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Table of Contents

1. Acknowledgments *
1. Governor’s Council on State-Operated Care Facilities *
2. Subcommittees *
3. Public Hearings *
4. Consultants *
5. Support and Technical Staff *
2. Introduction *
1. Scope of Charges *
2. Olmstead Decision*
3. Identification of Weaknesses/Problems in the State-Operated Care Facility (SOCF) System*
4. Indiana Veterans’ Home (IVH) and Indiana Soldiers’ and Sailors’ Children’s Home (ISSCH)*
5. Overview of Final Report*
3. Description of Regional Systems of Care and Regional Centers*
1. Overview of Regionalization *
2. Best Practices*
3. Single Point of Entry/Gatekeeper*
4. Establishment of Boundaries*
5. Description of Regional Hubs*
6. Suggested Local and Regional Planning Councils*
4. Criteria and Recommendations for Regional Centers*
1. Development Of Specific Criteria For The Regional Centers*
2. Identification of Populations Receiving Regional Services*
3. Projected Census*
4. Anticipated Capital Needs for Each Facility*
5. Recommendations by Population*
6. Staffing*
5. Quality Assurance *
1. Monitoring and Accrediting Organizations*
2. Data Management Systems*
3. Performance Indicators *
6. Implementation Plan*
7. Conclusion*

1. Acknowledgments

The development of comprehensive recommendations and completion of this final report would not have been possible without the hard work and dedication of a variety of people. The Council recognizes and thanks those who donated their time, energy and expertise to the Council throughout the 16-month process.

A. Governor’s Council on State-Operated Care Facilities

The active members of the Council, listed in Appendix A, were diligent in moving the Council forward toward the goal of developing a long-range plan with specific recommendations that would significantly impact the quality of care provided in the facilities. These members actively participated in monthly council meetings and subcommittee meetings, and reviewed and discussed a variety of reports and summaries throughout their tenure.

B. Subcommittees

The Council relied heavily on subcommittees to complete the research and analysis necessary to complete the charges. These subcommittees consisted of Council members, consumers, family members, advocates, experts in the fields under review, providers, union representatives, educators, government agency representatives, and consultants.

Members of these subcommittees, listed in Appendix B, contributed a great deal of time and energy to provide the Council with the information necessary to develop solid recommendations. The subcommittees met biweekly, allowing them the time to focus on specific issues and analyze a great deal of information before providing summaries to the Council. The Council acknowledges the contributions made by subcommittee members and is thankful for the time and energy put into the work completed.

C. Public Hearings

Four public hearings were held to provide residents, family, facility staff, advocates, local citizens and government officials an opportunity to give their input to the Council. The Council would like to thank everyone who attended those meetings, as well as Patrick Taylor, from the Indiana Coalition on Housing and Homeless Issues, who coordinated the hearings and completed the Report of the Citizen’s Comment.

The Council would also like to thank the staff of the four facilities visited, including Indiana Veterans’ Home, Evansville State Hospital, Fort Wayne Developmental Center, and Madison State Hospital for hosting the hearings and providing tours and information to the Council.

D. Consultants

The Council relied on consultants to complete more in-depth analyses of issues under review. These analyses provided the Council with the needed level of information to make informed decisions about the future direction of the state-operated care facilities.

The Council thanks Mike Walker, Berkshire Advising Inc., for his hard work in completing the Management and Staffing Study. We are also thankful for the input and report that Nancy Callahan and John Whitbeck, from I.D.E.A Consulting, completed for the Quality Assurance subcommittee.

The Council is thankful for all the help it received from Indiana University Consultants. In particular, the Council thanks Chris Newman for her diligence in completing best practice research, facilitating the numerous subcommittee meetings, and drafting the interim and final reports.

E. Support and Technical Staff

A number of support staff were of great assistance throughout the Council’s work. The Council thanks Sondra Morris and Sheryl Rader from the Indiana Institute of Disability and Community for completing the minutes of the monthly council meetings. The Council also thanks Beth Werner, Linda French, Nancy Manier, and Tonja White for their administrative help in the subcommittee meetings, as well as Sue Bell, Edward Lutz and Caroline Muegge for their work on the mapping.

2. Introduction

   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. A summary of each facility is in Appendix C. The Council has relied on input from a variety of individuals, including consumers, family members, providers, legislators, government officials, unions, facility staff, educators, advocates, and consultants to develop the recommendations included in this report. This input was obtained from public hearings, visits to facilities, and formation of subcommittees.

   1. Scope of Charges

   Before recommendations could be developed, however, the Council first clarified the scope of the charges set forth by the Governor. After much discussion, the Council agreed that the state-operated care facility system could not be evaluated in isolation. The important linkages between the facilities and community services had to be included in the scope of work in order to successfully address and impact the quality of care provided in the facilities. In addition, the Council agreed that it should clearly identify the role the facilities will play in the future. This role is described in the following summary of beliefs used to formulate the Council’s recommendations:

   The Council believes that people with developmental disabilities, mental illnesses, and other health or educational needs should have access to an array of appropriate services and supports provided in the least restrictive environment within integrated settings in their local communities whenever possible. 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.

   2. Olmstead Decision

   The Council’s beliefs and recommendations are in keeping with the Olmstead Decision, a ruling by the United States Supreme Court in June 1999 that states that the unnecessary segregation of individuals with disabilities in institutions may constitute discrimination based on disability. The ruling is based on the Americans with Disabilities Act, and may require states to provide the option of community-based services rather than institutional placements for individuals with disabilities when:

   1. The state treatment professionals reasonably determine that such placements are appropriate.
   2. The affected persons do not oppose such treatment.
   3. The placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others receiving state supported services.
   3. Identification of Weaknesses/Problems in the State-Operated Care Facility (SOCF) System

   Over the past 16 months the Council, working with subcommittees and consultants, has completed analyses of the current systems of care and has identified the following weaknesses and/or problems in the current SOCF system:

   • Weak and/or inconsistent linkages exist between communities and the SOCF’s.
   • Quality assurance monitoring is fragmented and inconsistent between facilities.
   • Provision of active treatment on evenings and weekends is inconsistent.
   • Implementation of service line models within the facilities is inconsistent.
   • Many of the facilities need significant capital improvement within the next ten years in order to continue to provide existing services. These capital needs do not include any retrofitting or upgrading of the facilities into regional centers.
   • Funding for community resources remains separate from funding for care provided in facilities.
   • Facilities are not appropriated funding in a flexible manner so that individual needs can consistently be addressed when transitioning clients back into the community.
   • Few/no incentives for efficiency exist since unspent money reverts to the general fund rather than being kept by the facilities to invest in their needs.
   • Budget/resource decisions are made based on history, not necessarily on an assessment of current needs and priorities across the system.
   • Personnel and procurement systems are slow and inefficient and not designed to address needs quickly.
   • Options for public/private partnerships that capitalize on the strengths of each sector are rarely pursued.
   4. Indiana Veterans’ Home (IVH) and Indiana Soldiers’ and Sailors’ Children’s Home (ISSCH)

   As the Council began to solidify the overall direction for its recommendations, it realized that this direction was not appropriate for the unique populations receiving services at the Indiana Veterans’ Home (IVH) and the Indiana Soldiers’ and Sailors’ Children’s Home (ISSCH). Preliminary recommendations were developed for these facilities in the Council’s June report. The Council recommends that the government entity responsible for IVH and ISSCH examine these recommendations, and work in collaboration with all major stakeholders to implement the recommendations that are deemed appropriate.

   5. Overview of Final Report

      For the remaining nine facilities, the Council has developed specific recommendations that address many of the weaknesses listed above and could ultimately improve the quality of care provided in the state-operated care facilities. These recommendations are based on the Council’s belief that:

      1. Clients should have access to an array of appropriate services and supports provided in the least restrictive environment within integrated settings in their local communities whenever possible.
      2. State-operated care facilities should serve as a safety net, providing one part of an array of services.

      The Council’s recommendations are presented in four parts. First, in keeping with the emphasis on development and enhancement of community-based services, recommendations that address the overall systems of care in the state are discussed. Second, the recommendations that relate to the state-operated care facilities are summarized. Third, specific quality assurance recommendations are provided. In conclusion, the need for development of an implementation plan, based on the recommendations provided throughout the report, is discussed.

3. Description of Regional Systems of Care and Regional Centers
   1. Overview of Regionalization

   The Council recognizes the need to significantly improve the linkages that are in place between the facilities and community resources. Mapping of the counties of origin for consumers in the facilities illustrates that, for the most part, facilities serve their surrounding counties, creating an informal regional system (see Appendix D). However, no formal systems are in place that adequately address the gaps in community resources or that assist in developing linkages between the facilities and community services provided within these informal regions.

