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Transcript
Community MH Crisis Prevention and
Intervention Model for Persons with Intellectual
and Developmental Disabilities
What is START?
• The START Model provides prevention and intervention services to
individuals with developmental disabilities and complex behavioral
needs through crisis response, training, consultation, and respite.
The goal is to create a support network that is able to respond to
crisis needs at the community level. Providing supports that enable
an individual to remain in their home or community placement is the
first priority.
• START does not replace existing services in the community. START
provides training and technical assistance to enhance the ability of
the community to support individuals with DD and co-occurring
mental illness/complex behavioral needs.
Role of START
• Provide support and technical assistance to community
MH crisis and intervention supports
• Create and maintain linkages and relationships with
community partners
• Coordinate support meetings and cross systems crisis
plans for individuals
• Provide on-going consultation to providers and/or
families
• Provide training and technical assistance to community
partners
• Provide short-term respite – both emergency and
planned
History
• START Model was recommended by the DDPIC to the Division of MH/DD/SA
• START Model was presented to the Legislative
Oversight Committee in February 2008
• Funds were appropriated for community based
crisis
• Division held a training with Joan Beasley on
START for eligible providers and LME’s
• Two providers were designated to implement
this community based model
NC-START
- WEST
Alleg.
Ashe
Watauga
NC-START
-CENTRAL
Madison
Stokes
Person
Rockingham
Caswell
GranWarren
ville Vance
Forsyth
Guilford
Catawba
Graham
Rutherford Cleve
land
Polk
Lee
Cabarrus
Gaston
Beaufort
Pitt
Lincoln
Henderson
Jackson
Hyde
Stanly
Meck.
Montgomery
Greene
Wayne
Harnett
Moore
Lenoir
Craven
Trans
Cherokee
Tyrrell
Wilson
Chatham
Randolph
Rowan
Johnston
Haywood
Wash.
Martin
Buncombe
Swain
Edgecombe
Wake
Davidson
Burke
Bertie
Nash
Davie
Alex.
Iredell
McDowell
Halifax
Franklin
Alam. Orange
Durham
Caldwell
Hertford
Wilkes
Avery
Yancey
Gates
Northampton
Surry
Yadkin
Mitch
NC-START
- EAST
Macon
Cumberland
Clay
Union
Richmond
Hoke
Sampson
Jones
Pamlico
Duplin
Anson
Carteret
Onslow
Scotland
Robeson
Bladen
Pender
Columbus
New
Han
Brunswick
Dare
Planned Structure per Region Based on Gap Analysis
Current Structure per Region
Who is eligible for NC START?
• Individual has confirmed developmental
disability and is eighteen years of age or older
• Individual has significant behavioral challenges
and/or a co-occurring mental illness
• Individual demonstrates significant behavioral
challenges that require further psychological
and/or psychiatric intervention
• Current treatment attempts are unsuccessful
• Prior to full admission, case manager/care
coordinator is identified and participating
IDD and Mental Illness
• Psychiatric disorders in persons with IDD are
common but often not appropriately identified
• Determining accurate psychiatric diagnosis
becomes especially difficult as the level of
intellectual functioning declines
• As many as one third of people with IDD have
significant behavioral, mental, or personality
disorders requiring mental health services
• Beware of “diagnostic overshadowing” –
psychopathology overlooked because it is attributed
to ID (withdrawal, aggression, manic behavior)
IDD and Mental Illness
 Dual Diagnosis – defined as a person who has both an
intellectual disability and a psychiatric (mental) disorder
 Psychiatric disorders in persons with IDD are common
but often not appropriately identified
 As many as one third of people with IDD have
significant behavioral, mental, or personality disorders
requiring mental health services
 Determining accurate psychiatric diagnosis becomes
especially difficult as the level of intellectual functioning
declines
› Individuals with mild ID more often get diagnosed with
psychiatric disorders while individuals with severe/profound ID
are diagnosed with behavioral problems
Main Reasons Identified
(Presenting Problems) when People
with ID/ASD are referred for mental
health services:
• AGGRESSION
– To self
– To others
– To property
• Highly Disruptive or destructive
behavior
• People with IDD rarely self-refer for mental
health help
Charlot, 2014
11
Aggression is like a “fever”
• Not diagnostically specific
– MANY OF OUR PATIENTS HAVE A
“LIMITED BEHAVIORAL REPRTOIRE”
• When tired,…
• When upset about changes in
routine….
• When unhappy about an interaction
with a peer…
• When ill….
THE SAME SET OF symptoms of
ALTERED MOOD AND BEHAVIOR MAY
BE manifested for a different reason
Charlot, 2014
each time
12
• Most common disorders are mood and
anxiety disorders
• Bipolar Disorder and Psychosis are less
common, but very severe when they
occur
• Children often have symptoms of
ADHD
• Diagnosis is more challenging
• Many individuals have Mental health
service needs, even without Axis 1
conditions
Charlot, 2014
13
Why might misdiagnoses
occur?
