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Public Oversight Hearing on FY 2005 and 2006 Performance of the Department of Mental Health

Monday, March 6, 2006

Public Oversight Hearing on FY 2005 and 2006 Performance of the Department of Mental Health

Ella Thomas

Good morning, Chairperson Catania, members of the Council and staff. I am Ella Thomas, Interim Director of the Department of Mental Health. I would like to introduce the staff with me at the table: Marcia Jones, Chief of Staff; Anne Sturtz, General Counsel; and Joyce Jeter, Agency Fiscal Officer. 

As you know, the Mayor nominated Stephen Baron as Acting Director of the Department of Mental Health. Mr. Baron will officially assume that role on April 10, 2006, the day of the Department’s Fiscal Year 2007 budget request hearing.

I would like to thank you, as the Chair of the Committee on Health, for your support of the Department during my tenure as the Interim Director, and the Mayor’s Office for the privilege of leading the Department on an interim basis.

I am happy to report that the National Alliance for the Mentally Ill just issued its annual report grading the states’ mental health systems. The District placed above the national average in all four categories:  infrastructure; information access; services and recovery supports. While we received an overall grade of C, the national average was D.  

Having led the Department and seen the many challenges it faces from the perspective of the Interim Director, I believe that the most important service that I can provide to the Department, its employees, its consumers, and providers is to speak plainly about the enormity of those challenges.

Between FY 2001, when we were established and September 30, 2005, the Department of Mental Health has enjoyed many successes. The most important is expanding access to mental health services and supports for District residents. 

Our system includes:

    • Directly operating <?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /?><?xml:namespace prefix = st2 ns = "urn:schemas:contacts" /?>St.ElizabethsHospital that provides long-term inpatient care to more than 450 of the District’s most severely mentally disabled adults.
    • A separate psychiatric emergency treatment facility, the Comprehensive Psychiatric Emergency Program, that provided more than 3,000 mobile and on-site crisis care visits.
    • A Core Services Agency, the DC Community Services Agency (DCCSA) that provides comprehensive community-based services to more than 6,000 District residents.
    • A 24/7 service access telephone line, the Access HelpLine, that links individuals to both our public and private inpatient and community-based services.
    • A youth assessment center based at the DC Superior Court that provided more than 1,000 assessments to the court for court-involved youth, multiple diversion programs for children, youth and adults that enable us to serve them in the community, thus avoiding costly institutional services
    • More than 180 community-based treatment and housing providers that constitute a network in which nearly 19,000 citizens are enrolled.

I will discuss details of these services in my testimony.

Unfortunately, along the way we have not been realistic about the Department’s ability to achieve specified goals and objectives. Our sense of urgency to meet the mental health needs of District residents, who were previously deprived of the care they needed, blinded us to the practical matters of system development and development of the infrastructure to support it. 

Now we face the doubly difficult task of fixing fundamental problems with the mental health system while handling the daily problems that crop up in any large organization experiencing uncontrolled growth.

If there were an easy fix to these problems, I would have ordered it when I was named Interim Director.

Specifically, DMH and its providers must find a way to ensure that our dollars are spent on the most medically and financially needy.  As well, we need to bring our partners – DC government agencies, advocates and consumers – together in a meaningful way to strengthen the system and plot its future.

In FY 2006, DMH took the first steps towards planning a mental health system as opposed to simply certifying providers. In addition, we began addressing our infrastructure and financial management issues. 

In the attempt to better manage our resources, DMH reacted without taking the time to fully analyze that issue.  Instead, we re-integrated an electronic treatment planning tool into the Mental Health Rehabilitation Services claims processing system so that care could be authorized only if the provider’s contract had enough dollars to pay for that care. Trying to attain that well-intentioned outcome, produced unintended and unforeseen consequences, and the system has not worked as smoothly as we had hoped. 

Now, rather than create another quick fix on top of the previous one, we conducted a full analysis of the problem, presented that information to the providers and now we are working out the solution.   

As we discussed at our February 10, 2006 hearing, the Department has presented 51 contracts for ratification to the DC Office of Contracting and Procurement.  Thirty-four of these contracts require Council approval and we appreciate your support in introducing them for Council approval at the March 7 Legislative Meeting.

We have taken corrective actions to address the problems that led to this predicament, including fully funding contracts for the entire fiscal year at the beginning of the year.  As well, for FY 2006 $1 million and more contracts, we have submitted these contracts to OAG and they will be forwarded to the Council for approval.

