Long Term Care Services: Future of LTCS

WHAT DOES THE FUTURE HOLD FOR LONG TERM CARE SERVICES (LTCS)?

With the current fiscal environment and a growing state hospital population, LTCS needs to be creative in the management of current issues while maintaining the commitment to safety, security and quality care and treatment. Identified below are several on-going issues and the methods by which LTCS is managing these issues.

Public Safety and Security:

All state hospitals now have a secured perimeter within which forensic patients are treated. The Department currently has a total of 3,876 secured beds for use in the treatment of forensic patients. LTCS conducts annual security audits at each state hospital to ensure they are in compliance with safety and security directives and that safety for patients, staff and the general public is not compromised.

NIMBY (Not In My backyard):

“Not In My Backyard” is a recurrent theme from communities when the Department of Mental Health (DMH) attempts to increase the number of patients served in current community resources, select a site for a new hospital or residential service, or place a patient locally. It continues to be a barrier to developing residential options for Conditional Release Program (CONREP) patients. The system is currently saturated, and unless additional resources can be developed, the Department’s ability to provide community programming for patients will be seriously restricted. The DMH is committed to following all laws that pertain to community placement for patients. LTCS attempts to manage these issues by educating the public on the specific laws pertaining to community placement for patients, recognizing and treating mental illness, and reducing negative stereotypes of people with mental illness.

CONREP Housing and Treatment of Sexually Violent Predators (SVP):

The DMH treatment program for SVPs is a five-phase program that includes as the fifth and final phase, Outpatient Treatment & Supervision in CONREP. In this phase, the patient applies the skills he has learned in the four inpatient phases in an outpatient setting. To ensure public safety in outpatient treatment programs, Forensic Services established a process for the development of a Community Safety Plan for SVPs. This plan is administered through a CONREP, which is a contract entity. DMH contracted with a new CONREP-SVP provider, Liberty HealthCare, to serve this patient population in 58 counties. Liberty HealthCare is from Pennsylvania and provides outpatient services in 2 other states.

Population Management:

Since 1993, the numbers of patients committed to DMH state hospitals as Incompetent to Stand Trial, Not Guilty By Reason of Insanity, Sexually Violent Predators or Mentally Disordered Offenders have increased significantly. The growth of patients in these forensic commitment categories is projected to continue. Until the new state hospital in Coalinga is opened, the DMH must provide short-term solutions to the problem of population projections exceeding the number of secure state hospital beds. To address the secure bed shortages that will occur beginning in 2003-04, DMH will have to house more patients than allowed under current licensing capacity at Patton (PSH) and Atascadero (ASH) state hospitals. To accomplish this will require DMH to convert space now utilized for rehabilitation activities, treatment, and office space into patient living space. Modular buildings will be used to replace space lost to temporary bed conversion. This will allow for the placement of additional patients at the hospitals. PSH and ASH are being used for this over- bedding as these are the DMH’s two most secure facilities, and have an extensive history serving forensic patients.

Seclusion and Restraint:

As part of DMH’s commitment to provide treatment services that are the least restrictive possible and which respect patient dignity, state hospital staff continually strive to employ effective alternatives to minimize the use of emergency interventions such as seclusion and restraint. Strategies currently being utilized are: a restructure of philosophy to focus on safety rather than control; increased patient involvement with a stronger emphasis on patient preferences and choices; improved early intervention practices; utilization of special individualized behavior treatment plans for high risk patients; implementation of violence reduction programs; enhanced staff training on de-escalation techniques; and data assessment to ascertain what environmental aspects or other factors may prompt dangerous behavior. LTCS has embraced the concept of a violence free and coercion free environment that over time will result in the future reduction of seclusion and restraint.

Recruitment:

With the growth in the state hospital patient population and the addition of programs at the state hospitals, (the 258-bed addition at ASH, the new Salinas Valley Psychiatric Program, and the new hospital in Coalinga), comes the need for staff. Further, there is a shortage of clinical staff in many areas including psychiatrists, psychologists, social workers, nurses and psychiatric technicians to meet the competing needs of DMH, Department of Developmental Services (DDS), California Youth Authority (CYA), California Department of Corrections (CDC) and the private sector. Recruitment of staff remains a formidable challenge.

