Baltimore Mental Health Systems, Inc. (BMHS)

FY'99 Annual Report

(July 1, 1998 to June 30, 1999)

During FY'99 BMHS staff focused on improving the range of services and access to services. Some of the highlights of our accomplishments include the implementation of a crisis system for children, adolescents, and their families; increased referrals to Baltimore Crisis Response Inc. (BCRI) by the community and Maryland Health Partners (MHP); a continued expansion of school-based mental health services; providing training to the Public Housing Authority staff; working closely with MHP and providers to resolve billing and claims issues; and, the resumption of the capitation program.

In FY'99 there were 30,603 Baltimore City residents authorized for a service within the public mental health system. This is a 6% increase as compared to FY'98. A breakdown of the utilization of the public mental health system is included in Appendix I-IV.

In FY'99 the public mental health system budgeted $130,587,347 for all inpatient and outpatient mental health services for individuals on Medicaid or uninsured. A financial breakdown is included in Appendix V-VII.

The following were the FY'99 goals and BMHS's progress in accomplishing them.

A. Collaboration with Key Stakeholders

1. Schedule meetings with all COMAR regulated mental health providers for the purpose of addressing and resolving problems, identify gaps in the system, establishing priorities for new initiatives, and disseminating information.

Throughout the year BMHS staff met with providers of the public mental health system (PMHS) to assist them in addressing the service needs for Baltimore City residents. BMHS established quarterly meetings to create a regular forum for addressing problems and disseminating pertinent information. In addition, BMHS's staff regularly met with child and adolescent service providers, rehabilitation programs including residential providers, case management programs and providers of services to the homeless mentally ill.

BMHS and the Baltimore City Public School System (BCPSS) have worked throughout the year to strengthen the capacity of the BCPSS and school-based providers to bill for mental health services. Preliminary 1998-1999 school year data for the 66 school-based programs indicate that more than 4,400 students were newly referred for service. More than 10,000 different students (unduplicated client count) were seen by school-based mental health clinicians who provided more than 21,000 individual and more than 20,000 group contacts; contacts/consultations to teachers exceeded 8,500; and, more than 4,500 family contacts/sessions were conducted.

BMHS entered into several collaborative efforts to obtain Federal funding to address the unique needs of Baltimore City children.. These have included: a joint proposal to address and prevent school violence with the BCPSS, the Johns Hopkins University (JHU) - School of Hyiene and Public Health, the Department of Juvenile Justice (DJJ), the Family League of Baltimore City (FLBC), the Baltimore City Police Department (BCPD), the Baltimore City Health Department (BCHD), and numerous other school and community partners. Marcia Glass-Siegel and Dr. Raymond Crowel of BMHS were called on to develop the mental health component to the grant, which was submitted on June 1, 1999. A similar proposal to promote the healthy development of children aged 0-6 was written in collaboration with the FLBC, the Baltimore City Department of Social Services (BCDSS), the Safe and Sound Program and BMHS.

BMHS has recently joined with MHA and DJJ in an effort to improve the scope and quality of services provided to children and adolescents who are involved with DJJ.

BMHS collaborated with the Mental Hygiene Administration (MHA), and DJJ in the development of a multi-site proposal to the Governor's Office of Crime Control and Prevention. MHA received notice that the proposal will be funded in fiscal year (FY) 2000. This will help support a pilot program with the Woodbourne Center to provide services in a DJJ facility.

Other collaborative efforts that have taken place during the year have included the development and implementation of a child and adolescent crisis system. This effort is the product of a joint effort between BMHS, BCDSS, and FLBC. The crisis system began pilot operations in East Baltimore in June and is expected to become fully operational in the Fall of 1999. BMHS met with MHA and MHP regarding the development of a "bundled authorization" process that allows the Baltimore Child and Adolescent Response System (B-CARS) to contact MHP and request a broad array of crisis related services. This "bundled authorization" allows the B-CARS team to provide and bill for services without additional authorization request calls to MHP. This ensures a more rapid crisis response and reduces the load on the MHP Care Managers and clinicians.

