CCSC Recommendations Report FINAL...
Transcript of CCSC Recommendations Report FINAL...
ColoradoCrisisSteeringCommittee
FinalReportand Recommendations
PreparedbySHGAdvisorsJune2018
TheColoradoCrisisSteeringCommittee
TheColoradoCrisisSteeringCommitteeisagroupofdiversestakeholderswhoworkedtogethertoproviderecommendationstotheColoradoDepartmentofHumanServices(CDHS)onhowtoimproveandenhancetheState’sbehavioralhealthcrisissystem.TheCommitteemettoidentifygapsincurrentservicedelivery,aswellasopportunitiestoincreasesystemefficienciesthatwillimproveresponseinallcommunitiesandreachthosepopulationsathighestrisk.Additionally,theCommitteesoughttounderstandhowdatacouldbebetterusedtodemonstratetheeffectivenessofthesystem.
Thisdocumentistheresultofthecombinedeffortsoftheindividualslistedbelowandthestakeholdersandcontentexpertswhosharedtheirinsights,knowledge,andperspectivestoadvancetheCommittee’swork.
TheresaAnselmoColoradoAssociationofLocalPublicHealthOfficials
TomBarrettMentalHealthColorado
AubreyBoggsColoradoMentalWellnessNetwork
JasonDeaBuenoSouthernColoradoCrisisConnection
RickDoucet CommunityCrisisConnection
JoshuaEwingColoradoHospitalAssociation
GretchenHammerDepartmentofHealthCarePolicy&Finance
CamilleHardingColoradoDepartmentofHumanServicesOfficeofBehavioralHealth
JarrodHindmanColoradoDepartmentofPublicHealth&Environment
CheriJahnStateSenator
TracyKraft-TharpStateRepresentative
LoisLandgrafStateRepresentative
BevMarquezRockyMountainCrisisPartners
MichaelMcIntoshCountySheriffsofColoradoAssociation
DafnaMichaelsonJenetStateRepresentative
JerenePetersenColoradoDepartmentofHumanServices
LarryPottorffNortheastBehavioralHealth
ShellySpauldingWestSlopeCASA
SarahVaineSummitCountyGovernmentDepartmentofHumanServices
RobertWerthwein,CommitteeChairColoradoDepartmentofHumanServicesOfficeofBehavioralHealth
TonyaWheelerAdvocatesforRecovery
Specialthanksto:MicheleLueckandEmilyJohnsonoftheColoradoHealthInstitutefortheirdataanalysisandrecommendations.
ColoradoCrisisServicesEstablishedin2014,ColoradoCrisisServicesispartoftheState’s“StrengtheningColorado’sMentalHealthSystem:APlantoSafeguardAllColoradans.”ItisaninitiativechampionedbyGovernorHickenlooper,andisthefirststatewideresourceformentalhealth,substanceabuseoremotionalcrisishelp,informationandreferrals.Itspurposeistoprovidegreateraccesstomentalhealthservices,ensuringColoradansgettherightservicesintherightlocationsattherighttime.Thesystempromotesaccesstothemostappropriatesupportsandresourcesasearlyaspossibletodecreasetheutilizationofhospitalemergencydepartments,jails,prisonsandhomelessprogramsforbehavioralhealthemergencies.Thissystemisrevolutionary,and,initsinfancy,hasalreadytransformedcrisisservicesinColorado.Yet,therearestillchallengestoacknowledgeandimprovementstobemade.Ultimately,itwillreflectacontinuumofcarefromcrisisresponsethroughstabilizationandsafereturntothecommunitywithadequatesupportfortransitionstoeachstage.Thecrisissystemisstrivingtomakeaculturalshift,andthosetypesofevolutions–andtheirimpacts–taketime.
ColoradoCrisisServicescurrentlyconsistsoffivemodalities:(1) StatewideHotline.Thestatewidecrisishotlineisa24/7,year-round,community-basedsystemofcrisisintervention
servicesfromwhichpeopleexperiencingmentalhealthand/orsubstanceabusecrisiscanbesafelyandeffectivelystabilizedandefficientlylinkedtoappropriatefollow-upcareandservices.
(2) MobileServices.MobileServicesrespondtowheretheclientis,within1hourinurbanareasand2hoursinruralareas.
Itisstatewideandavailable24/7/365.MobileServicesworkscollaborativelywithtelephonecrisisservices,walk-inservices,crisisstabilizationunitsandcrisisresidential-andcommunity-basedservices.MobileServicesworkscloselywithlawenforcement,schoolsandhospitalemergencydepartments.
(3) Walk-InCenters.Atthewritingofthisreport(June2018),thereare12Walk-InCentersacrosstheState.Walk-In
Centersareopen24/7andofferconfidential,in-personassistance.Servicesareprovidedtocustomerswithin1hourofarrivaltime,andcustomerscanstayforupto23hours.ThefocusofWalk-InCentersincludesintervention,education,connectingtocommunityresourcesandreferralstohigherlevelsofcare(ifapplicable).
