Table of Contents

Commissioners Letter ................................................................................................................... 1 The Current New York State-Operated Mental Health System: Making the Case for Change.......................................................................................................... 7 Regional Centers of Excellence Listening Tour Presentation ..................................................... 15 Regional Centers of Excellence Tour Dates ................................................................................ 35 Regional Plans ............................................................................................................................. 39 Additional Background Forces of Change Challenges and Opportunities for New York State ............................ 49 Be the Change Spotlight Oneida County ......................................................................... 55 Summary of Inpatient Changes ........................................................................................... 57

Western New York Region

Regional Center of Excellence Great Lakes RCE Location Inpatient Services State Operated Community Service Hubs Elmira Rochester Buffalo

Buffalo, NY

Adult, Child, Adolescent

Western New York Forensic Center of Excellence

Rochester, NY

Forensic Adult

Central New York Region

Regional Center of Excellence Empire Upstate RCE Location Inpatient Services State Operated Community Service Hubs Ogdensburg Binghamton Utica Syracuse Statewide Outpatient in Prisons

Syracuse, NY Utica, NY

Adult Child and Adolescent

Central New York Forensic Center of Excellence

Marcy, NY

Forensic Adult, SOMTA

Ogdensburg, NY

SOMTA

Hudson River Region

Regional Center of Excellence Capital District RCE Lower Hudson RCE Location Inpatient Services State Operated Community Service Hubs Albany Orangeburg Middletown Poughkeepsie Westchester County

Albany, NY Orangeburg, NY

Adult Adult, Child, Adolescent

Nathan Kline Research Center of Excellence

Orangeburg, NY

Adult

New York City Region

Regional Center of Excellence Greater New York Childrens RCE Location Bronx, NY Queens, NY Inpatient Services Child, Adolescent Child, Adolescent State Operated Community Service Hubs Bronx Queens Brooklyn Manhattan Dix Hills (Serving Nassau and Suffolk) Bronx Upper Manhattan Brooklyn Staten Island Brooklyn Lower Manhattan Queens Washington Heights

Bronx RCE Brooklyn RCE South Beach RCE

Bronx, NY Brooklyn, NY Staten Island, NY

Adult Adult Adult, Adolescent

Queens RCE New York Psychiatric Institute Research Center of Excellence Manhattan Forensic Center of Excellence

Queens, NY Manhattan, NY

Adult Adult

Wards Island, NY

Forensic Adult

Long Island Region

Regional Center of Excellence Island RCE Location Brentwood, NY Inpatient Services Adult State Operated Community Service Hubs Brentwood (Serving Nassau and Suffolk)

The Current New York State-Operated Mental Health System: Making the Case for Change
The mission of OMH is to promote the mental health of all New Yorkers, with a particular focus on providing hope and recovery for adults with serious mental illness and children with serious emotional disturbance. To achieve this, OMH has a dual role to: 1) set policy and provide funding for community services; and, 2) operate inpatient and outpatient services. The OMH vision has evolved over time to become much more community-oriented and recovery-focused; however, OMHs safety net role as a hospital provider remains premised on a chronic disease and caretaker mentality from centuries past. In any given year, 1 in 4 New York adults have a diagnosable mental disorder; while 1 in 17 have a serious mental illness. In many cases, those with serious mental illness also suffer from a chronic medical condition, such as diabetes, asthma, obesity, or heart disease. Today, the majority of individuals with mental illness choose to access treatment in primary care settings. Approximately 715,000 individuals access care in specialty mental health settings each year. 10,000 of those individuals were served in OMH inpatient hospitals in 2012, which now has a census below 4,000 and once stood at 93,000 in the 1950s. That leaves more than 700,000 New Yorkers being served in the community. Despite significant reforms to become more recovery-oriented, OMH remains overly reliant on extended inpatient hospitalization for those with serious mental illness. This reliance comes at a great cost. Over $1.3 billion per year is spent on OMH hospital treatment and care for 10,000 individuals, while $5.3 billion is spent on mental health care in the community for a population of more than 700,000 people. New Yorks historical choice to maintain 24 State operated hospitals is no longer sustainable.

People Served
OMH hospitals 1% All other settings 99% OMH hospitals 20%

Gross Spending

All other settings 80%

Number of State The undeniable forces of State Population Psychiatric Hospitals healthcare reform; the 18 million 24 Affordable Care Act, Medicaid New York 37 million 5 Redesign, mental health parity, California Texas 25 million 8 and budget demands have laid 10 million 3 the groundwork for a more Michigan 9 million 4 efficient and effective New Jersey consumer-oriented model. The momentum of change cannot be halted and the moral force of recovery cannot be denied. With its transformation completed, our whole New York State mental health system can be equipped to enter the new world of healthcare delivery. The only other option is to avoid change, and fail to be a player on the new healthcare field. In short, OMH resources must be aligned with what is known to promote access, resiliency, and recovery for the majority of people served. Shifting those resources to better support the needs of the majority of people in the community- where they do, will, or should reside. How OMH Inpatient Services Look Today New York State spends one fifth of its overall mental health budget to maintain and operate the States outsized psychiatric hospital system, which has 3 times the number of state-run hospitals compared to the next largest state operated inpatient system OMHs inpatient capacity includes fifteen adult hospitals, four for children, three for forensic populations, and several additional child and forensic units attached to the adult facilities. OMH also operates two sex offender treatment programs, two research institutions, and dozens of community outpatient, residential and care management programs. The size and scale of the OMH physical plant is tremendous, with a capital portfolio of over 830 buildings over 2,300 acres of land (and this only for buildings and land associated with currently operating facilities). In keeping with New Yorks long history of institutional operations, many buildings were built over a century ago, and over 300 OMH facility buildings are over 50 years old. Maintenance and extensive capital repairs are continual challenges and require constant maintenance and major financial commitments. The OMH interest obligations alone for facility capital bonds are over $1 billion and the annual debt repayment averages $230 million, exceeding some State agencies full annual budgets. There are many indications that the safety net identity no longer works. Presently, in OMH operated hospitals, overall census numbers are declining and the hospitals are challenged with treating two very different populations: those persons with short-term stabilization needs and those persons who require longer-term rehabilitation services so they can return to the community. In most adult facilities, census declines are masking actual increases in admissions /discharges for individuals who need acute care and are stabilized within three months. OMHs inpatient services for children and youth also treat significantly different populations, with one sector providing primarily acute care that should be provided in the community, while the other group serves intermediate care needs for children transferred from community hospitals. Both of these populations call for transformation of the mental health system as a whole and to right-size and reform state hospitals in order to prevent disruptive
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admissions, and to create a smooth transition and stability in the community. The remaining inpatient need, which OMH is well positioned to fill, will focus on specialty assessment, treatment, and stabilization - with an emphasis on recovery and return to the community, and making every day matter.