BMHS addressed a variety of issues related to the development and implementation of the mental health system of care for children and families. Particular issues have included the development of non-fee-for-service projects to ensure that gaps in the fee-for-service system are addressed and to develop or expand new and existing programs such as Community Oriented Policing Services (COPS), Families Involved Together (FIT), and the National Alliance for the Mentally Ill's Living With Schizophrenia and Family to Family initiatives. These four programs were approved for funding by MHA as part of BMHS's FY'00 budget.

In April, Sharla Rice-Moore of BMHS assumed chairmanship of the Local Coordinating Council (LCC). As part of this change, the LCC and BMHS have begun conducting site visits to the in-State residential treatment facilities currently serving Baltimore City children.

2. Regularly meet with the Mental Hygiene Administration (MHA) and Maryland Health Partners (MHP) for the purpose of addressing and resolving issues, and influencing policies that affect Baltimore City citizens and providers.

BMHS regularly met with providers and MHP to help resolve billing and claims issues. Specifically, BMHS assisted Sinai Hospital, Liberty Medical Center, Urban Behavioral Health, Johns Hopkins Hospital, and the North Baltimore Center to address MHP issues and concerns. During the year, BMHS received 24 complaints (See Appendix VIII).

BMHS convened a meeting with the Outpatient Mental Health Clinics (OMHCs) in Baltimore City to address concerns of low reimbursement rates. A proposal to provide support for the OMHCs was submitted to MHA for FY'00.

BMHS met with MHA and the State Licensing and Certification (L&C) Division to further develop the policies and procedures for the new regulations for residential crisis beds. Although Baltimore Crisis Response, Inc. (BCRI) has been approved, how new providers will be selected and approved continues to need clarification. This will be addressed by an ongoing workgroup.

BMHS participated on a MHA and Developmental Disability Administration (DDA) sponsored workgroup that recommended that a mobile admission diversion team be developed and piloted to improve clinical outcomes for individuals with developmental disabilities who may be in need of acute mental health evaluation.

BMHS developed a plan for FY'00 that would reimburse general hospitals for psychiatric consultations provided for Medical Assistance (MA) and uninsured (grey zone) consumers by non medical doctors and mental health professionals in the hospitals' emergency rooms (ERs). This plan will be implemented by October 1999 in Baltimore City.

BMHS worked with MHP and MHA to develop the composition of reports to be developed by MHP for the Core Service Agencies (CSAs). Much of this work is on hold as MHP will be operating with new and expanded management information system (MIS) hardware and software by early FY'00.

3. Continue to work with other local and state agencies to develop and maintain collaborative projects.

BMHS participated on a workgroup for the Baltimore City Circuit Court (BCCC) to improve the existing policy and procedures to assure that individuals with mental illness who are to be transferred from the Baltimore City Detention Center (BCDC) by order of the BCCC are transported immediately.

BMHS developed and implemented a comprehensive plan for Baltimore City to reduce the number of City residents living in one of the State psychiatric facilities. The initiative is the Community Enhancement Initiative (CEI). The goal set by MHA was that the number of City individuals in Spring Grove and Springfield Hospitals be reduced by 33 in FY'99 and even more in the following fiscal year. To achieve this goal, individuals would move out of Residential Rehabilitation Programs (RRPs) into supported living settings which would create vacancies for State hospital individuals to move into. The plan also called for the development of two handicap accessible group homes, one earmarked for geriatric individuals. The two capitation programs also would be responsible enrolling individuals discharged from State hospitals into their programs. BMHS was fully funded for this plan by MHA. Of the 33 individuals targeted to move out by the end of June 1999, 20 were to go to RRPs and 13 were to go to capitation programs. With only the last quarter of FY'99 to accomplish this goal, Baltimore City providers managed to move 18 individuals into RRPs and nine individuals into the capitation programs. This represented an 81% success rate. BMHS is monitoring the project closely and tracking the status of each person in the CEI.

