The Behavioral Health Coordinating Council annual report, 2013

2013
A Report of the Behavioral Health Coordinating Council
BHCC
Submitted by: Georgia Department of Behavioral Health &
Developmental Disabilities Frank W. Berry, Commissioner
March 2014

REPORT OF THE BEHAVIORAL HEALTH COORDINATING COUNCIL MARCH 2014
BACKGROUND__________________________________________________________________________
In 2009, the 150th Georgia General Assembly established the Behavioral Health Coordinating Council (O.C.G.A. 37-2-4) when it passed HB 228, which reorganized and reestablished Georgia's state health and human services agencies. HB 228 was signed by Governor Sonny Perdue and the act went into effect on July 1, 2009. The Behavioral Health Coordinating Council is administratively attached to the Department of Behavioral Health and Developmental Disabilities as provided by O.C.G.A. 50-4-3.
AUTHORITY, POWERS AND FUNCTIONS_______________________________________________________
The Behavioral Health Coordinating Council (the "Council") performs four categorical functions: it makes recommendations, sets goals, monitors and evaluates, and develops measures. The council is specifically tasked with:
Developing solutions to systemic barriers to or problems with the delivery of behavioral health services by making recommendations that implement funding, policy and practice changes, and evaluation of specific goals designed to improve service delivery and outcomes for individuals served by the various state agencies;
Focusing on specific goals designed to resolve issues for provision of behavioral health services that negatively impact individuals serviced by at least two departments;
Monitoring and evaluating the implementation of established goals; and Establishing common outcome measures.
COUNCIL COMPOSITION__________________________________________________________________
By statute, the Council is comprised of following persons:
The Commissioner of Behavioral Health and Developmental Disabilities The Commissioner of Community Affairs The Commissioner of Community Health The Commissioner of Corrections The Commissioner of Human Services The Commissioner of Juvenile Justice The Commissioner of Labor The Commissioner of Public Health The State School Superintendent The Chair of the State Board of Pardons and Paroles The Disabilities Services Ombudsman An adult consumer of public behavioral health services A family member of a consumer of public behavioral health services A parent of a child receiving public behavioral health services A member of the Georgia House of Representatives A member of the Georgia State Senate
The various agency commissioners, the state school superintendent, the chair of the State Board of Pardons and Paroles, and the ombudsman are members of the Council as a matter of law. The adult
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consumer of public behavioral health services; the family member of a consumer of public behavioral health services; and the parent of a child consumer of behavioral health services are appointed by the governor. Representative Katie Dempsey (13th) represents the House of Representatives and was appointed by Speaker David Ralston, and Senator Renee Unterman (45th) represents the Senate as appointed by Lieutenant Governor Casey Cagle. All members serve at the pleasure of their appointing authority with no term limit. LEADERSHIP___________________________________________________________________________ The Council is led by an executive committee comprised of a chair, vice-chair, secretary, and two members-at-large. The Commissioner of the Department of Behavioral Health and Developmental Disabilities (DBHDD) serves as the chair of the executive committee. The vice-chair and secretary are elected by and by the members of the Council and serve two-year terms; they may succeed themselves. The chair, vice-chair and secretary, and two members appointed by the chair make up the five-member executive committee.
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COUNCIL INITIATIVES ____________________________________________________________________
The Council maintained a quarterly meeting schedule in 2013. Meetings were open to the public and well attended by a variety of stakeholders. Meeting minutes and supporting documentation are posted in accordance with the Open Meetings Act (O.C.G.A 5-18-70 et. seq.) and can be found on the DBHDD website at http://dbhdd.georgia.gov/georgia-behavioral-health-coordinating-council.
Interagency Directors Team (IDT) A multi-agency leadership effort to design, manage, facilitate, and implement an integrated approach to a child and adolescent system of care is necessary to support the developmental needs of Georgia's children. Shared funding and resources and informed policy and practice will help to create and sustain a responsive child and adolescent system. The current work of the Interagency Disciplinary Team (IDT) is addressing these challenges and has requested to partner with the Council.
Transition Care Workgroup Co-Chairs Jay Neal, Director, Governor's Office of Transition, Support and Reentry Terri Timberlake, Ph.D., Director, Georgia Department of Behavioral Health and Developmental Disabilities, Office of Adult Mental Health
The Transition Care Workgroup is charged with exploring interagency barriers and developing a plan to coordinate services between agencies to better facilitate access to community mental health services and supports for individuals transitioning from the correctional system into the community. The workgroup initially convened in May 2013 and has held 14 meetings.
Committee Representation Governor's Office of Transition, Support and Reentry Georgia Department of Behavioral Health and Developmental Disabilities:
Division of Developmental Disabilities Division of Mental Health: Office of Forensic Services; Jail Diversion and Trauma Recovery; Adult Mental Health; Child and Adolescent Mental Health Georgia Department of Community Affairs Georgia Department of Community Health Georgia Department of Corrections Georgia Department of Juvenile Justice Georgia Department of Veteran Services Georgia Vocational Rehabilitation Agency State Board of Pardons and Paroles City Of Atlanta Solicitor's Office Emory University Fuqua Center for Late-Life Depression
Accomplishments Each partnering agency within the correctional system (i.e. Department of Corrections, Department of Juvenile Justice, Board of Pardons and Paroles) has educated other members of the workgroup on its processes for diagnosis, treatment, pre-release planning and discharge. Identified barriers to successful transition into society Developed recommendations to address top four priority barriers as identified by the workgroup.
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The Aging & Disability Resource Connection gave a presentation on how to use its website (www.georgiaadrc.com) to members of the workgroup; the presentation included information on searching for and accessing information, and how to find available services.
Established process for monthly data sharing between state agencies on total population of incarcerated individuals who have mental health problems

