1

SEVENTEENTH REPORT OF THE INDEPENDENT REVIEWER

ON PROGRESS TOWARD IMPLEMENTATION OF THE SETTLEMENT

AGREEMENT BETWEEN THE KENTUCKY CABINET FOR HEALTH AND

FAMILY SERVICES AND KENTUCKY PROTECTION AND ADVOCACY

Submitted by Diane Brewer May 14, 2018

I. INTRODUCTION

This report addresses progress by the Kentucky Cabinet for Health and Family Services

(Cabinet) toward meeting the provisions and intent of the Interim and Amended

Settlement Agreements (Settlement) between the Cabinet and Kentucky Protection and

Advocacy (P&A). The information provided herein represents the cumulative progress

since September 1, 2013, with specific emphasis on the quarter year January 1, 2018 to

March 31, 2018.

The Settlement specifies that the Cabinet will have transitioned 675 persons with serious

mental illness (SMI), previously in personal care homes (PCH), to community-based

housing by October 1, 2018. Individuals in this disability group are to receive Housing

Assistance to attain and maintain integrated, affordable housing with full rights of

tenancy. Housing Assistance as described in the Settlement also includes the receipt of

needed tenancy support services to allow individuals to maintain their housing. October

1, 2018 represents the five-year mark of the Settlement with a total of $31 million

pledged by the Cabinet to meet the terms of the Settlement. There have been 519

individuals transitioned, and there are currently 346 still in their housing.

The DBHDID’s behavioral health division has worked to develop and expand Assertive

Community Treatment (ACT) services and Peer Support services within the 14

community mental heath center (CMHC) regions. These have been key areas on which

to focus for the purpose of influencing attitudes about recovery, and for understanding the

types of outcomes that can be expected when knowledgeable, recovery-oriented staffs

utilize evidence based practices. Another important effort aimed in part at achieving

these same goals, was contracting for the person centered planning learning collaborative

provided by expert consultants, Janis Tondora and Diane Grieder. In addition to

addressing the long-standing problem of treatment plan documentation not reflecting the

“golden thread” of medical necessity, the learning collaborative stressed the expectation

of recovery and client self-determination in planning for goal achievement. Influencing

attitudes about recovery within the leadership of provider agencies and the leadership of

the Cabinet and its Departments and Offices is a key piece in the success of the

Settlement. Section I.B. of the Settlement states that in addition to ensuring services are

provided in the most integrated setting, as defined in federal law, “the Parties intended

that steps to achieve the goal of community integration and self-determination would be

undertaken”. Stakeholders with a role in achieving this goal of the Settlement must work

from a place of knowing that persons in this identified disability group can experience

full community integration when provided with the necessary individualized supports and

services. The Cabinet must determine what that array of supports and services would

2

look like in order to take action to ensure access to, and availability of those supports and

services. As with any disability group, there is a wide range of support needs. This

reviewer has asked direct service staff what they believe the service system needs in

order to support high-need individuals with SMI in the community. Some have cited the

need for 24/7 staffed houses similar to the system available for persons with intellectual

and developmental disabilities. More often, these staffs talk about the desire for larger

ACT teams with supportive prescribers, or just the capacity to provide more frequent in-

home services by community support associates, peer specialists, and others. The

supports needed to avoid institutionalization can range from simple and minimal, to

extensive oversight with coordination of several resources. This reviewer spoke to a

woman who had been living on her own in a rural area with support from her brother who

would come by to “look in on her and take her to the store”. She stated that when “his

legs got bad” he was no longer able to come by and she was taken a PCH to live. On the

other end of the spectrum, a CMHC determined that they were unable to support a man

who had been living in a beautiful neighborhood home staffed 24 hours a day. There was

not a higher level of care available to him, though it is possible that additional resources

and natural supports wrapped around him in that environment could have made a

difference. He was sent to one of the most run-down PCHs in the state where he will

have less oversight and receive fewer services than where he was. Section I.J. of the

Settlement states that the Parties acknowledge that the terms of the Settlement are

voluntarily accepted for the purpose of refocusing the Cabinet’s use of PCHs. This

aspect of the Settlement remains largely unaddressed, in that there has been no change in

the extent to which PCHs are used as a housing solution. Studies on the benefits of

supported housing have been conducted since the late 1980’s. These studies have shown

that not only is housing crucial to the recovery process, but that custodial housing is

undesirable and has long-term negative affects on morale and well-being. “Assistance in

finding safe and affordable permanent housing that is consistent with consumer

preferences leads to better consumer outcomes” (Corrigan, Mueser, Bond, Drake,

Solomon (2008) Principles and Practice of Psychiatric Rehabilitation: An Empirical

Approach). The work toward achieving the goals and substantive provisions of the

Settlement will move Kentucky forward in its pursuit of an evidenced based service

system that upholds the civil rights of this disability group.

II. SOURCES OF INFORMATION

Information for this report was obtained though a combination of Cabinet reports, data

reports from the Kentucky ISA/ASA Tracking Tool, and participation in meetings.

KY ISA/ASA Tracking Tool reports:

Referrals

Aftercare report

User report 2 - Time

Referrals not transitioned after 119 days

Referrals currently transitioned

Other documentation:

3

DIVERTS EBP Status form and summaries

Meetings this quarter have included:

1 Cabinet level meeting

5 Regional Transition Team meetings

1 P&A/DBH meeting

1 meeting with P&A staff

1 DBH Statewide meeting

Observations in the field

visit to Centerstone staff and client

visit to Bluegrass staff and client

visit to Mountain Comp. staff and clients

visit to Venture Homes PCH

III. CABINET ACTIONS/PROGRESS

The Cabinet has made progress toward each of the Settlement’s substantive provisions.