BMHS's Director of Geriatric Services represents the PMHS on the Interagency Aging Committee (IAC), chaired by the Commission on Aging. Primary activities have included:

• Participated on the Triad Committee to improve collaboration between the Baltimore City Police Department (BCPD) and the sheriff's department, the American Association for Retired Persons (AARP) and the providers in the aging service network. Provided training to one Neighborhood Service Center (NSC) and has scheduled one training with BCRI in August (See Appendix IX).

• Participated in two trainings for the Commission on Aging Guardianship Unit (CAGU). This has resulted in the planning of a workshop for hospital discharge planners and guardianship programs to clarify roles, responsibilities and to improve collaborative efforts to transition individuals from inpatient units to the appropriate community settings.

• Chaired a clinical subcommittee to address the needs of complex and difficult multi-agency connected elderly individuals (See Appendix X). Since December, the committee has staffed nine individuals with follow-up from referring agencies.

• In addition, BMHS continues to participate on the Mental Health Association's "Coalition on Mental Health and Aging," the MHA's "Geropsychiatric Transition Project," and the "Maryland Psychogeriatric Outreach Network".

BMHS continued its collaboration with Baltimore City's Office of Homeless Services (OHS). OHS's grant award from the Department of Housing and Urban Development (HUD) included funding renewals for case management and mobile treatment services for homeless individuals who have a mental illness. FY'99 marked the first year of HUD funding for the Presumptive Eligibility for Federal Entitlements program at the University of Maryland.

B. Planning

4. Conduct a provider satisfaction survey by December 1, 1998.

The survey was completed and results presented to BMHS's Board of Directors and PMHS providers in April (See Appendix XI). A detailed analysis was done of surveys from respondents who indicated being dissatisfied with one or more identified areas. BMHS' Quality Improvement (QI) staff will be contacting individual programs to learn more about their specific concerns. BMHS has taken several steps to make improvements that incorporate feedback from the survey, e.g., the development of a policy manual that will be available to providers, revision of the income documentation waiver policy and provision of training to providers.

5. Complete a needs assessment of elderly residents in State hospitals by November 30, 1998.

The needs assessment was completed in the second quarter and incorporated into MHA's CEI. The assessment is updated quarterly. Two individuals have been placed in the community with additional/new supports. One Not Criminally Responsible (NCR) client has been placed in a nursing home. One client at Spring Grove Hospital will require extensive interagency collaboration, specialized services and additional funding in order to return to the community.

Three individuals have been identified for potential placement in BMHS's new geriatric group home with extensive transition planning. Two more recent admissions have been identified for evaluation.

6. Community Housing Associates (CHA) to complete a satisfaction survey of its tenants by February 28, 1999.

This goal was not pursued at this time because CHA received a grant from the Maryland Association of Non-Profit Organizations (MANO) to complete a strategic plan on housing needs which includes a focus group with tenants. The Technical Assistance Consortium (TAC), a Boston-based group, has begun the study and will complete its report by November1999.

7. Develop a planning initiative for the design of a continuum of care for transitional youth.

BMHS's C&A and Adult Services staff have developed a proposal for transition aged youth (TAY) intended to promote the healthy transition from childhood to young adulthood for those currently in need of mental health services from the PMHS. The proposal was submitted to MHA for funding.

8. Complete the planning with the Family League of Baltimore for a demonstration capitation program for "high end" children and adolescents and a community crisis system.

This planning process has continued throughout the year and has evolved to address the many concerns of the stakeholders. While planning was not completed in this year, the collaborative group which includes MHA, FLBC, BCDSS, and DJJ will continue to meet.

9. Develop a community education program.

BMHS's QI staff worked with consumers, advocates, providers, and others to develop a plan for working closer with community organizations to educate the residents of Baltimore City about the PMHS. This included developing BMHS's first brochure and distributing it throughout the community. Other printed materials were developed (magnets, post cards) and distributed (Enclosed). Steps were initiated to seek approval to place stickers with BCRI's telephone number in the BCPD's patrol cars. Negotiations for this initiative continue. The education plan also includes working with the nine neighborhood service centers (NSCs). QI staff has scheduled presentations that will begin in Fall 1999 and will work with the Safe and Sound Program's youth ambassadors to get the message out about mental health.

