Community MH Crisis Prevention and Intervention Model for Persons with Intellectual and Developmental Disabilities

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Community MH Crisis Prevention and Intervention
Model for Persons with Intellectual and
Developmental Disabilities
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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.

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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

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History

• START Model was recommended by the DD-PIC 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 LMEs
• Two providers were designated to implement this
  community based model

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NC-START - WEST
NC-START -CENTRAL
NC-START - EAST
Gates
Northampton
Alleg.
Currituck
Camden
Gran- ville
Person
Surry
Ashe
Stokes
Rockingham
Warren
Hertford
Caswell
Pasquotank
Vance
Halifax
Perquimans
Wilkes
Watauga
Bertie
Yadkin
Chowan
Franklin
Forsyth
Alam.
Orange
Guilford
Avery
Mitch
Durham
Edgecombe
Nash
Alex.
Caldwell
Davie
Dare
Wash.
Yancey
Tyrrell
Martin
Madison
Wake
Iredell
Davidson
Wilson
Chatham
Burke
Randolph
Rowan
Catawba
McDowell
Beaufort
Pitt
Buncombe
Hyde
Johnston
Greene
Haywood
Lincoln
Swain
Lee
Wayne
Graham
Harnett
Cabarrus
Rutherford
Mont- gomery
Cleve land
Henderson
Craven
Stanly
Moore
Lenoir
Jackson
Polk
Meck.
Gaston
Trans
Cherokee
Pamlico
Macon
Jones
Cumberland
Sampson
Clay
Duplin
Hoke
Richmond
Union
Anson
Carteret
Onslow
Scotland
Robeson
Pender
Bladen
Columbus
New Han
Brunswick
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Planned Structure per Region Based on Gap Analysis
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Current Structure per Region
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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

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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)

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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

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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

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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
  each time

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• 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

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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

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Diagnostic Overshadowing

• Diagnostic overshadowing refers to the process of
  over-attributing an individuals 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 doesnt investigate
  it further when it could be an important
  indicator of Johns medical condition

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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 skills- individual
  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?

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• 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

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• 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

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• 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

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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

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Core Principles

• Positive Psychology
• Trauma Informed Approach
• Systemic Approach

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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 in community
• Implement and maintain community partnerships

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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.

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From the data

• Average age early 20s
• 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).

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• 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.

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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.

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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
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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.