(4) CrisisStabilizationUnits.CrisisStabilizationUnits(CSUs)provideonsitetherapyforuptofivedays.Thesupportmaybe
intheformofone-on-onecounseling,grouptherapy,medicationmanagement,oracombinationofallservices.CSUsareavailableforinvoluntaryandvoluntaryadmissions.Afterstabilizingthecrisis,therapistsintheunitworkwiththepatienttocreatealong-termtreatmentplanandhelpthemreintegratebackintothecommunity.AcrossColorado,thereare107CSUbedsavailableasofJune2018.
(5) Respite.Respitecareservicesprovidetherapymanagement,medicationmanagementandin-patientmentalhealth
treatmentforupto14days.Colorado’smentalhealthcrisissystemhastwotypesofrespiteservices,oneforadultsandanotherforchildrenandadolescents.Adultrespiteservicesconnectpatientstodesignatedbedsinthecommunity,wheretheycanremainforupto14days.Respitecarelocationsoffercounseling,medicationmanagement,andsupportforfamiliesandcaregivers.Respiteservicesareavailableforvoluntaryadmissionsonly.
CommitteePurposeTheColoradoCrisisSteeringCommitteewasformedinearly2018to:
• Identifygapsincurrentservicedeliveryoraccess.• Addresstheuseofdatatodemonstratetheeffectivenessofthesystem.• Increasesystemefficienciesforcrisisservicesandimprovemobileresponseincommunities.• Establishservicesandclinicalstandardstomeettheneedsoftheintendedpopulation.• Ensurethatservicesarereachingthosepopulationsathighestriskofsuicideincludingadolescents,adultmenand
veterans.• Addresslicensingchallengesandprioritizeregionalsolutionsforco-locatedandfullyintegratedservices.
TheCommitteeistaskedwithdescribingtherecommendationsitwouldliketoseeimplemented.OBHwilldeterminethe“when”andthe“how.”ProcessTheSteeringCommitteemeteighttimesbetweenMarchandJune2018.Allmeetingswereopentothepublic,withobserversinattendance,andincludedopportunitiesforpublicinput.SHGAdvisors,alocalconsultingfirm,facilitatedanddocumentedtheprocess.
Overthethirteen-weekperiodduringwhichitmet,theSteeringCommitteespenttimeunderstandinghowthecurrentsystemisfunctioning.TwosurveysweredisseminatedacrosstheState:onetosolicitinputfromstakeholders,especiallythoseinruralareas;andanothersurveytosolicitinputfromconsumers(orfamily/friendsofconsumers)whohaveusedthecrisissystem.Twosub-groupsformed(oneforthehotline&MobileServices;andtheotherforwalk-incenters,crisisstabilizationunitsandrespite)toidentifyprioritizedrecommendations.Theserecommendationswerepresentedatanall-dayworkshoponMay18th,atwhichtimeCommitteemembersinformallyvotedontherecommendationstheymostsupported.TheserecommendationswerecompiledanddistributedtothefullCommitteeforanelectronicvote.(SeeAppendixB:SummaryofTaskForceMeetingAgendasandPresentations.SeetheCDHSCrisisSystemExecutiveSteeringCommitteewebsiteformeetingagendas,presentations,minutes,andrelatedmaterials.)
Initsfirstmeeting,theCommitteediscussedandagreeduponthefollowingmechanismtomakedecisionsgoingforward:
• Uponvoting,themajorityvotewins.o IfaCommitteemember(s)votesintheminority,theyhavetheoptiontowriteandsubmita
summaryoftheiropinion.o TheCommitteewillvoteontheminorityreporttoensurethatitaccuratelyreflectsthe
conversationwhenthevotetookplace.Ifvotedintheaffirmative,theminorityreportwillbeincludedinthefinalreportsubmittedtotheCDHSDirector.
OnJune15,2018,theSteeringCommitteeapprovedtherecommendationssharedinthisreport.
RecommendationsTheCrisisSteeringCommitteeembracedtheideaof“NoWrongDoor.”Inotherwords,ifapersonisinneedofcrisisservices,theyshouldbeabletoaccessservicesusinganyofthemodalitiesavailablethroughthecrisissystem.Thecrisissystemaimstoprovidetherightservices,intherightlocations,attherighttime.Itshouldbeaflexible,integratedsystemthatmeetsthecommunityneedsandacknowledgeseachcommunity’snuances.Giventheever-changingenvironmentinwhichwelive,thesystemshouldremaincurrentandrelevant.AcknowledgingthatthecrisissystemneedstoprovidegreateraccesstomentalhealthservicestoensureColoradansgettherightservicesintherightlocationsattherighttime,theserecommendationsweresupportedbythemajorityofCommitteememberswhovoted:
RecommendationOne:Increasethebreadthanddepthofservicesforyouthandchildren.ThereareanumberofstepsthatCDHScantaketoensurethatyouthandchildrenhaveaccesstobehavioralhealthservices:
• Launchatargetedmarketingcampaign.ReviewtheresultsfromthepilotconductedinColoradoSprings(targetedat10-16-yearolds)and,ifsuccessful,considerscaling.
• YouthMentalHealthFirstAid(YMHFA).ExpandYMHFAtrainingtoparents,familymembers,caregivers,teachers,schoolstaff,andpeers.InstructpartnersthatanyState-sponsoredorState-fundedactivity/initiativeinwhichyouthparticipaterequiresthattheColoradoCrisisHotlinenumberisaddedtotheyouth’scellphone.