C. Expanding the range of services

10. Increase the number of forensic individuals placed in the community.

During FY'99 there were a total of 149 individuals who were on conditional release as granted by the BCCCs. There were 96 individuals actively on conditional release prior to FY'99 who continued their conditional release through the end of the fiscal year, with 26 new individuals placed on conditional release during FY'99. During FY'99 nine individuals were revoked, thus, losing their release to the community status; and there was one death. Finally, there were 17 individuals who successfully completed their conditional release during the fiscal year.

The jail diversion program, Forensic Alternative Services Treatment (FAST) under the auspices of the Medical Services Division of the Circuit Court, continues to grow in the number of referrals of individuals who are appropriate for diversion from incarceration. A total of 900 individuals were screened by FAST; 94 individuals were released to the community and placed on monitoring status with linkage to community based mental health services. This brings the number of monitored individuals to nearly 200. FAST staff continues to assist families and interested parties with the filing of Emergency Petitions. Assistance with the filing of petitions was provided to 160 individuals who presented at Eastside Court.

With the agreement of MHA, all competency evaluations requested by the Baltimore City District Court are now being referred to the Walter P. Carter Center (WPCC) if the defendant needs to be admitted to an inpatient facility. By having all the evaluations performed at the WPCC, the wait in jail for an evaluation has been reduced from weeks to days. Additionally, six individuals were able to have their charges abated and mental health treatment continued.

11. Increase the number of consumers involved in paid employment.

During the past year, the supportive employment programs (SEP) have grown at Bayview Medical Center, Alliance, Inc. the Schapiro Training and Employment Program (STEP), People Encouraging People (PEP), Harbor City Unlimited, Transitions and Harford Belair. Each of the programs received grants to enable them to employ staff to develop community based competitive employment opportunities. There were 200 approved requests for vocational assessments and 190 requests for actual placements with job coaching. The number of employed individuals receiving job coaching through the Department of Rehabilitations Services (DORS) is not known. Ninety three individuals are known to be in jobs and receiving supported employment services through these eight SEPs. This is an increase of eight individuals over FY'98. BMHS believes that there is an even greater increase in the number of individuals whose support is reimbursed by DORS.

12. Continue to expand and monitor the impact of BCRI.

BCRI experienced an increase in referrals for its mobile crisis services and crisis residential beds this past year. MHP became a significant referral source and frequently made eight or more referrals each week. Due to the limitation of its budget BCRI did not have the staff to respond to all of the requests. During some weeks it was not able to accept more than 30% of the referrals. BMHS has successfully requested to MHA that BCRI's budget be increased by $345,000 so it can establish two new mobile teams and six additional crisis beds. The expansion will take place in FY'00. BCRI conducted many trainings during the fiscal year and served as triage for the Hands In Partnership (HIP) initiative. In addition, B-CARS has contracted with BCRI to perform the hotline functions for the child and adolescent crisis system. This will allow BMHS to establish one phone number to access crisis services in Baltimore City.

The following chart summarizes BCRI's FY'99 activities in comparison to the previous year.

Service	FY'98	FY'99	Variation
Hotline Calls	7,567	6,955	(8%)
Mobile Crisis Referrals	1131	1,367	21%
Crisis Bed Admissions	522	684	31%

BCRI reported that the majority of hotline calls were more crisis oriented and less information and referral than in previous years.

13. Develop a proposal for an initiative to increase services to isolated or homebound elderly.

BMHS has two programs that target this population: Psychogeriatric Assessment and Treatment in City Housing (PATCH) and Geropsychiatric Case Management Program (GCMP). Both programs provide assessment and treatment in the client's home. Each program has been evaluated (See Appendix XII).

14. Develop a request for proposal for a consumer drop-in center.

BMHS approved a consumer group, Project H.O.P.E., to be funded as a provider of a consumer run drop-in-center. The group has strong ties to the case management unit at the Johns Hopkins Hospital and together they have worked with CHA on the selection of a site to be rented by both programs. BMHS submitted a Federal grant application to HUD through OHS to enhance the funding base for Project H.O.P.E. The grant was well ranked by the reviews and was submitted to HUD. BMHS is waiting to learn if it will be funded. In addition, BMHS has designated $75,000 for Project H.O.P.E in its FY'00 budget.