CASE STUDIES FOR CHANGE Adult Long Stays: Many individuals have serious chronic medical conditions in addition to serious mental illness, and may be more appropriately served in supported residential settings with integrated specialty medical and behavioral healthcare. A Gap in Childrens Acute Interventions: In Syracuse, NY the Hutchings Psychiatric Center is the only local hospital with childrens acute mental health capacity despite several community hospitals in the area. Many commercial insurance companies will not pay for Hutchings childrens inpatient services in part due to costs exceeding the norm. As a result, many children in need of acute care must travel great distances to private hospitals with specialized care for serious emotional disturbance.

THE WIDENING GAP BETWEEN CENSUS AND COSTS

Census Trend - All Facilities, 2004-2013

6,000 5,000 Census at SFY End 4,000 3,000 2,000 1,000 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 3,869
Total Adult Forensic Children

5,275

Total facility census has declined over the past decade by over 25%. This has been driven primarily by reductions of adult facility census, which respectively has been driven by a reduction in long stays.

Adult Facility Daily Cost of Services

$900 Average per-person/per-day cost $800 $700 $600 $500 $400 $300 $200 $100 $0 2004 2005 2006 2007 2008 2009 2010 2011 $557 $802

High fixed costs, including administrative overhead, capital maintenance and staffing requirements have increased per diem costs as census has decreased. i

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Who OMH Serves and Where They Are Served: Adult, Children & Youth, and Forensic Facilities Adults OMH currently operates fifteen (15) adult facilities that served 6,500 individuals with a census of 2,869 at the 2012-13 State fiscal year end. ii This represents a continuing census decline over the past five years, due in large part to proactive transition planning, intensive care management, and strong collaboration between facility staff and community providers. Two OMH PCs now operate with a census below 100, even when including the childrens units in the count; the third is just over 100 when the childrens unit is added. iii
OMH Adult Inpatient Facilities (15) Western NY Buffalo Elmira Rochester Central NY Greater Binghamton Hutchings St. Lawrence Hudson River Capital District Rockland Nathan Kline Institute New York City Bronx Creedmoor Kingsboro Manhattan South Beach Psychiatric Institute *Orange indicates adult & child/adolescent combined census under 120 *Blue indicates adult & child/adolescent combined census above 120 *Brown indicates a Research Institute. Psychiatric Institute includes the Washington Heights adult unit. Long Island Pilgrim

Quick Facts: Adult Facilitiesiv

Facilities Census Staff Admissions Average daily cost Median length of stay by census Median length of stay by discharge 15 2,869 9,567 3,889 $802 370 days 72 days

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Children & Youth OMH operates four (4) Childrens Psychiatric Centers (CPC) and six (6) units for children and youth attached to adult facilities, which collectively served 2,038 children with a census of 405 at the 2012-13 State fiscal year end. v
OMH Children & Youth Inpatient Facilities (4) and Units (6) Western NY Western NY CPC Central NY Elmira* Greater Binghamton* Hutchings* Mohawk Valley* St. Lawrence* *Indicates C&Y unit attached to adult facilities Hudson River Rockland CPC New York City NYC Children's Center Bronx Brooklyn Queens South Beach* Long Island Sagamore CPC

Childrens facility census and overall capacity levels have been relatively stable, with only a moderate decline in census and capacity over the past ten years. Meanwhile, admissions to childrens facilities have increased over the past several years, a trend that has been absorbed by the rapid turnaround of capacity: More children are being admitted, for shorter periods of time. Many of the childrens facilities serve primarily acute care functions, similar to a community hospital. A majority of admissions to childrens facilities, in certain regions of the State, are from emergency rooms, signifying a considerable jump from little or no services to extremely intense, high levels of service - and nothing in between. This indicates in part, a deficit in the appropriate community interventions and supports that must be addressed. An improved vision of care for children will establish the appropriate levels of intervention for children and families in the community, so children no longer need to enter institutional settings, often far from home. We should reserve our childrens inpatient facilities for specialty care, while acute interventions become more accessible and integrated into communities across the State.

Quick Facts: Children & Youth Facilities vi

Centers (CPCs) Units Census Staff Admissions Average daily cost Median length of stay by discharges Unit census length of stay <30 days CPC census length of stay <30 days 4 6 405 1,867 1,873 $1,432 32 days 76.5% 20.3%

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Forensics OMH operates three (3) secure forensic psychiatric hospitals, two (2) regional forensic units, and two (2) secure treatment facilities for sex offenders committed under Article 10 of Mental Hygiene Law. Additionally, approximately 600 individuals under forensic status receive psychiatric care in OMH adult facilities under particular circumstances. The forensic facility census (excluding sex offender and civil facilities) at the 2012-13 State fiscal year-end was 654.
Secure Forensic Facilities and Regional Forensic Units Western NY Rochester RFU* Central NY Central NY PC Northeast RFU* *Indicates a Regional Forensic Unit Hudson River Mid-Hudson PC New York City Kirby PC Long Island

Forensic facility census has remained relatively stable over the past ten years, with a moderate downward trend. Overall admissions have been declining more sharply than the small drop in census, which is likely the result of a changing admissions profile: individuals committed to forensic facilities under Correction Law 402 (who typically have shorter lengths of stay) have declined relative to increasing admissions of individuals found incompetent to stand trial with greater lengths of stay. The net result has been a stable census number. Forensic admissions are largely determined by courts, with the general purpose of forensic facilities being specialty treatment for individuals involved in the criminal justice system. Some individuals are treated in these facilities until they are deemed to no longer have a dangerous mental disorder, whereupon they can move to a lower level of care. A second major specialty for these facilities is for the competency restoration and treatment of acute symptoms and stabilization of inmates. An enhanced forensic treatment model will focus on improved forensic evaluations, risk informed treatment and transition planning, specialized programming for difficult-to-treat populations (such as Axis II diagnosed individuals), and greater continuity of care through closer collaboration with community providers. Such evidence-based reforms will allow us to reduce readmissions from the community and to more efficiently assist in the transition of individuals to more appropriate levels of care through effective treatment.

