State’s mental health system reforms OK’d

349px-Seal_of_DelawareWILMINGTON — Chief Judge Leonard B. Stark, U.S. District Court for the District of Delaware, signed an order Tuesday to release the State of Delaware from the Settlement Agreement entered in 2011 between the U.S. Department of Justice and the State, a decision the State said affirms it has successfully met the terms of the agreement and effectively reformed its public mental health system.

The dismissal was jointly sought by the U.S. Department of Justice and the State of Delaware, signaling the cooperation and mutual agreement of the parties. In filing a joint motion to dismiss, the U.S. Department of Justice and the State wrote to the Court that “the State has implemented reforms that have transformed its service-delivery system for people with serious and persistent mental illness (SPMI), greatly expanded and enhanced capacity to deliver community-based services, minimized reliance on segregated institutional services, and generally improved outcomes for people with SPMI in Delaware.”

Gov. Jack Markell said, “Implementing the critical reforms to the State’s treatment of individuals with serious and persistent mental illness has been a very high priority of my Administration for the past five years, and one in which we have invested a great deal of resources.

“Secretary Landgraf has spent hundreds of hours personally overseeing the implementation of these reforms, and her tireless efforts and exemplary leadership are reflected in this outcome. I am happy that the Court agrees with the U.S. Department of Justice, the Court Monitor and my Administration that our adult behavioral health treatment system is far better equipped to meet the needs of this population than it was when we began this journey five years ago.

“I would also like to thank Dr. Robert Bernstein for his dedicated service as the Court Monitor, and the U.S. Department of Justice attorneys, including current Labor Secretary and former Assistant Attorney General for the Civil Rights Division Tom Perez, for their willingness to work collaboratively with the State throughout the course of the Agreement.”

According to Department of Health and Social Services Secretary Rita Landgraf, “The robust community-based system of care we have built is not perfect; no system is.

“But we have built a strong foundation to support individuals with serious and persistent mental illness as fully engaged members of the community. I believe we will sustain these improvements and continue to evolve the public mental health system because of the ongoing involvement of individuals, their families, peers, advocates, behavioral health professionals, legislators and government officials.”

Chief Judge Stark’s Order follows a September report filed with the Court by Robert Bernstein, who was appointed Court Monitor for the Settlement Agreement, finding that the State was in “substantial compliance” with the requirements of the agreement.

The Settlement Agreement grew out of a U.S. Department of Justice investigation into allegations of unnecessary institutionalization of individuals at the Delaware Psychiatric Center in violation of the Americans with Disabilities Act.

On July 15, 2011, the State and the Justice Department signed the Settlement Agreement, creating benchmarks for the State over the agreement’s five years in building a more robust community-based system of mental health care for Delawareans with serious and persistent mental illness, including schizophrenia, clinical depression and bipolar disorder.

Accomplishments detailed

Over those five years, DHSS said accomplishments include:

• Developed and made available a 24/7 Crisis Hotline – one service number for New Castle County (800-652-2929) and one number for Kent and Sussex counties (800-345-6785) – which provides immediate phone counseling for individuals who are in crisis or their families. In Fiscal Year 2016, a total of 28,262 calls were received.

• Created mobile crisis teams to respond to a person in crisis anywhere in the state, and trained state and local law enforcement officers about the availability and purse of the teams. For calls that triggered an emergency face-to-face response from DHSS’ Mobile Crisis Services, the average response time in Fiscal Year was 40 minutes, well below the one-hour requirement of the Settlement Agreement.

• Opened a crisis walk-in center in Ellendale in August 2012 in order to evaluate and assess people in crisis, diverting them away from hospital emergency departments at rates of 80 percent to 90 percent. After assessment, individuals are referred for further treatment services as needed. In July 2016, DHSS opened a similar Recovery Response Center in Newark to better serve people in New Castle County.

• Reformed crisis stabilization services by implementing and expanding the use of specialized crisis centers aimed at de-escalation and diversion from hospitalization as well as ensuring that those who are hospitalized meet with their intensive services providers within 24 hours of admission to begin a timely return to the community.