A Compliance With Substantive Provisions Grid was included as part of the first

quarterly report and was first scored in the third quarterly report using a 5-point Likert

scale ranging from ‘No Progress’ to ‘Complete’. Some of the Cabinet’s ongoing ratings

of ‘Modest Progress’ (progress by roughly 50%) or ‘Minimal Progress’ (progress by

roughly 25%) have been a result of uneven implementation across the state. There are

pockets of excellence across the state where provider agencies do effective in-reach and

take action to transition individuals with high need, while other provider agencies might

determine similar individuals are inappropriate for Housing Assistance. There are

provider agencies that add and modify services when faced with barriers to maintaining

successful community tenure, while other provider agencies go directly to the PCH

system as a back-up housing solution. These differences, in part, reflect recovery

attitudes and the agencies’ prioritization of effective tenancy support services; but the

CMHCs also face barriers of poorly funded services and difficulties having services

authorized and/or reauthorized by the managed care organizations. As efforts continue

for the improvement of service quality and service access, the Cabinet must determine

how the service system for adults with SMI will move toward the evidence based practice

of permanent supportive housing and away from an antiquated system of large

congregate housing. This report is structured to address each of the sections in the

Compliance with Substantive Provisions Grid along with scoring explanations.

Section III.A.1 Adequate and Appropriate Public Services

This provision is measured by the extent to which the Cabinet has provided adequate and

appropriate community based services to persons residing in or at risk of entry into a

PCH, so that they have the choice to live in the community. This has been rated Modest

Progress, acknowledging that choice has been made available to 519 individuals. Areas

to improve are:

4

Availability of choice for community services upon discharge from state

psychiatric facilities to avoid trans-institutionalization.

Need for consistency of opportunity for community integration regardless of

which PCH you reside in.

Development of, and access to services that will allow choice to persons whose

needs exceed the capabilities of the service providers and/or the limits of existing

services.

Adequate tenancy support services that will allow choice to continue to live in the

community without being returned to a PCH.

In Regional Transition team meetings, the state hospital representatives report on the

numbers of discharges to the different PCHs. They have admitted that the discharge

location is often not the choice of the client, but instead, is due to the lack of community

based service options. State guardians have also stated that their decision to place a ward

in a PCH, or have them discharged to a PCH from a state psychiatric facility is based less

on client choice and more on whether or not they believe sufficient community services

will be available and ongoing for their ward. Many understand that this is not a ‘level of

care’ decision, in terms of the PCH offering a higher level of mental health and physical

health services; but instead, a decision based more on the availability of some

surveillance, meals, and medications at the PCH. An indicator of progress in the area of

true client choice will be the reduction of hospital discharges to PCHs. This is one

indicator that has remained relatively unchanged throughout the time of the Settlement.

The chart below shows the quarterly comparisons between first time PCH discharges

from state psychiatric hospitals and total transitions. This quarter there were a total of

147 persons discharged from state hospitals to PCHs, with 40 of those being discharged

to a PCH for the first time.

3136

30

53 54

43

3235

30

18

44

2330

15

26

05

1015202530354045505560

10/14 1/15 4/15 7/15 10/15 1/16 4/16 7/16 10/16 1/17 4/17 7/17 10/17 1/18 4/18

Quarterly Comparison: Number of Transitions and

Number of Hospital Discharges to PCH-1st time

D/C to PCH

Transitions

5

The average annual percentages of PCH discharges across the 4 hospitals have been

consistent each year from FY ’15 to present. There has been an average of 52 discharges

to PCHs each year with an average of 14 not in a PCH prior to admission (or 28%

discharged to a PCH for the first time). The majority of PCH discharges are made by

ESH and WSH. The numbers of persons going to a PCH for the first time are a little

larger at ESH, but with the prevalence of PCHs in the WSH area, there is a greater

chance that the WSH patients have come to the hospital from a PCH.

Differences in opportunities for choice depending on the PCH in which you reside, can

be seen in the numbers of discharges from each of the free-standing PCHs. This chart

shows the number of transitions from each PCH, and one boarding home in the Bluegrass

region that was included in the Settlement. It is divided by service region and includes

the number of licensed PCH beds, the number of transitions, and the number of state

wards represented in the total number transitioned.

REGION PERSONAL CARE HOME PCH BEDS Number of

persons

transitioned

State

Guardianship

(from total)

1

Fern Terrace of Mayfield 104 38 2

Autumn Ridge Personal Care 24 5 0

Totals 128 43 2

2

Christian County Manor 78 21 3

Highland Homes 100 3 0

The Oaks PCH/Madisonville 58 6 2

Pennyrile Home 94 8 2

The Homestead 58 13 3

Trigg County Manor 68 2 0

Sparks Nursing Center 88 1 0

Totals 544 54 10

3

DAVECO Rest Home 92 10 1

Sunny Acres 32 7 4

Henderson Manor 64 2 0

The Oaks PCH/Lewisport 56 7 4

Bishop Soenneker Home 66 2 0

Fern Terrace of Owensboro 68 2 1

Totals 378 30 10

4

Fern Terrace of Bowling Green 114 20 5

Hart County Manor 54 11 5

Cornerstone Manor 36 23 9

Harper’s Home for The Aged 27 10 5

Scottsville Manor 40 8 2

Totals 271 72 26

5

6

Breckinridge Manor 40

(now closed)

5 2

Totals 5 2

6

Colonial House of Shepherdsville 62 25 3

Colonial Hall Manor 57 21 3

Totals 119 46 6

7

Colonial Gardens 80 1 1

Valley Haven Rest Home 45 7 2

Carrollton Manor 32 5 4

Jonesville Rest Home 26 0 0

Falmouth Nursing Home 28 5 0

Regency Manor North 30 4 1

Regency Manor 59 5 0

Front Gate 19 2 0

Totals 319 29 8

9/10

Russell Convalescent Home 28 15 6

Frasure’s Personal Care Home 61 16 8

Artrips Personal Care Home 22 3 2

Hamilton’s Personal Care Home 22 1 0

Hilltop Manor 36 1 0

Totals 169 36 16

11

Venture Home of Paintsville 56 12 2

Golden Years Rest Home 84 8 3

Totals 140 20 5

12

Caney Creek Rehabilitation

Complex

80

(now closed)

