SMHC conducted a through and organized planning process. They wrote a business plan for implementation. This business plan has been submitted to the Foundation for start-up funding as part of the Primary Care and Supportive Services RFP.

• SMHC hired a consultant to develop a heath questionnaire that SMHC staff administered to 289 clients with severe mental illnesses. Key findings include that 50% reported using the emergency room at least once in the past year, 33% had a medical hospitalization in the past year, and 25% reported that they did not have a primary care physician.
• The consultant help SMHC develop focus group questions and trained staff on how to conduct focus groups. SMHC conducted two consumer focus groups that included 28 participants. Consumers pointed out many barriers in accessing medical care and many indicated that they would use primary care services if offered on-site at SMHC.  SMHC conducted three staff focus groups that included 30 staff members. Staff report that significant numbers of their clients have health problems and most thought clients would use an on-site clinic.
• SMHC asked case managers to review their case loads (1,734 clients). The case managers reported that 32% (539) of their clients has at least on serious chronic medical condition and that 55% of the clients smoked.

SMHC met with representatives from local hospitals, health clinics, and private providers. SMHC determined that working with a private provider as a collaborating physician for the nurse practitioners was the best alternative.

SMHC met with representatives from local hospitals, health clinics, and private providers. SMHC determined that working with a private provider as a collaborating physician for the nurse practitioners was the best alternative.

SMHC conducted a literature review and made contact with five mental health and primary care integration programs.

SMHC wrote a business plan to hire a nurse practitioner to provide primary care services on-site at its three office locations (Adams, Lawrence, and Scioto Counties). A local private physician will serve as the collaborating partner for the nurse practitioner. The Southern Ohio Medical Center will handle the billing for the health services. Since smoking is so prevalent, a smoking cessation program will be offered.

SMHC decided that it was not feasible to implement PACT/ACT at this time due to the:

• low number of clients appropriate for PACT/ACT in Adams County to sustain the program,
• difficulty in recruiting and retaining the qualified staff required for the PACT/ACT model, and
• prohibitive costs of implementing the PACT/ACT model.
  • SMHC has no available space for a PACT/ACT team and would have to lease space.
  • Adams, Lawrence, and Scioto Counties do not have tax levies for mental health services. All the PACT/ACT teams that SMHC visited stated that they would not be able to sustain the teams without tax levies to supplement Medicaid billing.
  • The local ADAMHS Board is having trouble keeping up with current Medicaid match requirements; adding PACT/ACT services would place an additional burden on the already struggling Board.
  • The ADAMHS Board cut non-Medicaid dollars to SMHC in November and another cut is expected in the spring 2003.

Even though SMHC decided not to implement PACT/ACT, the planning provided insight into current practices that could be modified for better client outcomes and greater efficiency. The planning work showed:

• Some low-need clients receive high amounts of service and some high-need clients do not receive adequate services. The PACT/ACT consultant provided SMHC with information of levels of care systems that help agencies match client need with appropriate service levels. SMHC plans to explore adoption of a level of care system.
• Case manager caseloads are high and filled with low-need clients who need only periodic appointments with the psychiatrist. SMHC is testing a system that assigns one case manager to the doctor-only clients. This frees up the other case managers to devote time to clients who need more intensive services.
• SMHC operates under a maintenance philosophy that maintains clients in the community by providing mental health services indefinitely. SMHC wants to move to a recovery philosophy that believes people with mental illnesses can recover and achieve meaningful roles in society. SMHC plans to revise its admission and discharge criteria for its community support services to better foster growth, self-determination, and independence.

SMHC did a thorough job on this planning project. Although SMHC decided not to implement PACT/ACT at this time, the agency did benefit from other learnings in the project.

The project coordinator led a thorough planning process and developed the results into a business plan for a Crisis Intervention Team (CIT) for Adams, Lawrence, and Scioto Counties. The project participants:

• Established a system of collaboration among key stakeholders: The project coordinator convened advisory committees of key stakeholders in each of the three counties. These committees included judges, sheriffs, jail administrators, probation officers, prosecutors, defense attorneys, and mental health and substance abuse service providers. The coordinator also attended the local Community Corrections Boards’ meetings, met with each county’s commissioners, and received technical assistance from the National GAINS Center and the Ohio Department of Mental Health’s Coordinating Center of Excellence for Criminal Justice.
• Conducted a needs assessment to determine the scope of the problem: The project coordinator and Shawnee Mental Health Center (SMHC) staff conducted a needs assessment that included a review of SMHC records of mental health screenings done in the jails. Of the 76 people screened over a 12-month period, 36 (47%) were experiencing serious psychiatric symptoms at the time of their incarceration and were incarcerated because police had no other options. The coordinator also conducted a survey in the jails and found that 19% of the jail population (280 people) reported having received prior treatment for a mental illness.
• Developed a strategic plan for enhancing current services and selected one of the services as a priority for funding: Based on input from the three advisory committees, SMHC selected the CIT model and developed a plan for implementation.
• Developed a business plan for implementation of that chosen service: The project coordinator and SMHC staff developed a business plan for the implementation of the CIT program in Adams, Lawrence, and Scioto Counties.

The project coordinator and SMHC staff identified facilitators and barriers in the planning process:

Barriers

• Limited resources made all the planning participants cautious about starting new services.
• Lack of understanding of each other’s system sometimes created challenges among participants.
• The resignation of a Municipal Court judge delayed the planning in that county until a new judge was appointed several months later.
• The absence of a psychiatric hospital in the region complicated planning for a response site to divert people with severe mental illnesses.
• Some of the key participants did not have prior knowledge about mental health systems.

