behalf”).

In sum, the evidence plainly demonstrates that the size of
 the proposed ADA and RA class “is so numerous that joinder of all
 members is impracticable.”

24


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 25 of 46
B. Commonality
 Rule 23(a)(2) requires that there be “questions of law or
 fact common to the class.” Fed. R. Civ. P. 23(a)(2). Although a
 court need find only a “single common question,” Wal-Mart, 131
 S. Ct. at 2556 (quotation and alterations omitted), a certain
 rigor, as prescribed by the Supreme Court in Wal-Mart, must
 attend the commonality inquiry.

The plaintiffs in Wal-Mart were current and former female
 employees who brought Title VII employment discrimination claims
 against the defendant company. Id. at 2547. They alleged that
 Wal-Mart operated under a general policy of gender discrimination
 relating to pay and promotion decisions, specifically, that the
 company had a policy of leaving such decisions to the discretion
 of local managers within a corporate culture suffused with
 gender-biased stereotypical thinking. Id. at 2548. The district
 court certified a class under Rule 23(b)(2), and the appellate
 court affirmed. On appeal to the Supreme Court, the company
 argued that certification was improperly granted. It contended,
 among other things, that there was no commonality among class
 members because plaintiffs had not shown that the company
 operated under a general policy of discrimination that affected
 all class members. The Court agreed.

25


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 26 of 46
“Commonality,” the Court stated, “requires the plaintiff to
 demonstrate that the class members have ‘suffered the same
 injury.’” Id. at 2551 (quoting General Telephone Co. of
 Southwest v. Falcon, 457 U.S. 147, 157 (1982)). This requirement
 cannot be met, however, simply by showing that the class members
 “have all suffered a violation of the same provision of law,”
 since such a showing would “give[] no cause to believe that all
 [class members’] claims can productively be litigated at once.” 
 Id. at 2551. Rather, “claims must depend upon a common
 contention” that is “capable of classwide resolution – which
 means that the determination of its truth or falsity will resolve
 an issue that is central to the validity of each one of the
 claims in one stroke.” Id. “‘What matters to class
 certification,” the Court emphasized, “is not the raising of
 common questions — even in droves — but, rather the capacity of a
 classwide proceeding to generate common answers apt to drive the
 resolution of the litigation.’” Id. at 2551 (quoting Richard A.
 Nagareda, Class Certification in the Age of Aggregate Proof, 84
 N.Y.U. L. Rev. 97, 132 (2009)) (emphasis in original). Notably,
 “dissimilarities within the proposed class . . . have the
 potential to impede the generation of common answers.” Id. at
 2551 (quotation omitted).

26


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 27 of 46
Applying those principles to the case before it, the Court
 held that the named plaintiffs were required to provide
 “significant proof” that the defendant “operate[d] under a
 general policy of discrimination” that “touch[ed] and concern[ed]
 all members of the class.” Id. at 2552, 2557 & n.10 (quotations
 omitted). The Court found that plaintiffs did not carry their
 burden. Although they alleged that the defendant had a
 companywide policy of allowing local managers to exercise
 discretion in hiring and promotion decisions, plaintiffs failed
 to “identif[y] a common mode of exercising discretion that
 pervade[d] the entire company.” Id. at 2555. Their primary
 evidence of a common mode or practice was testimony from a
 sociological expert that gender “stereotypes play[ed] a
 meaningful role” in local managers’ exercise of discretion. Id.
 at 2553. But, the Court noted, the expert could not say “whether
 .05 percent or 95 percent of the employment decisions” were
 affected by stereotyped thinking. Id. at 2554. The Court also
 rejected as insignificant the affidavits of 120 female employees
 detailing their experiences of sex discrimination. Those
 employees, the Court noted, comprised only a very small
 percentage of the class (“about 1 for every 12,500 class
 members”). Id. at 2556. Plaintiffs’ regression analysis, which
 showed a gender disparity in promotions, likewise, did not
 provide the required significant proof. The analysis failed to

27


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 28 of 46
link local decisions with the disparity shown. Id. at 2555. At
 bottom, plaintiffs did not “provide . . . convincing proof of a
 companywide discriminatory pay and promotion policy.” Id. at
 2556-57. The Court held, therefore, that the district court
 erred in certifying the class. Id.

Under Wal-Mart’s clarification of the commonality
 requirement, therefore, plaintiffs seeking class certification
 must, among other things, (1) avoid framing common questions so
 generally that they encompass myriad, distinct claims; (2)
 provide significant proof that “there exists a common policy or
 practice . . . that is the alleged source of the harm to [the]
 class members,” M.D. v. Perry, 2013 WL 4537955, at *14 (S.D. Tex.
 August 27, 2013); (3) identify common questions of fact or law
 that can be “answered either ‘yes’ or ‘no’ for the entire class,”
 that is, identify central questions whose answers “‘will not vary
 by individual class members,’” Raposo v. Garelick Farms, LLC,
 2013 WL 3733461, at *3 (D. Mass. July 11, 2013) (quoting Donovan
 v. Philip Morris, USA, Inc., 2012 WL 957633, at *21 (D. Mass.
 Mar. 21, 2012)); and (4) show that “dissimilarities in the
 proposed class” do not “impede the generation of common answers.” 
 Wal-Mart, 131 S. Ct. at 2551. Plaintiffs here have done all of
 that.

28


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 29 of 46
Substantial evidence suggests that the State’s policies and
 practices have created a systemic deficiency in the availability
 of community-based mental health services, and that that
 deficiency is the source of the harm alleged by all class
 members. The State’s own reports, for example, demonstrate that
 there is a dearth of available community-based services within
 New Hampshire’s mental health system. They further show that
 this systemic condition “is a result of the way the State manages
 the system and is something that the State . . . can control.” 
 M.D., 2013 WL 4537955, at *38 (finding that the States’ policies
 and practices brought about the challenged systemic conditions). 
 In addition, the evidence suggests a causal connection between
 that systemic condition and the harm experienced by all class
 members: a serious risk of unnecessary institutionalization,
 which includes a serious risk of continued unnecessary
 institutionalization. As noted above, the State’s own reports
 show a “front door” and a “back door” problem, both of which the
 reports attribute to the systemic deficiency. Likewise,
 plaintiffs’ experts corroborate the reports’ findings, concluding
 that there is a high rate of unnecessary placement into
 institutions and unnecessary continued institutionalization, both
 resulting from the short supply of community-based services.4

4 Evidence of a serious risk here seems substantial in light of
 cases applying that standard. See e.g., Hunter ex rel. Lynah v.
 Cook, 2013 WL 2252917, at *6 (N.D. Ga. May 22, 2013); Pashby v.

29


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 30 of 46
The plaintiffs have also shown that common questions
 susceptible to common answers are present. For instance, whether
 there is a systemic deficiency in the availability of community-
 based services, and whether that deficiency follows from the
 State’s policies and practices, are questions central to
 plaintiffs’ theory of the case. These questions will,
 necessarily, be answered similarly for every class member. And,
 whether the systemic conditions, if shown to exist, expose all
 class members to a serious risk of unnecessary
 institutionalization, including continued unnecessary
 institutionalization, is a central and common contention whose
 resolution will defeat or advance the claims of all class
 members, whether institutionalized or not. In short, these
 common questions can be “answered either ‘yes’ or ‘no’ for the
 entire class,” and the answers “will not vary by individual class
 members.” Donovan, 2012 WL 2012 WL 957633, at *21.

Cansler, 279 F.R.D. 347 (E.D.N.C. 2011) aff’d Pashby v. Delia,
 709 F.3d 307, 322 (4th Cir. 2012). Moreover, the cases seem to
 indicate, at least by implication, that no individualized
 inquires need be made to determine whether a systemic condition
 places class members at serious risk of unnecessary
 institutionalization; instead, the inquiry can properly turn on
 systemwide proof. Notably, as evidenced by its 2011
 “Investigation of the New Hampshire Mental Health System,” its
 brief in this case, and its comments at oral argument, the United
 States seems to agree with this interpretation of its regulation. 
 Of course, whether plaintiffs can prove their claim is a question
 for trial.

30


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 31 of 46
The State argues that plaintiffs have, at most, shown the
 impact of myriad, distinct State funding and provision practices
 that relate to several types of community-based services. The
 State posits, in other words, that its alleged practice of
 failing to provide an adequate array of community services is
 really a collection of separate, discrete practices relating to
 “numerous different types of community-based treatments,” broadly
 articulated by plaintiffs as a single “systemic failure[].” Def.
 Br., doc. no. 77, at 46-47. Therefore, it says, the class
 members have nothing in common except for the fact that they each
 alleged a violation of the integration mandate — something
 Wal-Mart does not allow. See 131 S. Ct. at 2551.

The State points to the recent decision in D.L. v. Dist. of
 Columbia, 713 F.3d 120 (D.C. Cir. 2013), in which the appellate
 court found that plaintiffs had not met Wal-Mart’s commonality
 test. Id. at 127-28. But DL was decidedly different, and is
 distinguishable from this case. In DL, plaintiffs alleged
 numerous violations of the Individuals with Disabilities
 Education Act (“IDEA”), 20 U.S.C. § 1400 et seq. DL, 713 F.3d at
 122. Specifically, they challenged the defendants’ practices
 with respect to four distinct steps in the IDEA’s “Child Find”
 process. Id. The appellate court held that plaintiffs had not
 shown the existence of a common question because, contrary to

31


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 32 of 46
Wal-Mart’s teaching, they articulated a common question at the
 highest level of generality – that is, whether “the District has
 violated the IDEA as to each class member” – in order to sweep
 within the question’s scope the defendants’ “multiple, disparate
 failures.” Id. at 128 (quotation omitted).

Unlike the disparate practices and deficiencies challenged
 in DL, the State practices plaintiffs challenge here all pertain
 to a discrete set of community-based services — services the
 State itself has persuasively identified as critical to solving
 the crisis in New Hampshire’s mental health system. Although it
 may be a matter of degree, and perhaps discretion, as to where
 the line should be drawn, the court is persuaded that common
 questions — such as, whether there is a systemic deficiency in a
 core set of community-based mental health services and whether
 this deficiency has placed class members at serious risk of
 unnecessary institutionalization or continued unnecessary
 institutionalization — are at a low enough level of generality
 (or high enough level of specificity) to pass muster under Wal-
 Mart. In other words, the common questions here are not
 amorphous or “superficial.” Jamie S. v. Milwaukee Public Sch.,
 668 F.3d 481, 497 (7th Cir. 2012).

32


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 33 of 46
Moreover, and not unimportantly, in disability cases both
 pre- and post-Wal-Mart, the commonality requirement has been held
 to be met where, as here, plaintiffs challenge more than a single
 service deficiency and seek more than one service enhancement or
 improvement as part of the remedy. See e.g., Gray v. Golden Gate
 Nat’l Recreation Area, 279 F.R.D. 501, 511-19 (N.D. Cal. 2011)
 (holding, post-Wal-Mart, that commonality was satisfied where
 defendant’s general policies and practices failed to address
 “access barriers,” despite the fact that different types of
 access barriers were at issue, the types and levels of class
 members’ disabilities differed, and different types of
 accommodation would be required); Lane v. Kitzhaber, 283 F.R.D.
 587 (D. Or. 2012) (post-Wal-Mart); Rolland v. Cellucci, 1999 WL
 34815562 (D. Mass. Feb, 2, 1999) (pre-Wal-Mart).

The State also argues that dissimilarities in class member
 needs and preferences for community-based services, and
 dissimilarities in their current preferences and future needs as
 between institutional care and community-based services, make
 class certification improper. “There is no commonality,” it
 says, “when each class member needs or wants a different mix of
 community supports,” or when some class members prefer acute
 psychiatric or nursing care over care in the community and,
 therefore, “want to remain in their current [institutional]

33


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 34 of 46
setting.” Def. Br., doc. no. 77, at 5; Def. Surreply, doc. no.
 88 at 1.5

1. Needs and Preferences for Different Community-
 Based Services

The State posits that the limited funding “pie” will
 necessarily pit class members needing and wanting a particular
 community service, or mix of services, against other members
 needing and wanting some other community service or mix of
 services. The intra-class conflict that the State posits is
 premised on its assertion that “the class as a whole cannot seek
 maximum dollars for each [community] service, without turning
 their rebalancing of the system into a fundamental alteration.” 
 Def. Surreply, doc. no. 88, at 6, n.1. In seeking to defeat
 class certification, the State, it seems, is venturing into
 issues that are properly addressed at trial, in the context of
 its fundamental alteration defense, but which are not
 particularly relevant to the class certification inquiry. See
 Amgen, 133 S. Ct. at 1203-04 (rejecting defendant’s attempt to

5 The State also argues that another relevant dissimilarity is
 that between class members who are already receiving community
 services and those who are not. That difference, however, does
 not destroy commonality because, under plaintiffs’ modified class
 definition, those class members who are receiving community
 services (meaning, they are not “unnecessarily
 institutionalized”) are, nevertheless, “at serious risk” of
 needless institutionalization – a status that implies inadequacy
 or insecurity of community service options.

34


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 35 of 46
litigate a defense as part of class certification). See also
 Glazer, 2013 WL 3746205, at *8 (“[D]istrict courts may not ‘turn
 the class certification proceedings into a dress rehearsal for
 the trial on the merits.’”) (quoting Messner v. Northshore Univ.
 HealthSys., 669 F.3d 802, 811 (7th Cir. 2012)). In any event, if
 the State turns out to be right in predicting an intra-class
 conflict, the creation of “independently represented sub-classes”
 stands as an available managerial device to resolve such
 potential issues. Ortiz v. Fibreboard, Corp., 527 U.S. 815, 864
 (1999). See also Manning v. Boston Med. Ctr. Corp., __ F.3d __,
 2013 WL 3942925, at *21 (1st Cir. Aug. 1, 2013).

2. Future Need for Institutional Care
 The State also contends that differences in future needs
 among the class members destroy commonality. It has submitted
 evidence suggesting that an increase in funding for community
 services will result in a critical reduction in already
 inadequate acute care services. This is problematic, it says,
 because many class members may need acute care in the future,
 but, if plaintiffs secure the relief they seek, institutional
 treatment may not be available. According to Erik Reira,
 Administrator of the New Hampshire Bureau of Behavioral Health,
 if community-based services are expanded to the extent sought by
 plaintiffs, “[t]he State would have to radically alter its mental

35


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 36 of 46
health care budget to the detriment of individuals who need acute
 in-patient care or long-term care.” Reira Aff., doc. no. 77-2,
 at ¶ 24. He further states that, “[t]o make the expenditures
 sought by Plaintiffs without raising the overall mental health
 care budget will require drastic cuts to important programs the
 Department runs.” Id. at ¶ 29. He concludes that “[c]uts of
 magnitude demanded by the expenditures Plaintiffs seek could only
 be accomplished by a drastic reduction in funding for NHH and
 Glencliff Home.” Id. Reira’s factual assertions are more
 properly addressed in the context of the State’s fundamental
 alteration defense.

3. Preference for Institutional Care
 The State's point about differences in treatment preferences
 between community services and institutional care likely
 overstates the willingness of individuals with serious mental
 illness to accept needless institutionalization over services in
 the community. But even so, the existence of preference
 differences among class members does not change the fact that the
 State's practices with regard to community services have been
 shown, by substantial proof, to affect all class members. See
 Glazer, 2013 WL 3146205, at *9 (on remand after Wal-Mart,
 affirming district court's finding of commonality in products
 liability case, explaining that, where the question of the

36


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 37 of 46
product's defectiveness was common to all class members, “[t]he
 existence [in the class] of currently satisfied [product] owners
 did not preclude the district court from certifying the . . .
 class.”). And, because preferences can change, class members who
 today might prefer institutionalization, can reasonably be
 thought to also have an interest in the availability of
 community-based treatment options should their preferences change
 tomorrow. 

The State seems, therefore, to “exaggerate[] the impact on
 the feasibility and desirability of class action treatment of the
 fact” that some class members may prefer institutionalization. 
 McReynolds v. Merrill Lynch, Pierce, Fenner & Smith, 672 F.3d
 482, 490 (7th Cir. 2012) (Posner, J.) (finding commonality after
 Wal-Mart, where plaintiff minority stockbrokers submitted
 sufficient proof of a company-wide policy affecting all class
 members, even though “the exercise of discretion at the local
 level is undoubtedly a factor in the differential success of
 brokers, even if not a factor that overwhelms the effect of the
 corporate policies”). Indeed, the relatively recent decision in
 Voss, 592 F.3d at 253, provides some assurance of feasibility
 because it supports the notion, albeit by implication, that the
 claims of people with different treatment preferences “can
 productively be litigated at once.” Wal-Mart, 131 S. Ct. at

37


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 38 of 46
2551. See Voss, 592 F.3d at 253 (approving class settlement
 providing for an increase in community services for
 developmentally disabled persons, and leaving for the State’s
 individual service planning process, placement decisions that
 would take individual preferences into account).6

For all of these reasons, the court finds that plaintiffs
 have met the commonality requirement of Rule 23(a)(2).

C. Typicality and Adequacy of Representation
 Rule 23(a)(3) provides that “the claims or defenses of the
 representative parties [must be] typical of the claims or
 defenses of the class.” Fed. R. Civ. P. 23(a)(3). Rule 23(a)(4)
 requires that “the representative parties . . . fairly and
 adequately protect the interests of the class.” Fed. R. Civ. P.
 23(a)(4). The typicality and adequacy requirements overlap. 
 Shanley, 277 F.R.D. at 69. The State argues that the named

6 Such a process may best ensure vindication of rights under the
 ADA and RA, since the meaningful exercise of a preference will be
 possible only if an adequate array of community services are
 available to those who do not need institutionalization. As
 plaintiffs point out, preferences may be “conditioned by
 availability, . . . limited by information, and are likely to
 evolve in a system that complies with the ADA.” Pl. Reply Br.,
 doc. no. 82, at 49. See also Simpatico Supp. Aff. doc. no. 82-1,
 ¶ 10. Cf. Green v. Cty. Sch. Bd. of New Kent Cty., 391 U.S. 430,
 441 n.5 (1968) (recognizing — but not deciding for the case
 before it — that vestiges of segregation may influence minority
 students and parents to choose segregated schools under so-called
 “freedom of choice” desegregation plan).

38


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 39 of 46
plaintiffs are not adequate representatives of the class and that
 their claims are not typical of class member claims because (1)
 they seek to shift funds away from institutional care, yet some
 class members currently prefer institutional care, or may need
 care at a particular institution in the future; (2) some class
 members need or prefer different, or a different mix of,
 community-based services than the named plaintiffs; and (3) the
 State’s review of the named plaintiffs’ medical files purportedly
 reveals that some either need or prefer institutionalization, or
 may need institutionalization in the future. The arguments are
 unpersuasive.

The court has determined that all class members, as defined
 and without regard to current preferences, have an abiding
 interest in securing the availability of community-based services
 options sufficient to preclude unnecessary institutionalization. 
 Moreover, as noted, the State’s arguments that funding for
 institutional care will be unavailable if the named plaintiffs
 get what they want, and that the funding “pie” is not large
 enough to maximize the funding of all four community-based
 services, are issues properly addressed at trial in the context
 of the State’s fundamental alteration defense.

39


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 40 of 46
In addition, it has been adequately shown that, due to a
 shortage of the types of community-based services sought, each of
 the named plaintiffs either continues to experience unnecessary
 institutionalization, has experienced unnecessary
 institutionalization in the past, or, although currently not
 institutionalized, is otherwise at serious risk of being
 unnecessarily institutionalized. Plaintiffs’ evidence also
 suggests that these same circumstances are shared by the defined
 class members. Although the State submitted contradictory
 evidence from its own experts with regard to the needs and
 preferences of the named plaintiffs, plaintiffs countered with
 supplemental affidavits from their mental health experts, and
 from the named plaintiffs themselves or their guardians. Having
 reviewed this evidence, the court finds that plaintiffs have
 shown that the named plaintiffs’ experiences and claims are
 typical of those of the members of the class, and that the named
 plaintiffs are adequate representatives of the class.

The State does not challenge the experience or
 qualifications of the putative class attorneys, nor, reasonably,
 could it. The court finds, therefore, that plaintiffs’ attorneys
 will adequately represent the class.

40


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 41 of 46
V. Rule 23(b)(2)
 Plaintiffs seek to maintain this suit as an injunctive class

action under Rule 23(b)(2). As noted, plaintiffs have submitted
 evidence to support their allegation that a systemic deficiency
 in the State's community-based mental health services system
 affects the class. As the court of appeals for the Fifth Circuit
 noted in M.D. v. Perry, 675 F.3d 832, 841 (5th Cir. 2012), the
 requirements of Rule 23(b)(2) are met where plaintiffs show that
 the “State engages in a pattern or practice of agency action or
 inaction – including a failure to correct a structural deficiency
 within the agency . . . with respect to the class.” Plaintiffs
 have, therefore, met their burden to show that the State has
 “acted or refused to act on grounds that apply generally to the
 class, so that final injunctive relief or corresponding
 declaratory relief is appropriate respecting the class as a
 whole.” Fed. R. Civ. P. 23(b)(2).

Nevertheless, the State argues that certification of a
 (b)(2) class is improper because the class member claims are not
 “cohesive.” There is some debate, even after Wal-Mart, whether
 Rule 23(b)(2) contains an implicit cohesiveness requirement (see
 Newberg, Sec. 4:33), and the court of appeals for this circuit
 has never endorsed one. See Donovan v. Philip Morris USA, Inc.,
 268 F.R.D. 1, 11-12 (D. Mass. 2010) (finding that there is no

41


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 42 of 46
authority in the First Circuit for grafting a cohesiveness
 requirement onto Rule 23(b)(2)). The court need not address that
 legal issue, however, because in any event, the class here is
 sufficiently cohesive.

A class is “cohesive” where common questions predominate and
 there are “few conflicting interests among its members.” Allison
 v. Citgo Petroleum Corp., 151 F.3d 402, 413 (5th Cir. 1998). The
 State argues, primarily, that the proposed class is not cohesive
 given the same dissimilarities between and among class members
 that it believes undermine commonality, typicality, and adequacy
 of representation. It argues, in sum, that the class members
 here do not “have a ‘strong commonality of interests,’” such that
 all of them will benefit from a single injunction. Def. Br.,
 doc. no. 78, at 13 (quoting Gates v. Rohm & Hass Co., 655 F.3d
 255, 264 (3d Cir. 2011) (applying cohesiveness requirement)). 
 See also Def. Surreply, doc. no. 88, at 2. The court has
 addressed and rejected the State's arguments regarding class
 member dissimilarities, finding that all class members share a
 strong common interest in enhanced options for community
 treatment. Injunctive relief prohibiting a discriminatory lack
 of community service options would, therefore, benefit all class
 members. See D.G. ex rel. Stricklin v. Devaughn, 594 F.3d 1188,
 1200 (10th Cir. 2010) (holding that class was cohesive, noting

42


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 43 of 46
that, “because the Named Plaintiffs assert that excessive
 caseloads are harming or putting at risk of harm all children in
 the class, the imposition of caseload limits would apply to the
 entire class.”) (emphasis deleted).

For these reasons, the court finds that plaintiffs have met
 the requirements of Rule 23(b)(2).

Conclusion
 Reasonable minds may of course differ as to whether the
 traditional approach taken in ADA integration cases (or related
 disability cases) of certifying broad classes of persons with
 different specific disabilities, needs, and preferences (an
 approach taken both before and after Wal-Mart), is in tension
 with Wal-Mart's recent procedural commands. But plaintiffs here
 have defined the class more narrowly than is usually done in ADA
 integration cases; their class claims are limited to parallel
 claims under the ADA and RA; they challenge alleged deficiencies
 related to a discrete set or class of services; and they seek a
 single declaration or injunction aimed at correcting a systemic
 discriminatory imbalance (not mini-injunctions for each class
 member), thus leaving individual treatment determinations for the
 State's existing individually-targeted administrative process. 

43


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 44 of 46
All of this, the court concludes, has enabled plaintiffs to meet
 Wal-Mart's commands.

Accordingly, plaintiffs' motion for class certification,
 doc. no. 73, is granted in part and denied in part. The
 requirements of Federal Rule of Civil Procedure 23(a) and (b)(2)
 are met with regard to the ADA and Rehabilitation Act claims, but
 not with regard to the PASSAR claim.

The class certified is:
 All persons with serious mental illness who are

unnecessarily institutionalized in New Hampshire
 Hospital or Glencliff or who are at serious risk of
 unnecessary institutionalization in these facilities.

At risk of institutionalization means persons who,
 within a two year period: (1) had multiple
 hospitalizations; (2) used crisis or emergency room
 services for psychiatric reasons; (3) had criminal
 justice involvement as a result of their mental
 illness; or (4) were unable to access needed community
 services.

Upon certification, the court must appoint class counsel. 
 See Fed. R. Civ. P. 23(g). Plaintiffs here seek the appointment
 of four firms or legal services organizations as class
 co-counsel: DRC, Devine, Millimet & Branch, the Bazelton Center,
 and CPR. These firms and organizations, and their designated
 attorneys, meet the requirements of Rule 23(g)(1)(A). Pursuant
 to this court's authority under Rule 23(g)(1)(C)-(E), class
 counsel shall submit ex parte, or under seal, a proposed budget

44


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 45 of 46
related to anticipated fees in this case within sixty (60) days
 from the date of this order. Given the number of attorneys
 seeking active participation in this litigation, it seems prudent
 to ensure some control and oversight over the generation of fee
 claims at the outset, in the interest of both plaintiffs' counsel
 and defendants, who may at some point be asked to pay those fees.

Undoubtedly, class certification carries risk, but such
 decisions are conditional, and the court retains the authority to
 modify the class description, or even decertify the class, if
 subsequent developments suggest that either is appropriate. 
 Should decertification become advisable or necessary, the
 involvement of the United States – which seeks system-wide
 remedies – substantially reduces the risk that litigation efforts
 and resources will have been wasted. 

Finally, given that the class is certified under Rule
 23(b)(2), and notice is discretionary, the court declines to
 require that notice be given to all members of the class, since
 the relief sought is systemic in nature and can only benefit
 members of the class. See Fed. R. Civ. P. 23(c)(2)(A).

45


Case 1:12-cv-00053-SM Document 90 Filed 09/17/13 Page 46 of 46
SO ORDERED.

____________________________ Steven J. McAuliffe United States District Judge September 17, 2013
 cc: Ira A. Burnim, Esq.
 Anne M. Edwards, Esq.
 Richard J. Farano, Esq.
 Deena S. Fox, Esq.
 Aaron J. Ginsberg, Esq.
 Catharine A. Mallinson, Esq.
 Jennifer Mathis, Esq.
 David W. McGrath, Esq.
 Amy B. Messer, Esq.
 Elaine M. Michaud, Esq.
 Kathryn L. Rucker, Esq.
 Steven J. Schwartz, Esq.
 James Q. Shirley, Esq.
 Brian D. Thomas, Esq.
 John M. Turner, Esq.
 Daniel E. Will, Esq.
 Rebecca L. Woodard, Esq.
 Joshua M. Wyatt, Esq.

46


 
 NEW HAMPSHIRE ADA MENTAL HEALTH SETTLEMENT FACT SHEET Amanda D., et al. v. Hassan, et al.; United States v. New Hampshire, No. 1:12-CV-53 (SM)
Overview
The United States Department of Justice, a coalition of private plaintiff organizations, and the State of New Hampshire, have entered into a comprehensive Settlement Agreement that will transform New Hampshire’s mental health system by significantly expanding and enhancing mental health service capacity in integrated community settings. The Agreement will enable a class of adults with serious mental illness to receive needed services in the community, which will foster their independence and enable them to participate more fully in community life. The expanded and enhanced community services will significantly reduce visits to hospital emergency rooms and will avoid unnecessary institutionalization at State mental health facilities, including New Hampshire Hospital (“NHH”) (the State’s only psychiatric hospital) and the Glencliff Home (a State-owned and -operated nursing facility for people with mental illness). The Agreement requires the State to expand and enhance community services over the next six years.
Remedial Relief and Legal Framework in Settlement Agreement
Target Population
- The Agreement provides relief to several thousand adults within New Hampshire who have serious mental illness and who are institutionalized or at serious risk of institutionalization at New Hampshire Hospital or the Glencliff Home. Those at serious risk of institutionalization include those within the target population who, within the last two years: have been admitted multiple times to New Hampshire Hospital, have used crisis or emergency services for mental health reasons, have had criminal justice involvement as a result of their mental illness, or have been unable to access needed community services.
Crisis Services
- Over the first four years of the Agreement, the State will develop a crisis system that: is available at all times; provides timely and accessible services and supports; stabilizes individuals and assists them to return to their pre-crisis level of functioning; provides interventions to avoid unnecessary hospitalization, incarceration, and admission to an institution; provides services at the site of the crisis, including in individual homes; and promptly assesses individual needs and connects people to critical services and supports in a timely manner.
- For the first time, the State will create mobile crisis teams in the three largest population centers in the state – Manchester, Concord, and Nashua – that will be able to respond onsite in the community to any individual crisis within one hour from the time of contact. The mobile crisis teams will be: available at all times; comprised of trained clinicians and peers; able to respond onsite in individual homes; provide face-to-face interventions to de-escalate crises without removing people from their homes; able to provide services beyond the immediate crisis; and able to work with law enforcement during a crisis.
- As an alternative to hospitalization or institutionalization, each mobile crisis team will have available to it, also for the first time, at least four community crisis apartment beds, with no more than two beds per crisis apartment. These apartments will have sufficient clinical and peer staff onsite at all times, whenever necessary to meet individual needs.

Assertive Community Treatment (“ACT”)
- The State will expand and enhance community ACT team services in order to deliver comprehensive, individualized, and flexible services and supports to people at all times, in a timely manner as needed, and face-to-face and onsite in homes and other natural environments, so as to allow people a reasonable opportunity to live independently in the community.
- The State will elevate the performance of all of its ACT teams to better comport with good practice and to better achieve desired outcomes.
- For the first time, the State will provide statewide ACT coverage in each mental health region.
- Over the first three years of the Agreement, the State will expand ACT team service capacity so as to be able to serve at least 1,500 people in the target population; this expansion will provide ACT team services to hundreds of additional people in need.
- The State will develop effective regional and statewide plans going forward to provide sufficient ACT services to ensure reasonable access by additional eligible individuals.
Housing
- The State will provide additional supported housing for hundreds of people throughout the state that: is scattered-site, permanent housing with tenancy rights, where tenancy is not conditioned on an individual’s participation in treatment or compliance with mandatory programmatic criteria; includes flexible services and supports to enable people to attain and maintain integrated affordable housing; and is predominantly single-occupancy or single-family supported housing.
- The State will create additional supported housing whenever there are too many people on a housing waiting list for too long, per specified triggering criteria.
- For the first time, the State will create community settings to meet the needs of people at Glencliff with complex health care needs, who cannot readily be served in supported housing.
- Going forward, the State will develop an effective plan for providing sufficient community-based residential supports for additional people at Glencliff who have complex health care needs.
Supported Employment
- For the first time, the State will deliver supported employment services in accordance with the Dartmouth evidence-based model. These services will help enable individuals to obtain and maintain paid, competitive employment in integrated community settings. Over the life of the Agreement, this provision will impact thousands of people.
- Over the first five years of the Agreement, the State will increase its penetration rate of people with serious mental illness receiving supported employment services by about seven percent, to 18.6 percent of eligible individuals with serious mental illness; this means that several hundred additional people, approaching 1,000 people, will get needed supported employment services.
- For those not getting such services, the State will develop an effective plan for providing sufficient supported employment services to eligible individuals going forward. 2

Family and Peer Supports
- The State will ensure that there is an effective family support program to meet the needs of families throughout the state. This program will teach families skills and strategies for better supporting their family members’ treatment and recovery in the community.
- The State will ensure that there is an effective peer support program throughout the state to help individuals manage and cope with their mental illness. The State will expand peer support services offered through peer support centers, ensuring that the centers are open a minimum of eight hours per day, five-and-a-half days per week, or the hourly equivalent.
Transition Planning and Transition Plans
- The State will provide each person in NHH and Glencliff with effective, person-centered transition planning that starts with the presumption that individuals can live in the community with sufficient services and supports. Transition planning will be based on the principle of selfdetermination; it will not exclude anyone from consideration for community living based solely on level of disability. Transition planning will be based on the individual’s needs, not on the availability, perceived or actual, of current community resources and capacity.
- The State will also provide these people with an effective written transition plan that sets forth timeframes and details on the particular services and supports each person needs to successfully transition to and live in the community, whether or not a suitable community setting is currently available; it will set forth who has responsibility for deliverables before, during, and after the transition; it will include barriers to transition and how to overcome them; and it will include a post-transition schedule of community monitoring to see if individual needs are being met.
- Going forward, the State has agreed to avoid placing people into nursing home settings.
- The State will avoid placing people with developmental disabilities in NHH; the State will provide those already there with effective transition planning and plans using resources from both the State’s mental health system and system for people with developmental disabilities.
- The State will create a central team to address and overcome barriers to discharge identified through the transition planning process. The team will be composed of people who have experience and expertise in how to successfully resolve barriers to discharge.
- The State will conduct in-reach activities to help institutionalized individuals transition to the community; team activities will include visits to community settings and facilitated talks with individuals who have already successfully transitioned from institutions to the community.
Quality Assurance and Performance Improvement
- The State will develop and implement a quality assurance and performance improvement system, emphasizing the use of client-level outcome tools and measures to ensure that individuals are provided with sufficient services and supports of good quality to best ensure their health, safety, and welfare. The goal is to help individuals achieve increased independence and greater integration in the community, obtain and maintain stable housing, avoid harms, and decrease the incidence of hospital contacts and institutionalization. 3

- The State will ensure that there is an adequate network of qualified community providers with expertise/competency to deliver needed services and supports per performance-based contracts.
- The State will regularly review community providers and programs to identify gaps and weaknesses, as well as areas of highest demand, to provide assist with comprehensive planning, administration, resource-targeting, and implementation of needed remedies; the State will develop and implement effective measures to address any gaps or weaknesses.
- The State will conduct face-to-face Quality Service Reviews to evaluate the quality of services and supports and to see whether individuals’ needs are being met.
Independent Monitor - The Agreement creates an independent monitoring official, called the “Expert Reviewer,” who
will assess the State’s implementation of and compliance with the terms of the Agreement, provide technical assistance when asked, and mediate disputes between and among the parties. - The Expert Reviewer is to be independent, with no party having supervisory authority over activities, reports, or recommendations; the Court will resolve any payment disputes. - The Expert Reviewer is to have full access to the people, places, and documents necessary to assess compliance with the Agreement. - The Expert Reviewer may retain consultants to assist with the monitoring work. - The Expert Reviewer will issue at least two public reports each year. Legal Architecture - The Settlement Agreement is a full consent decree to be entered by the Court as a Court order. - The case may not be dismissed until the State has complied with all provisions of the Agreement and maintained compliance for one year.
4 


 
 Case 1:12-cv-00053-SM Document 104 Filed 02/12/14 Page 1 of 2

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

Amanda D., et al., and others similarly situated,
Plaintiffs, v. Margaret W. Hassan, Governor, et al.,

U.S. DISTRICT COURT DISTRICT OF NEW HAMPSHIRE
i 1 3 • . 201*
FILED

Defendants. United States of America,

Civ. No. l:12-cv-53-SM

Plaintiff-Intervenor,

v.

State of New Hampshire,

Defendant.

ORDER FOR FINAL APPROVAL OF PROPOSED SETTLEMENT AND ENTRY OF JUDGMENT
This Court, having read and reviewed the Parties' Joint Motion for Final Approval of Proposed Settlement, the Parties' separately-filed memoranda of law in support of the Joint Motion, the Assented-to Motion for Attorneys' Fees and Costs and supporting memorandum of law, and any objections or comments submitted to the Court on the Proposed Settlement Agreement, hereby approves the Settlement Agreement and enters Judgment as follows:
1. On January 3, 2014, the Court granted preliminary approval of the Parties' Proposed Settlement Agreement.
2. Any member of the class that wished to file an objection or comments was required to do so on or before January 31, 2014.

Case 1:12-cv-00053-SM Document 104 Filed 02/12/14 Page 2 of 2

3. A hearing for final approval of the proposed Settlement Agreement was held on February 12, 2014.

4. The Court has considered submitted objections and comments to the Proposed Settlement Agreement.
5. After a full and comprehensive review of the Proposed Settlement Agreement, the Parties' memoranda of law in support of the Agreement, and any objections/comments raised, this Court finds that the Settlement Agreement is fair, reasonable, and in the best interests of the class.
6. Consistent with the terms of the Settlement Agreement, the Court's class certification order of September 17, 2013 (Doc. 90) is hereby modified to include all claims brought pursuant to the Nursing Home Refonn Act, 42 U.S.C. §§ 1396r(b)(3)(F) and 1396r(e)(7).
7. This Court grants the Parties' Joint Motion for Final Approval of the Class Action Settlement Agreement, approves the Settlement Agreement, and enters it as an order of the Court, consistent with the terms of the Settlement Agreement. The Court will also sign the Settlement Agreement itself.
8. The Court incorporates the Settlement Agreement into this Order and retains jurisdiction over this matter, consistent with terms of the Settlement Agreement.
9. Further, the Court has reviewed Plaintiffs' Assented-to Motion for Attorney's Fees and Costs and accompanying memorandum of law, grants the Plaintiffs' motion, and approves the agreed upon attorneys' fees and costs set forth in the Settlement Agreement.

Date: i

H'lJlfi

. i_

McAuliftf District Judge

 
 Case 1:12-cv-00053-SM Document 110 Filed 12/29/14 Page 1 of 3

IN THE UNITED STATES DISTRICT COURT
 FOR THE DISTRICT OF NEW HAMPSHIRE


Amanda D., et al., and

)


others similarly situated,

)


)


Plaintiffs,

)


)


v.

)

)

Margaret W. Hassan, Governor, et al.,

)

)

Defendants.

)

___________________________________ )

United States of America,

)

)


Plaintiff-Intervenor,

)


)


v.

)


)


State of New Hampshire,

)


)


Defendant.

)

___________________________________ )

Civ. No. 1:12-cv-53-SM

PLAINTIFFS’ AND UNITED STATES’ STATUS REPORT ON EXPERT REVIEWER’S FIRST REPORT

The Plaintiffs and United States’ file this status report to inform the Court that Stephen

Day, the Expert Reviewer, has issued his first public report in this matter consistent with the

terms of the Settlement Agreement.

1. On February 12, 2014, the Court granted final approval of the Parties’ proposed

Class Action Settlement Agreement (“Agreement”), entered it as a court order, and signed the

Agreement. Agreement, ECF Nos. 104, 105.

2. The Agreement includes a provision that “[t]wice a year, or more often if deemed

appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a pubic

report on the State’s implementation efforts and compliance with the provisions of th[e]

Case 1:12-cv-00053-SM Document 110 Filed 12/29/14 Page 2 of 3

Settlement Agreement, including, as appropriate, recommendations with regard to steps to be

taken to facilitate or sustain compliance with the Settlement Agreement.” Agreement, ECF No.

105 at § VIII.K.

3. On December 26, 2014, Mr. Day submitted his report to the Parties in the matter.

4. In order to keep the Court apprised of the status of implementation of the

Agreement, the Plaintiffs and the United States have appended the Expert Reviewer’s report to

this status report as Attachment A.

WHEREFORE the Plaintiffs and the United States respectfully notify the Court that Mr.

Day’s first report has been completed consistent with § VIII.K. of the approved Class Action

Settlement Agreement.

Dated: December 29, 2014

Respectfully submitted,

FOR THE PLAINTIFFS:

Amanda D., Kenneth R., by his guardian, TriCounty CAP, Inc./GS; Amanda E., by her guardian, Office of Public Guardian, Inc.; and Jeffrey D., by his guardian, Monique Doukas, By their Attorneys:

Pro Hac Vice Applications Accepted:


DISABILITIES RIGHTS CENTER


Steven Schwartz (MA BBO 448440) Kathryn Rucker (MA BBO 644697) CENTER FOR PUBLIC REPRESENTATION 22 Green Street Northampton, MA 01060 (413) 586-6024 SSchwartz@cpr-ma.org KRucker@cpr-ma.org

By: /s/ Amy Messer
 Amy B. Messer (NH Bar 8815)
 Adrienne Mallinson (NH Bar 17126)
 Aaron Ginsberg (NH Bar 18705)
 18 Low Ave
 Concord NH 03301
 (603) 228-0432 amym@drcnh.org adriennem@drcnh.org aarong@drcnh.org

2


Case 1:12-cv-00053-SM Document 110 Filed 12/29/14 Page 3 of 3

Ira Burnim (DC Bar 406154)

By:

Jennifer Mathis (DC Bar 444510)

JUDGE DAVID L. BAZELON CENTER

FOR MENTAL HEALTH LAW

1101 15th Street, NW, Suite 1212

Washington, DC 20005

(202) 467-5730

irab@bazelon.org

jenniferm@bazelon.org

/s/ Joshua Wyatt DEVINE, MILLIMET & BRANCH PROFESSIONAL ASSOCIATION Elaine M. Michaud (NH Bar 10030) Daniel E. Will (NH Bar 12176) Joshua M. Wyatt (NH Bar 18603) 111 Amherst Street Manchester NH 03101 (603) 669-1000 emichaud@devinemillimet.com dwill@devinemillimet.com jwyatt@devinemillimet.com

FOR THE UNITED STATES:

By: /s/ Richard Farano RICHARD J. FARANO District of Columbia Bar No. 424225 Senior Trial Attorney United States Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, NW Patrick Henry Building – Room 5020 Washington, DC 20530 Telephone: (202) 307-3116 richard.farano@usdoj.gov

CERTIFICATE OF SERVICE


I hereby certify that a copy of the foregoing document was filed electronically and served on all parties of record by operation of the court's electronic case filing system.

Date: December 29, 2014

/s/ Amy B. Messer

3


Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 1 of 25

ATTACHMENT A


Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 2 of 25
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number One
December 26, 2014
I. Introduction
This is the first semi-annual report of the Expert Reviewer under the Settlement Agreement in the case of Amanda D. et. al. v. Margaret W. Hassan, Governor, et. al.; United States v. New Hampshire, No. 1:12-cv-53-SM. 1 For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement. Section VIII.K of the Agreement specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement. The Expert Reviewer was mutually appointed by the Parties effective July 1, 2014.2 The first six months of Expert Reviewer activity have been the “orientation phase.” That is, during this first period, Expert Reviewer activities have focused on meeting state administrators and visiting inpatient and community based service providers throughout the state to: (a) gain an understanding of the structure and functioning of important elements of the mental health system; (b) to introduce to these entities the functions of the Expert Reviewer vis-à-vis the Community Mental Health Agreement; and (c) to begin to formulate a baseline status assessment of the mental health system as a foundation from which to identify and document progress made in implementation of the Agreement. As of the submission of this report, the Expert Reviewer has:3
 Met with senior officials and staff of the New Hampshire Department of Health and Human Services (DHHS)
1 Class Action Settlement Agreement Amanda D. et. al. v. Margaret W. Hassan, Governor, et. al.; United States v.
 New Hampshire, No. 1:12-cv-53-SM.
 2 Implementation efforts related to the Community Mental Health Agreement had been underway prior to that date,
 and to the extent possible these activities are reflected in this report.
 3 Schedules of meetings and site visits for the period July 1, 2014 through December 15, 2014, are included in Appendix A of this report.
1

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 3 of 25
 Met on three occasions with the State Mental Health Coordination Team  Visited all ten regional Community Mental Health Centers in the state  Visited five Peer Supports Agency sites  Visited the Glencliff Home  Visited New Hampshire Hospital  Visited the transitional housing operated by NAFI on the grounds of the state hospital
complex  Visited the Yellow Pod at Concord Hospital  Had a brief tour of the Cypress Center in Manchester  Met with Ken Norton, Executive Director of NAMI New Hampshire  Met with the Statewide Mental Health Consumer Council  Conducted a preliminary de-briefing with state officials to discuss findings and
observations from the initial round of site visits  Conducted a formal debriefing with all Parties to the Agreement to discuss findings
and observations from the orientation phase of the Expert Review activity (The agenda for this meeting is included in Appendix B of this report)  Reviewed voluminous data and documents relevant to the Agreement.
The system orientation activities conducted during the early months of implementation included an assessment of existing data sources that could potentially be used to track progress and performance related to the terms of the Agreement. Several useful sources of data have been identified, as will be discussed further in subsequent sections of this report. However, as would be expected, there is not at this time a unified, comprehensive or validated set of data that can be used to directly report on performance across various components of the Agreement. A major task for the next few months of implementation will be to further explore the various data sets and sources and develop a plan for how these can be best used to inform the Parties and the Expert Reviewer about performance related to the quantitative and qualitative aspects of the Agreement. Pending more detailed data planning and analyses, this Report does not attempt to use existing data to reach concrete conclusions about performance related to specific elements of the Agreement.
Another focus of initial orientation activities was the need for technical assistance designed to assist New Hampshire to effectively implement the Agreement. This assessment of possible technical assistance needs was included in recognition that: (a) the mental health system is in the early stages of implementation; and (b) implementation of modern evidence based and promising practices is difficult and complex, requiring a combination of state-wide and locally based efforts. This report includes some recommendations for technical assistance efforts to support early implementation efforts. In addition, this Report recognizes that technical assistance will be an important element of efforts to attain and sustain compliance with certain elements of the Agreement.
2

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 4 of 25
Because the initial phase of activity for the Expert Reviewer was focused on system orientation, an explicit effort was made to remain non-judgmental and non-critical as visits were conducted and preliminary information collected. Thus, this first Report reflects assessment of the implementation structure and process rather than being a critical assessment of current compliance with specific requirements of the Agreement. The Report identifies areas in which there may be concerns about implementation and for which additional monitoring and technical assistance might be appropriate. However, there is no attempt or basis at this stage to document either compliance or non-compliance with the Agreement.
It is the current impression of the Expert Reviewer that all parties to the implementation of components of the Community Mental Health Agreement are committed to and supportive of efforts to implement the Agreement. This includes the Governor, state officials, state facilities, CMHCs, and other state contractors. Representatives of the Plaintiffs4 have also demonstrated commitment to a collaborative and positive process to implement the Agreement.
II. Brief Summary of Observations to Date
The following general observations pertain to: (a) the process for implementing and assuring compliance and quality under the terms of the Agreement over time; and (b) environmental factors that could influence implementation of the agreement.
A. Implementation Structure and Plan
It is the experience of the Expert Reviewer that two preconditions must be met for any implementation process to be successful. These are:
1. There must be an implementation structure. This structure needs to be comprised of officials with sufficient authority over relevant parts of the system to be able to make decisions and assure accountability for the implementation process; and
2. There must be a detailed implementation plan with measurable milestones and assignment of responsibility for each step in the implementation process.
New Hampshire has designated the Mental Health Coordination Team as the implementation oversight entity, or implementation structure, for the Community Mental Health Agreement. The membership of the group includes:
 Katja Fox, Health Care Policy Specialist, Office of the Commissioner (Chair of the Coordination Tam and designated single point of contact for the Community Mental Health Agreement)
 Geoff Souther, Interim Administrator, Bureau of Behavioral Health
4 The term “plaintiffs” throughout this report includes the United States
3

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 5 of 25
 Ry Perry, Legal Counsel, Bureau of Behavioral Health  Greg Burdwood, Community Integration Specialist, Bureau of Behavioral
Health  Diane Langley, Director, Bureau of Adult and Elderly Services  Bob McLeod, CEO, New Hampshire Hospital  Rebecca Woodward, Assistant Attorney General, Department of Justice  Todd Bickford, Administrator of the Glencliff Home  Dave Rollins, Project Manager, Project Management Office
The Mental Health Coordination Team has developed a detailed implementation plan with measurable milestones and assignments of responsibility for each key action step. The plan reflects each specific component of the Agreement, and uses the dates and major milestones in the Agreement as its primary performance targets. The implementation plan is, appropriately, very detailed and operational. The plan is also a “living document” in that it continuously undergoes changes, updates and mid-course corrections related to the detailed implementation steps. The implementation plan is essential to the effectiveness of the implementation process, but it is not by itself an Agreement compliance report. Nor does an indication on the plan that a specific action step has been completed indicate per se that an Agreement requirement has been satisfied.
The implementation plan cannot totally reflect activities related to quality and performance under the Community Mental Health Agreement. For example, it does not reflect all data sources, reporting mechanisms and time frames, and analytic frameworks to be developed and used over time to track the movement of priority target groups from institutionalization or risk of institutionalization into stable community living arrangements with evidence based services. Nor does the plan reflect some of the qualitative elements included in the quality management/quality assurance components of the Agreement. These quality components include direct assessment of service participant experiences with housing and services in the community and participant self report of the quality and effectiveness of services. These components are intended to be developed more fully in subsequent months of the planning and development process.
It should be noted that the Mental Health Coordination Team includes representation of New Hampshire Hospital, but does not include representation of other key participants in Agreement implementation and performance. For example, the ten Regional Mental Health Centers in New Hampshire, which are responsible for implementation of most of the community based best practice service elements and are critical to transition from inpatient facilities, are not directly included in Coordination Team activities. Unlike New Hampshire Hospital and Glencliff, the mental health centers are contracted entities, not part of state government, and thus it is appropriate that they not be members of the State Mental Health Coordination Team. However, it is recommended that formal mechanisms be implemented to enhance ongoing communication
4

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 6 of 25
with the CMHCs regarding Coordination Team activities and plans, and to regularly solicit input from the CMHCs regarding the work of the Mental Health Coordination Team. As will be noted throughout this Report, it is critical that all parties to the Agreement and all elements of the implementation process be engaged, informed and involved as implementation proceeds.
B. General Systems Issues – Environment for Implementation
In addition to the implementation structure and plan, other important variables affecting the success of any implementation process include environmental factors that could potentially facilitate or constrain implementation of elements of the agreement. These factors constitute the dynamic reality in which the Agreement is to be implemented. Some of these key environmental factors are briefly described below.
1. Limited Resources
In the experience of the Expert Reviewer, there is no state or local jurisdiction in the United States that has sufficient resources to meet all the health and behavioral health needs of its citizens. In addition, because of economic conditions and related factors, most states, including New Hampshire, experienced reductions in mental health resources between 2007 and 2012. An environment of constricted resources may heighten competition for services among disparate priority service populations, and may create incentives for payers to attempt to shift costs to other sectors of the service system. Scarce resources may also affect the staffing levels needed to implement new and enhanced service modalities while also attempting to maintain current service activities. All parties in New Hampshire will need to be respectful of the difficulties of forging ahead with a complex and multi-faceted implementation process in this environment of scarce resources.
However, scarce resources are not a reason to slow down or impede implementation of the Community Mental Health Agreement. Recent New Hampshire system assessments, as well as the findings leading up to the Agreement, have identified disproportional allocations of resources to institutional and congregate facilities at the expense of community alternatives. Shifting the balance towards investments in more cost effective best practice service modalities in concert with more affordable supportive housing resources is an objective of the Agreement. Accomplishing this shift promises better outcomes at reduced per-person costs in terms of investment of state (and federal/state) resources for mental health services.
State and regional system managers will need to assure that new resources are used in concert with existing (base) resources to accomplish the objectives of the Agreement. Nothing in the Agreement specifies that only new resources are to be used for attainment of Agreement objectives and requirements.
2. Community and Service System Culture
5

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 7 of 25
System culture issues can influence implementation of the Agreement. These include:
 The relative capacity of components of the mental health system to accept and manage risk in the community; and
 The relative willingness to embark on a system change process that results in substantial changes in traditional ways in which elements of the mental health system function and relate to each other.
In the experience of the Expert Reviewer, every mental health system in the United States has to continuously focus on managing risk throughout the system. In this context, the term “risk” encompasses decisions made at various points of the system when addressing difficult, complex, and sometimes volatile people and situations. The ability to tolerate, accept and manage risk affects:
 Decisions made by police and other first responders about whether to seek hospitalization or jail as opposed to a less intensive interventions;
 Decisions made by emergency room physicians related to whether involuntary commitment is necessary or whether community diversion or voluntary admission could be effectuated;
 Decisions made by CMHC Emergency Services staff related to managing psychiatric crises in non-hospital settings and effectuating community alternatives to hospitalization;
 Decisions made by psychiatric inpatient hospital staff related to how long someone must stay in a facility and what type of settings might be appropriate when returning to the community;
 Decisions made by clinical staff, families and guardians about whether a conditional discharge is necessary for movement into a community setting;
 Decisions by CMHCs related to people who can be successfully served in community settings with ACT and related services; and
 Decisions by housing sponsors and landlords about who can successfully enter into a lease agreement and sustain tenancy in the community.
In every case noted above, and in numerous other day-to-day decisions made throughout the mental health system, the capacity to accept and manage risk influences whether more restrictive or less restrictive interventions are employed. Every time a more restrictive setting is employed, there are consequences related to the individuals involved, and related to discontinuity of services and community supports, wait lists, increased inpatient census, prolonged discharge planning, and necessity to rebuild community supports to assure success in the community.
Implementation of the new transition planning process, new crisis service capacities, and the best practice ACT, supportive employment and supportive housing resources envisioned in the Agreement are specifically designed to increase the capacity of both the hospital and community
6

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 8 of 25
elements of the mental health system to increase tolerance for and management of risk and to thereby to reduce the default to more restrictive settings and increase the efforts made to assure successful and long term community living.
At the same time, influencing the degree to which the community and the mental health system can tolerate and manage risk requires changes at all levels in treatment philosophy and approaches, and in the communications and interactions among elements of the system. These types of fundamental system changes are difficult to implement under any circumstances. This is one reason why the implementation structure and plan are so necessary to the implementation process. The difficulty and complexity of implementation also requires that all parties at all levels are mutually engaged information sharing, mutual implementation strategy development, collaboration in implementation action steps, and tracking of implementation successes and midcourse corrections. The state will need to exercise leadership and support to enhance the capacities of CMHC’s and facilities to implement and sustain key elements of the agreement.
The Expert Reviewer, in the role of providing technical assistance as well as in the monitoring role, will focus on the environment factors of culture and natural resistance to change as part of the overall Expert Reviewer activity. The Expert Reviewer will also take whatever steps are necessary to make sure that all parties, including the Plaintiffs as well as state and local mental health system participants, are fully informed and engaged in the implementation process.
3. Medicaid Expansion and Medicaid Managed Care
Medicaid is by far the largest source of payment for mental health services relevant to the Community Mental Health Agreement in New Hampshire. And, as Medicaid Expansion adds new enrollees, Medicaid is likely to increase its overall share of payments for mental health services relative to other payer sources. The expansion of Medicaid eligibility is likely to assist previously uninsured individuals to access needed mental health services. In addition, the Medicaid Expansion population will have access to new substance use service benefits, which could improve substance use service access and coordination opportunities for this group.
New Hampshire has implemented fully integrated health and behavioral health managed care for Medicaid beneficiaries via two (and potentially three) statewide managed care organizations (MCOs). These MCOs and the ten regional CMHCs in New Hampshire have been negotiating per member per month (PMPM) reimbursement mechanisms for the portion of the overall mental health benefit delivered to Medicaid beneficiaries by the CMHCs. PMPM contracts have been signed with Well Sense Health Plan/Beacon Health Strategies, and negotiations are continuing with New Hampshire Healthy Families/Cenpatico.
Another Medicaid initiative that could influence implementation of the Agreement is the planned submission of an 1115 Demonstration waiver. Some components of the waiver request are intended to provide additional resources and organizational support to the behavioral health system in general and the Community Mental Health Agreement in particular. In addition, the
7

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 9 of 25
new 1115 waiver, in concert with the Medicaid coverage expansion and managed care initiatives, is intended to foster increased integration of physical health and behavioral health services. These integration efforts are intended to benefit many of the same people identified as priority consumers under the Agreement. Assuming the federal Centers for Medicare and Medicaid Services (CMS) approves the final waiver submission, activities under the waiver will be monitored to the extent they directly contribute to attainment of the objectives and quality standards of the Agreement.
The increased influence of Medicaid in the mental health and substance use service arenas, plus the roles of the MCOs vis-à-vis oversight of provider performance and coordination of care for certain beneficiaries is likely to affect the traditional accountability relationship between the CMHCs and the state Department of Health and Human Services (DHHS). As implementation of the Community Mental Health Agreement progresses, it will be important to clarify chains of communication and oversight among state agencies, the MCOs and the CMHCs. It will also be necessary to clearly define the data sets and sources that will be used to track progress and performance related to the Agreement in the context of Medicaid MCOs and PMPM payment mechanisms. For example, the state will need to be able to track and document the various ways in which both existing (base) Medicaid resources and any newly appropriated resources that pass to CMHCs via the MCOs are directly supporting implementation and operations of services consistent with the Agreement. The Expert Reviewer expects that the state will carry out whatever leadership and oversight is necessary and appropriate of both the Medicaid MCO’s and the CMHCs to assure compliance with the Agreement. As long as the objectives of the Agreement are met within the defined timeframes and with the desired fidelity and quality, and as long as there is transparency related to the use of funds designated for use in meeting the terms of the Agreement, then it will not be necessary to become more deeply involved in how that oversight and transparency is achieved by the state and its contracted entities.
4. Emergency Department Boarding
As with many other states, emergency department boarding is a critical issue in New Hampshire that is receiving considerable state and local attention and corrective efforts. Emergency department boarding is likely to be symptomatic of issues in the overall mental health system that directly impinge on the objectives and requirements of the Agreement. For example, as New Hampshire Hospital and the CMHCs work to effectuate speedier discharges and lower readmission rates, there should be more beds available at NHH for clinically necessary inpatient admissions. Further, as mobile crisis services and crisis respite services are implemented and expanded, a higher rate of hospital diversion ought to be accomplished before people in psychiatric crisis even reach hospital emergency departments. Finally, effective use of fidelity model best practices such as ACT, SE and supportive housing should substantially increase community tenure, thereby reducing admission rates and demand for inpatient services.
8

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 10 of 25
For the above reasons, the Expert Reviewer will continue to review data on ED boarding as one possible indicator of changes in the overall MH system. It will also be important to document the degree to which strategies to reduce ED boarding, other than those listed above, comport with the objectives and requirements of the Agreement.
5. Variability in the System
As expected during the orientation phase of the Expert Reviewer activity, some variation among CMHCs, and also among services within CMHCs, was observed during the site visits. Some degree of variation is considered to be a positive element of New Hampshire’s system of regional CMHCs. However, a high degree of consistency is to be expected of the CMHCs with regard to implementation of components of the Agreement, including attainment of fidelity and quality standards and timely and accurate submission of all required data for tracking progress and performance under the Agreement.
Variations in size, geographic area, service population demographics, staffing and revenues could also result in varying capacities at the CMHC level to implement and manage the required elements of the Agreement. The Expert Reviewer will assist all parties to identify issues related to the capacity to implement and manage components of the Agreement. Technical assistance strategies can be developed and tailored to individual or groups of CMHCs as applicable to their capacities and resources.
III. Observations Related to Agreement Components
The following sections of the Report provide some preliminary observations about specific elements of the Community Mental Health Agreement. Where available, data produced by the state have been summarized to provide some indicators of relative progress or performance related to components of the Agreement. However, the Expert Reviewer and all parties, including the United States and Plaintiffs, are still working to validate data sources and reporting formats, and to develop methods to use data from a variety of sources to track and document the degree to which certain objectives of the Agreement are being attained. It is premature to reach concrete conclusions from the data available and reported at this point. As noted above, for the purposes of his report, no conclusions are reached with regard to either compliance or non­ compliance with the Agreement.
a. Assertive Community Treatment (ACT)
As specified in the Agreement, there is now an ACT team at some stage of development in each of the ten CMHC regions. One CMHC has two ACT teams, so there are 11 teams currently at some stage of development/operations in the state. DHHS reports that as of October, 2014 there were a total of 641 individuals enrolled in ACT services in the 11 ACT teams. Because some
9

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 11 of 25
teams are in the early stages of development, the caseloads are currently lower than would be expected at full implementation. The ACT enrollment target specified in the Agreement is 1,300 enrollees by June 30, 2015. Thus, it will be important to track enrollment rates in ACT over the next few months, and to provide technical assistance if the caseload targets are not being attained.
There is no documentation at this point of the extent to which the current ACT enrollees meet the target population definitions in the Agreement. However, anecdotal reports from the site visits indicate that most of the CMHCs are using clinical criteria for assignment to ACT that are consistent with best practice expectations and the Agreement. For subsequent reporting periods it will be important to identify additional data sources that can be used to verify that the target population guidelines are being met.
DHHS receives monthly data reports from the CMHCs related to progress implementing the ACT services and on the number of consumers enrolled in ACT services. The CMHCs have also recently completed fidelity self assessments for their ACT teams, and have reported this information to DHHS. Some of the results of the fidelity self assessment are reported to be incorporated into the monthly ACT reports. At this point there has been no review or external validation of the results of the self assessments. However, DHHS is reported to be working with CMHCs that have self-reported areas of non-compliance with fidelity standards, with the goal of increasing fidelity to ACT standards throughout the system as soon as possible. For example, DHHS is working with the CMHCs to assist them in the process of recruiting peer specialists to function as members of ACT teams. Independent validation of fidelity self-assessment information will need to be carried out in the future.
Fidelity to ACT staffing models and caseload ratios is a necessary pre-condition to attaining the positive outcomes for consumers that have been demonstrated with the ACT model. However, meeting these basic criteria does not assure that an ACT team is functioning as well as it can. It is also important to assure that: (a) the team is serving the highest risk/highest need consumers in the system; (b) that the team is actually functioning as a team, in that consumers experience and are comfortable with interactions with several members of the team; (c) that the team is realistically capable of responding to enrollee crises on a 24/7 basis, and is not relying on other emergency services capabilities for crisis response; (d) that supported employment and peer supports are provided to ACT enrollees by bona fide members of the ACT team, not staff shared from other service components of an agency; (e) that the team is in reality doing whatever it takes to support each enrollee to be successful in the community and to avoid hospitalization and incarceration; and (f) that over time enrollees in ACT experience positive outcomes such as independent housing, employment, increased community tenure, and reduced emergency department and inpatient hospital episodes of care. Once basic fidelity standards are met, these qualitative and outcome oriented aspects of ACT team functioning will receive greater emphasis from the perspective of both monitoring and technical assistance.
10

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 12 of 25
b. Supported Employment
According to information provided by DHHS, each CMHC in New Hampshire has an operational supported employment (SE) program. Consistent with the Agreement and with DHHS policy and funding requirements, these SE programs are intended to meet fidelity standards for the Individual Placement and Supports (IPS) model. DHHS reports that CMHCs have completed fidelity self assessments for these SE programs, but the Expert Reviewer has not yet seen the results of these self assessments. Based on anecdotal information from the site visits, it appears that certain SE staff have been trained in IPS. However, the degree to which IPS fidelity practices are followed within each CMHC is not currently reported or externally validated.
DHHS reports that as of the end of the first quarter of state Fiscal Year 20155, a total of 710 consumers are enrolled in SE throughout the 10 CMHCs. It is not known at this point how many of these individuals are actively engaged in specific job-seeking and actual employment activities. Nor do the data currently document target population membership for consumers enrolled in SE. As with ACT services, anecdotal reports by CMHCs suggest that appropriate clinical criteria are generally used to identify priority consumers for referral to and enrollment in SE. However, additional validation of this from other data sources will be important to future monitoring of SE.
The average penetration rate for SE services across all CMHCs for the first quarter of 2015 was reported by DHHS to be 12.7%. The target penetration rate specified in the Agreement for June 30, 2015 is 16.1%. It is not clear that current calculations of SE penetration rates accurately reflect the number of priority consumers engaged in fidelity model IPS in a consistent manner throughout the state. This will be clarified in the next reporting period. Once the calculation of penetration rates is validated, it will be possible to document progress towards meeting the specified target penetration rate by the end of the next reporting period.
The Agreement specifies that enrollees in ACT teams must receive SE services from employment specialists on their ACT Teams. Several CMHCs stated that trained employment specialists were on their ACT Teams, but others implied that SE staff with broader SE caseloads were participating in providing SE to ACT enrollees. This is an issue for further follow-up in the next six months.
c. Crisis Services – Hospital Diversion
Based on information provided by DHHS, and also on interviews and observations from the CMHC site visits, there are 24/7 crisis services available to people in psychiatric crisis in each
5 July, August and September, 2014
11

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 13 of 25
region of the state. There do not seem to have been any structural or programmatic changes to the basic crisis service capacity of the CMHCs since the initiation of the Agreement. To date, the Expert Reviewer has not reviewed statewide and comparative data reports specific to the CMHC crisis services programs,6 nor has there been a qualitative review of crisis service interventions and dispositions. These will be a priority over the next year of implementation.
DHHS has been preparing an RFP for the first Mobile Crisis Team and Crisis Apartments, to be implemented in Mental Health Region 4 (Concord) by June 30, 2015. The draft RFP is currently being reviewed by the Parties to the Agreement, and is intended to be issued soon. Because the review process for this RFP is not complete, it is premature to comment on progress made to date in moving towards implementation of the mobile crisis and crisis apartment services specified in the Agreement.
Crisis/emergency response services are at the core of community service systems designed to assist people with mental illness to live and work successfully in the community. Such services are also essential to efforts to reduce inpatient hospital admissions and census. Anecdotally, most crisis response services currently provided by CMHCs in New Hampshire are initiated after a person in psychiatric crisis has presented in a hospital emergency department (ED). And, many crisis response services are reported to be physically delivered in hospital EDs. In some cases, crisis staff are anecdotally reported to be assisting ED staff to find an available inpatient psychiatric bed for a person in crisis in the ED.
Frequently, once a person has arrived at the ED it is too late in the process to effectuate a safe and effective diversion back to a person’s home and community. This is one reason why the implementation of mobile crisis services is an important component of the Agreement. In addition, there will need to be concerted efforts over the next several months to expand existing crisis response and hospital diversion services beyond the confines of Hospital EDs, with greater focus on up-stream interventions that can assist to stabilize an incipient crisis before hospital admission becomes inevitable.
d. Family and Peer Supports
Information provided by DHHS indicates that there are functioning Peer Supports programs in each of the ten regions, and that these programs are generally open and available to members 44 hours per week.7 Documentation is not currently available that would indicate actual member participation during the hours that the Peer Supports Centers are open. The Expert Reviewer was not able to complete visits to Peer Support Agencies within each of the ten regions during
6 For the most part BBH and the CMHCs refer to these programs as “emergency services” rather than “crisis services” programs. Most of the CMHCs did provide some data on emergency services presentations and dispositions as part of the site visits.
 7 These hours do not necessarily reflect time spent by peer members of the programs providing supports to others via 
 warm lines, crisis respite programs, etc.

12

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 14 of 25
the first six months. Thus, it is premature to report on any observations with regard to these programs. These will be addressed in the next semi-annual report.
The Expert Reviewer was also unable review the Family Supports program during the first six months. DHHS and NAMI New Hampshire confirmed that this program is on-going, but there has been no review of activities, participation, or other information related to the program.
Based on anecdotal information from members of the Statewide Consumer Council, from CMHCs, from DHHS, and from the few Peer Supports programs visited, there are several areas for further information collection and possible technical assistance related to peer supports includes:
 Examine ways in which DHHS and other state agencies could assist Peer Supports programs to participate in supplying peer specialists and other staff with lived experience for ACT teams and other mental health programs;
 Increase/enhance the roles of people with lived experience in facility inreach, transition planning, and effectuating transitions independent community living;
 Encourage increased membership and participation in the Peer Support Programs; and  Increase the degree of collaboration and communication among the CMHCs and Peer
Supports programs, and increase the degree of participation of Peer Supports programs in integrated health and wellness programs on a statewide basis.
e. Supportive Housing
DHHS reports that there are sufficient funds to provide 290 supportive housing units via the state Bridge Subsidy Program by December 31, 2014.
According to tentative information provided by DHHS, as of October 31, 2014 there were 210 people in leased bridge subsidy apartments, with an additional 15 people approved for a bridge rent subsidy who are in the process of finding an apartment and moving in. The above reported occupancy data do not include individuals who have transitioned from the bridge subsidy to mainstream housing choice vouchers or other affordable supportive housing resources, and who may continue to receive community services and supports as well as housing. Thus, it is premature to reach any conclusions about performance related to the provision of supportive housing relative to the Agreement. In addition, the Expert Reviewer has not yet visited Harbor Homes, the state’s vendor for the Bridge Subsidy program, and thus has no information or impressions from that agency.8 The process of attaining supportive housing, from initial referral and eligibility determination (by defined criteria), to housing search and rent-up, needs to be
8 This visit is scheduled for December 16, 2014, too late for information from that visit to be included in this Report.
13

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 15 of 25
clarified and documented. Supportive housing will be an important priority for data collection and monitoring over the next few months.
From anecdotal information and some preliminary discussions with the Parties, it appears that there are several important questions to be addressed with regard to supportive housing. These include:
 The state supportive housing bridge subsidy is not the only source of affordable scattered site housing for priority target population people as defined in the Agreement. For example, if the federal Department of Housing and Urban Development funds New Hampshire’s application for Section 811 PRA funds, there will be a new source of rental subsidies. In addition, some members of the priority target population undoubtedly obtain Housing Choice Vouchers (HCVs – Section 8) or Shelter Plus Care subsidies without first participating in the Bridge Subsidy program. The Bridge Subsidy program is currently the only supportive housing program for which the state reports information on the number of people occupying units.
 There is currently no data source that specifically identifies the exact source of referrals into the Bridge Subsidy program. For example, how many tenants receiving units after the Agreement was signed came to the Bridge Subsidy program via transition planning form NHH and Glencliff? When a subsidy becomes available, who among the target population is awarded the subsidy and on what basis?
 Nor is there currently reported data related to the community services and supports received by supportive housing tenants. For example, how many supportive housing tenants are receiving ACT and SE services? Are all supportive housing tenants receiving services from their cognizant CMHCs? What agencies are accountable at the local level to assure that supportive housing tenants experience continuity of care, adequate crisis response, tenancy supports, eviction prevention, etc.?
 Finally, from anecdotal information from state officials and CMHC site visits, there appears to be some variability regarding the Bridge Subsidy program in the referral and lease-up process, communications and relationships among state facilities doing transition planning, housing acquisition, and service coordination and delivery. As noted above, this process will need to be clarified over the next few months.
f. Community Residences
DHHS is reported to be developing a draft Request for Proposals (RFP) for the four community residence beds identified in the Agreement (Section V.E.3.g) as being available by June 30, 2015. This RFP is not yet available for review, so it is premature to reach any conclusions or recommendations regarding this provision of the Agreement. This will be addressed in the next semi-annual report.
14

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 16 of 25
g. Transition Planning
The Community Mental Health Agreement contains detailed specifications for transition planning from New Hampshire Hospital (NHH) and Glencliff, to be in place by June 30, 2014. A version of transition planning had been in place in each facility prior to the Agreement, but new policies and procedures were necessary to meet the standards for transition planning in the Agreement. Glencliff Home issued its new transition planning policy August 14, 2014; NHH issued its revised policy effective October 22, 2014.
The New Hampshire Department of Health and Human Services is also procuring a new Preadmission Screening and Resident Review (PASSR) entity, to assure clinical necessity and appropriateness of admissions to Glencliff. The new vendor has been selected, but implementation is in the very early stages, so it is premature to comment on how that provision of the Agreement is being implemented.
For both NHH and Glencliff, the transition planning policies and practices are too newly issued to be able to comment on their implementation or effectiveness. It is also too early in the implementation process to comment on inreach activities on the part of CMHCs, peer support agencies and other community entities as specified in the Agreement. Transition planning will be another important focus of monitoring and technical assistance over the next six months. Several best practice approaches related to transition planning will be addressed during the next year. These include:
 Including a projected discharge date in the individual person centered transition plans developed by NHH and Glencliff. Without a specific date by which the transition is projected to be accomplished, it is difficult for patients, families, and caregivers to plan. It is also difficult to assure that the necessary community housing, services and supports are in place to effectuate the transition by the projected discharge date. Finally, a projected transition date allows the state, facility managers and other involved parties to track and document the effectiveness of the transition planning process. Monitoring the degree to which discharge dates are incorporated into individual transition plans, as well as the degree to which these dates are met, will become part of the ongoing monitoring of the transition planning process as specified in the Agreement.
 Specifying in the individual person centered transition plan the service and skill building activities that are to be carried out by the facility leading up to a successful discharge. As with the discharge date, specification of pre-discharge services should be included in the individualized transition plans. There is a need to hold CMHCs and other community providers and caregivers accountable for providing the community housing and services to accomplish successful transitions. In the same way, there needs to be a basis in the transition plans for holding facilities accountable for providing the services and skill­
15

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 17 of 25
building necessary to assure that each individual will be ready for and successful in the community.
DHHS is reported to be developing a data tracking system to identify people at the point of transition from facilities, and to track their service utilization, continuity of care, readmission episodes, etc. after transition. Assuming this data system is implemented, it will fill a current gap in available information related to facility transitions and the linkage of services to these priority consumers in the community. The Expert Reviewer will continue to participate in discussions about the design and implementation of this system over the next few months.
Finally, the Agreement calls for the establishment of a central team to assist and addressing and overcoming barriers to effectuate transitions to the community. Formation and membership of this team is still in development, and thus will be a topic for the next semi-annual report.
Note: Expert Reviewer comments and observations related to other components of the Agreement, including assurance of compliance with the target population definitions, steps to address the needs of people with development disabilities in the target population, measures put in place to prevent placement in nursing homes or other institutional settings, and implementation of quality management services, are reserved for the next semi-annual report, due in June, 2015.
IV. Conclusion
As described in this first Report of the Expert Reviewer, numerous steps have begun to be taken to implement the Community Mental Health Agreement. The parties to the Agreement appear to be committed to meeting the targets and requirements of the Agreement, and also seem committed to a transparent and collaborative implementation process. Progress towards implementing Agreement requirements is evident within most components of the Agreement, and concrete action steps are being developed to keep the process moving forward in the right direction.
Of course, it is very early in the implementation of the Agreement. Most of the implementation process has just begun and, as noted throughout the Report, it is premature to reach any conclusions about meeting the performance and quality requirements of the Agreement. Considerable effort will be necessary within each component of the Agreement to sustain progress already made and to attain the level of quality and results specified by the Agreement.
There are several important priorities both for the implementation process itself and for the monitoring of implementation over the next six months. Perhaps the most important will be to identify the data sets and sources that will be used to inform all parties as to progress and performance related to each discrete component of the Agreement. Several available data
16

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 18 of 25
sources have been identified, but it is necessary define how these will be used, and how information will be analyzed and interpreted, to document quality and performance under the Agreement going forward. The task of identifying applicable data and designing analytic frameworks must include all Parties, since all Parties will have to agree that data is timely and reliable and that it accurately responds to the requirements of the Agreement. The supportive housing component of the Agreement is a high priority for data definition and analysis in the next six months.
Other priority items for monitoring in the next six months include:
 Implementation of the Central Team for transition planning and facilitation of discharges for NHH and Glencliff;
 Results of discharge planning as implemented at NHH and Glencliff;  Award of a contract and early implementation of the mobile crisis and crisis
apartment services in the Concord region;  Assurance of service linkage and provision to tenants in supportive housing;  Full lease up of bridge subsidy and other designated supportive housing resources;
and  Addition of peer specialists to the ACT teams.
The Expert Reviewer has identified several areas in which the state may wish to request technical assistance related to implementation of the Agreement. These include:
 Attainment and sustainability of fidelity for ACT and SE –  Employment of peers as members of ACT teams, and perhaps also for in-reach
services related to transitions from facilities to the community; and  Workforce development and retention applicable to ACT, SE and other related skill
building and community support services within the CMHCs.
The Expert Reviewer is grateful to all the people and agencies that assisted with the six month orientation process. All of the state officials, facilities, CMHCs, Peer Support Agencies and other people and agencies participating in interviews and site visits were cooperative and forthcoming with any information that was requested. The orientation phase is not entirely complete, but a solid foundation of information and exposure to key system components has been established for the ongoing monitoring of quality and performance consistent with the Community Mental Health Agreement.
17

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 19 of 25

Appendix A Schedule of Expert Reviewer Meetings and Site Visits for July through December, 2014
18

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 20 of 25

Master Schedule for Expert Reviewer Site Visits

Date

Interview/Site Visit

Comments

Monday, July 14
Tuesday, July 15 Wednesday, July 16 Thursday July 17 Tuesday July 22 Wednesday, July 23 Thursday July 24 Tuesday August 12
Wednesday Aug 13

9:00: Meet with Katja 9:30-10:00: DHHS Senior Management PM: Interim BBH Administrator 1:30-3:30: Mental Health Coordination Team 10:00-11:30: CMHC Executive Directors Meeting – Concord 1:00-2:00: Ken Norton, NAMI-NH 12:15-12:45: Governor Hassan, DHHS Commissioner Toumpas, Attorney General Foster 9:00-11:00: Glencliff 1:30 PM: Riverbend - Concord 9:00-12:00: Community Partners ­ Dover 1:30-4:30: Seacoast - Portsmouth 9:00-12:00: MHC of Greater Manchester & Cypress Center 2:00-4:00: NH Hospital 9:00-12:00: Northern Human Services –Berlin 1:30-4:30 PM: Genesis Behavioral Health - Laconia 9:30-12:00: Monadnock Family Services –Keene 1:30-4:30: West Central - Lebanon

Rescheduled to 9/4, 1:30-4:30 Rescheduled to 8/27, 1:00-4:00

Tuesday August 26 9:00-12:00: Greater Nashua MHC 1:00-4:00: Center for Life Management - Derry

Wednesday, August 27 Wednesday, Sept 3

2:00-5:00: West Central Behavioral Health - Lebanon 9:30-10:30: Greg Burdwood, Dave Rollins, Katja Fox 1:00-2:00: Michele Harlan-Main Bildg 2:00-3:00: Kelley Capuchino-Main Bldg

DHHS Brown, Room 433
BBH Director’s Office, Main Building BBH Director’s Office, Main Building

19

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 21 of 25

Thursday, September 4 Tuesday, Sept 9 Tuesday, Sep 16
Thursday, Sept 18
November 5, 2014 10:00am

3:00-4:00: Diane Langley-Brown #249 1:30-4:30: Community Partners – Dover 10:00-11:00 TH-NFI 3:00-4:30: Debrief with State Team 10:00-1:00: Consumer Council
2:30-4:30: Meet with all parties in Concord
On the Road to Recovery (region 10)

Diane’s Office
Howard Rec Center DHHS Brown, Room 468 Fox Chapel, DHHS Main Building (*Time on agenda will be confirmed) Debrief on orientation phase Discussion of next steps: DHHS Brown Building, Room 468 12 Birch Street Derry NH, 03038

November 5, 2014 On the Road to Recovery (region 7) 13 Orange Street

2:00pm

Manchester NH, 03105

November 12, 2014 1:00-2:00 November 20, 2014
1:30pm

Community Mental Health Center Directors Seacoast Consumer Alliance

1 Pillsbury Street Concord 544 Islington Street
Portsmouth, NH 03801

December 3, 2014 Concord Peer Support Center 10:00am

55 School Street Concord, NH 03301

December 3, 2014 Cornerbridge of Laconia 2:00pm

328 Union Ave Laconia, NH 03247

December 4, 2014 Tri-City Coop 1:30pm

36 Wakefield Street Rochester, NH 03867

December 9, 2014 10:00-11:00 December 9, 2014 11:00-12:00 December 10, 2014
1:30pm

Meeting with Commissioner, Katja Fox & Jeff Meyers re: integration Quality Management MeetingDHHS Staff Alternative Life Center

Commissioner’s Office Brown Bldg, Concord Brown Bldg, Room 403
6 Main Street Conway, NH 03818

December 11, 2014 Monadnock Area Peer Support 10:30am

64 Beaver Street Keene, NH 03431

20

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 22 of 25

December 11, 2014 The Stepping Stone Drop-In Assn. 108 Pleasant Street

2:00pm

Claremont, NH 03743

December 16, 2014 Harbor Homes 9:00-11:00

Manchester

21

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 23 of 25
 Appendix B

Agenda for All Parties Debriefing Meeting – September 18, 2014

22

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 24 of 25
Expert Reviewer New Hampshire Meeting of the Parties to the
Community Mental Health Agreement
September 18, 2014
Agenda
1. Purpose of the meeting 2. Summary of system orientation activities to date
a. Data and documents b. Site visits c. State staff meetings 3. Brief summary of observations to date a. Implementation planning process b. Structure and resources for implementation and operations
i. Mental Health Planning Group c. Service delivery and operations “culture” as it might affect implementation and
effectiveness of the mental health agreement d. General systems issues – environment for implementation
i. MCO implementation and CMHC payment mechanism ii. Medicaid expansion iii. Medicaid expansion benefit design – MH and SUD iv. Emergency Department boarding v. Capacity of CMHCS vi. Availability of data 4. Observations related to Agreement components a. ACT b. Supported Employment c. Crisis Services – hospital diversion d. Peer supports e. Supportive housing f. Community residences g. Transition planning h. Targeting to priority populations i. Quality Improvement/quality management 5. Issues for future tracking/analysis a. Service access and priority population tracking b. Transition planning – roles/activities of CMHCs c. Fidelity of EBPs – particularly ACT and SE d. Crisis service system evolution i. Mobile crisis
23

Case 1:12-cv-00053-SM Document 110-1 Filed 12/29/14 Page 25 of 25
ii. Crisis respite capacity iii. Up-stream interventions e. State and MCO oversight of contract and financing agreements specifically related to the agreement f. Specification of outcomes/results to be tracked and data sources to be used related to the agreement 6. Specific issues related to the agreement a. Need to move towards providing emergency services/crisis response at the site of the crisis, not just in the ED or office
i. Track issuance of Mobil Crisis RFP (Planned for November 2014) b. ACT – question if all teams can meet standards by October 1, 2014 7. Specific Priorities for Technical Assistance a. TA and training related to ACT and SE – both development and sustainability
related to fidelity standards and the philosophy/vision for the EBPs b. TA related to the use of peer support services and re: employment of peers as
members of ACT and CSP teams, in-reach services, etc. c. Additional support and TA related to workforce development and retention
24

 
 Case 1:12-cv-00053-SM Document 112 Filed 07/02/15 Page 1 of 3

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW HAMPSHIRE

Amanda D., et al., and

)

others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

Margaret W. Hassan, Governor, et al.,

)

)

Defendants.

)

___________________________________ )

United States of America,

)

)

Plaintiff-Intervenor,

)

)

v.

)

)

State of New Hampshire,

)

)

Defendant.

)

___________________________________ )

Civ. No. 1:12-cv-53-SM

PLAINTIFFS’ AND UNITED STATES’ STATUS REPORT ON EXPERT REVIEWER’S SECOND REPORT

Plaintiffs and the United States file this status report to inform the Court that Stephen

Day, the Expert Reviewer, has issued his second public report in this matter.

1. On February 12, 2014, the Court granted final approval of the Parties’ proposed

Class Action Settlement Agreement (“Agreement”), signed the Agreement, and entered it as a

court order. ECF Nos. 104, 105.

2. The Agreement includes a provision that “[t]wice a year, or more often if deemed

appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public

report on the State’s implementation efforts and compliance with the provisions of th[e]

Settlement Agreement, including, as appropriate, recommendations with regard to steps to be

Case 1:12-cv-00053-SM Document 112 Filed 07/02/15 Page 2 of 3

taken to facilitate or sustain compliance with the Settlement Agreement.” Agreement, ECF No.

105 at § VIII.K.

3. On June 30, 2015, Mr. Day submitted his second report to the Parties.

4. In order to keep the Court apprised of the status of the implementation of the

Agreement, the Plaintiffs and the United States have appended the Expert Reviewer’s second

report to this status report as Attachment A.

WHEREFORE the Plaintiffs and the United States respectfully notify the Court that Mr.

Day’s second report has been completed consistent with § VIII.K. of the Agreement.

Dated: July 2, 2015

Respectfully submitted,

FOR THE PLAINTIFFS:

Amanda D., Kenneth R., by his guardian, TriCounty CAP, Inc./GS; Amanda E., by her guardian, Office of Public Guardian, Inc.; and Jeffrey D., by his guardian, Monique Doukas, By their Attorneys:

Pro Hac Vice Applications Accepted:

DISABILITY RIGHTS CENTER - NH

Steven Schwartz (MA BBO 448440) Kathryn Rucker (MA BBO 644697) CENTER FOR PUBLIC REPRESENTATION 22 Green Street Northampton, MA 01060 (413) 586-6024 SSchwartz@cpr-ma.org KRucker@cpr-ma.org

By: /s/ Adrienne Mallinson Amy B. Messer (NH Bar 8815) Adrienne Mallinson (NH Bar 17126) Aaron Ginsberg (NH Bar 18705) 18 Low Ave Concord NH 03301 (603) 228-0432 amym@drcnh.org adriennem@drcnh.org aarong@drcnh.org

Ira Burnim (DC Bar 406154)

By:

Jennifer Mathis (DC Bar 444510)

JUDGE DAVID L. BAZELON CENTER

FOR MENTAL HEALTH LAW

/s/ Daniel E. Will DEVINE, MILLIMET & BRANCH PROFESSIONAL ASSOCIATION Elaine M. Michaud (NH Bar 10030)

2

Case 1:12-cv-00053-SM Document 112 Filed 07/02/15 Page 3 of 3

1101 15th Street, NW, Suite 1212 Washington, DC 20005 (202) 467-5730 irab@bazelon.org jenniferm@bazelon.org
FOR THE UNITED STATES:

Daniel E. Will (NH Bar 12176) Joshua M. Wyatt (NH Bar 18603) 111 Amherst Street Manchester NH 03101 (603) 669-1000 emichaud@devinemillimet.com dwill@devinemillimet.com jwyatt@devinemillimet.com
By: /s/ Richard Farano RICHARD J. FARANO District of Columbia Bar No. 424225 Senior Trial Attorney United States Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, NW Patrick Henry Building – Room 5020 Washington, DC 20530 Telephone: (202) 307-3116 richard.farano@usdoj.gov

CERTIFICATE OF SERVICE

I hereby certify that a copy of the foregoing document was filed electronically and served on all parties of record by operation of the court's electronic case filing system.

Date: July 2, 2015

/s/ Adrienne Mallinson

3

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 1 of 23
ATTACHMENT A

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 2 of 23
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Two
June 30, 2015
I. Introduction
This is the second semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Hassan,; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement. The ER was mutually appointed by the parties effective July 1, 2014.1 The first six months of ER activity was the “orientation phase”; ER activities focused on meeting state administrators and visiting inpatient and community-based service providers throughout the state to: (a) gain an understanding of the structure and functioning of important elements of the mental health system; (b) introduce to these entities the functions of the ER vis-à-vis the CMHA; and (c) begin to formulate a baseline status assessment of the mental health system as a foundation from which to identify and document future progress in implementing the CMHA.
In the second six-month time period, from January 1, 2015 through June 30, 2015, the ER has concentrated on:
1. Working with the parties and state officials to identify data elements and sources to be used to track and document progress and performance related to the CMHA;
2. Beginning to work with state officials on the implementation of Quality Management (QM) and Quality Service Review (QSR) provisions in the CMHA; and
3. Working with the parties to develop collective understandings of how the data tracking and QM/QSR activities will be used to provide the most accurate and timely
1 Implementation efforts related to the CMHA had been underway prior to the appointment of the ER, and to the extent possible, those activities were reflected in the first ER report.
1

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 3 of 23
information to the ER and the parties with regard to attainment of the performance targets, outcomes, and quality requirements of the CMHA.
The ER has continued to make regular visits to New Hampshire, both to observe the implementation of certain key service elements of the CMHA, and to continue discussions with relevant parties related to implementation efforts and the documentation of progress and performance related to the CMHA. Thus far, the ER has:
 Completed visits to peer supports programs in each of New Hampshire’s 10 regions. Seven of these were conducted during the first six-month period;
 Conducted on-site reviews of Assertive Community Treatment (ACT) teams/services in Manchester, Nashua, Concord, Laconia, Keene, and Berlin;
 Conducted on-site reviews of Supported Employment (SE) services in Nashua, Concord, Laconia, Keene, and Berlin;
 Met with officials, administrators, and staff at New Hampshire Hospital (NHH) (twice) and Glencliff to discuss and observe transition planning functions;
 Met with the peer supports group at Glencliff;  Met with NHH staff and the liaisons to the Community Mental Health Centers
(CMHCs) to discuss discharge planning issues;  Met with Ken Norton, Executive Director of NAMI New Hampshire;  Participated in one CMHC Director’s meeting;  Met with representatives of the Nashua Police Department;  Met with representatives of the Emergency Department of Androscoggin Valley
Hospital in Berlin;  Participated in three meetings of the Department of Health and Human Services
(DHHS) Mental Health Coordination Team;  Participated in several meetings with representatives of the Plaintiffs and the United
States (hereinafter “plaintiffs”);  Conducted numerous meetings with DHHS officials to discuss QM/QSR, data
tracking, and data elements and reporting related to the CMHA; and  Conducted in-person meetings with the parties in Concord on January 26, 2015,
March 3, 2015, and June 10, 2015.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward, even outside the context of QSR reviews, to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people per CMHA requirements.
2

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 4 of 23
II. Data
As indicated above, a key priority for the ER during this second six-month period has been working with DHHS to further identify and access data that can be used to routinely track progress related to each element of the CMHA. Data includes participant-level service access and encounter data from CMHCs, NHH, and Glencliff. Updated information derived from this data is included where applicable in the service-specific sections of the report. Consistent with the CMHA, a goal of DHHS is to provide data regularly and in formats that are useful for analysis.
DHHS has been working to produce the requested data, and there have been improvements in the reliability and timeliness of some of the data provided to the ER and the parties. However, some data has still not been supplied at regular intervals, in standardized formats with standardized date ranges. In addition, DHHS is still developing its capacity to match participant-level information across several data bases, including Medicaid claims data, Phoenix 2, and the Avatar system for NHH. Early testing of this data-matching capability has been promising, and when fully developed, will be beneficial to the overall effort to assure performance and quality for the priority target population of the CMHA.
In the course of identifying and testing existing data sources for analyses related to the CMHA, several gaps in current information have been identified. For example, there is no current data on the degree to which participants in Supported Employment (SE) are engaged in competitive employment in integrated community settings consistent with their individual treatment plans as opposed to other SE activities. Competitive employment in integrated community settings consistent with individual treatment plans is a key indicator of the fidelity and success of SE services, and thus another data source will need to be identified to obtain this information. Another gap in data is related to people receiving Supportive Housing (SH) under the Bridge subsidy program. These participants are not clearly identified in the Phoenix 2 system, and thus it is difficult to document the degree to which these individuals are: (a) connected to local CMHA services and supports; or (b) actually receiving services and supports to meet their individualized needs on a regular basis in the community. DHHS has identified a strategy to link data from the Bridge program to the Phoenix 2 system, so a solution to this data gap issue may be forthcoming. A third example is related to the Mobile Crisis program soon to be implemented in the Concord Region. Some data related to Mobile Crisis access and utilization will be captured and reported in the Phoenix 2 system. Other important data elements, such as encounter location, response time and disposition may have to be tabulated and reported separately pursuant to contractual and/or agreements with the prospective Mobile Crisis provider network.
The sporadic and inconsistent reporting of data from various entities has been a source of significant frustration for DHHS, the plaintiffs, and the ER over the past two reporting periods.
3

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 5 of 23
Thus, a major priority of the ER for the next two months will be to work with DHHS and the plaintiffs to:
 Define regular reports to be prepared and circulated to the ER and the parties on a routine and predictable basis. Report parameters will specify: the data and data sources; the time frame covered by the data in the report; the date the report is generated; the key contact person/author of the report; and the formulas or related methods used to compile and analyze the reported data;
 Identify methods, time frames and formats for the collection and reporting of some data not currently available in standard data bases and systems; and
 Develop the capacity to collect, cross walk and effectively integrate qualitative data and information collection through the QM and QSR process with service access and utilization data.
Given the importance of this process, and given the need for all parties to continue to have regular input into the data reporting design and development activities, the ER will continue to circulate memoranda and draft reports among the parties for review and comment. It is recognized that data reporting and analysis can always be improved, and that the act of using, questioning, and interpreting data is the best way to assure that it is constantly improved. Nonetheless, this initial data definition process is expected to be completed by October 1, 2015, and regular quarterly reports to be available shortly thereafter.
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile Crisis Services
The CMHA calls for the establishment of mobile crisis capacity and crisis apartments in the Concord region by June 30, 2015 (Section V.C.3 (a)). DHHS conducted a procurement process for this program, and a contract is reported to be ready to be awarded on June 24, 2015. The selected vendor and terms of the contract will not be public until the contract has been formally approved by the State.
Given the timing of the contract award, it is unlikely that the Concord mobile crisis program (mobile team and apartments) will be operational by June 30, 2015 as required by the CMHA. At this point, the timetable for implementation is not available for review, so it is difficult to predict what the programmatic impact of this delay will be, and when mobile crisis services will be available to target population members in the Concord region.
4

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 6 of 23
The ER will review the contract as soon as it is awarded and becomes public. Key elements of the contract are expected to include parameters set forth in the RFP, as well as: (a) a timetable and action steps for implementation of both the mobile team and the crisis apartments; (b) specification of inter- and intra-agency agreements and protocols to be put into place; and (c) identification of the data elements and reporting timeframes to be provided by the selected vendor to DHHS on a regular basis.
The Concord region mobile crisis program is an essential component of the CMHA for at least two reasons. The first is that it is expected to provide effective mobile crisis services to target population members in the Concord region, with the intended results of reduced hospitalization, reduced Emergency Department (ED) presentations, and increased housing stability and community tenure.
The second reason is that it will be the first of three mobile crisis programs implemented in New Hampshire under the terms of the CMHA, and therefore a model upon which to construct the larger crisis system. It is critical that all parties are in close communication about the roll-out of the Concord Mobile Crisis Program and that there is agreement on key elements of that service including its design, staff training and implementation plans.
For these reasons the ER intends to develop a specific implementation monitoring plan for the Concord mobile crisis program. A draft of this monitoring plan will be circulated to all parties as soon as possible after the contract is made available and after the ER has had one initial visit with the vendor and DHHS officials to discuss the implementation process and expectations. It is expected that the implementation monitoring plan will be circulated by the end of July 2015. It is further expected that full implementation of the mobile crisis program will proceed as quickly as possible, and that mobile crisis services will be available in the Concord region no later than September 30, 2015.
Assertive Community Treatment (ACT)
ACT is a key element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team; and
3. By June 30, 2015, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,300 individuals in the Target Population at any given time.
Taken together with the other ACT provisions, the CMHA requires a robust and competent system of ACT services throughout the State as of June 30, 2015.
5

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 7 of 23

Table I below summarizes data provided by DHHS as of May 15, 2015.

Table I

ACT Self-Reported Staff Capacity and Active Caseload: May 2015

DHHS Region/ CMHC
1. Northern 2. West Central 3. Genesis 4. Riverbend 5. Monadnock 6. Greater Nashua 7. Manchester 8. Seacoast 9. Community
Partners 10. Center for Life
Management Total

FTE ACT Staff May 2015
14.8 3.0 7.1 7.0 8.2 8.7 24.9 12.8 8.2
7.8
102.5

Staff Capacity
148 30 71 70 82 87 249 128 82

Current Active Caseload – May, 2015
60 16 22 79 47 63 254 73 16

Variance
-88 -14 -49 +9 -35 -24 +5 -55 -66

78

39

-39

1,025

669

-356

As can be seen in the table, as of May 15, 2015, there was a statewide total of 102.5 ACT staff. Using the 1:10 staff ratio defined in the ACT standards, the reported staffing results in an overall capacity of 1,025 active ACT participants. This current staff capacity is 275 lower than the 1,300 capacity specified for June 30, 2015 in the CMHA.
The reported statewide active monthly ACT caseload of 669 is 356 people below the current actual staff capacity of 1,025, and 631 people below the number of priority target population members that could be served at the capacity standard of 1,300. The State notes that the CMHA does not specify utilization as opposed to capacity. Strictly speaking, the 275 person gap between actual and required capacity is considered by the State to be the operative concern related to the June 30, 2015 CMHA requirements. However, the ER points out that unused capacity for ACT or any other CMHA service could result in difficulty meeting the overall goals and outcomes for priority target population members identified in the CMHA. It also may indicate that target population members are missing opportunities to enjoy improved and more successful lives in integrated community settings as opposed to encountering crises, potential loss of housing, increased hospitalizations, and potentially longer lengths of stay at hospital or institutional levels of care. This issue will require additional discussions with all Parties.
As can be seen from Table I, there is considerable variation in both capacity and active monthly caseload among the 10 regional CMHCs in New Hampshire. For example, Manchester is
6

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 8 of 23
reported to have 24.9 FTE staff, and to have an active monthly caseload of 254, slightly higher than the staff capacity would support. West Central has only three FTE ACT staff, and is also serving 14 fewer people than this capacity would support. Only two of the 11 ACT teams in New Hampshire currently have active monthly caseloads at or slightly above their reported staff capacity.
There also are inconsistencies among ACT teams with regard to their satisfaction of ACT team standards set out in the CMHA. For instance, the CMHA specifies a 1:10 staffing ratio for ACT, and requires certain types of staff competencies to be represented on each ACT team. Additionally, the CMHA requires that each ACT Team have at least one peer member on the team. Based on information provided by the CMHCs to DHHS, five of the 10 regions do not yet have a peer supports/peer counselor member on the teams and two other regions have peer capacity listed as less than one FTE. In addition, there are variations in the amount of staff provided within the competencies specified for each team. For example, some teams have more than one FTE of nursing, while other teams provide only 0.2 or 0.3 FTE of nursing. These numbers reflect important differences in service capacity and expertise among the ACT teams that may compromise the teams’ ability to deliver effective ACT services, and warrants further analyses and possible corrective actions by DHHS.
All of the staffing data reported by DHHS for ACT services discussed above had been reported by the CMHCs and has not yet been independently verified by DHHS or the ER. In addition, neither DHHS nor the ER has, to date, reviewed compliance on the part of all ACT teams with the performance and quality standards specified in CMHA Section V.D.2. To help address this issue, the ER expects that the new QM/QSR capacity being developed by DHHS will conduct on-site quality reviews of ACT services and report their findings within the up-coming 12 month period. These reviews are expected to prompt, whenever necessary, implementation of needed remedies to address any compliance concerns.
The ER has visited six CMHCs to receive an overview of seven of the ACT teams in place in the state. These visits were not fidelity or compliance reviews, and did not include any record reviews or separate interviews with team staff or ACT participants. The ER will conduct such reviews in upcoming months. Impressions gleaned from these on-site visits include:
1. As supported by the data summarized above, there appears to be substantial variation among the ACT teams. Some of this variation can be explained by the longevity of ACT service delivery in different areas, and some variation can be explained by differing geographic and socio-demographic conditions in various service areas. For example, several ACT teams had been operating for some years before the CMHA was initiated, while other ACT teams are still in the formation stages. Also, some teams operate in relatively dense urban areas, while others (particularly Northern Human Services) operate in sparse rural areas with large distances to travel. It is expected that DHHS, through its
7

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 9 of 23
QM/QSR capacity, will address the high degree of variation among the ACT teams to assure that ACT services meeting the CMHA standards are delivered statewide. 2. There seemed to be a high degree of understanding among ACT supervisors and team members with regard to ACT principles and practices. 3. Most of the teams visited by the ER expressed commitment to the model and enthusiasm for the results that can be obtained for ACT participants. Most teams believe that they are directly facilitating increased community tenure and quality of life for target population members participating in ACT in their regions. Team members for the most part reported commitment to the high intensity service model and team structure that are key to ACT services. However, some variation in the degree of enthusiasm with which these practices were being implemented was observed during the site visits. It will be important that the State implement measures to ensure consistently high performance among all ACT teams statewide. 4. The few ACT teams that employ a peer team member report the importance and positive contribution of the peer staff to the success of the overall team. 5. Many ACT team members reported being trained in and actively utilizing other evidence based service modalities, including Illness Management and Recovery (IMR); Motivational Interviewing (MI); Stages of Change; and Cognitive Behavioral Treatment (CBT) as part of their ACT team service delivery. Use of these evidence based practices in the context of ACT services is considered to be good, pending additional research. 6. All the ACT teams visited had qualified SE staff members assigned to the team, although it appears that most of them also provided SE services to non-ACT participants. The degree to which ACT enrollees participate successfully in SE is an important topic for consideration through the QM/QSR process. 7. Most teams reported having good and cooperative relationships with local primary health care providers, local police/law enforcement, local hospital EDs, local public housing agencies or other sources of affordable housing, and other local resources of importance to ACT participants. 8. Most of the ACT teams visited by the ER reported populating their caseloads with target population members who were already active clients of their CMHC. Teams also reported active outreach to people known to the CMHC who were homeless or otherwise not engaged in services; and also reported receiving referrals from NHH consistent with the NHH transition planning process. An important area for future focus will be to expand the reach of ACT services to target population members currently not connected to NHH or a CMHC, but still utilizing substantial hospital, ED, homeless service, and possible criminal justice resources.
In the coming months, it is expected that DHHS will: 1) develop one set of eligibility and discharge criteria for the provision of ACT services; 2) analyze the high degree of variation among existing ACT teams; 3) take any steps necessary to assure that ACT services are
8

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 10 of 23
consistently meeting the CMHA standards statewide, and; 4) expand the capacity of ACT to meet the requirements of the CMHA.
Supported Employment (SE) Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for supported employment (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2015, the state will increase its penetration rate of individuals with SMI receiving supported employment …to 16.1 percent of eligible individuals with SMI.” (Section V.F.2(c)). The baseline SE penetration rate at the beginning of the CMHA was 12.1% (2012). The State reports a current SE penetration rate of 11.3%; this is almost a full percentage point below the 2012 baseline. Moreover, this current rate is 4.8 percentage points below the CMHA target for June 30, 2015. Based on the data provided by DHHS, six CMHCs were below the original SE penetration rate of 12.1% listed in the CMHA for 2012 (Northern (7.1%), Genesis (9.4%), Monadnock (8.0%), Nashua (6.1%), Seacoast (10.5%), and Community Partners (8.1%). Table II below displays the self-assessed fidelity, current active SE caseload, and current SE penetration rate for each region/CMHC in New Hampshire. Seven of the CMHCs report themselves to be in the “good” fidelity range, and three of the CMHCs report themselves to be in the “fair” fidelity range2. Neither DHHS nor the ER has yet independently verified the CMHC fidelity self-assessments. It is expected that QM/QSR validation of CMHC fidelity self assessments will be a priority for the up-coming 12 month period. As with the ACT services discussed above, there is considerable variation among the CMHCs in the implementation and operations of SE services. Only one CMHC reports a penetration rate that exceeds the June 30, 2015 penetration rate target, while all the others report currently being below the target. Two of the CMHCs with self-reported fidelity scores in the “fair” range also have low penetration rates.
2 Note: these ranges are defined in the Dartmouth IPS Supported Employment evidence based practice fidelity scoring worksheets.
9

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 11 of 23

Table II

SE Participants and Penetration Rates

DHHS Region/CMHC

Self-Reported Fidelity Score

1. Northern

113

2. West Central

110

3. Genesis

106

4. Riverbend

98

5. Monadnock

101

6. Greater Nashua

93

7. Manchester

106

8. Seacoast

109

9. Community

92

Partners

Unique SE Participants (through March 31, 1015)
85 91 108 186 57 78 445 112 52

Penetration Rate (through March 31, 2015)
7.1% 13.5 9.4 14.9 8.0 6.1 14.6 10.5 8.1

10. Center for Life

109

Management

Statewide Average

107 1,321

16.3 11.3%

The number of active SE participants counted towards the penetration rate calculation currently includes people who have had only one encounter of SE. It is not known whether the “oneencounter” participants become full participants in SE. It will be important for the State to engage in further analyses regarding the “one-encounter” participants as it does not appear that one encounter will satisfy Dartmouth fidelity requirements or lead to actual employment as envisioned in the outcome criteria of the CMHA.
Information supplied by DHHS indicates that all CMHCs have corrective action plans in place to improve the penetration and fidelity of SE. The ER has not yet been able to see these plans or to verify that they are being implemented.
Five SE programs were briefly visited by the ER as adjuncts to the ACT team visits. These were introductory meetings, and did not include record reviews or participant interviews. The ER will conduct more in-depth SE reviews in upcoming months. From the site visits, it would appear that the SE staff of the visited programs are familiar with the Dartmouth Individual Placement and Support (IPS) SE best practices, and with the fidelity requirements. All reported good relationships with the local Vocational Rehabilitation (VR) offices, and several reported good relationships with large local employers.

10

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 12 of 23
Information provided by DHHS indicates that job development is a key element of SE for which fidelity has been difficult to attain and maintain. The SE programs visited by the ER reported that they did not believe that the current reimbursement rate for SE adequately covered the costs of job development, and thus, this element received lower priority. This may be a contributing factor to what anecdotally seems to be a smaller than expected number of SE participants participating in competitive employment for wages.
DHHS does not currently receive data from the CMHCs on the number of SE participants who are in competitive employment in integrated community settings consistent with their individual treatment plans, the number of hours they are working, or what they are being paid. DHHS is aware of these gaps in information, and will be working with the CMHCs to develop improved reporting mechanisms related to these factors.
The ER has three concerns about SE that will be a priority for monitoring in the upcoming months. These are:
1. The SE penetration rates have, on a statewide basis, gone down as opposed to up. The current statewide SE penetration rate is substantially below the June 30, 2015 target of 16.1%. Thus, the first priority for DHHS and the CMHCs will be to increase the SE participation rates to specified levels. Penetration rates should include only those who are actively engaged in efforts to gain employment and comply with CMHA outcome criteria, and should not include those who have had only cursory, one-time exposure to SE activities.
2. Most of the CMHCs report doing well on their own fidelity self-assessment. However, a few have reported having difficulty reaching the “good” level of fidelity. The ER recommends that DHHS validate the fidelity self-assessments, and then develop some targeted technical assistance efforts to assist CMHCs to address their specific fidelity issues.
3. SE providers acknowledge limitations in their ability to conduct the kind of job development necessary for the identification and cultivation of competitive, communitybased work. DHHS should investigate provider concerns in this area and take steps to offer additional technical assistance or other programmatic resources.
4. Overall, there appears to be a need for greater emphasis on competitive employment for SE participants. DHHS will need to collect competitive employment data as a first step in addressing this issue; this should include the number of people who are working in competitive employment, the number of hours they are working, and what they earn. Clearly, concrete data is necessary to address anecdotal impressions and to develop specific action plans for increasing competitive employment as indicated by the data.
11

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 13 of 23
Supportive Housing (SH)
The CMHA requires the State to achieve a target capacity of 340 supportive housing units funded through the Bridge subsidy program by June 30, 2015. At the time of the previous ER report in December of 2014, the State reported that there were 270 individuals under lease in Bridge subsidy funded apartments. As of May of 2015, the State reported an overall net increase in the program of seven people – resulting in a total of 277 participants. However, the actual number of new Bridge subsidy participants living in supportive housing cannot be determined without additional data specific to the dynamics of mental health bridge subsidy programs.
In order to determine the total number of new people added between December and May, the State must also collect data on the following:
1. The number of Bridge subsidy participants who relinquished their Bridge subsidy during that time period because they received a Housing Choice Voucher or other affordable housing subsidy;
2. The number of people who left the Bridge subsidy program during that time period, if any, without receiving a permanent housing subsidy;3
3. The number of new people who leased Bridge subsidy apartments during that time period after being given a “turnover” Bridge subsidy made available through (1) or (2) above;
4. The number of new people who leased Bridge subsidy apartments during that time period after being given a new Bridge subsidy.
DHHS reports that an additional 63 individuals have been approved for Bridge subsidies, and are currently in the housing search phase.4 The 277 current leases, plus the 63 approved but not leased, equals the CMHA target capacity of 340 supportive housing units to be available as of June 30, 2015. The housing search and lease-up process is different for each person, so it is not possible to predict when all 63 people with approved Bridge subsidies will be housed. .
DHHS also reports that an additional 110 Bridge subsidies will be funded in the upcoming year, which would result in the State meeting the CMHA total of 450 SH units by June 30, 2016.
The Bridge program appears to be successful in assisting people in the target population to obtain independent supportive housing in the community. Current concerns about the program at this point are related to: (a) criteria for approval of a Bridge subsidy; (b) transparency of the application and access process for Bridge rental assistance; (c) timely and accurate reporting of data about the Bridge program, including the information noted above; and (d) the amount and sufficiency of services and supports associated with the housing.
3 All rental subsidy programs experience some normal attrition due to changes in circumstances, such as a move out of state, certain changes in family composition, death, etc. 4 This information was provided verbally during the All Parties meeting on June 10, 2015. The ER will seek additional information and documentation to support this number.
12

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 14 of 23
DHHS reports that currently there is no wait list for Bridge subsidies. This may be due to the DHHS published Bridge program eligibility criteria being narrower than the target population criteria included in the CMHA. There also appears to be a lack of consistent knowledge in the field about the process and criteria for accessing the Bridge program. In combination, these factors seem to create unnecessary barriers for people in the target population to access the program. DHHS has acknowledged that it needs a more transparent set of policies and procedures to govern the program, and will be working with the ER and the parties to establish such policies in the near future. DHHS will also review the criteria for approval for Bridge subsidies and may modify them to be broader and better in conformance with the CMHA target population definition. The State will also establish written notice of acceptance/denial and appeals procedures. The ER will discuss with the parties a time frame for completing these activities. It is expected that drafts of these policies and procedures will begin circulating for review no later than September 1, 2015.
People receiving a Bridge subsidy, whether approved or fully leased, are not automatically entered into the Phoenix 2 system. Many of these individuals are likely clients of the CMHC system, and thus included in Phoenix 2, but whether or not they have a Bridge subsidy is not recorded in Phoenix. Thus, the current Phoenix 2 system is not capable of reporting: (a) the number of unique individuals receiving the Bridge subsidy at any given time; (b) whether the individual receiving the Bridge subsidy is connected to the local CMHC or other service provider in the area; or (c) the numbers and types of services and supports provided by the CMHC to facilitate successful tenancy and community tenure. DHHS has been testing a method for linking the Bridge subsidy participants with the Phoenix 2 system, and it seems to be feasible to accomplish this objective. If that methodology is implemented, then it will be possible to generate more reliable and timely reports on SH access and utilization.
However, even with successful linkage to the Phoenix 2 system, there will be some continuing gaps in information. For example, the number of people leaving the Bridge program, and the reason for departure, will not be available except as special reports for the SH vendor. There also does not at this time seem to be a method for identifying whether any SH tenants are sharing living arrangements with other people in the target population; this information is necessary to help determine whether the State’s SH comports with CMHA parameters. DHHS will have to work with the vendor to design and implement revised reporting that will complement the Phoenix 2 reports. The ER expects that the data reporting issues will be addressed and proposed solutions shared with the ER and the parties over the next three months. The ER also expects in upcoming months to conduct more in-depth reviews of SH and associated services and supports to see if they are meeting the needs of individuals, helping them to achieve positive outcomes per CMHA parameters.
13

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 15 of 23
Transition Planning
During the past six months the ER has visited both Glencliff and NHH to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities late last year. Transition planning activities related to specific current patients in both facilities were observed. In addition, discussions were held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for patients at both facilities. The following is a brief summary of information related to transition planning and effective community discharges for each facility.
1. Glencliff
In the three years from June 2012 through May 2015, Glencliff effectuated only 10 discharges from the facility; two of these were discharged between December 2014 and May 2015. About half of the 10 were placed in institutional settings: four were discharged to other nursing facilities and one was returned to prison. The average length of stay at Glencliff of this discharge cohort was 1,437 days – or almost four years. Only one of the individuals discharged during this time frame stayed for less than a year (167 days); two individuals had lived at Glencliff for more than nine years. As of May 13, 2015, the State reports that there have been no readmissions to Glencliff among this 10-person discharge cohort.
At the same time, Glencliff has had 46 admissions, nine of these since December 2014. Glencliff reports that there are approximately 15 individuals on the wait list for admission as of May 22, 2015.
DHHS is endeavoring to access the Enhanced Family Care service modality included in New Hampshire’s Home and Community-Based Services waiver for people who are aged or have disabilities. Currently, there are five individuals at Glencliff for whom this option is being developed. Although this option could be an effective and appropriate alternative to the creation of new intensive group home beds, some barriers to implementation have been encountered. Specifically, respondents have noted that the Enhanced Family Care rates may be too low to attract families to provide this level of care. This factor may be contributing to the overall dearth of providers of this service reported by some participants in the process. Glencliff and DHHS officials are reported to be working towards solutions to these issues. As of May 15, 2015, no individuals have yet been successfully discharged from Glencliff using Enhanced Family Care.
The initial review of transition planning processes at Glencliff did not include a full quality review, review of records, or interviews with patients for whom transition planning was being conducted. These activities will be included in subsequent reviews, after which it will be possible to comment more confidently on the quality and effectiveness of transition planning per CMHA parameters.
14

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 16 of 23
It should be noted that staff at Glencliff appear to be taking transition planning very seriously and appear to be committed to effectuating community discharges. Transition planning appears to be done conscientiously, but also appears to be quite cautious. This could be an indicator that, early in the process, transition planning staff need more exposure to the success of community living alternatives. Absent such experience, there is a temptation be overly concerned about replicating the assumed safety and comprehensiveness of care of the facility before transition plans are effectuated. Based on reports from both Glencliff and several CMHCs, it appears that CMHCs are increasing their efforts to communicate and coordinate with Glencliff, and to take greater responsibility for working towards discharge for residents of Glencliff previously living in their catchment areas. Increased inreach on the part of CMHCs should assist Glencliff transition planners to increase their knowledge of and comfort with community living arrangements available to effectuate discharges. The ER will document inreach activities more clearly within the next six months.
In addition to enhancing transition planning and discharges to the community of existing residents of Glencliff, it is important to also focus on the 15 or so people typically waiting for admission to Glencliff at any given time. It is frequently more feasible and desirable to divert individuals who have not yet been admitted, and have not yet had long lengths of stay away from their home communities.
It is recommended that the State’s Central Team, when appointed, make it a priority to address the issues noted above related to the Enhanced Family Care program. The resources set aside under the CMHA for these community settings offer a way to supplement existing waiver rates/state plan services for more complex clients, if that proves to be a barrier to effectively using this program. Over time, the Central Team should also assist DHHS to address the need to enhance and facilitate transition planning and community discharges from Glencliff through increased knowledge and trust of community alternatives in concert with more aggressive inreach from the CMHCs (and potentially the Peer Support Agencies).
PASSR
DHHS has selected the University of Massachusetts Medical School to perform PASSR functions in New Hampshire. Based on information supplied by DHHS, it is believed that PASSR reviews applicable to Glencliff applicants and residents will begin in July 2015. The ER will begin monitoring implementation of PASSR vis-à-vis Glencliff applicants and residents in the next few months.
New Hampshire Hospital
From January 2014 through mid-May 2015, the State reports that NHH effected a total of 2,093 discharges. Of these, 1,580 (75%) were discharged to home, of whom 621 were living alone and 959 were living at home with others. Eight individuals (0.04%) were discharged to Glencliff; 39 (1.9%) were transferred to an inpatient rehabilitation facility or nursing home; 79 (3.8%) were
15

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 17 of 23
discharged to a shelter or motel; 71 (3.4%) were discharged to a group home, DDS supported living, or peer support housing; and 32 (1.5%) went to a jail or correctional facility. The discharge destination was recorded as unknown for 264 (12.6%) of the discharges during this time frame.
The State reports that the median length of stay for 2015 (through March 2015) has been 10 days, and the mean has been 32 days. The large difference between the mean and median lengths of stay is explained by the relatively small portion of the inpatient cohort that has stays for long periods of time prior to discharge. A point-in-time snapshot of the NHH census on May 21, 2015, showed that 60% of the patients had been in the hospital for 90 days or less, whereas 40% had been inpatients for 91 days or more. Anecdotal information provided by NHH indicates that about 40 of the longer stay patients are in active transition/discharge planning at any given time.
The discharge data suggest a bifurcated inpatient cohort. The vast majority of discharges are of people who have been admitted and discharged after a median length of stay of 10 days. Transition planning for this short stay group begins on the day of admission, and is almost always focused on restoring functioning so that a person can return to her/his previous living arrangement with ongoing services from the local CMHC.
The second group, patients staying longer than 90 days, typically presents greater challenges to discharge than the shorter-stay cohort of patients. First, people who stay longer are more likely to have some combination of complex psychiatric and medical conditions, and/or criminal justice issues, which make planning for transition to the community somewhat more difficult. In addition, after staying 90 days or more, it is more likely that a person’s housing and community support system is no longer in place, thereby increasing the difficulty of arranging for an appropriate living arrangement with needed and chosen supports to effectuate timely discharges. These factors were reinforced as the ER observed transition planning activities and discussed transition planning with staff of the hospital.
The ER identified several specific issues and discussed them with State representatives while reviewing the transition planning process at NHH. One issue is the need to obtain intake assessments before establishing discharge plans for people who are not already connected to the CMHC system. Both NHH and several of the CMHCs verified that there is no current source of reimbursement for CMHCs when CMHC staff travel to NHH to conduct such assessments as part of the transition planning process. This results in a potential delay in accessing and initiating follow-along services and supports following discharge for some individuals, and has been reported to be a factor slowing down the discharge process.
Another barrier is the amount of time needed to effectuate discharges for people for whom Department of Corrections approval is necessary prior to discharge from NHH. It has been reported that several months can elapse between the time a person is clinically ready for
16

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 18 of 23
discharge and the approval is given by DoC. At the time of one site visit by the ER, it was reported that there were currently four such individuals awaiting DoC clearance before they could be discharged.
As with the Glencliff review summarized above, the initial review of transition planning processes at NHH did not include a full quality review, review of records, or interviews with patients for whom transition planning was being conducted. These activities will be included in subsequent reviews, after which it will be possible to comment more confidently on the quality and effectiveness of transition planning per CMHA parameters.
NHH and DRF Admissions and Waiting Lists
The Transition Planning requirements of the CMHA are focused on assisting people to move from inpatient and institutional settings into integrated community settings, and thereby to have successful lives in communities of their choice. Thus, the discharge data presented above are a key part of assessing progress and performance related to transition planning.
Admissions, readmission and hospital wait list information and trends are also relevant to transition planning, and more generally speaks to the adequacy of community capacity in the State’s mental health system. Any hospital contact or inpatient admission involves a certain degree of disruption to a person’s community living arrangements and supports, and the longer a person stays in the hospital or nursing facility the more likely it becomes that these arrangements and supports will have to be re-built to effectuate discharge. Each admission creates a new set of issues and dynamics that both the admitting facility and the CMHC/community supports system must resolve.
In addition, readmissions within 30, 90, and 180 days are considered to be an important indicator of the degree to which transition planning and community follow-through related to facility discharges is being carried out effectively. Moreover, contacts with, and prolonged waits at, hospital emergency departments (ED) reflect a lack of capacity in the community to address mental health crises. For these reasons the ER will be tracking and periodically reporting on NHH and DRF admission and readmission data, and also hospital ED wait list data, as indicators of how the overall system is functioning relative to reduced use of inpatient and nursing facilities and increased use of community alternatives.
According to data supplied by DHHS, in the first 10 months of FY 2015 NHH has had 1,246 admissions. The average daily census during these 10 months has been 129.9, a 97% occupancy rate. Of these 1,246 admissions, a total of 223 were re-admissions within 180 days of discharge (17.9% of admissions for the 10-month period). Of these 223 readmissions total, 128 (57.4%) were readmitted within 30 days of discharge; and an additional 76 (34.1%) were readmitted within 90 days of discharge. Thus, over 90% of the readmission cohort in FY 2015 we readmitted within 90 days of discharge.
17

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 19 of 23
The State reports that the two Designated Receiving Facilities (DRFs) at local hospitals (Elliot and Franklin) together have had 606 admissions to date in FY 2015; this projects to 808 admissions for the entire fiscal year. Admissions to DRFs have been steadily increasing in recent years – up 58% since 2013. This warrants close monitoring going forward. In addition, the Cypress Center, which is an Acute Psychiatric Residential Treatment Program (APRTP), had 590 admissions so far in FY 2015; this projects to over 780 admissions for the fiscal year. Current data on the average length of stay in Franklin and Elliot are not available. The average length of stay at Cypress Center has been 4.6 days during SFY 2015.5
The State reports that 75 percent of the admissions to the Franklin DRF during FY 2015 have been Involuntary Emergency Admissions (IEAs). At Elliot DRF, 20% of the FY 2015 admissions have been IEAs. At Cypress Center 15% of the admissions in FY have been IEAs. All three facilities have increased the proportion of IEA admissions compared to previous years. This too warrants close monitoring going forward.
Because NHH operates at full occupancy, a wait list has been established throughout New Hampshire of people awaiting admission to the facility, typically at a hospital ED. In FY 2015, the monthly average number of people waiting each day for a bed at NHH has been 22.3. The monthly average of people waiting has fluctuated between a high of 33 people in September 2014 to a low of 10 people in April 2015. Wait list data from January 2013 through the present seem to indicate that the spring months tend to have fewer people waiting on a daily basis, while the late summer and fall months experience spikes in the number of people waiting on a daily basis.
The Central Team
The CMHA requires establishment of a “…Central Team to assist in addressing and overcoming any of the barriers to discharge identified during transition planning and/or set forth in the transition plans.” (VI.A.6) This team is currently in formation, but has not yet been appointed or begun meeting. Implementation of this essential component was to have been substantially completed by June 30, 2014. As will be noted below, the ER believes implementation of this team should be among the highest priorities for the State in the next few months. Several of the issues related to transition planning identified above could be addressed by the Central Team as soon as it is formed. These include, but are not limited to:
 Work towards solutions for accessing Enhanced Family Care services under the aged and disability waiver to facilitate discharges to the community form Glencliff;
 Working with the CMHCs and perhaps the Peer Support Agencies to develop and implement enhanced inreach activities related to the transition planning process; and
5 One data point for future review is whether, or how many, people are discharged from DRFs to NHH.
18

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 20 of 23
Peer and Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services.
New Hampshire reports that it has a total of 16 peer support agency program sites, with at least one program site in each of the ten regions. The State reports that these sites have a cumulative total of 2,924 members, and there is an active daily participation rate of 169 people statewide. For a variety of geographic and historical reasons, the membership and daily participation numbers vary considerably among the 16 program sites. All peer support centers report being open eight hours per day, five and one half days per week.
The CMHA does not have specific membership or active daily participation targets. Other than the use of trained peer supports staff to provide services to help individuals in managing and coping with the symptoms of their illness, self advocacy, and identifying and using natural supports, there are no specific requirements as to the functions and activities of the peer supports programs.
Nonetheless, the peer supports programs appear to be a valuable resource for the overall New Hampshire community mental health system. Peer respite services are one good example of this. Utilization of peers as members of ACT teams and in the new mobile crisis services is already included in the CMHA, but peers can also be useful in hospital inreach related to transition planning, and with regard to employment-related activities and objectives.
IV. Quality
The CMHA has specific quality and participant-focused outcomes defined for the interventions and community services. In addition, the CMHA includes a set of overall quality standards applicable to the entirety of the CMHA and its priority target population. The CMHA states:
The goal of the State’s system will be to ensure that all mental health and other services/supports funded by the State are of good quality and are sufficient to provide reasonable opportunities6 to help individuals achieve increased independence, gain greater integration into the community, obtain and maintain stable housing, avoid harms, and decrease the incidence of hospital contacts and institutionalization. [ER emphasis added] (Section VII.A)
The QM/QSR System
DHHS has hired a team of QM/QSR staff, and has begun working on a QM/QSR system design and process. This work is in the very early development stages and will require a significant
6 It should be noted that in this context the term “reasonable opportunities” is intended to reflect that not all members of the target population will choose CMHA services and not all will equally benefit from such services,
19

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 21 of 23
investment of time and effort over the next six months in order to adequately measure the range of service fidelity, participant outcome and quality assurance issues identified above. The ER will be working with the QM/QSR Team over the next several months to assist in the development of this system, including the use of data as described throughout this report, and including the proposed design, methodology and implementation of a client review process. Early in the design process, there will be opportunities for all parties, particularly the plaintiffs, to participate in this early design phase, and to review and comment on QM/QSR materials as these are drafted.
The ER has been working with all parties to identify certain consumer focused outcome measures, for the most part available from existing data sources, which could be used as indicators of results for people in the target population consistent with the quality parameters included above and in other sections of the CMHA. The State reports some questions and concerns about some of the suggested consumer focused outcome and quality indicators, and thus the ER will continue working over the next three months with all parties to address these concerns and to reach consensus on a set of key indicators that can be employed in concert with qualitative and process related information derived through the QM/QSR process.
V. Summary of Expert Reviewer Observations
The ER has now been in place for 12 months. Much of the first year of activity for the ER has focused on:
1. Developing a comprehensive understanding of the New Hampshire Mental Health system as a foundation for tracking progress and performance related to the CMHA as well as for recommending feasible implementation strategies;
2. Working with state officials to identify data elements and sources to be used to track and document progress and performance related to the CMHA;
3. Beginning to work with state officials on the implementation of QM/QSR activities related to the CMHA; and
4. Working with all parties to the CMHA to develop mutual understandings of how the data tracking and quality/QSR activities will be used to provide the most accurate and timely information to all parties with regard to attainment of the performance targets and quality requirements of the CMHA.
Considerable work will be necessary to complete the development of the data tracking and QM/QSR elements of CMHA implementation. However, there is sufficient information available and experience derived from the first year of ER activity to identify specific priorities for attention and action in the up-coming months. Specifically, there are five major areas of concern that need to be addressed to assure that CMHA implementation and quality objectives can be met over the next six months:
20

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 22 of 23
1. The State needs to continue working to implement improvements in data collection, analysis and reporting consistent with the CMHA.
2. The State needs to continue expansion of capacity of ACT services for priority target population members under the CMHA. As of the most recent ACT report, there is functional capacity for 1,025 ACT participants, and the CMHA standard for ACT is capacity for 1,300 as of June 30, 2015. Renewed efforts will be required to meet the CMHA ACT capacity requirements scheduled for June 30, 2015. As noted in the body of the report, the current active ACT census is 669.lightly less than 2/3 of the reported capacity of 1,025. Active census, or ACT utilization, is not a specific compliance measure in the CMHA. However, the ER notes that this unused capacity presents an excellent opportunity for DHHS to expand needed services to the target population. Consistency of operations and attainment of CMHA staffing requirements also remain to be addressed within the ACT program statewide.
3. The State needs to immediately implement the Central Team, an essential component of NHH and Glencliff transition planning under the CMHA. DHHS is still developing a plan for the Central Team; implementation of this essential component was to have been substantially completed by June 30, 2014, yet the membership and processes associated with Central Team activities have not yet been executed.
4. The State needs to continue efforts to increase penetration of evidence-based SE services for members of the priority target population so as to achieve desired outcomes per CMHA criteria. The June 30, 2015 CMHA standard for SE penetration is 16.1%. The most recent statewide penetration rate reported by DHHS is 11.3%. Additional efforts to attain fidelity standards for SE in certain CMHCs will also be required.
5. The State needs to continue the rapid development the DHHS QM/QSR process, with an initial emphasis on assuring the quality and consumer-focused effectiveness of ACT, SE, SH, and facility transition planning. The QM/QSR capacity is essential to DHHS’ on-going efforts to use data on outcomes and performance to hold CMHCs and related contractors accountable under the terms of their contracts and the CMHA.
As of this writing, it is assumed that the contract for mobile crisis services in the Concord region will be in place, effective June 30, 2015. It is not known at what point effective capacity of the mobile team will be in place to actually respond to mental health crises in the community. Monitoring of this implementation effort will be one key priority of the ER over the next three months.
Nothing in the above list of concerns should be interpreted to disregard the level of commitment of New Hampshire officials, state agencies, CMHCs and other contractors to faithful implementation of the CMHA. To date, the ER has seen no evidence of diminished commitment or reduced willingness to collaborate on the part of the State. Nonetheless, an increased level of management attention and staff capacity will be required to prevent further slippage in meeting
21

Case 1:12-cv-00053-SM Document 112-1 Filed 07/02/15 Page 23 of 23 CMHA standards. As with the previous ER report, DHHS may have to develop statewide strategies to address technical assistance and workforce development strategies to assist CMHCs to meet the CMHA standards. DHHS assistance with finding appropriate reimbursements/financing for certain elements of CMHA services and facility transition services is also likely to be necessary. Central oversight of the implementation of the CMHA continues to be a critical element of overall CMHA implementation and performance objectives. Clear accountabilities for CMHA implementation and high quality management of services for the CMHA target population need to be reinforced at the state and contractor levels. Equally important, the State will need to increase its efforts to develop and use both quantitative and qualitative data to assure that accountability is maintained and that corrective actions are taken when necessary.
22

 
 Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 2 of 29
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Three
January 5, 2016
I. Introduction
This is the third semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Hassan,; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section V.III.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this third six-month period (July 1, 2015 through December 31, 2015), the ER has continued to observe the implementation of certain key service elements of the CMHA, and to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. In this period, the ER:
• Conducted on-site reviews of Assertive Community Treatment (ACT) teams/services and Supported Employment (SE) services at Center for Life Management, Seacoast, West Central, and Community Partners CMHCs. This completes the ER’s first round of site visits to each of the ten CMHCs to review ACT and SE services;
• Met again with officials, administrators, and staff at both New Hampshire Hospital (NHH) (twice) and Glencliff to discuss and observe transition planning functions;
• Met with the newly-formed Central Team, established to facilitate transitions from Glencliff and NHH;
• On two occasions, met with leadership and staff of the Riverbend CMHC to assess implementation of the new mobile crisis team and crisis apartments in the Concord region;
• Met with the NAMI New Hampshire family support group in Nashua, NH; • Met with members of Granite Pathways, a psychosocial clubhouse in Manchester,
NH;
1

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 3 of 29
• Met with the Chief of the Concord Police Department; • Met with representatives of the Emergency Department (ED) and the Designated
Receiving Facility (DRF) of the Franklin Hospital; • Participated in several meetings with representatives of the Plaintiffs and the United
States (hereinafter “plaintiffs”); • Conducted several meetings with DHHS officials to discuss Quality Service Reviews
(QSR), data tracking, and data elements and reporting related to the CMHA; and • Convened four meetings with the parties -- two meetings to discuss general progress
on implementation of the CMHA, and two meetings to provide input on the design and implementation of the QSR process.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people per CMHA requirements.
II. Data
The New Hampshire DHHS has made notable progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the DHHS July to September 2015 Quarterly Data Report, which incorporates standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The ER appreciates the efforts that have gone into developing these improved data reporting capabilities, and believes that, for those indicators included in the report, a firm foundation has now been laid for on-going tracking of performance related to certain CMHA standards. Specific data from the standard report are included in the discussion of individual CMHA services below.
In addition to the standardized reporting of certain types of data, DHHS continues to collect and report on other data necessary to monitor performance related to the CMHA. These include reports from the new mobile crisis services in the Concord Region; data on discharge destinations from NHH and Glencliff; reports of wait list numbers for ED boarding; and data on utilization of Designated Receiving Facilities (DRFs). Where applicable, these data are incorporated in the discussion of specific CMHA performance standards below.
DHHS has made progress in creating unified data systems that support the improved data reporting identified above. The new database systems also support conducting special analyses and quality reviews which can assist monitoring the performance of the state’s mental health system in the context of the CMHA. For example, cohort analyses of people discharged from NHH or people receiving a combination of ACT and SE services can be routinely conducted. Person-specific service access, timeliness, and utilization data can also be generated to support the QSR process discussed below.
2

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 4 of 29
As noted in the previous ER report, there continue to be important categories of data that are needed but not routinely collected and reported, and which will need to be developed in order to accurately evaluate ongoing implementation of the CMHA. For example, there continues to be no reported or analyzed data on the degree to which participants in SE are engaged in competitive employment in integrated community settings consistent with their individual treatment plans. Another gap in data is related to people receiving Supported Housing (SH) under the Bridge Subsidy Program. These participants are not yet clearly identified in the Phoenix II system, and thus it is difficult to document the degree to which these individuals are: (a) connected to local CMHA services and supports; or (b) actually receiving services and supports to meet their individualized needs on a regular basis in the community. DHHS has identified a strategy to link data from the Bridge program to the Phoenix II system, so a solution to this data issue may be forthcoming. Data reporting is incomplete in other areas as well. Some missing information is referenced in the substantive sections below. Such data includes, but is not limited to, additional data from NHH, state DRFs/APRTP, and the PASRR system. The ER will continue to work with the State to further augment and refine the data/information reporting process going forward.
In the previous ER report, the sporadic and inconsistent reporting of data was noted to have been a source of significant frustration for DHHS, the plaintiffs, and the ER. Consistent with the above discussion, several of the data reporting issues have been resolved. All parties to the CMHA are looking forward to continuing to receive these reports on a timely basis and to resolving the remaining outstanding issues related to data/information reporting.
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile Crisis Services and Crisis Apartments
The CMHA calls for the establishment of mobile crisis capacity and crisis apartments in the Concord Region by June 30, 2015 (Section V.C.3 (a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHA was the vendor selected to implement the mobile team and crisis apartments in the Concord Region.
Given the timing of the contract award, it was not possible for the mobile team and crisis apartments to be operational by June 30, 2015, as required by the CMHA. Nonetheless, Riverbend has made progress in implementing both the mobile team and the crisis apartments. As of October 2015, Riverbend reports that 135 unduplicated individuals have been served by its
3

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 5 of 29

new the mobile crisis program. Table I below provides Riverbend’s most recent available information on activities of its new crisis program.
Table I
Concord Region Self-Reported Mobile Crisis Services: July 1, 2015 through October 2015

Total unduplicated people served

135

Services provided in response to immediate crisis:

• Phone support/triage

179

• Mobile assessments

14

• Crisis stabilization appointments

45

• Emergency services medication appointments

18

Services provided after the immediate crisis:

• Phone support/triage

52

• Mobile assessments

5

• Crisis stabilization appointments

29

• Emergency services medication appointments

18

Referral source:

• Self

66

• Family

24

• Mental health provider

15

• Personal care physician

4

• Hospital emergency department

8

• Other (school, friend, guardian, VNA, co-worker, etc.)

18

Crisis apartment admissions

5

Law enforcement involvement

4

Total hospital diversions

39

The Concord region mobile crisis program is expected to provide effective mobile crisis services to target population members in the Concord region, resulting in reduced institutionalization, hospitalization, ED presentations, and incarceration, and increased housing stability and community tenure. It is too early in the implementation and operations of the program to be able to document that these expected results are being achieved. An essential component of the teams’ work, and a key outcome of the CMHA, is the delivery of crisis services in community locations. Given the very low number of mobile encounters reported above (14 out of 179 triaged calls), it will be important to closely monitor the location of service delivery, crisis teams’ capacity and willingness to go mobile, and the role of phone triage in determining encounter location. The ER will continue to closely monitor the implementation and operations of this program through the next six-month period and will continue to work with the State to ensure that the new crisis services are truly mobile and not delivered primarily via telephone
4

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 6 of 29
interactions. In addition, the ER will work with DHHS to refine some of the data reporting associated with mobile crisis and crisis apartment services. For example, a clear definition of what constitutes a hospital diversion would assist in interpreting the data. Also, data on the utilization of crisis apartments, including the number of days per admission, and disposition following admission, will allow the parties to evaluate the effectiveness of this service component. It will also be important to gather and report on interactions with law enforcement and the outcomes from mobile crisis engagement in these encounters.
The implementation and early operations experience of the new Riverbend mobile crisis program are likely to inform implementation of the next mobile crisis program, scheduled to be operational in the Manchester Region by June 30, 2016. DHHS released the request for proposals (RFP) for that new service on December 7, 2015. Hopefully, this early release of the RFP will facilitate timely selection of a qualified vendor and preparation for initial operations of the Manchester region mobile crisis program by June 30, 2016.
Given that the Mobile Crisis program is still early in the implementation process, this Report does not specifically address the State’s progress on each of the required elements and outcomes of the mobile crisis system per the CMH. Within the next six-month period the ER will work with the State to address the State’s progress in meeting each of the required elements and outcomes of the crisis system under Section V.C. of the CMHA.
Assertive Community Treatment (ACT)
ACT is a key element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team; and
3. By June 30, 2015, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,300 individuals in the Target Population at any given time.
Taken together with the other ACT provisions, the CMHA requires a robust and effective system of ACT services throughout the State as of June 30, 2015.
In the last ER report, it was noted that the reported statewide capacity of 1,025 was 275 less than the 1,300 capacity standard in the CMHA. In June 2015, the ACT system as a whole was serving 356 individuals fewer than the reported capacity of 1,025 would have supported; and 631 individuals fewer than the required capacity of 1,300 could effectively serve.
As displayed in Table II below, the staff capacity of the 11 adult ACT teams in New Hampshire has gone down by almost five percent since the last report. At the same time, the total active
5

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 7 of 29

caseload has increased by 77 individuals -- an increase of almost 12% since the previous report. Although the increased active caseload is positive, the reduced staff capacity means that the State remains out of compliance with the June 30, 2015 CMHA standard for ACT.

Table II

ACT Self-Reported Staff Capacity and Active Caseload: May-September 2015

DHHS Region/ CMHC
1. Northern 2. West Central 3. Genesis 4. Riverbend 5. Monadnock 6. Greater Nashua 7. Manchester 8. Seacoast 9. Community
Partners 10. Center for Life
Management Total

FTE ACT Staff May 2015 14.8
3.0 7.1 7.0 8.2 8.7 24.9 12.8 8.2
7.8
102.5

FTE ACT Staff September 2015
11.29 3.83 7.5 7.3 8.5 5.98 26.3 11.77 8.7
6.36
97.53

Percent Change
(23.7%) 27.7% 5.63% 4.29% 3.66% (31.3%) 5.62% (8.05%) 6.1%
(18.5%)
(4.85%)

Active Caseload – May, 2015
60 16 22 79 47 63 254 73 16
39
669

Active Caseload September 2015
72 19 30 60 54 74 265 65 70
37
746

Percent Change
20% 18.75% 36.4% (24.1%) 14.89% 17.46% 4.33% (10.96%) 337.5%
(5.13%)
11.51%

The ER recognizes that staffing levels may fluctuate within a statewide ACT program with 11 ACT teams. And, part of the almost five percent reduction in staffing capacity appears to be related to planned changes in the staffing of the Northern Human Services ACT team. It is also understood that there are challenges throughout the New Hampshire Health and Human Services system with regard to workforce shortages and difficulties in recruiting professional, licensed, and para-professional staff. Nonetheless, the current gap between staff capacity and the requirements of the CMHA cannot be explained or excused by routine staff turnover or workforce development and recruiting issues.

The ER notes that three of the 11 adult ACT teams have fewer than the 7 - 10 professionals specified for ACT teams in the CMHA. In addition, one region currently has no nursing staff and five others have less than one FTE nurse; three regions have no peer specialist staff and five others have less than one FTE peer specialist; and three regions have less psychiatry time than warranted by their active caseloads. From anecdotal information gathered by the ER during ACT team site visits, it also appears that substance abuse competence is not uniformly represented on the ACT teams – data shows less than one FTE in seven regions. In addition, seven of the 10 regions have less than one FTE SE specialist on an ACT team; and six of 10 have

6

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 8 of 29
no professional with housing experience. As a result of these and other significant variations in the type and levels of ACT staffing, the State has yet to achieve the level of consistency and fidelity of ACT service delivery required by the CMHA.
The ER recognizes that the CMHA does not specify utilization (active caseload or unduplicated number of persons served) as opposed to staff capacity. The current gap of 325 service recipient gap between the actual and required ACT team capacity is thus the first issue to be addressed. However, in the previous report, the ER noted that unused capacity for ACT or any other CMHA service could result in difficulty meeting the overall goals and outcomes for priority target population members identified in the CMHA. While it is a positive development that the ACT active caseload has increased by almost 12% since June 30, 2015, reports of unmet demand for ACT services are a source of significant concern across the various regions. Moreover, the system is still serving at least 500 fewer people than could be served if the state had attained the required capacity to serve 1,300 people.
ACT team services are critical to the State meeting the many outcome criteria expressly referenced throughout the CMHA, and it will be essential in the coming months for the State to rectify the significant deficiencies in ACT staffing and utilization in various regions throughout the State.
All of the staffing and utilization data reported by DHHS for ACT services discussed above had been reported by the CMHCs and has not yet been independently verified by the ER. In addition, neither DHHS nor the ER has, to date, reviewed compliance of all ACT teams with the performance and quality standards specified in CMHA Section V.D.2. To help address this issue, the ER expects that the new QSR capacity being developed by DHHS will prompt on-site quality reviews of ACT services with findings reports within the up-coming 12-month period. These reviews are expected to prompt, whenever necessary, implementation of needed remedies to address any compliance concerns.
The New Hampshire DHHS recently awarded a contract to the Community Council of Nashua (the designated CMHC for the Nashua region) for a new adult ACT team. That new team is not yet operational, and thus, does not yet contribute to either the capacity measures or the active caseload for ACT services within the state. The Community Council reports that workforce recruitment and retention issues are hindering timely implementation of this new team. At this point, it is not known when the new team will be accepting referrals of new ACT service participants. The ER will continue to monitor this matter going forward.
The ER has visited all ten CMHCs to receive an overview of the ACT teams in place in the state. These visits did not constitute fidelity or compliance reviews, but did provide qualitative impressions of the implementation and operations of the various ACT teams throughout the state. For the most recent four site visits, the ER has also reviewed a small and non-random sample of case records of people receiving ACT services.
7

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 9 of 29
Both the reported data and the qualitative impressions formed by the ER during the site visits support a conclusion that there is substantial variation among the ten CMHCs with regard to the implementation and operations of ACT under the CMHA. As noted in the previous ER report, some of this variation can be explained by how long a CMHC has provided ACT services in different areas, and some variation can be explained by differing geographic and sociodemographic conditions in various service areas. The degree of variation in ACT operations must be addressed through the quality management and fidelity review processes to ensure that all regions deliver effective ACT services to individuals in need.
The June 30, 2015 ER report contained the following statement:
“In the coming months, it is expected that DHHS will: 1) develop one set of eligibility and discharge criteria for the provision of ACT services; 2) analyze the high degree of variation among existing ACT teams; 3) take any steps necessary to assure that ACT services are consistently meeting the CMHA standards statewide, and; 4) expand the capacity of ACT to meet the requirements of the CMHA.”
DHHS has begun to work on item number one in the above paragraph, but the criteria remain in development. However, more progress is needed on item numbers 2, 3, and 4. The ER recognizes that the state is focusing efforts on mandating that CMHCs comply with their contracts with the State regarding ACT services. These efforts have included increased site visits and program audits, and have resulted in at least one plan of correction. The ER supports the State’s emphasis on enforcement as a necessary condition to attain compliance with the CMHA requirements, but recognizes that more assertive actions related to both program expansion and quality will be necessary. The ER expects that DHHS will immediately develop and begin implementation of a concrete and measurable action plan to assure that ACT services comply with CMHA requirements by June 30, 2016.
Supported Employment (SE)
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2015, the state will increase its penetration rate of individuals with SMI receiving supported employment …to 16.1% of eligible individuals with SMI.” (Section V.F.2(c)).
The baseline SE penetration rate at the beginning of the CMHA was 12.1% (2012). In the June 2015 ER report, the SE penetration rate was 11.3% -- almost a full percentage point below the 2012 baseline. The June 2015 ER report noted that the penetration rate at that time was 4.8 percentage points below the CMHA target for June 30, 2015.
8

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 10 of 29

For this reporting period, it appears that the State and the CMHCs have made progress in moving towards the 16.1% penetration rate specified for June 30, 2015 in the CMHA. As of September 2015, the statewide penetration rate was reported to be 15.7%, only slightly below the 16.1% target.

As shown in Table III below, all but one of the CMHCs report having increased the number of unique individuals reported to have received SE; and seven of the 10 CMHCs report having increased their penetration rates over the previous reporting period.

Table III

CMHC Self-Reported SE Participants and Penetration Rates through September 2015

DHHS Region/CMHC

Unique SE Participants 12 month period ending March 2015

1. Northern 2. West Central 3. Genesis 4. Riverbend 5. Monadnock 6. Greater Nashua 7. Manchester 8. Seacoast 9. Community
Partners 10. Center for Life
Management Statewide Average

85 91 108 186 57 78 445 112 52
107
1,321

Penetration Rate through March 2015
7.1% 13.5% 9.4% 14.9% 8.0% 6.1% 14.6% 10.5% 8.1%
16.3%
11.3%

Unique SE Participants 12 month period ending September 2015
106 83 118 194 157 116 821 161 98
153
2,003

Penetration Rate through September 2015
8.2% 12.9% 9.3% 14.2% 16.4% 7.7% 26.1% 13.1% 11.6%
21.4%
15.7%

The CMHA establishes a statewide penetration rate standard, not individual CMHC penetration rate requirements. There are three regions in the state in which priority Target Population members are reported to be receiving SE services at or above the June 30, 2015 penetration rate standard. However, the ER notes that seven of the 10 of CMHCs have penetration rates below the June 2015 standard, and four of these have penetration rates below the 12.1% baseline standard for SE. Wide variation in access to and utilization of SE services on a sub-state level could affect overall attainment of CMHA objectives for the target population. Thus, the ER will continue to monitor and report on individual CMHC penetration rates as well as the statewide total. As with the previous report, the ER will also continue to monitor implementation of

9

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 11 of 29
applicable CMHC plans of correction related to improving SE penetration and performance at the regional level.
Several others issues related to the implementation and monitoring of Supported Employment services will need to be resolved in the coming months. First, as noted earlier in this report, there is currently no consistently reported data on the extent to which SE service participants are attaining and sustaining competitive employment. Success in obtaining competitive employment is not a specific numerical standard in the CMHA. However, the CMHA does require the State to operate SE services in conformance with the Dartmouth fidelity standards, and attaining and sustaining competitive employment is an indicator of fidelity to those standards. The ER will be working with the State and the CMHCs to develop a consistent and reliable method for reporting on obtaining and sustaining competitive employment.
Second, there continues to be an issue with regard to the calculation of the penetration rates. Individuals referred for SE and receiving one intake visit, but no other SE services are currently included as SE service participants in the calculation, and thus may inflate the penetration rates. The ER believes that issues related to how SE participants are included in the SE penetration rate calculation occurred before and during the calculation of the baseline 12.1% penetration rate for the CMHA. Thus, it appears that from a methodological perspective the current and original calculations of penetration rates are consistent. Given this limitation in available data, and in order to demonstrate compliance with fidelity standards and corresponding client outcomes in the CMHA, it is necessary to identify the number of target population individuals that actually become engaged in SE and receive SE services in a manner anticipated by the SE fidelity standards. The ER believes that a special query of the Phoenix II database will permit analyses of those actually receiving SE services, excluding those who may have had one contact with the SE system in the past. This, in concert with data on the degree to which SE participants are obtaining competitive employment, should provide a more reliable picture of how well the SE service component is functioning within each CMHC and on a statewide basis.
The June 30, 2015 ER report summarized SE fidelity self-report information from the 10 CMHCs. The ER understands that new fidelity self-assessments have been submitted by the CMHCs to DHHS. However, that information has not yet been reviewed by DHHS, and is not available for this report. The ER expects that the June 30, 2016 report will include a summary of this new SE fidelity self-report analysis, as compared to the information contained in the June 30, 2015 report. The ER plans to provide the parties with updated information and analysis well in advance of the next report date. It should be noted that to date DHHS has not implemented a standardized process for validation of these CMHC fidelity self-reports. DHHS reports that it is exploring options to assure validation of SE fidelity self-reports. The ER expects that a proposal will be circulated for discussion and feedback by the parties in the coming months, and that the process for validation will be operational by June 30, 2016.
10

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 12 of 29

Supported Housing (SH)
The CMHA requires the State to achieve a target capacity of 340 SH units funded through the Bridge subsidy program by June 30, 2015. DHHS reports having 376 individuals in leased SH apartments as of September 30, 2015, thereby exceeding the June 30, 2015 CMHA requirement by 36 subsidized people/units. If Bridge program leasing continues at the current pace, it seems likely that the CMHA target of 450 SH units is attainable by June 30, 2016.
Table IV below summarizes recent data supplied by DHHS related to the Bridge Subsidy Program.

Table IV

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program as of September 30, 2015

Bridge Program Information Total housing slots (subsidies) available Total people for whom rents are being subsidized as of 9/30/2015 Individuals accepted but waiting for lease-up Individuals currently on the wait list for a bridge subsidy Total number served since the inception of the Bridge program Total number receiving a Housing Choice (Section 8) Voucher

Data 450 376
23 0 466 70

It should be noted that for this most recent time period, DHHS has made improvements in the ways that SH data is recorded and reported. Comparisons with data reported for previous time periods may not be entirely applicable, and thus previous data has not been included in the data table. However, the ER believes it is accurate to say that the number of people in leased units has increased by 99 individuals, a 36% increase over the previous period. At the same time, the number of people approved, but not yet leased, has been reduced by 40 people, a decrease of over 60% from the previous period. The substantial reduction in the number of people approved, but not yet leased, may indicate that the housing search and lease-up process is working more efficiently. However, there are no current data on the elapsed times between completion of an application, approval, and lease-up. This information is needed before the ER can reach conclusions about the degree to which the system is actually assisting target population members to acquire permanent housing of their choice quickly and effectively.
The Bridge Program is intended to be just that: a short term bridge to a permanent mainstream rental subsidy or other affordable permanent housing program. As shown in Table IV, 70 individuals served under the Bridge Program are reported to have obtained mainstream housing
11

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 13 of 29

subsidies via the federal Housing Choice Voucher (Section 8) program. This is a positive accomplishment, both for the people housed, and for the State.
The CMHA stipulates that “…all new supported housing …will be scattered site housing, with no more than two units or 10% of the units in a multi-unit building, whichever is greater, and no more than two units in a building with fewer than 10 units known to be occupied by individuals in the Target Population.” (V.E.1(b)). Table V below displays the reported number of units leased at the same address.

Table V

Self-Reported Bridge Subsidy Housing Concentration (Density)

Number of properties with one leased SH unit at the same

290

address

Number of properties with two SH units at the same address

27

Number of properties with three SH units at the same address

2

Number of properties with four SH units at the same address

4

Number of properties with five SH units at the same address

1

Number of properties with six SH units at the same address

1

As can be seen in the table, almost 90% of the leased units are at a unique address. This supports a conclusion that the Bridge Program, to a large degree, is operating as a scattered-site program. For the 10% of the units shown in Table V to be at the same address, it is not known at this time whether the unit density standards included in the CMHA are being met. For example, in the one property that is noted to have six units at the same address, the total number of units at that address is not yet reported. If that building has a total of 60 or more units, then having six Bridge program leases in that property would comport with the CMHA. However, if that property has fewer than 60 total units, then the six units leased in that building would exceed the scattered-site definition as quoted above. DHHS is collecting information on the total units in each building where there are two or more Bridge units at the same address, and this data will be reported in the next ER report.
It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)). DHHS reports, and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge program leased units. Data documenting the presence or absence of roommate situations will be included in the overall data reporting specification process outlined below.

12

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 14 of 29
Current data is also not available on the degree to which Bridge Program participants access and utilize supportive services and whether or not the services are effective and meet individualized needs. Receipt of services is not a condition of eligibility for a subsidy under the Bridge Program, but the CMHA does specify that “…supported housing included support services to enable individuals to attain and maintain integrated affordable housing….” (V.E.1(a)). DHHS is currently working on a method to cross-match the Bridge Program participant list with the Phoenix II and Medicaid claims data. This will allow documentation of the degree to which Bridge Program participants are actually receiving certain mental health services and supports. The ER expects that this information will be available for discussion by the parties in the coming months, and that an analysis of the data will be included the June 30, 2016 report.
In addition to the above data gaps, the ER has identified a number of important and needed data elements associated with the eligibility criteria and lack of a waitlist, as well as monitoring implementation of the SH program in the context of the CMHA. These include:
• Total number of Bridge Program applicants per quarter; • Referral sources for Bridge Program applicants; • Number and percent approved for the Bridge Program; • Number and percent rejected for the Bridge program;
o Reasons for rejection of completed applications, separately documenting those who are rejected because they do not meet federal HCV/Section 8 eligibility requirements;
• Number and disposition of appeals related to rejections of applications; • Elapsed time between application, approval, and lease-up; • Number of new individuals leased-up during the quarter; • Number of terminations from Bridge subsidies; • Reasons for termination:
o Attained permanent subsidized housing (Section 8, public housing, etc.); o Chose other living arrangement or housing resource; o Moved out of state; o Deceased; o Long term hospitalization; o Incarceration; o Landlord termination or eviction; or o Other; • Number of Bridge Program participants in a roommate situation; and • Lease density in properties with multiple Bridge Program leases.
The CMHA does not specifically establish requirements or targets related to some of the above data. However, most rental assistance programs collect and report such information, given its intrinsic value in monitoring program operations. Further, such data enhances DHHS’ ability to
13

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 15 of 29
demonstrate the timeliness and effectiveness of access of the priority target population to this essential CMHA program component. The ER will continue to work collaboratively with DHHS to identify sources and methods for such data collection and reporting.
DHHS and the plaintiffs are currently in discussions related to a draft of new Bridge Program rules. A final draft version is not available at the time of this report. The ER expects DHHS and the representatives of the plaintiffs to complete this review and revision process promptly.
Transition Planning
During the past 12 months the ER has visited both Glencliff and NHH on at least two separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities late last year. Transition planning activities related to specific current residents in both facilities were observed, and most recently, a small non-random sample of resident transition records have been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities. In the next report the ER plans to identify and discuss barriers to discharge that continue to affect transitions to the community two years after implementation of the CMHA. Finally, the ER participated in one meeting of the Central Team, now that it has been operationalized. As discussed below, it is important that the Central Team expand its capacity to receive and respond to referrals from NHH in order to avoid unnecessary delays in discharge planning for class members in that setting.
Glencliff
In the time period from July to September 2015, Glencliff reported that it has admitted four individuals, and has had no discharges. The wait list for admission has remained relatively constant: averaging 16 people during this time frame. At the same time, the average length of stay has increased from 2,258 days to 2,284 days, or more than six and a quarter years. There is no calculation of length of stay on discharge for this time period, since there have been no reported discharges. The ER is concerned about both the steady state of referrals to Glencliff and the lack of discharges to community settings for the reported quarter.
Section V.E.3(g) of the CMHA requires the State by now to: “…have the capacity to serve in the community four individuals with mental illness and complex health care needs residing at Glencliff….” The CMHA includes several options for attaining that goal, including the issuance of an RFP to secure four new residential services beds, and/or to access existing capacity in the residential services system. The CMHA also anticipates collaboration with the DHHS Elderly and Adult Services component to assist with implementing transition plans for this population.
As noted in the June 30, 2015 ER report, DHHS has been endeavoring to access the Enhanced Family Care service modality included in New Hampshire’s Home and Community-Based
14

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 16 of 29
Services waiver for people who are elderly or have disabilities. DHHS has also been exploring other Medicaid waiver and in-plan service authorities to piece together an array of services for each of the individuals at Glencliff for whom this type of transition planning is being conducted. Now, six months later, the technical and financial complexities of these mechanisms have not yet been resolved, and no Glencliff resident has yet been discharged to a community setting using one or more of these mechanisms.
The CMHA specifically identifies up to $100,000 per person that can been used, in concert with other applicable Medicaid waiver or similar financing approaches, to develop or acquire the capacity for community transitions for four Glencliff residents by June 30, 2015. None of these funds have been expended to date, and no RFP for enhanced residential capacity has been issued by the State. At the all parties meeting on December 9, 2015, DHHS announced it intended to contract with an agency to function as a “fiscal intermediary” to facilitate blending the $100,000 maximum per person funding availability with other service and financing resources to effectuate the desired transitions to community settings. It is not known at this point which agency might be selected for this role, or what purposes (or limitations) related to the use of these funds might be included in the contract. It is also worth noting that the State is required under the CMHA to serve an additional six individuals with mental illness and complex health care needs residing at Glencliff in the community by June 30, 2016. In working to come into compliance by serving the four individuals that were expected to move by this past June, the State should simultaneously be working to develop the capacity to serve the additional six individuals that must be served by June 30, 2016.
In the June 30, 2015 report, the ER noted that the Central Team specified in the CMHA had not yet been implemented. As of September 2015, the Central Team was constituted and began meeting. To date, DHHS reports that the Central Team has reviewed four potential transition plans for individuals residing at Glencliff, each of whom is in the medically complex category identified above. The ER has the impression that Central Team consideration of these transition plans has been positive and helpful. Nonetheless, as of this date, no actual transitions have resulted from the participation of the Central Team. The ER suggests that the Central Team become more aggressive in both reviewing applicable cases for transition and in effectuating solutions to facilitate such transitions to the community.
The ER finds that the State is not in compliance with Section V.E.3(g) of the CMHA. To date, no capacity has been created or identified to transition individuals meeting the criteria of this section, and no transitions have yet been accomplished. The ER believes that some of the strategies being developed by DHHS and the Central Team to effectuate such transitions have the potential to be effective – both for the individuals to be transitioned, and to facilitate future transitions for similar persons now residing at Glencliff. However, the ER finds that the progress in creating capacity and effectuating transitions has been much too slow, and to date ineffectual, to meet the requirements of the CMHA.
15

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 17 of 29
PASRR As noted in the June 30, 2015 report, DHHS has retained the University of Massachusetts Medical School to perform PASRR functions in New Hampshire. DHHS has reported verbally that the PASRR vendor has been conducting reviews related to applicants to Glencliff. To date no data has been provided relative to the overall number of PASRR reviews conducted; the number of these reviews related to Glencliff; and the number of people reviewed who have been approved for admission to Glencliff. Nor has data been presented to date on the number of people diverted from nursing facility placement, including diversions from Glencliff, resulting from the PASRR process. The ER has recently requested information as summarized above related to PASRR, and has requested that DHHS set up a meeting to discuss PASRR. Monitoring of the PASRR process, particularly for those awaiting placement at Glencliff, will be a priority for the ER early in 2016.
New Hampshire Hospital For the time period July 1, 2015 through September 30, 2015, the State reported that NHH effected 361 admissions and 373 discharges. The mean daily census was 132, and the median length of stay was 12 days. The NHH data provided during the six-month period covered by this report is more limited than in prior reporting periods. Prior data reports included important information regarding lengths of stay, including both mean and median data, as well as specific information on the percentage of NHH residents that had stayed less 1-10 days, 30-60 days, 6090 days, over 6 months, etc. The ER will work with DHHS to increase reporting of NHH data available through the Hospital’s AVATAR system, to assure that newly reported data is consistent with and comparable to the data provided for the initial ER reports. Table VI below compares NHH discharge destination information from the previous ER report to the current report time frame. It should be noted that the time frames covered by the data are different, and there may be some variations in the manner in which the data was recorded and reported.
16

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 18 of 29

Table VI

New Hampshire Hospital Self-Reported Data on Discharge Destination

Discharge destination

Number January Percent January

2014 through

2014 through

May 2015

May 2015

Home – live

612

alone

Home – live with 959

others

Glencliff

8

Shelter/motel 79

Group

71

home/DDS

supported living,

etc.

Jail/corrections 32

Nursing

39

home/rehab

facility

Unknown

264

29.3% 45.1% 0.4% 3.8% 3.4%
1.5% 1.9%
12.6%

Number July 1 2015 through September 30 2015 100
236
1 12 45
2 15
88

Percent July 1 2015 through September 30 2015 20.0%
47.3%
0.02% 2.4% 9.02%
0.04% 3.0%
17.64%

Based on the above data, there would appear to be some reductions in discharges to shelters and jails. At the same time, there appears to be increases in discharges to nursing facilities, group homes and related residential facilities. The ER remains concerned that a substantial number and percentage of the discharges have no reported destination. The ER expects that outstanding issues related to recording of discharge destinations will be resolved before the next ER report. In addition, the ER will work with the State and the plaintiffs to identify and monitor implementation of measures to minimize reliance on institutional destinations.
At the time of this report, the ER has not received new data on NHH readmissions. In addition, DHHS is working to improve the collection and reporting of data from DRFs and the APRTP in the state. There is no current information available on discharge destinations or readmission rates from the DRFs/APRTP. Given that there are questions about the available data, comparisons with previous time frames on these issues may not be reliable at this point. This information is critical in evaluating the extent to which transition planning is adequate and remedial services are effective in reducing the risk of institutionalization among the Target Population. The ER requests that this information be produced in the next 60 days so that NHH, DRF, and APRTP readmission rates and discharge destinations can be available for ongoing monitoring and included among the information analyzed in the June 30, 2016 report.

17

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 19 of 29
In the previous report, the ER had identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. In FY 2015, the reported monthly average number waiting each day for a bed at NHH was 22.3 adults. In the most recent reporting period, July 1, 2015 through September 30, 2015, the average number of adults waiting for admission to NHH was 16.6. This may indicate some improvements in some combination of ED diversions, hospital admission diversions, and/or speedier discharges from NHH that result in improved bed availability for admissions. It could also be the product of increased admissions to other institutional settings like DRFs and the APRTP as an alternative to NHH. The ER will continue to monitor this issue going forward, requesting additional information as needed. This information should also be included by the State in CMHA Quarterly Data Report.
Summary of Transition Issues
The ER has continued to note that the transitions process is moving very slowly. This appears to be true both at the individual consumer level, and at the system level. Although information at this point is anecdotal, interviews with both line staff and administrators, plus some selective record reviews, indicate that it is taking substantial amounts of time to overcome the many and varied barriers to discharge to the community. Although the Central Team is now in place, it has been concentrating on a small number of cases from Glencliff, and has not yet had time to facilitate NHH transition planning. At the all parties meeting on December 9, 2015, the ER emphasized that DHHS needs to take aggressive executive action to increase both the speed and effectiveness of transitions from NHH and Glencliff. This will be a major focus of ER monitoring during the next six-month period.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER met with the NAMI family support group in Nashua during the time frame of this report. This appeared to be a well-established group that was providing effective family support services to NAMI members. During discussions with the group, the ER heard family frustrations with access to and continuity of mental health services that suggest remedial services may not be readily available or provided with the duration and intensity needed by the Target Population. The voices of family members, as represented by NAMI family support groups, can provide important additional input to the overall state quality management process related to the CMHA, and should be included in the parties’ ongoing system monitoring discussions.
18

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 20 of 29
Peer Support Agencies
As noted in the June 30, 2015 report, New Hampshire reports having a total of 16 peer support agency program sites, with at least one program site in each of the ten regions. At the time of that report, the State reported that those sites had a cumulative total of 2,924 members, with an active daily participation rate of 169 people statewide. As can be seen from the data reports included in Appendix A, the State currently reports total membership to be 2,714, with active daily attendance averaging 171 people. The State reports that all peer support centers meet the requirement to be open eight hours per day, five and one half days per week.
The CMHA does not have specific membership or active daily participation targets. Other than the use of trained peer supports staff to provide services to help individuals in managing and coping with the symptoms of their illness, self advocacy, and identifying and using natural supports, there are no specific requirements as to the functions and activities of the peer supports programs. The ER has seen no change in Peer Support Agency operations since the last report.
Some of the Peer Support agencies have contracted with local CMHCs to supply peer support staff to the CMHC’s ACT teams. The ER will review this approach during the next six-month period.
IV. Target Population Outcomes and Quality Assurance Systems
The June 30, 2015 ER report included a lengthy section on Quality Management and Quality Service Reviews (QM/QSR). In the time period since that report, DHHS has begun to develop the QSR process; has assigned senior executive staff to oversee the design and implementation process; and has begun meeting with representatives of the plaintiffs to discuss QSR design and implementation. The ER is facilitating such meetings and is also providing technical assistance to DHHS on QSR design.
Achieving consensus on the design, methodology and implementation of the QSR process is critical to present and future monitoring efforts. Information gathered and analyzed by the annual QSR will play a major role in measuring compliance with the CMHA. If the parties and the ER have confidence in the integrity and reliability of the QSR process, and in its ability to produce actionable information, these findings can support common efforts and reduce disputes regarding the achievement of individual and systemic outcomes. With the continued good faith efforts of both parties, and the addition of technical assistance by the ER’s office, it is expected that major progress on QM/QSR will be made between now and March 2016. It is also possible that early information from piloting of the QSR process will be available to incorporate into the June 30, 2016 report.
19

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 21 of 29
The ER notes that there are separate but related issues regarding independent verification that ACT and SE services are being provided in a consistent manner by all CMHCs in conformance with the standards of the CMHA. DHHS reports it is working on a process for independent verification for ACT and SE. The ER expects that a concrete plan and action steps for independent verification of ACT and SE will be in place by the time of the next report.
V. Summary of Expert Reviewer Observations and Priorities
The ER has now been in place for 18 months. This has been a time period of learning, of program development and enhancement, and of developing and refining data reporting and other mechanisms to assure that the CMHA is implemented in a timely and effective manner. The ER has thus far avoided specific reference to compliance with the CMHA out of respect for the developmental process and with the expectation of good faith efforts on the part of the State to comply with the CMHA requirements.
However, after 18 months it is necessary for the ER to state specifically that the State is not in compliance with two critical provisions of the CMHA. These are:
1. Sections V.D.3(a, b, and c), which together require that all 11 ACT teams meet the standards of the CMHA; that each mental health region have at least one adult ACT Team; and that by June 30, 2015 (six months ago), the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,300 people in the Target Population at any given time.
2. Sections V.E.2(b) and V.E.3(g) which together require that by now the State “have the capacity to serve in the community four individuals with mental illness and complex health care needs residing at Glencliff…”
These are not the only provisions of the agreement for which the ER finds the State to not have achieved specific targets or dates, or to otherwise be moving too slowly with implementation and/or operations to meet the standards in the CMHA. However, these are the two areas found to be in substantial non-compliance. The ER stated clearly at the all parties meeting of December 9, 2015, that the State will need to develop clear, objective and measurable plans to assure compliance with these provisions as soon as possible. These plans need to be cognizant of the context of the CMHA, which, effective June 30, 2016, has numerical capacity targets for both of these items that are higher than the June 30, 2015 targets referenced here.
Based on the review of the status of implementation related to all components of the CMHA, the ER has determined the following priorities for close monitoring in the up-coming six-month period:
20

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 22 of 29
1. Effective implementation of plans to attain compliance with requirements of the CMHA as noted above;
2. Design, field testing, and implementation of the QSR process; 3. Implementation by DHHS of program rules and guidance related to more clearly defining
eligibility, access and related program standards for ACT and SH; 4. Design and implementation of mechanisms for independent verification of meeting
CMHA requirements for ACT and SE services; 5. Improvements in data related to SE, SH, hospital readmissions, DRF/APRTP utilization,
and institution discharge destinations; 6. On-going monitoring of transitions from NHH and Glencliff, with a priority of increasing
the speed and effectiveness of transitions from both facilities as well as involvement by the Central Team; and 7. Monitoring of the PASRR process to ensure individuals referred to Glencliff are appropriately assessed for and diverted to community-based services.
21

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 23 of 29
Appendix A New Hampshire Community Mental Health Agreement State’s Quarterly Data Report: July to September 2015
22

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 24 of 29
New Hampshire Community Mental Health Agreement Quarterly Data Report
July to September 2015
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement December 15, 2015
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence
23

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 25 of 29

Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 12/2/2015 Reporting Period: 7/1/2015-9/30/2015

1. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Unique

September Consumers

Center Name

July 2015 August 2015

2015 in Quarter

01 Northern Human Services

69

68

72

83

02 West Central Behavioral Health

17

16

19

19

03 Genesis Behavioral Health

27

27

30

30

04 Riverbend Community Mental Health Center

57

57

60

64

05 Monadnock Family Services

52

54

54

58

06 Community Council of Nashua

79

72

74

82

07 Mental Health Center of Greater Manchester

271

268

265

289

08 Seacoast Mental Health Center

66

67

65

71

09 Community Partners

72

73

70

75

10 Center for Life Management

38

37

37

42

Deduplicated Total

747

736

746

810

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 11/12/15; consumers are counted only one time regardless of how many services they

receive.

24

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 26 of 29
2. Community Mental Health Center Services: Assertive Community Treatment Staffing
September 2015 Full Time Equivalents

Nursing (nonAPRN) Masters Level Clinician Functional Support Peer Specialist Substance Abuse Treatment Residential Employment Total Psychiatry and APR N

Center Name

01 Northern Human Services

0.53 0.10 7.00 0.53 1.31 1.15 0.68 11.29

0.70

02 West Central Behavioral Health

0.26 3.05 0.00 0.20 0.13 0.00 0.19 3.83

0.14

03 Genesis Behavioral Health

0.20 2.00 3.60 0.70 0.00 0.20 0.80 7.50

0.40

04 Riverbend Community Mental Health

Center

0.40 1.20 4.00 0.50 1.00 0.00 0.20 7.30

0.40

05 Monadnock Family Services

0.00 2.00 2.00 0.00 0.50 1.00 3.00 8.50

0.40

06 Community Council of Nashua

1.00 2.48 1.25 0.00 0.00 0.25 1.00 5.98

0.25

07 Mental Health Center of Greater

Manchester

1.21 17.50 1.99 0.50 4.50 0.00 0.60 26.30

0.96

08 Seacoast Mental Health Center

1.43 3.00 5.10 1.00 0.24 0.00 1.00 11.77

0.90

09 Community Partners

0.40 1.85 5.90 0.00 0.25 0.00 0.30 8.70

0.60

10 Center for Life Management

1.00 0.10 3.86 1.00 0.10 0.00 0.30 6.36

0.30

Total

6.43 33.28 34.70 4.43 8.03 2.60 8.07 97.53

5.05

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health CMHC ACT Staffing Census Based on CMHC self-report

Notes: Data extracted 11/20/15

3. Community Mental Health Center Services: Annual Supported Employment Penetration Rates for Prior 12 Month Period

12 Month Period Ending September 2015

Center Name

Supported Employment
Consumers

Total Eligible Consumers Penetration Rate

01 Northern Human Services

106

1,288

8.2%

02 West Central Behavioral Health

83

641

12.9%

03 Genesis Behavioral Health

118

1,265

9.3%

04 Riverbend Community Mental Health Center

194

1,370

14.2%

05 Monadnock Family Services

157

957

16.4%

06 Community Council of Nashua

116

1,499

7.7%

07 Mental Health Center of Greater Manchester

821

3,151

26.1%

08 Seacoast Mental Health Center

161

1,226

13.1%

09 Community Partners

98

843

11.6%

10 Center for Life Management

153

715

21.4%

Deduplicated Total

2,003

12,748

15.7%

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 11/12/15; consumers are counted only one time regardless of how many services they

receive

25

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 27 of 29

4. New Hampshire Hospital: Adult Census Summary

July - September

Measure

2015

Admissions

361

Mean Daily Census

132

Discharges

373

Median Length of Stay in Days

12

Deaths

0

Revisions to Prior Period: None

Data Source: Avatar

Notes: Data extracted 11/12/15; Average Daily Census includes patients on leave and is rounded to nearest whole

number

5. Glencliff Home: Census Summary

Measure

June 2015

Admissions

0

Average Daily Census

114

Discharges

1

Mean Length of Stay for Discharges

1,480

Mean Length of Stay in Days

2,258

Readmissions

0

Mean Overall Admission Waitlist

17

Revisions to Prior Period: None

Data Source: Glencliff Home

Notes: Data Compiled 11/5/15; means rounded to nearest whole number

July - September 2015 4 115 0 NA 2,284 0 16

26

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 28 of 29

6. NH Mental Health Consumer Peer Support Agencies: Census Summary

Peer Support Agency

April - June 2015

Average Daily

Total Members

Visits

July - September 2015

Average Daily

Total Members

Visits

Alternative Life Center Total Conway Wolfeboro Outreach Berlin Littleton Colebrook

440

41

441

40

127

11

135

11

17

NA

18

NA

109

10

92

10

110

10

117

9

77

10

79

10

Stepping Stone Total Claremont Lebanon

799

23

527

22

670

18

397

18

129

5

130

4

Cornerbridge Total Laconia Concord Plymouth Outreach

287

11

288

12

122

4

128

3

133

7

126

9

32

NA

34

NA

MAPSA Keene Total

158

13

161

13

HEARTS Nashua Total

461

25

393

24

On the Road to Recovery Total Manchester Derry

379

33

356

32

226

23

215

23

153

10

141

9

SCA Portsmouth Total

266

12

263

13

TriCity Coop Rochester Total

279

16

285

15

Total

3,069

174

2,714

171

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 11/13/15; Average Daily Visits NA for Outreach Programs

7. Housing Bridge Subsidy Summary to Date

Subsidy Housing Bridge Subsidy Section 8 Voucher Revisions to Prior Period: None Data Source: Bureau of Behavioral Health Notes: Data Compiled 11/13/15

July - September 2015

Total individuals served at start of quarter

New individuals added during quarter

Total individuals served through end of quarter

428

38

466

66

4

70

27

Case 1:12-cv-00053-SM Document 113-1 Filed 01/05/16 Page 29 of 29

8. Housing Bridge Subsidy Current Census Summary

Measure

As of 9/30/2015

Housing Slots

450

Rents currently being paid

376

Individuals accepted but waiting to lease

23

Waiting list for slots

0

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health

Notes: Data Compiled 11/13/15; All individuals currently on the Bridge Program are actively transitioning from

the program (waiting for their Section 8 housing voucher).

9. Housing Bridge Subsidy Unit Address Density

Number of Unit(s)* at Same Address 1 2 3 4 5 6 *All units are individual units

Frequency as of 11/13/15 290 27 2 4 1 1

10. Designated Receiving Facility Admissions

July - September 2015

DRF

Voluntary Admissions Involuntary Admissions

Cypress

180

46

Elliot

73

35

Franklin

23

40

Portsmouth

4

31

Revisions to Prior Period: None

Data Source: DRF Self Reports

Notes: Data Compiled 12/15/15

Total Admissions 226 108 63 35

28

 
 IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF NEW HAMPSHIRE

_______________________________________________

LYNN E., by her guardian, Barry Ellsworth;

)

KENNETH R., by his guardian, Tri-County CAP,

)

Inc./GS; SHARON B., by her guardian, Office of

)

Public Guardian, Inc.; AMANDA D., by her guardian, )

Louise Dube; AMANDA E., by her guardian, Office of )

Public Guardian, Inc.; and JEFFREY D., on behalf of )

themselves and all others similarly situated,

)

)

Plaintiffs,

)

)

v.

)

)

JOHN H. LYNCH, Governor of the State of New

)

Hampshire; NICHOLAS A. TOUMPAS, Commissioner )

New Hampshire Department of Health and Human

)

Services; NANCY L. ROLLINS, Associate

)

Commissioner, New Hampshire Department of Health )

and Human Services, Community Based Care Services; )

MARY ANN COONEY, Deputy Commissioner, New )

Hampshire Department of Health and Human Services, )

Direct Programs/Operations; ERIK G. RIERA,

)

Administrator, New Hampshire Bureau of

)

Behavioral Health,

)

)

Defendants.

)

1:12-CV-53-LM

)

_______________________________________________ )

UNITED STATES’

THE UNITED STATES OF AMERICA,

)

PROPOSED

)

COMPLAINT-IN-

Plaintiff-Intervenor,

)

INTERVENTION

)

v.

)

)

THE STATE OF NEW HAMPSHIRE,

)

)

Defendant.