   2. Best Practices

   Best practice analyses identified several states that have reorganized DD and MI-type services into common agencies with some regional organization. In each case, the most successful efforts were driven by strong local planning entities that represented an active and enfranchised consumer population.

   This review of best practices from states that have regionalized their services, including Texas, Virginia, Oregon, Vermont and Michigan, uncovers some key issues that should be considered when reorganizing. First, no single "master plan" exists for reorganizing or restructuring at the state level. States have been successful in making changes by focusing on existing strengths in their system, by identifying the weaknesses, and by working with a variety of stakeholders to develop realistic and appropriate recommendations for changes.

   Second, many states have reorganized their systems by building on existing infrastructures as well as on existing lines of authority. This approach has been successful because it builds on expertise and strengths that already exist in the system and minimizes the negative impact of a large change.

   Finally, for states that already have county or regional systems with regional authority and autonomy, the processes for reorganizing are very different than for states, such as Indiana, where policy and funding decisions are ultimately made at the state level.

   Recommendation #1: The Council recommends that the state develop "formal" regional systems of care for the distinct populations being served.

   The goal is to develop regional systems of care for each population that include a comprehensive array of coordinated services. The emphasis should be on developing and strengthening community resources within each of these regions. The state-operated care facilities would become regional, multi-service centers, with units that provide services to distinct populations. These centers would provide one part of an array of services for the region and would focus on providing services that are not, and cannot in the near future, be provided in the communities, either due to the complex needs of the individuals or the safety needs of the communities.

   Recommendation #2: The Council recommends that the state establish and implement processes for providing person-entered planning and individualized treatment plans across the entire system of care.

   3. Single Point of Entry/Gatekeeper

   Regionalization alone, however, would not ensure that consumers have access to the array of services that the Council is recommending be developed or enhanced within each region. Many individuals with serious mental illness, serious emotional disturbance, multiple disabilities, chemical dependency and/or developmental disabilities require a mix of community, residential and inpatient services. Successful coordination of these services is an integral part of achieving an individual’s treatment or service goals.

   One approach that would help accomplish this coordination is establishment of single points of entry or gatekeepers in each system of care. For individuals receiving services in the public mental health system, nonprofit community providers, including community mental health centers, currently serve as gatekeepers, coordinating an array of services for each client they serve. This system has been successful at coordinating care needed by clients, both in the community as well as in state-operated care facilities.

   Consumers with developmental disabilities can enter the system a number of ways, with no single point of entry currently clearly defined. The Division of Disability, Aging and Rehabilitative Services (DDARS) is reviewing options for clear identification of a single point of entry that would continue to maintain clients’ options to choose where they receive their services.

   Recommendation #3: 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, including care provided in the regional centers.

   Regionalization, coupled with clear establishment of gatekeepers in each system, would allow the state to develop systems of care that emphasize the provision of care as close to home as possible and significantly strengthen the linkages between communities and the facilities. Equally important, by emphasizing the development and enhancement of community resources within these regions, these recommendations reinforce the change in focus from institutional-based care to community-based services in Indiana, and follow the service delivery trends seen in states across the nation.

   4. Establishment of Boundaries

   In order to ensure that a comprehensive array of services would be provided in each region, the Council agrees that specific regional boundaries should be identified. The following data analyses were completed by consultants to determine the appropriate boundaries for the regional service concept (maps illustrating these data are included in Appendix E):

   1. Prevalence analysis and current user point of origin for:

   • Adults with Serious Mental Illness (SMI)
   • Adults with Severe and Persistent Mental Illness (SPMI)
   • Children with Serious Emotional Disturbance (SED)
   • Adults with Developmental Disabilities (DD)
   • Children with Multiple Disabilities
   • Adults with Chemical Dependencies

   2. Provider concentrations:

   • Psychiatrists
   • Psychologists
   • Social Workers
   • Child Psychiatrists
   • Skilled Facilities for Individuals with Multiple Disabilities
   • ICF/MR beds (excluding those in state hospitals)
   • State Psychiatric Hospital locations
   • State Developmental Center locations
   • School Based Health Programs

   Recommendation #4: After considering the prevalence rates and the provider supply across the state and addressing the expressed desire for service access for most services within 100 miles, the Council recommends that the new regional hub boundaries follow the Bureau of Developmental Disability District Service Designations with the exception that Marion County share a region with the collar counties.

   The boundaries of the 30 mental health catchment areas do not coincide with this recommendation. These suggested boundaries, however, do not preclude organizations working within a multitude of boundary definitions and there is no expectation that mental health catchment areas would be reorganized.

   The Council also recognizes the need to develop recommendations that address the service needs of each region.

   Recommendation #5: In order to develop and enhance the community resources within these eight regions, the Council is recommending the establishment of regional hubs, described below, which include county and regional planning councils. The role of these councils would be to identify gaps in services and work toward developing collaboration within the regions. They should develop regional service recommendations. These councils would not serve as authorities, but as assessment and planning councils.

   5. Description of Regional Hubs

      In the next decade, a commitment to building a comprehensive array of community-based services will dominate policy and service delivery discussions. Indeed, the long-term goal of individuals with developmental disabilities over the next decade is the complete deinstitutionalization into community-based services for all who can be maintained safely in that environment. This goal is supported by Supreme Court rulings that require states to plan for and accommodate this change in service delivery strategy. In the course of this project, several steps of analysis have been performed to identify geographic cluster areas where common needs and concerns as well as supply issues might encourage regional planning and coordination of services.

      The long history of citizen participation and advocacy for these vulnerable populations requires major efforts to include local planning initiatives in making decisions about service delivery. Several of the state’s existing planning initiatives offer the potential to tap those community participants for assistance in designing and implementing a comprehensive regional system that offers a full continuum of services. However, some of the prevalence rates for various problems are low and result in numbers of individuals so small that duplication of all needed services in every county is not feasible. The processes for grouping of these areas has been to study 1) prevalence rates for problems, 2) public and private provider supply issues, and 3) population centers to determine a workable cluster for some regional planning and coordination of services.

      The goal is local planning and participation in service delivery design with a single point of entry for every individual, depending upon type of disability or illness, into the regional system of care. Regional coordination and planning would focus on making sure that supply of a mix of services is available within a reasonable commuting distance when local (county-level) provision is not economically feasible. Regional coordination hubs would also address their attention to availability of wrap-around, support services such as transportation where planning usually must cross county lines to be effective.

   6. Suggested Local and Regional Planning Councils

   One model that could be used to develop these regional hubs would utilize existing Step Ahead Councils along with development of a regional council. This model is outlined below. However, before Step Ahead Councils or any other organizations are selected to be planning organizations, there should be an evaluation to assure that any lead organization would have sufficient resources available to support the task.

   Suggested Local Planning Councils

   Step Ahead is a local planning process in all 92 counties that encourages community members of diverse backgrounds to come together to develop and/or enhance a county’s service delivery system for children and families. Each county Step Ahead Council would be supplemented with 3 subcommittees, whose members would include local providers, consumers, family members, advocates, local community school district’s special education director, etc. The council would be charged with assessing the local needs for individuals with MI and DD.

   Each local planning council would receive input from consumers, providers, formal surveys and other needs assessment processes to identify service needs and gaps in provision. Local councils would address the need for a variety of outpatient services, inpatient or residential treatment needs and educational services. Examples of the necessary services are outlined in Appendix F. Most of the services listed under outpatient are commonly available in at least some of the counties in each region. They range from general psychiatric and behavioral management services to waiver, group and supported living, and foster care as well as substance abuse services.

   The inpatient services would be provided in mental health clinics and multi-service centers within several of the regions. Needed services include crisis intervention, substance abuse services, respite care, three-four units for chronic care for individuals with needs for secure units, fluid intoxication services, diagnostic/evaluation for consumers with both mental illness and developmental disabilities, general psychiatric services and one high security unit for individuals with mental illness.

   Educational needs for all age groups include vocational training, age appropriate skill sets to transition from one age group to another, and life skills for independent living.

   After the local assessment is completed, each Step Ahead Council would select a designee to represent its county on a regional council. The designee would meet with other agency designees and community representatives to form the Regional Council (Appendix G).