Facilitators

• The project coordinator had experience in local and state government and knew many of the key stakeholders.
  
• Judges chaired two of the three advisory committees, which added clout to their work.
  
• Technical assistance was readily available from the Ohio Department of Mental Health, Office of Forensic Services, the National GAINS Center, Ohio’s Coordinating Center of Excellence for Criminal Justice, other diversion/reentry programs, and Lt. Michael Woody, a CIT expert in Ohio.
  
• NAMI Ohio provided financial support to SMHC to bring an experienced CIT officer to the area to help engage the police agencies in the planning process.
  
• SMHC’s Crisis Stabilization Unit emerged as a good option for the CIT response site.
  
• The willingness of the key stakeholders to participate in the planning process led to its success.
  

In December 2003, the Foundation funded SMHC to start CIT in Adams, Lawrence, and Scioto Counties to divert people with severe mental illness who come in contact with police to treatment.

SMHC provided vocational services to 87 clients in the first grant year and 79 in the second grant year.

SMHC's goal was to achieve a score of 66 or higher out of 75 on the supported employment fidelity scale. In the first year, the program scored 64 and in the second year 70. The scale was scored by SMHC's Director of Standards and Certification.

SMHC evaluated the program using a number of measures:

• Over the course of five quarters, SMHC administered a client satisfaction survey to 48 program clients and each sample showed that clients were 100% satisfied with the program
• 39 clients obtained employment (goal was 25)
• 73 of 166 (44%) clients became involved in meaningful activities (job, school, volunteer) within six months of admission to the program (goal was 20%)
• 28 of 39 (72%) clients maintained jobs for at least 60 days (goal was 50%)
• Crisis contacts decreased by 80% (goal was 25%)

SMHC generated enough revenue to sustain the program:

• SMHC billed $116, 013 to Medicaid (goal was $117, 508)
• SMHC received $90, 780 from RSC (goal was $81, 250)
• The revenue from Medicaid and RSC is enough to sustain the program

The Foundation approved a grant of $268,633 on November 20, 2003 to start Crisis Intervention Teams in Adams, Lawrence, and Scioto Counties, Ohio.  Due to delays in obtaining building permits for expansion of the Crisis Stabilization Unit (CSU), the Foundation approved a variance to extend the grant an additional 8 months.  Shawnee Mental Health Center (SMHC) returned $6,260 of unexpended funds.  The final grant amount was $262,373.

SMHC hired a project coordinator; convened an advisory committee; increased the number of beds at the CSU; hired staff; developed polices and procedures; developed a memorandum of understanding with law enforcement agencies; trained the staff; and published three articles about Crisis Intervention Team (CIT) in local newspapers.

SMHC trained 40 police officers and 7 mental health professionals.

The CIT served 196 people and although the target of 300 wasn't met, the number servered increased steadily each year of the grant from 34 year 1, to 56 year 2, and 106 year 3. Out of 196, police brought 44 people to the CSU. CIT officers de-escalated 115 offenders at the scene and referred them to appropriated services.  The goal was 30.  Another 12 were de-escalated at the scene and not referred for services.

SMHC sustained the CIT program by the end of the grant.

Outcomes:

• 6% (11 of 196) of the encounters that CIT officers had with people with mental illnesses resulted in arrest.
• 22% (44 out of 196) of the encounters CIT officers had with people with mental illnesses resulted in transport to the CSU. In addition, to these 44, jails released 5 people to the CSU that they had picked up. Prior to the implementation of CIT, this did not occur. Of the remaining people 72% (141 of 196) were de-escalated at the scene or referred for services.
• 2,101 jail days were prevented for a savings of $105,050.
• 44% (11 of 25) of those given a follow-up appointment for mental health services kept their appointment.
• SMHC administered the ODMH outcome survey to10 people. Of these 10 people, 4 completed a second survey. All showed an improvement in functioning as evidenced by a decrease in symptom distress and no new contact with law enforcement; 3 ended services before the date of the second survey; and 3 did not have enough time in services to complete a second survey before the grant ended.

Dealing with multiple police departments makes implementation of CIT challenging. Nonetheless, SMHC and the law enforcement agencies have a better understanding of each other s roles and responsibilities and by working together have initiated a collaboration that will grow stronger as the CIT program continues to evolve.

The juvenile probation officers administered the Massachusetts Youth Screening Instrument – Version 2 (MAYSI-2) to youth involved in the criminal justice system over a six-month period. Since parental permission was required for the instrument, the probation officers were only able to screen 39 youth out of approximately 100. Of these 39, 34 (87%) showed mental health problems. SMHC also reviewed agency caseloads and found an additional 35 youth who had juvenile court involvement and needed mental health services.

Members of planning committee reviewed literature on three treatment models. They made site visits to programs using the models under consideration, Multisystemic Family Therapy, Functional Family Therapy, and Multidimensional Family Therapy.

The planning committee ruled out Multisystemic Family Therapy because it was too expensive for them to implement and sustain. They compared various aspects of the other two models and selected Functional Family Therapy as the best fit for the needs of youth in Adams County.

SMHC prepared a business plan for the implementation of Functional Family Therapy in Adams County and submitted it for start-up funding from the Foundation.