Barriers and systemic challenges The workgroup identified eight categories of barriers.
1. Lack of mental health services in rural areas; linking consumers with appropriate aftercare is a challenge, particularly for those consumers who have dual diagnoses.
2. Lack of cultural competency with trauma-informed care 3. Awareness and access to information; training is needed to help ensure that the Department of
Corrections planning staff are aware of services available during the pre-release and reentry process. 4. Access to medication; difficulty obtaining prescriptions and doctor's appointments because services are not readily accessible to the reentry population 5. Lack of housing; the issue is further complicated for people with a history of substance abuse and sexual offense because many housing providers are not willing to accept them; need for more specialized placement and use of Transitional Housing for Offender Registry (THOR) 6. Transportation 7. Stigma creates barriers to housing and employment. 8. Difficulty linking persons to appointments prior to release; often, notice of the decision to release an individual on parole does not occur more than a week from the release date.

Four of the barriers above were selected as priorities. Stigma: This creates a barrier to employment and housing. Capacity and access: Community assessments are often inadequate, and many providers do not
understand how to serve individuals transitioning into society. Awareness and access to information: Parole officers need to know which providers are able to
address the unique needs of the reentry population. Housing: More resources are needed.

Recommendations

I.

Stigma

Integrate forensic peer mentors into the pre-release and transition process; create a

forensic peer mentor curriculum and a peer advisory committee.

Include speakers from the RESPECT Institute in meetings, orientation and trainings across all

agencies. Staff will benefit from hearing personal experiences from individuals with mental

health challenges.

Add stigma training to new employee orientation and ongoing training with the Georgia

Juvenile Services Association. The Department of Juvenile Justice (DJJ) currently has an 8- to

10-hour training on stigma that includes videos and exercises on adolescent growth and

development under both normal conditions and environmental trauma. It also identifies

healthy and unhealthy development. DJJ is one of ten systems in the country that offers this

curriculum.

Include a segment on mental health stigma during Department of Corrections (DOC) new

staff orientation and standard training. Suggestion: each warden may choose which topics

are presented during the two hours allocated to mental health training.

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Incorporate skills for community supervision into the 8-hour mental health first aid certification course for DOC's level 3 training. A segment on mental health stigma should be a standard component for Pardons and Paroles and DOC new officer training. Pardons and Paroles has a newly integrated training module that can incorporate these trainings. For DOC, no additional funding is needed if these trainings can be incorporated by the Georgia Public Safety Training Center.
Connect with the judges' councils for Juvenile, State and Superior Court systems. Training could be included in existing annual training for judges. Reach out to Chief Judge Herman Sloan (Municipal Court of Atlanta, Community Court Division) and Judge Brenda Weaver (chair of the Judges Council for the Appalachia Court system, which covers Pickens, Gilmer and Fannin Counties).
Partner with the Georgia Sheriff's Association to train sheriffs in mental health first aid and transition from jails.
Continue to work with the National Alliance on Mental Illness to coordinate trainings. Recommend to the Peace Officer Standards and Training Council (P.O.S.T) that annual
mental health stigma training be required for all certified P.O.S.T. officers, and that this training count for P.O.S.T. credit.

