Return on Community Investment (ROCI):
A High Impact Institute

Pre-Conference Data Collection
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Return on Community Investment Survey Responses

Respondent Name:

Joan Frances

E-Mail Address:

pphhsvision@earthlink.net

Organization Name:

Panhandle Pship for HHS

Phone:

(308) 235-4211   Ext.

Fax:

(308) 432-5092

Address:

P.O. Box 669   

City, State, Zip:

Chadron, NE    69337
Category: Your Community

What is the service area of your initiative (counties, city, etc.)?

The Panhandle of Nebraska - Region I: Scotts Bluff, Banner, Morrill, Box Butte, Dawes, Sheridan, Sioux, Garden, Cheyenne, Deuel and Kimball counties

What is the total population in your service area?

Approximately 90,410

What percentage of the total population lives below the federal poverty level?

13.6%

What percentage of the total population is uninsured?

Approximately 30%
Category: Your Program Initiative

Indicate which of the following categories your initiative falls in:

Outreach and navigation
Emergency room usage reduction
Case management of chronic disease
Access to affordable pharmaceuticals

Describe the purpose of your initiative (in one sentence, if possible):

The purpose of our initiative is to decrease the number of persons requiring emergency protective custody due to mental health/substance abuse crises, decrease utilization of inappropriately high levels of care, promote stabilization within the individual's home community so as to prevent future crises, and maximize the use of local community resources.

Describe the scale of your initiative in terms of budget, capacity, etc.:

Homeward Bound - Budget: $348,000 Capacity: Approximately 950 bed days per year Served 34 individuals in FY 2002-3 Local Crisis Response Teams/Emergency Service Coordination: Budget: $148,000 Capacity: No actual limits Served 172 individuals in FY 2002-3

Describe the operational components of your initiative:

Homeward Bound: Homeward Bound is an inpatient psychiatric program at Regional West Medical Center in Scottsbluff, Nebraska. Homeward Bound provides services to individuals committed by a Mental Health Board for inpatient psychiatric treatment. With an LOS of 28 days, Homeward Bound works intensively with community-based agencies to develop a discharge plan that will allow the client to transition successfully to independent life in the community and prevent recidivism. A significant component of this program is the use of Emergency Community Support Specialists. Emergency Community Support Specialists initiate a relationship with the client as soon as possible after the initial crisis, work with the client throughout their hospitalization, then follow them closely for 120 days after discharge. Local Crisis Response Teams/Emergency Community Support: Local Crisis Response Teams respond to individuals at the time of crisis. Working closely with law enforcement, hospital ER staff, EMS and other community entities, they attempt to provide immediate services so as to resolve the crisis without the need for emergency protective custody or an inappropriate high level of care outside the home community. Members of the Local Crisis Response Teams refer to Emergency Community Support for immediate and longer-term follow-up.

Describe your initiative's staffing level:

Homeward Bound: No additional staff; utilize the existing staff of the Regional West Medical Center's Behavioral Health inpatient unit. Local Crisis Response Teams/Emergency Community Support: 1 - Regional Emergency Service Coordinator (funded through other resources) Team Emergency Service Coordinators: 3 Team Members: Approximately 13 (part-time, working on an on-call basis) Emergency Community Support Specialists: 5 (each working as a 0.5 FTE)

If applicable, please describe your strategic use of an information system:

None at this time. We are in the process of developing a Service Point information network.

Please list the major, time-framed, measurable objectives your initiative is designed to achieve:

1) Decrease the number of EPCs by 20% for FY 2003-4. 2) Decrease the number of patient days in inpatient care by 20% for FY 2003-4. 3) Decrease the number of individuals re-EPC'd by 20% for FY 2003-4. 4) Decrease the number of individuals re-committed to inpatient hospital care by 20% for FY 2003-4.
Category: Measurable Results

Which of the following results can be attributed to your program initiative? Please check all that apply.

Coordinated System of Care Savings
Reduction of ER usage for non-urgent care
Savings from operational improvements within integrated system
Increasing awareness of programs and services
Services brought into the community
Pharmaceuticals acquired on behalf of clients
Improved health status
Improved productivity
Social justice implications
Increased attendance at work
Increased attendance at school

Please list any other actual, measurable results of your initiative:

1)Number of individuals placed in Emergency Protective Custody decreased by 33% since FY 2002. 2)Number of inpatient days decreased by 47% since FY. 2002. 3)Recidivism decreased to 11%. 4)Approximately $1 million in county and state funds saved in FY 2002-3.
Category: Your ROCI Strategy

How do you define ROCI?

