annual report - behavioral health system baltimore … · annual report and mental health plan ......

BALTIMORE MENTAL HEALTH SYSTEMS, INC.

ANNUAL REPORT FISCAL YEAR 2012

ONE-YEAR PLAN FISCAL YEAR 2014

Jane D. Plapinger, MPH John A. Gray, JD

President & CEO Board Chair

Baltimore Mental Health Systems, Inc.

Annual Report and Mental Health Plan

Table of Contents

Executive Summary .............................................................................................................5

Annual Report, Fiscal Year 2012

Introduction ......................................................................................................................9

Highlights of Accomplishments ......................................................................................9

Report of Activities ..........................................................................................................20

Goal I: Americans Understand that Mental Health is Essential to

Overall Health ..................................................................................20

Goal II: Mental Health Care is Consumer and Family Driven ...........................24

Goal III: Disparities in Mental Health are Eliminated .........................................29

Goal IV: Early Mental Health Screening, Assessment, and Referral

to Services Are Common Practice ....................................................49

Goal V: Excellent Mental Health Care is Delivered and Research is

Accelerated While Maintaining Efficient Service System

Accountability ..................................................................................57

Goal VI: Technology is Used to Access Mental Health Care Information .........79

One-Year Plan, Fiscal Year 2014

Introduction ......................................................................................................................82

Data on Service Utilization and Outcomes ......................................................................84

State Priority Areas .........................................................................................................143

Mission, Vision and Values .............................................................................................149

Goals, Objectives and Strategies......................................................................................150

Appendices

Appendix A: Glossary and Acronym Descriptions .........................................................167

Appendix B: FY 12 Quality Management Report ...........................................................175

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Executive Summary

Baltimore Mental Health Systems, Inc. (BMHS) is a non-profit agency established by Baltimore

City to perform the governmental function of managing the City’s public mental health system

(PMHS). As such, BMHS serves as the local mental health authority, or core service agency

(CSA), for Baltimore City. BMHS’ primary activities focus on: improving access to care and

expanding and improving the range of services available to Baltimore City residents with mental

illness. This is accomplished through active collaborations with City and State agencies, and

other system-level partners.

BMHS oversees a network of predominantly private, non-profit providers that deliver services to

over 43,000 Baltimore City residents who are Medicaid and/or Medicare recipients or uninsured.

The majority of public mental health system services are reimbursed through a statewide fee-for-

service system. In addition to overseeing the provision of these services, BMHS directly awards

public and private funds to support the development of innovative programs and the ongoing

operations of mental health services not reimbursable by the fee-for-service system.

During FY 12, BMHS was affiliated with two non-profit entities, Community Housing

Associates, Inc. (CHA) and the Behavioral Health Leadership Institute, Inc. (BHLI). CHA is

dedicated to developing and managing affordable housing for low-income individuals and

families in Baltimore City who are affected by mental illness. CHA owns or manages 217

housing units. BHLI (formerly Mental Health Policy Institute for Leadership and Training, or

MHPILT), the second affiliate, was established to address issues related to workforce

development in community behavioral health across disciplines, and the gap between research

findings, policy and practice. BMHS and BHLI disaffiliated as of June 30, 2012.

BMHS and the State’s 18 other CSAs are required to submit an annual report to Maryland’s

Mental Hygiene Administration (MHA) in which progress on goals delineated in the agency’s

immediately previous Mental Health Plan is described, and to develop an updated Plan based

both on progress made to-date and new opportunities. This document is BMHS’ Annual Report

for Fiscal Year 2012 (July 1, 2011 through June 30, 2012)1 and the agency’s One-Year Plan for

FY 14. The Annual Report addresses the activities and accomplishments of BMHS during FY

12, while the Mental Health Plan describes public mental health system utilization during FY 12,

strategies on eight of the State Priority Areas, and updated goals, objectives and strategies for FY

14.

The first part of the annual report is the Highlights of Accomplishments section, which presents

significant accomplishments, organized under the following headings: Expanding Prevention

1 Henceforth throughout this document, fiscal years; e.g., 2012, will be abbreviated FY 12.

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and Early Intervention, Increasing Access to Mental Health and Related Services, Improving the

Quality of Mental Health Service Delivery, Managing Public Funds, and Federal Healthcare

Reform. Some of the accomplishments noted in this section fall outside of the purview of the

plan previously created for this time period due to unforeseen opportunities and challenges, in

particular the passage of federal health care reform. Therefore, the work BMHS has begun

relative to federal health care reform is described in this section.

BMHS exercises significant authority over funds allocated to public mental health through its

coordination and oversight of the fee-for-service Public Mental Health System and its

management of a grants portfolio. In FY 12, BMHS awarded $19.6 million in grants, with 106

contracts issued to 57 provider agencies. The Report of Activities section of the annual report

provides a detailed description of programmatic activities related to these grant funds and the

related administrative activities of the agency. It identifies BMHS’ goals and associated

strategies and objectives for FY 12 and describes the extent to which the strategies were

accomplished. BMHS’ overarching goals were those put forth in New Freedom Commission on

Mental Health, Achieving the Promise: Transforming Mental Health Care in America:2

GOAL I: Americans Understand that Mental Health is Essential to Overall Health

GOAL II: Mental Health Care is Consumer and Family Driven

GOAL III: Disparities in Mental Health are Eliminated

GOAL IV: Early Mental Health Screening, Assessment and Referral to Services are

Common Practice

GOAL V: Excellent Mental Health Care is Delivered and Research is Accelerated

While Maintaining Efficient Service System Accountability

GOAL VI: Technology is Used to Access Mental Health Care Information

The one-year Mental Health Plan describes new developments in the local PMHS, utilization of

public mental health services, initiatives that promote eight of the State priority areas, and the

goals and objectives BMHS plans to focus on in the upcoming year. The Introduction provides

an update on planning relating to behavioral health integration and an overview of the Mental

Health Plan section. The Data on Service Utilization section presents summary service

utilization data for the 43,821 individuals served by the fee-for-service Public Mental Health

system and the associated $228,184,888 in expenditures. It includes a comparison of FY 12 and

previous years’ data and notes trends in individuals served, services rendered and expenditures.

Significant trends noted in the FY 12 data include:

Number of consumers served increased by 5%, while the cost per consumer decreased by 6%

Inpatient hospitalization decreased by 11%, while outpatient services increased by 5%

2 New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in

America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.

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The State Priority Areas section describes BMHS activities that advance the State’s behavioral

health priorities. The System Mission, Vision and Values for BMHS are then presented.

Finally, the Goals, Objectives and Strategies that BMHS intends to pursue in FY 14 are

presented.

There are two appendices:

Appendix A: Glossary and Acronym Description

Appendix B: FY 12 Quality Management Report

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ANNUAL REPORT

Introduction

This section of the Annual Report describes progress made during the past fiscal year. The

Highlights of Accomplishments section describes the significant and innovative achievements

that expanded prevention and early intervention, increased access to care, and improved the

quality of care, while effectively managing public funds and planning for health care reform. The

Report on Activities describes the progress made toward the goals, strategies and objectives

previously presented to MHA for FY 12.

Highlights of Accomplishments

Expanding Prevention and Early Intervention

Prevention and early intervention services aim to minimize the progression of mental disorders

and the associated personal and societal costs.

Provide Early Childhood Mental Health Services

Three thousand four hundred nine (3,409) children were enrolled in Head Start in FY 12.

Sixty-three percent (2,137) accessed mental health prevention, early identification, and/or

treatment services. Clinicians provided 339 classroom observations and 712 mental

health consultations. These Early Childhood Mental Health (ECMH) services were

provided in 11 out of 12 Baltimore City Head Start Centers. In addition, in FY 12,

clinicians implemented multiple evidenced-based practices that improved the quality of

services the children received.

One hundred two (102) out of 196 (52%) of Baltimore City public schools had clinicians

who provided Expanded School Mental Health (ESMH) services to students. Four

thousand six hundred sixty six (4,666) students received mental health prevention

services in FY 12. In FY 12, clinicians implemented multiple evidenced-based practices

that improved the quality of care the students received. Another major focus of FY 12

was BMHS’ implementation of web-based reporting, which will facilitate more accurate

data collection on the impact of services on local school children while also lowering the

burden of the reporting process on clinicians.

Train City Patrol Officers to Respond to Individuals Experiencing a Behavioral Health

Crisis - Behavioral Emergency Services Team (BEST)

One hundred sixty-two (162) patrol officers received BEST crisis intervention training in

the past year, a significant increase from last year (115 trained). BEST-trained officers

are trained to de-escalate mental health crises, minimize arrests, and decrease officer

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injury. The BEST project was successfully integrated into the training program of the

Police Department, so that all new police recruits now receive this training. Additionally,

the five agency partners signed an action plan which delineates responsibilities and

commits partners to a quarterly meeting to monitor and further develop the BEST project.

Increasing Access to Mental Health and Related Services

Increasing access to community-based alternatives to expensive, restrictive and often-

traumatizing mental health services improves outcomes for consumers and is cost-effective for

the public mental health system.

Divert Felony Defendants with Serious Mental Illness into Treatment

Defendants with serious mental illness started pleading into the Mental Health Case

Management Docket on June 1, 2011. This three-year pilot project in the Circuit Court of

Baltimore City provides mental health assessments, plans of care, monitoring and linkage

to services. Johns Hopkins Bloomberg School of Public Health was brought in to conduct

an evaluation to determine its impact in lowering arrest rates and promoting positive

mental health outcomes. As of the end of FY 12, the project had enrolled ten individuals,

with five additional individuals identified to enroll, following their completion of a six-

month residential substance abuse treatment program. The program goals are to increase

enrollment to 20 individuals and to then maintain that number at all times thereafter.

Reconnect Arrested Individuals with Mental Illness To Services

BMHS collaborated with the Department of Corrections (DOC) to restore a data-feed,

called DataLink, which identifies individuals known to the PMHS who have entered the

City jail. As of May 10, 2012, the data-feed became fully operational. On behalf of

identified individuals, BMHS contacts their most recent mental health provider to notify

them of the arrest and inform them of resources, such as the Forensic Alternative

Services Team, to reconnect the individual to community services. As of June 30, 2012,

101 notifications via email, telephone and facsimile were made to providers on behalf of

arrested individuals identified through DataLink.

Ensure Mental Health Services for Children in the Child Welfare System

Eight hundred fifty-three (853) youth who entered the Baltimore City Department of

Social Services (BCDSS) foster care system received evidence-based mental health

assessments through the Making All The Children Healthy (MATCH) program. These

assessments are part of an integrated care management unit within BCDSS, intended to

provide coordinated somatic and mental health care to children in the foster care system.

There was a 144% increase in the number of youth served (350 in FY 11); this was

attributable to: 1) FY 12 being the first full year of operation of the program; and 2) the

program expanding to include a larger age range of children.

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Expand Community-Based Services for Children and Reduce Institutionalization

BMHS worked closely with Wraparound Maryland (the care management entity for

Baltimore City), and ValueOptions® to enroll 82 youth in the Psychiatric Residential

Treatment Facility Waiver. This is more than double the 41 youth enrolled in FY 11, as

FY 12 was the first full year of implementation for this program. Through the waiver

program, these children received a higher level of care in a community-based setting and

avoided placement in a more restrictive residential treatment environment.

In an effort to expand the continuum of community-based services available to youth in

the foster care system, BMHS coordinated efforts with Baltimore City's Department of

Social Services (BCDSS) to blend family-driven, evidence-based practices within mental

health and child welfare for 81 children and adolescents with complex behavioral health

needs. Services provided focused on improving each child’s individual social,

emotional and behavioral health outcomes. This initiative was funded by a Substance

Abuse Mental Health Services Administration (SAMHSA) grant, titled Maryland Crisis

and At Risk for Escalation diversion Services for children (MD-CARES).

Expand the Continuum of Crisis Services for Individuals Experiencing a Behavioral Health

Crisis

BMHS developed and began to implement a plan to reduce City expenditures on

psychiatric hospitalization by $6 million, or about 15%, in response to the cost

containment item in the FY 13 State budget. BMHS’ plan is comprised of four

components: 1) communication and collaboration with emergency departments; 2) divert

to community-based services in lieu of inpatient admission; 3) reduction in 30-day

hospital readmissions; and 4) reallocation of funds to a provider that can coordinate care

for consumers visiting the emergency rooms and those who are identified as high cost

users. More specifically:

BMHS worked closely with Baltimore Crisis Response, Inc. (BCRI), the City’s crisis

provider for adults, to increase public access to mobile crisis services by expanding

the evening hours of its crisis response teams by two hours, now operating from 7 am

- midnight. In addition, grant funding was identified at the end of the year to hire

more staff at BCRI to strengthen the coordination of crisis response services with

emergency departments with the aim of reducing avoidable hospitalizations.

BMHS worked closely with Baltimore Child and Adolescent Response System

(BCARS), the City’s crisis provider for children and adolescents, to provide

accessible urgent care to children and adolescents in lieu of avoidable and costly

hospital emergency department visits. This new initiative places BCARS clinicians in

two local hospitals where they are providing mental health assessments, stabilization

services, and immediate linkage to other services. Since this initiative began on April

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16, 2012, 32 children have been diverted from emergency departments and linked to

community-based crisis services.

Engage High-Utilizers of Mental Health Services

In the spring of 2011, BMHS participated in a state-wide symposium, Balancing Public

Health and Individual Liberties: Exploring New Options in Outpatient Treatment,

sponsored by the University of Maryland Schools of Law, Medicine, and Social Work. It

focused on the challenge of better engaging individuals with serious mental illness who

have high rates of utilization of psychiatric inpatient care. The outcome was the creation

of a committee, chaired by BMHS, to design a program that would address the shortfalls

of existing programs geared to this population. A program that would provide intensive

engagement and flexible services was designed and a grant proposal to fund it was

submitted to the Centers for Medicaid and Medicare Services (CMS). The grant request

was not funded (only 8% of submitted proposals were funded via this very competitive

grant opportunity), and efforts to secure funding will continue.

Twenty (20) consumers with recent histories of inpatient psychiatric care were linked to

an Assertive Community Treatment (ACT) team with enhanced peer staffing as part of

the Peer Support Engagement Project (PSEP), a pilot project funded by the Maryland

Mental Health Transformation State Incentive Grant. The aim of the pilot project was to

determine whether enhanced peer support would enable consumers who are at high risk

for repeated hospitalization to be served and supported in the community and thus avoid

inpatient care. An analysis of the consumers served by the PSEP showed that the

initiative reduced: 1) visits to the emergency department (24%); 2) inpatient

hospitalizations (53%); 3) days of inpatient hospitalizations (42%); and 4) PMHS costs

associated with these consumers (18%).

Reduce Homelessness Among Individuals with Mental Illness

BMHS continued to work with the Mayor’s Office of Homeless Services to implement

the City’s ten-year plan to end homelessness. BMHS is involved in ongoing planning and

collaboration with system partners and continues to provide technical assistance to

mental health outreach providers. Additionally, BMHS co-facilitates Hands in

Partnership (HIP), a coalition of City homeless outreach teams. HIP teams engaged in

1,249 visits with individuals identified as vulnerable and in need of intensive, coordinated

outreach services. These services resulted in 11 individuals being placed into housing.

Six hundred seventeen (617) homeless individuals received street outreach services and

linkage to care from BMHS’ HUD-funded outreach teams. These teams made 3,119

contacts with homeless individuals. Forty-eight (48) of these individuals were placed into

permanent housing as a direct result of this outreach.

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Promote Housing Development

In order to more efficiently address the limited housing opportunities for individuals with

serious mental illness in Baltimore City, the Boards of Directors of BMHS and

Community Housing Associates, Inc. (CHA) approved a resolution for CHA to cease its

affiliation with BMHS. The disaffiliation will enable CHA to migrate its assets into a

larger organization that can further CHA’s mission to develop and operate housing for

persons with serious mental illness and histories of homelessness in Baltimore City. The

Request for Qualifications and Interest: To Merge Community Housing Associates with a

Larger Organization was issued in February for the purpose of identifying an interested

and qualified large organization, and this process concluded in June with the selection of

People Encouraging People (PEP). The planning process continues to move forward with

CHA, BMHS and PEP.

Improving the Quality of Mental Health Service Delivery

High quality of care is associated with beneficial outcomes and a better life for individuals with

mental illness. Evidence-based practices (EBPs) are service protocols or program models whose

beneficial impacts on consumers have been validated through research. Maryland certifies

programs that demonstrate fidelity to EBPs.

Expand Access to Evidence-Based Practices

Common Elements: To better ensure that children receiving mental health services in

Baltimore City schools receive quality care, BMHS funded a year-long professional

development training for 72 Expanded School Mental Health (ESMH) clinicians to learn

and practice Common Elements of Evidence-Based School Mental Health Practices.

Common Elements takes components of interventions that have been shown in clinical

trials to be effective in treating specific disorders of childhood and adolescence, and re-

bundles those elements to allow clinicians to more effectively provide behavioral health

interventions. It is expected that children at the schools where trained clinicians are

located will receive higher quality care, because the clinicians will utilize and adapt the

new strategies and techniques learned.

Integrated Dual Disorders Treatment (IDDT): As of April 10, 2012, individuals with a

co-occurring mental illness and substance abuse disorder who were court-ordered to

receive substance abuse treatment could access integrated treatment for both disorders.

IDDT is an evidence-based practice model for treating individuals with both mental

health and substance abuse disorders. The opening of enrollment in April followed a two-

year planning process by BMHS and bSAS to develop and implement these specialized

services. Three individuals have been enrolled to date.

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Promoting Trauma-Informed Care

In FY 12, BMHS realized an opportunity to better enhance the quality of care to

consumers by using grant funds to train nine outpatient mental health clinics to develop a

trauma-informed culture within their agency. This initiative will be achieved through a

training collaborative led by the National Council for Behavioral Healthcare. Trauma-

informed care is beneficial to the majority of individuals in the public mental health

system. It is estimated that 90% of pubic mental health system consumers have been

exposed to trauma on multiple occasions.3

Use Consumer Perceptions of Care Data to Improve Care in Grant-Funded Programs*

Starting in FY 12, BMHS required grant-funded direct service programs to collect and

use consumer feedback to inform their quality improvement efforts. (Consumers’

perception of care is a nationally recognized quality measure.) These providers are

required to use their FY 12 survey results to identify an aspect of care for focused quality

improvement activity in FY 13.

Implement Quality Improvement Framework for the Capitation Project

In FY 12, to continue BMHS’ efforts in improving the quality of care for consumers

enrolled in the Capitation Project, BMHS and the two Capitation Project providers

implemented the continuous quality improvement (CQI) framework that was created in

FY 11. CQI activities focused on increasing employment opportunities for Capitation

consumers – an area that was identified as a priority by consumers in the two Capitation

programs.

Managing Public Funds

BMHS exercises significant authority over public mental health funds through its coordination

and oversight of the fee-for-service public mental health system in the City with expenditures of

approximately $228 million in FY 124 and its management of a grants portfolio of $19.5 million.

This year, BMHS implemented a number of administrative infrastructure and operational

improvements focused on enhancing its management of public funds.

Fee-For-Service Public Mental Health System Funds

Manage the Public Mental Health System to Ensure Efficient Service Delivery

BMHS continued to collaborate with MHA and ValueOptions® to manage the resources

of the PMHS and its ever increasing population of individuals served in Baltimore City –

3 Muesar et al., in press; Muesar et al., 1998.

4 These data are incomplete and will likely be higher as claims may be submitted up to twelve months after the date

of service delivery.

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a projected 42,800 in FY 12. BMHS worked to authorize services for consumers with

public insurance, ensure access to care for uninsured individuals, and authorize and

manage access to the Capitation project and Residential Rehabilitation Program services.

Improve Risk Management of Capitation Project Funds

In FY 12, BMHS realigned its relationship with the City’s two Capitation programs, with

the transfer of financial risk from BMHS to the two providers. These modifications were

agreed upon and planned for in FY 11.

Grant Funds

Fund Critical Client Needs

BMHS granted over $3,600 in need-based client support funds on a case-by-case basis to

135 individuals to provide assistance with medications.

Repurpose Unspent Grant Funds

BMHS repurposed under-spent funds before the end of the contract year, distributing

$61,444 as supplemental grant awards to 13 providers in good standing to fund a variety

of one-time requests focused on improving care to clients. Knowing that the opportunity

to repurpose FY 12 unspent funds through “rollover” would be unlikely due to the tight

State budget, repurposing funds during the fiscal year became a priority for BMHS.

Greater provider compliance with fiscal reporting requirements and improved oversight

by BMHS facilitated this process.

Oversee Provider Contracting

Ninety seven percent (97%) of BMHS provider contracts (96 contracts with 56 different

providers) were renewed “on-time”, i.e., prior to the start of the 2013 fiscal year.

Renewing contracts on time is an important performance goal for BMHS, because it

ensures programs will receive timely payments from BMHS, enabling consumers to

receive uninterrupted services.

Improve Organizational Processes

As a result of continuing improvement efforts in contract monitoring and reporting, the

contractual compliance rate5 for FY 12 was 93%. Contractual compliance allows BMHS

to make more informed decisions about funding, including the repurposing of unspent

funds and strategic decisions about budget reductions that minimize the impact on service

delivery.

5 These rates measure compliance by grant-funded providers with programmatic deliverables, fiscal reports, and

submission of professional licenses, insurance and fidelity bonds.

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BMHS completed the planning of the implementation of an electronic contract

management system that is designed to replace what is currently a paper-intensive,

manual system. The contract management system aims to increase process efficiency;

create automated, customized reports; and allow users access to real-time and point-in-

time data. The system will benefit providers by enabling online submission of invoices

and reports and record-keeping capacity for provider documents.

BMHS brought on an organizational consultant, Stanton Executive Group, to strengthen

organizational operations in preparation for the growing workload relating to behavioral

health care integration and the planning of the merger of BMHS and bSAS. This

consultation has focused on internal processes, procedures and standards; workflow;

output and quality control. The consultation has enabled BMHS to reduce administrative

staffing and is laying a foundation for the merger-related planning in the areas of

operations, staffing and finance.

Contract-Funded Services

The table below, which lists just a portion of BMHS’ grant-funded contract portfolio,

indicates the range of services funded. These services are discussed in greater detail in

the Report on Activities section.

Contract-Funded Services, FY 12

Type of Service Services Provided # Served/ # Services

Provided

Consumer-Run:

Wellness and Recovery Centers Peer support 626 individuals

Family-Driven:

High Fidelity Wraparound

Mental health treatment and

supportive services 261 families

Forensic (adults):

Forensic Alternative Services Team

(FAST), Forensic Assertive

Community Treatment Team

(FACTT), Case Management,

Chrysalis House

Mental health treatment and

diversion

1,507 individuals; 40

discharged from State

Hospital

Forensic (youth):

Court Medical Evaluation Team Mental health assessments 289 individuals

Homeless:

Hands In Partnership

Outreach and Coordination

of care 284 individuals

Homeless:

Transitional Housing Housing services 265 individuals

Homeless:

HUD-funded projects Housing services 1,001 individuals

Trauma: Trauma-focused 88 calls

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Child Development Community

Policing

interventions

Early Childhood Prevention and treatment

services

339 classroom

observations and 712

mental health

consultations

School-Based Prevention and treatment

services

4,666 students in 102

schools

Crisis (adults):

Baltimore Crisis Response Inc.

(BCRI)

Crisis intervention and

follow-through

28,444 calls

1,665 crisis team visits

Crisis (youth):

Baltimore Child and Adolescent

Response Systems (BCARS)

Crisis intervention and

follow-through

1,829 calls;

384 families receiving

crisis stabilization

services

Hospital Diversion Project Hospital diversion 317 individuals

Veterans:

Pro Bono Counseling Project Mental health counseling 104 veterans

Develop and Implement Agency Quality Management Plan

BMHS’ Quality Management Plan was launched in FY 12. Quality management efforts

focused on three measures of the performance of BMHS-funded programs – consumer

perceptions of care, provider compliance with contractual requirements, and program

quality – and three measures of BMHS performance – consumer complaint resolution,

timely contract renewals, and help call satisfaction. A Quality Management Committee

was established and met throughout the year to review data related to these measures (and

other quality-related activities such as site visits and provider applications), and identify

and plan opportunities for improvement.

Behavioral Health Integration/Federal Healthcare Reform

Federal healthcare reform offers opportunities to improve care, particularly for individuals with

multiple health issues – mental, somatic and substance use disorders – who will benefit from its

focus on greater integration of care, improved experience of care and better outcomes. With the

continued progress in planning for both federal healthcare reform implementation and

behavioral health integration in Maryland this year, BMHS increased its focus on related

planning activities.

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Planning for Behavioral Health Integration

BMHS actively participated in the nine-month State planning process aimed at the

selection of an integrated financing model for state-funded mental health and substance

abuse services. BMHS management advocated at the workgroups and larger DHMH

planning meetings, through its leadership in the Maryland Association of Core Service

Agencies (MACSA) and its representation of MACSA at Maryland Mental Health

Coalition meetings. The focus of the advocacy was the continuation of the strengths of

the current financial model and the continuation and expansion of the role of local mental

health authorities (which will evolve into local behavioral health authorities).

BMHS executive management established a weekly internal behavioral health integration

planning meeting to begin to develop a common vision of programmatic opportunities

that could be pursued through behavioral health integration.

The focus of FY 12 quarterly BMHS all-staff meetings was behavioral health integration

– its relevance to the work of BMHS and the need for all staff to “own” the opportunities

to promote integration in their specific areas of work.

The focus of the three FY 12 provider meetings was likewise integration. BMHS invited

subject matter experts to present at these meetings. The speakers included: Chuck

Ingoglia, Vice President for Public Policy, National Council for Community Behavioral

Health and Brian Hepburn, Executive Director for the Mental Hygiene Administration

(MHA).

BMHS continued weekly meetings with bSAS to collaborate on promoting integrated

behavioral health care through the IDDT project (see page 13), and expanded those

discussions to lay the foundation for broader programmatic collaboration aimed at

promoting a more integrated approach at the systems level to behavioral health care

access and service delivery in the City.

In the spring, both BMHS and bSAS Boards of Directors agreed to commence planning

for the creation of a local behavioral health authority that will replace BMHS and bSAS.

An Integration Steering Committee, comprised of the President & CEO of BMHS and of

bSAS, chair of each board, and five representatives of each agency, was established.

Develop and Strengthen Key Partnerships

In the fall of 2011, BMHS conducted a needs assessment as part of the development of its

three-year plan. A consultant was hired to conduct interviews and focus groups with

stakeholders to determine gaps in mental health services for Baltimore City residents as

well as to determine barriers to quality mental health care. Twenty-two (22) individual

interviews and two focus groups were conducted in October 2011. A total of 46

stakeholders participated, which included representatives from local hospitals and

Federally Qualified Health Centers (FQHCs).

The Partnership Advisory Council was established and launched in accordance with a

resolution approved at the June 2011 BMHS Board meeting. The Partnership Advisory

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Council meetings serve as a high-level forum for leaders in partner organizations to

identify shared priorities and opportunities to collaborate – to expand access to mental

health services, including prevention, to specific populations and within specific locales

(schools, child welfare, criminal justice system, etc.).

BMHS recognizes that FQHCs are key healthcare reform partners. Therefore, throughout

FY 12, executive management began to meet individually with local FQHCs.

Additionally, school-based clinicians funded thorough the Expanded School Mental

Health initiative are now required to partner with FQHCs located in the school’s

community to connect somatic care and behavioral health services and to increase access

to care.

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Report on Activities, Fiscal Year 2012

Unless otherwise indicated, all strategies were accomplished.

GOAL I: Americans Understand that Mental Health

is Essential to Overall Health.

Objective 1.1: Baltimore Mental Health Systems (BMHS) will increase public awareness of

mental health disorders, prevention mechanisms, treatment services, and supports.

STRATEGY 1: Provide direction, funding and ongoing consultation to organizations that

implement public education and training activities.

Action Step: Support organizations that provide public educational workshops,

distribute educational literature, and offer information and referrals:

■ Mental Health Association of Maryland (MHAMD);

■ National Alliance on Mental Illness (NAMI);

■ Maryland Coalition of Families for Children’s Mental Health;

■ On Our Own of Maryland.

BMHS continued to support the agencies listed above, which provide outreach and

education to a wide variety of audiences on a range of topics. In FY 12, over 30,000

individuals received training, participated in educational programs, or attended

workshops sponsored by these agencies.

Indicator: Report on progress to date.

MHAMD held 367 performances of the “Kids on the Block,” with 22,757 attendees and

distributed 69,997 publications, general children’s mental health information and

campaign materials for Children’s Mental Health Matters. MHAMD also participated in

30 health fairs for adults, conducted 33 Older Adult Mental Health issues trainings and

10 advanced directive trainings, participated in 39 health fairs and also distributed 35,786

educational materials.

NAMI served 233 family members through 7 Family-to-Family courses, and conducted

90 workshops about mental health topics, with 1,275 individuals attending. One

consumer was trained by NAMI National in a workshop facilitator refresher course. Two

consumers were trained by NAMI National as peer-to-peer mentors. Twenty-seven (27)

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were trained as mentors to teach the peer-to-peer education course, which 97 consumers

completed. Twenty-four (24) support group facilitators were trained. An additional 24

family members completed the train-the-trainer course. NAMI also held their annual

NAMI Walk, a public education event that promotes awareness of mental illness, at two

locations this year. Over 1,000 individuals participated, including a BMHS team.

Maryland Coalition of Families for Children’s Mental Health held 10 webinars, with 200

participants; 14 family trainings, with 122 participants; and 10 Family Leadership

Institutes, with 74 participants. They also responded to 308 calls for information, referral

or support, and continued to be the lead coordinator for a statewide Children’s Mental

Health Awareness Week campaign.

On Our Own of Maryland provided assistance and referrals by phone or in person to

5,024 individuals. They completed 51 educational presentations which focused on the

stigma of mental illness, with 927 participants, and worked with 24 local consumer-run

organizations through their participation in various educational events.

STRATEGY 2: Participate in community events that promote awareness of mental health.

Action Step: Provide education and outreach regarding depression and available

mental health services through the Behavioral Health Leadership Institute.

The education of paraprofessionals, clients and community stakeholders continues to be

an ongoing effort of the Poverty and Depression Project Connections (hereafter “Project

Connections”). Project Connections provides training to paraprofessionals on mental

health issues at five community sites, and provided informal educational groups to clients

about symptoms of depression, parenting skills and issues, and other relevant topics. The

educational activities continue to focus on reducing stigma about mental health treatment

among both outreach workers and clients.

Baltimore City’s Youth MOVE (Motivating Others Through Voice of Experience) is the

local chapter of a national youth-led organization, which works to improve services and

systems that support positive youth and family growth and development. BMHS

established the local chapter in March 2010 to provide public education and outreach

regarding mental health and mental health services to City youth. It is dedicated to

eliminating the stigma of mental health illness and educating young people with mental

health illnesses to become advocates for themselves and peers. Members of this group

participate in health fairs across Baltimore City and coordinate fundraising activities to

support local homeless youth shelters.

Indicators: Number of community events.

22

Number of Individuals Attending Educational Events

Community Event Individuals

9 Health Fairs 2,000

Client Education Groups at 5 Project Connections Sites 70

Project Connections Staff Training Series 15

STRATEGY 3: Collaborate with the Baltimore City Health Department (BCHD) and

Federally Qualified Health Centers to identify opportunities to provide educational

information about mental health issues and access to care.

Action Step: Reach out to staff at BCHD, with priority to those working with

populations at high risk for mental health disorders.

In FY 12, BMHS collaborated with BCHD’s Office of Youth Violence on a presentation

for the Inter-American Development Bank (IDB), the largest source of social and

economic development financing for Latin America and the Caribbean. One of the main

topics of the presentation was the correlation between mental health and community

violence. Recommendations and best-practices on establishing violence prevention

initiatives were also discussed.


See above for progress to date.

In FY 12, BMHS began to reach out and meet individually with local FQHCs.

Additionally, school-based clinicians funded through the Expanded School Mental Health

initiative are now required to partner with FQHCs located in the school’s community to

promote access to somatic care and coordination between behavioral health services and

somatic care.

Objective 1.2: BMHS will educate public safety personnel regarding current information

about mental illness, managing mental health emergencies and available services.

Strategy I was partially accomplished.

STRATEGY 1: Improve the capacity of the City’s police officers, Downtown Partnership

Safety Guides and other public safety personnel (e.g., parole and probation officers, 911

operators and correctional officers) to respond to psychiatric emergencies.

23

Action Step: In collaboration with the Baltimore Police Department, provide

leadership to the Behavioral Emergency Services Team (BEST) to train police

officers.