15. Develop housing for adults with mental illness and functional disabilities who need 24 hour awake supervision services.

CHA purchased property at Glenmore Avenue to house a group home for eight adults as well as a site for On Our Own, a consumer run drop in center. The Glenmore Avenue property will be used for the project which will serve adults with functional disabilities. In March, BMHS distributed a Request for Proposal (RFP) to nine psychiatric rehabilitation program (PRP) providers, seeking applications to provide residential rehabilitation program (RRP) services in the home. Four proposals were submitted. In May, a review committee evaluated the proposals and selected Alliance, Inc. to operate the project. BMHS anticipates that Glenmore will open in mid October.

D. Improving continuity of care

16. Increase the number of contacts by intensive case management staff to individuals in inpatient facilities.

An initial meeting on this initiative was held and a plan of action will be developed.

17. Increase the number of homeless individuals with a mental illness seen by a mental health provider as a result of the BMHS/Downtown Partnership (DP) Hands in Partnership (HIP) initiative.

HIP began in the Spring of 1998 to create collaboration between the mental health outreach services teams, the BCDSS outreach team, the Downtown Partnership (DP) and BCRI. During this year 91 calls were received by BCRI requesting assistance for individuals who were 'living on the streets' in downtown Baltimore. BCRI teams responded to approximately one half of the calls and the mental health teams from Liberty Medical Center, Sinai Hospital and Johns Hopkins Hospital responded to approximately one third of the calls.

The program is beginning to receive national recognition for the collaboration of public service providers and the DP and was accepted to present at the "Fifteenth Annual National Assertive Community Treatment Conference" held in Detroit, Michigan in June.

In addition to responding to calls the teams meet regularly with the DP's safety guides to provide training, develop initiatives to work with identified individuals and to maintain collaborative efforts.

18. Implement the child crisis initiative by June 30, 1999.

BMHS successfully completed its proposal process and awarded a contract to develop and implement a child crisis service system for Baltimore City. The contract was awarded to a provider consortium consisting of the Woodbourne Center, Villa Maria, the Johns Hopkins Hospital, and the Johns Hopkins Bayview Medical Center. Known as B-CARS, the consortium has developed an intricate crisis system that consists of mobile response, residential and in-home crisis respite care and coordination with linkage to long term community service programs. This program intervention serves both as an ER and inpatient diversion service, and, as a step down program that facilitates early inpatient discharges. B-CARS began its pilot operations in June and is expected to be fully operational by the Fall of 1999.

19. Extend the adult capitation beyond the demonstration period that ends 6/30/99.

At the end of FY'98 a moratorium was placed on referrals to the capitation while a Department of Health and Mental Hygiene (DHMH) medical review committee reviewed the program. The reason for the moratorium was concern about deaths of some of the participants. The medical review committee reviewed the program and felt the program should continue. The committee made several recommendations which BMHS implemented. These included the hiring of a part-time medical director at BMHS for the program, incorporating greater medical review of the admissions, and formalizing an informed consent process. The moratorium was formerly lifted in November 1998. In addition, the capitation program was extended beyond its initial demonstration period. BMHS, the two programs and MHA agreed upon a new rate and the conditions for its new contract.

E. Housing

20. Increase the range of affordable housing for adults with mental illness developed and/or managed by CHA by 20 units.

CHA received an award of 100 Section-8 certificates through the Mainstream Program for individuals with disabilities. A new request for an additional 75 certificates was submitted to HUD.

Twelve units of housing in Charm City Housing Associates, a subsidiary of CHA, were acquired and renovated. The units will house twelve individuals who are homeless and have a serious mental illness (SMI).

The Department of Human Resources (DHR) has provided funds for CHA to hire a Residential Advocate. The purpose of the position is to help avoid evictions by providing early interventions.