II.

Capacity and access

Implement the Department of Behavioral Health and Developmental Disabilities' (DBHDD)

Transition Action Plan during the pre-release process to aid comprehensive assessment of

needs, eligibility, and risks. Share information between agencies.

Improve data sharing between DOC and community service boards (DBHDD).

Ensure that transition reentry specialists complete benefits applications early in the pre-

release process.

Require a certain number of priority appointment slots for persons with mental illness and

psychotropic prescriptions who are transitioning out of prison.

III. Awareness and access to information Create a directory (called "Georgia Helps") listing state agencies and housing, health care, and vocational support resources. Georgia Helps would be linked to state agency and partner (e.g. the Georgia Sheriff's Association and clinicians in the court system) websites. Promote via hospitals, public areas (such as MARTA stations), and peer specialists. Distribute a survey to all government agencies to solicit feedback on other areas for improvement.

IV. Housing Support of a concept proposal for the Department of Community Affairs (DCA) and DOC to place transitional case managers in five prisons. These case managers would locate housing for individuals and facilitate their transition into the housing. They would also arrange meetings between providers and prisoners before they are released from jail. Use reentry specialists and/or multifunctional officers to help identify problems and barriers before a person is released. This would help to address treatment, medication needs, and appointments prior to release. Create a benefits specialist position in transition centers and other state agencies to assist in the preparation of applications to mainstream resources (e.g. Supplemental Security Income (SSI/SSDI), Medicaid, and Supplemental Nutrition Assistance Program) upon release. On average, it takes 118 days to receive SSI/SSDI benefits after reentering the community if the