Significant progress was made this past year with the BEST project, an ongoing initiative

that trains police officers in crisis intervention to de-escalate mental health crises,

minimize arrests, and decrease officer injury. The focus of activities in FY 12 continued

to be training all new police recruits, who start out as patrol officers. Five training classes

were held, with 156 new patrol officers and six experienced officers successfully

completing the course. More than double the number of officers participated in FY 12

compared to FY 11. The Police Department predicts that if the project maintains the same

pace of training, most patrol officers will be BEST-trained within the next three years.

Progress was also made toward obtaining certification of the course by the Maryland

Police and Correctional Training Commissions (PCTC) by completing lesson plans for

all modules included in the training. It is anticipated that additional required materials

will be submitted to PCTC for review during the next fiscal year and certification will be

granted. Certification by PCTC will grant in-service credit to officers who successfully

complete the course.

Additionally, progress was made toward the creation of a video to be shown at daily roll-

calls for patrol officers. The video will provide a brief summary of de-escalation

strategies and resources officers can utilize in mental health crisis situations. BMHS will

continue to coordinate with the BPD Video Unit to complete the video with an

anticipated completion date within the next year. This will substantially increase the

dissemination and reinforcement of the BEST concepts throughout the Department.

Action Step: Collaborate with public safety organizations to identify opportunities

to provide educational information about mental health issues.

Efforts to improve the capacity of public safety personnel to respond to psychiatric

emergencies again focused predominantly on the Police Department this past year. The

training of additional public safety personnel, such as Downtown Partnership Safety

guides, 911 operators, and Parole and Probation staff will continue to be explored next

year.

Indicators: Number of personnel trained; Report on progress to date.

162 Baltimore City police officers (156 new recruits and 6 experienced officers) were

trained in FY 12. See above for progress to date.

24

GOAL II: Mental Health Care is Consumer and Family Driven

Objective 2.1: Promote efforts that facilitate recovery and build resiliency.

STRATEGY 1: Promote and support consumer-operated programs.

Action Step: Provide direction, funding, and consultation to the City’s three (3)

Wellness & Recovery Centers: Helping Other People through Empowerment

(HOPE), On Our Own, Inc. and Hearts and Ears.

Wellness and Recovery Centers continue to be a vital component of the City’s public

mental health system. Two of these Wellness and Recovery Centers are unique in the

state: Helping Other People through Empowerment (HOPE) serves homeless individuals,

and Hearts and Ears serves lesbian, gay, bi-sexual, transgender (LGBT) individuals. On

Our Own, Inc. operated their transitional age youth (TAY) center for its second year,

again serving a population for whom more targeted programs are needed. While a total of

626 consumers were served, between FY 11 and FY 12, there was an 8% decrease in the

number of consumers served by the Wellness and Recovery Centers, with an increase at

HOPE and a decrease at Hearts and Ears and at On Our Own. Although the numbers of

individuals served at On Our Own decreased, the Center surpassed the target set by the

state of 300 persons served for the second year in a row. On Our Own also met or

surpassed the target for the number of support services, especially the number of WRAP

classes and WRAP support groups. Hearts & Ears relocated in FY10 to the west side of

Baltimore and experienced a decrease in persons using the Center as a direct result of this

move. In June of 2012, Hearts & Ears again relocated back to the Mount Vernon district

as this area of the city is more easily accessed by LGBT consumers. There was

significant staff and board turnover in FY 12, and BMHS has taken an active role in

assisting the program to enhance leadership and strengthen board functioning.

Baltimore’s three Wellness and Recovery Centers continue to provide consumer-centered

peer support services and have been serving a vital role in promoting the use of Wellness

Recovery Action Plan (WRAP) among the City’s consumers. The Centers have continued

efforts to sustain On Our Own’s WRAP project by recruiting and training consumers as

peer WRAP facilitators.

The chart below details the peer support and educational services provided by the

Centers. It should be noted that in recent years, MHA’s Office of Consumer Affairs has

clarified the definition of services and refined data collection so that Wellness and

25

Recovery Centers across the state are collecting data in the same way. Therefore, some of

the changes in the numbers of services provided may be due to the way data are now

being collected.

Peer Support/Educational Services Provided

Wellness and Recovery Center Outreach

Sessions Peer Support

Sessions Educational

Forums

On Our Own 17 113 6

Helping Other People Through

Empowerment 12 40 10

Hearts and Ears 4 40 9

TOTAL 33 193 25

Indicator: Number of consumers served.

Number of Consumers Served by Wellness and Recovery Centers

Center Consumers

On Our Own 329

Helping Other People Through Empowerment 241

Hearts and Ears 56

TOTAL 626

STRATEGY 2: Increase implementation of consumer-centered practices such as Wellness

and Recovery Action Planning (WRAP), use of peer staff and consumer-directed recovery

planning.

Action Step: Provide direction, funding and ongoing consultation to the Human

Services Training program at Goodwill, Inc. that trains consumers for employment

in the human services field.

The Human Services Training program at Goodwill, the only service of this kind in the

State, enrolled 48 consumers in the training program for careers in public mental health.

Although the number of consumers enrolled represents a 4% decrease from FY 11, the

program still exceeded its goal of serving 40 consumers for the year. Of those enrolled,

27 (56%) graduated from the training compared to 34 (68%) in FY 11. All consumers

graduating from the program are offered referrals to supported employment programs at

Goodwill and other SEP providers to further assist in gaining employment or to receive

assistance in maintaining employment.

26

Action Step: Provide education and technical assistance to providers in

implementing practices targeted at assisting consumers to move to their defined

next level of recovery.

BMHS continued to provide technical assistance to the two Capitation programs to

implement a Continuous Quality Improvement process, the goal of which is to identify

and implement change projects aimed at improving targeted aspects of care. The area of

focus for FY 12 was supported employment. Both providers achieved their FY 12 goals

of enhancing supported employment program services. The baseline percentage of

members participating in the supported employment program who were working at

Mosaic/Chesapeake Connections was 11%. The target goal was 15%, and within 12

months, 20% were employed. The baseline percentage of members participating in the

supported employment program who were working at Bayview/Creative Alternatives was

16%.The target goal was 25%, and within 12 months, 43% were employed.

Implementing the CQI plan had a positive impact on overall employment for members of

both Capitation Projects.

In FY 12, based on BMHS’ nomination, the University of Maryland Medical Center

(UMMC) received technical assistance and consultation on person-centered planning for

individuals with mental illness. The goal of this project, which is coordinated and funded

by MHA, is for treatment planning to become more consumer-oriented.

In FY 12, BMHS collaborated with bSAS to host a joint meeting between the Wellness

and Recovery Centers (mental health funded programs) and the Threshold to Recovery

Centers (substance abuse funded programs). This meeting created a dialogue between

consumers and consumer advocates with the goal of identifying opportunities to integrate

efforts among the consumer-run behavioral health programs in the city.

Indicators: Number of consumers served; Report on progress to date.

See above for numbers served and progress to date.

Objective 2.2: Help families be active advocates for their children on the system, program

and individual level.

STRATEGY 1: Increase family input in planning and evaluation of mental health services.

Action Step: Elicit feedback from family support and advocacy organizations

concerning mental health needs of children and families in the community.

27

Maryland Coalition of Families for Children’s Mental Health, along with Wraparound

Maryland, The MATCH Program, the University of Maryland School of Social Work,

and BMHS, hosted seven focus groups for an information exchange on the cultural and

linguistic needs of families and youth with mental health needs who are in or at-risk of

entering the foster care system. The focus groups centered around three themes: the

emotional impact on youth in foster care, foster families and natural or biological families

(including parents, grandparents, adoptive families and other relatives).

Action Step: Provide funding, oversight, and evaluation of services to meet the

mental health needs of families in Baltimore City.

In FY 12, Villa Maria served a total of 53 youth in the Planned Respite program, 14 of

whom were served in facility-based respite care and 39 of whom were served in home-

based care. The total number of youth served represents a 25% increase over the number

of youth served in FY 10. More children were served in home-based care for FY 12 (FY

11- 48%; FY 12 - 74%). The number of children receiving respite services in the fee-for-

service system also increased. This correlates with the increased number of youth

receiving services under the Medicaid waiver, which broadens the services available to

youth through the Public Mental Health System.

Indicators: Annual feedback on mental health service needs; composite summary of

family satisfaction with continuum of mental health services available in the City.

Villa Maria collected surveys from 115 participants (this included families and the youth)

who received Planned Respite services in FY 12. An overwhelmingly number (98%), of

those surveyed indicated being satisfied with the services they received.

STRATEGY 2: Promote leadership development and advocacy skills among families.

Action Step: Provide funding and support to the Maryland Coalition of Families for

Children’s Mental Health for their sponsorship of family leadership trainings.

The Coalition provided family leadership trainings to support families. Evaluations for

the family leadership trainings showed a 100% satisfaction rate among participants who

submitted evaluations. In addition, the Coalition provided peer-to-peer training and

family-to-family support and also conducted workshops on infrastructure development

for family-serving organizations.

Indicator: Number of family members who attended leadership training.

74 family members attended 10 family leadership trainings.

28

Objective 2.3: Promote family-driven and family-centered initiatives.

STRATEGY 1: Provide support and consultation to family-centered initiatives implemented

in Baltimore City.

Action Step: Participate in statewide and local planning for the implementation of

home and community-based wraparound services for youth who would otherwise

require residential treatment level of care.

BMHS staff continued to participate in state and local planning in an effort to reduce the

number of Baltimore City youth entering more restrictive institutional placements. Staff

worked closely with the Care Management Entity for Baltimore City, Wraparound

Maryland, and other stakeholders to remove barriers for youth in need of community-

based services via the wraparound process. Eighty-seven (87) youth received

comprehensive community-based services in lieu of being placed in residential treatment

centers. These youth were enrolled in the Psychiatric Residential Treatment Center

(RTC) Medicaid Waiver through Wraparound Maryland in partnership with BMHS.

There were 67% more youth served in FY 12 than FY 11.

Changes were projected for the availability of slots through the RTC Waiver for the end

of FY 12 and beginning of FY 13. Maryland was making preparations in FY 12 to close

out the federally-funded RTC Demonstration Waiver (1915c). Locally, BMHS and

partners at The Institute for Innovation and Implementation coordinated with families on

the waiting list to ensure their enrollment into services prior to the September 30th

deadline. At the end of FY 12 the RTC Waiver waiting list closed as the State made plans

to move forward with a Medicaid State Plan Amendment to add the 1915i as a

replacement.

Wraparound Maryland also provided care coordination and connected 62 DSS-involved

youth to behavioral health services this past year. Wraparound Maryland continued to

provide services to DJS-involved youth during this fiscal year, and a total of 31 DJS

youth participated in FY 12. In addition, MD-CARES, the federal system of care

cooperative agreement, made it possible for 81 youth and their families involved with

Baltimore City’s Department of Social Services to receive care coordination and clinical

services.

In the spring of FY 12, the Governor’s Office for Children (GOC) issued a Request for

Proposals to procure services for a statewide Care Management Entity that would serve

all 26 of Maryland’s independent jurisdictions. The contract was awarded to Maryland

Choices at the end of FY 12. As a result, BMHS collaborated with city stakeholders to

29

ensure a smooth transition for children and families, as well as providers involved in their

care. Under the new agreement, DSS and DJS slots for wraparound services are now

statewide, with each lead agency funding 75 slots. MD-CARES was reduced by one slot

to a new total of 40 in the City for FY 13.


There was a 59% increase in the total number of youth served by the care management

entity. In March 2011, a reinterpretation of the Code of Maryland Regulations (COMAR)

was authorized by Medicaid, allowing each jurisdiction, including Baltimore City, to

immediately fill open slots with youth on the waiting list for the RTC Waiver. As a result,

the number of youth enrolled in the RTC Waiver nearly doubled from FY 11 to FY 12.

In addition, there have been ongoing efforts to inform families and community agencies

about the eligibility requirements along with the availability of this home- and

community-based service. A new partnership was created with Johns Hopkins Hospital

Child & Adolescent Psychiatric Inpatient Unit through the MD-CARES grant so that

youth with severe emotional disturbances at-risk for DSS involvement could be referred

to wraparound services in the community. Of the 81 youth served through MD-CARES,

13 youth were referred by JHH in FY 12.

Care Management Entity

Population/Funding Stream # Served

RTC Waiver 87

MD-CARES 81

Group Home Diversion - DJS 31

Group Home Diversion - DSS-Place Matters 62

TOTAL 261

GOAL III: Disparities in Mental Health are Eliminated.

Objective 3.1: Improve access to culturally and linguistically competent public mental

health services for racial and ethnic minority individuals.

STRATEGY 1: Recruit and retain racial and ethnic minorities and multi-lingual

professionals in the mental health services workforce.

Strategy 4 was not accomplished.

30

Action Step: Provide direction, funding and ongoing consultation to the Maxie

Collier scholarship program at Coppin State University, which encourages minority

students to pursue careers in mental health.

In FY 12, 10 Maxie Collier scholars enrolled in classes. Internship sites included Johns

Hopkins University Department of Child and Adolescent Community Psychiatry,

University of Maryland’s Department of Child Psychiatry Clinical Research Program,

Project PLASE and Life Renewal Services Dual Diagnosis Clinic.

The Maxie Collier scholarship program has had 52 graduates since the program first

accepted students in 1996.

In collaboration with the Maxie Collier scholarship program, Coppin State offers a course

entitled “Emerging Issues in Mental Health,” which is open to all students and intended

to increase the number of students who are exposed to the mental health field.

Representatives from the provider community, the Mental Hygiene Administration, core

services agencies, and the mental health advocacy community regularly present on

mental health topics as part of the curriculum. An estimated 706 students have attended

the class since the program’s inception, and 31 students completed this class in FY 12.

Indicators: Number of students enrolled by discipline.

Maxie Collier Scholars (n=10)

Discipline # Students

Nursing 3

Psychology 5

Natural Sciences 1

Social Work 1

Action Step: Provide direction, funding and ongoing consultation to the Johns

Hopkins Hospital Hispanic Clinic, which provides mental health treatment to

Spanish-speaking individuals and families through the use of bilingual staff.

In FY 12, the Johns Hopkins Hispanic Clinic served 31 individuals and provided 325

therapeutic sessions to Spanish-speaking individuals and families, using models of care

such as Motivational Interviewing, Trauma Focused Cognitive Behavioral Therapy,

Abuse Focused Cognitive Behavioral Therapy, Psychodynamic Therapy and Gradual

Exposure Therapy.

31

STRATEGY 2: Develop collaborations with community-based organizations working to

increase understanding of mental health issues and to improve access for services among

racial, ethnic and linguistic minorities.

Action Step: Provide direction, funding and ongoing consultation to the Black

Mental Health Alliance for Education and Consultation in promoting awareness of

the needs of African Americans with mental illness and offering information,

support and referrals to individuals and families.

The Black Mental Health Alliance (BMHA) continued to advocate for mental health

issues, providing consultation to 139 community-based providers regarding issues of

culture and mental illness. Through collaborations with other advocacy organizations,

BMHA organized National Minority Mental Health Month awareness activities and

sponsored five educational programs and five depression screening events.


Through support groups, information, referrals, educational programs and individual

support services, BMHA served 268 families and provided consultation to 139 providers.

STRATEGY 3: Develop collaborations with health care providers, mental health care

providers, community-based Latino organizations and other willing partners to identify

opportunities to improve access to mental health care for Baltimore City’s growing Latino

population.

Action Step: Implement at least one recommendation identified either in the Latino

Needs Assessment Report or through dialogue with key partners.

As reported in FY 11, BMHS hired a Spanish-speaking staff member with extensive

history working with the Latino community throughout Maryland. This staff member

continues to attend the Latino Providers Network for updates on community initiatives

and Latino community needs. In FY 12, she developed a resource guide of Spanish-

speaking mental health programs. In addition, BMHS partnered with City School’s

International Student Center to provide a list of resources for psychoeducational materials

translated in multiple languages for families. Lastly, as recommended by the Latino

Needs Assessment Report, NAMI Baltimore provided a Spanish language version of their

Family-to-Family program.



32

STRATEGY 4: Collaborate with faith-based organizations to reduce barriers resulting from

religious beliefs about mental illness and treatment.

Action Step: Provide direction, funding and ongoing consultation to the Center for

the Integration of Spirituality and Mental Health in sponsoring educational

programs that target racial and ethnic minorities.

Funding for the Center for the Integration of Spirituality and Mental Health (CISMH)

was eliminated at the end of FY 11 due to budget reductions. There is no FY 12 activity

to report.


None.

Objective 3.2: Improve access to mental health services for special populations that are

underserved by the public mental health system.

Strategies 8 and 10 were not accomplished.

STRATEGY 1: Provide direction, funding and ongoing consultation to agencies that serve

transitional age youth.

Action Step: Contract with a vendor(s) to provide residential rehabilitation and case

management services for youth who have complex mental health and social needs.

BMHS funded two vendors to provide residential rehabilitation and case management

services for transitional age youth (TAY), those who are 18-25 years old. People

Encouraging People (PEP) and the University of Maryland Medical Center (UMMC)

Harbor City Unlimited were funded to provide enhanced support, which includes

overnight supervision, community living skills development, vocational and educational

services and social/recreational activities to better address the complex presenting needs

of transitional age youth. It should be noted that the requests for assistance to provide

enhanced residential and case management services far outnumber the slots available.

Action Step: Provide technical assistance to child and adolescent mental health

providers and other child serving systems regarding accessing the adult mental

health system and strategies to assist youth in developing skills needed for success in

the adult system.

In FY 12, there was a legislative change redefining the mission of the Local Care Teams

throughout the state. The Local Care Teams (LCT) are now charged with reviewing all

33

requests for Voluntary Placement through the Department of Social Services. In addition,

referrals also come from Department of Juvenile Services and Department of Social

Services, case managers, and families looking for resources to meet a child’s needs. All

referred TAY individuals who meet Medicaid eligibility criteria were encouraged to

complete and submit applications to the appropriate CSA in order to ensure a smooth and

timely transition to adult services.

Indicators: Number of youth who receive services; report on technical assistance

provided.

In FY 12, one third, or four, of the youth referred to the LCT were TAY consumers, and

30 of the Certificates of Need (CON) reviewed by BMHS were for TAY consumers.

BMHS staff provided technical assistance in all cases, which resulted in 100% of TAY

consumers being encouraged to apply for adult services within the PMHS.

TAY Contracts

Vendor # Individuals Served

PEP Case Management 15

PEP Enhanced RRP 8

UMMC Enhanced RRP 7

TOTAL 29

STRATEGY 2: Facilitate access to treatment for war returnees, especially those from Iraq

and Afghanistan.

Action Step: Make available free mental health treatment by contracting with a vendor

to recruit and provide specialized training for volunteer mental health professionals.

The Pro Bono Counseling Project continued to provide free mental health treatment services

to veterans and war returnees by utilizing a network of volunteer clinicians. In FY 12, 104

individuals and families received information and referrals, and 47 were linked with a

clinician for free mental health care. A total of 393 hours of clinical services were provided

statewide.

While 19 more individuals and families were served this year compared to FY 11, there were

only 19 more clinical hours reported. Of all services provided, 13% were provided to

Baltimore City residents, which was a decrease from FY 11. In addition, the Pro Bono

Counseling Project recruited 66 new clinicians to the program, and sponsored a one-day

34

training for therapists who will be working with veterans and other war returnees throughout

the State.

In FY 12, depression and couples issues were the top reasons care was requested, the same as

in FY 11. In FY 12 though, grief and loss became the third highest reason care was requested

(16), whereas in FY 11, grief and loss was the least provided reason (4). Also, in FY 12, the

Project expanded its list of reasons care was requested to include suicide, brain injury,

legal/accounting, life transition and family dysfunction.

Air Force 9% Air National Guard

8%

Army 41%

Army National Guard 15%

Marines 6%

Navy 9%

Army Reserves 6%

Unknown 6%

Individuals Served by Pro Bono Counseling Project (n=104)

35

Indicator: Number of individuals served.

See above for number of individuals served.

STRATEGY 3: Provide direction, funding and/or ongoing consultation to agencies that

interact with individuals involved with the criminal justice system.

Action Step: Divert individuals from incarceration by providing support and

technical assistance to the Baltimore City Mental Health Court, Forensic Assertive

Community Treatment Team (FACTT) and Forensic Alternative Services Team

(FAST).

BMHS provided support to the Baltimore City Mental Health Court, Circuit Court Case

Management Docket project (further described on page 37), FACTT, CHHS, and FAST

throughout the year. BMHS staff regularly attended meetings with Mental Health Court,

Circuit Court Case Management Docket project and CHHS personnel. Access to services

within the Public Mental Health System and the role of the service providers in serving

court-involved clients were recurring topics. BMHS continues to use the reference

document Mental Health Services for Adults in Baltimore City to create more alignment

between the Court’s requests for services and those services available in the community.

To further align the Court’s expectations of community-based services, BMHS continued

to organize regular educational meetings between Mental Health Court and Circuit Court

30 25

16 12

8 7 7

6 6 6

5 3

1 1

Depressed Couples

Grief and Loss Family dysfunction

Anxiety Life transition

Anger History of Mental Illness

PTSD Stress

Legal/Accounting Medication Only

Brain injury Suicidal

0 5 10 15 20 25 30 35

Pro Bono Counseling Project: Reason Care was Requested (n=104)

36

Case Management Docket personnel and community providers. The meetings focused on

educating providers on the Court’s role and educating the Court on the provider’s role in

serving clients with court involvement. Several providers presented overviews of their

services to orient Court personnel to the range and scope of available community-based

services.

FAST continued to provide jail diversion activities and actively participate in Mental

Health Court. FAST screened 1,370 individuals for diversion services, an increase of

40% from FY 11. Of the 1,370 screenings, FAST conducted 431 face-to-face assessments

to determine eligibility for appropriate services and possible return to the community.

This represented a 16% reduction in face-to-face assessments from FY11. In addition,

FAST monitored 38 individuals in the community as part of court-ordered plans. The

FAST program continues to rely on the judicial system for the majority of its referrals,

which determines the number of individuals who are screened.

FACTT, a specialized ACT team, continued to provide intensive services to individuals

with either court involvement or forensic histories. FACTT outcomes data show that in

FY 12, FACTT served a total of 116 individuals with 30 new referrals. Of the new

referrals, 67% (20) were referred from State hospital facilities, an increase from FY11

(52%, 12 referrals). There were four referrals (13%) from jails and the six other referrals

(20%) were community referrals to FACTT. BMHS has worked with FACTT to target

high users of psychiatric services in the community who met the legal requirements for

FACTT services.

Jail Personnel 14%

Judge 16%

Family/Self 8% Drug Court

8% Defense 14%

State's Attorney 10%

Other 19%

Community Provider

11%

Source of FAST Referrals (n=1,370)

37

Action Step: Collaborate with the Baltimore City Circuit Court to develop

alternatives to incarceration for sentenced individuals.

In FY 11, BMHS leveraged a small amount of BMHS and DHMH funds to secure private

foundation funds (The Leonard and Helen R. Stulman Foundation, The Charles Crane

Family Foundation, The Aaron and Lillie Straus Foundation and the Baltimore

Community Foundation) to implement a 3-year pilot project in the Circuit Court of

Baltimore City for felony defendants called the Circuit Case Management Docket project.

This three-year project funds a clinician to provide behavioral health assessments and

link eligible defendants to behavioral health services in the community. The goals of this

project are to decrease recidivism, increase mental health service utilization among

defendants with mental illness and increase public safety.

In FY 12, this project enrolled 14 participants, who received an intensive behavioral

health assessment, linkage to community-based behavioral health services, and continued

case management and coordination with providers. The target is to serve an ongoing

caseload of 20 individuals each year. At this point, this project has been fully integrated

into the operation of the consolidated mental health docket in the Circuit Court of

Baltimore City.

Action Step: Provide support and technical assistance to the Chrysalis House

Healthy Start Program, which serves pregnant and post-partum women and their

babies as an alternative to incarceration.

Chrysalis House has continued to focus on enhancing its service array and building

collaborations with referral sources to increase the number of individuals utilizing

services. In FY 12, Chrysalis House served a total of 21 women from different statewide

referral sources. Of the 21 women served in FY 12, 11 were new admissions. In addition,

seven babies were born to mothers in the CHHS program in FY 12. BMHS provided

financial assistance to Chrysalis House to enable the program to purchase furniture to

accommodate and enhance the overall living environment. Furthermore, BMHS provided

housing assistance to all of the women who successfully graduated from the program in

FY 12 (a total of four).

In FY 12, LEVELheaded, Inc. conducted interviews with 22 past and current residents of

the Chrysalis House Healthy Start program to obtain baseline, post-delivery and

discharge information as part of an updated evaluation of the Chrysalis House program.

The findings from the FY 12 updated evaluation are generally very consistent with the

key findings identified in the original 2010 evaluation conducted by LEVELheaded.

38

Key findings from the interviews indicated that 26% of the women admitted into the

program were from the Baltimore City Detention Center and 17% from the Baltimore

City Women’s Detention Center. The mean number of arrests for the women prior to

admission was five. Of the 22 interviewed, 76% reported receiving a diagnosis of mental

illness, and 87% reported a history of trauma. Other key findings from the evaluation

include:

● Significant improvements reported in mental health, cognitive functioning,

and day-to-day functioning while enrolled in the program.

● Significant reductions reported in criminal behavior, including the use of

illegal drugs and receiving money from illegal sources.

● Increases in the amount of money received from benefits such as TANF

(Temporary Assistance for Needy Families) and SNAP (Supplemental

Nutritional Assistance Program), formerly known as Food Stamps.

● Increases in enrollment in trainings and/or school programs.

● High level of satisfaction with the services received from the Chrysalis

House Healthy Start program.

Indicators: Number of individuals served; report on progress to date.

In FY 12, there was an overall 34% increase in the number of individuals with forensic

histories served by FAST, FACTT and the Chrysalis House Healthy Start program.

Number of Individuals with Forensic Histories Served, FY 12

Program # of Individuals

FAST 1370

FACTT 116

Chrysalis House Healthy Start 21

TOTAL 1,507

Individuals with Forensic Histories Discharged from State Hospitals, FY 12

Program # of Individuals

RRP 17

FACTT 20

Capitation Project 1

Geriatric Community Placements* 2

TOTAL 40

*Coordinated by the Geropsychiatric Nurse Specialist

39

STRATEGY 4: Fund mental health services targeted to individuals who are deaf and hard of

hearing.

Action Step: Contract with a vendor to provide residential rehabilitation,

psychiatric rehabilitation, and outpatient mental health treatment services to this

population.

BMHS continued to fund People Encouraging People, Inc. to provide signing services for

individuals who are deaf and hard of hearing. The services were provided in the

following programs: residential rehabilitation, psychiatric rehabilitation, outpatient

mental health treatment and supported employment.

Indicators: Number of individuals served and level of care received.

18 unduplicated individuals who are deaf or hard of hearing received signing services in

the following levels of care:

PMHS Services Received by Deaf or Hard of

Hearing Individuals

Level of Service # Individuals

Psychiatric Rehabilitation 17

Residential Rehabilitation 8

Outpatient Mental Health Treatment 5

Supported Employment 4

STRATEGY 5: Fund mental health services targeted to individuals with traumatic brain

injury (TBI).

Action Step: Contract with a vendor to provide individualized therapeutic activities

in a residential setting, including life skill services and family supports.

BMHS funded Mary T. Maryland to provide residential services for three individuals

with traumatic brain injury discharged from a state hospital facility. Services provided by

Mary T. Maryland are individualized to each client and based upon a thorough

assessment of the individual’s needs. Because the three individuals enrolled in the

program were ineligible for the Medicaid waiver, which would otherwise cover their cost

of care, there was no turnover in the program in FY 12.


40

3 individuals with TBI received residential support services.

STRATEGY 6: Provide funding and/or consultation to programs that offer outreach or

mental health services to individuals and families who are homeless.

Action Step: Provide leadership to the multi-agency coalition of homeless outreach

advocates and providers known as the Hands in Partnership (HIP) initiative to

identify, engage and coordinate outreach services to individuals experiencing

homelessness.

In collaboration with the Mayor’s Office of Human Services (formerly Baltimore

Homeless Services) and HealthCare Access Maryland, BMHS continued to co-facilitate

HIP. The goal of HIP is to provide coordinated, goal-directed outreach to vulnerable

homeless individuals and families on the street or in emergency shelters. Using HUD and

PATH funding, BMHS oversees four outreach teams that participate in HIP. In FY 12,

service providers met weekly to coordinate services to homeless individuals and families.

Data are tracked and analyzed to ensure accountability and to document the movement of

clients from homelessness to permanent housing. Training of outreach workers and

resource sharing is a regular aspect of HIP, with presentations from outside entities

occurring at least monthly.

In FY 12, outreach teams engaged in 1,249 visits with approximately 284 homeless

individuals and families identified as vulnerable and in need of intensive, coordinated

outreach.6 These services resulted in 11 individuals placed into housing. The number of

individuals housed is expected to significantly increase in FY 13, as the Mayor’s Office

of Human Services was recently notified that they would have access to approximately

150 Housing Choice Vouchers by the Housing Authority of Baltimore City, and these

vouchers will be designated for individuals being served by HIP.

In addition to the above HIP activities, Baltimore City was an active participant in the

SSI/SSDI Outreach Assistance and Recovery (SOAR) initiative through the work of

Health Care for the Homeless and LEVELheaded, Inc. SOAR, which teaches providers

how to expedite entitlement applications, continues to experience tremendous growth in

both the number of providers trained in SOAR methodology and the number of SSI/SSDI

claims submitted. SOAR allows individuals to receive the benefit of expedited access to

income, health insurance and treatment services as well as support through the SSI/SSDI

application process, which helps alleviate the associated anxiety experienced by many

consumers. Providers report that SOAR has been a successful tool in engaging

6 There was a change in data collection methodology from FY 11 to FY 12.

41

individuals in services and has assisted in the therapeutic process by helping to identify

diagnoses and treatment needs during the application process.

In FY 12, Health Care for the Homeless (HCH) collaborated with LEVELheaded, Inc. to

provide five 2-day Stepping Stone to Recovery SOAR trainings to providers in Baltimore

City and other jurisdictions. LEVELheaded, Inc. also coordinated and delivered one

additional statewide 2-day SOAR training and one refresher training in Maryland. In all,

184 case managers benefited from the six 2-days SOAR trainings. An additional 16 case

managers also benefited from the one refresher training.

In FY 12, the two BMHS-funded SOAR case managers at HCH provided technical

assistance to HCH staff and other Baltimore City providers to submit a total of 358

SSI/SSDI applications using the SOAR methodology on behalf of Baltimore City

consumers. The Social Security Administration made benefit decisions on a total of 135

SOAR applications statewide in FY 12. Eighty-three percent (83%) of the benefit

decisions were approved, leaving the statewide approval rate unchanged at over 80%. Of

the total statewide SOAR claims approved in FY 12, 44% were from Baltimore City,

whose SOAR approval rate remained at over 90% (93%).

Additionally, LEVELheaded, in collaboration with other Baltimore City SOAR-

Workgroup partners (BMHS, HCH, State Disability Determination Administration),

instituted a pilot SOAR-Certification program in Baltimore City and Montgomery

County. In all, eight SOAR trained case managers received certification, including four

full-certifications and four-provisional certifications.

In FY 12, five counties were assisted to develop SOAR implementation workgroups, and

nine other counties and Baltimore City received technical assistance from LEVELheaded.

Additionally, LEVELheaded co-presented on the SOAR initiative at three conferences

including: MHA Office of Special Needs Populations, MHA-Case Management and the

Brain Injury Association of Maryland annual conferences. LEVELheaded also presented

an “Introduction to SOAR” at the Continuous Learning Center of Montgomery County

and the Anne Arundel NAMI Chapter.

Action Step: Provide direction, funding and ongoing consultation to HUD-funded

projects: three (3) mental health outreach teams; two (2) Safe Havens; one (1) SSI

Presumptive Eligibility Outreach program; and one (1) Wellness and Recovery

Center for homeless individuals.

BMHS was again awarded $1,991,410 from HUD to fund projects as described above.

Funding from HUD has remained level since the inception of each project. As a result,

42

programs have been forced to manage rising operational costs by increasing their match

beyond the level required by HUD and have consequently struggled to balance budgets.

Both safe havens have had particular difficulty meeting increased operational costs this

year.

Representatives from every City HUD-funded project are active in HIP. It is through

regular meetings of HIP and site visits to the providers that BMHS provides guidance and

support to the HUD-funded projects. In FY 12, these projects served 1,001 unduplicated

individuals, a slight decrease from FY 11 (1,161). Despite the overall number served

remaining relatively stable, there was a 33% increase in the number of families served,

and a 10% decrease in the number children served from FY 11.

