State Operated Care Facilities Council's Executive Summary
The Governor’s Council on State-Operated Care Facilities, created by Governor O’Bannon in September 1999, was given the charge of developing a long-range plan that will ensure the provision of high quality, cost-efficient care in the eleven state-operated care facilities under review. The Council relied on input from a variety of key stakeholders to develop specific recommendations that successfully achieve this charge. Before developing these recommendations, the Council reviewed a wide range of information; including overviews of the current systems of care in place in Indiana, summaries of best practices in other state systems, and summaries of trends in service delivery for all populations under the charge.
In addition to reviewing the above information, the Council also recognized the need for developing a consensus on a summary of beliefs that would guide them during the decision-making process. The Council’s summary of beliefs is as follows:
The Council believes that people with developmental disabilities, mental illness, and other health or educational needs, should have access to an array of appropriate services and support. Whenever possible, these services should be provided in the least restrictive environment within integrated settings in their local communities. The Council also believes that one key role the state-operated care facilities will have in the future is to serve as a safety net. In this role as a safety net, the facilities will provide crisis treatment, rehabilitation or intervention in settings as close to home as possible. The Council also recognizes that some individuals will continue to require and/or prefer sustained care in an institutional environment.
The Council’s recommendations are summarized in four areas. First, in keeping with the emphasis on community-based services, recommendations are addressed that impact the overall systems of care in Indiana. Second, recommendations that relate to the state-operated care facilities are discussed. Third, specific quality assurance recommendations are given that address care in both the facilities and the communities. In conclusion, the need for developing an implementation plan is discussed.
- Recommendations for Overall Systems of Care
- Recommendations for Regional Centers
- Recommendations for Specific Populations
- Staffing Recommendations
The important role that staffing plays in the quality of care provided in the facilities cannot be overstated. Many of the state-operated care facilities have implemented service line models, resulting in increased accountability and improved communication throughout the facility. The Council recommends that the service line model be implemented in each regional or multi-service center. Once implemented correctly, the systems of care and accountability would be improved by developing service teams that work together to provide the integrated care needed by the individuals receiving services.
- Quality Assurance Recommendations
- Development and Assessment of Implementation Plan
- Conclusion
The directional recommendations put forth by the Council are in keeping with the service trends seen across the country as well as in Indiana. Specific recommendations have been developed that address monitoring of the quality of care provided both in the regional centers and in the community whenever possible. Developing a regional system with regional hubs would provide communities with the opportunity to provide crucial local input to the state. Identifying and/or strengthening the gatekeeper role in each system of care would ensure that services are coordinated and that problems would be addressed efficiently for all populations receiving services.
Overview of Regionalization
The Council acknowledges the need to significantly improve the linkages that exist between the facilities and community resources. A review of current service trends in Indiana verifies that the state-operated care facilities currently function as "informal" regional facilities, serving for the most part the counties surrounding them. However, no formal systems are in-lace that address the gaps in the community resources or that assist in developing the linkages between the facilities and community resources.
Best Practices
Service trends in states across the nation reveal a significant change in emphasis from institutional-based care to community-based services throughout the country, as well as in Indiana. The focus in these states is on developing and strengthening the community resources needed to provide services in integrated settings close to home.
Many of these states have regionalized their systems of care in order to effectively achieve these changes. While no single "master plan" exists for reorganization, other states have been successful by building on existing strengths within the system and addressing the weaknesses. This can be achieved by building on existing infrastructures and lines of authority, which allow states to rely on the expertise and strengths that already exist in the system.
The Council recommends that the State of Indiana regionalize its systems of care for the distinct populations being served. The emphasis would be on developing and strengthening community resources in each region, while ensuring the enhancement of quality care in regional centers, with the focus on development of a comprehensive array of services within each region. The state-operated care facilities would become regional or multi-service centers, providing one part of the array of services needed for each population.
Regionalization alone, however, would not necessarily guarantee that the quality of care would be significantly impacted. Many consumers require multiple services and the coordination of these services is often fragmented and incomplete. The Council recommends that each system of care focus on developing or strengthening the role of gatekeeper that would serve as a single point of entry and coordinator of care for each client served in the system. A single point of entry would improve consumers’ access to a comprehensive array of services and allow for coordination of the services needed, including services provided by the regional centers.
Establishment of Regional Hubs
In order to successfully provide an array of services in each region, assessments of current services available and identification of gaps in services would need to be completed on an ongoing basis within each region. In order to ensure that this occurs on a consistent basic throughout Indiana, the Council recommends the establishment of regional hubs, which include local and regional planning councils.