I define ROCI as the following process: 1) Defining specific needs and strategies for meeting those needs through extensive dialogue with the community. 2) Finding funding and developing programming that will meet the need identified 3) Planning for sustainability at the outset of the project through a thoughtful and detailed business plan 5) Providing excellent services that the community values and would want to continue and build 6) Collecting data to substantiate success 7) Correlating clinical data with financial goals - money saved, earned or wisely invested 8) Identifying key people who can assist in developing sustainability 9) Communicating success, data, objectives met to key people and community as a whole 10) Developing collaborative relationships with other resources so as to synergize services and funds 11) Blending multiple funding streams - not having all one's eggs in one basket

Describe your ROCI objectives and strategy:

1) Extensive dialogue with involved communities, resource agencies and state leadership occurred to determine the need for local crisis response teams, emergency service coordination and local committed inpatient treatment. 2) Much lobbying was done to obtain funding for these projects through multiple funding streams, including state funds, HCAP, and Excellence in Health Care Cash Grant and tobacco funds. 3) The projects were developed involving collaboration between a variety of agencies. 4) Excellent service and training was provided, and scrupulous data was collected to substantiate this. 5) Information about our projects were widely disseminated through a variety of means, including television and print media. 6) When Nebraska began contemplating state-wide behavioral health care reform, efforts to disseminate information were intensified and conversations were held with state leaders, including legislators, Health and Human Services, Medicaid and the governor. 7) Data was shared showing positive results and cost-savings. 8)Other Regions of the state asked for and received training to develop similar programs in their areas. 9) Homeward Bound, local crisis response teams and emergency service coordination became recognized as models to be replicated state-wide. 10) The necessary funding for maintaining and enhancing our programs was assured through state funding for existing programs and behavioral health care reform.

Describe the players involved in the ROCI conversation (by title and/or function):

Region I Mental Health/Substance Abuse Administration Consumers Regional Program Director County Commissioners Region I Mental Health/Substance Administration Emergency Services Coordinator Regional West Medical Center Behavioral Health Directors - administrative, clinical, and medical Health and Human Services administrative personnel Panhandle Partnership members Chairman, Nebraska Unicameral Health and Human Services Committee Police Chiefs, Sheriffs, County Attorneys from involved areas Hospital Administrators and Nursing Directors from involved hospitals Mental Health and Substance Abuse Services Providers Governor of Nebraska

List the milestones in your ROCI strategy that pertain to deal making (a prospective approach):

1)Proposal linking sustainability directly to outcomes and cost-savings 2) Collecting data that could prove our ability to improve services and provide cost-savings in comparison to past practices and other areas 3) Developing a positive relationship with law enforcement, mental health boards and primary care services 4) Receiving attention from the media 5) Having the opportunity to speak directly with state leadership through meetings and legislative hearings 6) Being invited to participate in state-wide behavioral health care reform

List the milestones in your ROCI strategy that are tied to outcomes (a retrospective approach):

1)Number of consumers served 2)Data illustrating: - decreased EPC's - decreased numbers of persons in expensive, higher levels of care - decreased recidivism - decreased need for law enforcement involvement and transport - decreased length of stay in inpatient care - decreased dependence on state regional hospitals - decreased usage of costly and unnecessary ancillary services 3) Ability to demonstrate significant cost-savings 4) Formation of new programs. linkages and collaborations that ultimately improved services and saved additional state funds

List the milestones in your ROCI strategy that are linked to sustainability:

1) See above 2) Having other Regions, areas and agencies contact us for training and begin to copy our programs 3) Demonstrating to the legislature that our programs could be a vital piece of the plan to reform behavioral health services - receiving direct legislative approval for carve-out funding 3) Having positions we created given state service definitions by Health and Human Services, and having a state-wide committee formed to study ways of expanding these positions and the services they provide 4) Receiving endorsement from County Commissioners for continued funding 5) Having provider agencies, local colleges and county entities agree to help shoulder the cost of additional and ongoing training 6) Inextricably linking a program that could receive additional funding to a program that definitely would receive additional funding 7)By using leverage, got a great deal of services out of a small initial investment
Category: Your ROCI Methodology

Describe the analytic or economic logic underlying your ROCI method:

No specific logic model used.

Is your method supported by scientific research? If yes, please describe:

Yes - I did an exhaustive review of the psychiatric, community mental health and law enforcement literature on the following topics: 1) Crisis response/intervention 2) Suicidology 3) Risk assessment 4) Emergency psychiatric care 5) Law enforcement involvement/training in mental health 6) Crisis prevention 7) Community transition 8) Community wrap-around services 9) Psychiatric sub-acute inpatient care 10) Behavioral health care reform All of the programming, training, assessment/intervention practices, and documentation tools we use are based on established best practices described in the professional literature. As well as a search of the scientific literature, I also conducted a search for communities and agencies across the country providing similar services. I contacted a number of these entities, and received valuable information. I also spent time doing ''ride-alongs'' with police officers to observe first-hand the situations they encountered and how they managed them. Finally, I made myself thoroughly familiar with the Nebraska statutes related to emergency mental health care, problems related to emergency mental health care being dealt with by state leadership, state financial goals, and the governor's priorities.

Describe the measures that you used to define "returns" or value:

1)Customer satisfaction - demonstrated improved quality of life for individuals being served. 2) Numbers of persons served 3)Reduction in the number of emergency protective custody situations throughout our Region. 4)Decreased inappropriate utilization of costly levels of care 5) Decreased inpatient length of stay 6) Decreased recidivism 7) Increased utilization of our services by law enforcement 8) Increased collaboration with law enforcement, mental health and substance abuse care providers, and local social service agencies 9) Satisfaction expressed by collateral customers within the community, demonstrating that needs were being addressed in the manner expected 10) Cost-savings to the state, counties and agencies involved

Describe the measures that you used to define investments or costs:

1)Miscellaneous start-up costs - use of facilities, equipment, supplies, transportation 2) Planning time; meetings with communities and stakeholders 3) Administrative time 4) Training 5) Staff salaries - paid as fee-for-service 6) Flex funds to assist clients with procuring housing, medications, food, transportation, etc.