• Increasebedcapacity.Increaseoptionsforyouthwithsubstanceusedisorders,eitherasrespiteorlonger-termplacement.Improveresidentialtreatmentcapacity.ThiscouldimprovegivenMedicaid’srecenteffortstoobtainawaivertoprovideinpatientandresidentialsubstanceusedisordertreatment.
• Increaserespitecapacity.Inthelastlegislativesession,thefinancecommitteeapprovedanincreaseinmoneyforin-homerespite.Ensurethatthisisbeingusedeffectively.
• Offertwo-waytextingcapacity.Thistechnologyoffersaconversationalnatureoftexting,andenhancestheSMSconversationbyactivelyengagingyouth.Youthcouldindicateiftheyare“okay”ornot.Dependingontheresponse,theyouthwouldbeconnectedtoa“live”person.
RecommendationTwo:Increasepeersupportinallareas.Peersupportspecialists(PSS)arepeoplelivinginrecoverywithmentalhealthconditionsand/orsubstanceusedisorderswhohavebeentrained,basedoncorecompetencies.Peersupportworkswhenindividualsaretrainedandhavepropersupervisionandsupport.Peer-runservicesarenottrulypeer-rununlesspeersareinvolved–trulyinvolved–everysinglestepofthewayinbuildingthoseservices.ThereareseveralstepsthatCDHScantaketoeffectivelyincreasePSS:
• Definetrainingstandards(modelsforthisexist)forPSS.InColorado,peersarecurrentlymadePSSbymanydifferentstandards.TheidealstandardforaPSStrainingprogramisonebasedoffoffeedbackfromthepeercommunity.Peoplewithlivedexperienceshouldbetheonescreatinganddefiningwhatthattraininglookslike.
• Addressandensureappropriateandsupportivesupervision.EstablishstandardsforpeersupervisionsothatPSSwillavoidburnoutmoreeasily.Considerusingthe5PillarsofPeerSupportSupervision.
• Offerpeerrespite.Peerrespitesaremostoftenovernight/short-termprogramsthatarecompletelyvoluntary.Peerrespiteshaveastaffandleadershipthatare100%peoplewithlivedexperienceofmentalhealthconditionsand/orsubstanceusedisorders,thebehavioralhealthsystem,and/orcrisissystemexperience,oratleastthatthemajorityofthestaffhavelivedexperience.Peerrespitesoftenvaryinservices,policies,size,andmore,buttheonethingthatiscommonacrosspeerrespiteisthattheyarevoluntary,recovery-focused,trauma-informed,andarerunandoperatedbythepeercommunity.
RecommendationThree:Leveragetechnologytoconnectandsimplifythestateandlocalcrisislines.TherearetwooptionsthatCDHScouldexploreunderthisrecommendation:
• CreateaGPS-enabledappthatpeoplecanusetofindthecrisisresourcesclosesttothem.Thisoptionoffersalocal-andregional-basedface-to-faceservicechoiceatpointofaccess.Thisoptioncouldincludetheabilitytotalktoacounseloronthetelephoneviathestateorlocalagencycallline.Thestatehotlinecouldusethesametechnologytotriagetothelocal/regional-basedface-to-faceoption.ItwouldbebeneficialforallpartiestohavesharedElectronicHealthRecordssothatclientscanbetracked,medicalhistoriesareaccessible,andresponsesareconsistentthroughoutthecrisissystem.
• MaintainastatewidehotlineintheColoradoCrisisServicesprogramandcreateanappforcustomerstoaccessthehotline/text/peersupportlineandnavigateColoradoCrisisServicesasaprogram(anappnamecouldbeeasiertorememberthanaphonenumber).Thestatehotline
couldalsousethetechnologytolocatein-the-momentwalk-incapacity,waittimes,etc.,aswellaslocateanddispatchmobilecrisisdirectlytowheretheclientislocated.Itwouldbebeneficialtosharecrisissystemclientdatasothatclients’historiesinthecrisissystemareknownacrossallmodalities,andfollow-upisconsistent,anddatacomprehensiveandmeaningful.
