Long Term Care Services: Accomplishments

WHAT WERE THE ACCOMPLISHMENTS OF LONG TERM CARE SERVICES (LTCS) OVER THE LAST FEW YEARS?

ALL STATE HOSPITALS:

All four state hospitals are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and were successfully surveyed under the JCAHO Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services.

LTCS successfully sited and started construction of a new state hospital in the City of Coalinga.

In November 1998, LTCS published the first Best Practices Catalog as part of the Division’s Excellence Project. The catalog is updated annually. This is an effective management tool for communication of successful management practices and treatment programs. Best practices are regularly highlighted in system-wide conferences and meetings.

For years 1999-2003, 37 state hospital staff members received the Governor’s Safety Award. In 2002, 115 state hospital and headquarters staff received Sustained Superior Accomplishment Awards. In addition, DMH was recognized for the greatest improvement in managing workers’ compensation costs during FY 2000-2001.

With cooperation from the Department of Health Services (DHS), all state hospitals have temporarily added beds to their licensed capacities. This will assist with population management efforts until Coalinga State Hospital is activated.

Security Reports, authored by the California State Auditor in March 1998 and by
Jay Farbstein and Associates in December 1999, regarding security of state hospitals emphasized that internal and external audits should be performed at the hospitals to evaluate security policies and procedures, assess current physical security, and identify security issues for future consideration. The LTCS formed a Security Committee that was charged with creating a protocol and audit tool for the purpose of conducting internal and external state hospital security audits with existing staff and resources. The Committee was made up of state hospital and headquarters personnel. A protocol and audit tool was developed for use by the statewide LTCS audit team from the state hospitals and headquarters. These staff were trained to conduct annual audits of internal and external security of the state hospitals.

The patients’ rights identified in Section 5325 of the Welfare and Institutions Code were expressly designed for and apply only to persons involuntarily detained for evaluation and/or treatment under the provisions of the Lanterman Petris Short (LPS) Act or voluntarily admitted for psychiatric evaluation or treatment to any mental health facility. The LPS patients’ rights are appropriate and adequate for the LPS population residing in state hospitals and community mental health facilities. There are no distinct patients’ rights in statute for the non-LPS patients in the state hospitals and other DMH administered programs. Non-LPS patients require special consideration related to patients’ rights in order to accommodate and ensure the safety and security of the institution, staff, other patients and the public. While rights have been administratively implemented for non-LPS patients to meet the existing safety and security needs of the facility and public safety, such administrative policies are subject to challenge and litigation and need to be formalized in regulations. These regulations accomplish several objectives: clarify what matters are properly patients' rights issues for non-LPS patients; allow patients' rights issues to be reviewed and addressed by patients' rights advocates while referring other complaints and grievances to hospital/facility management for review and resolution; and, allow patients' rights advocates to perform their jobs more efficiently while reducing confusion and litigation related to alleged patients' rights violations. These regulations have been approved by the Office of Administrative Law and have been implemented at each state hospital upon completion of training for patients and staff.

Atascadero State Hospital:

Construction of a 258-bed addition at Atascadero State Hospital (ASH) was completed in September 2002. These were the first new state hospital beds added since the 1950’s.

The ASH Clinical Safety Project (CSP) is an internal applied research program that has as its focus the monitoring and prevention of inpatient violence and staff-patient boundary violations. In the past year the CSP produced four hospital-wide events for staff and patients entitled, “A Celebration of a Season of Non Violence”. These events showcased the work of the patient government “Violence Abatement Committee” and provided the units with several patient-developed models including the use of Therapeutic Community Meetings to reduce inpatient violence. ASH held a highly successful Verbal Respect poster contest for patients and contributed to the hospital’s new Verbal Behavior Report system. The CSP is working on final edits of a patient orientation video designed to dispel the prison culture and assist new patients in making the transition from prison to hospital. ASH has developed and provided a Relationship Security (RS) AB 409 Program (Basic Supervision for New Supervisors) and an RS handbook for supervisors to assist them to effectively manage the risks associated with helping boundaries. The work of the CSP has been presented at several national conferences this past year and has contributed articles in several publications.

ASH was the recipient in 1998 of the “Ernest A. Codman Award” from the Joint Commission on Accreditation of Healthcare Organizations. This award is given to recognize excellence in the use of performance measures to achieve healthcare quality improvement.

