Cheryl Strange, LMHC, MPA
David Kludt, MPA
Joan B. Beasley, Ph.D.
Unfortunately, it is not uncommon for individuals with multiple service needs that occur across service systems to have difficulty in accessing effective care. Often these individuals find gaps in the system that are difficult to overcome. In response to the need to improve services to individuals with developmental disabilities and mental health needs, a cross systems approach to quality enhancement and service implementation has been undertaken in the state of Washington.
Washington States Department of Social and Health Services (DSHS) maintains numerous levels of oversight and quality assurance for all the services it provides. These structures include, but are not limited to, certification and licensing of services, facilities, and department subcontractors. An annual assessment of clients is conducted to determine the appropriate level of care needed and to develop a plan of care. The plan must be consistent with identified need and assure that all services are provided by qualified providers. Policies and procedures identify, resolve, and define preventive measures regarding possible incidents of abuse, neglect and/or exploitation of consumers with developmental disabilities.
In addition to these routine quality assurance measures, the Division of Developmental Disabilities (DDD) and the Mental Health Division (MHD) are in the process of implementing the final stages of an enhanced quality assurance process for individuals with developmental disabilities who have co-existing mental health issues and who have been discharged from a state psychiatric hospital. These activities include four additional tiers of quality assurance:
A DDD/MHD Cross Systems Committee;
An Internal Oversight Review Team;
Comprehensive reviews of a sample of randomly selected class members conducted by regional DDD staff and the regional Mental Health Regional Support Networks (RSNs); and
DDD community follow-up reviews for class members during the year following their discharge.
DDD/MHD Cross Systems Committee
The Cross Systems Committee (CSC) provides accountability for the implementation of the cross system collaboration between developmental disabilities and the network of providers responsible for delivering- the states mental health program.
The CSC is chaired by the directors of the DSHS Mental Health Division and the Division of Developmental Disabilities. Other members include program management staff from DDD headquarters, MHD, DDD field services management, and representatives from state hospitals, the RSNs, and quality assurance staff from both divisions.
The committee meets quarterly to review and analyze program activity data in order to monitor program performance and make policy level recommendations for systemic improvements. The committee conducts trend analyses, identifies service gaps, and identifies funding needs to improve services and supports.
Regional Comprehensive Reviews of Randomly Selected Individuals
In order to assess the system as a whole, comprehensive reviews are conducted on individuals discharged from the state psychiatric hospital using a standardized assessment tool. These individuals are randomly selected (10% annually) in each of the 6 DSHS regions. These reviews are conducted quarterly and include an evaluation of the following 10 components:
1. Cross system crisis plans;
2. Functional analysis/Positive behavior support plans;
3. Care planning;
4. Incident reporting;
5. Residential services;
6. Vocational services;
7. Outpatient mental health services, including Medicaid State Plan services and DDD-funded services;
8. In-patient mental health services;
9. Crisis stabilization services; and
10. Cross system collaboration.
Internal Oversight Review Team
The Internal Oversight Review Team (IORT) is a four-member team made up of a psychiatrist with experience in the care and treatment of individuals with developmental disabilities and co-occurring mental illness; a licensed psychologist trained in the development and implementation of plans of care, functional assessments and positive behavior support plans; and two mental health professionals who are also developmental disability specialists trained in cross system crisis planning, enhanced crisis prevention and intervention methodologies, and diversion activities.
The IORT meets quarterly and has the following responsibilities:
Conduct system reviews and provide consultation at the request of the DDD/MHD CSC to address areas of possible concern,;
Maintain the standardized tool used by both divisions to assess individual care and systemic issues; and
Review results of the regional comprehensive reviews (10% annually).
At least annually, the IORT reviews individual cases where a comprehensive review resulted in a referral for immediate action in response to an imminent threat to the persons health and safety.
DDD Community Follow-Up Reviews
DDD conducts community follow-up reviews for all clients discharged from state psychiatric hospitals who have been in-residence for a minimum of 90 days. These reviews include three face-to-face reviews at 30, 90 to 180 days (at the discretion of reviewer), and one-year post-hospital discharge. The review takes an in-depth look at the persons residential and vocational program activities, and the persons ability to retain resilience in context of the core values of health, safety, competence, status, choice and relationships.
The role of public policy is to incorporate effective strategies into the fabric of the service delivery system in order for positive outcomes to become permanent solutions. The enhanced process just outlined provides a structural and strategic public policy approach intended to indelibly change the way services individuals with dual diagnosis are provided in the state of Washington.
Cheryl Strange, previously MH Program Manager, Division of Developmental Disabilities, Aging & Disability Services Administration, Department of Social & Health Services, Washington State. Currently Assistant Director, Mental Health Division, Health & Recovery Services, Department of Social & Health Services, Washington State