• Many individuals with IDD are unable to adequately describe
their mood or cognitive states due to limited expressive
language or cognitive disorganization in response to
environmental stressors
• Some are unable to provide useful information or fully
understand the process of the psychiatric examination
• A failure to consider the contribution of a
medical/neurological illness or medication side effect can
also lead to the misdiagnosis of serious neurological
disorders (e.g. delirium) as a mental illness
Diagnostic Overshadowing
 Diagnostic overshadowing refers to the process of overattributing an individual’s symptoms to a particular condition,
resulting in key co-morbid conditions being undiagnosed and
untreated
 It was originally described in people with developmental
disabilities, where their psychiatric symptoms and behaviors
were falsely attributed to their disability, leaving any
comorbid psychiatric illness undiagnosed
 Research has shown that comorbid medical conditions are
often “diagnostically overshadowed” by the presence of a
prior psychiatric disorder or developmental disability
diagnosis
› For example: A doctor in the hospital assessment unit says (of
John) rubbing his head, “It may be a pattern of behavior as a
result of his disability.” In other words, he interprets John's
head-rubbing as being symptomatic of his developmental
disability and doesn’t investigate it further when it could be an
important indicator of John’s medical condition
Other factors that might affect diagnosis
Intellectual distortion
› Emotional symptoms are difficult to elicit
because of deficits in abstract thinking and
in receptive/expressive language skillsindividual cannot accurately understand
the question
› Questions are too complex and answers
often meaningless
› “Do you hear voices when no one is
there?”
› “Do you take drugs? Do you drink?”
Psychosocial masking
› Symptomology occurs within a
developmental framework (e.g., mania
presenting as a belief that one can drive a
car)
› A delusion of being the chief of police may
be mistaken for a harmless fantasy
› An imaginary friend may be mistaken for a
delusion
Cognitive disintegration
› Lack of “cognitive reserve” - Decreased
ability to tolerate stress, leading to
anxiety-induced decompensation under
stress (lose skills, become mute, etc.)
› Sometimes misinterpreted as psychosis,
bipolar disorder, or dementia
Baseline exaggeration
› Increase in the severity or frequency of
chronic maladaptive behavior after onset
of psychiatric illness
› Challenging behavior that exists at a low
rate and low intensity may increase
dramatically under stress or when there is
a mental health issue
› Often the behavior becomes the focus
when it is a sign or symptom
Essential Components








Linkages
Expertise, training
Family support and education
Planned and emergency therapeutic resources (respite
services)
Crisis Response
Cross-systems crisis prevention and intervention
planning
Employs evidence-informed practices and outcome
measures (advisory council, clinical team, data analysis)
Learning communities, local, regional, statewide,
national
Numbers Benefitting from
Intervention
System gap analyses, work force development and identification of risk factors
Primary Intervention: Improved access to services, treatment
planning, integration of health and wellness, and development
of service linkages
Effective Strategies
‘Changing the odds’
Secondary Intervention: Identification of
individual/family stressors, crisis
planning/prevention, respite services,
medication monitoring and crisis
intervention services
Improved Supports
‘Beating the odds’
Potential
impact of
intervention
Tertiary Intervention:
Emergency room services,
hospitalizations and law
enforcement
interventions
Accurate
Response
‘Facing
the
odds’
Required
intensity of
intervention
Core Principles
• Positive Psychology
• Trauma Informed Approach
• Systemic Approach
Outcomes
•
•
•
•
•
•
•
•
Maintain stable community residence
Access and engage resources
Decrease behavioral challenges
Decrease mental health symptoms
Decrease state facility and hospital utilization
Increase community involvement
Increase crisis expertise incommunity
Implement and maintain community partnerships
Caseloads
• -From 2011-2012 START had an 18% increase in caseload with
another 18% increase from 2012-2013. From 2013 through the first
quarter of FY14 there was an increase of 15%.
• -Overall, since 2010 the teams have seen a 41% increase in
caseloads
• Caseloads in the Central region have exceeded 50. The West is
approaching this number also. START Model is based on 25-30
cases per coordinator.
From the data
•
•
•
•
Average age – early 20’s
Psychiatric and medical complexity
Approximately half have mild ID
Increase in referrals from ED (most recent
quarter 37%)
• Disposition for large majority of referrals
continues to be avoiding higher level of
care and higher costs.(around 70%
maintain current setting).
• Current active caseload is 560 with the average
caseload per coordinator at about 46.
• Most individuals served (67%) are
Medicaid/non-Innovations recipients with limited
services and supports.
• Approximately 50 individuals were denied NC
START services in the Central region due to
capacity issues this most recent quarter.
Recent Quarter Data
• Over 500 people supported
• 130 respite admissions: ALOS for planned - 4 days; and crisis
respite at – 21 days.
• The number of denied respite requests has risen steadily this fiscal
year with the current quarter reflecting 101. 53, or half, of all denials
were due to the homes being at capacity. An additional 13 had no
return address.
• 1814 hours of planned services (cross system crisis planning
development, intake assessments, family support, and transition
planning with our developmental centers and state hospitals).
• 140 hours of training was provided to the system including training
to MCO staff, providers, family members, and police or emergency
response. This is the prevention work that the teams should focus
on; but due to limited resources are unable to do so.
Trends
FY 2010
FY 2011
FY 2012
FY2013
FY 2014
(est)
# Served
394
340
402
474
600
Funding
Medicaid
Non-waiver
52%
56%
64%
63%
67%
Predominant
Referral
Source
Clinical
Home/Case
Mgmt
Clinical
Home/Case
Mgmt
Clinical
Home/Case
Mgmt
Hospital ED
35%
Hospital ED
Referrals
from ED
87
207
231
383
Hours of
training
1085
1057
1211
802
Less than
half of
previous
year
On-going Support to System
• Teams continue to support EDs, providers, and MCOs; and prevent
unnecessary more intensive services
• CET – Clinical Education Team – case presentations and training in
a community forum
• Quarterly regional Advisory Council meetings
• Transition planning supports to developmental centers for
individuals transitioning to the community.
• Clinical collaborative meetings with state hospitals on a monthly
basis to collaborate on the treatment needs and planning, including
discharge planning, for individuals with an intellectual/developmental
disability (IDD) in the state hospital.