2 0

Totals 2 0

13

Generations Center of

Middlesboro

64 4 1

The Laurels 82 3 0

Totals 146 7 1

14

Dishman Personal Care Home 49 5 3

Somerview Personal Care Home 50 3 0

Cumberland Manor Rest Home 49 1 0

Totals 148 9 3

15

Rose Terrace Lodge 40 3 0

Central KY Recovery Center 32 69 10

Shady Lawn 75 3 1

Parkside Manor 51 3 1

Waynesburg Manor 28 0 0

Messner’s 38 1 1

7

Totals 264 79 13

Grand Total 2,626 432 102

The chart seems to show that opportunity for transition is greater in region 4, region 6, or

if you are at Central KY Recovery Center. Also affecting choice is whether or not the

opportunity exists to be sufficiently supported in the community. A region may have

several transitions from PCHs in their area, but then have for example, a 52% loss of

housing. The following chart reflects the number of transitions in each region with the

top shading indicating the number no longer in housing.

The relatively high percentage of persons no longer in housing as specified in the

Settlement is an indicator that the system cannot yet provide adequate and appropriate

public services and supports in the most integrated setting.

CMHCs enter a post transition code in the KY ISA Tracking Tool when someone is no

longer in their housing, to indicate the nature of the housing status change. The

following pie chart separates out seven categories of housing status changes within the

current total of all transitions.

05

101520253035404550556065707580859095

100105110

Total Transitioned by Serving Region Top Shading Indicates Number No Longer In Housing

8

Of the 519 total transitions, 173 persons (33%) are no longer in housing under the

Settlement. There have been 25 deaths. Ninety-two (92) have been re-institutionalized

in a PCH. Twenty-six (26) needed a higher level of care through staffed residences,

nursing homes, or SCL placement. Thirteen (13) left their housing to live with family or

friends. Fourteen (14) were evicted, left their housing, or otherwise were considered lost

by the CMHC. Three (3) lost housing due to incarceration.

Section III.A.2. Involvement of all guardians

All guardians are to receive information from the Cabinet to encourage their wards to

participate in decisions affecting them to the maximum extent of their abilities.

Decisions made by the guardian about where the individual will live are to reflect the

individual’s written preferences to the extent possible. This provision is rated Substantial

Progress due to the level of involvement of the Department of Aging and Independent

Living (DAIL) and their training of field workers to support transitions to the most

integrated setting appropriate to meet the needs of their wards. More work needs to be

done to get information to private guardians and the one public guardian in Paducah who

works with some of the persons referred for Housing Assistance. This could potentially

be addressed through brochures given to private guardian by CMHCs describing the

community based service they offer and through courts providing potential guardians

information on the Settlement’s services and on KRS 387.640.

Section III.B.1 Regulation

This provision is rated Complete. 908 KAR 2:065 was filed Dec. 2, 2015 and finalized

June 3, 2016.

Section III.C.1.2. Community Based Supported Housing

Status Changes after Transition

Still in housing that meetscriteria-346Deaths-25

Returned to PCH-92

To Staffed residences-8

To friends/family-13

Nursing home/SCL-18

Homeless/unable tolocate-14Incarcerated-3

9

This provision is evaluated by the extent to which eligible persons have access to

community based supported housing. The provision is rated Modest Progress,

acknowledging the Housing Assistance provided to 519 individuals, while also

acknowledging the extent of housing needed to accelerate transitions from PCHs and

allow hospital discharges to the community. CMHCs that have a designated staff person

for housing can do more toward developing relationships with local landlords and local

housing authorities; they can ensure a smooth process in submitting housing vouchers

and requests for OHI funding; and they can better manage existing vouchers being used

by the agency’s clients. The housing specialist’s supervisor and CSP Director must also

be knowledgeable about housing issues, so that when there is turnover in the housing

specialist position, it doesn’t result in loss of knowledge and in clients falling through the

cracks. Housing specialist turnover has at times left the job of training new CMHC staff,

and/or the job of intervening with local landlords, to the Kentucky Housing Corporation

(KHC). There are several CMHCs that have reported good relationships with local

landlords, so that the landlord calls them when apartments become available. The

landlord is able to trust that rent will be paid, that their tenants will receive on-going

support, and that there is someone to contact with any issues that may arise.

Section III.C.3.(a) Schedule for Housing Assistance

This provision spells out the target dates and benchmarks for the required number of

transitions to the community. The benchmark for Oct. 1, 2017 was 600 and the

benchmark for Oct. 1, 2018 is 675. At this second quarter of the Settlement year, the

benchmark is 637.5. This provision is rated Substantial Progress because 519 transitions

represents 81% of this quarter’s benchmark. The chart below shows the total number of

persons transitioned at the time of each reporting period in relation to the target goals as

specified in the Interim Settlement Agreement, then the Amended Settlement Agreement.

8 21 52 88118

171

225

268300

335

365383

427 450480

493 519

050

100150200250300350400450500550600650700

4/14 7/14 10/14 1/15 4/15 7/15 10/15 1/16 4/16 7/16 10/16 1/17

Number of Persons Transitioned in Relation to Target

(targets adjusted 10/19/15 retroactive to 10/1/15)

Target

Actual

4/17 7/17 10/17 1/18 4/18

10

The KY Housing Corporation has funding for approximately 25 housing vouchers,

depending on how many of the recently issued vouchers are used and how many tenants

discontinue use of current vouchers. It is anticipated that there will be a waiting list for

vouchers in the near future.

