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Here’s how agencies plan to succeed
Your mission, should you chose to accept it, is to use $10 million in state taxes to provide integrated services to the homeless and mentally ill in your community in an effort to keep them off the streets and out of the criminal justice system. Here’s the catch: To retain your state funding, you must prove that you’ve made a signifi- cant improvement in the health and function of this population in roughly six months.
Would you accept this assignment? Two mental health service providers in California say they are up to the challenge. The Turning Point Community Programs in Sacramento and The Village Integrated Services Agency of the Mental Health Association of Los Angeles County in Long Beach have accepted the challenge presented them by California state legislators and are actively working to develop a service model that keeps the homeless, mentally ill off the streets and on the road to rehabilitation.
AB 34 was signed in mid-October 1999 and the two agencies primarily responsible for developing the pilot programs have hit the ground running. Turning Point Community Programs, which is running AB 34-sponsored programs in Sacramento and Stanislaus counties, received its AB 34 funding the first of November and already had enrolled and housed 17 clients by the third week of that month — just a small start on the projected 100 clients it will eventually serve.
"We’ve been working at a fast and furious rate," says John A. Buck, MBA, executive director of the Turning Point Community Programs in Sacramento. "This legislation is beyond anything previously attempted in mental health. The legislation was just passed and we have to show objective and measurable results by May 2000. We didn’t have time to sit and talk about how this should be done. We had to bolt ahead," he notes. (For information on how AB 34 providers plan to measure outcomes, see story on p. 8. For more on the bill and how it was passed, see p. 10.)
"AB 34 is the most exciting development in mental health care in this country in recent years. It means more agencies are going to involved in an integrated service model that is really designed to rehabilitate the mentally ill, not warehouse them," says Richard Van Horn, president of the Mental Health Association in Los Angeles County, which operates The Village Integrated Services Agency. "We’re ready for the challenge."
Seeking an edge
The need to show results before the next state budget cycle in May of this year led the State Department of Mental Health to turn to experienced providers with a proven track record to run the three pilot programs authorized by AB 34, notes Vince Mandella, BS, chief of adult systems of care for the California State Department of Mental Health in Sacramento.
"Given the short time span, we had to look for an edge. Both Turning Point and The Village have a long history of providing community-based mental health services. We knew by turning to them, it would take very little for these agencies to piece together services they already had delivered to other populations and move down the road to success. Under the circumstances, we couldn’t select providers we had to spend time explaining how to do this. We needed folks who could begin the minute the funding arrangement was completed."
The Village has a 10-year history of providing capitated, community-based, mental health services to the seriously mentally ill. "When we first started, Los Angeles County was spending an average of $23,000 and change annually [per patient] on services to the seriously mentally ill with 71% of the population in 24-hour care. We changed that to an average of $17,000 a year with only 17% in 24-hour care."
Turning Point provides a similar program for the seriously mentally ill in Sacramento and Stanislaus counties. Both Buck and Van Horn attribute the success of their programs to an integrative approach to mental health services that addresses the issues that often prevent the mentally ill from remaining stable and becoming productive.
The plan Turning Point presented to the state calls for an "active, assertive, ongoing partnership model with community resources, such as mobile assessment teams, medical teams, case management, and other service providers."
Specific targeted services identified in the plans written by Turning Point and The Village include:
• Housing. Clients will be assisted in choosing, getting, and keeping housing of their choice which is the most independent and least restrictive feasible in the community.
"Housing is a major focus of ours," says Buck. "It’s the first thing we address. It’s not to tell the client, You need a psychiatrist.’ It’s to say, "Where can you be comfortable and safe?’ Other needs are secondary to getting these folks temporary housing."
Finding that temporary housing for clients, has been a real challenge, he adds. "All of our folks are becoming housing experts. We have found places for clients in hotels, in apartments. We have to be very aggressive about finding housing, and it has to be appropriate housing. When it comes to finding temporary shelter, we could get a room at the Hyatt for $200 a day, but would our clients be comfortable there? Would the Hyatt be comfortable with our clients? We could also go to the other end of the spectrum and probably find space in some flea-bag motel, but is that where we want to put someone we are hoping to rehabilitate? No, we’re looking for mid-range options — Spartan, but clean and nice."
• Comprehensive wrap-around services. "This just means coordinating care with existing community service agencies, such as veterans’ services, consumer advocacy groups, and developing a homeless peer advocacy group — people have worked their way successfully out of homelessness to give hope to our clients," says Buck.
Clients are referred into the pilot programs through a variety of sources. In Sacramento and Stanislaus counties, most referrals come from outreach workers who actually walk the streets and levies along the Sacramento River talking to the homeless and offering them service options. "The outreach workers are part of a homeless project that marries law enforcement officers with outreach workers from community agencies such as the Vietnam Veterans and Volunteers of America," says Buck. "We are staffed 24 hours a day. If an outreach worker convinces someone to come in, we want someone there for them to talk to and a place ready for them to stay."