Over 200 clinicians attended a two-day training session at ASH presented by Dr. Karl Hansen, a research psychologist with the Canadian Department of the Solicitor General. Dr. Hansen presented research findings with respect to assessing the future risk of sex offenders. This training was pertinent to the further refinement of Sexually Violent Predator (SVP) clinical evaluations and treatment of the growing population of SVP commitments at ASH. The audience included ASH clinical staff and private contractor SVP evaluators.

Coalinga State Hospital:

Coalinga State Hospital (CSH) is presently under construction and is scheduled to open by March 2006. This is a 1,500-bed facility designed to house and treat SVP commitments. At full capacity it will employ over 2,400 staff.

In July 2001, CSH activation staff partnered with West Hills College to establish a new Psychiatric Technician (PT) Training Program for the new facility in Coalinga. The first class started in September 2001.

In early 2002, the Governor announced his Nurse Workforce Initiative that provided $6 million for the DMH Central Valley Careers Training Initiative (CVHCTI). The focus of the CVHCTI is to train additional nurses, PT’s and other healthcare workers in the Central Valley locale where CSH is scheduled to open in May 2005. The CVHCTI, under the leadership of West Hills Community College, is making steady progress towards increasing the numbers of healthcare workers being trained. The West Hills PT program has now tripled its capacity from one class to three classes each year. In May 2003, the college also received the initial approval from the Board of Vocational Nursing & Psychiatric Technicians to increase class capacity from 45 to 60 students per trimester class. West Hills Community College also opened a Registered Nurse (RN) program at the Lemoore campus. West Hills, Porterville and Delano Community Colleges will partner with Bakersfield Community College, becoming satellite class locations under Bakersfield’s existing two-year RN training program. Under this regional collaborative nursing education program, each associated Community College will be able to admit 10 RN students per semester. Collectively this would allow for an additional 60 RN student admissions each year.

A CSH activation team of administrative, personnel and support staff has been hired. These staff have prioritized their focus to include community outreach, working with Pleasant Valley State Prison regarding shared services agreements (perimeter security, patient escort and transportation, fire protection, etc), establishing staff recruitment activities for workforce development needs, equipment and supplies procurement and establishing required policies and procedures. In May 2004, hiring will begin for administrative department and support staff such as Information Technology, Personnel Services, Accounting, Police Services, Pharmacy, Health & Safety, Training, Standards Compliance, Procurement, and Plant Operations staff. These staff will be developing the basic infrastructure that is needed to meet DHS licensing regulations and facility operational needs prior to opening and receiving patients. This core staff will also be heavily involved in recruitment activities to ensure that adequate staff is available to open the hospital in May 2005.

Metropolitan State Hospital:

Metropolitan State Hospital (MSH) recently adopted the Psycho-Social Recovery Model (PSR) as the basis for all treatment throughout the hospital. PSR is wellness based and strength oriented. It focuses on individuals not on illnesses or symptoms, and it is founded on the belief that the individuals we serve can, with the proper interventions, develop the skills necessary to lead happier and more productive lives. As a part of the implementation of the PSR model, MSH is developing treatment malls in order to maximize the diversity, quality, and quantity of treatment offered to all of the individuals we serve. A treatment mall is a centralized area where patients and staff from multiple units come together to receive and to provide services. The treatment mall is similar to a retail mall with many choices for the consumers. However, instead of many different stores catering to retail consumers needs, the treatment malls offer many different educational and therapeutic groups catering to the needs of the patients of the hospital. The use of treatment malls helps to insure that each patient will receive intensive (approximately four hours per day, five days per week) individualized services to promote their increased wellness and their ability to thrive in the world. All decisions regarding what is offered on each mall are driven by the needs of the patients.

The new California Youth Authority (CYA)/DMH Intermediate Care Program will reside at the Southern Youth Correctional Reception Center and Clinic (SYCRCC) in Norwalk. This DMH run psychiatric treatment program will be operated by MSH and will serve 20 wards/patients needing short term, intensive psychiatric services from an interdisciplinary treatment team. The program will be licensed and accredited, and will provide rapid stabilization and return to a normal level of functioning for that individual. Interventions will be provided within the framework of Psychosocial Rehabilitation, and will include individual and group therapy, educational and other mandated services. Wards/patients will remain in the program for 90 to 120 days and then return to a lower level of care within the CYA system. The facility has an anticipated intermediate care licensure date of January 2004. DMH assumed operation of the Correctional Treatment Center (CTC) at SYCRCC for CYA effective October 1, 2003 and will operate under the CTC license until the program is converted to an ICF license.