The planning councils, consisting of consumers, family members, providers, advocates, and state-agency personnel, would identify gaps in services and work towards developing service collaboration within the regions on an ongoing basis. The regional councils would develop specific service recommendations for each region based on the assessments completed. In addition, these councils would work with the State to develop the appropriate services based on the recommendations.
Potential Impact of Regionalization
Regionalization would significantly improve the linkages between the regional centers and the regions they serve. Establishment of local and regional councils would improve the lines of communications between all providers and consumers within a region, resulting in better linkages and coordination of care for consumers receiving services. The focus would be on development and enhancement of community service infrastructures in each region.
The Council next developed specific criteria and recommendations for the populations receiving services in the regional or multi-service centers. Included are specific recommendations for each population, as well as staffing recommendations that apply to all the regional centers.
However, before specific recommendations could be developed, the Council reviewed two analyses that directly impacted the nature and direction of the recommendations: a projected census for the facilities for 2005 and an assessment of capital needs for the facilities over the next ten years.
Projected Census 2005
The Council evaluated the populations currently receiving services in the facilities to determine how many could benefit from a less restrictive environment. The agency analysis projects that the state-operated care facility census could decrease from 2,121 individuals to 1,360 individuals by the year 2005. This projection is based on the availability of additional funding to develop and enhance community services necessary to provide services to these individuals.
Anticipated Capital Needs
The Council, working with consultants, also completed an analysis of anticipated capital needs for the current facilities over the next ten years. This analysis concluded that all the facilities have significant capital needs that will need to be addressed in order to continue providing the same services they are currently providing. These capital needs do not include any retrofitting or upgrading of the facilities into regional centers. Further analysis will need to be completed to determine which facilities will provide the best physical layout at the most efficient cost.
Each population has service needs that differ depending on the availability services within, the community as well as the community system of care already in place. The Council, therefore, developed specific recommendations for each population receiving services in the regional or multi-service centers.
The Council also recommends the establishment of a l00-bed high security facility for individuals with mental illness who exhibit dangerous behaviors. This facility would service the entire state and provide the security and therapeutic environment required for these individuals.
The Council also identified the need to ensure that active treatment is provided on evenings and weekends on a consistent basis in all the regional centers. The goal of this recommendations is to increase the ability of the facilities to assist clients in developing and maintaining skills and behaviors that allow them to function as independently as possible, ultimately impacting their quality of life.
The Council recognizes the need to develop specific quality assurance recommendations that would monitor the health and safety of individuals receiving services in the centers. These recommendations include expansion of the Adult Protective Services program, creation of a system-wide toll free number to report complaints, and development of a uniform complaint system in all regional facilities as well as in the community.
Equally important, the Council recognizes the need to monitor and assess clinical issues such as outcomes, treatment, and treatment planning within the regional centers. Therefore comprehensive recommendations have been developed that address the data system used in the centers as well as that identify specific performance indicators that should be monitored. The goals of these recommendations are to provide accurate data collection and analysis throughout the systems of care as well as to provide tools to identify both significant quality of care problems and best practices.
Based on the regionalization recommendation, as well as the downsizing projections and the anticipated capital needs for the facilities, the Council recommends that an implementation plan be developed that take into account the direction of the recommendations outlined in its final report. This direction includes establishing regional centers that provide high quality services to multiple populations in smaller, more personal settings.
The optimal number and geographic location of these centers should be determined by evaluating the projected census for each population, the service needs of individuals in each region, and the projected capital costs for each facility. The staffing and quality assurance recommendations should be included so that the quality of care provided within the centers is monitored.
An assessment should be completed every two years to monitor the progress made and to make appropriate adjustments.
The emphasis on development and enhancement of community resources, along with the downsizing plan outlined in this report, would allow for funds to be channeled appropriately to develop the community infrastructure necessary to provide a comprehensive array of high quality services, and ensure that quality services are provided in the regional, multi-service centers. Establishing clear complaint processes for individuals throughout the system helps ensure that the quality of care being provided is monitored and problems are addressed.
Finally, the Council recommends the need for development and executive of a comprehensive implementation plan that would involve all key stakeholders and would consider the recommendations and evaluations detailed in this report. Additionally, assessment of the plan should be completed every two years to ensure that the state is moving forward without negatively impacting the quality of care provided to any segment of its most vulnerable populations.