Quick Facts: Forensic Facilitiesvii

Facilities Regional forensic units Total Forensic Facility Census Forensic census all facilities Admissions (forensic facilities only) Average daily cost
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3 2 654 1577 936 $859

DATA CITATIONS
Adult cost data for this chart for quarters ending in December of each year noted. OMH Statistical Tables, Inpatient Census as of week ending March 28, 2013. iii Not all facilities indicated in this table include childrens units, though all with combined census below 120 do. iv Data Note: Data used are not all from the same point in time due to data collection and processing lags between categories. Attempts were made to obtain the most recent data and/or data that could be compared across population categories. Census is as of week ending March 28, 2013. Staffing levels as of March 2012. Cost is for quarter ending 12/31/11. Length of stay by census is for census on 4/1/13. v OMH Statistical Tables, Inpatient Census as of week ending March 28, 2013. vi Data Note: Childrens data used are same point in time as for adults as indicated in endnote iv, with the following exceptions: Cost data is for full fiscal year 2010-11. Length of stay by discharge is for 2012-13 SFY, and length of stay over and under 30 days is for census as of 4/1/12. vii Data Note: Data sources are the same as adult, with the exception of forensic census all facilities which are from 4/1/13. These data do not include commitments pursuant to MHL Article 10.
ii i

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So Whats Next Listening Tour

Date
April 3, 2013 Albany April 9, 2013 Albany

Location
ACL Board Meeting Towne Place Marriott CDPC 75 New Scotland Avenue, Albany Large Auditorium Facility Staff Meeting CDPC Large Auditorium

Time-Frame
1:00 PM-2:30 PM 1:00 PM- 4:00 PM

11:30 AM-12:30 PM

April 10, 2013 CSEA April 15, 2013 Rockland Co.

NYS & CSEA Partnership for Education and Training Corporate Plaza East - Suite 502 240 Washington Ave. Ext. Albany, NY 12203 Nathan Kline Institute 140 Old Orangeburg Road Orangeburg, NY 10962

1:00 PM-4:00 PM

10:00 AM-1:00 PM

Auditorium Facility Staff Meeting Nathan Kline Institute Auditorium Rockland Childrens PC 2 First Avenue Orangeburg, NY 10962 Auditorium Greater Binghamton Health Center 425 Robinson Street Binghamton, NY 13904 Auditorium Facility Staff Meeting Greater Binghamton Health Ctr. Auditorium Hutchings PC 620 Madison Street Syracuse, NY 13210 Auditorium Facility Staff Meeting Hutchings PC Auditorium 1:00 PM-2:00 PM 5:30 PM-8:00 PM

April 18, 2013 Rockland Co. Evening April 22, 2013 Binghamton

1:00 AM- 4:00 PM

11:00 AM-12:00 PM

April 23, 2013 Syracuse

10:00 AM-1:00 PM

2:00 PM-3:00 PM

Date
April 23, 2013 Syracuse Evening April 24, 2013 Western Region

Location
Hutchings PC 620 Madison Street Syracuse, NY 13210 Auditorium Rochester PC 1111 Elmwood Avenue, Bldg 16 Rochester, NY 14620 Auditorium Facility Staff Meeting Rochester PC Auditorium Buffalo PC 400 Forest Avenue, Butler Bldg Buffalo, NY 14213 Auditorium Facility Staff Meeting Buffalo PC Auditorium NYAPRS Hotel Albany CLMHD Holiday Inn Saratoga Pilgrim PC 998 Crooked Hill Road West Brentwood, NY 11717 Rehab Building #102, Auditorium Facility Staff Meeting Pilgrim PC Rehab Building#102, Auditorium OPWDD 75 Morton Street NY, NY 10014 Activities Center Facility Staff Meeting Activities Center

Time-Frame
5:30 PM-8:00 PM

9:00 AM-12:00 PM

8:00 AM-9:00 AM

April 24, 2013 Western Region

2:30 PM-5:30 PM

5:30 PM-6:30 PM

April 25, 2013 Albany April 29, 2013 Saratoga May 2, 2013 Long Island

1:30 PM-2:30 PM 10:45 AM-11:15 AM

1:00 PM-4:00 PM

11:00 AM-12:00 PM 10:00 AM-1:00 PM

May 3, 2013 NYC

2:00 PM-3:00 PM

Date
May 7, 2013 Saratoga ACL Membership Hilton Saratoga

Location

Time-Frame
12:30 PM-2:00 PM

May 8, 2013 Albany Evening

NYS Rehabilitation Association Holiday Inn Saratoga Capital District PC 75 New Scotland Avenue Albany, NY 12208 Large Auditorium PEF 1168-70 Troy Schenectady Road Albany, NY 12212 St. Lawrence PC 1 Chimney Point Drive Ogdensburg, NY Unity Building Facility Staff Meeting May 14, 2013 Unity Building

3:00 PM-4:30 PM

5:30 PM-8:00 PM

May 9, 2013 PEF May 15, 2013 North Country

1:00 PM-4:00 PM

10:00 AM-1:00 PM

5:00 PM-7:30 PM

OMH Regional Centers of Excellence

Many participants in the Office of Mental Healths (OMH) Listening Tour remarked that the decision regarding where to locate the Regional Centers of Excellence (RCE) would be a very difficult one. Indeed it has been. These recommendations have been shaped by forces of reform, an analysis of the current OMH state-operated system, regional health care systems, the unique needs of each region and the extensive feedback OMH received through the Listening Tours held throughout April and May, 2013. The release of this plan marks the start of a multi-year implementation, which will commence in July, 2014. The multi-year plan will result in the creation of 15 RCEs, including three Forensic RCEs and two Research Centers of Excellence. It is important to note that the RCEs will employ State staff who will be assigned to the inpatient program located within the RCE (hospital) or to a variety of community based services that will be located across the region. Community services will have administrative support via hubs located in communities with significant population and historical service use. Facility catchment areas are no longer necessary, and individuals will be free to access RCE care anywhere in the State. Accountability in Implementation Successful change in the state psychiatric system requires an accountable and transparent process. The Medicaid Redesign Team process was highly successful as a tool to build stakeholder involvement while driving needed change. OMH will use this blueprint in the implementation of Regional Centers of Excellence. Teams known as RCE Teams will be established in each of OMH's five regions: Western New York Region; Central New York Region; Hudson River Region; New York City Region; and Long Island Region. Each RCE Team will contribute to the RCE implementation workplan, identify regional priorities for community service expansion, develop regional outcome metrics, and develop alternative use plans for state property in consultation with Regional Economic Development Councils, within the state fiscal plan. Each RCE Team will have shared leadership co-chaired by: an OMH Senior Executive, a County Commissioner of Mental Health/Director of Community Services, and a community representative; all to be appointed by the OMH Commissioner. RCE Teams will have up to 15 members (not including the cochairs) appointed by the Commissioner who represent a wide variety of stakeholder interests in the mental health system. The RCE Teams will begin work no later than August 1, 2013 and must submit their reports with findings and recommendations to the Commissioner and the Statewide RCE Steering Committee by October 1, 2013. If the RCE Team is unable to arrive at a consensus, the Commissioner shall make the final determination of the community-mental health supports to be developed for that region. The co-chairs from each RCE Team will constitute the Statewide RCE Steering Committee with responsibility for assisting the Commissioner with development of a final implementation plan for RCEs, inclusive of each region's plan. The Commissioner will choose RCE Team members among those who express interest in serving in this capacity.

