Importance: Studies show us that most people in rehabilitation and recovery do better when they live in their home communities. Our clients must be able to get the care and supports they need in the settings they need and want. The Governor’s Office, our agency and others are embarking on an ambitious Mental Health Transformation project to increase the availability of specialized supports in adult family homes and other facilities for individuals in recovery. We also are focused on developing more community living alternatives so people diagnosed with developmental disabilities so they can live, work and play closer to their families, friends and loved ones.
Based on this, DSHS has established the following strategic objectives to support how we will serve people in their home community.
MENTAL HEALTH TRANSFORMATION
Mental Health Transformation – provide new long-term services and supports for individuals transitioning from state psychiatric hospitals.
Decision Packages: 050 - ML - EF - Continue Discharge Placements, 050 - ML - EN - ESF - Capacity Mental Health
Importance: Washington has an identified gap in community options for individuals with behavioral challenges and personal care needs, particularly for those ready for discharge from the state psychiatric hospitals. Under a state law enacted in 2016, and as part of the Governor-directed Mental Health Transformation, the Aging and Long-Term Support Administration (ALTSA) received funding to increase community alternative options that prioritize the transition of those ready for discharge from state psychiatric hospitals who have long-term care needs. ALTSA’s success in meeting this objective and ensuring individuals receive the right array of services to meet their individual needs is a shared responsibility across DSHS administrations, including the Behavioral Health Administration. It will require extremely close coordination and a new level of collaboration between ALTSA, state hospitals, behavioral health organizations, managed care organizations, accountable communities of health and community providers.
Success Measures: Consistently achieve a quarterly average of 74 clients transitioning from state psychiatric hospitals into community settings by June 2019.
Action Plan:
- Increase types and capacity of specialized community options available to home and community-based clients, including Enhanced Services Facilities, Expanded Community Services, Specialized Behavior Support Adult Family Homes, and Supportive Housing by June 2023.
- Work with local partners to address barriers and develop additional community providers who have the expertise and sufficient staffing levels to serve a high-needs population, reducing hospital readmissions.
- Coordinate across agencies to successfully transition individuals from state and community psychiatric hospitals into community settings that are able to address the unique and complex needs using an individualized and person-centered approach, helping to ensure access to intensive care coordination.
- Create a regulatory structure that supports providers willing to provide high-quality care to individuals with complex needs who are able to relocate out of institutional settings and proactively provide the necessary technical assistance and education that assists them in being successful in serving this population.
QUALITY OF LIFE
Support individuals with developmental disabilities to be able to receive services that support them in living in their own communities rather than in facility-based settings.
Decision Packages: 040 - PL - 4S - Community Transition Expansion, 040 - ML - DA - Utilization of Residential Services, 040 - ML - DH - Continue 47 SOLA Placements, 040 - ML - EF - Continue Discharge Placements, 040 - PL - 4S - Community Transition Expansion, 040 - PL - 4Y - Community Residential Rate Increase, 040 – ML – EF - Continue Discharge Placements
Importance: Individuals with developmental disabilities should have access to services and resources that meet their needs and promote activities, routines and relationships. This includes being able to live in communities, rather than in facility-based settings.
Success Measure: Increase the percentage of Developmental Disabilities Administration (DDA) clients served in home and community-based settings from 97.4 percent in July 2017 to 97.6 percent by June 2019.
Action Plan:
-
Ensure all clients requesting services receive an assessment to determine eligibility for community-based services.
-
Provide Roads to Community Living funds to assist clients with their transition during the first 12 months after moving.
-
Conduct quarterly performance data reviews at the executive level to ensure targets are met.
Success Measure: Increase State Operated Living Alternative (SOLA) placements for 15 individuals who reside at Western and Eastern State Hospitals by June 2019.
Action Plan:
- Work with staff at Western and Eastern State hospitals to determine client discharge readiness.
- Obtain homes in the community and recruit, hire and train staff to support clients in the SOLA program as funding becomes available and as clients are ready for discharge.
- Conduct at least three quality assurance surveys during the first 12 months after a client has moved to ensure that service and support needs are being met.
Ensure that services and supports provided to clients in certified residential settings meet regulatory requirements and quality of care standards.