The playground for the Child and Adolescent Program was completed in August 1999. The first event was a Summer Games and BBQ hosted by the Marines and Friends, a volunteer organization. The playground has been utilized by the Program to support a variety of events.

In July 2000, the Child and Adolescent Program, with the assistance of the County Steering Advisory Committee, designed and opened a new Youth Coed Transitional Unit to meet the needs of high risk youth transitioning into the community. The program focuses on life skills, vocational opportunities and intensified discharge preparation for its higher functioning coed youth population.

The Foster Grandparent Program started on April 1, 1999, with 9 foster grandparents. Today, the Child and Adolescent Program has 20 foster grandparents. Foster grandparents serve 20 hours a week providing mentoring, tutoring and emotional support in the classrooms and on the units. The children have demonstrated improved academic skills and social behaviors on the units and in the classrooms as a result of the grandparents’ involvement. The grandparents benefit by their increased socialization and feeling healthier, accomplished, loved and needed.

MSH opened a Work Training Center that includes a Bike Repair Program and a “Twice Treasured” Retail Training Program. The bike repair component provides comprehensive vocational education in the care, maintenance and repair of different types of bicycles to the children in Program I. The “Twice Treasured” Retail Training Program offers retail sales instruction through on-the-job training. The skills taught to the patients include conducting inventory, creating displays, pricing items, maintaining a retail environment, and appropriate retail dress and demeanor. Activities take place in a mock retail store co-located next to the Bike Repair Program in the Work Training Center. The program provides industrial therapy employment opportunities for LPS patients throughout the hospital.

Opened in 2000, MSH’s “Fertile Ground Nursery” is comprised of a shade house, greenhouse and full-sun growing area which acts as the hub for horticulture activities throughout the hospital and is the site for vocational education in horticulture for LPS patients. It also supports the MSH Grounds Department by maintaining plant stock utilized in landscaping throughout the hospital. The program of horticulture instruction for patients in the forensic compound has literally transformed the face of the forensic compound grounds. Patients maintain the grounds in conjunction with their educational and employment activities. Patients who complete the 16-week vocational education course may be assigned to one of several work crews and receive compensation for attending to the compound’s landscaping needs.

Napa State Hospital:

Napa State Hospital (NSH) has incorporated patients as participants on 14 different operational committees. To assist in the overall success of the patient serving as a committee member and the outcome of the committees, the Client Advisory Council members and patients who participate on hospital committees have received the same team building/problem solving/negotiation training as the hospital staff.

The NSH Forensic Training Project secured the services of Richard Yarvis, M.D., M.P.H., former Chief, Division of Forensic Psychiatry, University of California, Davis, School of Medicine, to provide specialized training to the staff. This four track forensic training project addresses therapeutic culture, safety and security, boundaries, violence, malingering, clinical treatment issues, understanding criminality, institutional liability, and more complex treatment and legal issues. Different tracks target the learning needs of non-clinical staff, hospital police, unit staff and advanced clinical staff.

NSH developed a program to increase functional range of motion for older patients and stop the progression of immobility in our most debilitated patients. The program established a Mobility Enhancement Team that develops and implements individualized mobility enhancement plans to address the specific needs of each patient. The development of the team to specifically focus on mobility issues of the patients has led unit-nursing staff to increase their focus and attention on providing nursing care, which has improved the overall quality of care on the unit.

NSH has implemented a screening procedure in all forensic programs to facilitate early identification of patients who have Language/Learning Disabilities, Attention Deficit Disorder, and/or Traumatic Brain Injury difficulties. Patients identified have new curriculum options that include strategies to self-determination skills, and offer higher level, language-based training with specific transition skills.

Identifying a need for additional substance abuse treatment services, the hospital opened an additional off-unit treatment site, Substance Abuse Focused Education (SAFE). SAFE provides an alternative program for patients to receive treatment and education about substance abuse through the use of modules that vary from two to six weeks. SAFE is a multidimensional program which integrates a variety of therapeutic methods and teaching techniques to assist patients in understanding and recognizing the impact that substance abuse has had on their lives and provides them with the necessary skills for a healthier lifestyle.