Action Step: Collaborate with the Mayor’s Office of Human Services to implement

the City’s 10-year plan to end homelessness.

In FY 12, the Mayor’s Office began to take steps toward review and revision of the Plan

and the restructuring of the governance practices of the Continuum of Care. BMHS

actively participated in this process by serving on the planning committee with other

homeless service providers and taking part in several surveys and focus groups to provide

feedback on the current performance of the Continuum. BMHS continues to assist with

the coordination of services between the city’s homeless service providers and mental

health providers to ensure that the immediate and ongoing mental health needs of

homeless individuals are met.

Additionally, BMHS played an active role during FY 12 in the planning process for the

City’s first ever Project Homeless Connect, a city-wide event that provided

comprehensive services to individuals who are at risk of or experiencing homelessness.

This event was based on a national model that has been replicated in over 620 cities

across the U.S. and focused on going beyond the traditional resource fair by providing an

array of on-site services directly to participants. The event took place in August 2012 and

attracted over 1,000 participants.

BMHS also partnered with the Mayor’s Office, the Housing Authority of Baltimore City,

and the Veteran’s Administration to take part in a national training in the implementation

of a Registry Week, a new, innovative method for carrying out the Point-in-Time census.

This method is modeled after the 100K Homes campaign and incorporates a more

thorough approach to identifying and targeting services to the City’s most vulnerable

homeless individuals and families. BMHS has taken a leadership role in the initial

planning activities in anticipation of implementing the Registry Week in January 2013.

43

Action Step: Provide funding and consultation to programs serving homeless

children and families.

BMHS continued to fund a therapeutic nursery program, PACT, which offers specialized

childcare, including mental health and educational services for children under the age of

three. Services are provided to families that either currently live in homeless shelters or

that have recently experienced homelessness. The primary focus of services is to provide

mental health interventions that promote parent-child attachment and improve stability in

the family. Services are community-based and include those delivered in a family shelter,

providing ease of access for families in Baltimore City. In FY 12, there was a 34% (44)

decrease in referrals to PACT and a 35% (102) decrease in the number of children and

parents served. The decreases in FY 12 are attributed to a lower rate of turnover in the

shelter compared to FY 11. The average length of stay for families in FY 11 was eight to

nine weeks. In FY 12, the length of stay per family was 11 to 12 weeks. The high

turnover rate in FY 11 resulted in more families being served and more referrals being

made.

Indicators: Report on progress to date; number of individuals served.


Services Provided by HUD-funded Providers to Homeless Individuals and Families in Baltimore City

Provider # Individuals not

in Families # Adults in Families

# Children

Total # of Individuals

# Families

Bon Secours Outreach

158 32 43 233 32

HOPE Drop-In Center

167 9 20 196 9

HOPE Safe Haven 62 0 0 62 0

Johns Hopkins Hospital Outreach

43 17 32 94 17

People Encouraging People Outreach

109 16 26 151 16

UMMS Safe Haven 78 0 0 78 0

UMMS SSI Project 140 18 29 187 18

TOTAL 757 92 150 1,001 92

44

STRATEGY 7: Fund transitional housing opportunities.

Action Step: Contract with a vendor(s) to provide transitional housing services.

BMHS funded five agencies to provide transitional housing for individuals experiencing

homelessness in Baltimore City with funding from MHA and HUD. Housing continues to

be a priority need for Baltimore City residents. Almost all transitional housing programs

experienced turnover in the BMHS funded beds. Due to inconsistencies in data reporting,

it is difficult to determine an accurate understanding of the reasons why individuals

vacated transitional housing beds when movement into permanent housing continued to

be a major problem. BMHS will continue to collaborate with the providers and the City

to collect more meaningful data in order to better understand the outcome of transitional

housing services.

In FY 12, Project PLASE served a total of 14 individuals experiencing homelessness in

Baltimore City. Six (43%) individuals had co-occurring mental illness and substance

abuse diagnoses and 12 (85%) were referred or linked to mental health care. Of the 14

individuals served, 10 (71%) exited the program; of those, nine (90%) obtained housing

and one (10%) individual was hospitalized. Of those who obtained housing, two moved

into Shelter-Plus Care permanent housing, three obtained Section-8 permanent housing

vouchers, one obtained a non-subsidized rental unit, two reunited permanently with

family members, and one moved in with friends for temporary housing. In all, 89% of

individuals housed were placed in permanent housing placements.

In FY 12, Ethel Elan Safe Haven served a total of 62 individuals experiencing

homelessness in Baltimore City. Of the 43 individuals who exited the program in FY 12,

16 (37%) moved into permanent housing. Safe Haven I served a total of 78 individuals

experiencing homelessness in Baltimore City. Of the 60 individuals who exited the

program in FY 12, 36 (60%) moved into permanent housing. Jacobs Well served a total

of 60 individuals experiencing homelessness in Baltimore City, 23 in transitional housing

and 37 in permanent housing. Of the 3 individuals who exited the transitional housing

program in FY 12, 2 (67%) moved into permanent housing. Lastly, My Sister’s Place

Lodge, a program of Associated Catholic Charities, served a total of 51 individuals

experiencing homelessness in Baltimore City. Of the 28 individuals who exited the

program in FY 12, 23 (82%) moved into permanent housing.

45

Indicators: Number of beds funded; number of individuals served.

Transitional Housing Opportunities

Provider # of Beds # of Individual

Served

At Jacob’s Well 42 60

Safe Haven I 20 78

Ethel Elan Safe Haven II 19 62

My Sister’s Place Lodge 27 51

Project PLASE 3 14

TOTAL 91 265

STRATEGY 8: Identify opportunities for BHLI to increase attention to and action regarding

Baltimore City’s homeless youth population.

Action Step: Collaborate with organizations serving homeless youth to identify

opportunities to develop outreach to youth ages 12 to 17 years.

BHLI no longer works with homeless youth. This strategy and action step will not be

included in future reports.

Action Step: Participate in the Baltimore Homeless Youth Initiative and other

forums addressing this problem.

Same as above.

Action Step: Convene meeting of local foundations around this topic.

Same as above.

Action Step: Advocate for increased resources to address the problem of homeless

youth and support efforts to address consent-to-treatment barriers through

legislation.

Same as above.

Indicator: Progress to date.

There is no progress to report.

46

STRATEGY 9: Provide mental health screening, intervention, and referral for children

exposed to violence.

Action Step: Provide funding and oversight to the Child Development Community

Policing (CDCP) program, which provides mental health outreach, assessment, and

referral for children who are witnesses or victims of a violent crime, and trains

volunteers about the needs of this population.

CDCP works collaboratively with families, police officers, mental health clinicians and

community members to break the cycle of violence by providing early intervention,

mental health services, training and community outreach. The intervention occurs shortly

after a child has witnessed or been impacted by violence and/or a traumatic event. The

CDCP team consists of community coordinators (e.g., a retired police officer) and a

mental health clinician. Funding for the CDCP was reduced for FY 11, which led to

reduced staffing and a more restricted geographic region (eastern Baltimore) being

served. Consequently, the numbers served by this project decreased by 79% between FY

10 - 12.

Indicators: Number of requests to CDCP; number of children and adolescents served.

Of the 88 calls, 50 families required face-to-face services by the CDCP response team:

● 12 (14%) were in response to children witnessing a traumatic event in the

community.

● 36 (41%) were in response to children being victims of assault.

● 29 (33 %) were in response to children being victims of other traumas, i.e.

car/bike accidents, falls, and dog bites.

CDCP Calls Received

Fiscal Year # Calls

FY 06 129

FY 07 323

FY 08 384

FY 09 496

FY 10 400

FY 11 84

FY 12 88

47

CDCP Calls Received by Age of Child

Age Groups # Calls

0-5 years 16 (18%)

7-12 years 22 (25%)

13 years & up 50 (57%)

As part of the training and community outreach, 155 individuals, including police

officers, youth and other community members were trained as specified below.

● 34 police officers received Trauma-Informed Training;

● 69 fellows received 640 hours of Fellows Training; and

● 41 youth from local churches and city elementary schools participated in

CDCP-facilitated violence prevention activities.

STRATEGY 10: Provide mental health services to individuals suffering from depression and

trauma and living in highly vulnerable communities.

Action Step: Through BHLI’s Connections Project, in partnership with Johns

Hopkins Bayview Medical Center, provide mental health services on-site in non-

traditional community-based settings.

Project Connections (PC) has successfully engaged and retained clients in this program, a

major goal of the project. Among the 164 clients discharged in FY 11, 68% who received

an initial evaluation returned for treatment services. With respect to program retention,

the average length of enrollment was 11 months. In addition to client engagement and

retention, PC has played a role in improving the overall mental health status of the clients

served, as exhibited by increases in Global Assessment of Functioning (GAF) scores,

which measure overall mental health and functioning over the course of treatment.

Furthermore, on average, participation in PC has been associated with an increased

likelihood of participating in entitlement programs, obtaining a primary care doctor and

receiving appropriate medication to treat mental health problems.

Indicators: Number of sites; number of individuals served.

In FY 12, Project Connections (PC) served 240 individuals at 4 sites.

STRATEGY 11: Fund mobile psychiatric assessment and treatment for elderly individuals.

48

Action Step: Contract with vendor(s) to identify, assess, treat, and link elderly

clients to services.

BMHS funded two vendors to provide mobile assessment and treatment for elderly

individuals: Johns Hopkins Hospital for the Psycho-Geriatric Assessment and Treatment

in City Housing (PATCH) program and the University of Maryland for the Senior

Outreach Services (SOS) program. Over the last 15 years, the funding for these programs

has not kept pace with increasing operating costs, and both providers have had difficulty

maintaining balanced operational budgets. To address the funding challenges, PATCH

downsized from two teams to one at the end of FY 10. Despite the downsizing from FY

11 to FY 12, there was a 28% increase in the number of individuals in active treatment as

well as a 53% increase in the number of individuals assessed.


Elderly Individuals Served by PATCH and SOS

Program

# Individuals

Assessed

# Individuals

in Active

Treatment*

Senior Outreach Services (SOS) 77 72

PATCH 53 19

TOTAL 130 91

*At end of fiscal year

STRATEGY 12: Provide technical assistance and consultation to coordinate access to

community-based services for elderly individuals.

Action Step: Assist State hospital facilities to transition elderly residents to

community placements.

BMHS continued to employ a Geropsychiatric Nurse Specialist to collaborate with State

hospital facilities to assist with discharge planning and to track clients’ progress when

discharged to the community. As a part of this effort, the Nurse Specialist meets regularly

with staff at State hospital facilities to review clinical information and progress toward

discharge for all elderly or medically fragile residents in the facility, which includes

clients who are 65 years of age or older and clients who are younger and medically

compromised. In addition, the Geropsychiatric Nurse Specialist works with assisted

living facilities and nursing homes in the community to provide education, technical

assistance and case consultation with the goal of assisting the client to remain in his/her

community placement after discharge from a State hospital facility.

49

In FY 12, the Geropsychiatric Nurse Specialist served 103 individuals statewide, 52% of

whom were Baltimore City residents, in 25 nursing homes and 30 community assisted

living facilities. Of the 20 new referrals, 55% were Baltimore City residents, 55% were

discharged to a community assisted living facility, and none were rehospitalized at a state

hospital facility within one year of placement. Following consultation with MHA and

significant outreach from the Geropsychiatric Nurse Specialist, collaboration between

community facilities and state hospital staff increased as did the timeliness of referrals to

the Geropsychiatric Nurse Specialist, which resulted in a 54% increase in referrals from

FY 11 to FY 12.

In addition to the work of the Geropsychiatric Nurse Specialist, BMHS provides funding

to Glenmore Manor, a residential rehabilitation program that provides enhanced staffing

for elderly and medically complicated individuals who have been discharged from State

hospital facilities. BMHS staff has worked closely with State hospital facilities and

Glenmore Manor to identify and transition individuals to this community setting.

Indicators: Number of individuals served.

See above for number of individuals served and progress to date.

GOAL IV: Early Mental Health Screening, Assessment, and Referral to

Services are Common Practice.

Objective 4.1: Promote healthy social and emotional development by making mental health

services available within settings where children grow and learn.

STRATEGY 1: Promote the provision of mental health promotion, prevention, and

intervention services in early childhood settings.

Action Step: Partner with Baltimore City Head Start to make mental health services

available on-site.

In FY 12, a total of 11 out of 12 (92%) Head Start Centers participated in the Early

Childhood Initiative, a collaborative effort between BMHS and BCHS to provide a

continuum of on-site mental health services, including mental health prevention, early

identification and intervention and/or treatment. Four organizations (Hope Health

Systems, Inc., University of Maryland, Change Health Systems, Inc. and Catholic

50

Charities/Villa Maria) provided 13 licensed mental health professionals who worked on a

multidisciplinary team to plan and implement mental health services within those 11

Head Start Centers throughout the City.

Indicators: Number of Head Start sites offering mental health services on-site; number of

mental health consultations provided.

Clinicians conducted 339 classroom observations and 712 mental health consultations.

The decrease in the number of classroom observations (61%) and mental health

consultations (35%) compared to FY 11 is attributed to clinicians implementing better

practices. In FY 11, clinicians were trained on four evidenced-based practices. In FY 12,

these practices were implemented, which resulted in children receiving higher quality

prevention activities and longer consultations. A higher quality of care was the emphasis

rather than the quantity of care.

STRATEGY 2: Promote the provision of mental health prevention, screening, assessment and

treatment services in public schools.

Action Step: Partner with the City Schools and Family League of Baltimore City to

fund school-based mental health services through the Expanded Mental Health

(ESMH) project.

BMHS continued to work with key stakeholders to provide expanded School Mental

Health (ESMH) services in 102 out of 196 (52%) of Baltimore City Public Schools in FY

12, a 5% increase from FY 11. The Sixth Grade - Expanded School Behavioral Health

Initiative (Sixth Grade Initiative) continued in 35 Baltimore City schools during the

2011-2012. This initiative is an innovative approach targeting sixth graders exhibiting the

following risk factors: attendance issues; behavioral issues; and low math and English

proficiency. The goal of this initiative is to support students during a critical transitional

period and to decrease the likelihood of school disengagement and drop-out. Funding for

this initiative is provided by Baltimore Substance Abuse Systems, Inc. and represents a

collaborative effort to promote resiliency and prevent substance use and other negative

outcomes for these at-risk sixth-graders.

Action Step: Track outcomes to demonstrate impact of school-based mental health

services.

In FY 12, a web-based database for the collection of ESMH data was launched to replace

the previous manual data collection and reporting process. The electronic database

enables ESMH clinicians to enter data in real-time and increases efficiency and accuracy.

The database also enables BMHS to create customized reports.

51

Action Step: Work with partners to explore possibilities for the expansion of ESMH

services.

An open and competitive procurement process was initiated in FY 11 that solicited high-

quality mental health providers to offer a full range of services in select City Schools for

academic year 2011-2012. The adjustment of funding levels that resulted from the

procurement process allowed 13 more schools to receive ESMH services in FY 12 as

compared to FY 11.

Action Step: Provide oversight and support to specialized school-based mental

health initiatives that serve targeted populations.

In FY 12, BMHS funded a year-long professional development training for ESMH

clinicians, known as The Common Elements. The Common Elements takes components

of interventions shown to be effective in treating specific disorders of childhood and

adolescents, and rebundles those elements, which provides more effective behavioral

health treatment. Seventy-two ESMH clinicians completed this training.

Indicators: Number of children and adolescents served; report on selected outcomes.

Expanded School Mental Health Services

FY 08 FY 09 FY 10 FY 11 FY 12

# of Schools Participating 96 106 102 89 102

# of Providers 13 12 12 9 4

Unduplicated Students Receiving Prevention Services

8,820 6,543 7,942 6,934 4,666

Total Funding Amount $3,009,950 $3,118,950 $2,964,500 $2,664,435 $2,304,000

During FY 2011-2012, 46,779 students in the 102 schools with ESMH services had

access to school-wide prevention activities, such as school assemblies and education

campaigns. This represents approximately 52% of the entire City Schools’ student

population. Four thousand six hundred sixty-six (4,666) students received mental health

prevention services7 in FY 12. As noted above, FY 12 was the implementation year of the

web-based database for the collection of ESMH data, which may be a reason as to the

decrease in the number of students served compared to previous years. In addition,

7 These prevention services differ from the school-wide prevention activities in that they specifically target at-risk

children rather than the general school population. In addition, these services are provided individually or in a small

group setting of 6 to 10 children.

52

similar to Head Start, which was discussed on page 49, in FY 12, ESMH clinicians

implemented better practices due to evidenced-based practice trainings provided in FY

11. These trainings resulted in the clinicians providing students higher quality prevention

services and longer consultations, but resulted in fewer students served.

Objective 4.2: Identify and seek to address the mental health needs of children and

adolescents in other child-serving systems.

STRATEGY 1: Work cooperatively with the Juvenile Justice System to identify and address

the mental health needs of involved youth.

Action Step: Provide consultation and technical assistance regarding mental health

services and resources on-site at Juvenile Court.

BMHS staff provided ongoing technical assistance and advocacy support services to

ensure that mental health services were delivered in a comprehensive family-friendly,

culturally competent manner. Meetings were held regularly with the service provider,

Hope Health Systems, in a continued effort to maximize service delivery within the

Juvenile Justice Center. Department of Juvenile Services (DJS) Administration continued

to express satisfaction with the quality of mental health services provided by Hope Health

Systems.

Action Step: Provide funding and oversight for the delivery of court-ordered mental

health assessments for post-adjudicated youth.

Despite additional budget reductions during FY 12, 289 youth received mental health

assessments. DJS outlined a plan in 2010 to gradually transition from a high volume of

in-house, grant-funded psychological evaluations to Medicaid-funded, fee-for-service

outpatient services, including assessment and treatment, through community mental

health clinics. As a result, DJS has developed plans for Reception/Assessment Centers at

various sites including Baltimore City Juvenile Justice Center, which are launching mid-

year FY 13. BMHS will continue to partner with DJS in order to support the transition of

this project to its new structure.

Action Step: In collaboration with Department of Juvenile Services (DJS), provide

funding and oversight for mental health and substance abuse screening and

treatment services for youth supervised by DJS at the Baltimore City Juvenile

Justice Center and in the community.

53

BMHS staff conducted site visits at the Baltimore City Juvenile Justice Center (BCJJC)

to provide technical assistance to ensure that mental health services are being delivered in

a comprehensive family-friendly, culturally competent manner. Youth in detention at

BCJJC continued to receive an array of mental health services, including screenings for

mental health and substance abuse issues, mental health treatment, and access to psycho

educational groups. In FY 12, 2,129 youth in detention were screened for mental health

and substance abuse issues, and 1,434 youth received mental health treatment during their

stay at BCJJC. (Note: some of the 1,434 youth were screened and began treatment in FY

11.) There was a 69% increase in the number of youth screened in FY 11 compared to FY

12, which is directly proportional to the number of youth cycling in and out of detention

during FY 12.

Indicator: Number of DJS-involved or court-involved youth served.

The data sets below outline the number of youth receiving court-ordered mental health

assessments at Baltimore Juvenile Justice Center (BCJCC). The program was

restructured in January 2012 to create a more streamlined referral process supported by

BMHS and Department of Juvenile Services (DJS) Resource Office. During this re-

organization process, DJS also began utilizing community-based resources to secure

mental health assessments, which diverted some referrals from this project; those

numbers are not captured in the below data. In addition, a reduction in funding also

contributed to the decrease in the number of youth who received mental health

assessments in FY 12 through this program.

Juvenile Mental Health Assessments Program (JMHAP) Court-Ordered Mental Health Assessments

Fiscal Year # of Assessments % Change FY 06 461 - FY 07 513 11% FY 08 662 29% FY 09 584 -12% FY 10 445 -24% FY 11 405 -9% FY 12 289 -28%

STRATEGY 2: Participate in statewide and local efforts to more adequately meet the mental

health needs of children and adolescents in foster care.

Action Step: Provide funding and oversight, in conjunction with MHA and

Department of Human Resources (DHR), of mental health assessments for children

at risk of entering or entering the foster care system.

54

BMHS staff continues to be involved in incorporating evidence-based mental health

assessments into the Making All the Children Healthy (MATCH) program, the integrated

care unit of Baltimore City’s Department of Social Services (BCDSS). Utilizing an

evidence-based assessment tool increases the likelihood that children entering the City’s

foster care system receive thorough health assessments that include a mental health

component. Those children who have identified treatment needs are linked to care.

In FY 12, Catholic Charities provided these mental health assessments. Through a

contract with the University of Maryland, up to 80 hours per month of

psychopharmacological chart review and medication management has been provided for

children involved in the foster care system. BMHS led quarterly implementation

meetings to ensure coordination among all involved partners. Eight hundred fifty-three

(853) youth who entered the BCDSS foster care system received evidence-based mental

health assessments and recommendations for appropriate mental health services through

this project, a 144% increase from FY 11 (350).

Action Step: Provide funding and oversight, in conjunction with MHA and DHR, of

mental health mobile crisis and stabilization services for children and families in the

foster care system.

In FY 12, BMHS continued to foster collaborative efforts with BCDSS and Catholic

Charities in implementing the BCDSS/BCARS Mobile Crisis Stabilization Program.

Steering committee meetings were held quarterly to provide updates on the work plan, to

review quarterly reports and otherwise act to strengthen collaboration around stabilizing

children and families in the foster care system.

Indicators: Number of children assessed; number of children able to maintain foster

care placement; number of mobile crisis responses.

BCARS/DSS Crisis Stabilization

FY 10 FY 11 FY 12

# of referrals/calls 177 385 135

# of youth eligible for services 130 352 123

# face-to-face assessments 67 95 88

% of children who maintained current DSS placement 90% 99% 95%

In FY 12, all 135 calls were responded to as per the policy of the program. Of the 123

youth and families eligible for services, 35 did not receive services for a variety of

reasons, including: families refused services, the youth’s foster care placement was

disrupted before BCARS could make contact, families could not be reached after the

referral was made or families canceled assessment appointments. Of the remaining 88

55

families who were eligible and willing to receive services, 52 families were admitted into

the program and received an assessment and treatment plan, and 36 families received

assessments only, with referrals to other community providers. Sixteen (16) families

required an immediate response and received face-to-face services in less than 2 hours as

per protocol. In FY 12, the average length of treatment associated with BCARS/DSS

stabilization services was 31 days, more than doubling the average length in FY11 (12

days). This trend is positive in that longer lengths of stay provide BCARS with a longer

period of time to implement a successful stabilization plan.

Of note, there was a 65% decrease in the number of referrals/calls compared to FY 11.

This is a direct result of a DSS policy change. In FY11, DSS made referrals to BCARS

without consulting with foster care workers, foster families or the youth. In FY 11,

referred services were declined 150 times (92%). In FY 12, DSS only referred individuals

and families that requested services. This, in turn, significantly decreased the rate of

declines for referred services; services were only declined 12 times out of 135 referrals in

FY 12 (9%).

Objective 4.3: Promote screening for mental health disorders, including co-occurring

disorders, and linkage to appropriate treatment and supports across the lifespan.

STRATEGY 1: Expand screening, assessment and coordinated treatment for individuals with

co-occurring mental health and substance use disorders.

Action Step: Continue planning activities with Baltimore Substance Abuse Services

(bSAS) and other Baltimore City stakeholders including the Expanded School

Mental Health Sixth Grade Initiative, and Integrated Dual Disorders Team (IDDT).

Continued intensive collaboration between bSAS and BMHS resulted in the

implementation of an Integrated Dual Disorders Treatment (IDDT) Initiative in February

of 2012 to serve individuals with co-occurring disorders who are court-ordered to

substance abuse treatment (8-507 designation). IDDT is an evidence-based practice

model that provides integrated mental health and substance abuse treatment to support

consumers in the recovery process. The first client was enrolled in April of 2012. There is

a projected enrollment of 55 clients for each of the three providers for a total of 165

clients served within the first year of operation.

BMHS also coordinated a joint mental health and substance abuse provider meeting with

bSAS in FY 12. Approximately 200 people attended. The guest presenter and speaker

was Chuck Ingoglia, Vice President of Public Policy for the National Council for

56

Community Behavioral Healthcare. He discussed behavioral health integration from a

national perspective.

Lastly, BMHS continued to collaborate with bSAS to implement the Sixth Grade

Initiative as part of the Expanded School Mental Health program, as described on page

50. This initiative provides prevention and early intervention services for youth who are

at risk of dropping out of school, which in turn is a risk factor for substance use.

Action Step: Continue efforts to increase knowledge among BMHS and BSAS staff

of treatment issues relating to individuals with co-occurring disorders and promote

closer collaboration between the two agencies.

BMHS and bSAS continue ongoing dialogue to generate ideas and identify opportunities

to improve the coordination of care for individuals with co-occurring disorders. The two

agencies hold regular management-to-management meetings that: increase shared

knowledge of both service systems; strengthen relationships between the agencies, their

staff and boards; and identify opportunities to strengthen their system-level collaboration.

In addition, BMHS held trainings with bSAS-funded providers and staff on the levels of

care available in the Public Mental Health System and how to access services.


BMHS participated in ongoing meetings with bSAS and various key partners to improve

integrated services for individuals with co-occurring disorders. See above for description

of activities.

STRATEGY 2: Make buprenorphine treatment available to individuals with mental illness

and opioid addiction.

Action Step: Through BHLI’s Project Connections, continue offering

buprenorphine treatment in coordination with mental health treatment at one site.

During FY 12, BHLI continued operations at Dee's Place, a 24-hour substance abuse

program, and opened a second site in December 2012, Recovery in Community.

.Indicators: Report on progress to date and number served.

In FY 12, there were 130 clients served between Dee’s Place and Recovery in

Community.

57

GOAL V: Excellent mental health care is delivered and research is

accelerated while maintaining efficient service system accountability.

Objective 5.1: Promote workforce development and training through educational activities

and technical assistance to mental health service providers and other service sectors.

STRATEGY 1: Sponsor continuing education and training opportunities in evidence-based

and emerging best practices.

Action Step: Sponsor community trainings for community-based mental health

clinicians.

During FY 12, BMHS contracted with the National Council for Behavioral Healthcare to

facilitate a Trauma-Informed Care Learning Community consisting of eight agencies

within the Baltimore City Public Mental Health System. Agencies participated in an

organizational self-assessment during two face-to-face learning community meetings and

two training webinars. The goals of the trainings were to create safe and secure

environments; address staff self-care; provide trauma-sensitive services; and to avoid

retraumatization of consumers. The agencies will become more trauma-informed through

critical policy and practice changes, implementing evidenced-based practices, expanding

consumer and peer support roles and partnering with human and social services agencies.

Action Step: Sponsor professional development sessions for school-based mental

health clinicians.

There were 3 professional development sessions for school-based mental health

clinicians, with 125 clinicians attending. The training topics for clinicians were as

follows:

● Back to School- Effective Collaborative Partnerships in Head Start Centers &

City Schools

● Informed by Common Elements (Basic)

● Informed by Common Elements (Plus)

Indicators: Number of training activities; number of participants.

See above for number of training activities and participants.

58

STRATEGY 2: Provide support and technical assistance to community service providers in

how the public mental health system works.

Action Step: Provide presentations to community service organizations about the

resources available for clients in need of mental health services.

BMHS staff received multiple requests to educate community service providers on how

the Public Mental Health System works. Presentations were made to Clifton T. Perkins

State Hospital social work staff, Union Memorial Hospital’s inpatient social work team,

providers receiving Ryan White funding, agencies participating in the Baltimore

Homeless Youth Initiative, Department of Public Safety and Correctional Services case

managers, Baltimore City Detention Center staff, Hands In Partnership (HIP) providers,

bSAS Care Coordinators, participants in the Department of Education Transition Age

Youth Resource Expo and various other caregivers.

BMHS continued to distribute its reference document, Mental Health Services for Adults

in Baltimore City, to guide presentations on community services available to adults in the

fee-for-service Public Mental Health System. This document was used for the majority of

the presentations listed above and was distributed at provider meetings and to the BMHS

board.

BMHS’ Geropsychiatric Nurse Specialist conducted 31 trainings to nursing home and

assisted living staff on a variety of topics related to aging and mental health resources.

Indicators: Types of community service organizations that received presentations;

number of presentations.

BMHS provided 44 trainings for community service organizations. Over 230 Mental

Health Services for Adults in Baltimore City documents have been distributed. See above

for types of organizations.

Objective 5.2: Provide access to services in the least restrictive setting.

Strategies 5 and 6 were partially accomplished.

STRATEGY 1: Strengthen crisis response services.

Action Step: Provide funding and oversight to Baltimore Crisis Response, Inc.

(BCRI) and to Baltimore Child and Adolescent Response System (BCARS).

59

Baltimore Crisis Response, Inc. (BCRI)

BMHS continued to fund BCRI for mobile crisis services and for a 24-hours-per-day, 7-

days-per-week crisis hotline. In addition to licensure as a residential crisis facility, BCRI

has licensure as a targeted case management program and an outpatient mental health

clinic and receives reimbursement through the State’s fee-for-service Public Mental

Health System for these services. This fee-for-service revenue was permitted by the state

and promoted by BMHS to compensate for the reduction in funding that occurred in FY

10, when funding for the diversion project was eliminated. In FY 12, BCRI was able to

increase the fee-for-service revenue which enabled the expansion of the mobile crisis

team hours, which had been reduced when the diversion project was eliminated. The

mobile crisis teams are now available from 7am to midnight. BCRI’s services continue to

be vital to the City’s mental health services continuum, and BCRI continues to provide

ER diversion services. BMHS continues to provide technical support both to assist BCRI

in their efforts to maximize the community’s utilization of BCRI services and in the

collection of fee-for-service revenue to support increased capacity.

BCRI’s call volume was 28,444 calls in FY 12, approximately 4% less than the number

of calls in FY 11. The distribution of types of calls in FY 12 was very similar to the

distribution in FY 11.

26,833 24,695

27,248

30,314 29,719 29,711 28,444

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

# C

alls

Fiscal Year

BCRI Hotline Calls, FY 06-FY 12

60

BCRI also experienced a slight (4%) decrease in the number of mobile crisis team face-

to-face visits.

BCRI Services

FY 09 FY 10 FY 11 FY 12 Mobile Crisis Team Referrals 2,534 2,556 1,991 1,969 Mobile Crisis Team Visits 2,285 2,325 1,736 1,665 % of referrals resulting in Mobile Crisis Team visit 90% 91% 87% 85%

In FY 12, there was an increase in the occupancy rate to 85% from 80% in FY 11, and a

slight increase in the length of stay in residential crisis beds. The increased occupancy

rate was in part due to BCRI’s participation in the coordination of services for high

inpatient users8 of psychiatric inpatient services. BCRI partnered with BMHS, Value

Options and MHA to coordinate services for these high inpatient users.

FY

10 %

Change FY

11 %

Change FY

12 %

Change

Individuals receiving Residential

Crisis Services 826 5% 710 -14% 732 3%

Residential Crisis Bed Days 5,351 0% 6,133 15% 6,537 7%

Residential Crisis Average Length of

Stay (Days) 6.5 -11% 8.8 35% 9 1%

8 A high inpatient user is a consumer who has been hospitalized for more than 30 days or has had five

hospitalizations within the last 6 months.

Information 63%

Crisis 6%

Suicide 4%

Supportive Counseling

2%

Referred to Other 1%

Detox 3%

BCARS 6%

Shelter Hotline 14%

Homeless 1%

BCRI Type of Call (n=28,444)

61

Baltimore Child and Adolescent Response Services (BCARS)

In the last quarter of FY 12, BCARS expanded their services and implemented a Pediatric

Emergency Room Department Diversion program with the University of Maryland

Medical Center and Johns Hopkins Hospital. BCARS also established a free-standing

BCARS Urgent Care Clinic. For the University of Maryland, BCARS provided a full-

time (8-hours a day, Monday through Friday) crisis clinician liaison who assisted referred

families to access services via telephone. At Johns Hopkins Hospital, a full-time BCARS

crisis clinician was present in the emergency department to also assist in accessing

services. The Urgent Care Clinic provided crisis response services in a clinic setting to

those youth and families who could access the clinic and were not in need of a mobile

response. The BCARS Emergency Room Diversion clinicians assisted with crisis

assessments and stabilization services. In addition to linking families to community based

services, the diversion program included crisis respite beds and up to eight weeks of care

coordination, in addition to the traditional two-week BCARS response. As one of the

crisis stabilization providers under the 1915c waiver, BCARS continued to provide crisis

services to a small number of families.

Indicator: Number of individuals served by each provider; progress to date.