Decision Packages: 040 – PL – DP - Supported Living Investigators, 040 – PL – 4Y - Community Residential Rate Increase, 040 – PL – 4V - Critical Services and Supports, 040 – ML – DM - Minimum Wage
Importance: More than 4,200 individuals across the state receive community-based residential services from more than 135 contracted providers. Timely and consistent background checks for staff, routine community engagement for the individuals we support and quality support plans reflecting industry best practices are three key indicators of safe, integrated and quality service.
Success Measure: Certified residential providers will receive fewer than four background-check-related citations each per quarter by June 2019.
Action Plan:
- Provide certified residential service providers with training and technical assistance.
- Give residential service providers the option of a background check tracking tool.
- Review performance data quarterly with central office and regional executive management teams to ensure targets are met and to note any issues.
Success Measure: Certified residential service providers sampled will provide clients with at least 4.6 days of support in accessing community-based activities for three consecutive quarters during the 2017-19 biennium.
Action Plan:
- Share community activity data and promote residential providers’ support of community activities at regional provider meetings.
- Follow up, involve case management and provide technical assistance as appropriate, for clients identified to have two or fewer community outings in sampled weeks.
- Provide access to online training and encourage residential provider staff to support clients in accessing community-based activities.
Success Measure: 180 Developmental Disabilities Administration (DDA) employees or DSHS contractors will complete a standardized “functional assessments and positive behavior support plan” training by June 2019.
Action Plan:
- Promote training through the DDA website, GovDelivery and residential provider meetings.
- Monitor regulatory compliance and encourage course completion for providers with citations related to behavior support planning.
- Offer ongoing access to online training and provide at least one instructor-led training each quarter for employees of certified residential providers.
Conduct timely oversight and compliance activities of facilities and agencies providing residential care and supports.
Decision Package: 050 - PL - DP - Supported Living Investigators
Importance: This measure reflects the core work done by our licensors and surveyors regularly to ensure all long-term care facilities and services are following regulations and are providing quality care and those adults who are vulnerable are protected from abuse. This work is done on behalf of all residents of the state who might access these services, whether they pay for them privately or are DSHS clients. Requirements for on-site visits vary by setting.
Success Measure: Maintain the percentage of timely re-inspection at 99 percent or higher for nursing homes, and increase the percentage of timely re-inspection to 99 percent for assisted living facilities and adult family homes by June 2019.
Action Plan:
- Optimize staffing through cross-training licensors among different settings and through recruitment and retention strategies.
- Request funding for additional staffing to license and inspect assisted living facilities, the fastest growing provider type.
- Develop and accept a Residential Care Services staffing workload model using key metrics such as facility and provider growth and changes.
Success Measure: Maintain timely quality assurance activities at 100 percent for services provided to people with developmental and intellectual disabilities.
Action Plan:
- Develop standard operating procedures for assuring quality for intermediate care facilities for individuals with intellectual disabilities (ICF/IID) in residential habilitation centers (RHCs) and for community ICF/IID.
- Expand Residential Care Services staffing for supported living to allow for program-specific quality assurance and enforcement.
SAFETY
Complete abuse and neglect investigations timely and thoroughly.
Decision Package: 050 - PL - E7 - IT - Systems Modernization
Importance: Protection of adults who are vulnerable requires consistent and timely investigations and the offering of protective services and referrals for services and supports. Delays create a greater risk of harm to the alleged victim. Also, timely investigation means that a confirmed perpetrator can be listed on a statewide registry of people who are not allowed to work with vulnerable adults. Although there are no state or federal standards or guidelines for Adult Protective Services, the Aging and Long-Term Support Administration (ALTSA) mirrors the Child Protective Services 90-day standard for investigations. Performance on this item has improved due to increases in staffing funded by the Legislature to meet increased reports of abuse and neglect.
Success Measure: Increase the percentage of adult abuse and neglect investigations completed within 90 days (or remaining open for “good cause”) from 95.4 percent in calendar year 2016 to 97 percent by June 2019.
See Chart AAC.2: Adult Abuse and Neglect Investigations Completed Timely
Action Plan:
- Ensure focused monitoring of “good cause” delay reason codes, and analyze for process improvements.