)

_______________________________________________ )

UNITED STATES’ COMPLAINT-IN-INTERVENTION 1. Because of the manner in which the State of New Hampshire (the “State”) plans,
structures, and administers its mental health service system, scores of people with mental illness in New Hampshire are unjustifiably forced to obtain needed mental health services in segregated residential institutions like the State’s psychiatric hospital, New Hampshire Hospital (“NHH”), and the State’s nursing facility for persons with mental illness, the Glencliff Home (“Glencliff”), and/or are placed at serious risk of institutionalization, even though they could be appropriately served in communitybased settings. The State’s failures have led to the needless and prolonged institutionalization of individuals with disabilities who could be served in more integrated settings in the community with adequate services and supports. 2. The State discriminates against individuals with mental illness by unnecessarily institutionalizing them in segregated, restrictive settings such as NHH and Glencliff, and by creating a serious risk of institutionalization for individuals with mental illness due to the State’s failure to provide them with sufficient community services. As a result, the State is in violation of Title II of the Americans with Disabilities Act of 1990 (“ADA”), 42 U.S.C. §§ 12131-12134, and Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794 (“Rehabilitation Act”). 3. Title II of the ADA prohibits the unjustified isolation of persons with disabilities, see 42 U.S.C. § 12132 and Olmstead v. L.C., 527 U.S. 581, 597 (1999), and requires states and other public entities to “administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.” 28
2

C.F.R. § 35.130(d); accord 29 U.S.C. § 794(a); 28 C.F.R. § 41.51(d) (Rehabilitation Act). 4. Integrated and appropriate alternatives for persons with mental illness already exist within New Hampshire’s mental health service system. These alternatives include supportive housing and an array of mental health services to support people with mental illness living in the community, including Assertive Community Treatment (“ACT”), mobile crisis services, and supported employment. If administered appropriately, these community-based services would be both cost-effective and capable of meeting the needs of people with mental illness. 5. Nonetheless, because of the manner in which the State has administered its service system, people with mental illness in institutions, and many of those at serious risk of institutionalization, have not been afforded meaningful access to adequate and effective community-based alternatives. Because adequate and effective community-based alternatives are not available in sufficient supply in the State’s system, people with mental illness are often given no choice but to enter an institution to receive needed mental health services from the State, many are forced to be readmitted multiple times, and many remain institutionalized for unnecessarily prolonged periods. 6. Gaps and weaknesses in the State’s mental health system too often subject individuals with mental illness to needless trauma, especially during a crisis. Individuals with mental illness who experience a crisis in New Hampshire often spend days in local hospital emergency rooms that are ill-equipped to address their needs, before ultimately being transported to the State’s psychiatric facility, sometimes by the police. This needlessly traumatic process, rife with delayed treatment and undue restrictions, is
3

costly and not therapeutic, especially when compared to proven and effective community alternatives. 7. The State has been candid about the many limitations, shortcomings, and deficiencies in its mental health system. Addressing the Critical Mental Health Needs of NH’s Citizens, A Strategy for Restoration (hereinafter “State Ten-Year Plan”), Aug. 2008; Addressing the Critical Mental Health Needs of NH’s Citizens, A Strategy for Restoration, Report of the Listening Sessions (hereinafter, “State Report”), Apr. 2009. The State has characterized its mental health system as “failing,” “broken,” and “in crisis,” and has recognized that people with mental illness are not receiving the care they need in the system. State Report at 1, 17. The State has concluded that the lack of adequate community capacity in its system is unnecessarily forcing these individuals into institutional settings to obtain needed services for their mental illness, and too often prompting unwanted contact with local law enforcement, hospital emergency rooms, the court system, and county jails. Id. 8. Although the State has drafted a remedial plan to address acknowledged deficiencies in its mental health system, the State has failed to sufficiently implement its plan or to put in place needed reforms to meet the needs of persons with mental illness. See N.H. Cmty. Beh. Health Ass’n (“CBHA”), N.H. Ten-Year Mental Health Plan Progress, Four Years Out, Mar. 5, 2012; and Two Years Out, Sept. 24, 2010 (both reports concluding that the State had failed to implement critical elements of its plan, most notably in the areas of housing and crisis services). 9. On February 9, 2012, six individually-named Plaintiffs filed this class action on behalf of themselves and other individuals with serious mental illness at NHH or Glencliff or
4

at serious risk of being institutionalized in these facilities. The suit alleges violations of federal law, including the ADA and the Rehabilitation Act, and seeks declaratory and injunctive relief. 10. Plaintiffs and the members of the plaintiff class, who receive services in, or are at serious risk of entry into an institutional setting, are individuals with mental illness that substantially limits one or more major life activities, such as personal care, working, concentrating, thinking, and/or sleeping. They are, therefore, qualified persons with a disability for the purposes of the ADA and Rehabilitation Act. 11. On April 7, 2011, the United States issued an extensive findings letter to New Hampshire Attorney General Michael A. Delaney, notifying the State that it was failing to comply with federal law by unnecessarily segregating individuals with mental illness in institutional settings and by placing individuals with mental illness living in the community at serious risk of placement into institutional settings. The letter reported in detail the findings of the United States’ investigation, provided the State notice of its failure to comply with the ADA and the Rehabilitation Act, and outlined the steps necessary for the State to meet its obligations pursuant to federal law. 12. The United States’ letter identified numerous remedial measures the State could take to comply with federal law, and further advised the State that, in the event that a resolution could not be reached voluntarily, the Attorney General may initiate a lawsuit pursuant to the ADA. 13. In the latter half of 2011, the United States met with State officials, including the New Hampshire Attorney General, on several occasions, both in person in Concord, New Hampshire, and by telephone, and exchanged several written proposals in an attempt to
5

reach agreement on remedial measures to address the deficiencies identified in the United States’ letter. Despite these good faith efforts, the United States has determined that voluntary compliance cannot be reached at this time. Judicial action is, therefore, necessary to remedy the violations of law identified in the United States’ letter and to vindicate the rights of the persons with mental illness in or at serious risk of being admitted to an institutional setting like NHH or Glencliff. 14. Through this intervention, the United States seeks to vindicate the rights of people with mental illness in New Hampshire’s institutions, and those at serious risk of entry into these institutions, to receive services in the most integrated setting appropriate to their needs.
JURISDICTION AND VENUE 15. This Court has jurisdiction of this action under Title II of the ADA, 42 U.S.C. § 12133,
Section 504 of the Rehabilitation Act, 29 U.S.C. § 794a, and 28 U.S.C. §§ 1331, 1345. The Court may grant the relief sought in this action pursuant to 28 U.S.C. §§ 22012202. 16. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b).
PARTIES 17. Plaintiff-Intervenor is the United States of America. 18. Defendant, State of New Hampshire, is a “public entity” within the meaning of the
ADA, 42 U.S.C. § 12131(1), and is therefore subject to Title II of the ADA, 42 U.S.C. § 12131 et seq., and its implementing regulations, 28 C.F.R. pt. 35.
6

19. At all times relevant to this action, the State of New Hampshire has been a “recipient” of “federal financial assistance,” including Medicaid funds, and is therefore subject to the Rehabilitation Act, 29 U.S.C. § 794.
20. The Plaintiffs bring this action on behalf of “themselves and other individuals with serious mental illness institutionalized at NHH or Glencliff or at serious risk of being institutionalized in these facilities.” Complaint ¶ 25, Feb. 9, 2012.
21. Each individually-named Plaintiff is a qualified individual with a disability, as defined by the ADA and the Rehabilitation Act. Each has one or more impairments that substantially limit one or more major life activities. According to their complaint, Plaintiff Lynn E. has schizophrenia and bipolar disorder with psychosis; Plaintiff Kenneth R. has depression and a mood disorder, a brain injury from a motor vehicle accident, and paraplegia; Plaintiff Sharon B. has a schizoaffective disorder, bipolar type, and post-traumatic stress disorder; Plaintiff Amanda D. has bipolar disorder, posttraumatic stress disorder, and borderline personality disorder; Amanda E. has schizoaffective disorder, post-traumatic disorder, and borderline personality disorder; and Plaintiff Jeffrey D. has bi-polar disorder with psychosis. These individuals bring their action on behalf of themselves and other qualified individuals with a disability. STATUTORY AND REGULATORY BACKGROUND
A. The Americans with Disabilities Act and the Rehabilitation Act 22. 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)(1). It found that “historically, society has tended to isolate and segregate individuals with disabilities, and, despite some improvements, such forms of
7

discrimination against individuals with disabilities continue to be a serious and pervasive social problem.” 42 U.S.C. § 12101(a)(2). 23. For those reasons, Congress prohibited discrimination against 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. 24. Title II of the ADA prohibits discrimination on the basis of disability by public entities. This encompasses the State of New Hampshire, its agencies, and its mental health system, because a “public entity” includes any state or local government, as well as any department, agency, or other instrumentality of a state or local government, and it applies to all services, programs, and activities provided or made available by public entities, such as through contractual, licensing, or other arrangements. 42 U.S.C. § 12131(1). 25. Congress directed the Attorney General to issue regulations implementing Title II of the ADA. 42 U.S.C. § 12134. The Title II regulations require public entities to “administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.” 28 C.F.R. § 35.130(d). The preamble discussion of this “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.F.R. pt. 35, App. B at 673 (2011). 26. Regulations implementing Title II of the ADA further prohibit public entities from utilizing “criteria or methods of administration” that have the effect of subjecting
8

qualified individuals with disabilities to discrimination or “[t]hat have the purpose or effect of defeating or substantially impairing accomplishment of the objectives of the public entity’s program with respect to individuals with disabilities[.]” 28 C.F.R. § 35.130(b)(3); accord 45 C.F.R. § 84.4(b)(4) (Rehabilitation Act). 27. In Olmstead v. L.C., 527 U.S. 581, 597 (1999), the Supreme Court held that Title II prohibits the unjustified segregation of individuals with disabilities. The Court explained that its holding “reflects two evident judgments.” Id. at 600. “First, 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. “Second, 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. 28. Under Olmstead, public entities are required to provide community-based services 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. 29. Discrimination on the basis of disability is also prohibited by Section 504 of the Rehabilitation Act, 29 U.S.C. § 794(a):
No otherwise qualified individual with a disability in the United States … shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance or under any program or activity[.]
9

30. The Rehabilitation Act’s implementing regulations provide that recipients of federal funds “shall administer programs and activities in the most integrated setting appropriate to the needs of qualified handicapped persons.” 28 C.F.R. § 41.51(d); see also 45 C.F.R. § 84.4.
31. Similarly, New Hampshire has numerous statutes and regulations that strongly favor integrated community services and supports. See the “Mental Health Services System” law, N.H. RSA 135-C, making it the policy of the State to provide mental health care that is within each person’s own community, is directed to promoting independence, and is the “[l]east restrictive to” the person’s freedom and participation in the community. N.H. RSA 135-C:1, 15. Regulations implementing the statute require that services must “promote community integration and participation.” He-M 401.10. Other regulations mandate that Community Mental Health Centers (“CMHCs”), the entities with which the State contracts to provide most community services, “strive to provide all services … in each consumer’s own community, and in a manner which promotes the personal self-sufficiency, dignity and maximum community participation of each consumer,” He-M 403.06, and that individuals receiving mental health services have a right to services that promote full participation in community living. He-M 309.06; He-M 311.06.
B. The Nursing Home Reform Amendments to the Medicaid Act 32. The federal Nursing Home Reform Act requires that states develop and implement a
Preadmission Screening and Resident Review (“PASRR”) program for all Medicaidcertified nursing facilities. 42 U.S.C. § 1396r(e)(7); 42 C.F.R. §§ 483.100 to 483.138.
10

33. Pursuant to PASRR, the State must identify all individuals seeking admission to a nursing facility who are suspected of having mental illness; this is known as a Level I PASRR review. 42 C.F.R. § 483.128(a). Then the State must assess these persons to determine, inter alia, whether the “individual’s total needs are such that his or her needs can be met in an appropriate community setting” (42 C.F.R. § 483.132(a)(1)), and “[i]f specialized services are recommended, [the evaluation must] identif[y] the specific … mental health services required to meet the evaluated individual’s needs[.]” 42 C.F.R. § 483.128(i)(5); see also 42 C.F.R. § 483.134. This evaluation is referred to as the Level II PASRR review. 42 C.F.R. § 483.128(a).
34. For individuals with mental illness in nursing facilities, “specialized services” means the services specified by the state which, combined with services provided by the nursing facility, results in the “continuous and aggressive implementation” of an individualized plan of care that is developed and supervised by an interdisciplinary team, and which, among other things, is “directed toward diagnosing and reducing the resident’s behavioral symptoms that necessitated institutionalization, improving his or her level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time.” See 42 C.F.R. § 483.120(a)(1).
35. If an individual in a nursing facility requires specialized services, then “[t]he State must provide or arrange for the provision of the specialized services needed by the individual while he or she resides in the [nursing facility].” 42 C.F.R. § 483.116(b)(2); see also 42 C.F.R. § 483.126.
11

36. The nursing facility must provide mental health services which are of a lesser intensity than specialized services to all residents who need such services. 42 C.F.R. § 483.120(c). FACTUAL ALLEGATIONS
A. New Hampshire’s Mental Health System 37. New Hampshire has a mental health service system through which it delivers services,
programs, and activities (hereinafter, “services”) to persons with mental illness. The State determines what mental health services to provide, who will provide them, in what settings to provide them, and how to allocate funds among various services and settings. 38. The New Hampshire Department of Health and Human Services (“DHHS”) is the State agency responsible for providing and administering mental health services for persons with mental illness, including setting strategic goals and determining how state, local, and federal resources will be deployed. The Commissioner of DHHS is responsible for the overall management of DHHS, which includes setting mental health policy for DHHS, overseeing the implementation of services for persons with mental illness, and providing the leadership and direction necessary to ensure the design and delivery of a comprehensive and coordinated system of mental health services. Within DHHS, the Division of Community Based Services (“DCBS”) manages the State’s mental health system. Also within DHHS, the State’s Office of Medicaid Business and Policy is responsible for the management of the State’s Medicaid program, which includes coverage of mental health, developmental disabilities, substance abuse, and other
12

services to Medicaid-eligible individuals in institutional and other settings. DHHS is the single state Medicaid agency. 39. As part of its mental health system, New Hampshire, through DHHS, delivers publiclysubsidized inpatient psychiatric and other mental health services in institutional settings – at NHH and at Glencliff. 40. NHH is a State-operated psychiatric facility. NHH provides acute treatment services for persons with severe mental illness. The State operates NHH under the administrative management of DCBS. 41. Glencliff is a State-operated Medicaid-certified nursing facility that provides long-term care for persons with severe mental illness and/or developmental disabilities. The State operates Glencliff directly through DHHS. 42. Both NHH and Glencliff are segregated, institutional settings. Physically, both NHH and Glencliff are isolated from the general community. They provide little opportunity for individuals with disabilities to interact with individuals without disabilities outside the institution. Institutionalized individuals live in close quarters, primarily with other persons with disabilities. Most aspects of their daily lives are regimented and limited by rigid rules and inflexible practices which segregate individuals from the community and impede interactions with people without disabilities. These rules and practices include rights restrictions, involuntary searches, imposed quiet times, structured meal and medication times, limits on the ability to have visitors, and limits on travel outside the facilities. As a result, most aspects of their daily lives are controlled by the institutions, and they have limited autonomy, privacy, or meaningful opportunities to participate in the community.
13

43. Within DCBS, its Bureau of Behavioral Health (“BBH”) is responsible for planning, coordinating services, allocating public funds, contracting, enforcing policies and regulations, and monitoring New Hampshire’s system of public mental health services. BBH is the State Mental Health Authority, obligated to ensure the provision of effective services to persons with severe mental, emotional, and behavioral impairments.
44. The State offers some community mental health support and residential services. BBH has designated ten community mental health regions throughout New Hampshire. BBH contracts with a CMHC to provide mental health services in each of the ten geographic regions. The CMHC’s are to offer a variety of mental health programs, including psychiatric services, individual and group therapy, symptom management, as well as more intensive services, such as ACT. Residential services include supportive housing and group homes.
45. BBH maintains responsibility for the services offered in the community through its provider network. BBH conducts various reviews of CMHC operations and requires financial and performance reporting. BBH also approves community service programs for each CMHC, provides staff training, and details what services are to be provided, how clinical records are to be maintained, and oversees other aspects of CMHC operations.
B. Individuals with Mental Illness Residing in NHH or Glencliff Are Qualified to Receive Services in More Integrated Settings
46. Upon information and belief, the vast majority of persons with mental illness who are or become institutionalized at NHH or Glencliff, including the individually-named
14

Plaintiffs and the members of the proposed plaintiff class, are qualified to receive mental health services, and can be served, in more integrated community settings. 47. People who are or become institutionalized at NHH or Glencliff are similar to people with mental illness who receive services in the community. They have similar diagnoses and needs as people who live successfully in more independent settings, with the types of supports and services that currently exist in the State’s community mental health system. 48. The State already offers an array of community-based services to individuals with mental illness, including supportive housing, crisis services, ACT, and supported employment which, if expanded to meet the needs of the plaintiff class, would enable them to live in the community. 49. Numerous individuals have expressed their desire to leave NHH or Glencliff and become members of their communities once again. Upon information and belief, persons with mental illness in NHH and Glencliff would not oppose moving to integrated settings if appropriate community services were available and they had a fully-informed choice and a realistic opportunity to do so. C. The State Discriminates Against Qualified Individuals with Mental Illness by
Unnecessarily Institutionalizing Them in Segregated, Restrictive Settings 50. New Hampshire unnecessarily segregates qualified individuals with mental illness in
institutions and/or places them at serious risk of institutionalization. The State’s planning, structuring, and funding of its system of mental health care has isolated qualified persons with mental illness, including individually-named Plaintiffs and members of the proposed plaintiff class, and has unnecessarily forced them to obtain needed mental health services in institutional settings like NHH and Glencliff, even
15

though they could be appropriately served in more integrated community-based settings. Systemic failures in the State’s system place certain other qualified individuals with disabilities, including individually-named Plaintiffs and members of the proposed plaintiff class, at serious risk of unnecessary institutionalization now and going forward. 51. The State of New Hampshire has recognized that its mental health system is failing, broken, and in crisis. In a public State report, the Commissioner of DHHS concluded: “NH’s mental health system is failing, and the consequence of these failures is being realized across the community. The impacts of the broken system are seen in the stress it is putting on local law enforcement, hospital emergency rooms, the court system and county jails, and, most importantly, in the harm under-treated mental health conditions cause NH citizens and their families.” State Report at 1. 52. Community capacity in New Hampshire has declined in recent years, and this has led to unnecessary institutionalization, unnecessarily prolonged institutionalization, and a heightened risk of institutionalization. Although the State offers an array of community-based services, scores of qualified individuals with mental illness in the community are at serious risk of being institutionalized because needed mental health services are in insufficient supply in the State’s community system. 53. The State has acknowledged that some people with mental illness “are not receiving the care that they need.” Id. at 2. The State has concluded that, in recent years, “[a]s community capacity to serve more people declined, access to critical services became more difficult to get. More individuals found themselves in a system that could no
16

longer meet their needs, some ending up in settings not designed to provide mental health care, such as the state corrections system and county jails.” Id. at 17. 54. The State has recognized that it has not been spending its money on services for persons with mental illness effectively, and that this has had a negative impact on community services and on the health and welfare of persons with mental illness in need of such services. Id. at 8. 55. In 2008, the State developed and publicized a ten-year plan purportedly to resolve the plainly-evident deficiencies in its mental health system. The State recognized the need to expand existing community capacity to meet outstanding needs in areas including, but not limited to: supportive housing, bridge subsidies for community housing, crisis services, ACT, and more intensive services and supports for persons with more complex health and/or mental health needs. State Ten-Year Plan at 9-15. 56. In spite of this, the State has thus far taken insufficient measures to implement its plan, especially in foundational bedrock areas needed to promote and achieve positive outcomes for persons with mental illness who are in need of residential, crisis, and other key community services. 57. In September of 2010, at about the two-year anniversary of the State’s publication of its plan, the New Hampshire Community Behavioral Health Association, the association of the State’s CMHC community contractors, issued a report on whether the State had met deadlines and accomplished what had been set forth in the plan. The CBHA concluded that the State had taken little or no action in a host of important areas. CBHA Progress Rep., Sept. 24, 2010, at 2-3. The CBHA very recently issued an updated report, once again finding that the State had failed to meet important
17

benchmarks within its ten-year plan, including in such areas as supportive housing, crisis services, intensive services like ACT, and services for persons with developmental disabilities. CBHA Progress Rep., Mar. 5, 2012, at 1-2. In separate correspondence, the CBHA recently informed a fellow federal agency that the situation in New Hampshire has deteriorated in recent years: “We regret to inform you that our community system has less capacity in January of 2012 than it had in August of 2008 when the “Ten-Year Plan” called for additional investment.” Letter from Roland P. Lamy, Exec. Dir., CBHA, to Kathleen Sebelius, Sec’y, U.S. Dep’t of Health & Human Svcs., Feb. 29, 2012, at 1. 58. With reasonable modifications, the types of services that already exist in New Hampshire’s community mental health system would be able to meet the needs of people with mental illness in institutions or at serious risk of being institutionalized. These services include but are not limited to, supportive housing, crisis services, ACT, integrated supported employment, and other intensive community supports. 59. Supportive housing is a program that is designed to meet the needs of persons with mental illness in the community. The State has acknowledged that supportive housing is an effective service for persons with serious mental illness and achieves positive outcomes in terms of housing and health stability and improvement in quality of life for persons with mental illness. State Ten-Year Plan at 3, 8-9. In the alternative, the State has recognized that “[u]nstable housing and homelessness leads to greater levels of impairment, more difficulty in accessing services and supports, and a loss of stability, which leads to hospitalization or in some cases incarceration and then difficulties with discharge from the hospital or other institutional settings.” Id. at 6.
18

60. Nonetheless, there is an insufficient amount of safe, affordable, and stable community housing, including supportive housing, for persons with mental illness in New Hampshire. The State has recognized that sufficient supportive housing is not available to meet the needs of persons with mental illness in New Hampshire, concluding that formal supportive housing “is not available to most NH residents with a mental illness disability,” in part, because “home-based services need to be further developed to meet the current need.” Id. at 8.
61. There are insufficient crisis, intensive, and other services and supports in the State’s community system, which cause unnecessary institutionalization and increase the risk of unnecessary institutionalization. The State has acknowledged that “care in the middle and at the higher intensity end of the spectrum of treatment … is not easily available to many individuals with severe mental illness, resulting in an overburden on [NHH] and poor outcomes for individuals who are unable to access sufficient treatment choices to remain in the community or to be discharged from the hospital when ready.” Id. at 4.
62. The State recognizes, and has seen first-hand, the benefits of intensive/crisis services like ACT in terms of promoting positive outcomes among persons with mental illness. Id. at 13. The State has concluded that ACT “has been shown to be effective at helping individuals with serious mental illness manage their illnesses while living independently in the community. When applied to homeless individuals with serious mental illness, ACT reduces homelessness. … When applied to individuals with frequent hospitalizations, ACT reduces their hospital use and enhances their ability to maintain employment and personal satisfaction.” Id.
19

63. In spite of this, the State has no ACT program in at least half of its ten geographic regions statewide, leaving thousands of persons in need without the ability to even access ACT. Not only does the State recognize that ACT can produce positive outcomes, it acknowledges that ACT is “cost-effective,” especially for frequentlyinstitutionalized individuals. Id. at 14.
64. In recent years, hundreds of persons with mental illness have been admitted or readmitted to NHH each year to address acute symptoms and/or crisis situations that could have been, but were not, addressed satisfactorily outside the confines of an institutional setting. Many individuals cycle through NHH because community capacity in the State’s system is not adequate. Admission and readmission rates to NHH are high and reveal that there are inadequacies in the State’s system that force people with mental illness to obtain needed services at an institutional facility, even though these services generally could be provided effectively and cost-effectively in integrated community settings. The State reported that the “primary finding” of its plan taskforce was that many individuals have been admitted to NHH because they have not been able to access sufficient community services in a timely manner (a “front door problem”), and remain there, unable to be discharged, because of a lack of viable community-based alternatives (a “back door problem”). Id. at 6.
65. Individuals with mental illness are often admitted to Glencliff without being appropriately assessed for whether they can be served in the community. The State’s PASRR program also does not adequately or appropriately assess whether an individual with mental illness needs specialized services. Moreover, the State fails to provide
20

necessary specialized services at Glencliff. The failure of the State’s PASRR program results in the unnecessary institutionalization of persons with mental illness. 66. Individuals at NHH and Glencliff are relegated to unnecessarily prolonged stays because discharge and transition planning and implementation efforts are insufficient and because housing and other critical services and supports are available in too limited supply in the community. Many individuals admitted to NHH and Glencliff, especially those with more complex physical and/or mental health needs, remain there longer than necessary simply because community-based alternatives with adequate and appropriate intensive services and supports are not available in sufficient supply in the community. The State has acknowledged that, once admitted to NHH, almost a third of the individuals remain “longer than necessary.” Id. at 6. The State has recognized that some individuals with complex mental health issues have lived at NHH for “prolonged periods of time” because adequate community housing and treatment alternatives are “not available.” Id. The State has concluded that the “scarcity of high intensity community resources, including supervised residences and intensive community treatment” is one of several “barriers to discharge.” Id. At Glencliff, the average length of stay is measured not in days or weeks, but in years, with some individuals having been at Glencliff for decades. In recent years, only a handful of individuals have been discharged to integrated community settings; in fact, more individuals have died at Glencliff than have been placed into community settings in any given year. 67. The State’s failure to develop sufficient community capacity and services is a barrier to the discharge of individuals from NHH and Glencliff who could be served in more integrated community settings with adequate and appropriate services and supports.
21

68. Individuals with mental illness and a dual diagnosis of a developmental disability or an acquired brain disorder have remained unnecessarily institutionalized, often for prolonged periods, in the State’s mental health system because of a lack of community alternatives with proper supports. Id. at 14-15. The State has acknowledged that about half of the persons with developmental disabilities at NHH remained there “longer than required” to provide acute evaluation and stabilization of their presenting psychiatric symptoms.” Id. at 14.
C. The State Can Provide Services in Integrated Settings By Reasonably Modifying its Mental Health Services System
69. The State can provide services in integrated community settings to institutionalized persons with mental illness and to persons with mental illness at serious risk of entry to an institution through reasonable modifications to its mental health services system.
70. The types of services needed to support people with mental illness in community-based settings already exist in New Hampshire’s community-based mental health service system, including but not limited to ACT teams, case management services, peer support services, supported employment services, psychosocial rehabilitation services, and crisis services. However, none of the services are provided in sufficient supply and geographic location to meet the needs of persons who are unnecessarily institutionalized. Supportive housing also exists in the State’s mental health system, but on a scale that is inadequate to meet the needs of persons who are unnecessarily institutionalized.
71. Much of the remedial action needed in New Hampshire could be achieved through redirection of resources. The State could redirect the ample funds it currently spends on
22

services in institutions and use them to better support persons with mental illness in more integrated community settings. 72. In spite of a challenging fiscal environment, the State has continued to fund costly institutional care at NHH and Glencliff, even though cost-effective and therapeutic alternatives could be developed in integrated community settings. Total expenditures for operations at NHH have risen steadily in recent years. It cost nearly ten million dollars more to run NHH in FY 2010 than it did in FY 2006. Virtually all of these costs are paid for with State-only dollars, as the federal government does not provide Medicaid matching funds for most services provided in psychiatric hospitals. State fund expenditures for operations at Glencliff have also risen steadily in recent years, rising about two million dollars from FY 2006 to FY 2010.
COUNT I VIOLATION OF TITLE II OF THE AMERICANS WITH DISABILITIES ACT
42 U.S.C. §§ 12131 et seq. 73. The allegations of Paragraphs 1 through 72 of this Complaint-in-Intervention are
hereby realleged and incorporated by reference. 74. Defendant, State of New Hampshire, is considered a public entity subject to Title II of
the ADA, 42 U.S.C. § 12131(1). 75. Plaintiffs and the members of the proposed plaintiff class are persons with a disability
covered by Title II of the ADA, and they are qualified to receive mental health services, programs, or activities from defendants. 42 U.S.C. §§ 12102, 12131(2). 76. Defendants violate the ADA by administering the State’s mental health service system in a manner that denies qualified individuals with a disability the benefits of the State’s
23

mental health services, programs, or activities in the most integrated setting appropriate to their needs and by failing to reasonably modify the State’s mental health services system to avoid discrimination against, and unnecessary segregation of, plaintiffs. 42 U.S.C. § 12132. 77. The State’s actions constitute discrimination in violation of Title II of the ADA, 42 U.S.C. § 12132, and its implementing regulations at 28 C.F.R. pt. 35.
COUNT II VIOLATION OF SECTION 504 OF THE REHABILITATION ACT
29 U.S.C. § 794 78. The allegations of Paragraphs 1 through 72 of this Complaint-in-Intervention are
hereby realleged and incorporated by reference. 79. The State of New Hampshire, as a recipient of federal financial assistance, is subject to
the Rehabilitation Act. 29 U.S.C. § 794. 80. Plaintiffs and the members of the proposed plaintiff class are persons with a disability
covered by the Rehabilitation Act and they are qualified to receive mental health services, programs, or activities from the State. 81. The State violates the Rehabilitation Act by discriminating against qualified individuals with a disability within the meaning of the Rehabilitation Act by administering mental health programs and activities receiving federal financial assistance in a manner that denies these individuals the benefits of such programs or activities in the most integrated setting appropriate to their needs and by failing to reasonably modify the State’s mental health services system to avoid discrimination against, and unnecessary segregation of, plaintiffs. 29 U.S.C. § 794(a).
24

82. The State’s actions constitute discrimination in violation of Section 504 of the Rehabilitation Act, 29 U.S.C. § 794, and its implementing regulations at 28 C.F.R. § 41.51(d); see also 45 C.F.R. § 84.4.
PRAYER FOR RELIEF WHEREFORE, the United States of America prays that the Court: A. Grant judgment in favor of the United States on its Complaint-in-Intervention and declare that the Defendant has violated Title II of the ADA, 42 U.S.C. §§ 12131 et seq., and Section 504 of the Rehabilitation Act, 29 U.S.C. § 794; B. Enjoin Defendant from: 1. failing to provide appropriate, integrated community services, programs, or activities
for Plaintiffs and the members of the plaintiff class, consistent with their individual needs; 2. discriminating against Plaintiffs and the members of the plaintiff class by failing to provide services, programs or activities in the most integrated setting appropriate to their needs; C. Issue a declaratory judgment declaring that: 1. Defendant has violated Title II of the ADA and Section 504 of the Rehabilitation Act by failing to make reasonable modifications to services, programs, or activities for persons with mental illness to enable Plaintiffs and the members of the plaintiff class to obtain the services, programs, and activities they require to reside in the most integrated setting appropriate to their needs; and D. Order such other appropriate relief as the interests of justice may require.
25

Dated: March 27, 2012

Respectfully submitted,

JOHN P. KACAVAS United States Attorney District of New Hampshire
JOHN J. FARLEY Assistant United States Attorney
New Hampshire Bar No. 16934 District of New Hampshire U.S. Attorney’s Office 53 Pleasant Street Concord, NH 03301 (603) 225-1552 John.Farley@usdoj.gov

/s/ Thomas E. Perez THOMAS E. PEREZ Assistant Attorney General
EVE L. HILL Senior Counselor to the Assistant Attorney General
ALISON BARKOFF Special Counsel for Olmstead Enforcement Civil Rights Division
/s/ Richard J. Farano JONATHAN M. SMITH, Section Chief JUDITH C. PRESTON, Deputy Chief RICHARD J. FARANO, Senior Trial Attorney
District of Columbia Bar No. 424225 DEENA S. FOX, Trial Attorney
New York Bar Registration No. 4709655 Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW – PHB Washington, DC 20530 Telephone: 202-307-3116 Facsimile: 202-514-0212 richard.farano@usdoj.gov
Counsel for Plaintiff-Intervenor, United States of America

26

 
 Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 1 of 65
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Four
June 29, 2016
I. Introduction
This is the fourth semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Hassan,; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this fourth six-month period (January 1, 2016 through June 30, 2016), the ER has continued to observe the State work to implement certain key service elements of the CMHA, and to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. In this period the ER:
 Conducted on-site reviews of Assertive Community Treatment (ACT) teams/services and Supported Employment (SE) services at the Mental Health Center of Greater Manchester; Riverbend CMHC, and Northern Human Services CMHC, Littleton Office; a non-random sample of ACT and SE records was reviewed at each of these sites;
 Conducted an on-site visit at the Cypress Center in Manchester;  Conducted a site visit at the Peer Support Agency in Littleton;  Met with the Central Team to review progress and discuss barriers to transition from
both New Hampshire Hospital (NHH) and Glencliff;  Met with Riverbend CMHC to assess implementation of the new mobile crisis team
and crisis apartments in the Concord region;  Met with certain CMHC Directors to discuss and receive input on the ER’s Third
Report;
1

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 2 of 65
 Participated in two meetings with New Hampshire Department of Health and Human Services (DHHS) Commissioner Jeffrey Meyers;
 Conducted a site visit with Harbor Homes to discuss the Bridge Subsidy Rental Assistance Program and related housing issues;
 Conducted an introductory meeting with DHHS staff involved with the PASRR program;
 Participated in several meetings with representatives of the Plaintiffs and the United States (hereinafter “plaintiffs”);
 Conducted several meetings with DHHS officials to discuss Quality Service Reviews (QSR), data tracking, and data elements and reporting related to the CMHA;
 Conducted a two day on-site working session with DHHS Quality Management/Quality Service Reviews (QM/QSR) staff to discuss design and implementation of the QSR process;
 Convened two meetings of a sub-set of representatives of the plaintiffs and DHHS QM/QSR staff to facilitate plaintiffs input to the QSR process; and
 Convened a meeting of all parties to discuss general progress and implementation issues related to the CMHA.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
II. Data
The New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the two most recent DHHS Quarterly Data Reports, which incorporate standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. It is now possible to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance. The State has also incorporated data on utilization of Designated Receiving Facilities (DRFs) in the Quarterly Report. Specific data from the quarterly reports are included in the discussion of individual CMHA services below.
In addition to the standardized reporting of certain types of data, DHHS continues to collect and report on other data necessary to monitor performance related to the CMHA. These include reports from the new mobile crisis services in the Concord Region; data on discharge destinations from NHH and Glencliff; reports of wait list numbers for ED boarding; and utilization of the Bridge Subsidy Program. DHHS shares data on these special program areas with the ER and representatives of the plaintiffs, but the data are not yet incorporated in the
2

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 3 of 65
quarterly report. Where applicable, these additional data are incorporated in the discussion of specific CMHA performance domains below.
As noted in previous ER reports, there continue to be important categories of data that are needed but not routinely collected and reported, and which will need to be developed in order to accurately evaluate ongoing implementation of the CMHA. For example, ACT team data is reported by region, not by ACT team. Thus, data for the two ACT teams in Manchester are merged together, potentially masking information relevant to the teams separately. A new ACT team is being developed in Nashua, and there is potential for another new team to be funded in the future. Thus, it will be important to have the data reporting reflect each individual team rather than aggregate regional data.
In addition, there continues to be no reported or analyzed data on the degree to which participants in SE are engaged in competitive employment in integrated community settings consistent with their individual treatment plans. This data is important in assessing the fidelity with which supported employment services are provided.
Another gap in data is related to people receiving Supported Housing (SH) under the Bridge Subsidy Program. These participants are not yet clearly identified in the Phoenix II system, and thus, it is difficult to document the degree to which these individuals are: (a) connected to local CMHA services and supports; or (b) actually receiving services and supports to meet their individualized needs on a regular basis in the community. As noted in the January 2016 ER Report, DHHS has identified a strategy to link data from the Bridge Subsidy Program to the Phoenix II system. However, no responsive data has been produced to date, leaving a significant gap in the ER’s ability to evaluate compliance with supported housing provisions of the CMHA.
Although the soon-to-be-initiated QM/QSR process will provide additional information related to the quality, effectiveness, and (where applicable) the fidelity of the services delivered, the data identified above is an essential complement to those client reviews and necessary in order for the ER, and the parties, to effectively measure ongoing implementation and to demonstrate compliance with the terms of the CMHA. A proposed deadline for reporting on the production of these data is among the action items identified at the conclusion of this Report.
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile Crisis Services and Crisis Apartments
The CMHA calls for the establishment of mobile crisis capacity and crisis apartments in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process
3

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 4 of 65 for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC was the vendor selected to implement the mobile team and crisis apartments in the Concord Region. Table I below includes Riverbend’s most recent available information on activities of its new crisis program.
4

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 5 of 65

Table I

Concord Region Self-Reported Mobile Crisis Services: October, 2015 and April, 2016

October 2015

April 2016

Total unduplicated people served

135

187

Services provided in response to immediate crisis:

 Phone support/triage

 Mobile assessments  Crisis stabilization appointments  Emergency services medication
appointments

179

253

14

39

45

20

18

29

Services provided after the immediate crisis:

 Phone support/triage

52

83

 Mobile assessments  Crisis stabilization appointments  Emergency services medication

5

6

29

20

18

24

appointments

Referral source:

 Self

66

226

 Family  Guardian  Mental health provider  Personal care physician  Hospital emergency department  Police

24

58

2

2

15

10

4

3

8

9

0

8



Crisis apartment admissions:

5

10

 Bed days

8

21

 Average length of stay

1.6

2.1

Law enforcement involvement

4

13

Total hospital diversions

39

93*

*Hospital diversions are instances in which services are provided to individuals in crisis resulting

in diversion from being assessed at the Emergency Department and/or being admitted to a

psychiatric hospital.

These data indicate a growth in the number of people accessing mobile crisis services, and in the number of crisis response services delivered. However, the number of mobile crisis assessments remains relatively low, given the volume of total crisis encounters. Over the next six months, the ER expects to closely monitor the evolution of this service, in order to ensure that crisis services are being delivered in the community whenever possible and that decisions not to dispatch the

5

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 6 of 65 mobile crisis team are reported and the rationale analyzed to ensure adherence to the service model and goals. Charts I, II, III and IV below show trends in mobile crisis services in the Riverbend region from September, 2015 through April, 2016, based on Riverbend’s self reports.
6

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 7 of 65

Chart I

Riverbend MCT: Unduplicated Individuals

250

210

200

195 172 179

187

150

150

135

100 79

50

0 SEPT 15 OCT 15 NOV 15 DEC 15 JAN 16 FEB 16 MAR 16 APR 16

Series1

Chart II

Riverbend MCT: Community Based Assessments

60

50

40

30

Series1

20

10

0 SEPT 15 OCT 15 NOV 15 DEC 15 JAN 16 FEB 16 MAR 16 APR 16

7

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 8 of 65

Chart III
Riverbend MCT: MCU Admissions

12 10
8 6 4 2 0
SEPT 15 OCT 15 NOV 15 DEC 15 JAN 16 FEB 16 MAR 16 APR 16

Series1

Chart IV

Riverbend MCT: Hospital Diversions

100 90 80 70 60 50 40 30 20 10 0 SEPT 15 OCT 15 NOV 15 DEC 15 JAN 16 FEB 16 MAR 16 APR 16

Series1

Given the data in Table I, it is evident that the vast majority of Riverbend’s crisis interventions are via telephone conversations. It appears that a relatively small percentage of crisis interventions are truly mobile – on-site in the community with the individual in crisis. In the future, the ER will work with the State and Riverbend to gain greater clarity on the effectiveness of both phone and on-site mobile interventions so as to better determine whether the crisis services offered are meeting individuals’ needs. In doing so, the ER will look to the outcome criteria at CMHA Section V.C.1(b) - (d).

8

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 9 of 65
In Table I, Riverbend reported that in April 2016, there were 13 instances of involvement with law enforcement during a crisis. In the future, the ER will work with the State and Riverbend to gather additional information about such instances with an emphasis on whether or not the crises are resolved in the community without subsequent arrest or contact with a hospital or other institutional setting.
Going forward, the ER will also track staffing and other requirements in the Crisis System Components section of the CMHA, Section V.C.2.
In mid-June 2016, DHHS awarded a contract to the Mental Health Center of Greater Manchester to establish the second Mobile Crisis Team and Crisis Apartments. Given the timing of the contract award, mobile crisis services will not be operational in the Manchester Region by June 30, 2016, as specified in the CMHA. However, the implementation and early operations experience of the existing Riverbend mobile crisis program should inform implementation and could potentially assist to reduce the elapsed time between contract award and full implementation of the Mobile Crisis Team and Crisis Apartment services in Manchester. The ER will closely monitor implementation of these services over the next several months.
Assertive Community Treatment (ACT)
ACT is a key element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team; and
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time.
Taken together with the other ACT provisions, the CMHA requires a robust and effective system of ACT services to be in place throughout the State as of June 30, 2015 (one year ago). Further, as of June 30 of this year, the State is required to have the capacity to provide ACT to 1,500 priority Target Population individuals.
As displayed in Table II below, the staff capacity of the 11 adult ACT teams in New Hampshire has increased by only two FTE in the six months since September of 2015. During the same time, the total active caseload has increased by only 93 individuals. As of the date of this report, the State is providing ACT services to 839 unique consumers and as a result is delivering only 56 percent of the ACT capacity required by the CMHA, and is out of compliance on this key CMHA service.
9

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 10 of 65

Table II Self-Reported ACT Staffing (excluding psychiatry): May 2015 through March 2016

Region

FTE May-15

Northern West Central Genesis Riverbend Monadnock Greater Nashua Manchester Seacoast Community Partners Center for Life Management

14.80 3.00 7.10 7.00 8.20 8.70 24.90 12.80 8.20 7.80

Total

102.50

FTE Sep-15
11.29 3.83 7.5 7.3 8.5 5.98 26.3 11.77 8.7 6.36
97.53

FTE Dec-15
11.15 2.64 6.4 6.7 7.75 7.5 29.75 11.77 7.9 8.16
99.72

FTE Mar-16
11.15 4.37 7.4
7 7.75 6.5 30.01 11.53 5.9 8.16
99.77

Chart V below shows ACT staffing trends for the last four reporting periods.

10

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 11 of 65

Chart V
Self-Reported ACT Staffing (excluding psychiatry) by Region: May 2015 through March 2016

35.00

30.00

25.00

20.00

15.00 10.00
5.00

May-15 Sep-15 Dec-15 March 2016

0.00

It is clear from this chart that ACT staffing has remained at best static, and in some cases has decreased, over the past four reporting periods. This is true despite previous findings that New Hampshire was out of compliance with the standards of the CMHA. Based on staffing shortages alone, more than 500 eligible individuals needing and choosing ACT services are not able to receive such services.
Table III and Chart VI below display trends in active caseloads for ACT services by Region.

11

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 12 of 65

Table III

Self-Reported ACT Caseload (Unique Adult Consumers) by Region: May 2015 through March 2016

Region

Active Cases May-15

Active Cases Sep-15

Active Cases Dec-15

Active cases Mar-16

Northern West Central Genesis Riverbend Monadnock Greater Nashua Manchester Seacoast Community Partners Center for Life Management

60

72

74

79

16

19

21

26

22

30

34

39

79

60

56

70

47

54

61

68

63

74

72

72

254

265

270

293

73

65

65

72

16

70

76

73

39

37

40

49

Total*

669

746

766

839

* unduplicated across regions

12

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 13 of 65

Chart VI
Self-Reported ACT Caseload (Unique Adult Consumers) Trends: May 2015 through March 2016

350

300

250

200

150

May-15

100

Sep-15

Dec-15 50
Mar-16
0

Based on self-reported staffing data, the Regions appear to have made some gains in enhancing staff capacity within certain ACT teams, while in others, there has been modest to no increase. For example, nine Regions now report substance use disorder (SUD) staff competency compared with the single region reporting SUD competency in the previous report. And, four of the Regions reported less than one FTE Supported Employment (SE) competency, as opposed to seven of the 11 reporting less than one FTE SE competency in the previous report.
However, three of the 11 adult ACT teams continue to have fewer than the 7 - 10 professionals specified for ACT teams in the CMHA. Two Regions have ACT staff:client ratios poorer than 1:10, which also falls outside CMHA parameters. In addition, five of the teams have less than one FTE nurse; three regions have no peer specialist staff and five others have less than one FTE peer specialist. Three Regions continue to have less psychiatry time than warranted by their active caseloads. The statewide figure for ACT psychiatry staffing falls below CMHA requirements with almost half of the Regions.
13

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 14 of 65
As with the ACT staffing displayed in Chart I, ACT caseloads have grown only minimally since May of 2015. As noted above, based on a minimal 1:10 staff:client ratio, the State currently has the capacity to provide ACT to 998 people, and thus is over 500 ACT slots below the required capacity. The March 2016 caseload of 839 unduplicated individuals is 661 people lower than the planned capacity to serve high risk people with SMI/SPMI in New Hampshire by June 30, 2016. Further, some CMHC teams are so far out of compliance with the ACT fidelity requirements for staffing and intensity of services that it is inappropriate to include their clients within the total number of people receiving ACT in New Hampshire.
While the New Hampshire DHHS has begun to take more aggressive action to work with CMHCs in certain Regions to increase their ACT staffing and caseloads, there has been difficulty increasing service capacity and ensuring ACT services are delivered consistent with the CMHA. One Region has developed and is implementing a plan of correction, but the State has not been able achieve fidelity with this Region yet. The State has notified two additional Regions that they must develop plans of correction. As of the drafting of this report, both of these Centers have submitted proposed plans of correction, and DHHS is in the process of reviewing these plans. In two previous reports, the ER has noted that unused capacity for ACT or any other CMHA service could result in difficulty meeting the overall goals and outcomes for priority Target Population members identified in the CMHA. While it is a positive development that the ACT active caseload has increased somewhat since May 2015, reports of unmet demand for ACT services are a source of significant concern across the various regions. The system is still serving at least 661 fewer people than could be served if the state had attained the required capacity to serve 1,500 people.
The staffing data reported by DHHS for ACT services has not yet been independently verified by the ER. In addition, neither DHHS nor the ER has, to date, reviewed compliance of all ACT teams with the performance and quality standards specified in CMHA Section V.D.2. The new QSR being developed by DHHS will examine the provision of ACT services, and QSR findings are expected to prompt additional corrective action plans where necessary.. However, DHHS must have additional methods for evaluating ACT services and the system’s adherence to fidelity standards, since the QSR process focuses primarily on the adequacy of class member services rather than program performance.
In November 2015, the New Hampshire DHHS awarded a contract to the Community Council of Nashua (the designated CMHC for the Nashua region) for a new adult ACT team. That new team is not yet fully staffed, and does not at this point contribute to either the capacity measures or the active caseload for ACT services within the state. DHHS reports that as of June 8, 2016, four staff have been hired for this team, and additional staff are being interviewed.
The ER has visited all ten CMHCs to receive an overview of the ACT teams in place in the state, and revisited three of the CMHCs (four teams) during the past six-month period.
14

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 15 of 65
The June 30, 2015 ER report contained the following statement:
“In the coming months, it is expected that DHHS will: 1) develop one set of eligibility and discharge criteria for the provision of ACT services; 2) analyze the high degree of variation among existing ACT teams; 3) take any steps necessary to assure that ACT services are consistently meeting the CMHA standards statewide; and 4) expand the capacity of ACT to meet the requirements of the CMHA.”
DHHS has been working on new regulations defining ACT service eligibility and access standards for the past year. The most recent draft of regulations was circulated to all parties in mid-May. It is problematic that these standards have remained outstanding for so long, and the ER urges the parties to try to reach agreement on the final rules as soon as possible in order to ensure consistent application of eligibility criteria and appropriate access to ACT services for members of the Target Population.
In addition to the compliance letters and plans outlined above, DHHS continues to hold ACT compliance calls with the CMHCs on a monthly basis. DHHS has modified the contract between the State and the Centers to assure that the Centers assert their understanding of and willingness to implement the standards and requirements of the CMHA. In addition, the calculation of the Medicaid funding available to CMHCs under the Managed Care Organization (MCO) contracts has been revised, resulting in slight increases in overall Medicaid funding available to the CMHCs via these contracts. The CMHCs are reported to be in the last stages of negotiating subcapitation contracts with the MCOs, so it is premature to report on the impact of the increased Medicaid funding amounts. Finally, DHHS is in the very early stages of implementing the new Medicaid 1115 Demonstration waiver that ultimately will make funds available to CMHCs for both infrastructure development and service expansion.
DHHS has new leadership at the Commissioner level as well as at within the newly formed Division of Behavioral Health. The new leadership has adopted a more assertive and positive set of strategies to work with the regional CMHCs to assure compliance with the CMHA for both ACT and SE. It is too early to see whether these activities will be successful, but the ER believes that steps are being taken to accelerate efforts to assure compliance. In addition, the CMHCs have initiated efforts to identify and address issues related to workforce shortages that appear to be hindering attainment of ACT and SE CMHA requirements. As with the state level actions, it is too early to assess the degree to which these workforce development and recruitment efforts will be successful. As will be noted below, the soon-to-be-implemented QSR process is intended to provide additional, actionable, information to support and guide the fidelity, quality, effectiveness, and capacity of ACT services, as well as all other services under the CMHA.
DHHS is currently analyzing data related to the number of active CMHC clients who are not receiving ACT services and who present in psychiatric crisis in hospital emergency rooms.
15

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 16 of 65
Since one purpose of ACT is to ameliorate and reduce psychiatric crises, this is an opportunity for state officials to work with local CMHCs to target these clients for ACT participation and thereby to reduce ED presentations, psychiatric boarding, and unnecessary inpatient admissions. This is just one example of the importance of ACT to a comprehensive system of care for people with serious mental illness. Recent initiatives notwithstanding, New Hampshire remains out of compliance with the requirements of the CMHA with regard to ACT service capacity. This is the third consecutive ER report in which the non-compliance with the ACT standards and targets in the CMHA has been noted. It is urgent that steps be taken to arrest this pattern and to implement concrete plans for correction.
Supported Employment
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2016, the state will increase its penetration rate of individuals with SMI receiving supported employment …to 18.1% of eligible individuals with SMI.” (Section V.F.2(d)). The baseline SE penetration rate at the beginning of the CMHA was 12.1% (2012). In the June 2015 ER report, the SE penetration rate was 11.3% -- almost a full percentage point below the 2012 baseline. The June 2015 ER report noted that the penetration rate at that time was 4.8 percentage points below the CMHA target for June 30, 2015. For this reporting period, the State reports that the CMHCs have achieved the 18.1% penetration rate specified for June 30, 2016 in the CMHA. Table IV and Chart VII below show the SE penetration rates for each of the 10 Regional CMHCs in New Hampshire
16

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 17 of 65

Table IV

Self-Reported CMHC SE Penetration Rates: March 2015 through March 2016

Region

Penetration Penetration Penetration Penetration

Mar-15

Sep-15

Dec-15

Mar-16

Northern West Central Genesis Riverbend Monadnock Greater Nashua Manchester Seacoast Community Partners Center for Life Management
CMHA Requirement Statewide Average

7.10% 13.50%
9.40% 14.90%
8.00% 6.10% 14.60% 10.50% 8.10% 16.30%
16.10% 11.30%

8.20% 12.90%
9.30% 14.20% 16.40%
7.70% 26.10% 13.10% 11.60% 15.70%
16.10% 15.70%

9.50% 14.30%
9.60% 14.60% 19.40%
8.60% 31.70% 12.70% 13.00% 13.00%
16.10% 17.90%

10.60% 15.30%
9.60% 14.10% 20.50%
9.00% 36.70% 11.00% 12.60% 24.70%
18.10% 19.30%

17

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 18 of 65

Chart VII Trends in Self-Reported SE Penetration Rates: March 2015 through March 2016

40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00%
5.00% 0.00%

Penetration Mar-15 Penetration Sep-15 Penetration Dec-15 Penetration Mar-16

As has been noted in previous reports, the CMHA establishes a statewide penetration rate standard, not individual CMHC penetration rate requirements. However, examination of penetration rates by region reveals significant inconsistencies in implementation across the network of SE providers. As with previous reports, there are three regions in the state in which priority Target Population members are reported to be receiving SE services at or above the June 30, 2016 penetration rate standard. However, the ER notes that seven of the ten CMHCs have penetration rates below the June 2016 standard, and four of these continue to have penetration
18

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 19 of 65
rates below the 12.1% baseline standard for SE in the CMHA. The number of programs falling below the required penetration rate has remained the same since the January 2016 ER Report.
The above table and chart make it clear that one CMHC, Manchester, is contributing disproportionately to the State meeting the June 2106 SE penetration rate standard. In fact, Manchester has 24.9% of the total statewide enrolled clients with SMI/SPMI, but has 47.2% of the total clients receiving SE (see Appendix A Table 3). If Manchester’s SE clients and total clients are subtracted from the totals, the SE penetration rate would be 13.6%, barely above the original CMHA SE target of 12.1%. This analysis demonstrates that the current statewide penetration rate is significantly skewed by one Region’s performance.
As noted in previous reports, this kind of wide variation in access to and utilization of SE services on a sub-state level affects overall attainment of CMHA objectives for the Target Population. Thus, the ER will continue to monitor and report on individual CMHC penetration rates as well as the statewide total. The ER will also continue to monitor implementation of applicable CMHC plans of correction related to improving SE penetration and performance at the regional level. Three CMHCs are currently developing such plans of correction under the guidance of DHHS.
Several other issues related to the implementation and monitoring of Supported Employment services will need to be resolved in the coming months. First, as noted earlier in this report, there is currently no consistently reported data on the extent to which SE service participants are attaining and sustaining competitive employment in integrated community settings. Success in obtaining competitive employment is not a specific numerical standard in the CMHA. However, the CMHA does require the State to operate SE services in conformance with the Dartmouth fidelity standards, and attaining and sustaining competitive employment in the community is an indicator of adherence to those standards. The ER will be working with the State and the CMHCs to develop a consistent and reliable method for reporting on obtaining and sustaining competitive employment in the community. The soon-to-be implemented QSR process, in concert with related DHHS SE fidelity assessment activities, will assist in addressing SE issues, but cannot take the place of independently verified fidelity assessments.
Supported Housing
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Subsidy Program by June 30, 2016. As of the end of April1 2016, DHHS reports having 423 individuals in leased SH apartments, 26 people approved for a subsidy but not yet leased, and one person unaccounted for. Assuming these people move into leased units soon, the State will be at or very close to compliance with the CMHA standards for SH effective June 30, 2016;
1 Note that the data in Table V below extends only through March, 2016, so some figures may differ from the text of this report.
19

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 20 of 65 the State has already attained the SH figure of 340 units by June 30, 2015, as required by the CMHA. Table V below summarizes recent data supplied by DHHS related to the Bridge Subsidy Program.
20

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 21 of 65

Table V

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program: September 2015 through March 2016

Bridge Subsidy Program Information

September 2015

March 2016

Total housing slots (subsidies)

450

450

available

Total people for whom rents are

376

being subsidized

415 *

Individuals accepted but waiting

23

22 *

to lease

Individuals currently on the wait

0

0

list for a bridge subsidy

Total number served since the

466

518

inception of the Bridge Subsidy

Program

Total number receiving a

70

71

Housing Choice (Section 8)

Voucher

*As of the end of April 2016, 423 individuals have signed leases, and 26 have been approved but are still waiting to lease.

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10% of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table VI below displays the reported number of units leased at the same address.

21

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 22 of 65

Table VI

Self-Reported Bridge Subsidy Housing Concentration (Density)

September 2015

March 2016

Number of properties with one

290

317

leased SH unit at the same

address

Number of properties with two

27

22

SH units at the same address

Number of properties with three

2

13

SH units at the same address

Number of properties with four

4

1

SH units at the same address

Number of properties with five

1

2

SH units at the same address

Number of properties with six

1

0

SH units at the same address

As can be seen in the table, almost 90% of the leased units are at a unique address. This supports a conclusion that the Bridge Subsidy Program, to a large degree, is operating as a scattered-site program. For the 10% of the units shown in Table V to be at the same address, it is not known at this time whether the unit density standards included in the CMHA are being met. For example, in the two properties that are noted to have five units at the same address, the total number of units at each address is not yet reported. If those buildings have a total of 50 or more units, then having five Bridge Subsidy Program leases in that property would comport with the CMHA. However, if those properties have fewer than 50 total units, then the five units leased in those buildings would exceed the scattered-site definition as quoted above. DHHS is collecting information on the total units in each property where there are two or more Bridge units at the same address, and this data will be reported in the next ER report.
It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)).

22

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 23 of 65
DHHS reports, and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge Subsidy Program leased units.2
Current data is also not available on the degree to which Bridge Subsidy Program participants access and utilize support services and whether or not the services are effective and meet individualized needs. Receipt of services is not a condition of eligibility for a subsidy under the Bridge Program, but the CMHA does specify that “…supported housing includes support services to enable individuals to attain and maintain integrated affordable housing and includes support services that are flexible and available as needed and desires….”. (V.E.1(a)). As noted in the January 2016 ER Report, DHHS has been working on a method to cross-match the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. This will allow documentation of the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports.
In the previous report, the ER identified a number of important and needed data elements associated with the SH eligibility criteria and lack of a waitlist, as well as monitoring implementation of the SH program in the context of the CMHA. These include:
 Total number of Bridge Subsidy Program applicants per quarter;  Referral sources for Bridge Subsidy Program applicants;  Number and percent approved for the Bridge Subsidy Program;  Number and percent rejected for the Bridge Subsidy Program;
o Reasons for rejection of completed applications, separately documenting those who are rejected because they do not meet federal HCV/Section 8 eligibility requirements;
 Number and disposition of appeals related to rejections of applications;  Elapsed time between application, approval, and lease-up;  Number of new individuals leased-up during the quarter;  Number of terminations from Bridge subsidies;  Reasons for termination:
o Attained permanent subsidized housing (Section 8, public housing, etc.); o Chose other living arrangement or housing resource; o Moved out of state; o Deceased; o Long term hospitalization; o Incarceration; o Landlord termination or eviction; or o Other;  Number of Bridge Subsidy Program participants in a roommate situation; and
2 DHHS reports that currently there is one voluntary roommate situation reflected in the above data.
23

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 24 of 65
 Lease density in properties with multiple Bridge Subsidy Program leases. This information is important in assessing whether a waitlist is properly maintained and in assessing whether or not support services are adequate to enable the individual to “attain and maintain integrated affordable housing” and whether services are “flexible and available as needed and desired.” Most rental assistance programs collect and report such information, given its intrinsic value in monitoring program operations. Further, such data enhances DHHS’ ability to demonstrate the timeliness and effectiveness of access of the priority target population to this essential CMHA program component. Most importantly, this data is necessary to help the ER determine compliance with CMHA Sections IV.B, IV.C, and VII.A. The ER will continue to work collaboratively with DHHS to identify sources and methods for such data collection and reporting. DHHS has been in the process of drafting Bridge Subsidy Program rules, in consultation with plaintiffs and the United States. A final draft version is not available at the time of this report. The ER expects DHHS to promulgate these rules promptly, as they are important to ensuring access to and assessment of the Bridge Subsidy Program.
Transitions from Institutional to Community Settings
During the past 18 months the ER has visited both Glencliff and NHH on at least three separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities late last year. Transition planning activities related to specific current residents in both facilities were observed, and most recently, a small non-random sample of resident transition records have been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities. The ER has participated in two meetings of the Central Team, now that it has been operationalized. The Central Team has about eight months of operational experience, and has started reporting data on its activities. To date, 13 individuals have been submitted to the Central Team, nine from Glencliff and four from NHH. Table VII below summarizes the discharge barriers that have been identified by the Central Team with regard to these individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total substantially higher than the number of individuals reviewed by the Central Team.
24

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 25 of 65

Table VII

Discharge Barriers Identified by the Central Team: September 2015 through April 2016

Discharge Barriers

NHH

Glencliff

Legal

1

2

Residential

2

6

Financial

1

4

Clinical

2

4

Family/Guardian

1

0

Other

1

0

Glencliff
In the time period from January to March 2016, Glencliff reports that it has admitted three individuals, and has had only one discharge. The wait list for admission has remained relatively constant: averaging 15 people during this time frame. The length of stay for the one person discharged was 1,492 days. Since September 17, 2015, Glencliff has discharged only five individuals: one to a five+ bed community residence; one to supported residential care; one to enhanced family care; one to their own home; and one to NHH. Only two of the five are clearly to small-scale community settings. Glencliff reports having 23 individuals engaged in discharge planning as of April of this year. Unfortunately, only a fraction of these individuals are in the “active” transition process and about half – 10 of 23 – are to be transitioned to institutional nursing home settings. Eleven individuals in the transition process are reported to have a dual diagnosis of intellectual/developmental disability (IDD), as well as mental illness. Between September 2015 and April 2016, NHH reports discharging nine patients to the Glencliff Home.
The ER remains concerned about both the steady flow of referrals to Glencliff (especially those referrals coming from NHH) and the lack of discharges to integrated community settings. In keeping with the goals of the CMHA, and its transition planning provisions, the ER recommends that any NHH patient for whom placement at Glencliff is being considered be referred to the Central Team for an evaluation of barriers to community living and an exploration of alternative dispositions. These cases also should receive heightened scrutiny under the state PASRR process.
Section V.E.3(g) of the CMHA requires the State by June 30, 2015 to: “…have the capacity to serve in the community four individuals with mental illness and complex health care needs residing at Glencliff….” This target increases to a total of ten such individuals to be discharged
25

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 26 of 65
to the community by June 30, 2016. The CMHA includes several options for attaining that goal, including the issuance of an RFP to secure new residential services beds and/or to access existing community capacity in the residential services system. The CMHA also anticipates collaboration with the DHHS Elderly and Adult Services component to assist with implementing transition plans for this population.
As noted in the June 30, 2015 and January 5, 2016ER reports, DHHS has been endeavoring to access the Enhanced Family Care service modality included in New Hampshire’s Home and Community-Based Services waiver for people who are elderly or have disabilities. DHHS has also been exploring other Medicaid waiver and in-plan service authorities to piece together an array of services for each of the individuals at Glencliff for whom this type of transition planning is being conducted. Now, 12 months later, the technical and financial complexities of these mechanisms have not yet been resolved, and no Glencliff resident has yet been discharged to a community setting using these mechanisms. The CMHA specifically identifies up to $100,000 per person that can be used, in concert with other applicable Medicaid waiver or similar financing approaches, to develop or acquire the capacity for community transitions for Glencliff residents. None of these funds have been expended to date, and no RFP for enhanced residential capacity has been issued by the State. DHHS reports that it is in negotiations with one or more vendors to effectuate discharge of residents with complex medical needs from Glencliff into small-scale community settings..
The ER continues to find that the State is not in compliance with Section V.E.3(g) of the CMHA, as well as a number of provisions throughout Section VI. To date, no capacity has been created or identified to transition individuals meeting the criteria of this section, and no transitions have been accomplished. The ER believes that some of the strategies being developed by DHHS and the Central Team to effectuate such transitions have the potential to be effective both for the individuals to be transitioned, and to facilitate future transitions for similar persons now residing at Glencliff. As in the January 2016 Report, the ER continues to find that the progress in creating capacity and effectuating transitions at Glencliff has been much too slow and ineffectual to meet the requirements of the CMHA.
PASRR
The ER met in April of this year with the DHHS staff overseeing the PASRR functions in New Hampshire. ,Based on verbal information provided by the staff, it appears the new PASRR vendor (University of Massachusetts Medical School) is performing PASRR functions in conformance with its contract with the State.
In the coming months, the ER will work with DHHS to develop data extraction and reporting methods that will facilitate ER analyses of this function. Monitoring of the PASSR process of those referred for admission to Glencliff remains a high priority for the ER in 2016.
26

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 27 of 65 New Hampshire Hospital For the time period January through March 2016,DHHS reported that NHH effectuated 309 admissions and 300 discharges. The mean daily census was 131, and the median length of stay for discharges was 11 days. Table VIII below compares NHH discharge destination information for the three most recent reporting periods. The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.
27

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 28 of 65

Table VIII

New Hampshire Hospital Self-Reported Data on Discharge Destination

Discharge Destination

Percent January 2014 through May 2015

Percent July 1 2015 through September 18, 2015

Percent September 19, 2015 through April 20, 2016

Home – live alone or with

74.4

67.3

others

80.2%

Glencliff

0.4%

0.02%

0.06%

Homeless Shelter/motel

3.8%

2.4%

2.7%

Group home 5+/DDS supported living, etc.

3.4%

9.02%

3.2%

Jail/corrections

1.5%

0.04%

1.4%

Nursing home/rehab facility 1.9%

3.0%

.08%

Unknown

12.6%

17.64%

6.8%

Based on the above data, there would appear to be some increases in discharges to independent living arrangements and parallel decreases in the number of discharges for which the destination is unknown. For the period September 2015 through April 2016, the figures above in Table VIII are based on a denominator of 1,527 total discharges from NHH. In addition, the State reports that there were 158 readmissions within 30 days, about ten percent of the discharges. Readmission data to NHH or equivalent institutional facilities is an important metric to help determine whether the community system is meeting individual needs and achieving outcome criteria in the CMHA. In the coming months, the ER will work with the state to gather discharge data at NHH and the other Designated Receiving Facilities (DRFs) or equivalent facilities within 30, 90, 180, and 365 days. The ER will include this data and an analysis of this data in the next ER report.
The most recent Quarterly Data Report contains new, consistently reported, information on the hospital-based DRFs/APRTP in New Hampshire. It is important to capture the DRF/APRTP data and combine it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. The ER appreciates the State gathering this information.. Table IX summarizes this data.
28

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 29 of 65

Table IX

Self-Reported DRF/APRTP Utilization Data: January through March 2016

DRF/APRTP Admissions Percent Involuntary

Average Census

Discharges Length of Stay for
Discharges

Franklin

69

53.6%

7.9

76

8.6

Cypress

257

18.7%

14.7

261

4.2

Center

Portsmouth

46

NA

NA

NA

NA

Elliot

65

18.5%

19.7

57

15

Geriatric

Elliot

121

30.6%

18.1

122

7.4

Pathways

Total*

512

26.2%*

60.1

516

8.8avg

*Totals do not include Portsmouth

It should be noted that to date DHHS is not reporting discharge destinations for the discharges from DRFs/the APRTP. The ER will continue to work with DHHS to develop a reporting mechanism for this information. Anecdotally, some proportion of discharges from the DRFs/ APRTP appear to go to institutional settings – NHH and nursing facilities -- so it will be important to track this data in the future.

In the previous two reports, the ER has identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. Based on recent information reported by DHHS, the average number of adults waiting for a NHH inpatient psychiatric bed was 24 per day in FY 2014; 25 per day in FY 2015; and to date in FY 2016 has been 28 per day. The constant and increasing number of adults awaiting inpatient admission to NHH is of concern to DHHS and many other parties in New Hampshire. In most mental health systems, a high number of adults waiting for inpatient admissions is indicative of a need for enhanced crisis response (e.g., mobile crisis) and high intensity community supports (e.g., ACT).

29

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 30 of 65
As noted earlier in this report, DHHS is analyzing data related to adults boarding in EDs who may have some connection to the mental health system. When complete, this data analysis should be used to identify members of the target population at risk of inpatient admission and to facilitate increasing enrollments in ACT and other community services designed to prevent or ameliorate mental health crisis, emergency department presentations and boarding, and hospital admissions. The ER will follow up and make this a priority.
Summary of Transition Issues
Over the past three reports, the ER has consistently noted that the transitions process at Glencliff is moving very slowly. This appears to be true both at the individual consumer level, and at the system level. Although information at this point is anecdotal, interviews with both line staff and administrators, plus some selective record reviews, indicate that it is taking substantial amounts of time to overcome the many and varied barriers to discharge to the community. Although the Central Team is now fully operational, it has been concentrating on a small number of cases . With respect to NHH, transition issues include the need to minimize or eliminate discharges to inappropriate settings like homeless shelters. At the all parties meeting on May 5, 2016, the ER reiterated that DHHS needs to take aggressive executive action to increase both the speed and effectiveness of transitions from NHH and Glencliff. The ER will closely monitor progress with discharge planning and transitions to the community over the next six months.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies
As noted in the June 30, 2015 report, New Hampshire reports having a total of 16 peer support agency program sites, with at least one program site in each of the ten regions. The State reports that all peer support centers meet the CMHA requirement to be open eight hours per day, five and one half days per week. At the time of that report, the State reported that those sites had a cumulative total of 2,924 members, with an active daily participation rate of 169 people statewide. As can be seen from the most recent quarterly data report included in Appendix A, the State currently reports total membership to be 2,879, with active daily visits averaging 142 people. In the September 2015 data report, the total membership was reported to be 2,714 people, with average daily statewide visits of 171. Thus, although statewide membership has remained somewhat stable, the active daily participation has gone down by about 17% in the most recent quarter.
30

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 31 of 65 The CMHA requires the peer support programs to be “effective” in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs.
31

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 32 of 65
IV. Quality Assurance Systems
The two previous ER reports have described the collaborative process being employed to design and implement a comprehensive Quality Management and Quality Service Review (QM/QSR) process in concert with the expectations of the CMHA. In the past 12 months, DHHS has made considerable progress in the design of the QSR process required by the CMHA.
At the request of DHHS, the ER engaged an experienced expert in QSR, Lyn Rucker, to work with the DHHS QSR team. Over the past several months, the ER and Ms. Rucker have:
 Reviewed three iterations of documents specifically related to the QSR design and implementation;
 Created a matrix to be used to cross-walk specific requirements and outcomes of the CMHA to the QSR process;
 Met by phone and in person with QM/QSR team members at least four times;  Conducted an on-site two day work session with members of the QM/QSR team to
discuss in detail the process, instrumentation, scoring, and utilization of the QSR information within the CMHA and DHHS quality frameworks; and  Participated in an additional joint meeting of the CMHA plaintiffs’ representatives and the DHHS QM/QSR team (including legal representatives of the State as well).
The DHHS QM/QSR team has made considerable progress in all elements of the QSR design, including development of:
 A QSR manual of procedures;  A random sampling methodology that reflects the priority populations served under the
CMHA;  A detailed schedule of on- and off-site activities related to each QSR review;  A QSR instrument that integrates information from all the various input sources for the
QSR;  Instruments for client and staff interviews and record reviews; and  A set of instrument scoring algorithms.
The initial field test of the QSR system will take place in July 2016. For the second field test, scheduled for September, Ms. Rucker will accompany the QSR team on-site to review and provide technical assistance on the QSR process. Following that September QSR field test, it is expected that the parties will meet to discuss any proposed changes to the QSR process or design, after which the QSR documents will be finalized and the QSR regional reviews will begin.
32

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 33 of 65
In previous reports, the ER has noted that there are separate but related issues regarding independent verification that ACT and SE services are being provided in a consistent manner by all CMHCs in conformance with the standards of the CMHA. As noted in the sections on ACT and SE, DHHS is working on a process for assuring fidelity for ACT and SE. Once the QSR process is fully operational, DHHS will be able to add QSR information to other data and oversight information to assure all CMHCs meet the CMHA fidelity standards.
V. Summary of Expert Reviewer Observations and Priorities
The CMHA and ER have now been in place for 24 months. At the last two all parties meetings, the ER has expressed increasing concern related to: (a) continued lack of compliance with at least two major requirements of the CMHA; and (b) long elapsed times and/or delays related to implementation of system improvements or capacities related to the CMHA. The ER has emphasized the need for the State to be more aggressive, assertive, planful, and timely in its implementation and oversight efforts to assure compliance with the CMHA.
As described in several sections of this report, DHHS has begun to implement more aggressive measures to both remove potential barriers to CMHA implementation, and to assure effective action on the part of the ten CMHAs to achieve compliance. The ER believes these management initiatives are positive and have the potential to improve performance vis-à-vis the CMHA.
Nonetheless, the State has been and currently remains out of compliance with at least two critical provisions of the CMHA. These are:
1. Sections V.D.3(a, b, and d), which together require that all ACT teams meet the standards of the CMHA; that each mental health region have at least one adult ACT Team; and that by June 30, 2016, the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time; and
2. Sections V.E.2(b) and V.E.3(g)(h) which together require that by now the State “have the capacity to serve in the community [ten] individuals with mental illness and complex health care needs residing at Glencliff….”
As clearly stated by the ER at the May 2016 all parties meeting, the time for patience on these issues is over. Priority Target Population members are going without needed ACT services; are boarding in hospital emergency departments; and are waiting for long periods of time in NHH or Glencliff for opportunities to live in the community. There is still insufficient data to assess compliance in other key areas of the CMHA, including fidelity with CMHA service standards and PASRR provisions.
33

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 34 of 65
In order to assure that the State continues to move forward with implementation obligations under the CMHA and to proactively address identified areas of noncompliance, the ER recommends that the State carry out the following action steps:
1. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and time lines to achieve compliance with the CMHA requirements for ACT services;
2. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA penetration rates and fidelity standards for supported employment throughout New Hampshire;
3. By August 1, 2016 circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA requirements to assist 10 residents of Glencliff with complex medical needs to move into integrated settings as soon as possible;
4. Starting September 1, 2016, and each month following, submit to all parties a monthly progress report of the steps taken and completed under these respective plans to assure compliance with CMHA requirements as identified in this report;
5. By October 1, 2016, complete the field tests and technical assistance related to the QSR, convene a meeting with plaintiffs and the United States to discuss any recommended design or process changes, and publish a final set of QSR documents governing the process for future QSR activities;
6. Complete at least one QSR site review per month between October 2016 and June 2017, with the exception of the month of December, and circulate to all parties the action items, plans of correction (if applicable), and updates on implementation of needed remedial measures (if applicable) resulting from each of these visits;
7. Starting July 1, 2016, circulate to all parties on a monthly basis the most recent data reports of the Central Team;
8. No later than October 1, 2016, assure that final rules for supportive housing and ACT services are promulgated in accordance with the draft rules developed with input from all parties;
9. By October 1, 2016, augment the quarterly data report to include: (a) ACT staffing and utilization data for each ACT team, not just for each region; (b) discharge destination data and readmission data (at 30, 90, and 180, days) for people discharged from NHH and the other DRFs; (c) reporting from the two Mobile Crisis programs, including hospital and ED diversions; and (e) supportive housing data on applications, time until determination, reason for ineligibility determination, and utilization of supportive services for those receiving supportive housing.
10. By October 1, 2016, (immediately prior to the next All Parties meeting) and then by December 1, 2016 (the time just before the next ER report), factually demonstrate that significant and substantial progress has been made towards meeting the standards and requirements of the CMHA with regard to the ACT, SE and placement of individuals with complex medical conditions from Glencliff into integrated community settings.
34

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 35 of 65 11. By October 1, 2016 demonstrate that aggressive executive action has been taken to
address the pace and quality of transition planning from NHH and Glencliff through the development of a specific plan to increase the speed and effectiveness of transitions from these facilities. Failure to accomplish these action steps in a timely way will likely result in additional findings of non-compliance on the part of the State with regard to the terms, standards and requirements of the CMHA.
35

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 36 of 65
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly Data Reports October to December 2015 And January to March 2016
36

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 37 of 65
New Hampshire Community Mental Health Agreement Quarterly Data Report
October to December 2015
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement March 17, 2015
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence
37

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 38 of 65
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 3/17/2016
Reporting Period: 10/1/2015-12/31/2015
Notable Changes from Prior Report  ACT staffing data is collected and reported through a new method that was adopted to increase accuracy in reporting. Data collection was streamlined in two ways: by redesigning the data collection tool to focus on CMHA reporting needs and by splitting the collection of full time equivalent and staff competency data. Reporting is now split into two areas, the first counts full time equivalent positions on the ACT teams by type of clinician (Nurse, Masters Level Clinician/or Equivalent, Functional Support Worker, Peer Specialist, Psychiatrist/Nurse Practitioner). The second set of reports provides staff competency tables. These tables reflect the sum of FTE's trained to provide each service type regardless of the clinician type. The competency values are not a reflection of the volume of time available to deliver services, rather the quantity of staff available to provide each service because if staff is trained to provide multiple competencies, their entire FTE value will be credited to each competency.  DRF reporting is collected through a new method that was adopted to increase accuracy in reporting. The new collection method captures patient stay data for all patients who were being treated in a DRF during a month and accurately and precisely records the admission and discharge dates for all patients. Additional information is also reported for each DRF to parallel the information provided for New Hampshire Hospital. Note: DRF data from Portsmouth only represents involuntary admissions. DHHS is working with Portsmouth to expand their reporting.  To be more meaningful, Glencliff Home length of stay reporting has been modified to show the actual lengths of stay for each discharge.
38

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 39 of 65

Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services

Publication Date: 3/17/2016

Reporting Period: 10/1/2015-12/31/2015

1. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Center Name

Unique

October November December Consumers

2015

2015

2015 in Quarter

01 Northern Human Services

72

73

74

79

02 West Central Behavioral Health

20

19

21

22

03 Genesis Behavioral Health

31

31

34

35

04 Riverbend Community Mental Health Center

59

57

56

61

05 Monadnock Family Services

57

57

61

62

06 Community Council of Nashua

69

73

72

76

07 Mental Health Center of Greater Manchester

272

269

270

286

08 Seacoast Mental Health Center

64

64

65

68

09 Community Partners

75

75

76

77

10 Center for Life Management

39

40

40

42

Total

756

757

766

808

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 3/1/16; consumers are counted only one time regardless of how many services they receive.

39

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 40 of 65
2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents
December 2015

NMuarssteers Level Clinician/or FEuqnuictviaolenanlt Support Worker PTeoetralSpecialist (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner

Center Name

01 Northern Human Services

0.53 2.60 7.49 0.53 11.15

0.70

02 West Central Behavioral Health 0.40 1.05 1.19 0.00 2.64

0.14

03 Genesis Behavioral Health

0.60 2.00 3.00 0.80 6.40

0.50

04 Riverbend Community Mental

Health Center

0.50 3.00 3.20 0.00 6.70

0.40

05 Monadnock Family Services

1.00 1.25 5.00 0.50 7.75

0.65

06 Community Council of Nashua 1.00 4.00 2.50 0.00 7.50

0.25

07 Mental Health Center of

Greater Manchester

2.03 18.00 9.22 0.50 29.75

1.00

08 Seacoast Mental Health Center 1.43 3.34 6.00 1.00 11.77

0.60

09 Community Partners

0.40 2.00 5.00 0.50 7.90

0.40

10 Center for Life Management

1.00 2.00 4.16 1.00 8.16

0.30

Total

8.89 39.24 46.76 4.83 99.72

4.94

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Substance Use Disorder Treatment

Center Name

December 2015

01 Northern Human Services

2.45

02 West Central Behavioral Health

1.13

03 Genesis Behavioral Health

4.90

40

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 41 of 65

04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

1.40 2.40 4.00
9.00 0.24 1.00 4.00 30.52

2c. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Housing Assistance

Center Name

December 2015

01 Northern Human Services

9.28

02 West Central Behavioral Health

3.00

03 Genesis Behavioral Health

5.40

04 Riverbend Community Mental Health

Center

6.00

05 Monadnock Family Services

1.00

06 Community Council of Nashua

5.50

07 Mental Health Center of Greater Manchester

24.50

08 Seacoast Mental Health Center

7.00

09 Community Partners

5.75

10 Center for Life Management

6.86

41

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 42 of 65

Total

74.29

2d. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Supported Employment

Center Name

December 2015

01 Northern Human Services

0.84

02 West Central Behavioral Health

0.19

03 Genesis Behavioral Health

2.80

04 Riverbend Community Mental Health

Center

0.20

05 Monadnock Family Services

1.00

06 Community Council of Nashua

6.50

07 Mental Health Center of Greater

Manchester

1.75

08 Seacoast Mental Health Center

1.00

09 Community Partners

0.25

10 Center for Life Management

0.30

Total

14.83

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health CMHC ACT Staffing Census Based on CMHC selfreport

Notes for 2b-d: Data extracted 3/1/16; The Staff Competency values reflect the sum of FTE's trained to provide each service type. These numbers are not a reflection of the services delivered, rather the quantity of staff available to provide each service. If staff is trained to provide multiple service types, their entire FTE value will be credited to each service type.

42

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 43 of 65

3. Community Mental Health Center Services: Annual Supportive Employment Penetration Rates for Prior 12 Month Period
12 Month Period Ending December 2015

Center Name

Supported Employment
Consumers

Total Eligible Consumers

Penetration Rate

01 Northern Human Services

121

1,277

9.5%

02 West Central Behavioral Health

92

642

14.3%

03 Genesis Behavioral Health

128

1,330

9.6%

04 Riverbend Community Mental Health Center

201

1,375

14.6%

05 Monadnock Family Services

188

971

19.4%

06 Community Council of Nashua

130

1,508

8.6%

07 Mental Health Center of Greater Manchester

999

3,154

31.7%

08 Seacoast Mental Health Center

159

1,252

12.7%

09 Community Partners

105

809

13.0%

10 Center for Life Management

179

746

24.0%

Deduplicated Total

2,294

12,842

17.9%

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 2/16/16; consumers are counted only one time regardless of how many services they receive

4. New Hampshire Hospital: Adult Census Summary

Measure

October - December 2015

Admissions

330

43

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 44 of 65

Mean Daily Census

126

Discharges

322

Median Length of Stay in Days for Discharges

12

Deaths

3

Revisions to Prior Period: None

Data Source: Avatar

Notes: Data extracted 3/1/16; Average Daily Census includes patients on leave and is rounded to nearest whole number

5a. Designated Receiving Facilities: Admissions

October - December 2015

Involuntary

Voluntary

Total

DRF

Admissions

Admissions Admissions

Franklin

27

42

69

Manchester (Cypress Center)

42

167

209

Portsmouth*

35

NA

36

Elliot

28

85

113

Total

132

295

427

* Portsmouth data only reflect involuntary admissions. DHHS is working with Portsmouth to expand their reporting to cover voluntary admissions for future releases of data.

44

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 45 of 65

5b. Designated Receiving Facilities: Mean Daily Census

October - December

DRF

2015

Franklin

7

Manchester (Cypress Center)

13

Portsmouth*

3

Elliot

13

Total

9

5c. Designated Receiving Facilities: Discharges

October - December

DRF

2015

Franklin

65

Manchester (Cypress Center)

207

Portsmouth*

37

Elliot

114

Total

423

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges

October - December

DRF

2015

Franklin

5

Manchester (Cypress Center)

4

Portsmouth*

5

Elliot

7

Total

5

45

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 46 of 65

* Portsmouth data only reflect involuntary admissions. DHHS is working with Portsmouth to expand their reporting to cover voluntary admissions for future releases of data.

Revisions to Prior Period: None

Data Source: NH DRF Database

Notes: Data Compiled 3/1/16; Information collection method for table was redesigned to increase accuracy

6. Glencliff Home: Census Summary Measure

October - December 2015

Admissions

4

Average Daily Census

114

Discharges

4

Individual Lengths of Stay in Days for Discharges

464, 1182, 1658, 3049

Readmissions

0

Mean Overall Admission Waitlist

16

Revisions to Prior Period: None

Data Source: Glencliff Home

Notes: Data Compiled 3/1/16; means rounded to nearest whole number

46

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 47 of 65

7. NH Mental Health Consumer Peer Support Agencies: Census Summary October - December 2015

Peer Support Agency

Total Members

Average Daily Visits

Alternative Life Center Total

455

39

Conway

135

10

Wolfeboro Outreach

18

0

Berlin

103

10

Littleton

118

10

Colebrook

81

9

Stepping Stone Total

490

21

Claremont

415

17

Lebanon

75

4

Cornerbridge Total

302

16

Laconia

133

4

Concord

133

12

Plymouth Outreach

36

NA

MAPSA Keene Total

166

15

HEARTS Nashua Total

423

26

On the Road to Recovery Total

377

33

Manchester

234

24

Derry

143

9

SCA Portsmouth Total

266

12

TriCity Coop Rochester Total

305

14

47

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 48 of 65

Total

2,784

175

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 3/1/16; Average Daily Visits NA for Outreach Programs

8. Housing Bridge Subsidy Summary to Date

October - December 2015

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

466

22

488

Section 8 Voucher

70

0

70

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health

Notes: Data Compiled 3/5/16

48

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 49 of 65

9. Housing Bridge Subsidy Current Census Summary

Measure

As of 12/31/2015

Housing Slots

450

Rents currently being paid

412

Individuals accepted but waiting to lease

25

Waiting list for slots

0

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health

Notes: Data Compiled 3/5/16; All individuals currently on the Bridge Program are actively transitioning from the program (waiting for their Section 8 housing voucher).

10. Housing Bridge Subsidy Unit Address Density Number of Unit(s)* at Same Address

Frequency as of 3/5/16

1

314

2

17

3

14

4

1

5

2

6

1

*All units are individual units

49

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 50 of 65
New Hampshire Community Mental Health Agreement Quarterly Data Report
January to March 2016
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement May 31, 2016
50

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 51 of 65
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence
51

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 52 of 65
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 5/31/2016
Reporting Period: 1/1/2016-3/31/2016
Notes  Additional detail was added to the Glencliff waitlist number to show the number of people who are “active” on the list. These are people who have been fully reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.  Elliot’s Designated Receiving Facility data is now split by their geriatric and nongeriatric units.  Portsmouth’s Designated Receiving Facility has declined to provide voluntary data as timely as the other DRFs. We are working with Portsmouth to provide quarterly data with a one quarter lag with the expectation that beginning in next quarter’s report, Portsmouth voluntary data will be included. We plan on restating all the DRF data for the lagged quarter, including Portsmouth, to provide correct statewide totals and averages.
52

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 53 of 65

Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services

Publication Date: 5/31/2016

Reporting Period: 1/1/2016-3/31/2016

1. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Center Name

January February

2016

2016

Unique March Consumers
2016 in Quarter

01 Northern Human Services

75

75

78

79

02 West Central Behavioral Health

20

23

24

26

03 Genesis Behavioral Health

35

33

39

39

04 Riverbend Community Mental Health Center

61

64

67

70

05 Monadnock Family Services

61

65

66

68

06 Community Council of Nashua

65

66

65

72

07 Mental Health Center of Greater Manchester

271

274

267

293

08 Seacoast Mental Health Center

68

68

65

72

09 Community Partners

71

69

66

73

10 Center for Life Management

45

43

41

49

Total

770

779

778

839

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 5/16/16; consumers are counted only one time regardless of how many services they receive.

53

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 54 of 65
2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents
March 2016

NMuarssteers Level Clinician/or FEuqnuictviaolenanlt Support Worker PTeoetralSpecialist (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner

Center Name

01 Northern Human Services

0.53 2.60 7.64 0.38 11.15

0.80

02 West Central Behavioral Health 0.40 1.18 2.19 0.60 4.37

0.14

03 Genesis Behavioral Health

0.60 2.00 4.00 0.80 7.40

0.50

04 Riverbend Community Mental 0.50 3.00 3.50 0.00 7.00

0.40

Health Center

05 Monadnock Family Services

1.00 1.25 5.00 0.50 7.75

0.65

06 Community Council of Nashua 1.00 3.00 2.50 0.00 6.50

0.25

07 Mental Health Center of

2.22 19.00 8.79 0.00 30.01

1.00

Greater Manchester

08 Seacoast Mental Health Center 1.43 3.10 6.00 1.00 11.53

0.60

09 Community Partners

0.40 2.00 3.00 0.50 5.90

0.40

10 Center for Life Management

1.00 2.00 4.16 1.00 8.16

0.20

Total

9.08 39.13 46.78 4.78 99.77

4.94

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Substance Use Disorder Treatment

Center Name

March 2016

01 Northern Human Services

2.55

02 West Central Behavioral Health

1.13

03 Genesis Behavioral Health

5.90

1.40 04 Riverbend Community Mental Health

54

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 55 of 65

Center 05 Monadnock Family Services 06 Community Council of Nashua 07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

2.40 3.00
9.00 0.00 1.00 4.00 30.38

2c. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Housing Assistance

Center Name

March 2016

01 Northern Human Services

9.28

02 West Central Behavioral Health

5.40

03 Genesis Behavioral Health

5.80

04 Riverbend Community Mental Health

Center

6.00

05 Monadnock Family Services

1.00

06 Community Council of Nashua

5.00

07 Mental Health Center of Greater Manchester

25.09

08 Seacoast Mental Health Center

7.00

09 Community Partners

3.75

10 Center for Life Management

6.86

Total

75.18

55

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 56 of 65

2d. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Supported Employment

Center Name

March 2016

01 Northern Human Services

0.84

02 West Central Behavioral Health

0.19

03 Genesis Behavioral Health

2.80

04 Riverbend Community Mental Health

Center

0.50

05 Monadnock Family Services

1.00

06 Community Council of Nashua

5.00

07 Mental Health Center of Greater

Manchester

1.78

08 Seacoast Mental Health Center

1.00

09 Community Partners

1.25

10 Center for Life Management

0.30

Total

14.66

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health CMHC ACT Staffing Census Based on CMHC selfreport

Notes for 2b-d: Data extracted 5/16/16; The Staff Competency values reflect the sum of FTE's trained to provide each service type. These numbers are not a reflection of the services delivered, rather the quantity of staff available to provide each service. If staff is trained to provide multiple service types, their entire FTE value will be credited to each service type.

56

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 57 of 65

3. Community Mental Health Center Services: Annual Supportive Employment Penetration Rates for Prior 12 Month Period
12 Month Period Ending March 2016

Center Name

Supported Employment
Consumers

Total Eligible Consumers

Penetration Rate

01 Northern Human Services

130

1,226

10.6%

02 West Central Behavioral Health

97

634

15.3%

03 Genesis Behavioral Health

125

1,308

9.6%

04 Riverbend Community Mental Health Center

207

1,465

14.1%

05 Monadnock Family Services

203

992

20.5%

06 Community Council of Nashua

136

1,510

9.0%

07 Mental Health Center of Greater Manchester

1,185

3,225

36.7%

08 Seacoast Mental Health Center

137

1,248

11.0%

09 Community Partners

102

812

12.6%

10 Center for Life Management

192

777

24.7%

Deduplicated Total

2,509

12,975

19.3%

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 5/16/16; consumers are counted only one time regardless of how many services they receive

4. New Hampshire Hospital: Adult Census Summary

Measure

January - March 2016

Admissions

309

57

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 58 of 65

Mean Daily Census

131

Discharges

300

Median Length of Stay in Days for Discharges

11

Deaths

0

Revisions to Prior Period: None

Data Source: Avatar

Notes: Data extracted 5/16/16; Average Daily Census includes patients on leave and is rounded to nearest whole number

5a. Designated Receiving Facilities: Admissions

January - March 2016

Involuntary

Voluntary

Total

DRF

Admissions

Admissions Admissions

Franklin

37

32

69

Manchester (Cypress Center)

48

209

257

Portsmouth*

46

NA

NA

Elliot Geriatric Psychiatric Unit

12

53

65

Elliot Pathways

37

84

121

Total

143

NA*

NA*

NA = Not available;

* Total not available due to lack of Portsmouth voluntary admission data. DHHS continues to work with Portsmouth to expand their reporting to cover voluntary admissions for future releases of data.

58

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 59 of 65

5b. Designated Receiving Facilities: Mean Daily Census

DRF

January - March 2016

Franklin

7.9

Manchester (Cypress Center)

14.7

Portsmouth

NA

Elliot Geriatric Psychiatric Unit

19.7

Elliot Pathways

18.1

Total

NA*

NA = Not available;

* Total not available due to lack of Portsmouth voluntary admission data. DHHS continues to work with Portsmouth to expand their reporting to cover voluntary admissions for future releases of data.

5c. Designated Receiving Facilities: Discharges

DRF

January - March 2016

Franklin

76

Manchester (Cypress Center)

261

Portsmouth

NA

Elliot Geriatric Psychiatric Unit

57

Elliot Pathways

122

Total

NA*

NA = Not available;

* Total not available due to lack of Portsmouth voluntary admission data. DHHS continues to work with Portsmouth to expand their reporting to cover voluntary admissions for future releases of data.

59

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 60 of 65

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges

DRF

January - March 2016

Franklin

8.6

Manchester (Cypress Center)

4.2

Portsmouth

NA

Elliot Geriatric Psychiatric Unit

15.0

Elliot Pathways

7.4

Total

NA*

NA = Not available;

* Total not available due to lack of Portsmouth voluntary admission data. DHHS continues to work with Portsmouth to expand their reporting to cover voluntary admissions for future releases of data.

Revisions to Prior Period: None Data Source: NH DRF Database Notes: Data Compiled 5/16/16

60

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 61 of 65

6. Glencliff Home: Census Summary Measure

January - March 2016

Admissions

3

Average Daily Census

113

Discharges

1

Individual Lengths of Stay in Days for Discharges

1,492

Readmissions

0

Mean Overall Admission Waitlist

15 (6 Active*)

Revisions to Prior Period: None

Data Source: Glencliff Home

Notes: Data Compiled 5/10/16; means rounded to nearest whole number. * Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

61

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 62 of 65

7. NH Mental Health Consumer Peer Support Agencies: Census Summary January - March 2016

Peer Support Agency

Total Members

Average Daily Visits

Alternative Life Center Total

453

45

Conway

138

12

Wolfeboro Outreach

18

0

Berlin

106

12

Littleton

122

12

Colebrook

69

9

Stepping Stone Total

520

18

Claremont

438

13

Lebanon

82

5

Cornerbridge Total

310

12

Laconia

137

4

Concord

137

8

Plymouth Outreach

36

NA

MAPSA Keene Total

170

14

HEARTS Nashua Total

444

25

On the Road to Recovery Total

396

44

Manchester

250

35

Derry

146

9

SCA Portsmouth Total

267

12

TriCity Coop Rochester Total

319

16

62

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 63 of 65

Total

2,879

142

Revisions to Prior Period: Prior period total of average daily visits was inadvertently listed as 179, the correct value is 142

Data Source: Bureau of Behavioral Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 5/16/16; Average Daily Visits NA for Outreach Programs

8. Housing Bridge Subsidy Summary to Date

January – March 2016

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

488

30

518

Section 8 Voucher

70

1

71

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health

Notes: Data Compiled 5/9/16

63

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 64 of 65

9. Housing Bridge Subsidy Current Census Summary

Measure

As of 3/31/2016

Housing Slots

450

Rents currently being paid

415

Individuals accepted but waiting to lease

22

Waiting list for slots

0

Revisions to Prior Period: None

Data Source: Bureau of Behavioral Health

Notes: Data Compiled 5/9/16; All individuals currently on the Bridge Program are actively transitioning from the program (waiting for their Section 8 housing voucher).

10. Housing Bridge Subsidy Unit Address Density Number of Unit(s)* at Same Address

Frequency as of 3/31/16

1
317
2
22
3
13
4
1
5
2
6
0
*All units are individual units

64

Case 1:12-cv-00053-SM Document 116-1 Filed 07/06/16 Page 65 of 65 65

 
 Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 1 of 96
ATTACHMENT A

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 2 of 96

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 3 of 96
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Five
January 6, 2017
I. Introduction
This is the fifth semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case ofAmanda D. v. Hassan,; United States v. New Hampshire, No. 1:12-cv-53-SM For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State's implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this six-month period (July I, 2016 through December 31, 20 16), the ER has continued to observe the State's work to implement certain key service elements ofthe CMHA, and has continued to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. During this period, the ER:
• Conducted on-site reviews of Assertive Community Treatment (ACT) teams/services and Supported Employment (SE) services at West Central Behavioral Health, Greater Nashua Mental Health, and Northern Human Services: a non-random sample of ACT and SE records was reviewed at each ofthese sites;
• Conducted an on-site visit related to implementation ofthe Mobile Crisis Program in Manchester;
• Met with the New Hampshire Consumer Council; • Met with Ken Norton, Executive Director ofNAMI New Hampshire; • Met with the State's Central Team to review progress and discuss barriers to
transition from both New Hampshire Hospital (NHH) and Glencliff Home (Glencliff); • Met with senior management and with a clinical team at NHH to review transition planning processes and issues; • Met with Glencliff leadership, clinical staff, and residents to discuss transition planning processes and issues;

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 4 of 96
• Met with New Hampshire Department of Health and Human Services (DHHS) Commissioner Jeffrey Meyers;
• Met with DHHS staff involved with the PASRR program to discuss the new contract for PASRR services and to identify data reporting issues;
• Participated in several meetings with representatives of the Plaintiffs and the United States (hereinafter "Plaintiffs");
• Met twice with DHHS Quality Management/Quality Service Review (QM/QSR) staff to discuss refinements to the QSR process; and
• Convened two all parties meetings to discuss general progress and implementation issues related to the CMHA.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
II. Data
The New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains ofthe CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (November 2016), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The ability to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve. Specific data from the quarterly reports are included in the discussion of individual CMHA services below.
In addition to the standardized reporting of certain types of data, DHHS continues to collect and report on other data necessary to monitor performance related to the CMHA. These include reports from the new mobile crisis services in the Concord and Manchester Regions; data on discharge destinations from NHH and Glencliff; reports of wait list numbers for Emergency Department (ED) boarding; and utilization ofthe Bridge Housing Subsidy Program.
As noted in previous ER reports, there continue to be important categories of data that are needed, but not routinely collected and reported, and which will need to be reported in order to accurately evaluate ongoing implementation of the CMHA. For example, there continues to be no reported or analyzed data on the degree to which participants in SE are engaged in competitive employment in integrated community settings consistent with their individual treatment plans. These data are important in assessing the fidelity with which SE services are provided. DHHS's efforts related to assuring the fidelity of SE services is discussed in theSE section of this report.
2

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 5 of 96
Another gap in data is related to people receiving Supported Housing (SH) under the Bridge Housing Subsidy Program. These participants are not yet clearly identified in the Phoenix II system, and thus it is difficult to document the degree to which these individuals are: (a) connected to local CMHA services and supports; or (b) actually receiving services and supports to meet their individualized needs on a regular basis in the community. As noted in the January 2016 ER Report, DHHS has identified a strategy to link data from the Bridge Subsidy Program to the Phoenix II system. However, such data has not been produced to date, leaving a significant gap in the ER's ability to evaluate compliance with SH provisions of the CMHA. Other gaps in data are referenced later in this report. Although the soon-to-be-initiated QM/QSR process will provide additional information related to the quality, effectiveness, and (where applicable) the fidelity of the services delivered, the data identified above is an essential complement to those client reviews and necessary in order for the ER and the parties to effectively measure ongoing implementation, and for the State to demonstrate compliance with the terms of the CMHA. The QM/QSR process is discussed later in this report.
III. CMHA Services
The following sections ofthe report address specific service areas and related activities and standards contained in the CMHA.
Mobile/Crisis Services and Crisis Apartments
The CMHA calls for the establishment of mobile crisis capacity and crisis apartments in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC is the vendor selected to implement the mobile team and crisis apartments in the Concord Region. Table I below includes the most recent available information on activities of its new crisis program.
3

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 6 of 96

Table I

Concord Region Self-Reported Mobile Crisis Services: April-June 2016 and JulySeptember 2016

Total unduplicated people served
Services provided in response to immediate
crisis:
• Phone support/triage • Mobile assessments • Crisis stabilization appointments • Emergency services medication
appointments
• Office based urgent assessments
Services provided after the immediate crisis :
• Phone support/triage • Mobile assessments • Crisis stabilization appointments • Emergency services medication
appointments
• Office based Urgent Assessments

April- June 2016
532
735 142 63 33
36
226 18 63 27
36

July - September 2016 549
927 157 64 69
46
427 27 64 33
46

Referral source:

• Self • Family • Guardian • Mental health provider • Primary care physician • Hospital emergency department • Police • CMHC Internal
Crisis apartment admissions:

282

310

111

101

23

0

18

28

16

18

24

64

23

25

94

63

• Bed days • Average length of stay

120

289

3.0

3.9

Law enforcement involvement

46

46

Total hospital diversions*

288

263

*Hospital diversions are instances in which services are provided to individuals in crisis resulting

in diversion from being assessed at the ED and/or being admitted to a psychiatric hospital.

These data indicate a growth in the number of people accessing crisis services, and in the number of crisis response services delivered. There has also been substantial growth in utilization ofthe crisis apartments. These data also suggest that there are hundreds oftriage callers each quarter
4

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 7 of 96
who receive neither a mobile crisis assessment nor an office-based appointment. In order to measure whether and to what extent class members have appropriate access to community-based MCI, a further examination and analysis ofMCI triage and dispatch decisions is needed.
In mid-June 2016, DHHS awarded a contract to the Mental Health Center of Greater Manchester to establish the second Mobile Crisis Team and Crisis Apartments. Given the timing of the contract award, mobile crisis services were not operational in the Manchester Region by June 30, 2016, as specified in the CMHA. However, as of December 2016 the Manchester Mobile Team is staffed and operational; the separate Mobile Crisis telephone system is in place; an interim crisis apartment has been identified and is in use; and outreach has begun to the Manchester police and other first responders in the community. Data from the Manchester Mobile Crisis program will be incorporated in the June 30, 2017 ER report. At that time, the ER hopes to include an analysis of whether the new crisis services are having a positive impact on reducing the number of ED presentations and the number of readmissions to NHH/DRFs in the Concord and Manchester regions.
DHHS reports that it will be incorporating Mobile Crisis and Crisis Apartment data in the Phoenix system, which will support routine collection and reporting ofthese data in the Quarterly Data Reports. DHHS also reports that the RFP for the new Mobile Team and Crisis Apartments to be developed in the Nashua region by July 1, 2017, was issued on December 19, 2016, and is expected to be approved in March 2017. In order to comply with the terms of the CMHA, and to avoid extended delays in implementation, like those seen in the Concord and Manchester Regions, DHHS must make every effort to ensure this procurement process proceeds rapidly enough to assure the selected vendor is ready to operate the program and begin serving class members by July 1, 2017.
Assertive Community Treatment (ACT)
ACT is a core element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team; and
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time.
The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30,2015 (18 months ago). Further, as of June 30,2016, the State is required to have the capacity to provide ACT to 1,500 priority Target Population individuals.
5

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 8 of 96

As displayed in Table II below, the staff capacity of the 12 adult ACT teams in New Hampshire has increased by only two FTEs in the three months between June 2016 and September 2016. During the same time, the total active caseload has increased by only 26 individuals. As of the date of this report, the State is providing ACT services to 865 unique consumers and as a result is delivering only 58 percent of the ACT capacity required by the CMHA, and is out of compliance on this key CMHA service.

Table II

Self-Reported ACT Staffing (excluding psychiatry): May 2015 through September 2016

Region

FTE

FTE

FTE

FTE

Northern West Central Genesis Riverbend Monadnock Nashua 1 Nashua 2 Manchester 1 Manchester 2 Seacoast Community Partners Center for Life Man.

May-15 Sep-15

14.80 3.00 7.10 7.00 8.20

11.29 3.83 7.5 7.3 8.5

12.80
8.20 7.80

11.77
8.7 6.36

Dec-15
11.15 2.64 6.4 6.7 7.75
11.77 7.9
8.16

March 2016 11.15
4.37 7.4 7
7.75
11.53
5.9 8.16

FTE
June
11.15 4.44 7.60 7.50 7.75 5.75 3.75
14.61 18.81 10.73

FTE
September 2016 10.25 5.44 7.00 7.50 7.25 6.25 5.25 15.46 20.24 8.73

%change JuneSept
-8.78% 18.38% -8.57%
0.00% -6.90% 8.00% 28.57% 5.50% 7.07% -22.91%

7.90 7.91

8.03 7.91

1.62% 0.00%

Total

68.90 65.25 62.47 63.26 107.90

109.31

1.29%

It is clear from this table that overall ACT staffing has remained at best static, and in some regions has decreased over the past four reporting periods. This is true despite previous ER findings that New Hampshire was out of compliance with the standards of the CMHA. Based on staffing shortages alone, more than 500 individuals potentially would not be able to receive such services due to the lack of capacity. This current pace of staff recruitment and capacity development is not sufficient to satisfy the State's outstanding obligations under the CMHA; nor will it allow for a prompt, statewide response to the needs of individuals eligible for ACT and identified through ongoing outreach efforts.
Table III below displays trends in active caseloads for ACT services by Region.

6

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 9 of 96

Table III

Self-Reported ACT Caseload (Unique Adult Consumers) by Region per Quarter: May 2015 through September 2016

Cases

Cases

May-15 Sep-15

Cases

Cases

Dec-15 Mar-16

Cases Sep-16

%Change Mar. to Sep

Northern West Central Genesis Riverbend Monadnock Greater Nashua Manchester Seacoast Community Partners Center for Life Man.

60

72

74

79

88

10.23%

16

19

21

26

33

21.21%

22

30

34

39

58

32.76%

79

60

56

70

81

13.58%

47

54

61

68

73

6.85%

63

74

72 72

76

5.26%

254

265

270 293

270

-8.52%

73

65

65

72

70

-2.86%

16

70

76

73

74

1.35%

39

37

40

49

47

-4.26%

Total*

669

746

766 839

865

3.10%

Based on self-reported staffing data, the Regions appear to have made some gains in enhancing staff capacity within certain ACT teams between June and September, 2016. Seven ACT Teams (including the two teams in Manchester and the two teams in Nashua) reported increases in ACT staffing from March through September, 2016, while five teams reported reductions in ACT staffing during that period. All ACT teams continue to report substance use disorder (SUD) staff competency. Four of the teams continue to report less than one FTE SE competency.
Three ofthe 12 adult ACT teams still have fewer than the 7- 10 professionals specified for ACT teams in the CMHA, and four teams continue to report having no peer specialist on the ACT Team. As with the previous report, only three teams report having at least one FTE peer specialist. Five teams continue to report having less than .5 FTE combined psychiatry/nurse practitioner time available to their ACT teams. Three teams report having less than 50% FTE Nursing on the Team (Note: this is a substantial improvement from the previous ER report, in which seven ACT Teams were noted to report less than 50% FTE nursing staffing).
Despite the progress noted above, remaining deficiencies in ACT team staffing and composition, leave the State out of compliance with the foundational service standards described in Section V.D.2 of the CMHA, and threaten its ability to provide a robust and effective system of ACT services throughout the State.

7

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 10 of 96
As noted in the previous ER Report, the New Hampshire DHHS has begun to take more aggressive action to work with CMHCs in certain Regions to increase their ACT staffing and caseloads. These actions include: (a) monthly ACT monitoring and technical assistance with DHHS leadership and staff; (b) implementation of a firm schedule for ACT self-assessments and DHHS fidelity reviews; (c) a small increase in ACT funding incorporated into the Medicaid rates for CMHCs; (d) active on-site monitoring and technical assistance for CMHCs not yet meeting CMHA ACT standards; and (e) substantial and coordinated efforts to address workforce recruitment and retention. Compliance letters and performance improvements plans (PIPs) have been initiated in three of the 10 Regions. Also, as noted in the previous ER report, the new QSR being implemented by DHHS will examine the provision of ACT services, and the QSR findings are expected to prompt additional PIPs where necessary.
DHHS and representatives of the Plaintiffs have been working collaboratively on new regulations defining ACT service eligibility and access standards over the past year. The ER understands that the revised ACT regulations were approved on December 15, 2016. The ER applauds the mutual efforts and spirit of open communication and compromise that have taken place to ensure that these new regulations were developed and promulgated in a positive fashion.
Based on continuing non-compliance with the ACT staffing and capacity standards in the CMHA, in the previous report the ER recommended that DHHS adopt several management initiatives to facilitate and speed up progress towards meeting the CMHA ACT requirements. Progress related to these suggested actions is summarized in the conclusion to this report.
Supported Employment
Pursuant to the CMHA's SE requirements, the State must accomplish three things: I) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.l); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: "By June 30, 2016, the State will increase its penetration rate of individuals with SMI receiving supported employment ...to 18.1% of eligible individuals with SMI." (Section V.F.2(d)).
For this reporting period, the State reports that it has achieved a statewide SE penetration rate of 20.4%, 2.3 points higher than the 18.1% penetration rate specified for June 30, 2016 in the CMHA. Table IV below shows theSE penetration rates for each of the 10 Regional CMHCs in New Hampshire.
8

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 11 of 96

Table IV

Self-Reported CMHC SE Penetration Rates: March 2015 through October 2016

Penetration Mar-15

Penetration Sep-15

Penetration Dec-15

Penetration Mar-16

Penetration Oct-16

% Change
Mar-Oct

Northern West Central Genesis Riverbend Monadnock Greater Nashua Manchester Seacoast Community Part. Center for Life Man . CMHA Target Statewide Average

7.10% 13 .50% 9.40% 14.90% 8.00% 6.10% 14.60% 10.50% 8.10% 16.30% 14.10% 11.30%

8.20% 12.90% 9.30% 14.20% 16.40% 7.70% 26 .10% 13.10% 11.60% 15.70% 16.10% 15.70%

9.50% 14.30% 9.60% 14.60% 19.40% 8.60% 31 .70% 12 .70% 13.00% 13.00% 16.10% 17.90%

10.60% 15.30% 9.60% 14.10% 20.50% 9.00% 36 .70% 11.00% 12.60% 24.70% 16.10% 19.30%

14.00% 17.50% 14.10% 13.70% 20.40% 11.90% 37 .10% 12 .00% 10.40% 23.00% 18.10% 20.40%

32.08% 14.38% 46.88% -2.84% -0.49% 32 .22% 1.09% 9.09% -17.46% -6.88% 0.00% 5.70%

As noted in Table IV, the State has exceeded the statewide CMHA penetration rate in the last two reporting periods. In addition, the New Hampshire DHHS is commended for continuing its efforts to: (a) measure the fidelity ofSE services on a statewide basis; and (b) work with the seven Regions with penetration rates below CMHA criteria to increase access to and delivery of SE services to target population members in their Regions. As can be seen in Table IV, five of the seven Regions with less than 18.1% SE penetration rates have improved their performance in the most recent reporting period. And, as with ACT services, the DHHS has implemented a combination of contract compliance, technical assistance, workforce recruitment and retention, and internal and external fidelity reviews to assure the quality and accessibility of SE services statewide. The ER expects the QSR process to measure whether and to what extent SE services are delivered in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans and the fidelity requirements of the CMHA. To that end, the ER expects to review employment data from each region during the next reporting period.
Supported Housing
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Subsidy Program by June 30,2016. As ofthe September 30,2016, DHHS reports having 451 individuals in leased SH apartments, and 28 people approved for a subsidy but not yet
9

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 12 of 96

leased. The State is in compliance with the CMHA numerical standards for SH effective June 30, 2016.

Table V below summarizes recent data supplied by DHHS related to the Bridge Subsidy Program.

Table V

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program: September 2015 through September 2016

B!l'lidge Subsidy Prog;ram lnfonnation

Septemb-er lij15

March 2'011() Septe•h-er Dl'

Total housing slots (subsidies)

450

450

479

available

Total people for whom rents are

376

415

451

being subsidized

Individuals accepted but waiting

23

22

28

to lease

Individuals currently on the wait

0

0

0

list for a bridge subsidy

Total number served since the

466

518

603

inception ofthe Bridge Subsidy

Program

Total number receiving a

70

71

83

Housing Choice (Section 8)

Voucher

The CMHA stipulates that" ...all new supported housing ...will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population." (V.E.l(b)). Table VI below displays the reported number of units leased at the same address.

10

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 13 of 96

Table VI

Self-Reported Bridge Subsidy Housing Concentration (Density)

September March

June

November

2015

2016

2016

2016

Number of properties with one

290

317

325

339

leased SH unit at the same

address

Number of properties with two

27

22

35

24

SH units at the same address

Number of properties with three

2

13

8

13

SH units at the same address

Number of properties with four

4

1

1

3

SH units at the same address

Number of properties with five

1

2

2

0

SH units at the same address

Number of properties with six

1

0

1

1

SH units at the same address

As noted in the previous report, almost 90% of the leased units are at a unique address or with one additional unit at that address. This supports a conclusion that the Bridge Subsidy Program, to a large degree, is operating as a scattered-site program. For the 24% of the units shown in Table VI at the same address, it is not known at this time whether the unit density standards included in the CMHA are being met. DHHS is collecting information on the total units in each property where there are two or more Bridge units at the same address, and this data will be reported in the next ER report.
It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1 (c)). DHHS reports, and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge Subsidy Program leased units. 1

1 DHHS reports that currently there is one voluntary roommate situation reflected in the above data.
11

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 14 of 96
As noted in the Data section of this report, current data is not available on the degree to which Bridge Subsidy Program participants access and utilize support services and whether or not the services are effective and meet individualized needs. Receipt of services is not a condition of eligibility for a subsidy under the Bridge Program, but the CMHA does specify that " ... supported housing includes support services to enable individuals to attain and maintain integrated affordable housing, and includes support services that are flexible and available as needed and desired ....". (V.E.l(a)). As noted in the January and June 2016 ER Reports, DHHS has been working on a method to cross-match the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. This will allow documentation of the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports.
In previous reports the ER has identified a number of important and needed data elements associated with the SH eligibility criteria and lack of a waitlist, as well as monitoring implementation ofthe SH program in the context of the CMHA. These include:
• Total number of Bridge Subsidy Program applicants per quarter; • Referral sources for Bridge Subsidy Program applicants; • Number and percent approved for the Bridge Subsidy Program; • Number and percent rejected for the Bridge Subsidy Program;
o Reasons for rejection of completed applications, separately documenting those who are rejected because they do not meet federal HCV/Section 8 eligibility requirements;
• Number and disposition of appeals related to rejections of applications; • Elapsed time between application, approval, and lease-up; • Number of new individuals leased-up during the quarter; • Number ofterminations from Bridge subsidies; • Reasons for termination:
o Attained permanent subsidized housing (Section 8, public housing, etc.); o Chose other living arrangement or housing resource; o Moved out of state; o Deceased; o Long term hospitalization; o Incarceration; o Landlord termination or eviction; or o Other; • Number of Bridge Subsidy Program participants in a roommate situation; and • Lease density in properties with multiple Bridge Subsidy Program leases.
This information is important in assessing whether eligibility is properly determined, whether a waitlist is properly maintained and in assessing whether or not support services are adequate to
12

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 15 of 96
enable the individual to "attain and maintain integrated affordable housing" and whether services are "flexible and available as needed and desired." Most rental assistance programs collect and report such information, given its intrinsic value in monitoring program operations. Further, such data enhances DHHS' ability to demonstrate the timeliness and effectiveness of access of the priority target population to this essential CMHA program component. Most importantly, this data is necessary to help the ER determine compliance with CMHA Sections IV.B, IV.C, and VILA. The ER will continue to work collaboratively with DHHS to identify sources and methods for such data collection and reporting. As described in the previous ER report, DHHS was in the process of drafting Bridge Housing Subsidy Program rules, in consultation with representatives ofthe Plaintiffs. These revised SH rules have been successfully promulgated, and, as with the ACT rules noted above, represent evidence of positive collaboration among the parties related to CMHA implementation.
Transitions from Institutional to Community Settings
During the past 18 months, the ER has visited both Glencliff and NHH on at least four separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities late last year. Transition planning activities related to specific current residents in both facilities were observed, and most recently, a small non-random sample of resident transition records has been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities. The ER has participated in three meetings of the Central Team. The Central Team has now had about 12 months of operational experience, and has started reporting data on its activities. To date, 21 individuals have been submitted to the Central Team, 14 from Glencliff and seven from NHH. Table VII below summarizes the discharge barriers that have been identified by the Central Team with regard to these individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total substantially higher than the number of individuals reviewed by the Central Team.
13

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 16 of 96

Table VII

Discharge Barriers Identified by the Central Team: September 2015

Through November 2016

Discharge Barriers

NHH

Glencliff

Legal

2

2

Residential

3

7

Financial

1

5

Clinical

3

4

Family/Guardian

1

0

Other

2

0

Glencliff
In the time period from April to September 2016, Glencliff reports that it has admitted nine individuals, and has had only two discharges. There have been no readmissions during this time frame. One of these two discharges is reported to have been to an independent apartment in the community. The wait list for admission has remained relatively constant: averaging 15 people during this time frame. The lengths of stay for the two persons discharged were 481 days and 2,871 days.
Section V.E.3(g) of the CMHA requires the State by June 30, 2015 to:" ... have the capacity to serve in the community four individuals with mental illness and complex health care needs residing at Glencliff. ..." The CMHA defines these as: "individuals ...who could not be costeffectively served in supported housing."2 This target increases to a total capacity for ten such individuals to be discharged to the community by June 30, 2016. The CMHA includes several options for attaining that goal, including the issuance of an RFP to secure new residential services beds and/or to access existing community capacity in the residential services system. The CMHA also anticipates collaboration with the DHHS Elderly and Adult Services component to assist with implementing transition plans for this population.
2 CMHA V.E.2(a)
14

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 17 of 96
As noted in the June 30,2015 and January 5, 2016 ER reports, DHHS has been endeavoring to access the Enhanced Family Care service modality included in New Hampshire's Home and Community-Based Services waiver for people who are elderly or have disabilities. DHHS has also been exploring other Medicaid waiver and in-plan service authorities to piece together an array of services for each of the individuals at Glencliff for whom this type of transition planning is being conducted. As of the date of this report, DHHS has: (a) identified a vendor to serve four individuals with complex health care needs in the community; and (b) has developed a funding mechanism through which the vendor can invoice for specialized individualized supports for these individuals. Four individuals have visited the new program site and have accepted transfers to this new program. The first individuals are expected to move to the program in January, and the remaining individual(s) are expected to transition in January. It is hoped that this program model and funding mechanism will provided a template and positive experience to accelerate transitions of individuals with mental illness and complex medical conditions from Glencliff into integrated community settings.
The ER notes that Glencliff continues to support and effectuate transitions of individuals to integrated community settings under a variety of other funding and living arrangements. DHHS reports that six individuals have transitioned from Glencliffto integrated community settings since the inception of the CMHA. This activity is to be commended, and hopefully will accelerate in parallel with facilitated transitions of individuals with complex health care needs into small program sites as noted above.
The ER continues to find that the State is not in compliance with Section V.E.3(g) and (h) ofthe CMHA, as well as a number of provisions throughout Section VI. Despite the commendable progress identified above, the ER continues to find that the progress in creating capacity for individuals with mental illness and complex health care needs who cannot be cost-effectively served in supportive housing does not yet meet the requirements of the CMHA.
After this report was drafted, the State provided some information on six individuals that it believes have been discharged from Glencliff consistent with this provision of the CMHA. However, neither the Plaintiffs nor the ER have been able within the time frame of this report to assess the information provided by the State. The ER will request input from the Plaintiffs, and may request additional information from the State. Any changes resulting from these discussions and information analyses will be reflected in future ER reports.
PASRR
In October 2016, the ER met with program staff of DHHS to discuss data reporting related to the State's PASRR Program. At that time the State was engaged in re-procuring the PASRR contract, a new vendor was in the process of being selected, and it was not possible to obtain detailed information about how the new vendor will collect and report data. The ER expects
15

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 18 of 96

DHHS will provide the requested data, and will facilitate a meeting between the ER and the new vendor, as soon as possible. The ER needs to be satisfied that PASRR reviews are being conducted as described under VI A.1 0, and that individuals whose needs could be met in the community are promptly referred to the appropriate area agency or CMHC in order to find that there is compliance with this CMHA requirement.

New Hampshire Hospital

For the time period July through September 2016, DHHS reported that NHH effectuated 373 admissions and 365 discharges. The mean daily census was 134, and the median length of stay for discharges was 8 days.

Table VIII below compares NHH discharge destination information for the three most recent reporting periods. The numbers are expressed as percentages because the length ofthe reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.

Table VIII

New Hampshire Hospital Self-Reported Data on Discharge Destination

Discharge Destination

Percent January 2014 through May 2015

Percent July 1 2015 through September 18, 2015

Percent September 19, 2015 through April20, 2016

Percent October and November
2016

Home - live alone or 74.4% with others

67.3%

80.2%

84.86%

Glencliff

0.4%

0.20%

0.60%

0.54%

Homeless Shelter/motel

3.8%

2.4%

2.7%

0.54%

Group home 5+/DDS 3.4% supported living, etc.

9.02%

3.2%

1.62%

Jail/corrections
Nursing home/rehab facility
Unknown

1.5% 1.9%
12.6%

0.40% 3.0%
17.64%

1.4% 0.80%
6.8%

3.64% 3.78%
1.62%

16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 19 of 96

The most recent Quarterly Data Report contains new, consistently reported information on the hospital-based DRFs/APRTP in New Hampshire. It is important to capture the DRF/APRTP data and combine it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. The ER appreciates the State gathering this information. Table IX summarizes this data.

Table IX

Self-Reported DRF/APRTP Utilization Data: January through September 2016

Admissions Jan - March 2016 April -June 2016 July - Sept 2016

Franklin Cypress Portsmouth Elliot Elliot Total Geriatric Pathways

69

257

NA

79

205

378

37

207

375

65

121

512

49

92

803

54

114

787

Percent involuntary Jan - March 2016 April- June 2016 July- Sept 2016

53.70% 55.70% 43.20%

18.70% 24.40% 29.50%

NA
20.40% 18.90%

18.50% 4.10% 13.00%

30.60% 48.90% 44.70%

26.20%* 25.50% 26.20%

Average Census Jan - March 2016 April- June 2016 July- Sept 2016

7.9

14.7

NA

19.7

18.1

60.1*

7.8

13.2

21.4

22.5

16.9

81.8

4.5

13.6

23 .2

25.6

14.5

81.4

Discharges Jan - March 2016 April- June 2016 July - Sept 2016

76

261

NA

78

206

363

35

213

380

57

122

516*

51

90

788

64

113

805

Mean LOS for

Discharges

Jan - March 2016

8.6

4.2

NA

15

April- June 2016

6

4

4

28

July- Sept 2016

7

5

4

24

*Totals do not include Portsmouth for Jan- March 2016.

7 .4

8.8*

7

5

8

5

DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table X below provides a summary of these recently reported data.

17

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 20 of 96

Table X

Self-Reported Discharge Dispositions for DRFs in New Hampshire

July 2016 through September 2016

Disposition Cypress

Home

188

Elliot GPU
16

Elliott Franklin Portsmouth

Pathways

Regional

102

27

245

Total 578

NHH

0

0

0

2

12

14

Nursing

Home

0

17

0

0

0

17

Residential

Facility

4

16

1

2

0

23

Other DRF

3

2

2

3

0

10

Death

0

2

0

0

0

2

Other or

Unknown

18

10

8

0

123*

159...

*The Other category for Portsmouth RegiOnal IS reported to mclude shelters, rehab facilities,

hotels/motels, friends/families, and unknown.

It should be noted that the above represents the first DHHS report of discharge disposition data to be included in this report. Thus, there is no reporting or analyses of trends in such discharge dispositions at this point. DHHS is to be commended for producing and sharing this data with the Parties to the CMHA.

In the previous two reports, the ER has identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. Based on recent information reported by DHHS, the average number of adults waiting for a NHH inpatient psychiatric bed was 24 per day in FY 2014; 25 per day in FY 2015; and through June ofFY 2016 was 28 per day. For the period July 1 through September 30, 2016 the average weekly wait list for admission to NHH was 31.5. The constant and increasing number of adults awaiting inpatient admission to NHH is of concern to DHHS and many other parties in New Hampshire. In most mental health systems, a high number of adults waiting for inpatient admissions is indicative of a need for enhanced crisis response (e.g., mobile crisis) and high intensity community supports (e.g., ACT).

As noted earlier in this report, DHHS is analyzing data related to adults boarding in EDs who may have some connection to the mental health system. DHHS is making these data available to CMHCs on a monthly basis, and expects the CMHCs to use these data to identify potential participants for ACT or related services to reduce the risk of hospitalization and support integrated community living. In future months, DHHS will be receiving information on the degree to which CMHCs have increased ACT (or other services') participation as a result of these analyses. The ER plans to include summaries ofthis information in future reports.

18

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 21 of 96
Summary of Transition Issues
Over the past three reports, the ER has consistently noted that the transitions process at Glencliff is moving very slowly. This appears to be true both at the individual consumer level, and at the system level. Although information at this point is anecdotal, interviews with both line staff and administrators, plus some selective record reviews, indicate that it is taking substantial amounts oftime to overcome the many and varied barriers to discharge to the community. Although the Central Team is now fully operational, it has been concentrating on a small number of cases, and referrals to the Central Team from Glencliff and NHH seems to have declined in the past two months for which data is available (N=l total referrals to the Central Team in October and November). This centralized resource is expected to play a larger role in addressing, overcoming and reporting on continued barriers to transition planning from both Glencliff and NHH, in keeping with the requirements ofthe CMHA. (Vl.A.6)
The ER will continue to follow up with Glencliff, NHH, and the Central Team to monitor improvements in transitions processes and successes, and to document continued barriers to transitions to the community from these facilities.
Finally, as noted earlier in this report, re-admission data for NHH remains incomplete. A single data point from November 2016 shows 17 readmissions over the previous 90 day period. Readmission rates are one important measure of the quality of discharge planning and community-based service provision. Without more complete information, the ER is unable to fully gauge the adequacy of transition planning for individuals in the target population or measure their resulting stability in the community. The ER renews outstanding requests for regular reporting of this data, as collected at 30/90/180 day intervals, and recommends that this population of individuals be a focus of the State's continued outreach efforts.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies
As noted in the June 30, 2015 ER report, New Hampshire reported having a total of 16 peer support agency program sites, with at least one program site in each of the ten regions. The State reported that all peer support centers meet the CMHA requirement to be open 44 hours per week. At the time of that report, the State reported that those sites had a cumulative total of2,924 members, with an active daily participation rate of 169 people statewide. As can be seen from the most recent quarterly data report included in Appendix A, the State currently reports total membership to be 3051, with active daily visits averaging 147 people. In the June 2016 data
19

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 22 of 96
report, the total membership was reported to be 2,978 people, with average daily statewide visits of 148.
The CMHA requires the peer support programs to be "effective" in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs.
Anecdotally, the ER believes that in many regions ofthe state, relationships and communications among the CMHCs and the Peer Support Programs have improved. Peer support programs are generally reported by CMHCs to be useful sources of employees for ACT and Mobile Crisis and Crisis Apartment services. In addition, CMHCs report that the peer operated crisis beds available in several regions are a useful intervention for some CMHC clients at risk of hospitalization.
IV. Quality Assurance Systems
In the past 18 months, DHHS has made considerable progress in the design of the QSR process required by the CMHA. Three QSR pilot test site visits were conducted in this reporting period. Based on the experiences ofthose QSR site visits, the QSR team determined that substantial revisions to the protocol and instruments were necessary. These changes have been made and are now under review by the ER (in the role of providing technical assistance on QSR to DHHS). A QSR site visit using the new instruments and process (as may be amended based on input from representatives of the Plaintiffs and the ER) is scheduled for mid-January 2017. Lyn Rucker, who has been providing technical assistance to DHHS under the aegis of the ER, will participate as an observer in that site visit, and offer additional feedback and written recommendations based on her observations.
Given the importance of completing the QSR design process, the ER expects the parties to accomplish the following activities over the next 60 days:
(a) On or before February! 0, 2017, DHHS will review and respond to Plaintiffs' written comments of December 13, 20 16;
(b) On or before February I0, 2017, DHHS will incorporate proposed recommendations from Lyn Rucker, the ER and Plaintiffs into a set of revised QSR documents and recirculate those documents to the ER and Plaintiffs;
(c) On or before February 24, 2017, DHHS will convene a face to face meeting ofthe QSR leadership and representatives ofthe Plaintiffs to discuss the findings of the pilot, the Plaintiffs' comments, and further proposed revisions to the QSR instrument; and
20

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 23 of 96
(d) Depending on the nature and extent ofthe revisions, an additional pilot of the revised instrument may be necessary. As soon as practicable thereafter, a final set ofQSR documents (protocol and instruments) will be developed.
It is essential that the QSR process produce information that is accurate, verifiable, and actionable. It is similarly essential that all parties, as well as the ER, have confidence in, and are able to rely upon, the QSR as a measure of compliance with the CMHA. Although the QSR process is part of broader DHHS quality management efforts, it must be directly responsive to the quality and performance expectations of the CMHA. This is why all Parties to the agreement have invested so much time and effort into the design and implementation of the QSR process. For the remaining time period covered by the CMHA, the QSR will produce essential core information by which all Parties assess compliance with all quality and performance standards and requirements of the CMHA. Thus, the ER expects that the action steps outlined above will be successfully completed on time, and the final version of the QSR can be implemented in a consistent fashion across the CMHC system.
As noted earlier in this report, DHHS has been conducting on-site ACT and SE fidelity reviews to supplement and validate the ACT and SE fidelity self-assessments conducted on an annual basis by the CMHCs. Three DHHS SE fidelity reviews have been completed and published, and two ACT on-site fidelity reviews have been completed, but the reports have not yet been published. DHHS has also engaged the Dartmouth/Hitchcock Center on Evidence Based practices to assist in attaining and assuring fidelity to the evidence based models of ACT and SE. The Dartmouth/Hitchcock team will also assist on workforce development and training for these and other evidence based practices under the aegis ofDHHS and the CMHCs. This partnership with the nationally respected Dartmouth/Hitchcock Center adds valuable expertise and experienced personnel to facilitate further development and operations of fidelity model ACT and SE in conformance with the CMHA.
Effective and validated fidelity reviews and consequent training and workforce development activities are essential to DHHS' overall quality management efforts for the community mental health system. The QSR and the fidelity reviews mutually support but do not supplant or replace each other. The QSR, in particular, examines outcomes from a personal as opposed to an organizational perspective. It assesses the quality, appropriateness and effectiveness of specific ACT and SE services at the individual participant level. Implementation of fidelity-based models of delivery does not necessarily mean that specific service interventions are working well or being delivered with the frequency or intensity required by a participant's individual treatment plan. That is why quality measures for ACT and SE are necessary aspects of the QSR, and essential tools for measuring the effectiveness of services under the CMHA.
21

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 24 of 96
V. Summary of Expert Reviewer Observations and Priorities
The CMHA and ER have now been in place for 30 months. At the last three All Parties meetings, the ER has expressed increasing concern related to: (a) continued lack of compliance with at least two major requirements of the CMHA; and (b) long elapsed times and/or delays related to implementation of system improvements or capacities related to the CMHA. The ER has emphasized the need for the State to be more aggressive, assertive, planful, and timely in its implementation and oversight efforts to assure compliance with the CMHA.
DHHS continues to implement more aggressive measures to both remove potential barriers to CMHA implementation, and to assure effective action on the part of the ten CMHAs to achieve compliance. The ER believes these management initiatives are positive and have the potential to improve performance vis-a-vis the CMHA. However, lack of measurable progress to date makes an assessment of the adequacy of these actions, or their ability to remedy ongoing implementation challenges and non-compliance, premature.
Specifically, the State has been and currently remains out of compliance with the CMHA. Two key examples of the State's non-compliance are:
1. Sections V.D.3(a, b, d, and e), which together require that all ACT teams meet the standards of the CMHA; that each mental health region have at least one adult ACT Team; and that by June 30, 2016, the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time; and
2. Sections V.E.2(b) and V.E.3(g)(h) which together require that by now the State "have the capacity to serve in the community [ten] individuals with mental illness and complex health care needs residing at Glencliff...."
With regard to ACT services, aggressive actions by DHHS and the CMHCs have resulted in a net increase in capacity (ACT staffing) of9.2 staff, thereby increasing capacity by 92- a 1.3% increase in staff capacity since last June. In the same time period, active ACT caseload has increased by 26 participants - a 3% increase since last March. The direction of change in ACT services continues to be positive, but the pace of change remains exceedingly slow. Chart I below illustrates the relatively slow progress of the CMHC system with regard to ACT capacity and active caseloads.
22

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 25 of 96

Chart I ACT Capacity and Active Caseloads Compared to the CMHA ACT Capacity Target

1600 1400 1200
- 1000
800 600 400 200
0

__.,..
...,.,-

-ACT capacity target -Actual ACT capacity -Actual ACT caseload

With regard to placements into integrated community settings of people with complex medical conditions from Glencliff, potential progress has been made. As described earlier in this report, a vendor and program space have been identified, and a payment mechanism has been implemented to support the necessary services and supports to maintain people in the community. However, to date no identified resident ofGlencliffwith complex medical conditions has moved into the new program or into any other qualifying integrated community setting. It is expected that four such individuals will be living in the new program by the end of January, 2017, but it is not possible for the ER to state for this report that compliance with the CMHA has been attained, as 10 people with complex medical conditions should have been transitioned at this time.
With regard to SE, DHHS is to be commended for exceeding the SE penetration rate target on a statewide basis. DHHS is also to be commended for continuing efforts to increase SE penetration in the seven regions of the state that do not meet the CMHA penetration rate standard.
It should be noted that the State continues to meet the SH capacity standards of the CMHA. This continues to be a positive aspect of the State's overall CMHA implementation efforts.
In the June 30, 2016 report, the ER recommended that the State carry out a number of action steps to increase access to key services for CMHA target population members and thereby to
23

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 26 of 96
increase compliance with the CMHA. The State agreed to voluntarily adopt the recommended action steps. The following is a brief summary of the ER's assessment of the degree to which the State has implemented these recommended action steps.
I. By August I, 20 I6, circulate to all parties a detailed plan with implementation steps and time lines to achieve compliance with the CMHA requirements for ACT services;
ER Finding: The State has implemented this recommendation and continues to track and report progress on the plan.
2. By August I, 20 I6, circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA penetration rates and fidelity standards for SE throughout New Hampshire;
ER Finding: The State has implemented this recommendation and continues to track and report progress in the context ofon the plan.
3. By August I, 20I6 circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA requirements to assist 10 residents ofGlencliffwith complex medical needs to move into integrated settings as soon as possible;
ER Finding: The State has implemented this recommendation and continues to track and report on four individuals with pending discharge plans. Progress towards fulfillment ofthe remaining obligations for capacity development and transition remains unclear under the plan.
4. Starting September I, 20I6, and each month following, submit to all parties a monthly progress report of the steps taken and completed under these respective plans to assure compliance with CMHA requirements as identified in this report;
ER Finding: The State has implemented this recommendation and continues to track and report on its progress, which varies depending on the sections ofthe plan.
5. By October 1, 20I6, complete the field tests and technical assistance related to the QSR, convene a meeting with Plaintiffs and the United States to discuss any recommended design or process changes, and publish a final set ofQSR documents governing the process for future QSR activities;
ER Finding: By agreement with the ER and representatives ofthe Plaintiffs, this action step has been delayed in order to develop andfield test new QSR protocols and instrumentation.
6. Complete at least one QSR site review per month between October 20I6 and June 20I7, with the exception of the month of December, and circulate to all parties the action items,
24

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 27 of 96
plans of correction (if applicable), and updates on implementation of needed remedial measures (if applicable) resulting from each ofthese visits;
ER Finding: Three QSR site visits were conducted, resulting in QSR team recommendations for substantial changes in the QSR protocols and instruments. The ER and representatives ofthe Plaintiffs agreed to postpone further site visits until these changes were made. The QSR site visits will begin again in 2017.
7. Starting July 1, 2016, circulate to all parties on a monthly basis the most recent data reports ofthe Central Team;
ER Finding: The State has implemented this recommendation and continues to track and report progress on the plan.
8. No later than October 1, 2016, assure that final rules for supportive housing and ACT services are promulgated in accordance with the draft rules developed with input from all parties;
ER Finding: The Supported Housing rules have been promulgated, and incorporate positive elements resulting from discussions among DHHS staffand representatives of the Plaintiffs. The ACT rulemaking has been filed, and is reported to have been approved and promulgated as ofthis date. The State and representatives ofthe PlaintijJs are to be commendedfor their collaborative work developing these two regulations.
9. By October 1, 2016, augment the quarterly data report to include: • ACT staffing and utilization data for each ACT team, not just for each region. ER Finding: The State has implemented this recommendation. • Discharge destination data and readmission data (at 30, 90, and 180, days) for people discharged from NHH and the other DRFs; ER Finding: Readmission data are not yet available for the DRF and readmission data for NHH are currently reported only for the 90 day interval. • Reporting from the two Mobile Crisis programs, including hospital and ED diversions. ER Finding: DHHS has determined a methodfor collecting and reporting Mobile Crisis data through the Phoenix system, and DHHS reports that these data will be incorporated in the next Quarterly Data Report. The most recent past Quarterly Data Report included information submitted by the Riverbend CMHC, but did not include data from the new Mobile Crisis Program in Manchester. The ER understands that Manchester data will be included in the next Quarterly Report. and; • Supportive housing data on applications, time until eligibility determination, reason for ineligibility determination, and utilization of supportive services for those
25

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 28 of 96
receiving supportive housing. ER Finding: DHHS has not agreed to supply these types ofdata at this point.
10. By October 1, 2016, (immediately prior to the next All Parties meeting) and then by December 1, 2016 (the time just before the next ER report), factually demonstrate that significant and substantial progress has been made towards meeting the standards and requirements of the CMHA with regard to the ACT, SE and placement of individuals with complex medical conditions from Glencliff into integrated community settings.
ER Finding: As noted in the introduction to this section, the State has made limited progress towards compliance with the ACT and Glencliffrequirements in the CMHA. Even this limited progress towards compliance remains slow, and the State remains out ofcompliance on these requirements. The State has achieved compliance with the statewide penetration rate standardfor SE, due in part to high penetration rates in one region. The ER encourages ongoing efforts by the State to elevate SE penetration rates in all regions to ensure appropriate access to SE services across all regions ofNew Hampshire. The ER also encourages continued independent assessments to ensure ACT and SE fidelity to CMHA standards.
11. By October 1, 2016 demonstrate that aggressive executive action has been taken to address the pace and quality of transition planning from NHH and Glencliffthrough the development of a specific plan to increase the speed and effectiveness of transitions from these facilities.
ER Finding: The Central Team has now been functioning for almost a year, and appears to have become more efficient in facilitating transitions from both NHH and Glencliff. The ER believes that both NHH and Glencliffhave evidenced, at a leadership and a stafflevel, increased efforts and commitment to facilitating timely transitions to integrated community settings, albeit with modest result to dates. As noted above, transitions from Glencliffremain exceedingly slow. It is expected that after the first four transitions ofmedically complex individuals from Glencliffhave been successfully accomplished, the pace offurther transitions will be substantially increased.
Conclusion
The ER concludes that the State has increased its level of effort and organizational commitment to achieving compliance with the CMHA. The State has committed additional staffing and leadership resources to CMHA compliance, and has begun to implement management tools and initiatives to facilitate and support compliance efforts. In addition, the State has created a more clear accountability structure that is designed to hold DHHS and the CMHCs to measurable and accountable action steps to attain increased compliance. The ER believes the State is better
26

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 29 of 96
positioned today than it has been in the past two years to oversee and effectuate positive steps towards implementing high quality and fidelity model community services to members ofthe CMHA target population. Nonetheless, as emphasized above, progress towards compliance over the past six months has been relatively minor and therefore far short ofthe significant and substantial progress identified as necessary for meeting the standards and requirements of the CMHA. The State remains out of compliance on ACT, and the current pace of change in ACT capacity and active caseloads is not sufficient to attain compliance in the near future. To date, there have been very few transitions from Glencliff, and it remains to be seen whether the pace of transitions to integrated community settings will improve. The initiatives and administrative actions taken by the State in the past six months have the potential to significantly improve access to CMHA services for CMHA target population members. It is hoped that with the continued effort ofDHHS, and the support and commitment of the new Governor, there will begin to be significant and measureable progress towards achieving compliance with the CMHA, as well as evidence of beneficial outcomes for adults with serious mental illness in New Hampshire. To achieve this end, the pace of change must rapidly increase over the next 3-6 months, or non-compliance with the CMHA will become an even more critical issue than it is now. The ER has stated previously that the time for patience has come and gone, and that the ER continues to be concerned and dissatisfied with the current status of compliance with the CMHA. The State also evidences concern with the current status of compliance with the CMHA. The action steps noted above must produce results, and accountability for attaining necessary service expansions and improvements must be measured and enforced. With a new Administration, there is a significant opportunity for new actions and efforts to reverse this longstanding pattern of noncompliance with several key provisions of the CMHA. If substantial progress is not clearly evident and well documents by the time of the next six month report, the ER will have to consider what other compliance enforcement mechanisms may be necessary, including possible involvement by the Court.
27

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 30 of 96
Appendix A New Hampshire Community Mental Health Agreement
State's Quarterly Data Report July to September 2016
28

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 31 of 96
New Hampshire Community Mental Health Agreement Quarterly Data Report
July to September 2016, Revised
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement December 23, 2016
The Department of Health and Human Services' Mission is to join communities and families in providing opportunities for citizens to achieve health and independence

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 32 of 96
July- September 2016
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 11/23/2016 Reporting Period: 7/1/2016- 9/30/2016
Notes for Quarter
• Prior quarter data was added to the tables for ease of reference. The current quarter is always shown first, followed by the prior quarter (either in the farthest right hand column or below the current quarter).
• Reporting was added on deaths of Glencliff residents.
• Connections Portsmouth Peer Support Agency data for the prior quarter that was previously unavailable has now been included.
• A new reporting mechanism is being implemented that will shift reporting of Mobile Crisis data to the Phoenix system. It is expected that this new mechanism will be used for the next quarterly report. While these future reports are expected to be more accurate and consistent than prior reports, they may not be directly comparable to the current report.

NH DHHS- OQAI- CMHA Quarterly Report

1

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 33 of 96
July- September 2016

Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 11/23/2016 Reporting Period: 7/1/2016 - 9/30/2016

1. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Unique

Unique Consumers

August September Consumers

in Prior

Center Name

July 2016

2016

2016 in Quarter

Quarter

01 Northern Human Services

75

80

83

88

82

02 West Central Behavioral Health 03 Genesis Behavioral Health

26

30

28

33

25

so

53

57

58

48

04 Riverbend Community Mental Health Center

63

74

75

81

73

OS Monadnock Family Services

68

72

70

73

70

06 Community Council of Nashua

72

71

69

76

72

07 Mental Health Center of Greater Manchester

259

252

252

270

283

08 Seacoast Mental Health Center

65

68

63

70

71

09 Community Partners

68

68

69

74

70

10 Center for Life Management

40

38

44

47

46

Total ..
Rev1s1ons to Prior Period: None

785

803

808

865

839

Data Source: NH Phoenix 2

Notes: Data extracted 11/18/16; consumers are counted only one time regardless of how many services they receive.

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CIT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

0.53 0.40 1.00 0.50 0.50 0.50 0.50 0.99 0.96 0.43 0.40 1.00 7.71

September 2016

t:: aa0 ..

..

:I

.!!!

""

i·aii

..aCll.
""

:.Cll

2.37 7.02 0.33

2.25 2.19 0.60

2.00 4.00 0.00

3.00 3.50 0.50

3.25 3.00 0.50

3.00 2.75 0.00

3.00 1.75 0.00

11.00 2.47 1.00

10.00 8.28 1.00

2.30 5.00 1.00

2.00 5.13 0.50

0.75 6.16 0.00

44.92 51.25 5.43

10.25 5.44 7.00 7.50 7.25 6.25 5.25
15.46 20.24
8.73 8.03 7.91 109.31

Cll ~
-z:::Ir ..
·I;l:l cCll
:'lcii .S.2
>1..1 1r.a.1
~;;. 0.80 0.14 0.50 0.30 0.65 0.25 0.25 0.72 0.63 0.60 0.50 0.10 5.44

June 2016

11.15 4.44 7.60 7.50 7.75 5.75 3.75
14.61 18.81 10.73
7.90 7.91 107.90

Cll

~

-z:::Ir ..

·I;l:l cCll

:'lcii

.2
.~

>1..1 tral

;t.Q.

0.80

0.14

0.50

0.40

0.65

0.25

0.25

0.56

0.56

0.60

0.50

0.10

5.31

NH DHHS- OQAI- CMHA Quarterly Report

2

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 34 of 96

July- September 2016

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Substance Use Disorder Treatment

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center OS Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for life Management Total

September 2016 2.42 1.20 4.50 1.30 3.40 3.00 3.00
11.00 2.00 0.20 1.00 2.7S
35.77

June 2016 2.SS 1.20 6.10 1.40 3.40 2.SO 1.SO
11.00 2.00 0.20 1.00 2.7S
35.60

2c. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Housing Assistance

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center OS Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for life Management Total

September 2016 7.9S S.40 6.00 6.00 1.00
s.oo
4.00 11.61 1S.79
s.oo
6.50 6.61 80.86

June2016 9.28 S.40 S.80 6.00 1.00 4.50 2.50
11.60 1S.14
6.00 6.7S 6.61 80.58

NH DHHS- OQAI- CMHA Quarterly Report

3

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 35 of 96
July- September 2016

2d. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Supported Employment

Center Name 01 Northern Human Services

September 2016 1.27

June 2016 0.84

02 West Central Behavioral Health

0.19

0.19

03 Genesis Behavioral Health

2.00

2.80

04 Riverbend Community Mental Health Center OS Monadnock Family Services

0.50 1.00

0.50 1.00

06 Community Council of Nashua 1

2.50

3.00

06 Community Council of Nashua 2

1.50

1.00

07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST

0.36

0.41

1.18

1.19

08 Seacoast Mental Health Center

1.00

1.00

09 Community Partners

1.00

1.25

10 Center for Life Management Total

0.30 12.80

0.30 13.48

Revisions to Prior Period: None
Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report Notes for 2b-d: Data compiled 11/18/16; The Staff Competency values reflect the sum of FTE's trained to provide each service type.
These numbers are not a reflection of the services delivered, rather the quantity of staff available to provide each service. If staff is
trained to provide multiple service types, their entire FTE value will be credited to each service type.

3. Community Mental Health Center Services: Annual Supported Employment Penetration Rates for Prior 12 Month Period

12 Month Period Ending September 2016

Penetration

Center Name

Supported Employment
Consumers

Total Eligible Consumers

Penetration Rate

Rate for Period Ending June 2016

01 Northern Human Services

152

1,071

14.2%

10.8%

02 West Central Behavioral Health

103

618

16.7%

16.1%

03 Genesis Behavioral Health

188

1,334

14.1%

12.6%

04 Riverbend Community Mental Health Center

216

1,601

13.5%

12.9%

OS Monadnock Family Services

209

939

22.3%

20.4%

06 Community Council of Nashua

174

1561

11.1%

10.3%

07 Mental Health Center of Greater Manchester

1,238

3,218

38.5%

37.6%

08 Seacoast Mental Health Center

146

1,263

11.6%

9.0%

09 Community Partners

81

744

10.9%

13.1%

10 Center for Life Management

197

821

24.0%

24 .1%

Deduplicated Total

2,698

12,917

20.9%

19.8%

Revisions to Prior Period: None

Data Source: NH Phoenix 2 Notes: Data extracted 11/18/16; consumers are counted only one time regardless of how many services they receive

NH DHHS- OQAI - CMHA Quarterly Report

4

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 36 of 96

July- September 2016

4. New Hampshire Hospital: Adult Census Summary

Measure

July- September 2016

April- June 2016

Admissions

373

327

Mean Daily Census

134

132

Discharges

365

330

Median Length of Stay in Days for Discharges

8

12

Deaths

0

0

Revisions to Prior Period: None

Data Source: Avatar

Notes: Data extracted 7/6/16; Average Daily Census includes patients on leave ond is rounded to nearest whole number

Sa. Designated Receiving Facilities: Admissions

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total
DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

July -September 2016

Involuntary Admissions Voluntary Admissions

16

21

61

146

71

304

7

47

51

63

206

581

April- June 2016

Involuntary Admissions Voluntary Admissions

44

35

so

155

64

314

2

47

45

47

205

598

Total Admissions 37
207 375
54 114 787
Total Admissions 79
205 378
49 92 803

5b. Designated Receiving Facilities: Mean Daily Census

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

July- September 2016 4.5
13.6 23.2 25.6 14.5 16.3

April- June 2016 7.8
13.2 21.4 22.5 16.9 16.4

5c. Designated Receiving Facilities: Discharges

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

July- September 2016 35
213 380
64 113 805

April- June 2016 78
206 363
51 90 788

NH DHHS- OQAI- CMHA Quarterly Report

5

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 37 of 96
July- September 2016

Sd. Designated Receiving Facilities: Median Length of Stay in Days for Discharges

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total Revisions to Prior Period: None Data Source: NH DRF Database
Notes: Data Compiled 11/18/16

July- September 2016 7 5 4
24 8 5

April- June 2016 6 4 4
28 7 5

6. Glencliff Home: Census Summary

Measure

July- September 2016

April- June 2016

Admissions

3

6

Average Daily Census Discharges

114

113

1f

1

Ind ividual Lengths of Stay in Days for Discharges

481

2,871

Deaths

5

4

Readmissions

0

0

Mean Overall Admission Waitl ist

15 (7 Active*)

14 (7 Active)

To mdependent apartment
Revisions to Prior Period: A discharge reported for the prior quarter actually occurred on 7/25 in the current quarter.
Data Source: Glencliff Home
Notes : Data Compiled 11/7/16; means rounded to nearest whole number. *Active wait/ist patients have been reviewed for
admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

7. NH Mental Health Consumer Peer Support Agencies: Census Summary

Peer Support Agency

July- September 2016

Average Daily

Total Members

Visits

April - June 2016

Average Daily

Total Members

Visits

Alternative Life Center Total Conway Wolfeboro Outreach* Berlin Littleton Colebrook

479

42

427

47

173

12

98

13

0

0

18

0

99

11

115

13

130

10

125

11

77

9

71

10

Stepping Stone Total Claremont Lebanon

547

20

534

21

460

14

448

15

87

6

86

6

Cornerbridge Total Laconia** Concord Plymouth Outreach
MAPSA Keene Total

222

16

326

15

149

5

141

5

147

11

145

10

40

NA

40

NA

179

15

178

14

NH DHHS- OQAI- CMHA Quarterly Report

6

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 38 of 96
July- September 2016

Peer Support Agency

July- September 2016

Average Daily

Total Members

Visits

April -June 2016

Average Daily

Total Members

Visits

HEARTS Nashua Total

411

24

452

24

On the Road to Recovery Total Manchester Derry

489

48

474

49

332

35

319

40

157

13

155

9

Connections Portsmouth Total

271

14

269

13

TriCity Coop Rochester Total

339

16

326

14

Total

3,051

147

2,978

148

Rev1.s.1ons to Pnor Penod: Connections Portsmouth for Apnl- June 2016, not previously available, IS now supplied, along w1th pnor

quarter totals

Data Source: Bureau of Mental Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 11/13/16; Average Daily Visits NAfor Outreach Programs;* Wolfeboro Outreach as a distinct program

ended operations 7/1/16, Alternative Life Center continues to do some transportation from Wolfeboro and has increased outreach

efforts at all four primary sites; **Cornerbridge Laconia estimated based on prior members and new reported members.

8. Housing Bridge Subsidy Summary to Date

Subsidy Housing Bridge Subsidy Section 8 Voucher
Subsidy Housing Bridge Subsidy Section 8 Voucher Revisions to Prior Period: None Data Source: Bureau of Mental Health Notes: Data Compiled 11/16/16

July- September 2016

Total individuals served at start of quarter 557

New individuals added during quarter 46

Total individuals served through end of quarter 603

80

3

83

April- June 2016

Total individuals served at start of quarter 518 70

New individuals added during quarter 39 10

Total individuals served through end of quarter 557 80

NH DHHS- OQAI- CMHA Quarterly Report

7

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 39 of 96
July- September 2016

9. Housing Bl"idge Subsidy Current Census Summary

Measure

As of 9/30/2016

As of 6/30/2016

Housing Slots

479

450

Rents currently being paid

451

445

Individuals accepted but waiting to lease

28

16

Waiting list for slots

0

0

Revisions to Prior Period: None Data Source: Bureau of Mental Health Notes: Data Compiled 11/16/16; All individuals currently on the Bridge Program are actively transitioning from the program (waiting for their Section 8 housing voucher).

10. Housing Bridge Subsidy Unit Address Density

Number of Unit(s)* at Same Address 1 2 3 4 5 6 *All UnitS are Indi.V.IdUal UnitS Revisions to Prior Period: None Data Source: Bureau of Mental Health Notes: Data Compiled 11/16/16

Frequency as of 11/16/16 339 24 13 3 0 1

Frequency as of 6/30/16 325 35 8 1 2 1

11. Mobile Crisis Services and Supports: Riverbend Community Mental Health

Measure Unduplicated People Served in Month

July 2016 August 2016

194

156

September 2016 199

JulySeptember
2016 549

April-June 2016 532

Services Provided by Type

Mobile Community Assessments

58

54

45

157

142

Crisis Stabilization Appointments

22

17

25

64

63

Office-Based Urgent Assessments

5

19

22

46

36

Emergency Service Medication Appointments

17

28

24

69

33

Phone Support/Triage

292

316

319

927

735

Services Provided after Immediate Crisis

Mobile Community Assessments -Post Crisis

12

4

11

27

18

Crisis Stabilization Appointments

22

17

25

64

63

Office-Based Urgent Assessments

5

19

22

46

36

Emergency Service Medication Appointments

4

15

14

33

27

Phone Support/Triage

120

162

145

427

226

Referral Source Emergency Department/EMS Family

9

27

28

64

24

49

21

31

101

111

NH DHHS- OQAI- CMHA Quarterly Report

8

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 40 of 96
July- September 2016

Measure Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal School Self VNA

July 2016 5 0 8
15 6
10 0
92 0

August 2016 3 0
12 7 9
27 1
128 0

September 2016 8 0 8 3 3 26 6 90 1

JulySeptember
2016 16 0 28 25 18 63 7
310 1

April-June 2016 9 23 18 23 16 94 12 282 0

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

28

23

23

74

40

103

92

94

289

120

3.7

3.9

4.1

3.9

3.0

Law Enforcement Involvement

17

17

12

46

46

Hospital Diversions Total

91

90

82

263

288

Revisions to Prior Period: Referrals for April to June 2016 are revised (prior report data were not deduplicated at the client level) Data Source: Riverbend CMHC submitted reports

Notes: Data Compiled 11/18/16

NH DHHS- OQAI- CMHA Quarterly Report

9

12/23/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 41 of 96
Appendix B New Hampshire Community Mental Health Agreement
Monthly Progress Reports November and December, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 42 of 96
New Hampshire Community Mental Health Agreement Monthly Progress Report
November 2016
New Hampshire Department of Health and Human Services November 3, 2016

CMHA Monthly Progress Report
PDF processed with CutePDF evaluation edition www.CutePDF.com

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 43 of 96

Acronyms Used in this Report

ACT: BOAS: BMHS: CFI: CMHA: CMHC: DHHS: DPHS: EMR: ION: IPS: MCO: MCSS: QSR: SE: SFY: WRAP:

Assertive Community Treatment Bureau of Drug and Alcohol Services Bureau of Mental Health Services Choices for Independence Community Mental Health Agreement Community Mental Health Center Department of Health and Human Services Division of Public Health Services Electronic Medical Record Integrated Delivery Networks Intentional Peer Support Managed Care Organization Mobile Crisis Services and Supports Quality Services Review Supported Employment State Fiscal Year Wellness Recovery Action Plan

CMHA Monthly Progress Report

2

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 44 of 96
Introduction This third Monthly Progress Report is issued in response to the June 29, 2016 Expert Reviewer Report, Number Four, action step 4. It reflects the actions taken in October, and month-over-month progress made in support of the Community Mental Health Agreement as of October 31, 2016. This report is specific to achievement of milestones contained in the agreed upon CMHA Project Plan for Assertive Community Treatment, Supported Employment and Glencliff Home Transitions, as updated and attached hereto (Appendix 1). Where appropriate, the Report includes CMHA lifetime-to-date achievements.

CMHA Monthly Progress Report

3

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 45 of 96
Executive Summary
Assertive Community Treatment Pro~:ress Achieved in October 2016 • ACT Statewide De-duplicated Enrollment Update (for the period ending September 30, 2016) 1
o September 2016- 808 o August 2016 - 802 o One Month Comparison- .7% increase over August 2016
• CMHCs Under ACT Compliance Plans (for the period ending September 30, 2016) 2: o September 2016- 237 o August 2016- 234 o One Month Comparison- 1.3% increase over August 2016
• Project Plan Milestones: o By 12/1/2016 DHHS will initiate ACT Fidelity Assessments • As of October 31,2016, six (6) CMHCs completed ACT Self-Fidelity Assessments, DHHS conducted one (1) ACT Fidelity Assessment. DHHS will conduct two (2) additional ACT Fidelity Assessments within 90 days, the tenth CMHC will complete its ACT Self-Fidelity Assessment in November 2016.
Supported Employment • Supported Employment Statewide Penetration Rate3 (for the period ending September 30, 2016)
o September 2016 Penetration Rate- 20.8% o August 2016 Penetration Rate- 20.1% o One Month Comparison: 3.4% increase over August 2016
• CMHCs Under Compliance Plan September SE Penetration Rates4: o September 2016- 12.6% o August 2016- 11.8% o One Month Comparison- 6.8% increase over August 2016
• Project Plan Milestones: o By 11/1/2016 Resolve barriers to achieving SE penetration goals • DHHS exceeded the 3/1/2017 targeted statewide SE Penetration rate in March 2016. In October, DHHS continued providing technical assistance and monitoring of CMHCs not yet meeting the targeted SE penetration goal on a regional level.

1 Based on preliminary data 2 Based on preliminary data 3 Based on preliminary data 4 Based on preliminary data; average of all four CMHCs under SE compliance plans

CMHA Monthly Progress Report

4

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 46 of 96
Glencliff Home Transitions into Inte~rated Community Settin~ • Discharge Update
o October Discharges: 2 • Independent Apartment 1 • Enhanced Family Care 1
• Project Plan Milestones: o By 12/1/2016 transition four (4) individuals to the community • October discharges consistent with this milestone- 2
• DHHS will meet the 12/1/2016 Project Plan Milestone in November when the first two (2) of (4) residents transition into a community residence. Two (2) additional residents will transition into the same residence in December.
• The community residence provider hired a contractor to complete the renovations required to meet the individual medical needs of these four residents. The work is on schedule for accepting the residents' transition beginning in mid-November.
• These Glencliff Home residents will transition one per week for four weeks.
• Community Mental Health Agreement Milestones: o By 6/30/2016, the capacity to serve six additional individuals (cumulative total of 10) in an integrated community setting. o By 6/30/2017, the capacity to serve six additional individuals (cumulative total of 16) in an integrated community setting. • As of 10/31/16, DHHS has transitioned seven (7) residents into compliant community residences. • By 12/31/16, DHHS will have transitioned eleven (11) residents into compliant residences. • By 12/31/16, DHHS will have exceeded the cumulative total required under the 6/30/2016 milestone, and will be on track to meetthe 6/30/2017 milestone.
Additional DHHS Efforts to Support CMHA Goals and Strenet;hen NH's Mental Health System
• New Hampshire Building Capacity for Transformation Medicaid Section 1115a o (Distributed $19.5m to Integrated Delivery Networks (IDNs) to support project plan development to integrate primary and behavioral health care statewide o Project plans submitted on October 31, 2016 and are under review. Upon approval, additional funds will be released for plan implementation.
• DHHS's proposed SFY 2018-19 budget includes $6.675mjyear in additional funding to enhance support for existing twelve (12) ACT teams and to add three additional ACT teams.
• DHHS seeking $350,000/year in additional funding for State Loan Repayment Program, which supports staff employed by certain providers, including CMHCs.
• Community Mental Health Centers and Medicaid managed care plans entered into contracts retroactive to July 1, 2016.

CMHA Monthly Progress Report

5

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 47 of 96

Schedule of State Fiscal Year 2017 Fidelity and Quality Services Review"

Center for Life Management

DHHS-conducted QSR

;.,IC
'ElS
-N

Mental Health Center of Greater Manchester DHHS-conducted SE Fidelity Assessment

Riverbend Community Mental Health

DHHS-conducted SE Fidelity Assessment

=""'Dl!IC West Central Behavioral Health

<~

DHHS-conducted QSR

Genesis Behavioral Health

=•.I.C..

DHHS-conducted QSR

OIQ
tllN

Northern Human Services

DHHS-conducted SE Fidelity Assessment

Center for Life Management

Self-conducted ACT Fidelity Assessment

Self-conducted SE Fidelity Assessment

Community Partners of Strafford County

Self-conducted ACT Fidelity Assessment

Genesis Behavioral Health

DHHS-conducted ACT Fidelity Assessment

Self-conducted SE Fidelity Assessment

Greater Nashua Mental Health Center

DHHS-conducted SE Fidelity Assessment

1.

Self-conducted ACT Fidelity Assessment

== .0o1\.C..
1jN

Mental Health Center of Greater Manchester Self-conducted ACT Fidelity Assessment

0

Monadnock Family Services

Self-conducted ACT Fidelity Assessment

Self-conducted SE Fidelity Assessment

Riverbend Community Mental Health

DHHS-conducted QSR- POSTPONED7

Self-conducted ACT Fidelity Assessment

Seacoast Mental Health Center

Self-conducted ACT Fidelity Assessment

Self-conducted SE Fidelity Assessment

West Central Behavioral Health

Self-conducted SE Fidelity Assessment

.

Community Partners of Strafford County DHHS-conducted SE Fidelity Assessment

.z.=e>O. N -.=.c.

Monadnock Family Services DHHS-conducted QSR- POSTPONED
Northern Human Services

DHHS-conducted ACT Fidelity Assessment

Mental Hea lth Center of Greater Manchester

DHHS-conducted QSR

West Central Behavioral Health

N =~';"

DHHS-conducted ACT Fidelity Assessment

.".". "I~ll

Seacoast Mental Health Center

N'!:l

DHHS-conducted QSR

... =- Qft)
"-I·

Greater Nashua Mental Health Center DHHS-conducted QSR

Ni: Qlll
.".".-~"BI-

Community Partners of Strafford County DHHS-conducted QSR

N> Q'CI
~2:

Northern Human Services DHHS-conducted QSR ~:s: ~~

.u.:=:l
QN

... = N ==-
"-1ft>

5 Schedule incorporated into Monthly Progress Report in response to the Center for Public Representation's 8/24/2016 request for additional information to ensure various tasks and deliverables are occurring at an appropriate pace. Schedule may be subject to change.
6 The three-month field test of the current QSR process ended in October. DHHS will revise instruments and processes and submit these revisions to the Expert Reviewer to obtain Technical Assistance by October 31, 2016. DHHS will release further-refined instruments and processes to Plaintiffs and stakeholders in November 2016 to receive feedback. DHHS will release finalized process and instruments in December 2016.
7The QSRs originally scheduled for October and November 2016 have been postponed to accommodate the revision of QSR tools and processes consistent with CMHA provision (VII.D.2), as discussed in the 9/6/2016 All Parties meeting, and to conduct re-training of QSR teams accordingly. DHHS will reschedule the two impacted QSRs to occur in 2017.

CMHA Monthly Progress Report

6

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 48 of 96

Actions Taken to Enable DHHS to Factually Demonstrate Significant and Substantial Progress
1. Assertive Communi Treatment • October Actions to Increase ACT Enrollment:
o DHHS implemented enhanced Emergency Department data reporting • CMHCs began monthly research of Emergency Department data • CMHCs using data to identify consumers for potential ACT enrollment
o DHHS actions to reduce inpatient behavioral health waitlist for individuals in hospital emergency rooms 10% by July 2017 or 25% by July 2018 • Initiated redesign of protocols to ensure CMHC daily contact with emergency departments; will address reporting and rapid resolution of barriers to discharges
• New Hampshire Healthy Families commenced monthly auditing of emergency department admissions; referred eight (8) consumers to CMHCs for potential ACT enrollment. MCO commenced weekly re-evaluation of data to report to DHHS and CMHCs any unresolved consumers to ensure resolution.
• New Hampshire Healthy Families commenced daily contact with emergency departments and applicable CMHCs for any consumer waiting and to expedite delivery of additional services or supports needed to return consumer to community or discharge to appropriate setting/treatment option.
o Continuing Actions to increase ACT Enrollment during October include: • CMHCs provided ACT training to internal staff • CMHCs provided overview of ACT to external stakeholders, such as law enforcement, housing and vocational rehabilitation providers • CMHCs improved internal ACT referral processes, such as revising written plans to better align with fidelity, and adjusting EMR to trigger consideration of ACT referral at quarterly evaluations.
• CMHCs Under ACT Compliance Plans (for the period ending September 3 0. 2016) 9:
o Northern Human Services • September 2016- 83 • August 2016- 80 • One Month Comparison- 3.8% increase over August 2016
o West Central Behavioral Health • September 2016- 28 • August 2016- 30 • One Month Comparison- 7% decrease under August 201610
o Genesis Behavioral Health • September 2016- 57 • August 2016- 53 • One Month Comparison- 7.5% increase over August 2016

8Effort is part of DHHS Innovation Accelerator Program (lAP), Goal #1, 9 Based on ):Jreliminary data
10 Staffing turnover and consumers moving out of region or graduating from program factor into decrease

CMHA Monthly Progress Report

7

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 49 of 96
o Greater Nashua Mental Health Center • September 2016- 69 • August 2016- 71 • One Month Comparison- 3% decrease under August 201611
• October Efforts to Increase ACT Capacity (Improve CMH CAbility to Recruit and Retain ACT StafO:
o DHHS and CMHC Executive Directors participated in the four hour kick-off meeting for the New Hampshire Building Capacity for Transformation Medicaid Section 1115a Demonstration Waiver project, "Behavioral Health Workforce Capacity Development.12"
o As required in Item 11 of the approved Project Plan (Appendix 1) DHHS completed research on State Loan Repayment Program (SLRP).
o To improve CMHC ability to recruit and retain Peer Support Specialists, DHHS hosted five-day nationwide WRAP training. The training brings the number of in-state Peer Support trainers to four (2 IPS trainers, 2 WRAP trainers); three (3) additional individuals are actively concluding IPS trainer requirements. • DHHS collaborated with the Peer Support Agency, Stepping Stone, to develop a coordinated approach to ensuring Peer Support Specialist IPS training needs statewide are identified and sufficient opportunities are made available. Stepping Stone agreed to serve as the repository for CMHC Peer Support Specialist IPS training needs and to coordinate with DHHS to meet those needs on an ongoing basis.
• October Actions to Ensure Fidelity
o Six CMHCs conducted ACT Self-Fidelity Assessments o DHHS conducted ACT Fidelity Assessment of Genesis Behavioral Health o DHHS granted one CMHC a one month extension to conduct the Center's ACT Self-
Fidelity Assessment13
• Upcoming Milestones to Ensure Fidelity
o In November, DHHS will review six ACT Self-Fidelity Assessments and work with applicable CMHCs to finalize reports, and develop compliance plans where appropriate. Final reports will be released in December 2016.
o In November, the final ACT Self-Fidelity Assessment for SFY2016 will be completed. DHHS will review the ACT Self-Fidelity Assessment and work with the CMHC to finalize the report, and develop a compliance plan if appropriate in December 2016. The final report will be released in January 2017.
o DHHS will complete the ACT Fidelity Assessment report, review and compliance plan if appropriate, for Genesis Behavioral Health, for release by December 31, 2017.

11 Staffing turnover and consumers moving out of region factor into decrease 12 See appendices for the approved project plan.
13 Extension granted due to multiple auditing/review events occurring in the CMHC during the month of October.

CMHA Monthly Progress Report

8

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 50 of 96

• October Actions Taken to Ensure Fidelity
o Four CMHCs conducted SE Self-Fidelity Assessments o DHHS conducted an SE Fidelity Assessment of Greater Nashua Mental Health Center o DHHS granted one CMHC a two-week extension for DHHS to conduct the Center's SE
Assessment14
• Upcoming Milestones to Ensure Fidelity
o In November, DHHS will review four SE Self-Fidelity Assessments and work with applicable CMHCs to finalize reports, and develop compliance plans where appropriate. Final reports will be released in December 2016.
o In November, DHHS will conduct the postponed SE Fidelity Assessment. DHHS will complete theSE Fidelity Assessment report, review and compliance plan, if appropriate, in December 2016. The final report will be released in January 2017.
o DHHS will complete theSE Fidelity Assessment report, review and compliance plan if appropriate, for Greater Nashua Mental Health Center, for release by December 31, 2017.
o Continuing Actions to Maintain SE Statewide Penetration Rate and Support all CMHCs to Reach or Exceed 16.8% Penetration Rate During October Include: • DHHS discussed monthly SE Penetration Rate data with CMHCs to encourage further collaboration to achieve effective SE programs • CMHCs provided SE training to internal staff and worked with regional employers to improve competitive employment opportunities
• CMHCs Under Compliance Plan September SE Penetration Rates15
o Northern Human Services • September 2016-14.2% • August 2016-11.1% • One Month Comparison- 27.9% increase over August 2016
o Genesis Behavioral Health • September 2016-14.1% • August 2016- 13.9% • One Month Comparison -1.4% increase over August 2016
o Greater Nashua Mental Health Center • September 2016- 11.1o/o • August 2016- 10.1o/o • One Month Comparison- 9.9% increase over August 2016
o Community Partners • September 2016-11.1% • August 2016- 12.1o/o • One Month Comparison- 8.3% decrease under August 201616

14 Extension granted due to staffing issues and unexpected leave of supervisory staff. 15 Based on preliminary data
16 Significant staffing shortage (loss of all SE staff) factor into decrease

CMHA Monthly Progress Report

9

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 51 of 96

3. Glencliff Home Transitions Into Integrated Community Setting
• Discharge Barrier Resolution Update
o Active Pending Discharges - 5
• Community Residence- 4 (commencing November 2016) • Budgets for the four residents were submitted to DHHS in October. DHHS completed its review; DHHS required the provider to resubmit four individual budgets, consistent with the Community Living Plan (Appendix 2). • Renovations initiated; provider confirmed residence will be ready for occupancy mid-November 2016
• Adult Family Home- 1 • Resident's family agreed to resident's placement in home in October. Glencliff Home staff initiated CFI provider contact and discharge planning is underway.
• Other October Actions Taken to Address Discharge Barriers
o DHHS approved resident for the ABD waiver; resident added to ABD waitlist.
o DHHS and Granite State Independent Living Housing Specialist commenced monthly meetings to examine transition/discharge needs for resolution development.
o DHHS initiated search for additional community residence site development with current provider for other regions in which residents are seeking appropriate housing.
• Project Plan Milestones
o By 12/1/2016 transition four (4) individuals to the community
• October discharges consistent with this milestone - 2 • DHHS will meet the 12/1/2016 Project Plan Milestone in November when the first
two (2) of four (4) residents transition into a community residence. Two (2) additional residents will transition into the same residence in December. • The community residence provider hired a contractor to complete the
renovations required to meet the individual medical needs of these four residents. The work is on schedule for accepting the residents' transition beginning in mid-November. • These Glencliff Home residents will transition one per week for four weeks.
• Community Mental Health Agreement Milestones:
o By 6/30/2016, the capacity to serve six additional individuals (cumulative total of 10) in an integrated community setting.
o By 6/30/2017, the capacity to serve six additional individuals (cumulative total of 16) in an integrated community setting.
• As of 10/31/16, DHHS has transitioned seven (7) residents into compliant community residences.
• By 12/31/16, DHHS will have transitioned eleven (11) residents into compliant residences.
• By 12/31/16, DHHS will have exceeded the cumulative total required under the 6/30/2016 milestone, and will be on track to meet the 6/30/2017 milestone.

CMHA Monthly Progress Report

10

November 3, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 52 of 96

Appendix 1
NH Department of Health & Human Services Community Mental Health Agreement (CMHA) Project Plan for Assertive Community Treatment, Supported Employment and Glencliff Home Transitions
October 31, 2016

Quarterly

JContinue to provide quarterly ACT reports with stakeholder input and distribute to CMHCs and other stakeholders.

ACT•Expandlnc capacity/penetration; Staffinc array
M. Brunette

Quarterly Reports 1100% and ng

2

6/30/2016-

letters sent

3

7/20/2016

M. Brunette

M.Harlan

resulted in a plan with steps for increased ACT capacity.

clients .

1

CMHA-Project Plan

10/31/2016

Appendix 1

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 53 of 96

region who had emergency department visits for psychiatric reasons, psychiatric hospitalizations, DRF admissions, and NHH admissions in the past quarter to facilitate CMHCs ability to assess people in their region for ACT.

screening.

5

10/1/2016 IAddress Peer Specialist Challenges- 1M.Brunette Behavioral Health Association

lack of standardized training.

in an effort to expedite increasing peer

specialists, will explore the SUD Recovery

specialists certification.

100%

rch completed. itional training capacity added. DHHS collaborated with Peer Support Agency to assist with coordination of meeting Peer Support Specialist training needs;
identification of

6 I 10/1/2016 IACT team data will be reported
separately by team.

1M. Brunette

IThe data will be separated starting the
month of July 2016 and will be reported in October 2016 report.

ACT team data will be 1100% separated on a quarterly basis moving forward.

7 I 10/1/2016 IDevelop organization strategies to
increase capacity.

M.Brunette

Each CMHC will conduct one education session between now and Oct. 1, 2016 to introduce ACT.

Increase community education .

150%

8 I 10/1/2016 IReview and make changes as

I
1M. Brunette

Each CMHC will review and evaluate their Learning Collaborative 50%

necessary to ACT referral process.

internal referral process and then share to share their

with the other CMHCs.

processes.

-
identify educational needs. Centers holding additional inservice sessions.
Internal CMHC review of referral process is underway. Some ideas already shared in learning collaborative.

2

CMHA-Project Plan

10/31/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 54 of 96

Appendix 1

Iselt-tidelity to evaluate their
"rlhF>r,nce to the ACT treatment They will provide a report to by 11/1/16.

This report will include their plan for improving their adherence to the model described in the Settlement Agreement.

10

I Work with TA to develop a report that will ACT Staffing Report

80%

communicate the strategies to address

ACT staffing issues in collaboration with

DHHS .

11

Increase number of

50%

staff eligible

12

M.Brunette

M. Brunette

IConcerted efforts by the CMHCs to assess
1dividuals in Community residences that be served on ACT. Train direct providers in coding appropriately
ACT services. Screen 100% eligible individuals for ACT.

3

CMHA-Project Plan

10/31/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 55 of 96

DHHS will request CMHCs with low compliance to provide DHHS a list of five (5) consumers who are eligible for and who will begin to receive ACT services each month starting August 1, 2016 through February 2017. DHHS will request all other CMHCs to provide DHHS a list of 3 consumers who are eligible for and who will begin to receive ACT services each month starting August 1, 2016 through February 2017.

Appendix 1

reports will be provided to each List of (5) consumers

on their specific list of individuals from low compliance

Emergency department visits and CMHCs who are eligible

m:vr.hi::~trist hospitalizations to allow

for ACT services each

to assess their center specific

month and a list of (3)

consumers from other

CMHCs who are eligible

for ACT services.

and reviewed with CMHCs in October. CMHC response reports are being submitted as October 31, 2016. DHHS actively reviewing reports for consultation
CMHCs. NH

15

6/30/2017 !Increase ACT capacity

16

6/30/2017

M. Brunette

I efforts by the CMHCs to assess By 6/30 2017 increase

1n01v1auals in Community residences that ACT capacity by an

be served on ACT. Train direct

additional 13.5%

I will provided DHHS with a monthly Monthly report with list

report of newly enrolled clients.

of consumers to

increase ACT capacity.

4

CMHA-Project Plan

10/31/2016

Appendix 1

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 56 of 96

17

5/20/16

ongoing penetration rates including staffing

and/or penetration with a request for

improvement plans .

Supported Employment (SE)

reports.

nee plan with qua

and evaluate 1100% improvement plans from CMHCs due 6/29/16.

I 18 I 6/1/16 and Continue to generate quarterly report 1M. Brunelle ongoing With stakeholder 1nput focusing on penetration of SE services distributed to the CMHCs and other stakeholders.

19

7/20/2016

MHC Executive M.Harlan

Directors will participate in a

facilitated session to establish a plan

to expand penetration and staffing

array.

20 I 7/6/2016

Use in Assistance calls with Centers to support continuing progress . Two out of four reported decreases in September; overall improvement is 6.8% over August for these 4 CMHCs.
calls; include 4 quarters for trend discussion.

21

7/12/2016 IOn-site fidelity assessments

conducted at CMHCs.

22

9/27/2016 1On-site fidelity assessments

conducted at CMHCs .

The second fidelity assessment took on 7/12/16 at Riverbend in Concord.

K.Boisvert

The third fidelity assessment will take place on 9/27/16-9/29/16 in Benin.

Report with results of the on-site fidelity assessments.

150%

November.

5

CMHA-Project Plan

10/31/2016

Appendix 1

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 57 of 96

24 I 10/1/2016 IMonitor monthly ACT staffing for presence of SE.

, M.Harlan

IMonitor monthly ACT staffing for presence lA monthly report will be 100% and

of SE on each team.

run through the Phoenix Ongoing

system for ACT staffing.

25 I 10/15/2016 IAll CMHCs will conduct self-fidelity assessments.

K.Boisvert

Self-fidelity assessments

Report to DHHS with 100% self-fidelity assessment results.

26 I 11/1/2016 ICMHCs will develop and maintain a M.Harlan list of SMI individuals who may benefit from but are not receiving SE
27 I 11/1/2016 IResolve barriers to achieving SE penetration goals.

Review individuals that are not on SE for Quarterly reports of

reasons why they are not enrolled.

individuals not on SE.

Educate internal CMHC staff on the goals Educational plan of SE.

28

12/1/2016 IExplore resources to conduct

M.Harlan

technical assistance and training.

CMHCs and DHHS will explore

strategies and barriers DHHS can use

to facilitate service delivery.

29 I 12/1/2016 I Increase the number of staff who are M. Harlan eligible for State Loan Repayment Program (SLRP).

CBHA and DHHS will explore the need for ' Report the barriers and 125% technical assistance and training. DHHS possible solutions. will conduct a subgroup of CMHC leaders Technical assistance to explore barriers and administrative burden that prevents service delivery.