The work toward developing and expanding access to safe, affordable housing can

positively impact the overall costs of caring for this disability group. Stable housing has

long been considered one of the important social determinants of health, and there is

extensive literature linking housing instability and health care costs. A 2016 study

conducted by the Center for Outcomes Research and Education found that affordable

housing reduced overall health care expenditures by 12% for Medicaid recipients. This is

partly due to the increase in primary care visits that in turn, decrease emergency room

use. Persons that have supports attached to housing usually have increased monitoring of

health issues to avoid emergencies, and have assistance with general wellness activities,

thus decreasing health costs. (Health in Housing: Exploring the Intersection Between

Housing and Health Care, August 29, 2016)

Section III.C.3.(b) Transition of state wards

The Settlement was written that out of the 675 provided Housing Assistance,

approximately 335 are state wards and approximately 340 are not state wards. This

provision is rated Modest Progress. Currently 119 state wards have been transitioned

which represents 23% of all transitions. The 26 transitions this quarter included 9 state

wards. Of the 173 persons who transitioned but are no longer in housing as defined by

the Settlement, 54 (31%) are state wards.

Section III.C.6.7. Housing criteria

Housing under the Settlement is to be permanent with full Rights of Tenancy; it is to

include support services needed to maintain housing; and it is to be fully integrated,

scattered site housing. Housing cannot include group homes, boarding homes, or

supervised living settings. This provision is scored Substantial Progress. Transitions

counted under the Settlement have generally met these criteria. Exceptions would be

apartment complexes that may have had more than 25% of the units occupied by persons

transitioned, or situations where the transition was counted but there were insufficient

support services to maintain housing.

Section III.D.1.2. Array and intensity of services

Persons represented under the Settlement are to have access to the array and intensity of

services necessary to successfully transition to and live in community based housing.

The services are to:

a. be evidence-based, recovery-focused and community based;

b. be flexible and individualized to meet needs

c. help individuals recognize and deal with situations that may otherwise

result in crisis; and

11

d. increase and strengthen individuals’ networks of community and natural

supports.

This provision is rated Modest Progress due to uneven availability of services that meet

this criteria. There are service teams that are recovery focused and that strive to provide

evidence based services to fidelity. There are other areas where services are limited and

narrowly defined, such that the client must possess prerequisite skills or attitudes in order

to qualify, rather than individualizing services to meet client needs. ACT has been

described as requiring a “whatever it takes” approach by the service team. This is also

true when planning for, and coordinating other services and supports. The Cabinet must

determine the array and intensity of services needed across the state that will enable

persons to be supported in a less restrictive environment. The belief that a person must

stay in a PCH because they are incapable of “living on their own” or “living

independently” does not take into account the purpose of the Settlement. The expectation

should not be that the individual can succeed on their own, or that they will not be

dependent on a variety of supports. An individual’s support needs are to be identified

through assessment, with appropriate coordination of services occurring as part of the

person centered planning process. In addition to the Cabinet identifying and putting in

place the needed service array, areas for improvement include ensuring a thorough person

centered planning process that identifies needs and anticipates potential crises. There

also needs to be a stronger focus on the development of natural supports.

Section III.D.3. Five named services

The Settlement specifically requires that ACT, case management, crisis services, peer

support, and supported employment be available to persons transitioned to the

community. This provision is rated Substantial Progress in that these services are

available to some degree in almost all areas. Areas for improvement include ensuring

that services can be authorized and sufficiently reimbursed, and that services are not

siloed to the extent that clients are unaware of what is available to them.

Section III.D.4. ACT teams that meet fidelity

ACT is one of the oldest evidenced based practices in the field of psychiatric

rehabilitation, with over 40 years of research reporting outcomes that can be expected

when the service is provided to fidelity. All ACT teams are required to operate to fidelity

to either the Dartmouth Assertive Community Treatment (DACT) scale or the Tool for

Measurement of Assertive Community Treatment (TMACT) scale. This provision is

rated Minimal Progress based on the last fidelity reviews conducted that showed only

five ACT teams met a good or acceptable level of fidelity.

The success of ACT in Kentucky is a key component in achieving the goals of the

Settlement. Most of the ACT teams seem to be invested in the success of their clients,

though some may differ in who they believe can be successful or appropriate for their

services. ACT team members and other in-home service providers often have the “best

view of recovery” and serve as advocates within their own agencies for the community

12

integration of persons previously institutionalized. During this reviewer’s home visits to

persons who have transitioned, the tenants invariably credit ACT team staff for helping

them achieve their goal. ACT teams need the support of their agencies; a lessening of

barriers to service authorization and payment; a caseload size that will help cover service

costs; and on-going training in how to work with the high-need clients for which ACT

was designed. Solutions must be found to adequately address frequently encountered

issues such as substance use and diabetes so that these do not rule out clients from

receiving Housing Assistance. An ACT team leader at Centerstone talked about his harm

reduction approach with a client. He encouraged the client to “just stay sober” until the

ACT team staff arrived each day. After experiencing some repeated successes with that,

the client was asked to “just stay sober until your [substance abuse] group in the

evening”. This approach to his treatment has helped him greatly reduced the frequency

of his use. The client was not very verbal when visited but was able to say he liked

where he was living. He was someone who had previously moved, was returned to a

PCH, then moved again with more intense services. Another young man in Paintsville

was asked about his hopes for his life. He said he would like to meet a girl his own age

for company and said that his long-term goal was to go back to school and get a two-year

business degree. He stated that he wants to get a desk job and to wear a tie.

Below is the story of a man in Lexington receiving supports from the Bluegrass.Org ACT

team.

“I feel like I have succeeded quite a bit.”

A referral was made for Richard in June of 2016 so that he could receive Housing

Assistance and services that would allow him to live outside of the personal care home he

was in. The possibility of “guesting” in one of Bluegrass’ transitional housing units was

discussed with Richard in October of that year. After waiting for a unit to become

available, he guested for 3 days in March of 2017, then moved into the transitional unit in

April. When he left the PCH, the administrator gave him his card and told him that he

could come back. On September 5, 2017, Richard moved to his own apartment. I had

visited Richard last year when he was in the PCH and was able to visit him recently in his

home. He was comfortable talking about his life and how things have changed for him.