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TABLE: 2017 Full Implementation of Regional Centers of Excellence

Western New York Region

Regional Center of Excellence Great Lakes RCE Location Buffalo Inpatient Services Adult, Child, Adolescent State Operated Community Service Hubs Elmira Rochester Buffalo

Western New York Forensic Center of Excellence

Rochester

Forensic Adult

Central New York Region

Regional Center of Excellence Empire Upstate RCE Location Syracuse Utica Inpatient Services Adult Child and Adolescent State Operated Community Service Hubs Ogdensburg Binghamton Utica Syracuse Statewide Outpatient in Prisons

Central New York Forensic Center of Excellence

Marcy Ogdensburg

Forensic Adult, SOMTA SOMTA

Hudson River Region

Regional Center of Excellence Capital District RCE Lower Hudson RCE Location Albany Orangeburg Inpatient Services Adult Adult, Child, Adolescent State Operated Community Service Hubs Albany Orangeburg Middletown Poughkeepsie Westchester County

Nathan Kline Research Center of Excellence

Orangeburg

Adult

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New York City Region

Regional Center of Excellence Greater New York Childrens RCE Location Bronx Queens Inpatient Services Child, Adolescent Child, Adolescent State Operated Community Service Hubs Bronx Queens Brooklyn Manhattan Dix Hills (Serving Nassau and Suffolk) Bronx Upper Manhattan Brooklyn Staten Island Brooklyn Lower Manhattan Queens Washington Heights

Bronx RCE

Bronx

Adult

Brooklyn RCE South Beach RCE

Brooklyn Staten Island

Adult Adult, Adolescent

Queens RCE New York Psychiatric Institute Research Center of Excellence Manhattan Forensic Center of Excellence

Queens Manhattan

Adult Adult

Wards Island

Forensic Adult

Long Island Region

Regional Center of Excellence Island RCE Location Brentwood Inpatient Services Adult State Operated Community Service Hubs Brentwood (Serving Nassau and Suffolk)

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Western New York

The Western Region, which is bordered by Lake Erie, Lake Ontario, Pennsylvania, Canada and the Niagara River, covers 13,000 square miles and has a population of three million people. Consisting of 19 counties, the region is a mix of urban, suburban and rural communities. The Western Region is also home to the Native American Nations of the Seneca, Tonawanda, and Tuscarora. State Fiscal Year 2014-15: Establish the Great Lakes RCE. Buffalo Psychiatric Center, Western New York Childrens Psychiatric Center and the Elmira Psychiatric Center will be merged into one center known as the Great Lakes RCE. All adult and childrens inpatient capacity will be located at the Great Lakes RCE at 400 Forest Ave, Buffalo, NY. The Great Lakes RCE will have 158 adult inpatient beds, and 36 child and adolescent beds. Rochester PC will begin transforming to a Regional Forensic Center of Excellence, merging adult inpatient capacity with both the Great Lakes RCE in Buffalo and the Empire Upstate RCE in Syracuse; this action is to accommodate expected patient choice in locations for accessing inpatient care. Outpatient and community services currently operated by Buffalo PC, Western New York CPC and Elmira PC will be continued as community hubs of the Great Lakes RCE. In fulfilling the vision to develop a strong network of highly specialized community services, the Great Lakes RCE will look to expand services at these hubs located in Buffalo and Elmira as well as Rochester. Community services will be targeted to individuals with the most complex mental illness and may include mobile treatment, crisis services, respite, mentoring, employment and specialized housing stability supports. The Great Lakes RCE will be positioned as a national leader in providing best practices, research-based care and a broad array of innovative psychiatric and addiction services for children, adolescents, adults, and seniors at every stage of their recovery. The Great Lakes RCE can affiliate with the State University of New York at Buffalos academic medical center, as well as with other colleges and universities in the region. It will be a training site for psychiatric residents, psychology doctoral interns, pharmacy doctoral interns, and will provide advanced training and research opportunities for a wide variety of mental health and related professions.

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State Fiscal Year 2015-16: Expand the Great Lakes RCE to include inpatient and community services for the Greater Rochester area and establish the Western New York Forensic Center of Excellence in Rochester. Rochester PC will continue its transformation to a Regional Forensic Center of Excellence. Adult inpatient and adult and child outpatient and community capacity at Rochester PC will be merged into the Great Lakes RCE. The RCE will then have a total adult inpatient capacity of 208 beds located at the Great Lakes RCE in Buffalo. Community and outpatient services will be operated by the Great Lakes RCE, but will remain in the Rochester area. The Great Lakes RCE will continue to operate community and outpatient services in community hubs located in Erie County, Elmira and Rochester. The Rochester Psychiatric Center campus will be transformed into the Western New York Forensic Center of Excellence operating 55 forensic inpatient beds in 2015-16 and 155 beds by 2016-17.

Central New York

The OMH Central Region consists of 20 counties with a combined population of nearly two million people. This region is bordered by Lake Champlain and Vermont on the east, Canada and the St. Lawrence River on the north, Lake Ontario on the west and the State of Pennsylvania to the south. 17 of the counties are considered rural and 14 of those counties have a population of fewer than 100,000 residents. This region is also home to three Native American Nations (Oneida, Onondaga and St. Regis Mohawk) as well as a very active and growing military base (Fort Drum). State Fiscal Year 2014-15: Establish the Empire Upstate RCE and the Central New York Forensic Center of Excellence. The Greater Binghamton Health Center, Hutchings Psychiatric Center and the Mohawk Valley Psychiatric Center will be merged to form the Empire Upstate RCE, extending from the Pennsylvania State line to the Canadian border. The Empire Upstate RCE will have two inpatient campuses, one serving adults with a capacity of 185 in Syracuse and a second in Utica with a capacity of 75 beds serving children and adolescents. As discussed in the overall plan, the elimination of catchment areas is expected to result in more individuals from the easternmost counties in the North Country choosing to receive inpatient care at the Capital District RCE. In anticipation of this service migration, one adult inpatient ward currently operated at St. Lawrence Psychiatric Center will be moved to the Capital District RCE in 2014-15.