Baltimore City Crisis Services

BCRI Services

Crisis Calls 28,444

Mobile Crisis Team Visits 1,665

Individuals receiving Residential Crisis Services 732

Individuals Receiving In-Home Interventions 361

BCARS Services

Crisis Calls 1,829

Families Receiving Crisis Stabilization Services 384

Emergency Room Diversion Program (last quarter FY 12) referrals 65

STRATEGY 2: Facilitate coordination of care for individuals using emergency rooms as their

point of access to psychiatric services.

Action Step: Facilitate access to community-based services for uninsured

individuals through the diversion project.

The Hospital Diversion Project, a pilot program that targeted uninsured consumers

visiting emergency rooms for psychiatric care, was eliminated in FY 11 due to greater

62

ease of inpatient admission for uninsured individuals presenting at local emergency

rooms. This was due to changes in the way the Emergency Medical Treatment and Active

Labor Act (EMTALA) was being implemented in Maryland. As a result, clients are more

frequently admitted from City emergency rooms to acute psychiatric inpatient care units,

and there are fewer requests for diversion. BCRI, the provider that previously operated

the Hospital Diversion Project, continues to serve clients, insured and uninsured, in

hospital emergency rooms. In FY 12, BCRI served 317 individuals in emergency rooms,

a 21% decrease from the number served in FY 11. Of all the referrals received by the

mobile crisis teams, 44% were from emergency rooms compared to 49% for FY 11.

Mobile Crisis Team Referrals from Emergency Rooms

FY 11 FY 12

Total # Referred 969 866

% Referred from Emergency Rooms 49% 44%

Action Step: Facilitate access to community-based services for clients identified by

MHA and the Administrative Services Organizations (ASO) as high inpatient

utilizers.

BMHS continued to coordinate services for individuals identified as high utilizers of

inpatient psychiatric services, i.e., those consumers who have either been hospitalized for

more than 30 days or who have had five or more hospitalizations in the last six months.

In FY 12, BMHS coordinated services for a total of 49 high inpatient user (HIU) project

consumers from various inpatient hospitals in and around Baltimore City. Of the 49

individuals, 28 (57%) were referred and successfully linked to community providers for

outpatient care. Individuals were referred to services such as case management, assertive

community treatment, outpatient mental health clinics, and RRP. BMHS staff continues

to collaborate with the ASO, local inpatient hospitals and community providers to

identify strategies to engage HIU project consumers not yet connected to care.

BMHS continued to receive funding through September of 2011 from the State’s Mental

Health Transformation Project to enhance a Baltimore City assertive community

treatment (ACT) team with two peer support specialists to provide enhanced assertive

engagement and support to HIU project consumers. The goal of the project, called the

Peer Support Engagement Project (PSEP) and operated by People Encouraging People,

Inc. (PEP), is to improve consumer outcomes and reduce avoidable use of hospital

emergency and inpatient care, along with associated costs. A majority of consumers

served in the HIU project during FY 12 were referred to PSEP and enrolled in care by the

63

team. Following the end of grant funding, this ACT team continued to serve HIU project

consumers through reimbursement through the State’s fee-for-service Public Mental

Health System (PMHS). The enhanced peer support, however, is no longer in place.

In FY 12, an analysis of 20 consumers served by the PSEP was done. These individuals

are adults ranging in age from 24 to 59, with 80% male, 20% female, 75% African-

American, and 25% Caucasian. Eighty-two percent (82%) of these individuals were

diagnosed with co-occurring mental health and substance use disorders. For 17 of the 20

consumers served, service utilization and claims data was available through the PMHS.

During the first nine months of enrollment in the PSEP, as compared to the nine months

prior, data for these 17 individuals shows that there was:

A reduction per consumer in visits to emergency departments (ED) (24.2%),

admissions to inpatient psychiatric hospitals (53%), and days of inpatient

psychiatric hospitalization (42.3%).

A reduction in the percentage of ED visits that resulted in an inpatient psychiatric

hospitalization from 71% to 44%.

An aggregate reduction in PMHS costs associated with these individuals of

17.6%, which includes a 39.3% reduction in inpatient psychiatric costs, a 24.4%

reduction in ED costs, and an 88.4% increase in community-based outpatient

costs.

The PSEP staff identified housing as a primary need for the majority of the 20 consumers

served, and that assisting these individuals in accessing permanent housing was an

essential component in reducing their use of ED and inpatient services. BMHS, through

its experience in funding the PSEP as well as the Capitation Project and FACTT,

continues to support the notion that the combination of comprehensive community-based

services with flexible consumer support funds and housing subsidies improves outcomes

and reduces overall system costs for individuals with multiple complex needs who are at

high risk for negative outcomes and are using a disproportionately high volume of the

most expensive services.


In FY 12, a total of 49 high inpatient utilization (HIU) project clients were served.

BCRI served 317 individuals in hospital emergency rooms.

64

STRATEGY 3: Whenever possible, divert children and adolescents from admission to

Residential Treatment Centers (RTCs) through offering alternative community-based

interventions and supports.

Action Step: Participate in the approval process for home- and community-based

wraparound services for children and adolescents.

In an effort to expand the continuum of community-based services available to youth, the

State of Maryland received a federal System of Care grant in 2007 to be implemented in

Baltimore City. This grant, titled Maryland Crisis and At Risk for Escalation diversion

Services for children (MD-CARES), strengthens cross-agency partnerships that blend

family-driven, evidence-based practices within mental health and child welfare to better

serve this high-risk population. In previous years, the 1915c waiver also expanded the

pool of children eligible to receive wraparound services. In FY 12, the 1915c waiver

enrollment, which had a sunset provision, ended. In FY 12, 81 children and adolescent

with complex behavioral health needs were served by Wraparound Maryland.

Action Step: Review Certificate of Need (CON) documents to ensure that all

referred youth meet eligibility requirements and community-based services have

been exhausted prior to determining whether an RTC level of care is needed.

BMHS staff reviewed 149 Certificates of Need, 39 for the 1915c Waiver and 109 for

traditional “brick and mortar” residential treatment centers, to ensure that children were

referred to the least restrictive, most appropriate treatment environment.

Indicators: Number of children and adolescents referred for RTC placement; number of

children and adolescents diverted from RTC services via the Care Management Entity

(CME).

Certificate of Need Packets Reviewed

FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

# of packets reviewed 107 99 104 106 82 143 149

# Approved 106 95 103 93 77 141 140

# Rejected 1 4 1 13 5 2 9

261 children were diverted from RTC admission; 81 children were served under the

1915c Medicaid Waiver within the Care Management Entity (CME); and 174 children

were served through other programs (e.g., MD-CARES, group home diversion) offered

65

within the CME. The increased number of CON packets reviewed is likely due to the

increased awareness of the above-mentioned services. It is also important to note that not

all children diverted from RTC required a CON.

STRATEGY 4: Provide support to programs that work with children and adults

transitioning out of inpatient/institutional facilities.

Action Step: Facilitate opportunities for communication between BCARS and

Wraparound Maryland, and child and adolescent psychiatric inpatient programs in

Baltimore City to increase utilization of BCARS or Wraparound Maryland to assist

youth in returning to the community following an inpatient admission.

BCARS continued to provide brief and intensive community-based services for children

in psychiatric crisis to divert or shorten inpatient hospitalization. BCARS also linked

clients to community providers for ongoing treatment once discharged from inpatient

settings. BMHS and BCARS staff communicated regularly to ensure that children and

their families were able to access the continuum of services across the public mental

health system, including services that facilitate a successful return to the community

following inpatient admissions.

Action Step: Collaborate with State hospital and acute care facilities in identifying

community resources to assist in discharge planning.

BMHS staff met monthly with the staff of Spring Grove Hospital, the State hospital

facility with the largest number of Baltimore City residents, to share resources and

collaborate on discharge planning. As part of this collaboration, a case review process

was utilized whereby individual client cases are reviewed and specific resources are

recommended to assist hospital staff in transitioning clients to the community. BMHS

facilitated collaboration among stakeholders to support the successful closure of the

Assisted Living Units (ALU) at Spring Grove and Springfield Hospitals, meeting the

target closure date established by MHA. This included facilitating the inclusion of court

personnel to enhance communication and collaboration between the state hospitals,

courts and the community-based services system, maximizing successful discharge

planning.

BMHS staff presented a workshop to the hospital’s social work department on the system

of services in Baltimore City in order to increase their knowledge of services available

and improve discharge planning. BMHS staff also provided training to hospital social

workers on effective discharge planning for individuals needing nursing home or assisted

living level of care in the community. This has resulted in a significant increase in

requests for BMHS’ Geropsychiatric Nurse Specialist to provide consultation.

66

BMHS facilitated one community provider presentation for staff and current clients at

Spring Grove Hospital Center (SGHC). Five (5) Baltimore City providers and five

consumers formerly hospitalized at SGHC provided education and encouragement to

individuals currently hospitalized to consider leaving the hospital and seeking community

placement. The presentation targeted hospital clients who have been reluctant to

transition to the community.

BMHS staff participated in monthly conference calls with Springfield Hospital social

work staff to share resources and collaborate on discharge planning for Baltimore City

residents. The BMHS Geropsychiatric Nurse Specialist also participated in monthly

interdisciplinary committee meetings to facilitate the successful discharge of individuals

needing nursing home or assisted living level of care to community providers throughout

the state.

BMHS staff collaborated more closely with social work staff at Clifton T. Perkins

Hospital in FY 12 to increase their knowledge of the array of community-based services

available in Baltimore and assist in developing discharge plans for those ready to return

to the community.

BMHS employs a Referrals Coordinator to manage the referral process for RRP, FACTT

and Capitation. Communication occurred almost daily with State hospital facilities to

ensure that individuals being discharged from these facilities were given priority for

vacancies in the above programs. RRP was the most frequent placement, with 26

individuals admitted from State hospital facilities. Of those individuals placed into RRP

beds, the average length of stay in a State hospital facility prior to discharge was 2.65

years, with a range of 18 days to 11 years. For Capitation, the average length of stay in a

State hospital facility prior to discharge was around 1 year, with a range of 10 months to

4 years.

On Our Own of Maryland, using funding from a grant from BMHS, provided peer

counseling services to 143 individuals hospitalized in state psychiatric hospitals. The goal

of this service is to assist clients in transitioning from the hospital to the community, and

improve tenure in the community following discharge. Seventy-three (73) individuals

served were discharged from the hospital to the community.

Indicators: Report on progress to date; number of individuals who transitioned from

inpatient/institutional facilities.

67

FY 12 Number of Individuals Discharged from State Hospitals

Forensic Non-Forensic Total Capitation Project 1 4 5

FACTT 20 0 20

Geriatric Community Placements* 2 18 20

RRP 17 9 26

TOTAL 40 31 71 *Coordinated by the Geropsychiatric Nurse Coordinator

Overall, there was a 5% increase in the number of individuals discharged from State

hospitals to public mental health services in FY 12 (total of 71) compared to FY 11 (total

of 68), with only the Capitation Project experiencing a decrease. These discharges are

largely dependent on State hospitals identifying consumers in need of public mental

health services. BMHS staff continue to work collaboratively with state hospital staff

toward more effective and rapid identification of consumers in state hospitals ready for

discharge and planning for their return to the community.

STRATEGY 5: Provide access to affordable housing for individuals and families with mental

illness.

Action Step: BMHS’ housing affiliate, Community Housing Associates (CHA), will

provide 266 units of safe and affordable housing throughout Baltimore City.

CHA provided housing to 217 households (159 individuals and 58 families). CHA

completed 10 additional units in FY 11, and 7 units in FY 12. CHA has a contract on a

property which will yield 9 units in FY 13. Ninety-seven percent (97%) of tenants

remained housed with CHA for over a year, 55% over 5 years and 5% over 10 years.

Indicators: Number of individuals and families housed; retention in housing greater than

6 months.


Strategy 6: Increase the number of affordable housing units available to individuals and

families with mental illness.

Action Step: CHA will apply for funding to develop housing for adults and families

with mental illness.

CHA applied for funding through the Department of Health and Mental Hygiene Capital

Bond Program and received $3.5, $2.9 and $2.5 million for FY 10, FY 11 and FY 12

68

respectively. CHA is matching the awarded funds with funds committed from the

Department of Housing and Community Development and the Housing Authority of

Baltimore City to develop 17 new units of affordable housing for individuals with

disabilities. CHA has a third property under contract which will be similarly funded by

DHM, DHCD and HABC.

Action Step: CHA will acquire and rehabilitate 20 units of affordable housing.

CHA has acquired 17 units of affordable housing. Ten (10) units were acquired in

December 2009, and seven additional units were acquired in June 2010. Construction is

now complete on 10 units of housing with occupancy planned for early FY

13. Construction of an additional seven units was completed in FY 12. CHA has a

contract pending on an additional 9 units to be completed in FY13.

Action Step: CHA will secure funding to acquire and rehabilitate an additional 20

units of housing to serve adults and families with mental illness.

Same as above.

Action Step: CHA will secure rental subsidies for all new units, ensuring tenants

pay no more than 30% of income for rent.

All new units will have Project-Based Section 8 rental subsidies, and tenants will pay no

more than 30% of their income towards rent.

Action Step: CHA will secure funds to make support services available to residents

of CHA housing.

Support for social services is incorporated in each of the budgets that fund the 17 units.

The social service funds were approved and will support a Resource Coordinator to

support the tenants.

Indicators: Number of applications submitted; number of individuals housed; number of

units developed; number of units with rental subsidy.

CHA submitted 2 applications to the Department of Housing and Community

Development and the Baltimore City Housing Authority, 1 application to the United Way

of Central Maryland, 1 renewal application for the Service Linked Housing program, 1

renewal application to Maryland’s Community Development Block Grant Program, and 2

renewal applications for the Shelter Plus Care Program. See above for progress to date.

69

Objective 5.3: Identify and promote the implementation of evidence-based, effective,

promising and best practices for mental health services.

Strategy 3 was not accomplished.

STRATEGY 1: Explore opportunities to increase access to evidence-based practices (EBP)

for children and adolescents.

Action Step: Collaborate with stakeholders throughout the City to establish a

continuum of EBP’s in Baltimore City.

In FY 12, BMHS collaborated with the National Council to establish evidenced-based

practice and emerging best practices in trauma-informed care for adults and children. In

addition, BMHS participated in monthly planning meetings facilitated by the Mental

Hygiene Administration’s Early Childhood Mental Health Committee to create four

demonstration sites, one in Baltimore City, that conduct evidenced-based practices in pre-

school settings. Lastly, BMHS partnered with Baltimore City Public Schools to fund The

Common Elements training for 72 ESMH clinicians.

Action Step: Provide oversight of and explore increased funding for the Center on

the Social and Emotional Foundations for Early Learning (CSEFEL) Positive

Behavior and Supports (an evidence-based practice) in at least one Head Start

Center.

In FY 12, five Head Start sites in Baltimore City were trained on SEFEL and began using

the evidence-based practice. Additionally, 18 of the 24 local school systems in the state

of Maryland have implemented or are making plans to implement SEFEL. BMHS

continues its participation in the statewide Steering Committee for Early Childhood’s

planning and monitoring of SEFEL. To date, there are over 350 individuals trained

throughout the State as trainers of this evidence-based practice model.

Indicators: Number of clinicians trained; progress report on implementation and

associated outcomes.


STRATEGY 2: Facilitate implementation of MHA’s evidence-based practice guidelines for

supported employment and assertive community treatment (ACT).

70

Action Step: Provide information, support and encouragement to programs

expressing interest in adopting evidence-based practices.

BMHS continued to promote the adoption of evidence-based practices in Baltimore City

for services to adults. Supported Employment Programs (SEPs) and Assertive

Community Treatment (ACT) teams are the two evidence-based practice models most

utilized for adults in the City.

BMHS continued to utilize mobile treatment provider meetings to promote the adoption

of evidence-based practices. This has given programs already certified by the State as

ACT teams the opportunity to offer guidance and support to programs interested in

becoming certified. Currently, six of the nine mobile treatment programs in Baltimore

City are certified as ACT teams. One additional mobile treatment team submitted a plan

for ACT certification after receiving technical assistance from BMHS, and is currently

receiving intensive training by the State. The remaining two mobile treatment programs

have expressed interest in further exploring the benefits of ACT certification.

BMHS staff provided technical assistance and support for five Supported Employment

Programs working toward evidence-based practice fidelity. In addition, BMHS staff

served on the leadership team for one of the programs that is considered a leader in

supported employment services for the state. Leadership teams are a recommended action

for programs interested in adopting SEP, and they provide support and guidance for the

program in implementing the EBP.

Finally, BMHS, in collaboration with bSAS, implemented an Integrated Dual Disorders

Treatment (IDDT) team, an evidence-based program model similar to ACT, for

individuals with co-occurring mental health and substance abuse disorders. See page 55

for a description of this initiative.

Indicators: Number and type of programs maintaining fidelity to the models.

There were 2 Supported Employment Programs (SEP) and 6 Assertive Community

Treatment (ACT) teams that maintained fidelity throughout the year.

STRATEGY 3: Identify opportunities to improve coordination in the provision of mental

health treatment and somatic care.

Action Step: Collaborate with MHA, Community Behavioral Health and other

interested partners in implementing practices that address somatic risk factors,

such as tobacco cessation, in mental health treatment settings.

71

The BMHS Geropsychiatric Nurse Specialist is an active participant in the Maryland Quit

Advisory Board and participates in two state-level groups formed to address smoking

cessation: the Department of Health and Mental Hygiene (DHMH) Maryland Leadership

Academy on Smoking Cessation and Wellness and the Mental Hygiene Administration

(MHA) Smoking Dependence Task Force. In addition, this staff person co-chairs a

workgroup with the Director of the Office of Chronic Disease Prevention for the DHMH

Leadership Academy as well as spearheads the efforts of MHA to address wellness and

smoking cessation. This staff person regularly provides updates n smoking cessation-

related activity and shares smoking cessation resources with BMHS staff.



Objective 5.4: Improve public mental health programs’ compliance with quality standards

established by Mental Hygiene Administration (MHA) and State and Federal regulations.

STRATEGY 1: Conduct quality assurance site visits to mental health programs.

Action Step: In collaboration with MHA and the Administrative Services Organization,

conduct audits of mental health programs to evaluate quality of services, billing practices

and compliance with State and Federal regulations.

BMHS staff collaborated with MHA, Office of Healthcare Quality (OHCQ) and Value Options

to conduct quality assurance site visits of mental health programs. Site visits were conducted

with 84 programs during FY 12. 30 programs failed to meet at least one quality standard and

were required to submit a Performance Improvement Plan (PIP). When requested, BMHS

provided technical assistance to providers in support of provider PIP submissions.

Action Step: Using data from compliance audits, identify areas where system-wide

improvements in services are needed and educate providers regarding deficiencies.

BMHS staff identified the following seven deficiencies that were most frequently cited by

compliance auditors for PMHS fee-for-service programs. These seven areas represent

opportunities for providers to improve care:

1. Transition and discharge planning are not done early or adequately.

72

2. Comprehensive strength and need assessments are not done, particularly for adults.

Many child-serving programs use Child and Adolescent Needs Assessments (CANs)

to address this issue.

3. Discharge follow-up is not done or not done adequately.

4. Collaboration with medical (somatic) providers is limited.

5. Individualized and differentiated treatment is lacking.

6. Treatment plan goals are not consumer-driven.

7. Case management providers frequently miss deadlines for assessment, re-assessment,

and service planning. Also, documentation of the condition of the home and of the

related presence or absence of safety issues is lacking.

BMHS staff noted that the technical assistance given to grant-funded providers has resulted in

these providers performing adequately in these seven areas. Therefore, it is likely that

providing similar technical assistance to the non-grant funded providers would result in fewer

deficiencies. Additionally, BMHS found that PRP providers are most frequently cited for not

adequately following specific COMAR treatment plan requirements, and that Case

Management providers are most frequently cited for missing deadlines for assessment, re-

assessment, and service planning (as in #7 above). These are additional areas where training

could lead to system-wide improvements in service delivery.

BMHS has implemented the following to address these concerns:

Increased technical assistance to case management providers through more frequent

site visits.

Identified training for PRP providers in compliance with the COMAR PRP treatment

plan requirements.

Indicators: Number of programs whose services meet quality standards; reduction in number

of programs found to be non-compliant.

84 programs received quality assurance site visits; 30 (36%) failed at least one standard and

were required to submit PIPs due to deficiencies. No programs received sanctions due to non-

compliance because their program improvement plans adequately addressed the issues of

concern.

There were 56 grant-funded providers; 2 (4%) were issued corrective action plans (CAPs) for

failing to meet one or more programmatic deliverables. 96% were compliant with contractual

obligations.

STRATEGY 2: Provide training and technical assistance to mental health programs.

73

Action Step: Offer education and technical assistance to new programs that submit

applications to deliver public mental health services.

Seven (7) new programs submitted applications to provide mental health services in Baltimore

City, and all of them received technical assistance. Some applicants were new providers to the

PMHS and others were current providers interested in establishing new programs. Providers

were asked to submit a business plan and a break-even cost analysis as part of their application

submission. These documents are reviewed by BMHS staff to ensure that system needs are

being addressed during the application process. Providers were given feedback on application

materials submitted and were given suggestions on how to attain compliance with COMAR.

Once an application adequately addressed the regulations, BMHS provided a letter of support.

Providers were then instructed to submit the revised application to the Office of Health Care

Quality to initiate the approval process.

Action Step: Offer technical assistance to existing providers in developing performance

improvement plans in response to quality assurance site visits.

BMHS staff provided technical assistance to 19 providers who received PIPs resulting from

failed OHCQ site visits. BMHS staff provided technical assistance to providers in developing

their performance improvement plans, which were then submitted to OHCQ for approval.

Indicators: Number of programs receiving technical assistance; reduction in the number of

non-compliant programs.

7 programs received technical assistance to start new programs. 19 programs received technical

assistance with PIPs.

STRATEGY 3: Monitor public mental health programs using a quality management

framework.

Action Step: Review and monitor quality management metrics in a newly established

quality management committee.

The Quality Management Committee was created at the beginning of FY 12 and met eight

times throughout the year. The Committee developed six measureable quality indicators, which

are as follows:

Measures of Quality within the City’s Publicly-Funded Mental Health Programs

1. Consumer Perceptions of Care

74

2. Provider Compliance with Contractual Requirements

3. Provider Program Quality

Measures of Quality Relating to BMHS Performance

4. Consumer Complaint Resolution

5. Timely Annual Contract Renewals

6. Help Call Satisfaction Rates

At each meeting, the Committee reviewed and analyzed data collected on the indicators,

identified improvement opportunities, and developed interventions to promote improvement.

In addition, quality assurance site visit results and provider applications to establish, expand

or close services/service lines were reviewed to assist in identifying PMHS service gaps and

provider trends.

Objective 5.5: Ensure that residential rehabilitation programs provide safe, affordable, and

quality housing.

STRATEGY 1: Inspect 100% of residential rehabilitation program (RRP) housing to

evaluate compliance with Code of Maryland Regulations.

Action Step: Conduct initial and annual housing inspections.

Every core service agency is required to conduct annual inspections of all residential

rehabilitation program (RRP) housing. BMHS also inspects the crisis residential beds in the

City. BMHS staff inspected 100% of the City’s 137 housing units, which have the capacity to

house a total of 381 residents. Units are defined as individual dwellings with leases or

ownership (i.e. apartment, house, group home, residential unit for crisis). Overall, the housing

was found to be in good repair, with all 137 inspections resulting in recertification after repairs

were completed.

Action Step: Conduct follow up inspections to determine if deficiencies identified during

inspections were corrected.

BMHS staff conducted 94 follow-up inspections of RRP and group home units that had

deficiencies during their annual inspection. An RRP receives either general approval when no

deficiencies are found or provisional approval for one or more deficiencies. Providers have 30

days to make repairs once they have received a provisional approval. Failure to make repairs

can lead to a program’s license being revoked by MHA. The most common deficiencies cited

75

in FY 12 were general maintenance that had not been performed. All deficiencies were

corrected, resulting in recertification.

Action Step: Assist the RRP’s by identifying and documenting the deficiencies so that

they can successfully complete the changes needed depending on their specific

circumstances.

BMHS staff works closely with providers during inspections to identify needed repairs, such as

safety issues, including working smoke alarms, proper food storage, etc. BMHS staff follows

up by sending written reports to providers listing all findings and requiring corrections to be

completed within the 30-day required timeframe. If the needed repairs are extensive, a provider

may submit a request for more time to complete repairs.

Action Step: Re-visit all RRP’s found to have had deficiencies.

Follow up inspections are conducted as described above.

Indicators: Number of RRPs inspected; reduction in the number of RRPs found to have

deficiencies.

FY 12 Residential Housing Inspections Conducted by QM staff

Provider Type of Housing # Housing

Units Beds

Inspected

Type of Approval Year End

General Provisional

Alliance Inc. RRP 14 46 14 0

Harford/ Belair RRP 15 46 15 0

Harbor City Unlimited RRP 19 51 19 0

Key Point RRP 21 49 21 0

Bon Secours-New Phases RRP 10 23 10 0

Mosaic/North Baltimore Center RRP 16 32 16 0

People Encouraging People RRP 34 80 34 0

Volunteers of America RRP 6 28 6 0

Mosaic Adult Group Home 1 5 1 0

BCRI Residential Crisis 1 21 1 0

Total 137 381 137 0

Objective 5.6: Provide an adequate network of mental health service providers to meet

community needs.

STRATEGY 1: Improve BMHS vendor contract management process.

76

Action Step: Assess vendor performance through submission of fiscal and

programmatic reports, and request corrective action plans from providers identified

as not meeting fiscal audit standards or programmatic deliverables.

There were 106 contracts issued in FY 12, totaling $19,550,168 in awards. Eighty-one

(81) contracts were funded by DHMH, and 25 were funded by various non-DHMH

funding sources. The provider contract compliance rate is measured by the percentage of

providers that receive payment on-time. Payments are held when the submission of

contractual documents, including quarterly program reports, invoices, quarterly fiscal

reports, insurance, audits and fidelity bonds are not timely, complete or accurate.

There was a 23% decrease in the number of contracts from FY 11 (137) to FY 12. This is

mainly attributed to the reduction in contracts for ESMH. In FY 11, there were 27

contracts for the ESMH initiative. In FY 12, the number of contracts was reduced to four

due to re-organization of ESMH into four regions. Regionalizing ESMH contracts allows

for better oversight and an increased efficiency of resources.

The average provider contract compliance rate improved from 59% in FY 10 to 92%, in

FY 11, and this improvement was sustained in FY 12 with 90% compliance. During the

contract renewal meetings, BMHS reviewed with providers contract reporting

requirements as well as the consequences of non-compliance, including payment

withholds, ineligibility for one-time supplemental funding, and nonrenewal of contracts

or delay in renewal. BMHS also increased communication with providers throughout the

year in an effort to promote greater compliance.

77

*Provider compliance rate is measured by the percentage of providers that receive payment on time.

Payments are held when the submission of contractual documents, including quarterly program reports, invoices, quarterly fiscal reports, insurance and fidelity bonds are not timely, complete or accurate.

The table below compares timeliness of contract execution over the past three years.

Efforts to improve the contract renewal process began in FY 10 and continued in FY 12,

resulting in 89% timeliness of contract executions. Delays in contract renewals were

caused by two issues this year. One provider required several new contracts, rather than

renewals, because of its contract process requirements, and a significant change in how

Expanded School and Early Childhood contracts were regionalized under four lead

agencies resulted in a delay in renewing them.

Timeliness of

Contract Execution

FY 10 59%

FY 11 92%

FY 12 89%

Action Step: Conduct random and targeted site visits to monitor vendor

performance, compliance with conditions in their contract, and regulatory

compliance; request performance improvement plans from providers identified as

non-compliant.

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00% P

erc

en

tage

of

pro

vid

er

com

plia

nt

BMHS Provider Contract Compliance Rates FY09 - FY12*

FY09 % Compliant

FY10 % Compliant

FY11 % Compliant

FY12 % Compliant

78

BMHS conducts site visits to verify that services purchased by the contract are being

delivered as reported and that the quality of those services is acceptable. Contracts funded

for more than $200,000 require an annual site visit. Contracts funded for less than

$200,000 are visited once every two years. During the site visit, BMHS interviews

program staff and consumers and then issues a written report to the program. The report

is provided to the program and is available to Mental Hygiene Administration (MHA) on

request. In FY 12, 84 site visits were conducted, compared to 90 in FY 11. These 84

visits constituted all required site visits. The number of required site visits fluctuates from

year to year based on the number of programs that require a regularly scheduled visit and

the number of programs that require a visit due to a previous finding or complaint. All

site visits were conducted either in accordance with mandated schedules or as required by

previous findings or complaints.

Additionally, at the request of MHA, BMHS began conducting site visits in FY 10 for

certification of the fee-for-service case management programs. Nine (9) case

management programs were reviewed and certified for an annual period. These programs

are now reviewed for re-certification annually.

Action Step: Provide technical assistance to non-compliant vendors; assess areas in

need of improvement, educate providers and schedule follow-up site visits to

evaluate progress.

As previously described on page 71, BMHS identified seven deficiencies related to

clinical service delivery that were cited most frequently during site visits. Additional

trends were noted for specific service types. Follow-up site visits were conducted to

provide technical assistance and training to providers and to assess whether deficiencies

were adequately addressed.

Indicators: Number of contracts in compliance; timeliness of contract execution;

program compliance ratings; reduction in the number of programs non-compliant;

percentage of providers who receive corrective action plans or performance

improvement plans, percentage of providers that, upon performance improvement plan or

corrective action plan follow-up, successfully improved performance.

See above for progress.

STRATEGY 2: Increase vendor understanding of BMHS contracts and policies through

education and technical assistance.

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Action Step: Provide education and training to vendors and staff through

contractual cycle, as needed.

All grant-funded vendors were given information about their contracts and a report

schedule to increase their understanding of their contractual obligations in reporting:

contractual documents, including progress reports; financial information, such as budgets,

invoices and quarterly fiscal documents; and insurance certificates and audits.

Indicator: Type and numbers of trainings provided.

All grant-funded providers attended a face-to-face contract renewal meeting.

GOAL VI: Technology is used to access mental health care information.

Objective 6.1: Explore the application of technology to improve service delivery, including

promoting the use of web-based technology as a tool to improve information sharing, data

collection, and evaluation.

STRATEGY 1: Use the BMHS integrated database to facilitate coordination of care.

Action Step: Train staff on utilizing database to extract and analyze client-level,

program-level and contract-level data to support improved agency operations and

performance.

Since BMHS’ integrated database was launched in FY 10, tutorials have been created to

provide guidance on how to use the database. All staff members have been trained on the

database, and all new staff members are trained as part of their orientation.

A quality improvement committee was established to determine why help call data were

not being adequately captured. The committee examined the drop-down menus and fields

for the help calls section of the database and presented their recommendations to improve

the menu structure to facilitate easier data entry. In addition, a comprehensive analysis of

the integrated databases functionality was conducted by the software vendor, which

resulted in a series of recommendations to effectively optimize the software and thereby

improve its functionality. All of these changes to the database are scheduled to be made

by the software vendor in FY 13.


80


STRATEGY 2: Maintain and publicize Baltimore City’s site for Network of Care, a web-

based application that includes a service directory and other mental health-related

resources.

Action Step: Collaborate with City providers to update and add new resources as

identified.

BMHS continues to review and approve new resources to be added to the Network of

Care website. All new resources are reviewed by BMHS’ quality management staff to

ensure that new vendors added to Network of Care are in good standing with the Office

of Health Care Quality and MHA.

Action Step: Provide training to City providers and other organizations on how to

use Network of Care to improve their delivery of services.

BMHS continues to encourage Baltimore City mental health providers to participate in

Network of Care with reminders during all meetings and conferences. In addition, BMHS

encouraged staff to include an introduction to Network of Care in trainings for

community stakeholders. A template Network of Care PowerPoint presentation was

created for staff to use in these trainings. Lastly, BMHS’ redesigned website increased

access to Network of Care by creating multiple links to it throughout the site.


The Network of Care website received 280,793 hits, or views, in FY 12 for Baltimore

City, compared to 137,061 in FY 11, a 105% increase, most likely caused by the

additional exposure from BMHS’ website and ongoing outreach activities as noted above.

STRATEGY 3: Develop redesigned agency website into an effective resource for the City’s

public mental health system, key partners and the general public.

Action Step: Update the website with important announcements, events and forms

that are pertinent to the Baltimore City provider community.

BMHS’ redesigned website was launched in March 2011. BMHS continually updates and

maintains the site to ensure current and relevant information is accessible.

81

Action Step: Keep resources and information on services up-to-date and easily

accessible to the general public.

BMHS staff review and update the website weekly to ensure it remains up-to-date and

easily accessible.



STRATEGY 4: Use Datalink to identify individuals in the City’s jails who have mental health

needs in order to increase access to mental health services.