He said that the most difficult part of being in the PCH was being surrounded by people,

not being left alone, having difficulty getting along with some people, and having a

roommate who insisted on leaving the door open all the time. He also talked about

having a romantic relationship with one of the staff that resulted in the staff person being

fired. Richard shared that in his family home he had experienced his mother’s struggle

with untreated schizophrenia and his father’s drinking. He talked about living in the

dorm at Eastern Kentucky University for a couple of years where he studied Art and got

A’s in English; and then, the resulting panic of experiencing some of the same symptoms

he had seen in his father and mother. He was sent to the PCH after a psychiatric

hospitalization. When asked how he felt living in the PCH, he said “ashamed of myself

for letting my world crumble and having to be put in a place like that”. When asked how

he feels now, he was able to say that he believes he has “succeeded quite a bit”, though

he added that his family still does not yet see him that way.

13

Section III.D.5. Person-Centered Plans

Each person transitioning is to have a person-centered service plan done with a qualified

professional who is clinically responsible for coordinating all aspects of the plan. The

Person Centered Recovery Plan (PCRP) learning collaborative has reached all 14 CMHC

regions, and to a lesser extent has involved MCOs, Peer Specialists, and prescribers.

Each CMHC has had to determine if, or how they would make changes within their

electronic health records to better capture aspects of this approach to planning, such as

goal statements in the client’s own words, the listing of strengths to be referenced within

objectives, and the inclusion of non-billable natural support interventions. This provision

is rated Modest Progress. A great deal of work has been done by DBHDID toward the

implementation of PCRPs. What is unknown at this point is the result of that work.

DBHDID has a PCRP Quality Indicator Tool that was developed by the consultants.

This tool is to guide practitioners in their work and is also to be used by Department staff

to conduct reviews of plans with follow-up feedback on points for improvement. This

reviewer has seen the results from the Department’s review of a small sample size from

three different CMHCs. More reviews will provide information needed to better evaluate

the success of the learning collaborative. Some CMHC compliance officers/performance

improvement staffs were a part of the trainings provided by the consultants. Their

understanding of the quality indicators and their involvement in intra-agency reviews and

training will be important for the continuation of the practice and dissemination of the

practice’s underlying values. The learning collaborative was not specific to working with

persons leaving PCHs or state psychiatric hospitals. Person-centered planning is written

into the Settlement to ensure that client wishes, and service and support needs have been

identified before leaving an institution; and that persons responsible for the safety and

success of an individual know the actions they need to take, with timelines for taking

action. In addition to treatment and care coordination, the plan would include the very

practical details of who is getting utilities turned on, who is ensuring food and

medications are at the apartment, who is visiting or calling the client that first weekend at

home, getting crisis numbers on the refrigerator, ensuring the client knows what to do in

the case of problems or perceived emergencies, etc.

Section III.D.6. Case Management

Case management has always been a key service in supporting persons with SMI. When

clients do not need the intensity of ACT, they typically receive case management. Some

CMHCs have used case management along with other services to wrap support around

persons who qualify for ACT, but do not have ACT services available to them where they

want to live. This provision is rated Substantial Progress. Case management has always

been a strength in Kentucky, but barriers to service authorization have recently been an

issue in maintaining client stability in the community. Clarifying these issues will be

essential for this service to be an available tenancy support to persons in need.

Section III.D.7. Crisis Services

14

Crisis services are to include mobile crisis teams, community-based residential crisis

services, and 24/7 crisis phone lines. The Cabinet is to monitor crisis services in order to

identify service gaps and implement effective measures to address any gaps or

weaknesses. Crisis services provided to persons who have transitioned are to be

consistent with an already developed individual crisis plan in order to prevent

unnecessary hospitalization, incarceration, or institutionalization. This provision is rated

between Modest and Substantial Progress. All regions have a 24/7 crisis phone line, but

not all regions have mobile crisis teams or community-based residential crisis services.

Areas of improvement include determining where service gaps exist and how those gaps

might affect the unnecessary hospitalization, incarceration, or institutionalization of

persons transitioned. Considering the role of crisis services can be an aspect of “post-

mortem” reviews of failed transitions, particularly those with very short community

tenure. It is important for the Cabinet to know if, and how individualized crisis plans are

completed and used, in order to assess crisis service needs in each region.

Section III.D.8 Peer Services

DBHDID’s push to expand peer support services in Kentucky has paid off. Every

CMHC region has at least one peer specialist employed, even if they do not have the

minimum .5 FTE on their ACT team (only one region does not) or the minimum 2.0 FTE

for services that are separate from ACT (four regions do not). Peer support certification

trainings have continued and there have been training opportunities for the required

continuing education. The PCRP consultants recently provided a training for peer

support specialists regarding their role in the person-centered planning process. This

provision is rated Substantial Progress. Areas of improvement include better clarifying

the peer support services provided to clients who have transitioned, and ensuring that

more CMHCs offer this separate service to persons transitioned. Nine regions report

providing peer support services to persons who have transitioned and five regions report

serving no one who has transitioned, separate from contact made by the ACT team staff.

Section III.D.9. Supported Employment

Supported employment services that meet fidelity to the Individual Placement and

Support (IPS) model are to be available to persons transitioned, for their pursuit and

maintenance of integrated, paid, competitive work opportunities. There are 11 IPS

supported employment programs across the state that have achieved Good or Exemplary

fidelity scores. These include 8 CMHCs and 3 other Behavioral Health Organizations.

This provision is rated Modest to Substantial Progress because of Kentucky’s strong

efforts over the years to establish this service and maintain regular fidelity reviews. The

concern in terms of the Settlement is that reports show only 15 persons statewide have

received the service post-transition. Verbal reports in regional transition team meetings

indicate fewer than 5 people are employed. It will be important to determine the causes

of this lack of service use and take actions needed to improve these numbers. A lack of

natural supports has often been cited when persons are unsuccessful post-transition.

