WAKE COUNTY BEHAVIORAL HEALTH SUMMIT - PowerPoint Presentation

WAKE COUNTY BEHAVIORAL HEALTH SUMMIT

WELCOME Sig Hutchison, Chairman Wake County Commissioners Donnie Harrison, Wake County Sheriff

Wake Directors 3 Alliance Behavioral Healthcare City of Raleigh NAMI Wake County N.C . Court System District 10 Raleigh Police Department Wake County Board of Commissioners Wake County District Attorney’s Office Wake County EMS Wake County Human Services Wake County Manager’s Office Wake County Sheriff’s Office Wake County Public Defender’s Office Wake County Public School System WakeMed Health and Hospitals UNC Health Care

SETTING THE CONTEXT Jim Hartmann , Wake County Manager Denise Foreman, Wake County Assistant Manager

Growth, Demographics and What We Need to Keep Our Eye On

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7 from natural increase 20 from net migration 47 Source: U.S. Census Bureau, County Population Estimates, July 1, 2016.

Wake County Population Growth 8 Wake’s estimated population grew by more than 145,000 residents 2010-2016: Sources:U. S. Census Bureau Census Counts (1990, 2000 and 2010)*U.S. Census Bureau Annual Population Estimates (July 1, 2016)**North Carolina Office of Budget and Management County Population Projections (July 1, 2020) * **

9 9 10 Fastest Growing Counties with > 1,000,000 Residents July 1, 2016 County Growth R ate , 2010-2016 Source : U.S . Census Bureau County Population Estimates, July 1, 2016. 2010 Census Base Estimates used to compute growth rates. San Antonio Tampa Dallas/Fort Worth Seattle Atlanta

Growth Rate = 250,000 per Decade 10 Apex Cary Holly Springs Morrisville Equivalent to the populations of:

When will our population grow again? 11 Wake County reached 1 million people in 2014 If we average 25,000 new residents a year, Wake reaches 2 million in 2054 2014 2 million

12 are renting 37%

13 Cost-burdened Households (paying >30% of income for housing) of renters 49% of owners 19%

Wake County Economic Health by Block Group ACS 2010-2014 14 The ACS Characteristics used were: % of persons living between 100%-200% the Federal Poverty rate % of persons on Food Stamps % of persons spending greater than 30% of income on rent % of persons spending greater than 30% of income on a mortgageMedian Household Income by Block Group

Community Needs: Hunger 15 14% of our population is food insecure That equals 131,800 people In Wake County Public Schools alone, 55,845 students qualify for free & reduced lunchThe Big Picture for Wake CountyData from 2015-2016 Source: Food Bank of Central & Eastern NC

Child Welfare: A Growing Need 16 Number of children in foster care in 2010 546 in 2016 778 + 30%

Community Needs: Homelessness

Community Needs: Homelessness 18 4,732 people are homeless in Wake County each year

Growing Concerns: Domestic Violence 19 Total number of direct victims of domestic and/or sexual violence that InterAct served in FY2016 8,875 clients

20 Unintentional Opioid-Related Overdose Deaths by Drug Type N.C. Residents, 2010-2016* *2016 data are provisional Source: N.C . State Center for Health Statistics, Death Certificate Data Heroin and/or Other Synthetic Narcotics Commonly Prescribed Opiod Medications AND Heroin and/or Other Synthetic Narcotics Commonly Prescribed Opioid Medications

Community Needs: Mental Health 21 Growing number of IVCs create a significant issue at local emergency rooms

Mental Health: A Growing Issue In Wake County, that could be as many as 200,000 people. www.wakegov.com More than 10 million adults in the U.S. have both mental health and addiction disorders.