Lest I paint an overly gloomy picture, I would like to take a few moments to share the more notable accomplishments of FY 2005 and 2006.

MENTAL HEALTH AUTHORITY INITIATIVES

In FY 2005, we saw progress in ensuring the availability of community hospital-based acute care services.  We completed an agreement with Greater Southeast Community Hospital to open 20 inpatient psychiatric beds for involuntary, emergency admissions authorized by the DMH Access HelpLine.  DMH also provided $750,000 in capital dollars to Greater Southeast to renovate approximately 7,000 square feet of existing patient space.  An additional $340,000 in capital dollars are slated for additional renovations as needed at Greater Southeast or other community-based hospitals that choose to provide acute care for consumers.

 We have an agreement, in principle, with GeorgeWashingtonUniversityHospital for additional acute care beds.

We also devoted considerable attention to increasing our capacity to meet the mental health services needs of adults touched by the criminal justice system.

    • We implemented the Outpatient Competency Restoration Program for defendants referred by the DC Superior Court with misdemeanor charges following passage of the Incompetent Defendants Criminal Commitment Act of 2004 in May 2005.  St. Elizabeths Hospital Forensic Services staff provided training and supervision to clinicians in the DC Community Services Agency in conducting competency restoration groups and co-led restoration groups during the balance of 2005.  Currently, the DCCSA is serving 14 consumers in this program.
    • We implemented the DMH Criminal Justice Expansion Project in August, which includes the DC Linkage Plus jail diversion program that connects inmates with mental illness to a group of providers to ensure continuity of care with the emphasis on decreasing recidivism.  The DCCSA is serving 65 of the more than 130 consumers in this program. 
    • We established three Assertive Community Treatment teams for those inmates who meet the criteria for this service. 
    • We also provided a grant to the N Street Village Recovery Housing Program, which has 21 beds and provides services for homeless women with co-occurring substance abuse and mental illness who are referred from the jail or in need of jail diversion supportive services.

For court-involved youth, DMH expanded its capacity to meet their mental health services needs. 

    • The AssessmentCenter experienced a 38 percent increase in the number of court-ordered assessments between FY 2004 and 2005.  When compared to FY 2003, DMH achieved a 118 percent increase in the number of court-ordered assessments.  These services are for the courts, which use the evaluations in their placement decision making for children in the foster care and juvenile justice systems.
    • Court and affiliated agencies rated the AssessmentCenter’s evaluations to be very good to outstanding 95 percent of the time. 

DMH staff met the needs of GulfCoast residents displaced by Hurricane Katrina.  Approximately 60 DMH staff provided services at the Armory and the DC GeneralKatrinaWalk-inCenter.  We provided 24/7 services at the Armory between September 6 and 19.  Approximately 20 guests were processed through the Access HelpLine and referred to Core Services Agencies.  Three DMH staff left the comfort of home and family to join other DC government employees who traveled to New Orleans to assist those they encountered.

We have not become complacent as some of the horror of September 11 recedes in our memories.  In FY 2006, DMH will use $297,000 in Department of Homeland Security funds to train approximately 600 DMH employees, Mental Health Rehabilitation Services providers’ employees, and emergency preparedness first and second responders to understand the underlying principles of All Hazards-Disaster Mental Health, responses and interventions, and their specific roles and responsibilities. 

A new grant is our more than $3 million, five-year SAMHSA grant to develop infrastructure to train providers to screen and assess all consumers who present at either DMH providers or Addiction Prevention and Recovery Administration providers to identify and treat those with co-occurring mental illness and substance abuse disorders. Evaluation is built into the grant and will be performed by the GeorgeWashingtonUniversity.

The DMH Office of Consumers and Family Affairs conducted Medicare Part D Day, a Medicare Part D prescription drug seminar for more than 90 consumers, case managers and family members to educate them about the new Medicare Part D prescription drug program. The seminar included experts in the field and attorneys of the State Health Insurance Project, George Washington University Health Assistance Partnership, Families USA, and the DC Department of Human Services, Income Maintenance Administration.

The OCFA also established the Medicare Part D Prescription Drug Hotline for consumers to contact DMH with questions or concerns about the new federal program to pay for prescription drugs. A consumer was trained to answer the hotline, answer questions and refer the caller to the appropriate agency for sign-up or information.

The DMH Office of Consumer and Family Affairs is extending its reach to consumers by conducting events, trainings and sponsorships on recovery, consumer rights and the grievance system, and employment readiness and job opportunities.