Action Step: Develop a plan in collaboration with the Department of Public Safety

and Correctional Services to utilize the data available through Datalink to improve

release plans for incarcerated individuals with mental illness.

BMHS started receiving data from the Datalink in mid-May of 2012. The data are sent to

BMHS each day in a report, with a list of individuals who have been arrested in

Baltimore City and have had one or more authorizations for public mental health services

within the last two years. BMHS staff uses this data to notify service providers that

consumers with active authorizations have been arrested, with the goal of improving

continuity of care.

BMHS staff also uses the Datalink reports to identify individuals who would benefit from

a face-to-face assessment and release planning by staff in the jail. In FY 13, BMHS will

begin making these referrals to the provider in the jail that will be doing this enhanced

release planning for individuals with serious mental illness.


In the last month and a half of FY 12, the Datalink identified 329 individuals who were

arrested in Baltimore City and had active authorizations for public mental health care.

BMHS notified providers on behalf of 101 (31%) of those individuals. BMHS initially

prioritized notifications to providers of higher levels of care (e.g., Residential

Rehabilitation Programs, Psychiatric Rehabilitation Programs, Mobile Treatment, and

Case Management). As the project has progressed, BMHS has also started to notify

providers of lower levels of care (e.g., outpatient clinics) as well. The goal established for

FY 13 is to notify providers on behalf of at least 65% of arrested individuals with active

authorizations for public mental health services.

82

MENTAL HEALTH PLAN, FISCAL YEAR 2014

Introduction

BMHS oversees approximately a quarter of a billion dollars of publicly funded mental health

services in Baltimore City. The majority of these services are funded through the statewide fee-

for-service Public Mental Health System; a broad range of additional services and programs not

reimbursable by Medicaid are directly funded by BMHS through grants. Through these and other

activities, BMHS seeks to expand the reach and quality of the public mental health system,

promote the development of new and innovative services and address specific population and

system-level needs.

While BMHS and other core service agencies are tasked by the State to manage public mental

health services within the specialty system of care, mental health is increasingly being

recognized as a leading public health issue. The World Health Organization recently identified

mental health problems as the leading cause of disability in youth between the ages of 10 and 24.

Forty-five percent (45%) of disability among this age group is related to some type of behavioral

health issue.9 Additionally, depression is the leading cause of disability in the United States for

individuals ages 15 to 44,10

and mental illness is one of the top five reasons individuals apply for

Social Security disability.11

There is a significant opportunity for prevention and early

intervention services, which BMHS seeks to expand for at-risk populations – both children and

adults – in Baltimore City. In addition, BMHS is committed to expanding treatment and support

services to all in need.

BMHS already works to serve many at-risk populations and sees opportunities to strengthen

prevention and early intervention in the future through collaborative partnerships. BMHS

maintains strong relationships with key partners in City and State agencies, with a focus on those

systems where at-risk populations can be identified, such as the Department of Juvenile Services,

Department of Social Services, Baltimore City Public Schools, Baltimore Police Department, the

District and Circuit Courts of Baltimore City and the Mayor’s Office of Human Services. It is

through these partnerships that BMHS will continue to expand over the next several years.

FY 12 marked the beginning of planning for historic changes for BMHS. Movement toward an

integrated behavioral health service delivery system began to be contemplated, with the initiation

of planning at both the state and local level. In December 2011, the State of Maryland announced

its intention to merge its substance abuse and mental health treatment systems to create an

integrated behavioral health system and commenced a public planning process. Recognizing that

9 Source: http://thechart.blogs.cnn.com/2011/06/06/mental-illness-leading-cause-of-disability-in-youth/

10 World Health Organization, 2004.

11 Council for Disability Awareness, 2011.

83

an integrated system can provide the highest-quality care to people with substance abuse and

mental health disorders, and recognizing the value to the City of moving into alignment with the

State’s future approach to managing and financing this care, the boards of directors of BMHS

and bSAS voted in the spring of 2012 to develop recommendations for merging the two

organizations into a single behavioral health authority for the City.

Under the leadership of Baltimore City’s Health Commissioner, BMHS and bSAS have

embarked on a year-long planning and implementation process. The goal is to create a strong and

forward-looking organization that will leverage the opportunities afforded through state-level

and federal-level health care reform to better serve the people of Baltimore City. The

overarching goal will be the creation of a “no wrong door” system where individuals will be

welcomed into treatment wherever they enter and receive a comprehensive assessment that

addresses both substance and mental health issues.

Furthermore, with the assistance and guidance of expert consultants, BMHS and bSAS are

working towards creating a new Baltimore City behavioral health authority that will be well-

organized and highly functional. We anticipate that the new organization will be able to (1)

expand access to behavioral health care, (2) improve the quality of behavioral health care, (3)

manage the public behavioral health care system to provide services more efficiently, (4)

emphasize behavioral health promotion, prevention, screening, and early intervention, and (5)

increase coordination with somatic care.

BMHS’ one-year (FY 14) plan describes the major activities BMHS will embark on over the

next year. BMHS recognizes that its work will likely undergo significant change with the

implementation of federal healthcare reform. The design of the mental health service delivery

system platform and its financing and regulatory structures will be different in ways that have yet

to be determined. With this in mind, BMHS plans to keep abreast of information on the

implementation of changes at the state and national levels in order to continue to play a proactive

role in promoting the behavioral health status of the City’s residents.

BMHS’ Mental Health Plan is divided into five sections: Data on Service Utilization and

Outcomes; State Priority Areas, Mission, Vision and Values; and Goals, Objectives, and

Strategies. BMHS has elected to again present its work using the framework of the goals put

forth in the New Freedom Commission on Mental Health’s Achieving the Promise:

Transforming Mental Health Care in America.

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Data on Service Utilization and Outcomes

DATA ON SERVICE UTILIZATION - SUMMARY

Baltimore City Population12

620,961 individuals, 0.1% increase

11% of the State’s population, no change

62% Non-Hispanic Black (1% decrease), 26% Non-Hispanic White (2% decrease), 5%

Hispanic, any race (1% increase), 3% Asian (1% increase), and 2% other races (1%

increase)

Prevalence of Mental Illness and Substance Use Disorders in Adults (18 years and older)

161,449 individuals (26%) have a mental disorder13

55,887 individuals (9%) have a substance use disorder14

13,114 – 23,469 individuals need both mental health and substance abuse treatment15

Utilization of the Public Mental Health System (PMHS)16

43,821 individuals served, a 5% increase

95% of individuals have Medicaid, 6% uninsured and 11% Medicaid State-funded17

41,600 individuals with Medicaid served in the PMHS, a 6% increase over the last year

27,601 adults 18 years and older served, a 5% increase

16,220 children/adolescents served, a 5% increase

16% decrease in the number of adults with inpatient hospitalizations, and 2% increase in

the number of children/adolescents with inpatient hospitalizations

6% and 5% increase, respectively, in adults and children/adolescents utilizing outpatient

services

Expenditures for Services

City consumers represent 30% of those served in the State, and 35% of State expenditures

Total PMHS expenditures in Baltimore City decreased by 1%

Average expenditure per adult consumer was $4,920, a 6% decrease

Average expenditure per child/adolescent consumer was $5,696, a 2% decrease

12

Unless otherwise noted, US Census Bureau Data from 2009 and 2010 are compared. 13

Estimates based on national prevalence data. Source: Kessler, R., Berglunc, P., Demler, O., Jin, R., Merikangas, K.,

Walters, (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity

Survey Replication. Archives of General Psychiatry, 62, 593-602. 14

Based on estimates from the National Survey of Drug Use and Health. 15

Based on estimates from the U.S. Department of Health and Human Services. 16

Unless otherwise noted, comparisons are to FY 10 data. 17

Many people use services in more than one service type and/ coverage type. As a result, the sum of the percentage of

people served across service types and across coverage types exceeds 100%.

85

Trends

More consumers served (5%) at a lower cost per consumer (6%)

Less inpatient hospitalization (11%) while more outpatient services (5%)

86

SOURCE OF DATA

Unless otherwise specified, the data presented in this section of the report are service utilization

and Outcome Measurement System (OMS) data collected by the Administrative Services

Organization (ASO) for Maryland’s fee-for-service Public Mental Health System (PMHS),

which is currently ValueOptions (VO). The utilization data describe the use of services and

associated expenditures for children and adults in FY 12, and the OMS data describe point-in-

time outcome measures of various dimensions of wellness, from July 1, 2011 through June 30,

2012. Data reports were run through October 9, 2012 (just over three months after the end of FY

12).

As in previous years, the most recent utilization data reported (FY 12) are incomplete, as claims

may be submitted up to 12 months after the date of service delivery. Therefore, the data for FY

12 do not reflect all of the claims for services rendered to Baltimore City individuals, while the

data for previous years, to which it is being compared, represent 100% of claims for those years.

This needs to be kept in mind when comparing FY 12 data to FY 11 and FY 10 data for trends.

When comparisons with previous years show increases in FY 12, it is likely that the actual

increase is somewhat greater. Conversely, decreases in FY 12 compared to previous years will be

somewhat offset by the missing claims data. This artifact of the PMHS is more pronounced for

expenditures and service data and less for numbers of consumers served, since the majority of

consumers served have a severe mental illness or emotional disorder and receive services for a

significant duration. The review of data throughout this section takes this information into

account. Therefore, the comments are focused on changes from previous years that appear to be

significant in magnitude.

This is the second year that OMS data are included in this document. FY 12, however, is the first

year that MHA is requiring specific OMS indicators to be reported. Consumers treated in other

settings are not included. The OMS data are gathered through interviews with individuals, ages

6-64, who are receiving outpatient mental health treatment services. Interviews are conducted at

the commencement of treatment and then every six months in licensed outpatient mental health

clinics, federally qualified health centers, and hospital-based clinics. Consumers who are dually

eligible for Medicaid and Medicare are not included.

Furthermore, the tables and charts that follow are required by Maryland’s Mental Hygiene

Administration (MHA) for inclusion in this report. They present summary data from the past

three fiscal years for Baltimore City and the past fiscal year for Maryland. It should be noted that

previously reported data for the three fiscal years prior to FY 12 have been updated to include

claims that were paid after September 30th

following the respective fiscal year and, therefore,

may differ from data reported in previous BMHS annual reports. The OMS data compare

outcomes for Baltimore City and the State for FY 12 only.

87

Finally, it should be noted that the data presented here do not provide a complete picture of the

utilization of publicly funded mental health services, since services funded by Medicare are not

included, nor are services funded through grant-funded contracts. Throughout this report, “those

served by the Public Mental Health System” refers only to individuals utilizing services funded

through Maryland’s fee-for-service PMHS.

88

OVERVIEW OF UTILIZATION DATA

Comments on the data that follow in this section will be limited to overall trends. Many of the

trends of interest are specific to particular age groups and program types and will be discussed

later in this section under the headings titled Service Utilization by Adults and Service

Utilization by Children and Adolescents, beginning on page 107.

Overall, there are four striking observations from the FY 12 data on service utilization in the

PMHS:

The PMHS in Baltimore City continues to expand, both in terms of the number of

individuals served (13% over the last three years to 43,821) and the total amount of

expenditures (3% over the past three years to $228 million)

The expansion in the number served in FY 12 was significantly greater than the increase

in expenditures, continuing the trend of an overall decrease in the cost per person of 6%

from FY 11 to FY 12.

There has been a continued increase in Medicaid consumers, 6% from FY 11 to FY 12,

and a continued decrease in uninsured, 2% from FY 11 to FY 12.

The number of consumers utilizing inpatient treatment has significantly decreased by

11% compared to FY 11, and the amount in expenditures for this service type has also

decreased by over $9 million (15%).

Consumers Served

While Baltimore City represents 11% of the State’s population, it represents 30% of those who

utilized the PMHS in FY 12. During the past three fiscal years, the number of City residents

served has increased by 13%, and the number of Maryland residents served has increased by

17%. The overall increase in the City is due to services being provided to more individuals in

nearly all age groups, but can be largely attributed to an increase of 1,431 or 6% in the number of

adults (22-64 years) who utilized services, followed by: children (6-12 years) which increased by

609 or 8%; young children (0-5 years) which increased by 116 or 5%; elderly (65 and over)

which increased by 47 or 13%; and adolescents (13-17 years) which increased by 42 or 1%.

There was 2% decrease, or 44 fewer, in transitional (18-21 years) youth served.

Expenditures

Total expenditures of $228,184,888 for Baltimore City account for 35% of the State’s total

expenditures on public mental health services in FY 12. During the past three years, City

expenditures increased at a slower rate than the State’s, 3% and 15% respectively, and in FY 12,

City expenditures decreased by 1% versus a 3% increase statewide.

89

While the total number of individuals served increased by 5%, expenditures have decreased by

1%. The average cost per person decreased for all age groups, except for early child, adolescent,

and elderly. The decrease of approximately $2 million in PMHS expenditures in Baltimore City

is largely due to decreases associated with two service types: inpatient ($9 million) and partial

hospitalization ($2 million), which were offset by an increase in outpatient treatment ($5 million)

and psychiatric rehabilitation ($3 million). This is significant because it suggests that care is

shifting from hospitals to less intensive community settings.

For inpatient treatment, the number of consumers served decreased by 11%, and expenditures

decreased by 15%. The cost per consumer for inpatient treatment decreased 4% this fiscal year

and remained steady for outpatient treatment and psychiatric rehabilitation. However, the cost

per consumer decreased by 25% for partial hospitalization, which experienced decreases in both

the numbers served and total expenditures. This is most likely due to some combination of longer

lengths of stay and more episodes of care for those served.

Insurance Coverage

The main source of health insurance coverage for public mental health services is Medicaid,

including Medicaid State-funded.18

Most noteworthy is the continued expansion of service to

individuals with Medicaid, which has increased by 15% (since FY 10) over the last three years

and 6% in the last year alone. The total number of uninsured consumers continued to decrease

over the past three years, mostly due to increased enrollment in Primary Adult Care (PAC), a

State program that covers outpatient mental health services and prescription drugs for adults who

meet income and assets eligibility and are not covered by Medicare. However, there was also a

decline in uninsured expenditures in FY 12, most likely due to the limited benefits package for

uninsured individuals.

Between FY 11 and FY 12, Medicaid expenditures for public mental health services decreased

by 1%, while the number of consumers in the PMHS receiving Medicaid increased at a higher

rate of 5.9%. Medicaid State-funded expenditures for public mental health services increased by

3%, and the number of individuals served in this category increased comparatively by 2%.

The following tables present overall data for Baltimore City and the State of Maryland. It should

be noted that statewide data include data from Baltimore City, which, as previously stated,

comprise about a third of all consumers served in Maryland and more than a third of State

expenditures.

18

Medicaid State-funded expenditures are state-only funds (versus those with a federal match) for State programs

such as Primary Adult Care (PAC) for individuals who are eligible based on certain income and assets criteria.

90

BALTIMORE CITY PUBLIC MENTAL HEALTH SYSTEM UTILIZATION

Baltimore City Total Consumers Served

FY2010 FY 2011 % Change FY 2012 % Change

Early Child (0-5) 2,013 2,169 7.7% 2,285 5.3%

Child (6-12) 7,229 7,743 7.1% 8,352 7.9%

Adolescent (13-17) 5,498 5,541 0.8% 5,583 0.8%

Transitional (18-21) 2,323 2,667 14.8% 2,623 -1.6%

Adult (22 to 64) 21,337 23,137 8.4% 24,568 6.2%

Elderly (65 and over) 373 363 -2.7% 410 12.9%

TOTAL 38,773 41,620 7.3% 43,821 5.3%

Baltimore City Consumers Served by Service Type


Case Management 927 1,059 14.2% 1,086 2.5%

Crisis 660 582 -11.8% 560 -3.8%

Inpatient 3,319 3,241 -2.4% 2,877 -11.2%

Mobile Treatment 816 892 9.3% 959 7.5%

Outpatient 36,411 39,373 8.1% 41,437 5.2%

Partial Hospitalization 1,438 860 -40.2% 738 -14.2%

Psychiatric Rehabilitation 6,368 6,850 7.6% 7,641 11.5%

Residential Rehabilitation 1,077 965 -10.4% 966 0.1%

Residential Treatment 133 165 24.1% 193 17.0%

Respite Care 80 75 -6.3% 87 16.0%

Supported Employment 389 440 13.1% 444 0.9%

BMHS Capitation 302 303 0.3% 303 0.0%

Emergency Petition 13 15 15.4% 36 140.0%

Purchase of Care 134 92 -31.3% 89 -3.3%

PRTF Waiver 11 36 227.3% 41 13.9%

**TOTAL 38,773 41,620 7.3% 43,821 5.3%

Baltimore City Consumers Served by Coverage Type


Medicaid 36,317 39,295 8.2% 41,600 5.9%

Medicaid State Funded 3,602 4,608 27.9% 4,676 1.5%

Uninsured 3,145 2,576 -18.1% 2,538 -1.5%

**TOTAL 38,773 41,620 7.3% 43,821 5.3%

91

Baltimore City Expenditures By Age

FY2010 FY 2011 % Change FY 2012

% Change

Early Child (0-5) $6,127,637 $6,640,360 8.4% $7,064,888 6.4%

Child (6-12) $45,132,263 $47,837,646 6.0% $46,543,275 -2.7%

Adolescent (13-17) $35,136,166 $35,328,393 0.5% $38,779,291 9.8%

Transitional (18-21) $11,156,257 $11,431,623 2.5% $10,408,565 -8.9%

Adult (22 to 64) $121,642,018 $125,636,434 3.3% $121,590,649 -3.2%

Elderly (65 and over) $3,219,504 $3,322,983 3.2% $3,798,220 14.3%

TOTAL $222,413,845 $230,197,439 1.7% $228,184,888 -0.9%

Baltimore City Expenditures by Service Type

FY2010 FY 2011 % Change FY 2012

% Change

Case Management 1,565,546 1,931,613 23.4% 1,875,542 -2.9%

Crisis 1,582,881 1,546,693 -2.3% 1,774,924 14.8%

Inpatient 62,342,879 62,792,000 0.7% 53,593,724 -14.6%

Mobile Treatment 7,128,441 7,608,588 6.7% 8,396,630 10.4%

Outpatient 85,170,184 90,957,047 6.8% 95,678,789 5.2%

Partial Hospitalization 7,467,995 5,274,948 -29.4% 3,383,972 -35.8%

Psychiatric Rehabilitation 33,300,683 35,987,907 8.1% 38,990,400 8.3%

Residential Rehabilitation 1,576,830 1,563,942 -0.8% 1,645,348 5.2%

Residential Treatment 12,278,290 12,698,735 3.4% 13,075,104 3.0%

Respite Care 164,273 125,218 -23.8% 165,284 32.0%

Supported Employment 799,607 875,612 9.5% 757,023 -13.5%

BMHS Capitation 7,868,650 8,025,300 2.0% 7,986,690 -0.5%

Emergency Petition 12,086 10,347 -14.4% 28,242 172.9%

Purchase of Care 1,150,009 756,212 -34.2% 769,472 1.8%

PRTF Waiver 5,489 43,275 688.4% 63,745 47.3%

**TOTAL $222,413,843 $230,197,437 3.5% $228,184,889 -0.9%

Baltimore City Expenditures by Coverage Type FY2010 FY 2011 % Change FY 2012 % Change

Medicaid 204,371,750 215,172,306 5.3% 213,002,300 -1.0%

Medicaid State Funded 11,575,080 10,506,077 -9.2% 10,827,683 3.1%

Uninsured 6,467,014 4,519,055 -30.1% 4,354,905 -3.6%

**TOTAL $222,413,844 $230,197,438 3.5% $228,184,888 -0.9%

92

Baltimore City Expenditures: Child / Adolescent (Age 0 – 17 Years)


Case Management 252,754 188,784 -25.3% 150,885 -20.1%

Crisis 7,074 5,367 -24.1% 3,415 -36.4%

Inpatient 19,312,936 18,939,193 -1.9% 17,535,851 -7.4%

Mobile Treatment 392,144 698,702 78.2% 672,118 -3.8%

Outpatient 43,633,571 45,824,391 5.0% 48,971,763 6.9%

Partial Hospitalization 2,998,231 3,010,232 0.4% 2,131,383 -29.2%

Psychiatric Rehabilitation 7,492,324 8,937,376 19.3% 10,054,015 12.5%


Residential Treatment 11,688,921 11,978,287 2.5% 12,633,860 5.5%

Respite Care 163,046 125,218 -23.2% 164,260 31.2%

Supported Employment 624 1,769 183.5% 1,248 -29.5%

BMHS Capitation 0 0 0.0% 0 0.0%

Emergency Petition 1,174 1,498 27.6% 0 0.0%

Purchase of Care 48,151 55,518 15.3% 16,527 -70.2%

**TOTAL $86,396,066 $89,806,399 3.0% $92,387,454 2.9%

Baltimore City Persons Served: Child / Adolescent (Age 0 – 17 Years)


Case Management 137 122 -10.9% 80 -34.4%

Crisis 1 3 200.0% 1 -66.7%

Inpatient 804 846 5.2% 859 1.5%

Mobile Treatment 108 103 -4.6% 103 0.0%

Outpatient 14,48

6

15,18

5 4.8%

15,88

9 4.6%

Partial Hospitalization 436 427 -2.1% 435 1.9%

Psychiatric Rehabilitation

2,733 3,124 14.3%

3,558 13.9%

Residential Rehabilitation

3 3 0.0%

1 -66.7%

Residential Treatment 125 150 20.0% 180 20.0%

Respite Care 77 75 -2.6% 86 14.7%


BMHS Capitation 0 0 0.0% 0 0.0%


Purchase of Care 7 9 28.6% 6 -33.3%

**TOTAL 14,740 15,453 4.8% 16,220 5.0%

93

Baltimore City Persons Served: Adult (Age 18+ Years)


Case Management 790 937 18.6% 1,006 7.4%

Crisis 659 579 -12.1% 559 -3.5%

Inpatient 2,515 2,395 -4.8% 2,018 -15.7%

Mobile Treatment 708 789 11.4% 856 8.5%

Outpatient 21,925 24,188 10.3% 25,548 5.6%

Partial Hospitalization 1,002 433 -56.8% 303 -30.0%

Psychiatric Rehabilitation 3,635 3,726 2.5% 4,083 9.6%


Residential Treatment 8 15 87.5% 13 -13.3%

Respite Care 3 0 0.0% 1 0.0%


BMHS Capitation 302 303 0.3% 303 0.0%


Purchase of Care 127 83 -34.6% 83 0.0%

**TOTAL 24,033 26,167 8.9% 27,601 5.5%

Baltimore City Expenditures: Adult (Age 18+ Years)


Case Management $1,312,792 $1,742,829 32.8% $1,724,657 -1.0%

Crisis $1,575,807 $1,541,326 -2.2% $1,771,508 14.9%

Inpatient $43,029,943 $43,852,807 1.9% $36,057,873 -17.8%

Mobile Treatment $6,341,296 $6,909,885 9.0% $7,724,513 11.8%

Outpatient $41,536,612 $45,132,657 8.7% $46,707,027 3.5%

Partial Hospitalization $4,469,764 $2,264,716 -49.3% $1,252,589 -44.7%


$25,808,359 $27,050,531 4.8%

$28,936,385 7.0%


$1,572,206 $1,563,674 -0.5%

$1,644,946 5.2%

Residential Treatment $589,368 $720,449 22.2% $441,243 -38.8%

Respite Care $1,228 $0 -100.0% $1,023 0.0%

Supported Employment $798,984 $873,843 9.4% $755,774 -13.5%

BMHS Capitation $7,868,650 $8,025,300 2.0% $7,986,690 -0.5%

Emergency Petition $10,913 $8,849 -18.9% $28,242 219.2%

Purchase of Care $1,101,858 $700,695 -36.4% $752,945 7.5%

**TOTAL $136,017,779 $140,391,040 0.8% $135,797,434 -3.3%

Source: ValueOptions

Based on claims paid through September 30, 2012 Run Date: October 9, 2012

94

Persons Served Expenditures

STATE* COUNTY STATE* COUNTY

AGE Number Per

Cent Number Per

Cent Number Per

Cent Number Per

Cent

Early Child 6,972 4.8% 2,285 5.2% $16,324,794 2% $7,064,888 3.1%

Child 28,221 19.5% 8,352 19.1% $120,736,993 18% $46,543,275 20.4%

Adolescent 20,599 14.3% 5,583 12.7% $118,066,675 18% $38,779,291 17.0%

Transitional 9,378 6.5% 2,623 6.0% $35,150,227 5% $10,408,565 4.6%

Adult 77,967 54.0% 24,568 56.1% $357,147,321 54% $121,590,649 53.3%

Elderly 1,284 0.9% 410 0.9% $11,657,127 2% $3,798,220 1.7%

TOTAL 144,421

43,821 $659,083,135 100% $228,184,888

SERVICE TYPE 0.303

Case Management 3,812 2.6% 1,086 2.5% $5,996,629 0.9% $1,875,542 0.8%

Crisis 1,680 1.2% 560 1.3% $5,579,823 0.8% $1,774,924 0.8%

Inpatient 9,537 6.6% 2,877 6.6% $138,956,568 21.1% $53,593,724 23.5%

Mobile Treatment 2,984 2.1% 959 2.2% $22,576,403 3.4% $8,396,630 3.7%

Outpatient 136,472 94.5% 41,437 94.6% $245,798,307 37.3% $95,678,789 41.9%

Partial Hospitalization 2,033 1.4% 738 1.7% $7,014,090 1.1% $3,383,972 1.5%

Psychiatric Rehabilitation 20,011 13.9% 7,641 17.4% $147,325,022 22.4% $38,990,400 17.1%

Residential Rehabilitation 4,356 3.0% 966 2.2% $10,515,406 1.6% $1,645,348 0.7%

Residential Treatment 711 0.5% 193 0.4% $51,639,705 7.8% $13,075,104 5.7%

Respite Care 447 0.3% 87 0.2% $1,277,691 0.2% $165,284 0.1%

Supported Employment 3,034 2.1% 444 1.0% $6,661,591 1.0% $757,023 0.3%

BMHS Capitation 368 0.3% 303 0.7% $9,529,979 1.4% $7,986,690 3.5%

Emergency Petition 950 0.7% 36 0.1% $442,346 0.1% $28,242 0.0%

Purchase of Care 704 0.5% 89 0.2% $5,454,495 0.8% $769,472 0.3%

PRTF Waiver 134 0.1% 41 0.1% $315,081 0.0% $63,745 0.0%

TOTAL 144,421

43,821 $659,083,135 $228,184,889

COVERAGE TYPE

Medicaid 134,133 92.9% 41,600 94.9% $593,327,277 90.0% $213,002,300 93.3%

Medicaid State Funded 19,964 13.8% 4,676 10.7% $47,037,187 7.1% $10,827,683 4.7%

Uninsured 11,259 7.8% 2,538 5.8% $18,718,671 2.8% $4,354,905 1.9%

TOTAL 144,421 43,821 $659,083,135 $228,184,888

95

State of Maryland and Baltimore City Cost per Person Served

State County Difference Per Cent

AGE

Early Child $2,341 $3,092 $750 24.3%

Child $4,278 $5,573 $1,294 23.2%

Adolescent $5,732 $6,946 $1,214 17.5%

Transitional $3,748 $3,968 $220 5.5%

Adult $4,581 $4,949 $368 7.4%

Elderly $9,079 $9,264 $185 2.0%

TOTAL $4,564 $5,207 $644 12.4%

SERVICE TYPE

Case Management $1,573 $1,727 $154 8.9%

Crisis $3,321 $3,170 -$152 -4.8%

Inpatient $14,570 $18,628 $4,058 21.8%

Mobile Treatment $7,566 $8,756 $1,190 13.6%

Outpatient $1,801 $2,309 $508 22.0%

Partial Hospitalization $3,450 $4,585 $1,135 24.8%

Psychiatric Rehabilitation $7,362 $5,103 -$2,259 -44.3%

Residential Rehabilitation $2,414 $1,703 -$711 -41.7%

Residential Treatment $72,630 $67,747 -$4,883 -7.2%

Respite Care $2,858 $1,900 -$959 -50.5%

Supported Employment $2,196 $1,705 -$491 -28.8%

BMHS Capitation $25,897 $26,359 $462 1.8%

Emergency Petition $466 $785 $319 40.6%

Purchase of Care $7,748 $8,646 $898 10.4%

$2,351

TOTAL $4,564 $5,207 $644 12.4%

COVERAGE TYPE

Medicaid $4,423 $5,120 $697 13.6%

Medicaid State Funded $2,356 $2,316 -$41 -1.7%

Uninsured $1,663 $1,716 $53 3.1%

TOTAL $4,564 $5,207 $644 12.4%

Source: ValueOptions Based on claims paid through September 30, 2012

Run Date: October 9, 2012

96

OVERVIEW

Baltimore City residents continue to comprise approximately one-third of all consumers served

in the State and one-third of total expenditures on PMHS services.


Based on claims paid through September 30, 2012


Compared to the State, Baltimore City residents have a higher rate of utilization of PMHS

services: 7% of the City population compared to the State’s 3%.

0

50,000

100,000

150,000

200,000

FY 10 FY 11 FY 12

Number of Consumers Served in Baltimore City and Maryland

Baltimore City State

$-

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

$600,000,000

$700,000,000

FY 10 FY 11 FY 12

Baltimore City and Statewide PMHS Expenditures

Baltimore City State

97

Between FY 10 and FY 12, Baltimore City consistently had a higher overall cost per consumer

than the State. In FY 12, the cost per consumer was 12% higher in Baltimore City than in

Maryland. This cost difference appears to be the result of the higher costs per consumer for a few

services, such as inpatient, outpatient, and partial hospitalization. For the third year in a row, the

overall cost per consumer for both Baltimore City and the State decreased; however, the gap

between City and State costs per consumer persists. This is likely related to the broader range of

higher intensity services such as ACT and Capitation available in Baltimore City.

The difference in expenditures and per-consumer costs reflect characteristics specific to

Baltimore City’s population and its PMHS. The Baltimore City population is among the poorest

in the State, as measured by median income, and likely experiences a higher rate of serious

mental illness/severe emotional disturbance, which requires more intensive services. The City’s

PMHS is the largest and most diversified in the State. There are more hospitals and, therefore,

proportionately more hospital-based services (i.e., inpatient and partial hospitalization) available.

Additionally, Baltimore City has services that many other jurisdictions do not currently have. For

example, Baltimore City is the sole jurisdiction with the Capitation Project, which serves

frequent users of inpatient and emergency services.

FY 10 FY 11 FY 12

Baltimore City 6% 7% 7%

State 2% 2% 3%

0%

1%

2%

3%

4%

5%

6%

7%

8%

Percentage of Baltimore City and Maryland residents who Utilize the PMHS, FY 10-12

Baltimore City

State

98



The chart below indicates that the cost per consumer is higher in Baltimore City for every age

group. The highest discrepancies in the average cost per consumer are for early child (0-5 years),

32%; child (6-12 years), 30%; and adolescent (13-17 years), 21%.




The gap between the proportion of adult and youth consumers served by the PMHS has

continued to grow over the last several years, from roughly equal numbers of

children/adolescents and adults served in FY 06 to two out of three PMHS consumers being

adults and one out of three being children/adolescents in FY 12. Adults represent 78% of the

total population in Baltimore City compared to 63% of consumers served in the PMHS, while

FY 10 FY 11 FY 12

Baltimore City $5,736 $5,531 $5,207

State $5,017 $4,798 $4,564

$-

$2,000

$4,000

$6,000

$8,000

Baltimore City and Statewide PMHS Average Cost Per Consumer

Early Child (0-5)

Child (6-12)

Adolescent (13-17)

Transitional (18-21)

Adult (22 to 64)

Elderly (65 and over)

TOTAL

Baltimore City $3,092 $5,573 $6,946 $3,968 $4,949 $9,264 $5,207

State $2,341 $4,278 $5,732 $3,748 $4,581 $9,079 $4,564

$-

$2,000

$4,000

$6,000

$8,000

$10,000

Baltimore City and Statewide PMHS Average Cost Per Consumer by Age Group

99

children/adolescents represent 22% of the total population compared to 37% of consumers

served.



The charts below show that the distribution of expenditures and cost per consumer by service

type in Baltimore City differs in several respects from that of the State. Overall expenditures are

higher in Baltimore City than for the State for four service types: outpatient, inpatient, partial

hospitalization, and Capitation. Overall expenditures are comparatively lower in Baltimore City

for three service types: psychiatric rehabilitation, residential rehabilitation and residential

treatment. Of note, despite being a Baltimore City program, the Capitation Project serves

residents of other jurisdictions, and the payment claims are submitted in the county of residence.