- Hire aggressively and improve retention to reduce staff vacancies and turnover.
- Evaluate the results of dedicating staff for specialized investigations on financial exploitation allegations and self-neglect.
Investigate complaints regarding facilities in a timely manner.
Importance: Complaints in long-term care facilities are investigated to protect residents from abuse, neglect and exploitation; to ensure services provided meet the health and safety needs of residents; to evaluate whether provider practice meets regulatory requirements; and to make quality referrals to entities that help protect victims. The high volume of complaints and the resulting workload, coupled with limited investigative staff, has made it difficult to meet response time goals, especially for medium and low-priority complaints (non-immediate jeopardy complaints). The backlog has been reduced, but until staffing levels are stable and sufficient, this item remains a concern.
Success Measure: Reduce the long-term care facility complaint investigation backlog of non-immediate jeopardy complaints from 152 in June 2017 to 100 or fewer by June 2019.
See Chart AAR.7: Backlog of Facility Complaint Investigations
Action Plan:
- Hire aggressively, improve retention to reduce staff vacancies and turnover and cross-train for all facility types.
- Continue to hire on-call staff to allow Residential Care Services to be more responsive to changing complaint volumes and staff availability.
- Monitor complaint investigations for all regions, units, and facility types monthly.
INDIVIDUAL STRATEGIC OBJECTIVES
Prepare Special Commitment Center (SCC) residents who are reentering the community.
Decision Package: 135 – PL – M4 - Wraparound Reentry
Importance: Governor Inslee’s Executive Order on Reentry requires reentry plans for all people leaving a juvenile rehabilitation facility, and by extension, all individuals preparing for release from civil commitment. Supporting a successful reentry in clear and direct ways may make the difference between recidivism and successful transition to the community. Planning ahead of time for post-release helps address the many pervasive obstacles faced by youth and adults in areas relating to employment, education, housing, and social services and improves their long-term outcomes significantly.
Success Measure: Increase the percent of SCC residents conditionally released to Least Restrictive Alternative (LRA) placement who participate in vocational rehabilitation orientation prior to release from 44 percent in 2018 to 75 percent by 2019.
See Chart SC1.9: SCC Residents Conditionally Released Participating in Orientation
Action Plan:
- Collaborate with the Division of Vocational Rehabilitation to include orientation and eligibility determinations into SCC transition treatment groups for residents recommended for least restrictive alternative.
- Residents who have or will have a court date for release will attend as part of overall transition program.
Consumer Directed Employer: Implement a new employment structure for in-home care providers that increases case management time available for clients and decreases administrative burden on the Department while maintaining consumer choice and consumer direction.
Importance: Over the years, managing the Individual Provider (IP) workforce has become increasingly complex due to the growth of the in-home caseload, the increased acuity of consumers and expanding demands brought on by new and changing state and federal requirements. Managing this workforce currently falls to DSHS and Area Agency on Aging (AAA) case management staff, which diverts their time away from working directly with consumers. Once implemented, the Consumer Directed Employer (CDE) will assume all administrative functions for the IP workforce including payroll, background check and training requirements, tax reporting, credentialing, electronic visit verification, etc. When the CDE is implemented, case managers will have more time for consumer assessments, service plan development and monitoring, addressing health and safety needs and other important case management activities.
Success Measure: Transition 100 percent of all personal care and respite hour authorizations formerly made to individual providers to the CDE by July 2020.
Action Plan:
- Issue a request for proposal to procure a CDE vendor that includes input from tribes and stakeholders received through a statewide public process.
- Successfully negotiate and sign a contract with up to two successful bidders to the CDE procurement.
- Complete all staff, consumer and IP readiness activities needed to successfully transition the IP workforce to the CDE.
Process financial applications, complete new assessments and re-assessments and develop service plans for those who apply for services in a timely way so that individuals can be supported in the setting of their choice.