Competitive employment offers a strong natural support. A 2008 study published in the

Psychiatric Rehabilitation Journal reported that participants were able to describe a

15

variety of positive benefits associated with paid employment. They discussed ways in

which work fostered pride and self-esteem, offered financial benefits, provided coping

strategies for psychiatric symptoms, and ultimately facilitated the process of recovery.

(Dunn, Wewiorski, Rogers. ‘The meaning and importance of employment to people in

recovery from serious mental illness: results of a qualitative study’, Psychiatric

Rehabilitation Journal, 2008 Summer;32(1):59-62). Some barriers are known, such as

minimal employment opportunities in rural areas, and potential hesitancy of the client to

take on another environmental goal soon after moving. Possible recommendations for

improvement include:

1. Ensure widespread benefits counseling to persons who are transitioning or who

have transitioned. This will often require persons outside of the supported

employment program such as in-reach workers, case managers, and ACT team

members, to understand how employment impacts benefits, and to also promote

the positive personal benefits of employment.

2. Improve statewide access to IPS supported employment services, including

Lexington and its surrounding counties.

3. Highlight the role of employment in fostering recovery, and the importance of

revisiting the goal of employment with persons who have adjusted to their new

living environment.

Section III.E.1. Informed Decision Making

The Cabinet is to ensure that individuals residing in or at risk of entry into a PCH are

accurately and fully informed in writing, and signed by the individual, about the

community based options provided under the Settlement. This provision is rated Modest

to Substantial Progress due to improvements made in getting information to persons in

PCHs. DBHDID has created posters that are displayed in PCHs regarding the

Settlement, and some CMHCs initially distributed brochures about ACT services. There

has not been a process for obtaining client signatures to indicate they have been fully

informed in writing. A complicating factor for compliance with this provision is that the

necessary community based options are not available to some persons wanting to leave

PCHs. This is particularly true for those being discharged from state psychiatric

facilities. Hospital staffs have reported patients wanting to be discharged to community

housing with services, but the only option available to them is discharge to a PCH.

Section III.E.2. Cabinet Level team

This provision was Complete with the establishment early on, of the Cabinet Level

Transition team. The team meets approximately twice a quarter and includes the Cabinet

Secretary’s office, representatives from key Cabinet Departments and Offices, P&A, and

the Independent Reviewer.

Section III.E.3.a. Development of Materials

16

DBHDID has developed requirements and materials for in-reach and transition teams so

this provision is rated Complete. The Cabinet must monitor for needed revisions or

adjustments, as these procedures were put in place early in the Settlement.

Section III.E.3.b. On-going in-reach

The Cabinet is to ensure that ongoing in-reach is occurring in PCHs and in state

psychiatric hospitals. This provision is rated Substantial Process due to overall

improvement in the frequency of in-reach. There are several issues that complicate full

compliance with this provision. Not all CMHCs regularly provide in-reach to all of the

free standing PCHs in their area, nor in the Cabinet owned or operated psychiatric

hospital in their area. There are also issues with the effectiveness of in-reach in some

areas. Effective in-reach can be negatively impacted by:

the lack of services available to address clients’ presenting needs;

the in-reach workers lack of knowledge about supports, services, or the

Community Integration Supplement;

a lack of experience with clients’ positive change and growth as a result of

change in their environment;

the inability to recognize recovery potential; or

working within an agency that does not prioritize full community integration of

persons in this disability group.

Section III.E.3.c. Assignment to Transition Team

Persons who request community housing and services are to be assigned to a transition

team within 15 days of initial contact by the CMHC. The Time report on the Tracking

Tool indicates that this reporting quarter, only 15% of eligible referrals were assigned to

a transition team in 30 days or less. This parameter takes into account that the CMHC

has 14 days to make their initial contact once a referral is made for a total of 29 days

from the time of referral until assignment to the transition team. This provision is rated

Minimal to Modest Progress considering the current percentage of 15%, and the overall

percentage of reaching the benchmark over the life of the Settlement of 52%.

Section III.E.3.d. Communicating available options

The Cabinet is required to share the in-reach and education materials with P&A, DAIL,

the MCOs, and Clerks of Court to ensure guardians understand the options available to

individuals under the Settlement. This provision is rated Complete, although it is unclear

if, or how materials are shared with Clerks of Court.

Section III.E.3.e. P&A’s representation

State guardians, P&A, and case managers are to work together to find the most integrated

setting appropriate to meet individual needs. This provision is rated Substantial Progress.

17

Efforts have been made throughout the time of the Settlement to improve communication

and better coordinate efforts.

Section III.E.3.f. Transition within 90 days

Transition and discharge planning is to be complete within 45 days after assignment to a

transition team. The actual discharge is to be completed within 90 days of assignment to

the transition team. This results in a combined total of 119 days when adding the 14-day

time frame for making the first contact, the 15-day timeframe for assignment to a

transition team after making the first contact, and the 90-day timeframe to transition. The

Tracking Tool’s ‘Total Time to Transition’ report shows only 15% of transitions meet

this required timeframe for discharge. There are currently 105 on the list of persons who

have been waiting between 120 days and 1,460 days for transition. There are additional

persons not on this list of 105, whose guardians do not approve transition from a PCH, or

the individual is coded as ‘clinically inappropriate’ to move, for example. This provision

is rated Minimal. Locating housing in a timely manner is one barrier to achieving

compliance with this provision. Improvements can be made by more quickly pulling

together a transition team of all persons who will play a role in ensuring a successful

transition. A more responsive person-centered transition planning process, along with the

strengthening of relationships with private landlords and local housing authorities, can

help improve the timeliness of transitions.