   Suggested Regional Planning Councils:

   Each of the eight Regional Councils would consist of:

   • Providers (no more than 1/3 of the total membership)
   • One consumer from each of the following communities—MI and DD (2 total)
   • One family member from each of the following communities—MI, DD, children with disabilities, children with serious emotional disturbance (4 total)
   • State-operated facility representative
   • Advocates
   • Step Ahead Council designees (one per county in region)

   Each Regional Council would develop three (3) subcommittees focusing on MI, DD, and children with disabilities. The subcommittees should, at a minimum, consist of family members, consumers, advocates, and providers, and be augmented by representatives from Department of Education (DOE), state-operated care facilities (SOFC), Division of Family Resources (DFR), Division of Disability, Aging, and Rehabilitative Services (DDARS), Indiana State Department of Health (ISDH), and Division of Mental Health (DMH) as needed for technical assistance and information. Consideration should be given to providing some type of support for expenses incurred by volunteers serving on the subcommittees.

   The regional planning goals do not require the establishment of a new bureaucracy. At the regional level, chairpersons would be selected to lead the Council’s attention first to production of a two-year assessment, which would include the identification of areas where coordination of services between counties can occur, and presentation of regional service recommendations to the state. Regional representatives would have multiple county level plans and analyses to review as well as input concerning quality performance. In addition to identifying needs and gaps, the regional assessment would include recommendations for interagency cooperation within the region, with attention to wrap-around services and transportation that would necessarily transcend county boundaries. The assessment should also identify the need and opportunity for cross training or retraining personnel to address service needs and gaps.

   The regional chairpersons would report to the Secretary of Family and Social Services Administration (FSSA). Advisors from different agencies and divisions who would interact to enhance and provide the full range of services may include (but not be limited to) DDARS, DMH, ISDH, DFR, DOE and the Department of Correction (DOC). DOC would need to play an advisory role at the state level due to the increasing multiple needs of the prison population who may need mental health, disability or substance abuse services.

   The state should finalize all contracts for providers identified and selected in the local and regional areas, supervise quality assessment and report card production, and coordinate finance, strategic planning and research and evaluation for the state.

   It has become clear that although some concerns and goals are common among the different service areas, there are also substantially different needs for individuals with MI and DD. In any reorganization for coordinating purposes, we should consider those differences and focus on the common themes of service provision that can benefit from regional planning and support.

   The identification of needs within a regional area and the cooperative planning of community-based responses within that area would lead to substantial improvement of access for consumers and their families, as well as improve their ability to participate more directly in the planning and delivery of their care.

   The Council’s recommendation for regional hubs with local and regional planning councils would allow for crucial assessment, planning and input from local consumers, providers, advocates and experts without significantly changing the administrative structure that is in place in Indiana. These councils would not be established as regional or county authorities but as planning councils, allowing the state to continue to make policy and funding decisions.

4. Criteria and Recommendations for Regional Centers

The Council, once again working with subcommittees and consultants, next focused on defining and describing the regional or multi-service center concept. Comprehensive recommendations for the regional centers, which are referenced throughout this section, have been developed based on the following information:

• Development of specific criteria for the regional centers
• Identification of populations that will continue to receive services in the regional centers over the next five years
• Completion of a projected census for each population receiving services in the facilities for the year 2005
• Estimations of anticipated capital needs for each facility to continue to provide existing services. These estimates do not include upgrading facilities into regional centers.
• Completion of administrative and cost analyses
• Summary of recommendations for each population
• Summary of staffing recommendations
1. Development Of Specific Criteria For The Regional Centers

The Council first identified specific criteria for the regional centers, regardless of the populations served. Each center should:

• Serve a defined geographical area
• Be located no more than 100 miles or 2 hours from home
• Be accessible to a workforce
• Have an appropriate physical plant
• Have appropriate staffing levels, including highly trained staff
• Be accessible to supportive healthcare and dietary services
• Have effective care coordination for health care
• Have available housing and other supportive services for family visits/involvement
• Provide accredited/certified services
• Have strong linkages to community resources for the region
• Be sized appropriately so that services can be provided in a more personal, home-like environment
• Receive state and federal funding

Recommendation #6: The Council is recommending that the regional centers continue to be operated by the state.

Research indicates that the optimal size of facilities, taking into account the treatment/service needs of the consumers along with the goal of achieving efficiencies in staffing and operations, ranges from 120 beds to 200 beds, depending upon type of individual served and geographic location. It is important to point out, however, that the size and design of the units within these facilities is of significant importance. Smaller units with more personal surroundings have been shown to significantly impact consumer satisfaction and quality of life, even in facilities that are larger than 200 beds.

2. Identification of Populations Receiving Regional Services

The Council next identified the populations (listed below) that would continue to require services in the regional centers for the near future. Emphasis should be placed, however, on developing a comprehensive network of community services for these populations. It should be noted that not every regional center would necessarily serve all the populations. In addition, the centers should have the flexibility needed to adapt to changes that occur in the populations requiring services in the future.


• Adults with serious mental illness (general psychiatric units)
• Adults with both mental illness and developmental disabilities
• Adults with developmental disabilities
• Adults with chemical dependencies
• Children with multiple disabilities
• Children with serious emotional disturbance

Specialty Units
The Council also identified the need for specialty units to provide services for specific "subpopulations". These units should be located in at least one center in the state, and may include:

• High security/secured unit(s)
• Fluid intoxication unit(s)
3. Projected Census

Once the regional concept and multi-service center concepts were developed, the Council evaluated individuals currently receiving services in the facilities to determine how many could be transitioned into the community with appropriate development of community resources. This evaluation, completed with representatives from DMH, DDARS, and ISDH resulted in development of a projected census for 2005 for each population currently being served in the facilities.

These projections are summarized in Figure 1, and are based on the assumption that additional funding would be available to develop and enhance the community resources necessary in order to transition people into the community over the next five years. The Council believes that strengthening community resources would also increase the possibility of diverting future admissions to the centers, as individuals have access to a wider array of community services. The Council considered these projections when developing specific recommendations for each population receiving services in the centers.

Figure 1: Projected Census by
Population for Regional Centers - 2005

Populations	Current Census	Projected Census 2005	Census per 100,000 population 2005****
DMH - Forensic High Security	55	75
SMI - High Security	10	25
Total High Security (DMH)	65	100	2
Secured Units – DD	0	100	2
SMI - General Population	690*	400	9
SMI - Long-term Population	300	200	4
Addictions	50	40	1
DD/MI	200	200	3
DD	650**	154	2
Children	166***	166	11
Totals	2121	1360	22

*Includes individuals with forensic involvement in general psychiatric units
**Current census includes approximately 100 individuals that are currently served on general units but would be served on secured units by 2005.
***Current census includes 101 children in state psychiatric hospitals and 65 children in Silvercrest Children’s Development Center
****Based on the following U.S. Census population projections for the year 2005:

1) Total population projection for state of Indiana in 2005 is 6,215,296
2) Population projection for individuals age 18 and older is 4,661,472
3) Population projection for children under age 18 is 1,553,824

Bed Days Per 100,000: Individuals with Serious Mental Illness
Figure 1 includes "Bed Days Per 100,000" for each population based on the projected census for 2005. A review of the current literature was completed to identify specific standards for the availability and funding of long-term psychiatric beds. In addition, a review of approaches other states and countries have used to determine the number of long-term psychiatric beds to fund was completed. This research indicates that a range of 12 to 16 long-term psychiatric beds per 100,000 adult population has been identified as an acceptable target to pursue. However, it should be noted that these are target figures based on the assumption that downsizing the long-term beds to this level would occur with a corresponding increase in the development and funding of community services.

This range is by no means generally accepted throughout the states but is one approach that is assisting some states and countries, such as Texas and Canada, in determining the appropriate "rightsizing" figures. Texas, which has regionalized its mental health system, funds 12 beds per 100,000 general population for each state hospital. The Health Services Restructuring Committee, formed in Canada to develop recommendations on restructuring their mental health system, estimates for Canada that the number of long-term psychiatric beds per 100,000 adult population should be reduced to 16 beds by the year 2000, and 14 beds per 100,000 by the year 2003. New Hampshire has certificate of need requirements that include 16 psychiatric beds per 100,000 state population.

Indiana’s state psychiatric hospitals provide long-term stabilization, and are therefore considered long-term beds. If the downsizing projections are followed, Indiana would have16 beds per 100,000 adult population in 2005, or 12 beds per 100,000 of the general population. This figure includes high security beds, SMI general beds, SMI long-term beds, and addiction beds.