RecommendationFour:DeterminehowtheCo-ResponderModel&MobileServicescanbeusedinacrisissituation.TheCo-ResponderModel,launchedin2018,partnerslawenforcementofficerswithbehavioralhealthspecialiststointerveneonmentalhealth-related911calls.Thesetwo-personteamsworktode-escalatesituationsbydivertingindividualsincrisisforimmediatebehavioralhealthassessmentsinsteadofarrest.BecausetheCo-Respondermodelissonew,itsimplicationsandimpactarenotyetclear.TheCo-ResponderModelinnotformallyacomponentofColoradoCrisisServices;however,itwouldbeworthwhiletounderstandtheimpactoneachsystem,howtominimizeredundancy,andhowtobetterleveragerelatedoroverlappingservicesasdataiscollectedthroughouttheModel’simplementation.RecommendationFive:Developandimplementanoutcomeevaluationsystem.Thecrisissystemwasdevelopedwiththeintentofprovidinggreateraccesstomentalhealthservices,ensuringColoradansgettherightservicesintherightlocationsattherighttime.Howthisismeasuredandtowhatcanbeattributedtoprogressisunclear.Anoutcomeevaluationsystemwillinvestigatetheextenttowhichthecrisissystemisachievingitsshort-termandmedium-termoutcomesoncethoseoutcomesaredefined.Itwillgeneratedatathatcandeterminetowhatdegreethoseoutcomesareattributabletothesystemitself.Itcouldmeasuretheeffectivenessofthesystem,andultimatelymakeitmoreeffectiveintermsofdeliveringtheintendedbenefits.Anoutcomeevaluationistypicallyimplementedafteraprogramhasoperatedforaperiodoftime,andshouldmeasureoutcomesagainstsettargets–whichmeansthattargetsneedtobeestablishedforthecrisissystem.Coursecorrectionscanbemadewhentargetsarenotreached.Becausethisareaissospecialized,theStatewillneedtocontractwithafirmtodevelopandimplementtheoutcomeevaluationsystem.RecommendationSix:EstablishaLeadershipCommittee.ThepurposeoftheLeadershipCommitteeistoprovideaconsistentqualityreviewoftheColoradoCrisisServices.TheLeadershipCommitteewouldincludeadiversesetofmembers,includingconsumers,communitymembers,hospitals,lawenforcement,andrepresentativesfrompublichealth,humanservicesandadvocacyorganizations.TheCommitteewillreviewprogresstowardoutcomes,aswellasidentifybarrierstoachievingoutcomes.TheLeadershipCommitteewillalsoidentifynewneeds(e.g.,publicsafety)anddeterminehowthecrisissystemcanaddressthoseneeds.HavingaLeadershipCommitteeinplacecouldpreventtheongoingneedforadditionalcommitteesandtaskforcestoreviewandmakerecommendationsrelevanttothecrisissystem.Additionally,theCommitteeshouldensurethatthevoicesofdiverseconsumersandfamiliesareintegratedintotheirmeetingsandconversations,andtheCommitteeshouldsolicitongoingfeedbackfromthesekeystakeholders.
RecommendationSeven:Improveintegrationofservicesformentalhealth/substanceabusedisorderwithinCrisisStabilizationUnits.Manypatientshaveco-occurringdiagnoses.Currently,theUniformServiceCodingStandardscodingmanualstatesthatnootherSUDservicescanbereimbursediftheyarebilledonthesamedayasdetox.OBHregulationscurrentlystate,“Innoeventshallafacilityadmitorkeepaclientwho…hasacutewithdrawalsymptoms,isatriskofwithdrawalsymptoms,orisincapacitatedduetoasubstanceabusedisorder.”Atpresent,perlicensingrules,MentalHealthandSubstanceUseDisorderclientsmustbekeptseparated.CreatingseparatesilosforMentalHealthandSubstanceUseDisordercasesiscounter-intuitive.Manyconsumersadmittedfordetoxalsohavementalhealthandmedicalneeds.Addressingtheseneedswouldhelpreducerecidivismandcontributetobetterpsychologicaladjustment.Inruralareas,thereisaneedtocombineMentalHealthandSubstanceUseDisordersduetolimitedspace(i.e.,smallerfacilitieswithfewbeds)andlimitedresources.TofullystaffadetoxfacilityandaCSUfacilitysidebyside,withonlyafewbedsineach,isinefficientandtoocostlyinruralareas.
RecommendationEight:Offerastatewide-integrateddataandresourcesystemfortheHotline.Anintegratedcrisissystemdatabasewouldallowforallcrisisproviderstodocumentandguidecrisissystemactivity.Regionalproviderswouldhaveincreasedconfidenceintheassessmentandtriagerecommendedbythecrisislineproviderbecauseoftheadditionalknowledgeofclientsbeingconsidered.Althougheachindividualprovidercurrentlyhasinternalandexternalfacingdashboardsoncoloradocrisisservices.org,dashboardactivitycouldbeexpandedtotheoperationssideofcrisisservices.Clientswouldbebetter
served,asserviceproviderswouldhaveaccesstounderstandtheirhistoryandhowtheirneedscanbestbemet.Itwouldbeeasiertofollowupwithclientsand/ortrackwheretheyreceivedservicesfollowingareferralor“warmhand-off.”RecommendationNine:Implementtargetedmarketingforthosepopulationsnotservedbythecrisissystem.Thereneedstobeananalysiscompletedtounderstandwhoiscurrentlynotbeingserved.Thiscouldbebetterunderstoodbyastreamlineddatacollectionandreportingsystem.Onlythencananappropriatemarketingstrategybedevelopedandimplementedtoensurethatthecrisissystemreachesallpopulations.