In regard to average cost per consumer, the three service types that are higher for Baltimore City

than the State are partial hospitalization (25%), inpatient (22%), and outpatient (22%). The

service types that have a relatively lower average cost per consumer for Baltimore City are

respite care (-51%), psychiatric rehabilitation (-44%), residential rehabilitation (-42%).

FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

Child and Adolecent 48% 45% 43% 41% 38% 37% 37%

Adult 52% 55% 57% 59% 62% 63% 63%

0%

10%

20%

30%

40%

50%

60%

70%

% o

f C

on

sum

ers

Baltimore City Percent of Adult and Child and Adolescent Consumers

100

Baltimore City and Statewide Expenditures by Service Type FY 12

Other 8%

Inpatient 23%

Mobile Treatment

4%

Outpatient 42%

Psychiatric Rehab 17%

Residential Treatment

6%

Baltimore City

Other 8%

Inpatient 21%

Mobile Treatment

4% Outpatient

37%

Psychiatric Rehab 22%


8%

Statewide

101

Changes in expenditures and the number of consumers served by different program categories

over the past three years are highlighted and discussed in the separate adult and child and

adolescent sections beginning on page 128.

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Case Management

Crisis

Inpatient

Mobile Treatment

Outpatient

Partial Hospitalization




Respite Care

Supported Employment

BMHS Capitation

Emergency Petition

Purchase of Care

PRTF Waiver

Baltimore City and Statewide Percentage of Expenditures, FY 12 State

Baltimore City

102



Although inpatient cost per child and adolescent consumer has continually declined, it remains

significantly higher than adult inpatient cost per adult consumer.

$- $20,000 $40,000 $60,000 $80,000

Case Management

Crisis

Inpatient

Mobile Treatment

Outpatient





Respite Care

Supported Employment

BMHS Capitation

Emergency Petition

Purchase of Care

PRTF Waiver

Baltimore City and Statewide Cost Per Consumer FY 12

State Baltimore City

$24,021

$17,109

$22,387

$18,310 $20,414

$17,868

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

Child and Adolescent Adult

Inpatient Cost per Consumer Children and Adolescents vs. Adults

FY10

FY 11

FY 12

103

INSURANCE COVERAGE

Most (95%) of the individuals being served by the public mental health system were covered by

Medicaid (including Medicaid State-funded), while 6% or 2,538 individuals were uninsured.19

Compared to the State’s 8% uninsured rate, Baltimore City has proportionately fewer individuals

served who were uninsured (6%), and the proportion of total expenditures for uninsured

individuals was slightly lower for the City, 2% versus 3%.




The total number of uninsured consumers served in Baltimore City decreased by 2% in FY 12

and by 19% over the last two years. Although there was a 17% decrease in the number of

uninsured adults served in FY 12, there was an 8% increase in uninsured children and

adolescents served. The increase in uninsured children and adolescents may be due to the

increase in the number of undocumented children deemed ineligible for Medicaid.

Medicaid has the highest cost per consumer of the three coverage types in the PMHS. This is

likely due to previously mentioned restrictions in access to care for uninsured individuals and a

more limited benefits package for the Primary Adult Care (PAC) program20

.

19

Many people use services in more than one category. As a result, the sum of the percentage of people served

across service categories and across insurance statuses will exceed 100%. 20

PAC accounts for a substantial portion of Medicaid State-funded. There are few other services that are State-only funded.

Medicaid 93%

Medicaid State

Funded 14%

Uninsured 8%

Statewide Consumers Served by Coverage Type, FY 12

Medicaid 95%

Medicaid State

Funded 11%

Uninsured 6%

Baltimore City Consumers Served by Coverage Type, FY 12

104

Baltimore City Cost Per Consumer by Coverage Type

Medicaid

Medicaid State-funded

Uninsured

FY 10 $5,627 $3,214 $2,056

FY 11 $5,476 $2,280 $1,754

FY 12 $5,120 $2,316 $1,716

FY 10-FY 12 % Change -9% -28% -17%

Between FY 10 and FY 12, the Medicaid State-funded population increased by 94% as a result

of the expansion of the Primary Adult Care (PAC) program, which began in 2006. The eligibility

criteria for PAC were expanded further at the end of FY 09. Between FY 09 and FY 10,

statewide PAC enrollment increased by 66%,21

and between FY 11 and FY 12, increased by

17%.

Source: Maryland Medicaid Program

Over the last five years, the number of Medicaid consumers receiving services in the PMHS has

increased both in the City and State, 47% and 65% respectively. Perhaps the increase was not as

21

Maryland Medicaid program, Overview of the Maryland Primary Adult Care (PAC) program presentation,

November 17, 2010.

24,093 27,351

29,087

36,020

41,008

17,264 20,243

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

Jul-

06

Oct

-06

Jan

-07

Ap

r-0

7

Jul-

07

Oct

-07

Jan

-08

Ap

r-0

8

Jul-

08

Oct

-08

Jan

-09

Ap

r-0

9

Jul-

09

Oct

-09

Jan

-10

Ap

r-1

0

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

# C

on

sum

ers

Total Statewide PAC Enrollment July 2006- July 2012

105

high in Baltimore City because proportionally more Baltimore City residents had already been

accessing PMHS services compared to other jurisdictions.

Source: DHMH Membership Data

The City’s Medicaid penetration rate, or the percentage of Medicaid enrollees accessing the

PMHS, increased by 13%. Since 2007, the City’s Medicaid penetration rate increased by 46% to

20.3%, which is the highest rate among the State’s four largest jurisdictions.

28,320 32,381 36,317 39,295

41,600

81,182

97,828

121,723 130,879

134,133

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012

Baltimore City and Statewide Medicaid Consumers Receiving PMHS Services, 2008 - 2012

Baltimore City

Statewide

106

Source: DHMH Membership Data

13.9% 13.5%

16.0%

18.1% 18.0%

20.3%

11.7% 10.9%

13.6%

15.0% 14.3%

16.5%

6.8% 6.2%

7.8% 8.8% 8.4%

9.8%

5.8% 5.1%

6.8% 7.4% 7.2%

8.5%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

Medicaid Penetration Rate, 2007 - 2012

Baltimore City Baltimore County Montgomery County Prince George's County

107

SERVICE UTILIZATION BY ADULTS

This section presents PMHS utilization data and trends specific to individuals 18 years and older.

Populations Served

In FY 12, 27,601 adults were served by the PMHS, an increase of 5% from FY 11. In contrast,

expenditures decreased by 3% for a total of $135,797,434 for all adult consumers, representing

60% of all City expenditures. In addition, there was a 6% decrease in the overall cost per

consumer. The decrease in expenditures and cost per consumer may be attributed to the

significant reduction in the number of adults utilizing inpatient services (16%) and partial

hospitalization services (30%).




In FY 12, there was a 3% decrease in the number of uninsured adult consumers utilizing the

PMHS. This corresponds with a 4% decrease in the overall number of uninsured adults in

Baltimore City22

and is likely attributable to the migration of uninsured individuals to PAC.

Conversely, there has been a 3% increase in the number of adults in the PMHS with Medicaid

State-funded coverage, which is also likely to be a reflection of the expansion of PAC.

There was a 1% decrease in uninsured expenditures between FY 11 and FY 12. This decrease is

due to the lower number of uninsured individuals served as well as a reduction in the benefits

package for uninsured individuals. Additionally, in FY 11, a change in the way the Emergency

22

US Census Bureau American Fact Finder (2008 & 2009). Health Insurance Coverage Status Retrieved November

16, 2010 from http://www.factfinder.census.gov.

FY 08 FY 09 FY 10 FY 11 FY 12

Cost Per Consumer $5,749 $5,963 $5,639 $5,247 $4,920

$-

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

Cost Per Consumer, Adults (18-65+)

108

Medical Treatment and Active Labor Act (EMTALA) is being implemented in Maryland has

made inpatient hospital admissions much more likely for uninsured clients. This contributed to

the decreased expenses for uninsured clients, because acute care hospitals are not paid by the

public mental health system for these consumers. Instead, hospitals receive a rate adjustment that

factors in uncompensated care for uninsured patients.



The proportion of adult consumers served by the PMHS with a diagnosis of a serious mental

illness (SMI) has remained relatively steady since FY 07 at about two out of three consumers

served.23

23

An individual qualifies as having a serious mental illness in the PMHS if he/she is 18 or older and is diagnosed

with one of the following: Schizophrenia, Schizoaffective disorder, Bipolar disorder, Major Depressive disorder,

other psychotic disorders, Schizotypal Personality disorder, or Borderline Personality disorder.

4,001

4,551

3,015 3,158 3,272

2,727

2,124 2,103

1,145 915

1,525 1,618 1,784

2,779

3,498 3,619

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

# C

on

sum

ers

Baltimore City Uninsured and Medicaid State-Funded Adult Consumers

Uninsured

Medicaid State-Funded

109



Most adults with SMI receive care in service types that provide community-based supports, such

as Capitation, mobile treatment, PRP, SEP and RRP.



The number of individuals with serious mental illness and co-occurring substance abuse has

remained relatively steady since FY 07, based on the most recent available data from FY 12. It

63.1%

66.0% 66.3%

67.1%

67.7%

66.4% 67.4%

68.1%

67.2%

60.0%

61.0%

62.0%

63.0%

64.0%

65.0%

66.0%

67.0%

68.0%

69.0%

FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

Percent of Adults with Serious Mental Illness (SMI) Served in the PMHS

96% 96% 95% 92% 86% 85% 83% 83% 77% 75% 73%

64%

38%

0%

20%

40%

60%

80%

100%

120%

Percent of Adults with SMI Served in the PMHS by Service Type, FY 12

110

should be noted that co-occurring substance abuse is most likely under-reported due to

inconsistencies in reporting this information in claims data.

In FY 12, a disproportionate number of individuals with co-occurring disorders continued to

utilize high-cost services. These individuals represented 52% of all adults served and 49% of the

total expenditures for adult services.



3,304

4,330 4,771

5,343 5,564 5,488 5,737 5,397 5,291

0

1000

2000

3000

4000

5000

6000

7000

FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY12

# o

f C

on

sum

ers

Fiscal Year

Number of Adult Consumers with Serious Mental Illness and Co-Occurring Substance Abuse Disorders

111

The majority (89%) of the adult population served by the PMHS is between the ages of 22 and

64. Transitional age youth (TAY) are between the ages of 18 and 21 and represent 10% of adults

served. Elderly consumers 65 and over represent only 1% of adults served. As displayed in the

charts below, the elderly population is underrepresented in the PMHS as compared to the total

Baltimore City adult population. This is most likely due to Medicare covering a significant

portion of the elderly population’s health care costs.



Although the percentage of TAY served in the PMHS remained steady at 6%, the number of

TAY served in the PMHS decreased by 2% in FY 12.

Transitional (18-21) Adult (22 to 64) Elderly (65 and over)

Baltimore City PMHS 6% 56% 1%

Baltimore City Population 7% 60% 12%

0%

10%

20%

30%

40%

50%

60%

70%

Baltimore City Population and Baltimore City PMHS Age Distribution

112




The only growth in service types utilized by TAY consumers in FY 12 were Residential

Rehabilitation and Crisis. The overall cost per TAY consumer decreased by 7% from FY 11 to

FY 12 ($4,286 in FY 11 to $3,968 in FY 12).

3.7% 3.1% 3.4%

4.2%

6.0% 6.4%

6.0%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

% o

f To

tal P

op

ula

tio

n

Fiscal Year

Percentage of Transitional Age Youth Who Utilize the PMHS, FY 06 - FY 12

113



As previously mentioned, it is difficult to assess trends in the utilization of the fee-for-service

PMHS by elderly consumers because these data do not include Medicare-funded mental health

services, which is the primary payer for inpatient and outpatient mental health treatment services

for individuals 65 and over. The data in this report only describe utilization by elderly consumers

who utilize those service types not funded by Medicare or those services in which the fee-for-

service PMHS is the secondary payer.

Between FY 11 and FY 12, there was a 13% increase in the number of elderly consumers

receiving services. Adults 65 and over represent only 1% of the adult population served by the

PMHS, yet they represent 15% of the total Baltimore City population. Services for the elderly

continue to be disproportionately expensive. There was an overall 14% increase in expenditures

for the elderly and a 1% increase in the cost per elderly consumer. This contributed to elderly

consumers continuing as the age group with the highest average cost per consumer, $9,264

versus $5,169 for adults younger than 65 in Baltimore City. This is to be expected because

Medicare is covering lower-cost services such as outpatient treatment, for which it is the primary

payer. This is supported by the fact that only 58% of elderly consumers in the PMHS utilize

outpatient services, compared to 95% of PMHS consumers overall.


Crisis Mobile

Treatment Supported

Employment Inpatient PRP

Case Management

Partial Hospitalizatio

n

Service 13% 2% -8% -13% -14% -17% -33% -50%

-60%

-50%

-40%

-30%

-20%

-10%

0%

10%

20%

% C

han

ge in

Co

nsu

me

rs

Service Type

TAY Consumer Percent Change in Service Utilization, FY 12

114




Utilization by Service Type

The following data describe trends in utilization of specific types of services.

Psychiatric inpatient care is of great interest because it is the most intensive and expensive

service type. It is also of interest because of an expanded effort to minimize preventable

hospitalizations in FY 12 by focusing on community-based care. Use of inpatient services

decreased by 5% in FY 11 and 16% in FY 12, after a 17% increase in FY 10 and a 9% increase

in FY 09.

$7,533 $7,637

$9,576 $8,806

$10,201

$8,631 $9,154 $9,264

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000


Co

st P

er

Co

nsu

me

r

Fiscal Year

Average Cost per Consumer Age 65+ FY 05 - FY 12

115



Over the past ten years, the percentage of Baltimore City adults in the PMHS receiving inpatient

services has steadily decreased from 15% in FY 03 to 6% in FY 12.




In addition, the percentage of Baltimore City adults diagnosed with SMI accessing inpatient

services has decreased from 19% in FY 05 to 9% in FY 12.

2,179 2,022 2,012 2,057 2,027 1,978 2,156

2,515 2,395 2,018

0

500

1000

1500

2000

2500

3000

FY 03 FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

# o

f C

on

sum

ers

Fiscal Year

Number of Adult Consumers in Baltimore City Utilizing Inpatient Mental Health Services, FY 05-FY 12

15% 13% 13% 13% 12% 11% 11% 8% 7% 6%

0%

5%

10%

15%

20%


% o

f C

on

sum

ers

Fiscal Year

Percentage of All Adult Consumers in Baltimore City PMHS Utilizing Inpatient Mental Health Services

FY 03-FY 12

116



Between FY 11 and FY 12, the cost per adult consumer utilizing inpatient services decreased by

4% from $19,374 to $18,628. Additionally, there was a 2% decrease in the number of adults with

SMI utilizing inpatient services between FY 11 and FY 12. The decrease since FY 05 indicates

that as more individuals with SMI are being treated successfully in the community, those who

need hospitalization and high levels of care often have longer lengths of stay.




Since FY 08, there has been a significant decline in the number of individuals utilizing partial

hospitalization services. In FY 10, partial hospitalization services were eliminated from the

19% 18% 16% 16% 16%

14% 14% 13% 11%

9%

0%

5%

10%

15%

20%


% o

f C

on

sum

ers

Fiscal Year

Percentage of Adults with SMI Served in Baltimore City PMHS Utilizing Inpatient Mental Health Services

FY 03-FY 12

$10,228 $10,846 $12,642 $13,491

$15,786 $18,784 $19,374 $18,628

$0

$5,000

$10,000

$15,000

$20,000

$25,000


Co

st p

er

Co

nsu

me

rs

Fiscal Year

Inpatient Mental Health Services Cost Per Consumer FY 05-FY 12

117

benefits package for uninsured individuals, resulting in a 70% decrease in the number of adults

receiving this service from FY 10 to FY 12.



Outpatient mental health services continue to be the most widely accessed type of service,

utilized by 93% of adult PMHS consumers. There has been a steady increase in the number of

adults receiving outpatient mental health care, with a 6% increase between FY 11 and FY 12.

1,854 1,856

1,585 1,701

1,345

1,002

422 303

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000


# o

f C

on

sum

ers

Fiscal Year

Number of Adult Consumers in Baltimore City Utilizing Partial Hospitalization Services

FY 05-FY 12

13,179 13,670 14,235 15,688

18,448 21,925

24,188 25,548

0

5,000

10,000

15,000

20,000

25,000

30,000


# o

f C

on

sum

ers

Fiscal Year

Number of Adult Consumers in Baltimore City Utilizing Outpatient Mental Health Services, FY 05-FY 12

118




The percentage of adults in the PMHS accessing outpatient services increased slightly in FY

12, continuing the steady increase observed since FY 08. The percentage of adults with SMI

utilizing outpatient services remained steady in FY 12, which indicates that most PMHS

consumers utilize outpatient services.





85% 86% 86% 87%

90% 91%

92% 93%

80%

85%

90%

95%


% o

f C

on

sum

ers

Fiscal Year

Percentage of Adult Consumers in Baltimore City PMHS Utilizing Outpatient Mental Health Services

FY 05-FY 12

78% 78% 79%

81%

85% 87%

89% 89%

70%

75%

80%

85%

90%


% o

f C

on

sum

ers

Fiscal Year

Percentage of Adults with SMI in Baltimore City PMHS Utilizing Outpatient Mental Health Services

FY 05-FY 12

119

While the number of consumers utilizing outpatient services has increased by 14% since FY

10, the cost per consumer has remained relatively steady during that time frame.



Inpatient care is such a high-cost service that it continues to account for a disproportionate share

of total public mental health expenditures, relative to the number of consumers served. In FY 12,

inpatient care for 7% of adult PMHS consumers accounted for 27% of total PMHS expenditures.

The 93% of adult PMHS consumers who utilized outpatient services accounted for 34% of total

PMHS expenditures, increasing from 33% of total expenditures in FY 11.

$1,624 $1,831

$2,102 $2,116 $2,059

$2,335 $2,302 $2,309

$0

$500

$1,000

$1,500

$2,000

$2,500


Co

st p

er

Co

nsu

me

r

Fiscal Year

Outpatient Mental Health Services Cost Per Consumer FY 05-FY 12

Inpatient Treatment Outpatient treatment

Expenditures 27% 34%

Person Served 7% 93%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

% C

on

sum

ers

Inpatient vs. Outpatient Treatment Spending for Adults, FY12

120




In FY 12, there were decreases in the utilization of several services, most notably residential

crisis and RRP. The number of adult consumers who received crisis services decreased by 4%,

most likely due to the increased access to inpatient care as a result of changes in the

implementation of the Emergency Medical Treatment and Active Labor Act (EMTALA) in

Maryland, which has increased access to inpatient hospital care for uninsured individuals.

In FY 12, BCRI, the only provider of residential crisis services in the City, received 44% of their

referrals from emergency rooms, compared to 49% in FY 11. In addition, in FY 12, BCRI saw a

7% increase in the number of crisis bed days used and a 1% increase in the length of stay,

resulting in an increase in the overall occupancy rate. This most likely contributed to the 19%

increase in cost per consumer for residential crisis services.




The percentage of adult consumers in the PMHS using residential crisis services has declined

from 4% to 2% since FY 05.

604

559 550 565

598

659

581 559

450

500

550

600

650

700


# o

f C

on

sum

ers

Fiscal Year

Number of Adult Consumers in Baltimore City Utilizing Residential Crisis Services, FY 05-FY 12

121



There was a 2% increase in the number of consumers utilizing RRP services from FY 11 to FY

12. The number of RRP beds remained steady until an increase in capacity at the end of FY 12

from 357 to 361. Because of this, the increase in the number served most likely represents an

increase in turnover of beds. This is a reversal of the trend from FY 10 to FY 11 in which the

number of individuals using RRP services decreased 12%, likely due to less turnover in beds.



4.0%

3.0% 3.0% 3.0% 3.0% 2.7%

2.2% 2.0%

0%

1%

2%

3%

4%

5%


% o

f C

on

sum

ers

Fiscal Year

Percentage of Adult Consumers in Baltimore City Utilizing Residential Crisis Services, FY 05-FY 12

991

949 946 952

1,016

1,076

944 966

850

900

950

1,000

1,050

1,100


# o

f C

on

sum

ers

Fiscal Year

Number of Adult Consumers in Baltimore City Utilizing Residential Rehabilitation Programs

FY 05-12

122

The percentage of individuals in the PMHS using residential rehabilitation services remains low

and has decreased by 33% since FY 05. This is because the number of individuals served by the

PMHS has continued to grow, while the number of available beds has increased slightly.




Psychiatric rehabilitation program (PRP) services continue as one of the faster growing service

lines in the PMHS. In FY 12 there was an increase of 10% in the utilization of PRP services.

There has been an 88% increase in the number of individuals utilizing PRP services since FY 05.

6.0% 6.0% 6.0%

5.0% 5.0%

4.5%

3.7% 3.5%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%


% o

f C

on

sum

ers

Fiscal Year

Percent of Adult Consumers in Baltimore City Utilizing RRP Services, FY 05-FY 12

123



Although the number of individuals utilizing PRP has increased significantly since FY 05, the

percentage of individuals in the PMHS using this service has remained relatively steady, at about

15%.

2,170 2,298 2,601

2,880 3,244

3,637 3,709 4,083

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500


# o

f C

on

sum

ers

Fiscal Year

Number of Adult Consumers in Baltimore City Utilizing PRP Services, FY 05-FY 12

14% 14% 16% 16% 16% 15% 14% 15%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%


# o

f C

on

sum

ers

Fiscal Year

Percentage of Adult Consumers in Baltimore City Utilizing PRP Services, FY 05-FY 12

124




In FY 10, case management services moved from being grant-funded to fee-for-service. Since

then, there has been a 20% increase in the number of adults utilizing this service.



BMHS has been particularly focused on adult consumers who utilize a disproportionate number

of high-end mental health services (e.g., inpatient treatment, partial hospitalization) and generate

disproportionately high expenditures, often without experiencing positive service outcomes. The

Capitation Project, in its 19th year, provides a community-based alternative to consumers with

histories of long and/or recurring inpatient admissions. Fifty percent (50%) of the admissions are

from State psychiatric hospitals. The Capitation Project has 354 slots, and the average cost per

year per consumer is $25,973. By comparison, the average cost per year in FY 10 for Baltimore

City residents treated at Spring Grove Hospital was $100,504.24

FY 12 data on the City’s 50 “high-cost” consumers, those whose public mental health service

costs were highest among all consumers served in Baltimore City, indicate they accounted for

4% of total adult expenditures. The costs for these individuals include inpatient treatment and

other service types within the PMHS.

24

Mental Hygiene Administration, November 9, 2011.

790

937 1,006

0

200

400

600

800

1,000

1,200

FY 10 FY 11 FY 12

# o

f C

on

sum

ers

Number of Adult Consumers in Baltimore City Utilizing Case Management Services, FY 10 - FY 12

125




High-cost consumers incur a disproportionate amount of the expenses for inpatient care. In FY

12, high-cost consumers (0.18% of all adult consumers) accounted for 14% of total inpatient

expenditures.

Utilization of Evidence-Based Practices

The implementation of the Substance Abuse and Mental Health Services Administration’s

(SAMHSA’s) evidence-based practices (EBPs) is a priority for Maryland’s PMHS. BMHS has

been actively promoting two EBP models for adults: Assertive Community Treatment (ACT)

and Supported Employment Programs (SEPs). ACT is an evidence-based model used by six of

the City’s nine mobile treatment teams. Outcomes data collected from mobile treatment and

ACT providers documented that 545 individuals (64%) were served by the nine ACT teams in

FY 12.

There has been a steady increase in the number of individuals served in mobile treatment/ACT

since FY 05. The 8% growth from FY 11 to FY 12 is most likely attributed to changes begun in

FY 11 and further implemented throughout FY 12. In FY 11 one ACT provider expanded

services to address the specific needs of homeless individuals, and an additional ACT team

actively worked to increase their census. The census of both teams continued to grow in FY 12.

$5,020

$141,503

$0

$50,000

$100,000

$150,000

All Adult Consumers (n=27,601)

High Cost Consumers (n=50)

Average Cost per Consumer for High-Cost Consumers Compared to All Adult

Consumers, FY 12

$17,868

$100,134

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

All Adult Consumers (n=2,018)

High Cost Consumers (n=50)

Average Inpatient Cost per Consumer for High-Cost Consumers Compared to all

Adult Consumers, FY 12

126




There has been a 40% increase in the number of consumers receiving supported employment

services through both EBP-certified and non-certified programs since FY 05. This increase may

be due to the State’s promotion of EBPs as well as promotion of the federal government’s

Employment for Individuals with a Disability (EID) Program, which provides a financial

incentive for Supplemental Security Income (SSI) recipients to work. While 441 individuals

were served according to the claims paid data, providers also report service data directly to

BMHS. According to these data, the number of individuals served actually totaled 559.25

SEP is

one of the least expensive service types, with a cost per consumer of $1,705, which is a 13%

decrease from FY 11. The percentage of individuals in the PMHS that utilized SEP services has

slightly increased in the last fiscal year by 1%.

25

There is often a discrepancy between the outcomes data that mobile treatment (including ACT) and supported

employment providers submit to BMHS and the claims data provided by ValueOptions. This could be due to the lag

time between service provision and claims payment, City-based mobile treatment teams providing services to

individuals who reside outside of Baltimore City and/or some claims being denied.

541 590

626 685 683 707

792 856

0

100

200

300

400

500

600

700

800

900


Number of Adult Consumers Utilizing Mobile Treatment Services

127



Two out of 13 supported employment programs were certified as evidence-based practice

programs in FY 12. Five additional providers are pursuing certification and have received

technical assistance from BMHS. According to outcomes data submitted to BMHS by SEP

providers, 45 individuals (9%) participating in SEP programs were served by evidence-based

SEP providers.

314 288 300

378 367 387

438 441

0

50

100

150

200

250

300

350

400

450

500


Number of Adult Consumers Utilizing Mental Health Supported Employment Services

128

SERVICE UTILIZATION BY CHILDREN AND ADOLESCENTS

This section presents PMHS utilization data and trends specific to children and adolescents, from

birth to 17 years of age.

Population Served

In FY 12, 16,220 children and adolescents were served by the PMHS, an increase of 5% from

FY 11. Expenditures increased by 3% for a total of $92,387,454 for all child and adolescent

consumers, representing 40% of all PMHS expenditures in Baltimore City. In addition, there was

a 2% decrease in the overall cost per consumer.




Due in part to the State receiving a Psychiatric Residential Treatment Facility (PRTF) 1915c

Medicaid waiver,26

which added additional services to the PMHS in FY 10, there was an increase

in the number of youth receiving public mental health services over the last two years. The

waiver added respite services (both in-home and out-of-home placements), crisis stabilization,

family-to-family and peer-to-peer support, expressive therapies and family training. Youth

enrolled in the PRTF waiver much faster than expected, which led to a waiting list once the 210

slots (statewide) were filled. The delay in additional youth being able to access home- and

community-based PRTF waiver services resulted in an increased number of Baltimore City

youth being placed in traditional residential treatment centers (RTCs) in FY 12 since more

people were aware of and, therefore, making referrals to these new services.

26

The PRTF 1915c Medicaid waiver is a Medicaid Psychiatric Residential Treatment Facility demonstration waiver

that provides families with the option of receiving comprehensive community-based services through a wraparound

process that provides a variety of services for youth with serious mental health needs.

15,085 14,576

13,600 13,643 13,925

14,740

15,453

16,220

12,000

13,000

14,000

15,000

16,000

17,000


Number of Baltimore City Children and Adolescents (0-17 years) Served in the PMHS, FY 05-12

129

While the cost per child and adolescent served steadily increased between FY 05 and FY 10, it

decreased slightly over the last two years. In FY 12, the number of children and adolescents

served increased by 5%. The decreased cost per child can be attributed in part to a decrease in

purchase of care (-70%), partial hospitalization (-29%), and case management (-20%).




The percentage of children and adolescents served by the PMHS who are diagnosed with a

severe emotional disturbance (SED) or as emotionally impaired27

(EI) gradually increased from

FY 05 to FY 10. In the last few years, however, the percentage has leveled off and slightly

decreased. Between FY 11 and FY 12, 723 additional youth were served, which is a 10%

increase. Full implementation of the Care Management Entity (CME) and PRTF waiver in FY 10

is a major contributing factor to the 10% increase of children and adolescents with SEDs who

were served by the PMHS from FY 10 to FY 12.

27

Emotionally impaired is the preferred terminology in Maryland, but severe emotional disturbance is more

commonly used nationwide.

$4,270

$4,836 $5,122 $5,311 $5,669 $5,861 $5,812

$5,696

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000


Child and Adolescent Cost per Consumer FY05-FY12

130





While the number of uninsured children and adolescents has increased, the percentage of

uninsured children and adolescents among those served by the PMHS has remained very small.

72% 72%

73%

74%

76% 76%

78% 78%

77%

68%

70%

72%

74%

76%

78%

80%

FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 FY 11 FY 12

% o

f C

on

sum

ers

Fiscal Year

Percent of Child and Adolescents with SED Served in the PMHS

268 280

348 329

359

419 454

435

0

50

100

150

200

250

300

350

400

450

500


# o

f C

on

sum

ers

Fiscal Year

Baltimore City Uninsured Child and Adolescent Consumers

131




There was a 6% increase in service utilization among the early childhood population (ages 0-5)

in Baltimore City, from 2,169 children served in FY 11 to 2,285 in FY 12.



1.8% 1.9%

2.6% 2.4%

2.6% 2.8% 2.9%

2.7%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%


# o

f C

on

sum

ers

Fiscal Year

Baltimore City Percentage of Uninsured Child and Adolescent Consumers

1,827 1,868 2,013

2,169 2,285

0

500

1,000

1,500

2,000

2,500

FY 08 FY 09 FY 10 FY 11 FY 12

# o

f C

on

sum

ers

Fiscal Year

Numbers of Young Children (Ages 0-5) Utilizing the PMHS

132

The percentage of young children in Baltimore City utilizing public mental health services has

remained relatively steady.



Utilization by Service Type

The chart below delineates the number of children and adolescents who received psychiatric

rehabilitation (PRP) services, partial hospitalization, inpatient hospitalization, and residential

treatment center (RTC) services. The most notable changes were the significant increases in the

utilization of PRP services (14%) and RTC services (20%).

Between FY 05 and FY 10, there was an overall declining trend in youth being placed in RTCs.

In FY 11 and FY 12, however, there was a 20% increase in youth served by RTCs. As stated

previously, the increased use of RTCs was correlated with the delay in youth receiving home-

and community-based PRTF waiver services. Because the number of youth eligible to receive

community-based services had exceeded the openings available to serve them, children and

youth were placed in traditional RTCs instead. In addition, youth placed on a waiting list waited

an average of four months to gain access to the PRTF waiver services during FY 12.

Consequently, those children and youth who otherwise would have received home- and

community-based services were served in residential treatment centers.

The number of youth who utilized inpatient treatment increased by 2%, while outpatient

utilization increased by 5%, which is equal to the overall increase in youths served. Psychiatric

rehabilitation increased at a significantly faster rate at 14% and residential treatment increased

15%.

5.5%

5.4%

5.2% 5.2% 5.2%

5.0%

5.1%

5.2%

5.3%

5.4%

5.5%

5.6%

FY 08 FY 09 FY 10 FY 11 FY 12

Percentage of Young Children (Ages 0-5) Utilizing the PMHS

133

Child and Adolescent Consumers Served by

PRP Partial Hospitalization Inpatient RTC

FY 05 1,420 455 806 201

FY 06 2,287 455 788 204

FY 07 2,434 403 730 155

FY 08 2,177 406 695 163

FY 09 2,247 446 756 138

FY 10 2,733 436 804 125

FY 11 3,124 427 846 150

FY 12 3,558 435 859 180



-300

200

700

1,200

1,700

2,200

2,700

3,200

3,700


Child and Adolescent Consumers Served by Select Service Types

PRP


Inpatient

RTC

134




Services provided through the PRTF waiver cost significantly less per consumer than traditional

residential treatment: $1,555 compared to $67,747, respectively.

9%

16%

18%

16% 16%

19%

20%

22%

3% 3% 3% 3% 3% 3% 3% 3%

5% 5% 5% 5% 5% 5% 5% 5%

1% 1% 1% 1% 1% 1% 1% 1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%


Percentage of Child and Adolescent PMHS Consumers Served by Select Service Types

PRP Partial Hospitalization Inpatient RTC

135

As with the adult population, inpatient care accounts for a disproportionate share of total public

mental health expenditures relative to the number of consumers served. Inpatient services

accounted for 19% of total child and adolescent expenditures and were utilized by 5% of the

corresponding PMHS consumer population. Outpatient services accounted for 53% of total child

and adolescent expenditures and were utilized by 98% of the corresponding consumer

population. The inpatient cost per consumer in FY 12 decreased by 9% compared to FY 11. This

may be a result of shorter lengths of stay and an expansion of home and community-based

service options.