Explore the possibility of increasing the Increase number of

50%

number of staff eligible for this program. staff eligible.

Reports submitted for November 1st deadline.
Discussed in monthly ACT/SE Implementation Workgroup calls to identify educational needs. Five CMHCs reported holding additional inservice sessions.
' Initial inventory of training needs underway in October.
Research completed. Will develop presentation to CMHC executive directors and early access plan to apply for SFY2018 funds.

6

CMHA-Project Plan

10/31/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 58 of 96

Appendix 1

;oormnator will outreach to provide I information on SE and will periodically
up with him/her. This strategy working with individual CMHCs
fall below the 18.6% penetration rate .

Glendlff Home Transitions

31

Ongoing at Establish process for identifying

Glencliff Staff

Inte rviews residents each year to

residents individuals interested in transitioning

if they want to transition back to

every 90 days

Glencliff to the community.

community.

monthly ACT/SE Implementation Workgroup calls to identify opportunities for improvement at center specific level and in Technical Assistance calls . Ideas discussed in Learning Collaborative.
continues to with CMHCs not

32

7/30/2016

M.Hart an

identified to transition back to the community. Detailed plans are being developed and DHHS has engaged a community provider who will further develop transition plans.

plans/1 ndividual budgets.

75%

ldevelooed. Individual developed (time
completion estimated 9/30/16). Budget received and reviewed in October; provider must resubmit revised budget consistent with Community Living Plan.

7

CMHA-Project Plan

10/31/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 59 of 96

Appendix 1

Identify community providers to

M.Harlan

coordinate and support transitional

and ongoing community living

including but not limited to housing,

medical and behavioral service

access, budgeting, community

integration, socialization, public

assistance, transportation, education,

employment, recreation, independent

living skills, legaUadvocacy and faith

based services as identified.

34 I 8/31/2016 Implement reimbursement processes M.Harlan
for non-Medicaid community transition

funds.

35 I 8/15/2016 IDevelop template for Community

M.Harlan

Living Plan for individuals transitioning

from Glencliff to the community.
I

I 36

7/25/2016 Transition three (3) individuals to the M.Harlan

community.

37 I 12/1/2016 ITransition four (4) individuals to the M.Harlan community.

Community providers have been identified and will further develop the transition/community living plans.

Transition/community living plans for individuals to transition to community.

Develop policies and procedures to allow Reimbursement

1100%

community providers to bill up to $100K in procedure documented,

general fund dollars.

tested and approved.

Completion of the template to be done as Community Living Plan 1100% a person centered planning process.

Three individuals have transitioned to the community.
Four individuals to transition into the community.

!Community placement
ICommunity placement

1100% 175%

38

3/1/2017 Transitions four (4) additional

individuals to the community.

39

6/30/2017 ITransition five (5) additional

individuals to the community.

M.Harlan M.Harlan

Four individuals to transition into the community.
Five individuals to transition into the community

Community placement 0% !Community placement IO%

14 residents visited community. Community provider completed assessment. Medicaid eligibility completed. Community Living Plans approved. 4 transitions to begin mid-November upon renovation completion.

8

CMHA-Project Plan

10/31/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 60 of 96

APPENDIX 2

Community Transitions Provider Billing Procedure

The following provider billing procedure is to be used by community providers for community transition General Fund reimbursement.

Billing Procedure

1. Glencliff staff identifies residents that meet the target population as defined by Community Mental Health Agreement (CMHA) and have a desire to transition into the community.

2. Glencliff staff identifies providers to coordinate and support transitional and ongoing community living including but not limited to housing, medical and behavioral service access, budgeting, community integration, socialization, public assistance, transportation, education, employment, recreation, independent living skills, legal/advocacy and faith based services.

a. If identified provider is not enrolled with Xerox, the Medicaid Management Information System (MMIS) as a Medicaid Provider, the provider must complete the enrollment process .

3. The selected community provider works with Glencliff Home to complete their comprehensive assessment,

intake and the Department of Health and Human Services (DHHS) Glencliff Transition of Care Community

Living

Plan

1 .

4. The selected community provider must develop an individual budget to support the Community Living Plan.

5. The selected community provider must submit the Individual Service Plan (ISP), the completed Community

Living

Plan

2 ,

Service

Authorization

(SA)

Requese,

and

individual

budget

to

the

Director

ofthe

Bureau

of

Mental Health Services for approval; all three documents must be submitted together.

6. Once the request is approved by the Director of the Bureau of Mental Health Services, the Bureau will forward the Service Authorization to the Office of Medicaid Services, Medical Services Unit for data entry into the MMIS system .

7. The Medical Services Unit will fax the SA number to the community provider for billing purposes and to the Bureau of Mental Health Services for its file.

8. The community provider will electronically submit CMS 1500 Form to Xerox for payment.

1 The Community living Plan is a personalized set of services that supports CMHA target individuals who have expressed a
desire to reside in the community rather than an institutional setting and ensures such individuals living in the community
can do so safely without re-entry into an institution. See Appendix 1 for Guidance on completing the Plan . 2 See Appendix 2 to access the Glencliff Transition of Care Community living Plan template . 3 See Appendix 3 to access the Request for Prior Authorization Community Transitional Serv ices form .

9/12/16

Page 1

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 61 of 96
APPENDIX 2
1. The annual budget will be authorized in equal quarterly increments. Continued authorization will be tied to
concurrent review and progress achieved.
2. The community provider may request an upfront payment of the annual approved budget in order to begin
work on the transition.
1. Billing will be done in per diem increments up to the maximum allowed amount approved through the
service authorization process.
2. Procedure modifier combination:
H2016 HWUI

9/12/16

Page 2

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 62 of 96
APPENDIX 2
Appendix 1
Guidance for Completing the Glencliff Transition of Care Community Living Plan
Necessity of Person- Centered Plans
The person centered planning process is an ongoing process involving the individual, their family, and other supports. Its intent is to identify and address an individual's strengths, goals, preferences and needs in order to develop a plan for community living.
Sample Questions to Consider: Strengths questions to ask:
• What am I good at? • What do I like to do? • What do other people think I'm good at? • What skills do I have?
Needs questions to ask: • What things are difficult for me? • Are there things I need to get better at in order to live in the community?
Opportunity questions to ask: • Who can help me with my goal for community living? • How can they help me? • What am I doing now that helps me get ready for community living?
Worries question to ask: • What do I worry about when I think about leaving Glencliff?

9/12/16

Page 3

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 63 of 96
APPENDIX 2

Glencliff Transition of Care Community Living Plan

Goal Category
Housing/Living Arrangements
Finances/Money Friendship/Social Life/Social Support Health Needs
Goal Category
Mental Health Needs
Behavioral Challenges
Transportation Education/Training Employment Recreation Community Involvement/Participation
Independent Living Skills including Activities of Daily Living(ADLs) eating, dressing, bathing grooming, toileting and mobility

Sample Questions to Consider
Where will they be living? Will they be living at home, in a supervised supported living arrangement, in a group home or in their own apartment? Any safety concerns? What about money? What will be their source of income? Will they require assistance with banking? If so, who will help with managing money? What will their social life look like? Is there a support network in place? What will their health needs be? Who will manage the health care needs? How will they live a healthy lifestyle i.e. smoking cessation? How will medications be managed? Will they need help making appointments and going to visits?
Sample Questions to Consider
What will their mental health needs be? Where will care be obtained? Is peer support available? Is there a crisis/emergency plan in place? Will they need help making appointments and going to visits? How much support is needed for the individual to live in the community? Are there non-aggressive inappropriate behaviors? Are there serious behavioral challenges? Does a plan for substance abuse prevention need to be in place? Other behavioral strategies that need to be included? What will their transportation needs look like? Can they navigate public transit or need assistance such as CTS? Does the individual want education or training and if so what arrangements will be made for this? Is there a desire to get a job? Will they go to a day program? What will they do for recreation? Can they go out in the community independently or will activities need to be supervised? What will they do during their spare time? Will they volunteer? What about spiritual and cultural activities? Do they have the self-care skills necessary to manage or are supports required? How often will supports be needed?

Instrumental Activities of Daily Living (IADLs) including meal preparation, shopping, housework, use of the telephone Communication
Community Resources
Legal/ Advocacy Service Coordination

Do they have the skills necessary to carry out the tasks or are supports required? How often will supports be needed?
What are the person's literacy skills? Can they communicate their needs appropriately? Any cognitive deficits? What other resources in the community will they need to access to support community living? Who will make the referrals and follow up on the connections? What will their legal needs be? Who will assist with this? Who is the best person to be the service coordinator and engage the individual?

9/12/16

Page 4

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 64 of 96
APPENDIX 2
Identifying Information: Name _________________________________________________________________
Date of Birth ------------------------------------------------------------
Diagnosis: Prima~ -----------------------------------------------------------Seconda~---------------------------------------------------------Other ____________________________________________________________
Prima~ Language Spoken---------------------------------------------------Person's Dreams & Vision: (What is important to this person?) ---------------------------------------------
Person Centered Planning Summary: Strengths -------------------------------------------------------------
Needs ------------------------------------------------------------------
Opportunities -----------------------------------------------------------
Worries ----------------------------------------------------- - - - - - - - - - -
Health Risk Assessment Summary (what was learned about this person's health status?)
Risk Assessment Summary (including any behaviors that might interfere with community living)

9/12/16

Page 5

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 65 of 96

Glencliff Transitron of Care Community living Plan

Goal Category
Housing/Living arrangements Finances/Money Friendship/Social life/Social Support Health Needs Mental Health Needs Behavioral Challenges Transportation Education/Training Employment Recreation Community Involvement/Participation Independent Living Skills Instrumental Activities of Daily Living Communication Community Resources Legal/ Advocacy Service Coordination

Plan

DHHS

Community Transitions

9/12/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 66 of 96

Appendix 2

REQUEST FOR PRIOR AUTHORIZATION

I

COMMUNITY TRANSITIONAL SERVI(ES

I

RECIPIENT NAME:

DATE OF REQUEST:

I

**'*PLEASE PRINT ALL INFORMATION.-.* RECIPIENT MEDICAID ID #: D.O.B.:
PROVIDER INFORMATION CONTACT PERSON:

TELEPHONE:

FAX#:

PROVIDER NAME:

PROVIDER#:

SERVICE(S} REQUESTED: DATE OF SERVICE/DATE RANGE:

I

I

TO

I

I

CPT CODE: H2016 HW Ul

PLEASE PRGVIDE TrHE Fc:lLLGWING AS NECESSARY Units Requested:
FOR INTERNAL USE ONLY

BMHS APPROVAL: AUTHORI2ATION COMPLETED BY:
DATE COMPLETED:

Signature Name

SERVICE AUTHORI2ATION NUMBER:
Return this form along with the initial community living plan and with all quarterly progress notes to
Michele Harlan Bureau of Mental Health Services
105 Pleasant Street Concord, NH 03301

DHHS

Community Transitions

9/12/16

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 67 of 96
Appendix 3
The following pages contain Preliminary Data for ACT and SE for the period ending September 30, 2016. DHHS will publish finalized data reports on a quarterly basis .

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 68 of 96

Data Source: Phoenix 2 Date Range: 07/01/2016 through 09/30/2016 Age Range: Adults Only
Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center OS Monadnock Family Services 06 Community Council of Nashua 07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Deduplicated Total

Unique Counts of Assertive Community Treatment Consumers

~,

. ~ .-..

'

0

July-2016 75 26
so
63 68 72 259 65 68 40 785

August-2016 80 30 53 74 72 71 251 68 68 38 802

September-2016 83 28 57 75 70 69 252 63 69 44 808

Deduplicated Totals 88 33 58 81 73 76 269 70 74 47 864

Consumer counts are determined by taking the unique counts of consumers receiving services in the following Cost Centers:

-Act Team #1

-Act Team #2 -Act Team #3 -Act Team #4 -Act Team #5

D' ,

(\'
I

1

Adults are consumers ages 18 and up.

Consumers are on ly counted 1 t ime, regardless of how many services they receive .

Report Produced on 10/26/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 69 of 96

Data Source: Phoenix 2
45 ,0%
40,0%
35.0%
r 30.0%
~ 25.00,.{, c
~ \! 1cii rf 20.0%
15.0%

Supported Employment Penetration Rates for The 12 Month Window Ending on: 09/30/2016

'"' l :-

----

8.5~~---------

5.0%

0.0%

01 Northern Human
Servtces

02 West Central Behavioral Health

Produced On: 10/26/2016

03 Genesis Behavioral 04 Riverbend Community OS Monadnock Family 06 Community Council of 07 Mental Health Center 08 Seacoast Mental Health 09 Community Partners

Health

Mental Health Center

Services

Nashua

of Greater Manchester

Center

• Penetration Rate

10 Center for Life Management

Deduplicated Total

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 70 of 96

tsJ I~' r'_sln' r:'nJ- t I-sJ /\:) !,QJ ll'

Chart User Guide

This chart displays Supported Employment Penetration for Each CMHC & The Weighted Average Penetration Rate across The Centers.

The height of each bar represents the total penetration rate for that center.

~~J ~Yi1D _,r

c=_,\

I
J

_.]"''r._'.rU\ JI

r-··J
J

..., I
EJ

(\! J

Chart Data
Unlque Counts of Consumers

CMHC Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health [04 Riverbend Community Mental Health Center ;OS Monadnock Family Services 06 Community Council of Nashua 07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Deduplicated Total

Supported Employment Consumers
152 103 188 216 202 174 1238 146 81 197 2691

Total Eligible Consumers
1071 618 1334 1601 939 1561 3218 1263 744 821 12917

Penetration Rate 14.2% 16.7% 14.1% 13.5% 21.5% 11.1% 38.5% 11.6% 10.9% 24.0% 20.8%

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 71 of 96

Supported Employment Penetration Rate Definitions The supported Employment program uses Penetration Rate as the primary KPI (Key Performance Indicator) to track each center's progress. While the metric is calculated at a CMHC level, the aggregate Penetration Rate for all CMHCs is the KPI for wh ich BBH is accountable. Th e Penetration Rate reflects 1 ful l calendar year of Supported Employment Services.
Penetration Rate consists of a numerator and denominator, the criteria for each is listed below: Numerator: The numerator consists of the count of unique consumers whom have received the Supported Employment service, or the Non Billable Supported Employment service during the report period (12 calendar months). Consumers only need to have received the Supported Employment service 1 time during the report period to be included in the numerator. Consumers wi ll only be counted once regardless of the frequency or quant ity of Supported Employment services received.
Denominator:
The denominator consists of the unique count of eligible consumers whom have received any services during the same report period as the numerator (12 calendar months) and have the following characteristics: Consumers must be 18 years old or older to be eligible. Consumers must have one of the following BBH eligibilities : Low Utilizer, SMPI or SMI. Eligible consumers will only be counted once in the denominator regardless of the number of services received during the calendar year. *if consumers have received services in the past, but not during the report period, they will not be included in the denominator The denominator reflects 100% of the eligible population.

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 72 of 96
New Hampshire Community Mental Health Agreement Monthly Progress Report
December 2016
New Hampshire Department of Health and Human Services December 5, 2016

CMHA Monthly Progress Report

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 73 of 96

Acronyms Used in this Report

ACT: BDAS: BMHS: CMHA: CMHC: DHHS: EMR: IDN: QSR: SE: SFY:

Assertive Community Treatment Bureau of Drug and Alcohol Services Bureau of Mental Health Services Community Mental Health Agreement Community Mental Health Center Department of Health and Human Services Electronic Medical Record Integrated Delivery Networks Quality Services Review Supported Employment State Fiscal Year

CMHA Monthly Progress Report

2

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 74 of 96
Jntroduction This fourth Monthly Progress Report is issued in response to the June 29, 2016 Expert Reviewer Report, Number Four, action step 4. It reflects the actions taken in November, and month-over-month progress made in support of the Community Mental Health Agreement (CMHA) as of November 30,2016. This report is specific to achievement of milestones contained in the agreed upon CMHA Project Plan for Assertive Community Treatment (ACT), Supported Employment (SE) and Glencliff Home Transitions, as updated and attached hereto (Appendix 1). Where appropriate, the Report includes CMHA lifetime-to-date achievements.

CMHA Monthly Progress Report

3

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 75 of 96

Executive Summary
Assertive Community Treatment Pro~ress Achieved in November 2016 • ACT Statewide De-duplicated Enrollment Update (for the period ending October 31, 2016)1
o October 2016 -- 815 o September 2016- 808 o One Month Comparison- 7 more consumers enrolled in ACT than in September 2016
• ACT Statewide Capacity Update (for the period ending October 31, 2016)2 o October 2016- 1,124 o September 2016- 1,093 o One Month Comparison- 31 more potential consumers than in September 2016
• Community Mental Health Centers (CMHCs) Under ACT Compliance Plans (for the period ending October 31, 2016)3: o October 2016- 245 o September 2016- 237 o One Month Comparison- 8 more consumers enrolled in ACT than in September 2016
• Project Plan Milestones: o By 12/1/2016 DHHS will initiate ACT Fidelity Assessments • As of November 30,2016, seven (7) CMHCs completed ACT Self-Fidelity Assessments, and DHHS conducted one (1) ACT Fidelity Assessment. November 28-December 1, DHHS conducted a second ACT Fidelity Assessment. In January 2017, DHHS will conduct the third and final ACT Fidelity Assessments for State Fiscal Year (SFY) 2017. • As of November 30, 2016, DHHS completed its initial review of the six (6) ACT Self-Fidelity Assessments conducted in October 2016. DHHS anticipates publishing final reports for these assessments in January 2017.
Supported Employment • Supported Employment Statewide Penetration Rate4 (for the period ending October 31, 2016)
o October 2016 Penetration Rate- 20.4% o September 2016 Penetration Rate- 20.8% o One Month Comparison: .4% lower than in September 2016
• CMHCs Under Compliance Plan- October SE Penetration Rates5: o October 2016- 12.8% o September 2016 - 12.6% o One Month Comparison- .2% higher than in September 2016
• Project Plan Milestones: o By 12/1/2016 explore resources to conduct technical assistance and training. CMHCs and DHHS will explore strategies and barriers DHHS can use to facilitate service delivery.

1 Based on preliminary data contained in Appendix 2
2 Based on preliminary data contained in Appendix 2 3 Based on preliminary data contained in Appendix 2 4 Based on preliminary data contained in Appendix 2 5 Based on preliminary data contained in Appendix 2; average of all four CMHCs under SE compliance plans

CMHA Monthly Progress Report

4

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 76 of 96
• DHHS exceeded the 3/1/2017 targeted statewide SE Penetration rate in March 2016. In November, DHHS continued providing technical assistance and monitoring of CMHCs not yet meeting the targeted SE penetration goal on a regional level.
Glencliff Home Transitions into Intei:rated Community Setting • Discharge Update
o November Discharges: No residents were discharged in the month of November. Five residents are in active discharge planning status with resolution anticipated in the coming weeks.
• Project Plan Milestones: o By 12/1/2016 transition four (4) individuals to the community • November discharges consistent with this milestone- None • DHHS anticipated meeting the 12/1/2016 Project Plan Milestone in November when the first two (2) of (4) residents were anticipated to transition into a community residence. The community residence provider experienced unanticipated delays in hiring a full staff complement required for safely meeting the residents' needs. At this time, DHHS anticipates the four residents will transition to the community residence beginning in mid-December.
• Community Mental Health Agreement Milestones: o By 6/30/2016, the capacity to serve six additional individuals (cumulative total of 10) in an integrated community setting. o By 6/30/2017, the capacity to serve six additional individuals (cumulative total of 16) in an integrated community setting. • As of 11/30/16, DHHS has transitioned six6 (6) residents into compliant community residences. • By 12/31/16, DHHS will have transitioned ten (10) residents into compliant residences. • By 12/31/16, DHHS will have met the cumulative total required under the 6/30/2016 milestone, and will be on track to meet the 6/30/2017 milestone.
Additional DHHS Efforts to Support CMHA Goals and Streninhen NH's Mental Health System
• New Hampshire Building Capacity for Transformation (NHBCT) Medicaid Section 111Sa o The NHBCT's Health Information Technology (HIT) and Workforce Development Statewide Taskforces continued meeting in November to address cross-Integrated Delivery Network (ION) planning for: improving information sharing around care for those individuals with Substance Use Disorders (SUD) and Mental Health (MH) complexity; and to consider solutions to effectively mitigate workforce gaps. o Integrated Delivery Network (ION) Project Plans submitted on October 31, 2016 were placed under initial review and assessment in November. On December 12th and 13th, an Independent Panel will conduct an impartial review of all proposed ION Project Plans. The two review sessions will be open to the public. o Upon DHHS approval of ION Project Plans, additional funds will be released for plan implementation.

6 In the November Monthly Progress Report, a seventh transition was reported in error. The transition is removed from the cumulative count as it occurred prior to execution of CMHA.

CMHA Monthly Progress Report

5

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 77 of 96

Schedule of State Fiscal Year 2017 Fidelity and Quality Services Review7

Center for Life Management

DHHS-conducted QSR

-as:-,ID Mental Health Center of Greater Manchester

-N

DHHS-conducted SE Fidelity Assessment

Riverbend Community Mental Health

DHHS-conducted SE Fidelity Assessment

a~~~D West Central Behavioral Health

<::I ~...

DHHS-conducted QSR

Genesis Behavioral Health

...~:·~.ID

DHHS-conducted QSR

G.IQ II:IN

Northern Human Services

DHHS-conducted SE Fidelity Assessment

Center for Life Management

Self-conducted ACT Fidelity Assessment

Self-conducted SE Fidelity Ass essment

Community Partners of Strafford County

Self-conducted ACT Fidelity Ass essment

Genesis Behavioral Health

DHHS-conducted ACT Fidelity Assessment

Self-conducted SE Fidelity Assessment

Greater Nashua Mental Health Center

..

DHHS-conducted SE Fidelity Assessment Self-conducted ACT Fidelity Assessment

&G~,..l-.e. Mental Health Center of Greater Manchester

~~

Self-conducted ACT Fidelity Assessment

0

Monadnock Family Services

Self-conducted ACT Fidelity Assessment

Self-conducted SE Fidelity Assessment

Riverbend Community Mental Health

DHHS-conducted QSR- POSTPONED8

Self-conducted ACT Fidelity Assessment

Seacoast Mental Health Center

Self-conducted9 ACT Fidelity Assessment

Self-conductedlO SE Fidelity Assessment

West Central Behavioral Health

Self-conducted SE Fidelity Assessment

.
G.l

Community Partners of Strafford County DHHS-conducted SE Fidelity Assessment

&al-.e.. Monadnock Family Services

G,)Q =-N

DHHS-conducted QSR- POSTPONED

zCl

Northern Human Services

DHHS-conducted ACT Fidelity Assessment

Mental Health Center of Greater Manchester DHHS-conducted QSR
West Central Behavioral Health DHHS-conducted ACT Fidelity Assessment
Seacoast Mental Health Center DHHS-conducted QSR
Greater Nashua Mental Health Center DHHS-conducted QSR
Community Partners of Strafford County DHHS-conducted QSR
Northern Human Services DHHS-conducted QSR

..·.I.D..
G.l= QN

-.N=-.-.l=~l=~l
N~
QID
..,.CT --~·
......Ni:
Qlll
-.~g.
QN'C>
~2:
N=~~';~<i~:
.=N -...l=iD=-

7 Schedule incorporated into Monthly Progress Report in response to the Center for Public Representation's 8/24/2016 request for additional information to ensure various tasks and deliverables are occurring at an appropriate pace. Schedule may be subject to change.
8 The QSRs originally scheduled for October and November 2016 were postponed in October to accommodate the revision of QSR tools and processes consistent with CMHA provision (Vli.D.2). DHHS will reschedule the two impacted QSRs to occur in 2017.
9 At its own discretion, Seacoast Mental Health Center utilized the services of an outside contractor to conduct its Self-Assessment 10 At its own discretion, Seacoast Mental Health Center utilized the services of an outside contractor to conduct its Self-Assessment

CMHA Monthly Progress Report

6

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 78 of 96
Actions Taken to Enable DHHS to Factually Demonstrate Significant and Substantial Progress
1. Assertive Community Treatment • November Actions to Increase ACT Enrollment :
o DHHS actions to reduce inpatient behavioral health waitlist for individuals in hospital emergency rooms 10% by July 2017 or 25% by July 2018 • New protocols to ensure CMHC daily contact with emergency departments are underway; BMHS actively engaged with CMHCs to seek rapid resolution of barriers to discharge.11 • DHHS requested that Well Sense develop aggressive approach to address emergency department admissions, identification and referral of consumers to CMHCs for potential ACT enrollment, and to develop a protocol to daily engage with emergency departments and applicable CMHCs to expedite delivery of additional services or supports needed to return consumer to community or discharge to appropriate setting/treatment option. Well Sense initiated development.
• New Hampshire Hospital (NHH) representatives provided information to the CMHC Executive Directors to increase understanding of the admission and discharge practices for the Inpatient Stabilization Unit at NHH. Identified areas for improved collaboration with CMHCs to expedite the return of patients to the community.
o Continuing Actions to increase ACT Enrollment during November include: • Enhanced monthly Emergency Department data reporting continues to be implemented • DHHS Data Analytics worked with CMHC representatives to develop streamlined reporting tools and reduce reporting redundancy. • CMHCs continue to use Emergency Department data to identify consumers for potential ACT enrollment. • CMHCs began monthly reporting to DHHS on the identification of consumers screened for ACT and providing explanations for consumers not enrolled. • CMHCs provided ACT training to internal staff • CMHCs provided overview of ACT to external stakeholders, such as law enforcement, housing and vocational rehabilitation providers • CMHCs improved internal ACT referral processes, such as revising written plans to better align with fidelity, and adjusting EMR to trigger consideration of ACT referral at quarterly evaluations. • New Hampshire Healthy Families continues monthly auditing of emergency department admissions and referring consumers to CMHCs for potential ACT enrollment. MCO continues weekly re-evaluation of data to report to DHHS and CMHCs any unresolved consumers to ensure resolution. • New Hampshire Healthy Families continues daily contact with emergency departments and applicable CMHCs for any consumer waiting and to expedite delivery of additional services or supports needed to return consumer to community or discharge to appropriate setting/treatment option.

11 Effort is part of DHHS Innovation Accelerator Program (lAP), Goal #1,

CMHA Monthly Progress Report

7

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 79 of 96

• CMHCs Un der ACT Compliance Plans (fo r th e period endin g October 31. 20 16) 12:
o Northern Human Services • October 2016 -- 88 • September 2016- 83 • One Month Comparison - 5 more consumers enrolled in ACT than in September 2016
o West Central Behavioral Health • October 2016 -- 28 • September 2016- 28 • One Month Comparison- no change from September 2016
o Genesis Behavioral Health • October 2016 -- 59 • September 2016- 57 • One Month Comparison- 2 more consumers enrolled in ACT than in September 2016
o Greater Nashua Mental Health Center • October 2016 -- 70 • September 2016- 69 • One Month Comparison- 1 more consumer enrolled in ACT than in September 2016
• November Effor ts to Increase ACT Capacity (Improve CMHC Abil ity to Recruit and Retain ACT StafQ:
o The DHHS State Loan Repayment Program (SLRP) administrator presented a program overview to the CMHC Executive Directors to promote interest and participation in the program.
o DHHS Bureau of Drug and Alcohol Services (BOAS) representatives provided an update on the Bureau's efforts to fight the opioid epidemic to the CMHC Executive Directors. Identified potential areas for further collaboration regarding administrative rules and available resources for the State's Substance Use Disorder and Mental Health treatment systems, including: training, certification and streamlined, non-duplicative reporting requirements- all factors that can negatively or positively impact recruitment and retention of ACT staff.
• November Actions to Ensure Fidelity
o DHHS completed its initial review of six CMHC ACT Self-Fidelity Assessments reports. o DHHS conducted an ACT Fidelity Assessment of Northern Human Services13• o The final CMHC required to conduct an ACT Self-Fidelity Assessment completed the
assessment in November.
• Upcoming Milestones to Ensure Fidelity
o In December, DHHS will provide its initial response to seven ACT Self-Fidelity Assessments to the applicable CMHCs. These centers will have two weeks to respond and work with DHHS to finalize the results of the assessments, and to develop and submit improvement plans. DHHS anticipates publishing final reports and improvement plans in January 2017.
o DHHS will complete the ACT Fidelity Assessment report, review and improvement plan if appropriate, for Genesis Behavioral Health , for release by December 31, 2017.

12 Based on preliminary data contained in Appendix 2 13 This assessment began November 28th and concluded December 1".

CMHA Monthly Progress Report

8

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 80 of 96

2. Supported Employment • November Actions Taken to Ensure Fidelity
o DHHS completed its initial review of five CMHC conducted SE Self-Fidelity Assessments.14
o DHHS conducted an SE Fidelity Asses sment of Community Partners of Strafford County. o On November 14, 2016, DHHS issued its final SE Fidelity Assessment Report for
Northern Human Services.
• Upcoming Milestones to Ensure Fidelity
o In December, DHHS will provide its initial review of five SE Self-Fidelity Assessments to applicable CMHCs. These centers will have two weeks to respond and work with DHHS to finalize the results of the assessments, and to develop and submit improvement plans. DHHS anticipates publishing final reports and improvement plans in January 2017.
o In December, DHHS will continue completion of SE Fidelity Assessment reports for and work with applicable CMHCS to obtain their responses and improvement plans. Final reports are anticipated for a January 2017 release.
o Continuing Actions to Maintain SE Statewide Penetration Rate and Support all CMHCs to Reach or Exceed 16.8% Penetration Rate During November Include: • DHHS discussed monthly SE Penetration Rate data with CMHCs to encourage further collaboration to achieve effective SE programs • CMHCs provided SE training to internal staff and worked with regional employers to improve competitive employment opportunities
• CMHCs Under Compliance Plan September SE Penetration Ratesls
o Northern Human Services • October 2016- 14.0% • September 2016-14.2% • One Month Comparison -.2% lower than in September 2016
o Genesis Behavioral Health • October 2016-14.1% • September 2016- 14.1% • One Month Comparison- no change from September 2016
o Greater Nashua Mental Health Center • October 2016- 11.9% • September 2016-11.1% • One Month Comparison- .8% higher than in September 2016
o Community Partners • October 2016- 10.4% • September 2016-11.1% • One Month Comparison -.7% lower than in September 201616

14 This number is one greater than previously reported; a CMHC originally identified for a DHHS conducted Fidelity Assessment erroneously
conducted a Self-Assessment DHHS agreed to review the Self-Fidelity Assessment 15 Based on preliminary data contained in Appendix 2 16 Significant staffing shortage (loss of all SE staff) factor into decrease

CMHA Monthly Progress Report

9

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 81 of 96
3. Glencliff Home Transitions into Integrated Community Setting
• Discharge Barrier Resolution Update Although there were no discharges in the month of November, progress continues to be made towards discharging several residents in the coming weeks: o Active Pending Discharges - 5 • Community Residence- 4 (commencing December 2016) • Full staffing complement to ensure residents' needs are safely met. • Enhanced Family Home - 1 • Resident with funded Acquired Brain Disorder (ABO) waiver anticipates meeting in December with potential home provider.
• Other November Actions Taken to Address Discharge Barriers o Ongoing identification and reporting of residents interested in transitioning: 24 residents o Continued effort to identifY services and placement opportunities for residents interested in transitioning.
• Project Plan Milestones: o By 12/1/2016 transition four (4) individuals to the community • November discharges consistent with this milestone- None. • DHHS anticipated meeting the 12/1/2016 Project Plan Milestone in November when the first two (2) of (4) residents were anticipated to transition into a community residence. The community residence provider experienced unanticipated delays in hiring a full staff complement required for safely meeting the residents' needs. At this time, DHHS anticipates the four residents will transition to the community residence beginning in mid-December.
• Community Mental Health Agreement Milestones: o By 6/30/2016, the capacity to serve six additional individuals (cumulative total of 10) in an integrated community setting. o By 6/30/2017, the capacity to serve six additional individuals (cumulative total of 16) in an integrated community setting. • As of 10/31/16, DHHS has transitioned six (6) residents into compliant community residences. • By 12/31/16, DHHS will have transitioned ten (10) residents into compliant residences. • By 12/31/16, DHHS will have met the cumulative total required under the 6/30/2016 milestone, and will be on track to meet the 6/30/2017 milestone.

CMHA Monthly Progress Report

10

December 5, 2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 82 of 96

Appendix 1
NH Department of Health & Human Services Community Mental Health Agreement (CMHA) Project Plan for Assertive Community Treatment, Supported Employment and Glencliff Home Transitions
November 30, 2016

ACT-Expanding capacity/penetration; Staffing array

Quarterly

Continue to provide quarterly ACT reports with stakeholder input and distribute to CMHCs and other st akeho lde rs.

M. Brunette

report focuses on three (3) key quality linrlicators: staffing array consistent with
Settlement Agreement; capacity/penetration; ACT service

Quarterly Reports 100% and ngoing

intensity, averaging three (3) or more

mters/week. This report is key as it CMHC leaders in understanding

ir performance in relation to quality indicators in the CMHA and past

performance .

2

6/30/2016. Letters sent to CMHCs with low

M. Brunette Quality improvement requested by DHHS Monthly compliance

100%-

letters sent compliance including staffing and/or

with detailed quality improvement plans calls and follow-up

letters,

capacity with a request for

with a focus on increasing the capacity of

monitoring

improvement plans . The CMHCs will

ACT.

and follow-

monitored and follow-up will occur.

up ongoing

Directors participated in a facilitated session to establish a plan to expand capacity and staffing array.

session resulted in a plan with action 'The goal was to

steps for increased ACT capacity.

establish a focused

workplan expected to

increase new ACT

clients.

1100%

n is ongo1ng under which the CMHCs and DHHS is operating with focused effort to achieve CMHA goals.

1

CMHA-Project Plan

11/30/2016

Appendix 1

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 83 of 96

region who had emergency department visits for psychiatric reasons, psychiatric hospitalizations, DRF admissions, and NHH admissions in the past quarter to facilitate CMHCs ability to assess people in their region for ACT.

use these quarterly reports to First report due from

their screening of people for ACT. CMHCs to DHHS by

CMHCs will provide quarterly reports to 7/29/2016. The

DHHS indicating that they have screened screening process and

each individual and the outcome of the reporting will utilize a

screening.

comprehensive

I template developed by
the ACT and SE

community stakeholder

group by 9/30/16.

5 I 10/1/2016 IAddress Peer Specialist Challenges- M.Brunette Behavioral Health Association and DHHS Work with BOAS to look 100%

lack of standardized training.

in an effort to expedite increasing peer

at their process.

specialists, will explore the SUD Recovery

specialists certification.

I
6 I 10/1/2016 IACTteam data will be reported separately by team.

I
IM.Brunette

The data will be separated starting the

ACT team data will be 100%

month of July 2016 and will be reported in separated on a quarterly

the October 2016 report.

basis moving forward.

7 I 10/1/2016 IDevelop organization strategies to
increase capacity.

I
IM.Brunette

Each CMHC will conduct one education Increase community session between now and Oct. 1, 2016 to education. introduce ACT.

80%

8 I 10/1/2016 IReview and make changes as

I I I M.Brunette Each CMHC Will rev1ew and evaluate their Learn1ng Collaborative

necessary to ACT referral process.

internal referral process and then share to share their

rO%

processes.

Idata for monthly
discussion with CMHC ACT coordinators.
Research completed. Additional training capacity added. DHHS collaborated with Peer Support Agency to assist with coordination of meeting Peer Support Specialist training needs; ongoing identification of training needs and coordinating delivery of training commenced in October.
Use monthly 1n Implementation Workgroup and Technical Assistance D'is"c' ussed in monthly ACT/SE Implementation Workgroup calls to identify educational needs. Centers holding additional inservice sessions.
IInternal CMHC review of
referral process is underway. Some ideas already shared in learning collaborative.

2

CMHA-Project Plan

11/30/2016

Appendix 1

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 84 of 96

12/1/2016

11

12/1/2016

12

12/1/2016

assessments.

13

2/28/2017 !Increase

capacity

a report that communicate the strategies to address ACT staffing issues in collaboration with DHHS .
M.Brunette

M.Brunette M. Brunette

Fidelity report

workforce development projects underway that include CMHC staffing (inclusive of ACT staffing).
made to increase understanding of how to access funds; DHHS seeking additional funding for program in 2018-2019 budget.
Yearly; 85% JConducted second of three ACT Fidelity Assessments (Nov 28Dec 1). Third and final is scheduled for January 17.
New monthly capacity (staffing) reports began in November. As of 10/31116, actual increased capacity is 16.6% toward goal of increase target.

3

CMHA-Project Plan

11/30/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 85 of 96

DHHS will request CMHCs with low compliance to provide DHHS a list of five (5) consumers who are eligible for and who will begin to receive ACT services each month starting August 1, 2016 through February 2017.
will request all other CMHCs to DHHS a list of 3 consumers are eligible for and who will begin receive ACT services each month August 1, 2016 through February 2017.

15

6/30/2017 !Increase ACT capacity

16 I 6/30/2017 that all CMHCs will continue
provide DHHS a list of 24 consumers who were hospitalized for psychiatric reasons or are otherwise eligible for ACT and were enrolled each month.

Appendix 1

reports will be provided to each List of (5) consumers

CMHC on their specific list of individuals from low compliance

who had Emergency department visits and CMHCs who are eligible

psychiatrist hospitalizations to allow

for ACT services each

CMHCs to assess their center specific

month and a list of (3)

clients .

consumers from other

CMHCs who are eligible

for ACT services.

Concerted efforts by the CMHCs to assess

0%

individuals in Community residences that

could be served on ACT. Train direct

service providers in coding appropriately

for ACT services. Screen 100% eligible

individuals for ACT.

tools and reviewed with CMHCs in October. CMHC response reports are being submitted as of October 31, 2016. DHHS actively reviewing reports for consultation with CMHCs. NH Healthy Families (MCO) is also supporting effort by daily monitoring of Emergency Department admissions, referrals to CMHCS, and weekly follow up to address ACT enrollment. DHHS requested similar action by WeiiSense in November; under development now.

4

CMHA-Project Plan

11/30/2016

Appendix 1

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 86 of 96

17

5/20/16

ongoing penetration rates including staffing

and/or penetration with a request for

improvement plans .

Supported Employment (SE)

reports .

nee plan with qua

18

I I 6/1/16 and Continue to generate quarterly report M.Brunette

This report is key as it assists CMHC

ongoing with stakeholder input focusing on

leaders in understanding their

penetration of SE services distributed

performance in relation to quality indicators

to the CMHCs and other stakeholders.

in the CMHA and past performance.

I I 19

7/20/2016 DHHS team and CMHC Executive

Directors will participate in a

M.Harlan

facilitated session to establish a plan

to expand penetration and staffing

array.

I 20

7/6/2016

On-site fidelity assessments conducted at CMHCs.

uate 1100%

Use in Technical Assistance calls with Centers to support continuing progress . Two out of four reported decreases in September; overall improvement is 6.8% over August for these 4 CMHCs.

Ongoing/Qu arterly

Use monthly in Implementation Workgroup and Technical Assistance calls ; include 4 quarters for trend discussion.

100%

Workplan is ongoing guide under which the CMHCs and DHHS is operating with focused effort to achieve CMHA goals.

21

7/12/2016

22

9/27/2016

The second fidelity assessment took on 7/12/16 at Riverbend in Concord.

Report with results of the on-site fidelity assessments.

The third fidelity assessment will take place on 9/27/16-9/29/16 in Berlin.

Report with the on-site fidelity assessments.

5

CMHA-Project Plan

11/30/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 87 of 96

Appendix 1

24

10/1/2016 IMonitor monthly ACT staffing for

M.Harlan

Monitor monthly ACT staffing

presence of SE.

of SE on each team.

25

10/15/2016 IAll CMHCs will conduct self-fidelity K.Boisvert Self-fidelity assessments

assessments.

26

11/1/2016

lnOIVIOUals that are not on reasons why they are not enrolled.

report will be 1100% and run through the Phoenix Ongoing system for ACT staffing.
Report to DHHS with 1100% self-fidelity assessment results.
reports of I0% individuals not on SE.

Assessment conducted. DHHS report in draft/review process. Will be sent to CMHC in December.
Use monthly in Implementation Workgroup and Technical Assistance calls.
DHHS completed its initial review of the assessments received .

27

11/1/2016 IResolve barriers to achieving SE

M.Harlan

I Educate internal CMHC staff on the goals Educational plan

penetration goals.

ofSE.

90%

Discussed in monthly ACT/SE Implementation Workgroup calls to identify educational needs. Five CMHCs reported holding additional inservice sessions. Learning Collaborative work has yielded all SE leads meeting with new clients within days of intake;
staff educated SE; SE education needs identified, motivational programs clients explored, etc.

6

CMHA-Project Plan

11/30/2016

Explore resources to technical assistance and training. CMHCs and DHHS will explore strategies and barriers DHHS can use to facilitate service delivery.

Appendix 1

CBHA and DHHS will explore the need for technical assistance and training. DHHS will conduct a subgroup of CMHC leaders to explore barriers and administrative burden that prevents service delivery.

Report the barriers and possible solutions. Technical assistance (TA) and training if needed.

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 88 of 96

29

12/1/2016 !Increase the number of staff who are IM. Harlan

re the possibility of increasing the Increase number of

75%

eligible for State Loan Repayment

number of staff eligible for this program. staff eligible.

Program (SLRP).

30

6/30/2017 !Increase SE penetration rate to

I Learning collaborative meets monthly and Monthly meetings of the 1100%
has developed a four question script to be Learning Collaborative. used at time of intake as an instrument to
introduce SE. If the individual is interested referral goes to the SE coordinator who
mcontact the individual within 3 days of
the intake to set up an appointment. If the individual is not interested the SE Coordinator will outreach to provide
information on SE and will periodically follow up with him/her. This strategy includes working with individual CMHCs that fall below the 18.6% penetration rate.

7

CMHA-Project Plan

11/30/2016

Appendix 1

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 89 of 96

Glendlff Home Transitions

31

Ongoing at l cstaousn process

Glencliff Staff

interviews residents each year to Section Q of MDS is a

residents individuals interested in transitioning

if they want to transition back to federal requirement.

every 90 days from Glencliff to the community.

community.

CMHCs have staff go to

Glencliff to discuss

transition planning with

residents.

32 I 7/30/2016 IDevelop individual transition plans, 1M. Harlan including a budget.

IIndividuals from Glencliff have been
identified to transition back to the . Detailed plans are being and DHHS has engaged a provider who will further
transition plans.

Individual transition plans/individual budgets.

85%

33 I 8/31/2016 IIdentify community providers to

M.Harfan

coordinate and support transitional

and ongoing community living

including but not limited to housing,

medical and behavioral service

access, budgeting, community

integration, socialization, public

assistance, transportation, education,

employment, recreation, independent

skills, legaVadvocacy and faith

services as identified.

34 I 8/31/2016 Implement reimbursement processes M.Harlan for non-Medicaid community transition funds.
M.Harfan

Community providers have been identified and will further develop the transition/community living plans.

Transition/community living plans for individuals to transition to community.

100 %

Develoo oolicies and orocedures to allow Reimbursement

100%

to
developed. Individual budgets received and reviewed in October. Provider continued budget revisions in November; will resubmit
rly December.
reviewed and approved. Providers identified and engaged. Community Living Plans developed.

36 I 7/25/2016 ITransition three (3) individuals to the IM.Harlan community.

8

CMHA-Project Plan

11/30/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 90 of 96

3/1/2017

39

6/30/2017

individuals to the community.

Appendix 1

Four individuals to transition into the community

Community placement I 0% placement I 0%

residents community. Community provider completed assessment. Medicaid eligibility completed. Community Living Plans approved. 4 transitions to delayed; will begin December due to staff recruitment delay.

9

CMHA-Project Plan

11/30/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 91 of 96
Appendix 2
The following pages contain Preliminary Data for ACT and SE for the period ending October 31, 2016. DHHS will publish finalized data reports on a quarterly basis.

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 92 of 96

Supported Employment Penetration Rates Split by Billable Vs. Non Billable Services for The 12 Month Window Ending on: 10/31/2016
Data Source: Phoenix 2 40% ,-----------------------------------------------------------------------------------------------------------------------------------------------------------------
37.1%
35%

30%

• -"~'..!I"

I.. ;..I -, '11-1

. . _, ____., -~ -~ II o

25% t--------------------------------------------------------------------------------------4

~
a:
0::
~ 20%
.10
0::
"-

17.5%

15%

10%

5%

0%
01 Northern Human Services

02 West Central Behavioral Health

Produced On : ll/ 29/2016

03 Genesis Behavioral 04 Riverbend Community 05 Monadnock Family 06 Community Council of 07 Mental Health Center 08 Seacoast Mental

Health

Mental Health Center

Services

Nashua

of Greater Manchester

Health Center

• Billable Services • Non Billable Services

Larger Font Is for Center Totals

09 Community Partners

10 Center for life Management

Statewide Total

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 93 of 96

Chart User Guide
This chart displays Supported Employment Penetration Rate Split by Billable and Non Billable services.
The total height of each bar represents the total penetration rate for that center. The smaller sections of each bar reflect the portion of the overall penetration rate that can be attributed to billable Vs. non billable services. If consumers have received both billable and non billable Supported Employment services, they will only be included in the Billable Services (blue bar) portion of the chart. If consumers have received only non billable Supported Employment Services, they will only be included in the non billable services (red bar) portion of the chart. Consumers are only counted 1 time in this report regardless of the frequency of services or if they receive both billable and non billable services.

r I ;) J -..... r•J ~ ~

(\I

,..:1 ~~·~·~·)
• ... ~ l r

Chart Data

Unique Counts of Consumers

Penetration Rate by Billable Type

Non

Billable

Non Billable

Total

Billable Billable Total Eligible

Penetration Penetration Penetration

CMHCName

Services Services Consumers

Rate

Rate

Rate

01 Northern Human Services

109

37

1044

10";1,

4%

14.0%

02 West Central Behavioral Health

96

10

607

16%

2%

17.5%

03 Genesis Behavioral Health

133

55

1331

10%

4%

14.1%

04 Riverbend Community Mental Health Center

221

0

1614

14%

0%

13.7%

OS Monadnock Family Services

129

63

942

14%

7%

20.4%

06 Community Council of Nashua

141

45

1564

9%

3%

11.9%

07 Mental Health Center of Greater Manchester

307

855

3129

10"11>

27%

37 ,1%

08 Seacoast Mental Health Center

99

56

1289

8%

4%

12.0"11>

09 Community Partners

40

36

728

5%

5%

10.4%

10 Center for Life Management

141

52

840

17%

6%

23 ,0";1,

Statewide Total

1413

1206

12846

11%

9%

20.4%

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 94 of 96

Supported Employment Penetration Rate Definitions jThe supported Employment program uses Penetration Rate as the primary KPI (Key Performance Indicator) to track each center's progress. While the metric is calculated at a CMHC level, the aggregate Penetration Rate for all CMHCs is the KPI for which BBH is accountable. The Penetration Rate reflects 1 full calendar year of Supported Employment Services.
Penetration Rate consists of a numerator and denominator, the criteria for each is listed below: Num.erator: The numerator consists of the count of unique consumers whom have received the Supported Employment service, or the Non Billable Supported Employment service during the report period (12 calendar months) . Consumers only need to have received the Supported Employment service 1 time during the report period to be included in the numerator. Consumers will only be counted once regardless of the frequency or quantity of Supported Employment services received.
De.nomlnator: The denominator consists of the unique count of eligible consumers whom have received any services during the same report period as the numerator (12 calendar months) and have the following characteri st!cs : Consumers must be 18 years old or older to be eligible. Consumers must have one ofthe following BBH eligibilities: Low Utilizer, SMPI or SMI. Eligible consumers will only be counted once in the denominator regardless of the number of services received during the calendar year. •11 consumers have received services in the past, but not during the report period, they will not be included in the denominator The denominator reflects 100% of the eiJgible population.

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 95 of 96

Data Source: Phoenix 2 Date Range: 08/01/2016 through 10/31/2016 Age Range : Adults Only
Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center OS Monadnock Family Services 06 Community Council of Nashua 07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Deduplicated Total

Unique Counts of Assertive Community Treatment Consumers

~·J I r1 ( ""'":: 1· 0

c

August-2016 80 30 53 74 72 71 251 68 68 38 802

September-2016 83 28 57 75 70 70 252 65 69 44 811

October-2016 88 28 59 77 64 70 250 64 70 45 815

Deduplicated Totals 93 31 60 82 73 76 270 71 72 47 871

Consumer counts are determined by taking the unique counts of consumers receiving services in the following Cost Centers:

-Act Team #1

-Act Team #2 -Act Team #3 -Act Team #4

!""\

.

J~

-Act Team #5

_,_/.,.

Adults are consumers ages 18 and up.

Consumers are only counted 1 time, regardless of how many services they receive.

Report Produced on 12/02/2016

Case 1:12-cv-00053-SM Document 117-1 Filed 01/09/17 Page 96 of 96

Septembe r 2016 Full Time f<} ulliaients

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center OS Monadnock Family Services 06 Communitv Councll of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-e n 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Panners 10 Cen ter for Life Managem ent Total

[p)[f@Q t1i1il~[ft)(IDrrr; @@ ~

Nurse 0.53 0 40 1,00

Mosters Level d l n i d a n/ o r• Eoulvalent 2.37 L25 2.00

Functional
Suooort Workf!l
7.02 L19 4,00

Peer Specialist 0.33 0 ,6 0 0 ,0 0

Total (ExtludlnB Psvchlatrvl 10 .25 5 ,44 7 ,0 0

050

3,00

3.50

0.50

750

050

3.25

3.00

0.50

7.25

0.50

3.00

2. 75

0.00

6 ,25

0.50

3.00

1.75

0.00

5.l5

0 99

11.00

2.47

1.00

15 46

0. 96

10 00

8.28

0.43

2.30

5.00

0.40

2 00

5.13

1.00

0.75

5.16

7.71

44.92

50.25

1.00

20 24

1.00

8 73

0.50

8.03

0.00

691

5.43

108.31

September 2016 ACT Staff Competencies

Substance Use

Center Name

ACT Staff Count

01 Nor1hern Human Services

2 42

02 West Central Behavioral Health 03 Genesis Behavioral Health

120 45 0

04 Riverbend Community Mental Health

Center OS Monadnock Family Services

1.40 3.40

06 Community Council of Nashua 1

300

06 Community Council of Nashua 2 07 Mental Health Center or Gr-eater

3.00

Manchester-en 07 Mental Health Center of Greater

1100

Manchester-MCST 08 Seacoas t Mental Health Center

2 00 0.20

09 Community Partners

1.00

10 Center for Life Management

2 75

Total

35.87

September 2016 ACT Staff Competencies

Housing_Assistance

Center Name

Acr Staff Count

01 Northern Human Services

7.95

02 West Central Behavioral Health

5.40

03 Genesis Behavio,al Health

6,00

04 Rlverbend Community Mental Health

Center

6.DO

OS Monadnock Family Services

1.00

06 Community Council of Nashua 1

5.00

06 Community Council of Nashua 2

4.00

07 Mental Health Center of Greater

Manchester-en

11 .61

07 Mental Health Center or Greater

Manch ester-MCST

15.79

08 Seacoast Mental Health Center

5.00

09 Community Partners

6.50

10 Center for Life Manac;ement

5.61

Total

79 .8 6

September 2016 ACT Staff Competencies
suo~tl!d EinPlOI'ment

Center Name

ACf Staff Count

01 Northern Human Services

1.27

02 West Central Behavioral Health

0 ,19

03 Genesis Behavioral Health

2.,00

04 Riverbend Community Me_ntal Heallh

0.50

05 Monadnock Famil Services

1 00

06 Community Council of Nashua 1

LSO

06 Community Council of Nashua 2

1.50

07 Mental Health Center of Greater

0.36

07 Mental Health Center of Greater

1,18

08 Seacoast Mental Health Center

100

09 Commu nity Partners

1..00

10 Center for Life Management

0.30

Total

12.80

Psychiatrist/Nurse Practitioner 0.80 0,14 0.50
0.40 0.65 0.25 0.25
0.72
0 63 0.60 0.50 0.10 5.54

-The Sluff CompeiMCJI valu~s. rtjlff.t the sum of f1E'5 /rained Ia provide each
:~;ervicetype
-TI•ese numbns ore not o reflettion of/he services delivered, tolhet the
~ I IJvO/UI)f/.nv!AtWe r~,-o.t*f"CCIIII;AW'~ -If slof/ is /ra ined IO p rovirk multiple service lypes, their-en/ire FTE value will
be rredil edto eCKh servicetypr.

 
 Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 1 of 109
ATTACHMENT A

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 2 of 109
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Six
June 30, 2017
I. Introduction
This is the sixth semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this six-month period (January 1, 2017 through June 30, 2017), the ER has continued to observe the State’s work to implement certain key service elements of the CMHA, and has continued to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. During this period, the ER:
 Conducted an on-site review of Assertive Community Treatment (ACT) teams/services and Supported Employment (SE) services at the Monadnock CMHC. A non-random sample of ACT and SE records was reviewed at that site;
 Met with the State’s Central Team to review progress and discuss barriers to transition from both New Hampshire Hospital (NHH) and Glencliff Home (Glencliff);
 Met with senior management and with a clinical team at NHH to review transition planning processes and issues;
 Met with Glencliff leadership, clinical staff, and a resident to discuss transition planning processes and issues;
 Met with DHHS staff involved with the PASRR program to discuss the new contract for PASRR services and to identify data reporting issues;
1

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 3 of 109
 Met with the Mobile Crisis Team (MCT) of Riverbend Mental Health Center (Concord NH) and with staff of the Yellow Pod mental health crisis program at Concord Hospital;
 Observed the five-day QSR review at Nashua Community Mental Health Center;  Met with the DHHS CMHA leadership team to discuss progress in the
implementation of CMHA standards and requirements;  Met with the New Hampshire NAMI Public Policy Committee;  Participated in several meetings with representatives of the Plaintiffs and the United
States (hereinafter “Plaintiffs”);  Met twice with DHHS Quality Management/Quality Service Review (QM/QSR) staff
to discuss refinements to the QSR process; and  Convened two all parties meetings to discuss design and implementation issues
related to the QSR process and Glencliff transitions to integrated community settings.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
Summary of Progress to Date
One year ago the ER recommended a number of action steps and timelines intended to facilitate movement towards compliance with the CMHA and to increase transparency and accountability related to State actions under the aegis of the CMHA. The State agreed to implement these recommendations, and has made progress in certain areas of compliance and accountability. Specific progress related to these recommendations is summarized below:
1. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and time lines to achieve compliance with the CMHA requirements for ACT services;
ER Finding: The State has implemented this recommendation by circulating such a plan, and continues to track and report on its implementation of various action steps and limited progress towards compliance with CMHA requirements. Failure to achieve State benchmarks for increased ACT capacity under the plan may require further revision to, and enhancement of, identified action steps. The most recent version of this report (March, 2017) is included as Appendix B to this report.
2. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA penetration rates and fidelity standards for SE throughout New Hampshire;
2

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 4 of 109
ER Finding: The State has implemented this recommendation by circulating such a plan, and continues to track and report on its implementation of various action steps and progress towards compliance with CMHA requirements.
3. By August 1, 2016 circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA requirements to assist 10 residents of Glencliff with complex medical needs to move into integrated settings as soon as possible;
ER Finding: The State has implemented this recommendation by circulating such a plan and it continues to track and report on individuals with pending discharge plans. This plan, and the current status of compliance, is discussed in greater detail under the Glencliff Transitions section of this report.
4. Starting September 1, 2016, and each month following, submit to all parties a monthly progress report of the steps taken and completed under these respective plans to assure compliance with CMHA requirements as identified in this report;
ER Finding: The State has implemented this recommendation and continues to track and report on its progress, which varies depending on the sections of the plan. The latest version of the monthly progress report is attached as Appendix B of this report.
5. By October 1, 2016, complete the field tests and technical assistance related to the QSR, convene a meeting with Plaintiffs to discuss any recommended design or process changes, and publish a final set of QSR documents governing the process for future QSR activities;
ER Finding: By agreement with the ER and representatives of the Plaintiffs, this action step has been delayed in order to further negotiate the scope and content of the QSR process. A more detailed discussion of progress with regard to the QSR is included under the QSR section of this report.
6. Complete at least one QSR site review per month between October 2016 and June 2017, with the exception of the month of December, and circulate to all parties the action items, plans of correction (if applicable), and updates on implementation of needed remedial measures (if applicable) resulting from each of these visits;
ER Finding: Ten QSR site visits have been conducted. Based on the experience of these site visits, and on input from representatives of the Plaintiffs, a revised set of QSR instruments and protocols are currently in development. The revisions are expected to be completed by August 9, 2017. As of the date of this Report, QSR Quality Improvement Plans have not yet been shared with the ER or the Plaintiffs. Six of ten QSR site visit reports have yet to be made public.
3

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 5 of 109
7. Starting July 1, 2016, circulate to all parties on a monthly basis the most recent data reports of the Central Team;
ER Finding: The State has implemented this recommendation by circulating monthly reports, and it continues to track and report progress towards compliance with CMHA requirements.
8. No later than October 1, 2016, assure that final rules for supportive housing and ACT services are promulgated in accordance with the draft rules developed with input from all parties;
ER Finding: The Supported Housing (SH) and ACT rules have been promulgated, and incorporate positive elements resulting from discussions among DHHS staff and representatives of the Plaintiffs.
9. By October 1, 2016, augment the quarterly data report to include:
 ACT staffing and utilization data for each ACT team, not just for each region.
ER Finding: The State has implemented this recommendation.
 Discharge destination data and readmission data (at 30, 90, and 180 days) for people discharged from NHH and the other Designated Receiving Facilities (DRFs).
ER Finding: The State has now complied with this recommendation. The new data is included in the most recent Quarterly Data Report, which is included as Appendix A of this report.
 Reporting from the two Mobile Crisis programs, including hospital and ED diversions.
ER Finding: Data for both Mobile Crisis Teams and Crisis Apartments is now included in the Quarterly Data Report.
 Supportive housing data on applications, time until eligibility determination, time on waiting list, reason for ineligibility determination, and utilization of supportive services for those receiving supportive housing.
ER Finding: As of June 30, 2017, DHHS is currently developing the system capacity to produce these data.
10. By October 1, 2016, and then by December 1, 2016, factually demonstrate that significant and substantial progress has been made towards meeting the standards and requirements of the CMHA with regard to ACT, SE and placement of individuals with complex medical conditions from Glencliff into integrated community settings.
4

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 6 of 109
ER Finding: The State remains out of compliance with the ACT standards of the CMHA. The State has begun to make progress towards compliance with the Glencliff requirements in the CMHA. See more detailed discussion of these issues under the ACT and Glencliff Transitions sections of this report. The ER notes that the State remains in substantial compliance with the SE penetration rate requirements of the CMHA. The ER will continue to work with the State to document that: (a) that SE services are delivered with adequate intensity and duration to meet individuals’ needs; and (b) that SE services are resulting in integrated, competitive employment.
11. By October 1, 2016 demonstrate that aggressive executive action has been taken to address the pace and quality of transition planning from NHH and Glencliff through the development of a specific plan to increase the speed and effectiveness of transitions from these facilities.
ER Finding: The ER believes that both NHH and Glencliff have evidenced, at a leadership and a staff level, increased efforts and commitment to facilitating timely transitions to integrated community settings, albeit with modest result to date. Transitions from Glencliff to integrated community settings appear to be accelerating.
II. Data
The New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (March 2017), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The ability to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve.
The Quarterly reports now include data from the new mobile crisis services in the Concord and Manchester Regions; data on discharge destinations from NHH, the DRFs, and Glencliff; admission, discharge and length of stay data for New Hampshire’s DRFs; and data on utilization of the Housing Bridge Subsidy Program.
As noted in previous ER reports, there continue to be important categories of data that are needed, but not routinely collected and reported, and which will need to be reported in order to accurately evaluate ongoing implementation of the CMHA. For example, there continues to be no reported or analyzed data on the degree to which participants in SE are engaged in competitive employment in integrated community settings consistent with their individual treatment plans. These data are important in assessing the fidelity with which SE services are provided. DHHS’s efforts related to assuring the fidelity of SE services are discussed in the SE section of this report. In addition, needed revisions to the QSR instruments and protocols may
5

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 7 of 109
provide more information on the degree to which SE participants are attaining competitive employment.
Another gap in data is related to people receiving Supported Housing (SH) under the Housing Bridge Subsidy Program. These participants are not yet clearly identified in the Phoenix II system, and thus it is difficult to document the degree to which these individuals are: (a) connected to local CMHC services and supports; (b) actually receiving services and supports to meet their individualized needs on a regular basis in the community; or (c) living at addresses with two or fewer SH units. 1 As noted in the January 2016 ER Report, DHHS has identified a strategy to link data from the Bridge Subsidy Program to the Phoenix II system. However, such data has not been produced to date. Without the information above, the ER is unable to determine whether or not the State has achieved substantial compliance with the CMHA outcomes and requirements for SH. Other outstanding data requests include SH data on applications, time until eligibility determination, time on waiting list, and the reason for ineligibility determinations,
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile/Crisis Services and Crisis Apartments
The CMHA calls for the establishment of MCTs and Crisis Apartments in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC was selected to implement the MCT and crisis apartments in the Concord Region.
The CMHA specified that a second MCT and Crisis Apartments be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. A third MCT and Crisis Apartment program is required to be operational in the Nashua region by June 30, 2017. The contract for that program has been awarded to Harbor Homes in Nashua. DHHS reports that Harbor Homes is on track to open the MCT and Crisis Apartments on schedule by June 30, 2017.
Table I below includes the most recent available information on activities of the two currently operational crisis programs.
Table I
1 “:...no more than two units or 10 percent of the units in a multi-unit building…” CMHA V.E.1(b)
6

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 8 of 109

Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs in the

Concord and Manchester Regions:

Concord Oct – Dec 2016

Concord Jan – Mar 2017

Manchester Oct – Dec
2016

Manchester Jan –Mar
2017

Total unduplicated people served

535

Services provided in response to

immediate crisis:

 Phone support/triage

666

 Mobile assessments

157

 Crisis stabilization

61

appointments

 Emergency services

77

medication appointments

 Office based urgent

53

assessments

Services provided after the

immediate crisis:

 Phone support/triage

197

 Mobile assessments

33

 Crisis stabilization

appointments

61

 Emergency services

medication appointments

49

 Office based Urgent

53

Assessments

Referral source:

 Self

254

 Family

71

 Guardian

19

 Mental health provider

31

 Primary care provider

12

 Hospital emergency

33

department

 Police

12

 CMHC Internal

50

Crisis apartment admissions:

85

 Bed days

316

 Average length of stay

3.7

Law enforcement involvement

57

608

NA

NA

641 157 62

67

82

NA 179 30
62 40
82

258

NA

110

11

32

16

58

12 41

95

NA

392 4.1

52

NA

413
1168 154
1
75
NA NA NA NA
NA
NA
275 152
3 17 10
4
45 68 5 17 3.4 45

7

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 9 of 109

Total hospital diversions*

327

488

NA

643

*Hospital diversions are instances in which services are provided to individuals in crisis resulting

in diversion from being assessed at the ED and/or being admitted to a psychiatric hospital.

These data indicate a growth in the number of people accessing crisis services, and in the number of crisis response services delivered. There has also been substantial growth in utilization of the crisis apartments in both Regions. The ER is concerned that the ration of mobile team responses to the total number of crisis calls is low. The ER is seeking data from other MCTs throughout the U.S. to see if there are norms or a longer history of implementation to assess the degree to which this ratio may be an issue. The ER plans to work with the State to document: 1) the number of times a mobile team was requested but not dispatched, and the reason for that decision; 2) the criteria used to determine whether a mobile versus office-based response is appropriate; and 3) the number of times a mobile response was determined to be appropriate, but the team could not be dispatched in a timely way.

It has been recommended that DHHS add questions to the QSR interview guides to elicit information about the quality and effectiveness of these programs, and to report on that information in the updated QSR instrument. This is one way to determine if individuals who would have benefited from a mobile crisis response received the crisis support their situation required.

The ER notes that between the two MCT programs a total of 1,131 hospital diversions were reported by the Concord and Manchester MCTs for the three month period ending March, 2017. This is a very positive result from the MCTs in those two regions. However, one would expect this level of reported diversions each quarter to have a more significant impact on the numbers of people presenting to, and boarding in, hospital EDs across the state. And, admissions to NHH and the DRFs have not decreased substantially as the MCTs were implemented. There are many factors that could account for these seemingly contradictory effects. The ER plans to work closely with DHHS over the next six month period to validate the numbers of reported diversions, and to obtain a clearer picture about ways MCTs and Crisis Apartments are impacting members of the CMHA target population.

Assertive Community Treatment (ACT)

ACT is a core element of the CMHA, which specifies, in part:

1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team;
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time; and
8

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 10 of 109 4. By June 30, 2017, the State, through its community mental health providers, will identify
and maintain a list of all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future. The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015 (24 months ago). Further, as of June 30, 2016, the State was required to have the capacity to provide ACT to 1,500 priority Target Population individuals. As displayed in Table II below, the staff capacity of the 12 adult ACT teams in New Hampshire has increased by only 1.21 FTEs in the first three months of 2017. During the same time, the total active caseload has increased by only 74 individuals. As of the date of this report, the State provided ACT services to 913 unique consumers and as a result is delivering only 61 percent of the ACT capacity required by the CMHA, and is out of compliance on this key CMHA service.
9

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 11 of 109

Table II

Self-Reported ACT Staffing (excluding psychiatry): May 2015 through March 2017

Region

FTE FTE FTE FTE FTE FTE FTE

May- Sep- Dec- Mar Sep – Dec- Mar-

15 15 15 - 16 16

16

17

Northern West Central Genesis Riverbend Monadnock Greater Nashua 1 Greater Nashua 2 Manchester -– CTT Manchester -– MCST Seacoast Community Partners Center for Life Management Total

14.80 3.00 7.10 7.00 8.20 8.70
12.80 8.20 7.80
77.60

11.29 3.83 7.5 7.3 8.5 5.98
11.77 8.7 6.36
71.23

11.85 2.78 6.9 7.3 8.4 7.75
12.37 8.3 8.46
74.11

11.15 4.37 7.4
7 7.75 6.5
11.53 5.9 8.16
69.76

10.25 5.44
7 7.5 7.25 6.25 5.25 15.46 20.24 8.73 8.03 7.91 109.31

11.49 5.5 11 9 7.25 6.25 5.25
15.53 21.37
9.53 6.85 7.17 116.19

11.89 7.75
11 10 6.7 6.25 5.25 14.79 21.86 9.53 4.08 8.3 117.4

It is clear from this table that overall ACT staffing has remained at best static, and in some regions has decreased over the past three reporting periods. This is true despite previous ER findings that New Hampshire was out of compliance with the standards of the CMHA. However, it should be emphasized that the combined ACT teams have a reported March 2017 staff complement of 117.4 FTEs, which is sufficient capacity to serve 1,174 individuals. But, in March, all ACT teams served only 913 individuals. At a minimum, the existing teams should be able to accept an additional 261 new ACT clients without adding any more staff. Tapping into this unused capacity could have an impact on alleviating ED boarding and hospital readmission rates across the state.
The current pace of client outreach and engagement is not sufficient to fill current or future required ACT team capacity. Similarly, team composition, staff recruitment and capacity development are not sufficient to satisfy the State’s outstanding obligations under the CMHA. Currently, there is a gap of 587 people between the active caseload and the 1,500 ACT capacity required by the CMHA 12 months ago.

Table III below displays trends in active caseloads for ACT services by Region.

10

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 12 of 109

Table III
Self-Reported ACT Caseload (Unique Adult Consumers) by Region per Month: May 2015 through March 2107

Region

Active
Cases May-
15

Active
Cases Sep15

Active
Cases Dec15

Active
Cases Mar-
15

Active
Cases Dec16

Active
Cases Mar-
17

%
change DecMar

Northern

60

72

74

79 104 108 3.85%

West Central

16

19

21

26

32

53 65.63%

Genesis

22

30

34

39

64

70 9.38%

Riverbend

79

60

56

70

73

83 13.70%

Monadnock

47

54

61

68

63

64 1.59%

Greater Nashua

63

74

72

72

74

83 12.16%

Manchester

254 265 270 293 248 270 8.87%

Seacoast

73

65

65

72

65

64 -1.54%

Community Partners

16

70

76

73

70

67 -4.29%

Center for Life Management 39

37

40

49

47

55 17.02%

Total*

669 746 766 839 839 913 8.82%

* unduplicated across regions

Four of the 12 adult ACT teams now have fewer than the 7 - 10 professionals specified for ACT teams in the CMHA, as opposed to the three teams with reported staffing below the defined threshold noted in the previous report. Two teams continue to report having no peer specialist on the ACT Team. Five teams now report having at least one FTE peer specialist, but that means that seven of the 12 teams report having less than one FTE peer on the team. Four teams continue to report having less than .5 FTE combined psychiatry/nurse practitioner time available to their ACT teams, and two teams report having less than 0.5 FTE nursing on the team; eight of the 12 teams report having less than one FTE nurse per team.
Ongoing deficiencies in ACT team staffing and composition leave the State out of compliance with the foundational service standards described in Section V.D.2 of the CMHA, and threaten its ability to provide a robust and effective system of ACT services throughout the state.
As noted in the previous ER Report, the New Hampshire DHHS has begun to take more aggressive action to work with CMHCs in certain Regions to increase their ACT staffing and caseloads. These actions include: (a) monthly ACT monitoring and technical assistance with DHHS leadership and staff; (b) implementation of a firm schedule for ACT self-assessments and DHHS fidelity reviews ; (c) incorporating a small increase in ACT funding into the Medicaid rates for CMHCs; (d) active on-site monitoring and technical assistance for CMHCs not yet
11

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 13 of 109
meeting CMHA ACT standards; and (e) substantial and coordinated efforts to address workforce recruitment and retention. However, external and self-reported fidelity reviews for the 10 CMHC regions have revealed deficient practices that are not in fidelity with the ACT model. See Appendix C. Compliance letters and Performance Improvement Plans (PIPs) have been initiated in several of the Regions. Over the next six months, the ER will look for evidence that these plans have been implemented.
Initial QSR field test reports also revealed that several CMHCs failed to ensure individuals were receiving ACT services using the team approach, and with the appropriate frequency to address their individual treatment needs. Quality Improvement Plans for these regions have yet to be shared with the ER or the Plaintiffs. The ER has emphasized to the State that the QSR process must measure the adequacy and effectiveness of individual ACT service provision, in order to demonstrate that these deficiencies are being corrected.
The ER believes the State, DHHS and many of the CMHCs are making good faith efforts to meet the ACT capacity and fidelity standards of the CMHA. Despite the continued compliance issues noted above, the ER believes there have been some improvements in the quality and effectiveness of ACT services provided in most parts of the state. However, while these improvements are welcome, it must be noted that the State is still far from compliance with the ACT standards of the CMHA. As with previous reports, the ER expects DHHS and the CMHCs to make use of capacity already available in the system at all deliberate speed, while at the same time addressing additional capacity and fidelity issues.
DHHS and the CMHCs have been attempting to identify individuals at risk of hospitalization, incarceration or homelessness who might benefit from ACT services. Individuals boarding in hospital emergency departments waiting for a psychiatric hospital admission, or who have done so in the recent past, are one important source of potential referrals. DHHS is currently tracking the extent to which identifying and referring these individuals to CMHCS is: (a) reducing ED boarding episodes and lengths of stay; and (b) resulting in enrollment of new qualified individuals in ACT services. As noted in the hospital readmission discussion below, almost onethird of all those discharged out of NHH return for readmission within 180 days. Robust ACT services can help to reduce the number of hospital readmissions throughout the state if affected individuals are promptly screened and referred, and their regional ACT teams have the capacity to deliver needed services.
At this point it must be the priority of the State and the CMHCs to focus on: 1) ensuring required ACT team composition; 2) utilizing existing ACT team capacity; 3) increasing new ACT team capacity; and 4) outreach to and enrollment of new ACT clients.
Supported Employment
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the
12

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 14 of 109

maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment …to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by June 30, 2017 “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)).

For this reporting period, the State reports that it has achieved a statewide SE penetration rate of 23.2 percent, 4.6 percentage points higher than the 18.6% penetration rate specified for June 30, 2017 in the CMHA. Table IV below shows the SE penetration rates for each of the 10 Regional CMHCs in New Hampshire.

Table IV

Self-Reported CMHC SE Penetration Rates*

Penetration Penetration Penetration Penetration Penetration

Mar-16

Oct-16

Sep-16

Dec-16

Mar-17

Northern

10.60%

West Central

15.30%

Genesis

9.60%

Riverbend

14.10%

Monadnock

20.50%

Greater Nashua

9.00%

Manchester

36.70%

Seacoast

11.00%

Community Part. Center for Life Man.

12.60% 24.70%

CMHA Target

18.10%

Statewide Average

19.30%

*12 month cumulative total

14.00% 17.50% 14.10% 13.70% 20.40% 11.90% 37.10% 12.00% 10.40%
23.00% 18.10% 20.40%

14.20% 16.70% 14.10% 13.50% 22.30% 11.10% 38.50% 11.60% 10.90%
24.00% 18.10% 20.90%

27.00% 21.50% 14.50% 13.80% 17.90% 12.40% 43.10% 12.00% 6.80%
21.10% 18.10% 22.90%

32.30% 23.20% 12.60% 15.00% 13.50% 15.00% 39.80% 14.40% 7.20%
19.70% 18.60% 23.20%

As noted in Table IV, the State has exceeded the statewide CMHA penetration rate in recent reporting periods. However, six of 10 regions fall below required CMHA penetration rates and penetration rates have decreased since December 2016 in four regions. The New Hampshire DHHS is to be commended for continuing its efforts to: (a) measure the fidelity of SE services on a statewide basis; and (b) work with the six Regions with penetration rates below CMHA criteria to increase access to and delivery of SE services to target population members in their

13

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 15 of 109 Regions. The ER will continue to monitor these issues going forward as the State works with the CMHCs to increase penetration rates to at least 18.6 percent in all regions. As with ACT services, the DHHS has implemented a combination of contract compliance, technical assistance, workforce recruitment and retention, and internal and external fidelity reviews to try to assure sufficient quality and accessibility of SE services statewide. [See Appendix C for summaries of the SE fidelity reviews for the CMHCs.] There is currently no mechanism for measuring whether individuals are receiving SE services consistent with their individual treatment plans, or whether SE services are delivered in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings (V.F.1). The ER has recommended that the QSR process measure whether and to what extent SE services are being delivered consistent with these requirements of the CMHA. To that end, the ER expects to review employment data from each region during the next reporting period.
14

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 16 of 109
Supported Housing
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Subsidy Program by June 30, 2016. As of March, 2017, DHHS reports having 505 individuals in leased SH apartments, and 48 people approved for a subsidy but not yet leased. The State is in compliance with the CMHA numerical standards for SH effective June 30, 2016. Table V below summarizes recent data supplied by DHHS related to the Bridge Subsidy Program.
15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 17 of 109

Table V

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

September 2015 through March 2017

Bridge Subsidy Program
Information

September

2015

March September December

2016

2016

2016

March 2017

Total housing slots

450

450

479

(subsidies) available

513

553

Total people for whom rents are being subsidized

376

415

451

481

505

Individuals accepted

23

22

28

but waiting to lease

32

48

Individuals currently

0

0

0

on the wait list for a

bridge subsidy

0

0

Total number served

466

518

603

since the inception

of the Bridge

Subsidy Program

643

675

Total number

70

71

83

receiving a Housing

Choice (Section 8)

Voucher

83

85

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table VI below displays the reported number of units leased at the same address.

16

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 18 of 109

Table VI

Self-Reported Housing Bridge Subsidy Concentration (Density)

Septem -ber
2015

March 2016

June 2016

Novem- February

ber

2017

2016

May 2017

Number of

290

317

325

339

349

367

properties with one

leased SH unit at

the same address

Number of

27

22

35

24

23

36

properties with two

SH units at the

same address

Number of

2

13

8

13

14

5

properties with

three SH units at

the same address

Number of

4

1

1

3

4

4

properties with

four SH units at

the same address

Number of

1

2

2

0

0

3

properties with

five SH units at the

same address

Number of

1

0

1

1

1

1

properties with six

SH units at the

same address

Number of properties with seven SH units at the same address

0

2

17

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 19 of 109
Data reveals that 95% of the leased units are at a unique address or with one additional unit at that address; 87% of the people in SH are living at addresses with two or fewer SH units. This supports a conclusion that the Bridge Subsidy Program, to a large degree, is operating as a scattered-site program. For the units shown in Table VI at the same address, it is not known at this time whether the unit density standards included in the CMHA are being met. DHHS is collecting information on the total units in each property where there are two or more Bridge units at the same address, and this data will be reported in the next ER report.
It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)). DHHS reports, and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge Subsidy Program units.2
As noted in the Data section of this report, current data is not available on the degree to which Bridge Subsidy Program participants access and utilize support services and whether or not the services are effective and meet individualized needs. Receipt of services is not a condition of eligibility for a subsidy under the Bridge Program, but the CMHA does specify that “…supported housing includes support services to enable individuals to attain and maintain integrated affordable housing, and includes support services that are flexible and available as needed and desired….” (V.E.1(a)). As noted in the January, June, and December 2016 ER Reports, DHHS has been working on a method to cross-match the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. This will allow documentation of the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports. The ER will continue to work with the State to document whether is the State is in substantial compliance with CMHA provisions on the availability and provision of support services to persons in SH..
In previous reports the ER has identified a number of important and needed data elements associated with the SH eligibility criteria and lack of a waitlist, as well as monitoring implementation of the SH program in the context of the CMHA. These include:
 Total number of Bridge Subsidy Program applicants per quarter;  Referral sources for Bridge Subsidy Program applicants;  Number and percent approved for the Bridge Subsidy Program;  Number and percent rejected for the Bridge Subsidy Program;
o Reasons for rejection of completed applications, separately documenting those who are rejected because they do not meet federal HCV/Section 8 eligibility requirements;
2 DHHS reports that currently there is one voluntary roommate situation reflected in the above data.
18

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 20 of 109
 Number and disposition of appeals related to rejections of applications;  Elapsed time between application, approval, and lease-up;  Number of new individuals leased-up during the quarter;  Number of terminations from Bridge subsidies;  Reasons for termination:
o Attained permanent subsidized housing (Section 8, public housing, etc.); o Chose other living arrangement or housing resource; o Moved out of state; o Deceased; o Long term hospitalization; o Incarceration; o Landlord termination or eviction; or o Other;  Number of Bridge Subsidy Program participants in a roommate situation; and  Lease density in properties with multiple Bridge Subsidy Program leases.
This information is important in assessing whether eligibility is properly determined, whether a waitlist is properly maintained, whether or not support services are adequate to enable the individual to “attain and maintain integrated affordable housing,” and whether services are “flexible and available as needed and desired.” Most rental assistance programs collect and report such information, given its intrinsic value in monitoring program operations. Further, such data enhances DHHS’ ability to demonstrate the timeliness and effectiveness of access of the priority target population to this essential CMHA program component. Most importantly, this data is necessary to help the ER determine compliance with CMHA Sections IV.B, IV.C, and VII.A. The ER will continue to work collaboratively with DHHS to identify sources and methods for such data collection and reporting. As noted in the Data section of this report, the State is developing system functionality to produce these data.
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain HUD funding for an additional 150 supported housing units for a total of 600 supported housing units.” (CMHA V.E.3(e)) In 2015 New Hampshire applied for and was awarded funds for 191 units of supported housing under the HUD Section 811 Program. All of these units are intended to be set aside for people with serious mental illness. As of the writing of this report, 57 of these units have been successfully developed and are occupied by members of the target population. It should be noted that over the life of the Bridge Subsidy Program the State has accessed 85 HUD Housing Choice Vouchers (HCV – Section 8). These have allowed the State to free up 85 Bridge Subsidy units for new applicants.
In addition, the CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more
19

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 21 of 109

than two months, the State will add program capacity on an ongoing basis sufficient that no individual waits longer than six months for supported housing.” The ER will monitor the development and implementation of this waiting list closely going forward, and will report on its maintenance in the next ER report.
Transitions from Institutional to Community Settings
During the past 24 months, the ER has visited both Glencliff and NHH on at least five separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities late last year. Transition planning activities related to specific current residents in both facilities were observed, and more recently, a small nonrandom sample of resident transition records has been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities.
The ER has participated in four meetings of the Central Team. The CMHA required the State to create a Central Team to overcome barriers to discharge from institutional settings to community settings. The Central Team has now had about 18 months of operational experience, and has started reporting data on its activities. To date, 30 individuals have been submitted to the Central Team, 19 from Glencliff and 11 from NHH. Of these, the State reports that 10 individual cases have been resolved, two individuals are deceased, and 18 individual cases remain under consideration. Table VII below summarizes the discharge barriers that have been identified by the Central Team with regard to these 18 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total substantially higher than the number of individuals reviewed by the Central Team.

Table VII

Discharge Barriers from NHH and Glencliff Identified by the Central Team: September 2015

Through March 2017

Discharge Barriers

Number

Percent of Cases (N=18)

Legal

8

44.4%

Residential

17

94.4%

20

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 22 of 109

Financial

9

Clinical

10

Family/Guardian

5

Other

4

50.0% 55.5% 27.7% 22.2%

Although this Report notes increased efforts and leadership at the State level with regard to the operations of the Central Team, the ER expects that the total number of referrals will grow, and the pace at which individual barriers are resolved will quicken, over the next six month period.

21

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 23 of 109
Glencliff
In the time period from January through March 2017, Glencliff reports that it has admitted five individuals, and has had seven discharges. There have been no readmissions during this time frame. The wait list for admission has remained relatively constant: averaging 15 people during the past two quarters. The lengths of stay for the seven persons discharged were reported to be 1,024, 1,691, 1,680, 629, 952, 486, and 3,207 days, an average of 1,381 days or 3.8 years.
CMHA VI requires the State to develop effective transition plans for all appropriate residents of NHH and Glencliff and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]3 individuals with mental illness and complex health care needs residing at Glencliff….” The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be costeffectively served in supported housing.”4 The ER notes that Glencliff continues to support and effectuate transitions of individuals to integrated community settings under a variety of other funding and living arrangements.
DHHS reports that the number of people with complex health conditions transitioned from Glencliff to integrated settings since the inception of the CMHA three years ago increased this quarter from 10 to 12. DHHS has agreed to provide the ER information about the recent two transitions that includes a brief clinical summary, length of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in the integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions who could not be cost-effectively be served in supported housing continue to experience transitions to integrated community settings.
Of the ten individuals reported by DHHS to have transitioned to community settings since the onset of the CMHA, the ER agrees five meet the criteria of being medically complex and not able to be served cost effectively in supported housing. Three of these currently reside in a newly developed small scale community residence, and two are living in enhanced family care homes (EFCs) with extensive Medicaid and non-Medicaid services.
DHHS/Glencliff has developed a list of ten additional individuals currently undergoing transition planning who could be transitioned when appropriate community settings and services are in place.
DHHS has also begun to implement certain action steps to enhance the process of: (a) identifying Glencliff residents wishing to transition to integrated settings; and (b) to increase the capacity,
3 Cumulative from CMHA V.E. (g), (h), and (i). 4 CMHA V.E.2(a)
22

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 24 of 109
variety and geographic accessibility of integrated community settings and services available to meet the needs of these individuals. Both sets of initiatives should facilitate and speed up such community transitions for additional Glencliff residents.
At this point the ER is reluctant to focus too narrowly on clinical conditions and arrays of services to monitor the State’s progress in assisting Glencliff Home residents to transition to integrated community settings. The ER will monitor that DHHS, Glencliff, the CMHCs and an array of other community partners collaborate to effectuate as many such transitions as possible over the next several years. The primary thrust and intent of the CMHA is to assure that individuals residing in Glencliff are offered and accept meaningful opportunities to transition to integrated community settings. It appears likely that the specific requirement in the CMHA for the State to create capacity to serve 16 individuals with complex medical conditions who cannot be cost-effectively served in supported housing will be attained if DHHS and its partners continue to increase the availability of integrated community settings, and provide meaningful in-reach and transition planning for Glencliff residents.
Thus, the ER intends to monitor the following topics/items going forward:
1. The number of transitions from Glencliff to integrated community settings per quarter. The ER will also monitor information about the clinical and functional level of care needs of these individuals; the integrated settings to which they transition; and the array of Medicaid and non-Medicaid mental health and health-related services and supports put in place to meet their needs and to assure successful integrated community living.
2. The number of Glencliff residents newly identified per quarter to engage in transition planning and move towards integrated community settings. The ER will also monitor at a summary level the clinical and functional level of care needs of individuals added to the transition planning list per quarter.
3. New integrated community setting capacity identified and willing to participate in facilitating integrated community transitions for Glencliff residents. These could include EFCs, AFCs, and new small-scale community residential capacity for people with complex medical conditions who cannot be cost-effectively served in supported housing. The ER will ask DHHS to identify any new community providers who express willingness and capacity to provide services in integrated community settings for people transitioning from Glencliff.
4. Within the discharge cohort, the number of transitioned individuals for whom the State special funding mechanism is utilized to effectuate the transition, and the ways in which these funds are used to fill gaps in existing services and supports.
5. Number and types of in-reach visits and communications by CMHCs and other community providers related to identifying and facilitating transitions of Glencliff residents to integrated community settings.
6. Specific documentation of efforts to overcome family and/or guardian resistance to integrated community transitions for Glencliff residents.
23

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 25 of 109 7. Number of individuals engaged in transition planning referred to the Central Team;
number of these resolved with an integrated community setting; and elapsed time from referral to resolution.
24

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 26 of 109
Preadmission Screening and Resident Review (PASRR) The ER has met with the DHHS PASRR Team and representatives of the PASRR vendor, and has reviewed the most recent PASRR report. The ER needs to be satisfied that PASRR reviews are being conducted as described under CMHA VI.A.10, and that individuals whose needs could be met in the community are promptly referred to the appropriate area agency or CMHC in order to document compliance with this CMHA requirement. Based on interviews with the PASRR contractor staff and a review of the data, the ER believes that conscientious efforts are being made to refer people to appropriate community alternatives at the time of initial screening. The ER notes that PASRR screens are typically completed before a person is referred to Glencliff, since Glencliff requires that applicants be rejected by at least three nursing facilities before being considered for admission to Glencliff. Thus, PASRR by itself only indirectly impacts admission decisions to Glencliff. For the next report, the ER will assess whether referrals by the PASRR team to Area Agencies or CMHCs are actually resulting in the development of, and individual transition to, integrated community alternatives.
New Hampshire Hospital For the time period January through March 2017, DHHS reports that NHH effectuated 263 admissions and 258 discharges. The mean daily census was 146, and the median length of stay for discharges was 12 days. Table VIII below compares NHH discharge destination information for the five most recent reporting periods. The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.
25

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 27 of 109

Table VIII

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Discharge Destination

Percent January 2014 through May 2015

Percent July 1 2015 through September 18, 2015

Percent September 19, 2015 through April 20, 2016

Percent October and November
2016

Percent January through March 2017

Home – live alone or with others

74.4%

67.3%

80.2%

85.1%

84.5%

Glencliff

0.4%

0.20%

0.60%

0.36%

1.55%

Homeless Shelter/motel

3.8%

2.4%

2.7%

2.54%

2.71%

Group home 5+/DDS supported living, etc.

3.4%

9.02%

3.2%

1.62%

5.7%

Jail/corrections 1.5%

0.40%

1.4%

2.9%

0.8%

Nursing home/rehab facility

1.9%

3.0%

0.80%

3.6%

1.9%

The State’s most recent Quarterly Data Report contains new, consistently reported information on the hospital-based DRFs and The Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and combine it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. The ER appreciates the State gathering this information. Table IX summarizes this data.

26

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 28 of 109

Table IX

Self-Reported DRF/APRTP Utilization Data: January 2016 through March 2017

Admissions Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017

Franklin Cypress Portsmouth Elliot

Elliot

Total

Geriatric Pathways

69

257

46

79

205

378

37

207

375

39

217

310

65

204

317

65

121

558

49

92

803

54

114

787

43

72

681

48

138

772

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017

53.70% 55.70% 43.20% 53.80% 70.70%

18.70% 24.40% 29.50% 28.60% 34.30%

NA 20.40% 18.90% 17.10% 21.80%

18.50% 4.10% 13.00% 16.30% 12.50%

30.60% 48.90% 44.70% 43.10% 43.50%

26.20%* 25.50% 26.20% 25.60% 32.50%

Average Census Jan - March 2016 April - June 2016 July - Sept 2016 Oct – Dec Jan - March 2017

7.9

14.7

NA

7.8

13.2

21.4

4.5

13.6

23.2

5.6

12.4

23.4

5

14.6

27.2

19.7

18.1

60.1*

22.5

16.9

81.8

25.6

14.5

81.4

24.8

11.5

77.7

31.2

24.6

102.6

Discharges Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017
Mean LOS for Discharges Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017

76

261

NA

78

206

363

35

213

380

41

213

309

65

211

305

57

122

516*

51

90

788

64

113

805

46

75

684

49

130

760

8.6

4.2

6

4

7

5

5

5

5

4

NA

15

4 28

4 24

5 24

5 27

7.4

8.8*

7

5

8

5

8

5

7

5

* Does not include Portsmouth 27

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 29 of 109

These data seem to suggest a small increase in DRF utilization, and a small increase in the proportion of total DRF admissions that are involuntary. Several more quarters of data reporting will be necessary to document whether these trends continue. The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and also should reduce the number of people waiting for psychiatric admissions in hospitals EDs. The DRF discharge cohort may also be a good source of referrals to CMHCs for ACT or other best practice community services. The ER will continue to work with DHHS to monitor the degree to which DRF functions and activities support the overall objectives of the CMHA.

DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table X below provides a summary of these recently reported data.

Table X

Self-Reported Discharge Dispositions for DRFs in New Hampshire

October 2016 through March 2017

Disposition

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

Total

Home

92

374

414

21

174

1075

NHH

4

4

16

0

2

26

Residential

3

3

0

57

2

65

Facility/

Assisted

Living

Other DRF

0

13

1

1

1

16

Hospital

2

0

0

7

1

10

Hospice

0

0

0

3

0

3

Death

0

0

0

7

0

7

Other or

4

28

183

2

25

242

Unknown

*The Other category for Portsmouth Regional is reported to include shelters, rehab facilities,

hotels/motels, friends/families, and unknown.

28

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 30 of 109

Hospital Readmissions
DHHS is now reporting readmission rates for both NHH and the DRFs. Table XI below summarizes these data:

Table XI

Self-Reported Readmission Rates for NHH and the DRFs

October – December 2016

NHH
Franklin
Cypress
Portsmouth Elliot Geriatric Elliot Pathways
Total

Number
30 Days 36 1 13 25

Percent 30
Days 13.0% 2.50% 6.00% 8.10%

Number
90 Days 78 1 21 44

2

4.70%

2

8

11.10%

9

85

155

Percent
90 Days 28.30%
2.5% 9.70% 14.20%
4.70%
12.50%

Number 180 Days 97 1 24 56

Percent 180 Days
35.10% 1.50% 11.10% 18.10%

Total
Number 211 3 58 125

4

9.30%

8

9 12.50% 26

191

431

NHH
Franklin
Cypress
Portsmouth Elliot Geriatric Elliot Pathways
Total

Number Percent Number 30
30 Days Days 90 Days

January - March 2017
Percent
90 Days

Number Percent

180

180

Days Days

Total

21

8.00%

52

0

0.00%

0

14 6.90% 24

23 7.30% 41

19.80% 0.00% 11.80% 12.90%

73 27.80% 146

1

1.50%

1

34 16.70% 72

58 18.30% 122

4

8.30%

5

10.40%

5 10.40% 14

4

2.90%

6

66

128

4.30%

10 7.20% 20

181

375

Readmission rates sometimes indicate that people being discharged from inpatient psychiatric systems are not connecting with necessary and appropriate services and supports in the community. Trends in readmission rates may also be indicators of increased or decreased pressures on the overall system of care. For example, decreased readmission rates could be an indicator that hospitals are not discharging people too quickly because of pressures to admit new patients. Decreases could also indicate that connections to appropriate community services and
29

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 31 of 109
supports are occurring more effectively. Right now, 180-day readmission rates to NHH are substantial, with almost one-third of those discharged returning to NHH within six months. It is also important to note that the data reported currently include only readmission rates to the same facility, thus underestimating the extent to which individuals in the target population may be subject to repeated admissions at more than one inpatient facility. In the next reporting period, the ER will work with the State to determine if data that reflects subsequent admission to any institutional facility can be made available – thus providing a more accurate picture of the rate and frequency with which individuals are relying on inpatient facilities statewide. The data in Table XI above has not been reported for a long enough period to identify trends in readmission rates with confidence. Nonetheless, they do provide some insight into the number of instances in which an appropriate community intervention could have prevented an unnecessary re-hospitalization. For example, if even ten percent of the readmissions between January and March 2017 were diverted through ACT and other community resources, there would have been 38 fewer hospital admissions during that period, with a concurrent lower number of hospital bed days utilized. The ER will continue to work with DHHS to monitor these data to interpret how they may contribute to overall system improvements consistent with the CMHA. In the previous two reports, the ER has identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. Based on recent information reported by DHHS, the average number of adults waiting for a NHH inpatient psychiatric bed was 24 per day in FY 2014; 25 per day in FY 2015; and through June of FY 2016 was 28 per day. For the period July 1 through September 30, 2016 the average weekly wait list for admission to NHH was 31.5. As shown in the chart below, there continues to be an average of over 20 people waiting in EDs for admission to NHH on a daily basis. In most mental health systems, a high number of adults waiting for inpatient admissions is indicative of a need for enhanced crisis response (e.g., mobile crisis) and high intensity community supports (e.g., ACT).
30

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 32 of 109

New Hampshire Hospital Daily Admission Delays July 1, 2016 - May 25, 2017
60

50

40

30

20

10

0

Series1

Linear (Series1)

DHHS continues to analyze data related to adults boarding in EDs who may have some connection to the mental health system. DHHS is making these data available to CMHCs on a monthly basis, and expects the CMHCs to use these data to identify potential participants for ACT or related services to reduce the risk of hospitalization and support integrated community living. In future months, DHHS will be receiving information on the degree to which CMHCs have increased ACT (or other services’) participation as a result of these analyses. The ER plans to include summaries of this information in future reports.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies

31

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 33 of 109
As noted in the June 30, 2015 ER report, New Hampshire reported having a total of 16 peer support agency program sites, with at least one program site in each of the ten regions. The State reported that all peer support centers meet the CMHA requirement to be open 44 hours per week. At the time of that report, the State reported that those sites had a cumulative total of 2,924 members, with an active daily participation rate of 169 people statewide. In the June 2016 data report, the total membership was reported to be 2,978 people, with average daily statewide visits of 148. For the January – March 2017 reporting period, total membership was reported to be 3,265, with an average daily participation of 138 (see Appendix A). It is unclear why daily participation rates at the Peer Support Programs are trending down, while State reports of total membership are increasing over time.
The CMHA requires the peer support programs to be “effective” in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs.
Anecdotally, the ER believes that in many regions of the state, relationships and communications among the CMHCs and the Peer Support Programs have improved. Peer support programs are generally reported by CMHCs to be useful sources of employees for ACT and Mobile Crisis and Crisis Apartment services. In addition, CMHCs report that the peer operated crisis beds available in several regions are a useful intervention for some CMHC clients at risk of hospitalization.
IV. Quality Assurance Systems
In the past 24 months, DHHS has made progress in the design of the QSR process required by the CMHA. Ten QSR site visits have been conducted to date, and reports of the findings of these site visits have been (or soon will be) posted for public review. As noted earlier in this report, the ER participated in one of the QSR site visits. Based on the experiences of those QSR site visits, plus on-going input from representatives of the Plaintiffs and the ER (in a technical assistance role), the QSR team continues to make revisions to the QSR protocol and instruments. The most recent round of changes recommended by the Plaintiffs and separately by the ER are currently in development. The revised QSR protocols and instruments are expected to be ready for implementation for the second round of ten CMHA QSR site visits commencing in August, 2017. The ER intends to participate in at least two of the QSR site visits scheduled for the fall of 2017. Participation in the QSR site visits is an important way for the ER to monitor the quality and outcomes of CMHA services at the consumer and point of service level. Such participation also provides opportunities for the ER to monitor the degree to which the QSR process itself is meeting the standards of the CMHA.
Given that the new QSR protocols and instruments are still in development, it is not currently possible for the ER to comment on them. However, the ER and the parties have offered detailed
32

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 34 of 109
recommendations intended to inform this final phase of revisions, and to ensure the ability of the QSR to measure the quality and effectiveness of CMHA service delivery at the individual level.
As noted in earlier reports, it is essential that the QSR process produce information that is accurate, verifiable, and actionable. It is similarly essential that all parties, as well as the ER, have confidence in, and are able to rely upon, the QSR as a measure of compliance with the CMHA. Although the QSR process is part of broader DHHS quality management efforts, it must be directly responsive to the quality and performance expectations of the CMHA. This is why all Parties to the agreement have invested so much time and effort into the design and implementation of the QSR process. The QSR will produce essential core information to assist the Parties to assess compliance with all quality and performance standards and requirements of the CMHA, and to document the extent to which CMHA-specified outcomes are attained for members of the target population.
As noted earlier in this report, DHHS has been conducting on-site ACT and SE fidelity reviews to supplement and validate the ACT and SE fidelity self-assessments conducted on an annual basis by the CMHCs (see Appendix C for summaries of the findings of these fidelity reviews). DHHS has also engaged the Dartmouth/Hitchcock Center on Evidence Based practices to assist in attaining and assuring fidelity to the evidence based models of ACT and SE. The Dartmouth/Hitchcock team will also assist on workforce development and training for these and other evidence based practices under the aegis of DHHS and the CMHCs. This partnership with the nationally respected Dartmouth/Hitchcock Center adds valuable expertise and experienced personnel to facilitate further development and operations of fidelity model ACT and SE in conformance with the CMHA. The ER commends DHHS for implementing the comprehensive fidelity review process and its attendant quality improvement and technical assistance activities.
Effective and validated fidelity reviews and consequent training and workforce development activities are essential to DHHS’ overall quality management efforts for the community mental health system. As noted in the previous ER report, the QSR and the fidelity reviews mutually support but do not supplant or replace each other. The QSR, in particular, examines outcomes from a consumer-centric perspective as opposed to an operational or organizational perspective. It is uniquely positioned to assess the quality, appropriateness and effectiveness of specific ACT and SE services at the individual participant level. The ER continues to believe that implementation of fidelity-based models of delivery does not necessarily mean that specific service interventions are working well or being delivered with the frequency or intensity required by a participant’s individual treatment plan. The ER has advised the parties that without recommend changes to the QSR, it will not be possible to support a conclusion that CMHA’s required individual outcomes are being attained for those in the target population.
Amended QSR instruments should be available for review by the ER and the plaintiffs on August 9, 2017. The ER is recommending that the parties confer in person or by phone to
33

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 35 of 109 discuss the most recent instrument revisions, as well as the State’s revised QSR report format. This discussion should occur on an expedited basis, prior to the end of August, 2017. Going forward, the ER will continue to monitor the degree to which the QSR process produces reliable information on individual outcomes the quality of CMHA service delivery. Over the next six months, the ER will evaluate the extent to which CMHC Quality Improvement Plans developed as part of the FY 2017 QSR site visits, are resulting in recommended practice changes and improved outcomes for those in the target population. .
34

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 36 of 109
V. Summary of Expert Reviewer Observations and Priorities
The CMHA and ER have now been in place for three years. Over that time frame, the ER has expressed escalating concern related to noncompliance with CMHA requirements governing ACT and Glencliff community transitions. In addition, the ER has consistently noted long elapsed times and/or delays related to implementation of system improvements or capacities related to the CMHA, including the full and effective functioning of the Central Team. Throughout these reports, the ER has emphasized the need for the State to be more aggressive, assertive, planful, and timely in its implementation and oversight efforts in these areas in order to come into compliance with the CMHA.
The ER now believes that the State is improving its oversight and management of the mental health system, including through the growing use of state-validated fidelity reviews for ACT and SE. It also appears that the State is making progress towards compliance with several of the CMHA requirements above, including Glencliff transition and discharge planning. The breadth and content of the final QSR instrument, and the reliability of information it produces, will determine to what extent it is possible to evaluate compliance with other individual outcomes contained within the CMHA, including the adequacy and effectiveness of ACT, SE, SH and MCT.
The one notable exception to this progress relates to ACT services. For the last two years the ER has stated that the State remains out of compliance with the ACT requirements of the Sections V.D.3(a, b, d, and e), which together require that all ACT teams meet the standards of the CMHA; that each mental health region have at least one adult ACT Team5; and that by June 30, 2016, the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time.
Despite the many positive initiatives and management efforts undertaken by the State, ACT capacity remains substantially below the required June 30, 2016 capacity to serve 1,500 people at any given time. Moreover, with an active caseload of only 913 people, the state currently is providing 587 fewer people with ACT than could be served if the State had developed the CMHA-specified capacity. This continues to be the single most significant issue in New Hampshire with regard to compliance with the CMHA, and one with negative implications for
5 The ER notes that each region of the state has had at least one ACT team, or ACT team-in-development, since the inception of the CMHA. However, as documented in the ACT section of this report, four regions continue to have ACT teams that do not meet the minimum staffing requirements for ACT as specified in the CMHA.
35

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 37 of 109
individuals who remain stuck in NHH, who continue to be readmitted to EDs and inpatient facilities, or who are otherwise at risk of admission due to inadequate community supports. DHHS reports working with the Governor’s office and the Legislature to develop a number of new program and budget initiatives that should, if enacted and implemented, assist the state to comply with the ACT requirements of the CMHA. Specifically, there is a budget initiative designed to increase funding for workforce recruitment and retention for ACT services in the CMHCs. Lack of adequate workforce has been identified as one barrier to ACT compliance, and it is hoped that this initiative will address that issue. However, even if the budget initiative is enacted, it will be several months into the future before it is likely to have a measurable effect. Although State efforts to date have yet to produce desired outcomes, these important provisions can and must be implemented in order to ensure the needs of the target population are met. If certain action steps identified by the State are failing to produce measurable results, alternative approaches should be considered with feedback from the ER, the parties, and other MH system stakeholders. The ER will continue to closely monitor State and CMHC efforts to meet all the ACT requirements in the CMHA. Substantial, measurable progress must be forthcoming within the next six months. Otherwise, it will be necessary to seek other remedies to move the State into compliance with these requirements. In addition, the ER will focus on resolving outstanding implementation and compliance issues including the measurement of integrated, competitive employment outcomes for SE participants, ensuring that support services associated with SH are sufficient to meet individual needs, and taking effective steps to reduce readmission rates to NHH (including ACT referrals and more comprehensive transition/discharge planning). Finally, the ER will closely monitor enhanced efforts to transition individuals from Glencliff to integrated, community-based services, and the ongoing conduct of the QSR process.
36

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 38 of 109
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly Data Report January through March, 2017
37

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 39 of 109
New Hampshire Community Mental Health Agreement Quarterly Data Report
January to March 2017
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement May 24, 2017
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 40 of 109
January – March 2017
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 5/24/2017 Reporting Period: 1/1/2017 – 3/31/2017
Notes for Quarter
 Manchester Mobile Crisis data reporting is now based on our new systematic record reporting process, similar to Phoenix data submission. This allows for routine quality assurance, more consistent reporting, and connection of data to other Phoenix records.

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

1

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 41 of 109
January – March 2017

Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 5/24/2017 Reporting Period: 1/1/2017 – 3/31/2017

1. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Unique

Unique Consumers

January February

March Consumers

in Prior

Center Name

2017

2017

2017 in Quarter

Quarter

01 Northern Human Services

102

102

108

111

107

02 West Central Behavioral Health

47

49

53

60

36

03 Genesis Behavioral Health

68

70

70

74

66

04 Riverbend Community Mental Health Center

77

77

83

88

82

05 Monadnock Family Services

67

66

64

69

67

06 Community Council of Nashua

88

83

83

93

83

07 Mental Health Center of Greater Manchester

256

257

270

281

273

08 Seacoast Mental Health Center

65

67

64

69

68

09 Community Partners

70

68

67

71

73

10 Center for Life Management

50

54

55

56

47

Total

888

890

913

970

901

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 5/10/17; consumers are counted only one time regardless of how many services they receive.

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents

March 2017

December 2016

Nurse Masters Level Clinician/or Equivalent Functional Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nurse Practitioner

Center Name

01 Northern Human Services

0.94

02 West Central Behavioral Health

0.60

03 Genesis Behavioral Health

1.00

04 Riverbend Community Mental Health Center

0.50

05 Monadnock Family Services

1.25

06 Community Council of Nashua 1

0.50

06 Community Council of Nashua 2

0.50

07 Mental Health Center of Greater Manchester-CTT

1.09

07 Mental Health Center of Greater Manchester-MCST 0.90

08 Seacoast Mental Health Center

0.43

09 Community Partners

0.40

10 Center for Life Management

1.00

Total

9.11

2.57 7.83 0.55 11.89 0.80 11.49 0.80

2.55 4.00 0.60

7.75 0.50

5.50 0.14

3.00 6.00 1.00 11.00 0.50 11.00 0.50

3.00 6.00 0.50 10.00 0.30

9.00 0.30

2.45 2.50 0.50

6.70 0.65

7.25 0.65

3.00 2.75 0.00

6.25 0.25

6.25 0.25

3.00 1.75 0.00

5.25 0.25

5.25 0.25

11.00 1.70 1.00 14.79 0.87 15.53 0.62

10.00 9.96 1.00 21.86 0.87 21.37 0.53

2.10 6.00 1.00

9.53 0.60

9.53 0.60

1.00 2.18 0.50

4.08 0.50

6.85 0.50

3.00 3.30 1.00

8.30 0.20

7.17 0.20

46.67 53.97 7.65 117.40 6.29 116.19 5.34

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

2

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 42 of 109
January – March 2017

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Substance Use Disorder Treatment

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

March 2017 2.27 1.20 2.50 1.30 2.60 3.00 3.00
11.00 1.00 0.00 1.00 3.00
31.87

December 2016 2.12 1.20 7.50 1.30 2.40 3.00 3.00
11.00 1.00 0.00 1.00 2.87
36.39

2c. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Housing Assistance

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

March 2017 9.07 5.85 9.00 8.50 2.00 5.00 4.00
11.72 16.64
6.00 2.43 6.00 86.21

December 2016 8.92 5.60 9.00 7.50 2.00 5.00 4.00
11.92 15.85
6.00 4.58 5.87 86.24

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

3

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 43 of 109
January – March 2017

2d. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Supported Employment

Center Name

March 2017 December 2016

01 Northern Human Services

1.08

1.08

02 West Central Behavioral Health

0.25

0.25

03 Genesis Behavioral Health

3.00

2.00

04 Riverbend Community Mental Health Center

0.50

0.50

05 Monadnock Family Services

1.00

2.00

06 Community Council of Nashua 1

2.50

2.50

06 Community Council of Nashua 2

1.50

1.50

07 Mental Health Center of Greater Manchester-CCT

0.55

0.56

07 Mental Health Center of Greater Manchester-MCST

0.93

1.29

08 Seacoast Mental Health Center

1.00

1.00

09 Community Partners

0.00

0.00

10 Center for Life Management

0.30

0.30

Total

12.61

12.98

Revisions to Prior Period: None

Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report

Notes for 2b-d: Data compiled 5/10/17; The Staff Competency values reflect the sum of FTE's trained to provide each service type.

These numbers are not a reflection of the services delivered, rather the quantity of staff available to provide each service. If staff is

trained to provide multiple service types, their entire FTE value will be credited to each service type.

3. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12 Month Period

12 Month Period Ending March 2017

Penetration Rate for Period

Supported

Ending

Employment Total Eligible

Penetration

December

Center Name

Consumers

Consumers

Rate

2016

01 Northern Human Services

419

1,299

32.3%

27.0%

02 West Central Behavioral Health

145

624

23.2%

21.5%

03 Genesis Behavioral Health

166

1,322

12.6%

14.5%

04 Riverbend Community Mental Health Center

249

1,662

15.0%

13.8%

05 Monadnock Family Services

128

945

13.5%

17.9%

06 Community Council of Nashua

229

1,522

15.0%

12.4%

07 Mental Health Center of Greater Manchester

1,295

3,253

39.8%

43.1%

08 Seacoast Mental Health Center

189

1,316

14.4%

12.0%

09 Community Partners

51

711

7.2%

6.8%

10 Center for Life Management

172

872

19.7%

21.1%

Deduplicated Total

3,040

13,108

23.2%

22.9%

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 5/10/17; consumers are counted only one time regardless of how many services they receive

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

4

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 44 of 109
January – March 2017

4a. New Hampshire Hospital: Adult Census Summary

Measure

January – March 2017 October – December 2016

Admissions

263

275

Mean Daily Census

146

137

Discharges

258

276

Median Length of Stay in Days for Discharges

12

10

Deaths

0

0

Revisions to Prior Period: None

Data Source: Avatar

Notes 4a: Data extracted 1/6/17; Average Daily Census includes patients on leave and is rounded to nearest whole number

4b. New Hampshire Hospital: Discharge Location for Adults

Discharge Location Home - Lives with Others Home - Lives Alone CMHC Group Home Homeless Shelter/ No Permanent Home Private Group Home DDS Supported Living Nursing Home Glencliff Home for the Elderly Other Residence Peer Support Housing Jail or Correctional Facility Discharge/Transfer to IP Rehab Facility Hotel-Motel
Unknown Individualized Service Option-ISO

January – March 2017 142 76 6 6 5 4 4 4 3 3 2 1 1
1
0

October – December 2016 141 94 5 1 0 3 3 1 5 1 8 7 6
0
1

4c. New Hampshire Hospital: Readmission Rates for Adults

Measure

January – March 2017 October – December 2016

30 Days

8.0% (21)

13.0% (36)

90 Days

19.8% (52)

28.3% (78)

180 Days

27.8% (73)

35.1% (97)

Revisions to Prior Period: None Data Source: Avatar

Notes 4b-c: Data compiled 5/10/17; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions look back period includes readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day

readmissions); patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

5

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 45 of 109
January – March 2017

5a. Designated Receiving Facilities: Admissions for Adults

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total
DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

January – March 2017

Involuntary Admissions Voluntary Admissions

46

19

70

134

69

248

6

42

60

78

251

521

October – December 2016

Involuntary Admissions Voluntary Admissions

21

18

62

155

53

257

7

36

31

41

174

507

Total Admissions 65
204 317
48 138 772
Total Admissions 39
217 310
43 72 681

5b. Designated Receiving Facilities: Mean Daily Census for Adults

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

January – March 2017 5.0 14.6 27.2 31.2 24.6 20.5

October – December 2016 5.6 12.4 23.4 24.8 11.5 15.6

5c. Designated Receiving Facilities: Discharges for Adults

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

January – March 2017 65 211 305 49 130 760

October – December 2016 41 213 309 46 75 684

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

6

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 46 of 109
January – March 2017

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges for Adults

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

January – March 2017
5 4 5 27 7 5

October – December 2016 5 5 5 24 8 5

5e. Designated Receiving Facilities: Discharge Location for Adults

DRF Franklin Manchester (Cypress Center) Portsmouth Regional Hospital Elliot Geriatric Psychiatric Unit Elliot Pathways Total
DRF Franklin Manchester (Cypress Center) Portsmouth Regional Hospital Elliot Geriatric Psychiatric Unit Elliot Pathways Total

January – March 2017

Assisted

Living/Group Home Deceased DRF Home Hospice Hospital NHH Other

2

0

0

54

0

2

3

4

2

0

5

189

0

0

2

13

0

0

1

222

0

0

8

74

27

3

0

14

0

5

0

0

2

0

0

116

0

1

0

11

33

3

6

595

0

8

13

102

October – December 2016

Assisted

Living/Group Home Deceased DRF Home Hospice Hospital NHH Other

1

0

0

38

0

0

1

0

1

0

8

185

0

0

2

15

0

0

0

192

0

0

8 109

30

4

1

7

3

2

0

2

0

0

1

58

0

0

2

14

32

4

10

480

3

2

13

140

5f. Designated Receiving Facilities: Readmission Rates for Adults

DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total
DRF Franklin Manchester (Cypress Center) Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

January – March 2017

30 Days

90 Days

0.0% (0)

0.0% (0)

6.9% (14)

11.8% (24)

7.3% (23)

12.9% (41)

8.3% (4)

10.4% (5)

2.9% (4)

4.3% (6)

5.8% (45)

9.8% (76)

October – December 2016

30 Days

90 Days

2.5% (1)

2.5% (1)

6% (13)

9.7% (21)

8.1% (25)

14.2% (44)

4.7% (2)

4.7% (2)

11.1% (8)

12.5% (9)

7.2% (49)

11.3% (77)

180 Days 1.5% (1) 16.7% (34) 18.3% (58) 10.4% (5) 7.2% (10) 14.0% (108)
180 Days 2.5% (1) 11.1% (24) 18.1% (56) 9.3% (4) 12.5% (9) 13.8% (94)

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

7

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 47 of 109
January – March 2017

Revisions to Prior Period: None Data Source: NH DRF Database Notes: Data compiled 5/9/17; discharge location of DRF are patients discharged back to the same DRF for a different level of care within the DRF; readmission rates calculated by looking back in time from admissions in study quarter; patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

6. Glencliff Home: Census Summary

October – December

Measure

January – March 2017

2016

Admissions

5

5

Average Daily Census

104

110

7 (3-medical model group

home, 1-private apartment, 3 (supported apartment,

Discharges

1-assisted living/ residential

enhanced family care

care home, 1-NHH, 1-ABD/ home, nursing facility)

enhanced family care home)

Individual Lengths of Stay in Days for Discharges

1024, 1691, 1680, 629, 952, 486, 3207

1027, 2785, 4545

Deaths

3

6

Readmissions

0

0

Mean Overall Admission Waitlist

16 (9 Active*)

14 (6 Active*)

*Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other

steps immediate to admission.

Revisions to Prior Period: None.

Data Source: Glencliff Home

Notes: Data Compiled 4/28/17; means rounded to nearest whole number.

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

8

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 48 of 109
January – March 2017

7. NH Mental Health Consumer Peer Support Agencies: Census Summary

Peer Support Agency

January – March 2017

Average Daily

Total Members

Visits

October – December 2016

Average Daily

Total Members

Visits

Alternative Life Center Total Conway Berlin Littleton Colebrook

504

38

492

39

178

12

179

12

107

8

102

10

137

10

134

8

82

8

77

9

Stepping Stone Total Claremont Lebanon

582

18

571

18

486

12

479

13

96

6

92

5

Cornerbridge Total Laconia Concord Plymouth Outreach

365

13

348

13

159

4

152

5

157

9

152

8

49

NA

44

NA

MAPSA Keene Total

184

16

180

16

HEARTS Nashua Total

473

26

433

24

On the Road to Recovery Total Manchester Derry

524

40

498

36

386

33

367

31

138

7

131

5

Connections Portsmouth Total

275

13

273

14

TriCity Coop Rochester Total

358

14

345

16

Total

3,265

138

3,140

140

Revisions to Prior Period: None

Data Source: Bureau of Mental Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 5/11/17; Average Daily Visits NA for Outreach Programs; Cornerbridge Laconia for October to December

2016 estimated based on prior members and new reported members.

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

9

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 49 of 109
January – March 2017

8. Housing Bridge Subsidy Summary to Date

Subsidy Housing Bridge Subsidy Section 8 Voucher
Subsidy Housing Bridge Subsidy Section 8 Voucher Revisions to Prior Period: None Data Source: Bureau of Mental Health Notes: Data Compiled 2/22/17

January – March 2017

Total individuals served at start of quarter 643

New individuals added during quarter 32

Total individuals served through end of quarter
675

85

2

85

October – December 2016

Total individuals served at start of quarter 603

New individuals added during quarter 40

Total individuals served through end of quarter
643

83

0

83

9. Housing Bridge Subsidy Current Census Summary

Measure

As of 3/31/2017

As of 12/31/2016

Housing Slots

553

513

Rents currently being paid

505

481

Individuals accepted but waiting to lease

48

32

Waiting list for slots

0

0

Revisions to Prior Period: None

Data Source: Bureau of Mental Health

Notes: Data Compiled 5/2/17; All individuals currently on the Bridge Program are actively transitioning from the program (waiting

for their Section 8 housing voucher).

10. Housing Bridge Subsidy Unit Address Density

Number of Unit(s)* at Same Address

Frequency as of 5/12/17 Frequency as of 2/23/17

1

367

349

2

36

23

3

5

14

4

4

4

5

3

0

6

1

1

7

2

0

*All units are individual units

Revisions to Prior Period: None

Data Source: Bureau of Mental Health data compiled by Office of Quality Assurance and Improvement

Notes: Data Compiled 5/12/17

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

10

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 50 of 109
January – March 2017

11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure Unduplicated People Served in Month

January 2017 232

February 2017 194

March 2017 182

January – March 2017 608

October – December
2016 535

Services Provided by Type

Mobile Community Assessments

57

56

44

157

157

Crisis Stabilization Appointments

29

13

20

62

61

Office-Based Urgent Assessments

26

23

33

82

53

Emergency Service Medication Appointments

34

27

6

67

77

Phone Support/Triage

188

288

165

641

666

Walk in Assessments*

5

5

7

17

NA

Services Provided after Immediate Crisis

Mobile Community Assessments-Post Crisis

13

10

7

30

33

Crisis Stabilization Appointments

29

13

20

62

61

Office-Based Urgent Assessments

26

23

33

82

53

Emergency Service Medication Appointments

17

17

6

40

49

Phone Support/Triage

45

80

54

179

197

Referral Source Emergency Department/EMS Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal School Self VNA DCYF

30

15

13

58

33

42

47

21

110

71

4

7

1

12

17

1

3

7

11

19

11

16

5

32

31

2

2

8

12

12

3

5

8

16

12

13

16

12

41

50

5

5

8

18

20

101

70

87

258

254

0

0

0

0

0

0

0

0

0

1

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

30

30

35

95

85

121

126

145

392

316

4

4.2

4.1

4.1

3.7

Law Enforcement Involvement

20

20

12

52

57

Hospital Diversions Total

167

167

154

488

327

*New category beginning with this report

Revisions to Prior Period: None

Data Source: Riverbend CMHC submitted reports

Notes: Data Compiled 5/9/17

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

11

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 51 of 109
January – March 2017

11b. Mobile Crisis Services and Supports: Mental Health Center of Greater Manchester

Measure Unduplicated People Served by Month

January 2017 152

February 2017 143

March 2017 201

January – March 2017 413

Services Provided by Type

Phone Support/Triage

399

361

408

1168

Mobile Community Assessments

31

46

77

154

Office-Based Urgent Assessments

30

21

24

75

Emergency Service Medication Appointments

1

0

0

1

Crisis Apartment Service

0

125

23

148

Referral Source Emergency Department Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal Self Other

0

2

2

4

36

56

60

152

8

7

7

22

1

1

1

3

2

3

12

17

4

8

33

45

1

0

9

10

29

16

23

68

64

98

113

275

13

22

24

59

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

0

2

0

11

0

5.5

3

5

6

17

2

3.4

Law Enforcement Involvement

4

8

33

45

Hospital Diversion Total

151

212

280

643

Revisions to Prior Period: NA Data Source: New Mobile Crisis Data Reporting System Notes: Data Compiled 5/19/17

October – December
2016 NA
NA NA NA NA NA
NA NA NA NA NA NA NA NA NA NA
NA NA NA
NA
NA

NH DHHS - OQAI - CMHA Quarterly Report, 5/24/17

12

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 52 of 109
Appendix B New Hampshire Community Mental Health Agreement
Monthly Progress Reports March, 2017
38

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 53 of 109
New Hampshire Community Mental Health Agreement Monthly Progress Report
March 2017
New Hampshire Department of Health and Human Services April 24, 2017

CMHA Monthly Progress Report

1

April 24, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 54 of 109

Acronyms Used in this Report

ACT: BMHS: CMHA: CMHC: DHHS: QSR: SE: SFY:

Assertive Community Treatment Bureau of Mental Health Services Community Mental Health Agreement Community Mental Health Center Department of Health and Human Services Quality Services Review Supported Employment State Fiscal Year

Background
This Monthly Progress Report is issued in response to the June 29, 2016 Expert Reviewer Report, Number Four, action step 4. It reflects the actions taken in February 2017, and month-over-month progress made in support of the Community Mental Health Agreement (CMHA) as of February 28, 2017. This report is specific to achievement of milestones contained in the agreed upon CMHA Project Plan for Assertive Community Treatment (ACT), Supported Employment (SE) and Glencliff Home Transitions, as updated and attached hereto (Appendix 1). Where appropriate, the Report includes CMHA lifetime-to-date achievements.

CMHA Monthly Progress Report

2

April 24, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 55 of 109

Progress Highlights

Assertive Community Treatment (ACT)
Goal CMHC fidelity to ACT evidence-based practice model annually assessed.

Status 10 of 10 completed

Provide ACT team services, consistent with standards set forth, with the capacity to serve at least 1,500 individuals.

Capacity: 1,190 Enrollment: 882

Supported Employment (SE)
Goal CMHC fidelity to SE evidence-based practice model annually assessed.

Status 10 of 10 completed

Increase penetration rate of individuals with a

Statewide

Serious Mental Illness (SMI) receiving SE services to penetration

18.6%.

rate is 23.3%

Glencliff Home Transitions into Integrated Community Setting

Goal

Status

Have capacity to serve in the community 16 (cumulatively) individuals with mental illness and

10 of 16 completed1

complex health care needs residing at Glencliff who

cannot be cost-effectively served in supported

housing.

By June 30, 2017, identify and maintain a list of all individuals with mental illness and complex health care needs residing at the Glencliff Home who cannot be cost-effectively served in supported housing and develop an effective plan for providing sufficient community-based residential supports for such individuals in the future.

Partially complete

February Actions Taken  CMHC-specific improvement
plans implemented  Statewide training program
implemented  CMHC-specific technical
assistance sessions implemented  CMHC-specific technical assistance provided to address ACT Team workforce shortages  Increase public awareness of ACT Team workforce shortages
February Actions Taken  CMHC-specific improvement
plans implemented  Statewide training program
implemented  CMHC-specific technical
assistance sessions implemented  BMHS provided technical assistance to CMHCs with penetration rates below 18.6%
February Actions Taken  Worked with providers to
transition 3 residents in coming weeks  Identified community resource challenges to transition additional residents by 6/30/17  Plan developed to provide additional resources to support such individuals in enhanced Adult Family Care homes  Multiple individuals identified for future transition to community

1 Indicates residents have been transitioned into an integrated community setting; compliance with CMHA requirements for such transitions is under review.

CMHA Monthly Progress Report

3

April 24, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 56 of 109

1400 1200

ACT Capacity by Quarter*

1000

800

600

400

200

0

Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17

1000 975 950

ACT Client Count by Month*

925

900

875

850

825

800

775

750

725

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
Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17

0.3
SE Statewide Penetration Rate by

0.25

Quarter*

0.2

0.15

0.1

0.05

0

42248 42278 42309 42339 42370 42401 42430 42461 42491 42522 42552 42583 42614 42644 42675 42705 42736 42767

* Data is a combination of preliminary monthly and finalized quarterly data from CMHA Quarterly Data Reports.

CMHA Monthly Progress Report

4

April 24, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 57 of 109
Appendix 1

NH Department of Health & Human Services Community Mental Health Agreement (CMHA) Project Plan for Assertive Community Treatment, Supported Employment and Glencliff Home Transitions
February 28, 2017

# Due Date

Task

Assignee Description

Deliverable

% Done Related Activities

ACT-Expanding capacity/penetration; Staffing array

1

Quarterly Continue to provide quarterly ACT M. Brunette This report focuses on three (3) key quality ACT Quarterly Reports 100% and Use monthly in

reports with stakeholder input and

indicators: staffing array consistent with

Ongoing Implementation

distribute to CMHCs and other

the Settlement Agreement;

Workgroup and

stakeholders.

capacity/penetration; ACT service

Technical Assistance

intensity, averaging three (3) or more

calls; include 4 quarters

encounters/week. This report is key as it

for trend discussion.

assists CMHC leaders in understanding

their performance in relation to quality

indicators in the CMHA and past

performance.

2

6/30/2016 - Letters sent to CMHCs with low

M. Brunette Quality improvement requested by DHHS Monthly compliance 100% -

Use in Technical

letters sent compliance including staffing and/or

with detailed quality improvement plans calls and follow-up

letters,

Assistance calls with

capacity with a request for

with a focus on increasing the capacity of

monitoring Centers to support

improvement plans. The CMHCs will

ACT.

and follow- continuing progress.

be monitored and follow-up will occur.

up ongoing

3

7/20/2016 DHHS team and CMHC Executive M.Harlan

This session resulted in a plan with action The goal was to

100%

Workplan is ongoing

Directors participated in a facilitated

steps for increased ACT capacity.

establish a focused

guide under which the

session to establish a plan to expand

workplan expected to

CMHCs and DHHS is

capacity and staffing array.

increase new ACT

operating with focused

clients.

effort to achieve CMHA

goals.

4

9/30/2016 DHHS will continue to provide each M.Brunette CMCHs will use these quarterly reports to First report due from Ongoing Monthly data distribution

CMHC a list of individuals in their

enhance their screening of people for ACT. CMHCs to DHHS by

began in October.

region who had emergency

CMHCs will provide quarterly reports to 7/29/2016. The

CMHCs monthly

department visits for psychiatric

DHHS indicating that they have screened screening process and

reporting to DHHS on

reasons, psychiatric hospitalizations,

each individual and the outcome of the reporting will utilize a

research conducted.

DRF admissions, and NHH

screening.

comprehensive

ACT/SE Implementation

admissions in the past quarter to

template developed by

Workgroup will use this

facilitate CMHCs ability to assess

the ACT and SE

data for monthly

people in their region for ACT.

community stakeholder

discussion with CMHC

group by 9/30/16.

ACT coordinators.

1

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 58 of 109
Appendix 1

# Due Date

Task

Assignee Description

Deliverable

% Done Related Activities

5

10/1/2016 Address Peer Specialist Challenges- M.Brunette Behavioral Health Association and DHHS Work with BDAS to look 100%

Research completed.

lack of standardized training.

in an effort to expedite increasing peer at their process.

Additional training

specialists, will explore the SUD Recovery

capacity added. DHHS

specialists certification.

collaborated with Peer

Support Agency to assist

with coordination of

meeting Peer Support

Specialist training needs;

ongoing identification of

training needs and

coordinating delivery of

training commenced in

October.

6

10/1/2016 ACT team data will be reported

M.Brunette The data will be separated starting the ACT team data will be 100%

Use monthly in

separately by team.

month of July 2016 and will be reported in separated on a quarterly

Implementation

the October 2016 report.

basis moving forward.

Workgroup and

Technical Assistance

calls.

7

10/1/2016 Develop organization strategies to M.Brunette Each CMHC will conduct one education Increase community 100%

Discussed in monthly

increase capacity.

session between now and Oct. 1, 2016 to education.

ACT/SE Implementation

introduce ACT.

Workgroup calls to

identify educational

needs. Centers holding

additional inservice

sessions.

8

10/1/2016 Review and make changes as

M.Brunette Each CMHC will review and evaluate their Learning Collaborative 100%

Internal CMHC review of

necessary to ACT referral process.

internal referral process and then share to share their

referral process

with the other CMHCs.

processes.

complete. Fidelity

assessment process and

ED admissions yielded

changes.

9

11/1/2016 DHHS will require CMHCs to conduct M.Brunette This report will include their plan for

CMHCs Self-Fidelity 100%

DHHS received 7out of 7

self-fidelity to evaluate their

improving their adherence to the model Report to DHHS.

CMHC reports; final

adherence to the ACT treatment

described in the Settlement Agreement.

reports and improvement

model. They will provide a report to

plans have been

DHHS by 11/1/16.

published on the DHHS

website.

2

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 59 of 109
Appendix 1

# Due Date

Task

Assignee Description

Deliverable

% Done Related Activities

10

12/1/2016 Evaluate potential/structural/systemic M. Brunette Work with TA to develop a report that will ACT Staffing Report 90%

issues resulting in high staff

communicate the strategies to address

turnover/inability to recruit and retain

ACT staffing issues in collaboration with

staff.

DHHS.

11

12/1/2016 Increase the number of staff who are M.Brunette Explore the possibility of increasing the Increase number of 75%

eligible for State Loan Repayment

number of staff eligible for this program. staff eligible

Program (SLRP).

Collected information from several health care workforce development projects underway that include CMHC staffing (inclusive of ACT staffing).
Presentation to CMHC Executive Directors made to increase understanding of how to access funds; DHHS seeking additional funding for program in 2018-2019 budget.

12

12/1/2016 DHHS will Initiate ACT fidelity

assessments.

13

2/28/2017 Increase ACT capacity

M.Brunette DHHS will conduct ACT fidelity using the Fidelity report ACT toolkit.

100%

M. Brunette

Concerted efforts by the CMHCs to assess By 2/28/17 increase individuals in Community residences that ACT capacity by 25 %. could be served on ACT. Train direct service providers in coding appropriately for ACT services. Screen 100% eligible individuals for ACT.

40%

Conducted final ACT Fidelity Assessments (Jan 30-31). Final repors and improvement plans will be published in Feb. and Mar. 2017.
New monthly capacity (staffing) reports began in November. As of 2/28/17, actual increased capacity is 38% toward goal of increase target. Training is underway.

14

3/1/2017 DHHS will request CMHCs with low M.Brunette Quarterly reports will be provided to each List of (5) consumers 85%

compliance to provide DHHS a list of

CMHC on their specific list of individuals from low compliance

five (5) consumers who are eligible for

who had Emergency department visits and CMHCs who are eligible

and who will begin to receive ACT

psychiatrist hospitalizations to allow

for ACT services each

services each month starting August

CMHCs to assess their center specific month and a list of (3)

1, 2016 through February 2017.

clients.

consumers from other

DHHS will request all other CMHCs to

CMHCs who are eligible

provide DHHS a list of 3 consumers

for ACT services.

who are eligible for and who will begin

to receive ACT services each month

starting August 1, 2016 through

February 2017.

Preliminary reporting steps completed. Reporting is ongoing. Quality of data submitted and achievement of monthly enrollment goal is current objective being monitored.

3

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 60 of 109
Appendix 1

# Due Date

Task

Assignee Description

Deliverable

% Done Related Activities

15

6/30/2017 Increase ACT capacity

M. Brunette

Concerted efforts by the CMHCs to assess By 6/30/2017 increase 0%

individuals in Community residences that ACT capacity by an

could be served on ACT. Train direct

additional 13.5%

service providers in coding appropriately

for ACT services. Screen 100% eligible

individuals for ACT.

16

6/30/2017 After February 2017 DHHS will

M. Brunette CMHCs will provided DHHS with a monthly Monthly report with list 100%

request that all CMHCs will continue

report of newly enrolled clients.

of consumers to

to provide DHHS a list of 2-4

increase ACT capacity.

consumers who were hospitalized for

psychiatric reasons or are otherwise

eligible for ACT and were enrolled

each month.

Reporting mechanism implemented.

4

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 61 of 109
Appendix 1

# Due Date

Task

Assignee Description

Deliverable

% Done Related Activities

Supported Employment (SE)

17

5/20/16 and Letters sent to CMHCs with low

M.Brunette Request for compliance plan with quarterly Receive and evaluate 100%

ongoing penetration rates including staffing

reports.

improvement plans from

and/or penetration with a request for

CMHCs due 6/29/16.

improvement plans.

Use in Technical Assistance calls with Centers to support continuing progress. Two out of four reported decreases in September; overall improvement is 6.8% over August for these 4 CMHCs.

18

6/1/16 and Continue to generate quarterly report M.Brunette This report is key as it assists CMHC

Quarterly Report SE Ongoing/Qu Use monthly in

ongoing with stakeholder input focusing on

leaders in understanding their

Penetration Rate to

arterly

Implementation

penetration of SE services distributed

performance in relation to quality indicators CMHCs.

Workgroup and

to the CMHCs and other stakeholders.

in the CMHA and past performance.

Technical Assistance

calls; include 4 quarters

for trend discussion.

19

7/20/2016 DHHS team and CMHC Executive M.Harlan

This session will result in a plan with action The goal is to establish 100%

Directors will participate in a

steps for increased SE capacity.

a focused workplan

facilitated session to establish a plan

expected to result in a

to expand penetration and staffing

total of 18.6% SE

array.

clients by 6/30/17.

Workplan is ongoing guide under which the CMHCs and DHHS is operating with focused effort to achieve CMHA goals.

20

7/6/2016 On-site fidelity assessments

conducted at CMHCs.

K.Boisvert

The first fidelity assessment took place 7/6-7/8/16 in Manchester.

Report with results of the on-site fidelity assessments.

100%

Tools developed. Assessment conducted. DHHS report issued. Voluntary program improvemeent plan developed by Center.

21

7/12/2016 On-site fidelity assessments

conducted at CMHCs.

K.Boisvert

The second fidelity assessment took place Report with results of

on 7/12/16 at Riverbend in Concord.

the on-site fidelity

assessments.

100%

Tools developed. Assessment conducted. DHHS report issued with recommendations.

22

9/27/2016 On-site fidelity assessments

conducted at CMHCs.

K.Boisvert

The third fidelity assessment will take place on 9/27/16-9/29/16 in Berlin.

Report with results of the on-site fidelity assessments.

100%

Final report issued 11/14/16.

5

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 62 of 109
Appendix 1

# Due Date

Task

Assignee Description

Deliverable

% Done Related Activities

23

10/24/2016 On-site fidelity assessments

conducted at CMHCs.

K.Boisvert

The fourth fidelity assessment will take place on 10/4-5/16 in Nashua.

Report with results of the on-site fidelity assessments.

100%

Assessment conducted. DHHS final report issued 12/20/2016.

24

10/1/2016 Monitor monthly ACT staffing for

M.Harlan

Monitor monthly ACT staffing for presence A monthly report will be 100% and Use monthly in

presence of SE.

of SE on each team.

run through the Phoenix Ongoing Implementation

system for ACT staffing.

Workgroup and

Technical Assistance

calls.

25

10/15/2016 All CMHCs will conduct self-fidelity K.Boisvert Self-fidelity assessments

assessments.

Report to DHHS with 100% self-fidelity assessment results.

DHHS completed its initial review of the assessments received.

26

11/1/2016 CMHCs will develop and maintain a M.Harlan

Review individuals that are not on SE for Quarterly reports of

75%

list of SMI individuals who may benefit

reasons why they are not enrolled.

individuals not on SE.

from but are not receiving SE

services.

CMHCs began referral screening process incorporated into quarterly treatment plan reviews in Oct. 2016. Process will trigger SE referrals when appropriate. Data reporting to BMHS is in initial phases.

6

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 63 of 109
Appendix 1

# Due Date

Task

27

11/1/2016 Resolve barriers to achieving SE

penetration goals.

Assignee M.Harlan

Description

Deliverable

Educate internal CMHC staff on the goals Educational plan of SE.

% Done Related Activities

100%

Discussed in monthly ACT/SE Implementation Workgroup calls to identify educational needs. Five CMHCs reported holding additional inservice sessions. Learning Collaborative work has yielded all SE leads meeting with new clients within days of intake; internal staff educated about SE; SE education needs identified, motivational programs for clients explored, etc. Voc Rehab actively engaged for inter-agency collaboration. DHHS developed ongoing educational plan.

28

12/1/2016 Explore resources to conduct

M.Harlan

CBHA and DHHS will explore the need for Report the barriers and 100%

technical assistance and training.

technical assistance and training. DHHS possible solutions.

CMHCs and DHHS will explore

will conduct a subgroup of CMHC leaders Technical assistance

strategies and barriers DHHS can use

to explore barriers and administrative

(TA) and training if

to facilitate service delivery.

burden that prevents service delivery.

needed.

DHHS began developing plan to resource provision of additional technical assistance to CMHCs. Fidelity Assessment result analysis complete. Identified specific areas of focus for training and TA needs. DHHS developed plan for ongoing training and technical assistance for 2017. Plan is underway.

7

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 64 of 109
Appendix 1

# Due Date

Task

Assignee Description

Deliverable

29

12/1/2016 Increase the number of staff who are M. Harlan Explore the possibility of increasing the Increase number of

eligible for State Loan Repayment

number of staff eligible for this program. staff eligible.

Program (SLRP).

% Done Related Activities

75%

Presentation to CMHC Executive Directors made to increase understanding of how to access funds; DHHS seeking additional funding for program in 2018-2019 budget.

30

6/30/2017 Increase SE penetration rate to 18.6% M. Harlan Learning collaborative meets monthly and Monthly meetings of the 100%

has developed a four question script to be Learning Collaborative.

used at time of intake as an instrument to

introduce SE. If the individual is interested

the referral goes to the SE coordinator who

will contact the individual within 3 days of

the intake to set up an appointment. If the

individual is not interested the SE

Coordinator will outreach to provide

information on SE and will periodically

follow up with him/her. This strategy

includes working with individual CMHCs

that fall below the 18.6% penetration rate.

ACT/SE Implementation Workgroup, SE Learning Collaborative, Training program, and CMHCspecific Technial Assistance post SE Fidelity Analysis underway. DHHS continues to consult with CMHCs not at 18.6% goal for region.

8

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 65 of 109
Appendix 1

# Due Date

Task

Assignee Description

Deliverable

% Done Related Activities

Glencliff Home Transitions

31

Ongoing at Establish process for identifying

Glencliff Staff Glencliff interviews residents each year to Section Q of MDS is a 100% and Monitor referrals to

residents individuals interested in transitioning

assess if they want to transition back to federal requirement. Ongoing Central Team. Research

every 90 days from Glencliff to the community.

the community.

CMHCs have staff go to Glencliff to discuss

CMHC inreach activities. Introduce and deliver

transition planning with

community living

residents.

curriculum to increase

resident positive

engagement.

32

7/30/2016 Develop individual transition plans, M.Harlan

Individuals from Glencliff have been

Individual transition

100%

including a budget.

identified to transition back to the

plans/individual

community. Detailed plans are being

budgets.

developed and DHHS has engaged a

community provider who will further

develop transition plans.

33

8/31/2016 Identify community providers to

M.Harlan

Community providers have been identified Transition/community 100%

coordinate and support transitional

and will further develop the

living plans for

and ongoing community living

transition/community living plans.

individuals to transition

including but not limited to housing,

to community.

medical and behavioral service

access, budgeting, community

integration, socialization, public

assistance, transportation, education,

employment, recreation, independent

living skills, legal/advocacy and faith

based services as identified.

Individual plans developed and budgets approved.
Tools developed, reviewed and approved. Providers identified and engaged. Community Living Plans developed.

34

8/31/2016 Implement reimbursement processes M.Harlan

Develop policies and procedures to allow Reimbursement

100%

for non-Medicaid community transition

community providers to bill up to $100K in procedure documented,

funds.

general fund dollars.

tested and approved.

35

8/15/2016 Develop template for Community

M.Harlan

Completion of the template to be done as Community Living Plan 100%

Living Plan for individuals transitioning

a person centered planning process.

from Glencliff to the community.

36

7/25/2016 Transition three (3) individuals to the M.Harlan

Three individuals have transitioned to the Community placement 100%

community.

community.

1-10/6/14; 1-11/30/15; 13/14/16

37

12/1/2016 Transition four (4) individuals to the M.Harlan

Four individuals to transition into the

Community placement 100%

1-7/25/16; 1-10/11/16; 1-

community.

community.

10/31/16; 1-1/12/17

9

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 66 of 109
Appendix 1

# Due Date

Task

38

3/1/2017 Transitions four (4) additional

individuals to the community.

39

6/30/2017 Transition five (5) additional

individuals to the community.

Assignee M.Harlan
M.Harlan

Description
Four individuals to transition into the community.
Five individuals to transition into the community

Deliverable

% Done Related Activities

Community placement 75%

1-1/13/17; 1/17/17; 1/30/17;

Community placement 0%

10

CMHA-Project Plan

2/28/2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 67 of 109
Appendix C Assertive Community Treatment & Supported Employment Fidelity Reviews
Summary Report: April 2017
39

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 68 of 109

Assertive Community Treatment & Supported Employment Fidelity Reviews 2017 Summary Report

April 2017

New Hampshire Department of Health and Human Services Division for Behavioral Health Bureau of Mental Health Services April 14, 2017

ACT/SE Fidelity Review 2017 Summary Report

1

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 69 of 109

Acronyms Used in this Report

ACT: BMHS: CMHA: CMHC: DHHS: QSR: SE: SFY:

Assertive Community Treatment Bureau of Mental Health Services Community Mental Health Agreement Community Mental Health Center Department of Health and Human Services Quality Services Review Supported Employment State Fiscal Year

ACT/SE Fidelity Review 2017 Summary Report

2

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 70 of 109

Introduction
This Assertive Community Treatment (ACT) and Supported Employment (SE) Fidelity Review Summary Report releases the State Fiscal Year (SFY) 2017 Fidelity Review scores for New Hampshire’s ten (10) Community Mental Health Centers (CMHC), and the Bureau of Mental Health Services (BMHS) analysis of statewide and CMHC-specific fidelity to the Evidence-Based Models (EBM) for ACT and SE.

The ACT and SE Fidelity Reviews for SFY 2017 were conducted by either DHHS, through a team of DHHS staff with expertise in the programs or in conducting Quality Service Reviews, or by the CMHC, as a selfassessment utilizing CMHC staff with expertise in the programs. Table 1 indicates which team conducted each Fidelity Review:

Table 1

Community Mental Health Center Northern Human Services West Central Behavioral Health Genesis Behavioral Health Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Center Mental Health Ctr. of Greater Manchester Seacoast Mental Health Center Community Partners of Strafford County Center for Life Management

ACT DHHS DHHS DHHS CMHC CMHC CMHC CMHC CMHC1 CMHC CMHC

SE DHHS CMHC CMHC DHHS CMHC DHHS DHHS CMHC2 DHHS CMHC

The Fidelity Review is a manualized process described in published toolkits. It includes conducting the assessment, a bi-directional review of the assessment scores wherein both DHHS, through BMHS, and the applicable CMHC share feedback, and recommendations for each criterion are developed and agreed upon. Based on the Fidelity Review, improvement plans are developed, setting the path forward for the coming year to improve fidelity at each CMHC. In order to improve areas of the practices, CMHCs may utilize technical assistance, additional training and participation in learning collaboratives. DHHS and CMHCs follow up on progress being made throughout the year.
At the conclusion of the SFY 2017 Fidelity Reviews, BMHS analyzed the results and developed this Summary Report that evaluates quality across the state. Beginning in State Fiscal Year 2018 – once a full cycle (10 CMHCs) of baseline data is available3 from Quality Service Reviews (QSRs) – the Fidelity Review process will conclude with a summary report that incorporates statewide, system level findings from the QSR cycle –ensuring a fully comprehensive analysis supports program improvement for subsequent years.

1 Seacoast Mental Health Center chose to have an independent consultant conduct its ACT self-assessment. 2 Seacoast Mental Health Center chose to have an independent consultant conduct its SE self-assessment. 3 QSRs were piloted in SFY2017. The pilot QSRs will not be used to create the baseline data necessary for this purpose; only
the QSRs that use the finalized QSR process and tools wil contribute to the baseline data.

ACT/SE Fidelity Review 2017 Summary Report

3

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 71 of 109
1. Assertive Community Treatment (ACT)
The EBM for ACT includes the Fidelity Review tool4 that was utilized for the SFY 2017 Fidelity Review process. The tool assesses ACT Fidelity, including the ACT Team Components described in Section V.D.2. (a) through (g) of the Community Mental Health Agreement, which are briefly described below:
 Availability – 24 hours per day, 7 days per week with on-call availability midnight to 8:00 a.m.;
 Comprehensive and individualized service delivery in consumer homes, natural environments, and community settings, or by telephone where appropriate;
 Appropriate ACT team composition – multidisciplinary team of between 7 and 10 professionals;
 Each ACT team serves appropriate number of consumers – no more than 10 consumers per ACT team member;
 Service delivery able to de-escalate crises without removing consumer from home or community program, consistent with safety concerns; and
 ACT teams work with law enforcement personnel to respond to consumers experiencing a mental health crisis.
The ACT Fidelity Review tool measures ACT Fidelity across three areas:
 Human Resources: Structure and Composition – 11 criterion assess ACT team staffing, caseload size, program size, etc.;
 Organizational Boundaries – 7 criterion assess admission criteria, intake rates, responsibility for treatment services, crisis services, hospitalization and discharge planning, etc.; and
 Nature of Services – 10 criterion assess community-based services, engagement mechanisms, intensity of service, informal support system, Substance Use Disorders, cooccurring disorders, dual disorders, etc.
In whole, 28 criterion are measured against five (5) possible ratings/anchors, for a maximum total score potential of 140. Table 2 (pg 5) provides the SFY 2017 scoring results for every CMHC.

4 See Appendix 1—ACT Fidelity Review Tool

ACT/SE Fidelity Review 2017 Summary Report

4

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 72 of 109

ACT Fidelity Scale NHS
State Fiscal Year 2017 Review

WCBH

GBH

RCMH

MFS

GNMHC

MHCGM

SMHC CP

Region I

II

III

IV

V

VI

VII

VIII

IX

Type of Review (DHHS or CMHC conducted)

DHHS

DHHS

DHHS

CMHC

CMHC

CMHC

CMHC CMHC CMHC CMHC

Human Resources

H1 - Small Caseload

4.7

5

5

5

5

5

5

5

5

4

H2 - Team Approach

3.3

5

5

5

4

5

4

4

4

5

H3 - Program Meeting

3.7

4

3

4

4

5

4

4

4

5

H4 - Practicing ACT Leader

4.7

4

4

3

5

5

3

3

3

2

H5 - Staff Continuity

4.3

3

4

5

5

4

3

4

3

1

H6 - Staff Capacity

4.7

4

4

5

4

3

4

3

3

4

H7 - Psychiatry

3.7

3

4

2

4

3

3

3

5

4

H8 - Nursing

2.3

4

3

2

2

3

3

2

2

2

H9 - Substance Abuse

2.7

2

1

3

5

5

5

5

1

4

H10 - Vocational (SE)

3

2

2

2

3

5

4

3

5

4

H11 - Program Size

2

3

4

4

3

5

5

5

4

5

Organizational Boundaries

O1 - Admission Criteria

5

5

5

4

4

4

5

5

5

5

O2 - Intake Rate

5

5

4

5

5

5

5

5

5

5

O3 - Service Responsibility

5

5

4

5

5

4

5

5

4

5

O4 - Crisis Responsibility

2

2

4

2

5

5

5

5

4

4

O5 - Hospital Admits

5

5

5

4

5

5

5

5

2

4

O6 - Hospital Discharges

5

5

5

5

5

5

4

5

5

4

O7 - Time Unlimited Svcs

5

5

5

4

5

5

4

4

5

5

Nature of Services

S1 - Community-Based Svcs

4.7

5

5

4

5

5

4

5

4

5

S2 - No Dropout Policy

5

4

5

5

5

5

5

5

5

5

S3 - Assertive Engagement

5

5

4

5

5

4

5

5

5

5

S4 - Intensity of Svcs

2.7

3

5

5

4

5

5

5

2

5

S5 - Frequent Contact

2.3

4

4

4

4

5

5

5

2

5

S6 - Work with Support Sys

4

3

3

3

4

2

5

5

2

4

S7 - Ind Substance Tx

4

4

2

2

4

3

5

4

1

3

S8 - Co-Occurring Group

1

3

1

1

1

1

2

1

1

1

S9 - Dual Disorder Model

3.7

5

2

3

5

4

5

5

2

5

S10 - Consumer on Team

2

2

5

3

3

1

4

1

5

5

Total

105.3

109

107

104

118

115

122

116

98

115

Notes: The Bureau of Mental Health Services hired a contractor to do the ACT Fidelity Review Summary.

Items that were rated low (1 or 2) are highlighted in yellow.

Items that were rated fair (3) are highlighted in blue.

Fidelity items with mean scores in red text may be targeted for potential quality improvement activities at the system level.

CLM
X
CMHC
5 4 5 4 3 4 2 5 5 2 4
5 5 4 5 5 5 4
4 4 5 3 3 2 4 2 4 4 111

Mean Score
4.88 4.39 4.15 3.70 3.57 3.88 3.34 2.75 3.52 3.18 4.00
4.73 4.91 4.64 3.91 4.55 4.82 4.64
4.61 4.82 4.82 4.06 3.94 3.36 3.27 1.36 3.97 3.18 110.94

Score Guide: 28 items, each with a score possible of up to 5, for a total possible score of 140 points. Total scores result in the following ratings:
84 and below = Not ACT 85 - 112 = Fair Implementation 113 - 140 = Full Implementation

ACT/SE Fidelity Review 2017 Summary Report

5

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 73 of 109

ACT Fidelity Review Summary
Based on scores from the SFY 2017 ACT Fidelity Review, half of New Hampshire’s Community Mental Health Centers were rated as “Full Implementation,” and half were rated as “Fair Implementation.” The provision of integrated treatment of co-occurring substance use disorders was a major area in need of improvement across many centers. The role of the team leader and working with the consumer’s support system were two additional significant areas in need of improvement at many centers. Other areas for quality improvement include adequate staffing for the roles of peers, supported employment specialists, psychiatrists and nurses on ACT teams.
BMHS ACT Program Improvement Plan
DHHS will work to improve quality by:
1) Providing bi-monthly technical assistance (or monthly if requested) at centers with Fair Implementation fidelity scores to:
a. Help teams identify and implement steps towards improvement; b. Help teams organize and deliver their co-occurring substance abuse services; and c. Help teams organize their team meeting and team activity scheduling.
2) Providing trainings for all CMHCs focused on:
a. Skills and strategies for substance abuse services – 5 half-day modules for staff who are identified as substance abuse experts, and ongoing supervision for addiction services skills;
b. Overall ACT skills refresher for ACT specialists; and c. ACT Summit – 2-day training to assist CMHCs with the sustaining and improvement
of ACT services. Training objectives include: i. To increase knowledge of target audiences for ACT services; ii. To enhance understanding of the ACT philosophy, values and practice
principles; iii. To increase knowledge of engagement strategies for ACT; iv. To improve knowledge about effective strategies for ACT outreach; v. To develop strategies for improving ACT team retention; vi. To understand the role of Specialty and Generalist services in ACT; and vii. To develop a working understanding of the ACT fidelity scale for quality
improvement.
3) Supporting the development of an ACT learning collaborative with:
a. Data reports; and b. Expert technical assistance.
4) Ongoing exploration of additional funding resources and supports for workforce development.

ACT/SE Fidelity Review 2017 Summary Report

6

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 74 of 109
2. Supported Employment (SE)
The EBM for SE includes the Fidelity Review tool5 that was utilized for the SFY 2017 Fidelity Review process. The tool assesses SE Fidelity, including the SE provisions described in Section V.F.1. of the Community Mental Health Agreement, which are briefly described below:
 Deliver Supported Employment services in accordance with the Dartmouth EBM;  Provide individualized assistance in identifying, obtaining, and maintaining integrated, paid,
competitive employment;  Provide services in the appropriate amount, duration and intensity;  Provide services including but not limited to job development, co-worker and peer
supports, time management training, benefits counseling, job coaching, etc.
The SE Fidelity Review tool measures ACT Fidelity across three areas:
 Staffing: 3 items assess SE staffing and caseload size;  Organization: 8 items assess integration of rehabilitation with mental health treatment,
vocational rehabilitation, zero exclusion criteria, the SE team leader’s role, and agency focus on competitive employment; and  Services: 14 items assess work incentives, vocational assessment, job search and development, individualized follow-along supports, community-based services, team engagement and outreach, etc.
In whole, 25 items are rated; each item is rated on a 5-point scale ranging from 1 (meaning not implemented) to 5 (meaning fully implemented), for a maximum potential score of 125. Table 3 (pg 8) provides the SFY 2017 scoring results for every CMHC.

5 See Appendix 2 – SE Fidelity Review Tool

ACT/SE Fidelity Review 2017 Summary Report

7

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 75 of 109

SE Fidelity Scale State Fiscal Year 2017 Review
Region Type of Review (DHHS or CMHC
conducted) Staffing 1. Caseload 2. SE Services staff 3. Voc generalists Organization 1. Integration of rehab w/MH tx 2. Integration rehab w/freq contact 3. Collab w/VR 4. Voc Unit 5. SE Supervisor 6. Zero Exclusion 7. Competitive Employment 8. Exec Team Support Services 1. Work incentives planning 2. Disclosure 3. On-going work based assess 4. Rapid job search 5. Individualized job search 6. Job development-employer contact 7. Job Development-quality contact 8. Diversity of jobs 9. Diversity of employers 10. Competitive jobs

NHS
I
DHHS
4.5 4.5 5
5 5 2.5 4.5 4 4.5 3 4
5 5 4 4 5 2.5 5 4 4 3

WCBH
II
DHHS
4 5 5
2 5 3 3 3 4 4 5
5 5 5 4 4 2 5 5 5 5

GBH
III
CMHC
5 5 4.5
4.5 4.5 5 5 5 4 4 4
5 5 4 4 5 2 4 5 5 5

RCMH
IV
DHHS
4 5 5
3 4 3 5 3 4 3 3
5 5 4 4 4 2 4 5 5 5

MFS GNMHC MHCGM SMHC

V

VI

VII

VIII

CMHC CMHC DHHS CMHC

3

4

5

5

5

5

5

5

4

5

3

3

5

5

4

2

5

4

4

5

4

4

5

4

5

5

4

4

5

5

5

5

2

2

5

4

5

4

5

5

5

5

4

5

5

5

5

5

5

4

4

4

4

5

5

5

5

4

5

3

5

3

5

5

4

3

5

5

5

5

4

3

5

5

4

2

4

5

5

4

5

4

5

5

CP
IX
CMHC
1 1 1
1 1 1 1 1 1 4 3
1 4 4 3 1 1 1 3 5 4

CLM
X
CMHC
4 5 5
5 4 5 5 5 5 5 5
5 5 5 5 5 2 4 4 5 5

11. Individualized follow along supports 5

3

5

5

5

4

5

5

1

5

12. Time unlimited follow-along

5

3

5

5

5

5

5

5

1

13. Community based services

4.5

3

2.5

5

5

5

5

5

1

14. Assertive engagement

1

4

5

3

5

4

5

5

1

Total Score:

103.50 101.00 112.00 103.00 113.00 108.00 118.00 109.00 47.00

Notes: The Bureau of Mental Health Services hired a contractor to do the SE Fidelity Review Summary.

Items that were rated low (1 or 2) are highlighted in yellow.

Items that were rated fair (3) are highlighted in blue.

Fidelity items with mean scores in red text may be targeted for potential quality improvement activities at the system level.

5 5 5
118.00

Mean Score
3.85 4.55 4.55
3.95 4.05 3.45 4.35 3.60 3.95 4.00 4.20
4.20 4.90 4.40 4.10 4.40 2.15 4.10 4.40 4.80 4.70
4.30
4.40 4.10 3.80 103.25

Score Guide: 25 items, each with a score possible of up to 5, for a total possible score of 125 points. Total scores result in the following ratings:
73 and below = Not Supported Employment 74 - 99 = Fair Fidelity 100 - 114 = Good Fidelity 115 - 125 = Exemplary Fidelity

ACT/SE Fidelity Review 2017 Summary Report

8

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 76 of 109
SE Fidelity Review Summary
Based on scores from the SFY 2017 SE Fidelity reviews, most of New Hampshire’s Community Mental Health Centers (9 of 10) were implementing Supported Employment with at least “good fidelity.” One center scored poorly because their SE team staff left the agency, and the center had not yet successfully completed recruitment to hire staff to replace the team.
Analysis of individual scores indicated that contact with employers for job development was the single area where most centers needed significant improvement. Other potential areas for improvement, based on at least three centers scoring a 3 or lower, include: collaboration with Vocational Rehabilitation, integration of mental health and SE, variety of competitive employment jobs, community based services and assertive engagement.
BMHS SE Program Improvement Plan
BMHS will work to improve quality by:
1) Providing bi-monthly technical assistance (or monthly if requested) to:
a. Help the center that is restarting their SE program. b. Help all other SE teams address individualized barriers as identified by the fidelity
review or the team leader.
2) Providing trainings for all centers focused on:
a. Skills and strategies for job development – engaging employers and engaging families. b. Overall SE skills – basic skills for SE specialists (delivered February 23rd and 28th, 2017). c. Illness Management and Recovery (IMR) training that will help SE workers with basic
mental health counseling skills.
3) Working with Vocational Rehabilitation leaders at the state level to facilitate SE services in the state by:
a. Facilitating interagency agreements. b. Encouraging regional Vocational Rehabilitation to provide job development services.
4) Supporting the SE learning collaborative with:
a. Data reports. b. Expert technical assistance.
5) Ongoing exploration of additional funding resources and supports for workforce development.

ACT/SE Fidelity Review 2017 Summary Report

9

April 14, 2017

January 2017

Feb. 2017

March 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 77 of 109

Schedule of State Fiscal Year 2017 Fidelity and Quality Services Review6

July 2016

Aug. 2016

Sep. 2016

Center for Life Management DHHS-conducted QSR
Mental Health Center of Greater Manchester DHHS-conducted SE Fidelity Assessment
Riverbend Community Mental Health DHHS-conducted SE Fidelity Assessment
West Central Behavioral Health DHHS-conducted QSR
Genesis Behavioral Health DHHS-conducted QSR
Northern Human Services DHHS-conducted SE Fidelity Assessment
Center for Life Management Self-conducted ACT Fidelity Assessment Self-conducted SE Fidelity Assessment
Community Partners of Strafford County Self-conducted ACT Fidelity Assessment
Genesis Behavioral Health DHHS-conducted ACT Fidelity Assessment Self-conducted SE Fidelity Assessment
Greater Nashua Mental Health Center DHHS-conducted SE Fidelity Assessment Self-conducted ACT Fidelity Assessment
Mental Health Center of Greater Manchester Self-conducted ACT Fidelity Assessment
Monadnock Family Services Self-conducted ACT Fidelity Assessment Self-conducted SE Fidelity Assessment
Riverbend Community Mental Health Self-conducted ACT Fidelity Assessment
Seacoast Mental Health Center Self-conducted7 ACT Fidelity Assessment Self-conducted8 SE Fidelity Assessment
West Central Behavioral Health Self-conducted SE Fidelity Assessment
Community Partners of Strafford County DHHS-conducted SE Fidelity Assessment
Monadnock Family Services DHHS-conducted QSR - POSTPONED
Northern Human Services DHHS-conducted ACT Fidelity Assessment

Mental Health Center of Greater Manchester DHHS-conducted QSR
West Central Behavioral Health DHHS-conducted ACT Fidelity Assessment
Seacoast Mental Health Center DHHS-conducted QSR
Greater Nashua Mental Health Center DHHS-conducted QSR
Community Partners of Strafford County DHHS-conducted QSR
Northern Human Services DHHS-conducted QSR
Riverbend Community Mental Health DHHS-conducted QSR

October 2016

November 2016

April 2017

May 2017

Dec. 2016

June 2017

6 Schedule may be subject to change. 7 At its own discretion, Seacoast Mental Health Center utilized the services of an outside contractor to conduct its Self-Assessment. 8 At its own discretion, Seacoast Mental Health Center utilized the services of an outside contractor to conduct its Self-Assessment.

ACT/SE Fidelity Review 2017 Summary Report

10

April 14, 2017

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 78 of 109 Appendix 1
The following pages contain the ACT Fidelity Review Tool used for SFY2017.

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 79 of 109
Community Mental Health Center (CMHC) Assertive Community Treatment (ACT) Fidelity Report
October 2016 CMHC: Report Date: Review Date: Reviewers: (list all) Overview: This report describes Assertive Community Treatment (ACT) services. The fidelity review is considered an integral component to complement and validate self-fidelity measures and is intended to promote and assure fidelity to the model and compliance with the Community Mental Health Agreement (CMHA). Executive Summary: (Enter brief summary of review results)
This review resulted in an Implementation rating of:
Out of a possible 140 points the Center scored:

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 80 of 109 Method: This review consisted of: (Describe how the Center conducted its review)
The ACT Fidelity Scale is divided into three sections, including: Human Resources – Structure and Composition; Organizational Boundaries; and Nature of Services. Each item to be scored (criterion) is rated on a 5-point response formation ranging from 1 to 5 with each criterion having a specific anchor assigned to each point within the 5-point range. The following tables (next 3 pages) specify the criterion and the associated ratings/anchors the CMHC must use in conducting its ACT Fidelity Self-Assessment.
Page 2 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 81 of 109

Human Resources: Structure and Composition

Ratings / Anchors

Criterion

H1 Small caseload: Consumer/provider ratio = 10:1

H2

Team approach:

Provider group functions as team rather than as individual ACT team members; ACT team members know and work with all consumers

H3

Program meeting:

Meets often to plan and review services for each consumer

H4

Practicing ACT leader:

Supervisor of Frontline ACT team members provides direct services

H5

Continuity of staffing:

Keeps same staffing over time

H6

Staff capacity:

Operates at full staffing

H7

Psychiatrist on team:

At least 1 full-time psychiatrist for 100 consumers works with program

H8

Nurse on team:

At least 2 full-time nurses assigned for a 100consumer program

H9

Substance abuse

specialist on team:

A 100-consumer program with at least 2 staff members with 1 year of training or clinical experience in substance abuse treatment

H10

Vocational specialist on

team:

At least 2 team members with 1 year training/experience in vocational rehabilitation and support

H11

Program size:

Of sufficient absolute size to consistently provide necessary staffing diversity and coverage

1
50 consumers/team member or more Less than 10% consumers with multiple team face-to-face contacts in reporting 2-week period
Service-planning for each consumer usually 1x/month or less
Supervisor provides no services
Greater than 80% turnover in 2 years
Operated at less than 50% staffing in past 12 months
Less than .10 FTE regular psychiatrist for 100 consumers
Less than .20 FTE regular nurse for 100 consumers
Less than .20 FTE S/A expertise for 100 consumers
Less than .20 FTE vocational expertise for 100 consumers
Less than 2.5 FTE staff

2
35 – 49
10 – 36%
At least 2x/month but less often than 1x/week
Supervisor provides services on rare occasions as backup 60 – 80% turnover in 2 years 50 – 64%
.10 – .39 FTE for 100 consumers
.20 – .79 FTE for 100 consumers
.20 – .79 FTE for 100 consumers
.20 – .79 FTE for 100 consumers
2.5 – 4.9 FTE

3
21 – 34
37 – 63%
At least 1x/week but less than 2x/week
Supervisor provides services routinely as backup or less than 25% of the time 40 – 59% turnover in 2 years 65 – 79%
.40 – .69 FTE for 100 consumers
.80 – 1.39 FTE for 100 consumers
.80 – 1.39 FTE for 100 consumers
.80 – 1.39 FTE for 100 consumers
5.0 – 7.4 FTE

4
11 – 20
64 – 89%
At least 2x/week but less than 4x/week
Supervisor normally provides services between 25% and 50% time 20 – 39% turnover in 2 years 80 – 94%
.70 – .99 FTE for 100 consumers
1.40 – 1.99 FTE for 100 consumers
1.40 – 1.99 FTE for 100 consumers
1.40 – 1.99 FTE for 100 consumers
7.5 – 9.9

5
10 consumers/team member or fewer
90% or more consumers have face-to-face contact with >1 staff member in 2 weeks
Meets at least 4 days/week and reviews each consumer each time, even if only briefly Supervisor provides services at least 50% time
Less than 20% turnover in 2 years
Operated at 95% or more of full staffing in past 12 months At least 1 full-time psychiatrist assigned directly to 100-consumer program
2 full-time nurses or more are members for 100consumer program 2 FTEs or more with 1 year S/A training or supervised S/A experience
2 FTEs or more with 1 year voc. rehab. training or supervised VR experience
At least 10 FTE staff

Page 3 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 82 of 109

Organizational Boundaries

Ratings / Anchors

Criterion

O1

Explicit admission

criteria:

Has clearly identified

mission to serve a

particular population. Has

and uses measurable and

operationally defined

criteria to screen out

inappropriate referrals.

O2

Intake rate:

Takes consumers in at a

low rate to maintain a

stable service

environment.

O3

Full responsibility for

treatment services:

In addition to case

management, directly

provides psychiatric

services, counseling/

psychotherapy, housing

support, substance abuse

treatment, employment

and rehabilitative services.

O4

Responsibility for crisis

services:

Has 24-hour responsibility

for covering psychiatric

crises.

O5

Responsibility for

hospital admissions:

Is involved in hospital

admissions.

O6

Responsibility for

hospital discharge

planning:

Is involved in planning for

hospital discharges.

O7

Time-unlimited services

(graduation rate):

Rarely closes cases but

remains the point of

contact for all consumers

as needed.

1
Has no set criteria and takes all types of cases as determined outside the program
Highest monthly intake rate in the last 6 months = greater than 15 consumers/month Provides no more than case management services
Has no responsibility for handling crises after hours
Is involved in fewer than 5% decisions to hospitalize Is involved in fewer than 5% of hospital discharges
More than 90% of consumers are expected to be discharged within 1 year

2
Has a generally defined mission but admission process dominated by organizational convenience
13 – 15
Provides 1 of 5 additional services and refers externally for others
Emergency service has programgenerated protocol for program consumers
ACT team is involved in 5% – 34% of admissions 5% – 34% of program consumer discharges planned jointly with program From 38 – 90% of consumers expected to be discharged within 1 year

3
Tries to seek and select a defined set of consumers but accepts most referrals
10 – 12
Provides 2 of 5 additional services and refers externally for others
Is available by phone, mostly in consulting role
ACT team is involved in 35% – 64% of admissions 35% – 64% of program consumer discharges planned jointly with program From 18 – 37% of consumers expected to be discharged within 1 year

4
Typically actively seeks and screens referrals carefully but occasionally bows to organizational pressure
7 – 9
Provides 3 or 4 of 5 additional services and refers externally for others
Provides emergency service backup; e.g., program is called, makes decision about need for direct program involvement ACT team is involved in 65% – 94% of admissions 65 – 94% of program consumer discharges planned jointly with program From 5 – 17% of consumers expected to be discharged within 1 year

5
Actively recruits a defined population and all cases comply with explicit admission criteria
Highest monthly intake rate in the last 6 months no greater than 6 consumers/month Provides all 5 services to consumers
Provides 24-hour coverage
ACT team is involved in 95% or more admissions
95% or more discharges planned jointly with program
All consumers served on a timeunlimited basis, with fewer than 5% expected to graduate annually

Page 4 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 83 of 109

Nature of Services

Ratings / Anchors

Criterion

S1

Community-based

services:

Works to monitor status,

develop community living

skills in community rather

than in office.

S2

No dropout policy:

Retains high percentage of

consumers.

S3

Assertive engagement

mechanisms:

As part of ensuring

engagement, uses street

outreach and legal

mechanisms

(probation/parole, OP

commitment) as indicated

and as available.

S4

Intensity of service:

High total amount of

service time, as needed.

S5

Frequency of contact:

High number of service contacts, as needed.

S6

Work with informal

support system:

With or without consumer

present, provides support

and skills for consumer’s

support network: family,

landlords, employers.

S7

Individualized substance

abuse treatment:

1 or more team members

provides direct treatment

and substance abuse

treatment for consumers

with substance-use

disorders.

S8

Co-Occurring disorder

treatment groups:

Uses group modalities as

treatment strategy for

consumers with

substance-use disorders.

S9

Dual Disorders (DD)

Model:

Uses a non-

confrontational, stage-wise

treatment model, follows

behavioral principles,

considers interactions of

mental illness and

substance abuse, and has

gradual expectations of

abstinence.

S10

Role of consumers on

team:

Consumers involved as

team members providing

direct services.

1
Less than 20% of face-to-face contacts in community
Less than 50% of caseload retained over 12-month period Passive in recruitment and re-engagement; almost never uses street outreach legal mechanisms
Average 15 minutes/ week or less of face-toface contact for each consumer Average less than 1 face-to-face contact/ week or fewer for each consumer Less than .5 contact/ month for each consumer with support system
No direct, individualized substance abuse treatment provided
Fewer than 5% of consumers with substance-use disorders attend at least 1 substance abuse treatment group meeting a month Fully based on traditional model: confrontation; mandated abstinence; higher power, etc.
Consumers not involved in providing service

2
20 – 39%
50 – 64%
Makes initial attempts to engage but generally focuses on most motivated consumers
15 – 49 minutes/ week
1 – 2x/week
.5 – 1 contact/ month for each consumer with support system in the community
Team variably addresses SA concerns with consumers; provides no formal, individualized SA treatment
5 – 19%
Uses primarily traditional model: e.g., refers to AA; uses inpatient detox & rehab; recognizes need to persuade consumers in denial or who don’t fit AA
Consumers fill consumer-specific service roles (e.g., self-help)

3
40 – 59%
65 – 79%
Tries outreach and uses legal mechanisms only as convenient
50 – 84 minutes/week
2 – 3x/week
1 – 2 contact/month for each consumer with support system in the community
While team integrates some substance abuse treatment into regular consumer contact, no formal, individualized SA treatment 20 – 34%
Uses mixed model: e.g., DD principles in treatment plans; refers consumers to persuasion groups; uses hospitalization for rehab.; refers to AA, NA
Consumers work part-time in casemanagement roles with reduced responsibilities

4
60 – 79%
80 – 94%
Usually has plan for engagement and uses most mechanisms available
85 – 119 minutes/week
3 – 4x/week
2 – 3 contacts/month for consumer with support system in the community
Some formal individualized SA treatment offered; consumers with substance-use disorders spend less than 24 minutes/week in such treatment 35 – 49%
Uses primarily DD model: e.g., DD principles in treatment plans; persuasion and active treatment groups; rarely hospitalizes for rehab. Or detox except for medical necessity; refers out some SA treatment Consumers work full-time in case management roles with reduced responsibilities

5
80% of total face-toface contacts in community
95% or more of caseload is retained over a 12-month period Demonstrates consistently wellthought-out strategies and uses street outreach and legal mechanisms whenever appropriate
Average 2 hours/week or more of face-to-face contact for each consumer
Average 4 or more face-to-face contacts/week for each consumer
4 or more contacts/month for each consumer with support system in the community
Consumers with substance-use disorders average 24 minutes/week or more in formal substance abuse treatment
50% or more of consumers with substance-use disorders attend at least 1 substance abuse treatment group meeting/month
Fully based in DD treatment principles, with treatment provided by ACT staff members
Consumers employed full-time as ACT team members (e.g., case managers) with full professional status

Page 5 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 84 of 109 Areas of focus: (Describe the areas of focus the Center wishes to prioritize for improvement in the coming year as a result of this review; include any recommendations for each area)
Page 6 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 85 of 109

ACT Fidelity Report:

Human Resources: Structure and Composition

H1 Small caseload: Consumer/provider ratio = 10:1 Comments:
Sources of Information: Recommendations:

Rating = _____ out of 5

H2 Team approach: Provider group functions as team rather than as individual ACT team members; ACT team members know and work with all consumers
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

H3 Program meeting: Meets often to plan and review services for each consumer
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

H4 Practicing ACT leader: Supervisor of Frontline ACT team members provides direct services
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

Page 7 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 86 of 109

H5 Continuity of staffing: Keeps same staffing over time
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

H6 Staff capacity: Operates at full staffing
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

H7 Psychiatrist on team: At least 1 full-time psychiatrist for 100 consumers works with program
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

H8 Nurse on team: At least 2 full-time nurses assigned for a 100-consumer program
Comments:

Rating = _____ out of 5

Sources of Information:

Recommendations:

Page 8 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 87 of 109

H9 Substance abuse specialist on team: A 100-consumer program with at least 2 staff members with 1 year of training or clinical experience in substance abuse treatment
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

H10 Vocational specialist on team: At least 2 team members with 1 year training/experience in vocational rehabilitation and support
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

H11 Program size: Of sufficient absolute size to consistently provide necessary staffing diversity and coverage
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

Page 9 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 88 of 109

Organizational Boundaries
O1 Explicit admission criteria: Has clearly identified mission to serve a particular population. Has and uses measurable and operationally defined criteria to screen out inappropriate referrals.
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

O2 Intake rate: Takes consumers in at a low rate to maintain a stable service environment.
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

O3 Full responsibility for treatment services: In addition to case management, directly provides psychiatric services, counseling/ psychotherapy, housing support, substance abuse treatment, employment and rehabilitative services.
Comments:

Rating = _____ out of 5

Sources of Information:

Recommendations:

O4 Responsibility for crisis services: Has 24-hour responsibility for covering psychiatric crises.
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

Page 10 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 89 of 109

O5 Responsibility for hospital admissions: Is involved in hospital admissions.
Comments: Sources of Information:
Recommendations:
O6 Responsibility for hospital discharge planning: Is involved in planning for hospital discharges.
Comments: Sources of Information:
Recommendations:
O7 Time-unlimited services (graduation rate): Rarely closes cases but remains the point of contact for all consumers as needed.
Comments: Sources of Information:
Recommendations:

Rating = _____ out of 5 Rating = _____ out of 5 Rating = _____ out of 5

Page 11 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 90 of 109

Nature of Services
S1 Community-based services: Works to monitor status, develop community living skills in community rather than in office.
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

S2 No dropout policy: Retains high percentage of consumers.
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

S3 Assertive engagement mechanisms:
As part of ensuring engagement, uses street outreach and legal mechanisms (probation/parole, OP commitment) as indicated and as available.
Comments:

Rating = _____ out of 5

Sources of Information:

Recommendations:

S4 Intensity of service: High total amount of service time, as needed.
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

S5 Frequency of contact: High number of service contacts, as needed.
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

Page 12 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 91 of 109

S6 Work with informal support system: With or without consumer present, provides support and skills for consumer’s support network: family, landlords, employers.
Comments:

Rating = _____ out of 5

Sources of Information:

Recommendations:

S7 Individualized substance abuse treatment: 1 or more team members provides direct treatment and substance abuse treatment for consumers with substance-use disorders.
Comments:
Sources of Information:
Recommendations:

Rating = _____ out of 5

S8 Co-Occurring disorder treatment groups: Uses group modalities as treatment strategy for consumers with substance-use disorders.
Comments:

Rating = _____ out of 5

Sources of Information:

Recommendations:

S9 Dual Disorders (DD) Model:
Uses a non-confrontational, stage-wise treatment model, follows behavioral principles, considers interactions of mental illness and substance abuse, and has gradual expectations of abstinence.
Comments:

Rating = _____ out of 5

Sources of Information:

Recommendations:

Page 13 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 92 of 109

S10 Role of consumers on team:

Rating = _____ out of 5

Consumers involved as team members providing direct services.

Comments:

Sources of Information:

Recommendations:

Page 14 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 93 of 109

# H1. H2. H3. H4. H5. H6. H7. H8. H9. H10. H11.
# O1. O2. O3. O4. O5. O6. O7.
# S1. S2. S3. S4. S5. S6. S7. S8. S9. S10.

Human Resources: Structure and Composition

Item

Assessor 1

Small Caseload

Team Approach

Program Meeting

Practicing ACT Leader

Continuity of Staffing

Staff Capacity

Psychiatrist on Team

Nurse on Team

Substance Abuse Specialist on Team

Vocational Specialist on Team

Program Size

Organizational Boundaries

Item

Assessor 1

Explicit Admission Criteria

Intake Rate

Full Responsibility for Treatment Services

Responsibility for Crisis Services

Responsibility for Hospital Admission

Responsibility for Hospital Discharge Planning

Time-unlimited Services (Graduation Rate)

Nature of Services

Item

Assessor 1

Community Based Services

No Dropout Policy

Assertive Engagement Mechanisms

Intensity of Services

Frequency of Contact

Work with Informal Support System

Individualized Substance Abuse Treatment

Co-occurring Disorder Treatment Group

Dual Disorders (DD) Model

Role of Consumers on Team

Total Mean Score

Assessor 2 Assessor 2 Assessor 2

Consensus Consensus Consensus

Score Range 113 – 140 85 – 112 84 and below

Implementation Rating Good Implementation Fair Implementation Not Assertive Community Treatment

Page 15 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 94 of 109 Appendix 2
The following pages contain the SE Fidelity Review Tool used for SFY2017.

