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Pennsylvania Olmstead Plan

Berks County

July 2012

I. Introduction: Brief introduction of the county including the Olmstead

planning process used to complete this plan. In the introduction, the

specialized needs outlined in the Olmstead Plan (Section 2.) should be

acknowledged and included within the below areas.

Following the release of the Department of Public Welfare’s Office of Mental Health and

Substance Abuse Services Olmstead Plan for Pennsylvania’s State Mental Health System in

January 2011, the Wernersville Service Area Plan Steering Committee began to formulate a

cooperative strategy to move forward with implementing an incremental process of

addressing the needs outlined in developing a Service Area Integration Plan.

Utilizing the Community Support Plans for all individuals residing and receiving treatment at

Wernersville State Hospital, the Steering Committee began to develop a database inclusive

of all individual components of Community Support Plan. This database will serve as the

primary resource for all the collective and individual needs for persons receiving this level of

support. Every individual’s Community Support Plan data is to be entered into the database

upon completion and/or update of their plans. The database can encompass information

selected for each county, or the entire Service Area. From the database, each County

Mental Health Program can cull information that will identify what services, supports, and

infrastructure will be needed for those individuals.

This information can then be cross-referenced with the existing services and supports

currently available in each County as outlined in those counties’ environmental scan. By

cross-referencing both sets of information, each county will know exactly what areas of

support are sufficient in meeting the needs of these individuals, and what areas of support

need to be further enhanced, newly developed or accordingly altered. The outcome of

maximizing resources can be addressed through this process by ensuring a plan is set forth

to develop a regional or Service Area support or service if the demand is not sufficient to

develop a service in a particular county. This cooperative planning approach could be best

suited in meeting the specialized needs of individuals who have a dual diagnosis of mental

illness and an intellectual disability, individuals who have a dual diagnosis of mental illness

and substance abuse, individuals who have a dual diagnosis of mental illness and physical

disability, individuals who have a dual diagnosis of mental illness and acquired brain injury,

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individuals returning from incarceration, individuals who are deaf, individuals who are

homeless, individuals who are elderly, individuals who are medically fragile, individuals who

do not speak English, and individuals with any other identified special needs.

The database is intended to be a living document, subject to change based upon the

dynamic needs of the persons we serve. Each County will have a fully encompassing,

current representation of the community based support needs of each individual receiving

treatment and support at Wernersville State Hospital.

II. List of Services: Treatment services, supports, and infrastructure needed to

support individuals in the community that currently are at the state hospital.

Examples are included below. County(ies) can use the below bullet points

and add, delete or change to build a focused list for the county or regional

group.

Treatment Services:

o Peer Support Services

o Mobile Treatment Teams (Assertive Community Treatment Teams, mobile medication teams, mobile nursing, mobile therapy)

o Non-Residential Structured Programming (psychiatric rehabilitation services, mobile and site based)

o Community Psychiatrists

o Community Therapists

o Outpatient Services

o Partial programs (dual diagnosis partial programs, Spanish speaking partial programs)

o Dialectical Behavior Therapy

o Highly structured supervised setting (secure/non-secure)

o Long Term Structured Residence

o Crisis Residential

o Traumatic Brain Injury

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o Case Management Services (Blended Case Management, Forensic, and IDD Supports Coordinator Services)

o Supportive Living Services

o Consideration for specialized populations

o Social Rehabilitation Services

o Psychiatric Rehabilitation Services

o Community Housing Integration Project Program

o Community Residential Rehabilitation

Infrastructure Review of Services

o Community Residential Settings

o Skilled Nursing Care Facility that provides Psychiatric Services

o Specialized Personal Care Homes

Support Services:

o Family Education

o Work Opportunities

o Warmline

o Hispanic Center

o The Arc of Berks County (Rep-payee)

o The Greater Reading Mental Health Alliance

o Community Care Behavioral Health

o Medial Assistance (DPW)

o Social Security Income benefits

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III. List housing requests from individuals at Wernersville State Hospital who

have been at the state hospital 2 years or more, (who participated in the

peer assessment process associated with the CSP). Where did the individual

request to live? Suggestion is that a chart or matrix be used here to

summarize findings.