The Psychiatric Technician Training Candidate (PTTC) program offers limited term entry-level positions for people who want to become licensed Psychiatric Technicians. The objective of this program is to prepare selected employees for entrance into a Psychiatric Technician program at the end of the six-month term. The program offers courses to prepare the PTTC’s as certified nurse assistants as well as training as a Psychiatric Technician Assistant (PTA). Hospital Nursing Instructors offer tutoring and mentoring in various subjects to prepare the employee for college courses, as well as math and english placement testing.

A Client Positive Recognition event was established in 1999 as a formal method of recognizing individual patient achievement. A patient must achieve specific criteria to be nominated and recognized. The Client Advisory Council reviews all recommendations and votes for three patients to be recognized Hospital wide. They are presented a Certificate of Achievement and a gift certificate from the Executive Director at the Client Positive Recognition awards ceremony that is held quarterly.

Patton State Hospital:

At Patton State Hospital (PSH), Unit 35 was reorganized to provide specialized treatment for sex offenders that prepares the patients for discharge to the Conditional Release Program (CONREP) or the community while optimizing public safety. The program utilizes cognitive-behavioral treatment for sex offenders based on a Relapse Prevention model with five phases. This unit fills the treatment gap for patients who have a history of sex crimes but are not committed as sexually violent predators.

On April 11, 2000, PSH opened the Wellness/No Smoking Unit to provide for those patients who choose to live in a smoke free environment and participate in an active Smoking Cessation Program.

The Public Health Department at PSH, with input from the Department of Medicine, was successful in implementing the Hepatitis-C Screening and Management Program. The essential strategy of the program includes the primary prevention activities of screening of patients upon admission and annually and risk-reduction counseling. All RN case managers and physicians receive Hepatitis-C training in order to provide on-going counseling to patients.

In September of 2000, PSH started the Match-2 Prisoner Outreach Program (M-2), which provides caring friends for Patton's forgotten patients. During the programs' first eight months more than 25 volunteers were recruited and became regular visitors and friends to Patton's patients. The M-2 Program is coordinated through the Volunteer Coordinator at Patton. M-2 is for Patton patients who have less than three visitors per year. Documented research reveals that for those patients/inmates who have participated in the M-2 program for 12 months, 7 out of 10 patients/inmates do not return to prison after 1 year and 6 out of 10 remain out of prison after 2 years.

Salinas Valley Psychiatric Program:

DMH staff worked with California Department of Corrections (CDC) staff to design and implement an inpatient mental health program on the grounds of Salinas Valley State Prison for the highest security/custody CDC inmates. This program was licensed in May 2003 and admitted the first patients on June 2, 2003.

Vacaville Psychiatric Program:

The Acute Psychiatric Program (APP) designed and implemented a competency restoration program on Unit S-1 for inmate-patients who have been found incompetent to stand trial on charges brought against them during their incarceration at Pelican Bay State Prison or Corcoran State Prison. The treatment program includes a security risk evaluation, stabilization of psychiatric symptoms, competency assessment, psycho-educational competency restoration training, and a mock trial process. The program successfully addresses the unique treatment needs this population presents, including comprehensive assessment, security issues, and understanding the impact that trial and possible conviction may have on an already incarcerated individual.

The APP has successfully implemented an Integrated Clinical Evaluation and Treatment Planning process whereby each member of the treatment team assumes a leadership role for an individual patient’s care. Assessment processes are streamlined and conducted in a more efficient manner that allows clinicians to maximize the treatment they can provide to the patient population.

The Vacaville Psychiatric Program has reorganized its APP into the following units: Admissions, Major Mental Disorder (Axis I), and Behavioral (Axis II). These patients tend to have a high number of readmissions and dominate the attention of the treatment team due to their behavioral issues. This will ensure the effective utilization of these beds and provide more focused treatment for rapid stabilization of patients.

FORENSIC SERVICES:

During the last two years, CONREP-Operations developed the Risk Assessment Protocol for assessing violent re-offense risk in forensic patients. DMH CONREP Operations continues to train clinical service providers in the implementation and application of the protocol. DMH hosts training sessions using subject experts in the field of risk assessment at the annual meetings of the Forensic Mental Health Association of California in order to provide the highest quality and most current services available in the area of risk assessment.