Finally, this information needs to be viewed cautiously. First, the definition of a long-term bed versus an acute care bed needs to be considered. Throughout the literature there was no consistency in the definitions used. Second, we are addressing state funding of psychiatric beds. There are also private providers in the state that have long-term beds for individuals with serious mental illness. These targets are not for the entire population receiving long-term services, just for those receiving services in the public mental health system. Third, downsizing without providing the necessary community supports and resources would result in a significant decrease in the quality of life of people who are transitioned out of the facilities.

Bed days per 100,000: Individuals with Developmental Disabilities
Across the nation, states are continuing to decrease their reliance on institutional, state-operated beds for individuals with developmental disabilities. Unlike individuals with SMI, who have different treatment and service needs, there is no target "beds per 100,000" range found in current literature. The number of developmental disability beds per 100,000, however, can be used to monitor Indiana’s progress in transitioning people with developmental disabilities from the state developmental centers to more individualized residential alternatives in the community.

The institutional placement rate for the United States, reported in Developmental Disabilities Services in Indiana: Assessing Progress Through the Year 2000 (Braddock, Hemp 2000), is 17 per 100,000 of the general population. Indiana currently has an institutional placement rate of 13 per 100,000, putting us well below the national average. Based on the downsizing figures above, Indiana would have 7 beds per 100,000 of the general population as of 2005. This includes secured beds, MI/DD beds and DD beds. The Braddock report emphasizes that the system of residential services in Indiana has shifted away from institutional settings, with a corresponding increase in the numbers of individuals served in smaller settings over the past four years.

Once again this information needs to be viewed cautiously. The institutional placement rate quoted above does not include individuals in private residential settings, including private ICFs/MR. While a significant number of these ICF/MR beds are in smaller settings, individuals with DD are still receiving residential services in larger private ICFs/MR. As with the SMI population, the downsizing projections for individuals with DD are contingent on development of an array of community resources.

As the state works toward further downsizing its census in the facilities and developing community resources, it should also ensure that the regional centers provide services in a more personal, home-like environment, while still achieving cost efficiencies. In addition, each region should continue to have access to state-operated services within a reasonable distance from consumers’ homes.

4. Anticipated Capital Needs for Each Facility

As part of the work of the Council, FSSA hired BSA Design, an Indianapolis-based architectural and engineering firm noted for its health care experience, to conduct an assessment of the physical plant of each of the state-operated care facilities (excluding Evansville where a replacement hospital project is currently underway). The purpose of the BSA study is to evaluate the existing facilities and identify physical plant issues that must be addressed in order to maintain the existing services. The study does not address changes that would be necessary to implement quality of life improvements, such as introduction of new programs or reorganization of operations.

The nine facilities administered by FSSA and ISDH were built many years ago, with the oldest occupied building on the majority of campuses constructed before 1940. The State has invested funds to upgrade several of the facilities in recent years, including:

• Construction of a new 322-bed residential treatment center at Logansport completed in 1993.
• Construction of a client services building at Richmond. This project is currently underway, with construction anticipated to begin in the spring of 2001.
• Construction of a 228-bed replacement hospital at Evansville with occupancy anticipated early in 2003.

As the BSA study indicates, however, maintaining facilities that are 50 to 80 years old is very costly. All of the facilities have significant capital needs that must be addressed in order to ensure continued client health and safety. The state should determine which capital plan provides the best physical space at the most efficient cost. The estimates for each facility are summarized in Figure #2.

Figure 2: BSA Design’s Estimated Anticipated Capital Needs
For Next Ten Years – FSSA & ISDH Facilities

State-Operated Care Facility	BSA Design’s Estimate Of Capital Needs
Evansville Children’s Psychiatric Center	$4,762,500
Silvercrest Children’s Development Center	$12,697,500
Richmond State Hospital	$14,410,250
Logansport State Hospital	$26,376,875
Larue Carter Memorial Hospital	$32,945,000
Fort Wayne State Developmental Center	$39,820,000
Madison State Hospital	$48,321,750
Muscatatuck State Developmental Center	$84,127,000

Information from BSA Design Report to FSSA

Recommendation #7: The Council recommends that the state investigate the possibility of combining Evansville State Hospital and Evansville Psychiatric Children’s Center into a regional or multi-service center under one administration.

Recommendation #8: As the state completes an implementation plan for development of the regional concept outlined in this report, it should take into account the direction of the recommendations that the Council has outlined in this 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 censuses for each population, the service needs of individuals in each region, and the projected capital costs outlined above, with the focus remaining on development and strengthening of community resources throughout the state. In addition the regional boundaries suggested in this report should be evaluated to verify that they are the best approach for the state.

5. Recommendations by Population

Each population has service needs that differ depending on the availability of services within the community as well as the community system of care already in place. Specific recommendations, therefore, are being provided for each population, and are based on the information summarized above, including the projected census and specific criteria established for the regional centers.

1. Adults with Serious Mental Illness – General Psychiatric Units

Current System of Care
The Division of Mental Health contracts with community-based, nonprofit providers, most of which are community mental health centers or networks of community mental health centers, for the provision of community-based mental health services for adults with a serious mental illness.

These providers serve as the points of entry for individuals entering the current community public mental health system and are responsible for providing a specific array of services that includes:

1. Individualized treatment planning
2. Twenty-four (24) hour a day crisis intervention
3. Case management
4. Outpatient services
5. Day treatment
6. Medication evaluation and monitoring
7. Services to prevent unnecessary and inappropriate treatment and hospitalization
8. Acute stabilization services
9. Residential services
10. Family support services

The state-operated care facilities currently provide longer-term stabilization. There are also individuals in the state hospitals whose length of stay is over two years.

Recommendation #9: Given the current community system, the Council agreed on the following recommendations for units in the regional centers for adults with SMI:

• Each center should have a general psychiatric unit (throughout the state)
• The general psychiatric units should provide 24 hour a day, 7 day a week care
• The units should provide longer term care services to individuals (over 30 days)
• The units should follow the mental health commitment law/policies
• The units should provide general psychiatric services

2. Adults with Both Mental Illness and Developmental Disabilities

Current System of Care
Currently, adults with MI/DD are being served in the state developmental centers as well as in three ICF/MR units in the state psychiatric hospitals. An array of community services is also provided/coordinated by DDARS and BDDS. Adults with both mental illness and developmental disabilities can enter the state-operated care system through either the community mental health centers or through integrated field services. However, this population, because of the complexity of their service needs, tends to "fall through the cracks" and get caught between the DDARS and DMH systems, increasing the possibility of becoming involved in the correctional system at all levels.

Recommendation #10: The Council agreed on the following recommendations for units in the regional centers for adults with both MI and DD:

• Units should be located in most, if not all the regional centers
• They should provide evaluation and diagnostics
• They should include a research and training component
• They should provide treatment planning and referral services
• They should provide long-term care for appropriate individuals
• They should provide respite services/beds

In addition to the recommendations listed above, the Council has identified the immediate need for an accountability structure that ensures oversight of the provision of care for these individuals. Currently this population can and does receive services from both DDARS and DMH, with neither division clearly responsible for the coordination of all the care/services needed.

DMH and DDARS recognize the need to work together to address the complex service needs of these individuals. Representatives from each division have joined forces to develop specific strategies that will address accountability in the provision of services to

Individuals with mental illness and developmental disabilities.

3. Adults with Developmental Disabilities

Current System of Care
DDARS and BDDS District Offices are responsible for the design, delivery, and evaluation of services for people with developmental disabilities. These services include housing, habilitation, and employment services. Respite services are also provided. The current community system of services consists of a network of private community provider agencies, case managers, protective service agencies, advocates and state staff.

Housing services currently include:

• Supported living services
• Independent living services
• Semi-independent living services
• Alternative family homes
• Group home living
• State developmental centers

Habilitation and employment services currently include:

• Community-based employment services
• Vocational rehabilitation
• Individual and group habilitation services

In keeping with the direction the state of Indiana has taken in recent years as well as service trends seen in other states for persons with developmental disabilities, the Council agrees that emphasis should continue to be placed on developing and strengthening community resources. The Council has also identified specific services that should be included in the array of services for this population. These services, listed below in the recommendation, should be provided in the community and/or in the regional centers when appropriate.

Recommendation #11: The Council identified the need for the development/enhancement of the following regional services for adults with DD:

• Crisis intervention services
• Crisis beds
• Respite beds
• Respite services
• Ongoing specialized medical and health services
• Case management services
• Specialized behavioral services (cognitive behavior therapists)
• Education
• Geriatric program
• Social skills training
• Research and training component to providers
• Aiding/linking community through staff services and treatment

4. Adults with Chemical Dependencies

Current System of Care
Currently two state psychiatric hospitals, Madison and Richmond, have specific units for adults with chemical dependencies. The average length of stay for these units is approximately 75 days, and individuals are referred to the units by their managed care provider for substance abuse. During their stay individuals are provided intensive treatment for chemical dependencies. Upon discharge, persons return to their home community and are usually enrolled in outpatient treatment services for ongoing care.