28%

6%

5%

5% 25%

14%

14%

3%

Peer Assessments

CRR

Live with Roommate

Didn't Identify a Placement

Nursing Home

No Peer Assessment to Date

Independently Living

Live with Family

TBI Placement

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IV. List the current recommended level of care for individuals receiving

treatment at Wernersville State Hospital for 2 years or more. Suggestion is

that a chart or matrix be used here to summarize findings.

V. Current and projected array of housing options: (Place an X in the columns

of the listed services provided by county.)

County / Jointer

Independent Living

Fair Weather Lodge

Community Residential Rehab

Long Term Structured Residences

Specialized Community Residence

Enhanced Personal Care Home

Personal Care Home

Berks County X X X

44%

14%

6%

8%

22%

3%

3%

Clinical Assessments

CRR

LTSR

Nursing Home

PCBH

No Clinical Assessment to Date

Fairweather Lodge

TBI Placement

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“Housing First” – (models that do not require individuals to participate in services)

Type of housing program to

be Developed (Insert any

programs to be developed and

corresponding information)

Number of

individuals

to be

Served

Timeline for

Development

of the

Program

Strategy to use to maximize resources to meet

the housing needs of individuals:

HealthChoices Reinvestment

Housing Plan

TBD TBD Berks County will continue to explore “Housing

First” options based on the evolving needs of

consumers as expressed through the Community

Support Plans at Wernersville State Hospital,

specifically the Peer Assessments. At this time

the HealthChoices Reinvestment Housing Plan is

closed and has started the reapplication process.

There are five (5) Peer Assessments of Berks

County consumers at Wernersville State Hospital

who have been hospitalized for two (2) or more

years, who have indicated independent living as

a choice of housing. All five (5) in their Peer

Assessments, have indicated wanting mental

health services in the community. Housing First

needs will be tailored to fit the unique needs of

each consumer at Wernersville State Hospital.

Once all Peer Assessments are completed on

each Berks County consumer at Wernersville

State Hospital we will be able to provide the

number of individuals to be served and a timeline

for the development of such programs.

Subsidized Housing TBD TBD

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VI. Specific Non-Residential Supports and Services for consideration to develop.

Non-Residential Supports

and Service to be Developed

(Insert any to be developed

and corresponding

information)

Number of

Individuals

to be

Served

Timeline for

Development

of the

Program

Recovery

focused

service

(Y/N)

Anticipated Funding Sources

Warmline The

population

to be

served by

Warmline

would

include

consumers

from WeSH

as well as

consumers

in the

community.

The timeline

would be

determined

once funding

is

established.

Yes Anticipated funding source would be

through State Funding.

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VII. Congregate settings of more than 16 beds for persons with mental

illness. Complete the information for your county. Include a

narrative below the chart on how service needs will be addressed

and any policy changes that will occur to support the needs of the

individuals.

County / Jointer

# of Individuals with serious mental illness living in a personal care home exceeding 16 individuals

Total Number of PCH

Number of Homes that have over sixteen beds

Services Offered / Provided

Services which may be Needed

Berks County

Eighty-five (85) Twenty-nine (29) Twenty-eight (28)

Services offered/provided to Berks County consumers who currently reside in PCBH’s in Berks County include: Case Management. Rep-payee. Supported Living services. Assertive Community Treatment Team services. Outpatient services. Transportation to appointments. Partial. Peer Support services. CHIPP Services.

There are no identified needs at this time.

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No Peer Assessment of a Berks County consumer currently hospitalized at Wernersville State

Hospital for two years or more has indicated a preference for discharge to a Personal Care

Boarding Home. Intake Case Managers provide mobile outreach to Personal Care Boarding

Homes. Case Managers and Peer Specialists can engage Berks County residents in Personal Care

Boarding Home to educate them on the services Berks County provides which may support

these individuals in settings other than a Personal Care Boarding Home, should they choose to

leave and explore other housing options. Below is the Berks County Personal Care Boarding

Home Policy that is followed for discharge from Wernersville State Hospital into the

community.

