Baltimore Mental Health Systems, Inc.
One Year Comprehensive Plan
Fiscal Year 2003
Table of
Contents
SECTION II - Financial
Plan
SECTION III - Local Mental Health
Advisory Committee Recommendations
Description of the Mental Health Service System/Delivery
Baltimore Mental Health Systems, Inc. (BMHS), the Core Service Agency (CSA) for Baltimore City is committed to developing and managing a comprehensive community based mental health system of high quality care. The FY'03 strategic plan reflects this commitment. BMHS' mission, values, and principles guided the development of the plan. To develop its needs assessment, BMHS used a variety of methods to collect information, including but not limited to analysis of Maryland Health Partners (MHP) data, provider surveys and perceptions of key stakeholders. A major focus of this plan is its emphasis on outcomes that can demonstrate the effectiveness of services and BMHS' continued interagency collaborations.
The topics and population identified in the needs assessment attempt to ensure that Baltimore City residents are receiving a full range of services. The topics covered in the needs assessment are Research, Community, Education, Training and Advocacy; Public Health Issues; Consumer Supports and Drop In Centers; Quality Improvement; Special Populations; Crisis, Emergency, and Trauma Services; Affordable Housing; School-Based Services; and Vocational Services. The budget and the corresponding information support the need for the services, specify outcomes, and address why contract dollars are needed. All funding requests are within BMHS' allocation with the notation that the expected revenue from interest income is included in the funding base.
2. Introduction
BMHS' plan, while providing background on current activities, attempts to identify areas of focus for FY'03. In doing so we identify strengths and needs of the current Baltimore City PMHS as well as identifying specific funding requests for '03.
A. BMHS Board of Directors
In FY'02 BMHS' Board of Directors established five committees with the goal of improving the involvement of board members in governance issues of the Public Mental Health System (PMHS). The committees are chaired by BMHS board members and staffed by BMHS personnel. The committees and their memberships, which include providers and representatives of advocacy groups are located in Appendix 1.
B. Development of Affordable Housing
BMHS' housing subsidiary, Community Housing Associates, Inc. (CHA), provides access to more than 650 units of affordable, community-based housing. It is estimated in Baltimore City that up to 5,000 individuals with serious mental illness are inappropriately housed, living in substandard units, paying more than 30% of their adjusted income towards housing or are homeless. CHA's housing of people with serious mental illness living in Baltimore City, therefore, meets about 12% of the need.
In FY'01 and FY'02, CHA, working with BMHS' Adult Services Division, developed a model of supportive housing incorporating the best practices of Single Room Occupant (SRO) living and Residential Rehabilitation Programs. CHA developed two projects using this model. The housing is permanent housing, each tenant has his/her own room with a locking door, and tenants cannot be discharged from housing because they choose not to accept services. Tenants share living rooms, kitchens, and laundry facilities. Each tenant has an individual lease with CHA and is responsible for paying 30% of adjusted income towards rent and utilities. BMHS contracts with a mental health service provider to provide off-site PRP services. Both projects receive funding from DHMH and the Department of Housing and Urban Development (HUD). These projects added fourteen units to CHA' s inventory of housing.
During FY'02, CHA contracted with Main Street Housing, a subsidiary of On Our Own of Maryland, to provide consultation services for new housing development projects. They also contracted with the Technical Assistance Collaborative (TAC) regarding the development models used in the Olmstead Plan. Staff also met with the CSA Director and other agency heads from Harford County to discuss strategies and funding opportunities for creating supportive housing.
For FY'03, CHA plans to continue with all projects currently in development. These include a 9 unit SRO in East Baltimore, a 14 unit SRO in West Baltimore and a second Safe Haven for twenty people. Other than completing these projects and submitting a grant request for Section 8 vouchers (housing choice vouchers) through HUD's annual SuperNOFA CHA will focus its efforts on operations/property management, consulting for other agencies and Board development.
C. School-based Mental Health Initiatives
BMHS oversees a network of school-based providers which provide mental health services in 87 or 50% of the city public schools. The services are jointly funded by the Baltimore City Public Schools (BCPS), the Baltimore City Health Department (BCHD) and BMHS. Services funded through these sources are not fundable through the current fee for service structure. The school-based services are designed to promote healthy development, and to limit deeper involvement in special education, juvenile justice or mental health services. In FY'02 BMHS in collaboration with the Family League of Baltimore City (FLBC) and BCPSS received a $ 400,000 award from MHA to expand and strengthen the school-based mental health services specifically targeted toward reducing and addressing the impacts of violence.
D. Department of Juvenile Justice
(DJJ) initiatives
In collaboration with DJJ and MHA, BMHS has developed several service initiatives to address the needs of Baltimore City children and adolescents involved in the juvenile justice system, including conducting mental health screenings to all Baltimore city children admitted to the Cheltenham detention facility. In FY'01 more than 500 males were screened for the presence of mental health needs. Of this number, 82% were positive for a mental health need. This assessment was done using the Massachusetts Adolescent and Youth Screening Inventory (MAYSI). Current views of the MAYSI suggests that it is overestimates the presence of mental health needs. Despite this, the prevalence of mental health service need in the Juvenile Justice system is estimated to be above 60%. Additionally, with DJJ/MHA funding, BMHS has contracted to provide mental health services to the DJJ aftercare initiative. Universal Counseling and the East Baltimore Mental Health Partnership are the providers for this initiative which began '02.
E. Special Initiative Between BMHS and State Facilities
During the latter half of FY01 BMHS began an initiative with Springfield Hospital Center to continue the progress that had been initiated with the Community Enhancement Initiative (CEI). The program, known as Transitional Service Partnership requires Baltimore City community programs (especially the Intensive Case Management Programs) to collaborate with staff and patients at Springfield to develop a community placement that is acceptable to the patient. The service time required for the development of a relationship by the patient with community providers and the ensuing transition services are reimbursed through the use of monies that were saved from previous initiatives. It is expected that this program will continue in FY'03 and may be expanded to Baltimore City residents who experience difficulty in leaving long term hospitalization at Spring Grove. Although the program is not given special recognition at C. T. Perkins Hospital Center (CTP), it has and will continue to be implemented. For CTP patients, who nearly always are discharged on conditional release, a community placement 'fit' with a period of community adjustment is imperative. BMHS has assured that monies will be available to permit this transition period.
In addition, the Baltimore capitation program for adults continues to work closely with state facilities in helping individuals move into the community and will continue doing so as they have available capacity.
In, FY'03 BMHS will continue to interact with the Maryland Health Partners (MHP) and the MHA facilities to assure that community services for individuals are promoted prior to hospitalization in a State facility. Support for alternative community plans will be provided through individual consultation with Baltimore Crisis Response, Inc. (BCRI), general hospital psychiatric units and other providers as requested.
F. Interagency
Collaborations
A major focus of BMHS continues to be its collaborations with other agencies that serve individuals with mental illness. BMHS staff are involved in over 45 committees or workgroups that have an interagency focus.
The following collaborations are priorities for FY'03:
(1) BMHS/ National Alliance for the
Mentally Ill-Metropolitan Baltimore (NAMI)/Baltimore City Police Department
(BPD)
In FY'02 representatives of BMHS/BPD and NAMI-Metro Balto. began working together to develop a mental health/police initiative with the goal of improving outcomes of police interactions with mentally ill citizens. The initial work included BMHS, BPD and NAMI visiting the Memphis Police Department; and, meeting with representatives of Baltimore County and Montgomery County both of which have recently established mental health/police initiatives. In order to develop a plan for Baltimore City, BMHS/BPD and NAMI convened a twenty-member work group to develop a plan to train police in the best methods for intervening with mentally ill citizens and having the mental health system provide better support to the police. The committee consists of BMHS staff, police, NAMI members, mental health providers and consumers representatives. The committee will be looking at several models which exist in Maryland and across the country and identifying the needed components to develop a project for the city. A July, 2002 date for a draft report has been set with the hope of developing a pilot in '03 in the Southern and Central police districts.