It should be noted that services for individuals with chemical dependencies are provided in all the state hospitals. Individuals receiving these services may not require intensive treatment for chemical dependencies, but do need and receive services to address their chemical dependency.

Recommendation #12: The Council recommends that two units continue to be available for adults with chemical dependencies. As community services for these individuals continue to be developed and strengthened, the need for inpatient units should be reevaluated.

5. Children with Disabilities

Current System of Care
Five state-operated care facilities under review currently provide services to children with disabilities. Silvercrest provides services to children with multiple disabilities and four state psychiatric hospitals provide services to children with serious emotional disturbance. Although the service needs vary by diagnoses, many children with disabilities require similar services, including:

• Case management
• Respite care and/or respite beds
• Family counseling
• Family involvement
• Family training
• Self help skills
• Education
• Group counseling
• Individual counseling
• Recreation/activity therapy
• Medical treatment/monitoring including dietary
• Assessment and evaluation
• Habilitation training
• Behavioral specialist staff
• Physical therapy, occupational therapy and speech therapy
• 24 hour a day/seven day a week consistency in therapy milieu
• High control strategies
• Locked units

The recommendations for the two populations (children with multiple disabilities and children with serious emotional disturbance) will be addressed separately. The Council, however, emphasizes that the focus should be on development and enhancement of the needed services (listed above) for all children with disabilities being served in the community as well as those continuing to be served in facilities.

6.Children with Multiple Disabilities

Current System of Care
Silvercrest Children’s Development Center, under the auspices of the Indiana State Department of Health, provides services to children with multiple disabilities. Located in New Albany in southern Indiana, Silvercrest provides services to children throughout the state, with the majority of children coming from the southern part of Indiana. By statute Silvercrest provides assessment, remediation therapy, and program development to children ages birth to 22, who have 2 or more disabilities much like those listed in article 7 (511 IAC 7- 17 through 31). Children are referred to Silvercrest by their local education agency (LEA) and the average length of stay is approximately 12 months. As of October 2000, 65 children were receiving services at Silvercrest.

Services are also provided in the community for children with multiple disabilities. These services are coordinated by the local education agency or the Indiana State Department of Education, Division of Special Education, and include community services, alternative residential placements within the state, and residential placements in other states. Children with the same types of disabilities as those receiving services at Silvercrest are currently receiving services within their communities, as noted in Figure 3 below.

Figure 3: Indiana Incidence Percentages
Public School Enrollment – 986,933
1999-2000 School Year

Exceptionality Area	Total State Service Count
Multiple Handicap	1,279
Autism	2,462
Other health impairment	3,018
Severe Mental Handicap	1,094

Information provided by the Indiana Department of Education, Division of Special Education

Throughout the discussions, both in the subcommittees and in the Council meetings, members identified a number of criteria that they agree are important in the provision of care to children. These criteria include:

• Allowing children to remain in a setting most comfortable and familiar to them
• Enabling families to remain involved in children’s treatment on a day-to-day basis
• Providing services in least restrictive settings that will maximize the generalization and maintenance of behaviors
• Enabling children’s teachers to be actively involved in assessment, program development, and treatment on a day-to-day basis.

The development of diagnostic and program expertise throughout the state, combined with earlier intervention services for these children, would reduce their need for long-term placement in Silvercrest or other such facilities. While residential placements may still occur, such placements should be closer to home and more easily accessible to the family.

Recommendation #13: The Council recognizes the important role that Silvercrest plays in providing services to children with multiple disabilities. In keeping with the goal of providing services as close to home as possible, the Council recommends that the Department of Education, Division of Special Education and the Department of Health develop a collaborative plan that draw on their expertise to further expand these type of services throughout the state. This plan should be developed by December 31, 2001.

7. Children with Serious Emotional Disturbance (SED)

Current System of Care
Children with SED currently receive long-term stabilization services on units in one of four state psychiatric hospitals. In addition, a number of private providers located around the state provide services to this same population. The profile of children currently in the state psychiatric hospitals includes children with aggressive behaviors, sexually aggressive behaviors, and predatory behaviors. In many instances these children require high levels of services and have complicated needs. The average length of stay is approximately 10 to 12 months.

Figure 4: Summary of Waiting List for Children’s
Services in State Psychiatric Hospitals

Psychiatric Hospital	# Of Beds	# Of Available (Empty) Beds	# On Waiting List	Ages Served	Gender
Larue Carter	42	0	25	7-18*	M & F
Madison	28	10	0	13 – 18	M
EPCC	28	7	0	4-12	M &F
Richmond	20	0	5	13-18	M
Total	118	17	30	N/A	N/A

Information provided by the Indiana Division of Mental Health
*Larue Carter provides services to three age groups

Figure 4 provides a breakdown of the number and types of beds available for children in the state psychiatric hospitals. It also provides a snapshot of the waiting list for beds. Below are several reasons why children may be waiting for a bed when beds are available in other hospitals:

• Not all hospitals serve all age groups or both genders.
• Parents work with the community mental health center that serves as gatekeeper for the child. Parents can choose to wait for a bed at a specific hospital that is closer to home rather than accept the next available bed.
• Children may be waiting to go into a specific program at a hospital that provides that particular program.

Community mental health centers must deem appropriate or approve the admission of all children to a state hospital. However, the Division of Mental Health contracts with nonprofit, community providers (community mental health centers, networks of community mental health centers, and five other providers) to provide an array of community services that includes case management, outpatient therapy, medication management, crisis intervention, and acute stabilization services. The providers are responsible for coordinating the care of children upon discharge from a state hospital, and work with the state hospital during the hospital stay to coordinate the transition back to the community.

As with children with multiple disabilities, the Council agrees that emphasis should be placed on providing services as close to home as possible, in the least restrictive setting possible. Each child entering the state-operated care facilities has a gatekeeper whose role is to coordinate the child’s care, both in the community and in the state-operated care facilities. This gatekeeper role should continue to be available, and strengthened if possible, with the emphasis placed on providing services in the least restrictive setting.

The four facilities providing services to children currently function in many ways as informal regional centers, providing services to children from their surrounding counties. Each facility, however, does not provide services to all age groups or to both genders. The Council has also identified several geographical gaps in service coverage, including the northwest region of the state.

Overall, the Council has identified the need for intensive community-based wrap-around services and development of an infrastructure that can ensure provision of the array of services needed by this population.

Recommendation #14: The Council acknowledges that there will continue to be a need for long-term stabilization beds for children with SED for the near future. These services should continue to be provided in the hospitals until community resources are developed/strengthened for this population.

Recommendation #15: An assessment of current services available for children with SED should be completed for the northwest section of the state in order to identify gaps in needed services.

Recommendation #16: Given the recommendation of the Council to regionalize the systems of care, community planning with involvement of local people should occur that identifies gaps in services for children with SED and develop plans to address those gaps.

8. High Security Units for Adults with SMI/Secured Units for Adults with DD

Guidelines for High Security/Secured Units
The Council has evaluated the growing need for high security units for individuals with serious mental illness who exhibit violent behaviors, as well as secured units for individuals with developmental disabilities who exhibit violent behaviors. Specific guidelines have been established for these units. These guidelines include:

• The units should serve individuals exhibiting violent behaviors and individuals identified as sexually aggressive. These individuals may or may not have forensic involvement.
• Individuals served on high security units/secured units should be appropriately grouped together based on functional/program/treatment needs and gender.
• The units should be linked to another facility to help with the step-down process to facilitate reintegration into the community when appropriate. The units, however, do not need to be in close proximity to these facilities.
• The units should have flexibility to adapt to changes in the population.
• The units should be state-run.

Based on the individuals with violent behaviors (those with and without forensic involvement) currently being served by the state psychiatric hospitals, DMH has concluded that, over the next two to four years, 100 high security beds would be needed. Currently, only men reside on the Isaac Ray Unit. There is a growing need to make some accommodation for women as well. The 100 beds would serve women and men, and replace the Isaac Ray Unit. These beds would serve individuals with dangerous behaviors, including those with forensic involvement and those with dangerous behaviors who are not forensically involved. The level of necessary security would be analogous to what currently exists on the Isaac Ray Unit.

