SCR NO. 117Task Force Meeting 1

Presentation

October 19, 2006

Background HSH• Current issues driving the discussion:

– HSH census typically above construction/budgeted capacity

– HSH not physically configured for committed patientsGuensberg building outdated and not configured for current

patient mixLower Campus designed for rehabilitation

– Are there too many patients in State inpatient beds ?• HSH + contracted inpatient facilities + community hospitals

– Patient population• largely committed by criminal court (forensic)• Long term care for many patients post discharge-Rehab of

Hale Haloa may provide an option

HSHCampus Units

S,T, U

Unit F

Unit E

DispensaryUnit HAcuteMall

Unit IAdmin.and RehabMall

CafeteriaGym

Entrance

Lo’I(Garden)

HSH History I1989 U.S. Dept. of Justice (DOJ) investigation of

HSH conditions begins1991 Complaint and Settlement Agreement filed 1995 Stipulated Contempt citation; Remedial

Plan ordered; 1996 Additional Stipulations and Order to

improve conditions: Initial JCAHO accreditation achieved

1999 Special Monitor appointed; reaccredited by JCAHO

HSH History II2001 Special Master appointed; Guensberg

building closed and patients moved to lowercampus; Guensberg repairs ordered

2002 Final HSH Remedial Plan approved and ordered; Re accredited by JCAHO Kahi contract begins (16 patients,>>32,40)

2003 Community Plan approved and ordered;HSH opens Rehabilitation Mall

2004 US District Court dismisses claims againstHSH; action continues concerningCommunity Plan

HSH History III2005 JCAHO Reaccredited October 2006 US DOJ case re: Community Plan to be

dismissed November 30; Current census = 187 patients; served by approximately 650 staff; 41 additionalpatients on contracted unit

Process of Clinical Care• Focus of Treatment:

– Forensic: Deal with danger and legal realities– Medical: Effectively treat identified disorders – Recovery: Assist patient with personal goals

• Continuous treatment planning:– HSH clinical treatment team, led by

psychiatrist, includes patient, community providers and families

– Regularly updated plan coordinates• Medications, therapy/programming, social

rehabilitation with overall goal of patient recovery

Patient Programming

• Unit H: Admission Unit– Has its own programming “Mall”– Patients stay on the unit

• All other Units:– Patients attend programming at the

“Rehabilitation Mall” 9:00 to 1:30 weekdays– Patients are on “their” Units otherwise, unless

on outings or after hours/weekend programming

RehabilitationMall:Daily Schedule

Unit-supervised Activity (b)12:00-12:30Unit-supervised Activity (a)11:30-12:00

Return to Units13:30Collect in “Home Room”13:20-13:30Activity/Class 312:30-13:20Lunch Break (group b)12:00-12:30

Lunch Break (group a)11:30-12:00Home Room11:15-11:30Activity/Class 210:15-11:15Transition/Smoke break10:05-10:15Activity/Class I09:15-10:05Collect in “Home Room”09:00-09:15

Treatments: Summary• Medical/biological:

– Treat nonpsychiatric medical conditions (e.g.: Diabetes, Hepatitis)

– Psychiatric: Antipsychotics, Antidepressants, Mood Stabilizers, Antianxiety medications

• Psychological:– Individual/group therapy, cognitive/behavioral,

educational interventions • Social:

– Help resolve legal status issues– Food/clothing/shelter– Community reintegration, with meaningful activities

(job/education) and relationships

HSH Census 1989 – 2006

HSH Patient Census Overview(Average Daily Census / Fiscal Year) (89/90-05/06)

0

50

100

150

200

250

89/9

0

90/9

1

91/9

2

92/9

3

93/9

4

94/9

5

95/9

6

96/9

7

97/9

8

98/9

9

99/0

0

00/0

1

01/0

2

02/0

3

03/0

4

04/0

5

05/0

6

Fiscal Year

Ave

rage

dai

ly c

ensu

s

HSH Census 2004 - 2006HSH Patient Census

(Average Daily Cenus) (6/04-9/06)