(2) BMHS/Family League of Baltimore
City (FLBC)
The Family League of Baltimore City (FLBC) is the Local Management Board (LMB) for Baltimore City. In this role, they are responsible for planning, monitoring and ensuring that agencies responsible for children and adolescents are working together. BMHS' collaboration with the FLBC happens in several areas. One of the major area is that the leaders of both organizations sit on the others Board of Directors. In FY'03 there are five primary projects that will benefit children and adolescents who have complex emotional needs. These projects are the following:
a. Demonstration Capitation
Project
BMHS and the FLBC have developed an innovated intervention for children and adolescents who have not been well-served by the many child serving agencies. In FY'02, BMHS and FLBC have received support from the Mental Hygiene Administration (MHA) to plan for the implementation of a child and adolescent capitation project. The project identifies children and adolescents who are in a restricted level of care, are not stable in their community tenure, are having bad outcomes and are high-cost users in the PMHS. The goal is to have this intervention operational as a demonstration project in FY'03. Appendix 2 is a description of the project.
b. Truancy Initiative
BCPS report that between 10-15% of children in grades K-5 are absent on any given day. BMHS is a part of an FLBC initiative that received funding to target the elementary schools which have the highest truancy rates and to develop an intervention to lower absentee rates. The project should be fully operational in FY'03.
c. Reduction of Violent and Aggressive
Behavior in Elementary Schools
BMHS is a recent recipient of a federal grant, developed in partnership with the FLBC, which targets 50 youngsters in grades K-5 who have been expelled from school. Data from the last school rate indicate that 590 children in grades K-5 were expelled from school. This is a large number of children who are experiencing failure at an early age. Using the resources of our current school-based services and the new resources of the federal grant an assertive intervention will be implemented in '03 to target children who are at risk for expulsion.
d. Expanded School-based Services and
Violence Prevention
Through the collaborative efforts of the FLBC and BMHS staff, additional state funding has been received to expand school-based services and develop strategies to reduce violence in the public schools. These funds will support activities in 25 of the 87 schools that have mental health services. In FY'02 all participating schools in this initiative have been required to begin using the Skills Streaming Pro-Social Model which has been proven to be an effective intervention in public schools. In FY'03 this should be operational in all of the participating schools.
e. Resolving "Stuck Kids"
Cases
A partnership between BMHS, FLBC and DSS has been developed to help resolve cases where children are stuck in more restricted settings due to a lack of appropriate community setting and/or resources. While some of these children may be appropriate for the capitation project, this group will be working on these issues on case by case basis.
(3) Substance Abuse
Since a significant number of individuals receiving services in the PMHS have a co-occurring substance abuse problem BMHS has developed a strategic plan with the city's substance authority, Baltimore Substance Abuse Systems, Inc. (BSAS). The goal of the plan is to improve services for individuals with co-occurring disorders. For FY'03 the following strategies have been developed:
a. Improving Integrated Care at Clinical
Sites
BMHS/BSAS began in '02 a two-year initiative to improve the ability of mental health and substance abuse providers to deliver services to individuals with co-occurring disorders of mental illness and substance abuse. The objectives of the initiative are the following:
i. To develop a demonstration project with three primary substance abuse providers and three mental health providers who will incorporate integrated mental health and substance abuse treatment within their respective settings.
ii. To provide ongoing training
and clinical supervision to the demonstration sites;
iii. To develop standard mental
health and substance abuse screening to be used by the participating sites;
and,
iv. To hold an annual conference
on dual diagnosis for all Baltimore City mental health and substance abuse
providers;
We are hopeful that this initiative will help
foster systemic change in the methods of delivery of services to dually diagnosed
individuals. Our goal is to further expand this initiative in FY'03.
b. Gathering Information
on Need for Staff Training and Implementing Integrated Care
As part of continuing to identify training needs of providers in both the mental health and substance abuse symptoms, the BMHS/BSAS integrated care committee developed a survey which was sent to BSAS and BMHS providers.
The survey is included as Appendix 3.
c. Additional Residential Services for
Individuals with Substance Abuse Needs
In FY'02 BSAS is planning to open the city's first new residential facility in thirty years. The facility to operated by Gaundenzia will provide short-term detox as well as intermediate and long-term residential services. BMHS plans to work with BSAS and the provider to facilitate referrals of individuals who would have previously been hospitalized in a psychiatric unit in a general hospital or the Walter P. Carter Center. If this new service is able to divert individuals who would have previously been admitted to the Carter Center, BMHS would work with the State to see if the Carter Center could accommodate City residents who need intermediate psychiatric care.
(4) Baltimore City Health Department
on Domestic Preparedness
BMHS has worked closely with the BCHD to ensure that the City is prepared to provide mental health support in the event of a disaster. Domestic Preparedness has been a focal point within the Health Department for a number of years. A BMHS staff member has been trained in bio-chemical warfare response and has trained volunteers to be available to offer mental health services as secondary responders. It was reassuring to note that trained volunteers were available to travel to New York, Washington, D.C., and Pennsylvania in September and did offer to help the Baltimore Crisis Response's (BCRI) staff its hotline especially during the anthrax scare. This is an ongoing collaboration which has been extended to the Mental Hygiene Administration (MHA) to assist with the development of their disaster preparedness plan.
During FY'03 BMHS will continue to collaborate with the BCHD to improve the City's ability to respond to real or possible incidents of domestic disaster. Additional training for volunteers will be offered to assure that mental health counseling and supports are available as needed.
(5) Baltimore City Department of Housing
Office of Homeless Services
In collaboration with the City's Department of Housing and Community Development Office of Homeless Services (OHS), BMHS has applied for and received seven grants for services for homeless persons with mental illness and one hundred and seventy Shelter Plus Care rental assistance housing slots from Housing and Urban Development (HUD). These service grants provide funding for mental health outreach, a twenty-bed Safe Haven, a SSI presumptive eligibility program and a consumer run drop in center all targeted to homeless persons with mental illness. This collaboration is extended to a nationally acclaimed project known as HIP, Hands in Partnership. HIP brings together the outreach teams, BMHS, Baltimore Crisis Response, the City Police Department, the Department of Social Services, Baltimore Substance Abuse Systems, Health Care for the Homeless and the Office of Homeless Services. Together these agencies focus their outreach activities and support each other in their efforts to house homeless persons. HIP utilizes monthly meetings of the administrators and bi-monthly meetings of the service providers to achieve the goals of creating and actualizing policies and procedures necessary to engage homeless individuals.
Planning for HUD grant renewals and the implementation of a second Safe Haven for which an award was recently received will be continued in FY'03. Planning is underway to develop a data base to be in operation in FY'03 to be utilized by all HUD grant programs. The data base will be used to improve HUD service reporting to connect with the OHS ROSIE reporting program and improving BMHS' ability to monitor the City's population of homeless persons with mental illness.
(6) Geriatrics
BMHS represents the PMHS on the Baltimore City Interagency Aging Committee (IAC), chaired by the Commission on Aging. This is a unique activity for a CSA, as in all other jurisdiction the Health Department rather than the CSA represents mental health concerns on the local IAC. In Baltimore City the IAC's primary activities have included:
a. Triad Committee which seeks to improve collaboration with the BPD and the Sheriff's Department and providers in the aging service network.
b. A Clinical Subcommittee which includes private social service agencies who come together to review and plan for individuals who present with complex problems that involve multiple agencies. Recommendations are made to the client's care provider team with one agency assuming lead responsibility.
c. Consultation on mental health issues to the Guardianship and Case Management units at the Commission on Aging.
In addition BMHS' collaboration with geriatric units of general and state psychiatric units and MHA has improved service planning for older citizens to enable them to move to less restrictive settings. BMHS' working with CHA to open an eight unit residential rehabilitation program for older individuals with mental illness leaving state facilities during FY02 is a tangible outgrowth of this partnership.
During FY'03 BMHS will continue to participate with the Commission on Aging to provide education on mental illness in the elderly population to Assisted Living providers, Senior Centers and Adult Medical Day Care programs. Our Director of Geriatric Services and our psychogeriatric nurse will work closely with MHA facilities, other providers of mental health services and nursing homes to assure that individuals are receiving care in the least restrictive setting. We will continue to explore funding opportunities to provide outreach and in home services to this population.
(7) Criminal Justice - Courts and
Corrections
BMHS continues to have a strong presence in the criminal justice arena. Monthly forensic liaison meetings bring together the courts, Office of the Public Defender, State's Attorney's Office, the Detention Center, the Medical Service of the Circuit Court' Forensic Assessment Services Team (FAST), community providers, the Carter Center, Office of Forensic Aftercare, BSAS, BCRI and BPD. The meetings focus on problem solving issues that develop between agencies or impede rapid appropriate service planning and delivery for arrested individuals. These have included issues arising in the implementation of Emergency Petitions, competency evaluations and dispositions and medication for incarcerated individuals.
FY02 saw the establishment of a new collaboration 'Women In Need Group'(WING). WING developed out of the FY'02 needs assessment which identified specific needs of women in the criminal justice system, especially those incarcerated in the Women's Detention Center in Baltimore City. The group includes participation from F.A.S.T., Office of the Public Defender's Client Services, Division of Parole and Probation, You Are Never Alone (Y.A.N.A.), BSAS, Power Inside, Man Alive; Women at Risk; police; Maryland Correctional Institution for Women (MICW), Sidran, MHA, Prisoner's Aid; Women's Law Center; Health Care for the Homeless, Black Mental Health Alliance, Women's Detention Center (WDC) staff; private and public community mental health providers. There is a specific focus on trauma and trauma training.