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The RCE will provide a rich network of specialized community services to residents throughout the region when community and outpatient services operated by Binghamton, Hutchings and Mohawk Valley merge into the Empire Upstate RCE. Importantly, community-based services will operate via hubs located in Binghamton, Utica and Syracuse. Community services will be targeted to individuals with the most complex mental illness and may include mobile treatment, crisis services, respite, mentoring, employment and specialized housing stability supports. Empire Upstate RCE will build on the long standing affiliation OMH has enjoyed with SUNY Upstate Medical Universitys Department of Psychiatry for training new psychiatrists in care for both adults of all ages and children. Also, this affiliation provides opportunities for training nurses and social workers through annual rotations and internship programs. In addition, with close proximity to Syracuse University, professional training and research opportunities can be shared. The current Central New York Psychiatric Center will be transitioned to the Central New York Forensic Center of Excellence maintaining its inpatient and outpatient services. State Fiscal Year 2015-16: Expand the Empire Upstate RCE to include inpatient and community services for the North Country. St. Lawrence PC will be merged with the Empire Upstate RCE. Inpatient capacity for children will be expanded by merging child and adolescent inpatient services with a capacity of 90 beds which will be located at the Empire Upstate RCE in Utica. Outpatient and community services currently operated by St. Lawrence PC will be continued as a community hub of the Empire Upstate RCE. In fulfilling the vision to develop a strong network of highly specialized community services, the Empire Upstate RCE will look to expand services at these hubs located in Binghamton, Utica, Syracuse as well as Ogdensburg. Community services will be targeted to individuals with the most complex mental illness and may include mobile treatment, crisis services, respite, mentoring, employment and specialized housing stability supports. The St. Lawrence Psychiatric Center sexual offender program will continue operating in Ogdensburg but will be operated by the Central New York Forensic Center of Excellence.

Hudson River Region

The OMH Hudson River Region consists of 16 counties, representing a total population of 3.4 million people. The region is comprised of a highly concentrated metropolitan area in its southernmost counties, with a less densely populated northern region surrounding the Capital District and the City of Albany.

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State Fiscal Year 2014-15: Establish the Capital District RCE, the Lower Hudson RCE and the Nathan Kline Research Center of Excellence. The Capital District RCE will be created in Albany. This RCE will expand the inpatient capacity available in Albany to 161 beds. This will be accomplished through the relocation of one adult inpatient ward from St. Lawrence PC to accommodate an anticipated increase in the number of North Country residents likely to choose inpatient care in Albany due to the greater ease in traveling via the Adirondack Northway. Albany will also serve as a community hub, providing services for adults and children for the northern part of the Hudson River Region, and beyond as needed. Rockland Psychiatric Center and Rockland Childrens Psychiatric Centers will merge to form the Lower Hudson RCE located in Orangeburg. Inpatient service capacity at the Lower Hudson RCE will stand at 430 for adults and 45 for children and adolescents. Outpatient and community services currently operated by RPC and RCPC will be continued as community hubs of the Lower Hudson RCE. In fulfilling the vision to develop a strong network of high specialized community services, the Lower Hudson RCE will look to expand services at these hubs located in Middletown, Poughkeepsie, Westchester and Orangeburg. Community services will be targeted to individuals with the most complex mental illness and may include mobile treatment, crisis services, respite, mentoring, employment and specialized housing stability supports. OMH will establish the Nathan Kline Institute Research Center of Excellence through conversion of NKI, also in Rockland County, which is closely affiliated with New York University. This facility has earned a national and international reputation for its pioneering contributions in psychiatric research, especially in the areas of psychopharmacological treatments for schizophrenia and major mood disorders, and in the application of computer technology to mental health services. Both the Capital District RCE and Lower Hudson RCE will benefit greatly from previously established academic affiliations with Albany Medical Center, and through a unique academic research collaboration with New York University. There may also be opportunities for collaboration with the nearby Veterans Affairs Hospital in Albany. State Fiscal Years 2015-16 and 2016-17: Continue transition at Lower Hudson RCE. Shift Mid-Hudson Forensic PC capacity to the Western NY Forensic RCE and the Manhattan Forensic RCE. Mid-Hudson Forensic Psychiatric Center currently operates in a facility that is nearing the end of its useful life, with an estimated capital reconstruction cost of $220 million; an option that OMH and the New York State taxpayers cannot afford. To maximize the use of high quality existing space and to provide greater geographic coverage for forensic services, OMH will shift the inpatient capacity from Mid-Hudson to Forensic Centers of Excellence located in Rochester and Manhattan in 2016-17. MidHudson will no longer operate inpatient services. The Rockland PC Residential Care Center for Adults (RCCA) will be converted to two Transitional Placement Programs (TPPs) in 2015-16. Lower Hudson RCE will operate with a capacity of 405 adults at full implementation in 2016-17.

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New York City

* Community hubs will be located throughout the boroughs

New York City consists of five boroughs, each of which is a county of New York State. With a population of approximately 8.3 million individuals within just more than 300 square miles, this is the most densely populated major city in the US. As many as 800 languages are spoken in NYC and 36% of the citys population is foreign-born. State Fiscal Year 2014-15: Establish the Greater New York Childrens RCE, the Bronx RCE, the Brooklyn RCE, the Queens RCE, the South Beach RCE and the New York Psychiatric Institute Research Center of Excellence. The New York City Childrens Center (NYCCC) which involved the merger of the Brooklyn, Bronx and Queens Childrens Psychiatric Centers in 2012-13 was developed ahead of its time. In essence, NYCCC already serves as a RCE for children, by reducing reliance on institutional inpatient care and expanding outpatient services to meet the needs of children and their families in the community. The NYCCC and Sagamore Childrens Psychiatric Center will merge to form the Greater New York Childrens RCE (GNYC RCE) with a total inpatient capacity for children and youth of 172 beds located in Queens and the Bronx. Outpatient and community services currently operated by NYCCPC and Sagamore CPC will be continued as community hubs of the GNYC RCE. In fulfilling the vision to develop a strong network of highly specialized community services, the GNYC RCE will look to expand services at these hubs located in Bronx, Manhattan, Queens, Brooklyn and Dix Hills. Community services will be targeted to individuals with the most complex emotional disturbances and may include mobile treatment, crisis services, respite, mentoring, employment and specialized housing stability supports. Given the population size and the borough-based health care delivery system in New York City, OMH will establish a RCE for adults in each of the outer boroughs of New York City. This will result in the following RCEs being established with the following inpatient capacity for 2014-15: Brooklyn RCE, 140 capacity; Bronx RCE, 156 capacity; Queens RCE, 344 capacity; South Beach (Staten Island) RCE, 300 adult and 12 childrens capacity; and New York Psychiatric Institute Research CE, with a 62 bed capacity. Manhattan Psychiatric Center will begin the transition of adult inpatient and outpatient capacity to other New York City RCEs for adults and begin the transition to a Forensic Center of Excellence.