POLICY STATEMENT: In support of the Personal Care Boarding Home (PCBH) policy of DPW and

OMHSAS it will be the goal of Service Access and Management, Inc, (SAM, Inc.) on behalf of the

Berks County MH/DD program, to assist individuals so that they have an opportunity to live in

the least restrictive environment, preferably in the community. This policy discourages referrals

of individuals who receive mental health services to personal care boarding facilities that

exceed 16 beds. This policy will outline the process by which individuals make informed choice

regarding where they live and the criteria for which an exemption to the adopted OMHSAS

policy can occur.

If placement in a Personal Care Boarding Home (PCBH) is the most appropriate option, it will be

the goal to refer individuals to PCBH facilities with no more than 16 beds.

PURPOSE STATEMENT: Berks County MH/DD fully supports the Principles of Recovery. In the

context of Personal Care Homes, consumers, having an active role in making decisions, should

have a choice in selecting the most appropriate housing option which may include Personal

Care Homes. Housing is a critical component in the lives of individuals and frees us to pursue

meaningful, satisfying, and productive lives. The development of the policy and process

outlining the manner in which individuals will make informed choices regarding housing will

encourage them to live in a community integrated environment and to utilize resources and

services in the community as often as possible.

SCOPE STATEMENT: The policy includes all consumers considering a placement in a Personal

Care Boarding Home (PCBH) who are involved with the MH/DD program. For individuals who

may be capable of maintaining an independent living situation, options for rental assistance

may be available through the Tenant-Based Rental Assistance (TBRA) programs operated by

SAM, Inc. and the Berks County MH/DD Program. Specifically, the Housing Assistance Program

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available through the Berks County MH/DD Housing Plan may be able to provide rental

assistance which will enable former PCBH residents to find safe, decent and affordable housing.

SAM, Inc. will work very closely with individuals who desire this as an option, to ensure the

necessary support services are also available which will be required to prepare individuals for

the major life-style change from living in a PCBH to residing in and maintaining their own

apartment.

In all Tenant Based Rental Assistance (TBRA) programs, some sort of funding source is paying a

portion of the rent directly to the landlord for a specific period of time, with the individual

and/or family being responsible for the remaining portion of the rent. Like all such programs,

the TBRA programs operated by Berks County MH/DD and SAM, Inc. use HUD income

guidelines to both determine who is eligible to receive assistance, as well as to factor the

amount of assistance received by each individual/family participant/unit.

PROCEDURE:

Assessment of Choice

Consumers awaiting discharge from Wernersville State Hospital are afforded opportunities to

participate in treatment team meetings and also the creation of their Community Support Plan

(CSP) prior to discharge.

During treatment team meetings, the consumer, the Berks County Hospital Liaison, the

consumer’s social worker, and any other additional advocates or appropriate individuals will

discuss all housing and support options available upon discharge and will provide the consumer

with information on all options.

A current PCBH Directory published by the Department of Public Welfare

www.dpw.state.pa.us should be reviewed in order to locate a PCBH with 16 beds or less and to determine the status of their license.

Contact will be made to any PCBH less than 16 beds to determine appropriateness and acceptance of the individual. There is one PCBH in Berks County that meets this criteria:

Down on the Farm

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610-385-6175

If the individual is being referred to a PCBH with more than 16 beds, the individual will be encouraged by the Berks County Hospital Liaison and/or the consumer’s social worker to visit at least two alternative housing options which, if available, will include a smaller PCBH.

In the event that a referral is being made to a PCBH with a provisional license a member of the PCBH Risk Management Committee should be consulted. Further conversation will follow with a representative from OMHSAS.

The Personal Care Boarding Home Tracking spreadsheet (located in the Common Folder, Management Team subfolder within SAM, Inc.’s database) will be completed in instances when a consumer moves to a Personal Care Boarding Home.

Documentation of this treatment team meeting will exist in records kept by Wernersville State Hospital as well as via case notes written by the Berks County Hospital Liaison and saved within the database used by SAM, Inc. to maintain consumer records.

Based on the options available and appropriate, the consumer will make an informed choice

regarding his/her preference for housing upon discharge.