• Reduced the census for the target population at Delaware Psychiatric Center by more than 40 percent from 131 in Fiscal Year 2010 to 76 in Fiscal Year 2016. Some individuals who were discharged after years or, in some cases, decades at DPC now receive intensive treatment in the community with access to housing, employment, clinical services, medications and other services.

• Developed and now operate crisis apartments with 21 total beds statewide for individuals who are at risk for psychiatric hospitalization, greatly exceeding the requirement of the Settlement Agreement.

• Expanded Assertive Community Treatment and Intensive Case Management teams for individuals with serious and persistent mental illness to receive intensive support services in the community. In 2012, DHSS also initiated the Community Reintegration Support Project (CRISP), another intensive program for individuals with SPMI and the highest level of disability. CRISP provides 24/7 mobile, out-of-office services to individuals living in the community. In Fiscal Year 2016, DHSS was operating 15 ACT teams, two ICM teams and 2 CRISP teams statewide, far surpassing the requirement of four teams. The Settlement Agreement did not require DHSS to implement CRISP.

• Created three Targeted Case Management teams that support individuals in accessing essential community services such as housing, case management and medicine administration.

• Provided stable integrated housing in the community for individuals with SPMI who often had histories of institutionalization in mental health facilities, criminal justice settings or, hospitals, or who experienced homelessness. In Fiscal Year 2016, DHSS has funding available for 812 individuals.

• Collaborated with the Department of Labor’s Division of Vocational Rehabilitation to assist individuals with supported employment services as they prepare to enter or re-enter the workforce. A job is an important step toward self-sufficiency and an active and engaged role in the community. In Fiscal Year 2016, more than 3,000 individuals are received supported employment services, well above the target of 1,100 in the Settlement Agreement.

• Expanded such rehabilitation services as education, addiction treatment and training in functional skills to promote community integration to more than 2,000 individuals in Fiscal Year 2016, far exceeding the agreement’s requirement of 1,110.

• Created the position of peer support specialist, someone with a shared life experience, to support individuals in recovery as they navigate the health care system and live in the community. Peers operate drop-in centers at the Rick VanStory Resource Center in Wilmington and the A.C.E. Center in Seaford, as well as the Creative Vision Factory art center in Wilmington. In September 2016, 45 peers are certified with the state board, 99 people have completed Peer Support 101, and 122 have completed certification training. In his 10th Report to the U.S. District Court, the Court Monitor wrote, “In short, Peer Support services and the larger peer movement in Delaware have become a vibrant component of the service system for people with SPMI.”

• Embedded discharge planning for individuals hospitalized at Delaware Psychiatric Center and other psychiatric hospitals in the state. In Fiscal Year 2016, 97 percent of individuals were discharged to the community with necessary supports within 30 days of psychiatric stabilization. DPC’s rate was almost 81 percent for the same period because of such barriers to discharge as waiting for an opening at a group home, nursing home, or with an intensive care team in the community.

• Increased quality assurance and performance improvement measures toward achieving the goals of community integration, independence and self-determination.

• Won approval from the Centers for Medicare and Medicaid Services (CMS) in January 2015 to implement PROMISE (Promoting Optimal Mental Health for Individuals through Supports and Empowerment) to provide expanded community mental health services to Medicaid recipients. An estimated 3,000 Delawareans with behavioral health needs and functional limitations will be eligible for this Management Care Organization benefit package, better leveraging Medicaid funds and increasing employment opportunities.

• Worked with the General Assembly and stakeholders to update Delaware’s civil commitment health laws for the time in 50 years, reducing reliance on civil commitment and compelling providers to seek the least restrictive means to assist a person in crisis. As a result, Delaware has seen reductions in both inpatient and outpatient commitments. Between Fiscal Year 2011 and Fiscal Year 2016, inpatient commitments decreased 6.1 percent, and outpatient commitments decreased by 63.3 percent.

• Supported legislation signed by Gov. Markell in September 2016 to establish the Behavioral and Mental Health Commission, including the Adult Mental Health Peer Review Subcommittee to monitor the treatment services provided to adults with serious and persistent mental illness.

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