In the Fall of 1999, BMHS began its initiative with Patuxent Institution to work with the Department of Public Safety and Corrections (DOC) for discharge planning for persons with a diagnosed mental illness who are leaving incarceration on mandatory release. It is anticipated that this initiative will assist 20 Baltimore City individuals in the coming year and should form the ground work for better cooperation between these two State administrations especially in the area of planning for return to the community. This is especially important for Baltimore City as Baltimore City residents comprise 70% of the population of DOC facilities.
BMHS in conjunction with the judges, States Attorney Office, medical services of the Circuit Court and the Office of the Public Defenders are working on the development of an initiative to provide a comprehensive program for individuals who have a mental illness coming before the court. This initiative will be further developed in FY'03.
FY'03 will be an important year for collaboration with agencies associated with the criminal justice system. Planning for the development of a service program targeted to a population that has been found to be 'difficult to engage and maintain in treatment' will be on the drawing board. This will require each agency to invest in the process and the provision of services from pre-trial to probation, both mental health and substance abuse providers. The initiative will focus on the reduction of recidivism to both corrections and mental health inpatient care.
G. Evidence-Based Practices
BMHS has been involved in a national project to implement evidence-based mental health interventions for individuals with serious mental illness. In FY'03 our plan is to be participating with MHA to implement evidence-based practices in psycho-family education and supported employment. In addition to the state's initiative , BMHS is planning to promote Assertive Community Treatment (ACT) in the City. Baltimore City currently has six provider agencies that deliver a service that have the potential to comply with the fidelity of the ACT model. The Baltimore Veterans Administration (VA) has recently begun two ACT teams. The VA has committed to partnering with BMHS in using the tool kit for ACT and training through the evidence-based practice initiative. BMHS would identify two public mental health system ACT providers who along with the VA sites would participate in this project. To help offset the costs of the ACT project, BMHS has submitted proposals to several private foundations in FY'02.
H. Outcomes for the Public Mental Health
System
In FY'02, BMHS began a process to develop and track outcomes that can help us determine the effectiveness of a service and provider. BMHS collaborated with Psychiatric Rehabilitation Programs (PRP) and Mobile Treatment programs to develop measurable outcomes that are to be reviewed quarterly. The goal has been to identify outcomes that provided meaningful information to BMHS and the provider while attempting to use information that is easily attainable. In FY'03, our plan is to meet on a quarterly basis with adult and child PRP providers and mobile treatment providers to review their performance based upon the outcomes. We will also use these meetings to revise the outcomes as needed. A copy of the final document for PRP for adults is included as Appendix 4. A draft of the mobile treatment outcomes is included as Appendix 5.
I. Cultural Competence
Noting both the changes in demographics of Baltimore city, and the Surgeon General's report on the disparities in access and appropriateness of mental health services to persons of color, BMHS conducted it's first Cultural Competence Assessment. The assessment was conducted by having providers respond to a survey which was a requirement of their FY'02 contract. The survey was modeled on a similar national assessment conducted by Georgetown University, and sought to determine the provider communities knowledge regarding the diversity of the Baltimore City Service population, and the capacity to serve various populations in terms of linguistic and cultural competency.
A brief summary of the findings suggests:
Of 51 respondents 76% indicated that their primary service population consisted of African Americans. On average these providers indicated that African Americans comprised 72% of their total service population. Similarly, 24% of respondents identified their staff as being primarily white ( 62%).
The following table represents the number of
providers within an agency who provide service to specific cultural/ethnic
groups:
| Asian/Pacific Islander | 11 (22%) |
| Hispanic/Latino | 17 (33%) |
| Native American | 12 (24%) |
| Other | 18 (35%) |
The provider responses indicate the following
linguistic capacity:
Respondents indicating capacity to provide services by service type and language (N=58)
| Language | Intake | Ongoing | Written Materials |
| Spanish | 13 (22%) | 11 (19%) | 12 (21%) |
| Russian | 7 (12%) | 7 (12%) | 3 (5%) |
| Sign Language | 2 (3%) | 3 (5%) | N/A |
| Ibo | 2 (3%) | 2 (3%) | |
| French | 2 (3%) | 2 (3%) | |
| Korean | 1(2%) | ||
| Chinese | 2 (3%) | ||
| Translator Services | 7 (12%) | 7 (12%) |
Other findings include:
A majority of respondents indicate that cultural competency has been included in mission statements and policies
Almost all respondents indicate that advisory boards/committees have representatives of the multiple cultures served
A majority indicate that they have recruitment and training practices that are culturally appropriate, and that they make use of non-traditional services in working with ethnic/cultural groups.
Of 49 respondents, African Americans and Caucasians are represented in almost equal numbers as direct service providers, while Caucasians are responsible for the management of approximately 80% of programs.
Very few programs indicate that they have conducted a cultural competency assessment of their programs or agency to assess the level of appropriateness or access to services.
Very few programs have attempted to assess service or other outcomes related to culturally competent practices.
3. System Mission, Vision, and
Values
Mission Statement
The mission of Baltimore Mental Health Systems (BMHS) is to develop and manage a system of care in which Baltimore City residents have access to high quality public mental health services.
Vision Statement
Baltimore City will be a national leader in the development of high quality, innovative and effective public mental health services. Services will be developed to meet the needs of the community based on input received during ongoing planning processes. BMHS will be a model for other local mental health authorities throughout the country because of effective leadership, collaboration with the community, efficient management of costs, and a comprehensive data-driven quality management program.
Value Statement
BMHS Values:
To design a continuum of services specifically to meet the mental health needs of the citizens of Baltimore City,
To include the opinions and participation of staff, consumers, families, mental health providers, and other key stakeholders in developing and improving systems of care,
To recognize the rights of consumers and families to participate in care decisions and to be treated with dignity and respect,
To support individuals in their efforts to maximize their full potential,
To offer effective mental health services,
To ensure a cost-effective delivery of services,
To ensure a delivery of services in the least restrictive environment appropriate to the needs of consumers,
To have available a culturally competent system of care that respects the differences among individuals,
To educate, train and promote research,
To offer appropriate and affordable housing for persons with mental illness that is comfortable, attractive and safe,
To maximize all potential resources for the
purpose of delivering high quality care.
BMHS' Roles & Responsibilities in the Public Mental Health System
Leadership
Policy and planning
Systems development/program development
Facilitated access to appropriate levels of care
Procurement
Collaboration
Education, technical assistance and training
Quality improvement
Fiscal management
Collection and management of information
Research and evaluation
Development of a range of housing opportunities
4. Demographics of Baltimore City
Over the past 40 years Baltimore, similar to other urban areas in the U.S., has experienced a decline in population. Once the largest political jurisdiction in the State of Maryland, with 939,024 or 25% of the State's population, Baltimore is currently the fourth largest subdivision in the State with a population of 651,154 according to the 2000 census. This is approximately 14% of the State's population. (Maryland Vital Statistics Annual Report, 1996 for the Division of Health Statistics, Department of Health and Mental Hygiene). The majority of the individuals residing in Baltimore City are African-American (64%) with Caucasians making up 32% and other races the additional 4%.
In 1992, 21.5% of the households in the City had incomes below $10,000 compared to only 9% of households in the State of Maryland, and 15.6% of the households in the City had incomes above $50,000 while 34.7% of households in the State were above $50,000. (Baltimore City, Maryland, Brief Economic Facts). In 1998, the City's unemployment rate of 6.9% was the highest in the State. However, some neighborhoods have unemployment rates of more than 30%. Unemployment is highest among young African-American males. (Baltimore City, Maryland, Brief Economic Facts).
Baltimore is home to the largest concentration of poor people in Maryland, housing about one-half of the State's population living below the poverty level. The population of Baltimore City is about 30% of the metropolitan area (the City and the five surrounding counties) but the City is home to almost 68% of the region's poor. In 1960, the median income of City families was 91.2% of the metropolitan area median family income while in 1990 the median income of City families was 66.9%. (Baltimore: Past, Present and Future Trends and Projections, pg. 15). The poor are overwhelmingly children from single parent homes, African-American female single parents, and the elderly and disabled. (Baltimore: Past, and Future Trends and Projections, pg. 16).
Baltimore is also home to the largest number of Medical Assistance recipients of any of Maryland's political jurisdictions. As of November 1999, there were 129,329 Baltimore City residents on the Medicaid program which is almost 20% of the City's population and almost 40% of the number of MA enrollees Statewide. In addition, it has been determined that nearly 20% of the City's population has no health insurance. This would be approximately 135,000 individuals. Therefore, the Baltimore City population eligible for the public mental health system is approximately 265,000 individuals.
The elderly (more than 65 years of age) make up 13.7% of the City's population.