DDARS does not currently have secured or locked units. However, the need for such units has been identified and DDARS will need 100 secured beds over the next 2 to 4 years. These beds do not require the same level of security as the "high security" beds that are currently in place on the Isaac Ray Unit. Rather, the ability to "lock" the unit, along with appropriate staffing levels, would provide the necessary level of security.

Recommendation #17: Based on the projection that 100 high security beds would be needed over the next two to four years for individuals with serious mental illness, the Council recommends that one high security facility be established. Given the physical plant requirements needed to adequately serve these individuals, it is not economically feasible to establish smaller units around the state. Therefore, this one facility would serve the entire state. One facility would also allow for the provision of appropriate therapeutic services that address the needs of these men and women.

Recommendation #18: The Council also recommends that individuals with developmental disabilities needing secured units should be served in at least three regional centers located throughout the state. These units, which would consist of a total of 100 beds, would provide the intense therapeutic services necessary to meet the needs of these individuals.

Recommendation #19: Looking at the higher therapeutic needs of these individuals the Council recommends that a stronger focus be placed on intensifying the current services for this population in the community emphasizing prevention measures to keep them out of the high security/secured units.

9. Fluid Intoxication Unit

Current System of Care
A small but significant number of individuals with serious mental illness exhibit symptoms of fluid or water intoxication, which occurs when an individual consumes or "gorges" very high quantities of water over a short period of time. This gorging can result in mental disturbance, confusion, seizures, weakness, and in severe cases, death. A 25-bed fluid intoxication unit, located in Logansport State Hospital, currently provides the necessary treatment and safeguards needed for these individuals. Clients are provided four phases of treatment, and have an average length of stay of 12 months. They are referred to the unit either by a community mental health center or by another state hospital. Upon discharge the client usually returns to a less restrictive treatment unit, with the ultimate goal of returning to the community.

Recommendation #20: The Council recommends that a fluid intoxication unit continue to serve individuals who suffer from severe cases of fluid intoxication. Currently, the demand or need for more than one unit does not exist. Prevalence of the disorder should continue to be monitored, however, so that other units can be developed as needed.

6. Staffing

The Council identified two recommendations, consistent with advice received from Berkshire Advising Inc., that relate directly to staffing and can significantly improve the quality of care provided in the facilities. These recommendations are:

1. That the state implement a service line model throughout all facilities and
2. That the facilities increase the provision of active treatment to include evenings and weekends.

The Staffing Subcommittee reviewed these recommendations to determine if they could be implemented in the regional centers recommended by the Council. The subcommittee concluded that both recommendations listed above could be effectively implemented in regional centers, with the stipulations that they be implemented with appropriate training and that the services provided focus on meeting individuals’ needs.

The recommendations are reported in two sections, Service Line Model and Active Treatment.

Overall Findings and Recommendations: Service Line Model

Goals of Service Line Model
A key component of service line models is accountability, with the service line team, headed by a manager, responsible for ensuring that each individual receives high quality, cost-effective care. Within each service line, the service line manager provides a focal point for ensuring that all disciplines that provide services to consumers are providing integrated treatment. The result is that service line models allow the facilities to structure the services they provide around the needs of individuals they serve and to establish clear levels of accountability. The result of this increased accountability is a significant improvement in the quality of care provided in the facilities.

Below is a brief summary of the service line model concept.

• The service line model evolved out of the product line management approach used by manufacturing firms.
• It is an organizational approach that develops service lines based on the needs of the individuals receiving services. Larue Carter Memorial Hospital, for example, has three service lines: adult psychiatric services, youth services, and community reintegration services.
• The manager of each service line is responsible, or accountable for ensuring that each individual receiving services within that service line is receiving high quality, cost-effective care. Therefore, the manager and his/her team are concerned with both quality of care and control of costs.
• The organization’s mission, values, and goals are all an integral part of each service line within the organization.
• The model uses a matrix organizational structure, which interrelates service lines with operations and departments.
• Data collection and reporting are both key components of the service line model.
• The model involves moving staff resources directly onto the service units, close to individuals receiving services.

In order to determine if the service line model is appropriate for the state-operated care facilities, including regional centers, the Council established specific goals that it would require the model to achieve. Before discussing these goals, however, the Council agreed that the overriding goal is to ensure the provision of high quality care for each individual receiving services. High turnover, low pay rates, overtime, and absenteeism all adversely effect worker morale and eventually result in a negative impact on the quality of care being provided in the facilities. Any model recommended should address these concerns. These goals are listed below.

• The model should be consistently developed and implemented between facilities. The development process should include input from all stakeholders, including unions, facility staff (PAT, SAM PAT, ESM, COMOT, SAM COMOT, LTC, SAM LTC, and POLE) central office staff, individuals receiving services and family members.
• Each component of the model should be addressed in the development and implementation process, which should start with a detailed analysis of future needs. These components include accountability, flexibility, data collection, data reporting, and a matrix organizational structure.
• The model should include on-going training for all staff, including any new or existing classifications required by the model, verification of staff competency, verification of staff credentialing, and performance measures.
• The model should have enough flexibility to meet the unique needs of each facility without compromising the goals of the model.

Strengths and Weaknesses of Service Line Model: Feedback from State-operated care facilities Staff and Staffing Subcommittee Members
Currently a service line model is in use at Larue Carter Memorial Hospital, Logansport State Hospital, Madison State Hospital, Evansville State Hospital, Fort Wayne State Developmental Center, Richmond State Hospital, and Evansville Psychiatric Children’s Center. Silvercrest Children’s Development Center has a model similar to service lines, with an organizational structure that is close to the structure described in the Berkshire Report.

The Council received input from each of these facilities and determined that the models being implemented varied a great deal in terms of organizational structure, accountability, and data collection. While some inconsistencies were expected, it was not clear from the information provided that true "service line models" were actually in place in all the facilities.

Each facility listed above was asked to assess strengths and weaknesses of its service line model. Although the responses did not all directly address service line models specifically, several important strengths and weaknesses emerged across facilities that need to be considered.

Strengths of Service Line Model:

• Increased staff participation in development of programs.
• Matrix organizational structure has improved communication between all levels of staff as well as with the clients.
• Increase in accountability for all levels of staff.
• More timely response to meeting the needs of the service line, including staffing, supplies, and program needs.
• Enhancement of the team building process within each service line.
• More focus on specific consumer population needs.
• Better outcome measures.

Weaknesses of Service Line Model

• Not all facilities have the same "service line model" in place.
• Not as effective when adequate staffing levels are not maintained.
• Mandatory overtime still used in all but two state-operated care facilities that have implemented the model.
• High turnover still exists in some facilities that have implemented the service line model.

Recommendation #21: The Council recommends that true service line models be developed and implemented in each regional center.

A clear plan should be developed that addresses all aspects of implementation of the service line model. Facility staff, unions, government agencies, individuals receiving services, family members, and central office staff should all have an opportunity to provide input in the development of the plan. For the majority of facilities with the model already in place, this plan should include an analysis of the model currently being used, and recommendations on changes needed to achieve consistency and accountability throughout all the facilities. The model should have the critical elements of: a matrix organizational structure; accountability; clear mission and values that logically demonstrate a plan for active treatment for specific populations; verification of staff competency; verification of staff credentialing; performance measurement; and consistent data collection.

Recommendation #22: The Council recommends that on-going training be provided for all staff, especially during implementation of the service line model.

The role that training has in successful implementation of the model cannot be overstated. Providing training throughout the implementation process should increase staff morale and decrease difficulties that may occur during the transitional period. In addition, on-going training should be available, not only to address problem areas, but also to provide staff with effective ways to improve job performance. The ultimate goal is to improve the quality of care provided to clients.

2. Overall Findings and Recommendations: Active Treatment

The provision of active treatment during evenings and weekends is an important component of providing high quality services in a cost-effective manner. For individuals who need inpatient care, the goal of the facility should be to provide services that would assist the individual in completing a smooth transition back into the community in a timely manner whenever possible.

Description of Active Treatment –ICFs/MR
Active treatment, according to the Health Care Financing Administration, refers to:

"Aggressive, consistent implementation of a program of specialized and generic training, treatment, and health services. Active treatment does not include services to maintain generally independent clients who are able to function with little supervision in the absence of a continuous active treatment program. Components of active treatment include:

1. Comprehensive Functional Assessment
2. Individual Program Plan
3. Program Implementation
4. Program Documentation
5. Program Monitoring and Change"

Description of Active Treatment – State Psychiatric Hospitals
Treatment planning identifies care and services appropriate to the individual's specific needs and the severity of condition, impairment, or disability.