150.00155.00160.00165.00170.00175.00180.00185.00190.00195.00

Jun-

04Ju

l-04

Aug-

04Se

p-04

Oct

-04

Nov

-04

Dec

-04

Jan-

05Fe

b-05

Mar

-05

Apr-

05M

ay-0

5Ju

n-05

Jul-0

5Au

g-05

Sep-

05O

ct-0

5N

ov-0

5D

ec-0

5Ja

n-06

Feb-

06M

ar-0

6Ap

r-06

May

-06

Jun-

06Ju

l-06

Aug-

06Se

p-06

Month

Tota

l cen

sus

HSH and Kahi Census FY 02 - FY 06

0

50

100

150

200

250

FY 02 FY 03 FY 04 FY 05 FY 06

Fiscal Year

Ave

rage

Pat

ient

s/C

apac

ity

HSH

Kahi

Total

HSH Patients by Length of Stay

01020304050607080

>5yr >1yr >6mo >3mo <3mo

Length of Stay Category

Patie

nts Dec-03

Sep-06

Treatment Duration

2003 – 2006 compared

13271189Avg los

186176Hospital Totals as of Sept 1 Patients

11461047Avg. los(Hold and revocation)

4438PatientsConditional Release

23872857Avg. length of

stay (days)

6345PatientsAcquitted and Committed

20062003YearLegal Status

Current HSH Patients • Demographics: (Current census = 186 patients)

– Male/Female: 86/14%– Criminal Court Commitment: 85%– Civil Court Commitment: 8%– Voluntary 7%– Substance affected: 87%– Developmentally Disabled or cognitively impaired:

• DDD eligible or in evaluation process: 7 (4%)• Others with significant cognitive impairment: 15 (8%)

• Major legal status groups:– Unfit to proceed (406) 22%– Acquit and commit (411(1)(a)) 34%– Revocation of CR (413) 24%

Charges 2003 – 2006 Compared

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

cr i mes agai nst per son Not cr i mes agai nst per son Not

Fel ony A / B Fel ony A / B Fel ony C/ M i sd Fel ony C/ M i sd

C h a r g e s

2003

2006

HSH Role in MH System• Mental Health System of Care

– Full range of inpatient and outpatient services– MH/Health and forensic role

• Growth of the MH system of care– Moving from “#51” (Fuller-Torey) to “#11”

(NAMI)– Relationship to drug epidemic– Increasing number of persons served

• Clinical process of care– Evidence-based practices

Community Services GrowthNumber of Individuals Served By the AMHD

(2001-2006)

4,340 4,445

5,216

7,543

10,136

11,217

0

2,000

4,000

6,000

8,000

10,000

12,000

FY 2001 FY 2002 FY 2003 FY 2004 FY 2005 FY 2006

HSH Physical Plant Limitations• Aging Units

– Buildings and infrastructure (leaks, rusting equipment)

• Licensed Capacity– HSH constructed/budgeted for 168 patients,

can manage up to 178 in space available– AMHD also uses Kahi Mohala for additional

diversion beds (41 beds) and HHSC and other community hospitals

– Licensing has changed as census increased: 168, 178, 190 maximum licensed capacity

Water DamageWater Damage

Facility Problem Examples

Rust, corrosionRust, corrosion

Crowding:Crowding:Bathroom accessBathroom access

Visibility:Visibility:Line of sightLine of sight

Unit S: Ceiling Leaks

Daylight Daylight throughthrough

locklock

Concrete PostConcrete Post

Unit T: Examination Room

Ongoing water damage to wall despite Guensberg building roof repair: E.g.: Exam room

Unit U: Wall Damage

Unit I: Bathroom Access

Licensing problem: When census goes over 178, patients are forced to cross public areas for BR access

Unit F: Line of Sight

Lower campus buildings constructed

for nursing facility, not secure units; poor line

of sight increases staffing needs

Changing Hospital Role• Move from medically necessary treatment

to Court-ordered “detention, care and treatment”– Clark Permanent Injunction requires

admission within time frames irrespective of clinical status, census

• Drug epidemic results in patients arriving “sicker”

• Open campus, augmented by electronic security; fencing enhancement in progress

Clark Class Action• Clark v State (US Dist Ct CV99-00885)• Plaintiffs class members held in jail when:

– Acquitted and committed – Unfit to proceed– Dismissed and committed– Waiting CR revocation

• Federal Civil Rights complaint settled for:– $1,200,000. for 100 Class Members– Revoked CR: Admit within 48 hours– Acquitted/committed (411(1)(a)) and unfit to

proceed: Admit within 72 hours• Hospital less available to admissions from

the community, including other hospitals

HSH Overview• Serious physical plant configuration problems,

especially in upper campus• HSH lower campus not adequate for current

patient mix (acute/forensic, most non violent, some will require nursing home LOC post discharge)

• HSH cost = $614. per patient per day– Consider additional cost of 30 day continued stay

when hospitalization is no longer necessary for clinical reasons ($18,439)

– Kahi contract = ~ 642. per patient day