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To achieve a shift from an over-reliance on inpatient care to community-based care, the newly created RCEs in each outer borough will also serve as hubs for community services throughout each respective borough. Additionally, the Bronx RCE will also serve as a hub of community services for northern Manhattan and South Beach RCE will serve as community hub for lower Manhattan. The RCE Team for this region will consider the unique service needs and assets throughout New York Citys boroughs to develop effective community hubs. In anticipation of developing a Forensic Center of Excellence, Manhattan PC will begin to merge its inpatient capacity to RCEs in other boroughs of New York City, and will have an adult inpatient capacity of 153 beds in 2014-15. OMH will establish a Research Center of Excellence through conversion of the New York State Psychiatric Institute in Manhattan, which is closely affiliated with Columbia University. This facility has an international reputation as a leader in mental health research. New York City RCEs will also continue to strengthen ties with academic institutions throughout the City to train medical professionals in mental health treatment settings and transfer research-driven and evidence based practices to mental health service settings. State Fiscal Year 2015-16: Establish the Manhattan Forensic RCE and expand South Beach RCE, Brooklyn RCE and Queens RCE. Manhattan Psychiatric Center will complete the merger of all adult inpatient capacity to other New York City RCEs for adults and, together with Kirby Forensic PC, begin the transition to the Manhattan Forensic RCE. The Manhattah Forensic RCE will have a capacity of 368 beds located on Wards Island by 2016-17. Brooklyn RCE will have inpatient capacity of 165 beds and Queens RCE will have 394 bed capacity by 2015-16. South Beach RCE will develop further through 2015-16 with a capacity of 275 adult beds beginning in 2016-17.

Long Island

Long Island consists of two counties, Nassau and Suffolk, accounting for 2.8 million people; it is also home to two Native American Nations, the Unkechaug , and the Shinnecock. Nassau County borders
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New York City, and has a highly concentrated population extending to the eastern portions of Suffolk County. There is a great deal of movement between counties on Long Island, and between Long Island and New York City, which has allowed for a highly developed and rich provider network. Its fixed borders have contributed to high urban concentrations in many areas. State Fiscal Year 2014-15: Establish the Island RCE and Combine Childrens Inpatient and Community Services with the Greater New York Childrens RCE. Pilgrim Psychiatric Center will be transitioned to the Island RCE, reducing the historic over-reliance on long term inpatient care with a capacity of 335 beds in 2014-15. This will also involve expansion of services through a community hub in Brentwood to serve Nassau and Suffolk county residents, to build upon the large State/community network established in Long Island in accordance with recommendations from the RCE Team. Pilgrim is well situated as the Island RCE, as it provides a continuum of inpatient and outpatient psychiatric, residential, and related services serving Nassau and Suffolk Counties. All inpatient services currently provided by Sagamore Childrens Psychiatric Center will be merged into the Greater New York Childrens RCE to be located in Queens and the Bronx. Outpatient and community services currently operated by Sagamore CPC will be continued as community hubs of the GNY RCE in Dix Hills. In fulfilling the vision to develop a strong network of highly specialized community services, the GNY RCE will look to expand services at these hubs in Dix Hills, serving Long Island. Community services will be targeted to individuals with the most complex mental illness and may include mobile treatment, crisis services, respite, mentoring, employment and specialized housing stability supports. To further its development, the Island RCE can strengthen its ties with the nearby State University of New York at Stony Brooks Department of Psychiatry to enhance psychiatric training and research opportunities. It will also re-engineer its inpatient programs to provide more short term, state of the art care for complex psychiatric cases with quick discharge to supportive community services where recovery will continue in a person-centered, strength-based environment. State Fiscal Year 2015-16: Continue to develop the Island RCE. Island RCE will expand community services; adult inpatient capacity in Brentwood will be 310 by the end of 2015-16. The RCE Team for Long Island will focus in part on community residential options for the many individuals with chronic medical issues and extended lengths of stay who would be better served in residential settings with integrated physical healthcare and nursing services.

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Forces of Change - Challenges and Opportunities for New York State

We can offer far more to New Yorkers with mental illness by breaking down the walls between facilities and communities, and focusing on collaborative and integrated care that utilizes the strengths of our workforce and those of the community provider system. This contrast is perhaps most evident in looking at those who are served: 717,000 New Yorkers receive mental health services from the public mental health system each year; only 10,000, or 1.4% of those receive care in our state psychiatric centers, while accounting for 20% of OMH spending. While much great work has already been done to make our inpatient facilities more responsive to the needs of all those we serve, we face many additional challenges beyond the day-to-day operation of the largest psychiatric hospital network in the nation. Our entire state and national healthcare delivery system is shifting beneath our feet, and it is our collective obligation to take this opportunity to align state psychiatric services to succeed in this rapidly changing environment. Not only is adapting-tochange a necessary business strategy for any 21st century care provider, but there are many key opportunities and innovations that may - for the first time - allow us to move beyond an acute disease safety-net model, to one truly person-centered and recovery-oriented system of care for all New Yorkers. Oneida Countys response to the closure of two adult wards at the Mohawk Valley Psychiatric Center and the transfer of one ward to Hutchings Psychiatric Center in Syracuse has demonstrated that opportunities often come gift-wrapped as challenges and also that when dedicated state and local professionals work as a team, the end result of their diligence is success. Linda Nelson, Commissioner- Oneida County Department of Mental Health, on the 2012 restructuring of adult inpatient services in the Mohawk Valley

Challenges The challenges in operating and sustaining the current OMH facility system increase with each passing year. While State budget appropriations have remained nearly flat since 2008, operating costs naturally rise due to built-in cost inflators and long-term contractual obligations. This means that each year, reductions in spending on OMH State Operations must occur to avoid cuts to the community. Such State costs include maintenance, rehabilitation, and construction of facilities to maintain hospital accreditation and insure the safety and well-being of staff and individuals served. However, reductions to State Operations have reached a tipping point it is no longer sustainable to operate and maintain state inpatient care in its current form. Every year that true reform and transformation of the State facility system is delayed, even larger out-year budget gaps are created, which then limits our ability to invest more substantively in the mental health system as a whole. As providers, consumers, families, and governments; we are really all in this together.

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Every year that true reform and transformation of the State facility system is delayed, even larger out-year budget gaps are created, which then limits our ability to invest more substantively in the mental health system as a whole.
New York State is also under tremendous pressure to rapidly and radically transform the way we serve people with disabilities of all kinds, in order to comply with the United States Department of Justices enforcement actions pertaining to the Supreme Courts 1999 Olmstead v. L.C. decision. As of April 2013, there were forty-four (44) federal litigation matters in twenty-three (23) different states by the Justice Department to enforce the law that people with disabilities be not only served in the most-integrated setting appropriate, but also that states policy and financing plans promote independence and equal treatment for people with disabilities as a whole. 1 New York is one of those twenty-three (23) states, and as part of a broader strategy, Governor Cuomo created the Olmstead Implementation Cabinet via Executive Order #84 to develop an Olmstead Implementation Plan for the State of New York. Transforming New York States mental health system around the principles of most-integrated-setting services and supports is not only clinically and morally imperative; it is also the law of the land. Challenging the efforts to support independent community living, many New Yorkers with disabilities have been priced out of affordable housing, as fair market rates for studio and one-bedroom apartments have surpassed most SSI recipients entire monthly stipends. While many on SSI cannot afford an $800 per month rent, at what point did it become preferable or acceptable to instead provide these same individuals with housing in a psychiatric institution at a cost of $800 per day? The answer to this question, relating to affordable housing and residential development will factor largely in the effort to transform the State mental health system.