Section III.F.1. Quality Assurance and Performance Improvement

The Cabinet is required to have a quality assurance and performance improvement

monitoring system to ensure placements and services are developed in accordance with

the Settlement; and to ensure that the individuals who receive Housing Assistance are

provided the services and supports they need for their health, safety, and welfare.

Services and supports are to be “of good quality and sufficient to help individuals achieve

increased independence, gain greater integration into the community, obtain and maintain

stable housing, avoid harms, and decrease the incidence of hospital contacts and

institutionalization”. This provision is rated Modest Progress, acknowledging the

processes the Cabinet has put in place to:

1. prioritize housing vouchers for persons under the Settlement;

2. maintain standards of housing quality through inspection by KHC;

3. implement and monitor the practice of person centered recovery planning;

4. monitor ACT, supported employment, and peer support staffing, including the

numbers served;

5. regularly meet with CMHC and hospital representatives to review persons waiting

more than 119 days to transition, and persons discharged from the hospital to

PCHs; and

6. conduct Quality of Life surveys pre-transition, 6 months post transition, and I year

post transition.

18

Improvements are needed in tracking whether or not there is greater access to safe,

affordable housing, and whether or not services are sufficient to obtain and maintain

stable housing.

Section III.F.2. Data for performance improvement

The Cabinet is required to collect, aggregate, and analyze data related to in-reach and

person-centered discharge and community placement efforts. The KY ISA Tracking

Tool has largely accomplished this. The tool also tracks persons who maintain

community tenure for 6 months and for 1-year post transition. This provision also

requires the identification of problems and barriers to placing and keeping individuals in

the community so that the Cabinet can review this information every 6 months, then

develop and implement measures to overcome those problems and barriers. This

information is currently not captured in a way that can inform performance improvement

actions. This provision is rated between Modest and Substantial Progress. The quality

assurance and performance improvement system must be able to inform actions

necessary to achieve the outcomes described in the Settlement.

Section III.F.3. Sharing of data

The Quality Assurance System is to be shared with P&A on at least a quarterly basis

unless requested sooner. This provision is rated Modest Progress. The Cabinet has been

responsive in getting the information they have to P&A, but is lacking in needed

information about improved housing access, the quality and sufficiency of services, the

problems that result in re-institutionalization, and the needed action steps to address

service gaps. This is the last substantive provision included in the Compliance with

Substantive Provisions Grid.

Section III.G.3. requires an accounting of the original expressers, indicating where they

are in the process of being transitioned from PCHs. There have been no reported changes

since last quarter. P&A reported speaking with 9 original expressers (including 1 who

transitioned then returned to a PCH) who want to leave the PCH they are in.

Since the start of the Settlement, Housing Assistance has been provided to 29 (including

4 potential plaintiffs) of the original 133 expressers. For these 29:

18 are still in housing

4 returned to a PCH

3 are deceased

2 to a nursing home

1 to a staffed resident

1 to family

Of the remaining 96:

12 died before transitioning 22 received ID/DD Supports for Community Living 10 went to nursing homes

19

7 could no longer be located 3 were deemed ineligible for services 6 were deemed clinically inappropriate, and 36 changed their original request to leave the PCH (or guardian intervened to

prevent them from leaving)

IV. SUMMARY/RECOMMENDATIONS

Several recommendations have been made throughout this report and do not need to be

repeated in this section. The Cabinet has expressed its desire to meet the terms of the

Settlement for the benefit of Kentuckians with psychiatric disabilities. This requires a

well-coordinated effort that will need to include sufficient service reimbursement, a

determination on how provider agencies can best be utilized, and a system that allows for

the funding of provider agencies based on the achievement of meaningful outcomes.

COMPLIANCE WITH SUBSTANTIVE PROVISIONS GRID

April 1, 2018

Ratings 4 - Complete – fully met as determined by Agreement

3 - Substantial Progress – progress by roughly 75%

2 - Modest Progress – progress by roughly 50%

1 - Minimal Progress – some progress made, approx. 25%

0 - No Progress – no progress made

Amended

Settlement

Agreement

Reference

Provision Rating

0-4

Rating What’s being monitored

III.A.1

Appropriate

Supports and

Services in the

Most

Integrated

Setting

The Cabinet will continue to

develop and implement

effective measures to provide

adequate and appropriate public

services and supports identified

through person centered

planning in the most integrated

setting appropriate to meet the

needs of individuals with SMI,

and who are residing in or at

risk of entry into a PCH.

2 Modest

Progress

The extent to which

services and supports

are adequate to meet the

needs of persons with

SMI in the most

integrated setting

appropriate, as

evidenced by persons

able to leave PCHs

and/or having

community options

other than PCHs.

III.A.2 All guardians shall receive

information from the Cabinet to

encourage their wards…to

participate to the maximum

3 Substantial

Progress

The extent to which all

guardians have

information from

Cabinet about allowing

20

extent of his/her abilities in all

decisions that will affect

him/her…including…treatment

discussions and discharge

planning…Any decisions made

by the guardian about where the

individual will live should

reflect the individual’s written

preferences, to the extent

possible.

wards to be a part of all

discussions/decisions

affecting them and that

decisions reflects the

preferences of the wards

Averaged score 2.5

III.B.1

Regulation

Cabinet agrees to promulgate a

new regulation encompassing

and further describing the

services and supports in the ISA

and this Settlement Agreement

prior to December 1, 2015.

4 Complete Existence of Regulation

filed Dec. 2, 2015 and

finalized June 3, 2016

Averaged score 4

III.C.1.2.

Community

Based

Supported

Housing

Assistance

Cabinet will develop and

implement measures to provide

individuals outlined in

III.C.2.a-c access to

community-based supported

housing.

2 Modest The extent to which

there is access to

supported housing and

access to state or federal

housing vouchers or

subsidies.

III.C.3. The Cabinet will provide

Housing Assistance to 150

individuals by Oct. 1, 2015; 350

individuals by Oct. 1, 2016; 600

individuals by Oct. 1, 2017; and

675 individuals by Oct. 1, 2018

3 Substantial

Progress

Achievement of

benchmark numbers.