This choice will be documented by the Berks County Hospital Liaison within the database used by SAM, Inc. to maintain records.

In instances when the consumer’s preference (or need if due to exceptions listed in the section

of this document labeled Exceptions on page 3 of this policy) is to be discharged to a Personal

Care Boarding Home with a capacity greater than 16 beds, the Berks County Hospital Liaison

will document the decision and discuss the case with the CHIPP Coordinator within two (2)

business days of the treatment team meeting.

During the discussion between Hospital Liaison and CHIPP Coordinator, the reason/s for the

need for an exception will be reviewed as listed below:

Exceptions

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The following delineate reasons for the request that an exception be made for an individual to

reside in a PCBH with greater than 16 beds despite ongoing planning to locate and secure a bed

at a PCBH with 16 beds or less.

The individual chooses to live in a large PCBH No other housing options are available or viable for the individual that meets their

needs Ensure the opportunity for an individual to visit at least two (2) alternate housing

options that offer greater community integration than a PCBH with more than 16 beds The PCBH must meet the Adult Residential Licensing standards for the Certificate of

Compliance by DPW The individual does not want to move to another county The PCBH meets the person’s needs as documented in their Community Support Plan The person would not otherwise be discharged from Wernersville State Hospital if the

exception for him/her to reside in a PCBH with greater than 16 beds is not made.

In the event that an exceptional circumstance exists as listed above, the CHIPP Coordinator will

initiate the Process for Requesting Exceptions.

Process for Requesting Exceptions

A Memo will be completed by the CHIPP Coordinator at Service Access & Management Inc.,

detailing the following:

Name of the consumer All housing options about which the consumer was informed during the treatment team

meeting at Wernersville State Hospital. The housing choice made by the consumer during the treatment team meeting. The reason for requesting an exception for the consumer to reside in a PCBH with

greater than 16 beds.

1. The Memo will be addressed to the Berks County MH/DD Administrator and will be delivered to the Berks County MH/DD Administrator within one (1) business day of the determination that a request for an exception is necessary.

2. The Berks County MH/DD Administrator will review the Memo and determine the appropriateness of the request.

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3. If the request is deemed inappropriate, the Berks County MH/DD Deputy Administrator will contact the CHIPP Coordinator at Service Access & Management Inc. to further discuss the case.

4. If the request is deemed appropriate, the Berks County MH/DD Deputy Administrator will communicate with the regional office of OMHSAS to request approval for the exception. Once approval or denial is obtained from OMHSAS, the Memo with indication of such as well as signature of the Berks County MH/DD Administrator or designee will be returned to the CHIPP Coordinator at Service Access & Management Inc. within five (5) business days from the original date of receipt.

5. The CHIPP Coordinator will subsequently inform the Berks County Hospital Liaison of the approval or denial, and the Hospital Liaison will inform the consumer and his/her treatment team of this decision. If the request for exception is denied, the treatment team will reconvene to

discuss alternate housing options with the consumer. If the request for exception is approved, a Community Support Plan Advisory

Team will meet with the consumer and Berks County Hospital Liaison to develop a Community Support Plan (CSP).

CSP Advisory Team members include the following:

Facilitator- This person guides the CSP meeting and ensures that each participant present has an opportunity to provide input. This person ensures the consumer has the opportunity to express his/her wants/needs during the meeting as well.

Psychiatrist- This person is present to provide clinical perspective regarding the consumer and to inform the group of the psychiatric services that may be most beneficial to the consumer upon discharge.

Medical Doctor- This person is present to provide updates on the current medical condition of the consumer and to inform of any medical issues that will need to be considered upon discharge into the community.

Social Worker- The Social Worker is present to provide additional information regarding the wants and needs of the consumer as well as any information regarding the course of treatment and the consumer’s level of participation.

County Representatives- The Hospital Liaison and CHIPP Coordinator for Berks County are present to discuss services and discharge options available within the community. The Hospital Liaison uses the information obtained from the CSP to create a discharge plan.

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Co-Occurring Disorder Coordinator- This individual is present at CSP meetings only if the consumer has a history of drug/alcohol use when in the community. This person offers support and encouragement to the consumer to participate in drug/alcohol services once in the community and offers direction as to where such services are located.