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 95 of 109
Community Mental Health Center (CMHC) Supported Employment Fidelity Report
October 2016 CMHC: Report Date: Review Date: Reviewers: (list all) Overview: This report describes Individual Placement and Support/Supported Employment (IPS/SE) services. The fidelity review is considered an integral component to complement and validate self-fidelity measures and is intended to promote and assure fidelity to the Dartmouth IPS model and compliance with the Community Mental Health Agreement (CMHA). Executive Summary: (Enter brief summary of review results)
This review resulted in a Fidelity rating of: Out of a possible 125 points the Center scored:

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 96 of 109 Method: This review consisted of: (Describe how the Center conducted its review)
The Supported Employment Fidelity Scale is divided into three sections: including staffing, organization and services. Each item is rated on a 5-point response formation ranging from 1= no implementation to 5= full implementation with intermediate numbers representing progressively greater degrees of implementation. The following sections address the three areas based on the review.
Page 2 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 97 of 109 Areas of focus: (Describe the areas of focus the Center wishes to prioritize for improvement in the coming year as a result of this review; include any recommendations for each area)
Page 3 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 98 of 109

IPS Supported Employment Fidelity Report:

Staffing

1. Caseload Size
Employment specialists have individual employment caseloads. The maximum caseload for any full-time employment specialist is 20 or fewer clients.
Comments:
Sources of Information: Recommendations:

Rating = _____ out of 5

2. Vocational Services Staff
Employment specialists provide only employment services. Comments:
Sources of Information: Recommendations:

Rating = _____ out of 5

3. Vocational Generalists

Each employment specialist carries out all phases of employment services, including intake, engagement, assessment, job placement, job coaching, and follow along supports before step down to a less intensive employment support from another MH practitioner.
Comments:

Rating = _____ out of 5

Sources of Information: Recommendations:

Page 4 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 99 of 109

Organization

1. Integration of rehabilitation with mental health treatment through team assignment.

Employment specialists are part of up to 2 mental health treatment teams from which at least 90% of the employment specialist’s caseload is comprised.
Comments:

Rating = _____ out of 5

Sources of Information: Recommendations:

2. Integration of rehabilitation with mental health treatment through frequent team contact.

Employment specialists actively participate in weekly mental

Rating = _____ out of 5

health treatment team meetings (not replaced by administrative

meetings) that discuss individual clients and their employment

goals with shared decision-making. Employment specialist’s

office is in close proximity to (or shared with) their mental health

treatment team members. Documentation of mental health

treatment and employment services are integrated in a single

client chart. Employment specialists help the team think about

employment for people who haven’t yet been referred to

supported employment services.

 if applicable  if applicable
 if applicable

Employment specialist attends weekly mental health treatment team meetings.
Employment specialist participates actively in treatment team meetings with shared decision-making. Employment services documentation (i.e., vocational assessment/profile, employment plan, progress notes) is integrated into client’s mental health treatment

 if applicable
 if applicable

record. Employment specialist’s office is in close proximity to (or shared with) his or her mental health treatment team members. Employment specialist helps the team think about employment for people who haven’t yet been referred to supported employment services.

Comments:

Sources of Information: Recommendations:

Page 5 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 100 of 109

3. Collaboration between employment specialists and Vocational Rehabilitation.

Employment specialists and VR counselors have frequent contact for the purpose of discussing shared clients and identifying potential referrals.
Comments:

Rating = _____ out of 3

Sources of Information: Recommendations:

4. Vocational Unit.
At least 2 full-time employment specialists and a team leader comprise the employment unit. They have weekly client-based group supervision based on the supported employment model in which strategies are identified and job leads are shared. They provide coverage for each other’s caseload when needed.
Comments:
Sources of Information: Recommendations:

Rating = _____ out of 2

5. Role of employment supervisor.

Supported employment unit is led by a supported employment Rating = _____ out of 3

team leader. Employment specialists’ skills are developed and

improved through outcome-based supervision. All five key roles

of the employment supervisor are present.

 if applicable
 if applicable
 if applicable
 if applicable

One full-time supervisor is responsible for no more than 10 employment specialists. The supervisor does not have other supervisory responsibilities. (Program leaders supervising fewer than 10 employment specialists may spend a percentage of time on other supervisor activities on a prorated basis.) Supervisor conducts weekly supported employment supervision designed to review client situations and identify new strategies and ideas to help clients in their work lives. Supervisor communicates with mental health treatment team leaders to ensure that services are integrated, to problem solve programmatic issues and to be a champion for the value of work. Attends a meeting for each mental health treatment team on a quarterly basis. Supervisor accompanies employment specialists who are new or having difficulty

Page 6 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 101 of 109

 if applicable

with job development, in the field monthly to improve skills by observing, modeling and giving feedback on skills, e.g., meeting employers for job development. Supervisor reviews current client outcomes with employment specialists and sets goals to improve program performance at least quarterly.
Comments:

Sources of Information: Recommendations:

6. Zero exclusion criteria

All clients interested in working have access to supported employment services regardless of job readiness factors, substance abuse, symptoms, history of violent behavior, cognition impairments, treatment non-adherenece, and personal presentation. These apply during supported employment services, too. Employment specialists offer to help with another job when one has ended regardless of the reason that the job ended or the number of jobs held. If VR has screening criteria, the mental health agency does not use them to exclude anybody. Clients are not screened out formally or informally.
Comments:

Rating = _____ out of 5

Sources of Information: Recommendations:

7. Agency focus on competitive employment.

Agency promotes work through multiple strategies. Agency intake includes questions about interest in competitive employment. Agency displays written postings (e.g., brochures, bulletin boards, posters) about employment and supported employment services. The focus should be with the agency programs that provide services to adults with severe mental illness. Agency supports ways for clients to share work stories with other clients and staff. Agency measures rate of competitive employment and shares this information with agency leaders and staff.

Rating = _____ out of 3

Page 7 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 102 of 109

 if applicable  if applicable
 if applicable
 if applicable
 if applicable

Agency intake includes questions about interest in employment
Agency includes questions about interest in employment on all annual (or semiannual) assessment or treatment plan reviews.. Agency displays written postings (e.g., brochures, bulletin boards, posters) about working and supported employment services, in lobby and other waiting areas Agency supports ways for clients to share work stories with other clients and staff (e.g., agency-wide employment recognition events, in-service training, peer support groups, agency newsletter articles, invited speakers at client treatment groups, etc.) at least twice a year. Agency measures rate of competitive employment on at least a quarterly basis and shares outcomes with agency leadership and staff.
Comments:

Sources of Information: Recommendations:

8. Executive Team Support for Supported Employment

Agency executive team members (e.g., CEO/Executive Director, Rating = _____ out of 3

Chief Operating Officer, QA Director, Chief Financial Officer,

Clinical director, Medical Director, Human Resource Director)

assist with supported employment implementation and

sustainability. All five key components of executive team are

present.

 if

Executive Director and Clinical Director demonstrate knowledge regarding the

applicable

principles of evidence-based supported employment.

 if

Agency QA process includes an explicit review of the IPS SE program, or

applicable

components of the program, at least every 6 months through the use of the

Supported Employment Fidelity Scale, or until achieving high fidelity, and at least

yearly thereafter. Agency QA process uses the results of the fidelity assessment to

improve IPS SE implementation and sustainability.

 if

At least one member of the executive team actively participates at IPS SE

applicable

leadership team (steering committee) meetings that occur at least every six months

for high fidelity programs and at least quarterly for programs that have not yet

achieved high fidelity. Steering committee is defined as a diverse group of

stakeholders charged with reviewing fidelity, program implementation, and the

service delivery system. Committee develops written action plans aimed at

developing or sustaining high fidelity services.

 if

The agency CEO/Executive Director communicates how IPS SE services support

applicable

Page 8 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 103 of 109

 if applicable

the mission of the agency and articulates clear and specific goals for SE and/or competitive employment to all agency staff during the first six months and at least annually (i.e., SE kickoff, all-agency meetings, agency newsletters, etc.). This item is not delegated to another administrator. SE program leader shares information about EBP barriers and facilitators with the executive team (including the CEO) at least twice each year. The executive team helps the program leader identify and implement solutions to barriers.
Comments:

Sources of Information: Recommendations:

Services

1. Work incentives planning

All clients are offered assistance in obtaining comprehensive individualized work incentives planning (benefits planning) before starting a new job and assistance accessing work incentives planning thereafter when making decisions about changes in work hours and pay. Work incentives planning includes SSA benefits, medical benefits, medication subsidies, housing subsidies, food stamps, spouse and dependent children benefits, past job retirement benefits and any other source of income. Clients are provided information and assistance about reporting earnings to SSA, housing programs, VA programs, etc., depending on the person’s benefits
Comments:

Rating = _____ out of 5

Sources of Information: Recommendations:

2. Disclosure

Employment specialists provide clients with accurate information and assist with evaluating their choices to make an informed decision regarding what is revealed to the employer about having a disability.

Rating = _____ out of 3

Page 9 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 104 of 109

 if applicable  if applicable
 if applicable
 if applicable

Employment specialists do not require all clients to disclose their psychiatric disability at the work site in order to receive services.. Employment specialists offer to discuss with clients the possible costs and benefits (pros and cons) of disclosure at the work site in advance of clients disclosing at the work site. Employment specialists describe how disclosure relates to requesting accommodations and the employment specialist’s role communicating with the employer. Employment specialists discuss specific information to be disclosed (e.g., disclose receiving mental health treatment, or presence of a psychiatric disability, or difficulty with anxiety, etc.) and offers examples of what could be said to employers. Employment specialists discuss disclosure on more than one occasion (e.g., if clients have not found employment after 2 months or if clients report difficulties on the job).
Comments:

Sources of Information: Recommendations:

3. Ongoing, work-based vocational assessment

Initial vocational assessment occurs over 2-3 sessions and is updated with information from work experiences in competitive jobs. A vocational profile form that includes information about preferences, experiences, skills, current adjustment, strengths, personal contacts, etc. is filed in the client’s clinical chart and is updated with each new job experience. Aims at problem solving using environmental assessments and consideration of reasonable accommodations. Sources of information include client, treatment team, clinical records, and with the client’s permission, from family members and previous employers.
Comments:

Rating = _____ out of 2

Sources of Information: Recommendations:

4. Rapid search for competitive job.

Page 10 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 105 of 109

Initial employment assessment and first face-to-face employer contact by the client or the employment specialist about a competitive job occurs within 30 days (one month) after program entry.
Comments:

Rating = _____ out of 4

Sources of Information: Recommendations:

5. Individualized job search

Employment specialists make employer contacts are aimed at making a good job match based on clients’ preferences (relating to what each person enjoys and their personal goals) and needs (including experience, ability, symptomatology, health, etc.) rather than the job market (i.e., those jobs that are readily available). An individualized job search plan is developed and updated with information from the vocational assessment/profile form and new job/educational experiences.
Comments:

Rating = _____ out of 2

Sources of Information: Recommendations:

6. Job development-Frequent employer contact

Each employment specialist makes at least 6 face-to-face employer contacts per week on behalf of clients looking for work. (Rate for each then calculate average and use the closest scale point.) An employer contact is counted even when an employment specialist meets an employer twice in one week, and when the client is present or not present. Client specific and generic contacts are included. Employment specialists use a weekly tracking form to document employer contacts and the form is reviewed by the supervisor on a weekly basis.
Comments:

Rating = _____ out of 2

Sources of

Page 11 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 106 of 109

Information: Recommendations:

7. Job development-Quality of employer contact

Employment specialists build relationships with employers through multiple visits in person that are planned to learn the needs of the employer, convey what the SE program offers to the employer, and describe client’s strengths that are a good match for the employer.
Comments:

Rating = _____ out of 3

Sources of Information: Recommendations:

8. Diversity of jobs developed.

Employment specialists assist clients in obtaining different types of jobs.
Comments:

Rating = _____ out of 3

Sources of Information: Recommendations:

9. Diversity of employers.
Employment specialists assist clients in obtaining jobs with different employers.
Comments:
Sources of Information: Recommendations:

Rating = _____ out of 3

10. Competitive jobs.
Employment specialists provide competitive jobs options that have permanent status rather than temporary or time-limited

Rating = _____ out of 2

Page 12 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 107 of 109

status, (e.g., transitional employment positions). Competitive jobs pay at least minimum wage, are jobs that anyone can apply for and are not set aside for people with disabilities. (Seasonal jobs and jobs from temporary agencies that other community members use are counted as competitive jobs.)
Comments:
Sources of Information: Recommendations:

11. Individualized follow-along supports

Clients receive different types of support for working a job that are based on the job, client preferences, work history, needs, etc. Supports are provided by a variety of people including treatment team members (i.e., medication changes, social skills training, encouragement), family, friends , co-workers (i.e., natural supports) and employment specialist. Employment specialist also provides employer support (e.g., educational information, job accommodations ) at client’s request. Employment specialists offer help with career development, i.e., assistance with education, a more desirable job, or more preferred job duties.
Comments:

Rating = _____ out of 3

Sources of Information: Recommendations:

12. Follow-along supports – Time unlimited

Employment Specialists have face-to-face contact within 1 week before starting a job, within 3 days after starting a job, weekly for the first month, and at least monthly for a year or more, on average, after working steadily and desired by clients. Clients are transitioned to step down job supports from a mental health worker following steady employment. Employment specialists contact clients within 3 days of learning about a job loss.
Comments:

Rating = _____ out of 3

Page 13 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 108 of 109

Sources of Information: Recommendations:

13. Community-based services

Employment services such as engagement, job finding and follow-along supports are provided in natural community settings by all employment specialists. (Rate each employment specialist based upon their total weekly scheduled work hours then calculate the average and use the closest scale point.).
Comments:

Rating = _____ out of 4

Sources of Information: Recommendations:

14. Assertive engagement and outreach by integrated team.

Service termination is not based on missed appointments or fixed time limits. Systematic documentation of outreach attempts. Engagement and outreach attempts made by integrated team members. Multiple home/community visits. Coordinated visits by employment specialist with integrated team member. Connect with family, when applicable. Once it is clear that the client no longer wants to work or continue in SE services, the team stops outreach.
Comments:

Rating = _____ out of 5

Sources of Information: Recommendations:

Page 14 of 15

Case 1:12-cv-00053-SM Document 119-1 Filed 07/12/17 Page 109 of 109

Staffing

#

Item

1. Caseload size

2. Employment services staff

3. Vocational generalists

Organization

#

Item

1. Integration of rehabilitation with mental health thru team assignment

2. Integration of rehabilitation with mental health thru frequent team member contact

3. Collaboration between employment specialists and Vocational Rehabilitation

4. Vocational unit

5. Role of employment supervisor

6. Zero exclusion criteria

7. Agency focus on employment

Score Score

8. Executive team support for SE

Services

#

Item

1. Work incentives planning

2. Disclosure

3. Ongoing, work-based vocational assessment

4. Rapid job search for competitive job

5. Individualized job search

6. Job development—Frequent employer contact

7. Job development—Quality of employer contact

8. Diversity of job types

9. Diversity of employers

10. Competitive jobs held

11. Individualized follow-along supports

12. Time unlimited follow-along supports

13. Community-based services

14. Assertive engagement and outreach by integrated treatment team

Score Total:

Score Range 115 – 125 100 – 114 74 – 99
73 and below

Fidelity Level Exemplary Fidelity
Good Fidelity Fair Fidelity Not Supported Employment

Page 15 of 15

 
 Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 1 of 75
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Seven
January 10, 2017
I. Introduction
This is the seventh semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this six-month period (July 1, 2017 through December 31, 2017), the ER has continued to observe the State’s work to implement certain key service elements of the CMHA, and has continued to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. During this period, the ER:
 Conducted on site reviews of Assertive Community Treatment (ACT) and Supported Employment (SE) services at Community Partners and Seacoast Mental Health Centers. Non-random samples of ACT and SE records were reviewed at each site.
 Met with senior management and with a clinical team at NHH to review transition planning processes and issues;
 Met with Glencliff leadership, clinical staff, and a resident to discuss transition planning processes and issues;
 Met with the Mobile Crisis Team (MCT) of Harbor Homes, the agency selected to operate the MCT and crisis apartments in the greater Nashua region;
 Observed two five-day Quality Service Review (QSR) reviews; one at Genesis Mental Health Center; and one at the Center for Life Management;
 Met with the DHHS CMHA leadership team to discuss progress in the implementation of CMHA standards and requirements;

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 2 of 75
 Participated in several meetings with representatives of the Plaintiffs and the United States (hereinafter “Plaintiffs”);
 Met twice with DHHS Quality Management/Quality Service Review (QM/QSR) staff to discuss refinements to the QSR process; and
 Convened two all parties meetings to discuss design and implementation issues related to the QSR process and Glencliff transitions to integrated community settings.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
Summary of Progress to Date
Eighteen months ago the ER recommended a number of action steps and timelines intended to facilitate movement towards compliance with the CMHA and to increase transparency and accountability related to State actions under the aegis of the CMHA. The State agreed to implement these recommendations, and has made progress in certain areas of compliance and accountability. Specific progress related to these recommendations is summarized below:
1. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and time lines to achieve compliance with the CMHA requirements for ACT services;
ER Finding: The State has implemented this recommendation by circulating such a plan, and continues to track and report on its implementation of various action steps and limited progress towards compliance with CMHA requirements. However, as will be noted throughout this report, the State remains out of compliance with the ACT requirements of the CMHA. The ER expects the State to propose new and expanded initiatives and implementation strategies to be implemented to move the State closer to compliance in this critical area; and these new initiatives with attendant timelines must be included no later than March 1, 2018 in the ACT section of the monthly progress report. The most recent version of this report (October, 2017) is included as Appendix B to this report.
2. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA penetration rates and fidelity standards for SE throughout New Hampshire;
ER Finding: The State has implemented this recommendation by circulating such a plan, and continues to track and report on its implementation of various action steps and progress towards compliance with CMHA requirements. The State is in compliance with the statewide penetration rate standards for SE, but continues to work

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 3 of 75
aggressively with the four CMHCs that remain under the standard. Fidelity reviews resulted in Quality Improvement Plans for multiple CMHCs in 2017.
3. By August 1, 2016 circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA requirements to assist 16 residents of Glencliff with complex medical needs to move into integrated settings as soon as possible;
ER Finding: The State has implemented this recommendation by circulating such a plan and it continues to track and report on individuals with pending discharge plans. This plan, and the current status of compliance, is discussed in greater detail under the Glencliff Transitions section of this report.
4. Starting September 1, 2016, and each month following, submit to all parties a monthly progress report of the steps taken and completed under these respective plans to assure compliance with CMHA requirements as identified in this report;
ER Finding: The State has implemented this recommendation and continues to track and report on its progress, which varies depending on the sections of the plan. As noted above, the latest version of the monthly progress report is attached as Appendix B of this report.
5. By October 1, 2016, complete the field tests and technical assistance related to the Quality Service Review (QSR), convene a meeting with Plaintiffs to discuss any recommended design or process changes, and publish a final set of QSR documents governing the process for future QSR activities;
ER Finding: Working in concert with representatives of the plaintiffs and the ER, DHHS developed revised QSR instrumentation, instructions, and scoring algorithms. The revised QSR has been carried out at three of the Community Mental Health Centers. The ER participated in two of these on-site QSR reviews A more detailed discussion of progress with regard to the QSR is included under the QSR section of this report.
6. Complete at least one QSR site review per month between October 2016 and June 2017, with the exception of the month of December, and circulate to all parties the action items, plans of correction (if applicable), and updates on implementation of needed remedial measures (if applicable) resulting from each of these reviews;
ER Finding: See #5 above. It should be noted that all 10 of the CMHCs had an onsite QSR review using the previous instruments and protocols during the 2016-2017 period.
7. Starting July 1, 2016, circulate to all parties on a monthly basis the most recent data reports of the Central Team;

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 4 of 75
ER Finding: The State has implemented this recommendation by circulating monthly reports and it continues to track and report progress towards compliance with CMHA requirements.
8. No later than October 1, 2016, assure that final rules for supportive housing and ACT services are promulgated in accordance with the draft rules developed with input from all parties;
ER Finding: The Supported Housing (SH) and ACT rules have been promulgated, and incorporate positive elements resulting from discussions among DHHS staff and representatives of the Plaintiffs.
9. By October 1, 2016, augment the quarterly data report to include:
 ACT staffing and utilization data for each ACT team, not just for each region.
ER Finding: The State has implemented this recommendation.
 Discharge destination data and readmission data (at 30, 90, and 180 days) for people discharged from NHH and the other Designated Receiving Facilities (DRFs).
ER Finding: The State has now complied with this recommendation. The new data is included in the most recent Quarterly Data Report, which is included as Appendix A of this report.
 Reporting from the three Mobile Crisis programs, including hospital and ED diversions.
ER Finding: Data for the Mobile Crisis Teams and Crisis Apartments is now included in the Quarterly Data Report.
 Supportive housing data on applications, time until eligibility determination, time on waiting list, reason for ineligibility determination, and utilization of supportive services for those receiving supportive housing.
ER Finding: As of December 2017 DHHS has not produced the requested information. The ER expects the requested information to be provided to the ER and the Plaintiffs no later than March 1, 2018. Once produced, consideration can be given to including these data on a regular basis in the Quarterly Data Report.
10. By October 1, 2016, and then by December 1, 2016, factually demonstrate that significant and substantial progress has been made towards meeting the standards and requirements of the CMHA with regard to ACT, SE and placement of individuals with complex medical conditions from Glencliff into integrated community settings.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 5 of 75
ER Finding: The State remains out of compliance with the ACT standards of the CMHA. The State is making progress towards compliance with the Glencliff requirements in the CMHA. See more detailed discussion of these issues under the ACT and Glencliff Transitions sections of this report. The ER notes that the State remains in substantial compliance with the SE penetration rate requirements of the CMHA. The ER will continue to work with the State to document that: (a) that SE services are delivered with adequate intensity and duration to meet individuals’ needs; and (b) that SE services are resulting in integrated, competitive employment. As of December, 2017 DHHS has not produced data on the degree to which SE services are resulting in integrated, competitive employment. The ER expects that these data will be produced and delivered to the ER and the Plaintiffs no later than March 1, 2018. Once produced, consideration can be given to including these data on a regular basis in the Quarterly Data Report.
11. By October 1, 2016 demonstrate that aggressive executive action has been taken to address the pace and quality of transition planning from NHH and Glencliff through the development of a specific plan to increase the speed and effectiveness of transitions from these facilities.
ER Finding: The ER believes that both NHH and Glencliff have evidenced, at a leadership and a staff level, increased efforts and commitment to facilitating timely transitions to integrated community settings, albeit with modest result to date. Transitions from Glencliff to integrated community settings appear to be a priority now; nonetheless, only one person was scheduled to be discharged1 to an integrated community setting in the most recent quarter.
II. Data
The New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (July to September, 2017), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The ability to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve.
The Quarterly reports now include data from the mobile crisis services in the Concord, Manchester and Nashua Regions; data on discharge destinations from NHH, the DRFs, and Glencliff; admission, discharge and length of stay data for New Hampshire’s DRFs; and some data on utilization of the Housing Bridge Subsidy Program.
1 This person will actually be discharged in the current quarter, as modifications to the selected apartment were not able to be completed before the end of 2017.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 6 of 75
As noted in previous ER reports, there continue to be important categories of data that are needed, but not routinely collected and reported, and which will need to be reported in order to accurately evaluate ongoing implementation of the CMHA. For example, there continues to be no reported or analyzed data on the degree to which participants in SE are engaged in competitive employment in integrated community settings consistent with their individual treatment plans. These data are important in assessing the fidelity with which SE services are provided. DHHS’s efforts related to assuring the fidelity of SE services are discussed in the SE section of this report. In addition, revisions to the QSR instruments and protocols are expected to provide more information on the degree to which SE participants are attaining competitive employment.
Another gap in data is related to people receiving Supported Housing (SH) under the Housing Bridge Subsidy Program. These participants are not yet clearly identified in the Phoenix II system, and thus it is difficult to document the degree to which these individuals are: (a) connected to local CMHC services and supports; and (b) actually receiving services and supports to meet their individualized needs on a regular basis in the community. As noted in the January 2016 ER Report, DHHS has identified a strategy to link data from the Bridge Subsidy Program to the Phoenix II system. However, as noted above, these data have not yet been produced. Without the information above, the ER is unable to determine whether or not the State has achieved substantial compliance with the CMHA outcomes and requirements for SH. Other outstanding data requests include SH data on applications, time until eligibility determination, time on waiting list, and the reason for ineligibility determinations,
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile/Crisis Services and Crisis Apartments
The CMHA calls for the establishment of a MCT and Crisis Apartments in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC was selected to implement the MCT and crisis apartments in the Concord Region.
The CMHA specified that a second MCT and Crisis Apartments be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. Per CMHA V.C.3(c), a third MCT and Crisis Apartment program became operational in the Nashua region on July1, 2017. The contract for that program was awarded to Harbor Homes in Nashua.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 7 of 75
Table I below includes the most recent available information on activities of the three currently operational crisis programs.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 8 of 75

Table I

Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs in the Concord, Manchester and Nashua Regions:

Total unduplicated people served Services provided in response to immediate crisis:
 Phone support/triage  Mobile assessments  Crisis stabilization
appointments  Emergency services
medication appointments  Office based urgent
assessments Services provided after the immediate crisis:
 Phone support/triage  Mobile assessments  Crisis stabilization
appointments  Emergency services
medication appointments  Office based Urgent
Assessments

Concord July – September 2017
579
721 173 37
110 57
201 30 36 60 57

Manchester July – September 2017
476

Nashua July – September 2107
55

1,144

33

248

14

6

5

40

3

Referral source:

 Self

292

352

20

 Family

73

107

10

 Guardian

23

5

1

 Mental health provider

19

21

3

 Primary care provider

16

23

0

 Hospital emergency

46

5

3

department  Police  CMHC Internal

12

135

4

34

79

10

Crisis apartment admissions:

81

9

3

 Bed days

310

29

5

 Average length of stay

3.8

3.2

1.7

Law enforcement involvement

34

135

11

Total hospital diversions*

443

798

49

*Hospital diversions are instances in which services are provided to individuals in crisis resulting in diversion from

being assessed at the ED and/or being admitted to a psychiatric hospital.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 9 of 75
The Quarterly Data Report in Appendix A contains some historical data for the Concord and Manchester MCTs.
As noted in the previous report, the ER is concerned that the ratio of mobile team responses to the total number of crisis calls seems low. In addition, the number of hospital diversions reported by the MCTs seems to be high, given the number of interventions that do not include a mobile, face to face encounter. The ER will continue to work with the State to document: 1) the number of times a mobile team was requested but not dispatched, and the reason for that decision; 2) the criteria used to determine whether a mobile versus office-based response is appropriate; and 3) the number of times a mobile response was determined to be appropriate, but the team could not be dispatched in a timely way. The ER will also continue to explore with the State the numbers and types of hospital diversions that are reported by the MCTs. The ER notes that overall psychiatric admissions have not been substantially reduced in regions served by the MCTs. There could be a number of reasons for this trend, and at this point it is not clear whether this trend reflects on the existing MCTs.
DHHS has added questions to the QSR interview guides to elicit information about the quality and effectiveness of the MCTs and Crisis Apartments, and to report on that information in the updated QSR instrument. This is one way to determine if individuals who would have benefited from a mobile crisis response received the crisis support their situation required. To date, the CMHC regions for which the revised QSR has been conducted do not have MCT services, and thus it is not possible to report the results of the new QSR questions for those sites.
Assertive Community Treatment (ACT)
ACT is a core element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team;
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time; and
4. By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.
The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015 (24 months ago). Further, as of June 30, 2016, the State was required to have the capacity to provide ACT to 1,500 priority Target Population individuals.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 10 of 75

As displayed in Table II below, the staff capacity of the 12 adult ACT teams in New Hampshire has increased by only 8.03 FTEs (6.91%) since December of 2016. During the same time period, the twelve ACT teams added a total of 153 service participants, an increase of 18.24% (See Table III below).
Table II
Self-Reported ACT Staffing (excluding psychiatry): December 2016 – September 2017

Region

FTE Dec-16

FTE Mar-17

Northern West Central Genesis Riverbend Monadnock Greater Nashua 1 Greater Nashua 2 Manchester – CTT Manchester MCST Seacoast Community Partners Center for Life Management Total

11.49 5.5 11 9
7.25 6.25 5.25 15.53 21.37 9.53 6.85 7.17 116.19

11.89 7.75 11 10 6.7 6.25 5.25
14.79 21.86
9.53 4.08
8.3 117.4

FTE Jun-17
12.54 7.15 10.6 10 8.5 5.25 5.25
16.57 21.95
9.53 8.53
9.3 125.17

FTE % change Sep-17 Dec-Sept

12.43 6.95 10.8 10 7.9 6 5
16.27 22.31 10.53
6.73 9.3
124.22

8.18% 26.36% -1.82% 11.11%
8.97% -4.00% -4.76% 4.76% 4.40% 10.49% -1.75% 29.71% 6.91%

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 11 of 75

Table III

Self-Reported ACT Caseload (Unique Adult Consumers) by Region per Quarter: December 2016 – September 2017

Region

Active Cases Dec-16

Active Cases Mar-17

Active Cases Jun-17

Active Cases Sep-17

% change Dec-Sept

Northern

104

108

111

113

8.65%

West Central

32

53

76

68

112.50%

Genesis

64

70

74

74

15.63%

Riverbend

73

83

97

87

19.18%

Monadnock

63

64

70

69

9.52%

Greater Nashua

74

83

94

98

32.43%

Manchester

248

270

292

287

15.73%

Seacoast

65

64

69

67

3.08%

Community Partners

70

67

69

75

7.14%

Center for Life Management

47

55

55

54

14.89%

Total*

839

* unduplicated across regions

913

1,006

992

18.24%

It is clear from these tables that overall ACT staffing has remained low, and in four regions has decreased over the past four reporting periods. Four of the 12 adult ACT teams have fewer than the 7 - 10 professionals specified for ACT teams in the CMHA, as opposed to the two teams with reported staffing below the defined threshold noted in the previous report. Two teams continue to report having no peer specialist on the ACT Team. Five teams report having at least one FTE peer specialist, but that means that seven of the 12 teams continue to report having less than one FTE peer on the team. Five teams have at least 1.0 FTE supported employment staff, while seven continue to have less than a full time SE specialist on the ACT team. Five teams report having less than .5 FTE combined psychiatry/nurse practitioner time available to their ACT teams2; two teams report having less than 0.5 FTE nursing on the team; and seven of the 12 teams report having less than one FTE nurse per team.
The combined ACT teams have a reported September 2017 staff complement of 124.22 FTEs, which is sufficient capacity to serve 1,242 individuals based on the ACT staffing ratios contained in the CMHA. With a current statewide caseload of 992, the existing teams should theoretically be able to accept an additional 250 new ACT clients without adding any more staff. Tapping
2 The CMHA specifies at least .5 FTE Psychiatrists for teams with at least 70 active service participants. (CMHA V.D.2(e).

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 12 of 75
into this unused capacity, with appropriate outreach and targeting, should have an impact on alleviating ED boarding and hospital readmission rates across the state. Further, the CMHA requires the State to have capacity to serve 1,500 individuals, but the current ACT capacity of 1,242 is 258 below CMHA criteria.
It is clear from the above tables that State initiatives to expand ACT capacity have had some success, and that overall ACT staffing capacity and active caseloads in most parts of the state have increased in the past year. However, as noted in previous reports, the current pace of staffing increases in combination with client outreach and engagement together are still not sufficient to meet CMHA requirements for ACT team capacity.
Based on the above information, the ER finds that the State remains out of compliance with the foundational service standards described in Section V.D. of the CMHA. The State does not currently provide a robust and effective system of ACT services throughout the state as required by the CMHA.
Additionally, the State has yet to finalize a process for identifying all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and to develop effective regional and statewide plans for providing sufficient ACT services.
As noted in recent ER Reports, the New Hampshire DHHS has taken more aggressive action to work with CMHCs in certain Regions to increase their ACT staffing and caseloads. These actions include: (a) monthly ACT monitoring and technical assistance with DHHS leadership and staff; (b) implementation of a firm schedule for ACT self-assessments and DHHS fidelity reviews; (c) incorporating a small increase in ACT funding into the Medicaid rates for CMHCs; (d) active on-site monitoring and technical assistance for CMHCs not yet meeting CMHA ACT standards; and (e) substantial and coordinated efforts to address workforce recruitment and retention.
However, external and self-reported fidelity reviews for the 10 CMHC regions have revealed deficient practices that are not in fidelity with the ACT model. Compliance letters and Performance Improvement Plans (PIPs) have been initiated in several of the Regions. The ER continues to work with the State to assure that these PIPs have been implemented.
Initial QSR reports also revealed that several CMHCs failed to ensure individuals were receiving ACT services using the ACT fidelity model team approach, and with the appropriate frequency to address their individual treatment needs. The ER has emphasized to the State that the QSR process must measure the adequacy and effectiveness of individual ACT service provision, in order to demonstrate that these deficiencies are being corrected. The ER continues to monitor the implementation of quality improvement plans developed by CMHCs in response to these QSR findings.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 13 of 75
The ER believes the State, DHHS and many of the CMHCs are making good faith efforts to meet the ACT capacity and fidelity standards of the CMHA. Despite the continued compliance issues noted above, the ER believes there have been improvements in the quality and effectiveness of ACT services provided in most parts of the state. Nonetheless, while these improvements are welcome, it must be noted that the State is still far from compliance with the ACT standards of the CMHA. As with previous reports, the ER expects DHHS and the CMHCs to make use of capacity already available in the system at all deliberate speed, while at the same time addressing additional capacity and fidelity issues.
DHHS and the CMHCs have been attempting to identify individuals at risk of hospitalization, incarceration or homelessness who might benefit from ACT services. Individuals boarding in hospital emergency departments waiting for a psychiatric hospital admission, or who have done so in the recent past, are one important source of potential referrals. DHHS is currently tracking the extent to which identifying and referring these individuals to CMHCS is: (a) reducing ED boarding episodes and lengths of stay; and (b) resulting in enrollment of new qualified individuals in ACT services. As noted in the hospital readmission discussion below, almost onethird of all those discharged out of NHH return for readmission within 180 days. Robust ACT services can help to reduce the number of hospital readmissions throughout the state if affected individuals are promptly screened and referred, and their regional ACT teams have the capacity to deliver needed services. The ER has requested that the State provide a report of the results of these activities. The State has agreed to provide such a report, but at the time of this report such data had not been made available. As a result, the ER can make no findings regarding the scope or efficacy of ongoing outreach and screening procedures for ACT. However, given the over 18 percent increase in ACT utilization noted in Table III, it is possible these initiatives have begun to have some effect on the system.
The State has identified workforce recruitment and retention issues as being a major factor limiting the growth and expansion of the ACT teams. The State has been working collaboratively with the New Hampshire CMHC Association to identify and track workforce gaps and shortages, and to implement a variety of strategies to improve workforce recruitment and retention. The almost seven percent increase in ACT staffing capacity over the past nine months may be some evidence that these strategies are beginning to produce results.
The ER emphasizes, as in past reports, that it must be the first priority of the State and the CMHCs to focus on: 1) assuring required ACT team composition; 2) utilizing existing ACT team capacity; 3) increasing ACT team capacity; and 4) outreach to and enrollment of new ACT clients. As noted earlier in this report, the ER expects the State to propose new and expanded strategies for increasing ACT capacity to meet the requirements of the CMHA. The strategies and related timelines are to be incorporated into the ACT plan and Monthly Progress Report.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 14 of 75

Supported Employment

Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment …to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by June 30, 2017 “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)).

For this reporting period, the State reports that it has achieved a statewide SE penetration rate of 26.4 percent, 42 percent above the 18.6% penetration rate target specified in the CMHA. Table IV below shows the SE penetration rates for each of the 10 Regional CMHCs in New Hampshire.

Table IV

Self-Reported CMHC SE Penetration Rates

Penetration Penetration Penetration Penetration

Dec-16

Mar-17

Jun-17

Sep-17

Northern West Central Genesis Riverbend Monadnock Greater Nashua Manchester Seacoast Community Part. Center for Life Man. CMHA Target Statewide Average

27.00% 21.50% 14.50% 13.80% 17.90% 12.40% 43.10% 12.00% 6.80% 21.10% 18.10% 22.90%

32.30% 23.20% 12.60% 15.00% 13.50% 15.00% 39.80% 14.40% 7.20% 19.70% 18.60% 23.20%

37.20% 22.50% 22.00% 14.80% 14.00% 16.10% 40.00% 19.30% 10.30% 21.60% 18.60% 25.30%

40.90% 22.30% 20.70% 14.00% 12.30% 17.10% 42.00% 23.40% 14.60% 19.20% 18.60% 26.40%

As noted in Table IV, the State has exceeded the statewide CMHA penetration rate in recent reporting periods. In the previous ER report, six of the ten regions fell below required CMHA

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 15 of 75
penetration rates. For this reporting period, four of the ten continue to report penetration rates lower than the CMHA requirement. The New Hampshire DHHS is to be commended for continuing its efforts to: (a) measure the fidelity of SE services on a statewide basis; and (b) work with the Regions with penetration rates below CMHA criteria to increase access to and delivery of SE services to target population members in their Regions. The ER will continue to monitor these issues going forward as the State works with the CMHCs to increase penetration rates to at least 18.6 percent in all regions. As with ACT services, the DHHS has implemented a combination of contract compliance, technical assistance, workforce recruitment and retention, and internal and external fidelity reviews in an attempt to assure sufficient quality and accessibility of SE services statewide. There is currently no mechanism for measuring whether individuals are receiving SE services consistent with their individual treatment plans, or whether SE services are delivered in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings (V.F.1). In addition, as noted earlier in this report, there is no standard reporting of the extent to which SE participants are gaining integrated competitive employment. The ER has recommended that the QSR process measure whether and to what extent SE services are being delivered consistent with these requirements of the CMHA. As noted above, the ER expects the State to produce the requested data on SE integrated competitive employment by March 1, 2018.
Supported Housing
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Subsidy Program by June 30, 2016. As of September 2017, DHHS reports having 509 individuals in leased SH apartments, and 58 people approved for a subsidy but not yet leased. The number of people with rents paid has fallen by 36 compared to the prior quarter; the total number of slots has decreased from the prior quarter by 24 – from 591 slots to 567 slots. The State is in compliance with the CMHA numerical standards for SH effective June 30, 2016, but as is discussed below, not yet in compliance with 2017 CMHA criteria.
Table V below summarizes recent data supplied by DHHS related to the Bridge Subsidy Program.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 16 of 75

Table V

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

September 2015 through September 2017

Bridge Subsidy Program
Information

March 2016

Sept. 2016

Dec. 2016

March 2017

June 2017

Sept. 2017

Total housing slots

450

479

513

553

591

567

(subsidies) available

Total people for whom rents are being subsidized

415

451

481

505

545

509

Individuals accepted 22

28

32

48

46

58

but waiting to lease

Individuals currently 0

0

0

0

0

0

on the wait list for a

bridge subsidy

Total number served 518

603

643

675

701

742

since the inception

of the Bridge

Subsidy Program

Total number

71

83

83

85

85

96

receiving a Housing

Choice (Section 8)

Voucher

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table VI below displays the reported number of units leased at the same address.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 17 of 75

Table VI

Self-Reported Housing Bridge Subsidy Concentration (Density)

Sept. March June Nov. 2015 2016 2016 2016

Feb. May Nov. 2017 2017 2017

Number of

properties with one

leased SH unit at

290

the same address

317 325 339

349 367 383

Number of properties with two SH units at the 27 same address

22

35

24

23

36

31

Number of

properties with

three SH units at

2

13

8

13

14

5

6

the same address

Number of

properties with

four SH units at

4

the same address

1

1

3

4

4

5

Number of properties with five SH units at the 1 same address

2

2

0

0

3

0

Number of

properties with six

SH units at the

1

same address

0

1

1

1

1

0

Number of properties with seven + SH units at same address

0

2

3

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 18 of 75
These data show that 85% of the leased units are at a unique address or with one additional unit at that address. This supports a conclusion that the Bridge Subsidy Program, to a large degree, is operating as a scattered-site program. For the units shown in Table VI at the same address, it is not known at this time whether the unit density standards included in the CMHA are being met. DHHS is collecting information on the total units in each property where there are two or more Bridge units at the same address, and this data will be reported when it is made available.
It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)). DHHS reports, and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge Subsidy Program units.3
As noted in the Data section of this report, current data is not available on the degree to which Bridge Subsidy Program participants access and utilize support services and whether or not the services are effective and meet individualized needs. Receipt of services is not a condition of eligibility for a subsidy under the Bridge Program, but the CMHA does specify that “…supported housing includes support services to enable individuals to attain and maintain integrated affordable housing, and includes support services that are flexible and available as needed and desired….” (V.E.1(a)). As noted in the 2016 and 2017 ER Reports, DHHS has been working on a method to cross-match the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. This will allow documentation of the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports. As of the writing of this report, the ER has not received this requested information from the state. The ER expects that such information will be produced and delivered to the ER no later than March 1, 2018. The ER will also work with the State to review and analyze data to determine whether or not individuals have experienced improved outcomes after obtaining supported housing.
In previous reports the ER has identified a number of important and needed data elements associated with the SH eligibility criteria and lack of a waitlist, as well as monitoring implementation of the SH program in the context of the CMHA. These include:
 Total number of Bridge Subsidy Program applicants per quarter;  Referral sources for Bridge Subsidy Program applicants;  Number and percent approved for the Bridge Subsidy Program;  Number and percent rejected for the Bridge Subsidy Program;
o Reasons for rejection of completed applications, separately documenting those who are rejected because they do not meet federal HCV/Section 8 eligibility requirements;
 Number and disposition of appeals related to rejections of applications;
3 DHHS reports that currently there is one voluntary roommate situation reflected in the above data.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 19 of 75
 Elapsed time between application, approval, and lease-up;  Number of new individuals leased-up during the quarter;  Number of terminations from Bridge subsidies per quarter;  Reasons for termination:
o Attained permanent subsidized housing (Section 8, public housing, etc.); o Chose other living arrangement or housing resource; o Moved out of state; o Deceased; o Long term hospitalization; o Incarceration; o Landlord termination or eviction; or o Other;  Number of Bridge Subsidy Program participants in a roommate situation; and  Lease density in properties with multiple Bridge Subsidy Program leases.
This information is important in assessing whether eligibility is properly determined, whether a waitlist is properly maintained, whether or not support services are adequate to enable the individual to “attain and maintain integrated affordable housing,” and whether services are “flexible and available as needed and desired.” Most rental assistance programs collect and report such information, given its intrinsic value in monitoring program operations. Further, such data enhances DHHS’ ability to demonstrate the timeliness and effectiveness of access of the priority target population to this essential CMHA program component. Most importantly, this data is necessary to help the ER determine compliance with CMHA Sections IV.B, IV.C, and VII.A. The ER will continue to work collaboratively with DHHS to identify sources and methods for such data collection and reporting. As noted above, the state has yet to produce or deliver the requested information. And, as noted above, the ER expects production of all requested information pertaining to the SH program to be produced no later than March 1, 2018.
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain HUD funding for an additional 150 supported housing units for a total of 600 supported housing units.” (CMHA V.E.3(e)) In 2015 New Hampshire applied for and was awarded funds to develop a total of 191 units of supported housing under the HUD Section 811 Program. All of these units will be set aside for people with serious mental illness. As of the date of this report, nine of these new units have been developed and are currently occupied by members of the target population and an additional 69 units are in the development pipeline. It should be noted that over the life of the Bridge Subsidy Program the State has accessed 96 HUD Housing Choice Vouchers (HCV – Section 8). These have allowed the State to free up 96 Bridge Subsidy units for new applicants. Nonetheless, the current number of SH slots and units is below the 600 figure set out in the CMHA.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 20 of 75
In addition, the CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.” The ER notes that the State is still not maintaining or reporting on a wait list of people within the target population who are waiting for supported housing services. The State has shared information from October 2017 indicating that 20 individuals who could be discharged from New Hampshire Hospital remain unnecessarily hospitalized because of homelessness, that an additional 10 individuals are similarly stuck at NHH because they are awaiting transitional housing, and that 10 Glencliff residents referred to the Central Team were determined to have residential discharge barriers. Some of these individuals may be ineligible for Bridge housing but nonetheless fall within the Target Population and require supported housing. The ER expects that by March 1, 2018 the State will identify such individuals in a waitlist and maintain that waitlist going forward as required by the CMHA.
Transitions from Institutional to Community Settings
During the past 30 months, the ER has visited both Glencliff and NHH on at least six separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities late last year. Transition planning activities related to specific current residents in both facilities have been observed, and a small non-random sample of resident transition records has been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities.
The ER has participated in four meetings of the Central Team. The CMHA required the State to create a Central Team to overcome barriers to discharge from institutional settings to community settings. The Central Team has now had about 24 months of operational experience, and has started reporting data on its activities. To date, 34 individuals have been submitted to the Central Team, 21 from Glencliff and 13 from NHH. Of these, the State reports that 13 individual cases have been resolved4, two individuals are deceased, and 19 individual cases remain under consideration. Table VII below summarizes the discharge barriers that have been identified by the Central Team with regard to these 19 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total substantially higher than the number of individuals reviewed by the Central Team.
4 Two of these individuals were readmitted to NHH after 90 days, and the discharge dispositions for these two individuals are being reviewed.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 21 of 75

Table VII

Discharge Barriers for Open Cases Referred from NHH and Glencliff to the Central Team:

October 20175

Discharge Barriers

Number for Glencliff

Number for NHH

Legal

3 (10.3%)

4 (21.1%)

Residential

10 (34.5%)

5 (26.3%)

Financial

6 (20.7%)

3 (15.8%)

Clinical

7 (24.1%)

3 (15.8%)

Family/Guardian

1 (3.4%)

2 (10.5%)

Other

2 (6.9%)

2 (10.5%)

Although this Report notes increased efforts and leadership at the State level with regard to the

operations of the Central Team, the ER expects that the total number of referrals will grow, and

the pace at which individual barriers are resolved will quicken, over the next six month period.

Glencliff

In the time period from April through September, 2017, Glencliff reports that it has admitted 12 individuals, and has had four discharges. The average daily census through this period was 106.5 people. There have been no readmissions during this time frame. The wait list for admission has increased slightly, from 17 people in the previous quarter to 19 people for this quarter. Four discharges have been effectuated during this period; one of which was to an integrated community setting. Two current residents are in active transition planning, and both of whom are expected to be transitioned to integrated community settings within the next several months.

CMHA Section VI requires the State to develop effective transition plans for all appropriate residents of NHH and Glencliff and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]6 individuals with mental illness and complex health care needs residing at Glencliff….” The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be cost-effectively served in supported housing.”7 The ER notes that Glencliff continues to support and effectuate transitions of individuals to integrated community settings under a variety of other funding and living arrangements.

5 This is a point in time report for open cases. 6 Cumulative from CMHA V.E.(g), (h), and (i). 7 CMHA V.E.2(a)

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 22 of 75
DHHS reports that the total number of people with complex health conditions transitioned from Glencliff to integrated settings since the inception of the CMHA three years ago increased this quarter from 12 to 14. A fifteenth person is scheduled to transition to an individual apartment as soon as necessary modifications are completed. There are currently 12 individuals undergoing transition planning who could be transitioned to integrated community settings once appropriate living settings and community services become available. Ten of these individuals have been assigned to Choices for Independence (CFI) waiver case management agencies.
DHHS has agreed to provide the ER information about the recent transitions, including clinical summaries, lengths of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in the integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions who could not be cost-effectively be served in supported housing continue to experience transitions to integrated community settings.
Of the 14 individuals reported by DHHS to have transitioned to community settings since the onset of the CMHA, the ER agrees five meet the criteria of being medically complex and not able to be cost effectively served in supported housing. Three of these individuals currently reside in a newly developed small scale community residence, and two are living in enhanced family care homes (EFCs) with extensive Medicaid and non-Medicaid services. A sixth person with complex medical needs will be transitioned, as noted above, once apartment modifications are complete.
DHHS has also begun to implement certain action steps to enhance the process of: (a) identifying Glencliff residents wishing to transition to integrated settings; and (b) to increase the capacity, variety and geographic accessibility of integrated community settings and services available to meet the needs of these individuals. Both sets of initiatives should facilitate and speed up such community transitions for additional Glencliff residents.
As noted in the previous report, the ER is at this point reluctant to focus too narrowly on clinical conditions and sets of health, mental health and community services and supports for transitioned and transitioning individuals to monitor the State’s progress in assisting Glencliff Home residents to transition to integrated community settings. The ER will monitor the extent to which DHHS, Glencliff, the CMHCs and an array of other community partners collaborate to effectuate as many such transitions as possible over the next two years. The primary thrust and intent of the CMHA is to assure that individuals residing in Glencliff (and their families and guardians) are offered and are willing to accept meaningful opportunities to transition to integrated community settings. It appears likely that the specific requirement in the CMHA for the State to create capacity to serve 16 individuals with complex medical conditions who cannot be costeffectively served in supported housing will be attained if DHHS and its partners continue to increase the availability of integrated community settings, and provide meaningful in-reach and transition planning for Glencliff residents.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 23 of 75
Thus, the ER will continue to monitor the following topics/items going forward:
1. The number of transitions from Glencliff to integrated community settings per quarter. The ER will also monitor information about the clinical and functional level of care needs of these individuals; the integrated settings to which they transition; and the array of Medicaid and non-Medicaid mental health and health-related services and supports put in place to meet their needs to assure successful integrated community living.
2. The number of Glencliff residents newly identified per quarter to engage in transition planning and move towards integrated community settings. The ER will also monitor at a summary level the clinical and functional level of care needs of individuals added to the transition planning list per quarter.
3. New integrated community setting providers with the capacity to facilitate integrated community living for Glencliff residents. These could include EFCs, AFCs, and new small-scale community residential capacity for people with complex medical conditions who cannot be cost-effectively served in supported housing. The ER will monitor DHHS activities and successes relative to identification and engagement of new community providers who express willingness and capacity to provide services in integrated community settings for people transitioning from Glencliff.
4. Within the discharge cohort, the number of transitioned individuals for whom the State special funding mechanism is utilized to effectuate the transition, and the ways in which these funds are used to fill gaps in existing services and supports.
5. Number and types of in-reach visits and communications by CMHCs and other community providers related to identifying and facilitating transitions of Glencliff residents to integrated community settings.
6. Specific documentation of efforts to overcome family and/or guardian resistance to integrated community transitions for Glencliff residents.
7. Number of individuals engaged in transition planning referred to the Central Team; number of these individuals who successfully transition to an integrated community setting; and the elapsed time from referral to resolution.
Preadmission Screening and Resident Review (PASRR)
The State DHHS has provided recent data on PASRR screens for the period August 1, 2017 through October 31, 2017.
Table VIII below provided a high level summary of these data.
Table VIII
PASRR Level I and Level II Screens: 8/1/2017-10/31/20178
8 Note that reporting of PASRR data is not currently on the same quarterly basis as most of the other data in this report.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 24 of 75

Place of Residence at time of screen Assisted Living Facility Group Home Home Homeless Shelter Inpatient Hospital Inpatient Psychiatric Facility Nursing Facility Other
Total

PASRR Level I 7 10 56 2 35 7 41 1 159

PASRR Level II 2 6 10 1 16 2 21 1 59

According to the data provided by DHHS, 54 of the Level I screens in the time frame resulted in a referral for a Level II screen.9 Of these, 35 (65%) were referred because of mental illness; and 7 (13%) were for ID/DD. In this reporting period a total of 59 PASRR Level II screens were completed: 39 (59.7%) received full approval with no special services (SS)10; 4 (6.8%) were approved with SS; 14 (23.7%) received provisional approval with no SS; and 2 (3.4%) received provisional approval with SS.
From the data provided it is not possible to determine the disposition results for people referred for Level II screening by reason of mental illness versus those referred for ID/DD or other reasons. Nor is it possible to identify people within either the Level I or Level II categories that were referred to potential integrated community living alternatives. Finally, it is not possible to distinguish which among the Level I and Level II screens might represent a person referred or admitted to Glencliff.
The ER notes that PASRR screens are typically completed before a person is referred to Glencliff, since Glencliff requires that applicants be rejected by at least three nursing facilities before being considered for admission to Glencliff. Thus, a PASRR screen by itself might only indirectly impact admission decisions to Glencliff. Nonetheless, during the up-coming six month period the ER plans to review the individual PASRR screen documents for recent referrals and admissions to Glencliff.
New Hampshire Hospital and the Designated Receiving Facilities (DRFs)
For the time period April through September 2017, DHHS reports that NHH effectuated 497 admissions and 498 discharges. The mean daily census was 153, and the median length of stay for discharges was 13 days in the most recent quarter.

9 Referrals for Level II screens could have originated in a previous reporting period, so the number of referrals reported would not necessarily correspond to the number of completed Level II screens completed in the period. 10 Special services are to be provided over and above the nursing facility services that are included within the facility’s regular reimbursement rate.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 25 of 75

Table IX below compares NHH discharge destination information for the five most recent reporting periods (9/2015 through 9/2017). The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.

Table IX

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Discharge Destination

Percent September
2015 through April 2016

Percent October and November
2016

Percent January through March 2017

Percent April through
June 2017

Percent July through September
2017

Home – live alone or with others

80.2%

85.1%

84.5%

85.66%

88.3

Glencliff

0.60%

0.36%

1.55%

0,35%

0.49%

Homeless Shelter/motel

2.7%

2.54%

2.71%

3.5%

2.94%

Group home 5+/DDS supported living, etc.

3.2%

1.62%

5.7%

5.59%

3.92%

Jail/corrections 1.4%

2.9%

0.8%

1.05%

0.49%

Nursing home/rehab facility

0.80%

3.6%

1.9%

3.50%

2.45%

The State now consistently reports information on the hospital-based DRFs and The Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and analyze it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. The ER appreciates the State gathering this information. Table X summarizes this data.
Table X

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 26 of 75

Self-Reported DRF/APRTP Utilization Data: January 2016 through September 2017

Admissions Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017 April - June 2017 July - September 2017

Frankli n

Cypress

Portsmout h

Eliot Geriatric

Eliot Pathway
s

69

257

46

65

121

79

205

378

49

92

37

207

375

54

114

39

217

310

43

72

65

204

317

48

138

60

228

363

52

101

NA**

247

363

60

121

Total
558 803 787 681 772 804 NA

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017 April - June 2017 July - September 2017

53.70% 55.70% 43.20% 53.80% 70.70% 58.30% NA**

18.70% 24.40% 29.50% 28.60% 34.30% 21.50% 27.90%

NA 20.40% 18.90% 17.10% 21.80% 22.00% 25.60%

18.50% 4.10% 13.00% 16.30% 12.50% 11.50% 10.0%

30.60% 48.90% 44.70% 43.10% 43.50% 47.50% 50.40%

26.20%* 25.50% 26.20% 25.60% 32.50% 27.10%
NA

Average Census

Jan - March 2016

7.9

14.7

April - June 2016

7.8

13.2

July - Sept 2016

4.5

13.6

Oct – Dec 2016

5.6

12.4

Jan - March 2017

5

14.6

April - June 2017

4.5

12

July - September 2017

NA**

12.9

NA

19.7

18.1

60.1*

21.4

22.5

16.9

81.8

23.2

25.6

14.5

81.4

23.4

24.8

11.5

77.7

27.2

31.2

24.6

102.6

30.3

29.3

10

86.1

23.9

29.7

12.2

NA

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 27 of 75

Discharges Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017 April - June 2017 July - September 2017

Frankli n

Cypress

Portsmout h

Eliot Geriatric

Eliot Pathway
s

76

261

NA

57

122

78

206

363

51

90

35

213

380

64

113

41

213

309

46

75

65

211

305

49

130

59

232

365

54

105

NA**

243

355

63

121

Mean LOS for Discharges

Jan - March 2016

8.6

4.2

April - June 2016

6

4

July - Sept 2016

7

5

Oct - Dec 2016

5

5

Jan - March 2017

5

4

April - June 2017

6

4

July - September 2017 NA**

4

NA

15

7.4

4

28

7

4

24

8

5

24

8

5

27

7

5

22

8

4

27

7

* Does not include Portsmouth ** Franklin DRF did not report data for the July - September period.

Total
516* 788 805 684 760 815 NA
8.8* 5 5 5 5 9 NA

The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and should also reduce the number of people waiting for psychiatric admissions in hospital EDs. As will be discussed in a later section of this report, the State has received funding for additional general hospital DRF beds. The DRF discharge cohort may also be a good source of referrals to CMHCs for ACT or other best practice community services. The ER will continue to work with DHHS to monitor the degree to which DRF functions and activities support the overall objectives of the CMHA.
DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table XI below provides a summary of these recently reported data.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 28 of 75

Table XI Cumulative Self-Reported Discharge Dispositions for DRFs in New Hampshire
October 2016 through September 2017

Disposition

Franklin Cypress Portsmouth Eliot

Eliot

**

Geriatric Pathways

Total

Home

136

744

900

43

357

2,180

NHH

5

6

29

1

12

53

Residential

6

10

0

134

7

157

Facility/

Assisted

Living

Other DRF

1

20

9

2

2

43

Hospital

2

0

0

13

1

16

Death

0

0

0

17

0

17

Other or

15

54

331

3

52

455

Unknown

*The Other category for Portsmouth Regional is reported to include shelters, rehab facilities,

hotels/motels, friends/families, and unknown.

** Does not include Franklin data for the period July through September 2017.

Based on these self-reported data, 74.8% of the 2,915 discharges from DRFs and the Cypress Center are to home. This compares to the 85% or greater discharges to home reported by NHH. 5.3% of the total DRF discharges are to residential care or assisted living, which is similar to NHH discharges for this category. 1.7% of the DRF discharges are to NHH, 1.5% is to other DRFs. 15.6% of the total discharges are to the other/unknown category, but 73% of these are accounted for by the Portsmouth DRF. This might point to an anomaly in the ways facilities use this category in their reports to the state. The ER will work with the State to clarify what types of discharges are allocated to the other/unknown category for all of the DRFs and the Cypress Center.

Hospital Readmissions

DHHS is now reporting readmission rates for both NHH and the DRFs. Table XII below summarizes these data:

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 29 of 75

NHH Franklin Cypress Portsmouth Elliot Geriatric Elliot Pathways Total
NHH Franklin Cypress Portsmouth Elliot Geriatric Elliot Pathways Total

Table XII

Self-Reported Readmission Rates for NHH and the DRFs

October – December 2016

Numbe r
30 Days 36 1 13 25

Percen t 30
Days 13.0% 2.50% 6.00% 8.10%

Numbe r
90 Days 78 1 21 44

Percent
90 Days 28.30% 2.5% 9.70% 14.20%

2

4.70%

2

4.70%

8 11.10% 9

85

155

12.50%

Numbe r
180 Days
97 1 24 56

Percen t
180 Days 35.10% 1.50% 11.10% 18.10%

Total Numbe
r 211
3 58 125

4

9.30%

8

9 12.50% 26

191

431

Numbe r
30 Days

Percen t 30
Days

Numbe r
90 Days

January - March 2017
Percent
90 Days

Numbe r
180 Days

Percen t
180 Days

Total

21 8.00% 52

0

0.00%

0

14 6.90% 24

23 7.30% 41

19.80% 0.00% 11.80% 12.90%

73 27.80% 146

1

1.50%

1

34 16.70% 72

58 18.30% 122

4

8.30%

5

10.40%

5 10.40% 14

4

2.90%

6

66

128

4.30%

10

7.20%

20

181

375

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 30 of 75

April - June 2017

Number Percent Number

NHH Franklin Cypress Portsmout h Elliot Geriatric Elliot Pathways Total

30 Days 44 0 11

30 Days 15% 0.00% 4.80%

90 Days 71 0 21

37

10.20%

56

2

3.80%

2

7

6.90%

8

101

158

Percent
90 Days 24.20% 0.00% 9.20%
15.40%
3.80%
7.90%

Number 180 Days 94 0 30

Percent
180 Days 32.1 0.00%
13.20%

Total
Number 209 0 62

75

20.70% 168

3

5.80%

7

11

10.90%

26

213

472

July September
2017

Number Percent Number

30 Days 30 Days 90 Days

NHH

20

9.80%

44

Franklin

NA

NA

NA

Cypress

12

7.10%

21

Portsmout

h

33

11.50%

50

Elliot

Geriatric

0

0.00%

0

Elliot

Pathways

4

3.30%

8

Total

69*

123*

*Totals do not include Franklin readmissions.

Percent
90 Days 21.60%
NA 12.40%
17.50%
0.00%
6.60%

Number 180 Days 57 NA 27

Percent
180 Days 27.90%
NA 15.90%

Total
Number 121 NA 60

60

21.00% 143

0

0.00%

0

15 159*

12.40%

27 351*

In the previous report the ER noted that readmission rates may indicate that people being discharged from inpatient psychiatric facilities are not connecting with necessary and appropriate services and supports in the community. Trends in readmission rates may also be indicators of increased or decreased pressures on the overall system of care. For example, decreased readmission rates could be an indicator that hospitals are not discharging people too quickly because of pressures to admit new patients. Decreases could also indicate that connections to appropriate community services and supports are occurring more effectively. As of the data of

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 31 of 75
this report, 180-day readmission rates to NHH are substantial, with almost one-third of those discharged returning to NHH within six months.
It is also important to note that the data reported currently include only readmission rates to the same facility, thus potentially understating the extent to which individuals in the target population may be subject to repeated admissions at more than one inpatient facility. In the next reporting period, the ER will work with the State to determine if data that reflects subsequent admission to any institutional facility can be made available – thus providing a more accurate picture of the rate and frequency with which individuals are relying on inpatient facilities statewide.
The data in Table XII above has not been reported for a long enough period to identify trends in readmission rates with confidence. Nonetheless, they do provide some insight into the number of instances in which an appropriate community intervention could have prevented an unnecessary re-hospitalization. For example, if even ten percent of the readmissions between January and March 2017 were diverted through ACT and other community resources, there would have been 38 fewer hospital admissions during that period, with a concurrent lower number of hospital bed days utilized.
The ER will continue to work with DHHS to monitor these data to interpret how they may contribute to overall system improvements consistent with the CMHA.
In the previous three reports, the ER has identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. Chart A below displays daily adult admissions delays to NHH for the period July 1, 2016 through October 26, 2017. Chart B shows the average daily ED waiting list for the same time period. )

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 32 of 75

.
80

Chart A
New Hampshire Hospital Daily Admission Delays (Adults) July 1, 2016 - October 26, 2017

70

60

50

40

30

20

10

0 070/0770/1/7140/62/7110/62/8180/60/8140/61/8110/61/8180/62/9150/60/9110/60/9180/61/9150/62/9121/62/0191/60/0161/61/0131/62/0101/62/1171/60/1131/61/1101/61/1171/62/2141/60/2111/60/2181/61/2151/62/2120/62/1190/60/1150/61/1120/71/1190/72/2160/70/2120/70/2190/71/2160/72/3130/70/3120/70/3190/71/3160/72/3130/73/4100/70/4160/71/4130/72/4100/72/5170/70/5140/71/5110/71/5180/72/6150/70/6110/70/6180/71/6150/72/6120/72/7190/70/7160/71/7130/72/7100/72/8170/70/8130/71/8100/71/8170/72/8140/73/9110/70/9170/71/9140/72/9111/72/0181/70/0151/71/0121/71/019/72/167/17

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 33 of 75 Chart B

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 34 of 75
Average Daily Waiting List by Month (Adults) July 2016 - October 2017
80

70

60

50

40

65 67

30

60

45 46 43

20

40

39

35 36

32

49 44

28

24

25

10

0
Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 35 of 75
Based on information reported by DHHS and summarized above, the average number of adults waiting for a NHH inpatient psychiatric bed was 24 per day in FY 2014; 25 per day in FY 2015; and through June of FY 2016 was 28 per day. For the period July 2016 through September 2017, the average monthly wait list for admission to NHH was 42.4 adults. Not surprisingly, as can be seen from Carts A and B together, there appears to be a correlation between the numbers waiting in EDs and the daily admission rate at NHH.
DHHS continues to analyze data related to adults boarding in EDs who may have some connection to the mental health system. DHHS is making these data available to CMHCs on a monthly basis, and expects the CMHCs to use these data to identify potential participants for ACT or related services to reduce the risk of hospitalization and support integrated community living. In future months, DHHS will be receiving information on the degree to which CMHCs have increased ACT (or other services’) participation as a result of these analyses. The ER plans to include summaries of this information in future reports. The ER continues to encourage the State, in conjunction with the CMHCs, to conduct targeted outreach to those individuals who may need expanded or enhanced community services so as to minimize or eliminate contact with hospital or institutional settings.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies
As noted in the June 30, 2015 ER report, New Hampshire reported having a total of 16 peer support agency program (PSA) sites, with at least one program site in each of the ten regions. The State now reports having 15 PSAs. The State continues to report that all peer support centers meet the CMHA requirement to be open 44 hours per week. The State reports that those sites have a cumulative total of 2,685 members11, with an active daily participation rate of 167 people statewide. Membership and active daily participation for the PSAs seems to be relatively unchanged from reporting period to reporting period.
The CMHA requires the peer support programs to be “effective” in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs. Anecdotally, some of the CMHCs report making more concerted efforts to refer service participants to the PSAs in
11 The State reports that the Peer Support Agencies in the past year have made concerted efforts to verify and correct their membership lists. This activity has resulted in a small reduction in the number of members reported during this time period.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 36 of 75
their regions. Increased efforts to communicate and coordinate with PSAs have also been reported. However, as of the most recent report there has not been a consequent increase in active daily participation.
Anecdotally, the ER continues to believe that in some regions of the state, relationships and communications among the CMHCs and the Peer Support Programs have improved. Peer support programs are generally reported by CMHCs to be useful sources of employees for ACT and Mobile Crisis and Crisis Apartment services. In addition, CMHCs report that the peer operated crisis beds available in several regions are a useful intervention for some CMHC clients at risk of hospitalization.
IV. Quality Assurance Systems
In the past 30 months, DHHS has made substantial progress in the design of the QSR process required by the CMHA. Fifteen QSR site visits have been conducted to date, and reports of the findings of most of these site visits have been posted for public review. Based on the experiences of those QSR site visits, plus on-going input from representatives of the Plaintiffs and the ER (in a technical assistance role), the QSR team has continued to make revisions to the QSR protocol, instruments, and scoring algorithm. The most recent round of changes recommended by the Plaintiffs and separately by the ER are currently being implemented. Three on-site QSR visits have been conducted using the new instruments and are currently being scored, analyzed and reported using the revised scoring process. Reports of these QSR site visits have not yet been published. Nor have any quality improvements plans yet been developed by the respective CMHCs in response to the QSR findings. Thus, the ER is not able at this time to comment on the results of the revised QSR instrumentation, protocols and scoring methodologies.
Nonetheless, having participated in two QSR site visits, the ER is confident that: (a) the revised instruments and site interview protocols are working well; and (b) the results and findings of the revised QSR instruments and process reflect, to a large degree, the quality standards of the CMHA.
One key improvement in the revised QSR process has been the addition of several Overall Clinical Review (OCR) questions that provide opportunities for the QSR teams to integrate and summarize service participant-level information collected from a variety of information sources. These new questions include:12
1. Is the frequency and intensity of services consistent with the individual’s demonstrated need?
12 Note: detail follow-up questions have not been included in this list.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 37 of 75
2. Are there additional services the individual needs that are not identified in the assessment(s) or the treatment plan?
3. Is the individual receiving all the services s/he needs to ensure health, safety, and welfare?
4. Is the individual receiving adequate services that provide reasonable opportunities to support the individual to achieve independence and integration in the community?
5. Is the individual receiving adequate services to obtain and maintain stable housing? 6. Is the individual receiving adequate services to avoid harms and decrease the incidence of
unnecessary hospital contacts and/or institutionalization? 7. Is the individual receiving adequate services to live in the most integrated setting?
Questions have also been embedded in the QSR instruments to more accurately document that: (a) the assessment(s) accurately reflect the individual’s strengths, needs and goals; and (b) service delivery approaches and patterns reflect best practices, where applicable.
These types of questions reflect the essence of the QSR process: documenting that individual service participants receive the levels and types of services and supports that assist them to achieve their goals and meet their needs in the most integrated community setting possible. These questions also directly respond to target population outcomes and quality expectations of the CMHA. Going forward, responses to these questions are intended to form an important part of the six-month ER reports.
The ER is grateful to both the State and the representatives of the Plaintiffs who have worked long and hard to design and implement a QSR process that will legitimately and accurately reflect the quality and effectiveness of the community mental health system in New Hampshire. This QSR system is a critical element of the CMHA, but in fact it has much broader application and potential long term benefits for the entire mental health system.
As noted above, the State has continued to refine and revise the scoring algorithms within the QSR process. These changes, among many others, reflect the OCR questions as described above. Some issues remain among the State, representatives of the Plaintiffs, and the ER with regard to how the scoring algorithms will be applied across the entire QSR process, and how negative responses to OCR questions will inform required quality improvement plans. Finally, the ER and the parties continue to discuss how to increase expectations for CMHC performance in annual QSR reviews, while also ensuring all CMHCs achieve or exceed the minimum score of 70 percent. Publication of recent QSR site reports using the revised instruments and scoring protocol will assist all parties to reach closure on these issues.
As noted earlier in this report, DHHS has been conducting on-site ACT and SE fidelity reviews to supplement and validate the ACT and SE fidelity self-assessments conducted on an annual basis by the CMHCs. DHHS has engaged the Dartmouth/Hitchcock Center on Evidence Based practices to assist in attaining and assuring fidelity to the evidence based models of ACT and SE.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 38 of 75
The Dartmouth/Hitchcock team will also assist on workforce development and training for these and other evidence based practices under the aegis of DHHS and the CMHCs. This partnership with the nationally respected Dartmouth/Hitchcock Center adds valuable expertise and experienced personnel to facilitate further development and operations of fidelity model ACT and SE in conformance with the CMHA. Year-to-year comparisons and the CMHCs Performance Improvement Plan have been included in the publication of recent ACT and SE fidelity reviews. The ER commends DHHS for implementing the comprehensive fidelity review process and its attendant quality improvement and technical assistance activities.
Effective and validated fidelity reviews and consequent training and workforce development activities are essential to DHHS’ overall quality management efforts for the community mental health system. As noted in the previous two ER reports, the QSR and the fidelity reviews mutually support but do not supplant or replace each other. The QSR, in particular, examines outcomes from a consumer-centric perspective as opposed to an operational or organizational perspective. It is uniquely positioned to assess the quality, appropriateness and effectiveness of specific ACT and SE services at the individual participant level. The ER continues to believe that implementation of fidelity-based models of delivery does not necessarily mean that specific service interventions are working well or being delivered with the frequency or intensity required by a participant’s individual treatment plan The revised QSR instruments and protocols address many of these concerns. In combination, the fidelity reviews and the QSR can mutually support conclusions about the overall quality and effectiveness of the mental health system consistent with the CMHA.
The ER will continue to monitor the degree to which the QSR process produces reliable information on individual outcomes and the quality of CMHA service delivery. In addition, over the next six months, the ER will evaluate the extent to which CMHC Quality Improvement Plans developed as part of the 2017 QSR site visits, are resulting in recommended practice changes and improved outcomes for those in the target population.
V. New State Resources For the CMHA
In New Hampshire the Governor and the Legislature have evidenced increased support for implementation of the CMHA and for making continued improvement in the community mental health system. Table XIII below summarizes new resources appropriated for the current biennium.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 39 of 75

Table XIII

New Community Mental Health Resources in New Hampshire for SFY 2018 and 2019

Item

SFY 2018 SFY 2019

Total

Transitional Housing / Community Residence Beds: adds 20 beds in SFY 2018 and up to 20 more in SFY 2019; prioritized to support New Hampshire Hospital discharges.

$2,312,156 $5,424,000 $7,736,156

Mobile Crisis: funds additional crisis response capacity in area with high numbers of New Hampshire Hospital admissions and discharges.

$1,498,551 $3,421,696 $4,920,247

Designated Receiving Facility (DRF) $ 484,696 $ 721,440 $1,206,136
Beds: adds up to 20 additional DRF beds.

Additional Funding: to support workforce $1,500,000 $1,500,000 $3,000,000
development.

Biennium Total $16,862,539

In addition, a total of $4.3 million has been added to the Mental Health rate cells of the Medicaid capitation rates of the Managed Care Entities (MCEs) for the up-coming biennium in anticipation of increased utilization associated with the CMHA. An additional $2.0 million is available for inclusion in these rates after all CMHA services (excluding fee-for-service services) have been implemented. In addition, an additional $471,186 for general mental health services has been added to the CMHC state contracts. This is exclusive of the separate Mobile/Crisis Team contracts.
It should be noted that the crisis model currently envisioned by the State under this new appropriation is not a replica of the model implemented under the CMHA in the Concord, Manchester and Nashua Regions. The model currently being procured will be called a Behavioral Health Crisis Treatment Center (BHCTC), which is intended to provide center-based (as opposed to mobile) crisis services 24/7. Services will include crisis assessments and treatment, and service participants may include people with substance use disorders. A vendor has not yet been selected for this BHCTC service, and thus a detailed scope of work and

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 40 of 75
implementation schedule is not yet available. The ER is not able to comment at this time about the implementation of this model.
However, it is notable that this new BHCTC service may operate in a region in lieu of the mobile crisis teams and crisis apartments developed under the CMHA. While community-based crisis centers have been effective in some other states, those centers are typically integrated into a larger crisis service system, which includes mobile capacity and apartment settings, and are not operated as stand-alone settings. In New Hampshire, it is the mobile crisis team and crisis apartment model that has a demonstrated record of diverting individuals with mental illness from hospital emergency rooms. The ER is not aware of evidence that requiring individuals in crisis to present themselves for center-based crisis services is unlikely to achieve the same results for members of the target population. The ER is also not aware of evidence that it is easier for individuals in rural areas with limited transportation resources to present at a centralized crisis facility as opposed to having crisis teams go to the location most convenient and natural for individuals in crisis.
VI. Summary of Expert Reviewer Observations and Priorities
The CMHA and ER have now been in place for three and one half years. Within that time frame, the ER has expressed escalating concerns related to noncompliance with CMHA requirements governing ACT and Glencliff community transitions. In addition, the ER has noted long elapsed times and/or delays related to implementation of system improvements or capacities related to the CMHA, including the full and effective functioning of the Central Team. Throughout these reports, the ER has emphasized the need for the State to be more aggressive, assertive, planful, and timely in its implementation and oversight efforts in these areas in order to come into compliance with the CMHA.
More recently the ER has reported that the State is improving its oversight and management of the mental health system. Examples include more comprehensive and accurate data reporting, the revised QSR process, and the growing use of state-validated fidelity reviews for ACT and SE. The State has also substantially strengthened its central management of the mental health system, through improved management structures and increased leadership and operational staffing. The State is making progress towards compliance with several CMHA requirements above, including Glencliff transition and discharge planning. The breadth and content of the final QSR instrument, and the reliability of information it produces, will determine to what extent it is possible to evaluate compliance with other individual outcomes contained within the CMHA, including the adequacy and effectiveness of ACT, SE, SH and MCT.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 41 of 75
The one notable exception to this progress relates to ACT services. For the last two years the ER has stated that the State remains out of compliance with the ACT requirements of the Sections V.D.3(a, b, d, and e), which together require that all ACT teams meet the standards of the CMHA; that each mental health region have at least one adult ACT Team13; and that by June 30, 2016, the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time.
Despite the many positive initiatives and management efforts undertaken by the State, ACT capacity remains substantially below the required June 30, 2016 capacity to serve 1,500 people at any given time. Moreover, with an active caseload of only 992 people, the state currently is providing 508 fewer people with ACT than could be served if the State had developed the CMHA-specified capacity to serve 1,500 individuals. With the current ACT staff capacity to serve 1,242 people, there are 250 fewer people receiving ACT than the current ACT system could accommodate. This continues to be the single most significant issue in New Hampshire with regard to compliance with the CMHA, and one with negative implications for individuals who remain in NHH, who continue to be readmitted to EDs and inpatient facilities, or who are otherwise at risk of admission, homelessness, or incarceration due to inadequate community supports.
In addition, the ER continues to note that certain elements of information related to SE and SH have yet to be produced by the State, preventing findings of compliance with the CMHA. Finally, while the QSR system is much improved, the ER cannot fully evaluate the degree to which the revised QSR instruments and process is producing accurate and meaningful information related to the CMHA until several reports of site visits have been published, and attendant quality improvement plans have been developed and approved.
Based on the findings presented in this report, the ER expects the following action steps to be taken during the up-coming six month period:
1. By March 1, 2018 the State will update and expand strategies and action steps to accelerate expansion of ACT capacity to attain compliance with the CMHA. New plans and timelines will be added to the Monthly Progress Report as applicable. Data on outreach to, and screening of, potential ACT clients will be made available. In addition, the State will ensure that members of the target population in need of ACT are identified, and that both regional and statewide plans are in place to ensure their reasonable access to services.
2. By March 1, 2018 the State will produce information on SE and SH as specified above in the report.
13 The ER notes that each region of the state has had at least one ACT team, or ACT team-in-development, since the inception of the CMHA. However, as documented in the ACT section of this report, four regions continue to have ACT teams that do not meet the minimum staffing requirements for ACT as specified in the CMHA.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 42 of 75
3. By March 1, 2018, the State will circulate QSR reports of the first three QSR site visits using the revised instruments and scoring protocols. The ER intends to engage the State and representatives of the Plaintiffs in a final conversation to resolve any remaining issues related to the scoring of QSR responses and generating quality findings. The ER expects these discussions to be accomplished no later than the end of March, 2018.
4. By March 1, 2018, the State and its PASRR contractor will facilitate the ER’s review of the individual PASRR screen documents for recent referrals and admissions to Glencliff.
5. The State will continue to provide information requested by the ER for purposes of monitoring transition and discharge planning from Glencliff.
6. The State and its MCT contractors will work with the ER to document requested information on mobile crisis encounters and to explore the number and type of reported hospital diversions.
7. Consistent with the requirements of the CMHA, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, regardless of whether those individuals are eligible for a Bridge subsidy.
8. The ER requests the State to work collaboratively with the ER and representatives of the plaintiffs to consider the most effective and efficient model for the 4th crisis program that was funded by the Legislature, before awarding any contract for a facility based crisis center.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 43 of 75
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly Data Report July through September, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 44 of 75
New Hampshire Community Mental Health Agreement Quarterly Data Report
July to September 2017
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement November 27, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 45 of 75
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 46 of 75 July – September 2017
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 11/27/2017
Reporting Period: 7/1/2017 – 9/30/2017
Notes for Quarter
 Harbor Homes Mobile Crisis has been added to the report.  The Franklin DRF was unable to report data for the quarter. As a result total DRF data is
also unavailable. Data for the current quarter will be provided in the next quarterly report.  Peer Support Agencies were instructed to "purge their member lists" as of July 1, 2017 impacting the Number of Members but not Average Daily Census. The Bureau of Mental Health Services has instructed Peer Support Agencies to purge member lists annually to increase confidence and consistency in this information.
NH DHHS - OQAI - CMHA Quarterly Report, 11/27/17

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 47 of 75

Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services

Publication Date: 11/27/2017

Reporting Period: 7/1/2017 – 9/30/2017

1. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Center Name

July 2017

Unique

August September Consumers

2017

2017 in Quarter

Unique Consumers
in Prior Quarter

01 Northern Human Services

109

107

107

113

111

02 West Central Behavioral Health

48

47

63

68

76

03 Genesis Behavioral Health

74

73

71

74

74

04 Riverbend Community Mental Health Center

78

79

81

87

97

05 Monadnock Family Services

66

61

55

69

70

06 Community Council of Nashua

88

87

90

98

94

07 Mental Health Center of Greater

269

267

269

287

Manchester

292

08 Seacoast Mental Health Center

61

60

60

67

69

09 Community Partners

67

70

65

75

69

10 Center for Life Management

52

53

54

54

55

Total

912

904

915

992

1,006

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 11/14/17; consumers are counted only one time regardless of how many services they receive.

CMHA Monthly Progress Report

47

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 48 of 75

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents
September 2017

June 2017

Nurse Masters Level Clinician/or Equivalent Functional Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nu

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CTT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management
Total

1.09 2.40 8.39 0.55 12.43 0.75 12.54 1.10

0.60 2.35 3.50 0.50 6.95 0.40 7.15 0.10

1.20 2.00 6.60 1.00 10.80 0.75 10.60 0.50

0.50 3.00 6.00 0.50 10.00 0.48 10.00 0.30

1.25 3.25 2.70 0.70 7.90 0.65 8.50 0.65

0.50 3.00 2.50 0.00 6.00 0.25 5.25 0.25

0.50 3.00 1.50 0.00 5.00 0.25 5.25 0.25

0.98 11.00 3.29 1.00 16.27 0.62 16.57 0.52

1.05 10.00 10.2 1.00 22.31 0.62

6

21.95 0.52

0.43 3.10 6.00 1.00 10.53 0.60 9.53 0.60

0.00 2.00 4.23 0.50 6.73 0.50 8.53 0.50

1.00 2.00 5.30 1.00 9.30 0.40 9.30 0.40

9.10 47.10 60.2 7.75 124.2 6.27 125.1

7

2

7 5.69

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Substance Use Disorder Treatment

CMHA Monthly Progress Report

48

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 49 of 75

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

September 2017 2.05 1.20 2.75 1.48
2.40 4.00 3.00 12.00
1.00
1.00 2.00 3.00 35.88

June 2017 2.77 1.20 2.50
1.30 3.40 3.00 3.00
12.00
1.00 1.00 0.50 3.00 34.67

2c. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Housing Assistance

Center Name

September 2017

June 2017

01 Northern Human Services

9.95

9.95

02 West Central Behavioral Health

6.35

5.85

03 Genesis Behavioral Health

7.60

8.60

04 Riverbend Community Mental Health

8.50

8.50

CMHA Monthly Progress Report

49

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 50 of 75

Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

1.00 5.00 4.00 12.90
18.05
7.00 3.88 7.00 91.23

1.00 4.00 4.00
12.36
16.28 6.00 4.50 7.00
88.04

2d. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Supported Employment

Center Name

September 2017

June 2017

01 Northern Human Services

0.97

1.08

02 West Central Behavioral Health

0.25

0.25

03 Genesis Behavioral Health

4.00

3.00

04 Riverbend Community Mental Health Center

0.50 0.50

05 Monadnock Family Services

1.00

1.00

06 Community Council of Nashua 1

2.50

2.50

06 Community Council of Nashua 2

0.50

1.50

07 Mental Health Center of Greater Manchester-CCT

0.74 0.71

CMHA Monthly Progress Report

50

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 51 of 75

07 Mental Health Center of Greater Manchester-MCST

1.31 1.35

08 Seacoast Mental Health Center

1.00

1.00

09 Community Partners

0.15

0.00

10 Center for Life Management

0.30

0.30

Total

13.22

13.19

Revisions to Prior Period: None

Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report

Notes for 2b-d: Data compiled 11/13/17; the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, rather the quantity of staff available to provide each service. If staff is trained to provide multiple service types, their entire FTE value will be credited to each service type.

3. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12 Month Period
12 Month Period Ending September 2017

Center Name

Supported Employmen t Consumers

Total Eligible Consumers

Penetration Rate

Penetration Rate for Period
Ending June 2017

01 Northern Human Services

514

1,257

40.9%

37.2%

02 West Central Behavioral Health

162

725

22.3%

22.5%

03 Genesis Behavioral Health

267

1,288

20.7%

22.0%

04 Riverbend Community Mental Health Center

238

1,704

14.0%

14.8%

05 Monadnock Family Services

115

933

12.3%

14.0%

06 Community Council of Nashua

242

1,416

17.1%

16.1%

07 Mental Health Center of Greater Manchester

1,382

3,288

42.0%

40.0%

CMHA Monthly Progress Report

51

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 52 of 75

08 Seacoast Mental Health Center

341

1,456

23.4%

09 Community Partners

100

683

14.6%

10 Center for Life Management

170

884

19.2%

Deduplicated Total

3,525

13,375

26.4%

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 11/14/17; consumers are counted only one time regardless of how many services they receive.

4a. New Hampshire Hospital: Adult Census Summary

Measure

July – September 2017

April – June 2017

Admissions

204

293

Mean Daily Census

153

153*

Discharges

206

292

Median Length of Stay in Days for Discharges

13 10

Deaths

0

0

Revisions to Prior Period: *April to June 2017 mean daily census was revised due to improved methodology.

Data Source: Avatar

Notes 4a: Data extracted 11/16/17; Mean Daily Census includes patients on leave and is rounded to nearest whole number

4b. New Hampshire Hospital: Discharge Location for Adults

Discharge Location

July – September 2017

April – June 2017

Home - Lives with Others

109

138

Home - Lives Alone

73

107

CMHA Monthly Progress Report

52

December 1, 2017

19.3% 10.3% 21.6% 25.3%

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 53 of 75

CMHC Group Home Private Group Home Nursing Home Hotel-Motel Homeless Shelter/ No Permanent Home Discharge/Transfer to IP Rehab Facility Secure Psychiatric Unit - SPU Peer Support Housing Jail or Correctional Facility Glencliff Home for the Elderly Unknown

5

9

3

7

3

6

3

5

3

5

2

4

1

3

1

3

1

3

1

1

1

1

4c. New Hampshire Hospital: Readmission Rates for Adults

Measure

July – September 2017

April – June 2017

30 Days

9.8% (20)

15.0% (44)

90 Days

21.6% (44)

24.2% (71)

180 Days

27.9% (57)

32.1% (94)

Revisions to Prior Period: None.

Data Source: Avatar

Notes 4b-c: Data compiled 11/13/17; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions lookback period includes readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day readmissions); patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

5a. Designated Receiving Facilities: Admissions for Adults
DRF

July – September 2017

CMHA Monthly Progress Report

53

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 54 of 75

Franklin Cypress Center Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total
DRF Franklin Cypress Center Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

Involuntary Admissions

Voluntary Admissions

NA

NA

69

178

93

270

6

54

61

60

NA

NA

April – June 2017

Involuntary Admissions

Voluntary Admissions

35

25

49

179

80

283

6

46

48

53

218

586

Total Admissions
NA 247 363
60 121 NA
Total Admissions
60 228 363
52 101 804

5b. Designated Receiving Facilities: Mean Daily Census for Adults

July – September

DRF

2017

Franklin

NA

Cypress Center

12.9

Portsmouth

23.9

Elliot Geriatric Psychiatric Unit

29.7

Elliot Pathways

12.2

CMHA Monthly Progress Report

54

April – June 2017
4.5 12.0 30.3 29.3 10.0
December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 55 of 75

Total

NA

17.2

*Portsmouth Regional Hospital has a total of 12 DRF beds and Elliot Hospital has a total of 14 DRF beds split between Pathways and the Geriatric Psychiatric Unit.

5c. Designated Receiving Facilities: Discharges for Adults

July – September

DRF

2017

April – June 2017

Franklin

NA

59

Manchester (Cypress Center)

243

232

Portsmouth

355

365

Elliot Geriatric Psychiatric Unit

63

54

Elliot Pathways

121

105

Total

NA

815

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges for Adults

July – September

April – June 2017

DRF

2017

Franklin

NA

6

Manchester (Cypress Center)

4

4

Portsmouth

4

5

Elliot Geriatric Psychiatric Unit

27

22

Elliot Pathways

7

8

Total

NA

5

5e. Designated Receiving Facilities: Discharge Location for Adults

DRF

July – September 2017

CMHA Monthly Progress Report

55

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 56 of 75

Assisted Living/Group
Home

Decease d

Other

NH

Hom Hospit Hospita

DRF e

al

l

Franklin

NA

NA NA NA NA

NA

Manchester (Cypress Center)

1

0

0 166

0

1

Portsmouth Regional Hospital

0

0

4 221

0

5

Elliot Geriatric Psychiatric Unit

45

4

1 12

0

1

Elliot Pathways

4

0

1 101

0

6

Total

NA

NA NA NA NA

NA

April – June 2017

Assisted

Other

NH

Living/Group Decease

Hom Hospit Hospita

DRF

Home

d DRF e

al

l

Franklin

2

0

1 44

0

1

Manchester (Cypress Center)

4

0

7 204

0

1

Portsmouth Regional Hospital

0

0

4 265

0

7

Elliot Geriatric Psychiatric Unit

32

6

0 10

6

0

Elliot Pathways

1

0

0 82

0

4

Total

39

6 12 605

6

13

*Dispositions to ‘DRF’ represent a change in legal status from Voluntary to Involuntary within the DRF.
5f. Designated Receiving Facilities: Readmission Rates for Adults

Other NA 10 59 0 9 NA
Other 11 16 89 0 18
134

CMHA Monthly Progress Report

56

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 57 of 75

July – September 2017

DRF

30 Days

90 Days

180 Days

Franklin

NA

NA

NA

Manchester (Cypress Center)

7.1% (12)

12.4% (21)

15.9% (27)

Portsmouth

11.5% (33)

17.5% (50)

21% (60)

Elliot Geriatric Psychiatric Unit

0% (0)

0% (0)

0% (0)

Elliot Pathways

3.3% (4)

6.6% (8)

12.4% (15)

Total

NA

NA

NA

April – June 2017

DRF

30 Days

90 Days

180 Days

Franklin

0.0% (0)

0.0% (0)

0.0% (0)

Manchester (Cypress Center)

4.8% (11)

9.2% (21)

13.2% (30)

Portsmouth

10.2% (37)

15.4% (56)

20.7% (75)

Elliot Geriatric Psychiatric Unit

3.8% (2)

3.8% (2)

5.8% (3)

Elliot Pathways

6.9% (7)

7.9% (8)

10.9% (11)

Total

7.1% (57)

10.8% (87)

14.8% (119)

Revisions to Prior Period: None.

Data Source: NH DRF Database

Notes: Franklin DRF was unable to report data for the quarter. As a result total DRF data is also unavailable. Data for the current quarter will be provided in the next quarterly report. Data compiled 11/13/17; discharge location of DRF are patients discharged back to the same DRF for a different level of care within the DRF; readmission rates calculated by looking back in time from admissions in study quarter; patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

6. Glencliff Home: Census Summary
Measure

July – September 2017

April – June 2017

CMHA Monthly Progress Report

57

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 58 of 75

Admissions

3

9

Average Daily Census

107

106

Discharges

2 (1- Dept. of Corrections, 1 – Nursing Facility)

2 (1 private apartment, 1 ABD/ residential care home)

Individual Lengths of Stay in Days for Discharges

115, 366

4507, 399

Deaths

4

3

Readmissions

0

0

Mean Overall Admission Waitlist

19 (12 Active)

17 (9 Active)

Revisions to Prior Period: None.

Data Source: Glencliff Home

Notes: Data Compiled 10/23/17; means rounded to nearest whole number; Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

7. NH Mental Health Consumer Peer Support Agencies: Census Summary
July – September 2017

April – June 2017

Peer Support Agency

Total Average Members Daily Visits

Total Average Members Daily Visits

Alternative Life Center Total

532

46

516

45

Conway

189

15

183

16

Berlin

102

10

108

11

Littleton

141

8

139

7

Colebrook

100

13

86

11

Stepping Stone Total

386

18

592

20

Claremont

308

12

493

14

CMHA Monthly Progress Report

58

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 59 of 75

Lebanon

78

6

99

6

Cornerbridge Total

293

20

390

17

Laconia

109

6

171

5

Concord

127

14

167

12

Plymouth Outreach

57

NA

52

NA

MAPSA Keene Total

208

11

190

14

HEARTS Nashua Total

247

37

510

31

On the Road to Recovery Total

516

53

568

41

Manchester

382

31

418

34

Derry

134

22

150

7

Connections Portsmouth Total

278

11

278

11

TriCity Coop Rochester Total

225

24

382

20

Total

2,685

167

3,426

158

Revisions to Prior Period: None

Data Source: Bureau of Mental Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 11/14/17; Average Daily Visits NA for Outreach Programs; Peer Support Agencies were instructed to "purge their member lists" as of July 1, 2017 impacting the Number of Members but not Average Daily Census. The Bureau of Mental Health Services has instructed Peer Support Agencies to "purge member lists" annually to increase confidence and consistency in this information.

8. Housing Bridge Subsidy Summary to Date

July – September 2017

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

CMHA Monthly Progress Report

59

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 60 of 75

Housing Bridge Subsidy

701

41

742

Section 8 Voucher

85

11

96

April – June 2017

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

643

58

701

Section 8 Voucher

85

0

85

Revisions to Prior Period: None

Data Source: Bureau of Mental Health

Notes: Data Compiled 11/14/17

9. Housing Bridge Subsidy Current Census Summary

Measure

As of 9/30/2017

As of 6/30/2017

Housing Slots

567

591

Rents currently being paid

509

545

Individuals accepted but waiting to lease

58

46

Waiting list for slots

0

0

Revisions to Prior Period: None

Data Source: Bureau of Mental Health

Notes: Data Compiled 11/14/17; all individuals currently on the Bridge Program are actively transitioning from the program (waiting for their Section 8 housing voucher).

10. Housing Bridge Subsidy Unit Address Density
Number of Unit(s)* at Same Address

Frequency as of 11/9/17

Frequency as of 8/11/17

1
CMHA Monthly Progress Report

383

391

60

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 61 of 75

2

31

37

3

6

6

4

5

6

5

0

3

6

0

0

7

1

2

8 or more

2

1

*All units are individual units

Revisions to Prior Period: None

Data Source: Bureau of Mental Health data compiled by Office of Quality Assurance and Improvement

Notes: Data Compiled 11/14/17

11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure

July 2017

August 2017

Septembe r
2017

July – Septembe
r 2017

April – June 2017

Unduplicated People Served in Month

165

198

216

579

530

Services Provided by Type Mobile Community Assessments Crisis Stabilization Appointments Office-Based Urgent Assessments Emergency Service Medication Appointments
CMHA Monthly Progress Report

47

61

65

173

124

15

13

9

37

64

15

11

31

57

96

29

40

41

110

47

61

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 62 of 75

Phone Support/Triage Walk in Assessments

200

290

231

721

469

4

4

6

14

11

Services Provided after Immediate Crisis
Mobile Community Assessments-Post Crisis
Crisis Stabilization Appointments
Office-Based Urgent Assessments
Emergency Service Medication Appointments
Phone Support/Triage

4

10

15

13

15

11

16

21

49

111

16

30

4

8

36

15

31

57

15

23

60

29

41

201

200

Referral Source Emergency Department/EMS Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal Self Other

14

9

23

46

42

24

34

15

73

96

1

2

2

5

4

0

1

22

23

2

4

13

2

19

32

1

7

4

12

15

5

7

4

16

15

17

14

3

34

53

66

100

126

292

223

3

11

15

29

21

CMHA Monthly Progress Report

62

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 63 of 75

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

33

25

23

81

84

124

95

91

310

319

3.8

3.8

4.0

3.8

3.8*

Law Enforcement Involvement

10

17

7

34

32

Hospital Diversions Total

123

159

161

443

430

Revisions to Prior Period: *Apartment Average Length of Stay for prior quarter was corrected

Data Source: Riverbend CMHC submitted reports

Notes: Data Compiled 11/15/17; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

63

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 64 of 75

11b. Mobile Crisis Services and Supports for Adults: Mental Health Center of Greater Manchester

Measure

July 2017

August 2017

Septembe r
2017

July – Septembe
r 2017

Unduplicated People Served by Month

186

180

209

476

April – June 2017
579

Services Provided by Type Phone Support/Triage Mobile Community Assessments Office-Based Urgent Assessments Emergency Service Medication Appointments Crisis Apartment Service

380

353

411

1,144

1,127

72

72

104

248

270

12

11

17

40

53

0

1

5

6

2

57

108

52

217

0

Referral Source* Emergency Department Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal Self Other
CMHA Monthly Progress Report

2

1

2

5

7

29

31

47

107

111

3

4

2

9

13

2

2

1

5

13

6

5

10

21

12

33

32

70

135

89

4

8

11

23

22

28

21

30

79

76

111

120

121

352

324

23

17

22

62

87

64

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 65 of 75

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

3

3

3

9

9

8

13

8

29

29

4.0

3.3

2.7

3.2

3.2

Law Enforcement Involvement

33

32

70

135

89

Hospital Diversion Total

241

241

316

798

821

Revisions to Prior Period: * Prior quarter Referral Source was corrected

Data Source: New Mobile Crisis Data Reporting System

Notes: Data Compiled 11/14/17; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

65

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 66 of 75

11c. Mobile Crisis Services and Supports for Adults: Harbor Homes

Measure

July 2017

August 2017

Septembe r
2017

July – Septembe
r 2017

Unduplicated People Served by Month

7

24

25

55

Services Provided by Type Phone Support/Triage Mobile Community Assessments Office-Based Urgent Assessments Emergency Service Medication Appointments Crisis Apartment Service

3

15

15

33

3

4

7

14

1

1

1

3

0

2

3

5

2

1

1

4

Referral Source Emergency Department Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Self Other
CMHA Monthly Progress Report

0

3

0

3

7

2

1

10

0

0

3

3

0

0

1

1

0

0

3

3

0

3

1

4

0

0

0

0

1

3

6

10

3

8

9

20

4

8

3

15

66

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 67 of 75

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

1

1

1

3

3

1

1

5

3

1

1

1.7

Law Enforcement Involvement

0

6

5

11

Hospital Diversion Total

7

24

18

49

Revisions to Prior Period: NA

Data Source: New Mobile Crisis Data Reporting System

Notes: Data Compiled 11/14/17; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

67

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 68 of 75

Appendix B New Hampshire Community Mental Health Agreement
Monthly Progress Reports July, August, September, 2017

CMHA Monthly Progress Report

68

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 69 of 75
New Hampshire Community Mental Health Agreement Monthly Progress Report
July, August, September 2017
New Hampshire Department of Health and Human Services December 1, 2017

CMHA Monthly Progress Report

69

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 70 of 75

CMHA Monthly Progress Report

70

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 71 of 75

Acronyms Used in this Report

ACT: BMHS: CMHA: CMHC: DHHS: SE: SFY:

Assertive Community Treatment Bureau of Mental Health Services Community Mental Health Agreement Community Mental Health Center Department of Health and Human Services Supported Employment State Fiscal Year

Background
This Monthly Progress Report is issued in response to the June 29, 2016 Expert Reviewer Report, Number Four, action step 4. It reflects the actions taken in July, August and September 2017, and month-over-month progress made in support of the Community Mental Health Agreement (CMHA) as of September 30, 2017. Three months of data is released in this singular report due to delays experienced in receiving data from the Community Mental Health Centers. Data contained may be subject to change upon further reconciliation with CMHCs. This report is specific to achievement of milestones contained in the agreed upon CMHA Project Plan for Assertive Community Treatment (ACT), Supported Employment (SE) and Glencliff Home Transitions. Where appropriate, the Report includes CMHA lifetime-to-date achievements.

71

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 72 of 75

Progress Highlights Assertive Community Treatment (ACT)

Goal CMHC fidelity to ACT evidencebased practice model annually assessed.
Provide ACT team services, consistent with standards set forth, with the capacity to serve at least 1,500 individuals.

Status 2017: 10 of 10 completed
2018: 4 of 10 completed
Capacity: July – 1,265 August – 1,256 Sept. – 1,242
Enrollment: July – 912 August – 904 Sept. – 915

Recent Actions Taken
 3 fidelity reports issued, improvement
plans in place; 4th report in process
 2018 fidelity reports compare progress
from 2017
 New improvement plan template
developed and implemented
 Ongoing technical assistance at CMHC
specific level delivered by external DHHS consultant
 Launched 6-part training series
6/27/17 for ACT team leaders, substance use specialists, and team members on Co-Occurring Disorders (COD) treatment within ACT. Series capacity permits 4 ACT staff per session; participation is high; one MCO also participates. Series runs through December 2017. Topics include: initial training on addiction and recovery; substance use and affects; screening, assessment and functional analysis; stage-wise psychosocial and medication interventions; motivational strategies for people with COD; and group treatments for people with COD.

Supported Employment (SE)

Goal CMHC fidelity to SE evidencebased practice model annually assessed.
Increase penetration rate of individuals with a Serious Mental Illness (SMI) receiving SE services to 18.6%.

Status 2017: 10 of 10 completed
2018: 3 of 10 completed
Statewide penetration rate: July – 25.8% August – 26.4% Sept. – 26.4%

Recent Actions Taken
 3 fidelity reports issued, improvement
plans in place
 2018 fidelity reports compare progress
from 2017
 New improvement plan template
developed and implemented
 Ongoing technical assistance at CMHC
specific level delivered by external DHHS consultant
 Held Supported Employment Basic
Training in July 2017; each CMHC was allowed 2 participants. Training designed for new SE specialists.

72

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 73 of 75

Glencliff Home Transitions into Integrated Community Setting

Goal Have capacity to serve in the community 16 (cumulatively) individuals with mental illness and complex health care needs residing at Glencliff who cannot be cost-effectively served in supported housing.

Status 14 of 16 completed14

By June 30, 2017, identify and maintain a list of all individuals with mental illness and complex health care needs residing at the Glencliff Home who cannot be cost-effectively served in supported housing and develop an effective plan for providing sufficient community-based residential supports for such individuals in the future.

Completed; ongoing

Recent Actions Taken
 In July 2017, a former Glencliff
resident, discharged originally in 2015, sought readmission to Glencliff as behavioral health issues intensified. Through methods used to effectuate integrated community setting transitions, the individual was transitioned to a 4-person community residence
 In November 2017, a resident
transitioned to the community residence developed in late 2016.
 Coordinating a 15th transition
anticipated to be occur in December 2017
 12 residents on the list
 11 of the 12 residents have selected
their CFI transition case management service provider to actively support transition needs; the 12th is in process

14 Indicates residents have been transitioned into an integrated community setting; compliance with additional CMHA requirements for such transitions is under review.
73

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 74 of 75

30.0%
SE Statewide Penetration Rate by Quarter/Monthly*
25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

Sep- Dec- Mar- Jun- Sep- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul-17 Aug- Sep-

15 15 16 16 16 16 17 17 17 17 17 17

17 17

* Data is a combination of preliminary monthly and finalized quarterly data from CMHA Quarterly Data Reports.

74

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 75 of 75 75

 
 Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 1 of 75
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Seven
January 10, 2017
I. Introduction
This is the seventh semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this six-month period (July 1, 2017 through December 31, 2017), the ER has continued to observe the State’s work to implement certain key service elements of the CMHA, and has continued to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. During this period, the ER:
 Conducted on site reviews of Assertive Community Treatment (ACT) and Supported Employment (SE) services at Community Partners and Seacoast Mental Health Centers. Non-random samples of ACT and SE records were reviewed at each site.
 Met with senior management and with a clinical team at NHH to review transition planning processes and issues;
 Met with Glencliff leadership, clinical staff, and a resident to discuss transition planning processes and issues;
 Met with the Mobile Crisis Team (MCT) of Harbor Homes, the agency selected to operate the MCT and crisis apartments in the greater Nashua region;
 Observed two five-day Quality Service Review (QSR) reviews; one at Genesis Mental Health Center; and one at the Center for Life Management;
 Met with the DHHS CMHA leadership team to discuss progress in the implementation of CMHA standards and requirements;

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 2 of 75
 Participated in several meetings with representatives of the Plaintiffs and the United States (hereinafter “Plaintiffs”);
 Met twice with DHHS Quality Management/Quality Service Review (QM/QSR) staff to discuss refinements to the QSR process; and
 Convened two all parties meetings to discuss design and implementation issues related to the QSR process and Glencliff transitions to integrated community settings.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
Summary of Progress to Date
Eighteen months ago the ER recommended a number of action steps and timelines intended to facilitate movement towards compliance with the CMHA and to increase transparency and accountability related to State actions under the aegis of the CMHA. The State agreed to implement these recommendations, and has made progress in certain areas of compliance and accountability. Specific progress related to these recommendations is summarized below:
1. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and time lines to achieve compliance with the CMHA requirements for ACT services;
ER Finding: The State has implemented this recommendation by circulating such a plan, and continues to track and report on its implementation of various action steps and limited progress towards compliance with CMHA requirements. However, as will be noted throughout this report, the State remains out of compliance with the ACT requirements of the CMHA. The ER expects the State to propose new and expanded initiatives and implementation strategies to be implemented to move the State closer to compliance in this critical area; and these new initiatives with attendant timelines must be included no later than March 1, 2018 in the ACT section of the monthly progress report. The most recent version of this report (October, 2017) is included as Appendix B to this report.
2. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA penetration rates and fidelity standards for SE throughout New Hampshire;
ER Finding: The State has implemented this recommendation by circulating such a plan, and continues to track and report on its implementation of various action steps and progress towards compliance with CMHA requirements. The State is in compliance with the statewide penetration rate standards for SE, but continues to work

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 3 of 75
aggressively with the four CMHCs that remain under the standard. Fidelity reviews resulted in Quality Improvement Plans for multiple CMHCs in 2017.
3. By August 1, 2016 circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA requirements to assist 16 residents of Glencliff with complex medical needs to move into integrated settings as soon as possible;
ER Finding: The State has implemented this recommendation by circulating such a plan and it continues to track and report on individuals with pending discharge plans. This plan, and the current status of compliance, is discussed in greater detail under the Glencliff Transitions section of this report.
4. Starting September 1, 2016, and each month following, submit to all parties a monthly progress report of the steps taken and completed under these respective plans to assure compliance with CMHA requirements as identified in this report;
ER Finding: The State has implemented this recommendation and continues to track and report on its progress, which varies depending on the sections of the plan. As noted above, the latest version of the monthly progress report is attached as Appendix B of this report.
5. By October 1, 2016, complete the field tests and technical assistance related to the Quality Service Review (QSR), convene a meeting with Plaintiffs to discuss any recommended design or process changes, and publish a final set of QSR documents governing the process for future QSR activities;
ER Finding: Working in concert with representatives of the plaintiffs and the ER, DHHS developed revised QSR instrumentation, instructions, and scoring algorithms. The revised QSR has been carried out at three of the Community Mental Health Centers. The ER participated in two of these on-site QSR reviews A more detailed discussion of progress with regard to the QSR is included under the QSR section of this report.
6. Complete at least one QSR site review per month between October 2016 and June 2017, with the exception of the month of December, and circulate to all parties the action items, plans of correction (if applicable), and updates on implementation of needed remedial measures (if applicable) resulting from each of these reviews;
ER Finding: See #5 above. It should be noted that all 10 of the CMHCs had an onsite QSR review using the previous instruments and protocols during the 2016-2017 period.
7. Starting July 1, 2016, circulate to all parties on a monthly basis the most recent data reports of the Central Team;

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 4 of 75
ER Finding: The State has implemented this recommendation by circulating monthly reports and it continues to track and report progress towards compliance with CMHA requirements.
8. No later than October 1, 2016, assure that final rules for supportive housing and ACT services are promulgated in accordance with the draft rules developed with input from all parties;
ER Finding: The Supported Housing (SH) and ACT rules have been promulgated, and incorporate positive elements resulting from discussions among DHHS staff and representatives of the Plaintiffs.
9. By October 1, 2016, augment the quarterly data report to include:
 ACT staffing and utilization data for each ACT team, not just for each region.
ER Finding: The State has implemented this recommendation.
 Discharge destination data and readmission data (at 30, 90, and 180 days) for people discharged from NHH and the other Designated Receiving Facilities (DRFs).
ER Finding: The State has now complied with this recommendation. The new data is included in the most recent Quarterly Data Report, which is included as Appendix A of this report.
 Reporting from the three Mobile Crisis programs, including hospital and ED diversions.
ER Finding: Data for the Mobile Crisis Teams and Crisis Apartments is now included in the Quarterly Data Report.
 Supportive housing data on applications, time until eligibility determination, time on waiting list, reason for ineligibility determination, and utilization of supportive services for those receiving supportive housing.
ER Finding: As of December 2017 DHHS has not produced the requested information. The ER expects the requested information to be provided to the ER and the Plaintiffs no later than March 1, 2018. Once produced, consideration can be given to including these data on a regular basis in the Quarterly Data Report.
10. By October 1, 2016, and then by December 1, 2016, factually demonstrate that significant and substantial progress has been made towards meeting the standards and requirements of the CMHA with regard to ACT, SE and placement of individuals with complex medical conditions from Glencliff into integrated community settings.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 5 of 75
ER Finding: The State remains out of compliance with the ACT standards of the CMHA. The State is making progress towards compliance with the Glencliff requirements in the CMHA. See more detailed discussion of these issues under the ACT and Glencliff Transitions sections of this report. The ER notes that the State remains in substantial compliance with the SE penetration rate requirements of the CMHA. The ER will continue to work with the State to document that: (a) that SE services are delivered with adequate intensity and duration to meet individuals’ needs; and (b) that SE services are resulting in integrated, competitive employment. As of December, 2017 DHHS has not produced data on the degree to which SE services are resulting in integrated, competitive employment. The ER expects that these data will be produced and delivered to the ER and the Plaintiffs no later than March 1, 2018. Once produced, consideration can be given to including these data on a regular basis in the Quarterly Data Report.
11. By October 1, 2016 demonstrate that aggressive executive action has been taken to address the pace and quality of transition planning from NHH and Glencliff through the development of a specific plan to increase the speed and effectiveness of transitions from these facilities.
ER Finding: The ER believes that both NHH and Glencliff have evidenced, at a leadership and a staff level, increased efforts and commitment to facilitating timely transitions to integrated community settings, albeit with modest result to date. Transitions from Glencliff to integrated community settings appear to be a priority now; nonetheless, only one person was scheduled to be discharged1 to an integrated community setting in the most recent quarter.
II. Data
The New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (July to September, 2017), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The ability to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve.
The Quarterly reports now include data from the mobile crisis services in the Concord, Manchester and Nashua Regions; data on discharge destinations from NHH, the DRFs, and Glencliff; admission, discharge and length of stay data for New Hampshire’s DRFs; and some data on utilization of the Housing Bridge Subsidy Program.
1 This person will actually be discharged in the current quarter, as modifications to the selected apartment were not able to be completed before the end of 2017.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 6 of 75
As noted in previous ER reports, there continue to be important categories of data that are needed, but not routinely collected and reported, and which will need to be reported in order to accurately evaluate ongoing implementation of the CMHA. For example, there continues to be no reported or analyzed data on the degree to which participants in SE are engaged in competitive employment in integrated community settings consistent with their individual treatment plans. These data are important in assessing the fidelity with which SE services are provided. DHHS’s efforts related to assuring the fidelity of SE services are discussed in the SE section of this report. In addition, revisions to the QSR instruments and protocols are expected to provide more information on the degree to which SE participants are attaining competitive employment.
Another gap in data is related to people receiving Supported Housing (SH) under the Housing Bridge Subsidy Program. These participants are not yet clearly identified in the Phoenix II system, and thus it is difficult to document the degree to which these individuals are: (a) connected to local CMHC services and supports; and (b) actually receiving services and supports to meet their individualized needs on a regular basis in the community. As noted in the January 2016 ER Report, DHHS has identified a strategy to link data from the Bridge Subsidy Program to the Phoenix II system. However, as noted above, these data have not yet been produced. Without the information above, the ER is unable to determine whether or not the State has achieved substantial compliance with the CMHA outcomes and requirements for SH. Other outstanding data requests include SH data on applications, time until eligibility determination, time on waiting list, and the reason for ineligibility determinations,
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile/Crisis Services and Crisis Apartments
The CMHA calls for the establishment of a MCT and Crisis Apartments in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC was selected to implement the MCT and crisis apartments in the Concord Region.
The CMHA specified that a second MCT and Crisis Apartments be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. Per CMHA V.C.3(c), a third MCT and Crisis Apartment program became operational in the Nashua region on July1, 2017. The contract for that program was awarded to Harbor Homes in Nashua.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 7 of 75
Table I below includes the most recent available information on activities of the three currently operational crisis programs.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 8 of 75

Table I

Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs in the Concord, Manchester and Nashua Regions:

Total unduplicated people served Services provided in response to immediate crisis:
 Phone support/triage  Mobile assessments  Crisis stabilization
appointments  Emergency services
medication appointments  Office based urgent
assessments Services provided after the immediate crisis:
 Phone support/triage  Mobile assessments  Crisis stabilization
appointments  Emergency services
medication appointments  Office based Urgent
Assessments

Concord July – September 2017
579
721 173 37
110 57
201 30 36 60 57

Manchester July – September 2017
476

Nashua July – September 2107
55

1,144

33

248

14

6

5

40

3

Referral source:

 Self

292

352

20

 Family

73

107

10

 Guardian

23

5

1

 Mental health provider

19

21

3

 Primary care provider

16

23

0

 Hospital emergency

46

5

3

department  Police  CMHC Internal

12

135

4

34

79

10

Crisis apartment admissions:

81

9

3

 Bed days

310

29

5

 Average length of stay

3.8

3.2

1.7

Law enforcement involvement

34

135

11

Total hospital diversions*

443

798

49

*Hospital diversions are instances in which services are provided to individuals in crisis resulting in diversion from

being assessed at the ED and/or being admitted to a psychiatric hospital.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 9 of 75
The Quarterly Data Report in Appendix A contains some historical data for the Concord and Manchester MCTs.
As noted in the previous report, the ER is concerned that the ratio of mobile team responses to the total number of crisis calls seems low. In addition, the number of hospital diversions reported by the MCTs seems to be high, given the number of interventions that do not include a mobile, face to face encounter. The ER will continue to work with the State to document: 1) the number of times a mobile team was requested but not dispatched, and the reason for that decision; 2) the criteria used to determine whether a mobile versus office-based response is appropriate; and 3) the number of times a mobile response was determined to be appropriate, but the team could not be dispatched in a timely way. The ER will also continue to explore with the State the numbers and types of hospital diversions that are reported by the MCTs. The ER notes that overall psychiatric admissions have not been substantially reduced in regions served by the MCTs. There could be a number of reasons for this trend, and at this point it is not clear whether this trend reflects on the existing MCTs.
DHHS has added questions to the QSR interview guides to elicit information about the quality and effectiveness of the MCTs and Crisis Apartments, and to report on that information in the updated QSR instrument. This is one way to determine if individuals who would have benefited from a mobile crisis response received the crisis support their situation required. To date, the CMHC regions for which the revised QSR has been conducted do not have MCT services, and thus it is not possible to report the results of the new QSR questions for those sites.
Assertive Community Treatment (ACT)
ACT is a core element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team;
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time; and
4. By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.
The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015 (24 months ago). Further, as of June 30, 2016, the State was required to have the capacity to provide ACT to 1,500 priority Target Population individuals.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 10 of 75

As displayed in Table II below, the staff capacity of the 12 adult ACT teams in New Hampshire has increased by only 8.03 FTEs (6.91%) since December of 2016. During the same time period, the twelve ACT teams added a total of 153 service participants, an increase of 18.24% (See Table III below).
Table II
Self-Reported ACT Staffing (excluding psychiatry): December 2016 – September 2017

Region

FTE Dec-16

FTE Mar-17

Northern West Central Genesis Riverbend Monadnock Greater Nashua 1 Greater Nashua 2 Manchester – CTT Manchester MCST Seacoast Community Partners Center for Life Management Total

11.49 5.5 11 9
7.25 6.25 5.25 15.53 21.37 9.53 6.85 7.17 116.19

11.89 7.75 11 10 6.7 6.25 5.25
14.79 21.86
9.53 4.08
8.3 117.4

FTE Jun-17
12.54 7.15 10.6 10 8.5 5.25 5.25
16.57 21.95
9.53 8.53
9.3 125.17

FTE % change Sep-17 Dec-Sept

12.43 6.95 10.8 10 7.9 6 5
16.27 22.31 10.53
6.73 9.3
124.22

8.18% 26.36% -1.82% 11.11%
8.97% -4.00% -4.76% 4.76% 4.40% 10.49% -1.75% 29.71% 6.91%

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 11 of 75

Table III

Self-Reported ACT Caseload (Unique Adult Consumers) by Region per Quarter: December 2016 – September 2017

Region

Active Cases Dec-16

Active Cases Mar-17

Active Cases Jun-17

Active Cases Sep-17

% change Dec-Sept

Northern

104

108

111

113

8.65%

West Central

32

53

76

68

112.50%

Genesis

64

70

74

74

15.63%

Riverbend

73

83

97

87

19.18%

Monadnock

63

64

70

69

9.52%

Greater Nashua

74

83

94

98

32.43%

Manchester

248

270

292

287

15.73%

Seacoast

65

64

69

67

3.08%

Community Partners

70

67

69

75

7.14%

Center for Life Management

47

55

55

54

14.89%

Total*

839

* unduplicated across regions

913

1,006

992

18.24%

It is clear from these tables that overall ACT staffing has remained low, and in four regions has decreased over the past four reporting periods. Four of the 12 adult ACT teams have fewer than the 7 - 10 professionals specified for ACT teams in the CMHA, as opposed to the two teams with reported staffing below the defined threshold noted in the previous report. Two teams continue to report having no peer specialist on the ACT Team. Five teams report having at least one FTE peer specialist, but that means that seven of the 12 teams continue to report having less than one FTE peer on the team. Five teams have at least 1.0 FTE supported employment staff, while seven continue to have less than a full time SE specialist on the ACT team. Five teams report having less than .5 FTE combined psychiatry/nurse practitioner time available to their ACT teams2; two teams report having less than 0.5 FTE nursing on the team; and seven of the 12 teams report having less than one FTE nurse per team.
The combined ACT teams have a reported September 2017 staff complement of 124.22 FTEs, which is sufficient capacity to serve 1,242 individuals based on the ACT staffing ratios contained in the CMHA. With a current statewide caseload of 992, the existing teams should theoretically be able to accept an additional 250 new ACT clients without adding any more staff. Tapping
2 The CMHA specifies at least .5 FTE Psychiatrists for teams with at least 70 active service participants. (CMHA V.D.2(e).

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 12 of 75
into this unused capacity, with appropriate outreach and targeting, should have an impact on alleviating ED boarding and hospital readmission rates across the state. Further, the CMHA requires the State to have capacity to serve 1,500 individuals, but the current ACT capacity of 1,242 is 258 below CMHA criteria.
It is clear from the above tables that State initiatives to expand ACT capacity have had some success, and that overall ACT staffing capacity and active caseloads in most parts of the state have increased in the past year. However, as noted in previous reports, the current pace of staffing increases in combination with client outreach and engagement together are still not sufficient to meet CMHA requirements for ACT team capacity.
Based on the above information, the ER finds that the State remains out of compliance with the foundational service standards described in Section V.D. of the CMHA. The State does not currently provide a robust and effective system of ACT services throughout the state as required by the CMHA.
Additionally, the State has yet to finalize a process for identifying all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and to develop effective regional and statewide plans for providing sufficient ACT services.
As noted in recent ER Reports, the New Hampshire DHHS has taken more aggressive action to work with CMHCs in certain Regions to increase their ACT staffing and caseloads. These actions include: (a) monthly ACT monitoring and technical assistance with DHHS leadership and staff; (b) implementation of a firm schedule for ACT self-assessments and DHHS fidelity reviews; (c) incorporating a small increase in ACT funding into the Medicaid rates for CMHCs; (d) active on-site monitoring and technical assistance for CMHCs not yet meeting CMHA ACT standards; and (e) substantial and coordinated efforts to address workforce recruitment and retention.
However, external and self-reported fidelity reviews for the 10 CMHC regions have revealed deficient practices that are not in fidelity with the ACT model. Compliance letters and Performance Improvement Plans (PIPs) have been initiated in several of the Regions. The ER continues to work with the State to assure that these PIPs have been implemented.
Initial QSR reports also revealed that several CMHCs failed to ensure individuals were receiving ACT services using the ACT fidelity model team approach, and with the appropriate frequency to address their individual treatment needs. The ER has emphasized to the State that the QSR process must measure the adequacy and effectiveness of individual ACT service provision, in order to demonstrate that these deficiencies are being corrected. The ER continues to monitor the implementation of quality improvement plans developed by CMHCs in response to these QSR findings.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 13 of 75
The ER believes the State, DHHS and many of the CMHCs are making good faith efforts to meet the ACT capacity and fidelity standards of the CMHA. Despite the continued compliance issues noted above, the ER believes there have been improvements in the quality and effectiveness of ACT services provided in most parts of the state. Nonetheless, while these improvements are welcome, it must be noted that the State is still far from compliance with the ACT standards of the CMHA. As with previous reports, the ER expects DHHS and the CMHCs to make use of capacity already available in the system at all deliberate speed, while at the same time addressing additional capacity and fidelity issues.
DHHS and the CMHCs have been attempting to identify individuals at risk of hospitalization, incarceration or homelessness who might benefit from ACT services. Individuals boarding in hospital emergency departments waiting for a psychiatric hospital admission, or who have done so in the recent past, are one important source of potential referrals. DHHS is currently tracking the extent to which identifying and referring these individuals to CMHCS is: (a) reducing ED boarding episodes and lengths of stay; and (b) resulting in enrollment of new qualified individuals in ACT services. As noted in the hospital readmission discussion below, almost onethird of all those discharged out of NHH return for readmission within 180 days. Robust ACT services can help to reduce the number of hospital readmissions throughout the state if affected individuals are promptly screened and referred, and their regional ACT teams have the capacity to deliver needed services. The ER has requested that the State provide a report of the results of these activities. The State has agreed to provide such a report, but at the time of this report such data had not been made available. As a result, the ER can make no findings regarding the scope or efficacy of ongoing outreach and screening procedures for ACT. However, given the over 18 percent increase in ACT utilization noted in Table III, it is possible these initiatives have begun to have some effect on the system.
The State has identified workforce recruitment and retention issues as being a major factor limiting the growth and expansion of the ACT teams. The State has been working collaboratively with the New Hampshire CMHC Association to identify and track workforce gaps and shortages, and to implement a variety of strategies to improve workforce recruitment and retention. The almost seven percent increase in ACT staffing capacity over the past nine months may be some evidence that these strategies are beginning to produce results.
The ER emphasizes, as in past reports, that it must be the first priority of the State and the CMHCs to focus on: 1) assuring required ACT team composition; 2) utilizing existing ACT team capacity; 3) increasing ACT team capacity; and 4) outreach to and enrollment of new ACT clients. As noted earlier in this report, the ER expects the State to propose new and expanded strategies for increasing ACT capacity to meet the requirements of the CMHA. The strategies and related timelines are to be incorporated into the ACT plan and Monthly Progress Report.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 14 of 75

Supported Employment

Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment …to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by June 30, 2017 “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)).

For this reporting period, the State reports that it has achieved a statewide SE penetration rate of 26.4 percent, 42 percent above the 18.6% penetration rate target specified in the CMHA. Table IV below shows the SE penetration rates for each of the 10 Regional CMHCs in New Hampshire.

Table IV

Self-Reported CMHC SE Penetration Rates

Penetration Penetration Penetration Penetration

Dec-16

Mar-17

Jun-17

Sep-17

Northern West Central Genesis Riverbend Monadnock Greater Nashua Manchester Seacoast Community Part. Center for Life Man. CMHA Target Statewide Average

27.00% 21.50% 14.50% 13.80% 17.90% 12.40% 43.10% 12.00% 6.80% 21.10% 18.10% 22.90%

32.30% 23.20% 12.60% 15.00% 13.50% 15.00% 39.80% 14.40% 7.20% 19.70% 18.60% 23.20%

37.20% 22.50% 22.00% 14.80% 14.00% 16.10% 40.00% 19.30% 10.30% 21.60% 18.60% 25.30%

40.90% 22.30% 20.70% 14.00% 12.30% 17.10% 42.00% 23.40% 14.60% 19.20% 18.60% 26.40%

As noted in Table IV, the State has exceeded the statewide CMHA penetration rate in recent reporting periods. In the previous ER report, six of the ten regions fell below required CMHA

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 15 of 75
penetration rates. For this reporting period, four of the ten continue to report penetration rates lower than the CMHA requirement. The New Hampshire DHHS is to be commended for continuing its efforts to: (a) measure the fidelity of SE services on a statewide basis; and (b) work with the Regions with penetration rates below CMHA criteria to increase access to and delivery of SE services to target population members in their Regions. The ER will continue to monitor these issues going forward as the State works with the CMHCs to increase penetration rates to at least 18.6 percent in all regions. As with ACT services, the DHHS has implemented a combination of contract compliance, technical assistance, workforce recruitment and retention, and internal and external fidelity reviews in an attempt to assure sufficient quality and accessibility of SE services statewide. There is currently no mechanism for measuring whether individuals are receiving SE services consistent with their individual treatment plans, or whether SE services are delivered in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings (V.F.1). In addition, as noted earlier in this report, there is no standard reporting of the extent to which SE participants are gaining integrated competitive employment. The ER has recommended that the QSR process measure whether and to what extent SE services are being delivered consistent with these requirements of the CMHA. As noted above, the ER expects the State to produce the requested data on SE integrated competitive employment by March 1, 2018.
Supported Housing
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Subsidy Program by June 30, 2016. As of September 2017, DHHS reports having 509 individuals in leased SH apartments, and 58 people approved for a subsidy but not yet leased. The number of people with rents paid has fallen by 36 compared to the prior quarter; the total number of slots has decreased from the prior quarter by 24 – from 591 slots to 567 slots. The State is in compliance with the CMHA numerical standards for SH effective June 30, 2016, but as is discussed below, not yet in compliance with 2017 CMHA criteria.
Table V below summarizes recent data supplied by DHHS related to the Bridge Subsidy Program.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 16 of 75

Table V

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

September 2015 through September 2017

Bridge Subsidy Program
Information

March 2016

Sept. 2016

Dec. 2016

March 2017

June 2017

Sept. 2017

Total housing slots

450

479

513

553

591

567

(subsidies) available

Total people for whom rents are being subsidized

415

451

481

505

545

509

Individuals accepted 22

28

32

48

46

58

but waiting to lease

Individuals currently 0

0

0

0

0

0

on the wait list for a

bridge subsidy

Total number served 518

603

643

675

701

742

since the inception

of the Bridge

Subsidy Program

Total number

71

83

83

85

85

96

receiving a Housing

Choice (Section 8)

Voucher

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table VI below displays the reported number of units leased at the same address.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 17 of 75

Table VI

Self-Reported Housing Bridge Subsidy Concentration (Density)

Sept. March June Nov. 2015 2016 2016 2016

Feb. May Nov. 2017 2017 2017

Number of

properties with one

leased SH unit at

290

the same address

317 325 339

349 367 383

Number of properties with two SH units at the 27 same address

22

35

24

23

36

31

Number of

properties with

three SH units at

2

13

8

13

14

5

6

the same address

Number of

properties with

four SH units at

4

the same address

1

1

3

4

4

5

Number of properties with five SH units at the 1 same address

2

2

0

0

3

0

Number of

properties with six

SH units at the

1

same address

0

1

1

1

1

0

Number of properties with seven + SH units at same address

0

2

3

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 18 of 75
These data show that 85% of the leased units are at a unique address or with one additional unit at that address. This supports a conclusion that the Bridge Subsidy Program, to a large degree, is operating as a scattered-site program. For the units shown in Table VI at the same address, it is not known at this time whether the unit density standards included in the CMHA are being met. DHHS is collecting information on the total units in each property where there are two or more Bridge units at the same address, and this data will be reported when it is made available.
It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)). DHHS reports, and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge Subsidy Program units.3
As noted in the Data section of this report, current data is not available on the degree to which Bridge Subsidy Program participants access and utilize support services and whether or not the services are effective and meet individualized needs. Receipt of services is not a condition of eligibility for a subsidy under the Bridge Program, but the CMHA does specify that “…supported housing includes support services to enable individuals to attain and maintain integrated affordable housing, and includes support services that are flexible and available as needed and desired….” (V.E.1(a)). As noted in the 2016 and 2017 ER Reports, DHHS has been working on a method to cross-match the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. This will allow documentation of the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports. As of the writing of this report, the ER has not received this requested information from the state. The ER expects that such information will be produced and delivered to the ER no later than March 1, 2018. The ER will also work with the State to review and analyze data to determine whether or not individuals have experienced improved outcomes after obtaining supported housing.
In previous reports the ER has identified a number of important and needed data elements associated with the SH eligibility criteria and lack of a waitlist, as well as monitoring implementation of the SH program in the context of the CMHA. These include:
 Total number of Bridge Subsidy Program applicants per quarter;  Referral sources for Bridge Subsidy Program applicants;  Number and percent approved for the Bridge Subsidy Program;  Number and percent rejected for the Bridge Subsidy Program;
o Reasons for rejection of completed applications, separately documenting those who are rejected because they do not meet federal HCV/Section 8 eligibility requirements;
 Number and disposition of appeals related to rejections of applications;
3 DHHS reports that currently there is one voluntary roommate situation reflected in the above data.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 19 of 75
 Elapsed time between application, approval, and lease-up;  Number of new individuals leased-up during the quarter;  Number of terminations from Bridge subsidies per quarter;  Reasons for termination:
o Attained permanent subsidized housing (Section 8, public housing, etc.); o Chose other living arrangement or housing resource; o Moved out of state; o Deceased; o Long term hospitalization; o Incarceration; o Landlord termination or eviction; or o Other;  Number of Bridge Subsidy Program participants in a roommate situation; and  Lease density in properties with multiple Bridge Subsidy Program leases.
This information is important in assessing whether eligibility is properly determined, whether a waitlist is properly maintained, whether or not support services are adequate to enable the individual to “attain and maintain integrated affordable housing,” and whether services are “flexible and available as needed and desired.” Most rental assistance programs collect and report such information, given its intrinsic value in monitoring program operations. Further, such data enhances DHHS’ ability to demonstrate the timeliness and effectiveness of access of the priority target population to this essential CMHA program component. Most importantly, this data is necessary to help the ER determine compliance with CMHA Sections IV.B, IV.C, and VII.A. The ER will continue to work collaboratively with DHHS to identify sources and methods for such data collection and reporting. As noted above, the state has yet to produce or deliver the requested information. And, as noted above, the ER expects production of all requested information pertaining to the SH program to be produced no later than March 1, 2018.
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain HUD funding for an additional 150 supported housing units for a total of 600 supported housing units.” (CMHA V.E.3(e)) In 2015 New Hampshire applied for and was awarded funds to develop a total of 191 units of supported housing under the HUD Section 811 Program. All of these units will be set aside for people with serious mental illness. As of the date of this report, nine of these new units have been developed and are currently occupied by members of the target population and an additional 69 units are in the development pipeline. It should be noted that over the life of the Bridge Subsidy Program the State has accessed 96 HUD Housing Choice Vouchers (HCV – Section 8). These have allowed the State to free up 96 Bridge Subsidy units for new applicants. Nonetheless, the current number of SH slots and units is below the 600 figure set out in the CMHA.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 20 of 75
In addition, the CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.” The ER notes that the State is still not maintaining or reporting on a wait list of people within the target population who are waiting for supported housing services. The State has shared information from October 2017 indicating that 20 individuals who could be discharged from New Hampshire Hospital remain unnecessarily hospitalized because of homelessness, that an additional 10 individuals are similarly stuck at NHH because they are awaiting transitional housing, and that 10 Glencliff residents referred to the Central Team were determined to have residential discharge barriers. Some of these individuals may be ineligible for Bridge housing but nonetheless fall within the Target Population and require supported housing. The ER expects that by March 1, 2018 the State will identify such individuals in a waitlist and maintain that waitlist going forward as required by the CMHA.
Transitions from Institutional to Community Settings
During the past 30 months, the ER has visited both Glencliff and NHH on at least six separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities late last year. Transition planning activities related to specific current residents in both facilities have been observed, and a small non-random sample of resident transition records has been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities.
The ER has participated in four meetings of the Central Team. The CMHA required the State to create a Central Team to overcome barriers to discharge from institutional settings to community settings. The Central Team has now had about 24 months of operational experience, and has started reporting data on its activities. To date, 34 individuals have been submitted to the Central Team, 21 from Glencliff and 13 from NHH. Of these, the State reports that 13 individual cases have been resolved4, two individuals are deceased, and 19 individual cases remain under consideration. Table VII below summarizes the discharge barriers that have been identified by the Central Team with regard to these 19 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total substantially higher than the number of individuals reviewed by the Central Team.
4 Two of these individuals were readmitted to NHH after 90 days, and the discharge dispositions for these two individuals are being reviewed.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 21 of 75

Table VII

Discharge Barriers for Open Cases Referred from NHH and Glencliff to the Central Team:

October 20175

Discharge Barriers

Number for Glencliff

Number for NHH

Legal

3 (10.3%)

4 (21.1%)

Residential

10 (34.5%)

5 (26.3%)

Financial

6 (20.7%)

3 (15.8%)

Clinical

7 (24.1%)

3 (15.8%)

Family/Guardian

1 (3.4%)

2 (10.5%)

Other

2 (6.9%)

2 (10.5%)

Although this Report notes increased efforts and leadership at the State level with regard to the

operations of the Central Team, the ER expects that the total number of referrals will grow, and

the pace at which individual barriers are resolved will quicken, over the next six month period.

Glencliff

In the time period from April through September, 2017, Glencliff reports that it has admitted 12 individuals, and has had four discharges. The average daily census through this period was 106.5 people. There have been no readmissions during this time frame. The wait list for admission has increased slightly, from 17 people in the previous quarter to 19 people for this quarter. Four discharges have been effectuated during this period; one of which was to an integrated community setting. Two current residents are in active transition planning, and both of whom are expected to be transitioned to integrated community settings within the next several months.

CMHA Section VI requires the State to develop effective transition plans for all appropriate residents of NHH and Glencliff and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]6 individuals with mental illness and complex health care needs residing at Glencliff….” The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be cost-effectively served in supported housing.”7 The ER notes that Glencliff continues to support and effectuate transitions of individuals to integrated community settings under a variety of other funding and living arrangements.

5 This is a point in time report for open cases. 6 Cumulative from CMHA V.E.(g), (h), and (i). 7 CMHA V.E.2(a)

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 22 of 75
DHHS reports that the total number of people with complex health conditions transitioned from Glencliff to integrated settings since the inception of the CMHA three years ago increased this quarter from 12 to 14. A fifteenth person is scheduled to transition to an individual apartment as soon as necessary modifications are completed. There are currently 12 individuals undergoing transition planning who could be transitioned to integrated community settings once appropriate living settings and community services become available. Ten of these individuals have been assigned to Choices for Independence (CFI) waiver case management agencies.
DHHS has agreed to provide the ER information about the recent transitions, including clinical summaries, lengths of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in the integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions who could not be cost-effectively be served in supported housing continue to experience transitions to integrated community settings.
Of the 14 individuals reported by DHHS to have transitioned to community settings since the onset of the CMHA, the ER agrees five meet the criteria of being medically complex and not able to be cost effectively served in supported housing. Three of these individuals currently reside in a newly developed small scale community residence, and two are living in enhanced family care homes (EFCs) with extensive Medicaid and non-Medicaid services. A sixth person with complex medical needs will be transitioned, as noted above, once apartment modifications are complete.
DHHS has also begun to implement certain action steps to enhance the process of: (a) identifying Glencliff residents wishing to transition to integrated settings; and (b) to increase the capacity, variety and geographic accessibility of integrated community settings and services available to meet the needs of these individuals. Both sets of initiatives should facilitate and speed up such community transitions for additional Glencliff residents.
As noted in the previous report, the ER is at this point reluctant to focus too narrowly on clinical conditions and sets of health, mental health and community services and supports for transitioned and transitioning individuals to monitor the State’s progress in assisting Glencliff Home residents to transition to integrated community settings. The ER will monitor the extent to which DHHS, Glencliff, the CMHCs and an array of other community partners collaborate to effectuate as many such transitions as possible over the next two years. The primary thrust and intent of the CMHA is to assure that individuals residing in Glencliff (and their families and guardians) are offered and are willing to accept meaningful opportunities to transition to integrated community settings. It appears likely that the specific requirement in the CMHA for the State to create capacity to serve 16 individuals with complex medical conditions who cannot be costeffectively served in supported housing will be attained if DHHS and its partners continue to increase the availability of integrated community settings, and provide meaningful in-reach and transition planning for Glencliff residents.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 23 of 75
Thus, the ER will continue to monitor the following topics/items going forward:
1. The number of transitions from Glencliff to integrated community settings per quarter. The ER will also monitor information about the clinical and functional level of care needs of these individuals; the integrated settings to which they transition; and the array of Medicaid and non-Medicaid mental health and health-related services and supports put in place to meet their needs to assure successful integrated community living.
2. The number of Glencliff residents newly identified per quarter to engage in transition planning and move towards integrated community settings. The ER will also monitor at a summary level the clinical and functional level of care needs of individuals added to the transition planning list per quarter.
3. New integrated community setting providers with the capacity to facilitate integrated community living for Glencliff residents. These could include EFCs, AFCs, and new small-scale community residential capacity for people with complex medical conditions who cannot be cost-effectively served in supported housing. The ER will monitor DHHS activities and successes relative to identification and engagement of new community providers who express willingness and capacity to provide services in integrated community settings for people transitioning from Glencliff.
4. Within the discharge cohort, the number of transitioned individuals for whom the State special funding mechanism is utilized to effectuate the transition, and the ways in which these funds are used to fill gaps in existing services and supports.
5. Number and types of in-reach visits and communications by CMHCs and other community providers related to identifying and facilitating transitions of Glencliff residents to integrated community settings.
6. Specific documentation of efforts to overcome family and/or guardian resistance to integrated community transitions for Glencliff residents.
7. Number of individuals engaged in transition planning referred to the Central Team; number of these individuals who successfully transition to an integrated community setting; and the elapsed time from referral to resolution.
Preadmission Screening and Resident Review (PASRR)
The State DHHS has provided recent data on PASRR screens for the period August 1, 2017 through October 31, 2017.
Table VIII below provided a high level summary of these data.
Table VIII
PASRR Level I and Level II Screens: 8/1/2017-10/31/20178
8 Note that reporting of PASRR data is not currently on the same quarterly basis as most of the other data in this report.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 24 of 75

Place of Residence at time of screen Assisted Living Facility Group Home Home Homeless Shelter Inpatient Hospital Inpatient Psychiatric Facility Nursing Facility Other
Total

PASRR Level I 7 10 56 2 35 7 41 1 159

PASRR Level II 2 6 10 1 16 2 21 1 59

According to the data provided by DHHS, 54 of the Level I screens in the time frame resulted in a referral for a Level II screen.9 Of these, 35 (65%) were referred because of mental illness; and 7 (13%) were for ID/DD. In this reporting period a total of 59 PASRR Level II screens were completed: 39 (59.7%) received full approval with no special services (SS)10; 4 (6.8%) were approved with SS; 14 (23.7%) received provisional approval with no SS; and 2 (3.4%) received provisional approval with SS.
From the data provided it is not possible to determine the disposition results for people referred for Level II screening by reason of mental illness versus those referred for ID/DD or other reasons. Nor is it possible to identify people within either the Level I or Level II categories that were referred to potential integrated community living alternatives. Finally, it is not possible to distinguish which among the Level I and Level II screens might represent a person referred or admitted to Glencliff.
The ER notes that PASRR screens are typically completed before a person is referred to Glencliff, since Glencliff requires that applicants be rejected by at least three nursing facilities before being considered for admission to Glencliff. Thus, a PASRR screen by itself might only indirectly impact admission decisions to Glencliff. Nonetheless, during the up-coming six month period the ER plans to review the individual PASRR screen documents for recent referrals and admissions to Glencliff.
New Hampshire Hospital and the Designated Receiving Facilities (DRFs)
For the time period April through September 2017, DHHS reports that NHH effectuated 497 admissions and 498 discharges. The mean daily census was 153, and the median length of stay for discharges was 13 days in the most recent quarter.

9 Referrals for Level II screens could have originated in a previous reporting period, so the number of referrals reported would not necessarily correspond to the number of completed Level II screens completed in the period. 10 Special services are to be provided over and above the nursing facility services that are included within the facility’s regular reimbursement rate.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 25 of 75

Table IX below compares NHH discharge destination information for the five most recent reporting periods (9/2015 through 9/2017). The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.

Table IX

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Discharge Destination

Percent September
2015 through April 2016

Percent October and November
2016

Percent January through March 2017

Percent April through
June 2017

Percent July through September
2017

Home – live alone or with others

80.2%

85.1%

84.5%

85.66%

88.3

Glencliff

0.60%

0.36%

1.55%

0,35%

0.49%

Homeless Shelter/motel

2.7%

2.54%

2.71%

3.5%

2.94%

Group home 5+/DDS supported living, etc.

3.2%

1.62%

5.7%

5.59%

3.92%

Jail/corrections 1.4%

2.9%

0.8%

1.05%

0.49%

Nursing home/rehab facility

0.80%

3.6%

1.9%

3.50%

2.45%

The State now consistently reports information on the hospital-based DRFs and The Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and analyze it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. The ER appreciates the State gathering this information. Table X summarizes this data.
Table X

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 26 of 75

Self-Reported DRF/APRTP Utilization Data: January 2016 through September 2017

Admissions Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017 April - June 2017 July - September 2017

Frankli n

Cypress

Portsmout h

Eliot Geriatric

Eliot Pathway
s

69

257

46

65

121

79

205

378

49

92

37

207

375

54

114

39

217

310

43

72

65

204

317

48

138

60

228

363

52

101

NA**

247

363

60

121

Total
558 803 787 681 772 804 NA

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017 April - June 2017 July - September 2017

53.70% 55.70% 43.20% 53.80% 70.70% 58.30% NA**

18.70% 24.40% 29.50% 28.60% 34.30% 21.50% 27.90%

NA 20.40% 18.90% 17.10% 21.80% 22.00% 25.60%

18.50% 4.10% 13.00% 16.30% 12.50% 11.50% 10.0%

30.60% 48.90% 44.70% 43.10% 43.50% 47.50% 50.40%

26.20%* 25.50% 26.20% 25.60% 32.50% 27.10%
NA

Average Census

Jan - March 2016

7.9

14.7

April - June 2016

7.8

13.2

July - Sept 2016

4.5

13.6

Oct – Dec 2016

5.6

12.4

Jan - March 2017

5

14.6

April - June 2017

4.5

12

July - September 2017

NA**

12.9

NA

19.7

18.1

60.1*

21.4

22.5

16.9

81.8

23.2

25.6

14.5

81.4

23.4

24.8

11.5

77.7

27.2

31.2

24.6

102.6

30.3

29.3

10

86.1

23.9

29.7

12.2

NA

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 27 of 75

Discharges Jan - March 2016 April - June 2016 July - Sept 2016 Oct - Dec 2016 Jan - March 2017 April - June 2017 July - September 2017

Frankli n

Cypress

Portsmout h

Eliot Geriatric

Eliot Pathway
s

76

261

NA

57

122

78

206

363

51

90

35

213

380

64

113

41

213

309

46

75

65

211

305

49

130

59

232

365

54

105

NA**

243

355

63

121

Mean LOS for Discharges

Jan - March 2016

8.6

4.2

April - June 2016

6

4

July - Sept 2016

7

5

Oct - Dec 2016

5

5

Jan - March 2017

5

4

April - June 2017

6

4

July - September 2017 NA**

4

NA

15

7.4

4

28

7

4

24

8

5

24

8

5

27

7

5

22

8

4

27

7

* Does not include Portsmouth ** Franklin DRF did not report data for the July - September period.

Total
516* 788 805 684 760 815 NA
8.8* 5 5 5 5 9 NA

The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and should also reduce the number of people waiting for psychiatric admissions in hospital EDs. As will be discussed in a later section of this report, the State has received funding for additional general hospital DRF beds. The DRF discharge cohort may also be a good source of referrals to CMHCs for ACT or other best practice community services. The ER will continue to work with DHHS to monitor the degree to which DRF functions and activities support the overall objectives of the CMHA.
DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table XI below provides a summary of these recently reported data.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 28 of 75

Table XI Cumulative Self-Reported Discharge Dispositions for DRFs in New Hampshire
October 2016 through September 2017

Disposition

Franklin Cypress Portsmouth Eliot

Eliot

**

Geriatric Pathways

Total

Home

136

744

900

43

357

2,180

NHH

5

6

29

1

12

53

Residential

6

10

0

134

7

157

Facility/

Assisted

Living

Other DRF

1

20

9

2

2

43

Hospital

2

0

0

13

1

16

Death

0

0

0

17

0

17

Other or

15

54

331

3

52

455

Unknown

*The Other category for Portsmouth Regional is reported to include shelters, rehab facilities,

hotels/motels, friends/families, and unknown.

** Does not include Franklin data for the period July through September 2017.

Based on these self-reported data, 74.8% of the 2,915 discharges from DRFs and the Cypress Center are to home. This compares to the 85% or greater discharges to home reported by NHH. 5.3% of the total DRF discharges are to residential care or assisted living, which is similar to NHH discharges for this category. 1.7% of the DRF discharges are to NHH, 1.5% is to other DRFs. 15.6% of the total discharges are to the other/unknown category, but 73% of these are accounted for by the Portsmouth DRF. This might point to an anomaly in the ways facilities use this category in their reports to the state. The ER will work with the State to clarify what types of discharges are allocated to the other/unknown category for all of the DRFs and the Cypress Center.

Hospital Readmissions

DHHS is now reporting readmission rates for both NHH and the DRFs. Table XII below summarizes these data:

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 29 of 75

NHH Franklin Cypress Portsmouth Elliot Geriatric Elliot Pathways Total
NHH Franklin Cypress Portsmouth Elliot Geriatric Elliot Pathways Total

Table XII

Self-Reported Readmission Rates for NHH and the DRFs

October – December 2016

Numbe r
30 Days 36 1 13 25

Percen t 30
Days 13.0% 2.50% 6.00% 8.10%

Numbe r
90 Days 78 1 21 44

Percent
90 Days 28.30% 2.5% 9.70% 14.20%

2

4.70%

2

4.70%

8 11.10% 9

85

155

12.50%

Numbe r
180 Days
97 1 24 56

Percen t
180 Days 35.10% 1.50% 11.10% 18.10%

Total Numbe
r 211
3 58 125

4

9.30%

8

9 12.50% 26

191

431

Numbe r
30 Days

Percen t 30
Days

Numbe r
90 Days

January - March 2017
Percent
90 Days

Numbe r
180 Days

Percen t
180 Days

Total

21 8.00% 52

0

0.00%

0

14 6.90% 24

23 7.30% 41

19.80% 0.00% 11.80% 12.90%

73 27.80% 146

1

1.50%

1

34 16.70% 72

58 18.30% 122

4

8.30%

5

10.40%

5 10.40% 14

4

2.90%

6

66

128

4.30%

10

7.20%

20

181

375

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 30 of 75

April - June 2017

Number Percent Number

NHH Franklin Cypress Portsmout h Elliot Geriatric Elliot Pathways Total

30 Days 44 0 11

30 Days 15% 0.00% 4.80%

90 Days 71 0 21

37

10.20%

56

2

3.80%

2

7

6.90%

8

101

158

Percent
90 Days 24.20% 0.00% 9.20%
15.40%
3.80%
7.90%

Number 180 Days 94 0 30

Percent
180 Days 32.1 0.00%
13.20%

Total
Number 209 0 62

75

20.70% 168

3

5.80%

7

11

10.90%

26

213

472

July September
2017

Number Percent Number

30 Days 30 Days 90 Days

NHH

20

9.80%

44

Franklin

NA

NA

NA

Cypress

12

7.10%

21

Portsmout

h

33

11.50%

50

Elliot

Geriatric

0

0.00%

0

Elliot

Pathways

4

3.30%

8

Total

69*

123*

*Totals do not include Franklin readmissions.

Percent
90 Days 21.60%
NA 12.40%
17.50%
0.00%
6.60%

Number 180 Days 57 NA 27

Percent
180 Days 27.90%
NA 15.90%

Total
Number 121 NA 60

60

21.00% 143

0

0.00%

0

15 159*

12.40%

27 351*

In the previous report the ER noted that readmission rates may indicate that people being discharged from inpatient psychiatric facilities are not connecting with necessary and appropriate services and supports in the community. Trends in readmission rates may also be indicators of increased or decreased pressures on the overall system of care. For example, decreased readmission rates could be an indicator that hospitals are not discharging people too quickly because of pressures to admit new patients. Decreases could also indicate that connections to appropriate community services and supports are occurring more effectively. As of the data of

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 31 of 75
this report, 180-day readmission rates to NHH are substantial, with almost one-third of those discharged returning to NHH within six months.
It is also important to note that the data reported currently include only readmission rates to the same facility, thus potentially understating the extent to which individuals in the target population may be subject to repeated admissions at more than one inpatient facility. In the next reporting period, the ER will work with the State to determine if data that reflects subsequent admission to any institutional facility can be made available – thus providing a more accurate picture of the rate and frequency with which individuals are relying on inpatient facilities statewide.
The data in Table XII above has not been reported for a long enough period to identify trends in readmission rates with confidence. Nonetheless, they do provide some insight into the number of instances in which an appropriate community intervention could have prevented an unnecessary re-hospitalization. For example, if even ten percent of the readmissions between January and March 2017 were diverted through ACT and other community resources, there would have been 38 fewer hospital admissions during that period, with a concurrent lower number of hospital bed days utilized.
The ER will continue to work with DHHS to monitor these data to interpret how they may contribute to overall system improvements consistent with the CMHA.
In the previous three reports, the ER has identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. Chart A below displays daily adult admissions delays to NHH for the period July 1, 2016 through October 26, 2017. Chart B shows the average daily ED waiting list for the same time period. )

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 32 of 75

.
80

Chart A
New Hampshire Hospital Daily Admission Delays (Adults) July 1, 2016 - October 26, 2017

70

60

50

40

30

20

10

0 070/0770/1/7140/62/7110/62/8180/60/8140/61/8110/61/8180/62/9150/60/9110/60/9180/61/9150/62/9121/62/0191/60/0161/61/0131/62/0101/62/1171/60/1131/61/1101/61/1171/62/2141/60/2111/60/2181/61/2151/62/2120/62/1190/60/1150/61/1120/71/1190/72/2160/70/2120/70/2190/71/2160/72/3130/70/3120/70/3190/71/3160/72/3130/73/4100/70/4160/71/4130/72/4100/72/5170/70/5140/71/5110/71/5180/72/6150/70/6110/70/6180/71/6150/72/6120/72/7190/70/7160/71/7130/72/7100/72/8170/70/8130/71/8100/71/8170/72/8140/73/9110/70/9170/71/9140/72/9111/72/0181/70/0151/71/0121/71/019/72/167/17

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 33 of 75 Chart B

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 34 of 75
Average Daily Waiting List by Month (Adults) July 2016 - October 2017
80

70

60

50

40

65 67

30

60

45 46 43

20

40

39

35 36

32

49 44

28

24

25

10

0
Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 35 of 75
Based on information reported by DHHS and summarized above, the average number of adults waiting for a NHH inpatient psychiatric bed was 24 per day in FY 2014; 25 per day in FY 2015; and through June of FY 2016 was 28 per day. For the period July 2016 through September 2017, the average monthly wait list for admission to NHH was 42.4 adults. Not surprisingly, as can be seen from Carts A and B together, there appears to be a correlation between the numbers waiting in EDs and the daily admission rate at NHH.
DHHS continues to analyze data related to adults boarding in EDs who may have some connection to the mental health system. DHHS is making these data available to CMHCs on a monthly basis, and expects the CMHCs to use these data to identify potential participants for ACT or related services to reduce the risk of hospitalization and support integrated community living. In future months, DHHS will be receiving information on the degree to which CMHCs have increased ACT (or other services’) participation as a result of these analyses. The ER plans to include summaries of this information in future reports. The ER continues to encourage the State, in conjunction with the CMHCs, to conduct targeted outreach to those individuals who may need expanded or enhanced community services so as to minimize or eliminate contact with hospital or institutional settings.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies
As noted in the June 30, 2015 ER report, New Hampshire reported having a total of 16 peer support agency program (PSA) sites, with at least one program site in each of the ten regions. The State now reports having 15 PSAs. The State continues to report that all peer support centers meet the CMHA requirement to be open 44 hours per week. The State reports that those sites have a cumulative total of 2,685 members11, with an active daily participation rate of 167 people statewide. Membership and active daily participation for the PSAs seems to be relatively unchanged from reporting period to reporting period.
The CMHA requires the peer support programs to be “effective” in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs. Anecdotally, some of the CMHCs report making more concerted efforts to refer service participants to the PSAs in
11 The State reports that the Peer Support Agencies in the past year have made concerted efforts to verify and correct their membership lists. This activity has resulted in a small reduction in the number of members reported during this time period.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 36 of 75
their regions. Increased efforts to communicate and coordinate with PSAs have also been reported. However, as of the most recent report there has not been a consequent increase in active daily participation.
Anecdotally, the ER continues to believe that in some regions of the state, relationships and communications among the CMHCs and the Peer Support Programs have improved. Peer support programs are generally reported by CMHCs to be useful sources of employees for ACT and Mobile Crisis and Crisis Apartment services. In addition, CMHCs report that the peer operated crisis beds available in several regions are a useful intervention for some CMHC clients at risk of hospitalization.
IV. Quality Assurance Systems
In the past 30 months, DHHS has made substantial progress in the design of the QSR process required by the CMHA. Fifteen QSR site visits have been conducted to date, and reports of the findings of most of these site visits have been posted for public review. Based on the experiences of those QSR site visits, plus on-going input from representatives of the Plaintiffs and the ER (in a technical assistance role), the QSR team has continued to make revisions to the QSR protocol, instruments, and scoring algorithm. The most recent round of changes recommended by the Plaintiffs and separately by the ER are currently being implemented. Three on-site QSR visits have been conducted using the new instruments and are currently being scored, analyzed and reported using the revised scoring process. Reports of these QSR site visits have not yet been published. Nor have any quality improvements plans yet been developed by the respective CMHCs in response to the QSR findings. Thus, the ER is not able at this time to comment on the results of the revised QSR instrumentation, protocols and scoring methodologies.
Nonetheless, having participated in two QSR site visits, the ER is confident that: (a) the revised instruments and site interview protocols are working well; and (b) the results and findings of the revised QSR instruments and process reflect, to a large degree, the quality standards of the CMHA.
One key improvement in the revised QSR process has been the addition of several Overall Clinical Review (OCR) questions that provide opportunities for the QSR teams to integrate and summarize service participant-level information collected from a variety of information sources. These new questions include:12
1. Is the frequency and intensity of services consistent with the individual’s demonstrated need?
12 Note: detail follow-up questions have not been included in this list.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 37 of 75
2. Are there additional services the individual needs that are not identified in the assessment(s) or the treatment plan?
3. Is the individual receiving all the services s/he needs to ensure health, safety, and welfare?
4. Is the individual receiving adequate services that provide reasonable opportunities to support the individual to achieve independence and integration in the community?
5. Is the individual receiving adequate services to obtain and maintain stable housing? 6. Is the individual receiving adequate services to avoid harms and decrease the incidence of
unnecessary hospital contacts and/or institutionalization? 7. Is the individual receiving adequate services to live in the most integrated setting?
Questions have also been embedded in the QSR instruments to more accurately document that: (a) the assessment(s) accurately reflect the individual’s strengths, needs and goals; and (b) service delivery approaches and patterns reflect best practices, where applicable.
These types of questions reflect the essence of the QSR process: documenting that individual service participants receive the levels and types of services and supports that assist them to achieve their goals and meet their needs in the most integrated community setting possible. These questions also directly respond to target population outcomes and quality expectations of the CMHA. Going forward, responses to these questions are intended to form an important part of the six-month ER reports.
The ER is grateful to both the State and the representatives of the Plaintiffs who have worked long and hard to design and implement a QSR process that will legitimately and accurately reflect the quality and effectiveness of the community mental health system in New Hampshire. This QSR system is a critical element of the CMHA, but in fact it has much broader application and potential long term benefits for the entire mental health system.
As noted above, the State has continued to refine and revise the scoring algorithms within the QSR process. These changes, among many others, reflect the OCR questions as described above. Some issues remain among the State, representatives of the Plaintiffs, and the ER with regard to how the scoring algorithms will be applied across the entire QSR process, and how negative responses to OCR questions will inform required quality improvement plans. Finally, the ER and the parties continue to discuss how to increase expectations for CMHC performance in annual QSR reviews, while also ensuring all CMHCs achieve or exceed the minimum score of 70 percent. Publication of recent QSR site reports using the revised instruments and scoring protocol will assist all parties to reach closure on these issues.
As noted earlier in this report, DHHS has been conducting on-site ACT and SE fidelity reviews to supplement and validate the ACT and SE fidelity self-assessments conducted on an annual basis by the CMHCs. DHHS has engaged the Dartmouth/Hitchcock Center on Evidence Based practices to assist in attaining and assuring fidelity to the evidence based models of ACT and SE.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 38 of 75
The Dartmouth/Hitchcock team will also assist on workforce development and training for these and other evidence based practices under the aegis of DHHS and the CMHCs. This partnership with the nationally respected Dartmouth/Hitchcock Center adds valuable expertise and experienced personnel to facilitate further development and operations of fidelity model ACT and SE in conformance with the CMHA. Year-to-year comparisons and the CMHCs Performance Improvement Plan have been included in the publication of recent ACT and SE fidelity reviews. The ER commends DHHS for implementing the comprehensive fidelity review process and its attendant quality improvement and technical assistance activities.
Effective and validated fidelity reviews and consequent training and workforce development activities are essential to DHHS’ overall quality management efforts for the community mental health system. As noted in the previous two ER reports, the QSR and the fidelity reviews mutually support but do not supplant or replace each other. The QSR, in particular, examines outcomes from a consumer-centric perspective as opposed to an operational or organizational perspective. It is uniquely positioned to assess the quality, appropriateness and effectiveness of specific ACT and SE services at the individual participant level. The ER continues to believe that implementation of fidelity-based models of delivery does not necessarily mean that specific service interventions are working well or being delivered with the frequency or intensity required by a participant’s individual treatment plan The revised QSR instruments and protocols address many of these concerns. In combination, the fidelity reviews and the QSR can mutually support conclusions about the overall quality and effectiveness of the mental health system consistent with the CMHA.
The ER will continue to monitor the degree to which the QSR process produces reliable information on individual outcomes and the quality of CMHA service delivery. In addition, over the next six months, the ER will evaluate the extent to which CMHC Quality Improvement Plans developed as part of the 2017 QSR site visits, are resulting in recommended practice changes and improved outcomes for those in the target population.
V. New State Resources For the CMHA
In New Hampshire the Governor and the Legislature have evidenced increased support for implementation of the CMHA and for making continued improvement in the community mental health system. Table XIII below summarizes new resources appropriated for the current biennium.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 39 of 75

Table XIII

New Community Mental Health Resources in New Hampshire for SFY 2018 and 2019

Item

SFY 2018 SFY 2019

Total

Transitional Housing / Community Residence Beds: adds 20 beds in SFY 2018 and up to 20 more in SFY 2019; prioritized to support New Hampshire Hospital discharges.

$2,312,156 $5,424,000 $7,736,156

Mobile Crisis: funds additional crisis response capacity in area with high numbers of New Hampshire Hospital admissions and discharges.

$1,498,551 $3,421,696 $4,920,247

Designated Receiving Facility (DRF) $ 484,696 $ 721,440 $1,206,136
Beds: adds up to 20 additional DRF beds.

Additional Funding: to support workforce $1,500,000 $1,500,000 $3,000,000
development.

Biennium Total $16,862,539

In addition, a total of $4.3 million has been added to the Mental Health rate cells of the Medicaid capitation rates of the Managed Care Entities (MCEs) for the up-coming biennium in anticipation of increased utilization associated with the CMHA. An additional $2.0 million is available for inclusion in these rates after all CMHA services (excluding fee-for-service services) have been implemented. In addition, an additional $471,186 for general mental health services has been added to the CMHC state contracts. This is exclusive of the separate Mobile/Crisis Team contracts.
It should be noted that the crisis model currently envisioned by the State under this new appropriation is not a replica of the model implemented under the CMHA in the Concord, Manchester and Nashua Regions. The model currently being procured will be called a Behavioral Health Crisis Treatment Center (BHCTC), which is intended to provide center-based (as opposed to mobile) crisis services 24/7. Services will include crisis assessments and treatment, and service participants may include people with substance use disorders. A vendor has not yet been selected for this BHCTC service, and thus a detailed scope of work and

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 40 of 75
implementation schedule is not yet available. The ER is not able to comment at this time about the implementation of this model.
However, it is notable that this new BHCTC service may operate in a region in lieu of the mobile crisis teams and crisis apartments developed under the CMHA. While community-based crisis centers have been effective in some other states, those centers are typically integrated into a larger crisis service system, which includes mobile capacity and apartment settings, and are not operated as stand-alone settings. In New Hampshire, it is the mobile crisis team and crisis apartment model that has a demonstrated record of diverting individuals with mental illness from hospital emergency rooms. The ER is not aware of evidence that requiring individuals in crisis to present themselves for center-based crisis services is unlikely to achieve the same results for members of the target population. The ER is also not aware of evidence that it is easier for individuals in rural areas with limited transportation resources to present at a centralized crisis facility as opposed to having crisis teams go to the location most convenient and natural for individuals in crisis.
VI. Summary of Expert Reviewer Observations and Priorities
The CMHA and ER have now been in place for three and one half years. Within that time frame, the ER has expressed escalating concerns related to noncompliance with CMHA requirements governing ACT and Glencliff community transitions. In addition, the ER has noted long elapsed times and/or delays related to implementation of system improvements or capacities related to the CMHA, including the full and effective functioning of the Central Team. Throughout these reports, the ER has emphasized the need for the State to be more aggressive, assertive, planful, and timely in its implementation and oversight efforts in these areas in order to come into compliance with the CMHA.
More recently the ER has reported that the State is improving its oversight and management of the mental health system. Examples include more comprehensive and accurate data reporting, the revised QSR process, and the growing use of state-validated fidelity reviews for ACT and SE. The State has also substantially strengthened its central management of the mental health system, through improved management structures and increased leadership and operational staffing. The State is making progress towards compliance with several CMHA requirements above, including Glencliff transition and discharge planning. The breadth and content of the final QSR instrument, and the reliability of information it produces, will determine to what extent it is possible to evaluate compliance with other individual outcomes contained within the CMHA, including the adequacy and effectiveness of ACT, SE, SH and MCT.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 41 of 75
The one notable exception to this progress relates to ACT services. For the last two years the ER has stated that the State remains out of compliance with the ACT requirements of the Sections V.D.3(a, b, d, and e), which together require that all ACT teams meet the standards of the CMHA; that each mental health region have at least one adult ACT Team13; and that by June 30, 2016, the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time.
Despite the many positive initiatives and management efforts undertaken by the State, ACT capacity remains substantially below the required June 30, 2016 capacity to serve 1,500 people at any given time. Moreover, with an active caseload of only 992 people, the state currently is providing 508 fewer people with ACT than could be served if the State had developed the CMHA-specified capacity to serve 1,500 individuals. With the current ACT staff capacity to serve 1,242 people, there are 250 fewer people receiving ACT than the current ACT system could accommodate. This continues to be the single most significant issue in New Hampshire with regard to compliance with the CMHA, and one with negative implications for individuals who remain in NHH, who continue to be readmitted to EDs and inpatient facilities, or who are otherwise at risk of admission, homelessness, or incarceration due to inadequate community supports.
In addition, the ER continues to note that certain elements of information related to SE and SH have yet to be produced by the State, preventing findings of compliance with the CMHA. Finally, while the QSR system is much improved, the ER cannot fully evaluate the degree to which the revised QSR instruments and process is producing accurate and meaningful information related to the CMHA until several reports of site visits have been published, and attendant quality improvement plans have been developed and approved.
Based on the findings presented in this report, the ER expects the following action steps to be taken during the up-coming six month period:
1. By March 1, 2018 the State will update and expand strategies and action steps to accelerate expansion of ACT capacity to attain compliance with the CMHA. New plans and timelines will be added to the Monthly Progress Report as applicable. Data on outreach to, and screening of, potential ACT clients will be made available. In addition, the State will ensure that members of the target population in need of ACT are identified, and that both regional and statewide plans are in place to ensure their reasonable access to services.
2. By March 1, 2018 the State will produce information on SE and SH as specified above in the report.
13 The ER notes that each region of the state has had at least one ACT team, or ACT team-in-development, since the inception of the CMHA. However, as documented in the ACT section of this report, four regions continue to have ACT teams that do not meet the minimum staffing requirements for ACT as specified in the CMHA.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 42 of 75
3. By March 1, 2018, the State will circulate QSR reports of the first three QSR site visits using the revised instruments and scoring protocols. The ER intends to engage the State and representatives of the Plaintiffs in a final conversation to resolve any remaining issues related to the scoring of QSR responses and generating quality findings. The ER expects these discussions to be accomplished no later than the end of March, 2018.
4. By March 1, 2018, the State and its PASRR contractor will facilitate the ER’s review of the individual PASRR screen documents for recent referrals and admissions to Glencliff.
5. The State will continue to provide information requested by the ER for purposes of monitoring transition and discharge planning from Glencliff.
6. The State and its MCT contractors will work with the ER to document requested information on mobile crisis encounters and to explore the number and type of reported hospital diversions.
7. Consistent with the requirements of the CMHA, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, regardless of whether those individuals are eligible for a Bridge subsidy.
8. The ER requests the State to work collaboratively with the ER and representatives of the plaintiffs to consider the most effective and efficient model for the 4th crisis program that was funded by the Legislature, before awarding any contract for a facility based crisis center.

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 43 of 75
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly Data Report July through September, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 44 of 75
New Hampshire Community Mental Health Agreement Quarterly Data Report
July to September 2017
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement November 27, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 45 of 75
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 46 of 75 July – September 2017
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date: 11/27/2017
Reporting Period: 7/1/2017 – 9/30/2017
Notes for Quarter
 Harbor Homes Mobile Crisis has been added to the report.  The Franklin DRF was unable to report data for the quarter. As a result total DRF data is
also unavailable. Data for the current quarter will be provided in the next quarterly report.  Peer Support Agencies were instructed to "purge their member lists" as of July 1, 2017 impacting the Number of Members but not Average Daily Census. The Bureau of Mental Health Services has instructed Peer Support Agencies to purge member lists annually to increase confidence and consistency in this information.
NH DHHS - OQAI - CMHA Quarterly Report, 11/27/17

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 47 of 75

Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services

Publication Date: 11/27/2017

Reporting Period: 7/1/2017 – 9/30/2017

1. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Center Name

July 2017

Unique

August September Consumers

2017

2017 in Quarter

Unique Consumers
in Prior Quarter

01 Northern Human Services

109

107

107

113

111

02 West Central Behavioral Health

48

47

63

68

76

03 Genesis Behavioral Health

74

73

71

74

74

04 Riverbend Community Mental Health Center

78

79

81

87

97

05 Monadnock Family Services

66

61

55

69

70

06 Community Council of Nashua

88

87

90

98

94

07 Mental Health Center of Greater

269

267

269

287

Manchester

292

08 Seacoast Mental Health Center

61

60

60

67

69

09 Community Partners

67

70

65

75

69

10 Center for Life Management

52

53

54

54

55

Total

912

904

915

992

1,006

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 11/14/17; consumers are counted only one time regardless of how many services they receive.

CMHA Monthly Progress Report

47

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 48 of 75

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents
September 2017

June 2017

Nurse Masters Level Clinician/or Equivalent Functional Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nu

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CTT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management
Total

1.09 2.40 8.39 0.55 12.43 0.75 12.54 1.10

0.60 2.35 3.50 0.50 6.95 0.40 7.15 0.10

1.20 2.00 6.60 1.00 10.80 0.75 10.60 0.50

0.50 3.00 6.00 0.50 10.00 0.48 10.00 0.30

1.25 3.25 2.70 0.70 7.90 0.65 8.50 0.65

0.50 3.00 2.50 0.00 6.00 0.25 5.25 0.25

0.50 3.00 1.50 0.00 5.00 0.25 5.25 0.25

0.98 11.00 3.29 1.00 16.27 0.62 16.57 0.52

1.05 10.00 10.2 1.00 22.31 0.62

6

21.95 0.52

0.43 3.10 6.00 1.00 10.53 0.60 9.53 0.60

0.00 2.00 4.23 0.50 6.73 0.50 8.53 0.50

1.00 2.00 5.30 1.00 9.30 0.40 9.30 0.40

9.10 47.10 60.2 7.75 124.2 6.27 125.1

7

2

7 5.69

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Substance Use Disorder Treatment

CMHA Monthly Progress Report

48

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 49 of 75

Center Name 01 Northern Human Services 02 West Central Behavioral Health 03 Genesis Behavioral Health 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

September 2017 2.05 1.20 2.75 1.48
2.40 4.00 3.00 12.00
1.00
1.00 2.00 3.00 35.88

June 2017 2.77 1.20 2.50
1.30 3.40 3.00 3.00
12.00
1.00 1.00 0.50 3.00 34.67

2c. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Housing Assistance

Center Name

September 2017

June 2017

01 Northern Human Services

9.95

9.95

02 West Central Behavioral Health

6.35

5.85

03 Genesis Behavioral Health

7.60

8.60

04 Riverbend Community Mental Health

8.50

8.50

CMHA Monthly Progress Report

49

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 50 of 75

Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CCT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

1.00 5.00 4.00 12.90
18.05
7.00 3.88 7.00 91.23

1.00 4.00 4.00
12.36
16.28 6.00 4.50 7.00
88.04

2d. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Supported Employment

Center Name

September 2017

June 2017

01 Northern Human Services

0.97

1.08

02 West Central Behavioral Health

0.25

0.25

03 Genesis Behavioral Health

4.00

3.00

04 Riverbend Community Mental Health Center

0.50 0.50

05 Monadnock Family Services

1.00

1.00

06 Community Council of Nashua 1

2.50

2.50

06 Community Council of Nashua 2

0.50

1.50

07 Mental Health Center of Greater Manchester-CCT

0.74 0.71

CMHA Monthly Progress Report

50

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 51 of 75

07 Mental Health Center of Greater Manchester-MCST

1.31 1.35

08 Seacoast Mental Health Center

1.00

1.00

09 Community Partners

0.15

0.00

10 Center for Life Management

0.30

0.30

Total

13.22

13.19

Revisions to Prior Period: None

Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report

Notes for 2b-d: Data compiled 11/13/17; the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, rather the quantity of staff available to provide each service. If staff is trained to provide multiple service types, their entire FTE value will be credited to each service type.

3. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12 Month Period
12 Month Period Ending September 2017

Center Name

Supported Employmen t Consumers

Total Eligible Consumers

Penetration Rate

Penetration Rate for Period
Ending June 2017

01 Northern Human Services

514

1,257

40.9%

37.2%

02 West Central Behavioral Health

162

725

22.3%

22.5%

03 Genesis Behavioral Health

267

1,288

20.7%

22.0%

04 Riverbend Community Mental Health Center

238

1,704

14.0%

14.8%

05 Monadnock Family Services

115

933

12.3%

14.0%

06 Community Council of Nashua

242

1,416

17.1%

16.1%

07 Mental Health Center of Greater Manchester

1,382

3,288

42.0%

40.0%

CMHA Monthly Progress Report

51

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 52 of 75

08 Seacoast Mental Health Center

341

1,456

23.4%

09 Community Partners

100

683

14.6%

10 Center for Life Management

170

884

19.2%

Deduplicated Total

3,525

13,375

26.4%

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 11/14/17; consumers are counted only one time regardless of how many services they receive.

4a. New Hampshire Hospital: Adult Census Summary

Measure

July – September 2017

April – June 2017

Admissions

204

293

Mean Daily Census

153

153*

Discharges

206

292

Median Length of Stay in Days for Discharges

13 10

Deaths

0

0

Revisions to Prior Period: *April to June 2017 mean daily census was revised due to improved methodology.

Data Source: Avatar

Notes 4a: Data extracted 11/16/17; Mean Daily Census includes patients on leave and is rounded to nearest whole number

4b. New Hampshire Hospital: Discharge Location for Adults

Discharge Location

July – September 2017

April – June 2017

Home - Lives with Others

109

138

Home - Lives Alone

73

107

CMHA Monthly Progress Report

52

December 1, 2017

19.3% 10.3% 21.6% 25.3%

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 53 of 75

CMHC Group Home Private Group Home Nursing Home Hotel-Motel Homeless Shelter/ No Permanent Home Discharge/Transfer to IP Rehab Facility Secure Psychiatric Unit - SPU Peer Support Housing Jail or Correctional Facility Glencliff Home for the Elderly Unknown

5

9

3

7

3

6

3

5

3

5

2

4

1

3

1

3

1

3

1

1

1

1

4c. New Hampshire Hospital: Readmission Rates for Adults

Measure

July – September 2017

April – June 2017

30 Days

9.8% (20)

15.0% (44)

90 Days

21.6% (44)

24.2% (71)

180 Days

27.9% (57)

32.1% (94)

Revisions to Prior Period: None.

Data Source: Avatar

Notes 4b-c: Data compiled 11/13/17; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions lookback period includes readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day readmissions); patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

5a. Designated Receiving Facilities: Admissions for Adults
DRF

July – September 2017

CMHA Monthly Progress Report

53

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 54 of 75

Franklin Cypress Center Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total
DRF Franklin Cypress Center Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

Involuntary Admissions

Voluntary Admissions

NA

NA

69

178

93

270

6

54

61

60

NA

NA

April – June 2017

Involuntary Admissions

Voluntary Admissions

35

25

49

179

80

283

6

46

48

53

218

586

Total Admissions
NA 247 363
60 121 NA
Total Admissions
60 228 363
52 101 804

5b. Designated Receiving Facilities: Mean Daily Census for Adults

July – September

DRF

2017

Franklin

NA

Cypress Center

12.9

Portsmouth

23.9

Elliot Geriatric Psychiatric Unit

29.7

Elliot Pathways

12.2

CMHA Monthly Progress Report

54

April – June 2017
4.5 12.0 30.3 29.3 10.0
December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 55 of 75

Total

NA

17.2

*Portsmouth Regional Hospital has a total of 12 DRF beds and Elliot Hospital has a total of 14 DRF beds split between Pathways and the Geriatric Psychiatric Unit.

5c. Designated Receiving Facilities: Discharges for Adults

July – September

DRF

2017

April – June 2017

Franklin

NA

59

Manchester (Cypress Center)

243

232

Portsmouth

355

365

Elliot Geriatric Psychiatric Unit

63

54

Elliot Pathways

121

105

Total

NA

815

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges for Adults

July – September

April – June 2017

DRF

2017

Franklin

NA

6

Manchester (Cypress Center)

4

4

Portsmouth

4

5

Elliot Geriatric Psychiatric Unit

27

22

Elliot Pathways

7

8

Total

NA

5

5e. Designated Receiving Facilities: Discharge Location for Adults

DRF

July – September 2017

CMHA Monthly Progress Report

55

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 56 of 75

Assisted Living/Group
Home

Decease d

Other

NH

Hom Hospit Hospita

DRF e

al

l

Franklin

NA

NA NA NA NA

NA

Manchester (Cypress Center)

1

0

0 166

0

1

Portsmouth Regional Hospital

0

0

4 221

0

5

Elliot Geriatric Psychiatric Unit

45

4

1 12

0

1

Elliot Pathways

4

0

1 101

0

6

Total

NA

NA NA NA NA

NA

April – June 2017

Assisted

Other

NH

Living/Group Decease

Hom Hospit Hospita

DRF

Home

d DRF e

al

l

Franklin

2

0

1 44

0

1

Manchester (Cypress Center)

4

0

7 204

0

1

Portsmouth Regional Hospital

0

0

4 265

0

7

Elliot Geriatric Psychiatric Unit

32

6

0 10

6

0

Elliot Pathways

1

0

0 82

0

4

Total

39

6 12 605

6

13

*Dispositions to ‘DRF’ represent a change in legal status from Voluntary to Involuntary within the DRF.
5f. Designated Receiving Facilities: Readmission Rates for Adults

Other NA 10 59 0 9 NA
Other 11 16 89 0 18
134

CMHA Monthly Progress Report

56

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 57 of 75

July – September 2017

DRF

30 Days

90 Days

180 Days

Franklin

NA

NA

NA

Manchester (Cypress Center)

7.1% (12)

12.4% (21)

15.9% (27)

Portsmouth

11.5% (33)

17.5% (50)

21% (60)

Elliot Geriatric Psychiatric Unit

0% (0)

0% (0)

0% (0)

Elliot Pathways

3.3% (4)

6.6% (8)

12.4% (15)

Total

NA

NA

NA

April – June 2017

DRF

30 Days

90 Days

180 Days

Franklin

0.0% (0)

0.0% (0)

0.0% (0)

Manchester (Cypress Center)

4.8% (11)

9.2% (21)

13.2% (30)

Portsmouth

10.2% (37)

15.4% (56)

20.7% (75)

Elliot Geriatric Psychiatric Unit

3.8% (2)

3.8% (2)

5.8% (3)

Elliot Pathways

6.9% (7)

7.9% (8)

10.9% (11)

Total

7.1% (57)

10.8% (87)

14.8% (119)

Revisions to Prior Period: None.