$1,555

$67,747

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

Residential Treatment Waiver (n= 41) Traditional Residential Treatment (n= 193)

Residential Treatment Waiver vs. Residential Treatment Cost per Consumer, FY 12

Inpatient Outpatient

Expenditures 19% 53%

Persons Served 5% 98%

0%

20%

40%

60%

80%

100%

120%

Inpatient vs. Outpatient Spending for Child and Adolescents FY 12

136

The number of children and adolescents receiving respite services has steadily increased from

FY 05 to FY 12, with a slight decrease (3%) (from 77 in FY 10 to 75 in FY11) in FY 11. While

expenditures for respite services have fluctuated over this period, there was a significant decrease

of 23% in FY 11 and a significant increase of 31% in FY 12. This is most likely a result of the

efforts of the CME to provide wraparound services, with the aim of reducing residential

treatment utilization.

Based on the most recent data from FY 12, high-cost users were identified as consumers whose

PMHS costs were highest among all children and adolescents served in Baltimore City. A

comparison of FY 09 and FY 12 expenditures for child and adolescent high-cost users28

shows a

decrease of 80%. More specifically, the data show:

A 96% ($2,165,343) decrease in expenditures for RTC services, largely resulting from the

development of the CME, which provides community-based comprehensive mental health

treatment as an alternative to RTC services.

A 7% decrease in inpatient hospital expenditures, also largely resulting from the

development of the CME, which provides community-based comprehensive mental health

treatment. The CME was utilized as a step-down from inpatient hospitalization, resulting in

decreased length of hospital stays, which in turn lowered the total expenditures for high-cost

users.

28

High-cost users refer to consumers whose public mental health service costs were highest among all child and

adolescent consumers. Because data was not available for FY 10 and FY11 data, due to the transition to the new

ASO, ValueOptions, only the 22 individuals who were also high-cost users in FY 09 are included in this

comparison.

137


Run Date: December 11, 2012

$490,193

$2,165,343

$2,706,453

$122,792 $95,583 $228,395

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

Inpatient RTC Total

C&A High-Cost Users Expenditures FY 09 and FY 12 (n= 22 individuals)

FY 09 FY 12

138

Outcome Measurement System*^ Child and Adolescent Adults

STATE COUNTY STATE COUNTY

Aggregate Score

Aggregate Score

Aggregate Score

Aggregate Score

Adult BASIS 24® Subscales

Depression Initial

2.07 2.08

Depression Most Recent

1.73 1.76

Depression Change

-0.34 -0.32

Self Harm Initial

0.49 0.54

Self Harm Most Recent

0.33 0.37

Self Harm Change

-0.16 -0.17

CHILD KIDNET EMOTIONAL SUBSCALE

Emotional Initial 0.92 0.83 Emotional Most Recent 0.68 0.62 Emotional Change -0.24 -0.21

Outcome Measurement System*^ Child and Adolescent Adults


Percent Percent Percent Percent

POINT IN TIME DATA

Employed now or last 6 months

28.8% 20.6%

Actively looking for a job

30.0% 24.3%

Smoking cigarettes** 11.1% 7.4% 51.1% 53.5%

CHANGE OVER TIME DATA

Employed now or last 6 months

Gained Employment

9.7% 8.0%

Employed both interviews

15.5% 9.4%

Unemployed both interviews

63.5% 73.5%

Lost employment

11.3% 9.2%

Smoking cigarettes**

Stopped smoking 2.8% 1.8% 8.2% 8.4%

Not smoking either interview 88.7% 93.5% 43.3% 39.8%

Smoking both interviews 3.5% 1.8% 41.4% 44.7%

Started smoking 5.0% 2.8% 7.0% 7.1%

139

Outcome Measurement System*

Child and Adolescent Adults


Per Cent Per Cent Per Cent Per Cent

POINT IN TIME DATA

Homelessness in past six months 2.4% 2.3% 15.0% 19.9%

In jail or prison in the past six months

7.1% 7.3%

Have you been arrested in past six months 3.8% 3.8% 7.7% 7.9%

CHANGE OVER TIME DATA

Arrested in past six months

Decreased 2.3% 1.8% 6.7% 6.8%

Not arrested either interview 95.3% 95.9% 89.1% 88.8%

Arrested both interviews 0.5% 0.7% 1.3% 1.2%

Increased 1.9% 1.6% 2.9% 3.3%

Been to jail or prison in past six months

Decreased

5.5% 5.7%

No jail/prison either interview

91.3% 90.8%

Jail/prison both interviews

1.0% 1.0%

Increased

2.2% 2.6%

* Shaded boxes denote that data is “n/a”

** Most recent observation for each consumer in FY 12; provision data which may change slightly as Datamart refinement continues

^ Indicators MHA requires each CSA to report on

Data Source: http://maryland.valueoptions.com/services/OMS_Welcome.html

Most Recent Interview Only, FY 2012

140

OVERVIEW OF SERVICE OUTCOMES:

This section discusses the Outcome Measurement System (OMS) data. The data were collected

via survey from 25,636 Baltimore City residents and 81,185 individuals statewide, ages 6-64,

who received outpatient mental health treatment (hereinafter referred to as “respondents”).

Baltimore City respondents represent 32% of all respondents, the same proportion as the

numbers served in the PMHS. As previously stated, because Baltimore City data represent such a

large proportion of the State data, many of the outcomes do not differ significantly, as actual

differences between the City and the rest of Maryland are under-stated.

Wherever possible, the data collected through OMS have been compared to data describing the

general population. These comparisons, however, are only being used to make general

statements about differences in the populations. Limitations in comparisons are noted below.

For example, there are OMS data for both the adult and child populations; however, some of the

comparison data on the general population refer to all ages.

Employment

The data suggest that respondents both in Baltimore City and statewide continue to have

significantly lower rates of employment than the general population. At the time of interview,

21% of adults respondents in Baltimore City were employed, compared to 90% of all adults in

Baltimore City. The statewide comparisons were 29% versus 93%, respectively.29

Of further

concern for Baltimore City, the unemployment rate reported by respondents increased

significantly by 8% compared to FY 11 (13%), whereas the unemployment rate for the

respondents statewide only increased by 1% (FY 11 29%).

Smoking

Participating in outpatient mental health treatment is a stronger predictor of smoking than is

residence. Respondents report a significantly higher rate of smoking than the general population:

54% versus 27% for Baltimore City, and 51% versus 17% statewide,30

whereas adult

respondents had comparable rates of smoking in Baltimore City and statewide, 54% and 51%

respectively. This is consistent with FY 11 data, although there was a 3% decrease in the

smoking rate for respondents in both Baltimore City and statewide.

Child and adolescent respondents in Baltimore City had somewhat lower rates of smoking than

their counterparts statewide, 7% versus 11%. Comparison data for children and adolescents in

the general population could not be found.

29

Department of Labor, Licensing and Regulation, Division of Workforce Development and Adult Learning, 2012.

141

Homelessness

Compared to FY 11, the data continues to suggest a significantly higher rate of homelessness in

the last six months among adult respondents than the general population. While this is true for

both the State and Baltimore City within the OMS population, Baltimore City’s percentage rate

is higher, with 20% of adults homeless in the last six months (FY 11 20%) versus 15% for the

State (FY 11 16%). Children and adolescents reported very low rates of homelessness: 2% for

both Baltimore City and statewide.

Incarceration and Arrest

The data suggest a significantly higher rate of incarceration in the last six months among adult

respondents than the general population. Adults in the OMS population reported a 9%

incarceration rate during the past six months, whereas both the City and State have a general

population incarceration rate of 1%.31

32

Interestingly, adult respondents in Baltimore City

reported a lower rate of arrest than the general Baltimore City population, 9% compared to 12%.

Adult respondents statewide, however, had a higher rate of arrest than the general population,

8% compared to 4%. It is possible that Baltimore City has a lower arrest rate compared to the

general population due in part to multiple Baltimore City PMHS initiatives. Behavioral

Emergency Services Team (BEST) trains every new Baltimore City police officer in crisis

intervention to de-escalate mental health crises, minimize arrests, and decrease officer injury.

Forensic Alternative Service Team (FAST) provides jail diversion activities and participates in

Mental Health Court. Lastly, the Circuit Court Case Management Project provides behavioral

health assessments and linkage to behavioral health services to a small number of eligible

defendants, with the aim of reducing recidivism.

The child and adolescent respondents in both Baltimore City and statewide reported 4% arrest

rates in the past six months, which is the same rate as FY 11. No comparison data could be found

for this population.

Adult BASIS 24® Subscales

The BASIS 24 is a 24-item patient self-reporting questionnaire designed to assess treatment

outcomes by measuring symptoms and functional difficulties experienced by consumers seeking

mental health services. Questions are answered on a five-point scale. Scores range from 0 to 4,

with lower scores indicating lower levels of symptomatology; a score of 0 indicates no

31

Justice Policy Institute, Baltimore Behind Bars, June 2010. 32

Department of Public Safety and Correctional Services Fiscal 2012 Budget Overview, Department of Legislative

Services, January 2011.

142

symptoms and a score of 4 indicates maximum symptoms. This is the first year that this national

test is included in the OMS data.

The data show that adult respondents had a similar aggregate score for depression during the

initial survey, 2.07 statewide and 2.08 for Baltimore City. Over time, this data point reflects

incremental positive change: the difference between the initial and most recent surveys was -0.32

for Baltimore City and -0.34 statewide.

As with depression, the aggregate, initial self harm score was similar for Baltimore City (0.54)

and the State (0.49), and the difference between the initial and most recent surveys reflects

incremental positive change (-0.17 for Baltimore City and -0.16 for the State).

Child KIDNET Emotional Subscale

The KIDNET emotional subscale is similar to BASIS-24 in that questions are answered on a

five-point scale. Scores range from 0 to 4, with lower scores indicating lower levels of

symptomatology; a score of 0 indicates no symptoms and a score of 4 indicates maximum

symptoms. This is also the first year that this subscale is included in the OMS data.

The data show that child and adolescent respondents in Baltimore City and the State had similar

aggregate scores for feeling emotional during the initial survey, 0.79 for Baltimore City and 0.92

statewide. The change in aggregate score between the initial and most recent surveys was also

similar, -0.19 Baltimore City and -0.24 statewide.

143

State Priority Areas

FY 12 is the first year MHA is requiring CSAs to select and report on eight areas that: a)

improve communication; and b) support the implementation of health reform and coordination of

care in the delivery of services to individuals across the lifespan with mental illness and co-

occurring disorders for their respective jurisdictions.

BMHS has selected the below eight areas as priorities for Baltimore City:

1. Recovery Supports

2. Public Awareness and Education

3. Suicide Prevention

4. Efforts to Address Co-occurring Disorders/Promotion of Dual Diagnosis Capability Training

5. Access to Services

6. Evidence Based Practices

7. Diversion Efforts

8. Outcomes/Quality

The following sections will highlight current and future efforts in addressing these areas. Many

of the initiatives listed below are described in detail in the Annual Report section of this

document.

1. Recovery Supports

Supported Employment Programs - These programs provide supportive services for

individuals with serious mental illness who are not employed competitively33

, and for

who employment is a goal. The service includes five components: 1) pre-placement; 2)

placement in a competitive job; 3) intensive job coaching; 4) extended support services;

and 5) psychiatric rehabilitation program services.

Wellness and Recovery Centers - Baltimore’s three Wellness and Recovery Centers

continue to provide consumer-centered peer support services and have been serving a

vital role in promoting the use of Wellness Recovery Action Plan (WRAP) among the

City’s consumers. Two of these Wellness and Recovery Centers are unique in the State:

Helping Other People through Empowerment (HOPE) serves homeless individuals, and

Hearts and Ears serves lesbian, gay, bi-sexual, transgender (LGBT) individuals. On Our

Own, Inc. operated their transitional age youth (TAY) center for its second year, again

serving a population for whom more targeted programs are needed.

Co-occurring Disorder Supportive Housing Project - BMHS, in collaboration with

Mosaic Community Services, Inc., the State Hospital system and community providers,

33

Competitive employment refers to employment that 1) pays at least minimum wage; 2) takes place in an

integrated community setting; 3) is held by the individual worker (not by the program in which he or she

participates); and 4) is available to anyone qualified for the job (i.e. not set aside for people with disabilities).

144

will facilitate the transition of 25 or more consumers who have co-occurring mental

health and substance use disorders and forensic involvement from their current residence

in State Hospitals to community placements in Baltimore City. These consumers will be

provided with housing subsidies, peer support, and person-centered services, including

community-based, dual-diagnosis recovery supports that will meet their mental health,

substance use disorder and other needs.

Second-Chance Grant - Through the Second Chance Grant, People Encouraging People

(PEP) will provide case management and peer support services to 75 men with co-

occurring behavioral health disorders who are transitioning from prison (the Patuxent

Institution) to Baltimore City. PEP will begin engaging individuals several months prior

to their release in order to develop and then implement a comprehensive release plan that

addresses the individuals’ behavioral health and community living needs.

Continuous Quality Improvement with the Capitation Project - BMHS continues to

provide technical assistance to the two Capitation programs to implement a continuous

quality improvement process, the goals of which are to identify and implement change

projects aimed at improving targeted aspects of care. The area of focus for FY 12 was

supported employment. Both providers achieved their FY12 goals of enhancing

supported employment program services. For FY 13, the Capitation Project providers

will focus on improving the volunteer opportunities available to consumers. In addition,

both providers are hiring peer support specialists in FY 13.

2. Public Awareness and Education

BMHS continues to support the Mental Health Association of Maryland (MHAMD),

National Alliance on Mental Illness (NAMI), Black Mental Health Alliance for

Education and Consultation, Maryland Coalition of Families for Children’s Mental

Health; and On Our Own of Maryland.

MHAMD: provides children’s mental health information and campaign materials for

Children’s Mental Health Matters, participates in health fairs, conducts Older Adult

Mental Health issues trainings and advanced directive trainings and collaborates with

BMHS to disseminate Mental Health First Aid throughout the City.

NAMI: provides family support trainings and workshops on mental health topics and

coordinates its annual NAMI Walk, a public education event that promotes awareness

of mental illness.

Black Mental Health Alliance for Education and Consultation: provides culturally

competent trainings on mental health topics, promotes the growth of mental health

programs in schools and provides assistance and referrals to consumers via telephone

and in person.

145

Maryland Coalition of Families for Children’s Mental Health: provides webinars and

family trainings on mental health topics and coordinates the Family Leadership

Institute, which provides education and resources to parents, caregivers and family

members of children with mental health/behavioral challenges.

On Our Own of Maryland: provides presentations on the stigma of mental illness,

partners with local consumer-run organizations in various educational events and

provides assistance and referrals to consumers via telephone and in person.

3. Suicide Prevention

BMHS currently promotes suicide prevention by making crisis services available to at-risk

populations and more generally facilitating access to mental health treatment services for those

in need. By making crisis and urgent care services more readily available, more people could

receive the help they need when they need it, preventing and de-escalating crises that might end

in suicide. To this end, Baltimore Child and Adolescent Response System (BCARS) was

recently expanded. In addition, Baltimore Crisis and Response, Inc. (BCRI), maintains a 24/7

crisis hotline and provides Lifeline services (a national suicide prevention network). The Lifeline

services are funded by SAMHSA and the American Association of Suicidology. Additionally,

Network of Care – a Baltimore City website - and BMHS’ website provide information about

available treatment and crisis services.

4. Efforts to Address Co-occurring Disorders/Promotion of Dual Diagnosis Capability

Training

Integrated Dual Disorders Treatment (IDDT) - BMHS, in collaboration with bSAS,

developed a new IDDT initiative for Baltimore City in FY 12 to serve individuals with

co-occurring disorders who are court-ordered to substance abuse treatment. Enrolled

individuals have access to integrated services in two outpatient clinics and one Assertive

Community Treatment team. BMHS and bSAS meet regularly to develop strategies to

better coordinate services for this target population.

Trauma-Informed Training - BMHS formed a training collaborative to develop more

trauma-informed treatment in Baltimore City with funding from MHA that was allocated

for co-occurring disorders. (Present or past trauma is common in the lives of people with

co-occurring substance use and mental health disorders.) BMHS contracted with the

National Council for Behavioral Health Care to facilitate no-cost trainings for providers

to become more trauma-informed through critical policy and practice changes, and to

provide Trauma-Informed Cognitive Behavioral Therapy training to clinicians.

Co-occurring Disorder Supportive Housing Project - This project’s (previously

mentioned in #1 above) aim is to transition 25 consumers with co-occurring mental

health and substance use disorders from the State Hospitals into the community.

146

5. Access to Services

Maryland Crisis and At-Risk for Escalation Diversion Services (MD CARES) - This

federal System of Care grant seeks to strengthen cross-agency partnerships that blend

family-driven, evidence-based practices within mental health and child welfare systems

so that the high-risk youth population obtains greater access to quality services.

Early Childhood Mental Health and Expanded School Mental Health - These two

programs provide a continuity of care through the transition between Head Start and

elementary school. Both initiatives have a strong prevention and early intervention

emphasis and reach a significant number of children.

Temporary Assistance for Needy Families (TANF) Wellness Education Program -

This program identifies individuals in local DSS offices with mental health needs. These

individuals are assessed, provided brief interventions, and, if needed, connected to other

PMHS services.

6. Evidence-Based Practices

Integrated Dual Disorders Treatment (IDDT) – This initiative (previously mentioned

in #4 above) is an evidence-based practice model that provides integrated mental health

and substance abuse treatment to support consumers in the recovery process.

Assertive Community Treatment (ACT) – BMHS supports and funds ACT teams.

ACT is an evidenced-based practice model that requires mobile treatment providers to

receive specialized training and evaluation by the State of Maryland using the Dartmouth

Assertive Community Treatment Scale. Six of the nine mobile treatment programs in the

City are ACT certified. A seventh mobile treatment program is in the process of

converting to ACT.

Common Elements - BMHS funded a year-long professional development training for

72 Expanded School Mental Health (ESMH) clinicians to learn and practice Common

Elements. Common Elements is an evidence-based practice that takes components of

interventions that have been shown in clinical trials to be effective in treating specific

disorders of childhood and adolescence and re-bundles those elements to allow clinicians

to more effectively provide behavioral health interventions.

7. Diversion Efforts

Reducing Avoidable Emergency Department Visits and Inpatient Episodes

Adult Emergency Room Department Diversion - Baltimore Crisis and

Response, Inc. (BCRI) coordinates with emergency departments to maximize use

147

of community-based alternatives to inpatient admission. Point persons from BCRI

and BMHS provide technical assistance and consultation as needed for discharge

planning and to address other challenges.

Pediatric Emergency Room Department Diversion - Baltimore Child and

Adolescent Response System (BCARs) places clinicians in Johns Hopkins

Hospital and the University of Maryland Medical System where they provide

mental health assessments, stabilization services and immediate linkage to other

services.

High Inpatient Utilizer Project - This project identifies individuals who utilize

high levels of psychiatric inpatient care, i.e. those consumers who have either

been hospitalized for more than 30 days or who have had five or more

hospitalizations in the last six months, in order to facilitate appropriate

community-based treatment and support services. The goals are to enhance

assertive engagement and support services, while decreasing the high inpatient

utilizer’s cycle of reliance on preventable emergency room visits and acute

psychiatric inpatient admissions.

Diverting Mentally Ill Defendants from Incarceration

Forensic Alternative Service Team (FAST) - BMHS supports FAST, which

provides jail diversion activities and actively participates in Mental Health Court.

FAST screens individuals for diversion services and conducts face-to-face

assessments to determine eligibility for appropriate services and possible return to

the community.

Circuit Court Case Management Project - This three-year project funds a

clinician to provide behavioral health assessments and link eligible defendants to

behavioral health services in the community. The goals of this project are to

decrease recidivism, increase mental health service utilization among defendants

with mental illness and to increase public safety. The project has been fully

integrated into the operation of the consolidated mental health docket in the

Circuit Court of Baltimore City.

8. Outcomes/Quality

As previously discussed on page 73, in FY 12, BMHS implemented a formal Quality

Management Plan (QM Plan), focusing attention agency-wide on the quality of both the

City’s publicly-funded mental health programs and BMHS’ performance in key areas.

Indicators of quality performance for both BMHS and the PMHS were established, and

baselines were determined. Performance is monitored and analyzed on a monthly basis

to ensure that consumers are receiving quality services and that the City’s PMHS is

148

operating effectively and efficiently. The Quality Management Report for FY 12 is

attached as Appendix B.

As previously mentioned in #1 above, the Capitation project’s continuous quality

improvement process is an initiative with the goal of improving targeted aspects of care.

149

Mission, Vision and Values

Mission

The mission of 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

Baltimore City seeks to be a national leader in the development of high quality, innovative, and

effective public mental health services. Services are 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.

Values

BMHS strives to:

Design a continuum of services that meets the mental health needs of the residents of

Baltimore City;

Include the perspectives of consumers, families, mental health providers, and other key

stakeholders in developing and improving systems of care;

Recognize the rights of consumers and families to participate in care decisions and to be

treated with dignity and respect;

Support individuals in their efforts to maximize their full potential;

Offer high quality mental health services;

Ensure cost-effective delivery of services;

Ensure delivery of services in the least restrictive environment appropriate to the needs of

consumers;

Promote culturally competent services that respect differences among individuals;

Educate, train, and promote research; and

Offer safe, attractive, and affordable housing for persons with mental illness.

150

Goals, Objectives and Strategies

GOAL I: Americans Understand that Mental Health

is Essential to Overall Health.

Objective 1.1: Baltimore Mental Health Systems (BMHS) will increase public awareness of

mental health disorders, prevention mechanisms, treatment services, and supports.

STRATEGY 1: Provide direction, funding and ongoing consultation to organizations that

implement public education and training activities.

Action Step: Support organizations that provide public educational workshops, distribute

educational literature, and offer information and referrals:

Mental Health Association of Maryland (MHAMD);

National Alliance on Mental Illness (NAMI);

Maryland Coalition of Families for Children’s Mental Health;

On Our Own of Maryland.


STRATEGY 2: Participate in community events that promote awareness of mental health.

Action Step: Provide education and outreach regarding depression and available mental

health services through the Behavioral Health Leadership Institute.

Indicator: Number of community events.

STRATEGY 3: Collaborate with the Baltimore City Health Department (BCHD) and

hospitals and other healthcare providers and Federally Qualified Health Centers (FQHCs)

to identify opportunities to provide educational information about mental health issues and

access to care.

Action Step: Reach out to staff at BCHD and healthcare providersFQHCs, with priority to

those working with populations at high risk for mental health disorders.


151

Objective 1.2: BMHS will educate public safety personnel regarding current information

about mental illness, managing mental health emergencies and available services.

STRATEGY 1: Improve the capacity of the City’s police officers, Downtown Partnership

Safety Guides and other public safety personnel like parole and probation officers, 911

operators and correctional officers, to respond to psychiatric emergencies.

Action Step: In collaboration with the Baltimore Police Department provide leadership to

the Behavioral Emergency Services Team (BEST) to train police officers.

Action Step: Collaborate with public safety organizations to identify opportunities to

provide educational information about mental health issues.

Indicators: Number of personnel trained; report on progress to date.

GOAL II: Mental Health Care is Consumer and Family Driven.

Objective 2.1: Promote efforts that facilitate recovery and build resiliency.

STRATEGY 1: Promote and support consumer-operated programs.

Action Step: Provide direction, funding, and consultation to the City’s three (3) Wellness &

Recovery Centers: Helping Other People through Empowerment (HOPE), On Our Own, Inc.

and Hearts and Ears.

Indicator: Number of consumers served.

STRATEGY 2: Increase implementation of consumer-centered practices such as Wellness

and Recovery Action Planning (WRAP), use of peer staff and consumer-directed recovery

planning.

Action Step: Provide direction, funding and ongoing consultation to the Human Services

Training program at Goodwill, Inc. that trains consumers for employment in the human

services field.

Action Step: Provide education and technical assistance to providers in implementing

practices targeted at assisting consumers to move to their defined next level of recovery.

Indicators: Number of consumers served; Rreport on progress to date.

152

Objective 2.2: Help families be active advocates for their children on the system, program

and individual level.

STRATEGY 1: Increase family input in planning and evaluation of mental health services.

Action Step: Elicit feedback from family support and advocacy organizations concerning

the mental health needs of children and families in the community.

Action Step: Provide funding, oversight, and evaluation of services to meet the mental

health needs of families in Baltimore City.

Indicator: Composite summary of family satisfaction with continuum of mental health

services available in the City.

STRATEGY 2: Promote leadership development and advocacy skills among families.

Action Step: Provide funding and support to the Maryland Coalition of Families for

Children’s Mental Health for their sponsorship of family leadership trainings.

Indicator: Number of family members who attended leadership training.

Objective 2.3: Promote family-driven and family-centered initiatives.

STRATEGY 1: Provide support and consultation to family-centered initiatives implemented

in Baltimore City.

Action Step: Participate in statewide and local planning for the implementation of home and

community-based wraparound services for youth who would otherwise require residential

treatment level of care.


153

GOAL III: Disparities in Mental Health are Eliminated.

Objective 3.1: Improve access to culturally and linguistically competent public mental

health services for racial and ethnic minority individuals.

STRATEGY 1: Recruit and retain racial and ethnic minorities and multi-lingual

professionals in the mental health services workforce.

Action Step: Provide direction, funding and ongoing consultation to the Maxie Collier

scholarship program at Coppin State University, which encourages minority students to

pursue careers in mental health.

Action Step: Provide direction, funding and ongoing consultation to the Johns Hopkins

Hospital Hispanic Clinic, which provides mental health treatment to Spanish-speaking

individuals and families through the use of bilingual staff.

Indicator: Number of students enrolled by discipline.

STRATEGY 2: Develop collaborations with community-based organizations working to

increase understanding of mental health issues and to improve access for services among

racial, ethnic and linguistic minorities.

Action Step: Provide direction, funding and ongoing consultation to the Black Mental

Health Alliance for Education and Consultation in promoting awareness of the needs of

African Americans with mental illness and offering information, support and referrals to

individuals and families.


STRATEGY 3: Develop collaborations with health care providers, mental health care

providers, community-based Latino organizations and other willing partners to identify

opportunities to improve access to mental health care for Baltimore City’s growing Latino

population.

Action Step: Implement at least one recommendation identified either in the Latino Needs

Assessment Report or through dialogue with key partners.

154


STRATEGY 4: Collaborate with colleges and universities to improve cultural competence

among newly trained healthcare workers and professionals regarding the unique needs of

Baltimore City consumers.

Action Step: Reach out to the University of Maryland School of Social Work to provide

educational opportunities to improve cultural competence of graduating social work

professionals.

Indicators: Report on progress to date.

Objective 3.2: Improve access to mental health services for special populations that are

underserved by the public mental health system.

STRATEGY 1: Provide direction, funding and ongoing consultation to agencies that serve

transitional age youth.

Action Step: Contract with a vendor(s) to provide residential rehabilitation and case

management services for youth who have complex mental health and social needs.

Action Step: Provide technical assistance to child and adolescent mental health providers

and other child serving systems regarding accessing the adult mental health system and

strategies to assist youth in developing skills needed for success in the adult system.

Indicators: Number of youth who receive services; report on technical assistance provided.

STRATEGY 2: Facilitate access to treatment for war returnees, especially those from Iraq

and Afghanistan.

Action Step: Make available free mental health treatment by contracting with a vendor to

recruit and provide specialized training for volunteer mental health professionals.


STRATEGY 3: Provide direction, funding and/or ongoing consultation to agencies that

interact with individuals involved with the criminal justice system.

155

Action Step: Divert individuals from incarceration by providing support and technical

assistance to the Baltimore City Mental Health Court, Forensic Assertive Community

Treatment Team (FACTT) and Forensic Alternative Services Team (FAST).

Action Step: Collaborate with the Baltimore City Circuit Court to develop alternatives to

incarceration for sentenced individuals.

Action Step: Provide support and technical assistance to the Chrysalis House Healthy Start

Program, which serves pregnant, and post-partum women and their babies as an alternative to

incarceration.

Indicators: Number of individuals served; report on progress to date.

STRATEGY 4: Fund mental health services targeted to individuals who are deaf and hard of

hearing.

Action Step: Contract with a vendor to provide residential rehabilitation, psychiatric

rehabilitation and outpatient mental health treatment services to this population.

Indicators: Number of individuals served; level of care received.

STRATEGY 5: Fund mental health services targeted to individuals with traumatic brain

injury (TBI).

Action Step: Contract with a vendor to provide individualized therapeutic activities in a

residential setting, including life skill services and family supports.


STRATEGY 6: Provide funding and/or consultation to programs that offer outreach or

mental health services to individuals and families who are homeless.

Action Step: Provide leadership to the multi-agency coalition of homeless outreach

advocates and providers known as the Hands in Partnership (HIP) initiative to identify,

engage and coordinate outreach services to individuals experiencing homelessness.

Action Step: Provide direction, funding and ongoing consultation to HUD-funded projects:

three (3) mental health outreach teams; one (1) SSI Presumptive Eligibility Outreach

program; and one (1) Wellness and Recovery Center for homeless individuals.

156

Action Step: Provide funding and consultation to programs serving homeless children and

families.

Indicators: Report on progress to date; number of individuals served.

STRATEGY 7: Fund transitional housing opportunities.

Action Step: Contract with a vendor(s) to provide transitional housing services.

Indicators: Number of beds funded; number of individuals served.

STRATEGY 9: Provide mental health screening, intervention, and referral for children

exposed to violence.

Action Step: Provide funding and oversight to the Child Development Community Policing

(CDCP) program, which provides mental health outreach, assessment, referrals for children

who are witnesses or victims of a violent crime and trains volunteers about the needs of this

population.

Indicators: Number of requests to CDCP; number of children and adolescents served.

STRATEGY 10: Provide mental health services to individuals suffering from depression and

trauma and living in highly vulnerable communities.

Action Step: Through Baltimore Health Leadership Institute’s (BHLI) Connections Project,

in partnership with Johns Hopkins Bayview Medical Center, provide mental health services

on-site in non-traditional community-based settings.

Indicators: Number of sites; number of individuals served; number of services provided.

STRATEGY 11: Fund mobile psychiatric assessment and treatment for elderly individuals.

Action Step: Contract with vendor(s) to identify, assess, treat and link elderly clients to

services.


STRATEGY 12: Provide technical assistance and consultation to coordinate access to

community-based services for elderly individuals.

157

Action Step: Assist State hospital facilities to transition elderly residents to community

placements.


GOAL IV: Early Mental Health Screening, Assessment and Referral to

Services are Common Practice.

Objective 4.1: Promote healthy social and emotional development by making mental

health services available within settings where children grow and learn.

STRATEGY 1: Promote the provision of mental health promotion, prevention and

intervention services in early childhood settings.

Action Step: Partner with Baltimore City Head Start to make mental health services

available on-site.

Indicators: Number of Head Start sites offering mental health services on-site; Number of

mental health consultations provided.

STRATEGY 2: Promote the provision of mental health prevention, screening, assessment

and treatment services in public schools.

Action Step: Partner with the City Schools, Baltimore City Health Department and any

other interested partners to fund school-based mental health services through the Expanded

School Mental Health (ESMH) project.

Action Step: Track outcomes to demonstrate impact of school-based mental health services.

Action Step: Work with partners to explore possibilities for the expansion of ESMH

services.

Action Step: Provide oversight and support to specialized school-based mental health

initiatives that serve targeted populations.

Indicators: Number of children and adolescents served; report on selected outcomes.

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Objective 4.2: Identify and seek to address the mental health needs of children and

adolescents in other child-serving systems.

STRATEGY 1: Work cooperatively with the Juvenile Justice System to identify and address

the mental health needs of involved youth.

Action Step: Provide consultation and technical assistance regarding mental health services

and resources on-site at Juvenile Court.

Action Step: Provide funding and oversight for the delivery of court-ordered mental health

assessments for post-adjudicated youth.

Action Step: In collaboration with Department of Juvenile Services (DJS), provide funding

and oversight for mental health and substance abuse screening and treatment services for

youth supervised by DJS at the Baltimore City Juvenile Justice Center and in the community.

Indicator: Number of DJS-involved or court-involved youth served.

STRATEGY 2: Participate in statewide and local efforts to more adequately meet the mental

health needs of children and adolescents in foster care.

Action Step: Provide funding and oversight, in conjunction with MHA and Department of

Human Resources (DHR), of mental health assessments for children at risk of entering or

entering the foster care system.

Action Step: Provide funding and oversight, in conjunction with MHA and DHR, of mental

health mobile crisis and stabilization services for children and families in the foster care

system.