Certified Peer Specialist- The Certified Peer Specialist at WeSH attends the CSP to support the consumer during the CSP process.

CSS Peer/Family Specialist- This person conducts the Peer and Family Assessments sections of the CSP process with the consumer and his/her family. This person is present at the CSP meeting to offer his/her perspective on the assessments that had been completed.

Consumer- The consumer is present as it is his/her meeting. The consumer has the opportunity to express and have recorded the types of services and supports he/she wants/needs to be successful upon discharge into the community.

Advocates- An advocate from the Berks County Mental Health Association presents to ensure the wants/needs of the consumer are heard and recorded in the CSP.

Nurse/Aide- This person is present if he/she is available for the CSP meeting and is able to offer additional support and insight into the behavior of the consumer at WeSH.

Interpreter- An interpreter will present if the consumer is unable to speak or understand English, and this person will translate for the consumer as needed.

Family- Family members may present at the CSP upon request of the consumer and are to offer support on behalf of the consumer’s wants/needs.

One portion required for the successful development of a CSP is a discussion regarding housing

options available to the consumer which would enable the consumer to live in the least

restrictive, but most supportive environment possible

As the CSP is a written document, any discussion of the consumer’s desire to be discharged to a

PCBH after all housing options are discussed is documented on the support plan itself by the

team member responsible for taking notes at the meeting. The CSP remains on record at

Wernersville State Hospital. As treatment team meetings and CSP meetings are also attended

by the Berks County Hospital Liaison, any discussion and review of housing choices are

subsequently documented in case notes which become a part of the consumers record at

Service Access & Management, Inc.

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VIII. Comprehensive Funding Strategy to support the development of services:

Include the use of all funding sources that are currently available or may

become available (Medicaid, Medicare, waivers, housing funds, grants,

CHIPPs, etc.)

Potential Public and Private Funding Sources Available to Serve the Needs of Consumers:

State Funding

Medical Assistance

Medical Assistance Home and Community-Based Waivers

o Existing Waivers

o Assessment regarding whether a Waiver specifically for medically fragile

individuals with mental illness would be feasible

Medicare

Community Care Behavioral Health

Services Provided through the Pennsylvania Department of Aging and Office of Long

Term Living

Federal, State, and Local Housing Agencies (HUD, the Pennsylvania Housing Finance

Agency, Local Housing Team Options, and Local Housing and Redevelopment

Authorities)

IX. Summary or other information: This section can be used for purposes of

additional information or a summation of the plan.

The information captured above outlines the initial steps needed within Berks County

towards the Olmstead Plan. There currently are sixty-two (62) Berks County consumers

hospitalized at Wernersville State Hospital. This plan however only concentrates on the

thirty-six (36) Berks County consumers who are currently hospitalized at Wernersville State

Hospital for two (2) years or more. This is not an all inclusive plan. Not all Berks County

consumers at Wernersville State Hospital have gone through the Community Support Plan

process. Ten (10) of the Berks County consumers currently hospitalized at Wernersville

State Hospital for two (2) years or more have not had a Community Support Plan updated

since 2006. Nine (9) of the Berks County consumers currently hospitalized at Wernersville

State Hospital for two (2) years or more do not have a Peer Assessment. Seven (7) Berks

County consumers currently hospitalized at Wernersville State Hospital for two (2) years or

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more (7) do not have a Community Support Plan. Therefore this plan will constantly be

changing, evolving, and will be updated as each new Community Support Plan is completed.

Due to the unique needs of each Berks County consumer at Wernersville State Hospital,

services will be added and increased as each new consumer’s needs are assessed through

the Community Support Plan and Peer Assessment. Each new Berks County admission to

Wernersville State Hospital will also bring his/her own challenges and needs. Programs and

needs that have not been discussed will be added to the expanding catalogue of services

Berks County requires to successfully discharge all consumers back in to the community.

Accurate planning for services needed should Wernersville Sate Hospital close will require

the completion and consistent updating of Berks County Community Support Plans for all

Berks County consumers at Wernersville State Hospital.