Data Source: NH DRF Database

Notes: Franklin DRF was unable to report data for the quarter. As a result total DRF data is also unavailable. Data for the current quarter will be provided in the next quarterly report. Data compiled 11/13/17; discharge location of DRF are patients discharged back to the same DRF for a different level of care within the DRF; readmission rates calculated by looking back in time from admissions in study quarter; patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

6. Glencliff Home: Census Summary
Measure

July – September 2017

April – June 2017

CMHA Monthly Progress Report

57

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 58 of 75

Admissions

3

9

Average Daily Census

107

106

Discharges

2 (1- Dept. of Corrections, 1 – Nursing Facility)

2 (1 private apartment, 1 ABD/ residential care home)

Individual Lengths of Stay in Days for Discharges

115, 366

4507, 399

Deaths

4

3

Readmissions

0

0

Mean Overall Admission Waitlist

19 (12 Active)

17 (9 Active)

Revisions to Prior Period: None.

Data Source: Glencliff Home

Notes: Data Compiled 10/23/17; means rounded to nearest whole number; Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

7. NH Mental Health Consumer Peer Support Agencies: Census Summary
July – September 2017

April – June 2017

Peer Support Agency

Total Average Members Daily Visits

Total Average Members Daily Visits

Alternative Life Center Total

532

46

516

45

Conway

189

15

183

16

Berlin

102

10

108

11

Littleton

141

8

139

7

Colebrook

100

13

86

11

Stepping Stone Total

386

18

592

20

Claremont

308

12

493

14

CMHA Monthly Progress Report

58

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 59 of 75

Lebanon

78

6

99

6

Cornerbridge Total

293

20

390

17

Laconia

109

6

171

5

Concord

127

14

167

12

Plymouth Outreach

57

NA

52

NA

MAPSA Keene Total

208

11

190

14

HEARTS Nashua Total

247

37

510

31

On the Road to Recovery Total

516

53

568

41

Manchester

382

31

418

34

Derry

134

22

150

7

Connections Portsmouth Total

278

11

278

11

TriCity Coop Rochester Total

225

24

382

20

Total

2,685

167

3,426

158

Revisions to Prior Period: None

Data Source: Bureau of Mental Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 11/14/17; Average Daily Visits NA for Outreach Programs; Peer Support Agencies were instructed to "purge their member lists" as of July 1, 2017 impacting the Number of Members but not Average Daily Census. The Bureau of Mental Health Services has instructed Peer Support Agencies to "purge member lists" annually to increase confidence and consistency in this information.

8. Housing Bridge Subsidy Summary to Date

July – September 2017

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

CMHA Monthly Progress Report

59

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 60 of 75

Housing Bridge Subsidy

701

41

742

Section 8 Voucher

85

11

96

April – June 2017

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

643

58

701

Section 8 Voucher

85

0

85

Revisions to Prior Period: None

Data Source: Bureau of Mental Health

Notes: Data Compiled 11/14/17

9. Housing Bridge Subsidy Current Census Summary

Measure

As of 9/30/2017

As of 6/30/2017

Housing Slots

567

591

Rents currently being paid

509

545

Individuals accepted but waiting to lease

58

46

Waiting list for slots

0

0

Revisions to Prior Period: None

Data Source: Bureau of Mental Health

Notes: Data Compiled 11/14/17; all individuals currently on the Bridge Program are actively transitioning from the program (waiting for their Section 8 housing voucher).

10. Housing Bridge Subsidy Unit Address Density
Number of Unit(s)* at Same Address

Frequency as of 11/9/17

Frequency as of 8/11/17

1
CMHA Monthly Progress Report

383

391

60

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 61 of 75

2

31

37

3

6

6

4

5

6

5

0

3

6

0

0

7

1

2

8 or more

2

1

*All units are individual units

Revisions to Prior Period: None

Data Source: Bureau of Mental Health data compiled by Office of Quality Assurance and Improvement

Notes: Data Compiled 11/14/17

11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure

July 2017

August 2017

Septembe r
2017

July – Septembe
r 2017

April – June 2017

Unduplicated People Served in Month

165

198

216

579

530

Services Provided by Type Mobile Community Assessments Crisis Stabilization Appointments Office-Based Urgent Assessments Emergency Service Medication Appointments
CMHA Monthly Progress Report

47

61

65

173

124

15

13

9

37

64

15

11

31

57

96

29

40

41

110

47

61

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 62 of 75

Phone Support/Triage Walk in Assessments

200

290

231

721

469

4

4

6

14

11

Services Provided after Immediate Crisis
Mobile Community Assessments-Post Crisis
Crisis Stabilization Appointments
Office-Based Urgent Assessments
Emergency Service Medication Appointments
Phone Support/Triage

4

10

15

13

15

11

16

21

49

111

16

30

4

8

36

15

31

57

15

23

60

29

41

201

200

Referral Source Emergency Department/EMS Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal Self Other

14

9

23

46

42

24

34

15

73

96

1

2

2

5

4

0

1

22

23

2

4

13

2

19

32

1

7

4

12

15

5

7

4

16

15

17

14

3

34

53

66

100

126

292

223

3

11

15

29

21

CMHA Monthly Progress Report

62

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 63 of 75

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

33

25

23

81

84

124

95

91

310

319

3.8

3.8

4.0

3.8

3.8*

Law Enforcement Involvement

10

17

7

34

32

Hospital Diversions Total

123

159

161

443

430

Revisions to Prior Period: *Apartment Average Length of Stay for prior quarter was corrected

Data Source: Riverbend CMHC submitted reports

Notes: Data Compiled 11/15/17; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

63

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 64 of 75

11b. Mobile Crisis Services and Supports for Adults: Mental Health Center of Greater Manchester

Measure

July 2017

August 2017

Septembe r
2017

July – Septembe
r 2017

Unduplicated People Served by Month

186

180

209

476

April – June 2017
579

Services Provided by Type Phone Support/Triage Mobile Community Assessments Office-Based Urgent Assessments Emergency Service Medication Appointments Crisis Apartment Service

380

353

411

1,144

1,127

72

72

104

248

270

12

11

17

40

53

0

1

5

6

2

57

108

52

217

0

Referral Source* Emergency Department Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal Self Other
CMHA Monthly Progress Report

2

1

2

5

7

29

31

47

107

111

3

4

2

9

13

2

2

1

5

13

6

5

10

21

12

33

32

70

135

89

4

8

11

23

22

28

21

30

79

76

111

120

121

352

324

23

17

22

62

87

64

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 65 of 75

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

3

3

3

9

9

8

13

8

29

29

4.0

3.3

2.7

3.2

3.2

Law Enforcement Involvement

33

32

70

135

89

Hospital Diversion Total

241

241

316

798

821

Revisions to Prior Period: * Prior quarter Referral Source was corrected

Data Source: New Mobile Crisis Data Reporting System

Notes: Data Compiled 11/14/17; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

65

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 66 of 75

11c. Mobile Crisis Services and Supports for Adults: Harbor Homes

Measure

July 2017

August 2017

Septembe r
2017

July – Septembe
r 2017

Unduplicated People Served by Month

7

24

25

55

Services Provided by Type Phone Support/Triage Mobile Community Assessments Office-Based Urgent Assessments Emergency Service Medication Appointments Crisis Apartment Service

3

15

15

33

3

4

7

14

1

1

1

3

0

2

3

5

2

1

1

4

Referral Source Emergency Department Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Self Other
CMHA Monthly Progress Report

0

3

0

3

7

2

1

10

0

0

3

3

0

0

1

1

0

0

3

3

0

3

1

4

0

0

0

0

1

3

6

10

3

8

9

20

4

8

3

15

66

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 67 of 75

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

1

1

1

3

3

1

1

5

3

1

1

1.7

Law Enforcement Involvement

0

6

5

11

Hospital Diversion Total

7

24

18

49

Revisions to Prior Period: NA

Data Source: New Mobile Crisis Data Reporting System

Notes: Data Compiled 11/14/17; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

67

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 68 of 75

Appendix B New Hampshire Community Mental Health Agreement
Monthly Progress Reports July, August, September, 2017

CMHA Monthly Progress Report

68

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 69 of 75
New Hampshire Community Mental Health Agreement Monthly Progress Report
July, August, September 2017
New Hampshire Department of Health and Human Services December 1, 2017

CMHA Monthly Progress Report

69

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 70 of 75

CMHA Monthly Progress Report

70

December 1, 2017

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 71 of 75

Acronyms Used in this Report

ACT: BMHS: CMHA: CMHC: DHHS: SE: SFY:

Assertive Community Treatment Bureau of Mental Health Services Community Mental Health Agreement Community Mental Health Center Department of Health and Human Services Supported Employment State Fiscal Year

Background
This Monthly Progress Report is issued in response to the June 29, 2016 Expert Reviewer Report, Number Four, action step 4. It reflects the actions taken in July, August and September 2017, and month-over-month progress made in support of the Community Mental Health Agreement (CMHA) as of September 30, 2017. Three months of data is released in this singular report due to delays experienced in receiving data from the Community Mental Health Centers. Data contained may be subject to change upon further reconciliation with CMHCs. This report is specific to achievement of milestones contained in the agreed upon CMHA Project Plan for Assertive Community Treatment (ACT), Supported Employment (SE) and Glencliff Home Transitions. Where appropriate, the Report includes CMHA lifetime-to-date achievements.

71

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 72 of 75

Progress Highlights Assertive Community Treatment (ACT)

Goal CMHC fidelity to ACT evidencebased practice model annually assessed.
Provide ACT team services, consistent with standards set forth, with the capacity to serve at least 1,500 individuals.

Status 2017: 10 of 10 completed
2018: 4 of 10 completed
Capacity: July – 1,265 August – 1,256 Sept. – 1,242
Enrollment: July – 912 August – 904 Sept. – 915

Recent Actions Taken
 3 fidelity reports issued, improvement
plans in place; 4th report in process
 2018 fidelity reports compare progress
from 2017
 New improvement plan template
developed and implemented
 Ongoing technical assistance at CMHC
specific level delivered by external DHHS consultant
 Launched 6-part training series
6/27/17 for ACT team leaders, substance use specialists, and team members on Co-Occurring Disorders (COD) treatment within ACT. Series capacity permits 4 ACT staff per session; participation is high; one MCO also participates. Series runs through December 2017. Topics include: initial training on addiction and recovery; substance use and affects; screening, assessment and functional analysis; stage-wise psychosocial and medication interventions; motivational strategies for people with COD; and group treatments for people with COD.

Supported Employment (SE)

Goal CMHC fidelity to SE evidencebased practice model annually assessed.
Increase penetration rate of individuals with a Serious Mental Illness (SMI) receiving SE services to 18.6%.

Status 2017: 10 of 10 completed
2018: 3 of 10 completed
Statewide penetration rate: July – 25.8% August – 26.4% Sept. – 26.4%

Recent Actions Taken
 3 fidelity reports issued, improvement
plans in place
 2018 fidelity reports compare progress
from 2017
 New improvement plan template
developed and implemented
 Ongoing technical assistance at CMHC
specific level delivered by external DHHS consultant
 Held Supported Employment Basic
Training in July 2017; each CMHC was allowed 2 participants. Training designed for new SE specialists.

72

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 73 of 75

Glencliff Home Transitions into Integrated Community Setting

Goal Have capacity to serve in the community 16 (cumulatively) individuals with mental illness and complex health care needs residing at Glencliff who cannot be cost-effectively served in supported housing.

Status 14 of 16 completed14

By June 30, 2017, identify and maintain a list of all individuals with mental illness and complex health care needs residing at the Glencliff Home who cannot be cost-effectively served in supported housing and develop an effective plan for providing sufficient community-based residential supports for such individuals in the future.

Completed; ongoing

Recent Actions Taken
 In July 2017, a former Glencliff
resident, discharged originally in 2015, sought readmission to Glencliff as behavioral health issues intensified. Through methods used to effectuate integrated community setting transitions, the individual was transitioned to a 4-person community residence
 In November 2017, a resident
transitioned to the community residence developed in late 2016.
 Coordinating a 15th transition
anticipated to be occur in December 2017
 12 residents on the list
 11 of the 12 residents have selected
their CFI transition case management service provider to actively support transition needs; the 12th is in process

14 Indicates residents have been transitioned into an integrated community setting; compliance with additional CMHA requirements for such transitions is under review.
73

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 74 of 75

30.0%
SE Statewide Penetration Rate by Quarter/Monthly*
25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

Sep- Dec- Mar- Jun- Sep- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul-17 Aug- Sep-

15 15 16 16 16 16 17 17 17 17 17 17

17 17

* Data is a combination of preliminary monthly and finalized quarterly data from CMHA Quarterly Data Reports.

74

Case 1:12-cv-00053-SM Document 121-1 Filed 01/12/18 Page 75 of 75 75

 
 Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 1 of 95
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Nine
January 21, 2019
I. Introduction
This is the ninth semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv53-SM.1 For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this six-month period (June 1, 2018 through December 31, 2018), the ER has continued to observe the State’s work to implement certain key service elements of the CMHA, and has continued to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. During this period, the ER:
• Met with a clinical team at New Hampshire Hospital (NHH) to review transition planning processes and issues;
• Participated in an individual transition planning meeting, and met with Glencliff clinical staff to discuss transition planning processes and issues;
• Reviewed the Preadmission Screening and Resident Review (PASRR) and Minimum Data Set (MDS) records for the six most recent admissions to Glencliff;
• Met with the DHHS Central Team; • Met with DHHS and PASRR Contract agency staff to discuss the PASRR process
and data reporting;
1 Due to the lapse in appropriations, the United States was unable to provide input on a draft of this report that was circulated to the parties prior to finalization.
1

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 2 of 95
• Observed the Quality Service Review (QSR) conducted at Seacoast Mental Health Center;
• Met with the DHHS CMHA leadership team to discuss data reporting and progress being made in the implementation of CMHA standards and requirements;
• Conducted on-site reviews at the Monadnock and West Central Behavioral Health Centers. These on-site reviews included meetings with the respective Assertive Community Treatment (ACT) teams, reviews of ACT service recipient records, and meetings with senior clinical and administrative leadership;
• Met with DHHS staff to review the process for monitoring progress and performance related to CMHC implementation of Quality Improvement Plan (QIP) action plans. This included participation in telephone calls related to the QSR QIP action plan for Riverbend Mental Health Center and the ACT fidelity QIP for Greater Nashua Mental Health Center;
• Met with senior officials of DHHS and the NH Department of Justice to discuss progress in meeting the requirements of the CMHA;
• Met with DHHS Quality Management/Quality Service Review (QM/QSR) staff to discuss the Seacoast QSR review;
• Participated in a status conference with Judge McAuliffe and representatives of all parties to the CMHA; and
• Convened an All Parties meeting to discuss progress in meeting the requirements of the CMHA.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
Summary of Progress to Date
This report reflects the end of four and one half years of implementation of the CMHA. At this point in the process it is possible to document that some positive steps have been taken to improve the quality and effectiveness of services as envisioned in the CMHA. However, as will be discussed in detail below, implementation issues remain time consuming and frustrating, and there are areas of continued non-compliance with the CMHA. Notwithstanding these on-going concerns, the parties to the CMHA deserve credit for some real and measurable accomplishments.
As noted in the previous ER Report, the State has implemented a comprehensive and reliable QSR process. The QSR has been carried out in ten CMHA regions this fiscal year. The ER considers these QSR reviews to be methodologically correct and reliable, and that the QSR
2

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 3 of 95
reviews are producing findings that are accurate and actionable in terms of taking concrete steps to address quality issues in the CMHC system.
Another major accomplishment has been contracting with the Dartmouth-Hitchcock Medical Center to conduct external ACT and Supported Employment (SE) fidelity reviews using nationally validated fidelity review instruments and criteria. In concert with the QSR reviews mentioned above, the fidelity reviews are assisting the state and the CMHCs to develop comprehensive QIPs that address important ACT and SE quality and effectiveness issues at both the consumer and CMHC operational levels.2
Statewide data from both the QSR and fidelity reviews are reported later in this report. The ER envisions that these findings will play a central role in any final assessment of compliance with the CMHA, and in demonstrating the sustainability of systemic changes during the one year maintenance of effort period. This data may also provide a framework for the negotiation of terms for joint disengagement from the CMHA.
Much remains to be accomplished to meet all the requirements of the CMHA. The parties originally anticipated that the CMHA could be fully implemented in five years, with a sixth year for maintenance of effort. The CMHA was approved and filed with the Federal Court on February 12, 2014, and the five-year anniversary of that event is less than a month away. The ER was approved by the Parties and the Federal Court effective July 1, 2014, and the five-year anniversary of that event is six months from now. Thus it is critical for this report and for subsequent activities that the focus be on specific strategies and action steps necessary to meet all the requirements of the CMHA, and to plan for total or partial disengagement.
II. Data
As noted in previous reports, the New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (July to September, 2018), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The capacity to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve.
However, as will be detailed in subsequent sections of this report, the State has not yet completed its work to produce additional data requested by the ER. Examples include:
1. Complete and comparable data on the extent to which participation in SE results in integrated competitive employment;
2 The ER also notes, as will be discussed below, that the State remains in compliance with regard to statewide SE penetration rates.
3

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 4 of 95
2. Data on the extent to which participants in the Bridge Subsidy program are connected to and receive services from the CMHCs; and
3. Data on the extent to which CMHC outreach, screening and assessment activities result in actual enrollment in ACT services.
The ER continues to be concerned with delays in reporting. DHHS has acquired new staffing, and is providing renewed management attention to the data reporting processes. Report timeliness and contents are improving as of this report. However , it remains critical that all data and agreed-upon reports are provided on a timely delivery schedule.
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile/Crisis and Crisis Apartment Programs
The CMHA calls for the establishment of a Mobile Crisis Team (MCT) and Crisis Apartments in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC was selected to implement the MCT and Crisis Apartments in the Concord Region. The CMHA specified that a second MCT and Crisis Apartments be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. Per CMHA V.C.3(c), a third MCT and Crisis Apartment program became operational in the Nashua region on July1, 2017. The contract for that program was awarded to Harbor Homes in Nashua. Table I below includes the most recent available information on activities of these three MCT/Crisis Apartment Programs.34
3 At this point the three CMHCs hosting MCT and Crisis Apartment programs report data from their programs in different ways and not all programs report the same data elements. Thus, the data in Table I are difficult to correlate and interpret. The ER has requested that these data be made consistent in future reports. 4 The ER has questions about the reported (or not reported) data in the “after immediate crisis” category. These may be amended and/or expanded after further review.
4

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 5 of 95

Table I

Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs

Concord

Manchester

Nashua

July - September

July -September

July - September

2018

2018

2018

Total unduplicated people served

519

533

490

Services provided in response to

immediate crisis:

• Phone support/triage

776

1693

459

• Mobile assessments • Crisis stabilization
appointments

206

284

501

69

0

• Emergency services

medication appointments

4

• Crisis apartment serv.

• Office based urgent

53

assessments

• Case Management

13

0

465

41

168

395

371

• Peer support

Services provided after the immediate

crisis:

• Phone support/triage

151

• Mobile assessments • Crisis stabilization
appointments • Emergency services

Not

32

Not

Reported

61

Reported

medication appointments

4

• Office based Urgent

Assessments

53

Referral source:

• Self

477

• Family

16

• Guardian

30

• Mental health provider

24

• Primary care provider

7

• Hospital emergency

6

department

• Police

18

• CMHC Internal

34

5

• Friend

7

• Other

Crisis apartment admissions:

80

• Bed days

327

• Average length of stay

4.1

Law enforcement involvement

44

Total hospital diversions5

686

433

267

97

51

10

1

19

53

31

4

5

1

205

10

44

89

17

15

104

593

29

88

114

436

3.9

4.9

205

10

993

1,108

5 Hospital diversions are instances in which services are provided to individuals in crisis resulting in diversion from being assessed at the ED and/or being admitted to a psychiatric hospital. DHHS and the MCT providers have developed specific definition of hospital diversions, which will be utilized for future MCT reports.

5

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 6 of 95
The Quarterly Data Report in Appendix A contains some historical data for the three regional MCT/Crisis Apartment programs.
As noted in the previous report, the number of hospital diversions reported by the MCTs seems disproportionate, given the continued high admission and readmission rates for NHH and the Designated Receiving Facilities (DRFs), and the high number of people waiting on a daily basis for admission to NHH. The ER plans to visit each of the Mobile Crisis Team programs in the upcoming months to explore in greater depth how these diversions are occurring and being recorded. As part of these visits, the ER will also examine the MCT phone triage process and criteria used determine whether a mobile crisis intervention is delivered in community.
Assertive Community Treatment
ACT is a core element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team;
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time; and
4. By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.
The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015 (42 months ago). Further, as of June 30, 2016, the State was required to have the capacity to provide ACT to 1,500 priority Target Population individuals.
As displayed in Table II below, the staff capacity of the 126 adult ACT teams in New Hampshire actually decreased by .61 FTEs since December of 2016, and has only increased by 2.47 FTE since June of 2018. During the same time period, the 12 ACT teams added only 72 average monthly service participants.7
6 Note: one new ACT team was funded in the Nashua Region, thereby increasing the number of teams from 11 to 12. 7 Because of service participant turnover, the total number of people served across several months and quarters is somewhat higher than the monthly number of service participants.
6

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 7 of 95

Table II

Self-Reported ACT Staffing (excluding psychiatry): December 2016 – September 2018

Region

FTE

FTE

FTE

FTE

FTE

FTE

FTE

FTE

Dec-16 Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Jun-18 Sep-18

Northern

11.49

West Central

5.5

Lakes Region

11

Riverbend

9

Monadnock Greater Nashua 1 Greater Nashua 2 Manchester – CTT Manchester MCST

7.25 6.25 5.25 15.53 21.37

Seacoast

9.53

Community Part.

6.85

CLM

7.17

Total

116.19

11.89 12.54 12.43 13.04 11.64 12.73 13.07

7.75 7.15 6.95

6.2

5 5.15 5.25

11 10.6 10.8

9.4

5.7 5.55 8.35

10

10

10

10 10.25 10.50 10.50

6.7

8.5

7.9

7.9

8.7 8.50 8.70

6.25 5.25

6

5 5.75 5.75 5.50

5.25 5.25

5

5 5.75 5.75 4.50

14.79 16.57 16.27 12.83 17.26 15.50 14.75

21.86 21.95 22.31 19.04 19.51 16.25 17.75

9.53 9.53 10.53 10.53 11.53 9.53 10.53

4.08 8.53 6.73 7.85 9.75 9.60 9.13

8.3

9.3

9.3

9.3

9.3 8.30 7.55

117.4 125.17 124.22 116.09 120.14 113.11 115.58

7

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 8 of 95
It is clear from the above table that overall ACT staffing has remained low, and for five teams has actually decreased over the past four reporting periods. Three of the 12 adult ACT teams continue to have fewer than the 7 - 10 professionals specified for ACT teams in the CMHA. Four teams now report having no peer specialist on the ACT Team, the same number of teams with no peer support staff in the previous report. Five teams report having at least one FTE peer specialist, but seven of the 12 teams continue to report having less than one FTE peer specialist. Seven teams have at least 1.0 FTE SE staff, while five have less than a full time SE specialist. One team had no SE staff at the time of the most recent report. Six teams report having .5 or less FTE combined psychiatry/nurse practitioner time available to their ACT teams8; and six of the 12 teams report having less than one FTE nurse per team. Staff deficiencies, as noted above, render some of the current ACT teams out of compliance with the ACT service requirements in CMHA V.D.2(d) as of the date of the Quarterly Data Report. Table III below displays the active ACT caseloads by CMHC Region for the past 18 months. As noted above, the active monthly caseload has increased by only 72 participants. Since June of 2017 the active monthly caseload has actually decreased by 95 participants. Several ACT teams are reporting caseloads at or near their lowest levels since December 2016.
8 The CMHA specifies at least .5 FTE Psychiatrists for teams with at least 70 active service participants. (CMHA V.D.2(e).
8

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 9 of 95

Table III

Self-Reported ACT Caseload (Unique Adult Consumers) by Region in Specified Months: December 2016 – September 2018

Region

Active Cases Dec-16

Active Cases Mar-17

Active Cases Jun-17

Active Cases Sep-17

Active Cases Dec-17

Active Cases Mar-18

Active Cases Jul-18

Active Cases Sep-18

Northern

104

108

111

113

115

114

108 102

West Central

32

53

76

68

57

46

45 44

Lakes Region

64

70

74

74

65

64

59 53

Riverbend

73

83

97

87

81

80

78 82

Monadnock

63

64

70

69

53

55

55 55

Greater Nashua 74

83

94

98

76

74

85 84

Manchester

248

270

292

287

269

277

302 306

Seacoast Community Part.

65

64

69

67

54

66

69 69

70

67

69

75

64

66

59 61

CLM

47

55

55

54

55

59

57 55

Total*

839

913 1,006 992

881

901

917 911

* unduplicated across regions

The combined ACT teams have a reported September 2018 staff complement of 115.58 FTEs excluding psychiatry, which is sufficient capacity to serve 1,158 individuals based on the ACT non-psychiatry staffing ratios contained in the CMHA.9 Note that this is a minor (+2.47 FTE) increase in staff-based capacity from the previous ER report. With a statewide caseload of 911 as of September 2018, the existing teams should theoretically be able to accept an additional 247 new ACT clients without additional staff. Tapping into this unused capacity with appropriate outreach and targeting should have an impact on alleviating ED boarding and hospital
9 The total psychiatry capacity is 6.90 FTE, which is sufficient to serve 966 individuals based on the CMHA’s psychiatry staffing ratios.
9

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 10 of 95
readmission rates across the state. Further, the CMHA requires the State to have capacity to serve 1,500 individuals, but the current ACT capacity of 1,158 is 342 below CMHA criteria. As noted in previous reports, the current level of ACT staffing is not sufficient to meet CMHA requirements for ACT team capacity. Furthermore, current ACT enrollment of 911 individuals is 589 below the number that could be provided ACT services with the capacity required by the CMHA.
ACT Screening As has been documented in previous reports, the State has been implementing a number of strategies to increase ACT enrollment and participation. One of these strategies has been to require the ten CMHCs to conduct and report regular clinical screening for eligibility/appropriateness for ACT services, These clinical screens are conducted:
1. As part of the intake process at the CMHCs; 10 2. Upon referral to a CMHC following discharge from an inpatient facility; and 3. As part of regular quarterly and annual assessments and plan of care amendments for
current CMHC clients (including current active ACT participants) who may qualify for and benefit from ACT. Table IV below presents data on ACT screens conducted by CMHCs between January and March, 2018 and then September, 2018. This is the third reporting period in which these data are available, and it is too early to interpret or draw conclusions from them. The State continues to work on producing a report of the degree to which ACT screening and assessment activities result in ACT enrollments.
10 Note that a CMHC intake incorporating the ACT screen is performed when a CMHC emergency services staff or Mobile Crisis Team encounters and refers a person potentially needing CMHC services. In some cases these Emergency Services/ MCT referrals are made on behalf of individuals who have presented in crisis in hospital emergency departments and who may be waiting for a NHH admission. It would be useful to collect data on, and report the outcome of, these crisis screens/referrals, since ACT enrollment at this critical stage would support statewide diversion efforts and help members of the target population avoid unnecessary hospital admissions.
10

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 11 of 95

Table IV

Self-Reported Number of Unique Clients Screened for ACT Services

Conducted by CMHCs

Community Mental Health Center

January February March

2018

2018

2018

Sept 2018

01 Northern Human Services

157

121

217

314

02 West Central Behavioral

45

Health

41

85

81

03 Lakes Region Mental Health Center

181

250

244

156

04 Riverbend Community

500

445

598

456

Mental Health Center

05 Monadnock Family Services

239

159

226

175

06 Community Council of

416

412

534

281

Nashua

07 Mental Health Center of

783

Greater Manchester

735

690

971

08 Seacoast Mental Health

158

Center

652

435

436

09 Community Partners

207

170

202

167

10 Center for Life Management

133

161

151

99

Total

2,819

3,146

3,382

3,136

11

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 12 of 95
Of the 3,136 unique individuals screened for ACT during this period, the State reports that 217 were referred for an ACT assessment. This is a referral rate of less than seven percent. Most of the referrals for ACT screening are internal to the CMHCs. That is, people who have already had a CMHC intake, and who may already be receiving CMHC services, are those most likely to be screened for ACT services. Thus, it is perhaps not surprising that so few of the individuals screened are referred to the next step, which is the assessment for ACT. If this trend continues, it will be even more important to evaluate and expand screening efforts at other points of entry to the service system, including interactions with emergency departments, CMHC emergency services, and MCTs. In the next Quarterly Report the State will begin reporting the number of people enrolled in ACT as a result of this screening and assessment process. The State has begun collecting and reporting data on the number of individuals waiting for ACT services on a statewide basis. This information is displayed in Table V below. An individual eligible for ACT may have to wait for ACT services because the specific ACT team of the individual’s CMHC does not currently have staff capacity to accept new clients. The ER has documented above that there is a statewide gap between ACT staff capacity and ACT participation. However, in some CMHC regions new ACT staff must be hired before new ACT clients can be accepted into the program.
12

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 13 of 95

Table V

Self-Reported ACT Wait List: March and September, 2018

Time on List

Total

0-30 days

31-60 days

61-90 days

March 2018

9

7

2

0

June 2018

3

3

0

0

September 2018

11

9

2

0

Based on the above information, the ER finds that the State remains out of compliance with the ACT service standards described in Section V.D. of the CMHA. The State does not currently provide a robust and effective system of ACT services throughout the state as required by the CMHA.
As noted in recent ER Reports, the New Hampshire DHHS has taken deliberate steps to work with CMHCs in certain Regions to increase their ACT staffing and caseloads. These actions include: (a) quarterly ACT monitoring and technical assistance with DHHS leadership and staff; (b) implementation of a firm schedule for ACT fidelity reviews; (c) incorporating a small increase in ACT funding into the Medicaid rates for CMHCs; (d) active on-site and telephonic technical assistance based on CMHC needs related to improving the quality and fidelity of ACT services; and (e) substantial and coordinated efforts to address workforce recruitment and retention.
However, Dartmouth fidelity reviews for the ten CMHC regions have revealed some deficient practices that are not in fidelity with the ACT model. Currently all ten CMHCs meet at least the minimum threshold for “fair” fidelity of ACT services.11 However, for eight of the ten CMHCs the fidelity scores have gone down by an average of 10 points in a year to year comparison of total ACT fidelity scores.12 More information is provided on QSR and Fidelity activities in the QSR section of this report.
As of the date of this report the ER has reviewed ten QSR reports using the revised instruments. Nine of the ten CMHCs covered by these QSR reviews had scores below the 70% performance
11 Note: meeting the minimum threshold for ACT fidelity does not equate to meeting the requirements of the CMHA. ACT staffing requirements in the CMHA are more specific, in some regards, than the ACT Fidelity tool. 12 Some of this change may have resulted from the states shift to a contracted external organization to conduct ACT and SE fidelity reviews.
13

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 14 of 95
threshold on the QSR quality indicator related to the fidelity of ACT services. Quality Improvement Plans (QIPs) have been initiated based on these QSR findings. The State notes, and the ER agrees, that the QSR findings are not a substitute for the ACT fidelity reviews. Nonetheless, as intended in the design of the QSR, the QSR findings add important documentation of the degree to which ACT participants are or are not benefitting from fidelity ACT services. Taken together, the fidelity reviews and the QSR findings present reasonable and actionable information related to the quality and effectiveness of ACT services under the CMHA. The ER continues to review the State’s oversight and technical assistance conducted to assure that these QIPs are being properly implemented.
DHHS and the CMHCs have been attempting to identify individuals at risk of hospitalization, incarceration or homelessness who might benefit from ACT services. Individuals boarding in hospital emergency departments (EDs) waiting for a psychiatric hospital admission, or who have done so in the recent past, are one important source of potential referrals. DHHS is attempting to document the extent to which identifying and referring these individuals to CMHCS is: (a) reducing ED boarding episodes and lengths of stay; and (b) resulting in enrollment of new qualified individuals in ACT services. As noted in the hospital readmission discussion below, over a quarter of all those discharged from NHH are readmitted within 180 days. Robust ACT services could help reduce the number of hospital readmissions throughout the state if such individuals are promptly screened and referred, and their regional ACT teams have the capacity to deliver needed services.
The ER has requested that the State provide a report of the results of these activities. To date, the only report available addresses internal CMHC screening for ACT (see Table IV above), but does not report on the extent to which referrals from hospital EDs or other external sources are resulting in new enrollments in ACT services.
The State has identified workforce recruitment and retention issues as factors limiting the growth and expansion of the ACT teams. The State has been working collaboratively with the New Hampshire Community Behavioral Health Association to identify and track workforce gaps and shortages, and to implement a variety of strategies to improve workforce recruitment and retention. However, as noted above, ACT staffing has remained essentially static since December of 2016. Recently, the State has received approval from the federal Centers for Medicare and Medicaid Services (CMS) to use Medicaid waiver funds for directed payments (fee schedule adjustment) to CMHCs for recipients already enrolled in ACT and for each new ACT enrollee. CMS has also approved a fee schedule increase for people discharged from psychiatric inpatient services who receive a same- or next-day appointment at a CMHC. Taken together, these initiatives should provide incentives for CMHCs to sustain and increase their ACT caseloads. Three million dollars has been set aside under this plan to provide fee schedule increased for ACT enrollees. An additional 1.2 million dollars has been budgeted for same or next day CMHC appointments. The impact of this new funding is not likely to be measurable until at least the next ER report in June, 2019.
14

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 15 of 95
The ER believes the State, DHHS and many of the CMHCs are making efforts to meet the ACT capacity and fidelity standards of the CMHA. Despite the continued compliance issues noted above, the ER believes there have been improvements in the quality and effectiveness of ACT services provided in some parts of the state. Nonetheless, while these improvements are welcome, it must be noted that the State is still far from compliance with the ACT standards of the CMHA. As with previous reports, the ER expects DHHS and the CMHCs to make use of capacity already available in the system, while at the same time addressing additional capacity and continuing to improve fidelity.
The ER emphasizes, as in past reports, that it must be the first priority of the State and the CMHCs to focus on: 1) assuring required ACT team composition; 2) utilizing existing ACT team capacity; 3) increasing ACT team capacity; and 4) outreach to and enrollment of new ACT clients. As noted earlier in this report, the ER expects the State to propose new and expanded strategies for increasing ACT capacity to meet the requirements of the CMHA. The strategies and related timelines are to be incorporated into the ACT plan and Monthly Progress Report. In addition, the ER has requested representatives of the State and the Plaintiffs to participate in a short-term working group to focus on strategies to meet the CMHA requirements for ACT services. This working group is expected to deliver recommendations to the parties no later than April 1, 2019.
Supported Employment
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment …to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by June 30, 2017 “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)).
For this reporting period, the State reports that it has achieved a statewide SE penetration rate of 25.9 percent, 39 percent above the 18.6% penetration rate target specified in the CMHA. Table VI below shows the SE penetration rates for each of the 10 Regional CMHCs in New Hampshire.
15

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 16 of 95

Table VI Self-Reported CMHC SE Penetration Rates

Dec-16 Mar-17 Jun-17 Sep-17 Dec-17 Mar-18 Jun-18 Sep-18

Northern West Central Lakes Reg. Riverbend Monadnock Greater Nashua Manchester Seacoast Community Part. CLM CMHA Target Statewide Ave.

27.00% 21.50% 14.50% 13.80% 17.90% 12.40% 43.10% 12.00%

32.30% 23.20% 12.60% 15.00% 13.50% 15.00% 39.80% 14.40%

37.20% 22.50% 22.00% 14.80% 14.00% 16.10% 40.00% 19.30%

40.90% 22.30% 20.70% 14.00% 12.30% 17.10% 42.00% 23.40%

39.00% 25.30% 19.10% 13.20% 10.90% 16.80% 45.30% 28.00%

38.80% 26.20% 15.40% 12.60% 10.40% 14.90% 43.50% 30.10%

36.90% 31.20% 12.10% 11.80% 11.00% 14.20% 44.10% 29.80%

32.10% 33.80% 11.80% 16.60%
9.30% 12.60% 44.10% 29.90%

6.80% 21.10% 18.10% 22.90%

7.20% 19.70% 18.60% 23.20%

10.30% 21.60% 18.60% 25.30%

14.60% 19.20% 18.60% 26.40%

17.70% 20.00% 18.60% 26.70%

21.50% 20.90% 18.60% 26.40%

20.90% 17.50% 18.60% 25.90%

19.20% 20.80% 18.60% 25.90%

As noted in Table VI, the State has exceeded the statewide CMHA penetration rate in recent reporting periods. In the previous ER report, six of the ten regions fell below required CMHA penetration rates. For this reporting period, four of the ten continue to report penetration rates lower than the CMHA requirement. Three of these four had a slight reduction in penetration from the previous reporting period.
The New Hampshire DHHS is to be commended for continuing its efforts to: (a) assure the fidelity of SE services on a statewide basis; and (b) work with the Regions with penetration rates below CMHA criteria to increase access to and delivery of SE services to target population members in their Regions. The ER will continue to monitor these issues going forward as the State works with the CMHCs to increase penetration rates to at least 18.6 percent in all regions.
As with ACT services, DHHS has implemented a combination of contract compliance, technical assistance, workforce recruitment and retention, and external fidelity reviews in an attempt to assure sufficient quality and accessibility of SE services statewide. The QSR does collect information at the service participant level about the degree to which individuals have been effectively assessed for SE services, are receiving SE services consistent with their individual treatment plans, and/or that SE services are delivered in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings (V.F.1).

16

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 17 of 95
The QSR process has identified a number of SE performance issues among the CMHCs. For example, for the indicator related to comprehensive employment assessments, eight of the ten CMHCs scored below the 70% performance threshold. In the same manner, nine of the ten CMHCs scored below 70% on the indicator related to the adequacy of employment service delivery. Three of the CMHCs scored below the 70% threshold on the indicator related to employment treatment planning. In each case these findings have resulted in the development of QIPs, and in state technical assistance and monitoring activities designed to improve the quality and effectiveness of SE services. As with ACT services, the QSR findings are not a substitute for SE fidelity reviews, but they do add to the overall documentation of the degree to which SE services are delivered with quality and effectiveness. For example, a SE team can operate at relatively high fidelity, but if individuals are not assessed properly for inclusion in SE services, there could be issues related to matching individual needs with the services available.
System performance in supported employment assessment and service delivery, as documented by the QSR and corresponding provider fidelity reviews, indicates that the State is not yet providing SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans, and that eligible individuals may not be properly identified and provided reasonable access to supported employment services.
The State has initiated reporting requirements in which each CMHC will report on the number and percent of SE participants working in integrated competitive settings. These data are not yet fully accurate and comparable, and thus are not included and discussed in this report. The ER expects these data will be ready to be included in subsequent Quarterly Data and ER reports.
Supported Housing
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Program by June 30, 2016. As of September 2018, DHHS reports having 423 individuals leased in Bridge Program subsidized units, and having no people approved for a Bridge Program subsidy but not yet leased (although, as discussed below, there are 35 people on the waitlist for a Bridge subsidy). There has been a precipitous drop in the aggregate number of individuals either leased or approved but not yet leased in the Bridge Program – from 591 in June of 2017 to 423 in September of 2018. In terms of funded capacity of Bridge Program units, the State was in compliance with the CMHA standards for SH effective June 30, 2016. However, as noted above, the number has now dropped below 450, and currently there are no individuals reported to be approved and in the search process for a SH unit.
Table VII below summarizes recent data supplied by DHHS related to the Bridge Subsidy Program.
17

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 18 of 95

Table VII

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

September 2015 through March 2018

Bridge Subsidy Program
Information

Sept. 2016

Dec. 2016

March June 2017 2017

Sept. March 2017 2018

Sept. 2018

Total individuals 451

481

505

545

509

497

423

receiving a

Bridge Program

Subsidy

Individuals

28

32

48

46

58

7

0

accepted but

waiting to lease

Individuals

0

0

0

0

0

10

35

currently on the

wait list for a

bridge subsidy13

Total number

603

643

675

701

742

811

812

served since the

inception of the

Bridge Subsidy

Program

Total number

83

83

85

85

96

119

125

receiving a HUD

Housing Choice

Voucher (HCV)

In response to previous requests for information, the State, DHHS is now publishing quarterly reports of the number of Bridge Program applications and terminations (Table VIII) and also the wait list for Bridge Program subsidies (see Table VII above).

13 The State did not maintain a waitlist prior to 2018.
18

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 19 of 95

With regard to terminations, Table VII shows that a total of 812 people have been served by the Bridge Program since its inception. It appears that 125 of these 812 individuals have transitioned successfully to HCVs, and thus have moved off the Bridge Program. This includes 29 individuals reported to have transitioned to HCV from September 2017 to September 2018. That leaves a total of 264 Bridge Program exits that are potentially not accounted for in the current data. The State asserts that it intends to provide additional data14 on the reasons for people who have exited the SH program. Table VIII below is the first step taken by DHHS to report some of these data. The ER expects that expanded reporting on these items will begin with the next Quarterly Data report.

Table VIII

Self-Reported Housing Bridge Subsidy Applications and Terminations

Measure

April – June January – March

2018

2018

July – September 2018

Applications Received

44

28

32

Point of Contact CMHCS NHH

43

24

32

1

4

0

Applications Approved

10

5

7

Applications Denied

0

0

0

Denial Reasons

NA

NA

NA

Applications in Process*

34

165

197

Terminations

0

0

0

Termination Reasons

NA

NA

NA

*These data are currently being audited by BMHS and may be subject to change

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than

14 Prospectively, not retrospectively.

19

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 20 of 95

10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table IX below displays the reported number of units leased at the same address.

Table IX

Self-Reported Housing Bridge Subsidy Concentration (Density)

Nov. 2016

Feb. 2017

May Nov. Feb 2017 2017 2018

June 2018

Sept. 2018

Number of properties

with one leased SH unit

at the same address

339

349

367 383 372

354

339

Number of properties

with two SH units at the

same address

24

23

36 31

35

26

52

Number of properties

with three SH units at

the same address

13

14

5

6

13

10

24

Number of properties

with four SH units at the

same address

3

4

4

5

4

5

12

Number of properties

with five SH units at the

same address

0

0

3

0

1

0

0

Number of properties

with six SH units at the

same address

1

1

1

0

0

0

6

Number of properties with seven + SH units at same address

0

2

3

2

2

17

The ER has noted that data in this report does not comport with previous data reports on unit density, or on the number of units under lease. The State is exploring the reasons for these differences, and these data will be verified and corrected in the next ER report. These data
20

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 21 of 95
indicate a concerning increase in the unit density of Bridge apartments. The ER expects the State to report information on the number of total SH and non-SH apartment units at each address containing multiple SH units, so that the ER can assess whether the Bridge is operating as a scattered-site program in accordance with the maximum density standards of the CMHA.
It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)). DHHS reports, and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge Subsidy Program units.15
As noted in the Data section of this report, current data is not available on the degree to which Bridge Subsidy Program participants access and utilize support services and whether or not the services are effective and meet individualized needs. Receipt of services is not a condition of eligibility for a subsidy under the Bridge Program, but the CMHA does specify that “…supported housing includes support services to enable individuals to attain and maintain integrated affordable housing, and includes support services that are flexible and available as needed and desired….” (V.E.1(a)).
As noted in the ER Reports dating back to 2016, DHHS has been working on a method to crossmatch the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. This will allow documentation of the degree to which Bridge Subsidy Program participants who are engaged with a CMHC are actually receiving certain mental health or other services and supports. As noted in the Data section, the ER has not yet received this requested information from the state. The ER expects that such information will be produced and delivered to the ER no later than February 15, 2018.
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain HUD funding for an additional 150 supported housing units for a total of 600 supported housing units.” (CMHA V.E.3(e)) In 2015 New Hampshire applied for and was awarded funds to develop a total of 191 units of supported housing under the HUD Section 811 Program. All of these units will be set aside for people with serious mental illness. As of the date of this report, 2816 of these new units have been developed and are currently occupied by members of the target population and an additional 89 units are in the development pipeline. It should be noted that over the life of the Bridge Program the State has accessed 125 HUD HCVs. Accessing these HCVs has allowed the State to free up 125 Bridge Program slots for new applicants. The ER plans to work with the state and representatives of the plaintiffs to assure documentation of progress towards the 600 specified units is attained and sustained.
15 DHHS reports that currently there is one voluntary roommate situation reflected in the above data. 16 This number likely has increased since the last report. Revised information was not available at the time this report was prepared.
21

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 22 of 95
In addition, the CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.” There are 35 individuals on the wait list for the Bridge program as of September 2018;28 of these individuals have been on the wait list for more than 120 days and 23 of them have been waiting longer than six months for supported housing. The State reports that it has issued an RFP for with an annualized value of $500,000 to add capacity to the Bridge Program. The proposals were to be received by November 29, 2018. To date a vendor has not been selected and the contract for the new Bridge Program capacity has not been awarded. The State has not specified the number of new SH units expected to be added to the Bridge Program as a result of this RFP. The State has asserted that it will notify the ER and representatives of the Plaintiffs as soon as this contract is awarded.
Looking at the above data, it appears that: (1) the number of units under lease for the Bridge Program has fallen below the 450 capacity measure: (2) there are currently no individuals who have been approved for a Bridge subsidy and are actively seeking a unit; and (3) there are at least 28 people on the Bridge Program wait list who have been on the list for more than four months. The ER is very concerned about these recent data. In addition, if the information in Table IX is correct, the number of leased units in single occupancy buildings has gone down substantially, while at the same time the number of units in multi-occupancy buildings has increased. Taken together, it appears that SH is falling further out of compliance with the requirements of the CMHA. The ER intends to review this situation with the State early in the 2019, and will recommend further actions be taken to reverse these trends and to maximize available housing resources.
Transitions from Institutional to Community Settings
During the past 48 months, the ER has visited both Glencliff and NHH on at least eight separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities in 201417. Transition planning activities related to specific current residents in both facilities have been observed, and a small non-random sample of resident transition records has been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities.
The ER has participated in six meetings of the Central Team. The CMHA required the State to create a Central Team to overcome barriers to discharge from institutional settings to community settings. The Central Team has now had about 36 months of operational experience, and has
17 NHH updated its transition planning policies in 2018.
22

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 23 of 95

started reporting data on its activities. As of December, 2018, 50 individuals have been submitted to the Central Team, 31 from Glencliff and 19 from NHH. Of these, the State reports that 24 individual cases have been resolved18, two individuals are deceased, and 24 individual cases remain under consideration. Table X below summarizes the discharge barriers that have been identified by the Central Team with regard to these 24 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total higher than the number of individuals reviewed by the Central Team.

Table X

Self-Reported Discharge Barriers for Open Cases Referred from NHH and Glencliff to the Central Team:

October, 2018

Discharge Barriers

Number for Glencliff

Number for NHH

Legal

4 (7.7%)

3 (15%)

Residential

17 (32.7%)

7 (35%)

Financial

5 (9.6%)

3 (15%)

Clinical

15 (28.8%)

4 (20%)

Family/Guardian

10 (19.2%)

2 (10%)

Other

1 (1.9%)

1 (5%)

Glencliff In the time period from April through September, 2018, Glencliff reports that it has admitted 14 individuals, and has had three discharges and 16 deaths. The average daily census through this period was 115 people. There has been one readmission during this time frame. The wait list for admission has remained relatively constant at 22 to 23 people for the past six months. Of the three discharges effectuated during this period, none was to an integrated community setting.
18 Two of these individuals were readmitted to NHH after 90 days, and the discharge dispositions for these two individuals are being reviewed.
23

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 24 of 95
CMHA Section VI requires the State to develop effective transition planning and a written transition plan for all residents of NHH and Glencliff (VI.A.1), and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]19 individuals with mental illness and complex health care needs residing at Glencliff…”. The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be cost-effectively served in supported housing.”20
DHHS reports that the total number of people transitioned from Glencliff to integrated settings since the inception of the CMHA three years ago increased since the last ER Report from 16 to 1721. There are currently nineteen individuals undergoing transition planning who could be transitioned to integrated community settings once appropriate living settings and community services become available. Twelve of these individuals have been assigned to Choices for Independence (CFI) waiver case management agencies in order to access case management in the community to facilitate transition planning. The remaining seven individuals are in the process of eligibility determination for the Acquired Brain Disorder, Developmentally Disabled, or Choices for Independence waiver programs.
DHHS continues to provide information about Glencliff transitions, including clinical summaries, lengths of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in the integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions that could not be cost-effectively be served in SH continue to experience transitions to integrated community settings. To protect the confidentiality of individuals transitioned from Glencliff, this person-specific information is not included in the ER reports.
DHHS has implemented action steps to enhance the process of: (a) identifying Glencliff residents wishing to transition to integrated settings; and (b) increasing the capacity, variety and geographic accessibility of integrated community settings and services available to meet the needs of these individuals. Both sets of initiatives are intended to facilitate such community transitions for additional Glencliff residents. Despite these efforts, the frequency of transitions to integrated community settings from Glencliff has reduced in the past year. DHHS is currently working to revise funding procedures and provider related requirements to facilitate new transitions to integrated setting on a timelier basis. The ER will be closely monitoring whether these initiatives result in increased transitions over the next few months.
19 Cumulative from CMHA V.E.(g), (h), and (i). 20 CMHA V.E.2(a) 21 The ER is working with the State and representatives of the Plaintiffs to verify that the reported settings are in fact integrated community settings.
24

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 25 of 95
As noted in the previous report, the ER is at this point reluctant to focus too narrowly on clinical conditions and sets of health, mental health and community services and supports for transitioned and transitioning individuals to monitor the State’s progress in assisting Glencliff Home residents to transition to integrated community settings. The ER will monitor the extent to which DHHS, Glencliff, the CMHCs and an array of other community partners collaborate to effectuate as many such transitions as possible over the next year. The primary thrust and intent of the CMHA is to assure that individuals residing in Glencliff (and their families and guardians) are offered meaningful opportunities to consider transition to integrated community settings, and that services necessary to implement those transition are readily available. This includes effective inreach services, opportunities to explore community alternatives as part of transition planning, and documented efforts to identify and resolve potential barriers to community living.
The specific requirements in the CMHA for transition and community residential service capacity could still be attained if DHHS and its partners increase the availability of integrated community settings, and provide meaningful in-reach and transition planning for Glencliff residents.
However, progress towards effectuating transitions to integrated community settings for current Glencliff residents has been slow over the past 18 months. Unless additional efforts are brought to bear, the 19 individuals in active transition planning could remain at Glencliff indefinitely, and other residents will go without meaningful opportunities to explore potential community alternatives.
Thus, the ER will continue to monitor the following topics/items to inform his assessment of compliance:
1. The number of transitions from Glencliff to integrated community settings per quarter. The ER will also monitor information about the clinical and functional level of care needs of these individuals; the integrated settings to which they transition; and the array of Medicaid and non-Medicaid mental health and health-related services and supports put in place to meet their needs to assure successful integrated community living.
2. The number of Glencliff residents newly identified per quarter to engage in transition planning and move towards integrated community settings. The ER will also monitor at a summary level the clinical and functional level of care needs of individuals added to the transition planning list per quarter.
3. New integrated community setting providers with the capacity to facilitate integrated community living for Glencliff residents. These could include EFCs, AFCs, and new small-scale community residential capacity for people with complex medical conditions who cannot be cost-effectively served in supported housing. The ER will monitor DHHS activities and successes relative to identification and engagement of community providers who express willingness and capacity to provide services in integrated community settings for people transitioning from Glencliff.
25

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 26 of 95

4. Within the discharge cohort, the number of transitioned individuals for whom the State special funding mechanism is utilized to effectuate the transition, and the ways in which these funds are used to fill gaps in existing services and supports.
5. Number and types of in-reach visits and communications by CMHCs and other community providers related to identifying and facilitating transitions of Glencliff residents to integrated community settings.
6. Specific documentation of efforts to overcome family and/or guardian resistance to integrated community transitions for Glencliff residents.
7. Number of individuals engaged in transition planning referred to the Central Team; number of these individuals who successfully transition to an integrated community setting; and the elapsed time from referral to resolution.

Preadmission Screening and Resident Review (PASRR)

The State DHHS has provided recent data on PASRR Level II screens for the period May 1, 2018 through August 28, 2018. These data are summarized in Table XI below. A Level II screen is conducted if a PASRR Level I (initial) screen identifies the presence of mental illness, intellectual disability, or related conditions for which a nursing facility placement might not be appropriate. One objective of the Level II screening process is to seek alternatives to nursing facility care by diverting people to appropriate integrated community settings. Another objective is to identify the need for specialized facility based services if individuals are deemed to need nursing facility level of care.

Table XI

PASRR Level II Screens: May through August, 2018

Full Approval - No Special Services Full Approval with Special Services Long Term Care Not Recommended Provisional – No Special Services Provisional with Special Services Total Percent with Special Services

May 2018
11 0 1 3 0 15 0.00%

June, July and August. 2018
24 4 1 4 1 34 14.7%

Total
35 4 2 7 1 49 10.2%

26

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 27 of 95
As can be seen in Table XI, a total of 49 Level II screens were conducted in the four months covered by the reports. Two of these screens (4.1%) resulted in a recommendation to not provide care in a nursing facility/long term care setting. It is not known what alternative level of care or community setting was provided for these individuals. Five of the screens (10.2%) resulted in a recommendation for special services. The PASRR data reports do not indicate what specific types of special services have been indicated for the five individuals in this reporting period.
The ER has been seeking comparable data from other states to see if the 10% special services indication rate comports with the experiences of other jurisdictions. So far, information has been received from one state. That particular state has made recent efforts to improve the quality and effectiveness of its PASRR process. This state reports:
“Of the individuals authorized NF placement, the % of individuals recommended specialized behavioral health services has increased over the years. The percentages by calendar year are listed below:
• 2015 = 47% • 2016 = 68% • 2017 = 84% • 2018 = 88%”
The ER will continue to review comparable PASRR data as it becomes available.
For the period from June 1, 2018 through August 28, 2018, a total of 171 Level I screens are reported to have been completed. 86 of these resulted in “negative screening”, meaning that they were not approved for nursing facility level of care or that they were not applicable for the Level II PASRR screening process. 46 of the Level I screens resulted in a referral for Level II screening, and 37 (80.4%) of these were referred because of mental illness. The vendor for the New Hampshire PASRR program reports that the variance between the number of referrals for Level II screens, and the actual number of screens completed, is likely due to the time frame for reporting. That is, the referral for Level II screening came too late in the reporting period for the Level II screen to be completed within the reporting period. It should be noted that the above data represents PASRR activity related to all nursing facility admissions (or re-reviews) in New Hampshire, not just for those being screened for admission to Glencliff.
The ER has also reviewed the PASRR Level II screens and admission assessments for the six most recent admissions to Glencliff. Three of these were not completed: two because of the presence of dementia; and one because there was no diagnosed mental illness or related condition. For the three Level II screens that were completed, no special services were recommended.
27

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 28 of 95
For a variety of reasons, virtually all PASRR screens are conducted for people who are already in a nursing facility. For example, for the June to August reporting period, 160 of 171 PASRR Level I screens (93.6%) were conducted in nursing facilities; and for level II screens 33 of 34 (97.1%) were conducted in nursing facilities. A possible consequence of this is that prime opportunities for diversion to integrated community settings may have already been missed by the time the PASRR screen is conducted. In addition, individuals admitted to Glencliff must typically have been turned down by at least three other facilities before being considered for admission. In combination, these facts indicate that interventions to divert individuals from Glencliff or other nursing facilities must typically be used before the PASRR screening process is initiated. PASRR is important to assure that people with mental illness, ID/DD, or related conditions are not inappropriately institutionalized or placed in nursing facilities without access to necessary special services. However, PASRR is not by itself sufficient to divert people from nursing facility care. Up-Stream interventions at NHH, the DRFs, and among the CMHCs are also essential to prevent unnecessary facility placement.
New Hampshire Hospital and the Designated Receiving Facilities (DRFs) For the time period July through September 2018, DHHS reports that NHH effectuated 209 admissions and 212 discharges. The mean daily census was 153, and the median length of stay for discharges was 16 days. Table XII below compares NHH discharge destination information for the five most recent reporting periods (10/2016 through 9/2018). The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.
28

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 29 of 95

Table XII

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Percent Percent Percent Percent

Percent

Percent

Discharge Destination

October and
November 2016

January through March
2017

April through
June 2017

July through September
2017

October 2017
through March 2018

April 2018 through
September 2018

Home – live alone or with others

85.1% 84.5% 85.66% 88.3%

81.0%

81.7%

Glencliff

0.36% 1.55% 0,35%

0.49%

1.0%

1.45%

Homeless Shelter/motel

2.54%

2.71%

3.5%

2.94%

2.5%

3.13%

Group home 5+/DDS supported living, etc.

1.62%

5.7%

5.59%

3.92%

7.1%

4.57%

Jail/corrections

2.9%

0.8%

1.05%

0.49%

1.7%

1.45%

Nursing home/rehab facility

3.6%

1.9%

3.50%

2.45%

2.7%

5.3%

The State now consistently reports information on the hospital-based DRFs and The Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and analyze it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. The ER appreciates the State gathering this information. Table XIII summarizes these data.

29

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 30 of 95

Table XIII Self-Reported DRF/APRTP Utilization Data: January 2016 through September 2018

Admissions Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

69

257

NA

79

205

378

37

207

375

60

228

363

NA** 178

363

59

209

358

52

240

330

69

244

333

67

201

357

65

121

49

92

54

114

52

101

60

121

55

102

66

100

65

104

54

112

Total
NA 803 787 804 722 783 788 815 791

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018

Franklin Cypress Portsmouth Eliot

Eliot Total

Geriatric Pathways

53.70% 55.70% 43.20% 58.30% NA** 49.20% 44.20% 46.73% 28.36%

18.70% 24.40% 29.50% 21.50% 25.60% 30.10% 28.30% 25.82% 24.38%

NA 20.40% 18.90% 22.00% 25.60% 23.70% 21.50% 24.62% 19.33%

18.50% 4.10% 13.00% 1.00% 11.50% 12.70% 6.10% 9.23% 12.96%

30.60% 48.90% 44.70% 47.50% 50.40% 50.00% 47.00% 51.92% 49.11%

NA 25.50% 26.20% 30.06%
NA 30.00% 27.00% 29.08% 25.16%

30

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 31 of 95

Average Census Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

7.9

14.7

NA

7.8

13.2

21.4

4.5

13.6

23.2

4.5

12

30.3

NA** 12.9

29.7

10.1 12.3

27.7

6.7

11.6

32.5

9.1

11.9

31.7

11.8

8.4

39.6

19.7

18.1

22.5

16.9

25.6

14.5

29.3

10

29.7

12.2

32.6

16.1

34.6

NA

31.7

20.4

33.8

18.2

Total
NA 81.8 81.4 86.1 NA 19.7 NA 104.8 111.8

Discharges Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

76

261

NA

78

206

363

35

213

380

59

232

365

NA** 243

355

82

212

359

53

248

326

74

244

326

66

195

353

57

122

51

90

64

113

54

105

63

121

58

102

67

101

65

107

54

112

Total
516* 788 805 815 NA 813 795 816 780

Franklin Cypress Portsmouth Eliot

Mean LOS for Discharges

Geriatric

Jan - March 2016

8.6

4.2

NA

15

April - June 2016

6

4

4

28

July - Sept 2016

7

5

4

24

April - June 2017

6

4

5

22

July - September 2017 NA**

4

4

27

Oct. - Dec 2017

4

4

5

21

Jan. - March 2018

5

4

5

23

April - June, 2018

5

4

5

20

July - September 2018

4

4

4

21

7

* Does not include Portsmouth

** Franklin DRF did not report data for the July - September period.

Eliot Pathways
7.4 7 8 8 7 7 7 8 7

Total
8.8* 5 5 9 NA 5 5 5 5

31

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 32 of 95 The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and should also reduce the number of people waiting for psychiatric admissions in hospital EDs. However, at this time there has been no substantial reduction in NHH admissions, NHH readmissions, or the wait list for NHH admissions of people staying in hospital EDs. This could reflect an increased overall demand for inpatient psychiatric care or be an indicator of limited access to community-based mental health services like ACT. DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table XIV below provides a summary of these recently reported data.
32

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 33 of 95

Table XIV

Cumulative Self-Reported Discharge Dispositions for DRFs in New Hampshire

October, 2017 through September, 2018

Disposition

Franklin Cypress Portsmouth Eliot

Eliot

**

Geriatric Pathways

Total

Home

252

825

1,144

58

356

2,635

NHH

3

1

18

1

9

32

Residential

6

23

0

144

9

182

Facility/

Assisted

Living

Other DRF

10

14

6

0

2

32

Hospital

1

0

0

10

0

11

Death

0

0

0

23

0

23

Other or

3

36

193

5

43

280

Unknown

Total

275

898

1,361

241

419

3,194

*The Other category for Portsmouth Regional is reported to include shelters, rehab facilities,

hotels/motels, friends/families, and unknown.

Based on these self-reported data, 82.5% of 3,194 discharges from DRFs and the Cypress Center are to home. This is the same as the 81.7 % or greater discharges to home reported by NHH. 5.9% of the total DRF discharges are to residential care or assisted living, which is similar to NHH discharges for this category. 1.4% of the DRF discharges are to NHH, 0.10% is to other DRFs. 8.77% of the total discharges are to the other/unknown category, but 68.9% of these are accounted for by the Portsmouth DRF. This might point to an anomaly in the ways facilities use this category in their reports to the state. The State reports on-going efforts with the DRFs to improve their data reporting.

Hospital Readmissions

DHHS is now reporting readmission rates for both NHH and the DRFs. Table XV below summarizes these data:

33

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 34 of 95

Table XV

Self-Reported Readmission Rates for NHH and the DRFs

July 2017 through September 2018

NHH 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018

Percent 30 Days
9.80% 12.8% 13.7% 7.6% 8.6%

Percent 90 Days
21.60% 26.1% 22.7% 14.7% 19.6%

Percent 180 Days
27.90% 32.8% 29.9% 23.4% 25.4%

Franklin 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018

NA 10.2% 0.0% 4.3% 6.0%

NA 10.2% 0.0% 5.8% 9.0%

NA 10.2% 1.9% 5.8% 16.4%

Cypress 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018

7.10% 12.00% 4.20% 4.50% 8.50%

12.40% 18.70% 9.60% 8.20% 13.90%

15.90% 24.40% 15.80% 11.90% 18.90%

Portsmouth 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018

11.50% 8.70% 8.80% 10.20% 8.40%

17.50% 13.70% 15.50% 15.90% 12.90%

21.00% 17.60% 20.60% 21.90% 19.00%

Elliot Pathways 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018

3.30% 5.80%
NA 3.80% 0.9%

6.60% 7.70%
NA 6.70% 3.6%

12.40% 12.50%
NA 8.60% 3.6%

34

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 35 of 95

Elliott Geriatric 4/2018 to 6/2018 7/2018 to 9/2018

6.10% 5.60%

6.10% 11.10%

6.10% 11.10%

Two facts are documented for the 15 month period in which re-admission rate data has been reported. First, the rates of readmission have changed only slightly: sometimes higher and sometimes lower, but always in the same range. Second, the readmission rates, especially the 180 day readmission rate for NHH, remains very high. At least a quarter of all people discharged form NHH are back in the hospital within 180 days. These data, in concert with the hospital emergency room data presented below, indicate that gaps remain in community services for people with serious mental illness, and that the essential connection between inpatient care and community services is not being effectuated for sizeable numbers of people at risk of rehospitalization. These facts need to be understood in light of the States ongoing difficulties increasing ACT capacity and enrollment as documented in Section III of this report.
Hospital ED Waiting List
In the previous three reports, the ER has identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. Chart A below displays daily adult admissions delays to NHH for the period July 1, 2016 through November 20, 2018. Chart B shows the average daily ED waiting list for the same time period.

35

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 36 of 95 Chart A
36

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 37 of 95 Chart B
37

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 38 of 95
Based on information reported by DHHS and illustrated above, a monthly average of 46 adults was waiting for a NHH inpatient psychiatric bed from November of 2016 through November of 2018. As can be seen from Chart A, the average number of adults waiting for admission has trended up during the two year reporting period. As with hospital readmission rates, emergency room boarding should be understood in light of ongoing difficulties increasing ACT capacity.
DHHS continues to analyze data related to adults boarding in EDs who may have some connection to the mental health system. In future months, DHHS will be receiving information on the degree to which CMHCs have increased ACT (or other services’) participation as a result of these analyses. The ER plans to include summaries of this information in future reports. The State, in conjunction with the CMHCs, is conducting targeted outreach to those individuals who may need expanded or enhanced community services so as to minimize or eliminate contact with hospital or institutional settings.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies
DHHS continues to report having a total of 15 peer support agency program (PSA) sites, with at least one program site in each of the ten regions. The State continues to report that all peer support centers meet the CMHA requirement to be open 44 hours per week. The State reports that those sites have a cumulative total of 945 members, with an active daily participation rate of 132 people statewide. The total membership number has decreased substantially since the last report, from 2,881 members to 945 members. The State reports that all of the PSAs have been auditing and correcting their membership lists, and that the reduction in membership is primarily due to these activities.
The CMHA requires the PSAs to be “effective” in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs. There continue to be anecdotal reports that some of the CMHCs are making more concerted efforts to refer service participants to the PSAs in their regions. Increased efforts to communicate and coordinate with PSAs have also been reported. However, as of the most recent report there has been a slight reduction in active daily participation.
In addition, the ER has received anecdotal information that in some regions of the state, relationships and communications among the CMHCs and the Peer Support Agencies have
38

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 39 of 95
improved. Peer Support Agencies are generally reported by CMHCs to be useful sources of employees for ACT and Mobile Crisis and Crisis Apartment services. However, it must be noted that in two of the CMHC regions that contract with the local PSAs for staff for the ACT teams, there is currently no peer support reported for ACT services.
Finally, CMHCs have verbally stated that the peer operated crisis beds available in several regions are a useful intervention for some CMHC clients at risk of hospitalization.
IV. Quality Assurance Systems
As noted in the introduction to this report, the State has made substantial positive progress to implement a comprehensive, reliable and actionable QSR process. The ER has participated in five QSR site visits, and is increasingly confident that: (a) the revised instruments and site interview protocols are working well; and (b) the results and findings of the revised QSR instruments and process reflect, to a large degree, the quality standards of the CMHA.
One key improvement in the revised QSR process has been the addition of several Overall Clinical Review (OCR) questions that provide opportunities for the QSR teams to integrate and summarize service participant-level information collected from a variety of information sources. These new questions include:22
1. Is the frequency and intensity of services consistent with the individual’s demonstrated need?
2. Are there additional services the individual needs that are not identified in the assessment(s) or the treatment plan?
3. Is the individual receiving all the services s/he needs to ensure health, safety, and welfare?
4. Is the individual receiving adequate services that provide reasonable opportunities to support the individual to achieve independence and integration in the community?
5. Is the individual receiving adequate services to obtain and maintain stable housing? 6. Is the individual receiving adequate services to avoid harms and decrease the incidence of
unnecessary hospital contacts and/or institutionalization? 7. Is the individual receiving adequate services to live in the most integrated setting?
Questions have also been embedded in the QSR instruments to more accurately document that: (a) the assessment(s) accurately reflect the individual’s strengths, needs and goals; and (b) service delivery approaches and patterns reflect best practices, where applicable.
These types of questions reflect the essence of the QSR process: documenting that individual service participants receive the levels and types of services and supports that assist them to
22 Note: detailed follow-up questions have not been included in this list.
39

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 40 of 95

achieve their goals and meet their needs in the most integrated community setting possible. These questions also directly respond to target population outcomes and quality expectations of the CMHA. Going forward, responses to these questions are intended to form an important part of the six-month ER reports.
The ER is grateful to both the State and the representatives of the Plaintiffs who have worked long and hard to design and implement a QSR process that will legitimately and accurately reflect the quality and effectiveness of the community mental health system in New Hampshire. This QSR system is a critical element of the CMHA, but in fact it has much broader application and potential long term benefits for the entire mental health system.
DHHS has now completed the QSR process using the revised instruments and protocols for each of the ten CMHCs. Table XVI below summarizes the quality indicator scores for each domain of the QSR. Average scores for the OCR questions (see above) are all above the 70% threshold, so they are not included in this summary table. Highlighted scores are below the 70% performance threshold established for the QSR for the time period covered by this report.
Table XVI
QSR Total Indicator Scores: All CMHCs

Indicator Number

Indicator Content

1

Adequacy of Assessment

2

Approp. Tx Planning

3

Adequacy of Ind. Serv. Del.

4

Adequacy of Hsg. Assess.

5

Approp. Of Hsg. Tx Planning

6

Adequacy of HSG. Serv. Del.

7

Effect. Og Hsg. Supports Del.

8

Adequacy of Emp. Assessment

9

Approp. Of Emp. Tx Planning

10

Adequacy of Emp. Serv. Del.

11

Adequacy of Ass. Of Int. Needs

12

Integration in Community

13

Adequacy of Crisis Assess.

14

Appropriateness of Crisis Plns.

15

Comp. and Effec. Crisis Del. Syst.

16

Adequacy of ACT screening

17

Imp. Of high Fidel. ACT Servs.

18

Succ. Trans./Dich. From inpat.

40

Average
80.50% 89.80% 82.40% 99.50% 90.20% 84.20% 76.20% 57.90% 70.30% 59.70% 94.40% 79.50% 69.00% 80.80% 72.80% 90.60% 54.30% 78.10%

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 41 of 95
As demonstrated in the table, the CMHC system as a whole scores below the 70% performance threshold on four indicators. Each of these indicators is related to specific standards and requirements of the CMHA. As noted earlier in this report, DHHS requires CMHCs with a score below the performance threshold to develop a QIP, which is then monitored on at least a quarterly basis by DHHS staff. Improvements accomplished as a result of the QIPs should be evidenced in subsequent QSR reports. DHHS is committed to using the QSR process to continuously improve the quality and effectiveness of CMHA services as the community mental health system matures. For this reason the performance threshold for QSR scoring has been raised to 75% for the current time period. The ER applauds this change, since it moves closer to requiring a level of system and provider performance that the ER considers to be substantial compliance with the CMHA. As a companion to the QSR process, DHHS has been conducting on-site ACT and SE fidelity reviews. DHHS has engaged the Dartmouth/Hitchcock Center on Evidence Based practices to assist in attaining and assuring fidelity to the evidence based models of ACT and SE. The Dartmouth/Hitchcock team will also assist on workforce development and training for these and other evidence based practices under the aegis of DHHS and the CMHCs. This partnership with the nationally respected Dartmouth/Hitchcock Center adds valuable expertise and experienced personnel to facilitate further development of, and increased adherence to, fidelity model ACT and SE in conformance with the CMHA. Year-to-year comparisons and the CMHCs Quality Improvement Plans have been included in the publication of recent ACT and SE fidelity reviews. The ER commends DHHS for implementing the comprehensive fidelity review process and its attendant quality improvement and technical assistance activities. Table XVII below shows average changes in year-to-year fidelity scores for both ACT and SE. All CMHCs in the state meet the minimum performance threshold for “fair fidelity” both ACT and SE. However, as displayed in the table, the fidelity scores have recently been trending downward, not up-ward. For both ACT and SE, only one of the ten CMHCs showed improvement in the year-to-year comparisons. Fair fidelity scores also tended to correlate with deficits in individual service delivery and performance issues in the QSR. As with the QSR scores, QIPs related to fidelity findings should result in fidelity score improvements over the next round of fidelity reviews.
41

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 42 of 95

ACT SE

Table XVII

Trends in ACT and SE Fidelity Scores23

Performance Threshold
84 74

Average Year-to-Year Fidelity Score Change
-10.3 -14.3

Effective and valid fidelity reviews and consequent training and workforce development activities are essential to DHHS’ overall quality management efforts for the community mental health system. As noted in the previous two ER reports, the QSR and the fidelity reviews mutually support but do not supplant or replace each other. The QSR, in particular, examines outcomes from a consumer-centric perspective as opposed to an operational or organizational perspective. It is uniquely positioned to assess the quality, appropriateness and effectiveness of specific ACT and SE services at the individual participant level. The ER continues to believe that implementation of fidelity-based models of delivery does not necessarily mean that specific service interventions are working well or being delivered with the frequency or intensity required by a participant’s individual treatment plan The revised QSR instruments and protocols address many of these concerns. In combination, the fidelity reviews and the QSR can mutually support conclusions about the overall quality and effectiveness of the mental health system consistent with the CMHA.
The ER will continue to monitor the degree to which the QSR process produces reliable information on individual outcomes and the quality of CMHA service delivery. In addition, over the next six months, the ER will evaluate the extent to which CMHC Quality Improvement Plans developed as part of the 2017-2018 QSR site visits are resulting in recommended practice changes and improved outcomes for those in the target population.
The ER and the Parties to the CMHA have discussed how the QSR and external fidelity reviews can be used to measure compliance with the CMHA, including both the appropriate standards for compliance and the specific provisions of the QSR and fidelity reviews that would be used to assess compliance. These discussions are on-going, and the ER supports the collaborative efforts of both the State and the representatives of the Plaintiffs. The ER intends to employ both the

23 As noted earlier in this report, the state shifted two years ago from CMHC fidelity self-reports to a contracted organization conducting fidelity reviews, and thus there may be some issues related to the comparability of the year to year scores. In addition, some of the most recent fidelity review scores are not yet reflected in the data as reported above. DHHS will soon release a report of ACT and SE fidelity reviews. The ER hopes that that report will be able to serve as the baseline for future trend analyses of ACT and SE fidelity scores.
42

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 43 of 95
QSR and the fidelity reviews as tools to assess individual outcomes, analyze system performance, and ultimately measure compliance with the CMHA.
V. New State Resources
In New Hampshire the Governor and the Legislature have evidenced increased support for implementation of the CMHA and for making improvement in the community mental health system. These initiatives include:
1. A total of 40 new transitional residential beds prioritized to support NHH discharges; 2. A contract has been awarded to Riverbend Community Mental Health for a Crisis
Treatment Center to operate in coordination with the MCT and crisis apartment program in the Concord Region; 3. DHHS has issued an RFP to provide $500,000 to expand the Bridge SH Program; 4. DHHS has issued an RFP to select and fund a new ACT Team; and 5. The newly approved Medicaid waiver includes $3,000,000 for performance payments related to sustaining and increasing ACT enrollments; and $1,500,000 for performance payments related to same or next day appointments at CMHCs for people discharged for psychiatric inpatient care. These funds are in addition to the total of $3,000,000 previously appropriated to ACT rate enhancements and workforce development efforts.
The ER also notes that the transitional housing funding listed above is not intended to be included under the aegis of the CMHA. Twenty of these transitional housing units have been occupied, 14 in the greater Nashua area, and six in central New Hampshire. DHHS reports that all 20 of these units have been occupied by long stay patients from NHH. Twenty new transitional housing beds have now been funded, and are currently in development. These placements, although not directly contributing to the CMHA, nonetheless provide a potentially valuable resource to reduce long stays in NHH. They may also reduce certain barriers that have prevented integrated community placements in supportive housing.
VI. Summary of Expert Reviewer Observations and Priorities
The CMHA and ER have now been in place for four and one half years. Within that time frame, the ER has expressed escalating concerns related to noncompliance with CMHA requirements governing ACT and Glencliff community transitions.24 In addition, the ER has noted long
24 The State reports effectuating 17 placements to integrated community settings since the inception of the CMHA. The ER and the parties remain in discussions with regard to whether these transitions meet all the criteria in the
43

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 44 of 95
elapsed times and/or delays related to implementation of system improvements or data reporting. Throughout these reports, the ER has emphasized the need for the State to be more aggressive, assertive, planful, and timely in its implementation and oversight efforts in these areas in order to come into compliance with the CMHA.
More recently the ER has reported that the State is improving its oversight and management of the mental health system. Examples include more comprehensive and accurate data reporting, the revised QSR process, and the growing use of state-validated fidelity reviews for ACT and SE. The QIPs that result from QSR and QIP activities are an improved tool for State-directed technical assistance and monitoring of CMHCs to assure improved quality and effectiveness of services for the CMHA target population.
Despite the management and service delivery improvements noted in this report, the ER remains seriously concerned about compliance with the CMHA standards and requirements related to ACT services. For the last two and one half years the ER has reported that the State is out of compliance with the ACT requirements of the Sections V.D.3(a, b, d, and e), which together require that all ACT teams meet the standards of the CMHA; that each mental health region have at least one adult ACT Team25; and that by June 30, 2016, the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time.
ACT capacity remains substantially below the required June 30, 2016 capacity to serve 1,500 people at any given time. Moreover, with an active caseload of only 911 people, the state currently is providing 589 fewer people with ACT than could be served if the State had developed the CMHA-specified capacity to serve 1,500 individuals. With the current ACT staff capacity to serve 1,156 people, there are 245 fewer people receiving ACT than the current ACT system could accommodate. This continues to be the single most significant issue in New Hampshire with regard to compliance with the CMHA. ACT services are specifically designed to serve target population members at risk of hospital admission. Individuals who remain in NHH after being deemed ready for discharge, individuals with high rates of readmission to EDs and inpatient facilities, and individuals awaiting hospitalization in EDs are included in this population. This is a human issue, not just a system issue. The ER remains seriously concerned that individual lives are affected because the ACT service capacity specified in the CMHA has still not been attained.
CMHA. Pending resolution of those discussions, the ER intended to keep Glencliff Transitions high on the compliance monitoring priority list. 25 The ER notes that each region of the state has had at least one ACT team, or ACT team-in-development, since the inception of the CMHA. However, as documented in the ACT section of this report, four regions continue to have ACT teams that do not meet the minimum staffing requirements for ACT as specified in the CMHA.
44

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 45 of 95
In addition to the focus on ACT services for the target population, the ER intends to concentrate on the following priority CMHA compliance issues during the up-coming six month reporting period:
1. More closely monitoring the SH program, including Bridge program and other funding source lease-up rates, and monitoring data on the receipt of services by SH participants;
2. Documenting the receipt, circulation and interpretation of the new data reports as specified in the body of this report;
3. Expanding the analysis and report of recent PASRR data; 4. Monitoring of implementation of QIPs, particularly as they address issues related to ACT
and SE; 5. Monitoring of transitions from Glencliff to integrated community settings, particularly
with regard to implementation of revised models and financing procedures intended to engage new community provider capacity and facilitate individual transitions; 6. Continuing to assess the quality and effectiveness of CMHA services, including whether ACT and SE services are delivered with the intensity and duration necessary to meet individual’s needs; and 7. Continuing discussions with all Parties to the CMHA regarding the use of QSR and fidelity review findings to document compliance with the standards and requirements of the CMHA.
The first priority is the implementation of a short-term ad hoc ACT working group to develop strategies to rapidly increase ACT staff capacity and to meet related CMHA requirements applicable to ACT programs in New Hampshire. Given the overall importance and multiple dimensions of ACT service compliance in the CMHA, this working group is expected to focus solely on ACT.
ACT Working Group
DHHS and representatives of the Plaintiffs are expected to appoint a small (≈3 each) number of members to serve on the ACT working group on a time-limited basis. The ER intends to participate in each meeting/conversation of the ACT working group as well. No later than April 1, 2018 the ER expects the ACT working group to produce realistic and measurable action or implementation plans to meet the CMHA ACT requirements.
The expected priority topics the ACT working group include:
1. Strategies to increase and sustain adequate ACT staffing across the system to meet the CMHA requirement of capacity to provide ACT to 1,500 target population members: a. The State will notify parties when the projected RFP for a new ACT team is released;
45

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 46 of 95
b. The State will identify its strategies (to date) for improving recruitment and retention of ACT and SE staff, and identify what did and did not work (if any); and
c. The State will explore concept of statewide contract for ED ACT assessments and/or expedited ACT intake, assessment and enrollment processes
2. Strategies to assure that each ACT team in the state has staffing and staff competencies consistent with the ACT requirements in the CMHA and with the ACT fidelity standards (including the minimum number of non-psychiatry staff per team, sufficient psychiatry hours, adequate peer staff and nursing, as well as competencies in SE and substance use);
3. Strategies to assure the rapid referral, assessment, and enrollment of applicable target population members to ACT, including referrals of target population members in NHH and other DRFs (especially those with a recent readmission), in hospital emergency departments, etc.;
4. Strategies to assure equitable access of target population members to ACT in underserved areas of the state, or areas in which current ACT staffing inhibits rapid enrollment (i.e., the Wolfeboro area and regions with ACT wait lists, etc);
5. Strategies to enhance and sustain the quality of ACT services to address issues documented through the QSR reviews/reports and/or the Fidelity reviews/reports for all current and possible future ACT teams;
6. Strategies to produce more comprehensive data reporting on ACT screening, assessment, enrollment, timeliness of moving through the process, and reasons for non-enrollment; and
7. Strategies to improve ACT team crisis response compliance.
The State may wish to discuss the degree to which there is need for ACT capacity for 1,500 individuals, and if not, provide recommendations that demonstrate that equivalent best practice integrated community based services are delivered to the CMHA target population. Strategies developed under the topics outlined above are, in part, dependent on the outcome of this discussion. Thus, if the State wishes to discuss this issue, it should be the first agenda item for the working group.
For each of the strategies developed for the above topics, the ER expects that there will be a feasible implementation plan that incorporates: (a) measurable milestones and defined products/results; (b) specific assignments of staff accountable for, and resources dedicated to, meeting the defined implementation plans; and (c) concrete measurable indicators of success/completion that will satisfy all parties that the ACT requirements of the CMHA have been met and are capable of being sustained throughout the maintenance of effort year.
The first meeting of the ACT working group is expected to take place in February 2019.
46

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 47 of 95
Other Follow-up Issues
Participants in the December 5, 2018 All Parties meeting also identified a number of items for follow-up relevant to the CMHA target population and meeting the requirements of the CMHA.
The following is a brief summary of these action items:
I. Facility transitions A. NHH 1. Continue to document barriers to discharge a. DHHS will provide to Parties and ER the process for addressing access to ACT services, when appropriate, for individuals near or ready for discharge; b. DHHS will research and report back to Parties and ER whether Bridge Program applications are being completed, when appropriate, for individuals near or ready for discharge; c. DHHS will document the specific discharge barriers for individuals determined clinically ready for discharge but who remain at NHH (e.g., need for ACT, supported housing, etc.); and d. DHHS will work with the parties to identify factors contributing to readmission.
B. Glencliff Home 1. DHHS will issue procurement to expand community capacity-date not yet specified; a. Address in-reach from CMHCs and other community providers, and discuss a State proposal for system-wide inreach coordinator for Glencliff b. Ensure that there are sufficient and appropriate community services and settings for all individuals at Glencliff who have been identified for transition or who do not oppose transition 2. Medically complex individuals; a. DHHS to provide clinical information on two recent discharges from Glencliff b. ER and plaintiffs to review new clinical information c. Integrated community settings: ER to review info from Plaintiffs’ recent survey and record reviews 3. PASRR: The ER will review the percentage of Level II reviews resulting in special services recommendations and then review the availability and provision of such services at Glencliff.
47

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 48 of 95
C. SE
1. DHHS will work to improve SE penetration in low penetration regions
2. DHHS will work to improve SE staffing levels 3. The State will notify ER and plaintiffs when SE competitive
employment data are complete and reliable enough to analyze (anticipated P/E March 2018) D. Supported Housing: Bridge Program; 1. The State will notify ER and plaintiffs when RFP for $500,000 new Bridge subsidies is awarded 2. The State will, as soon as possible, provide ER with draft of report on access to and utilization of support services for Bridge program participants – ER will discuss wider circulation after reviewing draft 3. The State will provide data on elapsed times (beginning P/E December 2018) 4. The State will provide updated information on the development of 811 funded supported housing, including an explanation of any anticipated delays in bringing this capacity on line. 5. The State will review Bridge eligibility criteria and adjust them if necessary to ensure they do not exclude individuals who meet HCV eligibility criteria. 6. The State will expand SH capacity to meet CMHA numerical and waitlist requirements.
Conclusion
As noted early in this report, the Federal Court approved the CMHA almost five years ago. The expectation at that time was that the terms and requirements of the CMHA could be met within the subsequent five years, and that a maintenance-of-effort year could be initiated once the Parties and the ER agreed that CMHA requirements were met.
In reality, the requirements of the CMHA are far from being met. For example, staff capacity for ACT services has barely changed in the past 30 months; ACT enrollment has grown only slightly in that time frame; transitions from Glencliff to integrated community settings have slowed; four
48

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 49 of 95 regions of New Hampshire still do not meet the penetration rate standard for SE in the CMHA26; the number of people in SH units has recently decreased and the state does not now meet the CMHA standards for SH; ACT and SE fidelity scores appear to be trending downward instead of upward; and QSR scores show performance deficiencies in ACT, SE and crisis services – each of which is an important element of the CMHA. In short, the State has made progress in meeting some of the requirements of the CMHA, but much work remains to be done to meet the entirety of the CMHA’s expectations for New Hampshire’s citizens with serious mental illness. This is why the final section of this report is constructed as an action agenda rather than a series of passive observations. The ER intends to focus considerable attention on the above action agenda over the next six month period, with the expectation that the State will move quickly to meet the terms of the CMHA.
26 As stated earlier in this report, the SE penetration rate standard is a statewide requirement, and is not specifically applicable to each individual CMHC. However, the ER continues to note that four CMHC regions do not meet the statewide standard, which has the effect of reducing access to SE for individuals residing in those areas.
49

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 50 of 95
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly Data Report July to September 2018
50

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 51 of 95
New Hampshire Community Mental Health Agreement Quarterly Data Report
July to September 2018
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement November 21, 2018
51

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 52 of 95
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence
52

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 53 of 95 July to September 2018
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services Publication Date:
Reporting Period: 7/1/2018 – 9/30/2018
Notes for Quarter • Identified all CMHCs having technical difficulties with Employment Screening Status Collection reporting (Table 12c). OQAI and BMHS are working on guidance to encourage reporting compliance in order to improve data quality.
1

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 54 of 95

1a. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Community Mental Health Center

July 2018

August 2018

Septemb er
2018

Unique Consume
rs in Quarter

Unique Consume
rs in Prior Quarter

01 Northern Human Services

108

110

102

121

121

02 West Central Behavioral Health

45

44

44

67

67

03 Lakes Region Mental Health Center

59

55

53

68

68

04 Riverbend Community Mental Health Center

79

83

82

83

83

05 Monadnock Family Services

55

55

55

58

58

06 Community Council of Nashua

85

84

79

94

94

07 Mental Health Center of Greater Manchester

302

305

305

289

289

08 Seacoast Mental Health Center

69

68

69

70

70

09 Community Partners

59

60

61

68

68

10 Center for Life Management

57

58

54

58

58

Total

918

921

904

980

963

Unique Clients Receiving ACT Services 10/1/2017 to 9/30/2018

1,285

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 10/17/18; consumers are counted only one time regardless of how many services they receive.

1b. Community Mental Health Center Services: Assertive Community Treatment Screening

Community Mental Health Center

July 2018

August 2018

September 2018

2

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 55 of 95

Unique Clients Screen
ed

Screening Deemed
Appropria te for
Further ACT
Assessme nt

Unique Clients Screen
ed

Screening Deemed
Appropria te for
Further ACT
Assessme nt

Unique Clients Screen
ed

Screening Deemed
Appropria te for
Further ACT
Assessme nt

01 Northern Human Services

434

56

380

42

314

35

02 West Central Behavioral Health

112

16

113

11

81

0

03 Lakes Region Mental Health Center

294

19

202

15

156

12

04 Riverbend Community Mental Health

521

28

424

31

456

32

Center

05 Monadnock Family Services

201

3

186

21

175

3

06 Community Council of Nashua

350

2

328

7

281

2

07 Mental Health Center of Greater Manchester

948

75 1121

53

971

62

08 Seacoast Mental Health Center

422

32

436

27

436

28

09 Community Partners

173

23

50

7

167

12

10 Center for Life Management

324

41

296

33

99

31

Total ACT Screening

3779

295 3546

247 3136

217

Revisions to Prior Period: None

Data Source: NH Phoenix 2 and CMHC self-reported ACT screening records.

Notes: Data extracted 10/17/2018; Screening deemed appropriate for further ACT assessment defined as ACT screenings resulting in referral to ACT services assessment.

3

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 56 of 95

1c. Community Mental Health Center Services: Assertive Community Treatment Waiting List As of 9/30/18

Time on List

Total

0-30 days

31-60 days

61-90 days

11

9

2

0

As of 6/30/2018

Total

0-30 days

31-60 days

61-90 days

3

3

0

0

Revisions to Prior Period: None

Data Source: BMHS Report

Notes: Data extracted 11/19/18.

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents

September 2018

June 2018

Nurse Masters Level Clinician/or FEuqnuictviaolenanlt Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner

Community Mental Health Center
01 Northern Human Services
02 West Central Behavioral Health 03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2

1.09 1.10 10.2 0.68 13.07 0.80 12.73 0.80 0
0.60 1.70 1.65 1.30 5.25 0.25 5.15 0.45 0.80 2.00 4.55 1.00 8.35 0.75 5.55 0.75 0.50 3.00 6.00 1.00 10.50 0.50 10.50 0.50
1.25 4.25 2.70 0.50 8.70 0.65 8.50 0.65 0.50 4.00 1.00 0.00 5.50 0.25 5.75 0.25 0.50 3.00 1.00 0.00 4.50 0.25 5.75 0.25

4

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 57 of 95

07 Mental Health Center of Greater Manchester-CTT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management
Total

1.50 11.00 2.25 0.00 14.75 1.02 15.50 0.63

1.50 9.00 6.25 1.00 17.75 0.93 16.25 0.63

1.43 3.10 5.00 1.00 10.53 0.60 9.53 0.60

0.50 2.00 6.13 0.50 9.13 0.50 9.60 0.50

1.25 2.00 4.30 0.00 7.55 0.40 8.30 0.40

11.4 46.15 51.0 6.68 115.5 6.90 113.1 6.41

2

3

8

1

5

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 58 of 95

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Substance Use Disorder Treatment

Community Mental Health Center

September 2018

June 2018

01 Northern Human Services

6.00

3.70

02 West Central Behavioral Health

0.35

0.35

03 Lakes Region Mental Health Center

2.50

2.50

04 Riverbend Community Mental Health Center

1.50

1.50

05 Monadnock Family Services

2.40

2.40

06 Community Council of Nashua 1

4.25

4.25

06 Community Council of Nashua 2

2.00

3.00

07 Mental Health Center of Greater Manchester-CCT

11.00

13.00

07 Mental Health Center of Greater Manchester-MCST

3.00

4.00

08 Seacoast Mental Health Center

3.00

3.00

09 Community Partners

1.00

2.00

10 Center for Life Management

3.00

3.00

Total

40.00

42.70

6

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 59 of 95

2c. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Housing Assistance

Community Mental Health Center

September 2018

June 2018

01 Northern Human Services

10.15

9.85

02 West Central Behavioral Health

2.25

4.25

03 Lakes Region Mental Health Center

4.55

4.55

04 Riverbend Community Mental Health Center

8.50

8.50

05 Monadnock Family Services

4.00

4.00

06 Community Council of Nashua 1

5.00

5.00

06 Community Council of Nashua 2

4.00

5.00

07 Mental Health Center of Greater Manchester-CCT

11.75

12.50

07 Mental Health Center of Greater Manchester-MCST

12.75

12.50

08 Seacoast Mental Health Center

4.00

4.00

09 Community Partners

3.00

4.00

10 Center for Life Management

6.00

6.00

Total

75.95

80.15

7

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 60 of 95

2d. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Supported Employment

Community Mental Health Center

September 2018

June 2018

01 Northern Human Services

2.00

2.00

02 West Central Behavioral Health

0.40

0.40

03 Lakes Region Mental Health Center

3.00

3.00

04 Riverbend Community Mental Health Center

0.50

0.50

05 Monadnock Family Services

0.20

1.00

06 Community Council of Nashua 1

2.00

2.25

06 Community Council of Nashua 2

0.00

0.25

07 Mental Health Center of Greater Manchester-CCT

1.50

1.50

07 Mental Health Center of Greater Manchester-MCST

2.50

2.00

08 Seacoast Mental Health Center

1.00

1.00

09 Community Partners

1.25

0.15

10 Center for Life Management

0.30

0.30

Total

14.65

14.35

Revisions to Prior Period: None

Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report

Notes: Data compiled 10/17/18; for 2b-d: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, rather the quantity of staff available to provide each service. If staff is trained to provide multiple service types, their entire FTE value will be credited to each service type.

8

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 61 of 95

3. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12 Month Period

Community Mental Health Center

12 Month Period Ending September 2018

Supported Employment Total Eligible
Consumers Consumers

Penetration Rate

Penetration Rate for Period
Ending June 2018

01 Northern Human Services

396

1,234

32.1%

36.9%

02 West Central Behavioral Health

223

660

33.8%

31.2%

03 Lakes Region Mental Health Center

152

1,292

11.8%

12.1%

04 Riverbend Community Mental Health Center

303

1,827

16.6%

11.8%

05 Monadnock Family Services

87

935

9.3%

11.0%

06 Community Council of Nashua

226

1,787

12.6%

14.2%

07 Mental Health Center of Greater Manchester

1,444

3,271

44.1%

44.1%

08 Seacoast Mental Health Center

500

1,670

29.9%

29.8%

09 Community Partners

150

782

19.2%

20.9%

10 Center for Life Management

204

979

20.8%

17.5%

Deduplicated Total

3,672

14,182

25.9%

25.9%

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 10/25/2018; consumers are counted only one time regardless of how many services they receive. Riverbend non-billable services are currently not available so are not included in this report.

4a. New Hampshire Hospital: Adult Census Summary

Measure

July - September 2018

April - June 2018

Admissions

209

197

Mean Daily Census

262

178

9

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 62 of 95

Discharges

212

203

Median Length of Stay in Days for Discharges

16

14

Deaths

0

0

Revisions to Prior Period: None.

Data Source: Avatar

Notes 4a: Data extracted 10/17/18; Mean Daily Census includes patients on leave and is rounded to nearest whole number

4b. New Hampshire Hospital: Discharge Location for Adults

Discharge Location

July - September 2018

April - June 2018

Home - Lives with Others

109

92

Home - Lives Alone

67

71

CMHC Group Home

7

7

Private Group Home

2

1

Nursing Home

1

2

Hotel-Motel

3

1

Homeless Shelter/ No Permanent Home

1

8

Discharge/Transfer to IP Rehab Facility

9

10

Secure Psychiatric Unit – SPU

0

0

Peer Support Housing

0

2

Jail or Correctional Facility

4

2

Glencliff Home for the Elderly

4

2

Other

3

2

Unknown

2

3

10

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 63 of 95

4c. New Hampshire Hospital: Readmission Rates for Adults

Measure

July - September 2018

April - June 2018

30 Days

8.6% (18)

7.6% (15)

90 Days

19.6% (41)

14.7% (29)

180 Days

25.4% (53)

23.4% (46)

Revisions to Prior Period: None.

Data Source: Avatar

Notes 4b-c: Data compiled 10/17/18; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions lookback period includes readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day readmissions); patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

11

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 64 of 95

5a. Designated Receiving Facilities: Admissions for Adults

July - September 2018

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

19

48

Cypress Center

49

152

Portsmouth

69

288

Elliot Geriatric Psychiatric Unit

7

47

Elliot Pathways

55

57

Total

199

592

April - June 2018

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

32

37

Cypress Center

63

181

Portsmouth

82

251

Elliot Geriatric Psychiatric Unit

6

59

Elliot Pathways

54

50

Total

237

578

Total Admissions
67 201 357 54 112 791
Total Admissions
69 244 333 65 104 815

5b. Designated Receiving Facilities: Mean Daily Census for Adults

Designated Receiving Facility

July - September 2018

Franklin

11.8

Cypress Center

8.4

Portsmouth

39.6

April - June 2018
9.1 11.9 31.7

12

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 65 of 95

Elliot Geriatric Psychiatric Unit Elliot Pathways Total

33.8 18.2 111.8

31.7 20.4 104.7

5c. Designated Receiving Facilities: Discharges for Adults

Designated Receiving Facility

July - September 2018

Franklin

66

Manchester (Cypress Center)

195

Portsmouth

353

Elliot Geriatric Psychiatric Unit

54

Elliot Pathways

112

Total

780

April - June 2018
74 244 326 65 107 816

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges for Adults

Designated Receiving Facility

July - September 2018

April - June 2018

Franklin

4

5

Manchester (Cypress Center)

4

4

Portsmouth

4

5

Elliot Geriatric Psychiatric Unit

21

20

Elliot Pathways

7

8

Total

5

5

13

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 66 of 95

5e. Designated Receiving Facilities: Discharge Location for Adults July - September 2018

Designated Receiving Facility

Assisted Living/Group
Home

Decease d

Other

NH

Hom Hospit Hospita

DRF e

al

l

Other

Franklin

3

0

0 63

0

0

0

Manchester (Cypress Center)

4

0

2 186

0

0

3

Portsmouth Regional Hospital

0

0

1 304

0

2

46

Elliot Geriatric Psychiatric Unit

38

2

0 11

1

1

1

Elliot Pathways

4

0

0 97

0

1

10

Total

49

2

3 661

1

4

60

April - June 2018

Designated Receiving Facility

Assisted Living/Group
Home

Decease d

Other

NH

Hom Hospit Hospita

DRF e

al

l

Other

Franklin

1

0

9 63

0

0

1

Manchester (Cypress Center)

8

0

5 222

0

0

9

Portsmouth Regional Hospital

0

0

4 294

0

5

23

Elliot Geriatric Psychiatric Unit

29

12

0 18

2

0

4

Elliot Pathways

0

0

2 84

0

2

19

Total

38

12 20 681

2

7

56

*Dispositions to ‘DRF’ represent a change in legal status from Voluntary to Involuntary within the DRF.

14

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 67 of 95

5f. Designated Receiving Facilities: Readmission Rates for Adults July - September 2018

Designated Receiving Facility

30 Days

90 Days

Franklin

6.0% (4)

9.0% (6)

Manchester (Cypress Center)

8.5% (17)

13.9% (28)

Portsmouth

8.4% (30)

12.9% (46)

Elliot Geriatric Psychiatric Unit

5.6% (3)

11.1% (6)

Elliot Pathways

0.9% (1)

3.6% (4)

180 Days 16.4% (11) 18.9% (38) 19.0% (68)
11.1% (6) 3.6% (4)

15

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 68 of 95

Total

7.0% (55)

11.5% (90)

6.1% (127)

April - June 2018

Designated Receiving Facility

30 Days

90 Days

180 Days

Franklin

4.3% (3)

5.8% (4)

5.8% (4)

Manchester (Cypress Center)

4.5% (11)

8.2% (20)

11.9% (29)

Portsmouth

10.2% (34)

15.9% (53)

21.9% (73)

Elliot Geriatric Psychiatric Unit

6.1% (4)

6.1% (4)

6.1% (4)

Elliot Pathways

3.8% (4)

6.7% (7)

8.6% (9)

Total

6.9% (56)

10.8% (88)

4.6% (119)

Revisions to Prior Period: None.

Data Source: NH DRF Database

Notes: Data compiled 11/5/18.

Discharge location of “DRF” are patients discharged back to the same DRF for a different level of care within the DRF; readmission rates calculated by looking back in time from admissions in study quarter; patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

16

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 69 of 95

6. Glencliff Home: Census Summary Measure

July - September 2018

April - June 2018

Admissions

6

8

Average Daily Census

114

116

Discharges

2 (1 - NHH, 1 – Assisted Living/Residential Care)

1 (ABD Residential Care Home – 10 bed)

Individual Lengths of Stay in Days for Discharges

1 and 929

1045

Deaths

9

7

Readmissions

1

0

Mean Overall Admission Waitlist

22 – (13 Active)

23 (14 Active)

Revisions to Prior Period: None.

Data Source: Glencliff Home

Notes: Data Compiled 10/30/18; means rounded to nearest whole number; Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

17

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 70 of 95

7. NH Mental Health Consumer Peer Support Agencies: Census Summary

July - September

April – June

2018

2018

Peer Support Agency

Average

Average

Total Daily

Total Daily

Members Visits Members Visits

Alternative Life Center Total

169

46

587

49

Conway

12

13

196

13

Berlin

62

7

119

11

Littleton

47

11

158

10

Colebrook

48

15

114

15

Stepping Stone Total

240

18

435

18

Claremont

198

13

342

12

Lebanon

42

5

93

6

Cornerbridge Total

217

13

303

14

Laconia

120

4

130

4

Concord

76

9

153

10

Plymouth Outreach

21

0

20

0

MAPSA Keene Total

60

14

150

12

HEARTS Nashua Total

NA

NA

381

31

On the Road to Recovery Total

71

7

614

10

Manchester

34

4

446

4

Derry

37

3

168

6

Connections Portsmouth Total

77

14

289

15

TriCity Coop Rochester Total

111

27

292

27

18

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 71 of 95

July - September

April – June

2018

2018

Peer Support Agency

Average

Average

Total Daily

Total Daily

Members Visits Members Visits

Total

945

132

3,051

166

Revisions to Prior Period: None

Data Source: Bureau of Mental Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 11/20/18; Average Daily Visits NA for Outreach Programs; The Bureau of Mental Health Services (BMHS) annually requires Peer Support Agencies to “purge member lists” to increase confidence and consistency in this information. After a 2018 thorough review, BMHS identified inconsistencies in completing this process. The July-September 2018 data reflects a higher drop in total membership from previous years as a result; Peer Support Agency data not available at publication will be updated in a subsequent report.

19

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 72 of 95

8. Housing Bridge Subsidy Summary to Date

July - September 2018

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

811

1

812

Section 8 Voucher

125

0

125

April - June 2018

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

811

0

811

Section 8 Voucher

119

6

125

Revisions to Prior Period: Total served for Section 8 in the prior period was 108, not 102

Data Source: Bureau of Mental Health and Housing Bridge Provider

Notes: Data Compiled 11/5/18

20

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 73 of 95

9a. Housing Bridge Subsidy Applications and Terminations

Measure

July-Sep 2018

April - June 2018

Applications Received

32

28

Point of Contact

CMHCs: 32

CMHCs: 24 NH Hospital: 4

Applications Approved

7

5

Applications Denied

0

0

Denial Reasons

NA

NA

Applications in Process*

197

165

Terminations

0

0

Termination Reasons

NA

NA

Voucher Received: 7 Vouchers received: 7

Deceased: 1

Deceased: 2

Program Exits

Over income: 1

Over income: 1

Transitional Housing: 1 Relocated – Not NH: 1

Long-term Nursing Home: 1

*Total number of applications in process at close of reporting period; The Previous quarter data has been corrected based on a recent Bureau of Mental Health Services audit of Housing Bridge files.

Data Source: Bureau of Mental Health and Housing Bridge Provider

Notes: Data Compiled 11/5/18

9b. Housing Bridge Subsidy Approved Applications on Waitlist

As of 9/30/2018

Time on List

Total

0-30 days 31-60 days 61-90 days 91-120

days

35

5

2

0

0

As of 6/30/2018

121-150 days 1

151-180 days 4

181+ days 23

21

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 74 of 95

Total

0-30 days 31-60 days 61-90 days 91-120

days

28

0

0

4

1

Data Source: Bureau of Mental Health and Housing Bridge Provider

Notes: Data Compiled: 10/25/18

121-150 days 2

151-180 days 5

181+ days 15

9c. Housing Bridge Subsidy Current Census Measure

As of 9/30/2018

As of 6/30/2018

Rents Currently Being Paid

423

479

Individuals Accepted and Working Towards Bridge Lease

0

0

Waiting list for Housing Bridge funding

35

28

Revisions to Prior Period: None

Data Source: Bureau of Mental Health and Housing Bridge Provider

Notes: Data Compiled 11/5/18; all individuals currently on Bridge Program are intended to transition from the program to other permanent housing).

10. Housing Bridge Subsidy Unit Address Density Number of Unit(s)* at Same Address

Frequency as of 9/30/18

Frequency as of 6/30/18

1

339

354

2

52

26

3

24

10

4

12

5

5

0

0

6

6

0

7

7

0

8 or more

10

2

*All units are individual units

22

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 75 of 95 Revisions to Prior Period: None Data Source: Bureau of Mental Health data compiled by Office of Quality Assurance and Improvement Notes: Data Compiled 11/14/18
23

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 76 of 95 11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure
Unduplicated People Served in Month

July 2018
157

August 2018

Septembe r
2018

July Septembe
r 2018

221

248

519

April June
2018
562

Services Provided by Type Phone Support/Triage Mobile Community Assessments Office-Based Urgent Assessments Emergency Service Medication Appointments Crisis Stabilization Appointments Walk in Assessments MHE-4

206

293

277

776

838

68

73

65

206

207

10

17

26

53

83

4

0

0

4

47

29

18

22

69

47

12

9

9

30

25

NA

NA

2

2

NA

Services Provided after Immediate Crisis

Phone Support/Triage

49

73

29

151

235

Mobile Community Assessments-Post Crisis

9

18

5

32

51

Office-Based Urgent Assessments

10

17

26

53

83

Emergency Service Medication Appointments

4

0

0

4

25

Crisis Stabilization Appointments

29

18

14

61

47

24

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 77 of 95

Measure
Referral Source Emergency Department/EMS Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal Self Other
Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay
Law Enforcement Involvement
Hospital Diversions Total

July 2018

August 2018

Septembe r
2018

July Septembe
r 2018

April June
2018

4

1

1

6

35

5

4

7

16

64

0

1

4

5

9

1

10

19

30

74

1

11

12

24

22

4

8

6

18

16

0

4

3

7

16

10

10

14

34

42

131

167

179

477

431

1

3

3

7

16

26

28

26

80

94

104

117

106

327

346

4.0

4.2

4.1

4.1

3.6

4

17

23

44

67

250

214

222

686

458

25

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 78 of 95 Revisions to Prior Period: None Data Source: Riverbend CMHC submitted report, Riverbend MCRT data includes emergency services. Notes: Data Compiled 10/30/18; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc. MHE-4 is a new initiative at Concord Hospital in an attempt to ease congestion at the emergency department; if a patient is at low risk to self, they rapid triage them out of the emergency department to mobile services within an hour of their arrival at the hospital. Mobile crisis provides the evaluation.
26

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 79 of 95 11b. Mobile Crisis Services and Supports for Adults: Mental Health Center of Greater Manchester

Measure
Unduplicated People Served by Month

July 2018
222

July -

August September September

2018

2018

2018

241

228

533

April June 2018
534

Services Provided by Type Phone Support/Triage Mobile Community Assessments Office-Based Urgent Assessments Emergency Service Medication Appointments Crisis Apartment Service

607

493

593

1,693

1,503

103

77

104

284

268

21

14

6

41

45

4

2

7

13

5

218

80

167

465

109

Referral Source Emergency Department Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal Self Other

4

0

1

5

0

31

25

41

97

132

4

6

7

17

20

3

3

4

10

11

11

5

3

19

27

77

75

53

205

185

9

13

8

31

20

23

13

8

44

78

123

135

175

433

373

37

21

46

104

100

27

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 80 of 95

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

14

3

12

29

12

46

15

53

114

24

3.3

5.0

4.4

3.9

2.0

Law Enforcement Involvement

77

75

53

205

132

Hospital Diversion Total

336

299

358

993

946

Revisions to Prior Period: None.

Data Source: Phoenix 2

Notes: Data Compiled 10/25/18; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

28

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 81 of 95 11c. Mobile Crisis Services and Supports for Adults: Harbor Homes

Measure Unduplicated People Served by Month
Services Provided by Type Case Management Crisis Apartment Service Crisis Intervention Services ED Based Assessment Emergency Service Medication Appointments Mobile Community Assessments Office-Based Urgent Assessments Other Peer Support Phone Support/Triage Psychotherapy
Referral Source Emergency Department Family Friend

July 2018
213

August September

2018

2018

July September
2018

205

175

490

April June 2018
371

101

162

132

65

66

37

0

0

0

0

1

11

0

0

0

173

186

142

2

4

162

11

10

29

79

158

134

122

129

208

0

0

0

395

84

168

70

0

0

12

0

0

0

501

357

168

0

50

21

371

0

459

329

0

0

1

0

0

19

18

14

5

7

3

1

1

51

58

15

13

29

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 82 of 95

Guardian MCT Hospitalization Mental Health Provider Police Primary Care Provider CMHC Self Other

1

0

0

6

0

12

19

8

26

5

3

2

1

0

3

30

31

28

94

107

66

179

234

180

1

7

18

0

53

31

10

1

4

0

89

29

267

158

593

366

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

28

33

27

172

141

123

6.1

4.3

4.6

88

42

436

229

4.9

5.4

Law Enforcement Involvement

0

0

0

0

0

Hospital Diversion Total

365

403

340

1,108

563

Revisions to Prior Period: None

Data Source: Harbor Homes submitted data

Notes: Data Compiled 10/17/18; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc. Harbor Homes made significant data reporting improvements beginning in May 2018.

30

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 83 of 95

12a. Community Mental Health Center Consumers: Adult Employment Status – Total Note: Employment Status reporting, while accurately representing the data submitted from the CMHCs to DHHS, does not yet represent true employment status of consumers. Extensive revisions are expected to this data by the CMHCs as their reporting systems become better aligned to reporting requirements

July - September 2018

Reported Employment Status of Recent Supportive Reported Employment Status as

Employment Service Users

Percent of Total Adults

Percent Excluding Unknown

Employed now or in the past 3 months full time Employed now or in the past 3 months part time Unemployed Not In the Workforce Unknown Total Employed Full or Part Time Unemployed Not in Workforce Unknown In Workforce Employed Full or Part Time of Those in Workforce

Community Mental Health Center 01 Northern Human Services
02 West Central Behavioral Health 03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services
06 Community Council of Nashua
07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center
09 Community Partners
10 Center for Life Management Total

8

19

10

40 818

895 3.0% 1.1% 4.5% 91.4% 48.1%

16

28

77

74 216

411 10.7% 18.7% 18.0% 52.6% 62.1%

25

101

47 568 140

881 14.3% 5.3% 64.5% 15.9% 23.3%

99

261

92 869

34 1,355 26.6% 6.8% 64.1% 2.5% 34.2%

26

129 113 401

20

689 22.5% 16.4% 58.2% 2.9% 40.1%

113

201 743 211 114 1,382 22.7% 53.8% 15.3% 8.2% 83.4%

198

312 916 551

23 2,000 25.5% 45.8% 27.6% 1.2% 72.1%

143

219

82 681

8 1,133 32.0% 7.2% 60.1% 0.7% 39.5%

41

62 173 263

11

550 18.7% 31.5% 47.8% 2.0% 51.2%

47

136 493 102

22

800 22.9% 61.6% 12.8% 2.8% 86.9%

716 1,468 2,746 3,760 1,406 10,096 21.6% 27.2% 37.2% 13.9% 56.7%

73.0% 36.4% 72.8% 79.6% 57.8% 29.7% 35.8% 81.5% 37.3% 27.1% 44.3%

31

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 84 of 95

12b. Community Mental Health Center Consumers: Adult Employment Status – Recent Users of Supportive Employment Services (One Billable Service in Each of Month of the Quarter)

July - September 2018

Reported Employment Status of Recent Supportive Reported Employment Status as a

Employment Service Users

Percent of Total Adults

Percent Excluding Unknown

Employed now or in the past 3 months full time Employed now or in the past 3 months part time Unemployed Not In the Workforce Unknown Total Employed Full or Part Time Unemployed Not in Workforce Unknown Percent in Workforce (Employed or Unemployed) Employed Full or Part Time of Those in Workforce

Community Mental Health Center 01 Northern Human Services 02 West Central Behavioral Health 03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

0

0

0

0

34

34 0.0% 0.0% 0.0% 100.0% 0.0%

0.0%

0

7

5

1

13

26 26.9% 19.2% 3.8% 50.0% 92.3%

58.3%

0

8

3

8

11

30 26.7% 10.0% 26.7% 36.7% 57.9%

72.7%

3

28

17

4

0

52 59.6% 32.7% 7.7% 0.0% 92.3%

64.6%

1

10

5

1

0

17 64.7% 29.4% 5.9% 0.0% 94.1%

68.8%

5

6

10

5

5

31 35.5% 32.3% 16.1% 16.1% 80.8%

52.4%

5

34

29

4

0

72 54.2% 40.3% 5.6% 0.0% 94.4%

57.4%

0

6

7

11

0

24 25.0% 29.2% 45.8% 0.0% 54.2%

46.2%

0

6

6

4

0

16 37.5% 37.5% 25.0% 0.0% 75.0%

50.0%

1

16

5

0

0

22 77.3% 22.7% 0.0% 0.0% 100.0%

77.3%

15

121

87

38

63

324 42.0% 26.9% 11.7% 19.4% 85.4%

61.0%

32

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 85 of 95

12c. Community Mental Health Center Consumers: Employment Screening Status

Community Mental Health Center 01 Northern Human Services 02 West Central Behavioral Health 03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total
*Status More Than 105 Days Old

As of 9/30/18

Overdue*/ Current Unknown

Percent Total Overdue

213

682

895

76.2%

NA

NA

NA

NA

334

547

881

62.1%

1,218

137 1,355

10.1%

NA 1,309

NA

NA

73 1,382

NA 5.3%

1,550

450 2,000

22.5%

889

244 1,133

21.5%

421

129

550

23.5%

800

0

800

0.0%

NA

NA

NA

NA

CMHA Monthly Progress Report

33

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 86 of 95
Revisions to Prior Period: None
Data Source: Phoenix 2
Notes 12a-c: Data extracted 10/17/18.
• Employment Status shown in the tables reflects status data found in DHHS’s Phoenix system reported by the CMHCs. Phoenix tracks the individual consumer employment status over time. If more than one status was reported within the Quarterly Report timeframe the most recent update is used.
• Employed refers to consumers who are employed in a competitive job. Competitive jobs have these characteristics: exists in the open labor market, pays at least a minimum wage, anyone could have regardless of disability status, not set aside for people with disabilities, and wages (including benefits) not less than for the same work performed by people who do not have a mental illness.
• Full time employment is 20 hours and above; part time is anything 19 hours and below. • Unemployed refers to consumers who are not employed but are seeking or interested in employment. • Not in the Workforce are consumers who are homemakers, students, retired, disabled, hospital patients or residents of
other institutions, in a sheltered/non-competitive employment workshop, otherwise not in the labor force or not employed and not seeking or interested in employment. Unknown refers to consumers for with an “unknown” status, no status, or erroneous status code in Phoenix. • NA data not available due to known data submission issue which is undergoing active quality improvement efforts.

CMHA Monthly Progress Report

34

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 87 of 95
Appendix B CMHA Monthly Progress Report
August, 2018

CMHA Monthly Progress Report

35

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 88 of 95
New Hampshire Community Mental Health Agreement Monthly Progress Report
August 2018
New Hampshire Department of Health and Human Services November 13, 2018

CMHA Monthly Progress Report

36

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 89 of 95

Acronyms Used in this Report

ACT: BMHS: CMHA: CMHC: DHHS: SE: SFY:

Assertive Community Treatment Bureau of Mental Health Services Community Mental Health Agreement Community Mental Health Center Department of Health and Human Services Supported Employment State Fiscal Year

Background
This Monthly Progress Report is issued in response to the June 29, 2016 Expert Reviewer Report, Number Four, action step 4. It reflects the actions taken in August 2018, and month-over-month progress made in support of the Community Mental Health Agreement (CMHA) as of August 31, 2018. Data contained may be subject to change upon further reconciliation with CMHCs. This report is specific to achievement of milestones contained in the agreed upon CMHA Project Plan for Assertive Community Treatment (ACT), Supported Employment (SE) and Glencliff Home Transitions. Where appropriate, the Report includes CMHA lifetime-to-date achievements.

CMHA Monthly Progress Report

37

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 90 of 95

Progress Highlights

Assertive Community Treatment (ACT)

Goal

Status

CMHC fidelity to ACT evidence-based SFY 2019:

practice model annually assessed. 2 of 10

Completed

Provide ACT team services,

Capacity:

consistent with standards set forth, August – 1,040

with the capacity to serve at least

1,500 individuals.

Enrollment:

August – 921

Recent Actions Taken • 1 report issued, 0 improvement plans in
place., 1 improvement plan in development
• 3 post ACT Fidelity Review consultations with participating CMHCs have occurred during State Fiscal Year 2019 thus far.
• August newly* enrolled individuals: 25 *New is defined as an individual who is new to the ACT program or an individual who has not received an ACT service in more than 90 days.

Supported Employment (SE)
Goal CMHC fidelity to SE evidence-based practice model annually assessed. Increase penetration rate of individuals with a Serious Mental Illness (SMI) receiving SE services to 18.6%.

Status 2019: 1 of 10 completed
Statewide penetration rate: August – 25.4%

Recent Actions Taken
• 1 fidelity report issued, 1 improvement plan in place.
• 0 post SE Fidelity Review consultations with participating CMHCs have occurred during State Fiscal Year 2019 thus far.

Glencliff Home Transitions into Integrated Community Setting

Goal

Status

Recent Actions Taken

Have capacity to serve in the community 16 (cumulatively) individuals with mental illness and complex health care needs residing at Glencliff who cannot be costeffectively served in supported housing.

16 of 16 completed27

• Continued work toward improving the model for small group (4 people or less) residence homes.
• 1 individual planning to transition in October to a small group residence in Nashua.

By June 30, 2017, identify and maintain a list of all individuals with mental illness and complex health care needs residing at the Glencliff Home who cannot be cost-effectively served in supported housing and develop an effective plan for

Completed; ongoing

• 18 residents on the list
• Bi-weekly meetings between Glencliff Home staff and DHHS Interagency Integration Team representative to review cases of individuals needing multi-system supports to facilitate return to community setting

27 Indicates residents have been transitioned into an integrated community setting; compliance with additional CMHA requirements for such transitions is under review.

CMHA Monthly Progress Report

38

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 91 of 95
providing sufficient communitybased residential supports for such individuals in the future.

CMHA Monthly Progress Report

39

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 92 of 95

1,400 1,200 1,000

ACT Capacity by Quarter/Month* 1,093

1,190 1,181 1,174 1,160 1,123 1,252 1,265 1,256 1,242 1,251 1,168 1,160 1,245 1,119 1,201 1,118 1,083 1,131 1,131 1,040

901

800

600

400

200

0

CMHA Monthly Progress Report

40

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 93 of 95

1200 1100

ACT Client Count by Month

1000 900 800

786 806 810 828 838 845 889 888 913 925 927 920 912 904 915 910 899 887 902 877 813 907 913 902 911 921

700

600

500

400

300

200

100

0

CMHA Monthly Progress Report

41

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 94 of 95

30.0% 25.0%

SE Statewide Penetration Rate by Quarter/Monthly* 26.9%

25.3% 25.8% 26.4% 26.4% 26.6% 26.7% 26.7%

26.90%26.40%26.4% 26.3% 25.9% 25.9% 25.4%

24.1%

24.2% 24.7%

22.9% 23.3%

22.8%

20.9%

20.0%

15.0%

10.0%

5.0%

0.0%
* Data is a combination of preliminary monthly and finalized quarterly data from CMHA Quarterly Data Reports.

CMHA Monthly Progress Report

42

November 13, 2018

Case 1:12-cv-00053-SM Document 127-1 Filed 01/23/19 Page 95 of 95

CMHA Monthly Progress Report

43

November 13, 2018

 
 Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 1 of 86
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Ten
September 10, 2019
I. Introduction
This is the tenth semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this six-month period (January 1, 2019 through June 30, 2019), the ER has continued to observe the State’s work to implement key service elements of the CMHA, and has continued to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. During this period, the ER:
 Met with a clinical team and clinical leadership at New Hampshire Hospital (NHH) to review transition planning processes and issues;
 Reviewed the Preadmission Screening and Resident Review (PASRR) and Minimum Data Set (MDS) records for the six most recent admissions to Glencliff;
 Met with DHHS and PASRR contract agency staff to discuss the PASRR process and data reporting, and reviewed a set of PASRR level II assessment records;
 Observed the Quality Service Reviews (QSRs) conducted at Northern Human Services and the Mental Health Center of Greater Manchester;
 Conducted on-site visits to each of the three Mobile Crisis Teams (MCTs) and Crisis Apartment Programs (Concord, Nashua and Manchester);
 Met with DHHS Quality Management/Quality Service Review (QM/QSR) staff to discuss the Northern and Manchester QSR reviews; 1

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 2 of 86
 Convened an All Parties meeting to discuss progress in meeting the requirements of the CMHA;
 Convened three Assertive Community Treatment (ACT) working group meetings, with representatives of all parties, to discuss strategies for attaining CMHA compliance with regard to ACT services.
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
Summary of Progress to Date
This report reflects the end of five years of implementation of the CMHA. Within this five year period, a number of positive steps have been taken to improve the quality and effectiveness of services as envisioned in the CMHA. However, as will be discussed in detail below, implementation issues remain time consuming and frustrating, and there are areas of continued non-compliance with the CMHA. Notwithstanding these on-going concerns, the parties to the CMHA deserve credit for some real and measurable accomplishments.
As noted in the previous ER Report, the State has implemented a comprehensive and reliable QSR process. The ER considers these QSR reviews to be methodologically correct and reliable, and that the QSR reviews are producing findings that are accurate and actionable in terms of taking concrete steps to address quality issues in the CMHC system.
Another major accomplishment has been contracting with the Dartmouth-Hitchcock Medical Center to conduct external ACT and Supported Employment (SE) fidelity reviews using nationally validated fidelity review instruments and criteria. In concert with the QSR reviews mentioned above, the fidelity reviews are assisting the State and the Community Mental Health Centers (CMHCs) to develop comprehensive Quality Improvement Plans (QIPs) that address important ACT and SE quality and effectiveness issues at both the consumer and CMHC operational levels. Statewide data from both the QSR and fidelity reviews are provided later in this report. These findings will play a central role in any final assessment of compliance with the CMHA, and in demonstrating the sustainability of systemic changes during the one year maintenance of effort period.
The parties originally envisioned that the CMHA could be fully implemented in five years, with a sixth year for maintenance of effort. The CMHA was approved and filed with the Federal Court on February 12, 2014, and the five-year anniversary of that event occurred seven months ago. The ER was approved by the Parties and the Federal Court effective July 1, 2014, and the five-year anniversary occurred three months ago. Thus it is critical for this report and for
2

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 3 of 86
subsequent activities that the focus be on specific strategies and action steps necessary to meet all the requirements of the CMHA, and to plan for total or partial disengagement.
II. Data
As noted in previous reports, the New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (January to March, 2019), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The capacity to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve. The ER notes that completion of the six-month ER report was delayed by three months because the above-referenced Quarterly Data Report was produced too late to permit completion of this ER report by the expected June 30, 2019 date. The ER continues to emphasize that the State must take the steps necessary to produce the necessary data reports in a timely fashion.
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile/Crisis and Crisis Apartment Programs
The CMHA calls for the establishment of a Mobile Crisis Team (MCT) and Crisis Apartments in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC was selected to implement the MCT and Crisis Apartments in the Concord Region. The CMHA specified that a second MCT and Crisis Apartments be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. Per CMHA V.C.3(c), a third MCT and Crisis Apartment program became operational in the Nashua region on July 1, 2017. The contract for that program was awarded to Harbor Homes in Nashua. Table I below includes the most recent available information on activities of these three MCT/Crisis Apartment Programs.
3

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 4 of 86

Table I

Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs

Concord

Manchester

Nashua

Jan – March 2019 Jan – March 2019 Jan –March 2019

Total unduplicated people served

500

700

561

Services provided in response to

immediate crisis:

 Phone support/triage

959

1,520

764

 Mobile assessments  Crisis stabilization

157

283

434

54

113

0

appointments  Emergency services

0

0

1

medication appointments

 Office based urgent

123

assessments

0

 Case Management

0

 Peer support

65

19

132

405

0

340

Referral source:

 Self

589

 Family

38

 Guardian

25

 Mental health provider

40

 Primary care provider

15

 Hospital emergency

4

department

 Police

17

 CMHC Internal

63

 Friend

15

10

 School

4

 Other

433

218

151

50

25

1

33

98

251

4

2

41

210

7

30

100

18

14

0

47

128

393

Crisis apartment admissions:  Bed days  Average length of stay
Law enforcement involvement Total hospital diversions1

85

13

38

332

42

222

3.91

3.2

5.8

79

210

4

522

1,120

1,139

The Quarterly Data Report in Appendix A contains recent historical data for the three regional MCT/Crisis Apartment programs.
The ER conducted site visits at each of the MCT and Crisis Apartment programs in New Hampshire during the past six months. Each of the programs is fully staffed and, in the opinion of the ER, is generally operating in accordance with best practice approaches to mobile crisis and crisis apartment services. Each program is making good use of peer staff for both mobile crisis

1 Hospital diversions are instances in which services are provided to individuals in crisis resulting in diversion from being assessed at the ED and/or being admitted to a psychiatric hospital.
4

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 5 of 86
response and for staffing of the crisis apartments. To varying degrees, each program is developing more effective relationships with local law enforcement agencies and local hospital emergency departments. To date, crisis apartment average lengths of stay have remained within reasonable ranges. There is some anecdotal evidence suggesting that the mobile team and crisis apartment interventions are beginning to influence pathways into hospital emergency department, inpatient psychiatric services, and local jails.
The ER remains concerned that the very high number of reported hospital diversions overstates the effect these programs have had on both psychiatric hospitalization and on emergency department boarding. However, at the same time as the MCT and crisis apartment programs have matured, there have also been other forces influencing mental health crises and psychiatric hospitalization. These include population changes in some geographic areas and the current opioid epidemic. Thus, it is not possible to assume there will be a one-for-one relationship between the diversionary successes of the MCTs and crisis apartment programs and the actual rate of psychiatric hospitalization or emergency department boarding.
Assertive Community Treatment (ACT)
ACT is a core element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team;
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time; and
4. By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.
The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015 (45 months ago). Further, as of June 30, 2016, the State was required to have the capacity to provide ACT to 1,500 priority Target Population individuals.
As displayed in Table II below, the staff capacity of the 12 adult ACT teams in New Hampshire has only increased by 1.9 FTEs since December of 2016, and has decreased by 0.5 FTE since March of 2018.
5

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 6 of 86

Table II Self-Reported ACT Staffing (excluding psychiatry): December 2016 – March 2019

Region

FTE FTE FTE FTE FTE FTE FTE FTE FTE FTE

Dec- Mar- Jun- Sep- Dec- Mar- Jun- Sep- Dec- Mar-

16 17 17 17 17 18

18 18 18 19

Northern West Central Lakes Region Riverbend Monadnock Greater Nashua 1 Greater Nashua 2 Manchester – CTT Manchester MCST Seacoast Community Part. CLM Total

11.5 5.5
11.0 9.0 7.3
6.3
5.3
15.5
21.4 9.5 6.9 7.2
116.2

11.9 12.5 12.4 7.8 7.2 7.0
11.0 10.6 10.8 10.0 10.0 10.0
6.7 8.5 7.9

6.3 5.3 6.0

5.3 5.3 5.0

14.8 16.6 16.3

21.9 9.5 4.1 8.3
117.4

22.0 9.5 8.5 9.3
125.2

22.3 10.5
6.7 9.3 124.2

13.0 6.2 9.4
10.0 7.9
5.0
5.0
12.8
19.0 10.5
7.9 9.3 116.1

11.6 12.7 5.0 5.2 5.7 5.6
10.3 10.5 8.7 8.5

5.8 5.8

5.8 5.8

17.3 15.5

19.5 11.5
9.8 9.3 120.1

16.3 9.5 9.6 8.3
113.1

13.1 17.3 5.3 5.8 8.4 7.4
10.5 10.5 8.7 9.0

5.5 5.0

4.5 4.0

14.8 14.3

17.8 10.5
9.1 7.6 115.6

15.8 11.1
7.8 6.6 114.3

16.8 6.8 8.3
11.5 9.5
6.5
4.5
14.3
15.8 9.1 8.8 7.9
119.6

It is clear from the above table that overall ACT staffing has remained low. Three of the 12 adult ACT teams continue to have fewer than the 7 - 10 professionals specified for ACT teams in the CMHA. Seven teams have at least 1.0 FTE SE staff, while five have less than a full time SE specialist. Five teams report having .5 or less FTE combined psychiatry/nurse practitioner time available to their ACT teams2; and six of the 12 teams report having less than one FTE nurse per team. On a more positive note, all ACT teams are now reported to have at least .5 FTE Peer Staff as members of the teams.
Table III below displays the active ACT caseloads by CMHC Region for the past 21 months. The active monthly caseload decreased by four participants in the last quarter. Since June of 2017 the active monthly caseload has dropped by 83.

2 The CMHA specifies at least .5 FTE Psychiatrists for teams with at least 70 active service participants. (CMHA V.D.2(e).
6

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 7 of 86

Table III
Self-Reported ACT Active Caseload (Unique Adult Consumers) by Region in Specified Months: June 2017 – March 2019

Region

Sep- Dec- Mar-

Nov Dec- Mar-

Jun-17 17 17 18 Jul-18 Sep-18 Oct-18 -18 18 19

Northern

111 113 115 114 108 102 115 111 115

120

West Central 76

68 57 46 45 44 40 39 42

41

Lakes Region 74

74 65 64 59 53 53 51 51

51

Riverbend

97

87 81 80 78 82 83 83 87

96

Monadnock

70

69 53 55 55 55 57 56 56

59

Greater

Nashua

94

98 76 74 85 84 84 79 77

67

Manchester 292 287 269 277 302 306 310 312 312

303

Seacoast

69

67 54 66 69 69 67 67 71

70

Community

Part.

69

75 64 66 59 61 63 62 64

66

CLM

55

54 55 59 57 55 55 54 53

51

Total*

1,006 992 881 901 917 911 927 913 927

923

The combined ACT teams have a reported March 2019 staff complement of 119.61 FTEs excluding psychiatry, which is sufficient capacity to serve 1,196 individuals based on the ACT non-psychiatry staffing ratios contained in the CMHA. With a statewide caseload of only 923 as of March 2019, the existing teams should theoretically be able to enroll an additional 273 new ACT clients without additional staff. Tapping into this unused capacity with appropriate outreach and targeting should have an impact on alleviating ED boarding and hospital readmission rates across the state. Further, the CMHA requires the State to have capacity to serve 1,500 individuals, but the current ACT capacity of 1,196 is 304 below CMHA criteria.
As noted in previous reports, the current level of ACT staffing is not sufficient to meet CMHA requirements for ACT team capacity. Furthermore, current ACT enrollment of 923 individuals is 577 below the number that could be provided ACT services with the capacity required by the CMHA.

7

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 8 of 86
ACT Screening As has been documented in previous reports, the State has been implementing a number of strategies to increase ACT enrollment and participation. One of these strategies has been to require the ten CMHCs to conduct and report regular clinical screening for eligibility/appropriateness for ACT services. The clinical screens are conducted:
1. As part of the intake process at the CMHCs; 3 2. Upon referral to a CMHC following discharge from an inpatient facility; and 3. As part of regular quarterly and annual assessments and plan of care amendments for
current CMHC clients (including current active ACT participants) who may qualify for and benefit from ACT. Table IV below presents data on ACT screens conducted by CMHCs between October and December, 2018. This is the third reporting period in which these data are available, and only the first reporting period for which data on the actual number of ACT assessments that result in enrollment in ACT are available.
3 Note that a CMHC intake incorporating the ACT screen is performed when a CMHC emergency services staff or Mobile Crisis Team encounters and refers a person potentially needing CMHC services. In some cases these Emergency Services/ MCT referrals are made on behalf of individuals who have presented in crisis in hospital emergency departments and who may be waiting for a NHH admission.
8

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 9 of 86

Table IV

Self-Reported Number of Unique Clients Screened for ACT Services

Conducted by CMHCs

October through December 2018

Community Mental Health Center

Total Screened

Qualified for further
ACT Assessment

Receiving ACT/ wi 90
days of Assessment

01 Northern Human Services

1,192

24

6

02 West Central Behavioral Health

263

1

0

03 Lakes Region Mental Health

974

19

2

Center

04 Riverbend Community Mental

1,481

8

1

Health Center

05 Monadnock Family Services

203

4

1

06 Greater Nashua Mental Health

925

8

0

07 Mental Health Center of

2,576

7

0

Greater Manchester

08 Seacoast Mental Health Center

1,142

13

1

09 Community Partners

508

2

2

10 Center for Life Management

494

10

0

Total

10,028 96 (0.96%) 13 (13.5%)

Of the 10,028 unique individuals screened for ACT during this period, the State reports that 96 were referred for an ACT assessment. This is a referral rate of less than one percent. And, less than 14 percent of those referred for ACT assessments were enrolled in ACT services within 90 days of being screened. Most of the referrals for ACT screening are internal to the CMHCs. That is, people who have already had a CMHC intake, and who may already be receiving CMHC services, are those most likely to be screened for ACT services. Thus, it is perhaps not surprising
9

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 10 of 86

that so few of the individuals screened are referred to the next step, which is the assessment for ACT. The State has stated its intention to conduct CMHC reviews to confirm that ACT eligibility criteria were applied in line with State rules and appropriate clinical standards for a sample of clients. The ER intends to monitor and report on the results of these reviews.
The State has begun collecting and reporting data on the number of individuals waiting for ACT services on a statewide basis. This information is displayed in Table V below. An individual eligible for ACT may have to wait for ACT services because the specific ACT team of the individual’s CMHC does not currently have staff capacity to accept new clients. The ER has documented above that there is a statewide gap between ACT staff capacity and ACT participation. However, in some CMHC regions new ACT staff must be hired before new ACT clients can be accepted into the program.
Table V
Self-Reported ACT Wait List:

Time on List

Total

0-30 days 31-60 days 61-180 days

March 31, 2019

2

1

1

0

December 31,

6

2018

3

0

3

ACT Fidelity and Quality
In addition to staff capacity and active caseloads for ACT services, the ER has been tracking and reporting ACT fidelity and Quality Service Review processes and results for the past two years.
ACT Fidelity
Table VI shows ACT fidelity total scores for each CMHC for the three most recent fidelity reviews for each ACT team. Note that these have not always been completed in the same 12 month period, and thus are not always comparable among the CMHCs. In some cases, three years of fidelity scores are not available for individual CMHCs or ACT teams within the CMHCs. However, system-wide trends in ACT fidelity scores are reliably reported in Table VI below. Note that scores in the 113 to 140 range indicate full implementation of ACT; scores in the 85 to 112 range indicate fair implementation of ACT; and scores at 84 or below indicate that it is not ACT service.
10

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 11 of 86 11

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 12 of 86

Table VI

ACT fidelity Year-to Year Comparisons

CLM Nashua 1 Nashua 2 Lakes MFS MHGM CTT MHGM MCST NHS Berlin Conway Littleton Riverbend WCBH Claremont Lebanon Comm partners Seacoast

Oldest SFY2017
111 115 NA 107 118 122
116 105 NA NA NA 104 109 NA NA
115 98

Middle SFY2018
108 97 104 91 110 106
99 NA 115 100 106 106 NA 95 105
97 114 1,439

Latest SFY2019
113 88 90 104 107 100
92 NA 98 103 104 107
93 83
102 116 1417

Change
5 -9 -14 13 -3 -6
-7 NA -17 3 -2 1 NA -2 -22
5 2 -55

Average

95.9

92.3

-3.6

Unfortunately, the overall trend in ACT fidelity scores has been downward. In addition, one ACT team (Lebanon) fell below the Fidelity threshold of 84 in the most recent fidelity review.
ACT Quality Service Review Indicators
A CMHC is required to submit a Quality Improvement Plan (QIP) for any quality indicator identified as an area in need of improvement. That threshold is any quality indicator scoring less than 70% for state fiscal year 2018, less than 75% for state fiscal year 2019, and less than 80% for state fiscal year 2020 and subsequent years.”
Indicator #17 of the Quality Service Review (QSR) is specifically focused on the “implementation of high fidelity ACT services.” This indicator relies on input from clinical records, ACT participants, and ACT staff to generate a composite score of the degree to which actual consumers are experiencing the delivery of high fidelity ACT services. In the past two years, the CMHC system has averaged scores on indicator 17 that are below the 70% threshold
12

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 13 of 86
initially used to indicate the need for quality improvement plans. The current average score for indicator 17 of the QSR is 65.1%. This is based on all ten of the QSR reviews for the most recent annual cycle having been completed. The ER notes that the performance threshold for each QRS quality indicator has been increased to 80% for the SFY 2020 QSR cycle.
The ER notes that year to year comparisons show some improvement in the fidelity of ACT services as measured by the QSR. In the past year, eight of the CMHCs have improved their performance with regard to indicator 17, albeit none of these have increased scores to the 80% performance threshold. For two of the CMHCs, the score on indicator 17 went down in the year to year comparisons.
The DHHS has been using a standardized quality improvement process (QIP) to guide ACT remedial efforts and technical assistance when a given CMHC is identified by the fidelity review or QSR as needing improvement. There is some evidence that this QIP process is producing positive improvements in the field. For example, four CMHCs have been released from selected QIP requirements recently because their Fidelity or QSR scores improved sufficiently.
ACT Summary
Based on the above information, the ER finds that the State remains out of compliance with the ACT service standards described in Section V.D. of the CMHA. The State does not currently provide a robust and effective system of ACT services throughout the state as required by the CMHA.
ACT Working Group
As noted in recent ER Reports, the DHHS has taken deliberate steps to work with CMHCs in certain Regions to increase their ACT staffing and caseloads. These actions include: (a) quarterly ACT monitoring and technical assistance with DHHS leadership and staff; (b) implementation of a firm schedule for ACT fidelity reviews; (c) incorporating a small increase in ACT funding into the Medicaid rates for CMHCs; (d) active on-site and telephonic technical assistance based on CMHC needs related to improving the quality and fidelity of ACT services; and (e) coordinated efforts to address workforce recruitment and retention. The State has identified workforce recruitment and retention issues as factors limiting the growth and expansion of the ACT teams. The State has been working collaboratively with the New Hampshire Community Behavioral Health Association to identify and track workforce gaps and shortages, and to implement a variety of strategies to improve workforce recruitment and retention. However, as noted above, ACT staffing has remained essentially static since December of 2016.
Recently, the State has received approval from the federal Centers for Medicare and Medicaid Services (CMS) to use Medicaid waiver funds for directed payments (fee schedule adjustment) to CMHCs for recipients already enrolled in ACT and for each new ACT enrollee. CMS has also
13

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 14 of 86
approved a fee schedule increase for people discharged from psychiatric inpatient services who receive a same- or next-day appointment at a CMHC. Taken together, these initiatives should provide incentives for CMHCs to sustain and increase their ACT caseloads. Three million dollars has been set aside under this plan to provide fee schedule increases for ACT enrollees. An additional 1.2 million dollars has been budgeted for same or next day CMHC appointments. The impact of this new funding is not likely to be measurable until at least the next ER report in December, 2019.
These initiatives are welcome, but to date have not produced the desired results in terms of increased ACT capacity, active caseload, fidelity or quality.
Thus, the ER has requested that representatives of the Plaintiffs and the State participate in an ACT working group over the past few months. The purpose of this working group has been to develop a set of feasible, measurable action plans to quickly expand and improve ACT services consistent with the CMHA. The ACT working group has met three times, and is in process of developing a final set of concrete recommendations.
Recommendations will address at least the following topic areas:
1. Screening and referral for ACT services; 2. Assessment for ACT eligibility, including reporting on the degree to which ACT
assessments result in enrollment ACT services; 3. Facilitation of referrals from New Hampshire Hospital (NHH) to CMHCs for ACT
intake and assessment activities; 4. Analysis of pre and post hospitalization data, and hospital readmission data, to
identify individuals that could benefit from ACT; 5. Analysis of and reporting on the effectiveness of ACT directed payments as an
incentive to increase ACT enrollment; 6. Development of a data dashboard that reports on CMHCs’ performance and
participant outcomes relevant to ACT services; 7. Enhanced training, technical assistance and mutual support among CMHCs and ACT
teams; 8. Enhanced workforce recruitment and retention activities; and 9. Enhanced management oversight, monitoring, and technical assistance to assure
implementation of ACT strategies.
In support of the ACT working group efforts, DHHS has been conducting internal analyses from existing data bases, and also requesting certain new information from the CMHCs. DHHS has begun circulating the results of these analyses to the members of the ACT working group. The following is a brief list of some of the new information being made available:
1. ACT referrals from NHH by Region; 2. ACT penetration rates by Region;
14

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 15 of 86
3. Tabulation of ACT penetration rates from selected other states, and reported by the federal Substance Abuse and Mental Health Services Administration (SAMHSA);
4. Current diagnoses of active ACT clients by Region; and 5. Tabulation of Managed Care enhanced payments related to ACT initiatives by
Region.
The initiatives summarized above have the potential to increase the capacity and quality of ACT services, and also to assure that people in need of ACT services are identified, referred, assessed and served as expeditiously as possible. The ER commends the representatives of the Plaintiffs and the State for their good faith efforts to develop and implement ACT initiatives. The ER will closely monitor the implementation and management of the ACT strategies to determine if actual improvements are measurable in ACT capacity; enrollment; fidelity; and quality.
The ER emphasizes, as in past reports, that it must be the first priority of the State and the CMHCs to focus on: 1) assuring required ACT team composition; 2) utilizing existing ACT team capacity; 3) increasing ACT team capacity; and 4) outreach to and enrollment of new ACT clients.
Supported Employment (SE)
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment … to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by June 30, 2017, “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)).
As shown in Table VII below, for the past two quarterly reporting periods, the State has been unable to report on the statewide SE penetration rate. One of the CMHCs has been working to validate its SE reporting data, and as a result, it cannot be included in the statewide computation of penetration rates until those data are verified. Nonetheless, the ER assumes that the statewide SE penetration rate continues to exceed the CMHA requirement of 18.6% penetration.
15

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 16 of 86

Table VII Self-Reported CMHC SE Penetration Rates
Penet. Penet. Penet. Penet. Penet. Penet. Dec-17 Mar-18 Jun-18 Sep-18 Dec-18 Mar-19

Northern West Central Lakes Reg. Riverbend Monadnock Greater Nashua Manchester Seacoast Community Part. CLM CMHA Target Statewide Ave.

39.00% 25.30% 19.10% 13.20% 10.90% 16.80% 45.30% 28.00%

38.80% 26.20% 15.40% 12.60% 10.40% 14.90% 43.50% 30.10%

17.70% 20.00% 18.60% 26.70%

21.50% 20.90% 18.60% 26.40%

36.90% 31.20% 12.10% 11.80% 11.00% 14.20% 44.10% 29.80%

32.10% 33.80% 11.80% 16.60%
9.30% 12.60% 44.10% 29.90%

20.90% 17.50% 18.60% 25.90%

19.20% 20.80% 18.60% 25.90%

NA 32.20% 11.80% 17.20%
7.80% 13.00% 43.90% 31.00%
18.00% 22.90% 18.60%
NA

NA 27.20% 17.90% 18.60%
8.00% 13.50% 42.40% 32.10%
14.00% 21.00% 18.60%
NA

As noted in Table VII above, four of the nine reporting CMHCs continue to report penetration rates lower than the CMHA requirement.
The State has recently begun collecting and reporting data on the degree to which CMHC clients are working, either full or part time, in competitive employment. Table VIII summarizes the initial findings from these data collection efforts.

16

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 17 of 86

Table VIII Competitive Employment for CMHC Clients

CMHC
Northern WCBH LRMHC Riverbend Monadnock Nashua MHCGM Comm. Prtnrs. Seacoast CLM

Percent of Total Clients Emp. Full or Part Time January – March 2019 27.3% 19.1% 17.5% 25.8% 23.0% 23.9% 27.8% 34.7% 20.9% 22.8%

Percent of SE Active Clients Employed Full or Part Time
January – March 2019
44.2% 43.8% 27.9% 61.8% 52.0% 31.9% 54.3% 31.3% 57.1% 56.5%

Statewide October to December 2018 Statewide %

25.5% 22.3%

46.7% 42.6%

Access to competitive employment is an indicator of the quality and effectiveness of fidelity model SE services. The data reported above is too recent to support confident trend analyses, but they do provide a reasonable baseline for future analyses. The ER will continue to review these competitive employment data in concert with the available SE fidelity and QSR reports.
SE Fidelity and Quality
The DHHS is to be commended for continuing its efforts to: (a) assure the fidelity of SE services on a statewide basis; and (b) work with the Regions with penetration rates below CMHA criteria to increase access to and delivery of SE services to target population members in their Regions. The ER will continue to monitor these issues going forward as the State works with the CMHCs to increase penetration rates to at least 18.6 percent in all regions.
Table IX displays year-over-year comparisons of SE fidelity total scores for the ten CMHCs.

17

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 18 of 86

Table IX

Year over Year Comparisons of SE Fidelity Scores

Previous

Recent

Change

CLM

116

115

-1

Nashua

80

88

8

Lakes

91

95

4

MFS

103

98

-5

MHCGM

110

105

-5

NHS

Berlin

85

85

0

Conway

91

101

10

Littleton

89

93

4

Riverbend

106

98

-8

WCBH

80

77

-3

Seacoast

107

100

-7

Comm

partners

103

76

-27

total Average

1161

1131

-30

96.75

94.25

-2.5

As can be seen in Table IX, overall CMHC system SE Fidelity scores have gone down when compared to the previous year’s SE fidelity scores. The CMHC system SE scores have gone down by an average of 2.5, and only four SE programs improved SE scores in the year-to-year comparison. Two CMHCs scored below 80, close to the threshold score of 73, below which the services no longer qualify as fidelity SE.
The QSR process has identified a number of SE performance issues among the CMHCs. For example, for the indicator related to comprehensive employment assessments, nine of the ten CMHCs for which most recent QSR reports are published scored below the 75% performance threshold.4 In the same manner, two of the ten CMHCs scored below 75% on the indicator related to the adequacy of employment service delivery. In each case, these findings have resulted in the development of QIPs, and in state technical assistance and monitoring activities designed to improve the quality and effectiveness of SE services. As with ACT services, the QSR findings are not a substitute for SE fidelity reviews, but they do add to the overall documentation of the degree to which SE services are delivered with quality and effectiveness.
4 Although remaining under the QSR quality threshold, four of the nine did improve their scores for this indicator between last year and this year.
18

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 19 of 86
For example, a SE team can operate at relatively high fidelity, but if individuals are not assessed properly for inclusion in SE services, there could be issues related to matching individual needs with the services available. System performance in supported employment assessment and service delivery, as documented by the QSR and corresponding provider fidelity reviews, indicates that the State is not yet providing SE services in the amount, duration, and intensity to allow all target population members in New Hampshire opportunities to work the maximum number of hours in integrated community settings consistent with their individual treatment plans, and that eligible individuals may not be properly identified and provided reasonable access to supported employment services.
Supported Housing (SH)
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Program by June 30, 2016. As of March 2019, DHHS reports having 389 individuals leased in Bridge Program subsidized units, and having 11 people approved for a Bridge Program subsidy but not yet leased. There are 38 individuals who are reported to be on the Bridge Program wait list as of the end of March, 2019. Of these, 24 individuals have been on the wait list for more than two months. There has been a precipitous drop in the aggregate number of individuals either leased or approved but not yet leased in the Bridge Program – from 591 in June of 2017 to 400 in March 2019. In terms of funded capacity of Bridge Program units, the State was in compliance with the CMHA standards for SH effective June 30, 2016. However, as noted above, the number has now dropped substantially below 450, and currently there are only 11 individuals reported to be approved and in the search process for a SH unit. Table X below provides data regarding the number of current Bridge Subsidy participants; the number waiting to lease; the number on the Bridge Subsidy waiting list; the total number leased since the inception of the program; and the total number receiving a HUD Housing Choice Voucher (HCV). Table XI provides quarterly data regarding the number of Bridge Subsidy program applications and terminations.
19

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 20 of 86

Table X

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

December 2016 through March 2019

Bridge Subsidy Program
Information

Dec. 2016

March June 2017 2017

Sept. March Sept. March 2017 2018 2018 2019

Total individuals 481

505

545

509

497

423

389

leased in the

Bridge Subsidy

Program

Individuals in

32

48

46

58

7

process of leasing

0

11

Individuals on the 0

0

0

0

10

35

38

wait list for a bridge subsidy5

Total number

643

675

701

742

811

812

812

served since the

inception of the

Bridge Subsidy

Program

Total number

83

85

85

96

119

125

137

transitioned to a

HUD Housing

Choice Voucher

(HCV)

5 The State did not maintain a waitlist prior to 2018.
20

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 21 of 86

Table XI

Self-Reported Housing Bridge Subsidy Applications and Terminations

Measure

April – June
2018

July – September
2018

October – December
2018

January – March
2019

Applications Received

28

32

12

29

Point of Contact

CMHCS

24

32

12

22

NHH

4

0

0

5

Other

0

0

0

1

Applications Approved

5

7

5

14

Applications Denied

0

0

0

0

Denial Reasons

NA

NA

NA

NA

Applications in Process

at end of period

165

197

209

53

Terminations

0

0

0

1

Termination Reasons

NA

NA

NA

Over Income

1

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table XII below displays the reported number of units leased at the same address.

21

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 22 of 86

Table XII

Self-Reported Housing Bridge Subsidy Concentration (Density)

Nov. Feb 2017 2018

June 2018

Sept. Decem- March 2018 ber 2018 2019

Number of properties

with one leased SH unit

at the same address

383 372

354

339

329

315

Number of properties

with two SH units at the

same address

31

35

26

52

27

18

Number of properties

with three SH units at

the same address

6

13

10

24

4

3

Number of properties

with four SH units at the

same address

5

4

5

12

3

2

Number of properties

with five SH units at the

same address

0

1

0

0

1

2

Number of properties

with six SH units at the

same address

0

0

0

6

0

0

Number of properties

with seven + SH units at

same address

3

2

2

17

2

1

It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)).

22

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 23 of 86

DHHS reports and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge Subsidy Program units.6

As noted in the ER Reports dating back to 2016, DHHS has been working on a method to crossmatch the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. Table XIII summarizes the most recent iterations of these data.

Table XIII

Housing Bridge Subsidy Program Tenants Linked to Mental Health Services

Housing Bridge Tenants Linked

As of 12/31/18 373 of 443 (84%)

As of 3/31/19 337 of 400 (84.5%)

These data document the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports.7
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain federal Department of Housing and Urban Development (HUD) funding for an additional 150 supported housing units for a total of 600 supported housing units.” (CMHA V.E.3(e)) In 2015 New Hampshire applied for and was awarded funds to develop a total of 191 units of supported housing under the HUD Section 811 Program. All of these units will be set aside for people with serious mental illness. As of the date of this report, 43 of these new units have been developed and are currently occupied by members of the target population. It should be noted that over the life of the Bridge Program the State has accessed 137 HUD Housing Choice Vouchers (HCVs) and one HUD public housing unit. Accessing these HCVs should allow the State to free up Bridge Program slots for new applicants, rather than reduce or eliminate existing Bridge program capacity. The ER plans to work with the state and representatives of the plaintiffs to assure documentation of progress towards the 600 specified units is attained and sustained.
In addition, the CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.” There are currently reported to be 38 individuals on the wait list for the Bridge program; 24 of these individuals have been on the wait list for more than two months and 22 of them have been waiting longer than six
6 DHHS reports that currently there is one voluntary roommate situation reflected in the above data. 7 Note: some of these tenants might be receiving services from MH providers other than a CMHC.
23

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 24 of 86
months for supported housing. Based on the above data: (1) the number of units under lease for the Bridge Program has fallen below the 450 capacity standard in the CMHA: (2) there are currently only 11 individuals who have been approved for a Bridge subsidy and are actively seeking a unit; and (3) there are at least 24 people on the Bridge Program wait list who have been on the list for more than two months.
Therefore, the State is not currently in compliance with the CMHA requirements related to SH.
The State reports that it is considering changes to the management and operations of the Bridge Housing Program. As of the date of this report the State has not reported final decisions about these potential changes. The ER is not able to comment at this time about whether the anticipated changes in the Bridge Housing Program will be effective in bringing the State into compliance with the CMHA SH requirements.
Transitions from Institutional to Community Settings
During the past 60 months, the ER has visited both Glencliff and NHH on at least nine separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities in 20148. Transition planning activities related to specific current residents in both facilities have been observed, and a small non-random sample of resident transition records has been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities.
The ER has participated in six meetings of the Central Team. The CMHA required the State to create a Central Team to overcome barriers to discharge from institutional settings to community settings. The Central Team has now had about 48 months of operational experience. As of July 2019, 57 individuals have been submitted to the Central Team, 36 from Glencliff and 21 from NHH. Of these, the State reports that 29 individual cases have been resolved,9 two individuals are deceased, and 28 individual cases remain under consideration. Table XIV below summarizes the discharge barriers that have been identified by the Central Team with regard to these 28 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total higher than the number of individuals reviewed by the Central Team.
8 NHH updated its transition planning policies in 2018. 9 Two of these individuals were readmitted to NHH after 90 days, and the discharge dispositions for these two individuals are being reviewed.
24

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 25 of 86

Table XIV

Self-Reported Discharge Barriers for Open Cases Referred from NHH and Glencliff to the Central Team:

July 2019

Discharge Barriers

Number for Glencliff

Number for NHH

Legal

6 (7.14%)

1 (7.14%)

Residential

17 (30.4%)

5 (35.7%

Financial

7 (7.14%)

1 (7.14%)

Clinical

15 (26.8%)

4 (28.6%)

Family/Guardian

10 (17.86%)

3(21.4%)

Other

1 (1.79%)

0(7.14%)

Glencliff
In the time period from October 2018 through March 2019, Glencliff reports that it has admitted 18 individuals, and has had one discharge and 11 deaths.
The average daily census through this period was 112 people. There have been no readmissions during this time frame. The wait list for admission has remained relatively constant at 25 to 27 people for the past six months. The one discharge effectuated during this period was reported to be to an integrated community setting: a three-person medical model group home.
CMHA Section VI requires the State to develop effective transition planning and a written transition plan for all residents of NHH and Glencliff (VI.A.1), and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]10 individuals with mental illness and complex health care needs residing at Glencliff….” The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be cost-effectively served in supported housing.”11
10 Cumulative from CMHA V.E.(g), (h), and (i). 11 CMHA V.E.2(a)
25

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 26 of 86
DHHS reports that a total of 17 people have transitioned from Glencliff to integrated settings since the inception of the CMHA five years ago. There are currently 24 individuals undergoing transition planning who could be transitioned to integrated community settings once appropriate living settings and community services become available. Nine of these individuals have been assigned to Choices for Independence (CFI) waiver case management agencies in order to access case management in the community to facilitate transition planning, and five are currently in the application process. Four individuals have been found eligible for the Acquired Brain Disorder (ABD) or Developmental Disability (DD) waivers, and two have been denied eligibility for these waivers.
DHHS continues to provide information about Glencliff transitions, including clinical summaries, lengths of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions that could not be cost-effectively served in SH continue to experience transitions to integrated community settings. To protect the confidentiality of individuals transitioned from Glencliff, this person-specific information is not included in the ER reports.
DHHS has implemented action steps to enhance the process of: (a) identifying Glencliff residents wishing to transition to integrated settings; and (b) increasing the capacity, variety and geographic accessibility of integrated community settings and services available to meet the needs of these individuals. Both sets of initiatives are intended to facilitate such community transitions for additional Glencliff residents. Despite these efforts, the frequency of transitions to integrated community settings from Glencliff has essentially stalled in the past 18 months. DHHS is currently working to revise funding procedures and provider-related requirements to facilitate new transitions to integrated setting on a timelier basis. The ER will be closely monitoring whether these initiatives result in increased transitions over the next few months. DHHS reports it is also considering a new approach and possibly staffing for Glencliff inreach activities, but no definitive plans related to inreach have been announced to date.
As noted in previous reports, the ER is at this point reluctant to focus narrowly on clinical conditions and sets of health, mental health and community services and supports for transitioned and transitioning individuals to monitor the State’s progress in assisting Glencliff Home residents to transition to integrated community settings. Despite this reluctance, the ER is concerned that the State is not yet in compliance with the CMHA requirements with regard to transitions to integrated community settings for residents with complex medical needs. This concern is exacerbated by the extremely slow pace of transitions to integrated community placements over the past two years. In addition, there has been no additional small-scale community residential capacity developed to serve Glencliff residents with complex medical conditions. The ER will more closely monitor the extent to which DHHS, Glencliff, the CMHCs and an array of other community partners collaborate to effectuate as many such transitions as possible over the next year.
26

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 27 of 86
Progress towards effectuating transitions to integrated community settings for current Glencliff residents has been very slow over the past 18 months. Unless additional efforts are brought to bear, the 24 individuals in active transition planning could remain at Glencliff indefinitely, and other residents will go without meaningful opportunities to explore potential community alternatives.
As noted in previous reports, the ER will continue to monitor the following topics/items to inform his assessment of compliance:
1. The number of transitions from Glencliff to integrated community settings per quarter. The ER will also monitor information about the clinical and functional level of care needs of these individuals; the integrated settings to which they transition; and the array of Medicaid and non-Medicaid mental health and health-related services and supports put in place to meet their needs to assure successful integrated community living.
2. The number of Glencliff residents newly identified per quarter to engage in transition planning and move towards integrated community settings. The ER will also monitor at a summary level the clinical and functional level of care needs of individuals added to the transition planning list per quarter.
3. New integrated community setting providers with the capacity to facilitate integrated community living for Glencliff residents. These could include EFCs, AFCs, and new small-scale community residential capacity for people with complex medical conditions who cannot be cost-effectively served in supported housing. The ER will monitor DHHS activities and successes relative to identification and engagement of community providers who express willingness and capacity to provide services in integrated community settings for people transitioning from Glencliff.
4. Within the discharge cohort, the number of transitioned individuals for whom the State special funding mechanism is utilized to effectuate the transition, and the ways in which these funds are used to fill gaps in existing services and supports.
5. Number and types of in-reach visits and communications by CMHCs and other community providers related to identifying and facilitating transitions of Glencliff residents to integrated community settings.
6. Specific documentation of efforts to overcome family and/or guardian resistance to integrated community transitions for Glencliff residents.
7. Number of individuals engaged in transition planning referred to the Central Team; number of these individuals who successfully transition to an integrated community setting; and the elapsed time from referral to resolution.
Preadmission Screening and Resident Review (PASRR)
The State DHHS has provided recent data on PASRR Level II screens for the period April 1, 2019 through June 30, 2019. These data are summarized in Table XV below. A Level II screen is conducted if a PASRR Level I (initial) screen identifies the presence of mental illness,
27

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 28 of 86

intellectual disability, or related conditions for which a nursing facility placement might not be appropriate. One objective of the Level II screening process is to seek alternatives to nursing facility care by diverting people to appropriate integrated community settings. Another objective is to identify the need for specialized facility based services if individuals are deemed to need nursing facility level of care.

Table XV

PASRR Level II Screens: April through June 2019

Full Approval - No Special Services Full Approval with Special Services Provisional – No Special Services Provisional with Special Services Total

April through June 2019
23 23 15 19 80

Percent 28.8% 28.8 18.8 23.8 100%

In the previous ER report, 10.2% of the Level II screens were approved with a specification for special services. At that time, the ER questioned whether this was an unusually low rate for specification for special services. In a comparison with one other state, the ER found substantially higher approvals for special services than was evidenced in New Hampshire at that time. In the intervening period, the State and the PASRR contractor have been reviewing protocols for specification of special services in the Level II process. For this current report, the percentage of approvals with special services has increased to over 50%.
In addition, the State has been reviewing the New Hampshire Medicaid Plan to see if revisions may be appropriate for the section(s) of that Plan identifying what special services may be covered by Medicaid for recipients for whom the Level II screen results in a specification for special services. The State reports that it has not yet completed this review. The ER expects that the review and any changes to the Medicaid Plan with respect to special services will be completed no later than October 1, 2019.
The ER has also reviewed PASRR Level II screens and admission assessments for recent admissions to Glencliff. Three of these were not completed: two because of the presence of dementia; and one because there was no diagnosed mental illness or related condition. For the three Level II screens that were completed, no special services were recommended. The ER does not attempt to supplant the clinical judgment of others, particularly not when based solely on clinical records. Nonetheless, the ER did suggest to participating state personnel that at least
28

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 29 of 86
two of the PASRR Level II screens reviewed at Glencliff might have considered and specified special services related to the approval. For a variety of reasons, virtually all PASRR screens are conducted for people who are already in a nursing facility. For example, for May and June of 2019, 100% of Level II screens were conducted in nursing facilities. A possible consequence of this is that prime opportunities for diversion to integrated community settings may have already been missed by the time the PASRR screen is conducted. In addition, individuals admitted to Glencliff must typically have been turned down by at least three other facilities before being considered for admission. In combination, these facts indicate that interventions to divert individuals from Glencliff or other nursing facilities must typically be used before the PASRR screening process is initiated. PASRR is important to assure that people with mental illness, ID/DD, or related conditions are not inappropriately institutionalized or placed in nursing facilities without access to necessary special services. However, PASRR is not by itself sufficient to divert people from nursing facility care. Up-stream interventions at NHH, the DRFs, and among the CMHCs are also essential to prevent unnecessary facility placement.
New Hampshire Hospital and the Designated Receiving Facilities (DRFs) For the time period January through March 2019, DHHS reports that NHH effectuated 189 admissions and 182 discharges. The mean daily census was 149, and the median length of stay for discharges was 27 days. Table XVI below compares NHH discharge destination information for the five most recent reporting periods (4/2017 through 3/2019). The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.
29

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 30 of 86

Table XVI

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Percent Percent Percent Percent

Discharge Destination

April through
June 2017

July through September
2017

October 2017
through March 2018

April 2018 through
September 2018

Home – live alone or with others

85.66% 88.3%

81.0%

81.7%

Glencliff

0.35%

0.49%

1.0%

1.45%

Homeless Shelter/motel

3.5%

2.94%

2.5%

3.13%

Group home 5+/DDS supported living, etc.

5.59%

3.92%

7.1%

4.1%

Jail/corrections

1.05%

0.49%

2%

1.45%

Nursing home/rehab facility

3.50%

2.45%

2.7%

5.3%

Percent October
2018 through March
2019
73.26% 1.6% 6.68%
4.01%
2.94% 4.55%

The ER is concerned that the percentage of discharges to home has been trending downward, and that the percent discharged to homeless shelters or motels has increased. Restrictions or delays in access to the Bridge Subsidy program could be one factor contributing to this trend.
The State now consistently reports information on the hospital-based DRFs and the Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and analyze it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. Table XVII summarizes these data.

30

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 31 of 86

Table XVII Self-Reported DRF/APRTP Utilization Data: January 2016 through
March 2019

Franklin Cypress Portsmouth Eliot

Eliot

Total

Geriatric Pathways

Admissions

Jan - March 2016

69

257

NA

65

121

558

April - June 2016

79

205

378

49

92

803

July - Sept 2016

37

207

375

54

114

787

April - June 2017

60

228

363

52

101

804

July - September 2017 NA** 178

363

60

121

722

Oct. - Dec 2017

59

209

358

55

102

783

Jan. - March 2018

52

240

330

66

100

788

April - June, 2018

69

244

333

65

104

815

July - September 2018 67

201

357

October - December

2018

87

198

375

54

112

791

64

72

796

January - March 2019

126 182

349

56

123

836

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

Total

53.70% 55.70% 43.20% 58.30% NA** 49.20% 44.20% 46.73% 28.36%

18.70% 24.40% 29.50% 21.50% 25.60% 30.10% 28.30% 25.82% 24.38%

46.00% 23.20% 45.20% 18.10%

NA 20.40% 18.90% 22.00% 25.60% 23.70% 21.50% 24.62% 19.33%
22.40% 23.20%

18.50% 4.10% 13.00% 1.00% 11.50% 12.70% 6.10% 9.23% 12.96%

30.60% 48.90% 44.70% 47.50% 50.40% 50.00% 47.00% 51.92% 49.11%

NA 25.50% 26.20% 30.06%
NA 30.00% 27.00% 29.08% 25.16%

6.25% 51.40% 26.50% 12.50% 47.20% 28.20%

Average Census Jan - March 2016

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

Total

7.9 14.7

NA

19.7

18.1

31

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 32 of 86

April - June 2016

7.8 13.2

21.4

22.5

16.9

81.8

July - Sept 2016

4.5 13.6

23.2

25.6

14.5

81.4

April - June 2017

4.5

12

30.3

29.3

10

86.1

July - September 2017 NA** 12.9

29.7

29.7

12.2

NA

Oct. - Dec 2017

10.1 12.3

27.7

32.6

16.1

19.7

Jan. - March 2018

6.7 11.6

32.5

34.6

NA

NA

April - June, 2018

9.1 11.9

31.7

31.7

20.4 104.8

July - September 2018 11.8 8.4

39.6

33.8

18.2 111.8

October - December

2018

10.7 9.2

27.4

33.4

10.7

91.4

January - March 2019

8.5 14.5

30.4

22.6

14.9

90.9

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

Total

Discharges

76

261

NA

Jan - March 2016

78

206

363

April - June 2016

35

213

380

July - Sept 2016

59

232

365

April - June 2017

NA** 243

355

July - September 2017 82

212

359

Oct. - Dec 2017

53

248

326

Jan. - March 2018

74

244

326

April - June, 2018

66

195

353

October - December

2018

89

204

358

January - March 2019

124 177

348

57

122

516*

51

90

788

64

113

805

54

105

815

63

121

NA

58

102

813

67

101

795

65

107

816

54

112

780

62

79

792

56

106

811

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

Total

Mean LOS for Discharges

8.6

4.2

NA

Jan - March 2016

6

4

4

April - June 2016

7

5

4

July - Sept 2016

6

4

5

April - June 2017

NA

4

4

July - September 2017

4

4

5

Oct. - Dec 2017

5

4

5

Jan. - March 2018

5

4

5

April - June, 2018

4

4

4

October - December

2018

4

3

4

January - March 2019

5

5

6

15

7.4

8.8*

28

7

5

24

8

5

22

8

9

27

7

NA

21

7

5

23

7

5

20

8

5

21

7

5

31

7

5

18

8.5

6

32

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 33 of 86

The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and should also reduce the number of people waiting for psychiatric admissions in hospital EDs. However, at this time there has been no substantial reduction in NHH admissions or NHH readmissions. The wait list for NHH admissions of people staying in hospital EDs has been somewhat reduced, as shown in Charts A and B below. DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table XVIII below provides a summary of these recently reported data.

Table XVIII Self-Reported Discharge Dispositions for DRFs in New Hampshire
October, 2018 through March 2019

Disposition Frank- Cypress Ports-

Eliot

Eliot

lin

mouth Geriatric Pathways

Total

Home

195

331

515

33

162

1,236

NHH

0

0

6

0

3

9

Residential 2

16

1

62

2

83

Facility/

Assisted

Living

Other DRF 3

14

9

6

4

36

Hospital

0

0

0

0

0

0

Death

0

0

0

6

0

6

Other or

13

20

175

11

14

233

Unknown

Total

213

381

706

118

185

1,603

*The Other category for Portsmouth Regional is reported to include shelters, rehab facilities,

hotels/motels, friends/families, and unknown.

Based on these self-reported data, 77.1% of discharges from DRFs and the Cypress Center are to home. This is essentially the same as the 80.8% % discharges to home reported by NHH. In addition:

 5.2% of the total DRF discharges are to residential care or assisted living, which is similar to NHH discharges for this category.
 0.56% of the DRF discharges are to NHH, less than one half of the percent discharged to NHH from previous reporting periods.
 2.2% of discharges are to other DRFs.
33

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 34 of 86  4.5% of the total discharges are to the other/unknown category, but 75% of these are
accounted for by the Portsmouth DRF. Hospital Readmissions DHHS is now reporting readmission rates for both NHH and the DRFs. Table XIX below summarizes these data:
34

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 35 of 86

Table XIX Self-Reported Readmission Rates for NHH and the DRFs
July 2017 through March 2019

NHH 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019

Percent 30 Days
9.80% 12.8% 13.7% 7.6% 8.6% 7.3% 5.3%

Percent 90 Days
21.60% 26.1% 22.7% 14.7% 19.6% 18.1% 14.8%

Percent 180 Days
27.90% 32.8% 29.9% 23.4% 25.4% 25.9% 21.2%

Franklin 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019

NA 10.2% 0.0% 4.3% 6.0% 2.3% 7.9%

NA 10.2% 0.0% 5.8% 9.0% 4.6% 10.3%

NA 10.2% 1.9% 5.8% 16.4% 5.7% 10.3%

Cypress 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019

7.10% 12.00% 4.20% 4.50% 8.50% 7.10% 5.50%

12.40% 18.70% 9.60% 8.20% 13.90% 11.10% 14.80%

15.90% 24.40% 15.80% 11.90% 18.90% 15.20% 17.60%

Portsmouth 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019

11.50% 8.70% 8.80% 10.20% 8.40% 7.70% 12.90%

17.50% 13.70% 15.50% 15.90% 12.90% 14.90% 19.50%

21.00% 17.60% 20.60% 21.90% 19.00% 20.30% 23.50%

35

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 36 of 86

Elliot Pathways 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019
Elliott Geriatric 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019

3.30% 5.80%
NA 3.80% 7.00% 2.80% 4.90%
6.10% 5.60% 6.30% 5.40%

6.60% 7.70%
NA 6.70% 11.50% 5.60% 5.70%
6.10% 11.10% 7.80% 5.40%

12.40% 12.50%
NA 8.60% 16.10% 9.70% 7.30%
6.10% 11.10% 9.40% 5.40%

Two facts are documented for the 21month period in which re-admission rate data has been reported. First, the rates of readmission have trended down slightly, but have not changed substantially. Second, the readmission rates, especially the 180 day readmission rate for NHH, remains very high. At least 20% of all people discharged form NHH are back in the hospital within 180 days. These data, in concert with the hospital emergency room data presented below, indicate that gaps remain in community services for people with serious mental illness, and that the essential connection between inpatient care and community services is not being effectuated for sizeable numbers of people at risk of re-hospitalization. These facts need to be understood in light of the States ongoing difficulties increasing ACT capacity and enrollment as documented in an earlier section of this report.
Hospital ED Waiting List
In the previous three reports, the ER has identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. Chart A below displays daily adult admissions delays to NHH bi-weekly for the period July 2017 through June, 2019. Chart B shows the average daily ED waiting list by month for the same time period.
Chart A

36

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 37 of 86 37

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 38 of 86 Chart B
Based on information reported by DHHS and illustrated above, a monthly average of 34 adults was waiting for a NHH inpatient psychiatric bed from October 2018 through March 2019. This is lower than the previous 12 month average of 46 individuals waiting in emergency departments. As can be seen in Charts A and B, the average number of adults waiting for admission has trended downward since January of 2019. If these positive trends continue, they could be
38

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 39 of 86
evidence that system-wide management and service linkage interventions are beginning to take effect.
Family and Peer Supports
Family Supports Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies DHHS continues to report having a total of 15 peer support agency program (PSA) sites, with at least one program site in each of the ten regions. The State continues to report that all peer support centers meet the CMHA requirement to be open 44 hours per week. The State reports that those sites have a cumulative total of 1,763 members, with an active daily participation rate of 158 people statewide. The active daily participation has dropped from a reported 166 in the period ending December 2018, but is still above the 132 active participants reported at the end of October 2018. The State reports that all of the PSAs have been auditing and correcting their membership lists, and that the reduction in membership is primarily due to these activities. The CMHA requires the PSAs to be “effective” in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs. There continue to be anecdotal reports that some of the CMHCs are making more concerted efforts to refer service participants to the PSAs in their regions. Increased efforts to communicate and coordinate with PSAs have also been reported. However, as of the most recent report there has been a slight reduction in active daily participation. In addition, the ER has received anecdotal information that in some regions of the state, relationships and communications among the CMHCs and the Peer Support Agencies have improved. Peer Support Agencies are generally reported by CMHCs to be useful sources of employees for ACT and Mobile Crisis and Crisis Apartment services. Finally, CMHCs have verbally stated that the peer-operated crisis beds available in several regions are a useful intervention for some CMHC clients at risk of hospitalization.
39

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 40 of 86
IV. Quality Assurance Systems
The State has made substantial positive progress implementing a comprehensive, reliable and actionable QSR process. Within the past six months the ER has participated in two QSR site visits, and is increasingly confident that: (a) the revised instruments and site interview protocols are working well; and (b) the results and findings of the revised QSR instruments and process reflect, to a large degree, the quality standards of the CMHA. DHHS has now completed the QSR process using the revised instruments and protocols at least two times for each of the ten CMHCs. Table XX below summarizes the quality indicator scores for each domain of the QSR. Average scores for the OCR questions are all above the 80% threshold, so they are not included in this summary table. Highlighted scores are below the 75% performance threshold established for the QSR for the “year two” time period covered by this report.
40

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 41 of 86

Table XX QSR Total Indicator Scores: All CMHCs

Indicator Number
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Indicator Content Adequacy of Assessment Approp. Tx Planning Adequacy of Ind. Serv. Del. Adequacy of Hsg. Assess. Approp. Of Hsg. Tx Planning Adequacy of HSG. Serv. Del. Effect. Org Hsg. Supports Del. Adequacy of Emp. Assessment Approp. Of Emp. Tx Planning Adequacy of Emp. Serv. Del. Adequacy of Ass. Of Int. Needs Integration in Community Adequacy of Crisis Assess. Appropriateness of Crisis Plns. Comp. and Effec. Crisis Del. Syst. Adequacy of ACT screening Imp. Of high Fidel. ACT Servs. Succ. Trans./Dich. From inpat.

Prev. Avg (10 CMHCs)
80.5% 89.8% 82.4% 99.5% 90.2% 84.2% 76.2% 57.9% 70.3% 59.7% 94.4% 79.5% 69.0% 80.8% 72.8% 90.6% 54.3% 78.1%

Current Avg. (10 CMHCs)
87.4% 89.3% 83.5% 100.0% 86.5% 89.0% 84.6% 63.8% 70.8% 80.0% 100.0% 81.1% 78.0% 93.0% 72.5% 98.5% 65.1% 80.0%

Total Average

1410.2% 78.3%

1503.2% 83.5%

As demonstrated in the table, the CMHC system as a whole scores below the 75% performance threshold on four indicators. Each of these indicators is related to specific standards and requirements of the CMHA. As noted earlier in this report, DHHS requires CMHCs with a score below the performance threshold to develop a QIP, which is then monitored on at least a quarterly basis by DHHS staff. Improvements accomplished as a result of the QIPs should be evidenced in subsequent QSR reports.
DHHS is committed to using the QSR process to continuously improve the quality and effectiveness of CMHA services as the community mental health system matures. For this reason the performance threshold for QSR scoring has been raised to 80% for the up-coming annual cycle of QSR reviews. The ER applauds this change, since it moves closer to requiring a

41

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 42 of 86
level of system and provider performance that the ER considers to be substantial compliance with the CMHA (assuming that other CMHA metrics are attained). As a companion to the QSR process, DHHS has been conducting on-site ACT and SE fidelity reviews. DHHS has engaged the Dartmouth/Hitchcock Center on Evidence Based Practices to assist in attaining and assuring fidelity to the evidence based models of ACT and SE. The Dartmouth/Hitchcock team will also assist on workforce development and training for these and other evidence based practices under the aegis of DHHS and the CMHCs. This partnership with the nationally respected Dartmouth/Hitchcock Center adds valuable expertise and experienced personnel to facilitate further development of, and increased adherence to, fidelity model ACT and SE in conformance with the CMHA. Year-to-year comparisons and the CMHCs Quality Improvement Plans have been included in the publication of recent ACT and SE fidelity reviews. The ER commends DHHS for implementing the comprehensive fidelity review process and its attendant quality improvement and technical assistance activities. Table XXI below shows average changes in year-to-year fidelity scores for both ACT and SE. All CMHCs in the state meet the minimum performance threshold for “fair fidelity” both ACT12 and SE. However, as displayed in the table, the fidelity scores have recently been trending downward, not up-ward. Fair fidelity scores also tended to correlate with deficits in individual service delivery and performance issues documented in the QSR. As with the QSR scores, QIPs related to fidelity findings should result in fidelity score improvements over the next round of fidelity reviews.
12 The CMHC for which one ACT team fell below the ACT Fidelity threshold score of 84 has a second team that scored higher than the threshold. The average of the scores for these two teams is use for this table.
42

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 43 of 86

Table XXI

Trends in ACT and SE Fidelity Scores

Fidelity Topic
ACT SE

Average Year-to-Year Fidelity Score Change -3.6 -2.5

Effective and valid fidelity reviews and consequent training and workforce development activities are essential to DHHS’ overall quality management efforts for the community mental health system. As noted in the previous two ER reports, the QSR and the fidelity reviews mutually support but do not supplant or replace each other. The QSR, in particular, examines outcomes from a consumer-centric perspective as opposed to an operational or organizational perspective. It is uniquely positioned to assess the quality, appropriateness and effectiveness of specific ACT and SE services at the individual participant level. The ER continues to believe that implementation of fidelity-based models of delivery does not necessarily mean that specific service interventions are working well or being delivered with the frequency or intensity required by a participant’s individual treatment plan The revised QSR instruments and protocols address many of these concerns. In combination, the fidelity reviews and the QSR can mutually support conclusions about the overall quality and effectiveness of the mental health system consistent with the CMHA.
The ER will continue to monitor the degree to which the QSR process produces reliable information on individual outcomes and the quality of CMHA service delivery. In addition, over the next six months, the ER will evaluate the extent to which CMHC Quality Improvement Plans developed as part of the 2018-2019 QSR site visits are resulting in recommended practice changes and improved outcomes for those in the target population.
The ER and the Parties to the CMHA have discussed how the QSR and external fidelity reviews can be used to measure compliance with the CMHA, including both the appropriate standards for compliance and the specific provisions of the QSR and fidelity reviews that would be used to assess compliance. These discussions are on-going, and the ER supports the collaborative efforts of both the State and the representatives of the Plaintiffs. The ER intends to employ both the QSR and the fidelity reviews as tools to assess individual outcomes, analyze system performance, and ultimately measure compliance with the CMHA.