While many on SSI cannot afford an $800 per month rent, at what point did it become preferable or acceptable to instead provide these same individuals with housing in a psychiatric institution at a cost of $800 per day?
A final threat to the sustainability of OMHs institutional footprint is the need for OMH facilities to become financially viable and sustainable as Medicaid Redesign and the Affordable Care Act move individuals with mental illness into managed care plans - a move toward achieving the Triple Aim of better care, better health, and lower costs in health and behavioral healthcare delivery. OMH inpatient facility services will become part of the managed care benefit package for people requiring these levels of care in 2014, but they must offer a value worthy of the price. Unlike the current arrangement in which New York taxpayers continually deficit fund the operating losses incurred by both government and private providers, managed behavioral healthcare will not be expected to pay for care that does not offer sufficient value with the limited dollars that will be available to pay for a beneficiarys care. Under the future capitated payment system, a managed care organization will be allocated a set amount of
1

Bagenstos, S. (2013). Presentation to NYAPRS Executive Seminar, Albany NY, April 25, 2013. 50

funds to provide all health and behavioral health services necessary for each individual for whom they are responsible. As managed care plans will be responsible for securing any services an individual may need, it is unlikely that they or the covered individuals will be able to afford the current price of state facility care for extended periods of time. While it is uncertain whether $800 per day will be the market price for inpatient mental healthcare in the future, it is clearly unlikely that outcome-driven managed care organizations will pay this rate month after month as the State currently does for hundreds of individuals who spend months, if not years in facilities. As we aim to level the playing field, in the mental health services sector, State psychiatric center services will not be exempted from the financial and quality demands of a managed care environment. If world class mental health services are the expectation for the hundreds of thousands of New Yorkers whose lives are touched by mental illness each year, we must find a way to provide such care within the new realities of a rational healthcare financing system.

Opportunities Accountable Care Management and Mental Health Parity While the transition to managed care will apply financial and programmatic pressures in all service sectors, it will now be done so to reward quality care and outcomes. This is an incentive for collaboration rather than isolation; for recovery, rather than service-in-perpetuity. As much as it is a challenge, it is also a great opportunity. In addition to the regulatory flexibility afforded under a managed care waiver, which will allow for the coverage of less conventional non-medical model supports, there will also be clearer lines of accountability for care which will create incentives for managed care entities to coordinate care, and monitor quality and consumer satisfaction. These efforts to create a more accountable and coordinated system of care are underway not only in mental health, but across all health services, including physical health and substance use disorders. Under these new structures, individuals will experience their health care in a whole new way, benefitting from increased communication among health care providers, more seamless referrals, improved access to care, and more effective care coordination and management. The movement to managed behavioral healthcare is not new, nor is it an abrupt shift for New York State. Many behavioral health services have been and currently are managed by traditional managed care organizations, including outpatient mental health and rehabilitation programs. Secondly, OMH, with the Office of Alcoholism and Substance Abuse Services and the Department of Health have been ramping up the management and monitoring of behavioral health treatment and coordination services with Health and Recovery Plans (HARPS)- a multi-phase initiative to prepare individuals with mental health or substance use disorders for transition into a care management environment. The first phase of the initiative has focused both on educating OMH, local governments, providers of mental health services and insurers about the components of high quality managed care for individuals with serious mental illness and substance use disorders; and also on improving coordination among providers of

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physical and behavioral health services. The second phase will involve moving into a risk-based care management environment, set to take place in 2014. Managed behavioral healthcare has also become a more urgent policy matter as New York implements a Health Insurance Exchange pursuant to the Affordable Care Act (ACA), which will provide insurance to an estimated additional 1.7 million New Yorkers through premium subsidies, public insurance expansion, and enrollment assistance. The Exchange is a federally-mandated, standardized marketplace and eligibility clearinghouse for health insurance that will be required under the federal individual mandate for most New Yorkers beginning on January 1, 2014. The Exchange is relevant to mental health service transformation because all Exchange plans are required to offer mental health services at parity - in accordance with New York States Timothys Law and the federal Mental Health Parity and Addiction Equity Act. New York is building a statewide strategy for affordable and accountable managed behavioral healthcare that should benefit all New Yorkers, regardless of the name or logo on their insurance card. Under the ACA, a whole new set of doors are opening that will allow thousands of additional New Yorkers to obtain access to mental health coverage for the first time.

Mental Health Parity

Mental health parity refers to the concept that mental health disorders and the treatments they require should be afforded the same level of coverage and cost-sharing as for physical health. New York State has a State parity law (Timothys Law) which requires coverage for mental health disorders for all commercial group plans, and also sets minimum requirements for such coverage. Consumers are also protected under federal parity laws, which extend even greater protections for policyholders in New York while expanding the reach of both the State and Federal parity requirements to all plans provided under the upcoming Insurance Exchanges. While Parity has advanced access, individuals continue to struggle with the quality and availability of provider networks and service authorization processes.

The movement to full managed care is only one of the broader reform opportunities for addressing prevention, treatment and recovery of mental illness. In fact, there are many initiatives currently in progress or fully implemented at this point, which set the stage and provide a broader community safety-net for the transformation of our mental health system of care and the creation of Regional Centers of Excellence. These include Health Homes which will transform and expand the role of care managers for people with mental illness while integrating physical health treatment and chronic disease management. Also, through the early detection and intervention strategies deployed under the Collaborative Care initiative and Project TEACH, primary care physicians will play a stronger role in helping prevent and manage mental health issues before they become serious and chronic. Through our major efforts to develop and cultivate peer support, employment, and housing, our entire mental health system of care has worked tirelessly to pave the road to recovery and independence for the thousands of people we serve.