The following chart summarizes population
characteristics for Baltimore City. The source for this information is the
2000 census.
| Number | Percent | |
| TOTAL | 651,154 | |
| Male | 303,687 | 47% |
| Female | 347,467 | 53% |
| White | 205,982 | 32% |
| African-American | 418,951 | 64% |
| All Other Races | 26,221 | 4% |
5. Description of
Process
In its role as the CSA BMHS' administrative functions have focused on program and resource development, monitoring and oversight, planning, quality management, continuing our interagency collaborations and fiscal integrity. The needs assessment in our FY'03 Annual Plan reflects BMHS' commitment to these activities. In order to compile the needs assessment, BMHS used a variety of methods to collect information. These included, but were not limited to, analysis of data from MHP, information gathered from providers, consumers, family members, and input from the Mayor's Mental Health Advisory Committee.
A. Child and Adolescent Services
BMHS' Child and Adolescent (C&A) Division
conducted a series of surveys of providers and consumers to identify trends
and gaps. Data from MHP and the Human Service Data Collaborative, which is
maintained by the FLBC was used as well as the data collected through the
provider funding requests. A summary of the findings follows:
(1) Child and Adolescent Outpatient Mental Health Clinic (OMHC) Capacity and Other Service Gap Issues:
In FY'01 BMHS identified several access issues for child and adolescent consumers attempting to utilize Outpatient Mental Health Clinic (OMHC) services. In order to assess the extent of the problem BMHS C&A division enlisted the aid of Families Involved Together (FIT) in conducting mock calls to OMHC providers requesting services for two children. This assessment process was repeated in FY'02.
The following table compares the results of the FY01 and FY02 surveys conducted by FIT. FIT made a total of 26 calls to 13 OMHC's requesting services. The table summarizes the experience of FIT callers. FY01 findings are in brackets.
| Total Number of Calls | Appointments Given | Appointments Not Given | Reason |
| 26 (26) | 7 (6) | ||
| 10 (6) | Medicaid number required before appointment will be scheduled | ||
| 5 (5) | Caller placed in voice mail | ||
| 2 (0) | Provider did not serve a 4 year old child | ||
| 0 (2) | Told to call back at specific time | ||
| 1 (1) | Referrals taken from specific programs only | ||
| 0 (3) | Referral from MD/pediatrician required | ||
| 1 (2) | Caller needs to call MHP for auth. | ||
| 0 (1) | Not accepting referrals at this time |
Other comments reported by FIT included:
As was true in FY01, FIT reported that staff were by and large courteous although somewhat impersonal. On several occasions staff were rude or angry. In FY01 BMHS provided detailed feedback to providers regarding their intake process. The finding of only 27% of calls resulting in an appointment suggests the feedback provided little improvement to the system. For FY'03, BMHS will increase its training and monitoring activities to improve this outcome.
BMHS C&A staff has continued to conduct site visits on all Baltimore City children residing in-state residential treatment centers (RTC). Despite the decreases in the numbers of children in RTCs the lengths of stay appear to have lengthened. There continues to be a need for a high-cost users service that will provide a comprehensive community-based alternative to RTC and extended inpatient stay. Based on this finding, BMHS and the FLBC have continued to work with MHA on the development of a specially designed capitation proposal for children and adolescents to better serve these youths.
B. Adult Services
The Adult Services staff of BMHS conducted a series of needs assessments with each of the collaborative groups with which it meets on a regular basis. These groups include nearly all of the major agencies of the City and many of the principal providers of public mental health services. The purpose of each assessment was to identify the community's thoughts and ideas regarding needs, gaps and possible solutions to their identified concerns. Areas in which the mental health community believe the PMHS works well in Baltimore City were also discussed. The primary identified need in each group was identified as housing that could be quickly accessible especially for individuals whose entitlements where inactive. An additional Safe Haven was seen as the most appropriate alternative.
For the group which focuses on the problems faced by persons with mental illness in the criminal justice system housing especially transitional housing for women upon release from the Detention Center was identified. Other priorities included:
Improvement of mental health services within the Baltimore City Detention Center (BCDC)
Improved coordination with the police regarding the emergency petition process
Improvement of the mental health knowledge base of police cadets and seasoned police officers
Increased need for additional and improved transitional services from prisons and hospitals
Continuation of the interagency collaboration throughout the criminal justice to assure mental health services for individuals in need
A focus group to identify needs as expressed by homeless and formerly homeless persons with mental illness was conducted at HOPE, a consumer run drop in center which targets and welcomes homeless persons with mental illness. HOPE is a consumer run Drop-In Center jointly funded by HUD with matching funds from MHA. HOPE is a place where service linkages are available as well as a place for laundry facilities, showers, socialization, locker storage, and mailboxes. In meeting with the consumers, their concerns and needs were as follows:
Improved access to intensive case management services
Being able to afford transportation
Improved communication with mental health providers
Affordable housing
Access to a full range of medications
It is clear in reviewing the meeting minutes and needs assessment that mental health services for the homeless and its interactions with collateral services systems needs improvement. There is a lack of coordinated tracking of homeless persons which results in overlap in services for some, whereas others receive no services. In FY'03, BMHS will be collaborating with OHS on a database that will focus on service availability and identified consumers. Available and affordable housing and improved service linkages will continue to be given priority.
The group focuses on services and resources for women who have experienced trauma and the training needs for those who work with this population. A needs assessment was conducted in FY'02 which indicated that those who need to be trained are: mental health providers at all sites that serve the population, physicians, faith-based agencies and other non mental health professionals who serve this targeted population including correctional officers and other criminal justice staff, Parole and Probation staff, and legislators. The type/topics of training needed included development of a template for culturally sensitive group trauma treatment, assessment and evaluation in a trauma framework, symptom management and vicarious traumatization (e.g. how the practitioner feels or is effected by working with this population).
Another needs assessment was conducted by FAST in the Women's Detention Center. Thirty-two women participated in the survey. The initial review of the information indicates that one-third of the women have been diagnosed with a mental illness. Almost fifty percent (fifteen women) reported being a victim of trauma including sexual abuse, physical abuse, and rape.
From the participants at the WING meetings and the needs assessment conducted at both the Detention Center and at the Forensic Meetings, it is clear that there needs to be an expertise in trauma related disorders and that the most successful treatment will assess and treatment the effects of trauma.
At the December meeting of the Mayor's Mental
Health Advisory Committee, the over whelming response to the question of
what should be a priority for BMHS in FY'03 was improved relationships with
the Baltimore City Police. Specific emphasis was given to the need to improve
the police department's responses to persons with mental illness. This is
a BMHS FY'03 priority.
6. Reporting and Analyzing Data
A. Narrative Analysis of Service Utilization of the Public Mental Health System
The following is an analysis of the use of the PMHS by Baltimore City residents. The information used in the following analysis was compiled from MHP's claims data base. Therefore, it only reflects services for which there was a paid claim and for claims paid through 11/30/01
.
(1) Unduplicated Baltimore City Consumers
comparison of FY'99-FY'01
Category |
FY'99
Number and Percent |
FY'00
Number and Percent |
FY'01
Number and Percent |
| Medicaid recipients in the waiver | 19,228 (80%) | 20,033 (79%) | 21,152 (78%) |
| Gray zone (uninsured) individuals | 3,188 (13%) | 3,614 (14%) | 3,957 (15%) |
| Medicaid individuals not waiver eligible | 1,657 (7%) | 1,8345 (7%) | 2,025 (7%) |
| TOTAL | 24,073 | 25,482 | 27,134 |
(2) Unduplicated Baltimore City Consumers comparison by age group from FY'99-FY'01
| AGE GROUP | FY'99 | FY'00 | FY'01 |
| 0-5 | 1,194 (5%) | 1,117 (5%) | 1,356 (5%) |
| 6-12 | 5,619 (24%) | 6,074 (24%) | 6,677 (26%) |
| 13-17 | 2,787 (12%) | 3,088 (12%) | 3,599 (14%) |
| 18-21 | 735 (3%) | 815 (3%) | 934 (3%) |
| 22-64 | 11,882 (50%) | 12,444 (50%) | 12,368 (48%) |
| 65 AND OVER | 1,403 (6%) | 1,409 (6%) | 1,092 (4%) |
| TOTAL | 23,620 | 24,947 | 24,670 |
Please note the totals in the age report differ from the totals in the unduplicated number of consumers report. This problem has been reported to MHP.
