EVALUACIÓN DE LOS EFECTOS DEL PROGRAMA DE INTERVENCIÓN

damp, and dry.

In designing a continuum of services for homeless individuals and families with BH conditions, it is important to match housing design to what people actually want and need, including in relation to using substances. Consequently, it is important to develop a continuum of housing options that are dry (“abstinence-expected” or “sober living environments”), damp

(“abstinence-encouraged, but discussion of safe active use is welcomed”) and wet (“consumer choice: use substances as much as you want as long as you do not lose your housing”). Program design related to each of these options needs to be carefully developed in accordance with best practices. Although there are housing options in the continuum that are wet, damp, and dry, it is not clear how effectively consumers are matched to the right setting. Unfortunately, housing

“mismatch” is a frequent reason for housing service failure and discontinuation in permanent supportive housing settings.

Recommendations

As in previous sections, the recommendations in this section are divided into phases. The first phase will begin immediately and extend over approximately 12 months. The second phase will focus on implementation activities that would go on line no earlier than two years from now, and probably longer. Note again that we are viewing the Dallas County BHLT, working in partnership with MDHA, and with NTBHA and other NorthSTAR-area counties when appropriate, as the place wherein the design and implementation of the Dallas County BH homeless service system will take place.

Phase One: Immediate planning to improve integration of services and coordination of care for individuals and families with behavioral health needs who are homeless

1. Formal identification of a locus of planning and implementation of services for individuals and families with BH needs who are homeless. Our recommendation would be that this task is formally assigned to be coordinated by MDHA, with additional partners, as delegated by the Dallas County Behavioral Health Leadership Team. The purview of this group should cover homeless individuals and families with BH needs who present anywhere in the system, including primary health settings, PES, and so on.

2. Recognize the existing models of collaboration in MDHA as a system strength that can inform planning and partnership for the larger system. Note that the ability of MDHA to work in partnership with multiple stakeholders to leverage resources is part of the vision we are recommending for the potential of such a partnership in the larger system. Note also

that MDHA and The Bridge have leveraged an effective partnership with ValueOptions, in part because ValueOptions is only providing a relatively small percentage of their funding.

3. Begin to collect data across multiple sources (The Bridge, CJ, ValueOptions, Parkland) identifying homeless or marginally-housed individuals with BH needs (particularly those using high-end services of any type), and tracking whether they are engaged in services that are helping them make progress. There needs to be a systematic improvement

process to increase the extent to which every client is connected to BOTH suitable supports and suitable housing.

4. Develop a plan to track the provision of supported housing by SPNs, and expand the capacity of SPNs in this area. This begins not with housing units but with ensuring that clinical staff have the training, skills, and program support to provide supportive housing services to clients who need that support in order to maintain their existing housing. Note that service packages include supportive housing as a covered service, but there is no current data on how much it is being provided.

5. Develop a plan for tracking and coordinating availability and distribution of HUD vouchers for individuals with serious BH needs. This is aligned with NTBHA’s Strategic Plan, but requires organized coordination across multiple sources of information for tracking the homeless mentally ill population.

6. Conceptualize a plan for The Bridge (MDHA) to receive a flexible pool of sub-capitated dollars to manage a high-utilizer group of homeless individuals. This pool of resources could come from ValueOptions, Parkland, and any other sources that might be at risk. The starting place is to identify total costs of a current high-utilizer group, and use that to hypothesize a starting place for sub-capitated or case rate funding, and then allow The Bridge to establish a pilot using those funds with full flexibility to provide or purchase needed housing, health, BH and other services and supports, and to demonstrate cost effectiveness. If the original pilot is successful, the sub-capitation can be expanded to a larger group. Note that in at least one other system (Miami), the homeless services hub (The Homeless Trust) has evolved to become one of the system’s managed care

organization partners for a designated high-risk group of homeless clients.

7. Develop a strategic plan to leverage partnerships with selected boarding homes. The strategy followed in many other systems is to create a process for rewarding boarding homes that want to step up to provide better quality services and function as more

effective partners. There are a variety of approaches, but a common one is for the MCO (or another funder) to offer to credential them (thus assuring some standard of care) as a therapeutic residential setting, providing priority access to services and supports that help out the boarding home owner, and providing a financial enhancement to support additional

service provision. This arrangement should be designed to be a win/win for all concerned.

Another strategy that some systems follow is to identify funds that can be used to facilitate existing “good partner” agencies in acquiring and operating boarding homes, or even supportive apartments, themselves (for example, low-cost loans, loan guarantees, and other incentives). Ideally, the partners operate the homes in such a way that they become part of a continuum of supportive services. Finally, there needs to be a local effort to identify model regulations and licensing criteria for boarding homes that serve individuals with BH needs.

8. Develop program models for wet, damp, and dry housing. As noted above, it is our

observation that the vast majority of housing being developed is designed as “dry” housing, which creates a significant acquisition gap for seriously impaired individuals. There are very successful evidence-based models for damp and wet housing that require specific

modifications in program rules, program content, and staff treatment approaches. We recommend that these approaches be defined and then systematically expanded, implemented, and tracked within Dallas County.