43

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 44 of 86
I. Summary of Expert Reviewer Observations and Priorities
The ER has emphasized in this report that the State continues to be far from compliant with CMHA requirements for ACT. In fact, the State has made minimal progress in meeting CMHA ACT requirements over the past four reporting periods. For the last three years the ER has reported that the State is out of compliance with the ACT requirements of Sections V.D.3(a, b, d, and e), which together require that all ACT teams meet the standards of the CMHA; that each mental health region have at least one adult ACT Team13; and that by June 30, 2016, the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time.
Other areas of non-compliance identified in this report include:
1. Continued failure to meet the QSR quality threshold for SE for indicators related to employment assessments and employment treatment planning. In addition, at least four regions of the state continue to have penetration rates below the statewide target of 18.6%;
2. Failure to maintain the Housing Bridge Program at the CMHC required level of 450 units;
3. Failure to continue placing residents of Glencliff into integrated settings in accordance with the CMHA; and
4. Failure to provide agreed-upon data reports in a timely fashion.
Five years ago, all parties to the CMHA envisioned implementation of a number of remedial services and system interventions designed to assure positive outcomes for the defined target population. Most important among these outcomes was assurance of maximum community integration supported by housing and evidence based and high quality services meeting individual needs and choices. At the same time, the CMHA envisioned reduction of hospital and institutional admissions and increased access to integrated community settings for individuals residing in such facilities. The CMHA and its signatories envisioned high quality of life and improved personal outcomes for adult citizens of New Hampshire with serious mental illness.
Thus, frustration with slow or partial implementation of the CMHA is not solely based on bureaucratic inertia or structural barriers to implementation. Rather, the frustration is based on the realization that real people with real needs may face real life problems and real negative effects absent the services promised by the CMHA.
13 The ER notes that each region of the state has had at least one ACT team, or ACT team-in-development, since the inception of the CMHA. However, as documented in the ACT section of this report, three regions continue to have ACT teams that do not meet the minimum staffing requirements for ACT as specified in the CMHA.
44

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 45 of 86 The ER supports on-going State efforts to improve CMHA implementation, and has continued to applaud positive elements of implementation, such as the QSR and the external ACT and SE fidelity reviews. However, neither the Parties to the CMHA nor the ER should continue to tolerate non-compliance with the CMHA when peoples’ rights to community integration and quality of life are at risk. Real progress toward compliance with all CMHA standards and requirements must be clear and demonstrable by the end of the up-coming six month time frame.
45

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 46 of 86
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly Data Report January to March 2019
46

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 47 of 86
New Hampshire Community Mental Health Agreement Quarterly Data Report
January - March 2019
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement July 3, 2019
47

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 48 of 86
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence
48

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 49 of 86
January to March 2019
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services
Publication Date:
Reporting Period: 1/1/2019 – 3/31/2019
Notes for Quarter
 Revised and renamed Table 1b to improve outcome reporting of ACT screenings that result in new ACT clients. This table now reflects a retrospective analysis for the two most recent quarters that data is available. A retrospective analysis is used for this reporting because the receipt of ACT services commences after the client is found appropriate and then enrolled in ACT. The documentation of the delivery of ACT services to the client may take several weeks to capture within this report based on ACT cost center data cycles.
 Created a new Table 1c to report the total number of all individuals added to ACT during the current reporting period. These are individuals that began receiving ACT services within the current period based on data processed through the ACT cost center for the current period.
 Combined ACT Staffing Competencies into one table (formerly Tables 2b-2d); all competency data are displayed in Table 2b.
 Moved the Employment Status Point in Time data (formerly Tables 12a and 12b) to be directly following the Supported Employment Penetration Rate table. Tables 3a, 3b, and 3c now contain all employment and Supported Employment information.
 Renumbered the table reporting ACT Waiting List information to Table 1d; it was formerly Table 1c.  Tables 8 through 10 have been realigned to improve the clarity of information reported.  During the reporting period, and in preparation for the transition of the HBSP to a regionally delivered
program model, the Bureau of Mental Health Services, in collaboration with the Housing Bridge Subsidy Program provider and the CMHC referring agents, completed a review of pending HBSP applications and approved HBSP applicants waiting to obtain an HBSP funded unit. The review resulted in numerous status changes that are documented in Appendix A.

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

1

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 50 of 86

1a. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Clients

Community Mental Health Center

January February

2019

2019

March 2019

Unique Clients in
Quarter

Unique Clients in
Prior Quarter

01 Northern Human Services

117

116

120

126

123

02 West Central Behavioral Health

40

39

41

48

49

03 Lakes Region Mental Health Center

49

51

51

54

54

04 Riverbend Community Mental Health Center

94

96

96

106

93

05 Monadnock Family Services

59

58

59

61

62

06 Community Council of Nashua

72

75

67

79

87

07 Mental Health Center of Greater Manchester

319

309

303

335

333

08 Seacoast Mental Health Center

73

71

70

73

72

09 Community Partners

67

64

66

72

68

10 Center for Life Management

52

48

51

56

55

Total Unique Clients

942

926

923

1,007

997

Unique Clients Receiving ACT Services 4/1/2018 to 3/31/2019: 1,186

Revisions to Prior Period: None.

Data Source: NH Phoenix 2

Notes: Data extracted 4/17/2019; clients are counted only one time regardless of how many services they receive.

1b. Community Mental Health Center Services: Assertive Community Treatment Screening and Resultant New ACT Clients

October - December 2018

July – September 2018

Community Mental Health Center

Retrospective Analysis

Retrospective Analysis

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

2

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 51 of 86

Unique Clients Screened Appropriate for Further ACT Assessment: Individuals Not Already oNnewACClTients receiving ACT Services within 90 days of Screening Unique Clients Screened Appropriate for Further ACT Assessment: Individuals Not Already oNnewACClTients receiving ACT Services within 90 days of Screening

01 Northern Human Services

1,192

24

6

1,128

27

4

02 West Central Behavioral Health

263

1

0

306

9

2

03 Lakes Region Mental Health Center

974

19

2

652

17

0

04 Riverbend Community Mental

1,481

8

1

1,401

9

1

Health Center

05 Monadnock Family Services

203

4

1

562

7

2

06 Community Council of Nashua

925

8

0

959

8

1

07 Mental Health Center of Greater Manchester

2,576

7

0

3,040

5

0

08 Seacoast Mental Health Center

1,412

13

1

1,294

14

0

09 Community Partners

508

2

2

390

2

1

10 Center for Life Management

494

10

0

719

23

0

Total ACT Screening

10,028

96

13 10,451

121

11

Revisions to Prior Period: None

Data Source: NH Phoenix 2 and CMHC self-reported ACT screening records. ACT screenings submitted through Phoenix capture ACT screenings provided to clients found eligible for state mental health services. Phoenix does not capture data for non-eligible clients; 3 CMHCs submit this data through Phoenix. 7 CMHCs self-report; all such screenings are contained in this table.

Notes: Data extracted 5/17/2019. “Unique Clients Screened” is defined as individuals that had a documented ACT screening during the identified reporting period, including individuals already on ACT who were re-screened for ACT. “Screening Deemed Appropriate for Further ACT Assessment: Individuals Not Already on ACT” is defined as screened individuals not already on ACT that resulted in referral for an ACT assessment. “New Clients Receiving ACT Services within 90 days of ACT Screening” is defined as individuals

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

3

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 52 of 86 who were not already on ACT that received an ACT screening in the preceding quarter and then began receiving ACT services.
1c. Community Mental Health Center Services: New Assertive Community Treatment Clients January – March 2019 October - December 2018

January 2019 New ACT FCleibernutsary 2019 New AMCaTrcClhie2n0t1s9 New ACT Clients Total New ACT Clients October 2018 New ACT CNlioevnetsmber 2018 New ADeCcTeClmiebenrts 2018 New ACT Clients Total New ACT Clients

Community Mental Health Center

01 Northern Human Services

2 52 9

9

02 West Central Behavioral Health 2 2 4 8

4

03 Lakes Region Mental Health Center

1 22 5

0

04 Riverbend Community Mental

9 6 5 20

1

Health Center

05 Monadnock Family Services

1 02 3

2

06 Community Council of Nashua

2 41 7

2

07 Mental Health Center of Greater Manchester

12 10 4 26

8

08 Seacoast Mental Health Center 2 0 0 2

0

09 Community Partners

2 05 7

2

10 Center for Life Management

0 14 5

1

Total New ACT Clients

33 30 29 92 29

0

5 14

3

5 12

0

1

1

3

6 10

0

3

5

1

1

4

11

8 27

2

2

4

1

4

7

0

0

1

21 35 85

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

4

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 53 of 86
Revisions to Prior Period: None
Data Source: NH Phoenix 2
Notes: Data extracted 4/18/2019; New ACT Clients are defined as individuals who were not already on ACT within 90-days prior and then began receiving ACT services. This information is not limited to the individuals that received an ACT screening within the previous 90-day period and may include individuals transitioning from a higher or lower level of care into ACT.

1d. Community Mental Health Center Services: Assertive Community Treatment Waiting List As of 3/31/2019

Time on List

Total

0-30 days

31-60 days 61-90 days 91-120 days

121-150 days

151-180 days

2

1

1

0

0

0

0

As of 12/31/2018

Total

0-30 days

31-60 days 61-90 days 91-120 days

121-150 days

151-180 days

6

3

0

0

1

1

1

Revisions to Prior Period: None

Data Source: BMHS Report

Notes: Data compiled 5/6/2019

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents

March 2019

December 2018

Nurse Masters Level Clinician/or Equivalent Support Worke r Peer Specialist (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner

Community Mental Health Center

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

5

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 54 of 86

01 Northern Human Services
02 West Central Behavioral Health
03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services
06 Community Council of Nashua 1
06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CTT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center
09 Community Partners
10 Center for Life Management
Total

1.49 1.90 12.9 0.5 16.80 1.15 17.31 1.15 0 1

0.60 1.70 3.20 1.3 6.80 0.38 5.75 0.25 0

0.80 2.00 4.50 1.0 8.30 0.75 7.35 0.75 0

0.50 3.00 7.00 1.0 11.50 0.50 10.50 0.50 0

1.25 4.25 3.00 1.0 9.50 0.65 9.00 0.65 0

0.50 2.00 3.50 0.5 6.50 0.25 5.00 0.25 0

0.50 1.00 2.50 0.5 4.50 0.25 4.00 0.25 0

1.50 10.00 1.75 1.0 14.25 0.72 14.25 1.02 0

1.50 8.00 5.25 1.0 15.75 0.72 15.75 1.02 0

1.00 2.10 5.00 1.0 9.10 0.60 11.10 0.60 0

0.50 2.00 5.75 0.5 8.75 0.63 7.75 0.50 0

1.25 2.00 4.04 0.5 7.86 0.40 6.55 0.40 7

11.3 39.95 58.3 9.8 119.6 7.00 114.3 7.34

9

9 8

1

1

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

6

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 55 of 86

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies

Substance Use Disorder Treatment

Housing Assistance

Supported Employment

Community Mental Health Center

March 2019

Decemb er
2019

Marc h
2019

Decemb er 2019

March 2019

Decemb er 2019

01 Northern Human Services

4.75

4.95 12.55 12.75 2.35

2.35

02 West Central Behavioral Health

0.35

0.35 4.00

2.75 0.20

0.40

03 Lakes Region Mental Health Center

2.75

2.50 3.75

4.55 3.00

3.00

04 Riverbend Community Mental Health Center 1.50

1.50 9.50

8.50 0.50

0.50

05 Monadnock Family Services

2.40

2.40 4.00

4.00 0.50

0.50

06 Community Council of Nashua 1

1.25

2.25 5.50

4.50 1.50

1.50

06 Community Council of Nashua 2

2.00

1.00 3.50

3.50 0.50

0.50

07 Mental Health Center of Greater Manchester-CCT

11.72 12.02 11.75 11.75 1.00

1.00

07 Mental Health Center of Greater Manchester-MCST

4.72

6.02 12.75 12.75 1.50

1.50

08 Seacoast Mental Health Center

2.00

3.00 5.00

6.00 1.00

1.00

09 Community Partners

1.00

1.00 2.00

2.00 1.25

1.25

10 Center for Life Management

3.00

3.00 6.31

5.00 0.30

0.30

Total

37.44 39.99 80.61 78.05 13.60 13.80

Revisions to Prior Period: None
Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report
Notes: Data compiled 4/18/2019; for 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, rather the quantity of

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

7

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 56 of 86
staff available to provide each service. If staff is trained to provide multiple service types, their entire FTE value will be credited to each service type.

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

8

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 57 of 86

3a. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12 Month Period

Community Mental Health Center

12 Month Period Ending March 2019

Supported Employment
Clients

Total Eligible Penetration

Clients

Rate

Penetration Rate for Period Ending
December 2018

01 Northern Human Services

NA*

1,286

NA*

NA*

02 West Central Behavioral Health

173

635

27.2%

32.2%

03 Lakes Region Mental Health Center

232

1,298

17.9%

11.8%

04 Riverbend Community Mental Health Center

340

1,829

18.6%

17.2%

05 Monadnock Family Services

80

998

8.0%

7.80%

06 Community Council of Nashua

256

1,895

13.5%

13.0%

07 Mental Health Center of Greater Manchester

1405

3,317

42.4%

43.9%

08 Seacoast Mental Health Center

580

1,807

32.1%

31.0%

09 Community Partners

105

752

14.0%

18.0%

10 Center for Life Management

212

1,011

21.0%

22.9%

Total Unique Clients

NA*

14,602

NA*

NA*

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 4/17/2019; clients are counted only one time regardless of how many services they receive.

*Northern Human Services made an adjustment to its data reporting system that inadvertently resulted in an understatement of its Supported Employment penetration rate later extracted from Phoenix. It has since made an additional adjustment to correct this issue. The supported employment penetration rate is anticipated to reflect the correction in the reporting period ending June 30, 2019.

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

9

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 58 of 86

3b. Community Mental Health Center Clients: Adult Employment Status – Total
Reported Employment Status

Northern Human Services West Central Behavioral Health Lakes Region Mental Health Center Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Center Mental Health Center of Greater Manchester Community Partners Seacoast Mental Health Center Center for Life Management Statewide Total or Mean Percentage Previous Quarter Statewide Total or Mean Percentage October - December 2018

Begin Date: 01/01/2019 End Date: 03/31/2019

Employment Status

Update

Overdue Threshold:

105 days

Updated Employment Status:

Full time employed

72 29 37 102

41 107 215 195 40 52 890

now or in past 90 days Part time employed 180

46 125 272 131 229 359 256 74 136 1,808

now or in past 90 days

Unemployed

177

Not in the Workforce 470

Status is not known

25

Total of Eligible Adult 924

CMHC Clients

Previous Quarter:

869

91 32 89 155 589 893
71 144 90 392 927 1,446
396 876 1,365

130 751 889 87 155 488 2,889 436 216 586 756 266 103 4,470
11 106 10 3 11 46 520 749 1,409 2,059 1,297 546 825 10,57
7
725 1,375 2,015 1,175 563 837

Total of Eligible Adult

CMHC Clients Percentage by Updated Employment Status: Full time employed 7.8% 7.4% 4.0% 7.0% 5.5% 7.6% 10.4% 15.0% 7.3% 6.3% 8.4%

now or in past 90 days

Part time employed

19.5 11.7% 13.5 18.8% 17.5% 16.3 17.4% 19.7% 13.6 16.5 17.1%

%

%

%

% %

now or in past 90 days

Unemployed

19.2 23.2% 3.5% 6.1% 17.4% 53.3 43.2% 6.7% 28.4 59.2 27.3%

%

%

% %

Not in the Workforce

50.9 39.5% 63.5 61.6% 58.2% 15.3 28.5% 58.3% 48.7 12.5 42.3%

%

%

%

% %

Status is not known

2.7% 18.1% 15.5 6.4% 1.5% 7.5% 0.5% 0.2% 2.0% 5.6% 4.9% %

Percentage by Timeliness of Employment Status Screening:

Update is Current

30.4 37.8% 78.1 89.2% 70.0% 96.0 76.1% 92.8% 78.8 99.9 78.9%

%

%

%

% %

Update is Overdue

69.6 62.2% 21.9 10.8% 30.0% 4.0% 23.9% 7.2% 21.2 0.1% 21.1%

%

%

%

Previous Quarter: Percentage by Timeliness of Employment Status Screening:

Update is Current

19.6 24.2% 74.4 89.4% 50.9% 97.6 78.4% 70.8% 79% 100

%

%

%

%

Update is Overdue

80.4 75.8% 25.6 10.6% 49.1% 2.4% 21.6% 29.2% 21% 0%

%

%

762 1,622 2,847 3,809 1,156 10,196
7.0% 15.3% 26.6% 39.3% 11.8%
68.4% 31.6%

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

10

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 59 of 86

3c. Community Mental Health Center Clients: Adult Employment Status – Recent Users of Supportive Employment Services (At Least One Billable Service in Each of Month of the Quarter)

Northern Human Services West Central Behavioral Health Lakes Region Mental Health Center Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Center Mental Health Center of Greater Manchester Community Partners Seacoast Mental Health Center Center for Life Management Statewide Total or Mean Percentage Previous Quarter Statewide Total or Mean Percentage October - December 2018

Supported Employment Cohort

Reported Employment Status

Begin Date: 01/01/2019 End Date: 03/31/2019

Updated Employment Status:

Full time

1 0 0 1 0 3 7 0 0 3 15

employed now

or in past 90

days

Part time

18 7 12 33 13 12 37 10 8 23 173

employed now

or in past 90

days

Unemployed

9 6 3 13 7 22 30 8 4 20 122

Not in the

15 1 18 6 5 7 7 14 2 0 75

Workforce

Status is not

0 2 10 2 0 3 0 0 0 0 17

known

Total of

43 16 43 55 25 47 81 32 14 46 402

Supported

Employment

Cohort

Previous

40 18 31 56 21 42 99 26 14 45

Quarter: Total

of Supported

Employment

Cohort

Percentage by Updated Employment Status:

Full time

2.3% 0.0% 0.0% 1.8% 0.0% 6.4% 8.6% 0.0% 0.0% 6.5% 3.7%

employed now

or in past 90

days

22 145 113
56 56 392
4.8%

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

11

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 60 of 86

Part time

41.9% 43.8% 27.9% 60.0% 52.0% 25.5% 45.7% 31.3% 57.1% 50.0% 43.0% 34.5%

employed now

or in past 90

days

Unemployed 20.9% 37.5% 7.0% 23.6% 28.0% 46.8% 37.0% 25.0% 28.6% 43.5% 30.3% 28.2%

Not in the

34.9% 6.3% 41.9% 10.9% 20.0% 14.9% 8.6% 43.8% 14.3% 0.0% 18.7% 19.0%

Workforce

Status is not

0.0% 12.5% 23.3% 3.6% 0.0% 6.4% 0.0% 0.0% 0.0% 0.0% 4.2% 13.6%

known

Revisions to Prior Period: None

Data Source: Phoenix 2

Note 3b-c: Data extracted 4/18/2019. Updated Employment Status refers to CMHC-reported status and reflects the most recent update. Update is Current refers to an employment status most recently updated within the past 105 days. Update is Overdue refers to an employment status most recently updated in excess of 105 days. Actual client employment status may have changed since last updated by CMHC in Phoenix. Employed refers to clients employed in a competitive job that has these characteristics: exists in the open labor market, pays at least a minimum wage, anyone could have this job regardless of disability status, job is not set aside for people with disabilities, and wages (including benefits) are not less than for the same work performed by people who do not have a mental illness. Full time employment is 20 hours and above; part time is anything 19 hours and below. Unemployed refers to clients not employed but are seeking or interested in employment.

Not in the Workforce are clients who are homemakers, students, retired, disabled, hospital patients or residents of other institutions, or are in a sheltered/non-competitive employment workshop, or are otherwise not in the labor force or not employed and not seeking or interested in employment. Unknown refers to clients with an employment status of “unknown”, or without a status reported, or with an erroneous status code in Phoenix.

NH DHHS - OQAI - CMHA Quarterly Report, July 3, 2019

12

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 61 of 86

4a. New Hampshire Hospital: Adult Census Summary

Measure

January - March 2019

October - December 2018

Admissions

189

193

Mean Daily Census

149

153

Discharges

182

192

Median Length of Stay in Days for Discharges

27

20

Deaths

0

0

Revisions to Prior Period: None

Data Source: Avatar

Notes 4a: Data extracted 5/13/2019; Mean Daily Census includes patients on leave and is rounded to nearest whole number

CMHA Monthly Progress Report

13

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 62 of 86

4b. New Hampshire Hospital: Summary Discharge Location for Adults

Discharge Location

January - March 2019

October - December 2018

Home - Lives with Others

80

79

Home - Lives Alone

50

65

CMHC Group Home

4

8

Private Group Home

1

2

Nursing Home

1

2

Hotel-Motel

4

1

Homeless Shelter/ No Permanent Home

14

6

Discharge/Transfer to IP Rehab Facility

6

8

Secure Psychiatric Unit - SPU

1

0

Peer Support Housing

0

0

Jail or Correctional Facility

6

4

Glencliff Home for the Elderly

2

4

Other

4

7

Unknown

9

6

CMHA Monthly Progress Report

14

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 63 of 86

4c. New Hampshire Hospital: Summary Readmission Rates for Adults

Measure

January - March 2019

October - December 2018

30 Days

5.3% (10)

7.3% (14)

90 Days

14.8% (28)

18.1% (35)

180 Days

21.2% (40)

25.9% (50)

Revisions to Prior Period: None.

Data Source: Avatar

Notes 4b-c: Data compiled 5/13/2019; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions lookback period includes readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day readmissions); patients are counted multiple times – once for each readmission; the number in parentheses is the number of readmissions.

CMHA Monthly Progress Report

15

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 64 of 86

5a. Designated Receiving Facilities: Admissions for Adults

January - March 2019

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

57

69

Cypress Center

33

149

Portsmouth

81

268

Elliot Geriatric Psychiatric Unit

7

49

Elliot Pathways

58

65

Total

236

600

October – December 2018

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

40

47

Cypress Center

46

152

Portsmouth

84

291

Elliot Geriatric Psychiatric Unit

4

60

Elliot Pathways

37

35

Total

211

585

Total Admissions
126 182 349
56 123 836
Total Admissions
87 198 375
64 72 796

5b. Designated Receiving Facilities: Mean Daily Census for Adults

Designated Receiving Facility

January - March 2019

October - December 2018

Franklin

8.5

10.7

Cypress Center

14.5

9.2

CMHA Monthly Progress Report

16

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 65 of 86

Portsmouth Elliot Geriatric Psychiatric Unit Elliot Pathways Total

30.4

27.4

22.6

33.4

14.9

10.7

90.9

91.4

5c. Designated Receiving Facilities: Discharges for Adults

Designated Receiving Facility

January - March 2019

Franklin

124

Manchester (Cypress Center)

177

Portsmouth

348

Elliot Geriatric Psychiatric Unit

56

Elliot Pathways

106

Total

811

October - December 2018 89 204 358 62 79 792

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges for Adults

Designated Receiving Facility

January - March 2019 October - December 2018

Franklin

5

4

Manchester (Cypress Center)

5

3

Portsmouth

6

4

Elliot Geriatric Psychiatric Unit

18

31

Elliot Pathways

8.5

7

Total

6

5

CMHA Monthly Progress Report

17

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 66 of 86

5e. Designated Receiving Facilities: Discharge Location for Adults January - March 2019

Designated Receiving Facility

Assisted Living/Group
Home

Other

NH

Decease

Hom Hospit Hospita

d DRF* e

al

l

Franklin

1

0

1 116

0

0

Manchester (Cypress Center)

10

0

6 153

0

0

Portsmouth Regional Hospital

0

0

0 249

0

6

Elliot Geriatric Psychiatric Unit

28

3

2 20

0

0

Elliot Pathways

0

0

0 92

0

3

Total

39

3

9 630

0

9

October - December 2018

Designated Receiving Facility

Assisted Living/Group
Home

Other

NH

Decease

Hom Hospit Hospita

d DRF* e

al

l

Franklin

1

0

2 79

0

0

Manchester (Cypress Center)

6

0

8 178

0

0

Portsmouth Regional Hospital

1

0

9 266

0

0

Elliot Geriatric Psychiatric Unit

34

3

4 13

0

0

Elliot Pathways

2

0

4 70

0

0

Total

44

3 27 606

0

0

Other 6 8
93
3 11 121
Other 7
12 82
8 3 112

CMHA Monthly Progress Report

18

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 67 of 86

*Dispositions to ‘DRF’ represent a change in legal status from Voluntary to Involuntary within the DRF.

5f. Designated Receiving Facilities: Readmission Rates for Adults January - March 2018

Designated Receiving Facility

30 Days

90 Days

180 Days

Franklin

7.9% (10)

10.3% (13)

10.3% (13)

Manchester (Cypress Center)

5.5% (10)

14.8% (27)

17.6% (32)

Portsmouth

12.9% (45)

19.5% (68)

23.5% (82)

Elliot Geriatric Psychiatric Unit

5.4% (3)

5.4% (3)

5.4% (3)

Elliot Pathways

4.9% (6)

5.7% (7)

7.3% (9)

Total

8.9% (74)

14.1% (118)

16.6% (139)

October - December 2018

Designated Receiving Facility

30 Days

90 Days

180 Days

Franklin

2.3% (2)

4.6% (4)

5.7% (5)

Manchester (Cypress Center)

7.1% (14)

11.1% (22)

15.2% (30)

Portsmouth

7.7% (29)

14.9% (56)

20.3% (76)

Elliot Geriatric Psychiatric Unit

6.3% (4)

7.8% (5)

9.4% (6)

Elliot Pathways

2.8% (2)

5.6% (4)

9.7% (7)

Total

6.4% (51)

11.4% (91)

15.6% (124)

Revisions to Prior Period: None.

Data Source: NH DRF Database

Notes: Data compiled 5/17/2019.

CMHA Monthly Progress Report

19

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 68 of 86

6. Glencliff Home: Census Summary Measure

January - March 2019

October - December 2018

Admissions

13

5

Average Daily Census

112

111

Discharges

1 (3-person medical model group 0
home)

Individual Lengths of Stay in Days for

0

550

Discharges

Deaths

5

6

Readmissions

0

0

Mean Overall Admission Waitlist

27

25

Revisions to Prior Period: None.

Data Source: Glencliff Home

Notes: Data Compiled 5/7/2019; Mean rounded to nearest whole number; Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

CMHA Monthly Progress Report

20

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 69 of 86

7. NH Mental Health Client Peer Support Agencies: Census Summary January - March 2019

October December
2018

Peer Support Agency

Average

Average

Total Daily

Total Daily

Members Visits Members Visits

Alternative Life Center Total

224

36

257

42

Conway

33

9

28

11

Berlin

86

7

135

9

Littleton

56

10

46

10

Colebrook

49

10

48

12

Stepping Stone Total

377

14

262

15

Claremont

308

10

200

11

Lebanon

69

4

62

4

Cornerbridge Total

180

14

139

12

Laconia

69

6

54

5

Concord

84

8

59

7

Plymouth Outreach

27

NA

26

NA

MAPSA Keene Total

144

14

43

14

HEARTS Nashua Total

411

34

423

35

On the Road to Recovery Total

122

10

82

10

Manchester

64

5

48

5

Derry

58

5

34

5

Connections Portsmouth Total

130

15

45

17

CMHA Monthly Progress Report

21

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 70 of 86

January - March 2019

October December
2018

Peer Support Agency

Average

Average

Total Daily

Total Daily

Members Visits Members Visits

TriCity Coop Rochester Total

175

21

139

21

Total

1,763

158

1,390

166

Revisions to Prior Period: None

Data Source: Bureau of Mental Health Services and Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 5/23/2019; Average Daily Visits are not applicable for Outreach Programs.

CMHA Monthly Progress Report

22

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 71 of 86

8. Housing Bridge Subsidy Program: Summary of Individuals Served to Date January – March 2019

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

812

0

812

Section 8 Voucher-Transitioned from Housing Bridge

129

8

137

October - December 2018

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

812

0

812

Section 8 Voucher-Transitioned from Housing Bridge

125

4

129

Revisions to Prior Period: None

Data Source: Bureau of Mental Health Services and Housing Bridge Provider

Notes: Data Compiled 5/17/2019. Figures at start and end of each quarter are cumulative total of individuals served since CMHA quarterly reporting began in 2015.

CMHA Monthly Progress Report

23

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 72 of 86

8a. Housing Bridge Subsidy Program: Current Census of Units/Individuals with Active Funding Status

Measure

As of 3/31/2019

As of 12/31/2018

Rents Currently Being Paid

389

418

Individuals Accepted and Working Towards Bridge Lease

11

8

Total

400

426

Revisions to Prior Period: None

Data Source: Bureau of Mental Health Services and Housing Bridge Provider

Notes: Data Compiled 5/22/2019; all individuals currently on Bridge Program are intended to transition from the program to other permanent housing).

8b. Housing Bridge Subsidy Program: Clients Linked to Mental Health Care Provider Services

Measure

As of 3/31/2019 As of 12/31/18

Housing Bridge Clients Linked

337/400 (84%) 373/443 (84%)

Data source: Bureau of Mental Health Services data, Phoenix 2, and Medicaid claims

Notes: Data compiled 5/23/2019; “Housing Bridge Clients Linked” refers to Housing Bridge clients who received a mental health service(s) within the previous 3 months, documented as a service or claim data found in Phoenix or the Medicaid Management Information System (MMIS).

CMHA Monthly Progress Report

24

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 73 of 86

8c. Housing Bridge Subsidy Program: Density of HBSP Funded Units at Same Property Address*

Number of HBSP Funded Unit(s)* at Same Frequency as of Frequency as

Address

3/31/2019 of 12/31/2018

1

315

329

2

18

27

3

3

4

4

2

3

5

2

1

6

0

0

7

0

1

8 or more

1

1

*All units are individual units; property address may include multiple buildings, such as apartment complexes.

Revisions to Prior Period: None

Data Source: Bureau of Mental Health data compiled by Office of Quality Assurance and Improvement

Notes: Data Compiled 5/17/2019

CMHA Monthly Progress Report

25

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 74 of 86

8d. Housing Bridge Subsidy Program: Applications

Measure

January – March 2019

October - December 2018

Applications Received During Period

29

12

Point of Contact for Applications Received

CMHCs: 22; NHH: 5; Other (1)

CMHCs: 12

Applications Approved

14

5

Applications Denied

0

0

Denial Reasons

NA

NA

Total Applications in Process at End of Period

53

209

Revisions to Prior Period: Applications in Process at End of Period was incorrect.

Data Source: Bureau of Mental Health Services

Notes: Data Compiled 5/17/2019

CMHA Monthly Progress Report

26

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 75 of 86

8e. Housing Bridge Subsidy Program: Terminations

Type and Reason

January - March 2019

Terminations – DHHS Initiated

1

Over Income

1

Exited Program – Client Related Activity

27

Voucher Received

8

Deceased

1

Over Income

0

Moved Out of State

0

Declined Subsidy at Recertification

13

Higher Level of Care Accessed

1

Other Subsidy Provided

2

Moved in with family 2

October – December 2018 0 NA 15 4 1 1 3 3 3 0 0 0

Total

28

15

Data Source: Bureau of Mental Health Services and Housing Bridge Provider

Notes: Data Compiled 5/17/2019

8f. Housing Bridge Subsidy Program: Application Processing Times

CMHA Monthly Progress Report

27

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 76 of 86

Average Elapsed Time of Application Processing (calendar days)*

January - March 2019

October – December 2018

Completed Application to Determination

1

1

Approved Determination to Funding Availability (see waitlist, Table 9b for detail)

NA

NA

Referred to Vendor with Funded HB Slot

NA

NA

Leased Unit Secured

NA

NA

Data Source: Bureau of Mental Health Services

Notes: Data Compiled 5/17/19

*Elapsed time measure reporting was implemented 10/1/18 and applies to any application received on or after that date.

9. Housing Bridge Subsidy Program Waitlist: Approved Applications

As of 3/31/2019

Time on List

Total

0-30 days

31-60 days

61-90 days

91-120 121-150 151-180

days

days

days

181+ days

38

13

1

0

0

0

2

22

As of 12/31/2018

Total

0-30 days

31-60 days

61-90 days

91-120 121-150 151-180

days

days

days

181+ days

39

0

0

3

5

2

0

29

Revisions to Prior Period: The number of individuals waiting and the number of days waiting

were miscalculated.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider

Notes: Data Compiled: 5/17/2019.

CMHA Monthly Progress Report

28

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 77 of 86

10. Supported Housing Subsidy Summary

January March 2019

October December

2018

Subsidy

Total subsidies Total subsidies

by end of

by end of

quarter

quarter

Housing Bridge Subsidy:

389

Units Currently Active

418

Individual actively acquiring unit

11

8

Section 8 Voucher:

Transitioned from Housing Bridge*

137

129

Not Previously Receiving Housing Bridge

1

7

811 (PRA and Mainstream)*

43

40

Other (HUD, Public Housing, VA)

1

6

Total Supported Housing Subsidies

582

608

Revisions to Prior Period: Not Applicable – Table 10 is newly incorporated into this report.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider

Notes: Data Compiled 5/22/2019; Section 8 Voucher Not Previously Receiving Housing Bridge are CMHC clients that received a Section 8 Voucher without previously receiving a Housing Bridge subsidy; 811 (PRA and Mainstream) are CMHC clients that received a PRA or Mainstream 811 funded unit with or without previously receiving a Housing Bridge subsidy; Other (HUD, Public Housing, VA) are CMHC clients that received a unit funded through other HUD or Public Housing sources with or without previously receiving a Housing Bridge subsidy.

*These counts are cumulative; increasing over time since originally reporting this data within the CMHA Quarterly Data Report.

CMHA Monthly Progress Report

29

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 78 of 86

11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure Unique People Served in Month

January February

2019

2019

287

267

March 2019

January - October -

March December

2019

2018

243

500

689

Services Provided by Type

Case Management

0

0

0

0

0

Crisis Apartment Service

0

0

0

0

0

Crisis Intervention Services

23

20

11

54

66

ED Based Assessment

0

0

0

0

Medication Appointments or Emergency Medication Appointments

0

0

0

0

0

Mobile Community Assessments

51

49

57

157

167

Office-Based Urgent Assessments

38

43

42

123

138

Other

0

0

0

0

Peer Support

0

0

0

0

0

Phone Support/Triage

339

311

309

959

773

Psychotherapy

0

0

0

0

0

Referral Source CMHC Internal Emergency Department Family
CMHA Monthly Progress Report

22

20

21

63

50

2

1

1

4

7

14

15

9

38

40

30

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 79 of 86

Measure Friend Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self School

January February

2019

2019

4

6

10

5

0

0

10

18

1

1

8

6

10

3

200

191

6

1

March 2019

January - October -

March December

2019

2018

5

15

8

10

25

46

0

0

0

12

40

37

2

4

8

3

17

13

2

15

7

198

589

422

3

10

24

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

28

30

27

85

71

124

121

87

332

273

4.42

4.03

3.22

3.91

3.41

Law Enforcement Involvement

19

26

34

79

44

Hospital Diversions Total

183

168

171

522

566

Revisions to Prior Period: None

Data Source: Riverbend CMHC submitted report.

CMHA Monthly Progress Report

31

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 80 of 86
Notes: Data Compiled 4/23/2019; reported values other than the Unique People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

32

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 81 of 86

11b. Mobile Crisis Services and Supports for Adults: Mental Health Center of Greater Manchester

Measure Unique People Served in Month

January 2019
310

February 2019
273

March 2019

October -

January - December

March 2019

2018

267

700

587

Services Provided by Type

Case Management

46

Crisis Apartment Service

14

Crisis Intervention Service

38

ED Based Assessment

0

Medication Appointments or

0

Emergency Medication

Appointments

Mobile Community Assessments

102

Office-Based Urgent Assessments

21

Other

302

Peer Support

0

Phone Support/Triage

519

Psychotherapy

0

46

40

132

135

6

6

26

112

38

37

113

231

0

0

0

0

0

0

0

7

89

92

283

283

22

22

65

68

277

214

793

823

0

0

0

0

499

502

1,520

1,596

1

0

1

1

Referral Source CMHC Internal Emergency Department Family
CMHA Monthly Progress Report

8 1 45
33

11

11

30

35

1

0

2

3

57

49

151

124

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 82 of 86

Friend

5

Guardian

6

MCT Hospitalization

0

Mental Health Provider

13

Other

43

Police

68

Primary Care Provider

25

Self

154

School

0

Crisis Apartment

Apartment Admissions

7

Apartment Bed Days

18

Apartment Average Length of

2.6

Stay

Law Enforcement Involvement

68

Hospital Diversion Total

384

3

10

12

7

0

0

8

12

46

39

51

91

9

17

159

120

0

0

18

9

25

12

0

0

33

26

128

132

210

235

51

40

433

506

0

0

3

3

9

15

3.0

5.0

13

16

42

73

3.2

4.6

51

91

210

235

372

364

1,120

1,157

CMHA Monthly Progress Report

34

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 83 of 86
Revisions to Prior Period: None Data Source: Phoenix 2 Notes: Data Compiled 4/23/2019; reported values other than the Unduplicated People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

35

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 84 of 86

11c. Mobile Crisis Services and Supports for Adults: Harbor Homes

Measure Unique People Served in Month

January February

2019

2019

229

237

March 2019
219

January – March

October December
2018

2019

561

462

Services Provided by Type

Case Management

134

Crisis Apartment Service

109

Crisis Intervention Services

0

ED Based Assessment

17

Medication Appointments or

1

Emergency Medication Appointments

Mobile Community Assessments

152

Office-Based Urgent Assessments

7

Other

0

Peer Support

144

Phone Support/Triage

279

Psychotherapy

21

143

128

84

75

0

0

21

6

0

0

151

131

6

6

0

0

107

89

249

236

12

17

405

402

268

308

0

2

44

18

1

23

434

424

19

30

0

1

340

351

764

677

50

4

Referral Source CMHC Internal Emergency Department

35

37

28

16

8

17

100

112

41

0

CMHA Monthly Progress Report

36

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 85 of 86

Family Friend Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self Schools

18

16

16

2

2

10

0

1

0

1

0

0

52

22

24

150

129

114

4

0

3

0

2

2

40

83

95

18

13

16

50

41

14

17

1

0

1

0

98

68

393

497

7

21

4

0

218

162

47

40

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

16

12

10

82

70

70

5.13

5.83

7.00

38

62

222

315

5.84

5.08

Law Enforcement Involvement

4

0

0

4

0

Hospital Diversion Total

405

394

340

1,139

Revisions to Prior Period: None

Data Source: Harbor Homes submitted data

Notes: Data Compiled 4/23/2019; reported values other than the Unique People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

1,025

CMHA Monthly Progress Report

37

November 13, 2018

Case 1:12-cv-00053-SM Document 132-1 Filed 09/12/19 Page 86 of 86

Appendix A

A1 Housing Bridge Subsidy Program: Applications Previously in Pending Status Removed
156 previously pending applications were removed from the HBSP pending application log as the applications are no longer active due to the individual being deceased, obtaining other housing options through other sources, including on their own, or have moved away or are no longer in any contact with the referring agent

A2 Housing Bridge Subsidy Program Waitlist: Approved Applications Removed from Waitlist

Waitlist Removal Reason

January – March October - December

2019

2018

Deceased

1

NA

Individual disconnected from services

3

NA

Other permanent housing acquired

3

NA

Referring entity requested removal

8

NA

Total

15

NA

Data Source: Bureau of Mental Health Services and Housing Bridge Provider

Notes: Data Compiled: 5/17/2019.

CMHA Monthly Progress Report

38

November 13, 2018

 
 Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 1 of 103
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Thirteen
January 27, 2021
I. Introduction
This is the thirteenth semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report on the State’s implementation efforts and compliance with the provisions of this Settlement
DRAFT DRAFT
Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement. For the past 10 months, the State of New Hampshire has been seriously affected by COVID-19. The State reports Community Mental Health Centers (CMHCs) have remained functional and open as essential businesses during this period, although a majority of employees have been working remotely. Following Centers for Disease Control and Prevention (CDC) recommendations and NH Division of Public Health Services (DPHS) guidance, in addition to program specific emergency guidance provided by the Bureau of Mental Health Services (BMHS), CMHCs have focused on adjusting service delivery to maintain health and to implement safety protocols while serving participants in a way that met participant needs and preferences. Telehealth services are being provided for participants preferring that method due to COVID-19 concerns, and in-person services remain available for individuals who prefer this method. Mental Health (MH) facilities, including New Hampshire Hospital (NHH), Glencliff, and residential treatment centers, have modified safety protocols to protect residents/patients from COVID-19. The State has implemented numerous strategies, including Medicaid plan changes, eligibility certification improvements, staffing requirements, etc., to insure that, to the extent possible, service response rates and service continuity are maintained.
1

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 2 of 103
During this 10-month period, the ER has been unable to conduct on-site visits or observations. Although Quality Service Reviews have taken place during this period, the ER has not been able to observe any of these activities.
The ER has participated in a number of conference calls with State officials and representatives of the Plaintiffs, as outlined below. The ER has also continued to monitor the routine monthly and quarterly data reports produced by the State, as well as newly generated data reports related to the response to COVID-19. Nonetheless, by necessity, as with the previous ER Report, this report is limited by the inability to have face-to-face contact with service administrators, service providers and service participants.
During this period, the ER:
 Participated in three conference calls with State officials and representatives of the Plaintiffs to discuss and review transition planning policies and procedures for residents of Glencliff;
 Conducted a telephone interview with leadership and staff of Glencliff and the InReach contractor to discuss the implementation of the revised transition planning protocols and the in-reach process and preliminary results;
 Participated in two conference calls with State officials to discuss Mobile Crisis Teams and Crisis Apartment services on a statewide basis and specifically in Nashua;
DRAFT DRAFT
 Participated in two conference calls with the QSR team to discuss the QSR process during COVID, and also to de-brief on one specific QSR review; and
 Convened an All-Parties conference call meeting to discuss progress in meeting the requirements of the CMHA.
Summary of Progress to Date
This report reflects almost six- and one-half years of implementation efforts related to the CMHA. Within this period, a number of positive steps have been taken to improve the quality and effectiveness of services as envisioned in the CMHA. However, as will be discussed in detail below, there are areas of continued non-compliance with the CMHA. Notwithstanding these on-going concerns, the parties to the CMHA deserve credit for some real and measurable accomplishments.
As noted in previous ER reports, the State has implemented a comprehensive and reliable QSR process. The ER considers these QSR reviews to be methodologically correct and reliable, producing findings that are accurate and actionable in terms of taking concrete steps to address quality issues in the CMHC system.
Another major accomplishment has been contracting with the Dartmouth-Hitchcock Medical Center to conduct external Assertive Community Treatment (ACT) and Supported Employment
2

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 3 of 103
(SE) fidelity reviews using nationally validated fidelity review instruments and criteria. In concert with the QSR reviews mentioned above, the fidelity reviews are assisting the State and the CMHCs to develop comprehensive Quality Improvement Plans (QIPs) that address important ACT and SE quality and effectiveness issues at both the consumer and CMHC operational levels. The Fidelity Reviews have not been conducted since the onset of COVID-19. However, the State and the CMHCs have been using evidence Based Practice (EBP) check-lists to monitor fidelity to ACT and SE best practice standards during the pandemic. The State has also continued to provide technical assistance and oversight to CMHCs that had active Quality Improvement Plans (QIPs) related to ACT and SE at the time the fidelity reviews were suspended. The State intends to re-start the Fidelity Review process as early as possible in the coming year.
The parties originally envisioned that the CMHA could be fully implemented in five years, with a sixth year for maintenance of effort. The CMHA was approved and filed with the Federal Court on February 12, 2014, and the five-year anniversary of that event occurred about two years ago. The ER was approved by the Parties and the Federal Court effective July 1, 2014, and the five-year anniversary occurred 18 months ago.
Most of calendar year 2020 has been dominated by the response to the health risks associated with COVID-19 and by the restrictions necessitated by COVID-19. As will be seen in the subsequent sections of this report, most elements of the services system defined by the CMHA have remained relatively stable. Understandably, there has been little measurable progress, but
DRAFT DRAFT
there has also been a relatively consistent level of service delivery and performance. The State is to be congratulated for maintaining services to the CMHA Target Population during these very difficult circumstances. Nonetheless, it is important to emphasize that the pandemic has not altered the terms of the CMHA nor diminished the State’s obligations to members of the Target Population. Moreover, the delays and restrictions caused by COVID-19 necessarily require extension of the time periods for the State to complete its responsibilities under the CMHA.
In recent months, the State has undertaken three initiatives related to specific CMHA service components and requirements. These are:
1. Selection of a new vendor (Greater Nashua Mental Health) to operate the Mobile Crisis Team (MCT) and Crisis Apartment program in the Nashua region;
2. Implementation of contracted in-reach services and new transition planning and informed consent protocols at Glencliff; and
3. Addition of new funds to the Bridge Program to permit funding of a total of 500 units.
These initiatives seem positive, but they were begun too late in this reporting cycle to have yet produced positive results. The ER will continue to monitor the implementation of these initiatives over the upcoming year.
3

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 4 of 103
II. Data
As noted in previous reports, the New Hampshire Department of Health and Human Services (DHHS) continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (July 2020 through September 2020) incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The capacity to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve. The ER continues to emphasize that the State must produce the necessary data reports in a timely fashion.
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile/Crisis and Crisis Apartment Programs
The CMHA calls for the establishment of a Mobile Crisis Team (MCT)1 and Crisis Apartments (MCT/CA) in the Concord Region by June 30, 2015 (Section V.C.3 (a)). DHHS conducted a procurement process for this program, and the contract DRAFT was awarded on June 24, 2015.
DRAFT
Riverbend CMHC was selected to implement the MCT and Crisis Apartments in the Concord Region.
The CMHA specified that a second MCT/CA program be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. Per CMHA V.C.3(c), a third MCT/CA program became operational in the Nashua region on July 1, 2017. The contract for that program was awarded initially to Harbor Homes in Nashua. That contract has recently been transferred to another provider, Greater Nashua Mental Health (GNMH) which is in process of implementing the program. Full implementation is not expected until later in 2021.
As of the date of this report, the State reports that it has competitively reprocured the existing MCT/CA program contracts in Concord and Manchester until June 2022. The State reports the new contracts incorporated changes for these programs including: (a) new performance measures related to face-to-face assessments and follow-up engagement with peers; and (b) new data reporting elements related to presenting problems, police involvement, and intervention
1 Note that the State refers to these programs as Mobile Crisis Response Teams (MCRTs). The ER uses the MCT nomenclature to remain consistent with the terms used in the CMHA.
4

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 5 of 103
outcomes. The ER will monitor implementation of these new requirements over the next six month period. In Nashua, the original vendor (Harbor Homes) opted not to submit a bid for the program and to end its participation in the program. As a result, effective October 1, 2020, the State has contacted with the GNMH to operate the MCT/Crisis Apartment program. The transition between the previous and current vendors concluded November 1, 2020. Thus, data reported for the Nashua region reflects some reductions in service as the transition was under way. While the ER is pleased that a new MCT vendor was secured for the Nashua area, diminished service provision during the transition and the limited ability of GNMH to provide key elements of those services in late 2020, including crisis apartment capacity, is concerning and likely to negatively impact class members in this region. The ER will closely monitor ongoing efforts to implement all CMHA required elements of MCT in Nashua in the weeks ahead, and will request that the State provide preliminary data on MCT service delivery in this region, ahead of the standard quarterly reporting period. The Quarterly Data Report contained in Appendix A includes a detailed table of data from each of the Mobile Team/Crisis Apartment programs. Table I contains a summary of key data trends from the three programs.
DRAFT DRAFT
5

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 6 of 103

Table I Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs

Region

Variable

Jan. - Mar. Apr-June July – Sept

2020

2020

2020

Concord Manchester Nashua

Total Served Total Served Total Served

531

530

557

618

669

723

333

245

208

Concord Manchester Nashua

Phone triage/support Phone triage/support Phone triage/support

1173 1565
385

1343 1552
326

1294 1699
198

Concord Manchester Nashua

Mobile Assess./intervention Mobile Assess./intervention Mobile Assess./intervention

116

211

178

290

294

296

114

183

74

Concord Percent Referred by self

Manchester Percent Referred by self

Nashua

DRAFT
Percent Referred by self DRAFT

64.22% 46.93% 34.23%

56.60% 43.00% 56.40%

59.90% 40.30% 21.30%

Concord Manchester Nashua

Percent referred by police Percent referred by police Percent referred by police

4.33% 38.42% 3.60%

5.90% 23.20%
0.36%

2.80% 26.10%
2.70%

Concord Manchester Nashua

Percent Law Enforcement Inv. Percent Law Enforcement Inv. Percent Law Enforcement Inv.

8.70% 36.40% 0.00%

14.40% 37.20%
0.04%

8.80% 39.80%
0.05%

Concord Manchester Nashua

Hospital diversions Hospital diversions Hospital diversions

Concord Manchester Nashua

Apartment Admits Apartment Admits Apartment Admits

Concord Manchester Nashua

Apartment bed days Apartment bed days Apartment bed days

383 1,088 617

529 0551055
511

523 0751075
316

57

39

45

17

0

0

56

30

33

245

125

145

53

0

0

295

142

172

6

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 7 of 103

Table I shows some evidence of the effects of COVID restrictions on the operations of MCT and Crisis Apartment programs. The absence of Crisis Apartment admissions and bed days reported by Manchester is one example of this. Also, as would be expected, there has been a general reduction in levels of service in the Nashua area reflecting the transition to a new vendor.
Table II below includes data that reveal some recent changes in both emergency department waiting times for inpatient psychiatric admissions, NHH admissions, and for NHH readmission rates. These data may indicate that the MCT and Crisis Apartment programs could be having a positive effect on system indicators such as emergency department boarding and hospital recidivism rates. However, there may be numerous other factors influencing these data trends.

Table II

DHHS Report of Changes in Waiting Time for Inpatient Psychiatric Admission, NHH Admissions and NHH Readmission Rates

Comparison 12-mo Period

Average # Adults Waiting per Day for Inpatient Psychiatric Admission

NHH Admissions

NHH 180-day Readmissions Average

10/1/2018-9/30/2019 10/1/2019-9/30/2020 Change

34 31 Down 9%

812 DRAFT
867 DRAFT Up 6.8%

27.9% 22.7% Down 18.7%

The ER continues to be concerned about some apparent practice and data reporting variations among the three MCT/CA programs. For example, as can be seen in Table I, there are substantial differences among the three programs with regard to police referrals to, and law enforcement involvement in, the various programs. The ER expects additional State oversight of the MCT/CA programs, including increased reporting of program performance in key areas of MCT service delivery, such as phone triage, decisions to deploy mobile crisis teams to community locations, and the efficacy of crisis response. As noted above, the State has added new performance criteria and measures to the contracts for all three of the MCT/Crisis Apartment programs. Both the State and the ER will monitor adherence to these new performance expectations in the coming year, and will request that data on the impact of these new measures be shared with the parties.
The State recently funded a new Behavioral Health Crisis Treatment Center (BHCTC) that has been implemented by the Riverbend CMHC in Concord. The BHCTC is an additional crisis support outside those required by the CMHA. As such, data related to the operations of that program is not included in this report. The State asserts that it is not currently considering this model for expansion of crisis programs in New Hampshire.
7

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 8 of 103
DRAFT DRAFT
8

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 9 of 103

Assertive Community Treatment (ACT)

ACT is a core element of the CMHA, which specifies, in part:

1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team;
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time; and
4. By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.

The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015. Further, as of June 30, 2016, the State was required to have the capacity to provide ACT for 1,500 priority Target Population individuals.

Staffing

for

the

ACT

teams

has

remained

stable

during DRAFT DRAFT

the

10

months

affected

by

COVID.

However, the combined staffing of the ACT Teams is 5.95 full time equivalents (FTEs) below

the levels attained a year ago (September 2019).

9

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 10 of 103

Table III Self-Reported ACT Staffing (excluding psychiatry):
September 2017 – March 2020

Region

FTE FTE FTE FTE

Sep- Mar-

Sep-

17

19 Jun-19 19

FTE

FTE

FTE

FTE

Dec-19 Mar-20 Jun-20 Sep-20

Northern West Central Lakes Region Riverbend Monadnock Greater Nashua 1 Greater Nashua 2 Manchester – CTT Manchester MCST Seacoast Community Part. CLM Total

12.4 7.0
10.8 10.0
7.9
6.0
5.0
16.3
22.3 10.5
6.7 9.3 124.2

16.8 16.51 16.37 6.8 7.65 8.25 8.3 8.00 8.00
11.5 10.50 11.50 9.5 9.00 8.00

6.5 7.00 8.00

4.5 4.00 7.00

14.3

15.75

15.75
DRAFT
DRAFT

15.8 9.1 8.8 7.9
119.6

17.25 9.10
10.78 7.01
122.55

17.25 10.10 11.28
8.30 129.80

16.97 8.75 7.00
11.50 8.75
8.00
8.00
15.75
15.75 10.10 10.80
9.55 130.92

16.37 6.10 7.00
10.50 8.85
6.50
7.50
18.25
16.25 9.10
11.05 8.55
127.02

13.36 6.10 6.50
10.50 8.85
8.00
8.00
18.25
17.25 9.10 9.20 8.30
123.41

15.122 5.00 6.40 9.00
11.58
8.50
8.50
16.25
18.25 9.00 8.95 7.30
123.85

Five teams (West Central and Lakes Region and all three Northern teams) report having fewer than the required minimum of seven FTEs to qualify as an ACT team, an increase from the last report at which time only two teams (Riverbend and Community Partners) had fewer than the required minimum. Five teams (Northern [Berlin and Littleton Teams], Riverbend, Manchester CTT and Community Partners)) report having no peer support specialist. Two teams (Wolfeboro and Nashua 2) report having no SE staff capacity. Northern (Littleton) reports having no SUD treatment staff capacity. Eight teams report having 0.5 or less FTE combined psychiatry/nurse practitioner time available to their ACT teams; and seven of the 14 teams report having less than one FTE nurse per team. Although overall staffing levels have remained relatively stable across all ACT teams, shortages in discrete categories, like nursing and peer support, have worsened
2 There are now three teams operating in the Northern region. In future reports the ER will document staffing levels for each of these teams, as opposed to the aggregate staffing reflected in this report.
10

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 11 of 103

since the previous report. As a result, several teams do not meet the CMHA requirements for staffing or team criteria set out in the CMHA.

Table IV below displays the active ACT caseloads by CMHC Region since June 2017. The active monthly caseload has decreased by 14 participants since December 2019. Since June of 2017 the active monthly caseload has dropped by 86 participants.

Table IV

Self-Reported ACT Active Caseload (Unique Adult Consumers) by Region in Specified Months: June 2017 – March 2020

Region

Active
Cases Jun17

Active
Cases Sep17

Active
Cases Jun19

Active
Cases Sep19

Active Cases
Dec-19

Active Cases
Mar-20

Active Cases
Jun-20

Active Cases
Sep-20

Northern

111 113 115 122 118

115

117

121

West Central

76 68 46 47

43

42

57

43

Lakes Region

74 74 57 56

56

57

54

52

Riverbend

97 87 102 86

94

94

95

91

Monadnock

70 69 57 49

50

DRAFT

Greater Nashua 94

98

83

97 DRAFT

99

51

50

47

101

105

107

Manchester

292 287 287 300 286

262

254

265

Seacoast

69 67 66 68

65

66

69

74

Community

Part.

69 75 67 71

74

68

70

72

CLM

55 54 47 49

50

47

48

49

Total*

1,006 992 925 942 934

903

919

920

* unduplicated across regions

The combined ACT teams have a reported September 2020 staff complement of 123.85 FTEs excluding psychiatry, which is sufficient capacity to serve 1,238 individuals based on the ACT non-psychiatry staffing ratios contained in the CMHA. However, with a statewide caseload of only 920, as of September 2020, there is a gap between staff capacity and active participants of 318.
As noted above, the CMHA requires the State to have capacity to serve 1,500 individuals. The current ACT staffing levels are 26.15 FTEs (or capacity to serve 262 participants) below the capacity required by the CMHA. This gap between staff capacity and actual service participants

11

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 12 of 103
is particularly problematic, given that there are reported to be 11 individuals on the wait list for ACT (see Table VII below). As noted in previous reports, the current level of ACT staffing on many CMHC teams is not sufficient to meet CMHA requirements for ACT team capacity. Furthermore, the current ACT caseload of 920 individuals is 580 below the number that could be provided ACT services with the staffing capacity required by the CMHA.3
ACT Screening As has been documented in previous reports, the State has been implementing a number of strategies to increase ACT enrollment and participation. One of these strategies has been to require the ten CMHCs to conduct and report regular clinical screening for eligibility/appropriateness for ACT services. The clinical screens are conducted:
1. As part of the intake process at the CMHCs;4 2. Upon referral to a CMHC following discharge from an inpatient facility; and 3. As part of regular quarterly and annual assessments and plan of care amendments for
current CMHC clients5 who may qualify for and benefit from ACT. Table V below presents data on ACT screens conducted by CMHCs between April and June 2020. 6
DRAFT DRAFT
3 The ER notes that active ACT caseload is a static measure of ACT activity. The ER plans to work with the State and representatives of the Plaintiffs to incorporate other indicators, such as ACT enrollments and unduplicated ACT participants in subsequent reports. 4 Note that a CMHC intake incorporating the ACT screen is performed when a CMHC emergency services staff or Mobile Crisis Team encounters and refers a person potentially needing CMHC services. In some cases, these Emergency Services/MCT referrals are made on behalf of individuals who have presented in crisis in hospital emergency departments and who may be waiting for a NHH admission. 5 Until recently, data on the total number of ACT screenings included current ACT participants. Active ACT clients have now been removed from screening reports. 6 Note: this is a retrospective table, and thus is always one quarter behind most of the other state-reported data in this report. This supports the “look forward” component, which documents the extent to which individuals receive services within 90 days of a positive screen.
12

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 13 of 103

Table V

Self-Reported Number of Unique Clients Screened for ACT Services by CMHCs

April to June 2020

Community Mental Health Center

Total
Screened (not
already on ACT)

Appropriate for further
ACT Assessment

Receiving ACT/ w/i 90
days of Screening

Percent Receiving ACT of those Appropriate
for Assessment within 90
days

Percent Receiving ACT
of those appropriate for assessment in
Previous Report within
90 days

01 Northern Human Services

1,037

17

1

5.88%

21.05%

02 West Central Behavioral

201

3

Health

0

0.00%

100%

03 Lakes Region Mental

878

1

Health Center

0

0.00%

12.5%

04 Riverbend Community Mental Health Center
05 Monadnock Family Services

1,446 690

2

1

DRAFT

4

DRAFT

0

50% 0.0%

0.0% 0.0%

06 Greater Nashua Mental

802

7

Health

2

28.6%

0.00%

07 Mental Health Center of

1,561

14

Greater Manchester

3

21.4%

17.6%

08 Seacoast Mental Health

1,454

23

Center

1

4.3%

2.4%

09 Community Partners

262

0

0

0.0%

100%%

10 Center for Life Management

789

1

0

0.0%

0.0%

Total

9,120

72 (0.79% of all screened)

8 (11.1% of all assessed after
screening0.09% of all
screened)

Of the 9,120 unique individuals screened for ACT during this period, the State reports that 72 were referred for an ACT assessment. This is a referral rate of less than one percent, slightly
13

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 14 of 103

down from the previous report. Eleven percent (8 individuals) of those referred for ACT assessments was enrolled in ACT services within 90 days of being screened. Most of the referrals for ACT screening are internal to the CMHCs. That is, people who have already had a CMHC intake, and who may already be receiving CMHC services, are those most likely to be screened for ACT services. Thus, it is perhaps not surprising that so few of the individuals screened are referred to the next step, which is the assessment for ACT.

The State has reported that about 90 percent of individuals are linked to ACT without having gone through the ACT screening process. In general, this seems to be confirmed by the fact that 80 new clients were reported to be added, while the screening process only produced 8 new clients (10.0%). No specific data have been reported to date about where these referrals originate or how they avoided the CMHC intake and screening process. Because of this limitation, available screening data does not shed light on whether individuals outside of the CMHC system who would benefit from ACT services are being properly identified and referred for assessment. The ER recommends that the State develop and implement an initiative to identify and screen/assess individuals outside of the CMHC system, especially those in crisis or decline, such as those having contact with NHH, the DRFs, the MCTs, the ERs, homeless outreach workers and organizations or the criminal justice system.

New ACT Clients
DRAFT
The State has recently begun reporting the numberDRAFT of new ACT clients. Table VI summarizes these data from the four most recent reporting periods.

Table VI

Self-Reported New ACT Clients

CMHC
Northern Human Services West Central Behavioral Health Lakes Region MHC Riverbend CMHC Monadnock Family Services Greater Nashua Mental Health MHC of Greater Manchester Seacoast MHC Community Partners Center for Life Management
Total

New Clients New Clients New Clients New Clients

October January 2020 April – June July to Sept.

2019 –

– March

2020

2020

December

2020

2019

6

10

11

13

11

6

21

5

5

4

5

4

20

13

9

8

1

1

0

0

6

8

5

10

17

19

16

22

3

4

5

7

5

4

6

7

3

1

5

4

77

70

83

80

14

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 15 of 103

It should be noted that in the time period from October to December 2019, the State reported a decrease in active ACT caseload from 958 to 934, while at the same time reporting the addition of 77 new ACT clients. For the period January through March 2020, the State reported that the ACT active caseload decreased from 929 to 903, while at the same time reporting the addition of 70 new ACT clients. For the July to September quarter, the statewide monthly active caseload increased by one participant, whereas 80 new clients were reported to have been added during this time frame. This indicates that: (1) there is substantial turnover in the active ACT caseload over a relatively short time frame; and (2) thus, aggressive efforts to engage new ACT clients are necessary just to maintain steady state7 operations in the ACT program, much less to grow the program. In light of this data, and to provide further context for this fluctuation in active caseloads, the ER recommends the State begin capturing and reporting the following information: 1) participants’ average length of stay in the service; 2) the number of participants discharged each month; and 3) the reason for their discharge (i.e. withdrawal of consent; achievement of treatment goals; moved out of state, etc).

The State has been reporting data on the number of individuals waiting for ACT services on a

statewide basis for the past 27 months. This information is displayed in Table VII below. The

State and the CMHCs assert that an individual eligible for ACT may have to wait for ACT

services because the specific ACT team of the individual’s CMHC does not currently have staff

capacity to accept new clients. The ER has documented above that there is a statewide gap

between

ACT

staff

capacity

and

ACT

participation. DRAFT DRAFT

Indeed, other than Riverbend in September

2020 (for the first time at any CMHC), there is excess capacity in each region/team and enough

capacity to address the needs of people reported to be on the waitlist, especially in Manchester

which has a consistent recent record of causing people to wait for ACT services; both

Manchester ACT teams have a combined capacity to serve 345 people, but, as of September

2020, Manchester only served 265 people, leaving unused ACT capacity for 80 people.

Nonetheless, the State and the CMHCs note that in some CMHC regions, new ACT staff must be

hired before new ACT clients can be accepted into the program.

7 The CMHA does not specifically require “steady state” operations. Nor does the CMHA have specific caseload or enrollment requirements for ACT. However, ACT is a core remedial service directly related to meeting the qualitative and quantitative expectations of the CMHA. Thus, the ER intends to continue to monitor and report on ACT enrollment as a key indication of overall compliance with the CMHA.
15

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 16 of 103

December 31, 2018
March 31, 2019
June 30, 2019
September 30, 2019
December 31, 2019
March 31, 2020
June 30, 2020
September 30, 2020

Table VII Self-Reported ACT Wait List

Time on List

Total

0-30 days 31-60 days 61-180+ days

6

3

0

3

2

1

1

0

1

1

0

0

2

2

0

0

5

2

2

1

10

0

3

7

DRAFT

DRAFT

13

2

2

9

11

3

5

3

The ER notes that 8 of the 11 individuals reported to be on the wait list for ACT services have been waiting for greater than 30 days: three of the 11 have been waiting for more than 150 days. Given the excess ACT capacity noted above, the ER expects the State will intervene to assure that people in need of, and eligible for, ACT receive ACT services in a timely manner.
New Hampshire Hospital (NHH) Admissions and Discharge Data Relative to ACT
In concert with other strategies to improve access to ACT services, the State has begun tracking the extent to which individuals on ACT are admitted to NHH; are referred to ACT from NHH; and are accepted into ACT upon discharge from NHH. Table VIII summarizes data from the past two quarters on these issues.

16

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 17 of 103

Table VIII

Self-Reported Total ACT-Related Admissions to and Discharges from NHH

October 2019 through September 2020

Oct.-Dec 2019
Jan.-Mar. 2020 April –
June 2020 July to
Sept. 2020

On ACT Percent of Referred Percent of Accepted

at

all

to ACT on

all

into ACT on

admission Admissions Discharge8 Discharges Discharge

64

38.1%

25

24.0%

14

53

35.1%

28

28.6%

11

67

34.1%

33

25.4%

17

37

26.1%

28

26.7%

21

Percent of Those
Accepted into ACT
on Discharge
56.0%
39.3%
51.5%
75%

In concert with tracking admissions to and discharges from NHH related to ACT, the State has
DRAFT
begun reporting the reasons that individuals are not DRAFT accepted into ACT upon discharge from
NHH. Table VIX summarizes this reported information.

8 The State reports that this number refers only to individuals who were not enrolled in ACT on admission to NHH.
17

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 18 of 103

Table VIX

Self-Reported Reasons Not Accepted into ACT upon Discharge from NHH

October 2019 through March 2020

Reason Not Accepted into ACT on Discharge
Not Available in Individual’s Town of Residence Individual Declined Individual’s Insurance does not Cover ACT Does not Meet ACT Clinical Criteria Individual Placed on ACT Wait List Individual Awaiting CMHC Determination for ACT
Total Unique Clients

October – December
2019 0
1 0 2 0 8
11

January – March 2020 0
0 0 1 1 15
17

April – June 2020
0
0 1 0 1 14
16

July – Sept. 2020
0
0 0 0 0 7
7

In the April through June 2020 time period, 87.5% of the individuals referred but not accepted into ACT were reported to be awaiting CMHC determination of eligibility for ACT. In the July to September time period this number was 100%. This means that the elapsed time for CMHCs
DRAFT DRAFT
to determine ACT appropriateness has been the most prevalent reason why people referred for ACT have not yet received it post-NHH discharge. The ER remains concerned about these reported delays in accessing ACT services at the CMHC level. This concern is in addition to concerns about the number of people reported to be waiting more than 30 days for access to ACT services.
The ER understands that the State has been attempting to improve referrals to and acceptance in ACT services, and has implemented directed payments and other incentives to improve performance in this area. However, currently reported data does not support a conclusion that access has in fact been improved. Thus, the ER expects the State to take additional steps to align the reported excess capacity in the ACT system with the needs of individuals for ACT services, both on discharge from NHH and from the ACT waiting list. By March 1, 2021, the ER expects a written report from the State on: (1) the action steps being taken to address delays in accessing ACT services; and (2) the actual numerical progress being made to assure that individuals eligible for and in need of ACT, including those being discharged from NHH, receive timely access to these services.
ACT Fidelity and Quality
Despite the limitations imposed because of COVID-19, the State has been able to complete QSR reviews for all of the CMHCs during calendar year 2020. The results of the reviews are
18

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 19 of 103
summarized in the section on Quality later in the report and are tabulated in Appendix B. In previous reports, the ER has noted that one area of concern identified in the QSR reports has been the implementation of ACT services. With regard to QSR indicator number 17, implementation of ACT services, six of the ten CMHCs scored below the State’s performance threshold of 80%. This resulted in a system-wide score on this indicator of 74%, six percentage points below the desired performance threshold. It should be noted that, in general, CMHC scores on Indicator 17 have improved somewhat over the past two years. Nonetheless, the ER continues to be concerned about the quality issues identified with regard to ACT services, and the implications for compliance with the CMHA.
There have been no ACT Fidelity reviews conducted since March 2020, when restrictions were imposed because of COVID-19. Thus, there is no ACT Fidelity information available for this report. The ER plans to participate in both ACT Fidelity and QSR reviews as soon as possible after COVID restrictions are lifted. The ER will also continue to monitor quality and performance improvements implemented by the State and the CMHCs in response to the QSR findings noted above.
ACT Summary Findings
Based on the above information, the ER finds that the State remains out of compliance with the ACT service standards described in Section V.D. of the CMHA. The State does not
DRAFT
currently provide a robust and effective systemDRAFT of ACT services throughout the state as required by the CMHA.
In addition to the necessity to attain CMHA-specified ACT capacity, the ER continues to emphasize that the State and the CMHCs must focus on: (1) assuring required ACT team composition and staffing; (2) expanding ACT capacity to CMHA levels and utilizing existing ACT team capacity; (3) reducing the number of individuals on the ACT wait list and/or awaiting ACT services upon discharge from NHH, as well as reducing the length of time individuals are waiting for ACT services; and (4) markedly improving outreach to and enrollment of new ACT clients, especially those in decline or crisis who are outside the system or presenting to the system for the first time.
Supported Employment (SE)
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment … to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by
19

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 20 of 103
June 30, 2017, “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)). As noted in Table X below, six of the ten CMHCs now report penetration rates lower than the CMHA requirement. This is consistent with data from the previous reporting period, during which the same six CMHC regions reported being below the state standard of 18.6% penetration. While the State continues to meet the statewide standard for SE penetration in the CMHA, this is primarily due to strong SE penetration rates in two CMHC Regions (Manchester (41.9%) and Seacoast (38.7%). The ER is increasingly concerned that Target Population members in large portions of New Hampshire are reported to not have adequate or equitable access to this essential best practice service.
DRAFT DRAFT
20

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 21 of 103

Table X Self-Reported CMHC SE Penetration Rates
Penet. Penet. Penet. Penet. Penet. Penet. Jun-19 Sep-19 Dec-19 Mar-20 Jun-20 Sep-20

Northern West Central Lakes Reg. Riverbend Monadnock Greater Nashua Manchester Seacoast Community Part. CLM CMHA Target Statewide Ave.

14.90% 22.50% 18.90% 19.00%
6.80% 13.10% 39.00% 33.70%

15.80% 19.70% 18.90% 18.40%
6.20% 13.10% 39.30% 32.90%

15.00% 20.10% 19.60% 17.40%
6.20% 13.00% 40.50% 34.20%

14.20% 22.20% 15.90% 16.20%
7.30% 15.10% 41.70% 39.00%

12.00% 24.30% 21.50% 16.10%
4.80% 13.40% 42.80% 36.00%

11.80% 25.50% 26.90% 14.70%
4.10% 13.20% 41.90% 38.70%

8.60% 20.80% 18.60% 23.50%

7.80% 20.10% 18.60% 23.20%

10.10% 18.00% 18.60% 23.70%

11.70% 16.40% 18.60% 23.70%

11.20% 14.80% 18.60% 24.20%

13.70% 14.80% 18.60% 24.50%

DRAFT DRAFT
The State reports data on the degree to which CMHC clients are working, either full or part time, in competitive employment.9 Access to competitive employment is an important indicator of the quality and effectiveness of fidelity model SE services. Table XI summarizes some key findings from these data reporting efforts.

9 State data defines full time employment as working 20 hours a week or more.
21

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 22 of 103

Table XI
Self-Reported Competitive Employment for CMHC Clients Who Recently Used SE Services

CMHC
Northern WCBH LRMHC Riverbend Monadnock Nashua MHCGM Comm. Partners. Seacoast CLM

Percent of SE Active
Clients Employed
Full or Part Time
July – September
2019
38.9% 28.6% 34.9% 60% 40% 38.9% 58.3% 53.9%

Percent of SE Active
Clients Employed
Full or Part Time
Jan – March 2019
44.2% 43.8% 27.9% 61.8% 52.0% 31.9% 54.3% 57.1%

Percent of SE Active Clients Employed Full or Part Time Oct. Dec 2019
34.4% 42.1% 53.0% 64.3% 64.7% 37.8% 54.0% DRAFT
DRAFT
50.0%

Percent of SE Active Clients Employed Full or Part Time Jan. – Mar. 2020 40.5% 45.4% 40.6% 54.0% 36.4% 44.8% 52.0% 42.8%

Percent of SE Active Clients Employed Full or Part Time Mar-June 2020
27.3% 44.4% 51.5% 62.5% 45.5% 38.6% 54.4% 33.3%

Percent of SE Active Clients Employed Full or Part Time July – Sept 2020
36.4% 33.3% 51.3% 50.0% 61.9% 42.3% 60.5% 49.3%

36.3% 75%

31.3% 56.5%

32.3% 78.1%

28.3% 63.3%

50.1% 47.9%

31.5% 46.0%

Statewide

49.2%

46.7%

51.9%

46.7%

46.7%

47.9%

For adult CMHC clients not participating in SE, the overall numbers are lower, with only 26.49% currently engaged in full-time or part-time employment statewide. 10
These data provide a reasonable baseline for future analyses. At this point, there do not appear to be substantial changes in the degree to which SE participants are accessing full or part time competitive employment. The ER will continue to review these competitive employment data in concert with the available SE fidelity and QSR reports.
The State reports that 38 individuals are waiting for SE services. Twenty-three individuals (or 61 percent) have been waiting for over a month. This is a slight improvement from the previous

10 Some individuals in this non-SE cohort could have participated in SE in the past, but are no longer actively enrolled or participating in SE.
22

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 23 of 103
quarter, in which 38 individuals were waiting for SE and 60.5% had been waiting for more than a month. However, delays in access to SE services must be addressed to “ensure reasonable access to eligible individuals” per CMHA V.F.2(f).
SE Fidelity and Quality
As with ACT services, the limitations created by COVID-19 have prevented SE fidelity reviews from being conducted during much of the time frame covered by this report.
The State has completed QSR reviews for all CMHCs, and continues to report quality and performance concerns related to two QSR indicators. These are:
1. Indicator 8: Adequacy of employment assessment/screening (Statewide average score of 69%; nine of ten CMHCs below the performance threshold); and
2. Indicator 10: Adequacy of individual employment service delivery (Statewide average score of 78%; five of ten CMHCs below the performance threshold).
As with the QSR findings related to ACT services, the ER plans to participate in QSR and SE fidelity reviews, and to monitor performance improvements in SE related to the QSR findings.
Supported Housing (SH)
DRAFT DRAFT
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Program and HUD-funded subsidies by June 30, 2016. As of September, 2020, the State reports having 312 individuals leased in Bridge Program subsidized units and 96 people approved for a Bridge Program subsidy, but not yet leased. This 96 figure is high compared to past totals and may indicate that there may be issues related to finding and leasing appropriate apartments in some areas of the state. There has been a substantial drop in the aggregate number of individuals either leased or approved but not yet leased in the Bridge Program – from a high of 591 in June of 2017 to the current number of 312 units leased.
There are 85 individuals reported to be on the Bridge Program wait list as of the end of September 2020. Of these, 56 individuals have been on the wait list for more than two months.
Table XII below provides data regarding the number of current Bridge Subsidy participants; the number waiting to lease and the number on the Bridge Subsidy waiting list. Table XIII provides quarterly data regarding the number of Bridge Subsidy program applications and terminations. Table XIV presents information on the reasons that program participants have exited the program. Table XV provides information on unit density.
23

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 24 of 103

Table XII

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

September 2018 through September 2020

Bridge Subsidy Program
Information

Sept. 2018

Mar. 2019

June 2019

Sept. Dec.2 Mar. 2019 019
2020

June, 2020

Sept. 2020

Total individuals 423 389 365 338 340 327 328 312 leased in the Bridge Subsidy Program

Individuals in

0

process of leasing

11 13 35 54 94 79 96

Individuals on the 35 38 44 42 25 49 39 85

DRAFT

wait list for a

DRAFT

Bridge Subsidy11

Cumulative

125 137 133 151 163 179 192 19812

historical number

transitioned to a

HUD Housing

Choice Voucher

(HCV)

11 The State did not maintain a waitlist prior to 2018. 12 As of the date of this report, 75 individuals have HCV subsidies.
24

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 25 of 103

Table XIII

Self-Reported Housing Bridge Subsidy Applications and Terminations

April –
June 2019

JulySeptember
2019

October – December
2019

January – March
2020

April – June 2020

JulySept. 2020

Measure

Applications

28

22

Received

59

74

30

57

Point of Contact

CMHCS

11

13

51

63

29

50

NHH

14

9

8

11

29

6

Other

1

0

0

0

1

1

Applications

14

11

Approved

Applications

1

0

Denied

42

104

27

57

DRAFT DRAFT

0

0

0

0

Denial Reasons 0

NA

NA

NA

NA

NA

Applications in

Process at end of

period

74

75

79

49

41

0

Terminations

0

0

0

2

0

2

Termination Reasons
Over Income

NA

NA

NA

Not

0

Reported

Failure to pay rent

25

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 26 of 103

Table XIV Self-Reported Exits from the Housing Bridge Subsidy Program
April through September 2020

Type and Reason DHHS Initiated Terminations
Failure to pay rent Client Related Activity
HUD Voucher Received Deceased Over Income Moved out of State Declined Subsidy at Recert. Higher level of care accessed Other Subsidy provided Moved in with Family

April – June 2020
0
16 2 1 2 2 2 1 1

July – September 2020
2
24 1 1 3 10 4 2 0

Total

27

47

DRAFT DRAFT
The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table XIV below displays the reported number of units leased at the same address.

26

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 27 of 103

Table XV

Self-Reported Housing Bridge Subsidy Concentration (Density)

March June Sept. Dec.

2019

2019

2019 2019

Mar. June Sept. 2020 2020 2020

Number of properties

with one leased SH unit

at the same address

315 300 282 276 279 267 255

Number of properties with two SH units at the same address

18

16

18

18

14

15

20

Number of properties

with three SH units at

the same address

3

4

1

4

2

6

2

Number of properties DRAFT

DRAFT
with four SH units at

the same address

2

2

1

2

2

0

0

Number of properties

with five SH units at the same address

2

1

1

0

0

0

1

Number of properties

with six SH units at the

same address

0

0

0

0

0

1

0

Number of properties

with seven+ SH units at

same address

1

1

1

1

1

1

1

It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)). DHHS reports that there is currently only one voluntary roommate occurrence among the currently leased Bridge Subsidy Program units in the above data.
27

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 28 of 103

DHHS has developed a method to cross-match the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. Table XVI summarizes the most recent reporting of these data.

Table XVI

Self-Reported Housing Bridge Subsidy Program Tenants Linked to Mental Health Services

As of

As of As of

As of

As of

As of

6/30/19 9/30/19 12/31/19 3/31/2020 6/30/20202 9/30/2020

Housing Bridge Tenants Linked to
Mental Health Services

360 of 378
(95%)

339 of 373
(91%)

358 of 394
(91%)

348 of 421
(83%)

329 of 406
(81%)

335 of 409
(82%)

These data document the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports.13
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain federal Department of Housing and Urban Development (HUD) funding for an additional 150 supported housing units for a totalDRAFT of 600 supported housing units.” (CMHA
DRAFT
V.E.3(e)). In 2015, New Hampshire applied for and was awarded funds to develop a total of 241 units of supported housing under the HUD Section 811 Program (191 Program Rental Assistance [PRA] and 50 Mainstream). All of these units are to be set aside for people with serious mental illness. As of the date of this report, 151 (combined PRA and Mainstream) of these new units are reported to have been developed and to have been occupied by members of the Target Population. The State has not been able to provide the current number of people in 811 housing, only the cumulative total over time. Nor is there clear data at this point about the number of Mainstream vouchers (tenant-based rental assistance) versus PRA units (project-based rental assistance) that are currently occupied. The ER intends to follow-up with the State in the next reporting period to clarify the implementation and utilization of the 811 Program for Target Population members.
It should be noted that over the life of the Bridge Program the State has accessed 198 HUD Housing Choice Vouchers (HCVs)14 and seven HUD public housing or similar subsidized units. But in the notes to the State’s data table 10, the State can only confirm that 75 of those who have accessed federal HCV are currently getting it, so that is the figure the ER will use going forward.

13 Some of these tenants might be receiving services from MH providers other than a CMHC. 14 This total does not include the number of Section 811 Mainstream vouchers accessed.
28

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 29 of 103
The CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.” (V.E.3(f)). As referenced above, there are currently reported to be 85 individuals on the wait list for the Bridge program; 56 of these individuals have been on the wait list for more than two months. The State has recently allocated new funds to the Housing Bridge Subsidy Program. The State asserts that these funds will be sufficient to fund an additional 100 Bridge Program subsidies. Access to these new units will be based on priorities established by Bridge Program regulations. The State will continue to manage access of wait list individuals to new units in accordance with these priorities.
Because these funds have only recently been released, and individuals continue to wait for supported housing, it would be premature to conclude that this infusion of resources will fully address the existing unmet need, or result in sufficient additional capacity to ensure no class member waits longer than six months for supported housing. In the next 3-6 months, the ER will closely monitor the impact of additional subsidies on the State’s ability to move individuals off the supported housing wait list.
The State has recently implemented a major change in the administration of the Housing Bridge DRAFT DRAFT
Subsidy Program. Previously, the program had been administered on a statewide basis by an independent contractor. Under the new model, each of the ten CMHCs is now performing certain participant-level functions, such as housing search; lease-up and occupancy supports; landlord negotiations; arrangement of housing related services and supports, and eviction prevention. The CMHCs now also directly pay rent subsidies to landlords and are reimbursed for these costs by the State. The State is managing intake and eligibility determination functions and will maintain a statewide waiting list.
These administrative changes could be having an impact on the overall effectiveness of the Housing Bridge Subsidy Program; the fact that 96 individuals are enrolled in the Bridge program but are still seeking a unit supports this conclusion. However, it is too early in the implementation process to assess the effects of these changes. The ER will continue to monitor the implementation process as well as monitoring data regarding lease-ups, the waiting list, and other related performance data.
Transitions from Institutional to Community Settings
During the past six and one-half years, the ER has visited both Glencliff and NHH on at least ten separate occasions to meet with staff engaged in transition planning. The ER has also participated in six meetings of the Central Team. The CMHA required the State to create a
29

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 30 of 103
Central Team to overcome barriers to discharge from institutional settings to community settings. The Central Team has now had about 64 months of operational experience. As of November 2020, 70 individuals have been submitted to the Central Team, 43 from Glencliff and 23 from NHH. Of these, the State reports that 34 individual cases have been resolved, three individuals are deceased, 12 individuals at Glencliff Home are currently inactive and not interested in transitioning to the community due to COVID-19 or increased medical complexity, and 21 individual cases remain under consideration. Table XVII below summarizes the discharge barriers that have been identified by the Central Team with regard to these 21 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total higher than the number of individuals reviewed by the Central Team.
DRAFT DRAFT
30

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 31 of 103

Table XVII

Self-Reported Discharge Barriers for Open Cases Referred from NHH and Glencliff to the Central Team:

November 2020

Discharge Barriers

Number for Glencliff

Number for NHH

Legal

4 (7.1%)

2 (12.5%)

Residential

15 (26.8%)

5 (31.3%)

Financial

8 (14.3%)

2 (12.5%)

Clinical

15 (26.8%)

4 (25.0%)

Family/Guardian

14 (25.0%)

3 (18.8%)

Other

0 (0%)

0 (0%)

It is notable that 20 of the 21 open cases with the Central Team involve residential concerns,

which need to be addressed per the CMHA.

DRAFT DRAFT

Glencliff
In the time period from April through September 2020, Glencliff reports that it has admitted 11 individuals, and has had four discharges and seven deaths. The average daily census through this period was 116 people. There have been no readmissions during this time frame. There are currently 27 individuals on the wait list for admission to Glencliff.
CMHA Section VI requires the State to develop effective transition planning and a written transition plan for all residents of NHH and Glencliff (VI.A.1), and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]15 individuals with mental illness and complex health care needs residing at Glencliff….” The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be cost-effectively served in supported housing.”16
15 Cumulative from CMHA V.E.(.3(.(g), (h), and (i). 16 CMHA V.E.2(a).
31

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 32 of 103
DHHS reports that a total of only 20 people have transitioned from Glencliff to integrated settings since the inception of the CMHA five years ago.
Based on data supplied by the State for the previous report, there are currently 26 individuals undergoing transition planning who could be transitioned to integrated community settings once appropriate living settings and community services become available. Ten of these individuals have been assigned to Choices for Independence (CFI) waiver case management agencies in order to access case management in the community to facilitate transition planning, and seven are currently in the application process. Five individuals have been found eligible for the Acquired Brain Disorder (ABD) or Developmental Disability (DD) waivers, one is in the application process, one has been denied eligibility for these waivers, and prefers to transition to Vermont and is eligible for that state’s Choices for care waiver. One individual is reported to not meet criteria for referrals to one or more of the waivers. The remaining three individuals are undergoing transition planning absent CFI or other waiver eligibility.
DHHS continues to provide information about Glencliff transitions at the time of discharge, including clinical summaries, lengths of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions that could not be cost-effectively served in SH continue to experience transitions to integrated community settings. To protect the confidentiality of individuals
DRAFT DRAFT
transitioned from Glencliff, this person-specific information is not included in the ER reports.
The ER has been concerned about the slow pace of transitions to integrated community settings by residents of the Glencliff Home. Based on this concern, the ER conducted a three-day on-site review during the month of January 2020. This review focused on the following CMHA provisions specifically relevant to transitions planning and effectuating transitions to integrated community settings on the part of Glencliff residents:
Section VI.A.1 “The State, through its community mental health providers and/or other relevant community providers, will provide each individual in NHH and Glencliff with effective transition planning and a written transition plan ….” (Emphasis added);
Section VI.A.2 (a) through (e). Note that Section (e) states: that transition planning will “not exclude any individual from consideration for community living based solely on his or her level of disability”;
Section VI.A.4 , which states, in part: “... the State will make all reasonable efforts to avoid placing individuals into nursing homes or other institutional settings”;
Section VI.A.7 and 8, which require the State to implement a system of in-reach activities to enable Glencliff residents to meet with CMHPs to “develop relationships of trust” with CMHCs and other providers and to “actively support” residents to transition to the
32

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 33 of 103
community with proactive efforts to educate residents and family members/guardians about community options; and
Section V.E.2 (a) and (b) and Sections V.E.3(g) through (j), which require the State to develop integrated community living options for individuals with complex health care needs according to an implementation schedule and wait list provisions.
Based on the above information, the ER prepared recommendations for (State/DHHS-led) actions and interventions:
1. Substantially improve in-reach from the community to Glencliff. 2. Improve the success and timeliness of access to Medicaid waivers in support of
transitions to integrated community settings. 3. Have DHHS Bureau of Mental Health Services (BMHS) staff work more closely and pro-
actively with other DHHS officials and the Area Agencies to increase access to community providers. 4. Improve access to Bridge subsidies to facilitate transitions from Glencliff. 5. Expand access to small scale (3 - 4 person) community residential programs for Glencliff residents with complex medical conditions. 6. Make it a very high priority to develop new small scale residential settings for residents with complex medical conditions as soon as possible. This appears to be the most
DRAFT
feasible approach to re-starting movementDRAFT of people to integrated community settings. Some individuals have been waiting for transition for a long time. Others will be encouraged to choose community living by seeing the success and satisfaction of residents that have moved to these programs.
Over the last six months, the State has taken steps in response to the ER’s first recommendation on in-reach. Based in part on the findings of the ER Glencliff report, the State has developed a new transition planning policy and transition engagement protocols intended to expand and improve transition planning for all Glencliff residents. Representatives of the Plaintiffs provided substantial recommendations and examples to assist the State to design a more effective transition planning process. This revised process was finalized in October 2020. The results of implementing the improved transition planning process have not yet been documented. The State has executed a contract with Northern Human Services to provide transition support services for residents of Glencliff, and an “in-reach coordinator” has been hired. As of the date of this report, implementation of the in-reach functions and activities is at a very early stage. Implementation has been hindered by the COVID-19 restrictions that have been in effect in New Hampshire since March 2020. The State has not yet shared with the ER or representatives of the Plaintiffs the required monthly data reports from this new program. However, the State has recently provided some preliminary information on activities for the past two months. These include:
33

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 34 of 103
 In-reach coordinator 1:1 meetings (in-person or virtually) with approximately 33 residents – some multiple times as work progresses on cases;
 In-reach coordinator meetings (in-person, virtually or by telephone) with others, such as Glencliff Home staff, guardians and family members, approximately 40 times;
 In-reach coordinator meetings (in-person, virtually or by telephone) with providers approximately 40 times;
 In-reach coordinator’s work with CMHCs on intake has resulted in some individuals being determined to no longer be in the Target Population (confirmed by DHHS psychiatrists), and to identify a need for specific Registered Sex Offender (RSO) related solutions.
The ER expects that the State will begin sharing the monthly data reports required of the contracted in-reach program with the ER and representatives of the Plaintiffs no later than February 15, 2021.
The activities noted above represent potentially positive improvements of the transition planning and in-reach functions for Glencliff residents as established by the CMHA. However, as of the date of this report, the State has not demonstrated progress with regard to the other specific findings and recommendations enumerated in 2-6 above.
For instance, there has been no expansion of the number or capacity of integrated community DRAFT DRAFT
settings for Glencliff residents. This failure to develop appropriate, less restrictive alternatives to institutionalization at Glencliff is a major barrier to timely transition and the most common obstacle facing individuals currently waiting for more integrated options in the community. It also reflects an ongoing area of noncompliance with the terms of the CMHA.
The pace of community transitions from Glencliff has also remained stagnant, both before and during the pandemic. With the exception of accessing capacity in one existing program (Palm St. in Nashua), there have been no additional transitions to integrated settings this entire year, despite the fact that there are almost 30 individuals identified as being in active transition planning, and have been for months or years, and many more would benefit from transition to the community if appropriate residential services and supports were available. Nor is there any additional integrated community living capacity in the development pipeline specifically for individual or groups of Glencliff residents. Therefore, the ER will prioritize further action and reporting from the State in the remaining areas of recommendation over the next 3-6 months.
Once COVID restrictions are ended, the ER intends to closely monitor activities related to Glencliff transition planning. This monitoring of in-reach programming will focus on:
1. Implementation of the in-reach program, including written transition plans, individual meetings between Glencliff residents and CMHPs, community visits, CMHC communications, etc.;
34

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 35 of 103
2. Implementation of revised policies, procedures, forms, training contents, etc. related to transition planning and informed consent;
3. Tracking and analyzing data reported by the in-reach program to the State; 4. Assessing the degree to which all CMHCs in the state become re-engaged in transition
planning and in expanding integrated community settings for Glencliff residents; 5. Tracking progress of individuals on the active discharge planning list towards integration
into the community; and 6. Documenting the development of new integrated community settings for Glencliff
residents. The ER recognizes that the State intends to improve transition planning and to facilitate additional community integrated transitions for Glencliff residents. However, at this point, and based on the lack of progress since the ER’s January review, it is still not possible for the ER to document that the State is in compliance with CMHA provisions related to Glencliff transition planning or transitions to integrated community settings.
DRAFT DRAFT
35

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 36 of 103

Preadmission Screening and Resident Review (PASRR)

The State periodically provides data on PASRR Level II screens conducted in New Hampshire. Recent PASRR data are summarized in Table XVIII below. A Level II screen is conducted if a PASRR Level I (initial) screen identifies the presence of mental illness, intellectual disability, or related conditions for which a nursing facility placement might not be appropriate. One objective of the Level II screening process is to seek alternatives to nursing facility care by diverting people to appropriate integrated community settings. Another objective is to identify the need for specialized facility-based services if individuals are deemed to need nursing facility level of care.

Table XVIII

Self-Reported PASRR Level II Screens

Full Approval - No Specialized Services Full Approval with Specialized Services Provisional – No Specialized Services Provisional with Specialized Services Total

October 2019
through June 2020
Percent
37.9%
30.3%
16.7%
15.2%
100%%

April through
June 2019 Percent

July through
Sept 2019 Percent

28.8%
DRAFT DRAFT
28.8%

31.0% 38.0%

18.8% 19.7%

23.8% 11.3%

100% 100%

April – June 2020 Percent
64.4%
0.0%
23.1%
11.5%
100%

July – October
2020 Percent
61.3%
6.5%
0.0%
32.3%
100%

In the December 2018 ER report, 10.2% of the Level II screens were approved with a specification for specialized services. At that time, the ER questioned whether this was an unusually low rate for specification of specialized services. In a comparison with one other state, the ER found substantially higher approvals for specialized services than was evidenced in New Hampshire at that time. In the intervening period, the State and the PASRR contractor have been reviewing protocols for specification of specialized services in the Level II process. For the period April through June 2019, 52.6% percent of total Level II screens identified a need for special services. For July through September 2019, the percent was 49.3%. In the July to October 2020, time period, 38.8% of the PASRR Level II approvals included provisions for specialized services.
36

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 37 of 103
For a variety of reasons, virtually all PASRR screens in New Hampshire are conducted for people who are already in a nursing facility. For example, for October 2019 through March 2020, 96.7% of Level II screens were conducted in nursing facilities. In the April to June quarter this number was 100%. Prime opportunities for diversion to integrated community settings may have already been missed by the time the PASRR screen is conducted. In addition, individuals admitted to Glencliff must have been turned down by at least two other facilities before being considered for admission. Clearly, interventions to divert individuals from Glencliff or other nursing facilities must be initiated before the PASRR screening process is conducted. PASRR is important to assure that people with mental illness, ID/DD, or related conditions are not inappropriately institutionalized or placed in nursing facilities without access to necessary special services. However, PASRR is not by itself sufficient to divert people from nursing facility care. Up-stream interventions at NHH, the DRFs, and among the CMHCs are also essential to prevent unnecessary facility placement.
New Hampshire Hospital and the Designated Receiving Facilities (DRFs) For the time period July through September 2020, the State reports that NHH effectuated 244 admissions and 244 discharges. The mean daily census was 180, and the median length of stay for discharges was 21 days. Note that the average daily census for the January – March 2020 reporting period was 159, with 21 fewer beds being filled on average. This increased daily
DRAFT
census reflects the conversion of the children’s inDRAFT patient unit to an adult acute care unit. Table XIX below compares NHH discharge destination information for the six most recent reporting periods. The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.
37

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 38 of 103

Table XIX

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Percent Percent Percent Percent Percent

Discharge Destination

July through Septem
-ber 2019

October through Decem-
ber
2019

January through March
2020

April through
June
2020

July through Septem-
ber
2020

Home – live alone or with others

70.5%

70.76%

72.77%

80.6%

68.4%

Glencliff

0.4%

Homeless

4.38%

Shelter/motel

Group home 5+/DDS supported living, peer support housing etc.

3.98%

Jail/correction

1.2%

Nursing home/rehab facility

5.98%

Other17

0.42%
DRAFT DRAFT
7.11%

2.35% 5.16%

4.24% 3.29%

3.0%

1.41%

5.00% 4.69%

10.17% 10.33%

0 2.3% 3.0%
2.3% 3.3% 6.9%

0 2.87% 2.46%
3.28% 6.56% 5.33%

17 The ER did not include the “Other” category in previous reports.
38

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 39 of 103

The State now consistently reports information on the hospital-based Designated Receiving Facilities (DRFs) and the Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and analyze it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. Table XX summarizes these data.

Table XX

Self-Reported DRF/APRTP Utilization Data

January 2016 through September 2020

Admissions Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019 April to June 2019 July to September 2019 October - December 2019 January - March 2020 April - June 2020 July - September 2020

Franklin
69 79 37 60
NA** 59 52 69
67
87 126 108
104
96 114 105 116

Cypress
257 205 207 228
178 209 240 244
201
198 182 187
194
175 186 129 159

Portsmouth
46 378 375 363
363 358 DRAFT
DRAFT
330 333
357
375 349 371
391
350 333 298 348

Elliot Geriatric
65 49 54 52
60 55 66 65
54
64 56 89
52
63 52 36 51

Elliot Pathways
121 92 114 101
121 102 100 104
112
72 123 108
95
100 105 119 121

Parkland 54

Total
558 803 787 804
722 783 788 815
791
796 836 865
836
784 790 687 849

39

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 40 of 103

Franklin Cypress Portsmouth Elliot Elliot Parkland Geriatric Pathways

Total

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019 April to June 2019 July to September 2019 October - December 2019 January - March 2020 April - June 2020 July - September 2020

53.70% 55.70% 43.20% 58.30% NA**
49.20% 44.20% 46.73% 28.36%
46.00%
45.20% 61.10% 43.30%
63.50%
53.50% 53.51% 44.76%
48.28%

18.70% 24.40% 29.50% 21.50% 25.60%
30.10% 28.30% 25.82% 24.38%
23.20%
18.10% 20.90% 16.50%
23.40%
24.20% 24.19% 24.03%
39.00%

NA 20.40% 18.90% 22.00% 25.60%
23.70% 21.50% 24.62% 19.33%
22.40%
23.20% 19.40% 25.10%
24.00%
DRAFT
21.00%DRAFT 21.02% 25.84%
20.69%

18.50% 4.10% 13.00% 1.00% 11.50%

30.60% 48.90% 44.70% 47.50% 50.40%

NA 25.50% 26.20% 30.06%
NA

12.70% 6.10% 9.23% 12.96%

50.00% 47.00% 51.92% 49.11%

30.00% 27.00% 29.08% 25.16%

6.25% 51.40%

26.50%

12.50% 7.90% 11.50%

47.20% 47.20% 55.80%

28.20% 27.30% 28.00%

7.90% 40.00%

29.50%

9.60% 9.62% 13.89%

40.00% 40.00% 42.90%

28.16% 28.16% 31.59%

21.56% 42.97% 100.00% 36.16%

40

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 41 of 103

Franklin Cypress Portsmouth Elliot

Elliot Parkland

Geriatric Pathways

Total

Mean Census

7.9

14.7

NA

19.7

18.1

NA

Jan - March 2016

7.8

13.2

21.4

22.5

16.9

81.8

April - June 2016

4.5

13.6

23.2

25.6

14.5

81.4

July - Sept 2016

4.5

12

30.3

29.3

10

86.1

April - June 2017

NA** 12.9

29.7

29.7

12.2

NA

July - September

2017

10.1 12.3

27.7

32.6

16.1

19.7

Oct. - Dec 2017

6.7

11.6

32.5

34.6

NA

NA

Jan. - March 2018

9.1

11.9

31.7

31.7

20.4

104.8

April - June, 2018

11.8

8.4

39.6

33.8

18.2

111.8

July - September

2018

10.7

9.2

27.4

33.4

10.7

91.4

October - December

2018

8.5

14.5

30.4

22.6

14.9

90.9

January - March 2019 8.4

11.5

29.7

27

12.1

88.7

April to June 2019

9.4

12.2

24.1

24.1

12

81.8

July to September

2019

10.6 13.4

31.8

23.7

9.5

89

October - December

DRAFT

2019

10.6 13.7

29.2 DRAFT

20.5

12

86

January - March 2020 10.6 13.7

29.2

20.5

12

86

April - June 2020

8.5

11.1

24.8

11.9

11.7

68

July - September

2020

9.7

13.4

27.7

14.1

13

3.4

81.3

41

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 42 of 103

Franklin Cypress Portsmouth Elliot

Elliot Parkland

Geriatric Pathways

76

261

NA

57

122

Discharges

78

206

363

51

90

Jan - March 2016

35

213

380

64

113

April - June 2016

59

232

365

54

105

July - Sept 2016

NA** 243

355

63

121

April - June 2017

82

212

359

58

102

July - September

2017

53

248

326

67

101

Oct. - Dec 2017

74

244

326

65

107

Jan. - March 2018

66

195

353

54

112

April - June, 2018

89

204

358

62

79

October - December

2018

124

177

348

56

106

January - March 2019 108

193

368

55

111

April to June 2019

101

192

386

54

97

July to September

2019

102

198

353

60

123

October - December

2019

110

207

327

71

119

DRAFT

DRAFT

January - March 2020 110

207

327

71

119

April - June 2020

101

131

294

51

117

July - September

2020

117

164

324

41

121

48

Total
516* 788 805 815 NA 813
795 816 780 792
811 835 830
836
834 834 694
815

42

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 43 of 103

Franklin Cypress Portsmouth Elliot

Elliot Parkland

Geriatric Pathways

8.6

4.2

NA

15

7.4

Mean LOS for

Discharges

6

4

4

28

7

Jan - March 2016

7

5

4

24

8

April - June 2016

6

4

5

22

8

July - Sept 2016

NA

4

4

27

7

April - June 2017

4

4

5

21

7

July - September

2017

5

4

5

23

7

Oct. - Dec 2017

5

4

5

20

8

Jan. - March 2018

4

4

4

21

7

April - June, 2018

4

3

4

31

7

October - December

2018

5

5

6

18

8.5

January - March 2019 5

3

5

18

7

April to June 2019

6

4

6

26

8

July to September

2019

7

5

6

25

7

October - December

2019

6

5

DRAFT

6

DRAFT

20

8

January - March 2020 6

5

6

20

8

April - June 2020

6

6

6

27

8

July - September

2020

6

7

6

18

8

5

* Does not include Portsmouth

Total
8.8*
5 5 9 NA 5
5 5 5 5
6 5 6
7
6 6 7
7

43

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 44 of 103

The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and should also reduce the number of people waiting for psychiatric admissions in hospital EDs.
DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table XXI below provides a summary of these recently reported data.
Table XXI
Self-Reported Discharge Dispositions for DRFs in New Hampshire
April 2020 through September 2020

Disposition Frank- Cylin press

Home

199 264

NHH

6

0

Residential 1

0

Facility/

Assisted

Living

Other

0

10

DRF18

Hospital

0

0

Death

0

0

Other or

14

21

Unknown

Total

220 295

Portsmouth
434 10 0
5 0 0 175* 621

Elliot Geria-
tric
23
0 25
DRAFT DRAFT
4
0 0 45
97

Elliot Pathways
198
0 0

Park- Total Per-

land

cent

44 1,162 76.35

%

3

23 1.51%

0

28 1.84%

5

0

17 1.12%

0

0

0 0.00%

0

0

0 0.00%

36

1

292 19.19

241

48 1,522 100%

Based on these self-reported data, 76.35% of recent discharges from DRFs and the Cypress Center are to home. This is similar to the 68.4% discharges to home reported by NHH. It should be noted that discharges to hotels/motels or shelters are not specifically identified in the reported DRF data. Rather, these are included in the “Other” category. Thus, it is not possible to document whether discharges to hotels/motels and shelters have increased during COVID. For NHH, there was only a slight increase in discharges to hotels/motels and shelters during the most recent period, and over the past two years the proportion of such discharges from NHH has been reduced.

18 The State reports that these transfers reflect conversion from involuntary to voluntary status, not transfers among DRF facilities.
44

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 45 of 103 Hospital Readmissions DHHS is now reporting readmission rates for both NHH and the DRFs. Table XXII below summarizes these data:
DRAFT DRAFT
45

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 46 of 103

Table XXII

Self-Reported Readmission Rates for NHH and the DRFs

July 2017 through September 2020

NHH 7/2017 to 9/2017 10 to 12/2107 1/2018 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 1/2020 to 3/2020 4/2020 to 6/2020 7/2020 to 9/2020
Franklin 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 1/2020 to 3/2020 4/2020 to 6/2020 7/2020 to 9/2020

Percent 30 Days
9.80% 12.8% 13.7% 7.6% 8.6%
7.3% 5.3% 8.4% 10.5% 6.6% 9.7% 6.1%
DRAFT DRAFT
NA 10.2% 0.0% 4.3% 6.0%
2.3% 7.9% 6.5% 1.9% 3.5% 3.8% 2.5%

Percent 90 Days
21.60% 26.1% 22.7% 14.7% 19.6%
18.1% 14.8% 15.0% 18.6% 12.4% 14.7% 12.7%
NA 10.2% 0.0% 5.8% 9.0%
4.6% 10.3% 9.3% 6.7% 6.1% 4.7% 5.0%

Percent 180 Days
27.90% 32.8% 29.9% 23.4% 25.4%
25.9% 21.2% 20.3% 23.3% 21.1% 20.0% 16.4%
NA 10.2% 1.9% 5.8% 16.4%
5.7% 10.3% 12.0% 9.6% 7.8% 4.7% 5.9%

46

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 47 of 103

Cypress 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 1/2020 to 3/2020 4/2020 to 6/2020 7/2020 to 9/2020
Portsmouth 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 1/2020 to 3/2020 4/2020 to 6/2020 7/2020 to 9/2020

7.10% 12.00% 4.20% 4.50% 8.50%
7.10% 5.50% 9.90% 6.60% 3.50% 5.20% 3.10%
11.50% 8.70% 8.80% 10.20%
DRAFT
8.40% DRAFT
7.70% 12.90% 10.50% 8.20% 9.70% 7.30% 14.10%

12.40% 18.70% 9.60% 8.20% 13.90%
11.10% 14.80% 15.10% 9.20% 5.00% 11.90% 6.30%
17.50% 13.70% 15.50% 15.90% 12.90%
14.90% 19.50% 17.80% 12.00% 29.20% 15.00% 21.80%

15.90% 24.40% 15.80% 11.90% 18.90%
15.20% 17.60% 20.80% 12.80% 8.50% 18.70% 7.50%
21.00% 17.60% 20.60% 21.90% 19.00%
20.30% 23.50% 22.40% 12.00% 23.00% 23.60% 24.70%

47

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 48 of 103

Elliot Pathways 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 1/2020 to 3/2020 4/2020 to 6/2020 7/2020 to 9/2020

3.30% 5.80%
NA 3.80% 7.00%
2.80% 4.90% 5.50% 2.10% 9.70% 3.30% 6.60%

6.60% 7.70%
NA 6.70% 11.50%
5.60% 5.70% 5.50% 5.20% 14.20% 3.30% 8.30%

12.40% 12.50%
NA 8.60% 16.10%
9.70% 7.30% 5.50% 6.30% 15.90% 4.20% 9.10%

Elliott Geriatric 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 1/2020 to 3/2020 4/2020 to 6/2020 7/2020 to 9/2020

6.10% 5.60%
6.30% 5.40% DRAFT
DRAFT
10.10% 7.70% 9.40% 9.80% 2.00%

6.10% 11.10%
7.80% 5.40% 12.40% 9.60% 11.30% 9.80% 7.80%

6.10% 11.10%
9.40% 5.40% 14.60% 13.50% 18.90% 9.80% 7.80%

Parkland 7/2020 to 9/2020

1.90%

1.90%

1.90%

Readmission rates, especially the 180-day readmission rate for NHH and Portsmouth, are high. At least a 16% of all people discharged from NHH are readmitted within 180 days. For Portsmouth Hospital, 24.7% of individuals discharged have a readmission within 180 days. These data, in concert with the hospital emergency department data presented below, indicate that gaps remain in community services for people with serious mental illness, and that the essential connection between inpatient care and community services is not being effectuated for sizeable numbers of people at risk of re-hospitalization. These facts need to be understood in light of the State’s ongoing efforts to increase ACT capacity and enrollment as documented earlier in this report. The State must increase the focus on whether or not those readmitted to NHH or a DRF are being screened, assessed, and linked (when appropriate) to ACT and supported housing upon discharge.

48

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 49 of 103
Hospital ED Waiting List In the previous three reports, the ER has identified the hospital ED boarding wait for admission to NHH to be an important indicator of overall system performance. The following two charts display worsening adult admissions delays to NHH for the period April 2020 through November 2020.
Average Daily Waiting List of Adults, by week, for Inpatient Psychiatric Beds (All Designated Receiving Facilities, Including New Hampshire Hospital) December 2018 - November 2020
80 70 60 50 40
DRAFT DRAFT
30 20 10
0
49

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 50 of 103
DRAFT DRAFT
Until April of 2020, the overall trend in average daily wait lists for hospital admission was trending downward. However, in the past six months, the average daily wait list has increased significantly. This has occurred despite the addition of 30 beds at NHH, a new 4 bed IEA-DRF (Parkland) and 13 net new transitional housing beds statewide19. In addition, there continues to be excess capacity among several of the state’s CMHC-based ACT teams, which can and should reduce reliance on institutional services.
19 An additional 16 beds of transitional housing are pending.
50

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 51 of 103
In a recent all parties meeting, the State reported that there are 60 people at NHH clinically ready for discharge. The ER also notes that the recent State efforts to increase the number of hospital beds in the system, such that there are now more institutional beds in New Hampshire than at the start of the CMHA. A central purpose of the CMHA is to avoid unnecessary or prolonged institutionalization, and reduce over-reliance on institutional services by increasing community capacity. These two data points suggest that this purpose has not yet achieved, especially when additional investments are needed to ensure individuals have ready access to the remedial services and residential supports required for transitions from NHH and Glencliff. In addition, people awaiting psychiatric hospital admission are potential participants in ACT, MCT, crisis apartments, and other CMHA services. Thus, the ER intends to continue on reporting ED boarding in future reports.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services.
Peer Support Agencies
DHHS continues to report having a total of 15 peer DRAFT support agency program (PSA) sites, with at
DRAFT
least one program site in each of the ten regions. The State continues to report that all peer support centers meet the CMHA requirement to be open 44 hours per week. As of September 2020, the State reports that those sites have a cumulative total of 2,260 members, with an average daily participation rate of 128 people statewide.
The ER intends to conduct several PSA on-site visits within the next year (by December 30, 2021). Until those visits are complete, there will be no further information to report about these programs.
IV. Quality Assurance Systems
As noted earlier in this report, COVID restrictions have prevented the State from conducting the contracted ACT and SE fidelity reviews during the past 10 months. However, the State has been successful in conducting QSRs for all ten CMHCs during 2020. A summary tabulation of the results of these QSR activities is included as Appendix B of this report. Due to COVID, the ER has not been able to directly observe QSR CMHC reviews during this period, but has conducted two telephone interviews with the QSR leadership and team members.
All QSR reviews have been conducted remotely: that is, the service participant and staff interviews have been conducted by ZOOM or by phone. Nonetheless, participation and completion rates for the interviews have remained high, and quality checks of the interview
51

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 52 of 103

results have remained positive. The team members report that they believe the QSR review results remain valid, albeit conducted under difficult conditions.

For the most recent set of QSR reviews (SFY 2020) the State has increased the performance threshold from 70% to 80% for each indicator and for overall average performance. CMHCs scoring less than 70% on any indicator must submit a quality improvement plan (QIP), the implementation of which is monitored by the State. QIPs are also used to prioritize technical assistance and coaching efforts designed to assist CMHCs to improve performance. The ER also monitors implementation of the QIPs via interviews with both State and CMHC staff.

Overall, the CMHC system averages QSR performance scores above the 80% threshold. That is, each CMHC has an aggregate average score above 80%, and the aggregate average for the ten CMHCs together also exceeds 80%. These facts demonstrate that overall CMHC and systemwide performance has been steadily improving since in inception of the QSR review process.

However, there continue to be some areas of lower than desired performance and quality in the CMHC system as documented by the QSR findings. Of the 18 indicators summarized in the QSR reports, the CMHC system as a whole performs below the 80% threshold on four indicators. These are:

1. Indicator 8: adequacy of employment assessment (nine of 10 CMHCs below 80%; system

wide average 69%);

DRAFT

DRAFT

2. Indicator 10: adequacy of employment service delivery (five of 10 CMHCs below 80%;

system-wide average 78%);

3. Indicator 12: individual is integrated into the community, has choice, increased

independence and social supports (five of 10 CMHCs below 80%; system-wide average

79%); and

4. Indicator 17: implementation of ACT services (six of 10 CMHCs below 80%; state-wide

average 74%).

In addition, there are two indicators for which the state-wide average performance is above 80%, but for which five CMHCs are performing below the 80% threshold. These are:

1. Indicator 13: adequacy of crisis assessment; and 2. Indicator 15: crisis service delivery.

The ER notes that performance below the 80% QSR performance threshold is not, by itself, evidence of non-compliance with the CMHA. However, when taken together with data regarding service fidelity and class members’ outcomes, including successful community integration, QSR performance scores provide a powerful indication of: 1) whether specific remedial services are being delivered consistent with CMHA requirements; and 2) whether the purpose and objectives of the CMHA are being realized. In addition, scores below the performance threshold indicate a need for improved quality and improved implementation of

52

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 53 of 103
services vis-à-vis service participants. These findings trigger increased monitoring and technical assistance activities, which in turn are expected to both result in improved quality and service outcomes for the CMHA Target Population and increase compliance with the requirements of the CMHA.
As soon as possible after the COVID restrictions are eased, the ER intends to return to active observation of both QSR and Fidelity Review activities.
I. Summary of Expert Reviewer Observations and Priorities
The ER has emphasized in this report that the State continues to be far from compliant with the CMHA requirements for ACT. For the last four and one half years, the ER has reported that the State is out of compliance with the ACT requirements of Sections V.D.3, which together require that the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time.
Other areas of non-compliance identified in this report include:
1. With regard to Glencliff, the ER has documented failure to provide effective DRAFT DRAFT transition planning and in-reach activities, failure to transition residents of Glencliff into integrated community settings in accordance with the CMHA, and failure to expand community residential and other service capacity to meet the needs of Glencliff residents in alternative community settings. In addition, the ER cannot document or certify that residents of Glencliff have written transition plans in accordance with CMHA requirements; and
2. Although the State technically meets the statewide CMHA standard for SE penetration, the ER notes six of the ten CMHC regions of the state have penetration rates lower than the standard. At the very least, the ER considers that this demonstrates that Target Population members do not have equal access to SE services throughout New Hampshire.
As has been noted at several points in this report, the COVID-19 pandemic has significantly influenced the New Hampshire mental Health System over the past 10 months, although the areas of noncompliance noted in this report all predate the onset of the pandemic. In general, the State is to be congratulated for its efforts to provide basic levels of services for the CMHA Target Population, and also for striving to maintain the quality of services for the Target Population. The absence of progress towards compliance is not unexpected in light of these challenges, but it does have the practical effect of extending the period of time that is likely to be required before any maintenance of effort year can begin.
53

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 54 of 103
COVID has also directly affected the degree to which the ER could directly monitor and document compliance with the terms and requirements of the CMHA. The ER has not been able to conduct any direct on-site reviews or interviews in the past ten months, instead relying on telephonic conversations and analyses of secondary data. Absent other information, the ER concludes that while service delivery and quality has remained relatively consistent under COVID, there has also been relatively little documented progress made in addressing and making progress on issues related to compliance with the CMHA.
With the advent of vaccinations to prevent COVID infection, the ER is hopeful that the State will re-invigorate efforts to comply with the requirements of the CMHA. At the same time, as soon as it is safe to do so, the ER intends to re-engage in on-site and face-to-face monitoring to verify and document the degree to which compliance with the CMHA is being attained and maintained.
As the ER has stated in previous reports, the State will not be able to disengage from the CMHA until full compliance is reached for all requirements of the CMHA.
To facilitate progress towards compliance and disengagement, the ER expects the State to develop and implement measures to address all areas of non-compliance referenced above, and those issues in which further actions or data production is necessary in order to assess compliance, with the following specific actions to take place:
1. No later than March 1, 2021, the State willDRAFT provide a written update on the following: DRAFT implementation of specific ACT strategies to expand ACT capacity and enrollment, eliminate the wait list, and reduce the elapsed time for CMHAs to process individuals into ACT services. In addition, the ER expects the State to produce and report preliminary data on participants’ length of stay, discharge, and reason for their discharge.
2. No later than February 15, 2021 the State will begin sharing monthly report data, as specified in the contract, from the Glencliff in-reach program with the ER and representatives of the Plaintiffs.
3. No later than March 1, 2021 the State will provide a written report to the ER and representatives of the Plaintiffs documenting the number of new integrated community settings available, or in the development pipeline, specifically for residents of Glencliff.
4. No later than February 1, 2021, a written updated report on the availability of MCT services to class members in the Nashua region, including staffing levels and crisis apartment capacity.
5. No later than March 1, 2021, a written update on the supported housing waiting list, and specifically the utilization of new Housing Bridge subsides to move individuals waiting more than two months into the Bridge program.
54

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 55 of 103
DRAFT DRAFT
55

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 56 of 103
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly DRAFT Data Report DRAFT
January through March, 2020
56

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 57 of 103

New Hampshire Community Mental Health Agreement Quarterly Data Report

DRAFT DRAFT

July – September 2020

New Hampshire Department of Health and Human Services Bureau of Quality Assurance and Improvement December 28, 2020
57

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 58 of 103
DRAFT DRAFT
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence
58

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 59 of 103

Community Mental Health Agreement Quarterly Data Report
New Hampshire Department of Health and Human Services

Publication Date: December 28, 2020

Reporting Period: 7/1/2020 – 9/30/2020

Notes for Quarter

 On March 13, 2020, Governor Christopher T. Sununu issued Executive Order 2020-04, declaring a State of Emergency due to the Novel Coronavirus (COVID-19). On March 26, 2020, Governor Sununu issued related Emergency Order #17, implementing a stay-at-home, shelter in place of residence requirement, effective March 27, 2020 at 11:59 PM. Although the stay-at-home order expired June 15, 2020, the State of Emergency declared through Executive Order 2020-04 has been extended (Executive Order 2020-24, dated December 11, 2020, contains the latest extension). The data in this report regards service provision throughout the emergency period.

 Tables 2a-b. Community Mental Health Center Services: Assertive Community Treatment Staffing – Northern Human Services ACT staffing counts are now separated by ACT team. Additionally, some staff counts are lower due to COVID-19 and are not indicative of actual vacancies but individuals on leave related to the pandemic.

 Tables 5a-f. Designated Receiving Facilities (DRF) – In November and December 2019,

Portsmouth Regional Hospital and Parkland Memorial Center (respectively) received approval for

four (4) new DRF beds, for a total increase of eight (8) DRF beds. Reporting for Portsmouth’s new

beds was added in the last quarterly report. Parkland’s new beds are also now added to the

DRAFT

quarterly report.

DRAFT

 Table 5-e. Designated Receiving Facilities: Discharge Location for Adults – Improvement to the data-reporting tool used by the facilities to capture discharges in the “Home” category now includes individuals living with family members, living alone, and living with others (non-family). In the past, some facilities’ data did not provide this level of detail and was captured in the “Other” category as a result.

 Table 7. NH Mental Health Client Peer Support Agencies: Census Summary – Peer Support Agencies were open with limited on-site capacity due to COVID-19. The Average Daily Visits reported includes the number of individuals participating in groups online and on-site.

 Tables 11a-c. Mobile Crisis Services and Supports for Adults – several data elements reported as zero (0), or otherwise lower than normal volume, reflects the direct or indirect impact of the State of Emergency declared in response to COVID-19, such as lack of crisis apartment use due to distancing and quarantine protocols.

 Table 11c. Mobile Crisis Services and Supports for Adults – Harbor Care. Data reflects the final months of this program, as operated by Harbor Care. Capacity to provide services gradually decreased due to the loss of staff transitioning to other employment opportunities in anticipation of the closure.

Acronyms Used in this Report ACT: Assertive Community Treatment

NHH: New Hampshire Hospital

BMHS: Bureau of Mental Health Services Finance Authority

NHHFA: New Hampshire Housing

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 60 of 103

BQAI: Bureau of Quality Assurance and Improvement PRA:

CMHA: Community Mental Health Agreement

SE:

CMHC: Community Mental Health Center

VA:

Administration

DHHS: Department of Health and Human Services

DRF: Designated Receiving Facility

ED: Emergency Department

FTE: Full Time Equivalent

HBSP: Housing Bridge Subsidy Program

HUD: US Department of Housing and Urban Development

MCT: Mobile Crisis Team

Project Rental Assistance Supported Employment Veterans Benefits

1a. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Clients

DRAFT

DRAFT

Septemb

Unique

August

er Unique Clients in

July

Clients in

Prior

Community Mental Health Center

2020

2020

2020 Quarter Quarter

01 Northern Human Services

117

119

121

127

126

02 West Central Behavioral Health

50

39

43

55

62

03 Lakes Region Mental Health Center

54

54

52

57

60

04 Riverbend Community Mental Health Center

94

94

91

104

111

05 Monadnock Family Services

50

50

47

51

51

06 Greater Nashua Mental Health

106

109

107

115

108

07 Mental Health Center of Greater Manchester

257

266

265

279

269

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 61 of 103

08 Seacoast Mental Health Center

68

71

74

75

71

09 Community Partners

70

73

72

77

75

10 Center for Life Management

48

48

49

53

51

Total Unique Clients

913

922

920

990

984

Unique Clients Receiving ACT Services 10/1/2019 to 9/30/2020: 1,288

Revisions to Prior Period: None.

Data Source: NH Phoenix 2.

Notes: Data extracted 11/2/2020; clients are counted only one time regardless of how many services they receive.

1b. Community Mental Health Center Services: Assertive Community Treatment Screening and Resultant New ACT Clients

April – June 2020

January – March 2020

Retrospective Analysis
DRAFT DRAFT

Retrospective Analysis

Unique Clients Screened: Individuals Not Already on ACT* Appropriate for Further ACT Assessment: Individuals Not Already oNnewACClTients receiving ACT Services within 90 days of Screening Unique Clients Screened: Individuals Not Already on ACT* Appropriate for Further ACT Assessment: Individuals Not Already oNnewACClTients receiving ACT Services within 90 days of Screening

Community Mental Health Center

01 Northern Human Services

1,037

17

1 1,068

19

4

02 West Central Behavioral

201

3

0

212

2

2

Health

03 Lakes Region Mental Health Center

878

1

0

733

8

1

04 Riverbend Community

1,446

2

1 1,449

0

0

Mental Health Center

05 Monadnock Family

690

4

0

664

6

0

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 62 of 103

Services

06 Greater Nashua Mental Health

802

7

2

833

5

0

07 Mental Health Center of

1,561

14

3 1,610

17

3

Greater Manchester

08 Seacoast Mental Health

1,454

23

1 1,368

42

1

Center

09 Community Partners

262

0

0

254

1

1

10 Center for Life Management

789

1

0

831

1

0

Total ACT Screening

9,120

72

8 9,022

101

12

Data Source: NH Phoenix 2 and CMHC self-reported ACT screening records. ACT screenings

submitted through Phoenix capture ACT screenings provided to clients found eligible for state

mental health services. Phoenix does not capture data for non-eligible clients; three CMHCs

submit

this

data

through

Phoenix.

Seven

CMHCsDRAFT DRAFT

self-report.

All such screenings, excluding

individuals who are already on ACT, are contained in this table.

Notes: Data extracted 11/5/2020. “Unique Clients Screened: Individuals Not Already on ACT” is defined as individuals who were not already on ACT at the time of screening that had a documented ACT screening during the identified reporting period. “Screening Deemed Appropriate for Further ACT Assessment: Individuals Not Already on ACT” is defined as screened individuals not already on ACT that resulted in referral for an ACT assessment. “New Clients Receiving ACT Services within 90 days of ACT Screening” are defined as individuals who were not already on ACT that received an ACT screening in the preceding quarter and then began receiving ACT services.

1c. Community Mental Health Center Services: New Assertive Community Treatment Clients

July – September 2020

April – June 2020

July 2020 New ACT CAliuegnutsst 2020 New ACT SCleipetnetsmber 2020 New TAoCtTalCliNeenwts AACprTilCl2i0e2n0ts New ACT ClMiaeynt2s020 New ACT JCluineent2s020 New ACT Clients Total New ACT Clients

Community Mental Health Center

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 63 of 103

01 Northern Human Services

6 4 3 13 4 4 3 11

02 West Central Behavioral Health

1 1 3 5 8 7 6 21

03 Lakes Region Mental Health Center

211 41 13

5

04 Riverbend Community Mental Health 1 3 4 8 6 2 1

9

Center

05 Monadnock Family Services

000 00 00

0

06 Greater Nashua Mental Health

3 5 2 10 0 2 3

5

07 Mental Health Center of Greater Manchester

6 13 3 22 7 5 4 16

08 Seacoast Mental Health Center

034 70 23

5

09 Community Partners

124 72 13

6

10 Center for Life Management

112 42 21

5

Total New ACT Clients

21DRAFT

33

26

80 30 26 27

83

DRAFT

Revisions to Prior Period: None.

Data Source: NH Phoenix 2.

Notes: Data extracted 10/27/2020; New ACT Clients are defined as individuals who were not already on ACT within 90 days prior who then began receiving ACT services. This information is not limited to the individuals that received an ACT screening within the previous 90-day period, and may include individuals transitioning from a higher or lower level of care into ACT.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 64 of 103

1d. Community Mental Health Center Services: Assertive Community Treatment Waiting List As of 9/30/2020

Time on List

Total

0-30 days 31-60 days 61-90 days 91-120 days 121-150 days 151-180+*days

11

3

5

0

0

0

3

As of 6/30/2020

Time on List

Total

0-30 days 31-60 days 61-90 days 91-120 days 121-150 days 151-180 days

13

2

2

3

0

1

5

Revisions to Prior Period: None.

Data Source: BMHS Report.

Notes: Data compiled 10/31/2020. All individuals waiting are at MHCGM with the exception
DRAFT
of one individual with CLM whose referral for ACT DRAFT was received on the last day of the
reporting period. Increased services for individuals waiting at MHCGM are being provided by
the existing treatment team until assigned to an ACT team. *These individuals were no longer
waiting by the end of October.

1e. Community Mental Health Center Services: Assertive Community Treatment – New Hampshire Hospital Admission and Discharge Data Relative to ACT

July – September 2020

April – June 2020

On ACT a t Admissi o n d for ACT on Dischar gdeto ACT at Dischar gOen ACT a t Admissi o n d for ACT on Dischar gdeto ACT at Dischar

Community Mental Health Center 01 Northern Human Services 02 West Central Behavioral Health

Yes No Yes No Yes No Yes No Yes No Yes No 0 11 3 8 2 1 6 10 4 6 2 2 3 7 34 30 5 7 3 4 1 2

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 65 of 103

03 Lakes Region Mental Health Center

6 6 3 3 2 1 5 13 2 11 1 1

04 Riverbend Community Mental Health Center

11 15

3 12

3 0

9 18

3 15

3 0

05 Monadnock Family Services

1 16 2 14 2 0 4 13 0 13 0 0

06 Greater Nashua Mental Health

5 14 2 12 1 1 10 25 6 19 2 4

07 Mental Health Center of Greater Manchester

5 15 4 11 2 2 12 15 8 7 3 5

08 Seacoast Mental Health Center

4 5 32 30 8 9 1 8 0 1

09 Community Partners

1 11 1 10 1 0 8 17 5 12 4 1

10 Center for Life Management

1 5 41 22 0 3 1 2 1 0

Total

37 105 28 77 21 7 67 130 33 97 17 16

Revisions to Prior Period: None

Data Source: New Hampshire Hospital. DRAFT DRAFT
Notes: Data compiled 12/17/20.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 66 of 103

1f. Community Mental Health Center Services: Assertive Community Treatment – Reasons Not Accepted to ACT at New Hampshire Hospital Discharge Referral

Reason Not Accepted at Discharge

July - September 2020

April - June 2020

Not Available in Individual’s Town of Residence

0

0

Individual Declined

0

0

Individual’s Insurance Does Not Cover ACT Services

0

1

Individual’s Clinical Need Does Not Meet ACT

0

0

Criteria

Individual Placed on ACT Waitlist

0

1

Individual Awaiting CMHC Determination for ACT

7

14

Total Unique Clients

7

16

DRAFT
DRAFT
Revisions to Prior Period: None.

Data Source: New Hampshire Hospital.

Notes: Data compiled 12/17/2020. Six (6) individuals who were awaiting CMHC determination at discharge from NHH, were no longer waiting for determination and were not on the ACT Waitlist by the last day of the month of discharge – indicating the ACT determination and resolution had occurred. One (1) individual awaiting CMHC determination was placed on the ACT waitlist by the end of the month of discharge and was no longer waiting at the end of the following month. This indicates the individual was assessed for ACT and determined eligible by the end of the month of discharge, and then began receiving ACT in the next month (MHCGM).

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents

Community Mental Health Center

September 2020

June 2020

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 67 of 103

Nurse Clinician/or Equivalent Support Worke r Peer Specialist (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner

01 Northern Human Services - Wolfeboro
01 Northern Human Services - Berlin
01 Northern Human Services - Littleton
02 West Central Behavioral Health
03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services
06 Greater Nashua Mental Health 1
06 Greater Nashua Mental Health 2 07 Mental Health Center of Greater Manchester-CTT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners

0.4 0.00 1.00 4.00 0.57 5.57 0
13.36 1.20 0.3 0.65 0.80 4.50 0.00 5.95 5

0.4 0.60 0.00 3.00 0.00 3.60 5

0.5 6.10 0.50 0.60 1.20 2.70 0.50 5.00 0

0.7 6.50 0.75 0.40 1.00 0.00 1.00 6.40 5

DRAFT
DRAFT
0.50

0.5 10.50 0.50 1.00 7.50 0.00 9.00 0

0.6 8.85 0.65 2.00 1.25 0.00 1.10 11.58 5

0.2 8.00 0.25 1.00 1.00 5.50 1.00 8.50 5

0.2 8.00 0.25 1.00 1.00 5.50 1.00 8.50 5

0.9 18.25 0.91 1.00 10.00 5.25 0.00 16.25 1

0.9 17.25 0.91 1.00 9.00 7.25 1.00 18.25 1

0.6 9.10 0.60 1.00 0.00 4.00 1.00 9.00 0

0.00 2.00 6.95 0.00 8.95

9.20 0.70

0.7

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 68 of 103

10 Center for Life Management Total

5

0.4 8.30 0.40 1.00 1.00 4.30 1.00 7.30 0

10.7

60.4

123.8 7.6 123.41 7.62

5 30.25 5 8.17

5 7

DRAFT DRAFT

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 69 of 103

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies

Substance Use Disorder Treatment

Housing Assistance

Supported Employment

Community Mental Health Center

September

September

September

2020

June 2020

2020 June 2020

2020

June 2020

01 Northern Human Services - Wolfeboro

1.00

4.00

0.00

01 Northern Human Services - Berlin

1.80

3.55 3.00

8.75 0.50

1.00

01 Northern Human Services - Littleton

0.00

3.00

1.00

02 West Central Behavioral Health

0.20

0.20 2.10

4.10 0.60

0.60

03 Lakes Region Mental Health Center

3.00

1.00 6.40

5.50 2.00

2.00

04 Riverbend Community Mental Health Center
05 Monadnock Family Services

0.50
DRAFT DRAFT
1.40

1.50 8.00
1.40 4.00

9.50 0.50
2.00 1.00

0.50 1.00

06 Greater Nashua Mental Health 1

4.25

4.25 6.25

6.25 1.50

1.00

06 Greater Nashua Mental Health 2

5.25

5.25 7.00

7.00 0.00

0.00

07 Mental Health Center of Greater Manchester-CCT

10.91

13.75

2.00

8.91

11.75

2.00

07 Mental Health Center of Greater Manchester-MCST

5.91

12.75

2.00

5.91

13.75

2.00

08 Seacoast Mental Health Center

2.00

2.00 4.00

5.00 1.00

2.00

09 Community Partners

2.75

2.70 5.05

5.05 1.38

0.38

10 Center for Life Management

2.00

3.00 6.00

7.00 0.30

0.30

Total

38.97 41.67 84.30 86.65 13.78 12.78

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 70 of 103
Revisions to Prior Period: None. Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report. Notes: Data compiled 10/20/2020; for 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, but rather the quantity of staff available to provide each service. If staff are trained to provide multiple service types, their entire FTE value is credited to each service type.
DRAFT DRAFT

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 71 of 103

3a. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12-Month Period
12 Month Period Ending September 2020

Community Mental Health Center

Supported Employment
Clients

Total Eligible Clients

Penetration Rate

Penetration Rate for Period Ending
June 2020

01 Northern Human Services

155

1,317

11.8%

12.0%

02 West Central Behavioral Health

143

561

25.5%

24.3%

03 Lakes Region Mental Health Center

382

1,419

26.9%

21.5%

04 Riverbend Community Mental Health Center

278

1,887

14.7%

16.1%

05 Monadnock Family Services

46

1,112

4.1%

4.8%

06 Greater Nashua Mental Health
07 Mental Health Center of Greater Manchester

275

DRAFT

DRAFT

1,542

2,085 3,681

13.2% 41.9%

13.4% 42.8%

08 Seacoast Mental Health Center

795

2,053

38.7%

36.0%

09 Community Partners

115

841

13.7%

11.2%

10 Center for Life Management

187

1,265

14.8%

14.8%

Total Unique Clients

3,911

15,970

24.5%

24.2%

Revisions to Prior Period: None.

Data Source: NH Phoenix 2.

Notes: Data extracted 10/27/2020

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 72 of 103

Northern Human Services West Central Behavioral Health Lakes Region Mental Health Center Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Mental Health Center of Greater Manchester Seacoast Mental Health Center Community Partners Center for Life Management Statewide Total or Mean Percentage Previous Quarter Statewide Total or Mean Percentage April – June 2020

3b. Community Mental Health Center Clients: Adult Employment Status – Total
Reported Employment Status

Begin Date: 7/01/2020 End Date: 9/30/2020

Employment Status

Update

Overdue Threshold:

105 days

Updated Employment Status:

Full time employed

51 39 33 118 62 137 266 207 43 94 1,050

now or in past 90 days Part time employed 129 36 268 291 163 279 341 259 62 188 2,016

now or in past 90 days

Unemployed

180 122 33 89

Not in the Workforce 569 169 406 1010

Status is not known

6 27 312 40

Total of Eligible Adult 935 393 1,052 1,548

CMHC Clients Previous Quarter:

DRAFT
925 397 1,009 1,537DRAFT

Total of Eligible Adult

157 811 1036 129

487 319 601 880

3 103 20 3

872

2,264 1,478

1,649

833

2,215 1,464

1,451

197 558 3,312 227 132 4,800
14 59 587
543 1,031 11,76 5
528 967

CMHC Clients

Percentage by Updated Employment Status:

Full time employed 5.5% 9.9% 3.1% 7.6% 7.1% 8.3% 11.7% 14.0% 7.9% 9.1% 8.9%

now or in past 90 days

Part time employed

13.8 9.2% 25.5% 18.8% 18.7% 16.9 15.1% 17.5% 11.4 18.2 17.1%

%

%

% %

now or in past 90 days

Unemployed

19.3 31.0 3.1% 5.7% 18.0% 49.2 45.8% 8.7% 36.3 54.1 28.2%

% %

%

% %

Not in the Workforce

60.9 43.0 38.6% 65.2% 55.8% 19.3 26.5% 59.5% 41.8 12.8 40.8%

% %

%

% %

Status is not known 0.6% 6.9% 29.7% 2.6% 0.3% 6.2% 0.9% 0.2% 2.6% 5.7% 5.0%

Percentage by Timeliness of Employment Status Screening:

Update is Current

67.8 36.1 45.1% 84.8% 65.7% 96.2 89.5% 96.2% 63.4 99.9 81.1%

% %

%

% %

Update is Overdue

32.2 63.9 54.9% 15.2% 34.3% 3.8% 10.5% 3.8% 36.6 0.1% 18.9%

% %

%

Previous Quarter: Percentage by Timeliness of Employment Status Screening:

Update is Current Update is Overdue

61.6 41.1 3.9% 89.4% 64.2% 96.8 91.5% 94.3% 45.6 99.7

% %

%

% %

38.4 58.9 96.1% 10.6% 35.8% 3.2% 8.5% 5.7% 54.4 0.3%

%% *

%

992 2,013 3,067 4,739
515 11,326
8.8% 17.8% 27.1% 41.8%
4.5% 76.8% 23.2%

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 73 of 103
Revisions to Prior Period: None. Data Source: NH Phoenix 2. Notes: Data extracted 10/27/2020; *The high rate of overdue employment screening status reported by Lakes Region Mental Health Center for Previous Quarter (4/1/2020 – 6/20/2020) is due to an internal process/reporting change. This has been rectified in the current quarter report.

3c. Community Mental Health Center Clients: Adult Employment Status – Recent Users of Supportive Employment Services (At Least One Billable Service in Each of Month of the Quarter)

Northern Human Services West Central Behavioral Health Lakes Region Mental Health Center Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Mental Health Center of Greater Manchester Seacoast Mental Health Center Community Partners Center for Life Management Statewide Total or Mean Percentage Previous Quarter Statewide Total or Mean Percentage April – June 2020

Supported Employment Cohort
DRAFT DRAFT
Reported Employment Status

Begin Date: 7/01/2020 End Date: 9/30/2020

Updated Employment Status:

Full time

1 1 1 4 0 8 13 1

employed now

or in past 90

days

Part time

9 2 19 25 13 22 42 16

employed now

or in past 90

days

Unemployed

6 5 3 20 3 27 28 13

Not in the

13 1 5 9 5 13 8 24

Workforce

Status is not

0 0 11 0 0 1 0 0

2 3 34 29
7 20 175 173
6 23 134 132 4 4 86 77 0 0 12 11

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 74 of 103

known

Total of

29 9 39 58 21 71 91 54 19 50 441 422

Supported

Employment

Cohort

Previous

22 18 33 56 11 70 79 69 16 48

Quarter: Total

of Supported

Employment

Cohort

Percentage by Updated Employment Status:

Full time

3.4% 11.1% 2.6% 6.9% 0.0% 11.3% 14.3% 1.9% 10.5% 6.0% 7.7% 6.9%

employed now

or in past 90

days

Part time

31.0% 22.2% 48.7% 43.1% 61.9% 31.0% 46.2% 29.6% 36.8% 40.0% 39.7% 41.0%

employed now

or in past 90

days

Unemployed 20.7% 55.6% 7.7% 34.5% 14.3% 38.0% 30.8% 24.1% 31.6% 46.0% 30.4% 31.3%

Not in the

44.8% 11.1% 12.8% 15.5% 23.8% 18.3% 8.8% 44.4% 21.1% 8.0% 19.5% 18.2%

Workforce

DRAFT

DRAFT

Status is not

0.0% 0.0% 28.2% 0.0% 0.0% 1.4% 0.0% 0.0% 0.0% 0.0% 2.7% 2.6%

known

Revisions to Prior Period: None.

Data Source: Phoenix 2.

Note 3b-c: Data extracted 10/27/2020. Updated Employment Status refers to CMHC-reported status and reflects the most recent update. Update is Current refers to employment status most recently updated within the past 105 days. Update is Overdue refers to employment status most recently updated in excess of 105 days. Actual client employment status may have changed since last updated by CMHC in Phoenix. Employed refers to clients employed in a competitive job that has these characteristics: exists in the open labor market, pays at least a minimum wage, anyone could have this job regardless of disability status, job is not set aside for people with disabilities, and wages (including benefits) are not less than for the same work performed by people who do not have a mental illness. Full time employment is 20 hours and above; part time is anything 19 hours and below. Unemployed refers to clients not employed but are seeking or interested in employment. Not in the Workforce are clients who are homemakers, students, retired, disabled, hospital patients or residents of other institutions, and includes clients who are in a sheltered/non-competitive employment workshop, are otherwise not in the labor force, and those not employed and not seeking or interested in employment. Unknown refers to clients with

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 75 of 103

an employment status of “unknown,” without a status reported, or with an erroneous status code in Phoenix.

3d. Community Mental Health Center Services: Supported Employment Waiting List As of 9/30/2020

Time on List

Total

0-30 days 31-60 days 61-90 days 91-120 days 121-150 days 151-180+ days

38

15

9

3

8

2

1

As of 6/30/2020

Time on List

Total

0-30 days 31-60 days 61-90 days 91-120 days 121-150 days 151-180 days

42

20

7

2

3

5

5

DRAFT

Data Source: BMHS Report.

DRAFT

Notes: Data compiled 10/31/2020. Total days waiting are calculated for all individuals waiting when data collection began on January 1, 2020. Individuals waiting are at: LRMHC (29), MFS (3) and CP (6). LRMHC discovered an administrative error in October 2020 that revealed referrals for 6 of the 29 cases had not been submitted to the SE team by 9/30/20; the remaining 23 cases were no longer waiting to receive SE services by October 31, 2020. Five of the 6 individuals waiting at CP were no longer waiting to receive SE services by October 31, 2020; 1 individual has not engaged in services and case closure is anticipated. All 3 of the individuals waiting at MFS were no longer waiting to receive SE services by October 31, 2020.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 76 of 103

4a. New Hampshire Hospital: Adult Census Summary

Measure

July – September 2020

April – June 2020

Admissions

244

320

Mean Daily Census

180

172

Discharges

244

304

Median Length of Stay in Days for Discharges

21

13

Deaths

0

0

Revisions to Prior Period: None.

Data Source: Avatar.

Notes 4a: 10/29/2020; Mean Daily Census includes patients on leave and is rounded to nearest whole number.

DRAFT DRAFT

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 77 of 103

4b. New Hampshire Hospital: Summary Discharge Location for Adults

Discharge Location

July - September 2020

CMHC Group Home

5

Discharge/Transfer to IP Rehab Facility

14

Glencliff Home for the Elderly

0

Home - Lives Alone

64

Home - Lives with Others

103

Homeless Shelter/ No Permanent Home

3

Hotel-Motel

4

Jail or Correctional Facility

8

Nursing Home

2

Other

13

Peer Support Housing

DRAFT

0

DRAFT

Private Group Home

1

Secure Psychiatric Unit - SPU

1

Unknown

26

April - June 2020 5 5 0
117 128
1 6 7 5 5 1 3 0 21

4c. New Hampshire Hospital: Summary Readmission Rates for Adults

Measure

July – September 2020

April – June 2020

30 Days

6.1% (15)

9.7% (31)

90 Days

12.7% (31)

14.7% (47)

180 Days

16.4% (40)

20.0% (64)

Revisions to Prior Period: None.

Data Source: Avatar.

Notes 4b-c: Data compiled 10/29/2020; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions lookback period

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 78 of 103 includes readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day readmissions); patients are counted multiple times – once for each readmission; the number in parentheses is the number of readmissions.
DRAFT DRAFT

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 79 of 103

5a. Designated Receiving Facilities: Admissions for Adults July – September 2020

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

56

60

Cypress Center

62

97

Portsmouth

72

276

Elliot Geriatric Psychiatric Unit

11

40

Elliot Pathways

52

69

Parkland Regional Hospital

54

0

Total

307

542

April – June 2020

Designated Receiving Facility

DRAFT Involuntary
DRAFT
Admissions

Voluntary Admissions

Franklin

47

58

Cypress Center

31

98

Portsmouth

77

221

Elliot Geriatric Psychiatric Unit

5

31

Elliot Pathways

57

62

Parkland Regional Hospital

NA

NA

Total

217

470

Total Admissions
116 159 348
51 121
54 849
Total Admissions
105 129 298
36 119 NA 687

5b. Designated Receiving Facilities: Mean Daily Census for Adults

Designated Receiving Facility

July – September 2020

Franklin

9.7

April – June 2020 8.5*

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 80 of 103

Cypress Center

13.4

Portsmouth

27.7

Elliot Geriatric Psychiatric Unit

14.1

Elliot Pathways

13.0

Parkland Regional Hospital

3.4

Total

81.3

Revisions to Prior Period: * indicates corrected counts.

11.1 24.8* 11.9* 11.9*
NA 70.9*

DRAFT DRAFT

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 81 of 103

5c. Designated Receiving Facilities: Discharges for Adults

Designated Receiving Facility

July – September 2020

Franklin

117

Manchester (Cypress Center)

164

Portsmouth

324

Elliot Geriatric Psychiatric Unit

41

Elliot Pathways

121

Parkland Regional Hospital

48

Total

815

April – June 2020 101 131 294 51 117 NA 694

DRAFT DRAFT

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges for Adults

Designated Receiving Facility

July – September 2020

April – June 2020

Franklin

6

6

Manchester (Cypress Center)

7

6

Portsmouth

6

6

Elliot Geriatric Psychiatric Unit

18

27

Elliot Pathways

8

8

Parkland Regional Hospital

5

NA

Total

7

7

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 82 of 103

5e. Designated Receiving Facilities: Discharge Location for Adults July – September 2020

Designated Receiving Facility

Assisted Living / Group
Home

Other

NH

Decease

Hom Hospit Hospita Othe

d DRF* e**

al

l

r

Franklin

1

0

0 109

0

0

7

Manchester (Cypress Center)

0

0

6 151

0

0

7

Portsmouth Regional Hospital

0

0

0 261

0

8 55

Elliot Geriatric Psychiatric Unit

11

0

4 11

0

0 15

Elliot Pathways

2

0

1 105

0

1 12

Parkland Regional Hospital

0

0

0 44

0

3

1

Total

14

0 11 681

0

12 97

DRAFT

DRAFT

April - June 2020

Designated Receiving Facility

Assisted Living / Group
Home

Decease d

DRF*

Hom e

Other Hospit
al

NH Hospita
l

Othe r

Franklin

0

0

1 89

0

5

6

Manchester (Cypress Center)

0

0

4 113

0

0 14

Portsmouth Regional Hospital

0

0

2 172

0

2 118

Elliot Geriatric Psychiatric Unit

12

0

0 11

0

0 28

Elliot Pathways

0

0

0 92

0

3 22

Parkland Regional Hospital

NA

NA NA NA NA

NA NA

Total

12

0

7 477

0

10 188

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 83 of 103 *Dispositions to ‘DRF’ represent a change in legal status from Voluntary to Involuntary within the DRF. **Home includes individuals living with family, living alone, and living with others (non-family).
DRAFT DRAFT

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 84 of 103

5f. Designated Receiving Facilities: Readmission Rates for Adults July – September 2020

Designated Receiving Facility

30 Days

90 Days

Franklin

2.5% (3)

5.0% (6)

Manchester (Cypress Center)

3.1% (5)

6.3% (10)

Portsmouth

14.1% (49)

21.8% (76)

Elliot Geriatric Psychiatric Unit

2.0% (1)

7.8% (4)

Elliot Pathways

6.6% (8)

8.3% (10)

Parkland Regional Hospital

1.9% (1)

1.9% (1)

Total

7.9% (67)

12.5% (107)

April – June 2020

Designated Receiving Facility

30 Days

90 Days

Franklin

3.8% (4) DRAFT
DRAFT

4.7% (5)

Manchester (Cypress Center)

5.2% (7)

11.9% (16)

Portsmouth

7.3% (23)

15.0% (47)

Elliot Geriatric Psychiatric Unit

9.8% (4)

9.8% (4)

Elliot Pathways

3.3% (4)

3.3% (4)

Parkland Regional Hospital

NA

NA

Total

5.9% (42)

10.6% (76)

Revisions to Prior Period: None.

Data Source: NH DRF Database.

Notes: Data compiled 11/13/2020.

180 Days 5.9% (7) 7.5% (12) 24.7% (86) 7.8% (4) 9.1% (11) 1.9% (1) 14.2% (121)
180 Days 4.7% (5) 18.7% (25) 23.6% (74) 9.8% (4) 4.2% (5)
NA 15.8% (113)

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 85 of 103

6. Glencliff Home: Census Summary Measure

July – September 2020

April – June 2020

Admissions

3

8

Average Daily Census

117

115

Discharges

2 (One resident discharged to a 3 bed Medical Model
Group Home and one resident discharged back to the DOC/Concord Prison)

2 (One resident discharged to a 3 bed Medical Model
Group Home and one resident discharged to another nursing facility)

Individual Lengths of Stay in Days for Discharges

(1,139 and 870)

(756 and 1,057)

Deaths

1

6

Readmissions

0

0

Mean Overall Admission Waitlist

27

22

DRAFT

Revisions to Prior Period: None.

DRAFT

Data Source: Glencliff Home.

Notes: Data Compiled 11/2/2020; Mean rounded to nearest whole number; Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 86 of 103

7. NH Mental Health Client Peer Support Agencies: Census Summary July – September 2020

April – June 2020

Peer Support Agency

Total Members

Average Daily Visits Total Members

Average Daily Visits

Alternative Life Center

Total

605

36

276

30

Conway

271

9

54

7

Berlin

132

7

125

6

Littleton

86

8

51

7

Colebrook

116

12

46

10

Stepping Stone Total Claremont Lebanon

363

11

371

5

246

9

255

5

DRAFT

DRAFT

117

2

116

0

Cornerbridge Total

136

10

166

7

Laconia

49

5

44

4

Concord

72

3

102

3

Plymouth Outreach

15

2

20

0

MAPSA Keene Total

303

16

85

27

HEARTS Nashua Total

372

On the Road to Recovery

Total

137

41

418

53

10

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 87 of 103

Peer Support Agency
Manchester Derry Connections Portsmouth Total TriCity Coop Rochester Total

July – September 2020

April – June 2020

Total Members

Average Daily Visits Total Members

Average Daily Visits

169

10

75

4

96

4

62

6

73

6

98

5

100

6

246

9

265

0

Total

2260

128

1,850

128

Revisions to Prior Period: None.

DRAFT

DRAFT

Data Source: Bureau of Mental Health Services and Peer Support Agency Quarterly Statistical Reports.

Notes: Data Compiled 08/05/2020. Average Daily Visits are not applicable for Outreach Programs.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 88 of 103

8. Housing Bridge Subsidy Program: Summary of Individuals Served to Date July – September 2020

Subsidy

Total individuals served at start of quarter

New individuals added during quarter

Total individuals served through end of quarter

Housing Bridge Subsidy

944

35

979

Section 8 Voucher (NHHFA/BMHS) Transitioned from Housing Bridge

192

6

198

April – June 2020

Subsidy Housing Bridge Subsidy
Section 8 Voucher (NHHFA/BMHS) Transitioned from Housing Bridge

Total individuals served at start of quarter

New individuals added during quarter

Total individuals served through end of quarter

922
DRAFT DRAFT
179

22

944

13

192

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 09/30/2020. Figures at start and end of each quarter are a cumulative total of individuals served since CMHA quarterly reporting began in 2015. Figures for new individuals reflect activity throughout the quarter; these are not a point-in-time count at the end of the reporting period. New individuals added includes individuals newly approved for HBSP funding that have or have not yet secured an HBSP unit, some of whom may have also exited the program in the quarter. These individuals have been on the HBSP waitlist prior to funding approved in the quarter or have newly applied for and been approved for funding in the same quarter.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 89 of 103

8a. Housing Bridge Subsidy Program: Current Census of Units/Individuals with Active Funding Status

Measure

As of 9/30/2020

As of 6/30/2020

Rents Currently Being Paid

312

328

Individuals Enrolled and Seeking Unit for Bridge Lease

96

79

Total

408

407

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 09/30/2020. All individuals currently on the HBSP are intended to transition from the program to other permanent housing. Individuals seeking a unit include people who have not secured their first unit under HBSP and people who secured a unit previously and are seeking a different unit.

8b. Housing Bridge Subsidy Program: Clients Linked to Mental Health Care Provider

Services

DRAFT

Measure

DRAFT
As of 9/30/2020

As of 6/30/2020

Housing Bridge Clients Linked

335/409 (82%)

329/406 (81%)

Revisions to Prior Period: None.

Data source: Bureau of Mental Health Services data, Phoenix 2, and Medicaid claims.

Notes: Data compiled 11/10/2020; “Housing Bridge Clients Linked” refers to Housing Bridge clients who received one or more mental health services within the previous 3 months, documented as a service or claim data found in Phoenix or the Medicaid Management Information System.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 90 of 103

8c. Housing Bridge Subsidy Program: Density of HBSP Funded Units at Same Property Address*

Number of HBSP Funded Unit(s)* at Same Address

Frequency as of 9/30/2020

Frequency as of 6/30/2020

1

255

267

2

20

15

3

2

6

4

0

0

5

1

0

6

0

1

7

1

1

8 or more

0

0

Revisions to Prior Period: None.
DRAFT
Data Source: Bureau of Mental Health ServicesDRAFT and Housing Provider Data.

Notes: Data Compiled 09/30/2020. *All units are individual units; property address may include multiple buildings, such as apartment complexes.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 91 of 103

8d. Housing Bridge Subsidy Program: Applications

Measure

July – September 2020*

April - June 2020

Applications Received During Period

57

30

CMHCs 50; NHH 6; NFI CHMCs 29; NHH 1; NFI

Point of Contact for Applications Received

1

1

Applications Approved

57**

27

Applications Denied

0

0

Denial Reasons

NA

NA

Applications in Process at End of Period

0

41

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services.

Notes: Data Compiled 09/30/2020. *Data reflects only those applications that were received
during the quarter and no longer reflect carryover data from applications received in prior
DRAFT
quarters **Includes 15 awarded an HBSP subsidy DRAFT in the same quarter the application was
received, 3 of which also exited the program in the same quarter, and 42 added that remained
on the waitlist as of the quarter’s close.

8e. Housing Bridge Subsidy Program: Terminations

Type and Reason

July – September 2020

April - June 2020

Terminations – DHHS Initiated

2

0

He-M 406.08 (a)(5): Failure to pay rent for 3 or more consecutive months

2

0

Exited Program – Client Related Activity

45

27

Voucher Received Deceased Over Income Moved Out of State

24

16

1

2

1

1

3

2

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 92 of 103

Declined Subsidy at Recertification* Higher Level of Care Accessed** Other Subsidy Provided Moved in with family

10

2

4

2

2

1

0

1

Total

47

27

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 09/30/2020. This table only includes individuals who were receiving an HBSP subsidy or who had HBSP funding approved and were seeking a unit prior to exiting the program. *Includes all refusals, including refusal to initiate voucher and unable to contact. **Includes one individual at the Secure Psychiatric Unit (SPU).

8f. Housing Bridge Subsidy Program: Application Processing Times

Average Elapsed Time of Application Processing (calendar days)*
DRAFT DRAFT

July – September 2020

Completed Application to Determination

1

April - June 2020 1

Approved Determination to Funding Availability**

75

80

Referred to Vendor with Funded HB Slot

1

1

Leased Unit Secured***

95

80

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services.

Notes: Data Compiled 09/30/2020.

*Elapsed time measure reporting implemented 10/01/18 and applies to any application received on or after that date.

**Average calculated on 35 applications approved for which funding was made available in the quarter; 15 of these applications were received and approved for funding in the same quarter. ***Average calculated on 14 units leased during the quarter.
9. Housing Bridge Subsidy Program Waitlist: Approved Applications

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 93 of 103

Total

0-30

31-60

days

days

85

12

17

Total

0-30

31-60

days

days

39

6

9

Revisions to Prior Period: None.

As of 9/30/2020*

Time on List

61-90 91-120

days

days

12

7

As of 6/30/2020

Time on List

61-90 91-120

days

days

4

5

121-150 days 10

151-180 days 3

121-150 days 6

151-180 days 6

181+ days 24
181+ days
3

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 09/30/2020. *Includes some individuals formerly on inactive status returned to waiting status. Additionally, there are four individuals in a higher level of care who were not yet appropriate for discharge as of 9/30/2020 but for whom an HBSP subsidy has been approved, pending discharge. They are in inactive status and are not included in the waitlist count.

10. Supported Housing Subsidy Summary
DRAFT DRAFT

July – September April - June

2020

2020

Subsidy

Total subsidies by end of quarter

Total subsidies by end of quarter

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 94 of 103

Housing Bridge Subsidy:

Units Currently Active
Individuals Enrolled and Seeking Unit for Bridge Lease

312

328

96

79

Section 8 Voucher Transitioned from Housing Bridge*

(NHHFA):

Not Previously Receiving Housing Bridge

198

192

3

3

811 Units:

PRA Mainstream

89

81

62

44

Other Permanent Housing Vouchers (HUD, Public Housing, VA)

6 7

Total Supported Housing Subsidies

767

733

Revisions to Prior Period:

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 09/30/2020. Section 8 Voucher Not Previously Receiving Housing
DRAFT
Bridge are CMHC clients that received a Section DRAFT 8 Voucher without previously receiving a Housing Bridge subsidy. 811 Units (PRA and Mainstream) are CMHC clients or CMHA Target Population members that received a PRA or Mainstream 811 funded unit with or without previously receiving a Housing Bridge subsidy. Other Permanent Housing Vouchers (HUD, Public Housing, VA) are CMHC clients that received a unit funded through other HUD or Public Housing sources with or without previously receiving a Housing Bridge subsidy.

*These counts are cumulative; increasing over time since originally reporting this data within the CMHA Quarterly Data Report. 75 of these units are verified currently occupied units by former program participants; after 6 months of occupancy under the Section 8 Voucher, BMHS routine verification of occupancy discontinues.

Balance of page intentionally left blank.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 95 of 103

11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure

July 2020

August 2020

Septemb er
2020

July – Sept. 2020

April – June 2020

Unique People Served in Month

210

197

230

557

530

Services Provided by Type Case Management* Crisis Apartment Service* Crisis Intervention Services ED Based Assessment* Medication Appointments or Emergency Medication Appointments* Mobile Community Assessments Office-Based Urgent Assessments Other* Peer Support* Phone Support/Triage Psychotherapy*

0

0

0

0

0

0

0

0

0

0

5

5

4

14

1

0

0

0

0

0

DRAFT DRAFT

0

0

0

0

0

80

43

55

178

211

15

10

20

45

28

0

0

0

0

0

0

0

0

0

0

454

425

415

1,294 1,343

0

0

0

0

0

Referral Source CMHC Internal Emergency Department

14

17

23

1

9

16

54

34

26

9

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 96 of 103

Family Friend Guardian MCT Hospitalization* Mental Health Provider Other Police Primary Care Provider Self School

20

31

25

7

4

6

22

16

19

0

0

0

6

7

6

4

10

17

12

6

5

5

5

7

118

209

168

1

1

9

76

70

17

12

57

58

0

0

19

23

31

7

23

36

17

14

495

345

11

2

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

DRAFT
15 DRAFT

10

20

45

39

40

36

69

145

125

2.5

3.6

3.5

3.2

3.3

Law Enforcement Involvement

24

6

19

49

76

Hospital Diversions Total

188

160

175

523

529

Revisions to Prior Period: None.
Data Source: Riverbend CMHC submitted report.
Notes: Data Compiled 10/27/2020. Reported values other than the Unique People Served in Month value are not de-duplicated at the individual level; individuals can account for multiple instances of service use, hospital diversions, etc. *A data reporting issue resulting in no

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 97 of 103 services being captured for reporting purposes in some categories is being addressed with Riverbend.
DRAFT DRAFT

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 98 of 103

11b. Mobile Crisis Services and Supports for Adults: Mental Health Center of Greater Manchester

Measure Unique People Served in Month

July 2020
308

August September

2020

2020

303

305

July – Sept. 2020
723

April – June 2020
669

Services Provided by Type Case Management Crisis Apartment Service Crisis Intervention Service ED Based Assessment Medication Appointments or Emergency Medication Appointments Mobile Community Assessments Office-Based Urgent Assessments Other Peer Support Phone Support/Triage Psychotherapy

27 0
198 0 8
DRAFT DRAFT

22 0
181 0 5

107

92

3

10

254

264

16

6

619

520

2

1

50

99

118

0

0

0

262

641

646

0

0

0

4

17

14

97

296

294

7

20

23

249

767

754

17

39

36

560

1,699 1,552

3

6

11

Referral Source CMHC Internal Emergency Department

9

3

1

0

3

15

14

1

2

2

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 99 of 103

Family Friend Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self School

68

43

3

3

3

17

4

9

16

13

15

22

92

106

11

9

151

149

0

0

52

163

171

6

12

25

10

30

33

5

18

22*

16

45

18

19

56

55

90

288

249

9

29

21

145

445

462

0

0

2*

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

DRAFT

DRAFT

0

0

0.0

0 0 0.0

0

0

0

0

0

0

0.0

0.0

0.0

Law Enforcement Involvement

92

106

90

288

249

Hospital Diversion Total

373

351

351

1,075 1,055

Revisions to Prior Period: *Indicate corrected counts.

Data Source: Phoenix 2.

Notes: Data Compiled 10/27/2020. Reported values other than the Unduplicated People Served in Month value are not de-duplicated at the individual level; individuals can account for multiple instances of service use, hospital diversions, etc.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 100 of 103

11c. Mobile Crisis Services and Supports for Adults: Harbor Care

Measure Unique People Served in Month

July 2020
79

August September July – Sept.

2020

2020

2020

90

57

208

April – June 2020
245

Services Provided by Type Case Management Crisis Apartment Service Crisis Intervention Services ED Based Assessment Medication Appointments or Emergency Medication Appointments Mobile Community Assessments Office-Based Urgent Assessments Other Peer Support Phone Support/Triage Psychotherapy

11

20

75

47

0

0

4

5

0

0

DRAFT DRAFT
27

29

9

27

0

0

47

26

79

79

2

0

10

41

59

76

198

168

0

0

0

3

12

13

0

0

0

18

74

183

21

57

29

0

0

0

37

110

227

40

198

326

2

4

1

Referral Source CMHC Internal Emergency Department Family

6

10

1

6

13

15

3

19

13

4

11

1

7

35

32

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 101 of 103

Friend Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self Schools

4

2

0

0

0

0

7

7

5

16

7

1

0

1

58

68

0

0

2

8

3

0

0

0

0

0

0

2

16

27

7

28

217

0

8

1

2

3

1

41

167

80

1

1

1

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

12
DRAFT
63 DRAFT
5.3

9 39 4.3

12

33

30

70

172

142

5.8

5.1

4.8

Law Enforcement Involvement

0

0

1

1

1

Hospital Diversion Total

114

126

76

316

511

Revisions to Prior Period: None.

Data Source: Harbor Homes submitted data.

Notes: Data Compiled 10/27/2020. Reported values other than the Unique People Served in Month value are not de-duplicated at the individual level; individuals can account for multiple instances of service use, hospital diversions, etc.

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 102 of 103
DRAFT DRAFT
Appendix B QSR Summary Scores: 2020

Case 1:12-cv-00053-SM Document 135-1 Filed 02/01/21 Page 103 of 103

CMHC QSR Indicator Results: State Fiscal Year 2020
Indicator # Indicator

Region 1 Region 2 Region 3

NHS

WCBH LRMHC

Region 4 RMHC

Region 5 Region 6 Region 7 Region 8

MFS

GNMHC MHCGH

SMHC

Region 9 Region 10 STATE

CP

CLM

AVERAGE

1

Adequacy of Assessment

90%

89%

97%

96%

93%

85%

92%

94%

92%

96%

92%

2

Appropriateness of treatment planning

85%

93%

85%

96%

88%

89%

94%

100%

88%

96%

92%

3

Adequacy of individual service delivery

82%

86%

83%

95%

86%

90%

94%

90%

93%

96%

89%

4

Adequacy of Housing Assessment

100%

100%

100%

95%

100%

95%

100%

100%

95%

100%

99%

5

Appropriate of Housing Treatment Plan

95%

90%

86%

95%

100%

86%

100%

90%

86%

68%

90%

6

Adequacy of individual housing service delivery

88%

85%

86%

100%

95%

90%

91%

86%

92%

95%

91%

7

Effectiveness of Housing supports provided

82%

92%

87%

89%

90%

90%

86%

90%

86%

95%

89%

8

Adequacy of employment assessment/screening

70%

68%

55%

71%

68%

64%

78%

81%

64%

68%

69%

*Appropriateness of employment treatment

9

planning

88%

82%

63%

100%

82%

64%

90%

67%

100%

100%

83%

DRAFT

DRAFT

10

*Adequacy of individual employment service delivery

69%

63%

59%

95%

90%

90%

63%

82%

91%

78%

78%

Adequacy of Assessment of social and community

11

integration needs

100%

100%

100%

97%

100%

100%

100%

100%

98%

100%

100%

Individual is integrated into his/her community, has

choice, increased independence, and adequate social

12

supports

77%

83%

74%

82%

80%

77%

77%

84%

74%

86%

79%

13

*Adequacy of Crisis Assessment

75%

67%

83%

96%

72%

100%

91%

58%

75%

81%

80%

14

Appropriateness of crisis plans

88%

100%

82%

95%

93%

93%

92%

93%

84%

79%

90%

15

*Comprehensive and effective crisis service delivery

100%

70%

72%

100%

88%

88%

81%

75%

75%

63%

81%

16

Adequacy of ACT Screening

100%

100%

100%

100%

100%

95%

100%

100%

98%

100%

99%

17

*Implementation of ACT Services

*Successful transition/discharge from the inpatient

18

psychiatric facility

AVERAGE

36%

77%

73%

85%

81%

88%

80%

79%

71%

67%

74%

71%

83%

81%

80%

86%

82%

81%

86%

80%

91%

82%

83%

85%

81%

93%

88%

87%

88%

86%

86%

87%

86%

 
 Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 1 of 95
1
Exhibit A
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Twelve
August 18, 2020
I. Introduction
This is the twelfth semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report on the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
Community Mental Health Centers (CMHCs), remained functional and open as essential businesses during this period, and transitioned the majority of employees to remote working. Following Centers for Disease Control and Prevention (CDC) recommendations and NH Division of Public Health Services (DPHS) guidance, in addition to program specific emergency guidance provided by the Bureau of Mental Health Services (BMHS), CMHCs focused on adjusting service delivery to maintain health and to implement safety protocols while serving participants in a way that met participant needs and preferences. Telehealth services were provided for participants preferring that method due to COVID-19 concerns, and in-person services remained available for individuals who preferred this method.. Mental Health (MH) facilities, including New Hampshire Hospital (NHH), Glencliff, and residential treatment centers, modified safety protocols to protect residents/patients from COVID-19. And, State of New Hampshire officials who in regular times would be focused on implementation of the CMHA have instead been primarily focused on addressing the many challenges posed by COVID-19. The State has implemented numerous strategies, including Medicaid plan changes, eligibility certification improvements, staffing requirements, etc. to insure that to the extent possible service response rates and service continuity have been maintained. The State has also instituted new data tracking mechanisms to assess the degree to which COVID-19 has affected service access, service utilization, and hospitalization.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 2 of 95
2
During the review period, the ER has been unable to conduct on-site visits or observations, other than a three-day visit to Glencliff in January. Although some Quality Service review and Fidelity Reviews have taken place during this period, the ER has not been able to observe any of these activities. More recently, because of COVID-19, there has been a break in the continuity of QSR and Fidelity review data which has been used to assess progress towards compliance with the CMHA.
The ER has participated in a number of conference calls with State officials and representatives of the Plaintiffs, as outlined below. The ER has also continued to monitor the routine monthly and quarterly data reports produced by the State, as well as newly generated data reports related to the response to COVID-19. Nonetheless, by necessity this report will be limited by the inability to have face-to-face contact with service administrators, service providers and service participants.
During this period, the ER:
 Conducted an in-depth three-day site review at Glencliff, which included reviews of 50 clinical records and interviews with senior administrators and clinical staff;
 Conducted telephone interviews with state officials to discuss state policies and activities related to facilitating transitions of residents of Glencliff into integrated community settings;
 Participated in a conference call with state leaders to discuss the State’s response to COVID-19 as it relates to the mental health system;
 Convened two conference call meetings of the Parties to discuss transition planning and transitions to integrated community settings for Glencliff residents;
 Convened an All Parties conference call meeting to discuss progress in meeting the requirements of the CMHA.
Information obtained during these state level and on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. When it is again possible, the ER will resume conducting site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
Summary of Progress to Date
This report reflects more than five and one-half years of implementation efforts related to the CMHA. Within this period, a number of positive steps have been taken to improve the quality and effectiveness of services as envisioned in the CMHA. However, as will be discussed in detail below, there are areas of continued non-compliance with the CMHA. Notwithstanding these ongoing concerns, the parties to the CMHA deserve credit for some real and measurable accomplishments.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 3 of 95
3
As noted in previous ER reports, the State has implemented a comprehensive and reliable QSR process. The ER considers these QSR reviews to be methodologically correct and reliable, producing findings that are accurate and actionable in terms of taking concrete steps to address quality issues in the CMHC system.
Another major accomplishment has been contracting with the Dartmouth-Hitchcock Medical Center to conduct external Assertive Community Treatment (ACT) and Supported Employment (SE) fidelity reviews using nationally validated fidelity review instruments and criteria. In concert with the QSR reviews mentioned above, the fidelity reviews are assisting the State and the CMHCs to develop comprehensive Quality Improvement Plans (QIPs) that address important ACT and SE quality and effectiveness issues at both the consumer and CMHC operational levels.
Recently, following input from representatives of the Plaintiffs and the ER, the State has initiated or enhanced a number of strategies to expand ACT capacity and enrollment. Because of the impact of COVID-19 in New Hampshire, it is not possible at this time to gauge the full impact of these strategies. Recent data support mild optimism that ACT staffing is moving in a positive direction.
The parties originally envisioned that the CMHA could be fully implemented in five years, with a sixth year for maintenance of effort. The CMHA was approved and filed with the Federal Court on February 12, 2014, and the five-year anniversary of that event occurred 17 months ago. The ER was approved by the Parties and the Federal Court effective July 1, 2014, and the fiveyear anniversary occurred 12 months ago. Given these elapsed times, it is critical for this report and for subsequent activities that the focus be on specific strategies and action steps necessary to meet the requirements of the CMHA, and to plan for disengagement.
II. Data
As noted in previous reports, the New Hampshire Department of Health and Human Services (DHHS) continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (January 2020 through March 2020), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The capacity to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve. The ER continues to emphasize that the State must produce the necessary data reports in a timely fashion.
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 4 of 95 4
Mobile/Crisis and Crisis Apartment Programs
The CMHA calls for the establishment of a Mobile Crisis Team (MCT)1 and Crisis Apartments (MCT/CA) in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC was selected to implement the MCT and Crisis Apartments in the Concord Region. The CMHA specified that a second MCT/CA program be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. Per CMHA V.C.3(c), a third MCT/CA program became operational in the Nashua region on July 1, 2017. The contract for that program was awarded to Harbor Homes in Nashua. As of the date of this report, the State reports that it has extended the existing MCT/CA program contracts in Riverbend (Concord) and Manchester until June 2022. The State reports it has incorporated contract changes for these programs including: (a) new performance measures related to face-to-face assessments and follow-up engagement with peers; and (b) new data reporting elements related to presenting problems, police involvement, and intervention outcomes. The ER will monitor implementation of these new requirements over the next six month period. The vendor in Nashua (Harbor Homes) is reported to have opted out of its contract. To assure continuity of services, the State reports it has extended the current Nashua contract for four months, during which time a new vendor will be sought. The ER intends to monitor this situation closely over the next six months. The Quarterly Data Report contained in Appendix A includes a detailed table of data from each of the Mobile Team/Crisis Apartment programs. Table I contains a summary of key data trends from the three programs.
1 Note that the State refers to these programs as Mobile Crisis Response Teams (MCRTs). The ER uses the MCT nomenclature to remain consistent with the terms used in the CMHA.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 5 of 95 5

Table I Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs

Region

Variable

Concord Manchester Nashua

Total Served Total Served Total Served

April -June 2019 517 714 419

July - Sept. 2019 499 679 377

Oct. - Dec 2019 516 604 368

Jan. - Mar. 2020 531 618 333

Concord Manchester Nashua

Phone triage/support Phone triage/support Phone triage/support

1,143 1,795
522

1,104 1,833
530

1,139 1,482
463

1,173 1,565
385

Concord Manchester Nashua

Mobile Assess./intervention Mobile Assess./intervention Mobile Assess./intervention

136

211

149

116

319

280

303

290

245

231

189

210

Concord Manchester Nashua

Percent Referred by self Percent Referred by self Percent Referred by self

68.8% 31.8% 27.4%

61.6% 36.7% 29.8%

56.39% 75.7% 41.12%

64.22% 68.2% 34.23%

Concord Manchester Nashua

Percent referred by police Percent referred by police Percent referred by police

1.8% 28.2%
2.7%

3.7% 25.4%
2.1%

5.04% 37.25% 4.62%

4.33% 33.0% 3.60%

Concord Manchester Nashua

Percent Law Enforcement Inv. Percent Law Enforcement Inv. Percent Law Enforcement Inv.

14.1% 44.8%
0.0%

12.6% 40.2%
0.0%

5.00% 37.25% 0.00%

8.70% 33.0% 0.00%

Concord

Hospital diversions

Manchester Hospital diversions

Nashua

Hospital diversions

Concord Manchester Nashua

Apartment Admits Apartment Admits Apartment Admits

Concord Manchester Nashua

Apartment bed days Apartment bed days Apartment bed days

449

520

483

1,185

1,111

1,086

704

710 612

383 1,088 617

80

78

81

57

15

9

18

17

51

53

48

56

319

397

364

245

46

27

72

53

249

306

252

296

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 6 of 95 6
Table II below includes data that reveal some recent changes in both emergency department waiting times for NHH admissions, and for NHH readmission rates. These data may indicate that the fully implemented MCT and Crisis Apartment programs have a positive effect on system indicators such as emergency department boarding and hospital recidivism rates. However, there may be numerous other factors influencing these data trends.

Table II DHHS Report of Changes in Waiting Time for NHH Admissions and NHH Readmission Rates

12-month Period

Average # Adults Waiting per Day for NHH Admission

NHH Admissions

NHH 180-day Readmissions Average

4/1/18 – 3/31/19 4/1/19 – 3/31/20 Change

44 29 Down 34%

788 938 Up 19%

24% 21.9% Down 8.8%

The ER continues to be concerned about some apparent practice and data reporting variations among the three MCT/CA programs. For example, as can be seen in Table I, there are substantial differences among the three programs with regard to police referrals to and law enforcement involvement in the various programs. Late last year, in concert with representatives of the plaintiffs, the ER requested additional information from the State regarding the functioning of these programs. While the State reports conducting visits to the MCT/CA program sites, no performance assessments or other contractual reviews/program evaluations or QIPs (if applicable) have been published or shared with the ER or the parties. The ER expects additional State oversight and/or corrective action on the part of the MCT/CA programs, including an effort to measure program performance in key areas of MCT service delivery, like phone triage, decisions to deploy mobile crisis teams to community locations, and the efficacy of crisis response.
The State has issued an RFI related to MCT/CA programs, and responses have been received by the State as of the date of this report. The State asserts that the RFI indicates that it is “actively engaged in a comprehensive effort to explore best practices and model designs for MCT services, and we anticipate this effort also will inform the next contracts for the MCTs required under the CMHA.” 2 The ER previously recommended that the parties collectively review the responses to the RFI and that the ER and representatives of the Plaintiffs engage in discussions with the State about current program operations and future operations of MCT and similar programs in New Hampshire. The State has just recently shared the responses to the RFI with
2 State response to ER memo re: MCTs, December 12, 2019, page 1.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 7 of 95
7
the ER and representatives of the Plaintiffs. To date there have not been any substantive discussions among the Parties to the CMHA about future directions for the MCT/CA programs, but the ER expects that will occur after there has been sufficient time to review the RFI responses. Given the need to select a new vendor for the greater Nashua area, the ER expects these conversations to occur before October 1, 2020.
The State recently funded a new Behavioral Health Crisis Treatment Center (BHCTC) that has been implemented by the Riverbend CMHC in Concord. The BHCTC is an additional crisis support outside those required by the CMHA. As such, data related to the operations of that program is not included in this report. The State asserts that it is not currently considering this model for expansion of crisis programs in New Hampshire.
Assertive Community Treatment (ACT)
ACT is a core element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team;
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target population at any given time; and
4. By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.
The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015 (60 months ago). Further, as of June 30, 2016, the State was required to have the capacity to provide ACT for 1,500 priority target population individuals.
As displayed in Table III below, the staff capacity of the 13 adult ACT teams in New Hampshire has increased by 4.47 FTE since June of 2019. However, this represents a reduction of 3.9 FTE since December of 2019. It should be noted that this is a decrease of .08 FTE since September, 2017.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 8 of 95 8

Table III

Self-Reported ACT Staffing (excluding psychiatry):

September 2017 – March 2020

Region

FTE FTE FTE FTE

Sep- Mar-

Sep-

17

19 Jun-19 19

FTE

FTE

Dec-19 Mar-20

Northern West Central Lakes Region Riverbend Monadnock Greater Nashua 1 Greater Nashua 2 Manchester – CTT Manchester MCST Seacoast Community Part. CLM Total

12.4 7.0
10.8 10.0
7.9
6.0
5.0
16.3
22.3 10.5
6.7 9.3 124.2

16.8 16.51 16.37 6.8 7.65 8.25 8.3 8.00 8.00
11.5 10.50 11.50 9.5 9.00 8.00

6.5 7.00 8.00

4.5 4.00 7.00

14.3 15.75 15.75

15.8 9.1 8.8 7.9
119.6

17.25 9.10
10.78 7.01
122.55

17.25 10.10 11.28
8.30 129.80

16.97 8.75 7.00
11.50 8.75
8.00
8.00
15.75
15.75 10.10 10.80
9.55 130.92

16.37 6.10 7.00
10.50 8.85
6.50
7.50
18.25
16.25 9.10
11.05 8.55
127.02

Two teams (West Central and Nashua 1) report having fewer than the required minimum of seven FTEs to qualify as an ACT team. Two teams (Riverbend and Community Partners) report having no peer support specialist. One team (Nashua 2) reports having no SE staff capacity. Five teams report having 0.5 or less FTE combined psychiatry/nurse practitioner time available to their ACT teams3; and five of the 12 teams report having less than one FTE nurse per team.
Table IV below displays the active ACT caseloads by CMHC Region since June 2017. Note that, for economy of presentation, data for the reporting periods from December 2017 through April 2019 have been excluded from the table. The active monthly caseload has decreased by 31 participants since December, 2019. Since June of 2017 the active monthly caseload has dropped by 103.