(3) Service Utilization of Baltimore City Consumers for FY'99-FY'01. A consumer may use more than one service type
| Service Category | FY'99 | FY'00 | FY'01 |
| Case Management | 1,132 | 1,171 | 1,433 |
| Crisis | 415 | 519 | 545 |
| Inpatient | 3,367 | 3,009 | 2,729 |
| Mobile Treatment | 541 | 568 | 634 |
| Outpatient | 23,653 | 25,068 | 27,050 |
| Partial Hospitalization | 2 51 | 412 | 409 |
| Psychiatric Rehabilitation | 2,937 | 3,622 | 4,687 |
| Residential Rehabilitation | 448 | 452 | 455 |
| Respite Care | 19 | 4 | 18 |
| Residential Treatment | 216 | 239 | 186 |
| Supportive Employment | 235 | 348 | 426 |
| TOTAL | 33,214 | 35,412 | 38,572 |
| Year | Total
Expenditures |
Average
Expenditure
Per User |
| 1999 | $ 95,424,101 | $3,964 |
| 2000 | $100,391,669 | $3,940 |
| 2001 | $110,420,998 | $4,069 |
The following compares the number of individuals served and expenditures for five service types in '99 and '01.
| Service | # seen '99 | # seen '01 | % change | $s spend '99 | $s spend 01 | % change |
| O/P | 23,937 | 27,398 | 14% | 34,066,394
($1,423/user) |
44,070,918
($1,6083/user
Rates increased in '00 |
29% |
| Rehab. | 3,326 | 4,071 | 22% | 23,725,311 ($7,133/user) | 27,909,580 ($6,856/user) | 17% |
| Case
mgt |
1,131 | 1,433 | 27% | 1,782,745
($1,576/user) |
2,721,630 ($1,899/user) | 53% |
| I/P | 3,208 | 2,797 | (13%) | 30,015,448 ($9,356/user) | 24,570,434 ($8,785/user) | (18%) |
| RTC | 224 | 189 | (16%) | 9,592,743
($42,824/user) |
11,148,436 ($58,986/user | 16% |
During the past three years the cost of providing services has increased by almost $15 million or 16%. It is interesting to note that during this time the number of Baltimore City residents using inpatient psychiatric facilities and RTCs decreased. From 1999 to2001, there was reduction of 638 (19%) persons hospitalized with a reduction of expenditures of $5.5 million (18%). What is most perplexing about the cost savings is that the total number of days of service or days in the hospital increased by almost 18%. Which means either the cost per day decreased or there were more individuals admitted where Medicaid was a secondary coverage thus reducing the amount of dollars paid through MHP.
Possible reasons for the reduction of inpatient admissions and expenditures:
The community system is doing a better job.
Some individuals who have frequent users of inpatient facilities are being served by the Baltimore capitation programs which have reduced inpatient use and when an inpatient episode occurs the capitation provider pays the bill not MHP.
Inpatients units may be serving a larger number of uninsured individuals.
Baltimore Crisis Response System, Inc. (BCRI) is being utilized more effectively and is more successful in diverting individuals from hospitalizations.
MHP is performing more aggressive gatekeeping and prevents admissions and when an admission takes place their utilization reviews are more stringent.
The hospital financing methodology through the Hospital Cost Review Commission (HSCRC) provides incentives for short admissions. This may help explain the reduction in expenditures but doesn't explain the reduction in admissions.
More hospitalizations are taking place in private psychiatric facilities which have a lower per diem cost.
In addition, RTCs, another high end service, have seen a reduction in number of individuals served but an increase in expenditures. From the period of '99 to '01 there was a decrease of 30 children or adolescents admitted to a RTC which reflected a 14% decrease; and, an increase in expenditures of over $1.5 million or 16%. Days paid for in an RTC increased by 17%.
BMHS and the FLBC believe that our proposed capitation program for children and adolescents will contribute to a reduction of days spent in a RTC and an increase in positive community tenure for youth with very complex needs.
B. Narrative Analysis of Gaps in Services
Based upon our analysis of the data and our assessment of the service system, BMHS has
identified the following gaps. The needs assessment and our FY'03 goals will support and provide information regarding BMHS's plan to meet the identified need.
Due to the high rate of substance abuse among many of the individuals receiving services in the PMHS in Baltimore City, there is a need for integrated mental and substance abuse services.
The high rate of poverty, substance abuse in Baltimore City and violence witnessed or experienced by Baltimore City children requires specialized school-based and community-based services for children and adolescents.
The elderly have special needs that are not being addressed by the current system.
There is a need for expanded vocational services for individuals with serious mental illness.
Affordable housing for individuals with serious mental illness needs to be expanded.
Service providers need greater clinical expertise and comfort in providing services to the forensic population and those with co-occurring substance abuse disorders
There is a need to increase evidence-based
practices.
6. Needs Assessment
The following needs assessment addresses areas of need as well areas for which FY'03 funding is required.
I. RESEARCH, COMMUNITY EDUCATION, TRAINING & ADVOCACY
A.
Research
BMHS has a long history of involvement with mental health services research, and values the role of research in helping us shape PMHS. The establishment of BMHS as the local mental health authority for Baltimore City through the Robert Wood Johnson Program on Chronic Mental Illness included a national evaluation of the effectiveness of local mental health authorities. Since that time, BMHS has partnered with the local academic community to evaluate the effectiveness of several demonstration projects. These have included the University of Maryland School of Medicine's Department of Psychiatry on the effectiveness of Assertive Community Treatment for homeless individuals who have a serious mental illness; the Johns Hopkins School of Public Health on an evaluation of the East Baltimore Mental Health Partnership; and the Johns Hopkins School of Public Health to evaluate the Baltimore Capitation Project. In addition, BMHS has partnered with the FLBC to evaluate several outcomes of school based mental health services.
Currently, BMHS is interested in the application of evidence-based practices being incorporated into the PMHS. We are working with Dr. Tony Lehman at the University of Maryland's Center on Mental Health Services Research and Dr. Robert Drake at Dartmouth College's Mental Health Services Research Center to implement such a model. This project has been funded for its first phase which is to develop tool kits on six areas of mental heath practice for which there is documented evidence of efficacy. MHA is participating in this project and identified family psychoeducation and supported employment as tool kits to be implemented in Maryland. In addition, to the state's initiative, BMHS is working with the Veterans Administration (VA) to promote Assertive Community Treatment (ACT) in the City. ACT is a proven intervention for individuals who have histories of non-compliance with traditional outpatient mental health settings.
BMHS established a relationship with The MEDSTAT group in 1997 to collaborate with Dr. Anthony Lehman in a study entitled "Schizophrenia Care and Assessment Program" (SCAP). The study is funded by Eli Lilly and Company. BMHS'Director of Quality Improvement and Operations is the project coordinator for Baltimore City The primary goal of the program is to understand the treatment of schizophrenia (adults) and to determine which treatment options for which individuals produce the best clinical and functional outcomes at the lowest cost. A secondary goal is to demonstrate the feasibility and cost-effectiveness of implementing a continuous quality improvement feedback mechanism to improve the quality and outcomes of schizophrenia care. To accomplish its goals SCAP implemented a comprehensive research infrastructure in six study sites in the United States, with other sites in Great Britain and Australia. Participating providers in Baltimore City include Johns Hopkins Bayview Medical Systems, and University of Maryland Medical Systems (outpatient clinics). BMHS was successful in enrolling 400 individuals. There were approximately 1900 adults enrolled in the study from all study sites through August 31, 2000. The study will be completed in April, 2003.
B. Training Needs
Baltimore City has seen an increase in the number of mental health providers since the implementation of the Medicaid Waiver and the PMHS in 1997. BMHS' Quality Improvement (Q/I) staff worked directly with new providers in preparing applications and providing technical assistance, and training throughout the process. In addition, BMHS staff will continue its semi-annual training on medical records documentation.
BMHS is committed to ensuring best practices and that psychiatric residents in child psychiatry programs have public mental health experience. To meet this need, BMHS plans to continue our relationship with Johns Hopkins School of Medicine, Howard University and the Maxie Collier Scholars Program through Coppin State College.
In FY'03, BMHS will be exploring the development of a Training Institute to be linked with the major academic centers and the State with the goal of improving community psychiatry experiences for mental health professionals in graduate schools and working in the field.
C. Organizational Advocacy
In addition to encouraging education of consumers, their families and the community, BMHS has encouraged agencies formed to provide these services, to assist with planning advocacy of mental health services for the City and the State. These agencies which have assumed the primary responsibility for these tasks are: Mental Health Association, Black Mental Health Association, Families Involved Together, National Alliance of the Mentally Ill, the Maryland Coalition for Families and Pro-Bono Counseling.
These organizations participate in the development of policies and planning through attendance at BMHS provider meetings, conferences with key BMHS staff and through their educational activities in the community at large. These are all roles that BMHS and MHA have identified as essential, and there is a need for them to continue to help provide education, information and support the reduction of stigma that persons with mental illness experience.
For hearing impaired persons education on HIV Disease is provided through Federal funding to Family Services Foundation.
The Mental Health Association of Metropolitan
Baltimore operates PROJECT PRAISE whose goal is educating clergy and parishioners
on the value of mental health treatment. Project Praise has developed a structure
which trains church leaders in administering a depression screen and how
to link individuals in need of treatment with services.
II. PUBLIC
HEALTH
Many of the individuals receiving services in the PMHS have coexisting mental health and substance abuse treatment needs. The Walter P. Carter Hospital Center, an acute care State psychiatric facility primarily serving Baltimore City, reports that almost 80% of those persons admitted to its service have an active substance abuse problem. Baltimore City mental health providers report in excess of 60% of adults seeking psychiatric treatment in emergency rooms have an active substance abuse problem and in excess of 35% of the individuals seen in community mental health clinics and psychiatric rehabilitation programs have a co-occurring substance abuse disorder. In the city, BMHS and the substance abuse system managed by Baltimore Substance Abuse Systems, Inc. (BSAS) have developed a strategic alliance to improve services to individuals with co-occurring disorders.