Behavioral Health: A County Perspective

Key Changes in Behavioral Health Models since 2010 24 2010 2011 2012 December 2010 Dix Hospital no longer admitting new patients July 2013 Wake Co. divests behavioral health services; Alliance begins MCO operations July 2012 Wake Co. and Durham Co. merge LMEs to create Alliance Behavioral Healthcare August 2012 Dix Hospital closed September 2015 NCGA passes law to convert all Medicaid to managed care January 2011 WakeBrook Campus begins admitting patients 2013 2015 2019 July 2019 Medicaid Managed Care Go-Live

Wake County Persons Served Through Alliance

FY18 approved budget - $495,747,257 Revenue 73% Medicaid, 10% State, 7% County, 10 % administration Expenditures – 90% services , 10 % administration 82% of funding comes from Medicaid FY18 Alliance Budget

FY18 New Alliance Initiatives Crisis Services 7,921,326 Child Facility Based Crisis Mobile Crisis Paramedicine Interventions and Supports 563,400 Social Determinants of Health 600,000 Engagement and Self Management 125,000 Total $9,209,726

Non Medicaid Needs

State Funds Needed (*For Four County Alliance Service Area) *

County Commitment Areas of focus: Crisis Services Housing Criminal Justice Access /ServicesReduce need for crisis services; Reduce wait times; Improve access to servicesIncrease and improve housing options for behavioral health populationReduce interactions of mentally ill with criminal justice systemImprove behavioral health system to improve outcomes for individuals interacting with the system, including clients, families, providers, agencies

County Commitment - FY2018 Crisis Services $ 18.5 M WakeBrook and Holly Hill Adult Treatment $ 4 M Monarch and UNC Outpatient Foster care assessments/services Criminal Justice $ 1.3 M In-jail services and post releaseResidential $ 1 MTransitional living and housing supports/case managementCommunity Supports $ 1.4 MSchool based, SOAR, specialty programsRecovery $ 385KPeer led Recovery Center

Recent Studies in Wake County Partnered with North Carolina State University to study Wake County Detention Center population: Approximately one-quarter of those admitted to the jail are identified as having probable mental health problems. M ental health and substance use problems occur together 1/3 of the time.Individuals with probable mental health problems stay in Jail longer.

Recent Studies in Wake County Partnered with SAS to study individual interactions with High Cost Systems Data Match individuals in jail, homeless and EMS systemsUnderstand utilization patterns by most frequent users Break the cycle of recidivismCreate profile of ‘familiar faces’Identify patterns of behavior among the ‘familiar faces’

Intersection of Jail, EMS, and Homelessness 807 individuals were identified with at least one incident in all three systems. 26 of those individuals were classified as High UtilizersAnalysis of these 807 individuals shows that this group is 26 and 55 years old (70%) and is predominately male (75%). Black or African American men are disproportionally represented (46%) in this population.

Intersection of Jail, EMS, and Homelessness More than 70% of bookings for this intersecting group of 807 are misdemeanor level charges The intersection population had a higher frequency of charges for trespassing , city ordinance violations, and disorderly conduct85% of this population interacted with an emergency shelterThe intersecting population is likely to experience a longer stay in jail (18 days) than the jail’s familiar faces (11 days).

Timeline of Events: A Case Study A unified, strategic view Agency Event Event Start Event End Event Length Days Between Events Jail Arrest Misdemeanor: Intoxicated and Disruptive 03 Sep 2015 17 Sep 2015 14 10 EMS EMS Transported: No Lights/Siren 22 Sep 2015 22 Sep 2015 0 5 Jail Arrest Misdemeanor: Failure to Appear on Misdemeanor 23 Nov 2015 25 Nov 2015 2 62 Jail Arrest Misdemeanor: Failure to Appear on Misdemeanor 07 Dec 2015 10 Dec 2015 3 12 Jail Arrest Misdemeanor: Second Degree Trespassing 15 Dec 2015 22 Dec 2015 7 5 HMIS HMIS Shelter 30 Dec 2015 31 Dec 2015 1 8 HMIS HMIS Emergency Shelter 09 Jan 2016 10 Jan 2016 1 9 HMIS HMIS Emergency Shelter 12 Jan 2016 13 Jan 2016 1 2 HMIS HMIS Emergency Shelter 18 Jan 2016 24 Jan 2016 6 5 HMIS HMIS Emergency Shelter 25 Jan 2016 26 Jan 2016 1 1 Jail Arrest Misdemeanor: Second Degree Trespassing 26 Jan 2016 04 Feb 2016 9 0 EMS EMS Transported: No Lights/Siren 05 Feb 2016 05 Feb 2016 0 1 EMS EMS Transported: No Lights/Siren 14 Feb 2016 14 Feb 2016 0 9 Jail Arrest Misdemeanor: Intoxicated and Disruptive | Second Degree Trespassing 02 Apr 2016 14 Apr 2016 12 48 EMS EMS Transported: No Lights/Siren 26 Apr 2016 26 Apr 2016 0 12 EMS EMS Assist 09 May 2016 09 May 2016 0 13 HMIS HMIS Emergency Shelter 05 Jun2 016 06 Jun 2016 1 27