RecommendationTen:Exploreusinga3-digitnumberforcrisisline.Thecurrentstatewidehotlinenumberis844-493-TALK(8255).Inacrisis,itisalongnumberforapersontoremember.Itmaybebeneficialforthestatewidehotlinetouseaneworexisting3-digitnumber(suchas2-1-1,whichcurrentlyprovidesconnectionsforfood,housing,rent/utilityaid,emergencyshelter,etc.).Thefunctionsofthehotlineand211areverydifferentandcouldchangetheexperienceofthecallerdramatically.Thereisnationallegislationalreadyunderwaytoexplorethisoptionforthenationalsuicidepreventionlifeline,whichwouldimpactColoradoCrisisServiceslinevolumeaswell.Callerexperience,capacity,expertiseandcostsareimportanttoconsiderandneedtobestudiedcloselybeforeadecisionismade.
AlistofotherwidelysupportedrecommendationscanbefoundinAppendixA.
AdditionalRecommendations:DataTheColoradoHealthInstitute(CHI)wasengagedtocompletedataanalysisthroughoutthetimeframethattheSteeringCommitteemet.Threemajorthemesarounddataanalysisemergedaspartofthiswork:consistency,accuracyandthepresenceofdatagaps.Dataconsistencyreferstothepresenceofcontradictoryinformationdependingonthesource.Accuracypointstoconcernsoftheoverallcorrectnessofdata.Finally,thepresenceofdatagapsreferstotheinabilityofdatatoanswerkeyquestionsraisedbytheCommittee.
TABLE1:SummaryofDataAnalysisThemesTheme Description Examples
Consistency Differentvaluesindifferentsystems
Inconsistentdefinitions
SlightlydifferentvaluesofclientdemographicsinreportsfromCSOsversuscompileddatafromOBHbasedonmonthlyCSOdatasubmission
DifferencesbetweenCSOsonhowtheydefinedenominatorfornon-dispatchedmobileservices
Differentdefinitionsof“respite”
Accuracy GeneralconcernsAdministrativeerrors
PossibleincorrectlocationscodedforsomemobileservicesInvalidMedicaidIDsinHCPF-supplementedclaimsdatasetInvalidvaluesinclaimsdatacells(e.g.,firstnameslistedunderDOB)
PresenceofDataGaps
DatasilosDataincompleteness
UnabletoconnecthotlinedatatoCSOserviceprovision
Unabletoanswerquestionssuchaspayermixofclients
PotentialsolutionstotheseissueswereidentifiedduringCHI’sdataanalysis,stakeholderfeedbackandconversationswiththeSteeringCommittee,OBHandCBHC.Thesearediscussedbelowinorderofscope.
• Acentralizeddataandreportingsystemwilladdressmanyoftheproblemsidentified.Thissystemwouldcreatea
directconnectionbetweenasharedcrisissystemsdatabaseandelectronichealthrecords,ordesignateaspotforregulardatauploadsfromcrisisserviceproviders.Alldatapulls,includingdashboardsandkeyindicators,couldbebuiltoffasharedsystemandavailabletousersdesignatedthroughadataagreement.
Thissystemaddressestheproblemofconsistencybyeliminatingthepossibilityforcompetingvalues.Itaddressesaccuracybylimitingadministrativeerrorsduetotypos,whichoftenoccurwhenprocessesaremanual.Finally,shareddatabasesallowmoreflexibilityinansweringquestions—forexample,queriesmayberunoncustomagegroupings,orcross-tabulationscanbedonebygenderandcaresetting.
• Whetheronitsownorpartofacentralizedreportingsystem,thedevelopmentofadatadictionarywillgreatly
improvethedataqualityinthecrisisservicessystem,andthereforeallowformorerobustanalyses.Adatadictionarywillofferstandardandcompletedefinitionsforeverypieceofdatacollectedsothatthereisuniformityacrosslocationsandservices.Thiswillalleviatemanyoftheissuestouchingonconsistency.
• Currently,fewchecksexisttoensurethevalidityofdatacollectedwithincrisisservices.Athirdrecommendationis
toimplementdatavalidationsystemsandprocesses.Datavalidationcaninvolverelativelysimplechanges,suchastheuseofaformthatdoesnotallowuserstosubmitvaluesthatareinvalid(e.g.,charactersinanumericfield)ornonsensical(e.g.,anumberofclientsthatexceedsthenumberofvisits).
Theuseofdatavalidationiskeytoaddressingconcernsaboutdataaccuracybypreventingerrorsduetotyposormisunderstandingsofquestionsattheirsource.
• Afourthsolutiontodataissuesis,forthosewantingtolearnmoreaboutthecrisissystemanditsperformance,toidentifytherequireddatatheywillneedtogetacompletepicture.TheSteeringCommittee,serviceprovidersandotherstakeholdersshouldtakeaproactiveapproachinidentifyingwhattheywillneedtoproperlyunderstandthesystem.Whileashareddatabasewouldgoalongwaytoaddressingthisproblem,asthesystemexiststoday,dataofinterestmustbeidentifiedatthestartofserviceprovision—itcannotbededucedafterthefactifithasnotbeentrackedallalong.Thisaddressesissueswithdatagapsbyensuringthatquestionsaskedbystakeholderswillbeanswerableinthefuture.