The impact of escalating healthcare worker shortages is very significant. DMH competes with other state, county and private facilities that hire the same type of staff. Since the demand for staff often outstrips the supply, public and private employers operate from a base of trying to recruit staff from an inadequate employment pool. This results in a recurring cycle of escalating recruitment costs, higher pay/benefit packages and vacancies/overtime expenditures when staff moves from one facility to another based on the latest attractive package. For a definitive long-range solution, the number of healthcare workers must increase to balance the supply-demand equation.

In addition to educational affiliations used to develop candidate pools, recruitment efforts include advertisement on a national and local basis, recruitment and retention incentives for target classifications and development/funding of training programs for key clinical classifications.

Cost Containment:

Several years ago, LTCS management began to review the hospital budgets for areas where cost-containment efforts could be explored. We identified several areas within our control where these efforts could be pursued.

LTCS identified drug purchasing as an area to pursue as a cost-containment strategy in 2001. A workgroup of administrators and Medical Directors reviewed purchasing practices at the state hospitals to identify potential cost saving ideas. As the statewide buyer of pharmaceutical products for state institutions the Department of General Services (DGS) was requested to pursue the benefit of savings in all state departments that use medications. DGS created the Common Drug Formulary Committee composed of the DMH, CDC, CYA, and DDS. Other state, local, and public agency governmental entities have been given the option to participate in this committee. The Common Drug Formulary Committee serves as a steering committee to coordinate the efforts of participating agencies to develop cost-effective contracts for the purchase of pharmaceuticals and medical supplies. DMH is an active participant on the committee and frequently provides leadership due to the expertise of the staff.

LTCS identified community hospital contracts as another significant issue. DMH is currently working with CDC and CYA to explore joint contracting for these services.

The DMH has used videoconference technology for administrative purposes for years. The use of this technology has been instrumental in improving efficiency between state hospitals and headquarters. In addition, the use of video has resulted in substantial cost savings for employee travel and per diem compensation. DMH entered into discussions with the Los Angeles County Superior Court and the Los Angeles Public Defenders Office on the potential use of videoconference technology within the courtroom and the state hospitals. All Los Angeles Public Defenders now have the option of using video for the patient/attorney interviews and have recently started holding some court proceedings via video. The attorney will no longer be required to travel great distances to the state hospital just to conduct a simple patient/attorney consultation and the state hospital will no longer be required to provide transportation and staffing for these court proceedings. Although this is only a first step, DMH views this agreement as the basis for a much broader use of videoconference technology in the future. DMH envisions the use of videoconference technology in the courtroom as an effective way of reducing travel and supervision cost for patients required to attend court, as well as eliminating the public safety risk of transporting patients within the community. In addition, there is also a substantial cost savings when treatment staff from the hospital can use video technology to testify rather than be present in the courtroom. Overall, the use of videoconference technology will substantially reduce cost, reduce risk, and increase efficiency between the state hospital and the court.

By developing a secondary screening process, Forensic Services staff achieved cost savings in the Mentally Disordered Offender (MDO) evaluation process without impacting public safety. Currently, CDC refers potential MDOs as they near the end of their prison term. The secondary screening identifies repeat referrals from CDC where the clinical evaluation has already been done and found the inmate did not meet MDO criteria and there has been no change in the inmate’s mental health and criminal profile to make the prior evaluation invalid.

Capital Outlay:

The DMH state hospitals are primarily older buildings with the youngest state hospital having been constructed in the early 1950’s. The age of these buildings requires LTCS to preserve and maintain the infrastructures for continued use. In addition, some projects are necessary to make improvements to bring the buildings into Americans with Disability Act or Fire Life Safety compliance, for energy efficiency or to complete seismic retrofits.

LTCS has numerous capital outlay projects on-going at any one time. Currently, new perimeter fences, a multipurpose building, a new school building and an upgraded electric generator plant are a few of the major projects scheduled for the hospitals. In addition, several current buildings, kitchens, laundry rooms and sewer plants are scheduled for construction work.