• Case management/brokerage services. "We must have case management to assure continuity of care and to help clients access mental health, medical, educational, vocational, social, legal, and housing services," notes Buck. "Case management services start with plan development and that means listening to the client’s needs."
The Village has been careful to avoid the term "case management," notes Van Horn. "The consumer movement, and particularly the mentally ill, hate the term case management.’ Consumers respond, I am not a case and I don’t want to be managed.’ Instead, we call care coordinators personal service coordinators.’ Most of our personal service coordinators are bachelor’s level people. We also have an RN, a LCSW, and a half-time psychiatrist on a team, with each team being devoted to 40 clients."
Van Horn notes that the psychiatrist never acts as team leader. "The team leader is appointed from within the team, but is never the psychiatrist. We don’t want our psychiatrists burdened with administrative work — they’re too expensive," he says, adding that teams meet weekly to discuss clients on their caseloads.
At The Village, team members share a work area that is completely without private offices. "We wanted all members of the team, even the psychiatrist, working as peers to provide care to the clients. It takes special people. Especially our doctors. They have to be fairly devoid of ego," says Van Horn.
"When you focus that kind of attention on clients, you really reduce your hospitalization usage. You know when trouble is starting and you can address it before a client completely decompensates. If you listen, this system works well. Most people given a free choice will chose health and well-being. If you are willing to listen to clients and take them seriously, they are probably going to make choices that move them towards health."
• Treatment of psychiatric conditions in appropriate settings. Settings identified by Turning Point include emergency care, crisis residential facilities, acute hospital care, skilled nursing facilities, day treatment facilities and transitional and long-term residential treatment facilities, notes Buck.
• Medication support services. "We have set up a system to prescribe, administer, dispense, and monitor psychiatric medications necessary to alleviate symptoms of mental illness," says Buck. "Most of our clients are convinced they need medications. We use education to improve compliance, especially those who are resistant because they were on heavy-duty medications with unpleasant side effects in the past. We can’t and don’t force our clients to take anything, even when we think it might help them. If we do, they will run."
Instead, Turning Point encourages its psychiatrists to spend extra time with each client convincing them that a particular medication may be worth trying. "We never tell a client that we will refuse service if they resist treatment. We also try to link them up with other clients who have successfully used a medication. Often, having another client say, I tried this medication, and it really helped. I have a house. I have a job,’ is more effective than the psychiatrist saying, I really think this medication will help you.’ We just get a better response from the client to peer counseling in many cases."
The Village takes a similar approach to the use of psychiatric medications. "Our goal is not complete symptom relief, but maximum functionality. We ask the client, what dose, what medication works to help you do what you want to do? We look at medication as series of choices that help the client reach established goals. If you take that approach, then compliance becomes a non-issue because the client is helping to make medication decisions."
• Specialized group and individual programming. "This is meant for dually diagnosed patients who are mentally ill and also have a substance abuse problem," notes Buck. "We really push the recovery model. Rehabilitation is what we do for the client. We teach. We train. We link them up with people who have been successfully recovered from substance abuse."
• Individual service plans. "We try to establish plans that include the client’s stated goals and strengthen the client’s competence over his or her own life. We look at cultural issues, independent living arrangements, education, and employment, and we always put the client’s needs first," notes Buck.
"Our philosophy from the initial contact on is to put the client first. Our approach is to ask what is it you need or want that will help you to get out of this situation. And, more times than not, their first answer is to ask for a pair of underwear and a pair of socks. When you’re homeless, underwear and socks take on great importance. We could provide psychiatric services first, but we would probably have people running right back to the streets because all they wanted was clean clothes and something to eat."
The Village has a similar philosophy. "Our bias is to put the consumer first. Our approach has been that whatever somebody needed or desired we should find a way to make it available," says Van Horn. "When we first started asking clients what they wanted, they usually answered that they wanted easier access to a psychiatrist and 50-minute therapy hours and not much else. They simply didn’t know what to ask for because they had never been offered anything else. We had to suggest to them that there were more things. We had to make them aware of the possibility of rehabilitation. How would you like a house? How would you like a job? How would you like a girlfriend? Those questions were not within their realm."
• Round-the-clock crisis intervention. Turning Point has set up a crisis line for crisis interventions to help cope with an emergency that might lead to a hospitalization, or other threat to a client’s maintaining status as a community member.
The Village even addresses crises by providing psychiatric house calls. "We have found that one well-timed house call can avoid a hospital stay. It could be to address an emergency or it could be a client who has simply developed a fear of leaving the house and is running out of medication. If the client says, I really can’t go anywhere,’ the doctor or the nurse, depending on the needs, brings the medication to the client and evaluates the situation."
"I’ve read the plans written by both The Village and Turning Point and what they plan to do is very exciting. Everything has been engineered to get these programs off to the best possible start. If we can show some improvement, with a relatively small, new program, it’s going to be fascinating," says Mandella.