ST. ELIZABETHS HOSPITAL INITIATIVES

We are closing in on construction of the new hospital building.  In FY 2005, we began the early roads and utilities project, which was the precursor to the larger construction project.  We are seeking Council approval of the financing package and with that in hand, we can then go out to bid on the main construction.

We reduced the average length of stay for pre-trial defendants admitted to Forensic Services for inpatient treatment and examination for the third consecutive year. Average length of stay has gone from 118.5 days in FY 2002 to 91.6 days in FY 2005.

We established patient support and resource center where patients can go when not in a therapy session and receive peer support.

We instituted a series of Rational Behavioral Training for clinical managers to handle stress as a result of treating violent patients.

We established two new clinical teams.  The first is the Clinical Planning, Development and Implementation team to identify and implement clinical initiatives that address admissions, active treatment, grievances, and other critical elements of patient care.  The second is the interdisciplinary Clinical Consultation and Support Team, which provides consultation and support to treatment teams for our most difficult to manage patients.

We met the 28 percent increase in court-ordered screening examinations in FY 2005, and increased the pretrial inpatient evaluations by 32 percent.

We increased admissions to the treatment mall with the addition of forensic patients in this treatment area. 

In FY 2005, we celebrated the 150th anniversary of St. Elizabeths Hospital with a two-day symposium that attracted nationally-known mental health professionals and the Living History of Civil War Medicine, featuring reenactments of period medical, dental and surgical techniques and a very moving memorial service at the St. Elizabeths Hospital Civil War Cemetery.

DC COMMUNITY SERVICES AGENCY INITIATIVES

The DC Community Services Agency’s financial operations are maturing.  In FY 2005, the following accomplishments were achieved:

  • Benefits coordination was strengthened to increase the Medicaid penetration rate by identifying consumers’ Medicaid eligibility prior to receiving services as well as to ensure their continuing eligibility for Medicaid. 
  • In FY 2005, the DCCSA was certified to provide and bill services to the Medicaid Managed Care Organizations.  Additionally, the DCCSA is newly certified to provide and bill services for its Medicare consumers.  Billing these third-party insurers began in FY 2006.

In the 2005 Dixon Court Monitor Community Services Review, the DCCSA achieved an overall acceptable performance rating of 65 percent for adults and 67 percent for children as compared to 51 percent for adults and 47 percent for children for the DMH provider network.  The CSR also ranked the living, learning, recreational and working environments of 100 percent of children and families and 90 percent of the adults reviewed as safe.  The DCCSA exceeded the Dixon requirement for supporting children to stay in their homes by achieving a rating of 89 percent, while the criterion is set at 80 percent. 

In FY 2005, DCCSA labor and management forged a partnership and established a 16-person work group (six management and 10 labor representatives) to identify and implement strategies to improve DCCSA performance in meeting Dixon exit criteria and agency-wide improvements in overall clinical practices, thereby improving outcomes for DCCSA consumers. 

The workgroup’s other accomplishments include suggested interventions that reflect the Best Practice Recovery principles; a series of newsletters, “Labor Management Workgroup Missile,” a joint communication tool; and establishing other communication means:  the DCCSA Employee Feedback Line, both telephone and email access to allow staff to express their views and opinions, ask questions, or present concerns. 

The DCCSA successfully discharged more than 200 consumers from St.ElizabethsHospital in FY 2005 to community-based services.  The DCCSA exceeded the Dixon continuity of care exit criterion:  Demonstrated Continuity of Care Upon Discharge from Inpatient Facilities, which requires a face-to-face contact with 80 percent of discharged consumers within seven days of discharge.  The DCCSA exceeded that requirement by meeting with 91 percent of discharged consumers. 

While we have a lengthy list of accomplishments, we are mindful of the many challenges we face.  The following actions have been taken or are being taken to improve our organizational accountability:

    • DMH recently reintegrated its authorization process into the clinical practice and claims processing system for community-based services.  Despite the difficulties posed, this allows us to approve appropriate care and manage costs, necessary steps to preserve the MHRS system. 
    • DMH requires its providers to have relationships with Medicaid managed care organizations so that DMH is the payer of last resort.
    • DMH also has imposed a moratorium on certifying additional MHRS providers as we consider how to manage growing the system in the future.

I will conclude my remarks now and welcome any questions about these or other DMH issues.  Again, thank you for this opportunity.