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Continuity of Employment and Leveraging the Skills of the OMH Workforce There are many assets within the State operated system upon which Regional Centers of Excellence can be built; including a highly skilled workforce, world-class scientific research, and a service infrastructure that can offer more value to consumers in regionally and locally-integrated settings. OMH employs thousands of direct service and support staff within the twenty-four (24) facilities, and thousands more are serving consumers in community-based clinic, care management, and residential programs across the State. This workforce is skilled, experienced, and diverse - they will be extremely valuable in redirecting service and support resources from facilities into communities to offer all consumers best-in-nation care through a smaller inpatient footprint and a broader community system of care. Additionally, OMHs two world-class research institutions can support these transitions by assisting all programs with the development and implementation of evidence based practices, such as Assertive Community Treatment (ACT), Wellness Self-Management (WSM), and Individual Placement and Support (IPS), to name only a few. While some retraining of the current workforce will be necessary to align the current skill sets to a more community-integrated and recovery-oriented regional system of care, OMH has the technological and scientific resources, along with the motivated workforce to accomplish this goal.

Conclusion It is important to recognize that the forces of change are already well upon us, and the failure to adapt and change ourselves will result in far fewer opportunities to help people with mental illness realize recovery and their potential. With the help of a strong peer and recovery community, people with mental illness are empowering themselves to determine their own fate and path to recovery - in whatever terms they choose. As a State, we have already made many changes to the way we operate and where we make services and supports available, in part because most people do not want to live in large institutions. They want choice and control over where they live, work, socialize, and access services. This lowering of demand for institutional services is also the result of many years of thoughtful planning and policy which has reduced the primary need for institutional care, through the development of local services and supports that help people stay where they are rather than remove them from the community: mobile crisis, peer bridgers, respite services, community support teams, and a range of supportive housing and residential programs. With Regional Centers of Excellence, OMH will further enhance these community networks, while including state facilities and staff in this broader network of care to acknowledge the reality that the majority of individuals impacted by mental illness can pursue recovery effectively in the community. Through the enhancement of initiatives to improve mental health care quality and the provision of
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supports in the community, the reliance on inpatient, specialty care will continue to diminish. New Yorks Regional Centers of Excellence will move our State from the casualty model of mental health care that waits for problems to arise and then offers expensive and extensive treatment in inpatient settings. Instead, mental health care in New York will continue its inexorable evolution toward a more accountable, coordinated, early intervention model that supports people to live successfully in the community through the highest quality mental health care and supports.

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Be the Change Spotlight- Oneida County by Linda Nelson, Commissioner- Oneida County Department of Mental Health Oneida Countys response to the closure of two adult wards at the Mohawk Valley Psychiatric Center and the transfer of one ward to Hutchings Psychiatric Center in Syracuse has demonstrated that opportunities often come gift-wrapped as challenges and also that when dedicated state and local professionals work as a team, the end result of their diligence is success. What has impressed me about the work done by the Oneida County Department of Mental Health and the state Office of Mental Health is the tremendous focus on making this transition work for the people who depend upon the mental health system. What I have seen from their work is that our community has made a very big step in the transformation from the era of institutionalization of patients to a welldeveloped community care system. I know there is always more work to be done, but the work done to date is an outstanding example of service to the community, said Oneida County Executive Anthony J. Picente, Jr. Roughly one year ago, upon learning of the change, Oneida County embraced the opportunity to closely analyze the impact this would have on the continuum of care and the provision of services. We were particularly concerned about the impact on the three area 9.39 hospital inpatient units. We gathered data on admission rates, length of stay and overall occupancy rates. To date, there has been only a slight increase in these areas. We did, however, have several issues to resolve in learning how to better partner with Hutchings given that they were further away and new players and processes were required. The Department of Mental Health continues to facilitate meetings to assist our local hospitals. The overall question that we were forced to tackle initially was; where could we best intervene within the outpatient system to divert patients from long term, expensive hospitalization? With helpful, consistent technical assistance from the OMH Syracuse Field Office, it was determined that there were two points in service delivery where we could make a difference in avoiding emergency room visits and long term inpatient stays. The two points are at the crisis level and the forensic level given that patients who do not receive adequate care end up either in the emergency rooms or in jail. Based on our analysis and data, we proposed that additional funding would be required to meet these shortages that would emerge as a result of the closures. We proposed hiring four additional staff for the Mobile Crisis Assessment Team (MCAT). Expanded coverage at the 911 Emergency Response Center would place a crisis worker there for the majority of hours to be available to the dispatchers and callers to diffuse the situation and determine if law enforcement or the crisis team or both need to be activated. Additional MCAT staff is used to stabilize and prevent crises from re-occurring, provide suicide prevention and intervention and a variety of peer supports. We will measure effectiveness of these efforts and the desired outcomes include: a reduction in the number of individuals re-hospitalized within less than 30 days, improved cross systems response to crises, improved training for crisis responders, and an increase in utilization and compliance with outpatient mental health services. Resources were also allocated to support a transportation program for family members from Oneida County visiting patients at Hutchings Psychiatric Center.
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At the forensic level, we proposed expanding services to support diversion and post-release services and case management within the Utica Mental Health Court. Discharge planning done at Oneida County jail will be followed up by forensic case managers who pick up where the jail discharge planners leave off. We anticipate that this will improve the compliance rate for engagement in community supports, reduce homelessness, reduce recidivism rates and re-involvement with the criminal justice system and reduce emergency and inpatient treatment. These staff are not housed at the jail but in the community. They arrange transportation, home visitations, attend case management consultations with providers and serve as the liaison between providers and mental health staff at the jail and monitor the court process. A specific and specialized Mental Health Court case manager performs assessments, refers accepted candidates to appropriate service providers (including mental health, addictions, housing, medical, financial), develops and implements individualized service plans, attends case consultations, and acts as the liaison with the broader mental health system and Mental Health Court. Additionally, Oneida County will enhance the Adult Single Point of Access and Accountability (ASPOA/A) services to function in a more coordinated, efficient manner which will serve to divert unnecessary referrals to emergency departments and inpatient admissions. We will accomplish this through coordinating and managing related data and developing an integrated database and reporting system to coordinate services based on an analysis of the data. This integrated data set will include the receipts, distributions, openings and closing of over 1,000 referrals annually for care coordination and residential services, approximately 2500 annual hospital admissions and discharges, reports on Mental Hygiene Law 9.41, 9.45 and 2209 custody transports which together totaled over 1433 in 2011. The department is also responsible for the oversight of approximately 20 Assisted Outpatient Treatment referrals, and approximately 55 Criminal Procedure Law 730 examinations annually. This integrated database will provide an accurate view of the service history of the most vulnerable individuals. The county department of mental health will serve as the Hub of critical information to be available to the larger community to coordinate services. The people we serve are those who benefit from these enhancements, which have been funded by the State Office of Mental Health and implemented in a partnership that does not worry about turf, only results. We continue to operationalize the various components as partners. We look forward to measuring the effectiveness of our efforts and will make needed adjustments. What has been developed by the state and the county is a major step forward for not only our agencies, but above all for our communities and the people in them.

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