CONREP-Operations has continued to expand the intensive residential services available to forensic patients. There are currently 3 programs located throughout the state: 1) Northstar in Stockton; 2) Gateways Satellite in Los Angeles; and, 3) South Point in El Cajon. This program has successfully transitioned selected patients from the state hospital system into supervised community outpatient status by moving patients from an in-hospital environment through these intensive 120-day programs.

Forensic Services worked closely with the Department of Justice (DOJ) to create a database for CONREP patients. The database enables communication to flow between DMH, local law enforcement and DOJ regarding activities of CONREP patients as needed for revocation of conditional release. They also worked co-operatively to develop procedures for the inclusion of the CONREP patient data file into the Supervised Release File. The File, which is maintained by DOJ, is accessed by law enforcement officers on the street, via the computers in their patrol vehicles. Effective on July 1, 2001, the updated File became accessible to law enforcement officers on patrol as well as law enforcement agencies from other states.

In September 2001, CONREP-Operations, in collaboration with Information Technology, upgraded the software and hardware used in the CONREP data system that is used to track patient movement, monitor clinical services provided by contractors, and as an accounting system to track claims for services rendered. The purpose of the upgrade was to facilitate quicker data entry, speed data transmission, and establish uniform specifications and software applications for more efficient PC support and maintenance.

Significant savings were achieved in the Mentally Disordered Offender (MDO) evaluation budget by working with CDC to enhance the MDO screening and review process by adding a secondary level of review. This has resulted in a reduction in the number of evaluations needing to be completed and a reduction in the costs, without compromising public safety.

HOSPITAL OPERATIONS:

In collaboration with the contractor (Office of Patients’ Rights) providing direct patients rights advocacy services in the state hospitals, the patient complaint procedure was revised in 2002 to streamline the process, ensure response by the appropriate entity and enhance the response time. This new process allows the advocate to focus on addressing patients’ rights concerns, allows staff with the appropriate expertise to address non-rights issues and reduces the misconception by many patients that the advocate can prompt change in any or all areas of treatment or hospital operations.

Hospital Operations staff partnered with the Department of Developmental Services (DDS), the California Association of Psychiatric Technicians (CAPT), and Hacienda La Puente Adult Education to develop and fund a Psychiatric Technician (PT) training program. This program provides a career track for Psychiatric Technician Assistants (PTAs) who wish to gain eligibility for licensure as PT’s. The program will also be open community-wide to Licensed Vocational Nurses, Certified Nurse Assistants and others, such as PTAs who have entered state service as Psychiatric Technician Training Candidates (PTTC) through a separate welfare-to-work proposal.

LTCS in coordination with other state agencies and a task force composed of the Peer Self-Advocacy Unit of Protection and Advocacy, Inc., California Network of Mental Health Patients, and Capitol People First, is assisting the California Memorial Project. This project is to help restore dignity to patients who have died in a state institution by identifying the locations of gravesites and the patients who died, conducting research on the records of deaths and burials at the state facilities, developing a protocol for the future interment of patients who die while residing at a state hospital or developmental center, and developing a plan for the restoration of gravesites and cemeteries on state hospital and developmental center grounds.

Hospital Operations staff provide oversight of the energy projects being implemented at various State Hospitals including the approval of the design specifications, submittals (the contractor's choice of what brand of equipment or material that he is proposing to use to meet the conditions of the contract) and Requests for Information generated at the site. When completed in 2004, these energy conservation projects should generate annual savings ranging from $150,000 to $600,000 at each of the hospitals.

SEX OFFENDER COMMITMENT PROGRAM (SOCP):

DMH has held annual training conferences to keep its SVP clinical evaluators apprised of the latest techniques in risk assessment. International presenters have included David Thornton, developer of the STATIC 99 sex offender risk assessment instrument, Karl Hansen, author of several “meta-analyses” describing risk characteristics of sex offenders, and Robert Hare, developer of the Psychopathy Checklist, a widely used instrument for measuring psychopathy.

SOCP presented a workshop to the California District Attorneys Association (CDAA) on the subject of the DMH role in evaluation and treatment of sexually violent predators. Numerous counties have hired deputy district attorneys who now specialize in the SVP civil commitment process. CDAA invited DMH, the Board of Prison Terrms, and the Attorney General’s Office to explain the SVP process. SOCP was able to answer many questions about the initial SVP record review and clinical evaluation process, and the recommitment of SVP’s after a two-year period of treatment in a state hospital. CDAA plans to conduct additional workshops such as this as part of its legal training curricula.