Potential Interventions Know the Population Drive Your Decisions Measure Outcomes Feedback Loop

Key Learnings In addition to analytic findings, also learned : Committed partners key to working through barriers around data sharing Data collection gaps/system limitations may render important information unusableRecords management often incident based not client based P ower of sharing data and including more partners and more data points

“Access to safe, quality and affordable housing – and the supports necessary to maintain that housing – constitute one of the most basic and powerful social determinants of health. In particular, for individuals and families trapped in a cycle of crisis and housing instability due to poverty, mental illness, addictions or chronic health issues, housing can entirely dictate their health and health trajectory.” World Health Organization, 2008 Housing is a Healthcare Strategy

40 Improving Mental Health: Stability and Recovery www.wakegov.com

Permanent Supportive Housing Included in Wake County Affordable Housing Plan Engaged Corporation for Supportive Housing (CSH) to provide guidance in implementation CSH Conducted assessment of current supportive housing programs Addressing gaps in ability for community to sustain quality supportive housing opportunities

Other Housing Related Efforts Partnering with Alliance, State and City on additional supportive housing opportunities Exploring innovative approaches to assist with independent living Piloting bridge housing approach to assist individuals leaving institutions Partnering in Oak City Outreach Center to coordinate efforts to assess and address needs of individuals in need of assistance

43 Improving Behavioral Health in Wake County

Discuss and Prioritize “What can we do differently?” Kevin FitzGerald

5 Conversations: 45 Criminal Justice Crisis Services Familiar Faces Access and Coordination Housing

CRIMINAL JUSTICE District Attorney Lorrin Freeman

From Wake County sponsored study of jail detention data: 47 31,000 admissions in 2016 25-30% have probable mental health problems at the time of booking.Those with mental health problems stay in jail stay twice as long and are charged with misdemeanor offenses. Most lose their Medicaid after 30 days in jail.

Initiatives 48 S upplemental screenings of inmates with mental health symptoms E lectronic medical records in the JailExpansion of mental health education Implementation of a mental health deferral programForensic Post Release program Piloting an inmate education and workforce program

Gaps 49 Available housing Sufficient jail diversion options Coordinated reentry services.Substance abuse treatment in jailData sharing between the jail and other providers TransportationLack of access to needed behavioral health services

CRISIS SERVICES Ann Akland, Community Advocate

CRISIS SERVICES

Crisis Services: what are they? Behavioral health “open access,” urgent care Mobile crisis, EMS or Crisis Intervention Team ( CIT) Hospital emergency department, crisis assessment, facility based detox or crisis facility D ay hospital program or inpatient psychiatric hospital

FACTS Wake County’s crisis assessment capacity at WakeBrook is 12 slots. On diversion status 16% of the time in 2017. Hospital ED’s have many waiting for behavioral health care. There are approximately 1000 court ordered inpatient commitments each month in Wake County.

Initiatives Underway UNC WakeBrook provides 12 crisis assessment slots, 16 medical detoxification beds, 16 facility based crisis beds,28 inpatient psychiatric beds, and primary care medical clinic for behavioral health patients. WakeBrook,Holly Hill, & Strategic Behavioral Health, and Triangle Sp rings have expanded or have plans to expand adult beds. Medicaid rule may expand access to stand alone psychiatric hospitals with more than 16 beds.

Initiatives Underway Alliance is developing an adolescent crisis facility Several service providers offer walk-in clinics to help avoid hospitalization and crisis. Behavioral Health urgent care discussions are underway.