9. Advocacy for additional resources to provide housing support. In most states, Medicaid resources can be utilized for disabled people to maintain independent living in lieu of institutionalization, as required by Olmstead and the Americans with Disabilities Act. As of October 1, 2010, under the Affordable Care Act, states have increased flexibility about how to use these Medicaid dollars to provide supports in the community for individuals with any type of disability. Many of the “support” services that would be helpful to individuals with chronic psychiatric and substance disabilities could be provided potentially with separate Medicaid dollars than would be narrowly defined as BH services within ValueOptions. We do not know how well these resources can be leveraged in Texas, but we do know that Medicaid coverage will be expanding under health care reform. We also know that housing advocates in most states are not aware of the full potential of these new regulations.

Phase Two (12—36 months): Expanding the homeless service array

1. Defining and implementing system performance indicators: The basic work described above as first-year activity will permit both data acquisition and learning about successful models that can lead to more proactive and systematic implementation. As a target, the Dallas County BHLT, with MDHA and NTBHA, should be planning to identify new

performance indicators and incentives for the next ValueOptions contract and for the future RFP for the managed care system in general. These performance indicators can define how much expansion of supportive housing is required, how many “therapeutic boarding homes” or “sober living environments” are started, how many clients are sub-capitated to MDHA, and so on—more sensitive indicators than simply tracking TRAG scores.

2. Implementing a wet, damp, dry continuum: By Year Two, the housing plan should have some baseline targets for how much of the homeless population will need wet, damp, or dry housing options, and should be planning to organize both new and existing units to match those targets. This is activity that occurs WITHIN base resources. Current data indicates a high failure rate within current permanent supportive housing. The goal with these models is to design supportive housing that is more effectively matched to the clients, and therefore more likely to be successful. This will allow limited resources to go further.

3. Establishing improved regulatory and programmatic oversight of boarding homes: By Year Two, building on the introductory activities cited above, establishing more formal oversight, and leveraging expansion of boarding home services by quality “partners” would lead to improved housing supports for individuals who may benefit from a more therapeutic boarding home environment with wraparound supports.

4. Expansion of funding: Better partnerships are always able to leverage funding more effectively. MDHA has been very successful in obtaining a variety of HOUSING grants.

However, the system should be seeking additional dollars for “HOUSING SUPPORTS”. This is funding that goes to clinical support programs that help homeless individuals or families with MH and SUD attain and maintain housing. At least two such multiyear SAMHSA grants are currently in operation in Texas, one in Bexar County. It is our view that Dallas County would be able to put together a very successful application. We would also recommend that The Bridge partner with Parkland to seek funding for a model program that incorporates a truly integrated “Health Care Home” into The Bridge setting. This would provide valuable resources to expand both BH and physical health services within a homeless continuum, and reinforce the concept of The Bridge being a sub-capitated specialty provider for identified high need clients.

Step 11:

A Youth and Family Driven System of Care for Children, Adolescents and Families with Behavioral Health Needs

Background

This section addresses developing a true system of care (SOC) for children with severe BH needs and their families. Efforts would integrate three current silos operating largely independently and separated by rigid funding eligibility rules: (1) the juvenile justice system for the highest need individuals, (2) NorthSTAR BH services for people with targeted behavioral needs, and (3) Parkland COPC resources for lower needs. Currently, each system is accessed only if funding criteria are met (that is, an arrest for juvenile justice services, NorthSTAR eligibility for specialty services, lack of NorthSTAR eligibility for Parkland COPC services). One model of integration to help guide improvements is the Dallas Independent School District’s effective partnership with NorthSTAR and Parkland to implement its Youth and Family Centers, which integrates services for students in all three systems (NorthSTAR, Parkland, and non-NorthSTAR) and reached over 4,400 students last year.

The building blocks for an effective SOC are present. The recommendations in this section, as in the others, are organized according to phases of implementation, with the assumption for the children’s SOC that the Dallas County BHLT (and representatives of the BHLT working in

partnership with NTBHA, DSHS, and other counties in the NorthSTAR region) will work through its Child, Adolescent and Family Clinical Operations Team to oversee and coordinate the implementation process.

The recommendations in this section are based on a series of findings in our study, as well as additional findings related to the national SOC movement. These findings are listed below.

Findings

Finding 1: Dallas County’s juvenile justice system is state-of-the-art. Dallas County Juvenile Services has achieved remarkable across-the-board reductions in juvenile offense referral rates, with an overall 13.7% reduction from CY 1997 to CY 2009. Most of that reduction has been with younger youth, ages 10 to 15. Rates of detention have also fallen 19.5% since CY 2008 and 24.9% since CY 2005. Overall, the Dallas County Juvenile Justice system seems to have a strong array of best practices, backed up by rigorous outcomes tracking for the overall youth

population and service providers.

Finding 2: Dallas County’s juvenile justice system is largely dependent on county revenue