Intent of active treatment (for State Psychiatric Hospitals)
Delivering care and services effectively and efficiently requires planning. The treatment-planning process is designed to identify and incorporate each individual's unique needs, expectations, and characteristics into an individualized and appropriate plan. The nature of the individual's needs and condition, as determined through assessment, is a primary consideration during the planning process.

Goals of Active Treatment
The goals achieved by providing active treatment are linked closely with the quality of care provided to individuals within the facilities. These goals include:

1. Development and maintenance of skills and behaviors that allow individuals to function as independently as possible.
2. Improvement of the quality of care provided to individuals in facilities by implementing a treatment system that focuses on providing consistent treatment during the day, in the evening, and on weekends.
3. Decrease of the average length of stay in facilities by providing active treatment to individuals served 24 hours a day, seven days a week.

Recommendation #23: The Council recommends that specific guidelines for the provision of active treatment on evenings and weekends be established in each facility.

Recommendation #24: The Council recommends that an analysis be completed for each facility on staffing needs to determine the staffing required to adequately provide active treatment.

5. Quality Assurance

With the exception of the staffing recommendations, the recommendations of the Council discussed so far have emphasized the development of community resources and the strengthening of the linkages between the centers and the communities they serve. The Council also recognizes the need for quality assurance monitoring throughout the entire systems of care. However, the Council determined that developing comprehensive recommendations for both community services and regional centers was beyond the scope of the charges. Therefore, recommendations were developed that concentrate on quality assurance within the regional centers, with these recommendations applied to community services where appropriate.

Recommendation #25: The Council recommends that quality assurance guidelines be developed or strengthened for community services to ensure that services provided in the community are monitored on a consistent basis.

The Council’s recommendations that directly address quality focus on fundamental issues of health and safety, as well as clinical and care issues such as outcomes, treatment, and treatment planning. The focal point of the quality assurance recommendations put forth by the Council are built on the following definition of quality assurance: "the systematic collection of data and its subsequent analysis, reporting, and use in decision-making." The findings and recommendations are summarized in three sections:

1. Monitoring and Accrediting Organizations
2. Data Management Systems
3. Performance Indicators
1. Monitoring and Accrediting Organizations

The following recommendations are intended to significantly improve and streamline monitoring of the quality of care provided in the state-operated care facilities, both in terms of health and safety and in terms of treatment and/or service outcomes. Uniformity in monitoring systems in place throughout the facilities is a central focus of many of the recommendations.

Recommendation #26: The Council recommends expansion of the Adult Protective Services Program.

This expansion should include the addition of several investigators who are permanently assigned to investigations involving state-operated care facilities. This modification should include a reasonable physical presence at those facilities.

Recommendation #27: The Council recommends creation of a system-wide toll-free number to report complaints within the governance of the facilities.

This system would report complaints to superintendents of facilities and simultaneously to DMH, DDARS, or ISDH. This toll-free system would also be available for community-based residents and family members allowing better monitoring in the community and identification of when technical assistance would be beneficial to a provider or network.

Recommendation #28: The Council recommends development of a uniform complaint system, which should be instituted in all facilities.

This system would also be available for community-based residents and family members allowing better monitoring in the community and identification of when technical assistance would be beneficial to a provider or network. This system should include:

• Ready access of simple forms for recording complaints.
• Assistance in completing forms.
• Protection of confidentiality and methods for reporting other than to offending staff.
• Investigations completed by an entity outside the facilities.
• Standards for investigations be established and adhered to.

Recommendation #29: The Council recommends that each state-operated care facility have a Human Rights Committee.

Each committee would:

• Review each complaint, grievance, or incident of seclusion, restraint or abuse. This review should concentrate on systemic issues or patterns that could indicate areas for systemic improvement.
• Be composed of facility staff, members of the facility’s home community, residents, family members, and Protection and Advocacy in an advisory capacity.

Recommendation #30: The Council recommends that the state form a Human Rights Council that includes representation from each Human Rights Committee.

This Council would be charged with:

• Reviewing the product of facility committees for understanding of broader patterns that require multi-facility action.
• Developing uniform procedures and policies for the Human Rights Committees at each facility.
• Training and educating Councils on human rights issues.
2. Data Management Systems

   The FSSA facilities (Division of Mental Health psychiatric hospitals and Division of Disability, Aging and Rehabilitative Services developmental centers) have all recently moved to the same data system, developed by Creative Socio-Medics (CSM). The CSM system has three major components, including finance, client tracking, and clinical workstation. Each hospital has a complete installation, and they are linked together through a central server located at Larue Carter Memorial Hospital. Central Office staff can also access the server. On the central server is a "Decision Support System" (DSS) that includes information from the finance and client tracking systems and which is updated nightly. The clinical workstation provides a framework that is highly customizable. The workstations would collect significantly different data at DMH and DDARS facilities. The clinical workstation information is not planned to be available on the DSS.

   There are currently no comprehensive computerized data systems in place at Silvercrest, community-based services for persons with developmental disabilities, nor for children that are not part of the DMH treatment system.

   The Division of Mental Health recently instituted a web-based data system for collecting information on community-based services. The Community Services Data System (CSDS) collects information on enrollment and services for all DMH treatment populations.

   The impact that a central data system can have on the quality of care provided to individuals receiving services is significant. A central data system offers the opportunity to collect and analyze data that directly relates to the care being given. The ability to identify trends, problem areas and "best practices" provides powerful tools to make changes that would ultimately impact the quality of care being provided.

   Recommendation #31: The Council recommends expansion of the CSM DataSystem.

   The CSM data system should be expanded to Silvercrest and/or all regional facilities, unless there are specific reasons given the population served that another system is more appropriate.

   Recommendation #32: The Council recommends improvement of accessibility of data to central office staff.

   This issue can be addressed by providing a greater number of staff with direct desktop access to the DSS (Decision Support Services) data.

   Recommendation #33: The Council recommends strengthening Central Office capabilities for data analysis.

   This recommendation is closely tied with Recommendation #32. Central office staff with responsibilities for reporting, quality assurance, or management of facilities need the ability to create ad hoc or routine reports. In order for this to occur, central office should have dedicated staff with the technical capabilities to oversee the CSM data set and to report and analyze CSM data.

   Recommendation #34: The Council recommends that Clinical Workstations throughout the regional centers be uniform.

   The clinical workstation contains much of the information that is critical for quality assurance purposes. Workstations where similar populations are served should be as close to identical as possible. For example, information on DD clients should be uniform across facilities.

   Recommendation #35: The Council recommends that information from the Clinical Workstations should be on the Decision Support System.

   As stated above, the clinical workstations contain a great deal of information that pertains to quality assurance. The information, however, cannot be easily collected or analyzed unless it is reported on the DSS.

   • Recommendations for Further Study
   • As the system progresses, it will become necessary to have the ability to easily track individuals from the state facilities, into the community system, and any recidivism back into the facilities. The Division of Mental Health's CSDS system does not collect names or social security numbers. This is a barrier to easy data coordination, but is mandated by issues of confidentiality and interpretation of federal statute. However, establishment of unique identifiers that are the same in both systems can and should be completed and would allow for tracking between systems.
   • Unified comprehensive data systems for community-based services to children and to persons with developmental disabilities should be developed. Therefore a method should be investigated for uniting the CSM and CSDS systems, such as including the CSDS unique identifiers in the CSM system.
   • If a new data system is created for community-based services to children and to persons with DD, an attempt should be made to coordinate identifiers with the CSM system.
3. Performance Indicators

   The Council’s recommendations for performance indicators focus on policy level decision-making. The broad indicators listed below monitor specific issues and trends, and allow the regional centers to be benchmarked against each other, against themselves over time, and potentially against national information. The Council agreed, however, that data would need to be collected across the system in a common method and analyzed over a two-year period before any benchmarks could be established.

   At a minimum a governing board that looks at all regional facilities should receive a periodic report that concentrates on the following information. Additional information would be available when indicated by outliers on this report.

   Each indicator should be evaluated based on the population being served. For example, length of stay for individuals with DD may be significantly different than length of stay for individuals with SMI. This information needs to be evaluated accordingly.

   Recommended Indicators
   All of the indicators are examined by population or disability category. Within those categories, however, they are also to be examined by

   • Age
   • Gender
   • Ethnicity
   • Diagnosis
   • Facility
   • Gatekeeper or community service provider

   Recommendation #36: The Council recommends that the indicators defined in detail below be used on a policy decision-making level to monitor the quality of care being provided in the facilities.