Currently 80%

III.C.3. …with approximately half

given to state wards and half to

others

2 Modest

Progress

Achievement of

benchmark percentage.

Currently 22%

III.C.6,7

Housing is permanent with

Tenancy Rights; Tenancy

support services enable

residents to attain and maintain

housing; Services are available

but not a condition of tenancy;

Individuals with and without

disabilities have opportunities

to interact; Does not limit

ability to access community

activities; Scattered site housing

with no more than 25% of units

in development occupied by

3 Substantial

Progress

Extent to which housing

meets all specified

criteria.

21

individuals with a disability

known to the Cabinet; Choice

in daily life activities; Priority

of single-occupancy housing;

cannot be PCHs, group homes,

nursing facilities, boarding

homes, assisted living

residences, supervised living

settings, or any setting required

to be licensed. Averaged score 2.5

III.D.1.2.

Behavioral

Health

Services

Access to services and supports

which are evidence-based,

recovery-focused and

community-based; Flexible and

individualized; Help individuals

to increase their ability to

recognize and deal with

situations that may otherwise

result in crises; Increase and

strengthen individuals’

networks of community and

natural supports

2.0 Modest

Progress

Extent to which services

are accessible and meet

listed criteria, allowing

persons to live in

community-based

settings.

III.D.3. Community mental health

services of ACT teams, case

management services, crisis

services, peer support services,

and Supported Employment

Services

3 Substantial

Progress

Number of regions

providing all 5 services.

III.D.4. ACT teams meet fidelity 1 Minimal

Progress

Number of teams

achieving fidelity to

EBP and serving

persons under

settlement. Last fidelity

reviews showed 5 teams

at acceptable to good

fidelity.

III.D.5. Person-centered plans with

coordinating professional which

include psych. advance

directives and/or crisis plans

2 Modest

Progress

Evidence of person-

centered planning for

persons under

settlement. Small

sample sizes from 3

CMHCs averaged 40 out

of 52 possible points on

the Quality Indicator

Tool. All CMHCs have

22

received TA

III.D.6. Case management services

leading to goal achievement

3 Substantial

Progress

Case management

services sufficient to

support community

tenure.

III.D.7. Crisis service systems are

timely and accessible, crisis

services monitored and service

gaps are addressed, services are

in least restrictive setting.

2.5 Modest

Progress

Extent to which crisis

services are accessible

and extent to which

Cabinet monitors

service gaps.

III.D.8. Provision of peer support

services

3 Substantial

Progress

Number of regions

offering peer support

services to persons

under settlement

III.D.9. Will develop and implement

measures to provide Supported

Employment with fidelity to

IPS

2.5 Modest

Progress

Number of programs

meeting fidelity and

serving persons under

settlement. Averaged score 2.38

III.E.1.

Discharge and

Transition

Process

Individuals are accurately and

fully informed in writing and

signed by individual about

community-based options

2.5 Modest

Progress

Evidence of the extent

to which persons are

fully informed about

community-based

options available to

them under the

Settlement.

III.E.2. DBHDID will create an overall

transition team at the Cabinet

level which will provide

oversight and assist local

transition teams in overcoming

identified barriers to transition

4 Complete Cabinet level team

formed

III.E.3.a. DBHDID will develop

requirements and materials for

in-reach and transition

coordinators and teams.

4 Complete Requirements and

materials may need

revisions over time.

III.E.3.b. DBHDID will ensure on-going

in-reach to individuals in PCHs

and Cabinet owned and

operated psychiatric hospitals

for individuals meeting

requirements of Amended

Agreement.

3 Substantial

Progress

Extent to which regular,

effective in-reach occurs

in all free-standing

PCHs and state

psychiatric hospitals

III.E.3.c. Within 15 days of initial

contact, individuals who have

indicated they do not want to

1.5 Minimal

Progress

For this reporting

quarter, the benchmark

was met 15% of the

23

receive services in a PCH shall

be assigned to a transition team.

time. The overall

percentage for all

quarters is 52%

III.E.3.d. P&A, DAIL, Clerks of Court

receive in-reach and education

materials to ensure guardians

understand options available to

individuals

4 Complete Has occurred, but must

continue

III.E.3.e. State guardians will cooperate

with P&A and CMHC case

managers in finding the most

integrated setting and allow

P&A to represent wards

3 Substantial

Progress

Level of cooperation

among state guardians,

P&A, and CMHCs in

finding the most

integrated setting and

accessing services.

III.E.3.f. Transition and discharge

planning completed within 45

days of assignment to transition

team. Discharge if appropriate

will occur within 90 days of

assignment to transition team.

1 Minimal

Progress

90 day benchmark + 29

days. Overall 20%

completed within 119

days (12% this quarter)

Averaged score 2.88

III.F.1. Cabinet will develop and

implement a quality assurance

and performance improvement

monitoring system to ensure a

quality service system sufficient

to help individuals achieve

increased independence, gain

greater integration into the

community, obtain and

maintain stable housing, avoid

harms, and decrease the

incidence of hospital contacts

and institutionalization.

2 Modest

Progress

Implementation of a

quality assurance and

performance

improvement

monitoring system for

service quality and

effectiveness.

III.F.2. Collect, aggregate, and analyze

data related to in-reach and

person-centered discharge and

community placement efforts

(successful and unsuccessful

placements, problems/barriers

to integration). Review semi-

annually and develop and

implement measures to

overcome barriers

2.5 Modest

Progress

Extent to which data

identifies

problems/barriers to

integration and

measures are

implemented to

overcome barriers.

III.F.3. Quality Assurance System

information will be shared with

2.5 Modest

Progress

Availability of

performance

24

P&A quarterly unless requested

sooner

improvement data.

Averaged score 2.3

Overall average 2.76