Gaps Capacity for crisis assessment and immediate psychiatric services needs significant expansion. Substance use, especially increases in opioid addictions, has increased crisis referrals. Pressing crisis services not well-met: youth, elderly, violent individuals. Services for uninsured or under-insuredAccess to crisis services is confusing.

FAMILIAR FACES Dr. Brian Klausner , WakeMed

Context 58 WakeMed has developed analytics to identify some of the sickest and most vulnerable patients with high utilization across medical systems and work closely with them to help connect them with community services. When Jail, Homelessness and EMS caseloads are compared, slightly more than 800 persons are known to all three systems and 26 are considered to be top-5% utilizers of all three systems. There is no cross-system, comprehensive strategy to meet the needs of familiar faces.

Initiatives 59 Health-related organizations are actively working to improve coordination efforts Wake County Population Health Task Force has identified “familiar faces” as a key strategy.WakeMed recently implemented a case management program for frequent utilizers of emergency services; many of these patients have behavioral health diagnosesEfforts to enhance supportive housing and increase the quantity and quality of decent housingFirst-line providers are discussing how to standardize and improve behavioral health screenings A task group is being formed to identify ways to aide more coordinated service delivery through shared information technology

Gaps 60 There is a lack of a clear definition and coordinated case management for this population. Systems do not track outcomes for familiar faces on a consistent basis. There is a pressing need to provide preventive services earlier.    

ACCESS AND COORDINATION Dr. Kate Hobbs-Knutson, Alliance Behavioral Health Care

Context 62 For patients and families, service providers and institutions, way-finding is confusing. Access to services for indigent, uninsured, underinsured, and special needs patients is difficult. Legally sharing confidential health information is challenging. Integration of services between health and human services organizations is a challenge.Current behavioral health information systems are improving but lack the capacity to track quality and satisfaction outcomes for patients.

Initiatives 63 Mental Health First Aid Social Determinants of Health – most often being often food and housing insecurity, poverty and lack of reliable transportation. ACTT (Assertive Community Treatment Team ) School-based treatment services. WakeMed Community Case Management Mental Health Pilot WakeBrook primary medical care for behavioral health patients ACES (Adverse Childhood Experiences). Wake County Community Health Assessment has identified Behavioral Health as a key priority.

Gaps 64 Meaningful intervention often happens late, need to provide earlier prevention services Screening for behavioral health needs is inconsistent A ccess to a medical home that comprehensively addresses physical and behavioral health in an integrated fashion is challenging, especially for those who have no or inadequate insurance.Coordinated information technology infrastructure.

HOUSING David Ellis, Deputy County Manager

Context 66 Stable housing is an essential element of one’s physical and behavioral health. Over 42,000 Wake County households spend more than half of their income on housing. Households below the median income accounted for 66% of population growth in 2000-2015. For individuals who are considered special needs, have criminal records or persistent behavioral health issues, access to stable housing is very difficult. Many community providers assist in supporting the placement of housing services. However, there are insufficient resources to cover the demand for their services, especially for special needs individuals.

Initiatives 67 Wake County Affordable Housing Plan – synthesize current sustainable housing efforts and create a long term affordable housing vision. The State of North Carolina entered into a settlement agreement with the US Department of Justice to assure that persons with mental illness are allowed to reside in their communities in the least restrictive setting of their choice. Homeless services are consolidating their intake services at a new multi-service center to better coordinate service delivery. Housing-First strategy -- a bridge housing pilot project with supportive services will be opening soon to providing safe, temporary housing while awaiting permanent housing first placement.

Gaps 68 There is an unmet affordable housing need for 56,000 households earning less than $39,000 annually. Lack of housing options with appropriate supports and wrap-around services is a hurdle for moving behavioral health clients from non-institutional setting. The loss of housing or housing insecurity is often a factor in a person accessing behavioral health services.

NEXT STEPS

Follow-up Actions 70 Distribute action s ummary of today’s work Engage Wake Directors and stakeholders in development of work plans Draft work plans for stakeholders and Wake County in early 2018

Please… 71 Remain involved Stay in touch with someone you met today Keep learning Invite someone new

And finally… 72 Please fill out your evaluation. THANK YOU!