CHA received grant awards from the Goldseker Foundation (to set up a revolving loan fund), the Neighborhood Partnership Program (to sell State tax credits), the Maryland Affordable Housing Trust (to facilitate construction) and BMHS (to improve the quality of life of tenants).

One hundred and sixty one units of housing through the Shelter Plus Care program have been leased and are occupied. CHA is currently responsible for managing, leasing, or owning housing for over 400 individuals with mental illness.

F. Financial Management

21. Establish the appropriate accounting records to meet Department of Health and Mental Hygiene's and MHP accountability requirements.

The electronic MHP payments to providers from July 1, 1998 through December 31, 1998 were reviewed and areas of duplicate payments, overpayments, payments to facilities for services to grey zone individuals and payments to transition OMHCs were identified and verified. A report was prepared and submitted to MHP for resolution. MHP has assured BMHS of correction and BMHS will be running the data again for confirmation. A review of the second half of FY'99 electronic payments will be completed in the Fall of 1999 and MHP will be informed of areas requiring resolution.

22. Develop financial reports and submit to the Board on a regular basis.

The budgets were presented to BMHS's Board of Directors. Financial reports are developed monthly at BMHS and were presented to the Board in December 1998 and again in May 1999 with assurance that all budget expenditures were in line and a system surplus was anticipated.

G. Monitoring and Training

23. Participate in 100% of the site visits conducted by MHA and the division of Licensing and Certification.

BMHS's QI staff participated in 38 out of 42 site visits (90%). Findings from the visit are summarized (See Appendix XIII).

24. Provide 12 trainings to educate geriatric mental health providers, community geriatric providers, and consumers/families about resources, assisted living requirements, clinical issues and reimbursement issues.

Geriatric training in FY'99 has been focused on three areas: 1.) training on issues related to the new assisted living regulations, 2.) participating in monthly trainings to the Housing Authority of Baltimore City (HABC) support and security staff, and, 3.) providing training on the PMHS and access to care for other Baltimore City agencies (i.e. guardianship and NSCs). Training titles included "Implementation of Assisted Living Regulations", "Recognizing Behaviors/Effective Approaches in Working with Elderly Clients with Dementia", "Geriatrics and the Public Mental Health System", "Mental Health System - Geriatric Programs and Access", and "Psychogeriatric Services".

25. Provide orientation about the public system and BMHS to all newly licensed providers under COMAR.

BMHS's QI staff developed a new provider orientation which focuses on the design and structure of the PMHS, and, the roles and responsibilities of BMHS. Providers were notified of the availability of the training. QI staff provided orientation and technical assistance to new providers who requested it (See Appendix XIV).

26. Provide at least two trainings on relevant issues facing the public mental health system to public mental health providers.

BMHS contracted with Heritage Self-Empowerment Resources to provide trainings for HABC staff. The trainings titled "Aiding Residents in Crisis" were provided during this year. Eighty one employees including HABC police, building monitors and family support personnel received the training.

BMHS staff and representatives from BCRI, Sinai Hospital and the DP presented the HIP initiative at the annual meeting of Mobile Treatment Providers in Detroit, Michigan.

BMHS's C&A staff has provided numerous training sessions to the public and to providers in Baltimore City and throughout Maryland. Trainings have included: training school-based mental health providers to participate in the PMHS fee-for-service system and in community prevention and support activities; a training session for school-based mental health clinicians titled "School-Based Mental Health Programs: Ensuring Sustainability for the Year 2000 and Beyond;" a panel of experts on mental health billing presented at the Annual Spring Conference of the Maryland State School Health Council and at the Maryland Assembly on School-Based Health Care. In-service training on wraparound services and accessing the PMHS was provided to the BCDSS and to area providers throughout the year. Finally, a presentation was made to the BCPS's Board of Directors on the status of school-based mental health services.

Staff conducted several trainings this year to providers and other community agencies. BMHS began tracking the number and types of trainings conducted. A summary of the training provided and attended by staff is provided (See Appendix XIV).

27. Conduct site visits at non-licensed programs identified by management.

BMHS conducted a site visit at BCRI. BMHS's QI staff is working with management to develop a schedule for next fiscal year.