3 The CMHA specifies at least 0.5 FTE Psychiatrists for teams with at least 70 active service participants. (CMHA V.D.2(e)).

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 9 of 95 9

Table IV
Self-Reported ACT Active Caseload (Unique Adult Consumers) by Region in Specified Months: June 2017 – March 2020

Region

Active
Cases Jun17

Active
Cases Sep17

Active
Cases Jun19

Active
Cases Sep19

Active Cases
Dec-19

Active Cases
Mar-20

Northern

111 113 115 122 118

115

West Central

76 68 46 47

43

42

Lakes Region

74 74 57 56

56

57

Riverbend

97 87 102 86

94

94

Monadnock

70 69 57 49

50

51

Greater Nashua 94 98 83 97

99

101

Manchester

292 287 287 300 286

262

Seacoast

69 67 66 68

65

66

Community

Part.

69 75 67 71

74

68

CLM

55 54 47 49

50

47

Total*

1,006 992 925 942 934

903

* unduplicated across regions

The combined ACT teams have a reported March 2020 staff complement of 127.02 FTEs excluding psychiatry, which is sufficient capacity to serve 1,270 individuals based on the ACT non-psychiatry staffing ratios contained in the CMHA. However, with a statewide caseload of only 903, as of March 2020, there is a gap between staff capacity and active participants of 367.
As noted above, the CMHA requires the State to have capacity to serve 1,500 individuals. The current ACT staffing levels are 23 FTEs, (or capacity to serve 230 participants), below the capacity required by the CMHA. This gap between staff capacity and actual service participants is particularly problematic, given that there are reported to be 10 individuals on the wait list for ACT (see Table VII below). The State reports that all 10 are awaiting services from one of the two teams in Manchester, but State data reveals that the two teams in Manchester have unused ACT staffing capacity that could accommodate 83 new individuals right now. There appears to be no staffing explanation to justify the waitlist. An additional 15 individuals are reported to have been referred for ACT services, but they are awaiting a CMHC determination of appropriateness for ACT. It is not clear why there is a delay determining ACT appropriateness. As noted in previous reports, the current level of ACT staffing is not sufficient to meet CMHA requirements for ACT team capacity. Furthermore, the current ACT caseload of 903

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 10 of 95 10
individuals is 597 below the number that could be provided ACT services with the staffing capacity required by the CMHA.4
ACT Screening As has been documented in previous reports, the State has been implementing a number of strategies to increase ACT enrollment and participation. One of these strategies has been to require the ten CMHCs to conduct and report regular clinical screening for eligibility/appropriateness for ACT services. The clinical screens are conducted:
1. As part of the intake process at the CMHCs; 5 2. Upon referral to a CMHC following discharge from an inpatient facility; and 3. As part of regular quarterly and annual assessments and plan of care amendments for
current CMHC clients6 who may qualify for and benefit from ACT. Table V below presents data on ACT screens conducted by CMHCs between October and December, 2019.
4 The ER notes that active ACT caseload is a static measure of ACT activity. The ER plans to work with the State and representatives of the Plaintiffs to incorporate other indicators, such as ACT enrollments and unduplicated ACT participants in subsequent reports. 5 Note that a CMHC intake incorporating the ACT screen is performed when a CMHC emergency services staff or Mobile Crisis Team encounters and refers a person potentially needing CMHC services. In some cases, these Emergency Services/ MCT referrals are made on behalf of individuals who have presented in crisis in hospital emergency departments and who may be waiting for a NHH admission. 6 Until recently, data on the total number of ACT screenings included current ACT participants. Active ACT clients have now been removed from screening reports.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 11 of 95 11

Table V

Self-Reported Number of Unique Clients Screened for ACT Services by CMHCs October - December 20197

Community Mental Health Center

Total Screened

Appropriate for further ACT
Assessment

Receiving ACT/ w/i 90
days of Assessment

Percent Receiving ACT of those Qualified for Assessment

Percent Receiving ACT in Previous
Report

01 Northern Human

1,166

21

Services

2

9.5%

10%

02 West Central

221

2

Behavioral Health

2

100%

0.0%

03 Lakes Region Mental

906

11

Health Center

1

9.1%

0.0%

04 Riverbend

1,342

13

Community Mental

Health Center

2

15.4%

0.0%

05 Monadnock Family

576

3

Services

0

0.0%

0.0%

06 Greater Nashua

726

6

Mental Health

1

16.7%

62.5%

07 Mental Health Center 1,641

7

of Greater Manchester

1

14.3%

0.0%

08 Seacoast Mental

1,392

48

Health Center

0

0.0%

0.0%

09 Community Partners

434

0

0

0.0%

0.0%

10 Center for Life

779

2

Management

0

0.0%

0.0%

Total

9,183

113 (1.2% of all screened)

9 (7.96% of all assessed after
screening0.1% of all screened)

7 The most recent Quarterly Data Report contains screening data only through December 2019.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 12 of 95 12

Of the 9,183 unique individuals screened for ACT during this period, the State reports that 113 were referred for an ACT assessment. This is a referral rate of one percent. And, less than 8 percent (nine individuals) of those referred for ACT assessments were enrolled in ACT services within 90 days of being screened. Most of the referrals for ACT screening are internal to the CMHCs. That is, people who have already had a CMHC intake, and who may already be receiving CMHC services, are those most likely to be screened for ACT services. Thus, it is perhaps not surprising that so few of the individuals screened are referred to the next step, which is the assessment for ACT.

The State has reported that about 88% of individuals are linked to ACT without having gone through the ACT screening process. No specific data have been reported to date about where these referrals originate or how they avoided the CMHC intake and screening process. Because of this limitation, available screening data does not shed light on whether individuals outside of the CMHC system who would benefit from ACT services are being properly identified and referred for assessment.

New ACT Clients

The State has recently begun reporting the number of new ACT clients. Table VI summarizes these data from the two most recent reporting periods.

Table VI

Self-Reported New ACT Clients

CMHC
Northern Human Services West Central Behavioral Health Lakes Region MHC Riverbend CMHC Monadnock Family Services Greater Nashua Mental Health MHC of Greater Manchester Seacoast MHC Community Partners Center for Life Management
Total

New Clients October 2019 – December 2019
6 11 5 20 1 6 17 3 5 3 77

New Clients January 2020 – March 2020
10 6 4 13 1 8 19 4 4 1 70

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 13 of 95
13
It should be noted that in the time period from October to December, 2019, the State reported a decrease in active ACT caseload from 958 to 934, while at the same time reporting the addition of 77 new ACT clients. For the period January through March, 2020, the State reported that the ACT active caseload decreased from 929 to 903, while at the same time reporting the addition of 70 new ACT clients. This indicates that: (1) there is substantial turnover in the active ACT caseload over a relatively short time frame; and (2) thus, substantial efforts to engage new ACT clients are necessary just to maintain steady state operations in the ACT program, much less to grow the program. Indeed, for the January-March 2020 review period, the State reports that while 70 new ACT clients were added, over 100 were discharged from, or otherwise dropped out of, ACT services. The ER notes that the State does not currently report on dispositions for individuals who leave ACT services. This is an important topic for future discussions and reporting, especially with regard to any former ACT clients who then suffer decline or crisis after ACT services are terminated.
The State has been reporting data on the number of individuals waiting for ACT services on a statewide basis for the past 18 months. This information is displayed in Table VII below. The State and the CMHCs assert that an individual eligible for ACT may have to wait for ACT services because the specific ACT team of the individual’s CMHC does not currently have staff capacity to accept new clients. The ER has documented above that there is a statewide gap between ACT staff capacity and ACT participation. Indeed, there is excess capacity in each region/team and enough capacity to address the needs of people reported to be on the waitlist. Nonetheless, the State and the CMHCs note that in some CMHC regions, new ACT staff must be hired before new ACT clients can be accepted into the program.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 14 of 95 14

December 31, 2018
March 31, 2019
June 30, 2019
September 30, 2019
December 31, 2019
March 31, 2020

Table VII Self-Reported ACT Wait List

Time on List

Total

0-30 days 31-60 days 61-180 days

6

3

0

3

2

1

1

0

1

1

0

0

2

2

0

0

5

2

2

1

10

0

3

7

The ER notes that all 10 individuals reported to be on the wait list for ACT services have been waiting for greater than 30 days: seven of the 10 have been waiting for more than 60 days. Given the excess ACT capacity noted above, the ER expects the State will intervene to assure that people in need of, and eligible for, ACT receive ACT services in a timely manner.
New Hampshire Hospital (NHH) Admissions and Discharge Data Relative to ACT
In concert with other strategies to improve access to ACT services, the State has begun tracking the extent to which individuals on ACT are admitted to NHH; are referred to ACT from NHH; and are accepted into ACT upon discharge from NHH. Table VIII summarizes data from the past two quarters on these issues.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 15 of 95 15

Table VIII

Self-Reported Total ACT-Related Admissions to and Discharges from NHH

October 2019 through March 2020

Oct.-Dec 2019
Jan.-Mar. 2020

On ACT at Percent of Referred to Percent of

admission

all

ACT on

all

Admissions Discharge Discharges

64

38.1%

25

24.0%

53

35.1%

28

28.6%

Accepted into ACT
on Discharge
14
11

Percent of Those
Accepted into ACT
on Discharge
56.0%
39.3%

In concert with tracking admissions to and discharges from NHH related to ACT, the State has begun reporting the reasons that individuals are not accepted into ACT upon discharge from NHH. Table VIX summarizes this reported information.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 16 of 95 16

Table VIX

Self-Reported Reasons Not Accepted into ACT upon Discharge from NHH

October 2019 through March 2020

Reason Not Accepted into ACT on Discharge
Not Available in Individual’s Town of Residence Individual Declined Individual’s Insurance does not Cover ACT Does not Meet ACT Clinical Criteria Individual Placed on ACT Wait List Individual Awaiting CMHC Determination for ACT
Total Unique Clients

October – December
2019 0 1 0 2 0 8
11

January – March 2020
0 0 0 1 1 15
17

In the January – March 2020 time period almost 90% of the individuals referred but not accepted into ACT on discharge from NHH were reported to be awaiting CMHC determination of ACT. In the October – December time period this number was almost 75% of the total individuals referred but not accepted into ACT. This means that the long elapsed time for CMHCs to determine ACT appropriateness has been the most prevalent reason why people referred for ACT have not yet received it post NHH discharge. The ER remains concerned about these reported delays in accessing ACT services at the CMHC level. This concern is in addition to concerns about the number of people reported to be waiting more than 30 days for access to ACT services.
The ER understands that the State has been attempting to improve referrals to and acceptance in ACT services, and has implemented directed payments and other incentives to improve performance in this area. However, currently reported data does not support a conclusion that access has in fact been improved. Thus, the ER expects the state to take additional steps to align the reported excess capacity in the ACT system with the needs of individuals for ACT services, both on discharge from NHH and from the ACT waiting list. By October 15, 2020 the ER expects a written report from the state on: (1) the action steps being taken to address delays in accessing ACT services; and (2) the actual numerical progress being made to assure that individuals eligible for and in need of ACT, including those being discharged from NHH, receive timely access to these services.
ACT Fidelity and Quality
Limitations on ACT Fidelity reviews have been imposed because of COVID-19. Thus, there is limited fidelity information available for this report.
ACT Summary Findings

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 17 of 95
17
Based on the above information, the ER finds that the State remains out of compliance with the ACT service standards described in Section V.D. of the CMHA. The State does not currently provide a robust and effective system of ACT services throughout the state as required by the CMHA.
The ER emphasizes, as in past reports, that it must be the first priority of the State and the CMHCs to focus on: (1) assuring required ACT team composition; (2) utilizing existing ACT team capacity; (3) reducing the number of individuals on the ACT wait list and/or awaiting ACT services upon discharge from NHH, as well as reducing the length of time individuals are waiting for ACT services; and (4) markedly improving outreach to and enrollment of new ACT clients.
Supported Employment (SE)
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment … to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by June 30, 2017, “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)).
As noted in Table X below, seven of the ten CMHCs now report penetration rates lower than the CMHA requirement. This is an increase in the number of CMHC regions reporting SE penetration below the CMHC standard. In the previous reporting period, six CMHC regions reported being below the state standard of 18.6% penetration. While the State continues to meet the statewide standard for SE penetration in the CMHA, this is primarily due to strong SE penetration rates in two CMHC Regions (Manchester (41.7%) and Seacoast (39%). The ER is increasingly concerned that target population members in large portions of New Hampshire are reported to not have adequate or equitable access to this essential best practice service.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 18 of 95 18

Table X Self-Reported CMHC SE Penetration Rates
Penet. Penet. Penet. Penet. Jun-19 Sep-19 Dec-19 Mar-20

Northern West Central Lakes Reg. Riverbend Monadnock Greater Nashua Manchester Seacoast Community Part. CLM CMHA Target Statewide Ave.

14.90% 22.50% 18.90% 19.00%
6.80% 13.10% 39.00% 33.70%

15.80% 19.70% 18.90% 18.40%
6.20% 12.7% 39.30% 32.90%

15.00% 20.10% 19.60% 17.40%
6.20% 13.00% 40.50% 34.20%

14.20% 22.20% 15.90% 16.20%
7.30% 15.10% 41.70% 39.00%

8.60% 20.80% 18.60% 23.50%

7.80% 20.10% 18.60% 23.20%

10.10% 18.00% 18.60% 23.70%

11.70% 16.40% 18.60% 23.70%

The State reports data on the degree to which CMHC clients are working, either full or part time, in competitive employment.8 Access to competitive employment is an important indicator of the quality and effectiveness of fidelity model SE services. Table XI summarizes some key findings from these data reporting efforts.

8 State data defines full time employment as working 20 hours a week or more. The statewide percentage of SE users in full-time employment in the quarter ending September 30, 2019 was 6.0%.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 19 of 95 19

Table XI
Self-Reported Competitive Employment for CMHC Clients Who Recently Used SE Services

CMHC

Percent of SE Active Clients
Employed Full or Part
Time July – September 2019

Percent of SE Active Clients Employed Full or Part Time Jan – March
2019

Percent of SE Active Clients
Employed Full or Part
Time Oct. Dec
2019

Percent of SE Active Clients
Employed Full or Part
Time Jan. – Mar.
2020

Northern WCBH LRMHC Riverbend Monadnock Nashua MHCGM Comm. Prtnrs. Seacoast CLM

38.9% 28.6% 34.9% 60% 40% 38.9% 58.3% 53.9% 36.3% 75%

44.2% 43.8% 27.9% 61.8% 52.0% 31.9% 54.3% 57.1% 31.3% 56.5%

34.4% 42.1% 53.0% 64.3% 64.7% 37.8% 54.0% 50.0% 32.3% 78.1%

40.5% 45.4% 40.6% 54.0% 36.4% 44.8% 52.0% 42.8% 28.3% 63.3%

Statewide

49.2%

46.7%

51.9%

46.7%

For those eligible adults not involved in SE, the overall numbers are lower, with only 26.9% currently engaged in full-time or part-time employment statewide.
These data provide a reasonable baseline for future analyses. At this point, there do not appear to be substantial changes in the degree to which SE participants are accessing full or part time competitive employment. The ER will continue to review these competitive employment data in concert with the available SE fidelity and QSR reports.
The State reports that 54 individuals are waiting for SE services – 43 individuals (or 80 percent) have been waiting for over a month. This must be addressed to “ensure reasonable access to eligible individuals” per CMHA V.F.2(f).
SE Fidelity and Quality
As with ACT services, the limitations created by COVID-19 have prevented SE fidelity reviews from being conducted during much of the time frame covered by this report. The ER is hopeful

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 20 of 95
20
that quality and fidelity reporting related to SE services can be resumed for the next reporting period.
Supported Housing (SH)
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Program and HUD-funded subsidies by June 30, 2016. As of March, 2020, the State reports having 327 individuals leased in Bridge Program subsidized units and 94 people approved for a Bridge Program subsidy, but not yet leased. This 94 figure is high compared to past totals and seems to indicate that there may be an execution problem somewhere in the system. The State has not provided any localized data per region to expose the location of any problems with getting individuals into leased apartments. There are 49 individuals reported to be on the Bridge Program wait list as of the end of March, 2020. Of these, 18 individuals have been on the wait list for more than two months. There has been a precipitous drop in the aggregate number of individuals either leased or approved but not yet leased in the Bridge Program – from 591 in June of 2017 to 421 in March, 2020; the current number with leases being paid is only 327.
Table XII below provides data regarding the number of current Bridge Subsidy participants; the number waiting to lease; the number on the Bridge Subsidy waiting list; the total number leased since the inception of the program; and the total number receiving a HUD Housing Choice Voucher (HCV). Table XIII provides quarterly data regarding the number of Bridge Subsidy program applications and terminations.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 21 of 95 21

Table XII

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

June 2017 through March 2020

Bridge Subsidy Program
Information

June 2017

Sept. March June 2018 2019 2019

Sept. 2019

Dec. 2019

March 2020

Total individuals 545

423

389

365

338

340

327

leased in the

Bridge Subsidy

Program

Individuals in

46

0

11

13

35

54

94

process of leasing

Individuals on the 0 wait list for a Bridge Subsidy9

35

38

44

42

25

49

Total number

701

811

812

812

829

872

922

served since the

inception of the

Bridge Subsidy

Program

Total number

85

125

137

133

151

163

179

transitioned to a

HUD Housing

Choice Voucher

(HCV)

9 The State did not maintain a waitlist prior to 2018.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 22 of 95 22

Table XIII

Self-Reported Housing Bridge Subsidy Applications and Terminations

Measure

January – March 2019

April – June 2019

JulySeptember
2019

October – December
2019

January – March 2020

Applications

29

28

22

59

74

Received

Point of Contact

CMHCS

22

11

13

51

63

NHH

5

14

9

8

11

Other

1

1

0

0

0

Applications

14

14

11

42

104

Approved

Applications

0

1

0

0

0

Denied

Denial Reasons

NA

0

NA

NA

NA

Applications in

Process at end of

period

53

74

75

79

49

Terminations

1

0

0

0

2

Termination Reasons

1

NA

NA

NA

Not

Reported

Over Income

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target population.” (V.E.1(b)). Table XIV below displays the reported number of units leased at the same address.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 23 of 95 23

Table XIV

Self-Reported Housing Bridge Subsidy Concentration (Density)

December 2018

March 2019

June 2019

Sept. 2019

Dec. 2019

Mar. 2020

Number of properties

with one leased SH unit

at the same address

329

315

300

282

276

279

Number of properties

with two SH units at the

same address

27

18

16

18

18

14

Number of properties

with three SH units at

the same address

4

3

4

1

4

2

Number of properties

with four SH units at the

same address

3

2

2

1

2

2

Number of properties

with five SH units at the

same address

1

2

1

1

0

0

Number of properties

with six SH units at the

same address

0

0

0

0

0

0

Number of properties

with seven+ SH units at

same address

2

1

1

1

1

1

It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)). DHHS reports that there is currently only one voluntary roommate occurrence among the currently leased Bridge Subsidy Program units in the above data.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 24 of 95 24

As noted in the ER Reports dating back to 2016, DHHS was working on a method to crossmatch the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. Table XV summarizes the most recent iterations of these data.

Table XV

Self-Reported Housing Bridge Subsidy Program Tenants Linked to Mental Health Services

As of 3/31/19

As of As of As of As of 6/30/19 9/30/19 12/31/19 3/31/2020

Housing Bridge Tenants Linked to
Mental Health Services

337 of 400 (84.5%)

360 of 378
(95%)

339 of 373
(91%)

358 of 394
(91%)

348 of 421
(83%)

These data document the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports.10
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain federal Department of Housing and Urban Development (HUD) funding for an additional 150 supported housing units for a total of 600 supported housing units.” (CMHA V.E.3(e)). In 2015, New Hampshire applied for and was awarded funds to develop a total of 241 units of supported housing under the HUD Section 811 Program (191Program Rental Assistance [PRA] and 50 Mainstream). All of these units are to be set aside for people with serious mental illness. As of the date of this report, 119 (combined PRA and Mainstream) of these new units are reported to have been developed and to have been occupied by members of the target population. The State has not been able to provide the current number of people in 811 housing, only the cumulative total over time.
It should be noted that over the life of the Bridge Program the State has accessed 180 HUD Housing Choice Vouchers (HCVs) and five HUD public housing or similar subsidized units.
The CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.” (V.E.3(f)). As referenced above, there are currently reported to be 49 individuals on the wait list for the Bridge program; 18 of these individuals have been on the wait list for more than two months. The State has

10 Some of these tenants might be receiving services from MH providers other than a CMHC.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 25 of 95
25
recently submitted additional information about the status of individuals on the wait list. This report has not yet been discussed with representatives of the Plaintiffs or with the ER. The ER understands that the State is making efforts to assist people on the wait list to attain housing, but it is not yet possible to verify that the State complies with CMHA requirements with regard to the supported housing wait list.
The State has also recently supplied information on the total capacity of supported housing units dedicated to the target population of the CMHA in New Hampshire. This information has not yet been discussed with representatives of the Plaintiffs or the ER. Until this information is verified and accepted by the parties, the ER is not able to document that the State meets CMHA requirements with regard to supported housing capacity.
The ER intends to schedule a conference call with state officials and representatives of the Plaintiffs to discuss this new information by October 15, 2020.
The State has recently implemented a major change in the administration of the Housing Bridge Subsidy program. Previously, the program had been administered on a statewide basis by an independent contractor. Under the new model, each of the ten CMHCs will perform certain participant-level functions, such as housing search; lease-up and occupancy supports; landlord negotiations; arrangement of housing related services and supports, and eviction prevention. The CMHCs will also directly pay rent subsidies to landlords and will be reimbursed for these costs by the State. The State will manage intake and eligibility determination functions and will maintain a statewide waiting list.
These administrative changes could have an impact on the overall effectiveness of the Housing Bridge Subsidy Program. However, it is too early in the implementation process to assess the effects of these changes. The ER will continue to monitor the implementation process as well as monitoring data regarding lease-ups, the waiting list, and other related performance data.
Transitions from Institutional to Community Settings
During the past 70 months, the ER has visited both Glencliff and NHH on at least ten separate occasions to meet with staff engaged in transition planning. The ER has participated in six meetings of the Central Team. The CMHA required the State to create a Central Team to overcome barriers to discharge from institutional settings to community settings. The Central Team has now had about 58 months of operational experience. As of June, 2020, 63 individuals have been submitted to the Central Team, 41 from Glencliff and 22 from NHH. Of these, the State reports that 30 individual cases have been resolved,11 two individuals are deceased, and 31
11 Five of these individuals were readmitted to NHH after 90 days and five of these have returned to community settings as of this report.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 26 of 95
26
individual cases remain under consideration. Table XVI below summarizes the discharge barriers that have been identified by the Central Team with regard to these 31 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total higher than the number of individuals reviewed by the Central Team.

Table XVI

Self-Reported Discharge Barriers for Open Cases Referred from NHH and Glencliff to the Central Team:

June 2020

Discharge Barriers

Glencliff

NHH

Legal

6 (23.1%)

2 (40.0%)

Residential

22 (84.6%)

4 (80.0%)

Financial

12 (46.1%)

2 (40.0%)

Clinical

20 (76.9%)

5 (100%)

Family/Guardian

15 (57.7%)

3 (60.0%)

Other

1 (0.04%)

1 (20.0%)

Glencliff
In the time period from October 2019 through March 2020, Glencliff reports that it has admitted nine individuals, and has had two discharges and four deaths. The average daily census through this period was 111 people. There have been no readmissions during this time frame. The mean overall wait list for admission has remained relatively constant at 26 to 29 people for the past six months.
CMHA Section VI requires the State to develop effective transition planning and a written transition plan for all residents of NHH and Glencliff (VI.A.1), and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]12 individuals with mental illness and complex health care needs
12 Cumulative from CMHA V.E.(g), (h), and (i).

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 27 of 95
27
residing at Glencliff….” The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be cost-effectively served in supported housing.”13
DHHS reports that a total of 19 people have transitioned from Glencliff to integrated settings since the inception of the CMHA five years ago. Based on data supplied by the State for the previous report, there are currently 30 individuals undergoing transition planning who could be transitioned to integrated community settings once appropriate living settings and community services become available. Nine of these individuals have been assigned to Choices for Independence (CFI) waiver case management agencies in order to access case management in the community to facilitate transition planning, and four are currently in the application process. Three individuals have been found eligible for the Acquired Brain Disorder (ABD) or Developmental Disability (DD) waivers, and two have been denied eligibility for these waivers. Four individuals are reported to not meet criteria for referrals to one or more of the waivers. The remaining seven individuals may meet criteria for CFI, but have not applied for case management, as an appropriate placement type to meet their needs has not yet been determined.
DHHS continues to provide information about Glencliff transitions at the time of discharge, including clinical summaries, lengths of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions that could not be cost-effectively served in SH continue to experience transitions to integrated community settings. To protect the confidentiality of individuals transitioned from Glencliff, this person-specific information is not included in the ER reports.
DHHS has initiated action steps to enhance the process of: (a) identifying Glencliff residents wishing to transition to integrated settings; and (b) increasing the capacity, variety and geographic accessibility of integrated community settings and services available to meet the needs of these individuals. Both sets of initiatives are intended to facilitate such community transitions for additional Glencliff residents. Despite these efforts, transitions to integrated community settings from Glencliff have slowed in the past 30 months.
The ER remains very concerned about the slow pace of transitions to integrated community settings by residents of the Glencliff Home. Based on this concern, the ER conducted a threeday on-site review during the month of January. This review focused on the following CMHA provisions specifically relevant to transitions planning and effectuating transitions to integrated community settings on the part of Glencliff residents:
Section VI.A.1 “The State, through its community mental health providers and/or other relevant community providers, will provide each individual in NHH and Glencliff with effective transition planning and a written transition plan ….” (Emphasis added);
13 CMHA V.E.2(a).

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 28 of 95
28
Section VI.A.2 (a) through (e). Note that Section (e) states: that transition planning will “not exclude any individual from consideration for community living based solely on his or her level of disability”;
Section VI.A.4 , which states, in part: “... the State will make all reasonable efforts to avoid placing individuals into nursing homes or other institutional settings”;
Section VI.A.7 and 8, which require the State to implement a system of in-reach activities to enable Glencliff residents to develop relationships of trust with CMHCs and other providers and to actively support residents to transition to the community with proactive efforts to educate residents and family members/guardians about community options; and
Section V.E.2 (a) and (b) and Sections V.E.3(g) through (j), which require the State to develop integrated community living options for individuals with complex health care needs according to an implementation schedule and wait list provisions.
Steps Taken
During the on-site visit the ER completed a review of case files and transition plans for a total of 50 residents of Glencliff. One of these 50 transitioned to the Palm Street program in Nashua on the last day of record reviews, so the current review group is now 49. There are two social workers at Glencliff who manage the transition planning process. These individuals carry “caseloads” of residents who have indicated a desire to transition out of Glencliff, and they also work with most other residents to engage them in transition option discussions. There are currently 28 residents on the Active Transition Planning list. The two social workers identified an additional cohort of 21 residents who, in their judgment, were examples of residents who could be in the active transition planning cohort if they would indicate a desire to transition out of Glencliff. The basic mechanism for identifying residents for the active transition planning list is their response to Section Q of the Minimum Data Set (MDS) form. In the table below, residents who answered “yes” on Section Q are in the Active Transition Planning cohort; residents who answered “no” on the Section Q are in the second, non-active cohort.
Table XVII below provides a summary of the case files reviewed:

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 29 of 95 29

Table XVII

Glencliff Transition Planning Case Record Review

Residents on Active Transition Planning
List Residents with Potential to Be on the Active Transition Planning List
Total

Social Worker A 16 10 26

Social Worker B 12 11 23

Total 28 21 49

The ER also completed the following interviews:
1. Case by case discussion of each case file reviewed with the assigned case manager and the Glencliff manager with overall responsibility for admission, continuing stay, and transition from Glencliff;
2. Discussion with the administrative and clinical leadership of Glencliff regarding the overall transition planning process, including internal and external factors affecting transition planning;
3. Discussion with DHHS staff on the process for developing individual budgets for individuals with complex medical conditions transitioning to an integrated community setting. Such individualized budgets are the method by which the State commits state funds up to $100,000 to facilitate and support transition to programs such as the Palm Street residence;
4. Review of information submitted by DHHS in response to questions regarding: a. Current application of funds for integrated community settings/placements for Glencliff residents with complex health care needs; b. Process for stimulating and supporting the creation of additional housing and residential resources such as the Palm Street residence; c. Process for promoting and accelerating applications for the various Medicaid waivers. Acceptance into one of the waivers often seems to be a precondition for transition from Glencliff; and d. Process for working with State officials and designated community providers (such as CMHCs and Area Agencies) to promote and facilitate access to community providers who can serve people transitioning from Glencliff under one of the Medicaid waivers; and
5. Telephone conference with DHHS officials to discuss the information submitted.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 30 of 95
30
Based on the above information, the ER prepared a draft report for consideration by both the State and representatives of the plaintiffs.
The following is a very brief summary of ER recommendations for (State/DHHS led) actions and interventions:
1. Substantially improve in-reach from the community to Glencliff. 2. Improve the success and timeliness of access to Medicaid waivers in support of
transitions to integrated community settings. 3. Have DHHS Bureau of Mental Health Services (BMHS) staff work more closely and pro-
actively with other DHHS officials and the Area Agencies to increase access to community providers. 4. Improve access to Bridge subsidies to facilitate transitions from Glencliff. 5. Expand access to small scale (3 - 4 person) community residential programs for Glencliff residents with complex medical conditions. 6. Make it a very high priority to develop new small scale residential settings for residents with complex medical conditions as soon as possible. This appears to be the most feasible approach to re-starting movement of people to integrated community settings. Some individuals have been waiting for transition for a long time. Others will be encouraged to choose community living by seeing the success and satisfaction of residents that have moved to these programs.
All parties have now reviewed that draft report; the State reports that it is beginning to address some of its recommendations. In addition, representatives of the Plaintiffs provided a teleconference training session on informed consent and person-centered transition planning. In addition, the State has shared applicable case records with representatives of the Plaintiffs so that they can be better informed about specific issues related to transition planning for Glencliff residents.
The State has executed a contract with Northern Human Services to provide in-reach services for residents of Glencliff, and the in-reach coordinator has been hired. As of the date of this report, implementation of the in-reach functions and activities is at a very early stage. Implementation has been hindered by the COVID-19 restrictions that have been in effect in New Hampshire since March, 2020. In addition, the State has not yet shared with the ER or representatives of the Plaintiffs the data reporting format to be used to track and report on the activities and results of the in-reach program. It is too early to document whether the in-reach program is having the desired effect for Glencliff residents.
The ER intends to closely monitor activities related to Glencliff transition planning over the next six month period. This monitoring of in-reach programming will focus on:
1. Implementation of the in-reach program, including written transition plans, community visits, re-starting the HOPES program, etc.;

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 31 of 95
31
2. Reviewing, in concert with representatives of the Plaintiffs, all revisions to policies, procedures, forms, training contents, etc. related to transition planning and informed consent;
3. Tracking and analyzing data reported by the in-reach program to the State; 4. Assessing the degree to which all CMHCs in the state become re-engaged in transition
planning and in developing integrated community settings for Glencliff residents; 5. Tracking progress of the 28 individuals on the active discharge planning list towards
integration into the community; 6. Documenting the development of new integrated community settings for Glencliff
residents.
The ER recommends that the parties reconvene in the early fall of 2020 to examine preliminary data on the delivery of in-reach services, review the State’s proposed revisions to the transition planning and informed choice process, and discuss efforts to expand community residential service options for Glencliff residents, including access to medical model homes, Enhanced Family Care and Bridge subsidies.
The ER recognizes that the State intends to improve transition planning and to facilitate additional community integrated transitions for Glencliff residents. However, at this point, and based on the review conducted in January, the State is not in compliance with CMHA provisions related to Glencliff transition planning or transitions to integrated community settings.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 32 of 95 32

Preadmission Screening and Resident Review (PASRR)

The State periodically provides data on PASRR Level II screens conducted in New Hampshire. Recent PASRR data are summarized in Table XVIII below. PASRR data from two previous reporting periods are included for comparison purposes.

A Level II screen is conducted if a PASRR Level I (initial) screen identifies the presence of mental illness, intellectual disability, or related conditions for which a nursing facility placement might not be appropriate. One objective of the Level II screening process is to seek alternatives to nursing facility care by diverting people to appropriate integrated community settings. Another objective is to identify the need for specialized facility-based services if individuals are deemed to need nursing facility level of care.

Table XVIII

Self-Reported PASRR Level II Screens

Full Approval - No Specialized Services Full Approval with Specialized Services Provisional – No Specialized Services Provisional with Specialized Services Total

October 2019
through June 2020
25

October 2019
through June 2020
Percent
37.9%

April through June 2019 Percent

July through September
2019

28.8%

Percent 31.0%

20

30.3

28.8

38.0

11

16.7

18.8

19.7

10

15.2

23.8

11.3

66%

100%

100%

100%

In the December 2018 ER report, 10.2% of the Level II screens were approved with a specification for specialized services. At that time, the ER questioned whether this was an unusually low rate for specification of specialized services. In a comparison with one other state, the ER found substantially higher approvals for specialized services than was evidenced in New Hampshire at that time. In the intervening period, the State and the PASRR contractor have been reviewing protocols for specification of specialized services in the Level II process. For this current report, the percentage of approvals with specialized services has increased to 45.1%. For the period April through June 2019, the percent of total Level II screens indicating specialized services was 44%; for July through September 2019, the number was 49.3%.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 33 of 95
33
In addition, the State expressed its intent to review the New Hampshire Medicaid Plan to see if revisions may be appropriate for the section(s) of that Plan identifying what special services may be covered by Medicaid for recipients for whom the Level II screen results in a specification for special services. The State reports that it has not yet completed this review. The ER expects that the review and any changes to the Medicaid Plan with respect to special services will be completed no later than October 1, 2020.
For a variety of reasons, virtually all PASRR screens in New Hampshire are conducted for people who are already in a nursing facility. For example, for October 2019 through March 2020, 96.7% of Level II screens were conducted in nursing facilities. A possible consequence of this is that prime opportunities for diversion to integrated community settings may have already been missed by the time the PASRR screen is conducted.
In addition, individuals admitted to Glencliff must typically have been turned down by at least two other facilities before being considered for admission. In combination, these facts indicate that interventions to divert individuals from Glencliff or other nursing facilities must typically be used before the PASRR screening process is initiated. PASRR is important to assure that people with mental illness, ID/DD, or related conditions are not inappropriately institutionalized or placed in nursing facilities without access to necessary special services. However, PASRR is not by itself sufficient to divert people from nursing facility care. Up-stream interventions at NHH, the DRFs, and among the CMHCs are also essential to prevent unnecessary facility placement.
New Hampshire Hospital and the Designated Receiving Facilities (DRFs)
For the time period October 2019 through March 2020, the State reports that NHH effectuated 453 admissions and 452 discharges. The mean daily census was 159.5, and the median length of stay for discharges was 16 days.
Table XIX below compares NHH discharge destination information for the six most recent reporting periods. The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 34 of 95 34

Table XIX

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Percent Percent Percent Percent Percent Percent

Discharge Destination

October 2017
through March 2018

April 2018 through Septem -ber 2018

October 2018
through March 2019

July through Septem-
ber 2019

October through Decem-
ber
2019

January through March
2020

Home – live alone or with others

81.0%

81.7% 73.26%

70.5%

70.76% 72.77%

Glencliff
Homeless Shelter/motel
Group home 5+/DDS supported living, peer support housing etc.
Jail/correction
Nursing home/rehab facility
Other14

1.0% 2.5% 7.1%
2% 2.7%

1.45% 3.13%

1.6% 6.68%

4.1% 4.01%

1.45% 5.3%

2.94% 4.55%

0.4% 4.38%

0.42% 7.11%

2.35% 5.16%

3.98% 4.24% 3.29%

1.2% 5.98%

3.0% 5.00%

1.41% 4.69%

10.17% 10.33%

14 The ER did not include the “Other” category in previous reports.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 35 of 95
35
The State now consistently reports information on the hospital-based Designated Receiving Facilities (DRFs) and the Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and analyze it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. Table XX summarizes these data.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 36 of 95 36

Table XX

Self-Reported DRF/APRTP Utilization Data: January 2016 through

March 2020

Admissions Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019 April to June 2019 July to September 2019 October - December 2019 January - March 2020

Franklin Cypress Portsmouth Elliot

Elliot Total

Geriatric Pathways

69

257

NA

79

205

378

37

207

375

60

228

363

NA** 247

363

59

209

358

52

240

330

69

244

333

67

201

357

87

198

375

126

182

349

108

187

371

104

194

391

96

175

350

114

186

333

65

121

512

49

92

803

54

114

787

52

101

804

60

121

722

55

102

783

66

100

788

65

104

815

54

112

791

64

72

796

56

123

836

89

108

865

52

95

836

63

100

784

52

107

794

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 37 of 95 37

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019 April to June 2019 July to September 2019 October - December 2019 January - March 2020

Franklin Cypress Portsmouth Elliot

Elliot Total

Geriatric Pathways

53.60% 55.70% 43.20% 58.30% NA** 49.20% 44.20% 46.73% 28.36%

18.70% 24.40% 29.50% 21.50% 37.1% 30.10% 28.30% 25.82% 24.38%

46.00% 45.20% 61.10% 43.30%

23.20% 18.10% 20.90% 16.50%

63.50% 23.40% 53.50% 24.20%

NA 16.93% 18.90% 22.00% 25.60% 23.70% 21.50% 24.62% 19.33%
22.40% 23.20% 19.40% 25.10%
24.00% 21.00%

18.50% 4.10% 13.00% 1.00% 10.00% 12.70% 6.10% 9.23% 12.96%

30.60% 48.90% 44.70% 47.50% 50.40% 50.00% 47.00% 51.92% 49.11%

NA 25.50% 26.20% 27.10%
NA 30.00% 27.00% 29.08% 25.16%

6.25% 12.50% 7.90% 11.50%

51.40% 47.20% 47.20% 55.80%

26.50% 28.20% 27.30% 28.00%

7.90% 9.60%

40.00% 29.50% 40.00% 28.09%

Mean Daily Census Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019 April to June 2019 July to September 2019 October - December 2019 January - March 2020

Franklin Cypress Portsmouth Elliot

Elliot Total

Geriatric Pathways

7.9

14.7

NA

7.8

13.2

21.4

4.5

13.6

23.2

4.5

12

30.3

NA** 12.9

23.9

10.1 12.3

27.7

6.7

11.6

32.5

9.1

11.9

31.7

11.8

8.4

39.6

19.7

18.1

NA

22.5

16.9

81.8

25.6

14.5

81.4

29.3

10

86.1

29.7

12.2

NA

32.6

16.1

19.7

34.6

NA

NA

31.7

20.4 104.8

33.8

18.2 111.8

10.7

9.2

27.4

33.4

10.7

91.4

8.5

14.5

30.4

22.6

14.9

90.9

8.4

11.5

29.7

27

12.1

88.7

9.4

12.2

24.1

24.1

12

81.8

10.6 13.4

31.8

23.7

9.5

89

10.6 13.7

29.2

20.5

12

86

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 38 of 95 38

Discharges Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - Sep 2017 Oct - Dec 2017 Jan - March 2018 April - June 2018 Oct - Dec 2018 Jan - March 2019 April - June 2019 July - Sep 2019 Oct - Dec 2019 Jan - March 2020

Franklin Cypress Portsmouth Elliot

Elliot

Geriatric Pathways

Total

77

231

345

78

206

363

35

213

380

59

232

365

NA** 243

355

82

212

359

53

248

326

74

244

326

89

204

358

124

177

348

108

193

368

101

192

386

102

198

353

110

207

327

69

120

842

51

90

788

64

113

805

54

105

815

63

121

NA

58

102

813

67

101

795

65

107

816

62

79

792

56

106

811

55

111

835

54

97

830

60

123

836

71

119

834

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 39 of 95 39

Franklin Cypress Portsmouth Elliot

Elliot

Geriatric Pathways

Mean LOS for Discharges

Total

Jan - March 2016

6

4

5

18

7

6

April - June 2016

6

4

4

28

7

6

July - Sept 2016

7

5

4

24

8

7

April - June 2017

6

4

5

22

8

6

July - Sept 2017

NA

4

4

27

7

NA

Oct - Dec 2017

4

4

5

21

7

5

Jan - March 2018

5

4

5

23

7

5

April - June 2018

5

4

5

20

8

5

Oct - Dec 2018

4

3

4

31

7

4

Jan - March 2019

5

5

6

18

9

6

April - June 2019

5

3

5

18

7

5

July - Sept 2019

6

4

6

26

8

6

Oct - Dec 2010

7

5

6

25

7

7

Jan - March 2020

6

5

6

20

8

6

The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and should also reduce the number of people waiting for psychiatric admissions in hospital EDs.
DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table XXI below provides a summary of these recently reported data.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 40 of 95 40
Table XXI Self-Reported Discharge Dispositions for DRFs in New Hampshire
October 2019 through March 2020

Disposition Frank- Cy- Ports- Elliot

Elliot Total Per-

lin press mouth Geriatric Pathways

cent

Home

199 382

489

29

209

1,308 78.3%

NHH

6

0

6

0

0

12 0.72%

Residential 0

0

0

36

0

36 2.16%

Facility/

Assisted

Living

Other

0

13

5

1

DRF15

5

24 1.44%

Hospital

0

0

0

0

0

0 0.00%

Death

0

0

0

0

0

0 0.00%

Other or

7

10

180*

65

28

290 17.4%

Unknown

Total

212

405

680

131

242

1,670

*The Other or Unknown disposition category for Portsmouth Regional is reported to include

shelters, rehab facilities, hotels/motels, friends/families, and unknown16.

Based on these self-reported data, 78.3% of discharges from DRFs and the Cypress Center are to home. This is essentially the same as the 72.77% discharges to home reported by NHH.

Hospital Readmissions

DHHS is now reporting readmission rates for both NHH and the DRFs. Table XXII below summarizes these data:

15 The State reports that these transfers reflect conversion from involuntary to voluntary status, not transfers among DRF facilities. 16 The ER intends to ask the State for a more definitive breakdown of these data. In particular, the ER is concerned about discharges to shelters and to hotels/motels.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 41 of 95 41

Table XXII

Self-Reported Readmission Rates for NHH and the DRFs

July 2017 through March 2020

NHH 7 to 9/2017 10 to 12/2017 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 10/2019 to 12/2019 1/2020 to 3/2020

Percent 30 Days
9.80% 12.8% 13.7% 7.6% 8.6%
7.3% 5.3% 8.4% 10.5%
6.8% 6.9%

Percent 90 Days
21.60% 26.1% 22.7% 14.7% 19.6%
18.1% 14.8% 15.0% 18.6%
17.9% 12.4%

Percent 180 Days
27.90% 32.8% 29.9% 23.4% 25.4%
25.9% 21.2% 20.3% 23.3%
23.0% 21.1%

Franklin 7 to 9/2017 10 to 12/2017 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 10/2019 to 12/2019 1/2020 to 3/2020

Percent 30 Days
NA 10.2% 0.0% 4.3% 6.0%
2.3% 7.9% 6.5% 1.9%
3.1% 3.5%

Percent 90 Days
NA 10.2% 0.0% 5.8% 9.0%
4.6% 10.3% 9.3% 6.7%
6.2% 6.1%

Percent 180 Days
NA 10.2% 1.9% 5.8% 16.4%
5.7% 10.3% 12.0% 9.6%
9.3% 7.8%

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 42 of 95 42

Cypress 7 to 9/2017 10 to 12/2017 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 10/2019 to 12/2019 1/2020 to 3/2020
Portsmouth 7 to 9/2017 10 to 12/2017 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 10/2019 to 12/2019 1/2020 to 3/2020

Percent 30 Days
7.10% 12.00% 4.20% 4.50% 8.50%
7.10% 5.50% 9.90% 6.60%
10.30% 3.50%
Percent 30 Days
11.50% 8.70% 8.80% 10.20% 8.40%
7.70% 12.90% 10.50% 8.20%
7.50% 9.70%

Percent 90 Days
12.40% 18.70% 9.60% 8.20% 13.90%
11.10% 14.80% 15.10% 9.20%
13.90% 5.00%
Percent 90 Days
17.50% 13.70% 15.50% 15.90% 12.90%
14.90% 19.50% 17.80% 12.00%
8.80% 19.20%

Percent 180 Days
15.90% 24.40% 15.80% 11.90% 18.90%
15.20% 17.60% 20.80% 12.80%
21.10% 8.50%
Percent 180 Days
21.00% 17.60% 20.60% 21.90% 19.00%
20.30% 23.50% 22.40% 12.00%
15.30% 23.00%

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 43 of 95 43

Elliot Pathways 7 to 9/2017 10 to 12/2017 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 10/2019 to 12/2019 1/2020 to 3/2020
Elliott Geriatric 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019 10/2019 to 12/2019 1/2020 to 3/2020

Percent 30 Days
3.30% 5.80%
NA 3.80% 9.00%
2.80% 4.90% 5.50% 2.10%
3.90% 9.70%
Percent 30 Days
6.10% 5.60%
6.30% 5.40% 10.10% 7.70%
5.70% 9.40%

Percent 90 Days
6.60% 7.70%
NA 6.70% 3.60%
5.60% 5.70% 5.50% 5.20%
5.80% 14.20%
Percent 90 Days
6.10% 11.10%
7.80% 5.40% 12.40% 9.60%
7.10% 11.30%

Percent 180 Days
12.40% 12.50%
NA 8.60% 3.60%
9.70% 7.30% 5.50% 6.30%
8.70% 15.90%
Percent 180 Days
6.10% 11.10%
9.40% 5.40% 14.60% 13.50%
8.60% 18.90%

For the 36-month period in which re-admission rate data has been reported, the rates of readmission have trended down somewhat for all but three DRFs, which is a positive indicator overall. However, readmission rates, especially the 180-day readmission rate for NHH and Portsmouth, are high. At least 21.1% of all people discharged from NHH are back in the hospital within 180 days. These data, in concert with the hospital emergency department data presented below, indicate that gaps remain in community services for people with serious mental illness, and that the essential connection between inpatient care and community services is not being effectuated for sizeable numbers of people at risk of re-hospitalization. These facts need to be understood in light of the State’s ongoing efforts to increase ACT capacity and enrollment as documented earlier in this report. There needs to be increased focus on

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 44 of 95 44
whether or not those readmitted to NHH or a DRF are being screened, assessed, and linked (when appropriate) to ACT and supported housing upon discharge.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 45 of 95 45
Hospital ED Waiting List
In the previous three reports, the ER has identified the hospital ED boarding wait for admission to NHH to be an important indicator of overall system performance. The following two charts display adult admissions delays to NHH bi-weekly for the period April 2018 through March 2020.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 46 of 95 46

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 47 of 95 47
The overall trend has been downward since September 2018. The ER notes that many of the interventions implemented by the State are outside the direct scope of the CMHA. However, ED boarding can affect the CMHA target population in a variety of ways. And, people awaiting psychiatric hospital admission are potential participants in ACT, MCT, crisis apartments, and other CMHA services. Thus, the ER intends to continue on reporting ED boarding in future reports.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 48 of 95
48
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies
DHHS continues to report having a total of 15 peer support agency program (PSA) sites, with at least one program site in each of the ten regions. The State continues to report that all peer support centers meet the CMHA requirement to be open 44 hours per week. As of March 2020, the State reports that those sites have a cumulative total of 1,558 members, with an active daily participation rate of 170 people statewide. This represents a three-year high in active daily participation: 23% higher than in March 2017. The State reports that all of the PSAs have been working to increase their membership and daily participation rates.
The ER intends to complete a set of PSA on-site visits within the next year (by June 30, 2021). Until those visits are complete, there will be no further information to report about these programs.
IV. Quality Assurance Systems
The state-wide limitations implemented to minimize spread of COVID-19 have prevented the State from conducting QSR or Fidelity reviews since March 2020. This means that there are only a few QSR and Fidelity reports for the time period covered by this report. In addition, the lack of QSR and Fidelity reports for this time period makes it impossible to tabulate either cumulative or time-series data related to the QSR and Fidelity activities. For this reason, a discussion of Quality and Fidelity is not included in this report.
The State reports that QSR on-site reviews were re-started in June, 2020. The ER intends to observe several of these activities prior to completing the December 2020 report.
I. Summary of Expert Reviewer Observations and Priorities
The ER has emphasized in this report that the State continues to be far from compliant with CMHA requirements for ACT. For the last three and one half years the ER has reported that the State is out of compliance with the ACT requirements of Sections V.D.3, which together require that the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the target population at any given time.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 49 of 95
49
Other areas of non-compliance identified in this report include:
1. Pending further review and verification of State-reported information, the ER is not able at this time to document that the CMHA-required capacity of 600 supported housing units is currently available to the CMHA target population. In addition, approved applicants continue to remain on the wait list for excessive periods of time, in violation of the CMHA;
2. With regard to Glencliff, the ER has documented failure to provide effective transition planning and in-reach activities, failure to transition residents of Glencliff into integrated community settings in accordance with the CMHA, and failure to expand community residential and other service capacity to meet the needs of Glencliff residents in alternative community settings. In addition, the ER cannot document or certify that residents of Glencliff have written transition plans in accordance with CMHA requirements; and
3. Although the State technically meets the statewide CMHA standard for SE penetration, the ER notes seven of the ten CMHC regions of the state have penetration rates lower than the standard. At the very least, the ER considers that this demonstrates that target population members do not have equal access to SE services throughout New Hampshire.
More than five years ago, all parties to the CMHA envisioned implementation of a number of remedial services and system interventions designed to assure positive outcomes for the defined target population. Most important among these outcomes was assurance of maximum community integration supported by housing and evidence-based and high quality services meeting individual needs and choices. The signatories to the CMHA envisioned high quality of life and improved personal outcomes for adult citizens of New Hampshire with serious mental illness.
Now, more than five years later, the data and related information reported by the State and the ER show: (1) declining ACT enrollments; (2) declining SE penetration in many regions of the State; (3) declining utilization of Bridge Program SH subsidies; and (4) continued delays in effectuating access to integrated community living options for Glencliff residents. In light of these facts, the ER must report that in certain ways the CMHA target population is less wellserved in this time period than it had been in previous periods. In these areas, the State appears to be falling further from compliance with the CMHA rather than attaining greater compliance. As the ER has stated in previous reports, the State will not be able to disengage from the CMHA until full compliance is reached for all requirements of the CMHA.
In furtherance of this goal, the ER expects the State to develop and implement measures to address all areas of non-compliance referenced above, with the following actions to take place between now and October 15, 2020:

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 50 of 95
50
1) The State will provide a written update on implementation of specific ACT strategies identified in the working group memo, with emphasis on eliminating the wait list and on reducing the elapsed time for CMHAs to process individuals into ACT services.
2) The State will facilitate an all-parties review of responses to the MCT/CA RFI and will engage in discussions with the parties about how this information impacts current and future MCT/CA procurements and oversight and operations. These discussions should include the situation arising from Harbor Homes’ decision not to renew its MCT contract, and how the provision of MCT in the greater Nashua area will be addressed.
3) The State will draft new policies and procedures related to informed choice and transition planning for residents of Glencliff, and will engage the parties in review and comment on these before they are implemented (Note: a call to initiate review of these policies and procedures has been scheduled.) In addition, the State will take effective steps to ensure that the CMHCs, with the assistance of the Northern in-reach liaison, become more active in the transition planning process at every stage, especially with regard to the 49 individuals included in the ER’s Glencliff site review and report.
4) The State will develop a plan to expand access to other community residences, like Palm Street, or existing community programs, like extended family care homes or supported housing, for Glencliff residents with complex health conditions.
5) The State will provide all parties with a telephone briefing on the SH program, including an estimate of the total number of SH units that can be placed under lease and occupied in the next twelve months; clarification of the number of new 811 program occupants who have transitioned from the Bridge program as opposed to from other living arrangements; and specific strategies that have been implemented to assist individuals on the waiting list move to SH.
6) An All Parties meeting will be held to discuss progress and strategies related to disengagement from the CMHA.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 51 of 95 51
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly Data Report January through March, 2020

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 52 of 95 52
New Hampshire Community Mental Health Agreement Quarterly Data Report
January – March 2020
New Hampshire Department of Health and Human Services Bureau of Quality Assurance and Improvement June 8, 2020

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 53 of 95 53
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 54 of 95

Community Mental Health Agreement Quarterly Data Report
New Hampshire Department of Health and Human Services

Publication Date: June 8, 2020

Reporting Period: 1/1/2020 – 3/31/2020

Notes for Quarter
 On March 13, 2020, Governor Christopher T. Sununu issued Executive Order 2020-04, declaring a State of Emergency due to the Novel Coronavirus (COVID-19). On March 26, 2020, Governor Sununu issued related Emergency Order #17, implementing a stay-at-home, shelter in place of residence requirement, effective March 27, 2020 at 11:59 PM. This report includes data regarding service provision prior to and during the effective dates of these orders, which remained in place for the balance of the reporting period.
 Table 3d. Community Mental Health Center Services: Supported Employment Waiting List is newly added to this report.

Acronyms Used in this Report

ACT:

Assertive Community Treatment

BMHS: Bureau of Mental Health Services

BQAI: CMHA:

Bureau of Quality Assurance and Improvement
DRAFT
Community Mental Health Agreement

CMHC: Community Mental Health Center

DHHS: Department of Health and Human Services

DRF:

Designated Receiving Facility

ED:

Emergency Department

FTE:

Full Time Equivalent

HBSP: Housing Bridge Subsidy Program

HUD: US Department of Housing and Urban Development

MCT:

Mobile Crisis Team

NHH: New Hampshire Hospital

NHHFA: New Hampshire Housing Finance Authority

PRA:

Project Rental Assistance

SE:

Supported Employment

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 55 of 95

SFY:

State Fiscal Year

VA:

Veterans Benefits Administration

DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 56 of 95

1a. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Clients

Community Mental Health Center

January February

2020

2020

March 2020

Unique Clients in
Quarter

Unique Clients in
Prior Quarter

01 Northern Human Services

115

114

115

126

131

02 West Central Behavioral Health

44

45

42

47

52

03 Lakes Region Mental Health Center

57

56

57

60

62

04 Riverbend Community Mental Health Center

97

89

94

107

107

05 Monadnock Family Services

51

51

51

52

51

06 Greater Nashua Mental Health

99

103

101

106

105

07 Mental Health Center of Greater Manchester

278

270

262

294

312

DRAFT

08 Seacoast Mental Health Center

66

66

66

68

73

09 Community Partners

75

67

68

77

75

10 Center for Life Management

48

46

47

49

52

Total Unique Clients

929

907

903

985

1,017

Unique Clients Receiving ACT Services 4/1/2019 to 3/31/2020: 1,225

Revisions to Prior Period: None.

Data Source: NH Phoenix 2.

Notes: Data extracted 4/21/2020; clients are counted only one time regardless of how many services they receive.

1b. Community Mental Health Center Services: Assertive Community Treatment Screening and Resultant New ACT Clients

Community Mental Health

October – December 2019

July – September 2019

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 57 of 95

Center

Retrospective Analysis

Retrospective Analysis

Unique Clients Screened: Individuals Not Already on ACT* Appropriate for Further ACT Assessment: Individuals Not Already oNnewACClTients receiving ACT Services within 90 days of Screening Unique Clients Screened: Individuals Not Already on ACT* Appropriate for Further ACT Assessment: Individuals Not Already oNnewACClTients receiving ACT Services within 90 days of Screening

01 Northern Human Services

1,166

21

2 1,163

40

4

02 West Central Behavioral

221

2

2

250

1

0

Health

03 Lakes Region Mental Health Center

906

11

1

866

6

0

04 Riverbend Community

1,342

13

2 1,083

0

0

Mental Health Center

05 Monadnock Family Services

DRAFT

576

3

0

576

6

0

06 Greater Nashua Mental Health

726

6

1

708

8

5

07 Mental Health Center of

1,641

7

1 1,632

1

0

Greater Manchester

08 Seacoast Mental Health

1,392

48

0 1,257

31

0

Center

09 Community Partners

434

0

0

360

3

0

10 Center for Life Management

779

2

0

763

1

0

Total ACT Screening

9,183 113

9 8,658

97

9

Data Source: NH Phoenix 2 and CMHC self-reported ACT screening records. ACT screenings submitted through Phoenix capture ACT screenings provided to clients found eligible for state mental health services. Phoenix does not capture data for non-eligible clients; three CMHCs

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 58 of 95

submit this data through Phoenix. Seven CMHCs self-report. All such screenings, excluding individuals who are already on ACT, are contained in this table.

Notes: Data extracted 4/28/2020. “Unique Clients Screened: Individuals Not Already on ACT” is defined as individuals who were not already on ACT at the time of screening that had a documented ACT screening during the identified reporting period. “Screening Deemed Appropriate for Further ACT Assessment: Individuals Not Already on ACT” is defined as screened individuals not already on ACT that resulted in referral for an ACT assessment. “New Clients Receiving ACT Services within 90 days of ACT Screening” is defined as individuals who were not already on ACT that received an ACT screening in the preceding quarter and then began receiving ACT services.

1c. Community Mental Health Center Services: New Assertive Community Treatment Clients

January – March 2020

October -- December 2019

January 2019 New ACT FCleibernutsary 2019 New AMCaTrcClhie20nt1s9 New ACT TClioteanltsNew ACT Clients New ACT CNlioevnetsmber 2019 New ADeCcTeClmiebenrts 2019 New ACT Clients Total New ACT Clients

Community Mental Health Center DRAFT

01 Northern Human Services

2 4 4 10 1 2 3

6

02 West Central Behavioral Health

3 2 1 6 4 1 6 11

03 Lakes Region Mental Health Center

112 40 05

5

04 Riverbend Community Mental Health 8 4 1 13 6 7 7 20 Center

05 Monadnock Family Services

001 10 10

1

06 Greater Nashua Mental Health

350 84 20

6

07 Mental Health Center of Greater Manchester

8 7 4 19 10 3 4 17

08 Seacoast Mental Health Center

220 42 10

3

09 Community Partners

211 41 22

5

10 Center for Life Management

010 12 10

3

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 59 of 95

Total New ACT Clients

29 27 14 70 30 20 27 77

Revisions to Prior Period: None.

Data Source: NH Phoenix 2.

Notes: Data extracted 4/21/2020; New ACT Clients are defined as individuals who were not already on ACT within 90 days prior who then began receiving ACT services. This information is not limited to the individuals that received an ACT screening within the previous 90-day period, and may include individuals transitioning from a higher or lower level of care into ACT.

DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 60 of 95

1d. Community Mental Health Center Services: Assertive Community Treatment Waiting List As of 3/31/2020

Time on List

Total

0-30 days 31-60 days 61-90 days 91-120 days 121-150 days 151-180+* days

10

0

3

4

1

0

2

As of 12/31/2019

Time on List

Total

0-30 days 31-60 days 61-90 days 91-120 days 121-150 days 151-180 days

5

2

0

2

1

0

0

Revisions to Prior Period: None.

Data Source: BMHS Report.

Notes: Data compiled 04/20/2020. *1 case at 154 days and 1 at 197 days. All 10 cases are at
DRAFT
MHCGM; increased services are being provided by existing treatment team until assigned to
ACT team.

1e. Community Mental Health Center Services: Assertive Community Treatment – New Hampshire Hospital Admission and Discharge Data Relative to ACT

January - March 2020

October – December 2019

On ACT a t Admissi o n d for ACT on Dischar gdeto ACT at Dischar gOen ACT a t Admissi o n d for ACT on Dischar gdeto ACT at Dischar

Community Mental Health Center

Yes No Yes No Yes No Yes No Yes No Yes No

01 Northern Human Services

5 11 0 11 0 0 4 8 1 7 1 0

02 West Central Behavioral Health

4 8 35 12 3 5 1 4 1 0

03 Lakes Region Mental Health Center

3 3 1 2 0 1 5 10 2 8 1 1

11 18 5 13 3 2 8 20 5 15 4 1 04 Riverbend Community Mental Health

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 61 of 95

Center

05 Monadnock Family Services

64 13 10 3 8 2 6 0 2

06 Greater Nashua Mental Health

12 18 10 8 5 5 9 14 3 11 1 2

07 Mental Health Center of Greater Manchester

8 14 2 12 0 2 13 11 3 8 3 0

08 Seacoast Mental Health Center

0 6 24 02 7 8 3 5 0 3

09 Community Partners

1 12 4 8 1 3 6 14 1 13 0 1

10 Center for Life Management

3 4 04 00 6 6 4 2 3 1

Total

53 98 28 70 11 17 64 104 25 79 14 11

Revisions to Prior Period: None

Data Source: New Hampshire Hospital.

Notes: Data compiled 04/20/20.

DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 62 of 95

1f. Community Mental Health Center Services: Assertive Community Treatment – Reasons Not Accepted to ACT at New Hampshire Hospital Discharge Referral

Reason Not Accepted at Discharge

January - March 2020

October - December 2019

Not Available in Individual’s Town of Residence

0

0

Individual Declined

0

1

Individual’s Insurance Does Not Cover ACT Services

0

0

Individual’s Clinical Need Does Not Meet ACT

1

2

Criteria

Individual Placed on ACT Waitlist

1

0

Individual Awaiting CMHC Determination for

15

8

ACT

Total Unique Clients

DRAFT

17

11

Revisions to Prior Period: None.

Data Source: New Hampshire Hospital.

Notes: Data compiled 04/20/2020.

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents

March 2020

December 2019

Nurse Clinician/or Equivalent Support Worke r Peer Specialist (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner

Community Mental Health Center 01 Northern Human Services

12.2

1.2 16.97 1.20

1.81 1.80 5 0.51 16.37 0

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 63 of 95

02 West Central Behavioral Health
03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services
06 Greater Nashua Mental Health 1
06 Greater Nashua Mental Health 2 07 Mental Health Center of Greater Manchester-CTT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center
09 Community Partners
10 Center for Life Management
Total

0.5 8.75 0.50 0.70 1.20 3.70 0.50 6.10 0

0.7 7.00 0.75 1.00 2.00 3.00 1.00 7.00 5

0.5 11.50 0.50 0.50 2.00 8.00 0.00 10.50 0

0.6 8.75 0.65 2.00 2.25 3.50 1.10 8.85 5

0.2 8.00 0.25 0.50 1.00 4.00 1.00 6.50 5

0.2 8.00 0.25 0.50 1.00 5.00 1.00 7.50 5

0.9 15.75 0.91 1.00 11.00 5.25 1.00 18.25 1

DRAFT
1.00

0.9 15.75 0.91 7.00 7.25 1.00 16.25 1

0.6 10.10 0.60 1.00 2.10 5.00 1.00 9.10 0

0.6 10.80 0.63 0.50 3.00 7.55 0.00 11.05 3

0.4 9.55 0.40 1.25 2.00 4.30 1.00 8.55 0

11.7

69.8

127.0 7.5 130.92 7.55

6 36.35 0 9.11

2 5

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 64 of 95

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies

Substance Use Disorder Treatment

Housing Assistance

Supported Employment

Community Mental Health Center 01 Northern Human Services

March 2020

December 2019

January 2020

December 2019

January 2020

December 2019

2.55

3.15 10.75 10.75 1.50

1.50

02 West Central Behavioral Health

0.20

0.40 4.10

6.50 0.60

1.40

03 Lakes Region Mental Health Center

1.00

1.00 6.00

6.00 2.00

3.00

04 Riverbend Community Mental Health Center

1.50

9.50

0.50

1.50

9.50

0.50

05 Monadnock Family Services

1.40

1.40 2.00

2.00 1.00

1.00

06 Greater Nashua Mental Health 1

4.25

5.25 6.25

6.25 1.00

1.50

06 Greater Nashua Mental Health 2

5.25DRAFT

5.25 7.00

5.00 0.00

0.50

07 Mental Health Center of Greater Manchester-CCT

9.91

11.75

1.50

10.91

13.75

2.00

07 Mental Health Center of Greater Manchester-MCST

5.91

11.75

1.50

5.91

11.75

2.00

08 Seacoast Mental Health Center

2.00

2.00 5.00

6.00 2.00

2.00

09 Community Partners

2.63

2.63 5.05

5.10 0.68

0.38

10 Center for Life Management

3.00

4.00 7.00

8.00 0.30

0.30

Total

40.60 42.40 88.15 88.60 14.58 15.08

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report.

Notes: Data compiled 04/20/2020; for 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 65 of 95 delivered, but rather the quantity of staff available to provide each service. If staff are trained to provide multiple service types, their entire FTE value is credited to each service type.
DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 66 of 95

3a. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12-Month Period
12 Month Period Ending March 2020

Community Mental Health Center

Supported Employment
Clients

Total Eligible Clients

Penetration Rate

Penetration Rate for Period Ending
December 2019

01 Northern Human Services

189

1,330

14.2%

15.0%

02 West Central Behavioral Health

138

623

22.2%

20.1%

03 Lakes Region Mental Health Center

216

1,358

15.9%

19.6%

04 Riverbend Community Mental Health Center

304

17.4%

1,879

16.2%

05 Monadnock Family Services

58

1,089

7.3%

6.2%

06 Greater Nashua Mental Health

256
DRAFT

1,868

15.1%

13.0%

07 Mental Health Center of Greater Manchester

1,513

3,654

41.7%

40.5%

08 Seacoast Mental Health Center

737

2,036

39.0%

34.2%

09 Community Partners

90

767

11.7%

10.1%

10 Center for Life Management

187

1,139

16.4%

18.0%

Total Unique Clients

3,679

15,501

23.7%

23.7%

Revisions to Prior Period: None.

Data Source: NH Phoenix 2.

Notes: Data extracted 04/21/2020

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 67 of 95

Northern Human Services West Central Behavioral Health Lakes Region Mental Health Center Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Mental Health Center of Greater Manchester Seacoast Mental Health Center Community Partners Center for Life Management Statewide Total or Mean Percentage Previous Quarter Statewide Total or Mean Percentage October - December 2019

3b. Community Mental Health Center Clients: Adult Employment Status – Total
Reported Employment Status

Begin Date: 1/01/2020 End Date: 3/31/2020

Employment Status

Update

Overdue Threshold:

105 days Updated Employment Status:

Full time employed

63 34 29 113 54 103 272 221 45 71 1,005

now or in past 90 days Part time employed 144

54 251 315 140 240 363 257 69 161 1,994

now or in past 90 days

Unemployed

180

Not in the Workforce 524

Status is not known

6

Total of Eligible Adult 917

CMHC Clients

Previous Quarter:

944

106 34 87 155 422 958
49 227 51 398 963 1,524
DRAFT
412 930 1,485

134 763 939 104 144 490 2,981

466 278 564 819 266 132 4,584

4 76 83 2 18 49 565

798

2,221 1,403 542 903

1,460

11,12

9

801 1,468 2,202 1,274 512 866

Total of Eligible Adult

CMHC Clients

Percentage by Updated Employment Status:

Full time employed 6.9% 8.5% 3.0% 7.4% 6.8% 7.1% 12.2% 15.8% 8.3% 7.9% 9.0%

now or in past 90 days

Part time employed

15.7 13.6% 26.1 20.7% 17.5% 16.4 16.3% 18.3% 12.7 17.8 17.9

%

%

%

%% %

now or in past 90 days

Unemployed

19.6 26.6% 3.5% 5.7% 16.8% 52.3 42.3% 7.4% 26.6 54.3 26.8

%

%

%% %

Not in the Workforce

57.1 38.9% 43.8 62.9% 58.4% 19.0 25.4% 58.4% 49.1 14.6

%

%

%

% %

41.2 %

Status is not known

0.7% 12.3% 23.6 3.3% 0.5% 5.2% 3.7% 0.1% 3.3% 5.4% 5.1% %

Percentage by Timeliness of Employment Status Screening:

Update is Current

59.0 44.2% 70.4 87.3% 66.2% 97.3 90.5% 93.4% 60.5 99.9 82.9

%

%

%

%% %

Update is Overdue

41.0 55.8% 29.6 12.7% 33.8% 2.7% 9.5% 6.6% 39.5 0.1% 17.1

%

%

%

%

Previous Quarter: Percentage by Timeliness of Employment Status Screening:

Update is Current Update is Overdue

60.6 42.5% 73.7 84.2% 56.9% 96.6 91.5% 95.2% 84.6 99.9

%

%

%

% %

39.4 57.5% 26.3 15.8% 43.1% 3.4% 8.5% 4.8% 15.4 0.1%

%

%

%

956 1,938 2,979 4,557
464 10,894
7.3% 16.5% 19.5% 42.3%
0.3%
78.6% 21.4%

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 68 of 95

3c. Community Mental Health Center Clients: Adult Employment Status – Recent Users of Supportive Employment Services (At Least One Billable Service in Each of Month of the Quarter)

Northern Human Services West Central Behavioral Health Lakes Region Mental Health Center Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Mental Health Center of Greater Manchester Seacoast Mental Health Center Community Partners Center for Life Management Statewide Total or Mean Percentage Previous Quarter Statewide Total or Mean Percentage October-December 2019

Supported Employment Cohort

Reported Employment Status

Begin Date: 1/01/2020 End Date: 3/31/2020

Updated Employment Status:

Full time

1 3 0 4 0 5 9 0 1 4 27 21 DRAFT

employed now

or in past 90

days

Part time

14 7 13 23 4 21 31 13 5 27 158 167

employed now

or in past 90

days

Unemployed

12 9 4 18 3 19 27 14 5 16 127 92

Not in the

10 0 7 3 4 10 9 19 3 2 67 69

Workforce

Status is not

0 3 8 2 0 3 1 0 0 0 17 13

known

Total of

37 22 32 50 11 58 77 46 14 49 396 362

Supported

Employment

Cohort

Previous

32 19 51 42 17 45 76 31 8 41

Quarter: Total

of Supported

Employment

Cohort

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 69 of 95

Percentage by Updated Employment Status:

Full time

2.7% 13.6% 0.0% 8.0% 0.0% 8.6% 11.7% 0.0% 7.1% 8.2% 6.8% 5.8%

employed now

or in past 90

days

Part time

37.8% 31.8% 40.6% 46.0% 36.4% 36.2% 40.3% 28.3% 35.7% 55.1% 39.9% 46.1%

employed now

or in past 90

days

Unemployed 32.4% 40.9% 12.5% 36.0% 27.3% 32.8% 35.1% 30.4% 35.7% 32.7% 32.1% 25.4%

Not in the

27.0% 0.0% 21.9% 6.0% 36.4% 17.2% 11.7% 41.3% 21.4% 4.1% 16.9% 19.1%

Workforce

Status is not

0.0% 13.6% 25.0% 4.0% 0.0% 5.2% 1.3% 0.0% 0.0% 0.0% 4.3% 3.6%

known

DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 70 of 95

Revisions to Prior Period: None.
Data Source: Phoenix 2.
Note 3b-c: Data extracted 4/21/2020. Updated Employment Status refers to CMHC-reported status and reflects the most recent update. Update is Current refers to employment status most recently updated within the past 105 days. Update is Overdue refers to employment status most recently updated in excess of 105 days. Actual client employment status may have changed since last updated by CMHC in Phoenix. Employed refers to clients employed in a competitive job that has these characteristics: exists in the open labor market, pays at least a minimum wage, anyone could have this job regardless of disability status, job is not set aside for people with disabilities, and wages (including benefits) are not less than for the same work performed by people who do not have a mental illness. Full time employment is 20 hours and above; part time is anything 19 hours and below. Unemployed refers to clients not employed but are seeking or interested in employment. Not in the Workforce are clients who are homemakers, students, retired, disabled, hospital patients or residents of other institutions, and includes clients who are in a sheltered/non-competitive employment workshop, are otherwise not in the labor force, and those not employed and not seeking or interested in employment. Unknown refers to clients with an employment status of “unknown,” without a status reported, or with an erroneous status code in Phoenix.
DRAFT

3d. Community Mental Health Center Services: Supported Employment Waiting List As of 3/31/2020

Time on List

Total

0-30 days 31-60 days 61-90 days 91-120 days 121-150 days 151-180+ days

54

11

15

28

n/a

n/a

n/a

Data Source: BMHS Report.

Notes: Data compiled 04/20/2020. Total days waiting are calculated for all individuals waiting when data collection began on January 1, 2020.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 71 of 95

4a. New Hampshire Hospital: Adult Census Summary

Measure

January – March 2020 October -December 2019

Admissions

218

235

Mean Daily Census

159

160

Discharges

213

239

Median Length of Stay in Days for Discharges

17.0

15.0

Deaths

0

0

Revisions to Prior Period: None.

Data Source: Avatar.

Notes 4a: 04/24/2020; Mean Daily Census includes patients on leave and is rounded to nearest whole number.

DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 72 of 95

4b. New Hampshire Hospital: Summary Discharge Location for Adults

Discharge Location

January - March 2020

CMHC Group Home

5

Discharge/Transfer to IP Rehab Facility

6

Glencliff Home for the Elderly

5

Home - Lives Alone

62

Home - Lives with Others

93

Homeless Shelter/ No Permanent Home

4

Hotel-Motel

7

Jail or Correctional Facility

3

Nursing Home

4

Other

6
DRAFT

Peer Support Housing

0

Private Group Home

2

Secure Psychiatric Unit - SPU

0

Unknown

16

October – December 2019 6 9 1 68 99 14 3 7 3 4 1 3 1 20

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 73 of 95

4c. New Hampshire Hospital: Summary Readmission Rates for Adults

Measure

January – March 2020

October – December 2019

30 Days

6.9% (15)

6.8% (16)

90 Days

12.4% (27)

17.9% (42)

180 Days

21.1% (46)

23.0% (54)

Revisions to Prior Period: None.

Data Source: Avatar.

Notes 4b-c: Data compiled 04/24/2020; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions lookback period includes readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day readmissions); patients are counted multiple times – once for each readmission; the number in parentheses is the number of readmissions.

DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 74 of 95

5a. Designated Receiving Facilities: Admissions for Adults January - March 2020

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

61

53

Cypress Center

45

141

Portsmouth

70

263

Elliot Geriatric Psychiatric Unit

5

47

Elliot Pathways

42

65

Total

223

569

October - December 2019

Designated Receiving Facility Franklin

Involuntary Admissions
DRAFT
61

Voluntary Admissions
35

Cypress Center

41

134

Portsmouth

84

266

Elliot Geriatric Psychiatric Unit

5

58

Elliot Pathways

40

60

Total

231

553

Total Admissions
114 186 333
52 105 792
Total Admissions
96 175 350
63 100 784

5b. Designated Receiving Facilities: Mean Daily Census for Adults

Designated Receiving Facility

January - March 2020

Franklin

10.6

Cypress Center

13.7

Portsmouth

29.2

October - December 2019 10.6 13.4 31.8

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 75 of 95

Elliot Geriatric Psychiatric Unit

20.5

Elliot Pathways

12.0

Total

86.1

Revisions to Prior Period: *Total was miscalculated.

23.7 9.5
89.0*

DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 76 of 95

5c. Designated Receiving Facilities: Discharges for Adults

Designated Receiving Facility

January - March 2020

Franklin

110

Manchester (Cypress Center)

207

Portsmouth

327

Elliot Geriatric Psychiatric Unit

71

Elliot Pathways

119

Total

834

October - December 2019 102 198 353 60 123 836

5d. Designated Receiving Facilities: Median Length DRAFT of Stay in Days for Discharges for Adults

Designated Receiving Facility

January - March 2020

October - December 2019

Franklin

6

7

Manchester (Cypress Center)

5

5

Portsmouth

6

6

Elliot Geriatric Psychiatric Unit

20

25

Elliot Pathways

8

7

Total

6

7

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 77 of 95

5e. Designated Receiving Facilities: Discharge Location for Adults January - March 2020

Designated Receiving Facility

Assisted Living / Group
Home

Decease d

DRF*

Hom e

Other Hospit
al

NH Hospita
l

Othe r

Franklin

0

0

0 101

0

3

6

Manchester (Cypress Center)

0

0

7 197

0

0

3

Portsmouth Regional Hospital

0

0

1 220

0

2 104

Elliot Geriatric Psychiatric Unit

24

0

0 16

0

0 31

Elliot Pathways

0

0

2 98

0

0 19

Total

24

0 10 632

0

5 163

Designated Receiving Facility

October – December 2019

DRAFT
Assisted Living / Group
Home

Decease d

Hom DRF* e

Other Hospit
al

NH Hospita
l

Othe r

Franklin

0

0

0 98

0

3

1

Manchester (Cypress Center)

0

0

6 185

0

0

7

Portsmouth Regional Hospital

0

0

4 269

0

4 76

Elliot Geriatric Psychiatric Unit

12

0

1 13

0

0 34

Elliot Pathways

0

0

3 111

0

0

9

Total

12

0 14 676

0

7 127

*Dispositions to ‘DRF’ represent a change in legal status from Voluntary to Involuntary within the DRF.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 78 of 95

5f. Designated Receiving Facilities: Readmission Rates for Adults January - March 2020

Designated Receiving Facility

30 Days

90 Days

Franklin

3.5% (4)

6.1% (7)

Manchester (Cypress Center)

3.5% (7)

5.0% (10)

Portsmouth

9.7% (33)

19.2% (65)

Elliot Geriatric Psychiatric Unit

9.4% (5)

11.3% (6)

Elliot Pathways

9.7% (11)

14.2% (16)

Total

7.3% (60)

12.7% (104)

October – December 2019

Designated Receiving Facility

30 Days

90 Days

Franklin

3.1% (3)

6.2% (6)

Manchester (Cypress Center)

10.3% DRAFT (20)

13.9% (27)

Portsmouth

7.5% (28)

8.8% (33)

Elliot Geriatric Psychiatric Unit

5.7% (4)

7.1% (5)

Elliot Pathways

3.9% (4)

5.8% (6)

Total

7.0% (59)

9.2% (77)

Revisions to Prior Period: None.

Data Source: NH DRF Database.

Notes: Data compiled 05/06/2020.

180 Days 7.8% (9) 8.5% (17) 23.0% (78) 18.9% (10) 15.9% (18) 16.1% (132)
180 Days 9.3% (9) 21.1% (41) 15.3% (57) 8.6% (6) 8.7% (9) 14.6% (122)

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 79 of 95

6. Glencliff Home: Census Summary Measure

January – March 2020 October - December 2019

Admissions

9

0

Average Daily Census

111

111

Discharges

2 (One resident discharged to a 3 bed Medical Model Group
0 Home and one resident discharged to home with
Family)

Individual Lengths of Stay in Days for

(393 and 762)

N/A

Discharges

Deaths

0

4

Readmissions

0

0

Mean Overall Admission Waitlist

26

29

DRAFT

Revisions to Prior Period: None.

Data Source: Glencliff Home.

Notes: Data Compiled 05/11/2020; Mean rounded to nearest whole number; Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 80 of 95

7. NH Mental Health Client Peer Support Agencies: Census Summary

January – March 2020

October - December 2019

Peer Support Agency

Total Members

Average Daily Visits Total Members

Average Daily Visits

Alternative Life Center

Total

224

44

248

28

Conway

42

13

49

9

Berlin

105

7

114

9

Littleton

44

11

48

10

Colebrook

33

13

37

n/a*

Stepping Stone Total Claremont Lebanon

346

17

357

20

241

13

247

16

DRAFT

105

4

110

4

Cornerbridge Total

91

14

147

15

Laconia

25

6

37

6

Concord

58

6

93

6

Plymouth Outreach

8

2

17

3

MAPSA Keene Total

42

19

85*

19

HEARTS Nashua Total

400

On the Road to Recovery Total

36

409*

33

152

11

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 81 of 95

Peer Support Agency
Manchester Derry Connections Portsmouth Total TriCity Coop Rochester Total

January – March 2020

October - December 2019

Total Members

Average Daily Visits Total Members

Average Daily Visits

157

10

75

5

86

5

82

5

66

6

82

14

89

14

216

26

252

23

Total

1,558

170

1,739*

152*

Revisions to Prior Period: Corrected data indicated DRAFT by (*).

Data Source: Bureau of Mental Health Services and Peer Support Agency Quarterly Statistical Reports.

Notes: Data Compiled 05/07/2020; Average Daily Visits are not applicable for Outreach Programs.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 82 of 95

8. Housing Bridge Subsidy Program: Summary of Individuals Served to Date January – March 2020

Subsidy

Total individuals served at start of quarter

New individuals added during quarter

Total individuals served through end of quarter

Housing Bridge Subsidy

872

50

922

Section 8 Voucher (NHHFA/BMHS) Transitioned from Housing Bridge

163

16

179

October - December 2019

Subsidy

Total individuals served at start of quarter

New individuals added during quarter

Total individuals served through end of quarter

Housing Bridge Subsidy

829
DRAFT

Section 8 Voucher (NHHFA/BMHS) -

151

Transitioned from Housing Bridge

43

872

12

163

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 03/31/2020. Figures at start and end of each quarter are cumulative total of individuals served since CMHA quarterly reporting began in 2015.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 83 of 95

8a. Housing Bridge Subsidy Program: Current Census of Units/Individuals with Active Funding Status

Measure

As of 3/31/2020

As of 12/31/2019

Rents Currently Being Paid

327

340

Individuals Enrolled and Seeking Unit for Bridge Lease

94

54

Total

421

394

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 03/31/2020; all individuals currently on Bridge Program are intended to transition from the program to other permanent housing.

8b. Housing Bridge Subsidy Program: Clients Linked to Mental Health Care Provider Services

Measure

As of 3/31/2020

As of 12/31/2019

Housing Bridge Clients Linked

348/421 (83%)

358/394 (91%)

Data source: Bureau of Mental Health Services data, Phoenix 2, and Medicaid claims.

DRAFT
Notes: Data compiled 04/28/2020; “Housing Bridge Clients Linked” refers to Housing Bridge clients who received one or more mental health services within the previous 3 months, documented as a service or claim data found in Phoenix or the Medicaid Management Information System.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 84 of 95

8c. Housing Bridge Subsidy Program: Density of HBSP Funded Units at Same Property Address*

Number of HBSP Funded Unit(s)* at Same Address

Frequency as of 3/31/2020

Frequency as of 12/31/2019

1

279

276

2

14

18

3

2

4

4

2

2

5

0

0

6

0

0

7

0

0

8 or more

1

1

*All units are individual units; property address may include multiple buildings, such as apartment complexes.
DRAFT
Revisions to Prior Period: None.

Data Source: Bureau of Mental Health data compiled by Office of Quality Assurance and Improvement.

Notes: Data Compiled 03/31/2020.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 85 of 95

8d. Housing Bridge Subsidy Program: Applications

Measure

January - March 2020

October - December 2019

Applications Received During Period

74

59

Point of Contact for Applications Received

CMHCs 63; NHH 11

CMHCs 51; NHH 8

Applications Approved

104

42

Applications Denied

0

0

Denial Reasons

NA

NA

Applications in Process at End of Period

49

79*

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services.

Notes: Data Compiled 03/31/2020. *13 applications with incomplete required additional
documentation were withdrawn from the processing queue by the applicant or referring
DRAFT
agent. The reasons provided for withdrawal include: received other housing or vouchers (3),
incarceration (1), ineligibility (4), unable to locate applicant (4), and higher level of care was
needed (1).

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 86 of 95

8e. Housing Bridge Subsidy Program: Terminations

Type and Reason

January – March 2020

October - December 2019

Terminations – DHHS Initiated

2

0

Over Income

NA

NA

Exited Program – Client Related Activity

25

23

Voucher Received

16

16

Deceased

2

2

Over Income

4

0

Moved Out of State

1

2

Declined Subsidy at Recertification

1

0

Higher Level of Care Accessed

1

2

Other Subsidy Provided

DRAFT

0

0

Moved in with family

0

1

Total

27

23

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 03/31/2020.

8f. Housing Bridge Subsidy Program: Application Processing Times

Average Elapsed Time of Application Processing (calendar days)*

January - March 2020

Completed Application to Determination

1

October December 2019
1

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 87 of 95

Approved Determination to Funding Availability**

41

164

Referred to Vendor with Funded HB Slot

1

1

Leased Unit Secured

30***

18

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services.

Notes: Data Compiled 03/31/2020.

*Elapsed time measure reporting implemented 10/01/18 and applies to any application received on or after that date.

**Average calculated on 50 applications approved for which funding was made available in the quarter.

***Average calculated on 3 units leased during the quarter.

9. Housing Bridge Subsidy Program Waitlist: Approved Applications

Total

0-30

31-60

days

days

49

12

19

Total

0-30

31-60

days

days

25

18

4

Revisions to Prior Period: None.

As of 3/31/2020

Time on List

61-90 91-120

days

days

10

DRAFT

8

As of 12/31/2019

Time on List

61-90 91-120

days

days

0

1*

121-150 days 0
121-150 days 0

151-180 days 0
151-180 days 1*

181+ days
0
181+ days
1

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 03/31/2020. *Indicates hospitalized individuals who were not medically cleared for discharge as of 12/31/19 but for whom an HBSP subsidy has been approved, pending discharge

10. Supported Housing Subsidy Summary

January - March October -

2020

December 2019

Subsidy

Total subsidies by end of quarter

Total subsidies by end of quarter

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 88 of 95

Housing Bridge Subsidy:

Units Currently Active
Individuals Enrolled and Seeking Unit for Bridge Lease

327

340

94

54

Section 8 Voucher Transitioned from Housing Bridge*

(NHHFA):

Not Previously Receiving Housing Bridge

177

163

3

2

811 Units:

PRA Mainstream

75

60

44

44

Other Permanent Housing Vouchers (HUD, Public Housing, VA)

5 5

Total Supported Housing Subsidies

725

668

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 03/31/2020; Section 8 Voucher Not Previously Receiving Housing
DRAFT
Bridge are CMHC clients that received a Section 8 Voucher without previously receiving a Housing Bridge subsidy; 811 Units (PRA and Mainstream) are CMHC clients or CMHA target population members that received a PRA or Mainstream 811 funded unit with or without previously receiving a Housing Bridge subsidy; Other Permanent Housing Vouchers (HUD, Public Housing, VA) are CMHC clients that received a unit funded through other HUD or Public Housing sources with or without previously receiving a Housing Bridge subsidy.

*These counts are cumulative; increasing over time since originally reporting this data within the CMHA Quarterly Data Report.

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 89 of 95

11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure

January February

2020

2020

March 2020

January – March 2020

October Decembe
r 2019

Unique People Served in Month

215

199

199

531

516

Services Provided by Type

Case Management

0

Crisis Apartment Service

0

Crisis Intervention Services

10

ED Based Assessment

0

Medication Appointments or Emergency Medication Appointments

0
DRAFT

Mobile Community Assessments

42

Office-Based Urgent Assessments

39

Other

0

Peer Support

0

Phone Support/Triage

378

Psychotherapy

0

0

0

0

0

0

0

0

0

2

8

20

43

0

0

0

0

0

0

0

0

36

38

116

149

20

18

77

136

0

0

0

0

0

0

0

0

413

382

1,173

1,139

0

0

0

0

Referral Source CMHC Internal Emergency Department Family

20

17

17

54

52

4

7

7

18

10

22

20

26

68

77

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 90 of 95

Measure Friend Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self School
Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

January February

2020

2020

2

5

26

20

0

0

11

4

6

2

9

7

10

8

92

102

13

7

DRAFT

March 2020

January – March 2020

October Decembe
r 2019

6

13

8

13

59

43

0

0

0

5

20

22

5

13

5

7

23

26

5

23

20

97

291

341

11

31

26

25

17

15

57

81

98

82

65

245

364

3.9

4.8

4.3

4.3

4.5

Law Enforcement Involvement

10

15

20

45

26

Hospital Diversions Total

141

Revisions to Prior Period: None.

Data Source: Riverbend CMHC submitted report.

115

127

383

483

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 91 of 95 Notes: Data Compiled 04/09/2020; reported values other than the Unique People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.
DRAFT

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 92 of 95

11b. Mobile Crisis Services and Supports for Adults: Mental Health Center of Greater Manchester

Measure

January February

2020

2020

March 2020

January – October -

March December

2020

2019

Unique People Served in Month

251

233

266

618

604

Services Provided by Type Case Management Crisis Apartment Service Crisis Intervention Service ED Based Assessment Medication Appointments or Emergency Medication Appointments Mobile Community Assessments Office-Based Urgent Assessments Other Peer Support Phone Support/Triage Psychotherapy

39

33

16

12

91

80

0

0

7

4

DRAFT

104

106

10

23

270

234

22

13

528

514

4

0

19

91

84

6

34

35

71

242

254

0

0

0

4

15

7

80

290

303

21

54

65

277

781

735

7

42

83

523

1,565

1,482

5

9

11

Referral Source CMHC Internal Emergency Department Family

6

2

2

0

43

60

4

12

19

0

2

2

45

148

136

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 93 of 95

Friend Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self School

2

9

6

5

6

7

17

5

52

37

63

66

14

16

157

155

0

0

8

19

5

5

16

15

10

23

0

8

30

39

40

129

148

75

204

225

6

36

40

156

468

412

0

0

0

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

9

6

DRAFT
28

18

3.1

3.0

2

17

18

7

53

72

3.5

3.1

4.0

Law Enforcement Involvement

63

66

75

204

225

Hospital Diversion Total

373

366

349

1,088

Revisions to Prior Period: None.

Data Source: Phoenix 2.

Notes: Data Compiled 04/30/2020; reported values other than the Unduplicated People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

1,086

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 94 of 95

11c. Mobile Crisis Services and Supports for Adults: Harbor Homes

Measure

January February

2020

2020

March 2020

January – October -

March December

2020

2019

Unique People Served in Month

134

122

116

333

368

Services Provided by Type Case Management Crisis Apartment Service Crisis Intervention Services ED Based Assessment Medication Appointments or Emergency Medication Appointments Mobile Community Assessments Office-Based Urgent Assessments Other Peer Support Phone Support/Triage Psychotherapy

12

18

21

51

83

103

96

123

322

289

0

0

0

0

0

4

4

4

12

17

0

0

0

0

0

DRAFT
68

63

79

210

189

43

29

19

91

104

0

0

0

0

0

100

69

54

223

168

133

130

122

385

463

4

0

0

4

16

Referral Source CMHC Internal Emergency Department Family Friend

12

6

3

0

11

8

4

0

6

24

28

0

3

7

4

23

64

5

9

12

Case 1:12-cv-00053-SM Document 134-1 Filed 08/21/20 Page 95 of 95

Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self Schools

0

0

0

0

7

5

93

93

4

2

2

2

33

47

16

9

0

0

0

0

0

0

4

16

23

85

271

281

6

12

17

5

9

7

34

114

155

9

34

35

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

22

15

121

87

DRAFT
5.5

5.8

19

56

48

88

296

252

4.6

5.3

5.3

Law Enforcement Involvement

0

0

0

0

0

Hospital Diversion Total

227

198

192

617

612

Revisions to Prior Period: None.

Data Source: Harbor Homes submitted data.

Notes: Data Compiled 04/14/2020; reported values other than the Unique People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

 
 Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 1 of 86
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Eight
July 23, 2018
I. Introduction
This is the eighth semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv-53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this six-month period (January 1, 2018 through June 30, 2018), the ER has continued to observe the State’s work to implement certain key service elements of the CMHA, and has continued to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. During this period, the ER:
• Observed an on-site Assertive Community Treatment (ACT) fidelity review at Lakes Region Mental Health Center;
• Observed an on-site Supported Employment (SE) fidelity review at Greater Nashua Mental Health Center;
• Met with senior management and with a clinical team at New Hampshire Hospital (NHH) to review transition planning processes and issues;
• Met with senior management of NHH to discuss new transitional housing options targeted to longstay patients at NHH;
• Met with Glencliff leadership and clinical staff to discuss transition planning processes and issues; • Met with the Mobile Crisis Team (MCT) of Harbor Homes, the agency selected to operate the MCT
and crisis apartments in the greater Nashua region; • Observed two Quality Service Review (QSR) reviews; one at Greater Nashua Mental Health Center,
and one at Northern Human Services; • Met with the DHHS CMHA leadership team to discuss progress in the implementation of CMHA
standards and requirements; • Participated in meetings with representatives of the Plaintiffs and the United States (hereinafter
“Plaintiffs”); • Met three times with DHHS Quality Management/Quality Service Review (QM/QSR) staff to
discuss the Greater Nashua and Northern Human Services QSR reviews; and • Convened an All Parties meeting to discuss progress in meeting the requirements of the CMHA.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 2 of 86
Information obtained during these on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.
Summary of Progress to Date
This report reflects the end of four years of implementation of the CMHA. Looking back on the past four years, it is possible to document that some positive steps have been taken to improve the quality and effectiveness of services as envisioned in the CMHA. Implementation issues remain time consuming and frustrating. And, as will be discussed in detail below, there are areas of continued non-compliance with the CMHA. Notwithstanding these on-going concerns, the parties to the CMHA deserve credit for some real and measurable accomplishments.
One major accomplishment has been the implementation of a comprehensive and reliable QSR process. The QSR has been implemented in ten CMHA regions this fiscal year. The ER considers these QSR reviews to be methodologically correct and reliable, and that the QSR reviews are producing findings that are accurate and actionable in terms of taking concrete steps to address quality issues in the CMHC system.
Another major accomplishment has been contracting with the Dartmouth-Hitchcock Medical Center to conduct external ACT and SE fidelity reviews using nationally validated fidelity review instruments and criteria. In concert with the QSR reviews mentioned above, the fidelity reviews are assisting the state and the CMHCs to develop comprehensive Quality Improvement Plans (QIPs) that address important ACT and SE quality and effectiveness issues at both the consumer and CMHC operational levels.
The ER also notes, as will be discussed below, that the State remains in compliance with regard to statewide SE penetration rates, and continues to operate a robust and effective supportive housing (SH) program.
Much of the remainder of this report will, appropriately, focus on issues and concerns related to implementation of the CMHA. Nonetheless, it is important to recognize positive progress when it occurs within the context of the CMHA.
Two years ago the ER recommended a number of action steps and timelines intended to facilitate movement towards compliance with the CMHA and to increase transparency and accountability related to State actions under the aegis of the CMHA. The State agreed to implement these recommendations, and has made progress in certain areas of compliance and accountability. Specific progress related to these recommendations is summarized below:
1. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and time lines to achieve compliance with the CMHA requirements for ACT services;
ER Finding: The State has implemented this recommendation by circulating such a plan, and continues to track and report on its implementation of various action steps intended to achieve compliance with CMHA requirements. However, as will be noted throughout this report, the State remains out of compliance with the ACT requirements of the CMHA. In fact, there has been virtually no progress in expanding ACT capacity and enrollment over the past 18 months. Real progress towards attainment of the CMHA requirements must be achieved over the next year. Given the advanced stage of implementation of the CMHA, and the importance of achieving compliance with its

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 3 of 86
terms, the ER would benefit from the guidance of the Court. For this reason, the ER recommends, and at the Court’s request will make himself available for, a meeting with Judge McAuliffe during the next three months. The ER believes that such a meeting would also aid the Court in assessing the status of compliance with the Agreement, and clarifying the work which remains to be done in order to secure a timely resolution of this case.
2. By August 1, 2016, circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA penetration rates and fidelity standards for SE throughout New Hampshire;
ER Finding: The State has implemented this recommendation by circulating such a plan, and continues to track and report on its implementation of various action steps and progress towards compliance with CMHA requirements. The State is in compliance with the statewide penetration rate standards for SE, but continues to work collaboratively with the four CMHCs that remain under the standard. Fidelity reviews resulted in Quality Improvement Plans for most CMHCs in 2017 and 2018.
3. By August 1, 2016 circulate to all parties a detailed plan with implementation steps and timelines to achieve CMHA requirements to assist 16 residents of Glencliff with complex medical needs to move into integrated settings as soon as possible;
ER Finding: The State has implemented this recommendation by circulating such a plan and it continues to track and report on individuals with pending discharge plans. The current status of compliance is discussed in greater detail under the Glencliff Transitions section of this report.
4. Starting September 1, 2016, and each month following, submit to all parties a monthly progress report of the steps taken and completed under these respective plans to assure compliance with CMHA requirements as identified in this report;
ER Finding: The State has implemented this recommendation and continues to track and report on its progress, which varies depending on the sections of the plan. However, the delivery of this Monthly Progress Report has become quite slow. The most recent monthly report received by the ER is for February and March, 2018, but was not received until June 26, 2018. This plan does not currently contain new strategies to improve compliance with ACT capacity and enrollment. The ER continues to request that the State substantially improve the timeliness of the Monthly and Quarterly Reports. The latest version of the monthly progress report is attached as Appendix B of this report.
5. By October 1, 2016, complete the field tests and technical assistance related to the Quality Service Review (QSR), convene a meeting with Plaintiffs to discuss any recommended design or process changes, and publish a final set of QSR documents governing the process for future QSR activities;
ER Finding: Working in concert with representatives of the plaintiffs and the ER, DHHS developed revised QSR instrumentation, instructions, and scoring algorithms. The revised QSR has been carried out at ten of the CMHCs. The ER has participated in a total of four of these on-site QSR reviews A more detailed discussion of progress with regard to the QSR is included under the QSR section of this report. As noted above, the ER is satisfied that the QSR is being implemented effectively and is producing reliable and actionable results and findings.
6. Complete at least one QSR site review per month between October 2016 and June 2017, with the exception of the month of December, and circulate to all parties the action items, plans of correction (if

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 4 of 86
applicable), and updates on implementation of needed remedial measures (if applicable) resulting from each of these reviews;
ER Finding: See #5 above. It should be noted that all 10 of the CMHCs had an onsite QSR review using the previous instruments and protocols during the 2016-2017 period.
7. Starting July 1, 2016, circulate to all parties on a monthly basis the most recent data reports of the Central Team;
ER Finding: The State has implemented this recommendation by circulating monthly reports and it continues to track and report progress towards compliance with CMHA requirements. However, until this week, the most recent Central Team report was dated November, 2017. The ER has now received the May, 2018 Central Team report, showing only one new referral since November of 2017.
8. No later than October 1, 2016, assure that final rules for supportive housing and ACT services are promulgated in accordance with the draft rules developed with input from all parties;
ER Finding: The Supported Housing (SH) and ACT rules have been promulgated, and incorporate positive elements resulting from discussions among DHHS staff and representatives of the Plaintiffs.
9. By October 1, 2016, augment the quarterly data report to include:
• ACT staffing and utilization data for each ACT team, not just for each region.
ER Finding: The State has implemented this recommendation.
• Discharge destination data and readmission data (at 30, 90, and 180 days) for people discharged from NHH and the other Designated Receiving Facilities (DRFs).
ER Finding: The State has now complied with this recommendation. As with the previous ER report, these data are included in the Quarterly Data Reports, the most recent of which is included as Appendix A of this report.
• Reporting from the three Mobile Crisis programs, including hospital and ED diversions.
ER Finding: As noted in the prior ER Report, data for the Mobile Crisis Teams and Crisis Apartments has been included in the Quarterly Data Report.
• Supported housing (SH) data on applications, time until eligibility determination, time on waiting list, reason for ineligibility determination, and utilization of supportive services for those receiving supportive housing.
ER Finding: As of March 2018 DHHS has reported the number of people approved for the Housing Bridge Subsidy Program but on the wait list for funding. DHHS has assured the ER that it intends to supply information on the elapsed time on the waiting list and on the reasons for denials or terminations (if they occur) in the next Quarterly Data Report. As will be discussed in the Data section of this report, the State also has provided assurances that it will produce data on the receipt of supportive services for those receiving supportive housing. The ER will continue to closely monitor progress in reporting these essential data elements.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 5 of 86
10. By October 1, 2016, and then by December 1, 2016, factually demonstrate that significant and substantial progress has been made towards meeting the standards and requirements of the CMHA with regard to ACT, SE and placement of individuals with complex medical conditions from Glencliff into integrated community settings.
ER Finding: The State remains out of compliance with the ACT standards of the CMHA. The State has made some progress towards compliance with the Glencliff requirements in the CMHA, but recently the progress has been slower. More detailed discussions of issues related to ACT and Glencliff Transitions are included in the relevant sections of this report. The ER notes that the State remains in substantial compliance with the statewide SE penetration rate requirements of the CMHA. The ER will continue to work with DHHS to document that: (a) SE services are delivered with adequate intensity and duration to meet individuals’ needs; and (b) SE services are resulting in integrated, competitive employment. In response to several prior requests, in July, 2018 DHHS produced data on the degree to which SE services are resulting in integrated, competitive employment, and going forward these data will be included in the Quarterly Data Report.
11. By October 1, 2016 demonstrate that aggressive executive action has been taken to address the pace and quality of transition planning from NHH and Glencliff through the development of a specific plan to increase the speed and effectiveness of transitions from these facilities.
ER Finding: The ER believes that both NHH and Glencliff have evidenced, at a leadership and a staff level, increased efforts and commitment to facilitating timely transitions to integrated community settings, albeit with modest result to date. Only two people were transitioned from Glencliff to integrated community setting in the past six months.
II. Data
The New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (January to March, 2018), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The capacity to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve.
As noted in the previous ER report, he Quarterly Reports include data from the mobile crisis services in the Concord, Manchester and Nashua Regions; data on discharge destinations from New Hampshire Hospital (NHH), the Designated receiving Facilities (DRFs), and Glencliff; admission, discharge and length of stay data for New Hampshire’s DRFs; and some enhanced data on the SH Bridge Subsidy Program. As of the most recent Quarterly Data Report, data on ACT screening and wait lists has also been included.
As noted in previous ER reports, there continue to be important categories of data that are needed, but not routinely collected and reported, and which will need to be reported in order to accurately evaluate ongoing implementation of the CMHA. Some of these are noted above.
One gap in data is related to people receiving SH under the Housing Bridge Subsidy Program. As noted in the January 2016 ER Report, DHHS had identified a strategy to link data from the Bridge Subsidy Program to the Phoenix II system. However, as noted above, these data have not yet been produced. Further, as of the writing of this report the State has no concrete plan to produce these data. Without the information above, the ER is

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 6 of 86 unable to determine whether the State has achieved substantial compliance with the CMHA outcomes and requirements for SH.1 Other outstanding data requests include SH data related to waiting lists; and ineligibility determinations, as described in the ER Findings, above. As noted in several places above, the ER is becoming increasingly concerned with delays in reporting. DHHS had undergone personnel changes that have impeded timely reporting. Nonetheless, it is critical that all data and agreed-upon reports return to a timely delivery schedule immediately.
III. CMHA Services
The following sections of the report address specific service areas and related activities and standards contained in the CMHA.
Mobile/Crisis and Crisis Apartment Programs
The CMHA calls for the establishment of a MCT and Crisis Apartments in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC was selected to implement the MCT and Crisis Apartments in the Concord Region. The CMHA specified that a second MCT and Crisis Apartments be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. Per CMHA V.C.3(c), a third MCT and Crisis Apartment program became operational in the Nashua region on July1, 2017. The contract for that program was awarded to Harbor Homes in Nashua. Table I below includes the most recent available information on activities of these three MCT/Crisis Apartment Programs.
1 The ER notes that useful data on services related to SH are gleaned from the QSR reviews. However, these are not a substitute for system-wide data on the degree to which SH participants are linked to and receiving community mental health and related services.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 7 of 86

Table I

Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs

Total unduplicated people served Services provided in response to immediate crisis:
• Phone support/triage • Mobile assessments • Crisis stabilization
appointments • Emergency services
medication appointments • Office based urgent
assessments Services provided after the immediate crisis:
• Phone support/triage • Mobile assessments • Crisis stabilization
appointments • Emergency services
medication appointments • Office based Urgent
Assessments
Referral source: • Self • Family • Guardian • Mental health provider • Primary care provider • Hospital emergency department • Police • CMHC Internal • Friend • Other
Crisis apartment admissions: • Bed days • Average length of stay
Law enforcement involvement Total hospital diversions2

Concord Jan-March 2018
507

Manchester Jan-March 2018
457

Nashua Jan-March 2018
103

890

1332

131

180

217

54

46

45

6

2

93

35

0

350

Not

46

Not

46

Reported

Reported

28

93

302

385

87

52

85

13

55

1

0

26

17

9

13

18

0

6

4

1

15

159

2

36

68

24

12

11

3

65

97

18

97

9

886

441

29

8.6

4.5

3.2

46

159

18

450

844

130

The Quarterly Data Report in Appendix A contains some historical data for the three regional MCT/Crisis Apartment programs.
2 Hospital diversions are instances in which services are provided to individuals in crisis resulting in diversion from being assessed at the ED and/or being admitted to a psychiatric hospital. DHHS and the MCT providers have developed specific definition of hospital diversions, which will be utilized for future MCT reports.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 8 of 86
As noted in the previous report, the number of hospital diversions reported by the MCTs seems disproportionate, given the continued high admission and readmission rates for NHH and the DRFs, and the high number of people waiting on a daily basis for admission to NHH. The ER continues to work with the DHHS to clarify documentation of the numbers and types of hospital diversions that are reported by the MCTs.
DHHS and the three MCT programs have recently formed a working group/learning community to improve MCT/crisis apartment performance. One initial product of this collaboration is a clarified set of definitions of MCT activities and interventions that will result in more accurate and consistent data reporting. For example, the definition of “hospital diversions” has been refined, and future MCT quarterly report data should more accurately reflect hospital diversion results in the three MCT service areas.
DHHS has added questions to the QSR interview guides to elicit information about the quality and effectiveness of the MCTs and Crisis Apartments, and to report on that information in the updated QSR instrument. To date, two of the CMHCs with MCT/Crisis Apartment programs have participated in the revised QSR process. Concord scored above the 70% minimum performance threshold for all three crisis services indicators. Nashua3 received a 70% or higher score for crisis planning and service delivery, but scored only 36% for adequacy of crisis assessments.
Assertive Community Treatment (ACT)
ACT is a core element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team; 3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above
in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time; and 4. By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.
The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015 (36 months ago). Further, as of June 30, 2016, the State was required to have the capacity to provide ACT to 1,500 priority Target Population individuals.
As displayed in Table II below, the staff capacity of the 12 adult ACT teams in New Hampshire has increased by only 3.95 FTEs since December of 2016. During the same time period, the twelve ACT teams added only 62 average monthly service participants.4
3 Note that in Nashua the MCT vendor is Harbor Homes, not the Greater Nashua Mental Health Center. 4 Because of service participant turnover, the total number of people served across several months and quarters is somewhat higher than the monthly number of service participants.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 9 of 86

Table II

Self-Reported ACT Staffing (excluding psychiatry): December 2016 – March 2018

Region

FTE Dec-16

FTE Mar-17

FTE Jun-17

FTE Sep-17

FTE Dec-17

FTE Mar-18

Northern West Central Genesis/LRMHC Riverbend Monadnock Greater Nashua 1 Greater Nashua 2 Manchester – CTT Manchester MCST Seacoast Community Partners Center for Life Management Total

11.49 5.5 11 9 7.25 6.25 5.25
15.53 21.37 9.53
6.85
7.17 116.19

11.89 7.75 11 10 6.7 6.25 5.25 14.79 21.86 9.53
4.08
8.3 117.4

12.54 7.15 10.6 10 8.5 5.25 5.25 16.57 21.95 9.53
8.53
9.3 125.17

12.43 6.95 10.8 10 7.9
6 5 16.27 22.31 10.53
6.73
9.3 124.22

13.04 6.2 9.4 10 7.9 5 5
12.83 19.04 10.53
7.85
9.3 116.09

11.64 5 5.7
10.25 8.7 5.75 5.75
17.26 19.51 11.53
9.75
9.3 120.14

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 10 of 86

Table III

Self-Reported ACT Caseload (Unique Adult Consumers) by Region in specified Months: December 2016 – March 2018

Region

Active Cases Dec-16

Active Cases Mar-17

Active Cases Jun-17

Active Cases Sep-17

Active Cases Dec-17

Active Cases Mar-18

Northern

104

West Central

32

Genesis

64

Riverbend

73

Monadnock

63

Greater Nashua

74

Manchester

248

Seacoast

65

Community Partners

70

Center for Life

Management

47

108

111

113

115

114

53

76

68

57

46

70

74

74

65

64

83

97

87

81

80

64

70

69

53

55

83

94

98

76

74

270

292

287

269

277

64

69

67

54

67

69

75

64

66

55

55

54

55

59

Total*

839

* Deduplicated across regions

913

1,006

992

881

901

It is clear from these tables that overall ACT staffing has remained low, and on four teams has actually decreased over the past four reporting periods. Four of the 12 adult ACT teams continue to have fewer than the 7 - 10 professionals specified for ACT teams in the CMHA.. Four teams now report having no peer specialist on the ACT Team, doubling the number of teams with no peer support staff since the previous report. Four teams report having at least one FTE peer specialist, but that means that eight of the 12 teams continue to report having less than one FTE peer on the team. Seven teams have at least 1.0 FTE SE staff, while five have less than a full time SE specialist. Six teams report having .5 or less FTE combined psychiatry/nurse practitioner time available to their ACT teams5; three teams report having 0.5 or less FTE nursing staff on the team; and four of the 12 teams report having less than one FTE nurse per team. Staff deficiencies, as noted above, render some of the current ACT teams out of compliance with the ACT service requirements in CMHA V.D.2(d) as of the date of the Quarterly Data Report.
The combined ACT teams have a reported March 2018 staff complement of 120.14 FTEs, which is sufficient capacity to serve 1,201 individuals based on the ACT staffing ratios contained in the CMHA. Note that this is a minor increase in staff-based capacity from the previous report. With a statewide caseload of 901 as of March 2018, the existing teams should theoretically be able to accept an additional 300 new ACT clients without additional staff. Tapping into this unused capacity, with appropriate outreach and targeting, should have an impact on alleviating ED boarding and hospital readmission rates across the state. Further, the CMHA requires the State to have capacity to serve 1,500 individuals, but the current ACT capacity of 1,201 is 299 below
5 The CMHA specifies at least .5 FTE Psychiatrists for teams with at least 70 active service participants. (CMHA V.D.2(e). Teams with fewer than 70 clients are technically not out of compliance with this standard.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 11 of 86 CMHA criteria. This is a slightly larger gap between CMHA-required capacity and the current capacity of the 12 ACT teams documented in the ER’s December 2017 report. As noted in previous reports, the current level of ACT staffing is not sufficient to meet CMHA requirements for ACT team capacity. Furthermore, current ACT enrollment is 599 below utilization levels envisioned in the CMHA.
ACT Screening As has been documented in previous reports, the State has been implementing a number of strategies to increase ACT enrollment and participation. One of these strategies has been to require the ten CMHCs to conduct and report regular clinical screening for eligibility/appropriateness for ACT services, These clinical screens are conducted:
1. As part of the intake process at the6 CMHCs; 2. Upon referral to a CMHC following discharge from an inpatient facility; and 3. As part of regular quarterly and annual assessments and plan of care amendments for current CMHC
clients (including current active ACT participants) who may qualify for and benefit from ACT. Table IV below presents data on ACT screens conducted by CMHCs between January and March, 2018. This is the first reporting period in which these data are available, and it is too early to interpret or draw conclusions from them. In future reports, the State plans to include data from each CMHC regarding the degree to which screening activity results in actual referrals and admissions to ACT.
6 Note that a CMHC intake incorporating the ACT screen is performed when a CMHC emergency services staff or Mobile Crisis Team encounters and refers a person potentially needing CMHC services. In some cases these Emergency Services/ MCT referrals are made on behalf of individuals who have presented in crisis in hospital emergency departments and who may be waiting for a NHH admission.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 12 of 86
Table IV Self-Reported Number of Screens for ACT Services Conducted by CMHCs
January through March, 2018

Community Mental Health Center 01 Northern Human Services 02 West Central Behavioral Health 03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 07 Mental Health Center of Greater Manchester 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management Total

January February

2018

2018

157

121

45

41

181

250

500

445

March 2018 217 85 244 598

239

159

226

416

412

534

783

735

690

158 207 133 2,819

652 170 161 3,146

435 202 151 3,382

In addition, the State has begun collecting and reporting data on the number of individuals waiting for ACT services on a statewide basis. This information is displayed in Table V below. An individual eligible for ACT may have to wait for ACT services because the specific ACT team of the individual’s CMHC does not currently have staff capacity to accept new clients. The ER has documented above that there is a statewide gap between ACT staff capacity and ACT participation. However, in some CMHC regions new ACT staff must be hired before new ACT clients can be accepted into the program.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 13 of 86 Table V
Self-Reported ACT Wait List as of March 31, 2018

Total 9

0-30 days 7

Time on List 31-60 days
2

61-90 days 0

Based on the above information, the ER finds that the State remains out of compliance with the ACT service standards described in Section V.D. of the CMHA. The State does not currently provide a robust and effective system of ACT services throughout the state as required by the CMHA.
Additionally, the State reports beginning to develop but has yet to finalize a process for identifying all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and to develop effective regional and statewide plans for providing sufficient ACT services. State efforts to address these issues will be a focus of ER monitoring during the upcoming six month period.
As noted in recent ER Reports, the New Hampshire DHHS has taken deliberate action to work with CMHCs in certain Regions to increase their ACT staffing and caseloads. These actions include: (a) monthly ACT monitoring and technical assistance with DHHS leadership and staff; (b) implementation of a firm schedule for ACT fidelity reviews; (c) incorporating a small increase in ACT funding into the Medicaid rates for CMHCs; (d) active on-site monitoring and technical assistance for CMHCs not yet meeting CMHA ACT standards; and (e) substantial and coordinated efforts to address workforce recruitment and retention.
However, external fidelity reviews for the ten CMHC regions have revealed deficient practices that are not in fidelity with the ACT model. As of the date of this report the ER has reviewed six QSR reports using the revised instruments. Five of the six CMHCs covered by these QSR reviews had scores below the 70% performance threshold on the QSR quality indicator related to the fidelity of ACT services. Quality Improvement Plans (QIPs) have been initiated based on these QSR findings. . The State notes, and the ER agrees, that the QSR findings are not a substitute for the ACT fidelity reviews. Nonetheless, as intended in the design of the QSR, the QSR findings add important documentation of the degree to which ACT participants are benefitting from fidelity ACT services. Taken together, the fidelity reviews and the QSR findings present reasonable and actionable information related to the quality and effectiveness of ACT services under the CMHA.
The ER continues to review the State’s oversight and technical assistance conducted to assure that these QIPs are being properly implemented
DHHS and the CMHCs have been attempting to identify individuals at risk of hospitalization, incarceration or homelessness who might benefit from ACT services. Individuals boarding in hospital emergency departments

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 14 of 86
waiting for a psychiatric hospital admission, or who have done so in the recent past, are one important source of potential referrals. DHHS is attempting to document the extent to which identifying and referring these individuals to CMHCS is: (a) reducing ED boarding episodes and lengths of stay; and (b) resulting in enrollment of new qualified individuals in ACT services. As noted in the hospital readmission discussion below, almost one-third of all those discharged out of NHH return for readmission within 180 days. Robust ACT services could help reduce the number of hospital readmissions throughout the state if affected individuals are promptly screened and referred, and their regional ACT teams have the capacity to deliver needed services.
The ER has requested that the State provide a report of the results of these activities. To date, the only report available addresses internal CMHC screening for ACT (see Table IV above), but does not report on the extent to which referrals from hospital emergency departments or other external sources are resulting in new enrollments in ACT services.
The State has identified workforce recruitment and retention issues as being a major factor limiting the growth and expansion of the ACT teams. The State has been working collaboratively with the New Hampshire Community Mental Health Association to identify and track workforce gaps and shortages, and to implement a variety of strategies to improve workforce recruitment and retention. However, as noted above ACT staffing has remained essentially static since December of 2016. The State reports that new funds, over and above the small rate increases noted above, are currently being made available to assist with increasing ACT staffing. The impact of this new funding will not be measurable until at least the next ER report in December, 2018.
The ER believes the State, DHHS and many of the CMHCs are making efforts to meet the ACT capacity and fidelity standards of the CMHA. Despite the continued compliance issues noted above, the ER believes there have been improvements in the quality and effectiveness of ACT services provided in most parts of the state. Nonetheless, while these improvements are welcome, it must be noted that the State is still far from compliance with the ACT standards of the CMHA. As with previous reports, the ER expects DHHS and the CMHCs to make use of capacity already available in the system, while at the same time addressing additional capacity and continuing to improve fidelity.
The ER emphasizes, as in past reports, that it must be the first priority of the State and the CMHCs to focus on: 1) assuring required ACT team composition; 2) utilizing existing ACT team capacity; 3) increasing ACT team capacity; and 4) outreach to and enrollment of new ACT clients. As noted earlier in this report, the ER expects the State to propose new and expanded strategies for increasing ACT capacity to meet the requirements of the CMHA. The strategies and related timelines are to be incorporated into the ACT plan and Monthly Progress Report.
Supported Employment
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment …to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by June 30, 2017 “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 15 of 86
plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)).
For this reporting period, the State reports that it has achieved a statewide SE penetration rate of 26.4 percent, 42 percent above the 18.6% penetration rate target specified in the CMHA. Table VI below shows the SE penetration rates for each of the 10 Regional CMHCs in New Hampshire.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 16 of 86

Table VI

Self-Reported CMHC SE Penetration Rates

Penetration Penetration Penetration Penetration

Mar-17

Jun-17

Sep-17

Dec-17

Penetration Mar-18

Northern
West Central
Genesis
Riverbend
Monadnock Greater Nashua
Manchester
Seacoast Community Part. Center for Life Man.
CMHA Target Statewide Average

32.30% 23.20% 12.60% 15.00% 13.50%
15.00% 39.80% 14.40%
7.20%
19.70% 18.60%
23.20%

37.20% 22.50% 22.00% 14.80% 14.00%
16.10% 40.00% 19.30%
10.30%
21.60% 18.60%
25.30%

40.90% 22.30% 20.70% 14.00% 12.30%
17.10% 42.00% 23.40%
14.60%
19.20% 18.60%
26.40%

39.00% 25.30% 19.10% 13.20% 10.90%
16.80% 45.30% 28.00%
17.70%
20.00% 18.60%
26.70%

38.80% 26.20% 15.40% 12.60% 10.40%
14.90% 43.50% 30.10%
21.50%
20.90% 18.60%
26.40%

As noted in Table VI, the State has exceeded the statewide CMHA penetration rate in recent reporting periods. In the previous ER report, six of the ten regions fell below required CMHA penetration rates. For this reporting period, four of the ten continue to report penetration rates lower than the CMHA requirement. Each of these four had a slight reduction in penetration from the previous reporting period.
The New Hampshire DHHS is to be commended for continuing its efforts to: (a) measure the fidelity of SE services on a statewide basis; and (b) work with the Regions with penetration rates below CMHA criteria to increase access to and delivery of SE services to target population members in their Regions. The ER will continue to monitor these issues going forward as the State works with the CMHCs to increase penetration rates to at least 18.6 percent in all regions.
As with ACT services, DHHS has implemented a combination of contract compliance, technical assistance, workforce recruitment and retention, and external fidelity reviews in an attempt to assure sufficient quality and accessibility of SE services statewide. The QSR does collect information at the service participant level about the degree to which individuals have been effectively assessed for SE services; are receiving SE services consistent with their individual treatment plans, and/or that SE services are delivered in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings (V.F.1).
In the six CMHCs for whom new model QSR reports are available, a number of SE performance issues were identified. For example, for the indicator related to comprehensive employment assessments, five of the six CMHCs scored below the 70% performance threshold. In the same manner, five of the six CMHCs scored below 70% on the indicator related to the adequacy of employment service delivery. Three of the CMHCs scored below the 70% threshold on the indicator related to employment treatment planning. In each case these

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 17 of 86
findings have resulted in the development of QIPs, and in state technical assistance and monitoring activities designed to improve the quality and effectiveness of SE services. As with ACT services, the QSR findings are not a substitute for SE fidelity reviews, but they do add to the overall documentation of the degree to which SE services are delivered with quality and effectiveness. For example, a SE team can be operative a high fidelity, but if individuals are not assessed properly for inclusion in SE services, there could be issues related to matching individual needs and the services available.
The State has initiated reporting requirements in which each CMHC will report on the number and percent of SE participants working in integrated competitive settings. The first report of these data is not ready for inclusion in this report, but is expected to be included in subsequent Quarterly Data and ER reports.
Supported Housing
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Subsidy Program by June 30, 2016. As of March, 2018, DHHS reports having 497 individuals in leased SH apartments, and 7 people approved for a subsidy but not yet leased. The State is in compliance with the CMHA numerical standards for SH effective June 30, 2016, but as is discussed below, not yet in compliance with 2017 CMHA criteria. Moreover, there has been a steady drop in recent months in SH units occupied or accepted from 591 in June 2017 to 504 in March 2018.
Table VII below summarizes recent data supplied by DHHS related to the Bridge Subsidy Program.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 18 of 86

Table VII

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

September 2015 through March 2018

Bridge Subsidy Program Information

March 2016

Sept. 2016

Dec. 2016

March 2017

June 2017

Sept. 2017

March 2018

Total people

415

451

481

505

for whom rents

are being

subsidized

545

509

497

Individuals

22

28

32

48

46

58

7

accepted but

waiting to lease

Individuals

0

0

0

0

currently on

the wait list for

a bridge

subsidy7

0

0

10

Total number

518

603

643

675

served since

the inception of

the Bridge

Subsidy

Program

701

742

811

Total number

71

83

83

85

receiving a

Housing

Choice

(Section 8)

Voucher

85

96

119

7 The State did not maintain a waitlist prior to 2018.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 19 of 86
In response to previous requests for information, the State, DHHS is now publishing quarterly reports of the number of Bridge Program applications and terminations (Table VIII) and also the wait list for Bridge Program subsidies (see Table VII above). These are newly reported data, and no trend analysis is possible at this time.8

The State will be reporting on the reasons for application denials or program terminations, if these occur, in the next Quarterly Data Report. With regard to terminations, Table VII shows that a total of 811 people have been served by the Bridge Subsidy Program since its inception. 119 of these have received Housing Choice Vouchers, and thus have moved off the Bridge Program. That leaves a total of 195 program exits that are potentially not accounted for in the current data. The State asserts that it intends to provide additional data on the reasons for people who have exited the SH program. Table VII below is the first step taken by DHHS to report some of these data. The ER expects that expanded reporting on these items will begin with the next Quarterly Data report.

Table VIII

Self-Reported Housing Bridge Subsidy Applications and Terminations

Measure

January – March 2018

Applications Received

44

Point of Contact

CMHCs: 43 NH Hospital: 1

Applications Approved

10

Applications Denied

0

Denial Reasons

NA

Applications in Process

34

Terminations

0

Termination Reasons

NA

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table IX below displays the reported number of units leased at the same address.

8 It should be noted that Bridge funding for new subsidies was depleted for several months prior to July 1, 2018, which may have disincentivized applications; therefore, the reported application and wait list numbers may not reflect actual demand.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 20 of 86 Table IX

Self-Reported Housing Bridge Subsidy Concentration (Density)

Sept. March June Nov. 2015 2016 2016 2016

Feb. May Nov. Feb 2017 2017 2017 2018

Number of

properties with one

leased SH unit at

290

the same address

317 325 339

349 367 383 372

Number of

properties with two

SH units at the

27

same address

22 35

24

23

36

31

35

Number of

properties with three SH units at

2

13

8

13

14

5

6

13

the same address

Number of

properties with four SH units at

4

1

1

3

4

4

5

4

the same address

Number of properties with five SH units at the 1 same address

2

2

0

0

3

0

1

Number of

properties with six

SH units at the

1

same address

0

1

1

1

1

0

0

Number of properties with seven + SH units at same address

0

2

3

2

These data show that 95% of the leased units (and 85% of people in SH) are at a unique address or with one additional unit at that address. This supports a conclusion that the Bridge Subsidy Program, to a large degree, is operating as a scattered-site program. For the units shown in Table IX at the same address, it is not known at this time whether the unit density standards included in the CMHA are being met. DHHS is collecting information on the total units in each property where there are two or more Bridge units at the same address,

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 21 of 86
and this data will be reported when it is made available. The ER expects this information to be available by the time of the next Quarterly Data Report.
It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)). DHHS reports, and anecdotal information seems to support, that there are very few, if any, roommate situations among the currently leased Bridge Subsidy Program units.9
As noted in the Data section of this report, current data is not available on the degree to which Bridge Subsidy Program participants access and utilize support services and whether or not the services are effective and meet individualized needs. Receipt of services is not a condition of eligibility for a subsidy under the Bridge Program, but the CMHA does specify that “…supported housing includes support services to enable individuals to attain and maintain integrated affordable housing, and includes support services that are flexible and available as needed and desired….” (V.E.1(a)). As noted in the 2016 and 2017 ER Reports, DHHS has been working on a method to cross-match the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. This will allow documentation of the degree to which Bridge Subsidy Program participants who are engaged with a CMHC are actually receiving certain mental health or other services and supports. As noted in the Data section, the ER has not yet received this requested information from the state. The ER expects that such information will be produced and delivered to the ER no later than July 31, 2018. The ER will also work with the State to review and analyze QSR data to determine whether or not individuals have experienced improved outcomes after obtaining SH.
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain HUD funding for an additional 150 supported housing units for a total of 600 supported housing units.” (CMHA V.E.3(e)) In 2015 New Hampshire applied for and was awarded funds to develop a total of 191 units of supported housing under the HUD Section 811 Program. All of these units will be set aside for people with serious mental illness. As of the date of this report, nine10 of these new units have been developed and are currently occupied by members of the target population and an additional 69 units are in the development pipeline. It should be noted that over the life of the Bridge Subsidy Program the State has accessed 119 HUD Housing Choice Vouchers (HCV – Section 8). These have allowed the State to free up 119 Bridge Subsidy slots for new applicants. Nonetheless, the current number of SH slots/units is below the 600 figure set out in the CMHA.
In addition, the CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.” As can be seen in Table VII above, there are currently ten individuals on the wait list for the Bridge Subsidy program. DHHS is not currently reporting the length of time individuals stay on the wait list, but it is expected these data will be available for inclusion in the next Quarterly Data Report.
9 DHHS reports that currently there is one voluntary roommate situation reflected in the above data. 10 This number likely has increased since the last report. Revised information was not available at the time this report was prepared.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 22 of 86
Transitions from Institutional to Community Settings
During the past 36 months, the ER has visited both Glencliff and NHH on at least seven separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities late last year. Transition planning activities related to specific current residents in both facilities have been observed, and a small non-random sample of resident transition records has been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities. The ER has participated in five meetings of the Central Team. The CMHA required the State to create a Central Team to overcome barriers to discharge from institutional settings to community settings. The Central Team has now had about 30 months of operational experience, and has started reporting data on its activities. To date, 42 individuals have been submitted to the Central Team, 27 from Glencliff and 15 from NHH. Of these, the State reports that 13 individual cases have been resolved11, two individuals are deceased, and 27 individual cases remain under consideration. Table X below summarizes the discharge barriers that have been identified by the Central Team with regard to these 22 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total higher than the number of individuals reviewed by the Central Team. It is notable that only one new referral was made to the Central Team since the last report dated November of 2017.
11 Two of these individuals were readmitted to NHH after 90 days, and the discharge dispositions for these two individuals are being reviewed.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 23 of 86

Table X

Self-Reported Discharge Barriers for Open Cases Referred from NHH and Glencliff to the Central Team:

March 201812

Discharge Barriers

Number for Glencliff

Number for NHH

Legal

3 (6.3%)

3 (21.1%)

Residential

16 (33.3%)

5 (26.3%)

Financial

6 (13.0%)

3 (15.8%)

Clinical

14 (29.2%)

3 (15.8%)

Family/Guardian

7 (14.6%)

2 (10.5%)

Other

2 (4.17%)

2 (10.5%)

Glencliff
In the time period from October 2017 through March 2018, Glencliff reports that it has admitted 20 individuals, and has had two discharges. The average daily census through this period was 110 people. There have been no readmissions during this time frame. The wait list for admission has increased slightly, from 19 people in the previous quarter to 23 people for this quarter. Two discharges have been effectuated during this period; both of which were to integrated community settings.
CMHA Section VI requires the State to develop effective transition plans for all appropriate residents of NHH and Glencliff and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]13 individuals with mental illness and complex health care needs residing at Glencliff….” The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be cost-effectively served in supported housing.”14
DHHS reports that the total number of people transitioned from Glencliff to integrated settings since the inception of the CMHA three years ago increased this quarter from 14 to 1615. There are currently ten individuals undergoing transition planning who could be transitioned to integrated community settings once appropriate living settings and community services become available. All of these individuals have been assigned to Choices for Independence (CFI) waiver case management agencies.

12 This is a point in time report for open cases. 13 Cumulative from CMHA V.E.(g), (h), and (i). 14 CMHA V.E.2(a) 15 DHHS reports that one individual was transitioned to an integrated community setting in May, 2018, too late to be included in the
March 2018 Quarterly Data Report.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 24 of 86
DHHS continues to provide information about Glencliff transitions, including clinical summaries, lengths of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in the integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions who could not be cost-effectively be served in SH continue to experience transitions to integrated community settings. To protect the confidentiality of individuals transitioned from Glencliff, this person-specific information is not included in the ER reports.
DHHS has implemented action steps to enhance the process of: (a) identifying Glencliff residents wishing to transition to integrated settings; and (b) increasing the capacity, variety and geographic accessibility of integrated community settings and services available to meet the needs of these individuals. Both sets of initiatives are intended to facilitate such community transitions for additional Glencliff residents. Despite these efforts, the frequency of transitions to integrated community settings from Glencliff has reduced in the past year. DHHS is currently working to revise funding procedures and provider related requirements to facilitate new transitions to integrated setting on a timelier basis. The ER will be closely monitoring whether these initiatives result in increased transitions over the next few months.
As noted in the previous report, the ER is at this point reluctant to focus too narrowly on clinical conditions and sets of health, mental health and community services and supports for transitioned and transitioning individuals to monitor the State’s progress in assisting Glencliff Home residents to transition to integrated community settings. The ER will monitor the extent to which DHHS, Glencliff, the CMHCs and an array of other community partners collaborate to effectuate as many such transitions as possible over the next two years. The primary thrust and intent of the CMHA is to assure that individuals residing in Glencliff (and their families and guardians) are offered and are willing to accept meaningful opportunities to transition to integrated community settings. It appears likely that the specific requirement in the CMHA for the State to create capacity to serve 16 individuals with complex medical conditions who cannot be cost-effectively served in SH will be attained if DHHS and its partners continue to increase the availability of integrated community settings, and provide meaningful in-reach and transition planning for Glencliff residents.
However, progress towards effectuating transitions to integrated community settings for current Glencliff residents has been slow over the past 12 months. Thus, the ER will continue to monitor the following topics/items going forward:
1. The number of transitions from Glencliff to integrated community settings per quarter. The ER will also monitor information about the clinical and functional level of care needs of these individuals; the integrated settings to which they transition; and the array of Medicaid and non-Medicaid mental health and health-related services and supports put in place to meet their needs to assure successful integrated community living.
2. The number of Glencliff residents newly identified per quarter to engage in transition planning and move towards integrated community settings. The ER will also monitor at a summary level the clinical and functional level of care needs of individuals added to the transition planning list per quarter.
3. New integrated community setting providers with the capacity to facilitate integrated community living for Glencliff residents. These could include EFCs, AFCs, and new small-scale community residential capacity for people with complex medical conditions who cannot be cost-effectively served in supported housing. The ER will monitor DHHS activities and successes relative to identification and engagement of community providers who express willingness and capacity to provide services in integrated community settings for people transitioning from Glencliff.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 25 of 86
4. Within the discharge cohort, the number of transitioned individuals for whom the State special funding mechanism is utilized to effectuate the transition, and the ways in which these funds are used to fill gaps in existing services and supports.
5. Number and types of in-reach visits and communications by CMHCs and other community providers related to identifying and facilitating transitions of Glencliff residents to integrated community settings.
6. Specific documentation of efforts to overcome family and/or guardian resistance to integrated community transitions for Glencliff residents.
7. Number of individuals engaged in transition planning referred to the Central Team; number of these individuals who successfully transition to an integrated community setting; and the elapsed time from referral to resolution.
Preadmission Screening and Resident Review (PASRR)
The State DHHS has provided recent data on PASRR screens for the period May 1, 2018 through May 30, 2018.
The ER was unable to analyze or summarize these data in that same manner as in the previous report. The ER will work with the State to make sure the data reporting is complete, and to conduct trend analyses referencing the baseline information is the previous report. The ER will circulate a separate memorandum of this analysis within the next two months.
New Hampshire Hospital and the Designated Receiving Facilities (DRFs)
For the time period October 2017 through March 2018, DHHS reports that NHH effectuated 406 admissions and 407 discharges. The mean daily census was 152.5, and the median length of stay for discharges was 13.5 days.
Table XII below compares NHH discharge destination information for the five most recent reporting periods (9/2015 through 3/2018). The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 26 of 86

Table XII

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Discharge Destination

Percent September
2015 through April
2016

Percent October
and November
2016

Percent January through March
2017

Percent April through June 2017

Percent July
through September
2017

Percent
October 2017
through March 2018

Home – live alone or with others

80.2%

85.1% 84.5% 85.66% 88.3%

81.0%

Glencliff

0.60%

0.36% 1.55% 0,35%

0.49%

1.0%

Homeless

2.7%

Shelter/motel

2.54% 2.71% 3.5%

2.94%

2.5%

Group home 5+/DDS supported living, etc.

3.2%

1.62%

5.7%

5.59%

3.92%

7.1%

Jail/corrections 1.4%

2.9%

0.8%

1.05%

0.49%

1.7%

Nursing home/rehab facility

0.80%

3.6%

1.9%

3.50%

2.45%

2.7%

The State now consistently reports information on the hospital-based DRFs and The Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and analyze it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. The ER appreciates the State gathering this information. Table XIII summarizes this data.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 27 of 86

Table XIII

Self-Reported DRF/APRTP Utilization Data: January 2016 through March 2018

Admissions Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

69

257

46

79

205

378

37

207

375

60

228

363

NA** 178

363

59

209

358

52

240

330

65

121

49

92

54

114

52

101

60

121

55

102

66

100

Total
558 803 787 804 722 783 788

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018

Franklin Cypress Portsmouth Eliot

Eliot

Total

Geriatric Pathways

53.70% 55.70% 43.20% 58.30% NA** 49.20% 44.20%

18.70% 24.40% 29.50% 21.50% 25.60% 30.10% 28.30%

NA 20.40% 18.90% 22.00% 25.60% 23.70% 21.50%

18.50% 4.10% 13.00% 1.00% 11.50% 12.70% 6.10%

30.60% 48.90% 44.70% 47.50% 50.40% 50.00% 47.00%

26.20%* 25.50% 26.20% 30.06%
NA 30.00% 27.00%

Average Census Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

7.9

14.7

NA

19.7

18.1

7.8

13.2

21.4

22.5

16.9

4.5

13.6

23.2

25.6

14.5

4.5

12

30.3

29.3

10

NA** 12.9

29.7

29.7

12.2

10.1 12.3

27.7

32.6

16.1

6.7

11.6

31.7

34.6

17.5

Total
60.1* 81.8 81.4 86.1 NA 19.7 20.4

Discharges Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017

Franklin Cypress Portsmouth Eliot

Eliot

Geriatric Pathways

76

261

NA

78

206

363

35

213

380

59

232

365

NA** 243

355

82

212

359

57

122

51

90

64

113

54

105

63

121

58

102

Total
516* 788 805 815 NA 813

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 28 of 86

Jan. - March 2018

53

248

326

67

101

795

Mean LOS for Discharges Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018

Franklin Cypress Portsmouth Eliot

Eliot Median

Geriatric Pathways

8.6

4.2

6

4

7

5

6

4

NA**

4

4

4

5

4

NA

15

4 28

4 24

5 22

4 27

5 21

5 23

7.4

8.8*

7

5

8

5

8

9

7

NA

7

5

7

5

* Does not include Portsmouth ** Franklin DRF did not report data for the July - September period.

The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and should also reduce the number of people waiting for psychiatric admissions in hospital EDs. However, at this time there has been no substantial reduction in NHH admissions, NHH re-admissions, or the wait list for NHH admissions of people staying in hospital emergency departments. This could reflect an increased overall demand for inpatient psychiatric care or be a symptom of limited access to community-based mental health services like ACT.
DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table XIV below provides a summary of these recently reported data.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 29 of 86 Table XIV

Cumulative Self-Reported Discharge Dispositions for DRFs in New Hampshire

October, 2017 through March, 2018

Disposition

Franklin Cypress Portsmouth Eliot

Eliot

**

Geriatric Pathways

Total

Home

126

417

546

29

175

1,293

NHH

3

1

11

1

6

22

Residential

2

11

0

77

5

95

Facility/

Assisted

Living

Other DRF

1

7

1

0

0

2

Hospital

1

0

0

7

0

7

Death

0

0

0

9

0

9

Other or

2

24

124

0

14

164

Unknown

*The Other category for Portsmouth Regional is reported to include shelters, rehab facilities, hotels/motels,

friends/families, and unknown.

Based on these self-reported data, 81.2% of the 1592 discharges from DRFs and the Cypress Center are to home. This is the same as the 81% or greater discharges to home reported by NHH. 6.7% of the total DRF discharges are to residential care or assisted living, which is similar to NHH discharges for this category. 1.4% of the DRF discharges are to NHH, 0.13% is to other DRFs. 10.3% of the total discharges are to the other/unknown category, but 76% of these are accounted for by the Portsmouth DRF. This might point to an anomaly in the ways facilities use this category in their reports to the state. The State reports on-going efforts with the DRFs to improve their data reporting.

Hospital Readmissions

DHHS is now reporting readmission rates for both NHH and the DRFs. Table XV below summarizes these data:

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 30 of 86 Table XV
Self-Reported Readmission Rates for NHH and the DRFs July 2017 through March 2018

NHH 7 to 9/2017 10 to 12/2107 1 to 3/2018

Percent 30 Days
9.80% 12.8% 13.7%

Percent 90 Days
21.60% 26.1% 22.7%

Percent 180 Days
27.90% 32.8% 29.9%

Franklin 7 to 9/2017 10 to 12/2107 1 to 3/2018

NA 10.2% 0.0%

NA 10.2% 0.0%

NA 10.2% 1.9%

Cypress 7 to 9/2017 10 to 12/2107 1 to 3/2018

7.10% 12.00% 4.20%

12.40% 18.70% 9.60%

15.90% 24.40% 15.80%

Portsmouth 7 to 9/2017 10 to 12/2107 1 to 3/2018

11.50% 8.70% 8.80%

17.50% 13.70% 15.50%

21.00% 17.60% 20.60%

Elliot Pathways 7 to 9/2017 10 to 12/2107 1 to 3/2018

3.30% 5.80%
NA

6.60% 7.70%
NA

12.40% 12.50%
NA

* Elliott Geriatric is no longer included in this report because the reported re-admission rates are always 0.00%

As of the date of this report, the 180-day readmission rate to NHH is substantial, with almost one-third of those discharged returning to NHH within six months. Based on the data presented in Table XV above, there does not appear to have been significant changes in NHH or DRF re-admission rates since July of 2017.
Hospital ED Waiting List
In the previous three reports, the ER has identified the waiting list (hospital ED boarding) for admission to NHH to be an important indicator of overall system performance. Chart A below displays daily adult admissions delays to NHH for the period July 1, 2016 through May 24, 2018. Chart B shows the average daily ED waiting list for the same time period.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 31 of 86 Chart A

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 32 of 86 Chart B
. Based on information reported by DHHS and illustrated above, the average number of adults waiting for a NHH inpatient psychiatric bed was 24 per month in FY 2014; 25 per month in FY 2015; and through June of FY 2016 was 28 per month. For the period September 2017 through May 2018 the average monthly wait list for admission to NHH was 49 adults. Not surprisingly, as can DHHS continues to analyze data related to adults boarding in EDs who may have some connection to the mental health system. DHHS is making these data available to CMHCs on a daily basis, and expects the CMHCs to use these data to identify potential participants for ACT or related services to reduce the risk of hospitalization and support integrated community living. In future months, DHHS will be receiving

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 33 of 86
information on the degree to which CMHCs have increased ACT (or other services’) participation as a result of these analyses. The ER plans to include summaries of this information in future reports. The State, in conjunction with the CMHCs, is conducting targeted outreach to those individuals who may need expanded or enhanced community services so as to minimize or eliminate contact with hospital or institutional settings.
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies
As noted in the June 30, 2015 ER report, DHHS reported having a total of 15 peer support agency program (PSA) sites, with at least one program site in each of the ten regions. The State continues to report that all peer support centers meet the CMHA requirement to be open 44 hours per week. The State reports that those sites have a cumulative total of 2881 members, with an active daily participation rate of 158 people statewide. Membership and active daily participation for the PSAs does not significantly change from reporting period to reporting period.
The CMHA requires the PSAs to be “effective” in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs. There continue to be anecdotal reports that some of the CMHCs are making more concerted efforts to refer service participants to the PSAs in their regions. Increased efforts to communicate and coordinate with PSAs have also been reported. However, as of the most recent report there has been a slight reduction in active daily participation.
In addition, the ER has received anecdotal information that in some regions of the state, relationships and communications among the CMHCs and the Peer Support Agencies have improved. Peer Support Agencies are generally reported by CMHCs to be useful sources of employees for ACT and Mobile Crisis and Crisis Apartment services. However, it must be noted that in two of the CMHC regions that contract with the local PSAs for staff for the ACT teams, there is currently no peer support reported for ACT services.
Finally, CMHCs have verbally stated that the peer operated crisis beds available in several regions are a useful intervention for some CMHC clients at risk of hospitalization.
IV. Quality Assurance Systems
As noted in the introduction to this report, the State has made substantial positive progress to implement a comprehensive, reliable and actionable QSR process. The ER has participated in four QSR site visits, and is increasingly confident that: (a) the revised instruments and site interview protocols are working well; and (b) the results and findings of the revised QSR instruments and process reflect, to a large degree, the quality standards of the CMHA.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 34 of 86
One key improvement in the revised QSR process has been the addition of several Overall Clinical Review (OCR) questions that provide opportunities for the QSR teams to integrate and summarize service participantlevel information collected from a variety of information sources. These new questions include:16
1. Is the frequency and intensity of services consistent with the individual’s demonstrated need? 2. Are there additional services the individual needs that are not identified in the assessment(s) or the
treatment plan? 3. Is the individual receiving all the services s/he needs to ensure health, safety, and welfare? 4. Is the individual receiving adequate services that provide reasonable opportunities to support the
individual to achieve independence and integration in the community? 5. Is the individual receiving adequate services to obtain and maintain stable housing? 6. Is the individual receiving adequate services to avoid harms and decrease the incidence of unnecessary
hospital contacts and/or institutionalization? 7. Is the individual receiving adequate services to live in the most integrated setting?
Questions have also been embedded in the QSR instruments to more accurately document that: (a) the assessment(s) accurately reflect the individual’s strengths, needs and goals; and (b) service delivery approaches and patterns reflect best practices, where applicable.
These types of questions reflect the essence of the QSR process: documenting that individual service participants receive the levels and types of services and supports that assist them to achieve their goals and meet their needs in the most integrated community setting possible. These questions also directly respond to target population outcomes and quality expectations of the CMHA. Going forward, responses to these questions are intended to form an important part of the six-month ER reports.
The ER is grateful to both the State and the representatives of the Plaintiffs who have worked long and hard to design and implement a QSR process that will legitimately and accurately reflect the quality and effectiveness of the community mental health system in New Hampshire. This QSR system is a critical element of the CMHA, but in fact it has much broader application and potential long term benefits for the entire mental health system.
As noted earlier in this report, DHHS has been conducting on-site ACT and SE fidelity reviews. DHHS has engaged the Dartmouth/Hitchcock Center on Evidence Based practices to assist in attaining and assuring fidelity to the evidence based models of ACT and SE. The Dartmouth/Hitchcock team will also assist on workforce development and training for these and other evidence based practices under the aegis of DHHS and the CMHCs. This partnership with the nationally respected Dartmouth/Hitchcock Center adds valuable expertise and experienced personnel to facilitate further development and operations of fidelity model ACT and SE in conformance with the CMHA. Year-to-year comparisons and the CMHCs Quality Improvement Plans have been included in the publication of recent ACT and SE fidelity reviews. The ER commends DHHS for implementing the comprehensive fidelity review process and its attendant quality improvement and technical assistance activities.
Effective and valid fidelity reviews and consequent training and workforce development activities are essential to DHHS’ overall quality management efforts for the community mental health system. As noted in the previous two ER reports, the QSR and the fidelity reviews mutually support but do not supplant or replace each
16 Note: detailed follow-up questions have not been included in this list.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 35 of 86
other. The QSR, in particular, examines outcomes from a consumer-centric perspective as opposed to an operational or organizational perspective. It is uniquely positioned to assess the quality, appropriateness and effectiveness of specific ACT and SE services at the individual participant level. The ER continues to believe that implementation of fidelity-based models of delivery does not necessarily mean that specific service interventions are working well or being delivered with the frequency or intensity required by a participant’s individual treatment plan The revised QSR instruments and protocols address many of these concerns. In combination, the fidelity reviews and the QSR can mutually support conclusions about the overall quality and effectiveness of the mental health system consistent with the CMHA.
The ER will continue to monitor the degree to which the QSR process produces reliable information on individual outcomes and the quality of CMHA service delivery. In addition, over the next six months, the ER will evaluate the extent to which CMHC Quality Improvement Plans developed as part of the 2017-2018 QSR site visits are resulting in recommended practice changes and improved outcomes for those in the target population.
The ER and the Parties to the CMHA have discussed how the QSR and external fidelity reviews can be used to measure compliance with the CMHA, including both the appropriate standard for compliance and the specific provisions of the QSR and fidelity reviews that would be used to assess compliance. These discussions are ongoing, and the ER supports the collaborative efforts of both the State and the representatives of the Plaintiffs. The ER intends to employ both the QSR and the fidelity reviews as tools to assess individual outcomes, analyze system performance, and ultimately measure compliance with the CMHA.
V. New State Resources
In New Hampshire the Governor and the Legislature have evidenced increased support for implementation of the CMHA and for making continued improvement in the community mental health system. Table XVI below summarizes new resources appropriated for the current biennium.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 36 of 86 Table XVI

New Mental Health Resources in New Hampshire for SFY 2018 and 2019

Item

SFY 2018 SFY 2019

Total

Transitional Housing / Community Residence Beds: adds 20 beds in SFY 2018 and up to 20 more in SFY 2019; prioritized to support New Hampshire Hospital discharges.

$2,312,156 $5,424,000 $7,736,156

Mobile Crisis: funds additional crisis response capacity in area with high numbers of New Hampshire Hospital admissions and discharges.17

$1,498,551 $3,421,696 $4,920,247

Designated Receiving Facility (DRF) Beds: adds up to 20 additional DRF beds18.

$ 484,696 $ 721,440 $1,206,136

Additional Funding: to support workforce $1,500,000 $1,500,000 $3,000,000
development.

Biennium Total $16,862,539

In addition, a total of $4.3 million has been added to the Mental Health rate cells of the Medicaid capitation rates of the Managed Care Entities (MCEs) for the up-coming biennium in anticipation of increased utilization associated with the CMHA. An additional $2.0 million is available for inclusion in these rates after all CMHA services (excluding fee-for-service services) have been implemented. In addition, an additional $471,186 for general mental health services has been added to the CMHC state contracts. This is exclusive of the separate Mobile/Crisis Team contracts.
It should be noted that the crisis model currently envisioned by the State under this new appropriation is not a replica of the model implemented under the CMHA in the Concord, Manchester and Nashua Regions. The model currently being procured will be called a Behavioral Health Crisis Treatment Center (BHCTC), which is intended to provide center-based (as opposed to mobile) crisis services 24/7. Services will include crisis assessments and treatment, and service participants may include people with substance use disorders. A contract award has not yet been made for this BHCTC service, and thus a detailed scope of work and implementation schedule is not yet available.

17 The State reports that no providers expressed interest in operating a new mobile crisis team, and thus has issued an RFP for a sitebased Behavioral Health Crisis Treatment Center, as discussed below. 18 The State reports that no providers expressed interest in operating new or expanded DRF beds, and thus $500,000 of these funds are being allocated to SH.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 37 of 86
However, it is notable that this new BHCTC service may operate in a region in lieu of the mobile crisis teams and crisis apartments developed under the CMHA. The ER notes that the State has already developed the three MCT/Crisis Apartment programs required by the CMHA. However, CMHA V.C.3(d) also directs that the State shall maintain its current crisis services, or implement mobile crisis teams, in all other regions. While community-based crisis centers have been effective in some other states, those centers are typically integrated into a larger crisis service system, which includes mobile capacity and apartment settings, and are not operated as stand-alone settings. In New Hampshire, it is the mobile crisis team and crisis apartment model that has a demonstrated record of diverting individuals with mental illness from hospital emergency rooms. The ER is not aware of evidence that requiring individuals in crisis to present themselves for center-based crisis services is likely to achieve the same volume of hospital diversions for members of the target population. The ER is also not aware of evidence that it is easier for individuals in rural areas with limited transportation resources to present at a centralized crisis facility as opposed to having crisis teams go to the location most convenient and natural for individuals in crisis. It is not clear whether the BHCTC will be effective in reducing unnecessary hospitalizations for members of the Target Population or contribute to the goals of the CMHA.
The ER also notes that the transitional housing funding listed above is not intended to be included under the aegis of the CMHA. Twenty of these transitional housing units have been occupied, 14 in the greater Nashua area, and six in central New Hampshire. DHHS reports that all 20 of these units have been occupied by long stay patients from NHH. These placements, although not directly contributing to the CMHA, nonetheless provide a potentially valuable resource to reduce long stays in NHH. They may also reduce certain barriers that have prevented integrated community placements in supportive housing.
VI. Summary of Expert Reviewer Observations and Priorities
The CMHA and ER have now been in place for four years. Within that time frame, the ER has expressed escalating concerns related to noncompliance with CMHA requirements governing ACT and Glencliff community transitions.19 In addition, the ER has noted long elapsed times and/or delays related to implementation of system improvements or Data reporting. Throughout these reports, the ER has emphasized the need for the State to be more aggressive, assertive, planful, and timely in its implementation and oversight efforts in these areas in order to come into compliance with the CMHA.
More recently the ER has reported that the State is improving its oversight and management of the mental health system. Examples include more comprehensive and accurate data reporting, the revised QSR process, and the growing use of state-validated fidelity reviews for ACT and SE. The QIPs that result from QSR and QIP activities are an improved tool for State-directed technical assistance and monitoring of CMHCs to assure improved quality and effectiveness of services for the CMHA target population.
Despite the management and service delivery improvements noted in this report, the ER remains seriously concerned about compliance with the CMHA standards and requirements related to ACT services. For the last two years the ER has reported that the State is out of compliance with the ACT requirements of the Sections V.D.3(a, b, d, and e), which together require that all ACT teams meet the standards of the
19 The State reports effectuating 16 placements to integrated community settings since the inception of the CMHA. The ER and the parties remain in discussions with regard to whether these transitions meet all the criteria in the CMHA. Pending resolution of those discussions, the ER intended to keep Glencliff Transitions high on the compliance monitoring priority list.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 38 of 86 CMHA; that each mental health region have at least one adult ACT Team20; and that by June 30, 2016, the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time. Despite the many positive initiatives and management efforts undertaken by the State, ACT capacity remains substantially below the required June 30, 2016 capacity to serve 1,500 people at any given time. Moreover, with an active caseload of only 901 people, the state currently is providing 599 fewer people with ACT than could be served if the State had developed the CMHA-specified capacity to serve 1,500 individuals. With the current ACT staff capacity to serve 1,201 people, there are300 fewer people receiving ACT than the current ACT system could accommodate. This continues to be the single most significant issue in New Hampshire with regard to compliance with the CMHA, and one with negative implications for individuals who remain in NHH, who continue to be readmitted to EDs and inpatient facilities, or who are otherwise at risk of admission, homelessness, or incarceration due to inadequate community supports. As stated earlier in the ACT discussion and ER Findings sections of this report, the ER recommends, and at the Court’s request will make himself available for, a meeting during the next three months with Judge McAuliffe. In addition to the focus on ACT services for the target population, the ER intends to concentrate on the following priority CMHA compliance issues during the up-coming six month reporting period:
1. Documenting the receipt, circulation and interpretation of the new data reports as specified in the body of this report;
2. Completing an analysis and report of recent PASRR data; 3. Documenting the timeliness and completeness of all data reporting related to the CMHA; 4. Monitoring of implementation of QIPs, particularly as they address issues related to ACT and SE; 5. Monitoring of transitions from Glencliff to integrated community settings, particularly with regard to
implementation of revised rules and financing procedures intended to engage new community provider capacity and facilitate individual transitions; 6. Continuing to assess the quality and effectiveness of CMHA services, including whether ACT and SE services are delivered with the intensity and duration necessary to meet individual’s needs; and 7. Continuing discussions with all Parties to the CMHA regarding the use of QSR and fidelity review findings to document compliance with the standards and requirements of the CMHA.
20 The ER notes that each region of the state has had at least one ACT team, or ACT team-in-development, since the inception of the CMHA. However, as documented in the ACT section of this report, four regions continue to have ACT teams that do not meet the minimum staffing requirements for ACT as specified in the CMHA.

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 39 of 86
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly Data Report January through March 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 40 of 86 January – March 2018

New Hampshire Community Mental Health Agreement Quarterly Data Report

January to March 2018

NH DHHS - OQAI - CMHA Quarterly Report, 6/13/18

1

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 41 of 86 January – March 2018
New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement
June 13, 2018

Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services
Publication Date: 6/13/2018
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence

NH DHHS - OQAI - CMHA Quarterly Report, 6/13/18

2

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 42 of 86 January – March 2018
Reporting Period: 1/1/2018 – 3/31/2018
Notes for Quarter • Added Table 1b, ACT Screening. • Added Table 1c, ACT Waiting List. • Added Table 9a, Housing Bridge Subsidy Applications and Terminations. • Added Waiting List to Table 9b, Housing Bridge Subsidy Census. • Table 9b. Housing Bridge Subsidy Current Census was revised to better reflect program census. • Certain DRF data and the quarterly unduplicated count of Riverbend’s Mobile Crisis service users are not yet available for the quarter. These data will be included in the next quarterly report.

NH DHHS - OQAI - CMHA Quarterly Report, 6/13/18

3

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 43 of 86

1a. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Consumers

Community Mental Health Center

January February

2018

2018

March 2018

Unique Consume
rs in Quarter

Unique Consume
rs in Prior Quarter

01 Northern Human Services

115

114

114

121

120

02 West Central Behavioral Health

55

44

46

67

68

03 Lakes Region Mental Health Center

67

64

64

68

70

04 Riverbend Community Mental Health Center

68

75

80

83

85

05 Monadnock Family Services

58

48

55

58

57

06 Community Council of Nashua

80

78

74

94

95

07 Mental Health Center of Greater Manchester

267

272

277

289

294

08 Seacoast Mental Health Center

68

66

66

70

68

09 Community Partners

64

66

66

68

69

10 Center for Life Management

56

54

59

58

57

Total

897

879

901

971

981

CMHA Monthly Progress Report

4

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 44 of 86

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 5/22/18; consumers are counted only one time regardless of how many services they receive.

1b. Community Mental Health Center Services: Assertive Community Treatment Screening

Community Mental Health Center

January February

2018

2018

March 2018

01 Northern Human Services

157

121

217

02 West Central Behavioral Health

45

41

85

03 Lakes Region Mental Health Center

181

250

244

04 Riverbend Community Mental Health Center

500

445

598

05 Monadnock Family Services

239

159

226

06 Community Council of Nashua

416

412

534

07 Mental Health Center of Greater Manchester

783

735

690

08 Seacoast Mental Health Center

158

652

435

09 Community Partners

207

170

202

10 Center for Life Management

133

161

151

CMHA Monthly Progress Report

5

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 45 of 86

Total

2,819 3,146 3,382

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 6/12/18; NA=Not available from data submitter at time of reporting, will be included in next report 1c. Community Mental Health Center Services: Assertive Community Treatment Waiting List
As of 3/31/18

Time on List

Total

0-30 days

31-60 days

61-90 days

9

7

2

0

Revisions to Prior Period: None

Data Source: BMHS Report

Notes: Data extracted 5/22/18

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents

Community Mental Health Center

March 2018

December 2017

CMHA Monthly Progress Report

6

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 46 of 86

Nurse Masters Level Clinician/or FEuqnuictviaolenanlt Support Worker Peer Specialist Total (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner Total (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner

01 Northern Human Services 02 West Central Behavioral Health 03 Lakes Region Mental Health Center 04 Riverbend Community Mental Health Center 05 Monadnock Family Services 06 Community Council of Nashua 1 06 Community Council of Nashua 2 07 Mental Health Center of Greater Manchester-CTT 07 Mental Health Center of Greater Manchester-MCST 08 Seacoast Mental Health Center 09 Community Partners 10 Center for Life Management

1.09 1.00 9.00 0.55 11.64 0.75 13.04 0.75 0.60 2.55 1.65 0.20 5.00 0.45 6.20 0.64 1.00 0.00 3.70 1.00 5.70 0.75 9.40 0.75 0.50 3.00 6.00 0.75 10.25 0.48 10.00 0.48
1.25 3.25 3.10 1.10 8.70 0.65 7.90 0.65 0.50 3.00 2.25 0.00 5.75 0.50 5.00 0.25 0.50 4.00 1.25 0.00 5.75 0.25 5.00 0.25 1.50 10.00 5.76 0.00 17.26 0.63 12.83 0.63
1.50 9.00 9.01 0.00 19.51 0.63 19.04 0.63
1.43 3.10 6.00 1.00 11.53 0.60 10.53 0.60 1.00 2.00 6.25 0.50 9.75 0.50 7.85 0.50 1.00 2.00 5.30 1.00 9.30 0.40 9.30 0.40

CMHA Monthly Progress Report

7

June 18, 2018

Total

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 47 of 86

11.8 42.90 59.2 6.10 120.1 6.59 116.0 6.53

7

7

4

9

CMHA Monthly Progress Report

8

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 48 of 86

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Substance Use Disorder Treatment

Community Mental Health Center

March 2018

December 2017

01 Northern Human Services

3.65

2.05

02 West Central Behavioral Health

0.35

0.35

03 Lakes Region Mental Health Center

2.65

3.15

04 Riverbend Community Mental Health Center

1.48

1.48

05 Monadnock Family Services

2.40

2.40

06 Community Council of Nashua 1

4.50

3.00

06 Community Council of Nashua 2

3.00

3.00

07 Mental Health Center of Greater Manchester-CCT

14.60

12.60

07 Mental Health Center of Greater Manchester-MCST

1.00

2.00

08 Seacoast Mental Health Center

3.00

2.00

09 Community Partners

3.00

2.00

10 Center for Life Management

3.00

3.00

CMHA Monthly Progress Report

9

June 18, 2018

Total

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 49 of 86

42.63

37.03

CMHA Monthly Progress Report

10

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 50 of 86

2c. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Housing Assistance

Community Mental Health Center

March 2018

December 2017

01 Northern Human Services

9.30

10.70

02 West Central Behavioral Health

4.25

5.35

03 Lakes Region Mental Health Center

4.70

7.20

04 Riverbend Community Mental Health Center

8.50

8.50

05 Monadnock Family Services

1.00

1.00

06 Community Council of Nashua 1

3.00

4.00

06 Community Council of Nashua 2

5.00

4.00

07 Mental Health Center of Greater Manchester-CCT

14.92

11.98

07 Mental Health Center of Greater Manchester-MCST

16.17

16.54

08 Seacoast Mental Health Center

5.00

6.00

09 Community Partners

7.00

3.00

10 Center for Life Management

7.00

7.00

CMHA Monthly Progress Report

11

June 18, 2018

Total

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 51 of 86

85.84

85.27

CMHA Monthly Progress Report

12

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 52 of 86

2d. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies, Supported Employment

Community Mental Health Center

March 2018

December 2017

01 Northern Human Services

1.25

2.00

02 West Central Behavioral Health

0.40

0.15

03 Lakes Region Mental Health Center

3.00

3.90

04 Riverbend Community Mental Health Center

0.50

0.50

05 Monadnock Family Services

1.00

0.00

06 Community Council of Nashua 1

2.25

1.50

06 Community Council of Nashua 2

0.25

0.50

07 Mental Health Center of Greater Manchester-CCT

1.50

1.00

07 Mental Health Center of Greater Manchester-MCST

2.05

1.20

08 Seacoast Mental Health Center

1.00

1.00

09 Community Partners

0.15

0.15

10 Center for Life Management

0.30

0.30

CMHA Monthly Progress Report

13

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 53 of 86

Total

13.65

12.20

Revisions to Prior Period: None

Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report

Notes: Data compiled 5/1/18; for 2b-d: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, rather the quantity of staff available to provide each service. If staff is trained to provide multiple service types, their entire FTE value will be credited to each service type.

CMHA Monthly Progress Report

14

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 54 of 86

3. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12 Month Period

Community Mental Health Center

12 Month Period Ending March 2018

Supported Employment Total Eligible
Consumers Consumers

Penetration Rate

Penetration Rate for Period Ending
December 2017

01 Northern Human Services

483

1,244

38.8%

39.0%

02 West Central Behavioral Health

199

759

26.2%

25.3%

03 Lakes Region Mental Health Center

203

1,320

15.4%

19.1%

04 Riverbend Community Mental Health Center

226

1,788

12.6%

13.2%

05 Monadnock Family Services

99

954

10.4%

10.9%

06 Community Council of Nashua

258

1,735

14.9%

16.8%

07 Mental Health Center of Greater Manchester

1,433

3,292

43.5%

43.5%

08 Seacoast Mental Health Center

471

1,565

30.1%

28.0%

09 Community Partners

159

741

21.5%

17.7%

10 Center for Life Management

194

930

20.9%

20.0%

Deduplicated Total

3,717

14,059

26.4%

26.7%

CMHA Monthly Progress Report

15

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 55 of 86

Revisions to Prior Period: None

Data Source: NH Phoenix 2

Notes: Data extracted 5/22/18; consumers are counted only one time regardless of how many services they receive. Riverbend nonbillable services are currently not available so are not included in this report.

4a. New Hampshire Hospital: Adult Census Summary

Measure

January – March 2018

October – December 2017

Admissions

211

195

Mean Daily Census

153

152

Discharges

207

200

Median Length of Stay in Days for Discharges

14

13

Deaths

1

0

Revisions to Prior Period: None.

Data Source: Avatar

Notes 4a: Data extracted 5/23/18; Mean Daily Census includes patients on leave and is rounded to nearest whole number

CMHA Monthly Progress Report

16

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 56 of 86

4b. New Hampshire Hospital: Discharge Location for Adults

Discharge Location

January – March 2018

October – December 2017

Home - Lives with Others

90

89

Home - Lives Alone

68

82

CMHC Group Home

13

6

Private Group Home

4

6

Nursing Home

2

3

Hotel-Motel

1

1

Homeless Shelter/ No Permanent Home

5

3

Discharge/Transfer to IP Rehab Facility

4

2

Secure Psychiatric Unit - SPU

1

0

Peer Support Housing

1

2

Jail or Correctional Facility

5

2

Glencliff Home for the Elderly

3

1

Other

5

0

Unknown

4

3

CMHA Monthly Progress Report

17

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 57 of 86

4c. New Hampshire Hospital: Readmission Rates for Adults

Measure

January – March 2018

October – December 2017

30 Days

13.7% (29)

12.8% (25)

90 Days

22.7% (48)

26.1% (51)

180 Days

29.9% (63)

32.8% (64)

Revisions to Prior Period: None.

Data Source: Avatar

Notes 4b-c: Data compiled 5/23/18; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions lookback period includes readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day readmissions); patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

CMHA Monthly Progress Report

18

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 58 of 86

5a. Designated Receiving Facilities: Admissions for Adults

January – March 2018

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

23

29

Cypress Center

68

172

Portsmouth

71

259

Elliot Geriatric Psychiatric Unit

4

62

Elliot Pathways

47

53

Total

213

575

October – December 2017

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

29

30

Cypress Center

63

146

Portsmouth

85

273

Elliot Geriatric Psychiatric Unit

7

48

Elliot Pathways

51

51

Total Admissions
52 240 330 66 100 788
Total Admissions
59 209 358 55 102

CMHA Monthly Progress Report

19

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 59 of 86

Total

235

548

783

5b. Designated Receiving Facilities: Mean Daily Census for Adults

Designated Receiving Facility

January – March 2018

October – December 2017

Franklin

6.7

10.1

Cypress Center

11.6

12.3

Portsmouth

32.5

27.7

Elliot Geriatric Psychiatric Unit

34.6

32.6

Elliot Pathways

NA

16.1

Total

NA

19.7

CMHA Monthly Progress Report

20

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 60 of 86

5c. Designated Receiving Facilities: Discharges for Adults

Designated Receiving Facility

January – March 2018

October – December 2017

Franklin

53

82

Manchester (Cypress Center)

248

212

Portsmouth

326

359

Elliot Geriatric Psychiatric Unit

67

58

Elliot Pathways

101

102

Total

795

813

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges for Adults

Designated Receiving Facility

January – March October – December

2018

2017

Franklin

5

4

Manchester (Cypress Center)

4

4

Portsmouth

5

5

Elliot Geriatric Psychiatric Unit

23

21

Elliot Pathways

7

7

CMHA Monthly Progress Report

21

June 18, 2018

Total

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 61 of 86

5

5

CMHA Monthly Progress Report

22

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 62 of 86

5e. Designated Receiving Facilities: Discharge Location for Adults January – March 2018

Designated Receiving Facility

Assisted Living/Group
Home

Decease d

Other

NH

Hom Hospit Hospita

DRF e

al

l

Franklin

2

0

1 48

0

1

Manchester (Cypress Center)

4

0

2 232

0

0

Portsmouth Regional Hospital

0

0

1 266

0

10

Elliot Geriatric Psychiatric Unit

42

2

0 17

4

0

Elliot Pathways

1

0

0 90

0

3

Total

49

2

4 653

4

14

October – December 2017

Designated Receiving Facility

Assisted Living/Group
Home

Decease d

Other

NH

Hom Hospit Hospita

DRF e

al

l

Franklin

0

0

0 78

1

2

Other 1 10 46
0 6 63
Other 1

CMHA Monthly Progress Report

23

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 63 of 86

Manchester (Cypress Center)

7

0

5 185

0

1

14

Portsmouth Regional Hospital

0

0

0 280

0

1

78

Elliot Geriatric Psychiatric Unit

35

7

0 12

3

1

0

Elliot Pathways

4

0

0 85

0

3

8

Total

46

7

5 640

4

8

101

*Dispositions to ‘DRF’ represent a change in legal status from Voluntary to Involuntary within the DRF. 5f. Designated Receiving Facilities: Readmission Rates for Adults
January – March 2018

Designated Receiving Facility

30 Days

90 Days

180 Days

Franklin

0% (0)

0% (0)

1.9% (1)

Manchester (Cypress Center)

4.2% (10)

9.6% (23)

15.8% (38)

Portsmouth

8.8% (29)

15.5% (51)

20.6% (68)

Elliot Geriatric Psychiatric Unit

0% (0)

0% (0)

0% (0)

Elliot Pathways

NA

NA

NA

Total

NA

NA

NA

CMHA Monthly Progress Report

24

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 64 of 86

October – December 2017

Designated Receiving Facility

30 Days

90 Days

180 Days

Franklin

10.2% (6)

10.2% (6)

10.2% (6)

Manchester (Cypress Center)

12.0% (25)

18.7% (39)

24.4% (51)

Portsmouth

8.7% (31)

13.7% (49)

17.6% (63)

Elliot Geriatric Psychiatric Unit

0% (0)

0% (0)

0% (0)

Elliot Pathways

5.8% (6)

7.7% (8)

12.5% (13)

Total

8.7% (68)

13% (102)

16.9% (133)

Revisions to Prior Period: None.

Data Source: NH DRF Database

Notes: Data compiled 6/11/18; NA=Not available from data submitter at time of reporting, will be included in next report.

Discharge location of “DRF” are patients discharged back to the same DRF for a different level of care within the DRF; readmission rates calculated by looking back in time from admissions in study quarter; patients are counted multiple times for each readmission; number in parentheses is the number of readmissions

CMHA Monthly Progress Report

25

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 65 of 86

6. Glencliff Home: Census Summary Measure

January – March 2018 October – December 2017

Admissions

12

8

Average Daily Census

112

108

Discharges

1 (1-Supported Apartment)

1 (1-medical model group home)

Individual Lengths of Stay in Days for Discharges

426

274

Deaths

3

3

Readmissions

0

0

Mean Overall Admission Waitlist

23 (13 Active)

19 (13 Active)

Revisions to Prior Period: None.

Data Source: Glencliff Home

Notes: Data Compiled 4/4/18; means rounded to nearest whole number; Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

CMHA Monthly Progress Report

26

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 66 of 86

7. NH Mental Health Consumer Peer Support Agencies: Census Summary

January – March 2018

October – December 2017

Peer Support Agency

Average

Average

Total Daily

Total Daily

Members Visits Members Visits

Alternative Life Center Total

567

47

532

46

Conway

191

14

189

15

Berlin

116

10

102

10

Littleton

153

10

141

8

Colebrook

107

13

100

13

Stepping Stone Total

405

16

386

18

Claremont

319

11

308

12

Lebanon

86

5

78

6

Cornerbridge Total

327

15

293

20

Laconia

126

4

109

6

Concord

143

11

127

14

Plymouth Outreach

58

NA

57

NA

CMHA Monthly Progress Report

27

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 67 of 86

January – March 2018

October – December 2017

Peer Support Agency

Average

Average

Total Daily

Total Daily

Members Visits Members Visits

MAPSA Keene Total

150

12

208

11

HEARTS Nashua Total

280

31

247

37

On the Road to Recovery Total

606

10

516

53

Manchester

442

5

382

31

Derry

164

5

134

22

Connections Portsmouth Total

284

13

278

11

TriCity Coop Rochester Total

262

24

225

24

Total

2,881

158

2,685

167

Revisions to Prior Period: None

Data Source: Bureau of Mental Health Peer Support Agency Quarterly Statistical Reports

Notes: Data Compiled 5/20/18; Average Daily Visits NA for Outreach Programs; The Bureau of Mental Health Services has instructed Peer Support Agencies to "purge member lists" annually to increase confidence and consistency in this information.

CMHA Monthly Progress Report

28

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 68 of 86

8. Housing Bridge Subsidy Summary to Date

January – March 2018

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

798

13

811

Section 8 Voucher

108

11

119

October – December 2017

Subsidy

Total individuals
served at start of quarter

New individuals added during
quarter

Total individuals
served through end
of quarter

Housing Bridge Subsidy

742

56

798

Section 8 Voucher

96

12

108

Revisions to Prior Period: Total served for Section 8 in the prior period was 108, not 102

Data Source: Bureau of Mental Health

Notes: Data Compiled 5/17/18

CMHA Monthly Progress Report

29

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 69 of 86

9a. Housing Bridge Subsidy Applications and Terminations

Measure

January – March 2018

Applications Received

44

Point of Contact

CMHCs: 43 NH Hospital: 1

Applications Approved

10

Applications Denied

0

Denial Reasons

NA

Applications in Process

34

Terminations

0

Termination Reasons

NA

9b. Housing Bridge Subsidy Current Census Measure Rents Currently Being Paid Individuals Accepted and Working Towards Bridge Lease Waiting list for Housing Bridge funding
Revisions to Prior Period: None

As of 3/31/2018 497 7
10

CMHA Monthly Progress Report

30

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 70 of 86

Data Source: Bureau of Mental Health

Notes: Data Compiled 5/17/18; all individuals currently on Bridge Program are intended to transition from the program to other permanent housing).