• Astreamlineddatareportingprocesscansolvemanyoftheseproblemsaswell.Streamlinedreportingcanbeaccomplishedwithashareddatabase;yetevenintheabsenceofashareddatabase,amorestreamlinedprocessispossible.Theprocessshouldlimitmanualorduplicativeprocedures.Forexample,whencrisisprovidersreportdatatoOBH,OBHshoulduseamacrotohavethisdataautomaticallyinputintoatable,ratherthanusingamanualentryprocess.Thisaddressesaccuracyconcernsbylimitingadministrativeerrors.
• Theintegrationofdatacollectionsystemswillallowformorerobustreportingoncrisisservices.Onefrequentlycitedexamplewasarequesttointegratehotlineandmobileresponsedatacollectionsystems,butCHIsuggestsintegrationbetweenallservicesprovided,includingwalk-in,crisisstabilizationandrespite.
Thisintegrationwillservetoaddresstwoofthethemesidentified.Accuracywillimprovebecausedatafrommultiplesystemscannowserveascross-validation—forexample,whenvaluesonmobiledispatchesexceedvaluesofmobilerequests,thisflagsaninconsistencyinonesystem.Integratedsystemswillalsoallowformorerobustquestionsaskedbystakeholdersatmanyofthesemeetingstobeanswerableinthefuture.
• Finally,arelativelysimplewaytoaddresssomedataconcernsistoidentifythetimeframewithinwhichdataistrulyneeded.Withinthecrisisservicesreportinginfrastructure,apremiumiscurrentlyplacedondatafreshnessovercompletenessoraccuracy.DatasubmittedbyCSOsisoftenchangedafter-the-factduetoresolutionsinclaimsorotheredits.OBHmayconsiderwhetherJanuarydataistrulyneededinFebruary,orifthisinformationcanwaituntilMarch.Lesstimelydatamaybeanacceptablecostforthebenefits.
Improvementsinconsistencywillnaturallyfollowbyminimizingthenumberofdatasourceswithdifferingvalues—forexample,“January”valuesreportedinFebruarywillnowmatchthosereportedinMarch.Datawillalsobemoreaccuratebecauseoftheincreasedconfidenceincorrectvaluesatthetimethesearesubmitted.
ThereiscertainlyacknowledgementamongtheSteeringCommittee,CHIandotherstakeholdersthatnoneoftheserecommendationscomewithoutchallengesandconsiderations.Asharedstatewidedatabase,whileaddressingmanydataconcerns,isahigh-costandhigh-effortsolution,especiallyupfront.ItalsomayrequireprovidersattheCSOstoconducttheirworkacrosstwoplatforms—onethatfeedsintotheshareddatabaseandanotherusedfortheirnon-crisiswork.Inaddition,everyadditionaldatapointcollectedisanextraburdenonproviders,andthismustbeweighedagainstthedesireformorerobustinformation.
Finally,asneweffortsareundertaken,thecrisissystemmustremainvigilantthateverychangeprovidesatangiblebenefittotheclientswhoneedtheseservices.DataimprovementsmustalwaysbemadeinthecontextofadirectbenefittotheseColoradans.
AdditionalConsiderationsThroughoutthecourseoftheCommitteemeetings,therewereadditionalconsiderationsthatwereconsistentlyraised:
• Workforce.Coloradoisfortunatetohaveastrong,growingeconomy.Thenegativeresultofthatgrowthistheongoingchallengetofillmuch-neededpositionsincriticalfields–includingbehavioralhealth.Itisdifficulttorecruitqualifiedindividualswhoarewillingtoworkeveningsandweekendswithapopulationwhohascriticalhealthneeds–especiallywhenlicensedprofessionalscanearnahighersalaryinprivatepracticeandsettheirownofficehours.Itisequallydifficulttoretainthoseemployees.Positionsinthebehavioralhealthfieldareoftenstressful,whichleadstoincreasedturnover.Thisonlyimpedesthesystem’sabilitytoservepeoplewhoareinneedofservices.ItisevenmorechallengingintheruralandfrontierareasoftheState.Becausetherearesomanydifferentprofessionsthatarestrugglingtorecruitandretainqualifiedemployees,itwillbecriticalfortheBehavioralHealthsystemtodevelopcreativeinitiativestoattracttherightworkforce.Thereareanumberofwaysinwhichtheworkforcechallengecouldbeaddressed:
o Launchloanforgivenessprogramsthatincludenon-traditionaloutpatientserviceso OfferongoingworkforcedevelopmentforprofessionalstaffintheareaofCrisisServices(i.e.,a“crisis
track”atuniversities,colleges,etc.)o Createpartnershipsbetweenurbanandruralproviderstoleveragetheuseoftele-health
• Stigma.Almosteveryoneagreesthatstigmaisahugeissueandneedstobeaddressed.Therearealotofstepsthat
canbetakentoreducestigma–includingpubliceducation,thoughtfuluseoflanguage,integratingphysicalandmentalhealth–butitisamassivehurdletoovercome,andamindsetthatwillnotbeeasilychanged.Andyetitcannotbeignored.
• CulturalCompetency.Coloradohasagrowinganddiversepopulation.PerSAMHSA,culturalcompetence,theabilitytointeracteffectivelywithpeopleofdifferentcultures,helpstoensurethattheneedsofallcommunitymembersareaddressed.Culturalcompetencemeanstoberespectfulandresponsivetothehealthbeliefsandpractices—andculturalandlinguisticneeds—ofdiversepopulationgroups.IftheColoradoCrisisSystemistoserveallpersons,itmustreflectaculturallysensitiveenvironment.