Decision Packages: 050 - PL - E7 - IT - Systems Modernization, 050 - ML - 93 - Mandatory Caseload Adjustments, 050 - ML - 94 - Mandatory Workload Adjustments
Importance: In order to receive long-term services and supports (LTSS), an individual must be functionally eligible (they require unmet assistance with activities of daily living) and financially eligible (their assets and income must be within limits). This is not only necessary for determining eligibility for Medicaid and LTSS services but also ensures federal funding can be used to pay for services. Delays in access to medical and support services can: leave families without support for their loved one; lead to gaps in housing; and/or result in unnecessary institutional placement. Once approved for services, re-assessment occurs annually to determine continued eligibility.
Success Measure: Increase the percentage of timely financial eligibility determinations completed from 88 percent in June 2017 to 93 percent as of June 2019. (A financial eligibility determination is conducted timely when it is completed within 45 days from the date of intake or longer than 45 days if good cause exists.)
See Chart AAH.7: Financial Eligibility Determinations Processed Timely
Success Measure: Increase the percentage of initial functional assessments completed within 30 days of creation from 72 percent in June 2017 to 93 percent by June 2019. (Policy requires that assessments be completed within 30 days of when they are begun. Policy also requires an assessment be fully completed within 45 days of intake; data for this latter item is currently under development.)
See Chart AAH.5: Initial Functional Assessments Completed Timely
Success Measure: Increase the percentage of timely functional reassessments from 96.7 percent in June 2017 to 98 percent by June 2019. (A functional reassessment is timely when the case manager completes the annual reassessment within one year of the last assessment.)
See Chart AAH.12: Annual Function Re-Assessments Completed Timely (AAAs and HCS)
Action Plan:
- Monitor delay reason codes for initial and annual assessments to identify trends around delays resulting in assessment completion exceeding 30 days.
- Analyze new reports related to intake, worker assignment, and assessment completion to identify trends and training opportunities to improve staff performance and consistency using updated policy and procedure that defines intake dates and timeliness.
- Regional leadership will analyze staff performance based on new timeliness reports to identify areas of improvement or need for additional root cause analysis.
Build Department and partners’ expertise in working with Tribes as they develop capacity around government-to-government relations, especially around social services provision and contracting.
Importance: DSHS and its approach to government-to-government collaboration with tribes and Recognized American Indian Organizations (RAIOs) is recognized for its vision and leadership. Internally and with state departments, DSHS provides technical assistance and support to those seeking it. This has already taken place with the Department of Commerce and the former Department of Early Learning. Other noted work involves the recent expansion of the Indian Policy Advisory Committee meetings to include the Governor’s Office of Indian Affairs and various departments of state government.
The need for technical assistance is further demonstrated by the transition of the Department of Behavioral Health and Recovery to the Health Care Authority and the Department of Health, which will be working to create identified capacity by June 2019. An interagency memorandum of agreement among the three departments details the support the Office of Indian Policy will provide by continuing to manage contract consolidation and assisting with planning among tribes and departments involved.
Success Measure: Advance our government-to-government model within DSHS, Governor’s Office of Indian Affairs and other agencies to assist them in building needed and identified capacity. We will support our partners to achieve these goals by June 2019.
Action Plan: Coordinate collaboration and communication between the Office of Indian Policy, tribes, agencies and others including:
- Maintain contracts and reporting activities.
- Collaborate with tribes and departments to assist with continued planning activities.
- Provide training to partners where needed.
Provide education and training to DSHS staff and providers to better serve residents and clients who are deaf or hard of hearing.
Importance: Providing training and education to service providers and DSHS staff on various communication modalities ensures that access points to critical services are well-equipped for effective communication. This is paramount in meeting the needs of individuals who are Deaf, Deafblind, Deaf Plus, Hard of Hearing, Late Deafened, or who have speech disabilities to support equal access to the benefits afforded to the rest of the community.
Success Measure: Increase the number of DSHS and service-provider sites where education and training in communication access modalities (methods) for people who are deaf and hard of hearing is provided from 25 to 50 by June 2019.
See Chart DH1.8: Number of Sites with Education and Training Provided
(DSHS and Service Provider sites, Training in Communication Access Modalities for the Deaf or Hard of Hearing)
Action Plan:
- Start education and training in communication access modalities at Home and Community Services and Residential Care Services offices.