Currently, BMHS and BSAS have a demonstration
project to improve integrated care at six sites. In '03 we will be developing
strategies to continue this initiative.
III. CONSUMER SUPPORT AND DROP IN
CENTERS
A. Consumer Run Drop-in Centers
BMHS has long recognized the need for persons with mental illness to have the opportunity to support one another. These settings are described as consumer run drop in centers and have the distinction of providing support, education and advocacy for consumers without the aura of treatment. On Our Own, Inc. (OOO) was the first such group to organize to provide a place for mental health consumers to come together for mutual support and socialization. OOO has played a key role in advocating for the rights of the consumer, furthering the education of mental health practitioners and the general public about the Maryland law on the rights of persons with mental illness and to provide a role model for consumer run drop in centers across the State.
Several years ago, a survey was conducted with 89 consumers of mental health services in the City. Eighty five (85%) percent of respondents indicated that they had never attended a drop-in center but eighty four percent (84%) indicated that they would come to a drop-in center if it were available. At that time, there was only one consumer run drop-in center in Baltimore City. There continues to be a need to increase the number of consumer run drop-in centers in the City to better meet the needs of this growing population. These groups need to be readily accessible and may be targeted as special needs within the mental health consumer population.
In support of the expansion of these programs,
BMHS assisted two groups of consumers in the development of two new centers,
Helping Other People Through Empowerment (HOPE) and Hearts And Ears (H&E).
Both agencies were incorporated and obtained non-profit status. HOPE received
a HUD funded grant from BMHS to permit the site to offer peer counseling
and resources seven days a week. The Center opened in February, 2001 and
welcomes homeless persons with mental illness who have been unable to connect
to either treatment or appropriate housing. Through the support of peers
many of these individuals are joining HOPE and obtaining the services needed
to improve their quality of life. H&E has provided a unique support
opportunity for persons suffering from mental illness who are members of
the gay, lesbian, bisexual, transgendered or other sexual or gender minorities.
The members of H&E are residents of many counties of our Maryland. At
a recent holiday gathering members from a far away as the Lower Shore and
Philadelphia were in attendance.
In 1994, BMHS undertook an initiative to assist MHA with the closure of the Carter-Catonsville unit located on the grounds of Spring Grove Hospital Center. As a part of this program 10 persons from Carter-Catonsville unit or from one of the other regional hospital facilities were able to move to the community in placements supported as described by their individual discharge plans. The initiative continues to support 10 individuals; 6 of the original group and 4 persons identified as needing this assistance as space became available.
Beginning in late Spring, 1999, BMHS began to implement its plan for assisting MHA in the reduction of State hospital beds through the movement of persons from the hospital to the community. The project is known as the Community Enhancement Initiative. BMHS designed a process for this initiative that addresses not only the needs of those persons leaving the hospital, but also of those persons who were receiving residential rehabilitation services, who could move to independent living with minimal additional support for housing rent payments.
As of the end of FY'00, thirty-eight (38) persons have made the move to independent housing, thus opening RRP placements for persons ready to leave State Hospitals. For each person moving to the community additional monetary support has been available and utilized. Ongoing yearly support is needed for the client to maintain his or her community placement.
Based on an assessments of the community housing needs of this population, BMHS worked with Community Housing Associates (CHA) to obtain HUD 811 projects to develop two new residences. The two new homes are Glenmore Manor and Belair Manor. Both have been opened. Glenmore Manor will provide eight individuals who have medical needs with additional supports provided by nursing services. BMHS will provide a grant to support the costs for the additional staffing. It is expected that Springfield Hospital will be the primary referral source for Glenmore. Both of these residences provide 24 hour on site supervision.
As a result of the collaboration with Springfield Hospital for the community placements during FY'01, a new initiative was developed in FY'02 and will be continued in '03. This Collaboration is known as the Transition Partnership and will utilize funding to support case managers from the City's seven Intensive Case Management Programs to develop with the patient the hospital staff and the community a transition plan and community placement. This program is modeled on the Patuxent Initiative which has proven to be a successful mechanism for persons with mental illness who transition from incarceration to the community.
In addition, since 1994, the Baltimore Capitation program has admitted 193 individuals directly from state hospitals. While the programs are near their capacity, the programs are continuing to work with individuals who are current state hospital residents.
Funding
for medications and laboratory costs for grey zone individuals who are treated
by the Public Mental Health System is available through a process developed
at BMHS. These funds support an individual's need for medications or lab
services for a short period of time until another payer such as the Maryland
Pharmacy Assistance Program can be acquired. Each request for funds requires
that the recipient make application to Maryland Pharmacy Assistance Program.
The need for these services has continued to grow as information about their
availability is disseminated.
Transportation for patients and their families
between Baltimore City and Springfield Hospital Center continues to be used
for transitioning and visiting the community. People Encouraging People (PEP)
is the provider for this service and Springfield staff coordinate the need
for the service with PEP.
4. Client Support Funds
These monies have been utilized through the years to provide one time only specific funding for consumers who have a special need. The uses include but are not limited to one time only rent payments, security deposits and other first time costs associated with first time tenancy. Funding for conference attendance, burial expenses and mental health services that are not covered by the fee for service system are other uses of these funds. In FY03 furnishings for the second safe haven will be a planned use of these monies.
5. Support and Wrap-Around Services
Child and Adolescent Services
a. Purchase of Care
Each year BMHS receives over 500 child and adolescent help calls requesting a variety of supports and services for children with mental health needs. Callers may be family members or guardians, therapists, inpatient hospitals, or other city and state child serving agencies. The requests for help range from referrals to service provider to assistance in identifying and/or funding placements and/or supports that will help promote a stable community placement. In recent years these calls have most frequently included categories of children referred to as "Stuck Kids" and in-state diversion kids. In addition there are children whose service needs require therapeutic group home placements in lieu of inpatient stays, or respite. To address the multiple needs of this special population BMHS maintains a Purchase of Care (POC) funding budget line that allows us to plan at the local level for service needs that have not been anticipated or cannot be funded through the fee-for service system.
BMHS has joined with the Family League of Baltimore City (FLBC), DSS, and DJJ to ensure that appropriate funding sources are utilized in providing for children whose needs cross multiple agencies. We also actively work to ensure that a Medicaid fundable service provider is available before utilizing POC funds. The flexible POC dollars provide a variety of supports and resources necessary to maintain the child in the least restrictive setting, and to provide support services which enhance the families capacity to care for the child in the home or community. Services include community-based residential services, family supports, and other services such as limited transportation, and special activities.
b. Special Residential Services
In the city there is a need for special residential services offered by providers who are not part of the fee for service system including the 90 day stay program offered by the Woodbourne Bridges program. This program is for children and adolescents ages 7-15 who are not in the care and custody of another agency and are at risk for a long term out of home placement. The Bridges program is the only such service in Baltimore City. Demand for this type of service has been extremely high. This program provides an out of home placement alternative to an inpatient setting, when such a placement is required for an extended stay. This service is available at a lower per day cost than an inpatient facility, and allows the community-based service provider to maintain treatment continuity.
Recently, BMHS through a grant from MHA, established a Respite program for up to 20 youngsters. This is a short-stay program provided by Kennedy Krieger Institute.
c. Maryland Council of Special Equestrians
This support provides a therapeutic opportunity
for young children residing in RICA-Baltimore to gain experience in working
with, and caring for horses. It provides both a supportive and a skills
development opportunity for this group of children.
IV. SPECIAL
POPULATIONS
BMHS developed needs assessments for several special population sub-groups. They are the 0-5 age group, youngsters involved with the juvenile justice and Department of Social Services Systems, transitional age youth, high end youngsters, the adult forensic population, homeless individuals, dually diagnosed individuals, Spanish speaking individuals, and the elderly.
A. Birth to Age 5
This population is under served by the current City mental health system. Services for this are not readily accessible, adequate to meet the need, nor are staff adequately trained in early childhood development. There is only one provider in Baltimore City, the University of Maryland Baltimore's (UMB) Infant Studies Program, currently specializing in serving this population. A review of exiting data from a three year project between Head Start and Johns Hopkins University to meet the mental health needs of young children, indicates that of the 3,200 children annually enrolled in Baltimore City Head start, approximately 30% are either at risk, or showing early signs of emotional disturbance. Principle risk factors affecting these children include exposure to domestic violence, neglect, exposure to lead-based paint and familial substance abuse. Without prevention, early identification and intervention these children will be at risk for more severe emotional behavioral problems as they enter school.