   1. Admissions

   Admissions are a measure of access to the system. Changes in admission numbers can mean changes in access to services.

   Category	Most Recent Month	Most Recent 12 months	This Fiscal Year
   Number of unique clients admitted
   Number of admissions (may count the same individual more than once when a person is readmitted)

   2. Readmissions

   Of the admissions, how many were for individuals that had previously been in a state-operated care facility?

   Number of Previous Admissions	Most Recent Month	Most Recent 12 Months	This Fiscal Year
   0
   1
   2
   3 or more

   3. Length of Stay

   Length of stay is a primary measure of the treatment system. For some populations, the goal may be a very short length of stay for stabilization and return to the community. For others, the goal may be a permanent placement. Length of stay is often shown as an average or median. Showing it as percentages falling into different lengths of stay, however, provides a more graphic and accurate picture of the total population.

   There are two ways for computing length of stay. We recommend reporting it both ways as follows:

   Category	< 6 months	6 - 12 months	1 - 2 years	2 - 4 years	5 + years
   Of the present population - # that have been in the facility for:
   Of the present population - % that have been in the facility for:
   Of the individuals that left in the last twelve months - # that had been in the facility for
   Of the individuals that left in the last twelve months - % that had been in the facility for:

   4. Discharges

   Admissions are a measure of success in the system. Changes in discharge numbers can mean changes in access to services, and changes in the quality of services.

   Category	Most Recent Month	Most Recent 12 Months	This Fiscal Year
   Number of discharges (may count the same individual more than once when a person is readmitted)

   5. Use of Restraints.

   Restraints, either chemical, physical, or mechanical, are the most intrusive and most dangerous interventions in the facilities. It is recommended that they be monitored closely. There are broadly three types of restraints. Chemical restraints refer to the use of psychotropic medications for control purposes. Two point restraints generally restrain the consumer's arms. Four way restraints are tied to wrists and ankles. The table refers to the number of consumers that were put into restraints and the percentage that that number was of total consumers.

   Category	Most Recent Month - Number	Most Recent Month - Percent	Most Recent 12 Months - Number	Most Recent 12 Months - Percent	This Fiscal Year - Number	This Fiscal Year - Percent
   Chemical
   2 point
   4 point
   Mechanical

   There are other indicators for restraints that should also be reported, having to do with numbers of clients receiving restraints more than once in a time period, and average duration of restraint per client.

   6. Seclusion

   Category	Most Recent Month - Number	Most Recent Month - Percent	Most Recent 12 Months - Number	Most Recent 12 Months - Percent	This Fiscal Year - Number	This Fiscal Year - Percent
   Clients Secluded

   7. Medications

   Medications are an issue that is different for different populations. For person with mental illness, use of psychotropic medications is the norm, and use of new generation or "atypical" medications is encouraged. A great majority of persons hospitalized because of a mental illness are on more than one psychotropic medication. For persons with developmental disabilities, the use of psychotropic medications is looked on with skepticism. Too often, medications are used in lieu of behavior control and education. This is a case in which the same measure is viewed very differently for different populations.

   Category	Current Census - Number	Current Census - Percent	Census 12 Months Ago - Number	Census 12 Months Ago - Percent	Census at Year End - Number	Census at Year End - Percent
   One psychotropic medication
   One atypical medication
   More than one medication
   Atypical plus others
   No psychotropic medication
   Total		100%		100%		100%

   8. Living Situation

   State-operated care facilities differ widely, and within institutions situations differ widely. For a variety of purposes, it would be meaningful to develop and monitor the living situations within facilities. A typology of living situations should be developed that is uniform across all facilities. This might include categories like:

   • Highly secure
   • Certified Intermediate Care Facilities
   • Shared Living Arrangements
   • Single Rooms
   • Etc.

   Numbers and percent of individuals within each type of setting should be reported.

   9. Services / Processes

   The kinds of treatment and services that should make up much of the day of persons living in state-operated care facilities can fall into four major groups: employment, education, social, and active treatment. Each of these can be provided on site or off site. For instance, individuals in current state institutions have jobs at the facility, go to on site school, have activities at facility-based recreation centers, and engage in treatment on site. Others work in competitive jobs in the community, attend community schools, bowl, go to movies, shop in the town, and are seen by the local mental health center.

   Hours Per Week That Consumers Are Engaged In Selected Activities

   Activity	None - #	None - %	Less than 1 - #	Less than 1 - %	1 to 3 - #	1 to 3 - %	4 to 6 - #	4 to 6 - %	7 to 15 - #	7 to 15 - %	16+ - #	16+ - %
   Jobs on site
   Jobs in community
   Education on site
   Education in community
   Socialize on site
   Socialize in community
   Active treatment on site
   Active treatment in community

   10. Quality of Life

   Health Related Quality of Life instruments for mental illness or developmental disabilities include information on levels of functioning, symptoms, stress, and other indicators of an individual's quality of life.

   The Division of Mental Health uses an adult instrument for all individuals in that system. The instrument (Hoosier Assurance Plan Instrument for Adults or HAPI - A), along with factors such as age, gender, diagnosis, and types of drugs abused helps the Division classify consumers into functioning categories. These categories are used for rate setting and for measuring outcomes. The Division is currently developing a similar instrument for children (HAPI - C). No such instrument is in common use for persons with developmental disabilities.

   A quality of life instrument for persons with developmental disabilities should be developed for use across the developmental centers.

   Reports should be developed showing:

   • Numbers and percent of individuals within given functioning categories at admission.
   • Numbers and percent of individuals within given functioning categories within month end census.
   • Changes in quality of life scores for individuals compared to previous score (annual, quarterly)
   • Changes in quality of life scores for individuals from admission to discharge.

   11. Consumer and Family Satisfaction

   Silvercrest surveys families and children at multiple times after discharge from the facility. The Division of Mental Health has created a satisfaction survey that is completed by hospital consumers, but they do not similarly survey family members, and DDARS surveys neither.

   Surveys should be developed, benchmarked, and reported for all consumers and all family members within all of the regional centers.

   12. Incidents and Grievances

   The existing facilities have very well developed systems for reporting incidents and sentinel events. A system should be developed to summarize information on client injuries, client grievances, staff injuries and deaths.

   13. Staffing

   A central issue affecting quality of care is the availability of quality staff. Each facility is constantly recruiting, and has actual levels of staff that are much lower than the authorized staffing levels. Vacancies on staff affect quality of care and safety. It also affects cost since vacancies are often covered through contracts or overtime. Training is one successful method of improving quality of care and helping retain staff. Following is a list of staffing information that should be collected and analyzed:

   • Number and percent of funded positions vacant by facility and within staffing categories
   • Turnover rates: Number and percent of staff by facility and within staffing categories that left the job during the previous month.
   • Numbers of training programs by facility and type of program
   • Numbers of individuals attending each type of program.
6. Implementation Plan

The recommendations outlined above are designed to significantly improve the quality of care provided, not just in the state-operated care facilities, but in the community as well. The focus throughout the Council’s work has been to make recommendations that emphasize the provision of care in the least restrictive setting close to home whenever possible. The Council has also developed recommendations that significantly improve the linkages between the facilities and community resources, and that address the monitoring of quality in the facilities.

These recommendations, however, are just the beginning point. The next step should be to develop an implementation plan, based on these recommendations and analyses, that includes a step-by-step process to move Indiana forward over the next five years. It is suggested that this plan also include a specific assessment or reevaluation period that allows for analysis of the progress made and for appropriate adjustments to be completed that would keep Indiana on the path to regionalization.

Recommendation #37: The Council is recommending that an implementation plan be developed over the next two to four years, and be based on the recommendations and analyses provided in this report, including:

• The regional system recommendation with specific geographic regions, multi-service centers, and single points of entry
• The regional hub concept
• The downsizing figures for 2005 by population
• The anticipated capital needs for each facility
• The recommendations by population
• The staffing recommendations
• The quality assurance recommendations

The implementation plan should include identifying the location and physical environment of each regional center based on the service needs of the populations within the regions as well as on the anticipated capital needs of the facilities. An assessment should be completed every two years to monitor the progress made and to make the appropriate adjustments to the plan to ensure that the transition of the system to regionalization is as smooth as possible.

7. Conclusion

The long-range goals developed and discussed in this report are in keeping with service trends throughout the country. The Council recognizes that some individuals will continue to require services in the state-operated care facilities, and has developed recommendations that significantly improve both the quality of care provided in the facilities as well as the linkages between the facilities and community resources.

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.

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.

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 execution 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.

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