• Transportation.GiventhelargelandmassofColorado,itisessentialtoimproveandscaleuptransportationto
improveaccesstocrisisservices.Thesystemcanhelpgetapersoninneedofservicestotherightplacewithoutinvolvinglawenforcementortheexpenseofanambulanceride.
• Awareness.Itiscriticaltoraiseawarenessoftheexistenceofthecrisissystemthroughastrongercampaign–orby
whatevermethodswillmakethemostsignificantimpressions–sothatmoreColoradansareawareofit.Itisimportanttoespeciallytargetat-riskpopulations,suchasadolescents,adultmen,andveterans.
• Cross-AgencyAlignment.TheColoradoDepartmentofHumanServicesshouldworkwiththeColoradoDepartment
ofHealthCarePolicyandFinancetoworktogetheronalltherecommendationsinthisreport,toaddressitemssuchasratesandfinances,aswellasmaximizefederalfunding.
AppendixA:CommitteeVotingTallyonAllRecommendationsRecommendationstoimprovethecrisissystemwerepresentedbytwosub-groupsatanall-dayworkshoponMay18th,atwhichtimeCommitteemembersinformallyvotedontherecommendationstheymostsupported.TheserecommendationswerecompiledanddistributedtothefullCommitteeforanelectronicvote.Thetablebelowreflectsthetop10recommendationsvotedinfavorbytheCommittee.
TABLE2:SummaryofRecommendationsReceivingtheTop10Votes
Top10Recommendations Yes,Isupport
No,Idonotsupport
Concerns
Increasethebreadthanddepthofservicesforyouthandchildren 13 0
Increasepeersupportinallareas 12 1 Sustainabilitycouldbeachallenge
Leveragetechnologytoconnectandsimplifythestateandlocalcrisislines 12 1 Resourcesaretoolimitedtoinvestintechnology
Co-respondermodel&mobile:Determinehowthatcanbeusedinacrisissituation
11 2 Sustainabilitycouldbeachallenge
Developandimplementanoutcomeevaluationsystem 13 0
EstablishaLeadershipCommitteetoreviewandupdateoutcomes,identifyadditionalgapsandneeds,etc.
12 1Unclearonwhowouldbeonaleadershipcommittee,howoftenitwouldmeetandwhatpoweritwouldhave;notoptimisticthatthiswouldbeaneffectivegroup
Improveintegrationofservicesformentalhealth/substanceusedisorderwithinCSU 12 1 Sustainabilitycouldbeachallenge
OfferstatewideintegrateddataandresourcesystemfortheHotline 12 1 Resourcesaretoolimitedtoinvestintechnology
Considertargetedmarketingforthosepopulationsnotservedbythecrisissystem
12 1Sustainabilitycouldbeachallenge;whilesupportiveoftargetedmarketingbutquestionthecostandhowtodothiseffectivelystatewide
Exploreusinga3-digitnumberforthecrisisline 8 4
Peoplemaythinktheyarecallingagov'tnumberandbelesslikelytousethehotline;211wouldresultinanadditionalstepforpeopleincrisis;211doesnothavecliniciansmakingdecisionsaboutwhetherdispatchisnecessary;arethereenoughcallstojustifymovingtoa3-digitnumber?;willonlysupportifservicesarenottransitionedawayfromRMCP;thecomplexitiesofusinga3-digitnumberaretoovastNote:1personrecusedhim/herself
Considertargetedmarketingforthosepopulationsnotservedbythecrisissystem
12 1Sustainabilitycouldbeachallenge;Whilesupportiveoftargetedmarketingbutquestionthecostandhowtodothiseffectivelystatewide.
TheCommitteedevelopedanumberofotherrecommendations,allofwhichweresupportedbythemajorityofCommitteemembersthatvoted.Tables3and4reflectthoserecommendations.