10. Housing Bridge Subsidy Unit Address Density Number of Unit(s)* at Same Address

Frequency as of 5/30/18

Frequency as of 2/7/18

1

353

372

2

28

35

3

12

13

4

5

4

5

0

1

6

0

0

7

0

0

8 or more

2

2

*All units are individual units

Revisions to Prior Period: None

Data Source: Bureau of Mental Health data compiled by Office of Quality Assurance and Improvement

Notes: Data Compiled 5/31/18

CMHA Monthly Progress Report

31

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 71 of 86

11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure

January February

2018

2018

March 2018

January – March 2018

October – December
2017

Unduplicated People Served in Month

200

186

196

NA

516

Services Provided by Type Mobile Community Assessments Crisis Stabilization Appointments Office-Based Urgent Assessments Emergency Service Medication Appointments Phone Support/Triage Walk in Assessments

52

61

67

180

156

11

13

22

46

33

28

36

29

93

64

2

27

16

45

90

303

257

330

890

776

5

6

9

20

17

Services Provided after Immediate Crisis

Mobile Community Assessments-Post

17

11

18

46

29

Crisis

CMHA Monthly Progress Report

32

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 72 of 86

Measure Crisis Stabilization Appointments Office-Based Urgent Assessments Emergency Service Medication Appointments Phone Support/Triage

January February

2018

2018

11

13

28

36

10

12

March 2018

January – March 2018

October – December
2017

22

46

33

29

93

64

6

28

72

111

88

151

350

219

Referral Source Emergency Department/EMS Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Internal

1

4

1

6

22

21

18

13

52

40

5

3

4

12

11

20

20

15

55

52

11

3

12

26

36

4

3

8

15

20

3

3

7

13

13

11

12

13

36

41

CMHA Monthly Progress Report

33

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 73 of 86

Measure Self Other

January February

2018

2018

107

96

17

24

March 2018

January – March 2018

October – December
2017

99

302

313

24

65

39

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

33

32

32

97

77

155

154

132

441

258

4.7

4.8

4.1

4.5

3.4

Law Enforcement Involvement

6

9

31

46

33

Hospital Diversions Total

142

151

157

450

416

Revisions to Prior Period: None

Data Source: Riverbend CMHC submitted reports

Notes: Data Compiled 6/1/18; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

34

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 74 of 86

11b. Mobile Crisis Services and Supports for Adults: Mental Health Center of Greater Manchester

Measure

January February

2018

2018

March 2018

January – October –

March December

2018

2017

Unduplicated People Served by Month

185

165

194

457

513

Services Provided by Type Phone Support/Triage Mobile Community Assessments Office-Based Urgent Assessments Emergency Service Medication Appointments Crisis Apartment Service

479

413

440

1,332

1,219

75

73

69

217

218

18

7

10

35

32

4

1

1

6

4

71

24

10

105

212

Referral Source Emergency Department Family Friend
CMHA Monthly Progress Report

0

3

1

4

3

30

22

33

85

118

5

2

4

11

5

35

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 75 of 86

Guardian Mental Health Provider Police Primary Care Provider CMHC Internal Self Other
Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay
Law Enforcement Involvement
Hospital Diversion Total

0

1

0

1

2

6

5

6

17

18

53

55

51

159

196

6

2

10

18

23

28

22

18

68

57

130

113

142

385

334

27

42

28

97

97

3

3

3

9

11

8

13

8

29

38

4.0

3.3

2.7

3.2

3.5

53

55

51

159

136

285

266

293

844

840

CMHA Monthly Progress Report

36

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 76 of 86
Revisions to Prior Period: None. Data Source: Mobile Crisis Data Reporting System Notes: Data Compiled 5/29/18; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

37

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 77 of 86

11c. Mobile Crisis Services and Supports for Adults: Harbor Homes

Measure

January February

2018

2018

March 2018

January – October –

March December

2018

2017

Unduplicated People Served by Month

53

11

46

103

70

Services Provided by Type Phone Support/Triage Mobile Community Assessments Office-Based Urgent Assessments Emergency Service Medication Appointments Crisis Apartment Service Consultation Case Management

53

30

48

131

93

20

17

17

54

16

0

0

0

0

5

0

2

0

2

0

2

0

5

7

1

4

1

0

5

31

24

8

0

32

12

Referral Source Emergency Department

1

0

0

1

4

CMHA Monthly Progress Report

38

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 78 of 86

Family Friend Guardian Mental Health Provider Police Primary Care Provider CMHC Self Other
Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay
Law Enforcement Involvement

5

0

8

13

8

3

0

0

3

1

0

0

0

0

0

5

1

3

9

2

1

1

0

2

5

0

0

0

0

0

11

1

12

24

11

47

7

33

87

77

15

2

1

18

27

3

1

4

8

1

25

3

58

86

4

8.3

3.0

14.5

8.6

4

14

4

0

18

3

CMHA Monthly Progress Report

39

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 79 of 86

Hospital Diversion Total

71

10

49

130

124

Revisions to Prior Period: None

Data Source: Mobile Crisis Data Reporting System

Notes: Data Compiled 5/31/18; reported values other than the Unduplicated People Service in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

CMHA Monthly Progress Report

40

June 18, 2018

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 80 of 86
Appendix B New Hampshire Community Mental Health Agreement
Monthly Progress Reports February - March, 2018

CMHA Monthly Progress Report

41

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 81 of 86
New Hampshire Community Mental Health Agreement Monthly Progress Report
February-March 2018
New Hampshire Department of Health and Human Services June 25, 2018

CMHA Monthly Progress Report

42

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 82 of 86

Acronyms Used in this Report

ACT: BMHS: CMHA: CMHC: DHHS: SE: SFY:

Assertive Community Treatment Bureau of Mental Health Services Community Mental Health Agreement Community Mental Health Center Department of Health and Human Services Supported Employment State Fiscal Year

Background
This Monthly Progress Report is issued in response to the June 29, 2016 Expert Reviewer Report, Number Four, action step 4. It reflects the actions taken in February and March 2018, and month-over-month progress made in support of the Community Mental Health Agreement (CMHA) as of February 28, 2018. Data contained may be subject to change upon further reconciliation with CMHCs. This report is specific to achievement of milestones contained in the agreed upon CMHA Project Plan for Assertive Community Treatment (ACT), Supported Employment (SE) and Glencliff Home Transitions. Where appropriate, the Report includes CMHA lifetime-to-date achievements.

CMHA Monthly Progress Report

43

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 83 of 86

Progress Highlights

Assertive Community Treatment (ACT)

Goal CMHC fidelity to ACT evidence-based practice model annually assessed.

Status 2018: 10 of 10 Completed*

Provide ACT team services, consistent with standards set forth, with the capacity to serve at least 1,500 individuals.

Capacity: Feb. – 1,119 Mar. – 1,201

Enrollment: Feb. – 877 Mar. -- 813

Recent Actions Taken • 10 reports issued, 8 improvement plans in
place; 2 in development process.
• 11 post ACT Fidelity Review consultations with participating CMHCs have occurred during State Fiscal Year 2018 thus far.
• February newly* enrolled individuals: 29 • March newly enrolled individuals: 30 *New is defined as an individual who is new to the ACT program or an individual who has not received an ACT service in more than 90 days.

Supported Employment (SE)

Goal

Status

Recent Actions Taken

CMHC fidelity to SE evidence-based practice model annually assessed.

2018:

• 8 fidelity reports issued, 1 are in development. 7

9 of 10 completed* improvement plans in place.

Increase penetration rate of individuals with a Serious Mental Illness (SMI) receiving SE services to 18.6%.

Statewide penetration rate: Feb. – 26.9% Mar. – 26.4%

• 8 post SE Fidelity Review consultations with participating CMHCs have occurred during State Fiscal Year 2018 thus far.

*Information as of report date (not limited to March 31, 2018).

Glencliff Home Transitions into Integrated Community Setting

Goal

Status

Recent Actions Taken

Have capacity to serve in the community 16 (cumulatively) individuals with mental illness and complex health care needs residing at Glencliff who cannot be cost-effectively served in supported housing.

16 of 16 completed21

• In May 2018, a resident who initially transitioned from the Glencliff Home in May 2017 to a 10-bed residence, was successfully transitioned to an independent apartment.

By June 30, 2017, identify and maintain a list of all individuals with mental illness and complex health care needs residing at the Glencliff Home who cannot be costeffectively served in supported housing and develop an effective plan for providing sufficient community-based residential supports for such individuals in the future.

Completed; ongoing

• 13 residents on the list
• 12 of the 13 residents who are planning to transition with CFI services have selected their CFI transition case management service provider to actively support transition.
• The 13th resident is seeking transition under a DD Waiver at this time.

21 Indicates residents have been transitioned into an integrated community setting; compliance with additional CMHA requirements for such transitions is under review.

CMHA Monthly Progress Report

44

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 84 of 86

1,400

ACT Capacity by Quarter/Month*

1,200

1,080

1,093

975

997

998

1,000

800

600

400

200

0

1,1901,1811,1741,1601,1231,2521,2651,2561,2421,2511,1681,1601,2451,1191,201 901

Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

45

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 85 of 86

1200 1100

ACT Client Count by Month

1000 900 800

748 739 746 758 758 769 772 780 778 773 774 783 786 806 810 828 838 845 889 888 913 925 927 920 912 904 915 910 899 887 902 877 813

700

600

500

400

300

200

100

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-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17
Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

46

Case 1:12-cv-00053-SM Document 122-1 Filed 07/30/18 Page 86 of 86

30.0% 25.0% 20.0%

26.6%

26.9%

SE Statewide Penetration Rate by Quarter/Monthly* 25.3%

26.4% 26.4%

25.8%

26.7%26.7%

26.90% 26.40%

24.1%

24.7%

23.3% 22.9%

24.2% 22.8%

19.3%

19.8%

20.9%

17.9%

15.7% 15.0%

10.0%

5.0%

Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

0.0%
* Data is a combination of preliminary monthly and finalized quarterly data from CMHA Quarterly Data Reports.

47

 
 Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 1 of 88
EXHIBIT A
New Hampshire Community Mental Health Agreement
Expert Reviewer Report Number Eleven
January 28, 2020
I. Introduction
This is the eleventh semi-annual report of the Expert Reviewer (ER) under the Settlement Agreement in the case of Amanda D. v. Sununu; United States v. New Hampshire, No. 1:12-cv53-SM. For the purpose of this and future reports, the Settlement Agreement will be referred to as the Community Mental Health Agreement (CMHA). Section VIII.K of the CMHA specifies that:
Twice a year, or more often if deemed appropriate by the Expert Reviewer, the Expert Reviewer will submit to the Parties a public report of the State’s implementation efforts and compliance with the provisions of this Settlement
DRAFT
Agreement, including, as appropriate, recommendations with regard to steps to be taken to facilitate or sustain compliance with the Settlement Agreement.
In this three-month period (September 1, 2019 through December 31, 2019), the ER has continued to observe the State’s work to implement key service elements of the CMHA, and has continued to have discussions with relevant parties related to implementation efforts and the documentation of progress and performance consistent with the standards and requirements of the CMHA. During this period, the ER:
 Met with a clinical team and clinical leadership at New Hampshire Hospital (NHH) to review transition planning processes and issues;
 Observed the Quality Service Review (QSR) conducted at Lakes Regional Mental Health Center;
 Conducted site visits at three CMHCs (Monadnock, Community Partners and Center for Life Management). Each site visit consisted of meeting with the ACT and supported employment (SE) teams, and with the senior management of each CMHC;
 Met with the State CMHA Management Oversight Team to discuss new data elements and reports related to ACT, SE, and supported housing (SH);
 Met with State program leadership staff to discuss the management and monitoring of the Bridge supportive housing program and Glencliff transitions to integrated community settings, including the proposed new approach to Glencliff inreach;
1

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 2 of 88

 Observed an ACT fidelity review at Greater Nashua Mental Health Center; and  Convened an All Parties meeting to discuss progress in meeting the requirements of
the CMHA.

Information obtained during these state level and on-site meetings has, to the extent applicable, been incorporated into the discussion of implementation issues and service performance below. The ER will continue to conduct site visits going forward to observe and assess the quality and effectiveness of implementation efforts and whether they achieve positive outcomes for people consistent with CMHA requirements.

Summary of Progress to Date

This report reflects more than five years of implementation efforts related to the CMHA. Within this period, a number of positive steps have been taken to improve the quality and effectiveness of services as envisioned in the CMHA. However, as will be discussed in detail below, there are areas of continued non-compliance with the CMHA. Notwithstanding these on-going concerns, the parties to the CMHA deserve credit for some real and measurable accomplishments.

As noted in previous ER Reports, the State has implemented a comprehensive and reliable QSR

process. The ER considers these QSR reviews to be methodologically correct and reliable,

producing findings that are accurate and actionable in terms of taking concrete steps to address

quality issues in the CMHC system.

DRAFT

Another major accomplishment has been contracting with the Dartmouth-Hitchcock Medical Center to conduct external ACT and SE fidelity reviews using nationally validated fidelity review instruments and criteria. In concert with the QSR reviews mentioned above, the fidelity reviews are assisting the State and the Community Mental Health Centers (CMHCs) to develop comprehensive Quality Improvement Plans (QIPs) that address important ACT and SE quality and effectiveness issues at both the consumer and CMHC operational levels.

Recently, following input from representatives of the Plaintiffs and the ER, the State has initiated or enhanced a number of strategies to expand ACT capacity and enrollment. It is too soon to gauge whether these strategies are having the desired effect, although recent data support optimism that ACT staffing and enrollment trends are moving in a positive direction. Nonetheless, the State is to be commended for taking new steps to improve performance with regard to the ACT requirements of the CMHA.

The parties originally envisioned that the CMHA could be fully implemented in five years, with a sixth year for maintenance of effort. The CMHA was approved and filed with the Federal Court on February 12, 2014, and the five-year anniversary of that event occurred 11 months ago. The ER was approved by the Parties and the Federal Court effective July 1, 2014, and the fiveyear anniversary occurred six months ago. Given these elapsed times, it is critical for this report

2

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 3 of 88

and for subsequent activities that the focus be on specific strategies and action steps necessary to meet the requirements of the CMHA, and to plan for disengagement.

II. Data

As noted in previous reports, the New Hampshire DHHS continues to make progress in developing and delivering data reports addressing performance in some domains of the CMHA. Appendix A contains the most recent DHHS Quarterly Data Report (July to September 2019), incorporating standardized report formats with clear labeling and date ranges for several important areas of CMHA performance. The capacity to conduct and report longitudinal analyses of trends in certain key indicators of CMHA performance continues to improve. The ER continues to emphasize that the State must take the steps necessary to produce the necessary data reports in a timely fashion.

III. CMHA Services

The following sections of the report address specific service areas and related activities and standards contained in the CMHA.

Mobile/Crisis and Crisis Apartment Programs

The

CMHA

calls

for

the

establishment

of

a

DRAFT
Mobile

Crisis

Team

(MCT)1

and

Crisis

Apartments

in the Concord Region by June 30, 2015 (Section V.C.3(a)). DHHS conducted a procurement

process for this program, and the contract was awarded on June 24, 2015. Riverbend CMHC

was selected to implement the MCT and Crisis Apartments in the Concord Region.

The CMHA specified that a second MCT and Crisis Apartment program be established in the Manchester region by June 30, 2016 (V.C.3(b)). The Mental Health Center of Greater Manchester was selected to implement that program. Per CMHA V.C.3(c), a third MCT and Crisis Apartment program became operational in the Nashua region on July 1, 2017. The contract for that program was awarded to Harbor Homes in Nashua. All of these contracts will be expiring at the end of the current fiscal year; the State is in the process of issuing a RFP so as to continue the MCTs and crisis apartment services going forward.

The Quarterly Data Report contained in Appendix A includes a detailed table of data from each of the Mobile Team/Crisis Apartment programs. Table I contains a summary of key data trends from the three programs.

1 Note that the State refers to these programs as Mobile Crisis Response Teams (MCRTs). The ER uses the MCT nomenclature to remain consistent with the terms used in the CMHA.
3

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 4 of 88

Table I Self-Reported Data on Mobile Crisis Services and Crisis Apartment Programs

Region

Variable

April June 2019

July Sept. 2019

Concord Total Served

Manchester Total Served

Nashua

Total Served

517

499

714

679

419

377

Concord Phone triage/support

Manchester Phone triage/support

Nashua

Phone triage/support

1,143 1,795 522

1,104 1,833 530

Concord Mobile Assess./intervention

136

211

Manchester Mobile Assess./intervention

319

280

Nashua

Mobile Assess./intervention

245

231

Concord Number Referred by self

Manchester Number Referred by self

Nashua

Number Referred byDRAFT self

751

657

361

395

200

215

Concord Number referred by police

20

39

Manchester Number referred by police

320

273

Nashua

Number referred by police

20

15

Concord Pct Law Enforcement Inv.

Manchester Pct Law Enforcement Inv.

Nashua

Pc Law Enforcement Inv.

14.2% 44.8% 0.0%

12.6% 40.2% 0.0%

Concord Hospital diversions

Manchester Hospital diversions

Nashua

Hospital diversions

449 1,185 704

520 1,111 710

Concord Apartment Admits

Manchester Apartment Admits

Nashua

Apartment Admits

80

78

15

9

51

53

Concord Apartment bed days

Manchester Apartment bed days

Nashua

Apartment bed days

319

397

46

27

249

306

4

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 5 of 88

The ER conducted site visits at each of the MCT and Crisis Apartment programs in New Hampshire during the past nine months. Each of the programs is fully staffed and, in the opinion of the ER, is generally operating in accordance with best practice approaches to mobile crisis and crisis apartment services. Each program is making good use of peer staff for both mobile crisis response and for staffing of the crisis apartments. To varying degrees, each program is developing more effective relationships with local law enforcement agencies, other first responders, and local hospital emergency departments. To date, crisis apartment average lengths of stay have remained within reasonable ranges. There is some anecdotal evidence suggesting that the mobile team and crisis apartment interventions are beginning to influence pathways into hospital emergency department, inpatient psychiatric services, and local jails.

Table II below includes data that reveal some recent changes in both emergency department waiting times for New Hampshire Hospital (NHH) admissions, and for NHH readmission rates. These data may indicate that the fully implemented MCT and Crisis Apartment programs are beginning to have a positive effect on system indicators such as emergency department boarding and hospital recidivism rates. However, there may be numerous other factors influencing these data trends. The ER plans to discuss with the State some analytic approaches that could illuminate the relationships among the MCT programs and the other system indicators

Table II DHHS Report of Changes in Waiting Time for NHH Admissions and NHH Readmission Rates
DRAFT

State Fiscal Year

Average # Adults Waiting per Day for NHH Admission

NHH Admissions

NHH 180-day Readmissions Average

2018 2019 Change

50 39 Down 22%

807 818 Up 1.4%

28.5% 23.2% Down 18.6%

The ER continues to be concerned about some apparent practice and data reporting variations among the three MCT/Crisis Apartment programs. For example, as can be seen in Table I, there are substantial differences among the three programs with regard to police referrals to and law enforcement involvement in the various programs. Late last year, in concert with representatives of the plaintiffs, the ER requested additional information from the State regarding the functioning of these programs. The State has provided responses to certain information requests, and the ER will follow up with DHHS staff to supplement and clarify these responses early in this calendar year.
While the State reports conducting visits to the MCT program sites, no performance assessments or other contractual reviews/program evaluations have been shared with the ER or the parties. The State’s response indicates some need for additional State oversight and/or corrective action on the part of one or more of the programs, including an effort to measure program performance
5

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 6 of 88
in key areas of MCT service delivery, like phone triage, decisions to deploy mobile crisis teams to community locations, and the efficacy of crisis response.
The State has issued an RFP and an RFI related to MCT/Crisis Apartment programs, and responses have been received by the State as of the date of this report. The State asserts that the RFP and RFI indicate that it is “actively engaged in a comprehensive effort to explore best practices and model designs for MCT services, and we anticipate this effort also will inform the next contracts for the MCTs required under the CMHA” 2 Thus, the ER is recommending the parties collectively review the responses to the RFP and RFI and that the ER and representatives of the Plaintiffs to engage in discussions with the State about current program operations and future operations of MCT and similar programs in New Hampshire.
The State recently funded a new Behavioral Health Crisis Treatment Center (BHCTC) that has been implemented by the Riverbend CMHC in Concord. The BHCTC is an additional crisis support that outside those required by the CMHA. As such, data related to the operations of that program is not included in this report. The above-referenced RFI may elicit responses related to the BHCTC model as well as the MCT/Crisis Apartment models implemented under the CMHA. The ER expects that if the State is considering crisis program model variations in the reprocurement of the CMHA-required MCT/Crisis Apartment programs, the State will discuss its potential model with the ER and representatives of the Plaintiffs prior to issuing the reprocurement RFPs.
DRAFT
Assertive Community Treatment (ACT)
ACT is a core element of the CMHA, which specifies, in part:
1. By October 1, 2014, the State will ensure that all of its 11 existing adult ACT teams operate in accordance with the standards set forth in Section V.D.2;
2. By June 30, 2014, the State will ensure that each mental health region has at least one adult ACT team;
3. By June 30, 2016, the State will provide ACT team services consistent with the standards set forth above in Section V.D.2 with the capacity to serve at least 1,500 individuals in the Target Population at any given time; and
4. By June 30, 2017, the State, through its community mental health providers, will identify and maintain a list of all individuals admitted to, or at risk serious risk of being admitted to, NHH and/or Glencliff for whom ACT services are needed but not available, and develop effective regional and statewide plans for providing sufficient ACT services to ensure reasonable access by eligible individuals in the future.
2 State response to ER memo re: MCTs, December 12, 2019, page 1
6

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 7 of 88 The CMHA requires a robust and effective system of ACT services to be in place throughout the state as of June 30, 2015 (54 months ago). Further, as of June 30, 2016, the State was required to have the capacity to provide ACT to 1,500 priority Target Population individuals. As displayed in Table III below, the staff capacity of the 12 adult ACT teams in New Hampshire has increased by 7.25 FTE since June of 2019.
DRAFT
7

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 8 of 88

Table III Self-Reported ACT Staffing (excluding psychiatry):
September 2017 – September 2019

Region

FTE FTE FTE FTE FTE FTE FTE FTE FTE

Sep- Dec- Mar- Jun- Sep- Dec- Mar-

Sep-

17 17 18

18 18 18 19 Jun-19 19

Northern West Central Lakes Region Riverbend Monadnock Greater Nashua 1 Greater Nashua 2 Manchester – CTT Manchester MCST Seacoast Community Part. CLM Total

12.4 13.0 7.0 6.2
10.8 9.4 10.0 10.0
7.9 7.9

6.0 5.0

5.0 5.0

16.3 12.8

22.3 10.5
6.7 9.3 124.2

19.0 10.5
7.9 9.3 116.1

11.6 12.7 13.1 17.3 5.0 5.2 5.3 5.8 5.7 5.6 8.4 7.4
10.3 10.5 10.5 10.5 8.7 8.5 8.7 9.0

5.8 5.8 5.5 5.0

5.8 5.8 4.5 4.0

17.3 15.5 14.8 14.3
DRAFT

19.5 11.5
9.8 9.3 120.1

16.3 9.5 9.6 8.3
113.1

17.8 10.5
9.1 7.6 115.6

15.8 11.1
7.8 6.6 114.3

16.8 16.51 16.37 6.8 7.65 8.25 8.3 8.00 8.00
11.5 10.50 11.50 9.5 9.00 8.00

6.5 7.00 8.00

4.5 4.00 7.00

14.3 15.75 15.75

15.8 9.1 8.8 7.9
119.6

17.25 9.10
10.78 7.01
122.55

17.25 10.10 11.28
8.30 129.80

Overall, ACT team staffing has increased by 10.2 FTEs over the past two reported quarters. Nine teams have at least 1.0 FTE SE staff, while three have less than a full time SE specialist. Five teams report having .5 or less FTE combined psychiatry/nurse practitioner time available to their ACT teams3; and five of the 12 teams report having less than one FTE nurse per team. Six teams have increased the number of FTE substance use specialists, and only one team has less than a full FTE substance use specialist. All ACT teams are now reported to have at least .5 FTE Peer Staff as members of the teams.
Table IV below displays the active ACT caseloads by CMHC Region for the past 27 months. The active monthly caseload increased by 17 participants in the last quarter. Since June of 2017

3 The CMHA specifies at least .5 FTE Psychiatrists for teams with at least 70 active service participants. (CMHA V.D.2(e).
8

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 9 of 88

the active monthly caseload has dropped by 64. Over the past two reported quarters the ACT active caseload has increased by 19 participants.

Table IV

Self-Reported ACT Active Caseload (Unique Adult Consumers) by Region in Specified Months: June 2017 – September 2019

Region

Active
Cases Jun17

Active
Cases Sep17

Active
Cases Dec17

Active
Cases Mar18

Active
Cases Jun18

Active
Cases Sep18

Active
Cases Dec18

Active
Cases Mar-
19

Active
Cases Jun19

Active
Cases Sep19

Northern

106 107 115 114 108 102

West Central

56 63 57 46 48 44

Lakes Region

73 71 65 64 59 53

Riverbend

92 81 81 80 83 82

Monadnock

68 55 53 55 55 55
DRAFT

Greater Nashua 85 90 76 74 74 84

Manchester

275 269 269 277 290 306

Seacoast Community Part.

64 60 54 66 67 69 67 65 64 66 62 61

CLM

50 54 55 59 58 55

115 120 115 122 42 43 46 47 51 56 57 56 87 100 102 86 56 56 57 49 77 75 83 97 312 303 287 300 71 70 66 68 64 68 67 71 53 53 47 49

Total*

927 915 887 901 902 911

* unduplicated across regions

927 944

925 942

The combined ACT teams have a reported September 2019 staff complement of 129.8 FTEs excluding psychiatry, which is sufficient capacity to serve 1,298 individuals based on the ACT non-psychiatry staffing ratios contained in the CMHA. This increased staffing represents new capacity to increase active caseload by 102 participants over the capacity reported in the previous ER report. However, with a statewide caseload of only 942 as of September 2019, the gap between staff capacity and active participants has increased by 83 participants since the previous report. As noted above, the CMHA requires the State to have capacity to serve 1,500
9

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 10 of 88
individuals. The current ACT FTE staffing level, albeit improved, is still 202 participants below the capacity required by the CMHA. As noted in previous reports, the current level of ACT staffing is not sufficient to meet CMHA requirements for ACT team capacity. Furthermore, the current ACT caseload of 942 individuals is 558 below the number that could be provided ACT services with the capacity required by the CMHA.4
ACT Screening As has been documented in previous reports, the State has been implementing a number of strategies to increase ACT enrollment and participation. One of these strategies has been to require the ten CMHCs to conduct and report regular clinical screening for eligibility/appropriateness for ACT services. The clinical screens are conducted:
1. As part of the intake process at the CMHCs; 5 2. Upon referral to a CMHC following discharge from an inpatient facility; and 3. As part of regular quarterly and annual assessments and plan of care amendments for
current CMHC clients6 who may qualify for and benefit from ACT. Table V below presents data on ACT screens conducted by CMHCs between April and June, 2019.
DRAFT
4 The ER notes that active ACT caseload is a static measure of ACT activity. The ER plans to work with the State and representatives of the Plaintiffs to incorporate other indicators, such as ACT enrollments and unduplicated ACT participants in subsequent reports. 5 Note that a CMHC intake incorporating the ACT screen is performed when a CMHC emergency services staff or Mobile Crisis Team encounters and refers a person potentially needing CMHC services. In some cases, these Emergency Services/ MCT referrals are made on behalf of individuals who have presented in crisis in hospital emergency departments and who may be waiting for a NHH admission. 6 Until recently, data on the total number of ACT screenings included current ACT participants. Active ACT clients have now been removed from screening reports.
10

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 11 of 88

Table V

Self-Reported Number of Unique Clients Screened for ACT Services Conducted by CMHCs

April - June 2019

Community Mental Health Center

Total Screened

Appropriate for further
ACT Assessment

Receiving ACT/ w/i 90 days of Assessment

Percent Receiving ACT
of those Qualified for Assessment

01 Northern Human

1,158

37

3

8.1%

Services

02 West Central

287

5

4

80%

Behavioral Health

03 Lakes Region

823

9

Mental Health Center

0

0.0%

04 Riverbend

1,272

1

0

0.0%

Community Mental

DRAFT

Health Center

05 Monadnock Family

535

4

Services

0

0.0%

06 Greater Nashua

633

9

Mental Health

4

44.4%

07 Mental Health

1571

3

Center of Greater

Manchester

0

0.0%

08 Seacoast Mental

1286

16

0

0.0%

Health Center

09 Community Partners 401

1

1

100%

10 Center for Life

756

3

Management

1

33.3%

Total

8,722

88 (1.0%) of
all screened

13 (14.8%) of all
assessed after screening: 0.1% of all screened

11

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 12 of 88
Of the 8,722 unique individuals screened for ACT during this period, the State reports that 88 were referred for an ACT assessment. This is a referral rate of one percent. And, less than 15 percent of those referred for ACT assessments were enrolled in ACT services within 90 days of being screened. Most of the referrals for ACT screening are internal to the CMHCs. That is, people who have already had a CMHC intake, and who may already be receiving CMHC services, are those most likely to be screened for ACT services. Thus, it is perhaps not surprising that so few of the individuals screened are referred to the next step, which is the assessment for ACT. In fact, the State has reported that about 87% of individuals are linked to ACT without having gone through the ACT screening process. Because of this limitation, available screening data does not shed light on whether individuals outside of the CMHC system who would benefit from ACT services are being properly identified and referred for assessment. The State has begun collecting and reporting data on the number of individuals waiting for ACT services on a statewide basis. This information is displayed in Table VI below. The State and the CMHCs state that an individual eligible for ACT may have to wait for ACT services because the specific ACT team of the individual’s CMHC does not currently have staff capacity to accept new clients. The ER has documented above that there is a statewide gap between ACT staff capacity and ACT participation. Indeed, there is excess capacity in each region/team and enough capacity to address the needs of people reported to be on the waitlist. However, the State and the
DRAFT
CMHCs note that in some CMHC regions new ACT staff must be hired before new ACT clients can be accepted into the program.
12

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 13 of 88

December 31, 2018
March 31, 2019
June 30, 2019
September 30, 2019

Table VI Self-Reported ACT Wait List:

Time on List

Total

0-30 days 31-60 days 61-180 days

6

3

0

3

2

1

1

0

1

1

0

0

2

2

0

0

ACT Fidelity and Quality
Only three months have elapsed between this report DRAFT and the most recent previous ER report. In that interval, only a few ACT fidelity reviews and QSR reports have been published. Thus, the ER will reserve any updates to this section until the June 2020 report.
ACT Summary Findings
Based on the above information, the ER finds that the State remains out of compliance with the ACT service standards described in Section V.D. of the CMHA. The State does not currently provide a robust and effective system of ACT services throughout the state as required by the CMHA.
ACT Working Group
As noted in recent ER Reports, the DHHS has taken deliberate steps to work with CMHCs in certain Regions to increase their ACT staffing and caseloads. These actions include: (a) quarterly ACT monitoring and technical assistance with DHHS leadership and staff; (b) implementation of a firm schedule for ACT fidelity reviews; (c) incorporating a small increase in ACT funding into the Medicaid rates for CMHCs; (d) additional incentive-based payments related to ACT services; (e) active on-site and telephonic technical assistance based on CMHC needs related to improving the quality and fidelity of ACT services; and (f) coordinated efforts to address workforce recruitment and retention. The State has identified workforce recruitment and retention issues as factors limiting the growth and expansion of the ACT teams. The State has
13

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 14 of 88
been working collaboratively with the New Hampshire Community Behavioral Health Association to identify and track workforce gaps and shortages, and to initiate a variety of strategies to improve workforce recruitment and retention. However, as noted above, ACT staffing remains substantially below the levels required by the CMHA.
In October 2108 the State has received approval from the federal Centers for Medicare and Medicaid Services (CMS) to use up to $3.0 Million in Medicaid waiver funds for directed payments (incentive-based rate enhancements) to CMHCs for recipients already enrolled in ACT and for each new ACT enrollee. These incentive payments with be continued for Fiscal Years 2020 and 2021. CMS has also approved up to $1.2 Million for fee schedule increases for people discharged from psychiatric inpatient services who receive a same - or next-day appointment at a CMHC.
In June 2019 the State increased state funding in its CMHC contracts by $650,000 to achieve improved ACT and SE fidelity and to positively impact ACT staffing. This incentive-based funding supports recruitment and retention of certain ACT team staffing specialties; after hours crisis coverage training for ACT staff; and technology improvements.
Last year, the ER requested that representatives of the Plaintiffs and the State participate in an ACT working group. The purpose of this working group was to develop a set of feasible, measurable action plans to quickly expand and improve ACT services consistent with the CMHA. The ACT working group met three times, DRAFT and in the process developed a set of concrete recommendations. These recommendations address the following topic areas:
1. Screening and referral for ACT services; 2. Assessment for ACT eligibility, including reporting on the degree to which ACT
assessments result in enrollment in ACT services; 3. Facilitation of referrals from New Hampshire Hospital (NHH) to CMHCs for ACT
intake and assessment activities; 4. Analysis of pre- and post- hospitalization data, and hospital readmission data, to
identify individuals that could benefit from ACT; 5. Analysis of and reporting on the effectiveness of ACT directed payments as an
incentive to increase ACT enrollment; 6. Development of a data dashboard that reports on CMHCs’ performance and
participant outcomes relevant to ACT services; 7. Enhanced training, technical assistance, and mutual support among CMHCs and ACT
teams; 8. Enhanced workforce recruitment and retention activities; and 9. Enhanced management oversight, monitoring, and technical assistance to assure
implementation of ACT strategies.
14

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 15 of 88
In support of the ACT working group efforts, DHHS has been conducting internal analyses from existing data bases, and also requesting certain new information from the CMHCs. DHHS produced the following new information:7
1. ACT referrals from NHH by Region; 2. ACT penetration rates by Region; 3. Tabulation of ACT penetration rates from selected other states, and reported by the
federal Substance Abuse and Mental Health Services Administration (SAMHSA); 4. Current diagnoses of active ACT clients by Region; and 5. Tabulation of Managed Care enhanced payments related to ACT initiatives by
Region.
The initiatives summarized above have the potential to increase the capacity and quality of ACT services, and also to assure that people in need of ACT services are identified, referred, assessed and served as expeditiously as possible. The ER commends the representatives of the Plaintiffs and the State for their efforts to develop these ACT initiatives. The ER will closely monitor the implementation and management of the ACT strategies to determine if actual improvements are measurable in ACT capacity; enrollment; fidelity; and quality.
The ER emphasizes, as in past reports, that it must be the first priority of the State and the CMHCs to focus on: 1) assuring required ACT team composition; 2) utilizing existing ACT team capacity; 3) increasing ACT team capacDiRAFTty; and 4) outreach to and enrollment of new ACT clients.
Supported Employment (SE)
Pursuant to the CMHA’s SE requirements, the State must accomplish three things: 1) provide SE services in the amount, duration, and intensity to allow individuals the opportunity to work the maximum number of hours in integrated community settings consistent with their individual treatment plans (V.F.1); 2) meet Dartmouth fidelity standards for SE (V.F.1); and 3) meet penetration rate mandates set out in the CMHA. For example, the CMHA states: “By June 30, 2017, the State will increase its penetration rate of individuals with SMI receiving supported employment … to 18.6% of eligible individuals with SMI.” (Section V.F.2(e)). In addition, by June 30, 2017, “the State will identify and maintain a list of individuals with SMI who would benefit from supported employment services, but for whom supported employment services are unavailable” and “develop an effective plan for providing sufficient supported employment services to ensure reasonable access to eligible individuals in the future.” (V.F.2(f)).
7 Recent tabulations of data related to these items were not available at the time of this Report. The ER will incorporate such data in subsequent reports.
15

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 16 of 88

As noted in Table VII below, three of the ten CMHCs continue to report penetration rates lower than the CMHA requirement.
Table VII
Self-Reported CMHC SE Penetration Rates
Penet. Penet. Penet. Penet. Penet. Penet. Dec-17 Mar-18 Jun-18 Sep-18 Jun-19 Sep-19

Northern West Central Lakes Reg. Riverbend Monadnock Greater Nashua Manchester Seacoast Comm. Part. CLM CMHA Target Statewide Ave.

39.00% 25.30% 19.10% 13.20% 10.90% 16.80% 45.30% 28.00% 17.70% 20.00% 18.60% 26.70%

38.80% 26.20% 15.40% 12.60% 10.40% 14.90% 43.50% 30.10% 21.50% 20.90% 18.60% 26.40%

36.90% 31.20% 12.10% 11.80% 11.00% 14.20% 44.10% 29.80% 20.90% 17.50% 18.60% 25.90%
DRAFT

32.10% 33.80% 11.80% 16.60%
9.30% 12.60% 44.10% 29.90% 19.20% 20.80% 18.60% 25.90%

14.90% 22.50% 18.90% 19.00%
6.80% 13.1% 39.30% 33.70% 8.60% 20.80% 18.60% 23.50%

15.80% 19.70% 18.90% 18.40%
6.20% 12.7% 39.30% 32.90% 7.80% 20.10% 18.60% 23.20%

The State reports data on the degree to which CMHC clients are working, either full or part time, in competitive employment.8 Access to competitive employment is an important indicator of the quality and effectiveness of fidelity model SE services. Table VIII summarizes some key findings from these data reporting efforts.

8 State data defines full time employment as working 20 hours a week or more. The statewide percentage of SE users in full-time employment in the quarter ending September 30, 2019 was 6.0%.
16

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 17 of 88

Table VIII Competitive Employment for CMHC Clients

CMHC

Percent of SE Active Clients Employed Full or Part Time
July – September 2019

Percent of SE Active Clients Employed Full or Part Time April – June
2019

Northern WCBH LRMHC Riverbend Monadnock Nashua MHCGM Comm. Prtnrs. Seacoast CLM

38.9% 28.6% 34.9% 60% 40% 38.9% 58.3% 36.3% 53.9% 75%

44.2% 43.8% 27.9% 61.8% 52.0% 31.9% 54.3% 31.3% 57.1% 56.5%

Statewide

49.2% DRAFT

46.7%

For those eligible adults not involved in SE, the overall numbers are lower – with only 26% currently engaged in full-time or part-time employment statewide.
These data have not yet been collected and reported for a long enough period for reliable trend analyses, but they do provide a reasonable baseline for future analyses. The ER will continue to review these competitive employment data in concert with the available SE fidelity and QSR reports.
SE Fidelity and Quality
As with ACT services, insufficient time has elapsed since the previous ER report to update the SE fidelity and quality reporting. This section will be updated in the next ER report.
Supported Housing (SH)
The CMHA requires the State to achieve a target capacity of 450 SH units funded through the Bridge Program and HUD-funded subsidies by June 30, 2016. As of September 2019, DHHS reports having 338 individuals leased in Bridge Program subsidized units and having 35 people approved for a Bridge Program subsidy but not yet leased. There are 42 individuals reported to be on the Bridge Program wait list as of the end of September, 2019. Of these, 33 individuals
17

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 18 of 88 have been on the wait list for more than two months and 24 of the 33 have been on the waitlist for more than six months; these figures trigger CMHA V.E.3(f), which requires the State to add SH capacity to meet the unmet needs. There has been a precipitous drop in the aggregate number of individuals either leased or approved but not yet leased in the Bridge Program – from 591 in June of 2017 to 373 in September 2019. Table IX below provides data regarding the number of current Bridge Subsidy participants; the number waiting to lease; the number on the Bridge Subsidy waiting list; the total number leased since the inception of the program; and the total number receiving a HUD Housing Choice Voucher (HCV). Table X provides quarterly data regarding the number of Bridge Subsidy program applications and terminations.
DRAFT
18

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 19 of 88

Table IX

New Hampshire DHHS Self-Reported Data on the Bridge Subsidy Program:

December 2016 through September 2019

Bridge Subsidy Program
Information

June 2017

Sept. March Sept. March June 2017 2018 2018 2019 2019

Sept. 2019

Total individuals 545

509

497

423

389

365

338

leased in the

Bridge Subsidy

Program

Individuals in

46

58

7

process of leasing

0

11

13

35

Individuals on the 0 wait list for a Bridge Subsidy9

0

10

35

38

44

42

DRAFT

Total number

701

742

811

811

812

812

829

served since the

inception of the

Bridge Subsidy

Program

Total number

85

transitioned to a

HUD Housing

Choice Voucher

(HCV)

96

119

125

137

133

151

9 The State did not maintain a waitlist prior to 2018.
19

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 20 of 88

Table X

Self-Reported Housing Bridge Subsidy Applications and Terminations

July – October – January –

September December March

2018

2018

2019

April – June 2019

JulySeptember
2019

Measure

Applications

32

12

29

28

22

Received

Point of Contact

CMHCS

32

12

22

11

13

NHH

0

0

5

9

Other

0

0

1

0

Applications

7

5

14

14

11

Approved

Applications

0

0

DRAFT

0

1

0

Denied

Denial Reasons

NA

NA

NA

0

NA

Applications in

Process at end of

period

197

209

53

74

75

Terminations

0

0

1

0

0

Termination Reasons

NA

NA

1

NA

NA

Over Income

The CMHA stipulates that “…all new supported housing …will be scattered-site supported housing, with no more than two units or 10 percent of the units in a multi-unit building with 10 or more units, whichever is greater, and no more than two units in any building with fewer than 10 units known by the State to be occupied by individuals in the Target Population.” (V.E.1(b)). Table XI below displays the reported number of units leased at the same address.
20

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 21 of 88
DRAFT
21

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 22 of 88

Table XI

Self-Reported Housing Bridge Subsidy Concentration (Density)

June 2018

Sept. 2018

December 2018

March 2019

June 2019

Sept. 2019

Number of properties

with one leased SH unit

at the same address

354

339

329

315

300

282

Number of properties

with two SH units at the

same address

26

52

27

18

16

18

Number of properties

with three SH units at

the same address

10

24

4

3

4

1

Number of properties

with four SH units at the

DRAFT

same address

5

12

3

2

2

1

Number of properties

with five SH units at the

same address

0

0

1

2

1

1

Number of properties

with six SH units at the

same address

0

6

0

0

0

0

Number of properties

with seven + SH units at

same address

2

17

2

1

1

1

It should be noted that these data do not indicate whether any of the leased units are roommate situations, and if so, whether such arrangements meet the requirements of the CMHA (V.E.1(c)).

22

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 23 of 88

DHHS reports that there is currently only one voluntary roommate occurrence among the currently leased Bridge Subsidy Program units.10
As noted in the ER Reports dating back to 2016, DHHS was working on a method to crossmatch the Bridge Subsidy Program participant list with the Phoenix II and Medicaid claims data. Table XII summarizes the most recent iterations of these data.

Table XII Self-Reported Housing Bridge Subsidy Program Tenants Linked to Mental Health Services

As of 3/31/19 As of 6/30/19

As of 9/30/19

Housing Bridge Tenants Linked

337 of 400 (84.5%)

360 of 378 (95%)

339 of 373 (91%)

These data document the degree to which Bridge Subsidy Program participants are actually receiving certain mental health or other services and supports.11
The CMHA also states that: “By June 30, 2017 the State will make all reasonable efforts to apply for and obtain federal Department of Housing and Urban Development (HUD) funding for an additional 150 supported housing units for a total of 600 supported housing units.” (CMHA
DRAFT
V.E.3(e)) In 2015 New Hampshire applied for and was awarded funds to develop a total of 191 units of supported housing under the HUD Section 811 Program. All of these units will be set aside for people with serious mental illness. As of the date of this report, 72 (combined PRA and Mainstream) of these new units have been developed and are currently occupied by members of the Target Population. It should be noted that over the life of the Bridge Program the State has accessed 151 HUD Housing Choice Vouchers (HCVs) and one HUD public housing unit. Accessing these HCVs allows the State to free up Bridge Program slots for new applicants. The ER plans to work with the State and representatives of the Plaintiffs to assure documentation of progress towards the 600 specified units is attained and sustained.
In addition, the CMHA states that “By January 1, 2017, the State will identify and maintain a waitlist of all individuals within the Target Population requiring supported housing services, and whenever there are 25 individuals on the waitlist, each of whom has been on the waitlist for more than two months, the State will add program capacity on an ongoing basis sufficient to ensure that no individual waits longer than six months for supported housing.” As referenced above, there are currently reported to be 42 individuals on the wait list for the Bridge program; 33 of these individuals have been on the wait list for more than two months and 24 of them have been

10 DHHS reports that currently there is one voluntary roommate situation reflected in the above data. 11 Note: some of these tenants might be receiving services from MH providers other than a CMHC.
23

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 24 of 88
waiting longer than six months for supported housing, in violation of the terms of the CMHA. Based on the above data: (1) The State is reported to have 338 Bridge Program subsidies under lease, and an additional 72 HUD Section 811 units under lease, for a total of 410 supported housing units occupied: (2) there are currently only 35 individuals who have been approved for a Bridge subsidy and are actively seeking a unit; and (3) there are at least 33 people on the Bridge Program wait list who have been on the list for more than six months, and for whom no additional responsive housing capacity has been identified.
Therefore, the ER concludes that the State is not currently in compliance with the CMHA requirements related to SH.
The State has recently implemented a major change in the administration of the Housing Bridge Subsidy program. Previously, the program had been administered on a statewide basis by an independent contractor. Under the new model, each of the ten CMHCs will perform certain participant-level functions, such as housing search; lease-up and occupancy supports; landlord negotiations; arrangement of housing related services and supports, and eviction prevention. The CMHCs will also directly pay rent subsidies to landlords and will be reimbursed for these costs by the State. The State will manage intake and eligibility determination functions and will maintain a statewide waiting list.
These administrative changes could have a substantial impact on the overall effectiveness of the Housing Bridge Subsidy Program. However, it isDRAFT too early in the implementation process to assess the effects of these changes. The ER will continue to monitor the implementation process as well as monitoring data regarding lease-ups, the waiting list, and other related performance data. In addition, the ER will work with the State and the parties to ensure these 24 individuals are prioritized by their CMHC housing liaisons, and successfully transitioned to supported housing.
Transitions from Institutional to Community Settings
During the past 64 months, the ER has visited both Glencliff and NHH on at least nine separate occasions to meet with staff engaged in transition planning under the new policies and procedures adopted by both facilities in 201912. Transition planning activities related to specific current residents in both facilities have been observed, and a small non-random sample of resident transition records has been reviewed. Additional discussions have also been held with both line staff and senior clinicians/administrators regarding potential barriers to effective discharge to the most appropriate community settings for residents at both facilities.
The ER has participated in six meetings of the Central Team. The CMHA required the State to create a Central Team to overcome barriers to discharge from institutional settings to community
12 NHH updated its transition planning policies in 2018.
24

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 25 of 88

settings. The Central Team has now had about 52 months of operational experience. As of October 2019, 61 individuals have been submitted to the Central Team, 39 from Glencliff and 22 from NHH. Of these, the State reports that 28 individual cases have been resolved,13 two individuals are deceased, and 31 individual cases remain under consideration. Table XIII below summarizes the discharge barriers that have been identified by the Central Team with regard to these 31 individuals. Note that most individuals encounter multiple discharge barriers, resulting in a total higher than the number of individuals reviewed by the Central Team.

Table XIII

Self-Reported Discharge Barriers for Open Cases Referred from NHH and Glencliff to the Central Team:

October 2019

Discharge Barriers

Number for Glencliff

Number for NHH

Legal

6 (10.7%)

7 (10.1%)

Residential Financial

17 (30.4%)
DRAFT
7 (12.5%)

21 (30.4%) 8 (11.6%)

Clinical

15 (26.8%)

19 (27.5%)

Family/Guardian

10 (17.9%)

12 (17.4%)

Other

1 (1.8%)

2 (2.9%)

Glencliff
In the time period from April 2019 through September 2019, Glencliff reports that it has admitted five individuals, and has had two discharges and seven deaths. The average daily census through this period was 117 people. There have been no readmissions during this time frame. The wait list for admission has remained relatively constant at 23 to 25 people for the past six months.

13 Five of these individuals were readmitted to NHH after 90 days and five of these have returned to community settings as of this report.
25

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 26 of 88
CMHA Section VI requires the State to develop effective transition planning and a written transition plan for all residents of NHH and Glencliff (VI.A.1), and to implement them to enable these individuals to live in integrated community settings. In addition, Section V.E.3(i) of the CMHA also requires the State by June 30, 2017 to: “…have the capacity to serve in the community [a total of 16]14 individuals with mental illness and complex health care needs residing at Glencliff….” The CMHA defines these as: “individuals with mental illness and complex health care needs who could not be cost-effectively served in supported housing.”15
DHHS reports that a total of 17 people have transitioned from Glencliff to integrated settings since the inception of the CMHA five years ago. Based on data supplied by the State for the previous report, there are currently 26 individuals undergoing transition planning who could be transitioned to integrated community settings once appropriate living settings and community services become available. Nine of these individuals have been assigned to Choices for Independence (CFI) waiver case management agencies in order to access case management in the community to facilitate transition planning, and five are currently in the application process. Four individuals have been found eligible for the Acquired Brain Disorder (ABD) or Developmental Disability (DD) waivers, and two have been denied eligibility for these waivers. The remaining six individuals are reported to not meet criteria for referrals to one or more of the waivers.
DHHS continues to provide information about Glencliff transitions at the time of discharge, DRAFT
including clinical summaries, lengths of stay, location and type of community integrated setting, and array of individual services and supports arranged to support them in integrated community settings. This information is important to monitor the degree to which individuals with complex medical conditions that could not be cost-effectively served in SH continue to experience transitions to integrated community settings. To protect the confidentiality of individuals transitioned from Glencliff, this person-specific information is not included in the ER reports.
DHHS has initiated action steps to enhance the process of: (a) identifying Glencliff residents wishing to transition to integrated settings; and (b) increasing the capacity, variety and geographic accessibility of integrated community settings and services available to meet the needs of these individuals. Both sets of initiatives are intended to facilitate such community transitions for additional Glencliff residents. Despite these efforts, transitions to integrated community settings from Glencliff have stalled in the past 30 months.
The ER remains very concerned about the slow pace of transitions to integrated community settings by residents of the Glencliff Home. At this point, the ER does not have sufficient information to understand what factors contribute to the relative slowness of the transition planning process. There is not sufficient information currently available on efforts to engage
14 Cumulative from CMHA V.E.(g), (h), and (i). 15 CMHA V.E.2(a)
26

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 27 of 88
additional community-based providers, particularly for Glencliff residents with complex conditions. It is also necessary to obtain a better understanding of the blended financing mechanism to support integrated community settings for Glencliff residents with complex conditions. Finally, the State will soon be initiating a new capacity and process for community in-reach to Glencliff, and the ER will need to clarify performance expectations and data reporting related to results to be attained by this new in-reach function. Within the next three months, the ER recommends the parties confer regarding the status and implementation of these in-reach plans.
For all of these reasons, the ER plans to conduct a more intensive and focused review of Glencliff early this year. This review will entail:
1. A review of the clinical records (not just the transition plans) of the 27 individuals reported to be in the transition planning process;
2. Brief face-to-face interviews with individuals within the transition cohort willing to be interviewed;
3. Interviews with the Glencliff transition staff regarding the transition planning priorities and barriers for each of the individuals in the transition cohort;
4. With the assistance of Glencliff staff, identification of an additional cohort of individuals who could potentially transition from Glencliff to integrated community settings, but who have not yet indicated an interest in doing so (Minimum Data Set
DRAFT
[MDS] Section Q or other indication); 5. Record reviews and interviews with select individuals in this cohort; 6. Discussions with DHHS and Glencliff staff regarding the efforts to identify and
engage providers to serve people transitioning from Glencliff: this may entail interviews with certain community providers, Area Agencies, guardians, etc.; 7. Discussions with DHHS staff and providers about the specific details of the blended funding process for individuals transitioning from Glencliff, including discussion of reasons why providers have not been more enthusiastic about accessing this funding; and 8. Compilation of my findings in a report detailing barriers and solutions to increasing the number of individuals, including those with complex conditions, that transition from Glencliff into integrated community settings.
As noted in previous reports, the ER has been reluctant to focus narrowly on clinical conditions and sets of health, mental health and community services and supports for transitioned and transitioning individuals to monitor the State’s progress in assisting Glencliff Home residents to transition to integrated community settings. Despite this reluctance, the ER is concerned that the State is not yet in compliance with the CMHA requirements with regard to transitions to integrated community settings, including for residents with complex medical needs. This concern is exacerbated by the lack of transitions to integrated community placements over the
27

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 28 of 88
past two years. In addition, there has been no additional small-scale community residential capacity developed to serve Glencliff residents with complex medical conditions.
Given the lack of demonstrated progress in these areas, the ER will seek additional, periodic reporting on the status of the 26 individuals currenting engaged in transition planning at Glencliff, including any identified barriers to transition and action plans to resolve those barriers. Over the next three months, the ER also will more closely monitor efforts by DHHS, Glencliff, the CMHCs and other community partners to recruit, develop and fund the service capacity needed to transition interested residents in a timely way. .
Progress towards effectuating transitions to integrated community settings for current Glencliff residents has been very slow over the past 30 months. Unless additional efforts are brought to bear, the 26 individuals in active transition planning could remain at Glencliff indefinitely, and other residents will go without meaningful opportunities to explore potential community alternatives.
In addition to the above-described targeted analysis, the ER will continue to monitor the following topics/items to inform assessment of compliance:
1. Number of transitions from Glencliff to integrated community settings per quarter. The ER will also monitor information about the clinical and functional level of care needs of these individuals; the integrated settings toDRAFT which they transition, and the array of Medicaid and non-Medicaid mental health and health-related services and supports put in place to meet their needs to assure successful integrated community living.
2. Number of Glencliff residents newly identified per quarter to engage in transition planning and move towards integrated community settings. The ER will also monitor at a summary level the clinical and functional level of care needs of individuals added to the transition planning list per quarter.
3. New integrated community setting providers with the capacity to facilitate integrated community living for Glencliff residents. These could include EFCs, AFCs, and new small-scale community residential capacity for people with complex medical conditions who cannot be cost-effectively served in supported housing. The ER will monitor DHHS activities and successes relative to identification and engagement of community providers who express willingness and capacity to provide services in integrated community settings for people transitioning from Glencliff.
4. Within the discharge cohort, the number of transitioned individuals for whom the State special funding mechanism is utilized to effectuate the transition, and the ways in which these funds are used to fill gaps in existing services and supports.
5. Number and types of in-reach visits and communications by CMHCs and other community providers related to identifying and facilitating transitions of Glencliff residents to integrated community settings.
28

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 29 of 88

6. Specific documentation of efforts to overcome family and/or guardian resistance to integrated community transitions for Glencliff residents.
7. Number of individuals engaged in transition planning referred to the Central Team. number of these individuals who successfully transition to an integrated community setting; and the elapsed time from referral to resolution.

Preadmission Screening and Resident Review (PASRR)

The State DHHS has provided recent data on PASRR Level II screens for the period April 1, 2019 through September 30, 2019. These data are summarized in Table XIV below. A Level II screen is conducted if a PASRR Level I (initial) screen identifies the presence of mental illness, intellectual disability, or related conditions for which a nursing facility placement might not be appropriate. One objective of the Level II screening process is to seek alternatives to nursing facility care by diverting people to appropriate integrated community settings. Another objective is to identify the need for specialized facility-based services if individuals are deemed to need nursing facility level of care.

Table XIV

PASRR Level II Screens: April through September 2019

April
DRAFT
through
June 2019

Full Approval - No Special Services

23

Full Approval with Special Services

23

Provisional – No Special Services

15

Provisional with Special Services

19

Total

80

Percent
28.8% 28.8 18.8 23.8 100%

July through September
2019 22 27 14 8 71

Percent
31.0% 38.0% 19.7% 11.3% 100%

In the December 2018 ER report, 10.2% of the Level II screens were approved with a specification for special services. At that time, the ER questioned whether this was an unusually low rate for specification of special services. In a comparison with one other state, the ER found substantially higher approvals for special services than was evidenced in New Hampshire at that time. In the intervening period, the State and the PASRR contractor have been reviewing protocols for specification of special services in the Level II process. For this current report, the percentage of approvals with special services has increased to 49.3%.
In addition, the State has been reviewing the New Hampshire Medicaid Plan to see if revisions may be appropriate for the section(s) of that Plan identifying what special services may be covered by Medicaid for recipients for whom the Level II screen results in a specification for special services. The State reports that it has not yet completed this review. The ER expects that
29

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 30 of 88

the review and any changes to the Medicaid Plan with respect to special services will be completed no later than March 1, 2020.

For a variety of reasons, virtually all PASRR screens are conducted for people who are already in a nursing facility. For example, for July through September 2019, 99% of Level II screens were conducted in nursing facilities. A possible consequence of this is that prime opportunities for diversion to integrated community settings may have already been missed by the time the PASRR screen is conducted. In addition, individuals admitted to Glencliff must typically have been turned down by at least three other facilities before being considered for admission. In combination, these facts indicate that interventions to divert individuals from Glencliff or other nursing facilities must typically be used before the PASRR screening process is initiated. PASRR is important to assure that people with mental illness, ID/DD, or related conditions are not inappropriately institutionalized or placed in nursing facilities without access to necessary special services. However, PASRR is not by itself sufficient to divert people from nursing facility care. Up-stream interventions at NHH, the DRFs, and among the CMHCs are also essential to prevent unnecessary facility placement.

New Hampshire Hospital and the Designated Receiving Facilities (DRFs)

For the time period April through September 2019, DHHS reports that NHH effectuated 485

admissions and 481 discharges. The mean daily census was 157, and the median length of stay

for discharges was 16.3 days.

DRAFT

Table XV below compares NHH discharge destination information for the six most recent reporting periods (4/2017 through 9/2019). The numbers are expressed as percentages because the length of the reporting periods had not previously been consistent, although the type of discharge destination data reported has been consistent throughout.

30

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 31 of 88

Table XV

New Hampshire Hospital Self-Reported Data on

Discharge Destination

Percent Percent Percent Percent Percent Percent

Discharge Destination

April through
June 2017

July through Septem-
ber 2017

October 2017
through March 2018

April 2018 through Septem -ber 2018

Octobe r 2018 through March 2019

July through Septem-
ber 2019

Home – live alone or with others

85.66% 88.3%

81.0% 81.7% 73.26% 70.5%

Glencliff

0.35% 0.49% 1.0% 1.45% 1.6%

.4%

Homeless Shelter/motel
Group home 5+/DDS supported living, peer support housing etc.

3.5% 5.59%

2.94% 2.5%

3.92%

DRAFT
7.1%

3.13% 6.68% 4.64% 4.1% 4.01% 4.38%

Jail/corrections 1.05% 0.49%

2%

1.45% 2.94% 1.2%

Nursing home/rehab facility

3.50% 2.45% 2.7% 5.3% 4.55% 5.98%

The State now consistently reports information on the hospital-based DRFs and the Cypress Center in New Hampshire. It is important to capture the DRF/Cypress Center data and analyze it with NHH and Glencliff data to get a total institutional census across the state for the SMI population. Table XVI summarizes these data.

31

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 32 of 88

Table XVI

Self-Reported DRF/APRTP Utilization Data: January 2016 through

September 2019

Admissions Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019 April to June 2019 July to September 2019

Franklin Cypress Portsmouth Eliot

Eliot Total

Geriatric Pathways

69

257

79

205

37

207

60

228

NA** 178

59

209

52

240

69

244

67

201

87

198

126

182

108

187

104

194

46 378 375 363 363 358 330 333 357
375 349 371
DRAFT
391

65

121

558

49

92

803

54

114

787

52

101

804

60

121

722

55

102

783

66

100

788

65

104

815

54

112

791

64

72

796

56

123

836

89

108

865

52

95

836

Percent involuntary Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019 April to June 2019 July to September 2019

Franklin Cypress Portsmouth Eliot

Eliot Total

Geriatric Pathways

53.70% 55.70% 43.20% 58.30% NA** 49.20% 44.20% 46.73% 28.36%

18.70% 24.40% 29.50% 21.50% 25.60% 30.10% 28.30% 25.82% 24.38%

46.00% 45.20% 61.10% 43.30%

23.20% 18.10% 20.90% 16.50%

NA 20.40% 18.90% 22.00% 25.60% 23.70% 21.50% 24.62% 19.33%
22.40% 23.20% 19.40% 25.10%

18.50% 4.10% 13.00% 1.00% 11.50% 12.70% 6.10% 9.23% 12.96%

30.60% 48.90% 44.70% 47.50% 50.40% 50.00% 47.00% 51.92% 49.11%

NA 25.50% 26.20% 30.06%
NA 30.00% 27.00% 29.08% 25.16%

6.25% 12.50% 7.90% 11.50%

51.40% 47.20% 47.20% 55.80%

26.50% 28.20% 27.30% 28.00%

32

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 33 of 88

Average Census Jan - March 2016 April - June 2016 July - Sept 2016 April - June 2017 July - September 2017 Oct. - Dec 2017 Jan. - March 2018 April - June, 2018 July - September 2018 October - December 2018 January - March 2019 April to June 2019 July to September 2019

Franklin Cypress Portsmouth Eliot

Eliot Total

Geriatric Pathways

7.9

14.7

NA

7.8

13.2

21.4

4.5

13.6

23.2

4.5

12

30.3

NA** 12.9

29.7

10.1 12.3

27.7

6.7

11.6

32.5

9.1

11.9

31.7

11.8

8.4

39.6

19.7

18.1

NA

22.5

16.9

81.8

25.6

14.5

81.4

29.3

10

86.1

29.7

12.2

NA

32.6

16.1

19.7

34.6

NA

NA

31.7

20.4 104.8

33.8

18.2 111.8

10.7

9.2

27.4

33.4

10.7

91.4

8.5

14.5

30.4

22.6

14.9

90.9

8.4

11.5

29.7

27

12.1

88.7

9.4

12.2

31.7

24.1

12

89.4

Franklin Cypress Portsmouth Eliot

Eliot Total

Geriatric Pathways

Discharges

76

261

Jan - March 2016

78

206

April - June 2016

35

213

July - Sept 2016

59

232

April - June 2017

NA** 243

July - September 2017

82

212

Oct. - Dec 2017

53

248

Jan. - March 2018

74

244

April - June, 2018

66

195

October - December

2018

89

204

January - March 2019

124

177

April to June 2019

108

193

July to September 2019

101

192

DRAFT

NA

363

380

365

355

359

326

326

353

358 348 368 386

57

122

516*

51

90

788

64

113

805

54

105

815

63

121

NA

58

102

813

67

101

795

65

107

816

54

112

780

62

79

792

56

106

811

55

111

835

54

97

830

33

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 34 of 88

Franklin Cypress Portsmouth Eliot

Eliot Median

Geriatric Pathways

Median LOS for

Discharges

8.6

4.2

NA

Jan - March 2016

6

4

4

April - June 2016

7

5

4

July - Sept 2016

6

4

5

April - June 2017

NA

4

4

July - September 2017

4

4

5

Oct. - Dec 2017

5

4

5

Jan. - March 2018

5

4

5

April - June, 2018

4

4

4

October - December

2018

4

3

4

January - March 2019

5

5

6

April to June 2019

5

3

5

July to September 2019

6

4

6

15

7.4

8.8*

28

7

5

24

8

5

22

8

9

27

7

NA

21

7

5

23

7

5

20

8

5

21

7

5

31

7

5

18

8.5

6

18

7

5

26

8

6

* Does not include Portsmouth

DRAFT
The DRFs should theoretically relieve some of the pressure on NHH for inpatient admissions, and should also reduce the number of people waiting for psychiatric admissions in hospital EDs. At this time there has been no reduction in NHH admissions, but there has been an 18.6% reduction in NHH re-admissions. The wait list for NHH admissions of people staying in hospital EDs has been somewhat reduced, as shown in Charts A and B below.
DHHS has recently begun tracking discharge dispositions for people admitted to the DRFs and Cypress Center. Table XVII below provides a summary of these recently reported data.

34

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 35 of 88

Table XVII Self-Reported Discharge Dispositions for DRFs in New Hampshire
October 2018 through September 2019

Disposition Frank- Cy- Ports- Eliot

Eliot Total Per-

lin press mouth Geriatric Pathways

cent

Home

388 679 1,002

55

337

2,461 75.3%

NHH

1

0

19

0

8

28 .086%

Residential 5

23

1

133

7

169 5.1%

Facility/

Assisted

Living

Other

3

22

13

8

DRF16

8

54 65%

Hospital

0

0

0

0

0

0

Death

0

0

0

6

0

6 0.18%

Other or

25

42

425

25

33

550 16.8%

Unknown

Total

422

766 1,460

227

386

3,256

DRAFT

*The Other or Unknown disposition category for Portsmouth Regional is reported to include

shelters, rehab facilities, hotels/motels, friends/families, and unknown.

Based on these self-reported data, 75.3% of discharges from DRFs and the Cypress Center are to home. This is essentially the same as the 72.2% discharges to home reported by NHH. In addition:

 5.2% of the total DRF discharges are to residential care or assisted living, which is similar to NHH discharges for this category.
 0.86% of the DRF discharges are to NHH, slightly more than the percent discharged to NHH from previous reporting periods.
 16.8% of the total discharges are to the other/unknown category, but 77% of these are accounted for by the Portsmouth DRF.

Hospital Readmissions

DHHS is now reporting readmission rates for both NHH and the DRFs. Table XVIII below summarizes these data:

16 The State reports that these transfers reflect conversion from involuntary to voluntary status, not transfers among DRF facilities.
35

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 36 of 88
DRAFT
36

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 37 of 88

Table XVIII Self-Reported Readmission Rates for NHH and the DRFs
July 2017 through September 2019

NHH 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019

Percent 30 Days
9.80% 12.8% 13.7% 7.6% 8.6% 7.3% 5.3% 8.4% 10.5%

Percent 90 Days
21.60% 26.1% 22.7% 14.7% 19.6% 18.1% 14.8% 15.0% 18.6%

Percent 180 Days
27.90% 32.8% 29.9% 23.4% 25.4% 25.9% 21.2% 20.3% 23.3%

Franklin 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019

NA 10.2%
DRAFT
0.0% 4.3% 6.0% 2.3% 7.9% 6.5% 1.9%

NA 10.2% 0.0% 5.8% 9.0% 4.6% 10.3% 9.3% 6.7%

NA 10.2% 1.9% 5.8% 16.4% 5.7% 10.3% 12.0% 9.6%

Cypress 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019

7.10% 12.00% 4.20% 4.50% 8.50% 7.10% 5.50% 9.90% 6.60%

12.40% 18.70% 9.60% 8.20% 13.90% 11.10% 14.80% 15.10% 9.20%

15.90% 24.40% 15.80% 11.90% 18.90% 15.20% 17.60% 20.80% 12.80%

37

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 38 of 88

Portsmouth 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019
Elliot Pathways 7 to 9/2017 10 to 12/2107 1 to 3/2018 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019
Elliott Geriatric17 4/2018 to 6/2018 7/2018 to 9/2018 10/2018 to 12/2018 1/2019 to 3/2019 4/2109 to 6/2019 7/2019 to 9/2019

11.50% 8.70% 8.80% 10.20% 8.40% 7.70% 12.90% 10.50% 8.20%
3.30% 5.80%
NA 3.80% 7.00% 2.80% 4.90% 5.50%
DRAFT
2.10%
6.10% 5.60% 6.30% 5.40% 10.10% 7.70%

17.50% 13.70% 15.50% 15.90% 12.90% 14.90% 19.50% 17.80% 12.00%
6.60% 7.70%
NA 6.70% 11.50% 5.60% 5.70% 5.50% 5.20%
6.10% 11.10% 7.80% 5.40% 12.40% 9.60%

21.00% 17.60% 20.60% 21.90% 19.00% 20.30% 23.50% 22.40% 12.00%
12.40% 12.50%
NA 8.60% 16.10% 9.70% 7.30% 5.50% 6.30%
6.10% 11.10% 9.40% 5.40% 14.60% 13.50%

For the 27-month period in which re-admission rate data has been reported, the rates of readmission have trended down somewhat, which is a positive indicator overall. However, readmission rates, especially the 180-day readmission rate for NHH, remain high. At least 23% of all people discharged from NHH are back in the hospital within 180 days. These data, in concert with the hospital emergency room data presented below, indicate that gaps remain in community services for people with serious mental illness, and that the essential connection between inpatient care and community services is not being effectuated for sizeable numbers of

17 Note that data from July 2017 through March 2018 are not included in this table. The ER will work with the State to clarify these data, and the relevant information will be included in subsequent reports.
38

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 39 of 88 people at risk of re-hospitalization. These facts need to be understood in light of the States ongoing efforts to increase ACT capacity and enrollment as documented earlier in this report.
Hospital ED Waiting List In the previous three reports, the ER has identified the hospital ED boarding wait for admission to NHH to be an important indicator of overall system performance. Chart A below displays external data related to daily adult admissions delays to NHH bi-weekly for the period September 2017 through September 2019. Chart B shows the average daily ED waiting list by month for the same time period.
Chart A
DRAFT
39

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 40 of 88 Chart B
DRAFT
Although the number of people waiting in EDs for hospital admission has increased in recent months, the overall trend has been downward since September 2017. This appears to indicate that State interventions designed to reduce the number of individuals waiting for NHH
40

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 41 of 88 admissions, and the number of days spent waiting for admission to NHH, have begun to be effective. The ER notes that many of the interventions implemented by the State are outside the direct scope of the CMHA. However, ED boarding can affect the CMHA target population in a variety of ways. And, people awaiting NHH admission are potential participants in ACT, MCT, Crisis Apartments and other CMHA services. Thus, the ER intends to continue on reporting ED boarding in future reports.
DRAFT
41

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 42 of 88
Family and Peer Supports
Family Supports
Per the CMHA, the State has maintained its contract with NAMI New Hampshire for family support services. The ER will arrange for additional NAMI meetings during the next six months.
Peer Support Agencies
DHHS continues to report having a total of 15 peer support agency program (PSA) sites, with at least one program site in each of the ten regions. The State continues to report that all peer support centers meet the CMHA requirement to be open 44 hours per week. As of September, 2019, the State reports that those sites have a cumulative total of 1,403 members, with an active daily participation rate of 170 people statewide. This represents a three-year high in active daily participation: 23% higher than in March 2017. The State reports that all of the PSAs have been working to increase their membership and daily participation rates.
The CMHA requires the PSAs to be “effective” in helping individuals in managing and coping with the symptoms of their illness, self-advocacy, and identifying and using natural supports. As noted in previous reports, enhanced efforts to increase active daily participation appear to be warranted for the peer support agency programs. There continue to be anecdotal reports that some of the CMHCs are making more concerted efforts to refer service participants to the PSAs
DRAFT
in their regions. Increased efforts to communicate and coordinate with PSAs have also been reported.
In addition, the ER has received anecdotal information that in some regions of the state, relationships and communications among the CMHCs and the PSAs have improved. PSAs are generally reported by CMHCs to be useful sources of employees for ACT and Mobile Crisis and Crisis Apartment services.
Finally, CMHC officials have verbally stated that the peer-operated crisis beds available in several regions are a useful intervention for some CMHC clients at risk of hospitalization.
IV. Quality Assurance Systems
The State has made substantial positive progress implementing a comprehensive, reliable and actionable QSR process. Within the past six months the ER has participated in two QSR site visits, and is increasingly confident that: (a) the revised instruments and site interview protocols are working well; and (b) the results and findings of the revised QSR instruments and process reflect, to a large degree, the quality standards of the CMHA.
42

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 43 of 88

DHHS has now completed the QSR process using the revised instruments and protocols at least two times for each of the ten CMHCs. Table XIX below summarizes the quality indicator scores for each domain of the QSR.

Table XIX

QSR Total Indicator Scores: All CMHCs

Indicator Number

Indicator Content

SFY 2018 Average (10 CMHCs)

SFY 2019 Average (10 CMHCs)

1

Adequacy of Assessment

2

Approp. Tx Planning

3

Adequacy of Ind. Serv. Del.

4

Adequacy of Hsg. Assess.

5

Approp. Of Hsg. Tx Planning

6

Adequacy of HSG. Serv. Del.

7

Effect. Of Hsg. Supports Del.

8

Adequacy of Emp. Assessment

9

Approp. Of Emp. Tx Planning

10

Adequacy of Emp. Serv. Del.

11

Adequacy of Ass. Of Int. Needs DRAFT

12

Integration in Community

13

Adequacy of Crisis Assess.

14

Appropriateness of Crisis Plns.

15

Comp. and Effec. Crisis Del. Syst.

16

Adequacy of ACT screening

17

Imp. of ACT Servs.

18

Succ. Trans./Dich. From inpat.

80.5% 89.8% 82.4% 99.5% 90.3% 85.2% 76.3% 58.0% 70.2% 58.0% 94.3% 79.4% 68.9% 80.6% 72.9% 90.5% 54.2% 78.0%

87.4% 89.3% 83.5% 100.0% 86.5% 89.0% 84.6% 63.8% 70.8% 80.0% 100.0% 81.1% 78.0% 93.0% 72.5% 98.5% 65.1% 79.7%

As demonstrated in the table, the CMHC system as a whole scores below the 75% performance threshold on four indicators. In two domains, adequacy of crisis assessments and adequacy of employment services delivery, the system has moved from below to above the 75% threshold. Implementation of ACT services and employment assessments and treatment plans continue to be below the 75% threshold. As noted earlier in this report, DHHS requires CMHCs with a score below the performance threshold to develop a QIP, which is then monitored on at least a quarterly basis by DHHS staff. Improvements accomplished as a result of the QIPs should be evidenced in subsequent QSR reports.
DHHS is committed to using the QSR process to continuously improve the quality and effectiveness of CMHA services as the community mental health system matures. For this reason, the performance threshold for QSR scoring has been raised to 80% for the up-coming SFY 2020 cycle of QSR reviews. The ER applauds this change, since it moves closer to
43

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 44 of 88
requiring a level of system and provider performance that the ER considers to be substantial compliance with the CMHA (assuming that other CMHA metrics are attained).
As a companion to the QSR process, DHHS has been conducting on-site ACT and SE fidelity reviews. DHHS has engaged the Dartmouth/Hitchcock Center on Evidence-Based Practices to do the reviews and to help assist the CMHCs in attaining and assuring fidelity to the evidencebased models of ACT and SE. The Dartmouth/Hitchcock team is also assisting on workforce development and training for these and other evidence-based practices under the aegis of DHHS and the CMHCs. This partnership with the nationally respected Dartmouth/Hitchcock Center adds valuable expertise and experienced personnel to facilitate further development of, and increased adherence to, fidelity model ACT and SE in conformance with the CMHA. Year-toyear comparisons and the CMHCs QIPs have been included in the publication of recent ACT and SE fidelity reviews. The ER commends DHHS for implementing the comprehensive fidelity review process and its attendant quality improvement and technical assistance activities.
Effective and valid fidelity reviews and consequent training and workforce development activities are essential to DHHS’ overall quality management efforts for the community mental health system. As noted in the previous three ER reports, the QSR and the fidelity reviews mutually support but do not supplant or replace each other. The QSR, in particular, examines outcomes from a consumer-centric perspective as opposed to an operational or organizational perspective. It is uniquely positioned to assess the quality, appropriateness, and effectiveness of
DRAFT
specific ACT and SE services at the individual participant level. The ER continues to believe that implementation of fidelity-based models of service delivery does not necessarily mean that specific service interventions are working well or being delivered with the frequency or intensity required by a participant’s individual treatment plan. The revised QSR instruments and protocols address many of these concerns. In combination, the fidelity reviews and the QSR can mutually support conclusions about the overall quality and effectiveness of the mental health system consistent with the CMHA.
The ER will continue to monitor the degree to which the QSR process produces reliable information on individual outcomes and the quality of CMHA service delivery – both at the statewide and CMHC level. In addition, over the next six months, the ER will evaluate the extent to which CMHC QIPs developed as part of the 2018-2019 QSR site visits are resulting in recommended practice changes and improved outcomes for those in the Target Population.
I. Summary of Expert Reviewer Observations and Priorities
The ER has emphasized in this report that the State continues to be far from compliant with CMHA requirements for ACT. There is continued failure to meet the QSR quality threshold for implementation of high fidelity ACT services. For the last three and one half years the ER
44

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 45 of 88
has reported that the State is out of compliance with the ACT requirements of Sections V.D.3, which together require that the State provide ACT services that conform to CMHA requirements and have the capacity to serve at least 1,500 people in the Target Population at any given time.
Other areas of non-compliance identified in this report include:
1. Continued failure to meet the QSR quality threshold for indicators related to employment assessments and employment treatment planning. In addition, four regions of the state continue to have SE penetration rates below the statewide target of 18.6%;
2. Failure to supply the CMHA-required level of 600 supported housing units, and having approved applicants remain on the wait list for excessive periods of time; and
3. Failure to transition residents of Glencliff into integrated settings in accordance with the CMHA.
The ER has also identified the MCT/Crisis Apartment programs as an area of concern, albeit not currently in non-compliance with the CMHA. The State will be re-procuring the three MCT/Crisis Apartment programs this fiscal year, and the ER is concerned about both program stability and model fidelity.
DRAFT
More than five years ago, all parties to the CMHA envisioned implementation of a number of remedial services and system interventions designed to assure positive outcomes for the defined Target Population. Most important among these outcomes was assurance of maximum community integration supported by housing and evidence based and high quality services meeting individual needs and choices. At the same time, the CMHA envisioned reduction of hospital and institutional contact and increased access to integrated community services for individuals residing in such facilities. The signatories to the CMHA envisioned high quality of life and improved personal outcomes for adult citizens of New Hampshire with serious mental illness.
As noted above, the State remains out of compliance with the CMHA in several critical areas. The State will not be able to disengage from the CMHA until these requirements are met. The ER expects that the State will demonstrate substantial progress toward meeting all CMHA requirements by June 30, 2020.
In furtherance of this goal, the ER recommends the following actions take place between now and April 30, 2020:
1) The parties will convene to discuss the results of the ER’s Glencliff review and report findings/recommendations.
45

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 46 of 88 2) The State will share information related to the design and implementation of the new in-
reach position at Glencliff. 3) The State will provide written updates on the 24 individuals who have been waiting more
than six months for supported housing. 4) The State will provide a written update on implementation of specific ACT strategies
identified in the working group memo. 5) The parties will collectively review responses to the RFP and RFI and discuss how this
information impacts current and future crisis program oversight and operations. 6) An All Parties meeting will be held to discuss progress and strategies related to
disengagement from the CMHA.
DRAFT
46

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 47 of 88
Appendix A New Hampshire Community Mental Health Agreement
State’s Quarterly DRAFT Data Report July to September 2019
47

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 48 of 88

New Hampshire Community Mental Health Agreement Quarterly Data Report

DRAFT

July - September 2019

New Hampshire Department of Health and Human Services Office of Quality Assurance and Improvement December 5, 2019
48

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 49 of 88
DRAFT
The Department of Health and Human Services’ Mission is to join communities and families in providing opportunities for citizens to achieve health and independence
49

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 50 of 88 July – September 2019
Community Mental Health Agreement Quarterly Report
New Hampshire Department of Health and Human Services
Publication Date: December 5, 2019
Reporting Period: 7/1/2019 – 9/30/2019
Notes for Quarter
Table 1b, “Community Mental Health Center Services: Assertive Community Treatment Screening and Resultant New ACT Clients,” has been modified to report results exclusively for those individuals not already on ACT at the time of screening. Table 1e, “Community Mental Health Center Services: Assertive Community Treatment – New Hampshire Hospital Admission and Discharge Data Relative to ACT,“ and Table 1f, “Community Mental Health Center Services: Assertive Community Treatment – Reasons Not Accepted to ACT at New Hampshire Hospital Discharge Referral,” are new tables added to the report.
Table 8d, “Housing Bridge Subsidy Program: Applications,” has had the final field descriptor changed to improve understanding.
DRAFT

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

1

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 51 of 88 July – September 2019

1a. Community Mental Health Center Services: Unique Count of Adult Assertive Community Treatment Clients

Community Mental Health Center

July 2019

Septemb

August

er

2019

2019

Unique Clients in
Quarter

Unique Clients in
Prior Quarter

01 Northern Human Services

122

118

122

133

127

02 West Central Behavioral Health

49

47

47

54

52

03 Lakes Region Mental Health Center

56

57

56

58

61

04 Riverbend Community Mental Health Center

89

89

86

100

110

05 Monadnock Family Services

54

50

49

54

58

06 Greater Nashua Mental Health

86

90

97

104

88

07 Mental Health Center of Greater Manchester
08 Seacoast Mental Health Center

291

292

300

322

312

DRAFT

66

66

68

71

73

09 Community Partners

71

72

71

81

75

10 Center for Life Management

48

49

49

49

54

Total Unique Clients

932

928

942

1,022

1,007

Unique Clients Receiving ACT Services 10/1/2018 to 9/30/2019: 1,339

Revisions to Prior Period: None.

Data Source: NH Phoenix 2.

Notes: Data extracted 11/6/2019; clients are counted only one time regardless of how many services they receive.

1b. Community Mental Health Center Services: Assertive Community Treatment Screening and Resultant New ACT Clients

Community Mental Health Center

April – June 2019

January - March 2019

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

2

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 52 of 88 July – September 2019

Retrospective Analysis

Retrospective Analysis

Unique Clients Screened: Individuals Not Already on ACT* Appropriate for Further ACT Assessment: Individuals Not Already oNnewACClTients receiving ACT Services within 90 days of Screening Unique Clients Screened: Individuals Not Already on ACT* Appropriate for Further ACT Assessment: Individuals Not Already oNnewACClTients receiving ACT Services within 90 days of Screening

01 Northern Human Services

1,158

37

3

1,133

44

8

02 West Central Behavioral Health

287

5

4

269

4

2

03 Lakes Region Mental Health Center

823

9

0

809

9

1

04 Riverbend Community Mental

1,272

1

0

1,296

0

0

Health Center

05 Monadnock Family Services

535

4

0

651

9

0

DRAFT

06 Greater Nashua Mental Health

633

9

4

635

3

0

07 Mental Health Center of Greater Manchester

1,571

3

0

1,472

21

0

08 Seacoast Mental Health Center

1,286

16

0

1,451

6

0

09 Community Partners

401

1

1

403

1

1

10 Center for Life Management

756

3

1

751

0

0

Total ACT Screening

8,722

88

13

8,870

97

12

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

3

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 53 of 88 July – September 2019

Revisions to Prior Period: The field and data for “Unique Clients Screened: Individuals Not Already on ACT” was not included in the prior period. Instead, the “Unique Clients Screened” field and data was reported and included individuals on ACT who were re-screened during the period.

Data Source: NH Phoenix 2 and CMHC self-reported ACT screening records. ACT screenings submitted through Phoenix capture ACT screenings provided to clients found eligible for state mental health services. Phoenix does not capture data for non-eligible clients; three CMHCs submit this data through Phoenix. Seven CMHCs self-report. All such screenings, excluding individuals who are already on ACT, are contained in this table.

Notes: Data extracted 10/30/2019. “Unique Clients Screened: Individuals Not Already on ACT” is defined as individuals who were not already on ACT at the time of screening that had a documented ACT screening during the identified reporting period. “Screening Deemed Appropriate for Further ACT Assessment: Individuals Not Already on ACT” is defined as screened individuals not already on ACT that resulted in referral for an ACT assessment. “New Clients Receiving ACT Services within 90 days of ACT Screening” is defined as individuals who were not already on ACT that received an ACT screening in the preceding quarter and then began receiving ACT services.

1c. Community Mental Health Center Services: New Assertive Community Treatment Clients

July - September 2019
DRAFT

April - June 2019

July 2019 New ACT CAliuegnutsst 2019 New ACT SCleipetnetsmber 2019 New ACT Clients Total New ACT Clients April 2019 New ACT ClMiaeynt2s019 New ACT JCluineent2s019 New ACT Clients Total New ACT Clients

Community Mental Health Center

01 Northern Human Services

6 2 6 14 5

2 4

11

02 West Central Behavioral Health

6 1 3 10 5

5 4

14

03 Lakes Region Mental Health Center

2 1 0

34 32

9

04 Riverbend Community Mental Health Center 1 1 3

55 46

15

05 Monadnock Family Services

1 0 0

10 01

1

06 Greater Nashua Mental Health

3 8 10 21 2

7 5

14

07 Mental Health Center of Greater Manchester

14 11 12 37 6

6 2

14

08 Seacoast Mental Health Center

1 1 3

50 12

3

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

4

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 54 of 88 July – September 2019

09 Community Partners

3 7 3 13 3 3 3

9

10 Center for Life Management

3 1 0

41 00

1

Total New ACT Clients

40 33 40 113 31 31 29

91

Revisions to Prior Period: None.
Data Source: NH Phoenix 2.
Notes: Data extracted 10/22/2019; New ACT Clients are defined as individuals who were not already on ACT within 90days prior who then began receiving ACT services. This information is not limited to the individuals that received an ACT screening within the previous 90-day period, and may include individuals transitioning from a higher or lower level of care into ACT.

DRAFT

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

5

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 55 of 88 July – September 2019

1d. Community Mental Health Center Services: Assertive Community Treatment Waiting List As of 9/30/2019

Time on List

Total

0-30 days

31-60 days

61-90 days 91-120 days

121-150 days

151-180 days

2

2

0

0

0

0

0

As of 6/30/2019

Total

0-30 days

31-60 days

61-90 days 91-120 days

121-150 days

151-180 days

1

1

0

0

0

0

0

Revisions to Prior Period: None.

Data Source: BMHS Report.

Notes: Data compiled 10/28/2019.
DRAFT

1e. Community Mental Health Center Services: Assertive Community Treatment – New Hampshire Hospital Admission and Discharge Data Relative to ACT

July – September 2019

April – June 2019

On ACT a t Admissi o n d for ACT on Dischar gdeto ACT at Dischar gOen ACT a t Admissi o n d for ACT on Dischar gdeto ACT at Dischar g e

Community Mental Health Center

Yes No Yes No Yes No Yes No Yes No Yes No

01 Northern Human Services

6 7 3 4 3 0 3 13 4 9 2 2

02 West Central Behavioral Health

3 3 21 20 36 2 4 1 1

03 Lakes Region Mental Health Center

2 4 04 00 57 4 3 1 3

04 Riverbend Community Mental Health Center

10 17

6 11

2 4 13 20

9 11

7 2

05 Monadnock Family Services

55 23 11 59 1 8 0 1

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

6

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 56 of 88 July – September 2019

06 Greater Nashua Mental Health
07 Mental Health Center of Greater Manchester

3 18 6 12 4 2 3 11 5 6 4 1 8 11 8 3 7 1 12 14 6 8 5 1

08 Seacoast Mental Health Center

33 12 10 28 1 7 1 0

09 Community Partners

5 12 2 10 2 0 5 8 3 5 3 0

10 Center for Life Management

23 21 11 22 1 1 1 0

Total

47 83 32 51 23 9 53 98 36 62 25 11

Revisions to Prior Period: None; this table is new and was not in the prior report. Data Source: New Hampshire Hospital. Notes: Data compiled 11/22/2019.

DRAFT

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

7

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 57 of 88 July – September 2019

1f. Community Mental Health Center Services: Assertive Community Treatment – Reasons Not Accepted to ACT at New Hampshire Hospital Discharge Referral

Reason Not Accepted at Discharge

July - September 2019

April - March 2019

Not Available in Individual’s Town of Residence

0

0

Individual Refused

0

1

Individual’s Insurance Does Not Cover ACT Services

0

0

Individual’s Clinical Need Does Not Meet ACT

3

2

Criteria

Individual Placed on ACT Waitlist

0

1

Individual Awaiting CMHC Determination for ACT

6

7

Total Unique Clients

9
DRAFT

11

Revisions to Prior Period: None; this table is new and was not in the prior report.

Data Source: New Hampshire Hospital.

Notes: Data compiled 11/22/2019.

2a. Community Mental Health Center Services: Assertive Community Treatment Staffing Full Time Equivalents

September 2019

June 2019

Nurse Clinician/or Equivalent Support Worke r Peer Specialist (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner (Excluding Psychiatry) Psychiatrist/Nu rse Practitioner

Community Mental Health Center 01 Northern Human Services 02 West Central Behavioral Health

2.29 2.10 11.3 0.68 16.37 1.2 16.51 1.15

0

0

0.60 1.75 5.40 0.50 8.25 0.4 7.65 0.43 9

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

8

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 58 of 88 July – September 2019

03 Lakes Region Mental Health Center

1.00 2.00 4.00 1.00 8.00 0.7 8.00 0.75 5

04 Riverbend Community Mental Health Center

0.50 2.00 8.00 1.00 11.50 0.5 10.50 0.50 0

05 Monadnock Family Services

1.25 2.25 3.50 1.00 8.00 0.6 9.00 0.65 5

06 Greater Nashua Mental Health 1

0.50 1.00 5.50 1.00 8.00 0.2 7.00 0.25 5

06 Greater Nashua Mental Health 2

0.50 1.00 4.50 1.00 7.00 0.2 4.00 0.25 5

07 Mental Health Center of Greater Manchester-CTT

1.00 10.00 3.75 1.00 15.75 0.7 15.75 0.72 3

07 Mental Health Center of Greater Manchester-MCST

1.00 8.00 7.25 1.00 17.25 0.7 17.25 0.72 3

08 Seacoast Mental Health Center 09 Community Partners

1.00 2.10 6.00 1.00 10.10 0.6 0
DRAFT

9.10 0.60

0.50 3.15 7.13 0.50 11.28 0.6 10.78 0.63 3

10 Center for Life Management

1.00 2.00 4.30 1.00 8.30 0.4 7.01 0.40 0

Total

11.14 37.35 70.63 10.68 129.80 7.18 122.55 7.04

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

9

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 59 of 88 July – September 2019

2b. Community Mental Health Center Services: Assertive Community Treatment Staffing Competencies

Substance Use Disorder Treatment

Housing Assistance

Supported Employment

Community Mental Health Center

June

June

June

Septemb

Septemb

Septemb

er 2019 2019 er 2019 2019 er 2019 2019

01 Northern Human Services

4.75 3.75 10.95 11.95

2.35 2.35

02 West Central Behavioral Health

0.40 0.40

6.00 5.00

1.40 0.20

03 Lakes Region Mental Health Center

2.00 2.75

7.00 4.00

3.00 3.00

04 Riverbend Community Mental Health Center

1.50 1.50

9.50 9.50

0.50 0.50

05 Monadnock Family Services

1.40 2.40

2.00 3.00

1.00 1.00

06 Greater Nashua Mental Health 1

5.25 3.25

6.25 6.00

1.50 1.00

06 Greater Nashua Mental Health 2

5.25 DRAFT

3.00

5.00 3.00

0.50 0.00

07 Mental Health Center of Greater Manchester-CCT

11.73 11.72 11.75 11.75

1.50 1.00

07 Mental Health Center of Greater Manchester-MCST

4.73 4.72 12.75 12.75

2.00 1.50

08 Seacoast Mental Health Center

2.00 2.00

6.00 5.00

2.00 1.00

09 Community Partners

2.63 2.00

6.10 3.00

1.25 1.25

10 Center for Life Management

3.00 2.00

7.00 5.71

0.30 0.30

Total

44.64 39.49

90.30 80.66

17.30 13.10

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health CMHC ACT Staffing Census Based on CMHC self-report.

Notes: Data compiled 10/17/2019; for 2b: the Staff Competency values reflect the sum of FTEs trained to provide each service type. These numbers are not a reflection of the services delivered, but rather the quantity

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

10

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 60 of 88 July – September 2019
of staff available to provide each service. If staff are trained to provide multiple service types, their entire FTE value is credited to each service type.
DRAFT

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

11

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 61 of 88 July – September 2019

3a. Community Mental Health Center Services: Annual Adult Supported Employment Penetration Rates for Prior 12-Month Period

Community Mental Health Center

12 Month Period Ending September 2019

Supported Employment
Clients

Total Eligible Penetration

Clients

Rate

Penetration Rate for Period Ending
June 2019

01 Northern Human Services

208

1,318

15.8%

14.9%

02 West Central Behavioral Health

123

625

19.7%

22.5%

03 Lakes Region Mental Health Center

253

1,339

18.9%

18.9%

04 Riverbend Community Mental Health Center

333

1,806

18.4%

19.0%

05 Monadnock Family Services

65

1,042

6.2%

6.8%

06 Greater Nashua Mental Health

250

1,967

12.7%

13.1%

07 Mental Health Center of Greater Manchester

1,361 DRAFT

3,462

39.3%

39.0%

08 Seacoast Mental Health Center

611

1,859

32.9%

33.7%

09 Community Partners

57

731

7.8%

8.6%

10 Center for Life Management

211

1,052

20.1%

20.8%

Total Unique Clients

3,465

14,967

23.2%

23.5%

Revisions to Prior Period: None.

Data Source: NH Phoenix 2.

Notes: Data extracted 10/22/2019.

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

12

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 62 of 88 July – September 2019

3b. Community Mental Health Center Clients: Adult Employment Status – Total
Reported Employment Status

Northern Human Services West Central Behavioral Health Lakes Region Mental Health Center Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Mental Health Center of Greater Manchester Seacoast Mental Health Cente r Community Partners Center for Life Management Statewide Total or Mean Percentage Previous Quarter Statewide Total or Mean Percentage April-June 2019

Begin Date: 07/01/2019 End Date: 09/30/2019

Employment Status

Update

Overdue Threshold:

105 days

Updated Employment Status:

Full time employed

67 34 32 97 45 118 250 186 35 66 930

now or in past 90 days Part time employed 161

54 154 301 138 230 386 222 69 149 1,864

now or in past 90 days

Unemployed

185

Not in the Workforce 512

Status is not known

9

Total of Eligible Adult 934

CMHC Clients

104 50 94 162 535 924
62 125 52 416 896 1,468

135 773 930 82 141 486 2,980 449 262 556 765 274 107 4,546
10 93 11 3 15 41 421 777 1,476 2,133 1,258 534 849 10,74
1

Previous Quarter:

939 399 897 1,475 593 1,422 DRAFT 2,111 1,249 542 853

Total of Eligible Adult

CMHC Clients

Percentage by Updated Employment Status:

Full time employed 7.2% 8.2% 3.6% 6.6% 5.8% 8.0% 11.7% 14.8% 6.6% 7.8% 8.7%

now or in past 90 days

Part time employed

17.2 13.0% 17.2 20.5% 17.8% 15.6 18.1% 17.6% 12.9 17.6 17.4

%

%

%

%% %

now or in past 90 days

Unemployed

19.8 25.0% 5.6% 6.4% 17.4% 52.4 43.6% 6.5% 26.4 57.2 27.7

%

%

%% %

Not in the Workforce

54.8 38.9% 59.7 62.9% 57.8% 17.8 26.1% 60.8% 51.3 12.6

%

%

%

% %

42.3 %

Status is not known

1.0% 14.9% 14.0 3.5% 1.3% 6.3% 0.5% 0.2% 2.8% 4.8% 3.9% %

Percentage by Timeliness of Employment Status Screening:

Update is Current

55.2 39.4% 74.1 78.9% 46.1% 96.5 91.4% 94.0% 70.0 99.9 80.4

%

%

%

%% %

Update is Overdue

44.8 60.6% 25.9 21.1% 53.9% 3.5% 8.6% 6.0% 30.0 0.1% 19.6

%

%

%

%

Previous Quarter: Percentage by Timeliness of Employment Status Screening:

Update is Current Update is Overdue

51.4 43.9% 78.5 87.7% 32.7% 95.7 93.8% 94.6% 77.1 100

%

%

%

% %

48.6 56.1% 21.5 12.3% 67.3% 4.3% 6.2% 5.4% 22.9 0.0%

%

%

%

892 1,829 2,942 4,413
404 10,480
8.5% 17.5% 28.1% 42.1%
3.9%
82.5% 17.5%

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

13

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 63 of 88 July – September 2019

3c. Community Mental Health Center Clients: Adult Employment Status – Recent Users of Supportive Employment Services (At Least One Billable Service in Each of Month of the Quarter)

Northern Human Services West Central Behavioral Health Lakes Region Mental Health Center Riverbend Community Mental Health Monadnock Family Services Greater Nashua Mental Health Mental Health Center of Greater Manchester Seacoast Mental Health Center Community Partners Center for Life Management Statewide Total or Mean Percentage Previous Quarter Statewide Total or Mean Percentage January-March 2019

Supported Employment Cohort

Reported Employment Status

Begin Date: 07/01/2019 End Date: 09/30/2019

Updated Employment Status:

Full time

1 2 1 2

employed now

or in past 90

days

Part time

13 0 14 28

employed now

or in past 90

days

Unemployed

9 3 4 16

Not in the

13 2 15 4

Workforce

Status is not

0 0 9 0

known

Total of

36 7 43 50

Supported

Employment

Cohort

Previous

40 12 47 47

Quarter: Total

of Supported

Employment

Cohort

Percentage by Updated Employment Status:

Full time

2.8% 28.6% 2.3% 4.0%

employed now

or in past 90

0 6

DRAFT
6

15

5 18 4 10
0 5
15 54

18 55

0.0% 11.1%

6
43
31 4 0
84
87
7.1%

1
7
4 10
0 22
28
4.5%

1
6
3 3 0 13
18
7.7%

1
20
6 1 0 28
37
3.6%

21 152
99 66 14 352
6.0%

21 163 106
81 18 389
5.4%

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

14

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 64 of 88 July – September 2019

days

Part time

36.1% 0.0% 32.6% 56.0% 40.0% 27.8% 51.2% 31.8% 46.2% 71.4% 43.2% 41.9%

employed now

or in past 90

days

Unemployed 25.0% 42.9% 9.3% 32.0% 33.3% 33.3% 36.9% 18.2% 23.1% 21.4% 28.1% 27.2%

Not in the

36.1% 28.6% 34.9% 8.0% 26.7% 18.5% 4.8% 45.5% 23.1% 3.6% 18.8% 20.8%

Workforce

Status is not

0.0% 0.0% 20.9% 0.0% 0.0% 9.3% 0.0% 0.0% 0.0% 0.0% 4.0% 4.6%

known

Revisions to Prior Period: None.

Data Source: Phoenix 2.

Note 3b-c: Data extracted 10/22/2019. Updated Employment Status refers to CMHC-reported status and reflects the most recent update. Update is Current refers to employment status most recently updated within the past 105 days. Update is Overdue refers to employment status most recently updated in excess of 105 days. Actual client employment status may have changed since last updated by CMHC in Phoenix. Employed refers to clients employed in a competitive job that has these characteristics: exists in the open labor market, pays at least a minimum wage, anyone could have this job regardless of disability status, job is not set aside for people with disabilities, and wages (including benefits) are not less than for the same work performed by people who
DRAFT
do not have a mental illness. Full time employment is 20 hours and above; part time is anything 19 hours and below. Unemployed refers to clients not employed but are seeking or interested in employment. Not in the Workforce are clients who are homemakers, students, retired, disabled, hospital patients or residents of other institutions, and includes clients who are in a sheltered/non-competitive employment workshop, are otherwise not in the labor force, and those not employed and not seeking or interested in employment. Unknown refers to clients with an employment status of “unknown,” without a status reported, or with an erroneous status code in Phoenix.

NH DHHS - OQAI - CMHA Quarterly Report, December 5, 2019

15

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 65 of 88

4a. New Hampshire Hospital: Adult Census Summary

Measure

July -September 2019

April - June 2019

Admissions

258

227

Mean Daily Census

158

155

Discharges

251

230

Median Length of Stay in Days for Discharges

14.0

18.5

Deaths

0

0

Revisions to Prior Period: None.

Data Source: Avatar.

Notes 4a: 11/5/2019; Mean Daily Census includes patients on leave and is rounded to nearest whole number.

DRAFT

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 66 of 88

4b. New Hampshire Hospital: Summary Discharge Location for Adults

Discharge Location

July – September 2019

CMHC Group Home

7

Discharge/Transfer to IP Rehab Facility

10

Glencliff Home for the Elderly

1

Home - Lives Alone

64

Home - Lives with Others

113

Homeless Shelter/ No Permanent Home

6

Hotel-Motel

5

Jail or Correctional Facility

3

Nursing Home

5

Other

8

Peer Support Housing

DRAFT

1

Private Group Home

3

Secure Psychiatric Unit - SPU

0

Unknown

25

April - June 2019 5 7 4
69 114
8 1 1 2 7 0 1 0 8

4c. New Hampshire Hospital: Summary Readmission Rates for Adults

Measure

July – September 2019

April - June 2019

30 Days

10.5% (27)

8.4% (19)

90 Days

18.6% (48)

15.0% (34)

180 Days

23.3% (60)

20.3% (46)

Revisions to Prior Period: None.

Data Source: Avatar.

Notes 4b-c: Data compiled 11/5/2019; readmission rates calculated by looking back in time from admissions in study quarter. 90 and 180 day readmissions lookback period includes

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 67 of 88 readmissions from the shorter period (e.g., 180 day includes the 90 and 30 day readmissions); patients are counted multiple times – once for each readmission; the number in parentheses is the number of readmissions.
DRAFT

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 68 of 88

5a. Designated Receiving Facilities: Admissions for Adults July - September 2019

Designated Receiving Facility

Involuntary Admissions

Voluntary Admissions

Franklin

45

59

Cypress Center

32

162

Portsmouth

98

293

Elliot Geriatric Psychiatric Unit

6

46

Elliot Pathways

53

42

Total

234

602

April - June 2019

Designated Receiving Facility Franklin

Involuntary Admissions
DRAFT
66

Voluntary Admissions
42

Cypress Center

39

148

Portsmouth

72

299

Elliot Geriatric Psychiatric Unit

7

82

Elliot Pathways

51

57

Total

236

629

Total Admissions
104 194 391
52 95 836
Total Admissions
108 187 371
89 108 865

5b. Designated Receiving Facilities: Mean Daily Census for Adults

Designated Receiving Facility

July - September 2019

Franklin

9.4

Cypress Center

12.2

Portsmouth

31.7

April - June 2019 8.4
11.5 29.7

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 69 of 88

Elliot Geriatric Psychiatric Unit

24.1

Elliot Pathways

12

Total

89.4

5c. Designated Receiving Facilities: Discharges for Adults

Designated Receiving Facility

July - September 2019

Franklin

101

Manchester (Cypress Center)

192

Portsmouth

386

Elliot Geriatric Psychiatric Unit

54

Elliot Pathways

97

Total

830

DRAFT

27.0 12.1 88.7
April - June 2019 108 193 368 55 111 835

5d. Designated Receiving Facilities: Median Length of Stay in Days for Discharges for Adults

Designated Receiving Facility

July - September 2019

April - June 2019

Franklin

6

5

Manchester (Cypress Center)

4

3

Portsmouth

6

5

Elliot Geriatric Psychiatric Unit

26

18

Elliot Pathways

8

7

Total

6

5

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 70 of 88

5e. Designated Receiving Facilities: Discharge Location for Adults July – September 2019

Designated Receiving Facility

Assisted Living / Group
Home

Decease d

DRF*

Hom e

Other Hospit
al

NH Hospita
l

Othe r

Franklin

0

0

0 96

0

0

5

Manchester (Cypress Center)

2

0

2 175

0

0 13

Portsmouth Regional Hospital

0

0

3 251

0

7 125

Elliot Geriatric Psychiatric Unit

29

0

1 12

0

0 12

Elliot Pathways

3

0

4 82

0

0

8

Total

34

0 10 616

0

7 163

Designated Receiving Facility

April - June 2019

DRAFT
Assisted Living / Group
Home

Decease d

Hom DRF* e

Other Hospit
al

NH Hospita
l

Othe r

Franklin

3

0

0 97

0

1

7

Manchester (Cypress Center)

5

0

6 173

0

0

9

Portsmouth Regional Hospital

0

0

1 236

0

6 125

Elliot Geriatric Psychiatric Unit

42

0

1 10

0

0

2

Elliot Pathways

2

0

0 93

0

5 11

Total

52

0

8 609

0

12 154

*Dispositions to ‘DRF’ represent a change in legal status from Voluntary to Involuntary within the DRF.

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 71 of 88

5f. Designated Receiving Facilities: Readmission Rates for Adults July - September 2019

Designated Receiving Facility

30 Days

90 Days

Franklin

1.9% (2)

6.7% (7)

Manchester (Cypress Center)

6.6% (13)

9.2% (18)

Portsmouth

8.2% (32)

12.0% (47)

Elliot Geriatric Psychiatric Unit

7.7% (4)

9.6% (5)

Elliot Pathways

2.1% (2)

5.2% (5)

Total

6.3% (53)

9.9% (83)

April - June 2019

Designated Receiving Facility

30 Days

90 Days

Franklin

6.5% (7)

9.3% (10)

Manchester (Cypress Center)

9.9% (19) DRAFT

15.1% (29)

Portsmouth

10.5% (39)

17.8% (66)

Elliot Geriatric Psychiatric Unit

10.1% (9)

12.4% (11)

Elliot Pathways

5.5% (6)

5.5% (6)

Total

9.2% (80)

14.0% (122)

Revisions to Prior Period: None.

Data Source: NH DRF Database.

Notes: Data compiled 10/31/2019.

180 Days 9.6% (10) 12.8% (25) 12.0% (47) 13.5% (7)
6.3% (6) 11.3% (95)
180 Days 12.0% (13) 20.8% (40) 22.4% (83) 14.6% (13)
5.5% (6) 17.8% (155)

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 72 of 88

6. Glencliff Home: Census Summary Measure

July - September 2019

April - June 2019

Admissions

1

4

Average Daily Census

115

118

Discharges

1

1 (nursing home)

Individual Lengths of Stay in Days for Discharges

218

553

Deaths

5

2

Readmissions

0

0

Mean Overall Admission Waitlist

25

23

Revisions to Prior Period: None.

Data Source: Glencliff Home.

Notes: Data Compiled 10/22/2019; Mean rounded DRAFT to nearest whole number; Active waitlist patients have been reviewed for admission and are awaiting admission pending finalization of paperwork and other steps immediate to admission.

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 73 of 88

7. NH Mental Health Client Peer Support Agencies: Census Summary July - September 2019

April – June 2019

Peer Support Agency

Total Members

Average Daily

Average Daily

Visits Total Members

Visits

Alternative Life Center

Total

224

44

NA*

NA*

Conway

42

13

40

12

Berlin

105

7

100

10

Littleton

44

11

62

11

Colebrook

33

13

NA

NA

Stepping Stone Total

346

17

377

14

Claremont

241

13

335

12

Lebanon Cornerbridge Total

105

4

69

5

DRAFT

91

14

445

15

Laconia

25

6

272

7

Concord

58

6

142

8

Plymouth Outreach

8

2

31

NA

MAPSA Keene Total

42

19

159

19

HEARTS Nashua Total

245

36

506

35

On the Road to Recovery

Total

157

10

122

10

Manchester

75

5

73

6

Derry

82

5

63

4

Connections Portsmouth

Total

82

14

147

14

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 74 of 88

July - September 2019

April – June 2019

Peer Support Agency

Total Members

Average Daily

Average Daily

Visits Total Members

Visits

TriCity Coop Rochester

Total

216

26

201

24

Total

1,403

170

NA*

NA*

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services and Peer Support Agency Quarterly Statistical Reports.

Notes: Data Compiled 12/3/2019; Average Daily Visits are not applicable for Outreach Programs.

NA* Alternative Life Center did not report data from Colebrook for the April-June 2019 time period.

DRAFT

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 75 of 88

8. Housing Bridge Subsidy Program: Summary of Individuals Served to Date July - September 2019

Subsidy

Total individuals served at start of quarter

New individuals added during quarter

Total individuals served through end of quarter

Housing Bridge Subsidy

813

16

829

Section 8 Voucher (NHHFA/BMHS) Transitioned from Housing Bridge

140

11

151

April - June 2019

Subsidy

Total individuals served at start of quarter

New individuals added during quarter

Total individuals served through end of quarter

Housing Bridge Subsidy

812
DRAFT

Section 8 Voucher (NHHFA/BMHS) -

133

Transitioned from Housing Bridge

1

813

7

140

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 11/12/2019. Figures at start and end of each quarter are cumulative total of individuals served since CMHA quarterly reporting began in 2015.

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 76 of 88

8a. Housing Bridge Subsidy Program: Current Census of Units/Individuals with Active Funding Status

Measure

As of 9/30/2019

As of 6/30/2019

Rents Currently Being Paid

338

365

Individuals Enrolled and Seeking Unit for Bridge Lease

35

13

Total

373

378

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 11/12/2019; all individuals currently on Bridge Program are intended to transition from the program to other permanent housing.

8b. Housing Bridge Subsidy Program: Clients Linked to Mental Health Care Provider Services

Measure

As of 9/30/2019

As of 6/30/2019

Housing Bridge Clients Linked

339/373 (91%)

360/378 (95%)

Data source: Bureau of Mental Health Services data, Phoenix 2, and Medicaid claims.

DRAFT
Notes: Data compiled 11/13/2019; “Housing Bridge Clients Linked” refers to Housing Bridge clients who received one or more mental health services within the previous 3 months, documented as a service or claim data found in Phoenix or the Medicaid Management Information System (MMIS).

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 77 of 88

8c. Housing Bridge Subsidy Program: Density of HBSP Funded Units at Same Property Address*

Number of HBSP Funded Unit(s)* at Same Address

Frequency as of 9/30/2019

Frequency as of 6/30/2019

1

282

300

2

18

16

3

1

4

4

1

2

5

1

1

6

0

0

7

0

0

8 or more

1

1

*All units are individual units; property address may include multiple buildings, such as apartment complexes.
DRAFT
Revisions to Prior Period: None.

Data Source: Bureau of Mental Health data compiled by Office of Quality Assurance and Improvement.

Notes: Data Compiled 11/22/2019.

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 78 of 88

8d. Housing Bridge Subsidy Program: Applications

Measure

July - September 2019

April - June 2019

Applications Received During Period

22

28

Point of Contact for Applications Received

CMHCs: 13; NHH: 9 CMHCs: 11; NHH: 14; Other: 1

Applications Approved

11

14

Applications Denied

0

0

Denial Reasons

NA

NA

Applications in Process at End of Period

75

74

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services.

Notes: Data Compiled 11/12/2019.

DRAFT

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 79 of 88

8e. Housing Bridge Subsidy Program: Terminations

Type and Reason

July - September 2019

Terminations – DHHS Initiated

0

Over Income

NA

Exited Program – Client Related Activity

25

Voucher Received

13

Deceased

1

Over Income

0

Moved Out of State

1

Declined Subsidy at Recertification

4

Higher Level of Care Accessed

3

Other Subsidy Provided

0

DRAFT

3

Moved in with family

Total

25

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 11/12/2019.

April - June 2019 0
NA 26 11
0 0 5 7 1 0 2
26

8f. Housing Bridge Subsidy Program: Application Processing Times

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 80 of 88

Average Elapsed Time of Application Processing (calendar days)*

July September
2019

April - June 2019

Completed Application to Determination

1

1

Approved Determination to Funding Availability**

95

1

Referred to Vendor with Funded HB Slot

2

1

Leased Unit Secured

NA

NA

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services.

Notes: Data Compiled 11/12/2019.

*Elapsed time measure reporting implemented 10/1/18 and applies to any application received on or after that date.

**Average calculated on 16 applications approved for which funding was made available in the quarter.

9. Housing Bridge Subsidy Program Waitlist: Approved Applications

Total

0-30

31-60

days

days

42

5

3

Total

0-30

31-60

days

days

44

5

3

Revisions to Prior Period: None.

DRAFT
As of 9/30/2019

Time on List

61-90 91-120

days

days

5

3

As of 6/30/2019

61-90 91-120

days

days

5

13

121-150 days 0
121-150 days 2

151-180 days 1
151-180 days 0

181+ days 24
181+ days 16

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 11/12/2019. 10. Supported Housing Subsidy Summary

July - September April - June 2019 2019

Subsidy

Total subsidies by Total subsidies by

end of quarter

end of quarter

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 81 of 88

Housing Bridge Subsidy:

Units Currently Active
Individuals Enrolled and Seeking Unit for Bridge Lease

338

365

35

13

Section 8 Voucher Transitioned from Housing Bridge*

151

140

(NHHFA):

Not Previously Receiving Housing Bridge

0

0

811 Units:

PRA Mainstream

56

54

16

14

Other Permanent Housing Vouchers (HUD, Public Housing, VA)

1

5

Total Supported Housing Subsidies

597

591

Revisions to Prior Period: None.

Data Source: Bureau of Mental Health Services and Housing Bridge Provider.

Notes: Data Compiled 11/12/2019; Section 8 Voucher Not Previously Receiving Housing
DRAFT
Bridge are CMHC clients that received a Section 8 Voucher without previously receiving a Housing Bridge subsidy; 811 Units (PRA and Mainstream) are CMHC clients that received a PRA or Mainstream 811 funded unit with or without previously receiving a Housing Bridge subsidy; Other Permanent Housing Vouchers (HUD, Public Housing, VA) are CMHC clients that received a unit funded through other HUD or Public Housing sources with or without previously receiving a Housing Bridge subsidy.

*These counts are cumulative; increasing over time since originally reporting this data within the CMHA Quarterly Data Report.

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 82 of 88

11a. Mobile Crisis Services and Supports for Adults: Riverbend Community Mental Health Center

Measure Unique People Served in Month

July 2019
291

August 2019

Septemb

July -

er Septembe

2019

r 2019

337

308

499

April June 2019
517

Services Provided by Type

Case Management

0

Crisis Apartment Service

0

Crisis Intervention Services

11

ED Based Assessment

0

Medication Appointments or Emergency Medication Appointments

0
DRAFT

Mobile Community Assessments

52

Office-Based Urgent Assessments

32

Other

0

Peer Support

0

Phone Support/Triage

355

Psychotherapy

0

0

0

0

0

11

10

0

0

0

0

0

0

0

0

32

43

0

0

0

0

83

76

211

136

32

26

90

106

0

0

0

0

0

0

0

0

383

366

1,104

1,143

0

0

0

0

Referral Source CMHC Internal Emergency Department Family

29

48

18

95

66

0

13

19

32

1

20

38

6

64

63

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 83 of 88

Measure Friend Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self School
Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

July 2019
2 13
0 8 1 4 4 205 1
DRAFT

August 2019

Septemb

July -

er Septembe

2019

r 2019

4

4

10

1

3

17

0

0

0

16

28

52

19

5

25

16

19

39

16

19

39

226

226

657

0

36

37

April June 2019 23 64 0 55 10 20 17 751 21

24

31

23

78

80

87

186

124

397

319

3.6

6.0

5.4

5.1

4.0

Law Enforcement Involvement

17

18

28

63

73

Hospital Diversions Total

172

Revisions to Prior Period: None.

Data Source: Riverbend CMHC submitted report.

194

154

520

449

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 84 of 88 Notes: Data Compiled 10/29/2019; reported values other than the Unique People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.
DRAFT

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 85 of 88

11b. Mobile Crisis Services and Supports for Adults: Mental Health Center of Greater Manchester

Measure

July 2019

July -

August September September

2019

2019

2019

Unique People Served in Month

261

286

274

679

April June 2019
714

Services Provided by Type Case Management Crisis Apartment Service Crisis Intervention Service ED Based Assessment Medication Appointments or Emergency Medication Appointments Mobile Community Assessments Office-Based Urgent Assessments Other Peer Support Phone Support/Triage Psychotherapy

38

26

10

4

21

80

0

0

0

0

DRAFT

84

91

20

14

246

293

20

8

566

621

3

2

28

92

90

6

20

28

78

179

144

0

0

0

0

0

0

105

280

319

15

49

65

264

803

833

14

42

112

646

1,833 1,795

3

8

8

Referral Source CMHC Internal Emergency Department Family

9

11

0

0

28

32

5

25

23

0

0

2

51

111

168

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 86 of 88

Friend Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self School

4

6

4

14

15

4

3

8

15

29

0

0

0

0

0

13

18

43

74

36

28

45

54

127

123

99

85

89

273

320

12

15

14

41

58

132

159

104

395

361

0

0

0

0

0

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

4

2

3

9

15

DRAFT

10

7

10

27

46

2.5

3.5

3.3

3

3.1

Law Enforcement Involvement

99

85

89

273

320

Hospital Diversion Total

341

379

391

1,111 1,185

Revisions to Prior Period: None.

Data Source: Phoenix 2.

Notes: Data Compiled 10/30/2019; reported values other than the Unduplicated People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 87 of 88

11c. Mobile Crisis Services and Supports for Adults: Harbor Homes

Measure

July 2019

July -

August September September

2019

2019

2019

Unique People Served in Month

146

146

156

377

April June 2019
419

Services Provided by Type Case Management Crisis Apartment Service Crisis Intervention Services ED Based Assessment Medication Appointments or Emergency Medication Appointments Mobile Community Assessments Office-Based Urgent Assessments Other Peer Support Phone Support/Triage Psychotherapy

51

38

36

125

279

94

90

111

295

295

0

1

0

1

0

14

5

10

29

33

0

0

0

0

0

DRAFT
63

84

84

231

245

7

5

9

21

29

0

0

0

0

0

68

61

77

206

302

177

183

170

530

522

14

5

5

24

45

Referral Source CMHC Internal Emergency Department Family Friend

19

20

11

50

58

12

7

15

34

31

7

9

13

29

52

5

2

5

12

16

Case 1:12-cv-00053-SM Document 133-1 Filed 02/03/20 Page 88 of 88

Guardian MCT Hospitalization Mental Health Provider Other Police Primary Care Provider Self Schools

0

0

0

0

12

12

111

111

6

4

2

0

69

67

3

4

0

0

0

0

0

0

2

26

20

99

321

286

5

15

20

1

3

8

79

215

200

10

17

38

Crisis Apartment Apartment Admissions Apartment Bed Days Apartment Average Length of Stay

14

21

18

53

51

73

124

109

306

249

DRAFT

5.2

5.9

6.1

5.8

4.9

Law Enforcement Involvement

0

0

0

0

0

Hospital Diversion Total

243

232

235

710

704

Revisions to Prior Period: None.

Data Source: Harbor Homes submitted data.

Notes: Data Compiled 10/29/2019; reported values other than the Unique People Served in Month value are not de-duplicated at the individual person level; individual people can account for multiple instances of service use, hospital diversions, etc.

 
 u.s. Department of Justice
Civil Rights Division

Office of the Assistant Attomey General

Washington, D.C. 20530
APR - 7 1011

The Honorable Michael A. Delaney Attorney General State ofNew Hampshire Department of Justice 33 Capitol Street Concord, NH 03301
Re: United States' Investigation of the New Hampshire Mental Health System Pursuant to the Americans with Disabilities Act
Dear Attorney General Delaney:
We write to report the findings of the Civil Rights Division's investigation of the State of New Hampshire's mental health system, which offers services to persons with mental illness at the New Hampshire Hospital ("NHH") in Concord, NH, the Glencliff Home ("Glencliff') in Benton, NH, and other settings across the state. During our investigation, we assessed the State's compliance with Title II of the Americans with Disabilities Act ("ADA"), 42 U.S.C. §§ 12131-12134 (Part A), and its implementing regulations at 28 C.F.R. pt. 35, as interpreted in Olmstead v. L.C., 527 U.S. 581 (1999), requiring that individuals with disabilities, including mental illness, receive supports and services in the most integrated setting appropriate to their needs. The Department has authority to seek a remedy for violations of Title II of the ADA. 42 U.S.C § 12133; 28 C.F.R. §§ 35.170-174, 190(e). In our investigation, we did not assess or reach any conclusions about the quality of the care and services offered at NHH or Glencliff.
Consistent with legal requirements set forth in the ADA and its implementing regulations and in Title VI of the Civil Rights Act of 1964,42 U.S.C. § 2000d-1, we write to provide you notice of the State's failure to comply with important aspects of the ADA and of the steps New Hampshire needs to take to meet its obligations under the law. By implementing the remedies set forth in this letter, the State will correct identified ADA deficiencies, fulfill its commitment to individuals with disabilities, and better protect the public fisc.

-2-
I. SUMMARY OF FINDINGS AND CONCLUSIONS
We have concluded that the State of New Hampshire fails to provide services to qualified individuals with mental illness in the most integrated setting appropriate to their needs, in violation of the ADA. This has led to the needless and prolonged institutionalization of individuals with disabilities who could be served in more integrated settings in the community with adequate services and supports. Systemic failures in the State's system place qualified individuals with disabilities at risk of unnecessary institutionalization now and going forward.
Our findings here, in large measure, are consistent with the State's own conclusions and admissions about deficiencies, weaknesses, and unmet needs in the New Hampshire mental health system. We have made a point to include these State conclusions and admissions in this letter, and we adopt them as part of our findings. Our specific findings include:
• The State acknowledges, and we agree, that its mental health system is "broken," "failing," and that it is in "crisis."
• The State acknowledges, and we agree, that there are serious "unmet needs" and "weaknesses" in the State's mental health system that contribute to negative outcomes for persons with mental illness, such as the day-to-day harm associated with improperly and/or under-treated mental health conditions, needless visits to local hospital emergency departments, needless admissions to institutional settings like NHH and Glencliff, and the serious incidents that prompt involvement with law enforcement, the correctional system, and the court system.
• In spite of a challenging fiscal environment, the State has continued to fund costly institutional care at NHH and Glencliff, even though less expensive and mote therapeutic alternatives could be developed in community settings.
• Community capacity in New Hampshire has declined in recent years and this has led to unnecessary institutionalization, prolonged institutionalization, a heightened risk of institutionalization, and a greater likelihood that some will end up in even less desirable settings not designed to provide mental health care, such as the state corrections system and the county jails.
• The number of inpatient and residential acute/crisis bed alternatives to NHH and Glencliffhas diminished dramatically in recent years.
• There is a lack of safe, affordable, and stable community housing, including supported housing, for persons with mental illness in New Hampshire, which can lead to greater levels of impairment, more difficulty in accessing needed services and supports, a loss of stability, and a greater risk of hospitalization and/or institutionalization.
• High admission and readmission numbers to NHH reveal that there are inadequacies in the State's mental health system that are forcing persons with mental illness to obtain mental health services in an institutional setting.

-3-
• Many individuals admitted to NHH and Glencliff, especially those with intensive physical and/or mental health needs, remain there longer than necessary simply because community-based alternatives with adequate and appropriate services and supports are not available in sufficient supply in the community.
• The State's failure to develop sufficient community services is a barrier to the discharge of individuals from NHH and Glencliff who could be served in more integrated community settings with adequate and appropriate services and supports.. The State already provides the types of services and supports these individuals would need to live successfully in the community, but the State does not offer these needed services and supports in sufficient supply.
• Individuals with developmental disabilities have remained institutionalized in the State's mental health system because of a lack of community alternatives with proper supports.
• Even though the State recognizes, and has seen first-hand, the benefits of Assertive Community Treatment ("ACT") in terms of promoting positive outcomes among persons with mental illness, the State has no ACT program in at least half of its ten regions statewide, leaving thousands of persons in need without the ability to even access ACT. Not only does the State recognize that ACT can produce positive outcomes, it acknowledges that ACT is cost-effective, especially for frequently-hospitalized individuals.
• The State fails to provide adequate and appropriate employment opportunities, including supported employment, to persons with mental illness in integrated community settings. .
Reliance on unnecessary and expensive institutional care both violates the civil rights of people with disabilities and incurs unnecessary expense. Community integration with appropriate services and supports will permit the State to support people with disabilities, including mental illness, in settings appropriate to their needs in a more cost effective manner.
II. INVESTIGATION
On November 19, 2010, we notified you that we were opening an investigation of the State's mental health system pursuant to Title II of the ADA. On January 10,2011, we participated in a meeting at NHH with various State officials and counsel, and then participated in an onsite tour of the facility. The next day, we participated in a similar meeting and tour at Glencliff. On January 21,2011, as a follow-up to our onsite visits, we sent you a written request for documents and information. As agreed, several weeks later, you provided us with a written response to our request. On January 27,2011, we also participated in a meeting with various advocacy groups and the State with regard to the adequacy of the services and supports provided to persons with mental illness in the State's mental health system.
Before proceeding to the detailed substance of the letter, we would first like to thank the State for the assistance and cooperation extended to us thus far, and to acknowledge the courtesy

-4-
and professionalism of all of the State officials and counsel involved in this matter to date. We appreciate that the State facilitated the walk-through tours ofNHH and Glencliff, and that the State provided us with helpful documents and information both onsite during our January visit and in late February in response to our written request. We hope to continue our collaborative and productive relationship. We are certainly encouraged by our interactions thus far with State leadership, and hope that going forward, there is a desire to work toward an amicable resolution of this matter.
III. BACKGROUND
.The New Hampshire Department of Health and Human Services ("DHHS") is responsible for establishing, maintaining, and coordinating a comprehensive and effective service system for persons with mental illness in the state. The Department provides direct services to persons with mental illness primarily at two residential facilities: NHH, an acute psychiatric hospital; and Glencliff, a long-term care nursing facility.
NHH is a 202-bed facility, and it had a census of 175 on the day we visited in midJanuary; the NHH average daily census in FY 2010 was 167. NHH is the only state-operated psychiatric hospital in New Hampshire.!
Glencliff is a 114-bed facility and it had a full census on the day we visited in midJanuary; the Glencliff average daily census in FY 2010 was 111. Glencliff is located in a woody, isolated area, far from the nearest town, which makes it difficult for family members and other visitors to see their loved ones. The State informed us that Glencliff provides a specialized level of nursing home care for individuals with serious mental illness or developmental disabilities. Admission to Glencliff is subject to State long-term care approval and to Pre-Admission Screening and Annual Resident Review ("PASARR") approval.
In addition, the DHHS Division of Community-Based Care Services ("DCBCS") and its Bureau of Behavioral Health ("BBH"), which is the New Hampshire State Mental Health Authority, oversees community-based services for persons with mental illness by contracting
! As oflast year, the Philbrook Center for children is now located on a wing of the main NHH building. In addition, on the greater NHH campus, there is also a Transitional Housing Service ("THS") program, comprised of six houses with a total of about 49 beds, currently serving approximately 45 persons. The State informed us that the THS is technically not a component of NHH, although it is a part ofDHHS. According to the State, the THS provides an intermediary step between NHH and less restrictive community placement for individuals who it claims are not ready to fully transition to more independent living: In his 2011 budget address, the Governor announced plans to privatize the THS units and to replace them with community-based housing that will help integrate people back into their homes and lives. The Governor also announced that the State intended to close another unit at NHH, but he did not provide any further details about the unit closure or the THS privatization plan.

-5­
with ten regional Community Mental Health Centers ("CMHCs") located throughout the state? Each CMHC is supposed to be a full-service entity, offering a variety of programs and services in community settings, including: evaluation and assessment; emergency and crisis services; individual, family, and group therapy; medication monitoring; psychiatric evaluations; case management; symptom management services; and family support. While BBH leaves direct service delivery to each CMHC, BBH maintains oversight of the community system by conducting various types of reviews and requiring financial and performance reporting. In addition, BBH approves community service programs for each CMHC, provides staff training, and details what services are to be provided, how clinical records are to be maintained, and other aspects of CMHC operations.
The State informed us that in FY 2010, there were 51,305 persons served in the State's community mental health system; within this total figure, there were 19,577 persons designated as part of the State's "priority population" -- as either being an adult with "serious" or "severe mental illness" or a child or adolescent with "serious emotional disturbance."
As we discuss in greater detail below, the average cost of institutionalizing a person at NHH is approximately $287,000.00 per year. The average cost of institutionalizing a person at Glencliff is about $124,000.00 per year. By contrast, the cost of serving a person in the community is roughly $44,000.00 per year. Given this, New Hampshire can serve about six persons in the community for each person in NHH.
Per State policy, the State's mental health service system is to provide "adequate and humane care to severely mentally disabled persons in the least restrictive environment," and is to be directed toward "eliminating the need for services and promoting individuals' independence." RSA135-C:1, II.
IV. FINDINGS AND CONCLUSIONS
We conclude that New Hampshire fails to provide services to qualified individuals with disabilities, including mental illness, in the most integrated setting appropriate to their needs as required by the ADA.
Community capacity in New Hampshire has declined in recent years and this has led to unnecessary institutionalization, prolonged institutionalization, and a heightened risk of institutionalization for persons with mental illness who could be served with more independence and dignity, at a fraction of the cost, in more integrated settings in the community with adequate protections, services, and supports. People in the community, for example, are now often forced to seek services in the NHH institution simply because community resources are deficient -providing improper service or under-treatment of their mental health conditions. Many individuals recycle through NHH because community capacity in the State's system is just not
2 The State's BBH also contracts with: eight private, not-for-profit Peer Support Agencies that provide peer-to-peer support by people with mental illness at more than a dozen different sites; one Community Mental Health Provider that mainly provides community housing and other residential supports; and one family mutual support organization.

-6-
adequate. Individuals at Glencliff are relegated to prolonged stays at the nursing facility because discharge and transition planning and implementation efforts there are insufficient, and because housing and other critical supports and services are unavailable or in too limited supply in the community. At both NHH and Glencliff, individuals with more complex physical andlor mental health conditions typically must remain institutionalized longer than necessary simply because more intensive protections, services, and supports are not sufficiently available in the State's community mental health system.
The State's failure to develop sufficient community services is a barrier to the discharge of individuals from NHH and Glencliff who could be served in more integrated community settings with adequate and appropriate services and supports. The State already provides the types of services and supports these individuals would need to live successfully in the community, but just not in sufficient supply. In general, therefore, systemic failures in the State's system subject qualified individuals with disabilities, including those in the community, to undue and prolonged institutionalization and place them at risk of unnecessary institutionalization now and going forward. All of this violates the ADA.
A. The ADA Prohibits Discrimination on the Basis of Disability through Improper Segregation of Qualified Individuals with a Disability in Institutional Settings that Do Not Enable Them to Interact with Non-Disabled Peers to the Fullest Extent Possible
Congress declared that the simple purpose behind enacting the ADA was to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities. 42 U.S.C. § 12101(b)(1).3 Congress took action because it found that "society has tended to isolate and segregate individuals with disabilities," that this is a form of discrimination against individuals with disabilities, and that this continues to be a "serious and pervasive problem." 42 U.S.C. § 12101(a)(2).4 Specifically, Congress found that discrimination against individuals with disabilities often exists in such critical areas as
3 Congress found that people with disabilities, as a group, occupy "an inferior status in our society, and are severely disadvantaged socially, vocationally, economically, and educationally." 42 U.S.C. § 12101(a)(6). Congress explained that "individuals with disabilities are a discrete and insular minority who have been faced with restrictions and limitations, subjected to a history of purposeful unequal treatment, and relegated to a position of political powerlessness in our society, based on characteristics that are beyond the control of such individuals and resulting from stereotypic assumptions not truly indicative of the individual ability of such individuals to participate in, and contribute to, society." 42 U.S.C. § 12101(a)(7).
4Nearly 20 years before enacting the ADA, Congress recognized that society historically had discriminated against people with disabilities by unnecessarily segregating them from their family and community, and in response, enacted Section 504 of the Rehabilitation Act of 1973, which forbids any program receiving federal aid from discriminating against an individual by reason of a handicap. Our findings and conClusions in this letter also implicate the State's compliance with Section 504 of the Rehabilitation Act of 1973,29 U.S.C. § 794 et seq.

-7 -
institutionalization, housing, public accommodations, health services, access to public services, and employment. 42 U.S.C. § 12101(a)(3).
Congress declared that "the continuing existence of unfair and unnecessary discrimination and prejudice denies people with disabilities the opportunity to compete on an equal basis and to pursue those opportunities for which our free society is justifiably famous." 42 U.S.C. § 12101(a)(9). In enacting the ADA, Congress emphasized that "the Nation's proper goals regarding individuals with disabilities are to assure equality of opportunity, full participation, independent living, and economic self-sufficiency for such individuals." 42 U.S.C. § 12101(a)(8). Congress' basic intent was to invoke the "sweep of congressional authority" to address the major areas of discrimination faced day-to-day by people with disabilities. 42 U.S.C. § 12101(b)(4).
Title II of the ADA5 prohibits discrimination on the basis of disability by public entities. This would encompass the State of New Hampshire, its .agencies, and its mental health system, given that a "public entity" includes any State or local government, as well as any department, agency, or other instrumentality of a State or local government, and it applies to all services, programs, and activities provided or made available by public entities, such as through contractual, licensing, or other arrangements. 42 U.S.C. § 12131(1); 28 C.P.R. § 35.102(a); 28 C.P.R. § 35.130(b).
In Title II, Congress established a straightforward prohibition on discrimination: "no qualified individual with a disability6 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. The ADA's implementing regulations mandate that a "public entity shall administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities." 28 C.P.R. § 35.l30(d). See also 28 C.P.R. § 41.51(d) ("[r]ecipients [offederal financial assistance] shall administer programs and activities in the most integrated setting appropriate to the needs of qualified handicapped persons"). The "most integrated setting appropriate to the needs of qualified individuals with disabilities" means "a setting that enables individuals with disabilities to interact with non-disabled persons to the fullest extent possible."
5 In the ADA, Congress set forth prohibitions against discrimination in employment (Title I, 42 U.S.C. §§12111-12117), public services furnished by governmental entities (Title II, 42 U.S.C. §§ 12131-12165), and public accommodations and services provided by private entities (Title III, 42 U.S.C. §§ 12181-12189). Title II is the relevant subchapter with regard to the instant investigation of the State's mental health system.
6 Like those persons served in the State's mental health system here, a "qualified individual with a disability" is "an individual with a disability who, with or without reasonable modifications to rules, policies, or practices, the removal of architectural, communication, or transportation barriers, or the provision of auxiliary aids and services, meets the essential eligibility requirements for the receipt of services or the participation in programs or activities provided by a public entity." 42U.S.C. § 12131(2).

-8-

28 C.F.R. pt. 35 app. A. at 572 (July 1,2010) (Preamble to Regulation on Nondiscrimination on the Basis of Disability in State and Local Government Services (July 26, 1991)).

The ADA's implementing regulations stress that "[i]ntegration is fundamental to the purposes of the Americans with Disabilities Act. Provision of segregated accommodations and services relegates persons with disabilities to second-class status." Id. at 570. The overarching intent behind the selection of the various forms of discrimination delineated in the regulations is to forbid practices that exclude and unnecessarily segregate. See also id. at 569 ("Taken together, these provisions are intended to prohibit exclusion and segregation of individuals with disabilities and the denial of equal opportunities enjoyed by others, based on, among other things, presumptions, patronizing attitudes, fears, and stereotypes about individuals with disabilities. Consistent with these standards, public entities are required to ensure that their actions are based on facts applicable to individuals and not on presumptions as to what a class of individuals with disabilities can or cannot do.")

In construing the ADA's anti-discrimination provision, the Supreme Court held that "[u]njustified isolation ... is properly regarded as discrimination based on disability." Olmstead, 527 U.S. at 597. The Court recognized that unjustified institutional isolation of persons with disabilities is a form of discrimination because the institutional placement of persons who can handle and benefit from community settings "perpetuates unwarranted assumptions that persons so isolated are incapable or untrustworthy of participating in community life" and because "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 600-01.

The Court described the dissimilar treatment persons with disabilities must endure just to obtain needed services: "In order to receive needed medical services, persons with mental disabilities must, because of those disabilities, relinquish participation in community life they could enjoy given reasonable accommodations, while persons without mental disabilities can receive the medical services they need without similar sacrifice." Id. at 601.

A violation of the ADA's integration mandate is made out if the institutionalized

individual is "qualified" for community placement - that is, he or she can "handle or benefit

from community settings," and the affected individual does not oppose community placement.

Id. at 601-03. Indeed, the Court stressed that states "are required" to provide community-based

treatment for qualified persons who do not oppose placement in a more integrated setting unless

the State can establish an affirmative defense. Id. at 607.7

.

7 Olmstead, therefore, makes clear that the aim of the integration mandate is to eliminate unnecessary institutionalization and to enable persons with disabilities to participate in all aspects of community life. This is consistent with guidance from the President. See, e.g., 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. ").

I
. i I
I
- 9-
Both NHH and Glencliff are segregated, institutional settings.8 Contrary to the requirements of the ADA and its implementing regulations, neither is a setting that enables individuals with disabilities to "interact with non-disabled persons to the fullest extent possible." Instead, individuals housed at the two facilities live isolated lives, largely cut off from the rest of society. Most spend their entire day, every day, in an institutional setting. Individuals housed at these institutions are offered very limited opportunities day-to-day for community integration or meaningful employment, and, as a result, have few opportunities to interact with their nondisabled peers in community settings outside the institution. Moreover, both facilities limit individual autonomy and provide limitations on choice even while onsite.
B. The State Has Acknowledged Unmet Needs and Weaknesses in Its Mental Health System
In recent years, the State has been candid and open about the many limitations, shortcomings, and deficiencies in its mental health system. All of the State's admissions lend support to our conclusion that the State is failing to provide services to persons with mental illness in the most integrated setting as required by the ADA.
Just last year, the State submitted its 2011 application to the federal government9 in its attempt to secure block grant funding for its mental health system, where the State admitted that there are "unmet needs" within the State's mental health system, and admitted that there are "key issues that are weakening the system." New Hampshire Unif. Application 2011, State Plan, Community Mental Health Services Block Grant (hereinafter "State Application"), Aug. 31, 2010 at 58,60. The State reported that the "most emergent unmet needs" include the need to increase the availability of community residential supports through formal supported housing
8 An institutional setting is a segregated environment because individuals living in such a facility are separated from the community and walled off from the mainstream of society, isolated and apart from the natural community where all of us live, work, and engage in life's many activities. Individuals living in an institution are deprived of many of the personal freedoms that citizens in the community enjoy. Institutionalized persons typically live a regimented life tied to the needs of the institution, characterized by lack of privacy and few choices. Institutionalization also stigmatizes individuals and prevents them from building lives in the community, forming personal relationships, and obtaining employment. Community-based programs, on the other hand, are integrated services both because they are physically located in the mainstream of society and because they provide opportunities for people with disabili~ies to interact with nondisabled persons in all facets of life.
9 Within the federal government, the Substance Abuse & Mental Health Services Administration ("SAMHSA"), Center for Mental Health Services, provides grant funds to establish or expand an organized community-based system of care for providing non-Title XIX mental health services to children with serious emotional disturbances and adults with serious mental illness. States are required to submit an application for each fiscal year the State is seeking funds.

- 10 -.
programs, specialized housing, and new crisis support beds; increase capacity for communitybased inpatient psychiatric care; and develop additional Assertive Community Treatment ("ACT") teams. State Application at 60, 62.
The State reported that these unmet needs and key issues were previously identified in the August 2008 document, "Addressing the Critical Mental Health Needs ofNH's Citizens," commonly referred to as the "Ten-Year Plan." State Application at 58, 60. We discuss the TenYear Plan in greater depth below. The State, in part, was the author of this plan,10 and through its 2011 block grant application, reinforced that the findings, conclusions, and recommended action steps in the Ten-Year Plan have continuing relevance todayY As a result, the State's Ten-Year Plan is not an aspirational document or an historical remnant of a past time, but is instead a current roadmap for steps the State believes it needs to implement in order to meet the outstanding needs of persons with mental illness in New Hampshire.
In addition to the block grant application and the Ten-Year Plan, in April 2009, the State produced a follow-up report to its Ten-Year Plan that contained additional admissions about problems in the State's mental health system. This report was the product of five "listening sessions" across the state that produced hours of testimony and discussion and "scores of accounts" about the problematic state of mental health services in New Hampshire. Addressing the Critical Mental Health Needs ofNH's Citizens, A Strategy for Restoration, Report of the Listening Sessions (hereinafter "State Report"), April 2009, at 3.
Overall, the State admitted that the findings in its Ten-Year Plan were "stark and painted a picture of a system in crisis." State Report at 1. DHHS Commissioner Nicholas A. Toumpas concluded: "NH's mental health care system is failing, and the consequence of these failures is being realized across the community. The impacts of the broken system are seen in the stress it is putting on local law enforcement, hospital emergency rooms, the court system and county jails, and, most importantly, in the harm under-treated mental health conditions cause NH citizens and their families." Id.; see also id. at 4 (in summarizing the account of one community member during a listening session, the State characterized its mental health system as "broken").
The State reported that its State-sponsored listening sessions brought forth "very moving testimony that demonstrated the need for a long-term commitment to improve and restore the system and to help people who are not rece~ving the care that they need." Id. at 2. The State
10 The State's DHHS published the Ten-Year Plan in collaboration with the New Hampshire Hospital Bureau of Behavioral Health and the Community Behavioral Health Association.
11 Indeed, in its 2011 block grant application, the State adopted anew the recommendations contained in the Ten-Year Plan as the "key elements designed to address the unmet needs" of the State's mental health system. State Application at 62; see also id. at 60 (the State reported that its current "primary strategy" to reduce unmet needs is through the Ten-Year Plan, which centers on areas targeted for system, policy, and fiscal reform). Moreover, in his very recent 2011 budget address, the Governor expressly referenced the Ten-Year Plan as the blueprint for the State's efforts to develop and implement "fundamental changes" to the State's mental health system going forward.

- 11 -
reported that there were stories about people who had been "pushed aside by the system, and who have been denied access to basic services such as mental health screening, preventive care, and the level and type of care, in the correct setting, that would have meant a successful outcome for them and their families." Id. The State concluded that the personal stories "illustrated the need to restore New Hampshire's mental health system." Id.
The State reported that the "recurring themes" of its many listening sessions included "the lack of resources or appropriate resources in the correct places; the need for improved communication and coordination between systems with a focus on individuals' and families' needs; and earlier intervention and access to appropriate treatment so that individuals don't end up in acute care, incarcerated, or homeless because of treatable mental health conditions, to name just a few. There was a call for long-term solutions." Id. at 3.
In its Ten-Year Plan, the State outlined a series·of recommendations that were to be implemented over the course of the subsequent ten years. Specifically, these recommendations included the need to: increase supported community housing; to develop and maintain a community housing subsidy bridge program linked with clinical services; to·increase the number of community residential beds; to increase the number of community beds for persons in shortterm crisis, for persons with co-occurring mental illness and substance abuse problems, and for persons with serious mental illness who have histories of violence or criminal involvement; to increase capacity for community-based inpatient psychiatric care; to develop additional ACT teams in the community; and to facilitate discharge of persons with developmental disabilities at NHH. State Ten-Year Plan at 9-15.
In September of 2010, at about the two-year anniversary of the State's publication of its Ten-Year Plan, the New Hampshire Community Behavioral Health Association ("CBHA"), provided a short report on whether or not the State had accomplished what had been set forth in the plan. The CBHA noted some progress in a handful of areas, but concluded that little or no action had been taken in other important areas. For example, inconsistent with the State's plan, the CBHA concluded that: admissions to NHH had increased 104 percent over the previous ten years; the five ACT teams recommended in the plan were not added in FY 2009 or FY 2010, putting additional demand on NHH for inpatient care; none of the target items for persons with developmental disabilities were achieved; CMHCs had closed 44 community beds in the previous two years; there had not been appropriations for the addition of 132 community beds; . no additional DRF beds had been added; and a taskforce had not been convened to expand voluntary inpatient psychiatric care throughout the state. CBHA, New Hampshire Ten-Year Mental Health Plan Progress, Two Years Out, Sept. 24,2010, at 2-3.
C. The State Has Continued to Invest in Expensive, Segregated Institutional Services While Denying Resources to the Community System
In spite of a challenging fiscal environment, the State has continued to fund costly institutional care at NHH and Glencliff, even though less expensive and more therapeutic alternatives could be developed in integrated community settings. This misplaced emphasis on institutional care reinforces the conclusion that the State is violating the ADA with regard to services provided to qualified persons with a disability.

- 12-
The State informed us that its failure to implement recommendations from its Ten-Year Plan and other needed remedial measures is due, in part, to budget cuts and general fiscal constraints. These fiscal limitations have contributed to the State's failure to minimize the risk of institutionalization for qualified individuals with a disability pursuant to the ADA. For example, the State acknowledged that budget adjustments from deficits have caused staff reductions throughout DHHS, the closure of certain facilities and programs, and the potential reduction in certain services with an unknown specific impact on adult mental health services. Id. at 41.
In its 2011 block grant application, under the heading "A Stressed System," State Commissioner Toumpas admitted that millions of dollars in budget cuts to his Department in recent years have had an impact: "Given that the amount ... was so large, (and) ... coming on top of previous reductions, we could not avoid cutting into some of our direct services. Although every attempt was made to minimize the impact on clients, we simply cannot make reductions of this size and magnitude without there being consequences for the families and individuals we serve and for the staff who provide those services." Id. at 58.
The State acknowledged that the immediate and long-term impact ofthe State's budget crisis will "undoubtedly affect the State's approaches to achieving its vision" in transforming its mental health system. Id. at 67. The State admitted that the "demonstrated needs of the public far exceed the capacity of the state to meet those needs with limited and reduced public funds." Id. at 60. For example, the State reported that in New Hampshire, there is a "growing segment of the public that is clearly in high need of more accessible, available, and affordable mental health services." Id. The State reported that more individuals with mental health needs are presenting themselves to the CMHCs and that the intensity of care required is rising, at the same time that rates are being reduced, caseloads are increasing, and the number of emergency care beds is diminishing. Id. at 41.12
All of this is likely producing negative outcomes among inadequately or improperly served groups of persons with mental illness in the State's system. For example, the State acknowledged that in the year prior to the submission of its 2011 block grant application, there had been a 25 percent increase in the number of people taking their own lives and that the lack of sufficient staff-intensive monitoring outside the context of an in-patient stay at NHH could have played a role. Id. at 41.
All this is occurring while cuts are imposed on some important community programs. For example, the State reported that, during the 2009-2010 legislative session, spending on community behavioral health was reduced by approximately one million dollars. State Application at 44. More recently, proposed cuts to the state budget for the next biennium would, among other things, eliminate community case manager positions, eliminate community day
12 The Ten-Year Plan earlier had identified recommend~d services that were "never implemented, the erosion of mental health services over the last fifteen years and a growing state population with related rising demands for mental health care." State Ten-Year Plan at 3.

- 13 -
programs, and change eligibility requirements for Medicaid, making thousands of persons with disabilities ineligible for the program. This would directly affect persons with severe mental illness and could contribute to poor individual outcomes and additional pressures on emergency departments and law enforcement.
We note that there is a substantial difference in the cost of providing care in institutional and community settings, which breaks down as follows:
1. NHH
The State informed us that total expenditures for NHH operations have risen in each of the last five years. Indeed, it cost nearly ten million dollars more to run NHH in FY 20 I0 than it did in FY 2006.
The per diem cost to serve a person with mental illness in an acute setting like NHH was $788.00/day in FY 2010. 13 Projected out for a full year, this amounts to about $287,000.00 per NHH person per year. In 2009, Commissioner Toumpas admitted that "[w]e're spending money for mental illness but we are not doing it effectively ... It costs $275,000 to keep someone in NH Hospital and they are there because we don't have the resources in the community." State Report at 8. Importantly, services at NHH are primarily funded with State-only dollars without Federal matching funds, in contrast to community services where there is often a significant Federal matching contribution.
2. Glencliff
As with NHH, in recent years the State has continued to increase the flow of limited state funds to support institutional care and services at Glencliff. State general fund expenditures for Glencliff have steadily increased over the years, rising about two million dollars from FY 20062010, to a FY 2010 total of about $12.5 million.
The per diem rate at Glencliff, $340.71 per person, is less than that at NHH, but, as we set forth below, still much more than that for services in the community. Projected out for a full year, this amounts to about $124,000.00 per person at Glencliff.
3. Community
The institutional NHH and Glencliff cost figures contrast markedly with the much lower per diem figures for persons with mental illness living in the community. Since July 1,2009, the current community residence rate in New Hampshire has been $120.00/day. This projects out to an approximate annual cost of $43,800.00 - an amount which is about $243,000.00 per person per year lower than the annual cost of residing at NHH and about $80,000.00 per person per year
13 This per diem figure is slightly higher than the amount set in FY 2006 ($756.00/day) and much higher than the amount set in FY 2007, which was $671.00/day.

- 14 -
lower than the annual cost of care at Glencliff. So, for example, New Hampshire can serve roughly six people in the community for each person it serves at NHH. 14
According to State estimates, the community cost of serving even high-risk individuals with complex needs is less expensive in New Hampshire than serving them in an acute care setting like NHH or a nursing home setting like Glencliff. For example, in its Ten-Year Plan, the State recommended a rate increase to $170.00/day for community beds serving those with serious mental illness and complex medical conditions, and for community beds serving persons with serious mental illness and substance abuse; and a rate increase to $260.00/day for community beds for persons with serious mental illness who have a history of violence or criminal involvement. State Ten-Year Plan at 10-11.15 Even the highest rate of $260.00/day projects out to only about $95,000.00 per person per year - still $190,000.00 per person per year less than the current per diem rate at NHH; the lower $170.00/day rate would cost about $225,000.00 less per person per year compared to NHH.
D. The State Has Failed to Develop Adequate Capacity in Integrated Community. Settings to Minimize the Risk of Institutionalization for Qualified Persons with a Disability
The State has admitted repeatedly that community capacity within New Hampshire has declined andlor failed to meet the needs of individuals with mental illness. This has led to unnecessary institutionalization and a further deepening of the daily risk of institutionalization for persons in need of mental health services, in violation of the ADA's integration mandate.
In its 2009listenirig sessions report, the State concluded that, in recent years, "[a]s community capacity to serve more people declined, access to critical services became more difficult to get. More individuals found themselves in a system that could no longer meet their needs, some ending up in settings not designed to provide mental health care, such as the state corrections system and county jails." State Report at 17.
In its Ten-Year Plan, the State acknowledged that a number of factors have "eroded the current and future capacity of New Hampshire's system of care" for persons with mental illness. State Ten-Year Plan at 4.. For example, the State reported that funding for Medicaid services, the
14 This is not a neat comparison though, as we understand that the per diem figures for NHH and Glencliff include room and board, while the community figures do not. However, even adding a generous amount for room and board (assume $1,500.00/month) would only increase the community per diem cost by about $50.00/day, for a total of $170.00/day -- still far less than the $788.00/day at NHH. On the other hand, none of these figures reflect the increase in federal reimbursement through the Medicaid program that would be available to the State through community waiver and other funding programs; with institutional mental health care, like that provided at NHH, federal Medicaid matching funds are largely unavailable.
15 We understand that these recommended rates were never approved. The State informed us that the last community rate increase occurred on July 1,2009, from a per diem of $107.00/day to the current $120.00/day.

- 15 -

primary insurance for people with serious and persistent mental illness, has been restricted in New Hampshire as costs have increased. Id. at 5. The State concluded that the end result ofthis is less capacity to build additional community service options for a growing population that has more challenging needs. Id. The State reported that this will likely have a direct, negative effect . on outcomes, as research demonstrates, for example, that "decreasing appropriate outpatient services may contribute to disengagement from treatment, and an increase in symptoms and ability to do everyday tasks like caring for oneself or working, which results in increased frequency of visits to expensive emergency departments and often the need for hospitalizations." Id. Indeed, the State reported that "care in the middle and at the higher intensity end of the spectrum of treatment, including intensive outpatient care, residential care, and inpatient care, is not easily available to maily individuals with severe mental illness, resulting in an overburden on [NHH] and poor outcomes for individuals who are unable to access sufficient treatment choices to remain in the community or to be discharged from the hospital when ready." Id. at 4.

1. Acute/Crisis Beds

The State reported that inpatient and residential alternatives to NHH have diminished

over the previous 15 years in a number of specific ways. Id. at 5. In its 2011 block grant

application, the State acknowledged that the number of inpatient psychiatric beds available has

dropped from a total of 814 beds in 1990 to 496 beds in 2008, and that more psychiatry units

have closed and additional inpatient beds have been lost since then. State Application at 101.

The State recognized that there is New Hampshire and that this has

a "paucity" of hospital-based psychiatric care in rural put a "significant strain" on the local hospitals. Id. at

1a6re6a.s16of

The State characterized the situation as a "crisis," and, according to the New Hampshire Hospital

Association, reported that:

there were 236 voluntary inpatient beds in 1990, but only 186 such beds in 2008;17

over the previous eight years~ the number of community Designated Receiving Facility ("DRF") beds had "decreased dramatically" from 101 to 8 DRF beds (at just one hospital);18 and

16 The State acknowledged that it is a challenge for persons with mental illness in rural areas of the state to access needed mental health care and services: "Small rural hospitals do not have all the resources to treat mental illnesses, forcing patients to be stabilized then transported elsewhere for care." State Application at 100.
17 More recent State documents reveal that as ofFY 2009 (the most current figures available), this number has been reduced even further to 169 voluntary beds.
18 The State acknowledged that, because DRF care is now only available at one hospital, the State is lacking regional capacity for inpatient voluntary and involuntary care. State Ten-Year Plan at 12.

- 16 -
over the previous eight years, the number of Acute Psychiatric Residential Treatment Program ("APRTP") beds had decreased from 52 to 16 APRTP beds (now only located at the Cypress Center in Manchester as part ofthe CMHC there).
State Ten-Year Plan at 5, 11.
By the end of the current fiscal year, the State's Ten-Year Plan called for the creation of 12 new crisis beds, 10 new community beds for persons with co-occurring disorders, six new community beds for high-risk individuals, and 12-16 new DRF beds. Although the State informed us that it has requested additional funding for crisis/acute beds and services, it could provide no assurance that these requests will be approved. As a result, we are left with the current numbers which reveal that since FY 2008 (the time of the creation of the Ten-Year Plan), acute/crisis bed capacity in the community has dropped by at least 22 beds.
2. Community Housing
In addition, pursuant to the terms of its Ten-Year Plan, by the end of the current fiscal year the State was to have created 52 additional residential group home beds in the community. However, the State informed us that in the last five years, it had created a total of only 17 new supported housing beds at two locations, while closing 56 beds. Therefore, instead of adding to the community residential bed capacity in New Hampshire, the State has reduced community residential beds by 39. 19
In its Ten-Year Plan, the State admitted that "lack of safe, affordable and stable [community] housing is an increasing problem for individuals with serious mental illness in New Hampshire." Id. at 6. Indeed, during the State-sponsored listening sessions, a top official from BHH concluded that "we have some people at NH Hospital because they can't find housing." State Report at 6. The State has admitted that sufficient formal supported housing is not available to most persons with mental illness in New Hampshire and that home-based community services need to be "further developed to meet the current need." State Ten-Year Plan at 8.
The State has recognized that the lack of supported housing increases the risk of institutionalization. The State has declared that, for the individual struggling with the daily challenges of a serious mental illness, a lack of housing "leads to greater levels of impairment, more difficulty in accessing services and supports, and a loss of stability which leads to . subsequent hospitalizations." Id.
The State had concluded that housing for individuals with mental illness in their communities largely "evaporated" as rental costs increased, so the State's BBH created a housing
19 We note that group homes are not likely the most integrated setting appropriate for many NHH and Glencliff residents. Nevertheless, they are more integrated settings than those institutions.

- 17 -
transition program with bridge funding to cover reimbursement gaps. State Report at 17?0 One of the goals of this program is to show that a housing subsidy bridge program is a more clinically-effective (and cost-effective) model than institutional care. Id.; State Application at 97. The State informed us that this program was designed to increase access to safe, affordable housing for adults with serious mental illness, especially those who are homeless or at risk of . homelessness. The State reported that 37 individuals enrolled in the first 12 months of the bridge subsidy program, with half coming from NHH.
E. AdmissionslReadmissions Data Reveals Undue State Reliance on Institutional Services for Qualified Persons with a Disability
1. NHH
Because of the State's lack of community services, people with mental illness are forced to obtain mental health services in an institutional setting, in violation ofthe ADA. Admissions to NHH are high. The State reported that there were a total of2,380 admissions to NHH in FY 2010, and that there has been a steady increase in NHH admissions in each of the last five fiscal years. The high and increasing number of admissions each year reflects the need for enhanced community mental health services to address mental health concerns, especially when an individual goes into crisis. Indeed, individuals are typically admitted to NHH directly from local hospital emergency departments because they are in crisis.
The State acknowledged: "What was once a nationally recognized model of care ... began to decline in recent years. Admissions to NH Hospital doubled during a IS-year time period and the census of the hospital increased by 50%. The state lost over 100 psychiatric inpatient beds in local community hospitals, resulting in more admissions and demand for services at a facility that was already at maximum capacity." State Report at 13, 16-17.
The high number of institutional admissions typically reveals that individuals' needs are not being met in the community, often because of a lack of capacity. This is consistent with the State's own conclusions in recent years. Indeed, in its Ten-Year Plan, the State reported that the "primary finding" of its taskforce was that many individuals have been admitted to NHH because they have "not been able to access sufficient [community] services in a timely manner (a "frontdoor problem") and remain there, unable to be discharged, because of a lack of viable community based alternatives (a "back-door problem")." State Ten-Year Plan at 6.
The State's readmissions data reinforce this conclusion. The State informed us that scores of persons are admitted to and discharged from NHH multiple times each year, in search of effective treatment for their mental illness. The State informed us that its overall NHH readmission rate of about 33 percent is higher than the comparable national average of about
20 The State informed us that, thus far, much of the funding for this initiative has come from federal stimulus funds. Although this federal funding stream is ending, the State informed us that it expects to be able to continue the program going forward.

- 18 -
20 percent.21 Readmissions to NHH within 180 days of discharge represent about one-third of the annual admissions. In FY 2008,230 persons were readmitted to NHH a total of about 700 times; all 230 persons had a minimum of two readmissions and at least one person was readmitted to NHH 25 times. The State estimated that about one-third of those readmitted that year had four or more readmissions to NHH. Thus, certain critical supports and services necessary to keep persons stable and healthy in the community and away from institutional care are often not present in the State's mental health system. These deficiencies cause unnecessary institutionalization and create an undue risk of institutionalization that violate the ADA.
In its 2011 block grant application, the State acknowledged that adult 30-day and 180-day readmission numbers to NHH have worsened in recent years; for example, the number of adult NHH readmissions within 180 days of discharge increased about 73 percent from FY 2008 to FY 2009. State Application at 119, 120. The State cited a number of factors as causing an increase in readmissions to NHH: limited housing and community supports post-discharge combined with the increased need for inpatient psychiatric beds as the number of inpatient beds has been decreasing. Id. The State recognized that the lack of adequate, safe, stable, and affordable housing is likely to be detrimental to supporting resiliency and recovery for individuals with serious mental illness. Id. at 132. Certainly, repeated institutionalization makes it difficult for persons with mental illness to maintain apartments, jobs, and relationships in the community.
2. Glencliff
The admissions data for Glencliff stand in stark contrast to that for NHH. The State reports that in 2010, there were only 15 admissions to Glencliff. The average number of admissions to Glencliff from 2006 through 2010 was about 17 per year. While we were onsite, Glencliff officials informed us that about 60-70 percent of Glencliff admissions now come from NHH, and that this is an improvement from prior years where the percentage was about 85 percent. The State also informed us that there is a waitlist of about two dozen people who are seeking admission to Glencliff.
Glencliff readmission numbers are small; the State reported that no individual discharged from Glencliff has returned to the facility since April of2008. The State informed us that, since 2000, a total of seven persons discharged from Glenclifflater returned -- two individuals returned in 2008; two individuals returned in 2007; and three individuals returned in 2004.
Nonetheless, as referenced earlier, the acknowledged lack of capacity in the State's community system to serve persons with mental illness and/or developmental disabilities, especially those with complex health care needs, places increased emphasis on providing needed services to these individuals in an institutional setting like Glencliff. Naturally, community capacity limits would tend to create undue institutional pressure and impact on the State's' PASRR process, which is supposed to keep persons with mental illness andlor developmental disabilities out of institutional nursing home settings whenever possible. Sometimes, capacity
21 The NHH readmission figure includes individuals who had been released from the facility on a conditional discharge who then did not receive adequate services and supports in the community, thus necessitating re-institutionalization.

- 19 -
limits even prompt nursing home admissions of younger individuals. Indeed, the State's admissions data for Glencliff reveal that in recent years, it is tending to admit individuals who do not fall within traditional "frail elderly" parameters. For example, in 2009 and 2010, Glencliff admitted 37 persons, and about two-thirds of these individuals were 64 years old or younger, including 21 persons in their 40s or 50s. Glencliff is not exclusively admitting younger individuals, though; it admitted eight persons age 70 or older in 2009 and 2010.
F. Data on Length of Stay in State Institutions Reveals Unnecessary and Prolonged Institutionalization of Qualified Persons with a Disability
1. NHH
The State informed us that the majority of individuals admitted to NHH are discharged within 30 days of admission.22 Nonetheless, the State has acknowledged that, once admitted to NHH, almost a third of the individuals remain "longer than necessary." State Ten-Year Plan at 6. The State recognized that the doubling of admissions to NHH and the more than 50 percent increase in the NHH census occurred because "a number of individuals have stayed longer at [NHH] ... as community-based options for intensive treatment have declined." Id. at 4.
The State informed us that in FY 2010, for those who were in residence for less than a year, the average length of stay at NHH was 71 days. For those in residence for more than a year though, the average length of stay was 1,383 days, or more than three-.and-a-halfyears.
The State informed us that there are 31 persons who have remained at NHH for over one year, and of these, 17 individuals have been held for longer than two years. A number of these individuals have been involved in serious incidents, including those that involve law enforcement; a small sub-group has been determined at some point to be "not guilty by reason of insanity." Many individuals have complex mental health issues. In its Ten-Year Plan, the State explained that individuals such as these have lived at NHH for "prolonged periods of time" because adequate community housing and treatment alternatives are "not available." State TenYear Plan at 6. The State explained that the "scarcity of high intensity community resources, including supervised residences and intensive community treatment" is one of several "barriers to discharge." Id.
The State also admitted that about half of the persons with developmental disabilities at NHH remained there "longer than required" to provide acute evaluation and stabilization of their presenting psychiatric symptoms. Id. at 14. The State informed us that at least four of the individuals who have resided at NHH for more than a year have a developmental disability and that three of these individuals have been institutionalized at NHH for over seven years each. In its Ten-Year Plan, the State acknowledged that half of the individuals at NHH with developmental disabilities were "unable to be discharged due to a lack of residential placement or insufficient specialized community services." Id. The State reported that the majority of
22 The 30-day metric is important, as around this time, an institutionalized person is at greater risk of losing comniunity housing and other supports while away from a community home.

- 20-
these persons experience behavioral disturbances that require a high level of structure and support that it claimed is currently only available at NHH; but the State admitted that these individuals could be served in the community with appropriate services. Id.
2. Glencliff
Once again, the situation at Glencliff is decidedly different from that at NHH. Whereas a large number of individuals regularly enter and leave NHH, individuals who enter Glencliff typically stay for prolonged periods, without much prospect for discharge to the community. This implicates State compliance with the ADA.
For some time at Glencliff, the overall average length of stay per person has been over five years; this is true both for individuals currently at Glencliff and for those who have been discharged or died. Some individuals have lived at Glencliff for decades; the State informed us that as of the end oflast year, there were about a half-dozen individuals who have lived at Glencliff for over 20 years (with a total of 15 who have lived there for over ten years).
Some ofthese individuals at Glencliff have been involved in serious incidents over the years and many have complex physical and mental health concerns. However, in general, other than age in some cases, it does not appear that the individuals at Glencliff present any novel or different set of disabilities than their peers at NHH -- all of whom are at least nominally in the active, State-endorsed pipeline towards placement in a more integrated community setting. Given this, it is unclear then why similar placement efforts are not, and have not been, underway for the individuals at Glencliff. Certainly, maintaining individuals with mental disabilities unnecessarily in institutional settings violates the ADA, and is inconsistent with the State's own mandates, which require service in the least restrictive environment in the community. See RSA 135-C:l, II (the State's service system is to provid~ "adequate and humane care to severely mentally disabled persons in the least restrictive environment," and is to be directed toward "eliminating the need for services and promoting individuals' independence"); State Application at 37 (the objective of all programs in the State's system is the "reintegration of all persons into the community); Id. at 47 (State shall promote "respect, recovery, and full inclusion").
The State is maintaining two distinct and very different practices with regard to discharge planning and placement at the two facilities. The State informed us that at NHH, "[a]t the time of admission, there is a focus on developing a discharge plan for return back to the community, in collaboration with the individual, hislher family and the local community mental health center." But, at Glencliff, there appears to be virtually no immediate focus on discharge planning. Instead, the State takes a passive approach, generally not pursuing discharge and placement efforts unless and until a particular individual affirmatively asks for them. During our onsite visit, we learned that there was no meaningful discussion of community placement in any individual's regular Plan of Care meetings at Glencliff if the person does not expressly request it. As a result, team-driven placement plans are typically not developed or implemented for all but a handful of individuals at Glencliff each year. At best, it appears that there may only be a summary reference to placement status or interest in an individual's chart in the Plan of Care document, the Minimum Data Set ("MDS") data, and/or in the Social Services Progress Note section. In any event, this discharge planning is inadequate and a violation of the ADA.

- 21 -
The Glencliff placement data reinforces this conclusion. The State reported that no individual housed at Glencliff was discharged to a community residence in all of 2010, and that only one person was placed in the community in 2009. The only person discharged from Glencliff in 2008 was placed in NHH, perhaps an even more segregated and institutional setting than Glencliff.
The State reported that in the past ten years, from 2001-2010, a total of only eight individuals from Glencliff were placed in what the State designated as a community setting, and one of these individuals returned within two months of placement. This averages to less than one community placement per year from Glencliff. During this same ten-year period, the State reports that 11 individuals housed at Glencliff were placed in NHH or some other facility; all three of the people placed in an "other" facility though, eventually returned to Glencliff.
We find it troubling that in recent years, far more individuals housed at Glencliffhave died each year than have been placed into community settings. For example, in 2009, one person was placed in the community from Glencliff, but 16 individuals died.
G. Some Placements from NHH May Not Be to the Most Integrated Setting
Although many individuals are placed in private residences or households in the community, we are concerned that part of the State's community system relies heavily on congregate housing resembling institutions. The State reported that it currently utilizes about two dozen community group homes with an average census of about 11 persons per site; one unlicensed home in Manchester serves 23 persons at one location. The large census size of such group residences typically renders them more institutional, less therapeutic, and, as a result, often unable to meet the needs of many persons with serious mental illness.
It is also of concern that about ten percent of the individuals discharged from NHH in FY 2010 were sent to homeless shelters, j ail or other correctional facilities, or other residential or institutional settings. Indeed, in FY 2010, there were 687 persons served in the State's mental health system who were homeless or in a shelter. Consistent with the State's conclusions referenced above, without community housing, individuals with mental illness who are discharged to, or are at times living in, a homeless shelter are at increased risk of institutionalization going forward.
H. The State Has Developed Inadequate Assertive Community Treatment Team Resources to Prevent Unnecessary Risk of Institutionalization for Qualified Persons with a Disability
The State seems to recognize that in order to build needed capacity in the community so as to reduce the risk of institutionalization and to generally improve individual outcomes, it needs to expand its Assertive Community Treatment ("ACT") program.
ACT is a team-based model of providing comprehensive, intensive, and flexible treatment, services, and supports to individuals with mental illness, when and where they need

- 22-
them - in their homes, at work, and in other community settings - 24 hours a day, seven days a week. ACT teams combine treatment, rehabilitation, and support services from professionals in a variety of disciplines, including but not limited to, psychiatry, nursing, substance abuse, and vocational rehabilitation. ACT is often intended for persons with severe mental illness who are at an elevated risk of inpatient hospitalization. Often these persons have high rates of cooccurring substance-related disorders, health care issues, and social risks such as poverty and homelessness. When ACT teams operate with high fidelity to established evidence-based practice models, they can reduce the risk of institutionalization and improve the quality of life for persons with mental illness, especially those with severe mental illness. 23 The Dartmouth ACT Scale, for example, is a widely-recognized tool for measuring the fidelity of ACT teams.
As part of its statewide evidence-based practice initiative, New Hampshire has begun to develop ACT teams to provide more proactive services and supports to persons with mental illness who live in the community. In its Ten-Year Plan, the State reported that ACT has been shown to be effective at helping individuals with serious mental illness manage their illnesses while living independently in the community: ACT reduces homelessness among those with serious mental illness, and ACT reduces hospital use and enhances the ability to maintain employment among persons with frequent hospitalizations. State Ten-Year Plan at 13. In its 2011 block grant application, the State again made this point, reporting that ACT teams in New Hampshire have made a positive "impact on the quality of life" for some individuals with mental illness with increased or high-volume hospitalizations, those who have experienced homelessness, or have had a high number of legal and police involvement incidents. State Application at 89-90.
Through FY 2010, the State informed us that it had created six ACT teams - three adult teams in the Northern region, one adult team each in the Nashua region and the Manchester region, and one children's team in the Riverbend region (Concord). The State has taken steps to add an adult team in Riverbend and an adult team in the Center for Life Management ("CLM") region (Derry). Even with these two new teams, that would still leave no ACT team in five regions - half of the ten total regions throughout the state. This is important, as we understand that ACT teams from one region do not provide services and supports to persons in need in other regions, even if they are geographically nearby. As a result, many thousands of persons with mental illness in New Hampshire do not even have the ability to access ACT team services, a foundational bedrock support upon which the State is looking to reform its community-based service system.
The need to provide more proactive ACT team services to persons with mental illness in the community is a pressing issue, given the worsening readmission numbers at NHH and the increased use of inpatient psychiatric beds at NHH. Moreover, the State informed us that the
23 In its Ten-Year Plan, the State concluded that "[w]hen delivered with good fidelity to the model," ACT has been demonstrated to reduce psychiatric hospitalization rates for individuals with severe mental illness and to improve other outcomes. State Ten-Year Plan at 13. In its 2011 block grant application, the State re-emphasized that evidence-based practices are "known to be effective, when practiced with fidelity to the model." State Application at 121.

- 23 -
number of individuals receiving emergency services from CMHC Emergency Service Teams has increased over 16 percent from FY 2006-2010, totaling more than 10,000 individuals served in an emergency in FY 2010 alone.
In its Ten-Year Plan, the State called for the creation of five additional ACT teams by the end of the current fiscal year. Given that there were four ACT teams in FY 2008 (at the time of the creation of the Ten-Year Plan), that means that there should be nine ACT teams by the end of June 2011. With only six ACT teams, however, the State is far from its plan.
During our onsite visit, the State informed us that ACT teams in New Hampshire generally include, among other professionals, two Master's-level clinicians, a designated psychiatrist, and some nursing support. However, it is not clear that the New Hampshire ACT teams are currently operating with full fidelity to the ACT model. For example, the number of psychiatry hours appears to be somewhat limited in the New Hampshire ACT teams that are already operating. For example, the State informed us that the Riverbend children's team only has access to 0.15 Full-Time Equivalent ("FTE") of psychiatry, the Nashua adult team has access to 0.20 FTE of psychiatry, and the three Northern adult teams each only have access to between 0.07-0.20 FTE of psychiatry. The number of nursing hours are similarly limited, for example, never amounting to a full FTE at any of the ACT teams in Riverbend or Northern.
In spite of some important limitations, the State reported to us that as a result of its ACT initiatives, it had achieved very positive outcomes for individuals served thus far, including reduced admissions to institutions like NHH, and reduced visits to local hospital emergency rooms. For example, the State reported a 78 percent reduction in hospitalizations after its Riverbend children's ACT team began operations. The State also reported that in the first year of ACT in the Northern region, the annual bed day utilization dropped in half, from over 6,000 bed days per year to about 3,000 bed days per year. With regard to the Nashua region, the State informed us that, comparing the one-year period prior to ACT with the one-year period after ACT, the number ofhospit<itlizations dropped from 37 to 22, and more dramatically, the number .of inpatient days dropped from 1,454 days to 245 days - a notable 83 percent reduction.
Not only does the State recognize that ACT can promote positive outcomes for persons with mental illness, the State has also reported that ACT is fiscally prudent: when considering the overall cost of services, ACT is "cost-effective" for frequently hospitalized individuals, as one month of care at NHH costs a bit more than the cost for an entire year of ACT. State TenYear Plan at 14. Moreover, during our onsite visit, the State informed us that almost half of the cost of an ACT team is borne by the federal government through the Medicaid program. By comparison, the State reported that in FY 2010, Medicaid paid for less than five percent of total expenditures at NHH.
I. The State Fails to Provide Adequate Integrated Employment Opportunities for Qualified Persons with a Disability
The State is not currently meeting the needs of persons with mental illness who need adequate and appropriate employment opportunities in integrated community settings. These opportunities can arise in a variety of contexts, but typically involve employment in the private

- 24­
sector in the open market. The State reported that only 21.5 percent of adults in the mental health system are competitively employed to some extent. State Application at 130. The State reported that only 7.8 percent of adults with severe mental illness received supported employment services in FY 2009. rd. at 123.
The State provided us with its recent State Health Authority Yardstick ("SHAY") evaluation for supported employment in the state. NH SHAY Evaluation, Update on Recommendations, Janmiry 2011. The State informed us that it has addressed all of the recommended areas from this evaluation. However, the evaluation document primarily focused on process elements such as improving training efforts and written policies and regulations. There was nothing in the document that referenced increases in the number of persons with mental illness actually working in competitive andlor supported employment across the state. The positive momentum that may have been generated through this SHAY evaluation will only have meaning if outcomes have been achieved in that more persons are actively engaged in employment activities in integrated community settings.
V. RECOMMENDED REMEDIAL MEASURES
To remedy its failure to serve individuals with mental illness in the most integrated setting appropriate to their needs, consistent with the mandate of Title II of the ADA and its implementing regulations, the State should promptly implement the minimum remedial measures set forth below:
• The State should develop and implement a plan to address the already identified "unmet needs" and "weaknesses" in the State's mental health system that contribute to negative outcomes for persons with mental illness, such as the day-to-day harm associated with improperly andlor under-treated mental health conditions, needless visits to local hospital emergency departments, needless admissions to institutional settings like NHH and Glencliff, and the serious incidents that prompt involvement with law enforcement, the correctional system, and the court system. The State should develop and implement effective measures from its Ten-Year Plan that support this goal.
• The State should provide a sufficiently rich mix of supports and services for persons with disabilities, including mental illness, so as to support positive individual outcomes such as to minimize or eliminate the harm associated with improperly or under-treated mental illness, to minimize or eliminate institutionalization and the undue risk of institutionalization, to minimize or eliminate emergency room/hospital visits/admissions, and to minimize or eliminate serious incidents involving law enforcement, local jails and correctional facilities, and the court system. The State should develop and implement effective measures from its Ten-Year Plan that support this goal.
• The State should expand less expensive and more therapeutic community placements, with adequate and appropriate services and supports, as an effective alternative to the costly and less therapeutic institutional care offered at NHH and Glencliff.

- 25-
• The State should expand community capacity throughout the state so as to minimize or eliminate unnecessary institutionalization, prolonged institutionalization, and a heightened risk of institutionalization, and to reduce the risk that some qualified persons with a disability will end up in undesirable settings not designed to provide mental health care, such as the state corrections system and the county jails.
• The State should expand the number of inpatient and residential acute/crisis bed alternatives to NHH and Glencliff that have diminished in recent years.
• The State should expand safe, affordable, and stable community housing, including supported housing, for persons with mental illness in New Hampshire, so as to prevent greater levels of impairment, more difficulty in accessing needed services and supports, a loss of stability, and a greater risk of hospitalization and/or institutionalization. To this end, the State should increase the availability of community residential supports through formal supported housing programs, specialized housing with high-intensity community resources (especially for those with complex physical and/or mental health conditions that have led to serious incidents and/or past involvement with law enforcement), an adequate housing subsidy bridge program, and new short-term acute/crisis support beds, to meet the needs of persons with disabilities, including mental illness, in its mental health system in the most integrated community setting. Supported housing should provide individuals with their own leased apartments or home, where they can live alone or with a roommate of their choosing. The housing is to be permanent (e.g., not timelimited) and is not to be 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. Group homes should not constitute supported housing. The State should ensure that individuals in supported housing have access to a comprehensive array of services and supports necessary to ensure successful tenancy and to support the person's recovery and engagement in community life, including through ACT services.
• The State should ensure than any and all remedial plans cover and impact all individuals who are in or at risk of entering NHH, Glencliff, or other restrictive institutional settings.
• The State should create sufficient ACT teams to ensure that the needs of persons with disabilities, including mental illness, in the community are met and that undue risks of institutionalization are minimized or eliminated. 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 effective ACT models. At a minimum, there should be adequate ACT team services in each of the ten state regions. 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 indi"idual over time. ACT teams should have the full array of staff on each team that are 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

- 26-
successfully in the community. ACT teams should provide crisis services, including helping individuals increase their ability to recognize and deal with situations that may otherwise 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, seven days per week. Finally, the number of individuals served by an ACT team should be no more than ten individuals per ACT team member.
• The State should provide adequate integrated vocational services to qualified individuals with a disability through supported employment programs, the access to which should be facilitated by ACT teams. Supported employment services should assist individuals in finding competitive and other employment in an integrated setting based on the individual's strengths and interests. Supported employment programs should assist individuals in identifying vocational interests and applying for 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 to be integrated with the individual's mental health treatment. Enrollment in congregate day programs does not constitute supported employment.
• The State should expand upon the current community structure so as to create an effective statewide crisis system. The State should enhance crisis stabilization programs operated by community providers so that they provide psychiatric stabilization and detoxification services as an alternative to psychiatric hospitalization. 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 develop and implement criteria to assess the adequacy of the individualized supports and services provided to persons by CMHCs to see whether their efforts are: reducing repeated admissions to institutional settings; increasing the stability of community residences; 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 develop and implement a plan to promptly discharge all persons with a developmental disability at NHH and Glencliff to an integrated community setting that meets their individualized needs, including their need for habilitation, health care, and, where applicable, mental health care.

- 27-

VI. CONCLUSION
Please be aware that this is a public document. Although we have already had some preliminary discussions about needed remedial steps, we now hope to engage the State in a more in-depth dialogue about remedies in the context of structured negotiations. Ultimately, we hope to be able to reach agreement with the State on a written, enforceable, voluntary compliance agreement that would set forth the remedial actions to be taken within a stated period of time to address each outstanding area. Such a disciplined remedial structure would provide all interested parties with the greatest assurance that discrimination will not recur.
If the State declines to enter into voluntary compliance negotiations or if our negotiations are unsuccessful, the United States may then need to take appropriate action, including initiating a lawsuit, to obtain redress for outstanding concerns associated with the State's compliance with the ADA. Nonetheless, as referenced above, we are encouraged by our interactions thus far with State leadership, and hope there is a desire to work with the United States toward an amicable resolution here.
Thank you again for your ongoing cooperation in this matter. We will contact you soon to discuss the issues referenced in this letter and to set a date and time to meet in person to discuss a remedial framework in which to address any outstanding individual and systemic concerns. If you have any questions, please feel free to contact Jonathan M. Smith, Chief of the Civil Rights Division's Special Litigation Section, at (202) 514-5393, or Richard Farano, the lead attorney assigned to this matter, at richard.farano@usdoj.gov, and/or (202) 307-3116.
Sincerely,
~i.co

cc: Anne M. "Edwards Associate Attorney General Chief of Civil Litigation Department of Justice State of New Hampshire
Michael K. Brown Senior Assistant Attorney General Department of Justice State of New Hampshire

Thomas E. Perez Assistant Attorney General

John P. Kacavas United States Attorney District of New Hampshire
John Farley Assistant United States Attorney District of New Hampshire

- 28-