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process is started before release and processed under the SSI/SSDI Outreach, Access, and Recovery Technical Assistance model. Expand the number and/or capacity of transitional centers. (There were 500 people on a waiting list as of September 2013). Extend duration of reentry partnership housing, and increase per diem for providers. The daily cost of housing an inmate is $50* while the cost of supervising a parolee is $4.43. During fiscal years 20112013, the state saved $20.9 million by transitioning individuals from jail to parole. *This cost does not include any medications for individuals with mental health conditions. Build strong evaluation component into all data collected (utilization/access, etc.)
The above recommendations were presented to the Behavioral Health Coordinating Council Executive Committee in December 2013 and March 2014. The Council approved the following: integration of forensic peer mentors into the pre-release and transition process, and creation of a training module and peer advisory committee. To that end, a sub-group of DBHDD and DOC representatives have been working with the Georgia Mental Health Consumer Network and an out-of-state consultant who has developed a forensic peer initiative in Philadelphia. Implementation will include identification of one urban and one rural pilot DOC facility; development of a training curriculum; and implementation of the module. The Council also approved all recommendations for increased mental health training to address stigma, including incorporation of RESPECT Institute speakers, standardizing new employee/new officer mental health stigma training, and recommendations for mandatory P.O.S.T. training. Another subgroup has formed to research and offer recommendations for training curricula. Additional housing recommendations which have not been presented to the Council are listed below.
Housing recommendations: Provide housing assessments and increased training for DOC staff on available community resources. The housing planning process must include an assessment of the feasibility, safety and appropriateness of an individual living with family members. Individuals must receive information and training on strategies for finding and maintaining housing, and on their legal rights as tenants. Prison counselors/reentry specialists and parole and probation officers could benefit from training regarding housing laws. Prioritize individuals classified as level 3 and level 4* by DOC. This might include creating a different type of transitional center that focuses on independent living skills and vocational training, rather than specific job placement. Establish a pilot site for level 3 and 4 to implement the Transition Action Plan and categorize as high risk and high need. For DOC, request funding to provide housing options (transitional and/or permanent)
*The Department of Corrections classifies incarcerated persons by level of functions. Individuals at level 3 live in specialized units and supervision and assistance with activities of daily living. Individuals at level 4 need greater supervision and are lower-functioning.
Recommended next steps This workgroup will continue to work in concert with Governor's Office of Transition, Support and Reentry and will move forward with agency collaboration to support initiatives identified and approved by the Behavioral Health Coordinating Council.
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Interagency Collaboration State bureaucracy can lead to silos of policy, practice and communication. The work of state agencies can be strengthened by identifying approaches and solutions that address inefficiencies, gaps, challenges and effectiveness in Georgia's health and human service delivery systems.
Workforce Development Georgia has a shortage of licensed health care professionals. This workforce shortage poses a challenge to the state's current and future health care delivery system. Georgia faces a critical juncture at which it must determine its needs and address its challenges. Agencies working together around training, professional development, recruitment and retention, increasing job satisfaction, and networking/coordination will help address the growing shortage and develop Georgia's workforce.
Ben Robinson, Executive Director of Academic Affairs at the Georgia Board of Regents, presented the realities of Georgia's public sector workforce crisis and recommendations for consideration. A summary of the presentation appears below:
The Departments of Behavioral Health and Developmental Disabilities, Public Health and Community Health provide much of the public health care services available in Georgia. However, many state agencies, including the Departments of Education, Corrections, Juvenile Justice and Human Services, share this responsibility. Federal and state laws, as well as public expectations, require the provision of high-quality care regardless of available resources. An adequately trained and licensed workforce is critical to providing the health care services required by the public. Substantial workforce shortages exist for many health care professions in Georgia. Yet, the supply of workers is even more scarce in the public sector due to budgets that are generally constrained even in good times and the high level of responsibility demanded by the public.
The presentation is attached as Appendix B.
Recommended next steps Establish a Workforce Development Task Force to begin the implementation of the process described by Mr. Robinson.
OUTCOMES AND RECOMMENDATIONS________________________________________________________
Outcomes 1. Enhanced Council Governance: Amendments were made to the Council's by-laws in October 2010 and November 2011 to reflect its growth and development.
2. Enhanced Interagency Collaboration: The inception and work of the Council has enhanced interagency communication and relations. Synergy and shared interests have been created and identified through open discussions and dialogue between state agency heads and community stakeholders.
3. Identified Priority Areas: Three issues have been identified by the Council as focal points for 2013. The Council began addressing these shared priority areas in January 2013. Work towards these priorities will be accomplished through ad-hoc groups comprised of staff from the various agencies represented on the Council:
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Sharing of health information Partnerships Workforce development
Recommendations The Behavioral Health Coordination Council has identified as one of its targets the need to explore barriers, infrastructure, staffing, services, housing and educational needs for diverting and transitioning individuals with behavioral and developmental issues under the jurisdiction or care of the Department of Corrections, Pardons and Parole, Department of Juvenile Justice, and the Department of Behavioral Health and Developmental Disabilities' forensic services. This workgroup will provide regular progress reports and updates to the Council, and as an outcome of this transition workgroup, a plan and an interagency agreement will be developed encompassing all institutional and/or community-based entities needed to successfully transition persons into the community.
The Council supports a robust discussion of the multiple barriers impeding individual's transition from the Corrections/Justice System into appropriate community behavioral health services and access to necessary supports including housing and transportation.
2014 MEETING DATES_____________________________________________________________________
The Behavioral Health Coordinating Council meets at the Department of Behavioral Health and Developmental Disabilities on the 24th Floor in the Board room unless otherwise noted. Meetings begin at 10:00 a.m. The proposed meeting dates for 2014 are:
March 26, 2014 June 25, 2014 September 24, 2014 December 17, 2014
CONTACTS_____________________________________________________________________________
Frank W. Berry DBHDD Commissioner 2 Peachtree Street, 24th Floor Atlanta, GA 30303 fwberry@dbhdd.ga.gov (404) 463-7945
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Appendix A
History of Behavioral Health Coordinating Council Executive Committee

YEAR/OFFICE

CHAIR

VICE-CHAIR

SECRETARY

MEMBERS-AT-LARGE

2009

Frank E. Shelp, MD, MPH Albert Murray

BJ Walker

N/A

DBHDD Commissioner

DJJ Commissioner DHS Commissioner

2010 2011

Frank E. Shelp, MD, MPH DBHDD Commissioner
Frank E. Shelp, MD, MPH DBHDD Commissioner

Brian Owens DOC Commissioner
Brian Owens DOC Commissioner

BJ Walker DHS Commissioner
Clyde Reese DHS Commissioner

Clyde Reese DHS Commissioner & Brian Owens DOC Commissioner Amy Howell DJJ Commissioner

2012

Frank E. Shelp, MD, MPH DBHDD Commissioner (JanuaryAugust)
-----------------------------Frank W. Berry DBHDD Commissioner (AugustDecember)