Please briefly describe your data collection methods.

Each team or program is required to collect monthly data related to numbers of contacts, types of contacts, outcome of contacts, history of past contacts, referrals received and made, interventions used, mental health board commitments, length of stay in different levels of care, ER utilization, law enforcement involvement, involvement of local mental health/substance abuse/social service agencies, clinical characteristics, outcomes, customer satisfaction responses and quality improvement indicators. This information is sent to the Region I Mental Health/Substance Abuse Emergency Services Coordinator, who compiles the data and translates pertinent information into cost savings and goal attainment percentages. This information is then reported to Health and Human Services, Governing and Advisory boards, participating providers and Partnership members, law enforcement agencies and anyone else in the community who requests it.
Category: ROCI Communication and Negotiation

Describe the conversations that define your ROCI process:

We believe that it is important to start this at the earliest stages and planning. Our conversations began before we even had our initial funding, and included meetings with every stakeholder we could identify. The initial buy-in was necessary to set the stage for future conversations. As our projects progressed, we presented data to our governing board (made up of commissioners from every county in our Region), advisory board, network providers, law enforcement, Health and Human Services leadership and state government leadership. We presented our data at state and national conferences, ''town meetings'', and congressional hearings. We prepared press releases and provided television interviews. We also prepared numerous information packets for Governor Johans and his staff, and the legislators on the Health and Human Services Committee. Over time, we became recognized as the ''gurus'' of emergency behavioral health care and were invited to consult with other parts of the state eager to improve their services. Finally, we took care to gain a front-seat role in the process of behavioral health care reform. By that point we had strong, consolidated support from stakeholders in our own area who were willing to speak up for continued and increased funding. This, combined with recognition from the Governor, the legislature and HHS, assured continued funding. We were able to carve out nearly $400,000 in funding at a time when Nebraska was experiencing a huge budgetary shortfall.

Describe how ROCI conversations are tailored to specific audiences:

It is important to remember each group's focus, and where their ''heart'' is. For instance, when dealing with professional clinical staff, it is important to emphasize client outcomes such as harm reduction and symptom stabilization. Community groups are more interested in issues related to individual and community-wide quality of life. With state government leaders, cost-saving data is critical. If necessary, one should learn as much as possible about the prospective audience before approaching them. This has been particularly true for the law enforcement audience. I spent a lot of time ''learning their language'' before ever approaching them about our programs. I also studied a situation involving another agency that was not successful, and made certain not to repeat those mistakes.

Describe what enabled effective conversations to occur:

1)Developing collaborative, trusting relationships first 2)Making certain there was equal consideration on all sides - giving entities what they needed from us in order to win their support 3)Identifying the agendas of various key individuals and focusing on ways our programs supported those agendas. For instance, it is critical for proponents of behavioral health care reform legislation to win the support of law enforcement. We made an effort to bring law enforcement from our area to the table and show how they could be positively involved in behavioral health care reform. 4) Being very flexible in our communication methods 5) Being proactive in holding ''Community Forums'' 5) Having solid data to back up our claims and requests for more funding 6) Being willing to negotiate and compromise
Category: Results from the ROCI Process

Describe the outcomes, the successes of your ROCI strategy:

1) We have been able to ensure the continued funding of the Homeward Bound Program. 2) We have been able to secure rate increases for the Homeward Bound program. 3) We have been able to sustain continued funding for the local crisis response teams 4) We will receive funding to add another local crisis response team in 7/04. 5) We have been able to sustain continued funding for emergency service coordination. 6) We will be able to add at least one additional community support worker in 7/04. 7) We will receive funding for a new related service, psych crisis respite, beginning 7/04
Category: Lessons

What do you see as the critical success factors that can guide others?

1)Placing a very high priority on relationship-building and communication - be flexible and creative 2)Learning what is most important to key decision-makers involved in funding decisions and collecting data that will support their goals 3)Being scrupulous in collecting as much as data as possible and openly sharing that with others 4)Make certain clinical data reflects clinical excellence 5)Leveraging resources so as to achieve the most possible out of the initial investment 6) Developing programs that others want to replicate 7) Becoming integrally involved in larger initiatives 8) Being proactive with government leaders and/or the leadership of major funding sources

Do you believe that your results can be replicated successfully with other similar initiatives? Can you suggest how replication may be facilitated?

Yes, I do believe our results could be replicated successfully with other similar initiatives. We are already preparing to do that with other projects in our area, and have assisted two other Regions with starting similar initiatives. We are more than happy to provide consultation to anyone requesting it, and others are welcome to visit us and observe our projects first-hand.
Category: Share Your Resources

Resource Files you've shared with us:

Region I Local Crisis Response Team Info for Governor.doc
LCRT Training Data 703.doc