Indicators: Total number of calls; number of children assessed; number of children able to

maintain foster care placement; number of mobile crisis responses.

Objective 4.3: Promote screening for mental health disorders, including co-occurring

disorders and linkage to appropriate treatment and supports across the lifespan.

STRATEGY 1: Expand screening, assessment and coordinated treatment for individuals

with co-occurring mental health and substance use disorders.

159

Action Step: Continue planning activities with Baltimore Substance Abuse Services (bSAS)

and other Baltimore City stakeholders including the Expanded School Mental Health Sixth

Grade Initiative, and Integrated Dual Disorders Team (IDDT).

Action Step: Continue efforts to increase knowledge among BMHS and bSAS staff of

treatment issues relating to individuals with co-occurring disorders and promote closer

collaboration between the two agencies.


STRATEGY2: Make buprenorphine treatment available to individuals with mental illness

and opioid addiction.

Action Step: Through BHLI’s Project Connections, continue offering buprenorphine

treatment in coordination with mental health treatment at one site.

Indicators: Report on progress to date; number served.

GOAL V: Excellent mental health care is delivered and research is accelerated while

maintaining efficient service system accountability.

Objective 5.1: Promote workforce development and training through educational activities

and technical assistance to mental health service providers and other service sectors.

STRATEGY 1: Facilitate opportunities to educate and provide technical assistance in

emerging best practices. Sponsor continuing education and training opportunities in

evidence-based and emerging best practices.

Action Step: Support providers in identifying professional development

opportunities.Sponsor community trainings for community-based mental health clinicians.

Action Step: Sponsor professional development sessions for school-based mental health

clinicians.

Indicators: Number of training activities; number of participantsReport on progress to date.

160

STRATEGY 2: Provide support and technical assistance to service providers in how the

public mental health system works.

Action Step: Provide presentations to community service organizations, hospitals and

FQHCs about the resources available for clients in need of mental health services.

Indicators: Types of community service organizations that received presentations; number

of presentations.

Objective 5.2: Provide access to services in the least restrictive setting.

STRATEGY 1: Strengthen crisis response services.

Action Step: Provide funding and oversight to Baltimore Crisis Response, Inc. (BCRI) and

to Baltimore Child and Adolescent Response System (B-CARS).

Indicator: Number of individuals served by each provider; report on progress to date.

STRATEGY 2: Facilitate coordination of care for individuals using emergency rooms as

their point of access to psychiatric services.

Action Step: Facilitate access to community-based services for clients identified by MHA

and the Administrative Services Organizations (ASO) as high inpatient utilizers.


STRATEGY 3: Whenever possible, divert children and adolescents from admission to

Residential Treatment Centers (RTCs) by offering alternative community-based

interventions and supports.

Action Step: Participate in the approval process for home- and community-based

wraparound services for children and adolescents.

Action Step: Review Certificate of Need (CON) documents to assure that all referred youth

meet eligibility requirements and community-based services have been exhausted prior to

accessing whether an RTC level of care is needed.

Indicators: Number of children and adolescents referred for RTC placement; number of

children and adolescents diverted from RTC services via the 1915c Waivervia the State plan.

161

STRATEGY 4: Provide support to programs that work with children and adults

transitioning out of inpatient/institutional facilities.

Action Step: Facilitate communication between Baltimore Child and Adolescent Response

System (B-CARS) and the Care Management Entity (CME), Wraparound Maryland, and the

child and adolescent psychiatric inpatient programs in Baltimore City, to increase utilization

of B-CARS or Wraparound MarylandCME and thereby better assist youth to return to the

community following inpatient admission.

Action Step: Collaborate with State hospital facilities in identifying community resources to

assist in discharge planning.

Indicators: Report on progress to date; number of individuals who transitioned from

inpatient/institutional facilities.

STRATEGY 5: Provide access to affordable housing for individuals and families with mental

illness.

Action Step: BMHS’ housing affiliate, Community Housing Associates (CHA), will

provide 266 units of safe and affordable housing throughout Baltimore City.

Indicators: Number of individuals and families housed; retention in housing greater than 6

months.

Strategy 6: Increase the number of affordable housing units available to individuals and

families with mental illness.

Action Step: CHA will apply for funding to develop housing for adults and families with

mental illness.

Action Step: CHA will acquire and rehabilitate 20 units of affordable housing.

Action Step: CHA will secure funding to acquire and rehabilitate an additional 20 units of

housing to serve adults and families with mental illness.

Action Step: CHA will secure rental subsidies for all new units ensuring tenants pay no

more than 30% of income for rent.

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Action Step: CHA will secure funds to make support services available to residents of CHA

housing.

Indicators: Number of applications submitted; number of individuals housed; number of

units developed; number of units with rental subsidy.

Objective 5.3: Identify and promote the implementation of evidence-based, effective,

promising and best practices for mental health services.

STRATEGY 1: Explore opportunities to increase access to evidence-based practices (EBP)

for children and adolescents.

Action Step: Collaborate with stakeholders throughout the City to establish a continuum of

EBPs’ in Baltimore City.

Action Step: Provide oversight of and explore increased funding for the Center on the

Social and Emotional Foundations for Early Learning (CSEFEL) Positive Behavior and

Supports (an evidence-based practice) in at least one Head Start Center.

Indicators: Number of clinicians trained; Rreport on progress implementation and

associated outcomes.to date.

STRATEGY 2: Facilitate implementation of MHA’s evidence-based practice guidelines for

supported employment and assertive community treatment (ACT).

Action Step: Provide information, support and encouragement to programs expressing

interest in adopting evidence-based practices.

Indicators: Number and type of programs maintaining fidelity to the models.

STRATEGY 3: Identify opportunities to improve coordination in the provision of mental

health treatment and somatic care.

Action Step: Collaborate with MHA, Community Behavioral Health and other interested

partners in implementing practices that address somatic risk factors, such as tobacco

cessation, in mental health treatment settings.


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Objective 5.4: Improve public mental health programs’ compliance with quality standards

established by Mental Hygiene Administration (MHA) and State and Federal regulations.

STRATEGY 1: Conduct quality assurance site visits to mental health programs.

Action Step: In collaboration with MHA and the Administrative Services Organization,

conduct audits of mental health programs to evaluate quality of services, billing practices and

compliance with State and Federal regulations.

Action Step: Using data from compliance audits identify areas where system-wide

improvements in services are needed and educate providers regarding deficiencies.

Indicators: Number of programs whose services meet quality standards; reduction in

number of programs found to be non-compliant.

STRATEGY 2: Provide training and technical assistance to mental health programs.

Action Step: Offer education and technical assistance to new programs that submit

applications to deliver public mental health services.

Action Step: Offer technical assistance to existing providers in developing performance

improvement plans in response to quality assurance site visits.

Indicators: Number of programs receiving technical assistance; reduction in the number of

programs non-compliant.

STRATEGY 3: Monitor public mental health programs using a quality management

framework.

Action Step: Review and monitor quality management metrics indicators in an newly

established quality management committee.

Indicators: Report on progress of establishing metricsindicators, quality improvement

interventions, and the results of quality improvement interventions.

Objective 5.5: Ensure that residential rehabilitation programs provide safe, affordable,

and quality housing.

STRATEGY 1: Inspect 100% of residential rehabilitation program (RRP) housing to

evaluate compliance with Code of Maryland Regulations.

164

Action Step: Conduct initial and annual housing inspections.

Action Step: Conduct follow up inspections to determine if deficiencies identified during

inspections were corrected.

Action Step: Assist the RRP’s by identifying and documenting the deficiencies so that they

can successfully make the changes needed depending on their specific circumstances.

Action Step: Re-visit all RRP’s found to have had deficiencies.

Indicators: Number of RRPs inspected; reduction in the number of RRPs found to have

deficiencies.

Objective 5.6: Provide an adequate network of mental health service providers to meet

community needs.

STRATEGY 1: Improve BMHS vendor contract management process to strengthen

monitoring of grant-funded programs.

Action Step: Assess vendor performance through submission of fiscal and programmatic

reports, and request corrective action plans from providers identified as not meeting fiscal

audit standards or programmatic deliverables.

Action Step: Utilize contract management software.

Action Step: Conduct random and targeted site visits to monitor vendor performance,

compliance with conditions in their contract, and regulatory compliance; request

performance improvement plans from providers identified as non-compliant.

Action Step: Provide technical assistance to non-compliant vendors; assess areas in need of

improvement, educate providers and schedule follow-up site visits to evaluate progress.

Indicators: Number of contracts in compliance; timeliness of contract execution; program

compliance ratings; reduction in the number of programs non-compliant; percentage of

providers who receive corrective action plans or performance improvement plans,

percentage of providers that, upon performance improvement plan or corrective action plan

follow-up, successfully improved performance.

165

STRATEGY 2: Increase vendor understanding of BMHS contracts and policies through

education and technical assistance.

Action Step: Provide education and training to vendors and staff throughout contractual

cycle, as needed.

Indicator: Type and number of trainings provided.

GOAL VI: Technology is used to access mental health care information.

Objective 6.1: Explore the application of technology to improve service delivery including

promoting the use of web-based technology as a tool to improve information sharing, data

collection, and evaluation.

STRATEGY 1: Use the BMHS integrated database to facilitate coordination of care.

Action Step: Train staff on utilizing database to extract and analyze client-level, program-

level and contract-level data to support improved agency operations and performance.


STRATEGY 2: Maintain and publicize Baltimore City’s site for Network of Care, a web-

based application that includes a service directory and other mental health-related

resources.

Action Step: Collaborate with City providers to update and add new resources as identified.

Action Step: Provide training to City providers and other organizations on how to use

Network of Care to improve their delivery of services.


STRATEGY 3: Develop redesignedMaintain updated agency website asinto an effective

resource for the City’s public mental health system, key partners and the general public.

Action Step: Update the website with important announcements, events and forms that are

pertinent to the Baltimore City provider community.

166

Action Step: Keep resources and information on services up-to-date and easily accessible to

the general public.


STRATEGY 4: Use Datalink to identify individuals in the City’s jails who have mental health

needs in order to increase access to mental health services.

Action Step: Develop a plan in collaborationWork collaboratively with the Department of

Corrections to utilize the data available through Datalink to improve release plans for

incarcerated individuals with mental illness.


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Appendices

Appendix A: Glossary and Acronym Description

A

ACT – Assertive Community Treatment – An evidence-based practice of mobile, community-

based treatment provided by a multidisciplinary team to persons requiring higher level of care

than traditional outpatient programs.

ADAA – Alcohol and Drug Abuse Administration

ASO – Administrative Service Organization – An organization that assists MHA in the

operations of the PMHS. It switched from MAPS-MD to ValueOptions in August 2009.

B

BCARS – Baltimore Child & Adolescent Crisis Response System – A program that provides

mobile psychiatric crisis stabilization services to children and adolescents.

BCDSS – Baltimore City Department of Social Services

BCHD – Baltimore City Health Department

BCHS – Baltimore City Head Start

BCJJC – Baltimore City Juvenile Justice Center

BCPS – Baltimore City Public Schools

BCRI – Baltimore Crisis Response, Inc. – A program that provides 24/7 crisis intervention

services such as a crisis hotline, mobile crisis teams, and residential crisis beds.

BEST – Behavioral Emergency Services Team – A project that trains police officers and other

public safety personnel about mental illness and how to respond to psychiatric emergencies.

BHLI – Baltimore Health Leadership Institute (formerly Mental Health Policy Institute for

Leadership and Training or MHPILT) addresses the issues related to workforce development in

community behavioral health across disciplines and the gap between research findings, policy,

and practice.

BMHA – Black Mental Health Alliance

BMHS – Baltimore Mental Health Systems, Inc.

168

BMWPS – Bi-Annual Mental Wellness Promotion Service – An event coordinated by the Center

for the Integration of Spirituality and Mental Health that focuses on mental health topics and

provides mental health screenings.

BPD – Baltimore City Police Department

bSAS – Baltimore Substance Abuse Systems, Inc.

C

Capitation Project – Intensive community-based treatment service that removes categorical

funding barriers to facilitate high quality comprehensive care to clients in the community with

individualized, flexible and innovative treatment plans.

CANS – Child and Adolescent Needs Assessment

CBH – Community Behavioral Health

CDCP – Child Development Community Policing – Trauma response services provided to

children/adolescents who have witnessed or been a victim of violence.

CHA – Community Housing Associates, Inc

CHHS – Chrysalis House Healthy Start

CISMH – Center for Integration of Spirituality and Mental Health

CME – Care Management Entity

CMET – Court Medical Evaluation Team

COMAR – Code of Maryland Regulations

CON – Certificate of Need – Evaluation documents (i.e., psychiatric, psychological, psycho-

social assessment, and physical) required to validate a clinical recommendation for placing a

youth in a residential treatment center.

CQT – Consumer Quality Team – A consumer team that visits mental health programs and

interviews consumers with the goal of improving the quality of services within the PMHS.

Crisis Services – Short-term crisis interventions, including crisis beds, designed to address

psychiatric emergencies and reduce unnecessary hospitalizations.

CSA – Core Service Agency – Local mental health authority

169

CSEFEL – Center on the Social and Emotional Foundations for Early Learning – A national

resource center funded by the Office of Head Start and Child Care Bureau focused on promoting

the social emotional development and school readiness of young children, birth to age 5, and

responsible for disseminating research and evidence-based practices to early childhood programs

across the country.

D

DHMH – Department of Health and Mental Hygiene

DJS – Department of Juvenile Services

DOC – Department of Corrections

DPP – Division of Parole and Probation

DPSCS – Department of Public Safety and Correctional Services

E

EBP – Evidence-Based Practice – A service or service model that has been demonstrated

through research to be effective.

ECMH – Early Childhood Mental Health

EMTALA – Emergency Medical Treatment and Active Labor Act

ESMH – Expanded School Mental Health – Mental health prevention and treatment services

provided in identified Baltimore City public schools.

F

FACTT – Forensic Assertive Community Treatment Team

FAST – Forensic Alternative Services Team

FFT – Functional Family Therapy – A family-based prevention and intervention program

designed to improve long-term outcomes for youth who are in the care and custody of

Maryland’s Department of Juvenile Services.

FLBC – Family League of Baltimore City – Local management board for Baltimore City

designed to focus attention and resources on improving the well-being of children and families

by engaging communities and encouraging public and private partnerships.

FQHC – Federally Qualified Health Center

G

170

GAF – Global Assessment of Functioning

H

HCH – Healthcare for the Homeless

HEBCAC – Historic East Baltimore Community Action Center

High Fidelity Wraparound Services – A family-driven team process to develop, implement

and monitor a plan of care that is culturally competent, strength-based, and individualized to

achieve positive outcomes for the family of children with severe emotional disturbance.

HIP – Hands In Partnership – A coalition of outreach advocates jointly led by BMHS, Baltimore

Homeless Services, and Baltimore Health Care Access.

HIU – High inpatient utilizers

HOPE – Helping Other People through Empowerment – One of three of the City’s Wellness and

Recovery Centers; it focuses on serving homeless individuals.

Hospital Diversion – Coordination of services and linkage to the appropriate level of

community-based care for uninsured individuals using emergency departments as their primary

source of psychiatric care.

I

IDDT – Integrated Dual Disorders Treatment – An evidence-based practice model that fully

supports individuals with mental illness who are court-ordered to receive substance abuse

treatment.

J

N/A

K

N/A

L

LCT – Local Care Team – A collaborative body of child-serving agencies that meets regularly to

address the needs of youth with special or intensive needs requiring residential or community-

based placement due to behavioral, educational, developmental or mental health disabilities.

M

MACSA – Maryland Association of Core Service Agencies

171

MATCH – Making All The Children Healthy program – A program that provides evidence-

based mental health assessment to children in the child welfare system.

MBRFSS – Maryland Behavioral Risk Factor Surveillance Survey

MD-CARES – Maryland Crisis and At-Risk for Escalation diversion Services for children - The

State’s System of Care grant.

MHA – Maryland Mental Hygiene Administration

MHAMD – Mental Health Association of Maryland

MHPILT – Mental Health Policy Institute for Leadership and Training, now Behavioral Health

Leadership Initiative (BHLI). See BHLI for description.

N

NAMI – National Alliance on Mental Illness

O

OHCQ – Office of Health Care Quality – The agency within DHMH charged with monitoring

the quality of care in Maryland’s 8,000 health care and community residential programs.

OMHC – Outpatient Mental Health Clinic – Multidisciplinary community-based services such

as individual, group, and family therapies as well as medication management.

P

PAC – Primary Adult Care Program – A program in Maryland that provides health coverage for

a limited set of health services for income-eligible adults.

PATCH – Psycho-Geriatric Assessment and Treatment – A Johns Hopkins Hospital’s program

that provides mobile assessment and treatment for elderly individuals

PC – Project Connections

PEP – People Encouraging People, Inc.

PMHS – Public Mental Health System

PRP – Psychiatric Rehabilitation Program – A range of rehabilitation services designed to

maximize the ability of the mental health consumer to function successfully in the community.

PSEP – Peer Support Engagement Project – A project with goals to improve client outcomes and

reduce avoidable use of hospital emergency and inpatient care, along with associated costs.

172

Q

N/A

R

RRP – Residential Rehabilitation Program – Community-based residential services for adults

enrolled in psychiatric rehabilitation programs (may include adult group homes).

RTC – Residential Treatment Center – Intensive residential programs for children and

adolescents with serious emotional disturbance whose needs cannot be met in the community.

S

SAMHSA – Substance Abuse and Mental Health Services Administration

SEP – Supported Employment Program – Employment training and support to prepare persons

for employment and link to jobs.

SNAP – Supplemental Nutritional Assistance Program

SOAR – SSI/SSDI Outreach Assistance and Recovery – A Health Care for the Homeless

program that coordinates Social Security benefits for homeless individuals.

SOCTI – System of Care Training Institute

SOS – Senior Outreach Services – A University of Maryland program that provides mobile

assessment and treatment for elderly individuals.

SGHC – Spring Grove Hospital Center

T

TAC – Technical Assistance Collaborative

TANF – Temporary Assistance for Needy Families

TAY – Transitional Age Youth – Young people, between age 16 and 24, who are transitioning

from the child to the adult mental health system.

TF-CBT – Trauma-Focused Cognitive Behavioral Therapy – A type of psychotherapy that is

applicable to children and adolescents who are experiencing significant emotional and behavioral

difficulties related to traumatic life events.

U

UMMC – University of Maryland Medical Center

173

V

W

WRAP – Wellness Recovery Action Plan – A consumer-centered peer support service practice

X

Y

YO! Center – Youth Opportunity Center – Centers that serve youth who are working towards

receiving their GED

Youth MOVE (YM) – Youth Motivating Others through Voices of Experience – A youth-led

organization devoted to improving services and systems that support positive growth and

development.

Z

175

Quality Management Report

for

Fiscal Year 2012 (July 1, 2011 – June 30, 2012)

Presented to the Board of Directors

September 12, 2012

by

Jane Plapinger, President & CEO

Appendix B

176

Introduction

Baltimore Mental Health Systems’ Quality Management Plan serves as the foundation of BMHS’

commitment to continuously improve the quality of Baltimore City’s Public Mental Health System

(PMHS). Quality management is a strategy that uses data to monitor quality, identifies opportunities for

quality improvement and implements targeted interventions to improve processes associated with

meaningful outcomes.

All core service agencies, including Baltimore Mental Health Systems, Inc. (BMHS), are contractually

obligated to engage in quality management activities in their jurisdictions, and BMHS has three

dedicated quality management coordinators who conduct mandated quality assurance audits of the

City’s public mental health programs – both those funded through the State’s fee-for-service carve-out

and those grant-funded by BMHS. Until this year, the scope of these activities was limited to what the

state required, conducting site visits to programs and reviewing provider applications to establish,

expand or close programs. In FY11, BMHS decided to expand and formalize its quality improvement and

quality assurance activities, and developed its Quality Management (QM) Plan as a framework.

FY 12 was the first year of implementation of the QM Plan. The Plan requires that BMHS report to the

Board on an annual basis on its QM activities. This first report to the Board will summarize the goals of

the QM Plan for FY 12, and describe what was achieved. In addition, this report will describe the

indicators and targets that have been identified for FY 13.

The first step in implementing the QM Plan was establishing the Quality Management Committee34. The

Committee was created at the beginning of FY 12 and met eight times throughout the year. (The Plan

specified that the Committee meet no fewer than ten times, but the restructuring of the Administrative

Division and change in staff impacted the agency’s capacity to meet this goal.) The Committee

developed six measureable quality indicators, which are as follows:



2. Provider Compliance with Contractual Requirements

3. Provider Program Quality




6. Help Call Satisfaction Rates

34

Per the QM Plan, Committee membership includes: President & CEO, Director of Operations, CFO, Director of Adult Services, VP/Director of Child and Family Services, one Adult Services Manager, one Child and Family Services Manager and two Quality Management Coordinators.

177

At each meeting, the Committee reviewed and analyzed data collected on the indicators, identified

improvement opportunities, and developed interventions to promote improvement. In addition, quality

assurance site visit35 results and provider applications to establish, expand or close services/service lines

were reviewed to assist in identifying PMHS service gaps and provider trends. Specific details on each of

the quality management indicators follow below.



Total # of providers required to conduct a survey 58

Total # of providers that met the requirement 58

% of providers compliant 100%

A key quality measure in the Public Mental Health System is the consumer’s perception of the services

she or he received. This measure is a nationally recognized quality measure that many Baltimore City

providers routinely collect data on. BMHS’ aim is for all grant-funded direct service programs to elicit

and use consumer feedback to inform their quality improvement efforts.

To this end, in FY 12, BMHS added a requirement that BMHS-funded programs conduct an annual survey

of consumers to identify improvement opportunities. By including this requirement in our contracts,

BMHS is attempting to ensure that all providers are conducting surveys and utilizing the feedback to

focus improvement efforts.

In FY 12, the total number of providers that were required to conduct a survey was 58 and there was

100% compliance. In FY 13, these programs will be required to identify an area of improvement based

on the consumer feedback collected, and implement a quality improvement project which will be

described to BMHS as part of their FY 13 report of programmatic deliverables. This indicator will be

retained for FY 13 with a target of 100%.

2. BMHS Grant-Funded Provider Compliance with Contractual Requirements

Total # of grant-funded providers 56

Total # providers compliant with contractual obligations 52

% of providers in compliance 93%

35

A site visit is when BMHS’ Quality Improvement (QI) staff visit a mental health program to conduct a compliance audit. For fee-for-service providers, QI staff review the program for compliance with the Code of Maryland Regulations. For grant-funded providers, QI staff review the program for compliance with their BMHS contract. The frequency of site visits is determined by 1) the amount of funding for grant-funded programs, and 2) the requirements of the Mental Hygiene Administration for fee-for-service programs.

178

Contractual compliance is the accurate and timely submission of required fiscal, programmatic and

other contractual documents by grant-funded programs. It is important because the timely submission

of contractual documents enables BMHS to pay providers on schedule, since payment is withheld when

contractual documents are outstanding. Interrupted payments put programs at operational risk, which

could impact services to consumers. Also, the receipt by BMHS of timely and accurate information from

grant-funded providers enables it to better track City grant funds, identify opportunities to repurpose

funds unlikely to be spent, and make the best possible decisions about budget reductions. This indicator

is intended to assess provider contractual compliance rates.

Over the last fiscal year, BMHS has been working with the City’s grant-funded providers to improve

performance in this area. In FY 12, the total number of BMHS grant-funded providers was 56, while the

average number of providers compliant with contractual obligations was 5236, for an average

compliance rate of 93%.

This indicator will be retained for FY 13 with a target of 100%. BMHS is implementing a grant/contract

software management system which will go live in FY 13, and will support providers in achieving

contractual compliance with greater efficiency. This web-based system will enable providers to submit

contractual documents electronically instead of manually, as is currently done, and will provide real-

time and point-in-time information and data. This will facilitate timely and accurate reporting, and will

allow BMHS to more quickly identify non-compliance.

3. Quality per Site Visits and Compliance with Programmatic Deliverables

Fee-for-Service & Grant-Funded Programs

# of site visits 68

# of Performance Improvement Plans (PIPs) issued 30

% of programs that failed to meet one or more COMAR standards 44%

BMHS is responsible for quality oversight of two categories of publicly funded mental health programs:

grant-funded program funded through contracts with BMHS, and services that are funded on a fee-for-

service basis by ValueOptions®37 through the PMHS Medicaid carve-out. Program Improvement Plans

(PIPs) are generated when a site visit is conducted and the provider (grant-funded or fee-for-service) is

found to be non-compliant with one or more Code of Maryland Regulations (COMAR). Corrective Action

36

This indicator is a conservative measure of provider contractual compliance because multi-program providers are deemed noncompliant if one or more of their programs are noncompliant. 37

ValueOptions® is the current administrative service organization of the PMHS in Maryland.

Grant-Funded Programs

# of providers 56

# of Corrective Action Plans (CAPs) issued 2

% of providers failed to meet one or more programmatic deliverables 4%

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Plans (CAPs) are generated when a provider fails to meet one or more programmatic deliverables38

delineated in its contract with BMHS.

In FY 12, 68 site visits were conducted by BMHS staff to City mental health programs39, and 30, or 44%,

had findings which required a Performance Improvement Plan. Based on the submission of data on

deliverables by BMHS’ grant-funded providers, 2 out of 56, or 4%, were found to be deficient and were

required to develop and implement a Corrective Action Plan.

For FY 13, the Quality Management Committee decided not to set a target for the percent of audited

programs with PIPs, because BMHS has very limited control over quality in these programs, which are

governed by state regulations (COMAR) and funded through ValueOptions® . However, data on this

indicator will continue to be collected, since it will be useful in determining trends in quality of care.

Two additional related indicators were added for FY 13: 1) percent of programs that submitted a timely

and satisfactory PIP, and 2) percent of programs that fully implemented their PIP within the required

timeframe. On the other hand, since BMHS does have significant control over BMHS grant-funded

programs, the Committee set the FY 13 target at 100% for providers that are compliant with contractual

deliverables; i.e., no providers would be required to submit a Corrective Action Plan.

Technical assistance to the City’s publicly-funded mental health programs by BMHS staff has been, and

will continue to be, individualized for all programs that have either a PIP and/or a CAP in place. BMHS

staff have worked together with these providers to assist them to become compliant. One area of focus

for improvement within BMHS is the coordination of technical assistance between BMHS’ Quality

Management and Adult and Child & Family Services Divisions.



# of complaints received 63

# of complaints resolved 52

% of complaints resolved 81%

Addressing complaints relating to the quality and accessibility of publicly-funded mental health services

is an important core service agency function. BMHS aims to resolve all complaints to the satisfaction of

the complainant, and do so within a 30-day timeframe. The intention of these two indicators is to track

consumer complaints about both fee-for-service and grant-funded providers, and to determine the

extent to which they are resolved in a timely manner.

38

Programmatic deliverables are specific to each contract and often include: number of consumers served; number and type of services rendered, e.g., number of outreach contacts, number of consultation; number of trainings provided; number of clinical sessions administered; etc. 39

References both BMHS grant-funded programs and fee-for-service programs.

# of complaints received 63

# of complaints resolved within 30 days 41

% of complaints resolved timely 65%

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In FY 12, the Quality Management Committee defined a “resolved” complaint as one in which the

consumer was satisfied or, when consumer satisfaction was not possible to ascertain, one in which

BMHS had done everything possible to ensure satisfaction, including referring to the appropriate state

authorities. The total number of complaints received was 63, while the number of resolved complaints

was 52, for a resolution rate of 81%. The number of those complaints that were resolved within the

required timeframe (30 days) was 41 (65%).

In examining the above data, the Quality Management Committee determined that the frequent lack of

responsiveness by complainants to BMHS’ efforts to investigate complaints sometimes prevented full

resolution or the timely resolution of complaints. Therefore, the Committee set a FY 13 target of 85%

for the number of resolved complaints, a modest increase from the baseline number (81%). However,

the Committee decided not to set a target for the percent of complaints resolved within 30 days,

because it was determined that BMHS lacks the ability to reliably control complaint resolution within a

30-day timeframe. Instead, an additional sub-indicator, tracking the number of complaints “responded

to within the required timeframe,” was added, to measure BMHS’ responsiveness. Both sub-indicators

(“response” timeframe and “resolved” timeframe) will be useful indicators in determining how

effectively BMHS acts to resolve consumer complaints.


Total # of contracts being renewed 96

# of contracts renewed by the start of new contract period 93

% of contracts renewed timely 97%

Target 85%

The timeliness of contract renewals is important to the uninterrupted provision of service of BMHS’s

grant-funded programs, and is an aspect of the effective management of public funds. BMHS’ goal is for

all contracts to be renewed by the start of the new contractual period.

In FY 12, in an effort to continue improving BMHS’ on-time contract renewal rate, the agency shifted the

direct responsibility for coordination of the contract renewal meetings to the Adult and Child & Family

Services Divisions, while the Administrative Division provided both support to and oversight of the

contract renewal process. This joint effort proved to be an effective approach, and 93 out of 96, or 97%

of contracts were renewed on time.

The Quality Management Committee has set a FY 13 target of 100% of contracts renewed on time.

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6. Help Caller Satisfaction

# of help calls received 1,173

# of callers indicating satisfaction with result of their call 1,067

% of callers satisfied 91%

One of BMHS’ core functions is to provide information about the PMHS and assist individuals, families

and other interested stakeholders to access public mental health services. The intent of this indicator is

to monitor the number of individuals who are satisfied with the outcome of their help call.

In FY 12, the total number of help calls received was 1,173 while the number of callers who expressed

initial satisfaction40 with their call’s result was 1,067, or 91%. Discussions about this indicator by the

Quality Management Committee revealed a low level of confidence that BMHS was collecting valid

“satisfaction” data from the available information. A better measure would be to conduct follow-up

calls to ask callers whether they were satisfied with the information provided; however, it was agreed

that BMHS does not, at this time, have resources to obtain this information. Therefore, the Committee

decided not to set a target for this indicator in FY 13, but will continue to collect the data for this

indicator. The Committee plans to examine the help call process further to determine how we might

increase our ability to confirm caller satisfaction.

Conclusion

Summary of Recommendations for the FY 13 Quality Management Plan

The first year of implementation of BMHS’ Quality Management Plan created an agency-wide focus on

quality – both of the City’s publicly-funded mental health programs and of BMHS’ performance in

several key areas. The newly formed Quality Management Committee brought together diverse staff at

all levels of the agency to review quality-related data to understand trends, identify improvement

opportunities, and begin to act on those opportunities. FY 12 data indicates many areas of high

performance relating to both the City’s mental health programs and BMHS as a funder, overseer of

quality and public resource for assistance with access to care. The FY 12 data and ensuing discussions of

the Quality Management Committee also indicated opportunities to target for improvement.

The goals of the Quality Management Plan for FY 12 were largely met. The plan was implemented and

the Committee established. Baseline data were collected for each indicator. Improvements in

processes related to the indicators were initiated. The indicators and associated targets for FY 13 are

detailed in the table below.

40

We currently attempt to collect this information at the close of each phone call by asking the caller, “Are you satisfied with the results of this call?”

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FY 13 Quality Indicators and Targets

Provider Quality Measures

1. Consumer Perceptions of Care (BMHS Grant-Funded Providers)

Indicator # of providers that conducted a survey # of providers required to conduct a survey

Target 100%

Assessment

Frequency Annually

2. BMHS Grant-Funded Provider Compliance with Contractual Requirements

Indicator # of providers compliant with contractual obligations total # of providers

Target 100%

Assessment

Frequency Monthly

3. PMHS and BMHS Grant-Funded Provider Program Quality

Indicator A # of providers meeting contractual deliverables (no Corrective Action Plan) total # of BMHS grant-funded providers

Target 100%

Indicator B # of providers with a Performance Improvement Plan total # of PMHS providers with site visits

Target No target/monitoring only

Indicator C* # of programs that submit a satisfactory and timely Performance Improvement Plan

total # of programs that received a Performance Improvement Plan

Target Establish baseline in FY 13

Indicator D* # of programs that fulfilled all Performance Improvement Plan requirements total # of programs that received a Performance Improvement Plan


Assessment

Frequency Monthly

Agency Quality Measures


Indicator A # of resolved complaints total # of complaints

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*Denotes new indicators for FY 13.

Target 85%

Indicator B* # of complaints resolved within required timeframe total # of complaints

Target No target

Indicator C # of complaints responded to within required timeframe total # of complaints


Assessment

Frequency Monthly


Indicator # of contracts renewed prior to the new contractual period total # of contracts being renewed

Target 100%

Assessment

Frequency Annually

3. Help Caller Satisfaction

Indicator # of callers satisfied with result of their call total # of calls

Target No target/monitoring only

Assessment

Frequency Monthly

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