Brian Owens DOC Commissioner

Clyde Reese DHS Commissioner

Albert Murray PAP Chairman & Corinna Magelund Ombudsman Disability Services

2013

Frank W. Berry DBHDD Commissioner

Clyde Reese DHS Commissioner (JanuaryJuly) DCH Commissioner (JulyDecember)

Corinna Magelund Ombudsman Disability Services

Albert Murray PAP Chairman & Brian Owens DOC Commissioner

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Public Sector Health Workforce

Usual Suspects
MDs, RNs, APRNs, DMDs,
Some less than usual suspects
Laboratory personnel
Therapy professions

Unusual settings
Greater legal and budget constraints
Public expectations
Heavier Behavioral Health Focus
More difficult "patients"

Appendix B

Change in Hospital, Nursing Home and Home Health Staffing 2000 2010

Profession MD

FY 2000
Budgeted Positions
1,157

RN

30,527

LPN

10,555

Pharmacy

1,397

Other*

43,175

Total

86,811

* Includes nurse aides and allied health

FY 2010 Budgeted Positions
1,196 39,755 11,306 1,581 46,583 100,422

Change FY 2000 - 2010
39 9,228 751 184 3,408 13,611

Ranking of per capita number of Behavioral Health

Professionals in Georgia

Counselors

28th

Marriage & Family Therapists

31st

Psychiatric APRNs

28th

Psychiatrists

30th

Psychologists

42nd

RNs

40th

Physicians

40th

Social Workers

41st

Context: Extensive Shortages
Georgia struggles with health workforce
Growth in demand: Rapid growth in Population Aging of population Increases in capabilities of
workforce
Supply concerns: Aging workforce Historic short supply of key
professions Declines in production from
academic pipeline (under correction)
Shortages exist at national level
Appendix B

Context: Public vs. Private Sector
Public Sector competes with private settings for trained health Workforce personnel
Shortages of Personnel mean Seller's market Salary, benefits, scheduling.... Issues at work Challenges of work in public sector contribute
to difficulties Challenges of work in public sector at work Public sector agencies also compete with each
other
Appendix B

Aspects of Public Sector

can inhibit growth

Unique aspects
Service oriented
Personnel heavy
Budget disconnect
Size of budget not reflective of service demands
Budgeting driven by external considerations

Perverse Response
Cut staffing
Downgrade credentials
Staff-up on lower skilled personnel
Push duties down the professional network

Inelastic expectations

Pray nothing goes wrong

Provide services as demanded regardless of budget.....

Appendix B

Unique aspects of the Health Workforce
Elements of health profession legal, academic and practice constructs can restrict access to these professionals
Licensure requirements Practice constraints Education
However, these can also provide unique ways to connect
Appendix B

Results in
Workforce Problems
General shortages of personnel and challenges of public sector employment have produces major shortages in public sector
Corrections:
Worsening Staffing Ratios in key behavioral Health Professions - Psychology
Mental Health:
Heavy reliance on low skilled workforce
Public Health
Oral health and laboratory personnel shortages
K-12 Education
High impact of early health interventions difficult to access (DOE not necessarily employer)
Therapy personnel Pediatric subspecialties Vision and oral healthcare
Nurses in short supply across the public sector Appendix B

Goal for Public Sector
The right professionals Doing the right job For the right people With the right needs
Appendix B

Solutions: How to get there
This is not simply an HR problem
Many issues at work
Employer concerns exist benefits, salary Sector problems Exist Constraints of public
sector and personnel shortages Pipeline Problems exist Peculiarities of healthcare personnel exist Scope of Practice problems exist
Appendix B

Solutions
Build internal DBHDD workforce knowledge
Strengthen the education pipeline:
Create more education programs as needed (or enlarge existing ones)
Establish high quality clinical education experiences for students
Establish residency/internship/post doctoral
programs/experiences for medicine, nursing, psychology and others
Develop existing workers into needed professionals
Establish career pathways
Enhance supports (salary, stipend and supervisory) for students engaged in supervised clinical practice prior to full licensure
Appendix B

Solutions
Increase appeal of work in the public sector
Appropriately reduce work burden placed on clinical professionals
Maximize appropriate substitutions of work/professionals across the system. Apply training and workforce education efforts to this endeavor as needed.
Establish systems that attract needed clinicians to public sector
Improve the efficacy of the workforce
Properly align state law/rules governing workforce to align with public sector needs
Modernize knowledge and skills of existing clinical professionals through continuing education systems
Establish/enhance training pathways that target newer skills/professions that align with state of the art practices
Appendix B