TABLE3:SummaryofOtherRecommendationsSupportedbytheCommittee
Recommendations Yes,Isupport
No,Idonot
support
Irecusemyself Concerns
EnsurethatthecommunityunderstandshowtoaccessCSUservices
12 1 0 Doesn'tmakesensesinceyoucannotself-admit
Increasemarketingtoraisepublicawarenessformobileservices 9 3 1
Beyondthescopeofthiscommittee;needtoensurethatmobileisequippedandreadytomanageincreasedrequestsforservicesstatewide;marketingdollarsshouldbedirectedatincreasingawarenessofthecrisisservices/systemingeneralandnotconfusingthingsbyfocusingononecomponent
Markettoschoolsand/orcreatepartnershipsformobileservices 12 1 0 Beyondthescopeofthiscommittee
Growtheuseofwalk-inclinicsthroughawareness&referrals 13 0 0
Broadenreferralbaseforrespitebeyondcrisisclinicians 10 3 0 Beyondscopeofthiscommittee;lesserprioritygiven
limitedresources
Improvecultural&linguisticresponsivenessthroughtraining,diversificationofstaff,morewelcomingandusefulinterpretationservices
11 1 1 SupportiveofculturalawarenessbutbelievethecurrentCSOsalreadydoagoodjob
Betterleveragetheuseoftechnologyformobileservices 10 3 0 Thisisalesserprioritygivenlimitedresources
Offermobiletrainingtodeliverservicestoyouth 10 2 1 Thisisalesserprioritygivenlimitedresources
Identifybetternomenclatureorbetterdefinerespite 12 1 0 Beyondthescopeofthiscommittee
TABLE4:SummaryofOtherRecommendationsSupportedbytheCommittee
Recommendation Yes,Isupport
No,Idonot
support
Irecusemyself Concerns
Improvedatacollection/analyze/answertherightquestionstounderstandtheimpactofthesystem(toincludeotherstakeholders)
13 0 0
Haveongoingdiscussionsrelatedtocrisiscasemanagement/in-homerespite
12 1 0
EstablishCSUlicense 8 2 3
WouldprefertoseestandarddefinitionofwhatyougetatanATUversuscommunityclinicwithbedcapacity;thereisalreadyabodyreviewinglicensingandweshouldaskthemtoaddressthis&providerecommendation(s)
Improvetransportationoptions 13 0 0
Createformalagreementtoclarifytherelationshipbetweenhospitalsandmobileservices
11 2 0 Thisisalesserprioritygivenlimitedresources;wewouldbehardpressedtodictateagreementstohospitals
Reviewprotocolsfordispatchversuscallcenter(formobileservices) 13 0 0
Considerexpandingthedefinitionorcriteriaforwalk-inclinics 7 6 0
Beyondthescopeofthiscommittee;needtounderstandtheexistingneedsincommunitiesfirst;toovague;walk-indefinitionisalreadybroadandappropriate
Includepayersinconversationandineducatingpeopleabouttheirbenefits(forwalk-inservices)
11 0 1
EvaluationandcapturingofdailycensusofbedsforCSUstodeterminebestwaystomaximizeutilization
11 2 0Beyondthescopeofthiscommittee;needtounderstandtheexistingneedsincommunitiesfirst;thisisalesserprioritygivenlimitedresources
Ensurebothmentalhealth/substanceusedisorderneedsaremetviarespite 9 3 0
Beyondthescopeofthiscommittee;wouldonlysupportifwenarrowtheservicetothoseincrisis,asitseemsbroaderthanthescopeofcrisisservices
Reviewlicensingrulestosupportintegratedsubstanceusedisorderandmentalhealthservices
10 0 2
Reviewlicensingrulestosupportintegratedsubstanceusedisorderandmentalhealthservices
10 0 2
AppendixB:SummaryofCommitteeMeetingAgendasandPresentations
Meetings CommitteeMeetingObjectives* Speakers/PresentationsMtg.13/9/18
● IntroduceroleandpurposeofCommittee● Reviewhistoricalnarrativeofthecrisissystem,andcurrentstats● Determinedecision-makingprocessanddefiningsuccess
SummerGathercole,SHGAdvisors;EmilyJohnson,ColoradoHealthInstitute
Mtg.23/23/18
Hotline● Reviewofstatewidehotlineandpossiblerecommendations
BevMarquez,RockyMountainCrisisPartners;EmilyJohnson,ColoradoHealthInstitute
Mtg.34/6/18
MobileServices● Overviewofmobileservicesandcurrentstatistics
LoriBanks,AuroraMentalHealthCenter;MaureenHuff,NortheastBehavioralHealth;EmilyJohnson,ColoradoHealthInstitute
Mtg.44/20/18
MobileServices● Clarificationonservices● BillingprocessesLessonsfromOtherStates● Arizona
MaureenHuff,NortheastBehavioralHealth;JasonDeaBeuno,AspenPointe;EmilyJohnson,ColoradoHealthInstitute;CamilleHarding,CDHSOfficeofBehavioralHealth
Mtg.55/4/18
Walk-inClinics,CrisisStabilizationUnits,Respite● Overviewofservicesandcurrentstatistics
MaureenHuff,NortheastBehavioralHealth;BarbaraKleve,AspenPointe;TeresaManocchio,ColoradoHealthInstitute
Mtg.65/18/18
AllDayWorkshop• StakeholderSurveyResults• OBH’sPerspective• ReportsfromWorkingGroups(Hotline&Mobile,andWalk-
in/CSU/Respite)• InformalVotingonPrioritizedRecommendations• StatutoryPrinciples
SummerGathercole,SHGAdvisors;RobertWerthwein,CDHSOfficeofBehavioralHealth;CamilleHarding,CDHSOfficeofBehavioralHealth;VariousCommitteeMembers
Mtg.76/1/18
● SchoolToolkitreleasedbyMentalHealthColorado● ConsumerStakeholderResults● Discussionofdraftoutlineofreportandrecommendations
AndrewRomanoffandSarahDavidon,MentalHealthColorado;SummerGathercole,SHGAdvisors
Mtg.86/15/18
● Reviewandapprovaloffinalreport
SummerGathercole,SHGAdvisors
*Thegroupagreementsandstatutoryprincipleswerereviewedatthebeginningofeachmeeting.