In FY01 BMHS conducted a survey of mental health
providers active in Baltimore City, to determine the extent to which services
are provided to children age 0-5, and the level of staff training in early
child development. Of the agencies surveyed, 50% indicated that they served
this population, and 55% indicated that they served more than 10 children/year.
In addition a survey of current providers - revealed that many agencies provide
services to the population but staff is largely untrained on issues of early
childhood development. The following are BMHS's strategies to meet the needs
of the 0-5 population.
1. Head Start Initiative - BMHS in collaboration with Head start, Johns Hopkins University and Baltimore area providers developed a program at 6 Head-Start sites in FY'01 which have increased the presence of mental health services in Baltimore City Head start programs. We are learning a great deal of how to provide mental health services at an early childhood site and this program with appropriate modifications will continue in FY'03.
2. Center for Infant Studies - BMHS proposes continued support for the Center for Infant Studies to provide consultation and direct services to families with infants with and at risk for mental health issues.
3. PACT - BMHS proposes continued support for the PACT program to provide services to preschool aged homeless children and families. This service addresses the needs of families whose abilities to access even basic services has been compromised by homelessness.
B. Department of Juvenile Justice Population
The mental health needs of this population are largely unmet - both in DJJ facilities and in the community.
BMHS in collaboration with DJJ and MHA have identified youth in DJJ detention facilities as having largely unmet mental health needs. National studies, and local anecdotal data have suggested that between 30% and 50% of the children detained in such facilities have mental health needs resulting from a variety of psychosocial issues including, chronic exposure to violence, abuse and neglect and sexual abuse. Reports from mental health screenings conducted at Cheltenham Youth Facility by Universal Counseling in FY01 suggests that between 60 and 80% of Baltimore City males have a mental health need. Many of these children in the facilities are either awaiting judicial disposition, or long term placement. While waiting, their unmet mental health needs place them at greater risk for deeper end placement in the mental health system (i.e. residential, or inpatient services), and limit their potential for a successful return to the community.
BMHS has continued to support multiple initiatives to address the needs of this population of children. Universal Counseling provides mental health assessment for all children entering detention facilities, provides mental health supports and services for those children identified in need, and promotes service linkages to those children returning to the community when discharged from DJJ facilities. Johns Hopkins University - School of Medicine is developing a comprehensive assessment and service protocol to be implemented in the new Baltimore City Juvenile Justice facility in the spring of FY02. Universal Counseling and the East Baltimore Mental Health Partnership (EBMHP) provide mental health staff to seven DJJ Aftercare teams, addressing the needs of children once they have returned to the community.
Based on meetings with Baltimore City juvenile judges, probation officers and public defenders, it has become clear that there needs to be improved linkages between the court and mental health systems. BMHS will continue it's Child FAST program whose purpose is to work with the judges to identify, link and follow children and adolescents to the appropriate range of mental health services.
C. Homeless Families
Access to mental health service by this population is limited by life circumstances and bureaucratic processes.
Homeless families with children constitute the fastest growing segment of the homeless community according to OHS. Homelessness is traumatic for young children and they are at risk for a variety of mental health ailments. In addition, their families have often lost documentation that would make them eligible for public assistance. Providing support services to families in such circumstances helps to address the emotional impact and gains for them the resources necessary to access health and mental health services.
MANNA House: BMHS proposes
to continue funding for MANNA House services to provide support services
to Baltimore City's Homeless population. MANNA provides early identification
of children who are at risk or in need of mental health services; facilitates
linkages to appropriate community resources; and provides short term clinical
services to patients and children identified as in need but for whom the
time to gain authorization to the service system is
limited.
Child and Adolescent Services
As described in the interagency collaboration section, BMHS and the FLBC have developed a plan to address the needs of children and adolescents who have not been well served by the PMHS as well as other systems of care. Many of these children and adolescents have become high-cost users of the PMHS. The proposal addresses the following:
A target population of children and adolescents who have not been well-served in the current community system of care and have become high-cost users of the Public Mental Health System (PMHS).
1. A competitive bidding process to identify providers who are motivated to participate.
2. Well-defined outcomes
3. An adequate rate to support the services and incentives based on achieving good outcomes and appropriate risks.
4. An annual performance evaluation.
5. Monitoring and training.
Adult Services
BMHS capitation program for adults requires for admission that individuals must be high-cost users of the community system or long-term state hospital patients. This program will be entering its eighth year in '03 and our hope is to be able to expand the number of individuals it serves from 310 to 600. Expansion requires state approval.
The Adult Services Division meets with each
of the Residential Rehabilitation Program (RRP) providers to review the
rehabilitation plans being developed for the residents. Adult high cost users
are invariably residents of these programs. Therefore, during these reviews
special attention is paid to the services that the high cost users are receiving.
In most reviews the plan and service utilization of the consumer was found
to be appropriate. When they are not found to be appropriate BMHS staff work
with the provider and client to change the level of care to the most appropriate
level.
E. Transition-Aged Youth
As is the case nationally, the problems of transition aged youth also exist in Baltimore. BMHS, FLBC, and DSS have identified Baltimore City youngsters between the ages of 14-18 who are currently residing in Residential Treatment Centers (RTC), at risk for RTC placement, and/or aging out of the child welfare system as a priority population. Currently, there are approximately 115 Baltimore City adolescents in Maryland's RTCs. This population of children receives a comprehensive array of services in a highly restrictive environment. There are an additional identified 60 to 100 adolescents with identified mental health needs currently in group homes or therapeutic foster care placements. Upon discharge these children will return to a community with little in the way of independent living skills and will have only limited supports.
There are very few resources geared to this population within Baltimore City. Within the City's PMHS there is only one residential program specifically geared for transitional age youth, Harbor City Unlimited's six bed (males only) program. While several day programs in Baltimore City have developed young adult or transitional age programs, the need far exceeds the capacity for services. Specifically, People Encouraging People (PEP) has developed a transitional age program geared to individuals in their early twenties who are in need of psychiatric rehabilitation services; and, Schapiro Training Employment Program, Inc. (STEP) has developed vocational initiatives and has established a partnership with New Foundation middle school (a level V non-public school). North Baltimore Center has recently established a Psychiatric Rehabilitation Program that is intended to serve males between the ages of 16 and 21. In addition, the FLBC, the City's Local Management Board, funds Johns Hopkins East Baltimore Mental Health Partnership to provide case management services for youngsters returning from out of home placements. However, this service ends after two years or when the individual reaches age 21.
To meet this need BMHS has, with MHA support, developed a Transition-Aged Youth program that is operated by PEP to serve the needs of children and young adults aged 14-23 years. This system provides a range of services including a PRP, cross-training of staff in the development of services that facilitate increased readiness in youth to assume adult responsibilities, client support to continue to provide necessary support for young adults as they age out of the comprehensive array of child services, supported transitional housing, and specialized case management services tailored to address transition issues for both adolescents and young adults.
F. Adult Forensic Population
Forensic services include all facets of mental health care to persons involved with the criminal justice system. They include:
1. Persons adjudicated by the court as "not criminally responsible" and committed to the care of MHA - either in a State hospital or living in the community on conditional release;
2. Individuals at all stages of prosecution from arrest to conviction. These persons can be either incarcerated or living in the community while awaiting trial, on probation or parole; and
3. Individuals being released from incarceration having served their sentence who are in need of ongoing mental health care.
In a resolution passed by the City of Baltimore Council on Health Care of Newly Released Inmates (Bill 99-1113) it was resolved that ex-offenders have many urgent needs including mental health treatment and all were urged to advocate for services for this population. The U.S. Department of Justice and the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services jointly sponsored a national symposium on "People with Mental Disorders in the Justice System: Strategies for Building on What We Know" in July, 1999. The presentations left no doubt that jails across the country are becoming mental institutions especially for persons with co-occurring substance abuse disorders and that the time to address the issue is now. Mental Health Weekly. The Sun, and other publications have focused increasingly on this topic.
BMHS has been spotlighting this issue for many years with initiatives focused on persons with mental illness who have been charged with criminal wrong doing. An expansion of our services to the Baltimore City Detention Center created the Forensic Assessment Services Team (FAST) Program which targets individuals who may be diverted from incarceration either before trial or at trial. At the present time nearly 150 individuals are being monitored in the community by FAST.
The FAST program has developed a strong reputation as the linkage between the community and the pre-trial detention for persons with mental illness. In addition, FAST and BMHS provide support to the Walter P. Carter Center in the development and execution of community placements for individuals who have had inpatient evaluations for competency and have been found to be competent, not dangerous and in need of individualized community placement planning. This collaboration has been important in the centralization of adjudication of these cases within one court in the City.
BMHS and its RRP providers continue to be willing to provide services to individuals who have been adjudicated as Not Criminally Responsible. A staff person in BMHS' Adult Division meets regularly with staff of the State facilities, particularly Clifton T. Perkins (state forensic hospital) to assure that the referral of individuals are appropriately made to our providers. We have worked closely with staff of Perkins to assure that the referral process is as efficient as possible.