- Initiate an evaluation system for measuring client use and DSHS staff knowledge and application of communication modalities.
- Conduct outreach and disseminate information on available communication access modalities.
Expand case management services for specialized populations.
Importance: Individuals who are Deaf, Deafblind, Deaf Plus, Hard of Hearing, Late Deafened, or who have speech disabilities, especially adults who are older, the underemployed and those with multiple disabilities, face barriers that affect access to communication, education, health care, employment, legal, housing, transportation, insurance, public assistance and other benefits. Case managers are available to assist these individuals in obtaining needed services by coordinating services, translating documents, advocating on their behalf and/or teaching new abilities and skills. These services are provided by eight contracted, non-profit Regional Service Centers throughout Washington.
Success Measure: Increase the number of clients served by the Regional Service Centers of the Deaf, Deafblind, Deaf Plus, hard of hearing and late deafened from 600 in June 2018 to 690 by June 2019.
Action Plan:
- Monitor each Regional Service Center’s total caseload and contract performance and implement corrective actions for under-performance as necessary.
- Have new contracts in place with each center and contractors to reach out to a diverse communities.
Provide assistive communication technology services.
Importance: Many individuals with hearing loss depend on auditory supports and do not use sign language. Assistive communication technology, such as listening systems, aid in ensuring that effective communication occurs between people with hearing loss and employees or contractors providing DSHS services during in-person office visits. These assistive listening systems help clients access DSHS programs and services and include tools such as hearing induction loops and pocket talkers.
Success Measure: Increase the number of locations that serve the public and clients with assistive listening systems services from 263 locations to 363 locations by June 2019.
See Chart DH1.7: Number of DSHS and Contractor Sites with Assistive Listening Systems Services
Action Plan:
- Continue to distribute, install or maintain functionality of assistive listening technology including induction loops at the Legislature, Area Agencies on Aging, Home and Community Services Division and Residential Care Services offices statewide, including continuing training for DSHS staff.
- Initiate an evaluation system for measuring client use and staff knowledge of assistive communication technology.
- Install loop systems at residential facilities where individuals with hearing loss live.
Timely abuse and neglect investigations.
Decision Package: 050 - PL - E7 - IT - Systems Modernization
Importance: Adult Protective Services (APS) has two primary duties: offer protective services to vulnerable adults who are harmed and investigate allegations to determine if abuse occurred. Timely response is essential in order to protect health and safety, including providing protection orders and long-term services and supports. Investigations are categorized by priority. A high-priority investigation requires initiation within 24 hours of knowledge. A medium-priority investigation requires initiation within five working days, and a low-priority investigation requires initiation within 10 working days.
Success Measure: Increase timely initial response to investigations based on priority to 100 percent for high-priority investigations and maintain at 99 percent for medium and low-priority investigations by June 2019.
See Chart AAP.1: Adult Protective Services - Timely Initial Response
Action Plan:
- Increase public awareness of the APS on-line reporting system.
- Evaluate areas for improvement to ensure consistent intake decisions and timely assignment for investigation.
- Monitor newly implemented phone technology across each of the three DSHS regions.
Support people to transition from nursing homes to care in their homes or communities.
Importance: The majority of individuals who require personal care services choose to receive these supports in their home or in other community-based setting. Some individuals stay in nursing homes because they do not realize they have other options, or because they entered some time ago when their needs were more intense, such as after hospitalization. Providing community resource education and assisting interested individuals to move from nursing homes into a community setting of their choice, increasing quality of life and contributing to the financial health of Washington.
Success Measure: Consistently achieve a quarterly average of 950 nursing facility-to-community setting transitions by June 2019.
See Chart AAH.2: Number of Relocations from Nursing Facilities to Home and Community-Based Settings (Quarterly; Annuals Show Quarterly Average)
Action Plan:
- Provide staff with ongoing technical assistance, education, tools and resources to address the changing needs of clients.
- Work collaboratively with nursing facilities, residents and families to improve their understanding of the resources and benefits of living in the community and to transition individuals who may prefer a community-based option.
- Introduce and implement standards to improve quality outcomes and community stabilization for individuals choosing to relocate from nursing homes.