G. Homeless Individuals with Mental Illness
BMHS has continued its efforts to improve services for individuals who are homeless and have a serious mental illness. We have successfully partnered with the City's Office of Homeless Services (OHS) to receive HUD funding through the Continuum of Care initiative. HUD has enabled us to establish four outreach services teams, a 20-bed Safe Haven and a presumptive eligibility SSI project. MHA funding is utilized as match for those programs that can not earn income. These include Project HOPE and the University of Maryland Medical Systems' (UMMS) SSI Presumptive Eligibility Project and the Safe Haven. All of the programs meet and work together to provide services to homeless individuals with mental illness in an system of care that attempts to be as seamless as possible. Through the HUD funded outreach, case management and clinical providers services to the persons who are not yet ready for formal care are initiated using housing options such as the Safe Haven and then Shelter Plus Care as added support and incentives. Through these efforts we have identified a clear need for a second Safe Haven as the current Safe Haven operates at full capacity. In FY'02 Funding was awarded by HUD for the acquisition of the property and funding for operations of a new Safe Haven. Matching funds for staffing and operations will be required in FY'04. Monies for furnishings will be utilized in '03.
BMHS continues to provide funding for special residential programs and placements that meet the needs of adult consumers who are not appropriate for Residential Rehabilitation Programs under the fee for service system. These include two transitional housing programs, At Jacob's Well and Associated Catholic Charities Park Avenue Lodge which provide housing and supports for individuals many of whom have been homeless and have a mental illness. The additional funding also supports the case management and additional mental health milieu needed for these individuals.
Other programs that participate in our initiatives
directed to homeless individuals with mental illness are Health Care
for the Homeless and the Downtown Partnership.
H. Undocumented Spanish Speaking Immigrants
Baltimore City has an increasing population of persons of Hispanic origin. Many of these persons have chosen to live in the East Baltimore area of the City which is primarily served by the Johns Hopkins Hospital. Consequently, Hopkins' has identified a large number of Spanish speaking persons who are not eligible for health or mental health entitlements as a result of their immigration status nor are they able to pay for the cost of these services. In support of our mission to provide needed mental health care to City residents, BMHS identifies the need to partially support the cost of these services provided by Johns Hopkins staff at the Hispanic Clinic. Other OMHCs are provided reimbursement for needed services provided to undocumented residents on an individualized basis utilizing client support funds.
I. Geriatrics
Baltimore City has two Geriatric Mobile Outreach mental health programs, Psychogeriatric Assessment and Treatment in City Housing (PATCH) at Johns Hopkins and Johns Hopkins Bayview Medical Center and Senior Outreach Services (SOS) at University of Maryland. PATCH is a program that has been in operation since September, 1987 and currently provides in-home psychiatric assessment and treatment in all Baltimore City public housing sites for the elderly.
University of Maryland Medical Systems, Inc. (UMMS) Senior Outreach Services (SOS), modeled after the PATCH program, has been in operation since March, 1996. This service is available to provide assessment and in-home psychiatric treatment to any elderly Baltimore City resident living in the community, but not in public housing.
MHA developed an initiative in 1987 to place elderly individuals in need of skilled nursing care from State hospitals into nursing homes. To support the needs of these individuals a Psychogeriatric, nurse consultant was hired. This position is now part of the BMHS staff and in addition to her consultative role to the regional facilities and nursing homes, she provides consultation to general hospital psychiatric units on discharge planning on specific patients.
Case consultation and training for staff of
community programs, assisted living settings and nursing homes focus on the
management of medical and psychiatric needs to facilitate the placement of
elderly individuals into the least restrictive treatment
setting.
J. Head Trauma, Developmental Disabilities, and Other
Progressive Horizons provides three residential beds for individuals who have a serious mental illness and other special needs primarily developmental disabilities.
MHA identified ten adults who had a traumatic brain injury and who were residing in a state psychiatric hospital in 1996. The traumatic brain injuries are due to blunt trauma external to the brain. All of the individuals were post medical rehabilitation and many had been unsuccessful in community or nursing home placements prior to participation in the current project.
BMHS, through the RFP process, identified the Center for Neuro Rehabilitation (CNR) to provide the services. BMHS has monitored the project since 1996. In FY02 BMHS canceled this contract and in consultation with MHA, selected a new provider, Mary T.- Maryland. The transition was smooth and the program continues.
As the MHA has accepted responsibility for improving the services and resources for individuals with traumatic brain injury, funding has been made available to match a federal grant to accomplish this goal. BMHS will continue to monitor this contract.
Finally, funding is provided for individuals
identified by MHA as having special needs and requiring an individualized
community residential placement. Two persons are presently receiving this
support.
K. Entitlement Coordinators
A goal of the PMHS is for individuals without
resources to obtain all of the necessary entitlements including but not limited
to Medicaid, SSI, SSDI, foodstamps and Pharmacy Assistance. Since the majority
of individuals are seen in an Outpatient Clinic Mental Health Clinic (OMHC)
two OMHCs are funded to have an entitlements on staff to assist consumers
obtain these benefits..
V. CRISIS, EMERGENCY & TRAUMA
A. Crisis Response for Adults
The growth of a comprehensive crisis system has been an identified need in Baltimore by BMHS, providers, advocates and consumers for many years. Since its inception in 1992, Baltimore Crisis Response Inc. (BCRI) has been the agency identified to provide these services. BCRI has developed a 24 hour hotline to respond to calls requesting assistance in a mental health emergency and providing information and referral services. In FY'00 the hotline received 8,697 calls. This increased by 50% in FY01 to 12,981. An analysis of the data indicates that over the past two years there has been an increase in calls requesting mobile crisis intervention and a reduction in requests for information and referral. During FY'01 BCRI's mobile team responded to 2,299 calls. These responses resulted in an increased crisis residential use of 4% and an increase of in-home supports of 36%.
Another attempt to divert from in-patient care
was to establish in the spring of 1999, a hospital diversion
project in conjunction with BCRI and Johns Hopkins Bayview Medical Center
(JHBMC). A crisis worker stationed at JHBMC, was trained in BCRI protocols
and authorized to admit into BCRI services. With admitting authority, the
crisis worker is able to respond quickly and decisively to JHBMC clinicians
in the mental health programs and emergency department who are seeking BCRI
services in diverting inpatient hospitalizations.
B. Emergency Room Consultation
During the course of a year, there are more than 6,000 psychiatric consultations performed in general hospital emergency rooms in Baltimore City. For many years mental health evaluations performed in general hospitals in Baltimore were reimbursed through the MHA grant system. With the development of the Fee for Service reimbursement system of the PMHS, the use of grants was discouraged. It was established that the non-physician consultants that were used to perform the evaluations are not included in the charges approved by the HSCRC for the hospitals included in the program. BMHS believes that it is important for mental health evaluations to be provided by trained mental health professionals at this very critical point in the treatment continuum. This allows for all appropriate dispositions to be considered including referrals to BCRI and BCARS for community based crisis services. Without a reimbursement process the consultations were likely to be performed by emergency room personnel not necessarily trained in the diagnosis of mental illness nor familiar with the mental health system in the City.
Beginning in October, 1999, BMHS developed, in conjunction with MHA, a program for the funding of non-physician mental health professionals providing psychiatric evaluations/consultations in general hospital emergency rooms on a fee for service schedule. The non-physician consultant in this project is a mental health professional licensed in Maryland and privileged by the hospital to provide mental health evaluations and diagnosis.
Approximately 65% of the individuals who receive a mental health evaluation in a Baltimore City emergency room, have no insurance. Since the cost of providing a consultation by a mental health professional is not in the HSCRC rate, reimbursement for the consultations provided in the hospital's emergency room is for patients who are covered by Medical Assistance, as the primary insurer, or have no insurance. The reimbursement rates are $60.00 for adults and $70.00 for children and adolescents.
The rate is increased by 5% to pay for the time required to meet our data reporting requirements. Therefore the reimbursement for Medicaid and grey zone patients receiving a mental health evaluation in a general hospital emergency room is:
Adults $63.00
Child and Adolescents $73.50
All services are documented in a data base
which is electronically transmitted to BMHS. The data base program will provide
the billing for the program.
Child and Adolescent Services
C. Child Psychiatric Crisis and Violent Trauma Response
Due to the high levels of chronic exposure to violence and the high numbers of referrals to Emergency rooms and psychiatric inpatient settings, a City-wide need exists to provide psychiatric crisis response and trauma services to communities exposed to chronic violence.
BMHS commissioned a needs assessment in 1997 to determine the needs for a child psychiatric crisis response system in Baltimore City. The results of the survey indicated that the mental health provider network had limited recourse but to refer to area emergency rooms when
faced with a psychiatric crisis. The survey also noted that many such crises resulted in inpatient stays primarily due to the lack of community based alternatives. Finally the survey plus subse