Region 2 Regional Priority Setting Process

August 2012

Report Prepared By:

Kristie Barber, Executive Director, Region II Regional Mental Health Board Pamela Mautte, Director, Valley Substance Abuse Action Council Marlene McGann, Executive Director, South Central CT Substance Abuse Council Betsey Chadwick, Director, Middlesex County Substance Abuse Action Council

The DMHAS Priority Setting Process or Plan is a coordinated endeavor between the DMHAS planning division and each of the Regional Mental Health Board and the Regional Action Councils. The needs assessment process identifies prevention and treatment trends and needs at the local, regional, and state levels. After the initial few meetings with Al Bidorini, the DMHAS Director of Planning and Development, the above mentioned groups participated in the analysis of the provider survey data then held community forums to engage referral agencies or persons, and members of our regional community. This process enabled us to present the needs of the region to the DMHAS management team. We present a comprehensive analysis of the regions needs and offer recommendations for DMHAS to incorporate into their strategic plan for 2013. A provider survey was developed by the planning division of DMHAS and was the initial focal point for the project. In Region II, 27 surveys were distributed via Survey Monkey, 20 were returned yielding a 74% completion rate. A few hospitals in the region did not respond to the survey, however, there were staff members from a few emergency departments throughout our region that participated in the community forums. In addition to the survey community forums were held in all six catchment areas within our region. The community forums included police department officers, town social service department representatives, advocates, housing authority employees, caseworkers, soup kitchen employees, nurses, doctors, faith based organizations and catchment area council (CAC) members. Also, each CAC discussed the concerns of the area in their individual meetings and gave input for the outreach to the community. The CAC membership includes consumers, concerned citizens and providers of mental health and addiction services. The 36 towns in our region that are represented are: Ansonia, Bethany, Branford, Chester, Clinton, Cromwell, Deep River, Derby, Durham, East Haddam, East Hampton, East Haven, Essex, Guilford, Haddam, Hamden, Killingworth, Lyme, Madison, Meriden, Middlefield, Middletown, Milford, New Haven, North Branford, North Haven, Old Lyme, Old Saybrook, Orange, Portland, Seymour, Shelton, Wallingford, Westbrook, West Haven, and Woodbridge.

The RACs used a study by Dr Greene from Rhode Island Hospital and Brown University titled: Unintentional Prescription Opioid Poisoning Deaths in CT and RI: Prescription Monitoring and Community Responses to supplement their findings. The goal of this study was to conduct a rapid

assessment and response (RAR) to better understand why high rates of prescription opioid abuse and overdose is occurring in four communities, two in RI and two in CT, and to determine ways that prescription monitoring programs (PMPs) and other responses can be used to prevent fatal prescription overdose there.
These processes informed our assessment of the region as well as our recommendations for the region. In addition, the Region II Regional Mental Health Board (RMHB II) did their review and evaluation on Access to Services for River Valley Services (RVS). Throughout this project feedback was also collected by phone and personal interviews with individual members of the CACs, consumers, providers and town officials. The effort and input from all that participated in the 2012 Region II Priority Setting/Planning Process is greatly appreciated.

The assessment data was compiled, reviewed and completed over a few months time. Our findings were reported to the DMHAS management team in August 2012. The attendees in our regional presentation were Commissioner Patricia Rehmer, Al Bidorini, DMHAS Director of Planning, Wayne Starkey, DMHAS Regional Manager, Bill Pierce, DMHAS Clients Rights Officer, and Colleen OConner, UCONN Research Associate. This report is a culmination of the process and highlights statistical data, comparative data analysis from 2010, feedback received from the community forums and offers recommendations for DMHAS to consider in their planning process. The material obtained in the provider survey displays the comparative results from 2010 to 2012 Priority Setting Process in the following categories: Mental Health Service Availability Most Available Services

According to the providers who responded there is an increase in availablity for mental health outpatient servcies, crisis services, jail diversion, and appointments with a psychiatrist or an APRN for medication appointments. There is approximately a 20% increase in the each category compared to the 2010 results. This is a significant improvement. Providers in Region II have increased crisis services with some collaborative efforts, specifically between River Valley Services (RVS) and Rushford, Inc . which has increased the number of respite beds available to divert people from inpatient stays. The providers in Region II have made efforts to reduce wait times for appointments, such as creating walk in medication appointments for clients. Providers have also implemented strategies for reducing the time it takes for an initial assessment, such as overbooking the initial appointment based upon no show rate averages. There are improved Jail Diversion programs to help people with psychiatric issues to stay out of the criminal justice system. However, the forum feedback on the most available services were in contrast to what the providers reported and as mentioned above have taken steps to resolve. Wait time issues were an overwhelimingly consistent response to the question about service availability. There were a few areas of concern, the first being that some community members said that there was a 30 day wait for the initial assessment for a person going into treatment. The initial assessment is the key evaluation time for a new client. Very often it can take a person a long time to be ready for treatment. It is important to strike while the iron is hot and hearing the stories about such wait times is

concerning. This leaves the shelter employees, town social service persons, housing authority staff, family, etc., trying to manage a persons symptoms while waiting for the initial evaluation. In addition to this, once a person receives their initial evaluation the availability of an appointment to see an APRN or Psychiatrist can be up to 6-8 weeks. The emergency room staff cited that doctors are prescribing medications for an extended period of time so a patient can maintain some consistency in their medications. The obvious implication is a client/consumer may not get a renewal of their medication or not get a new medication prescribed in a timely manner. The impact is critical for the health and well being of the clients/consumers. Agencies are aware of the problem and try to accommodate the demand, however, it is a challenging task that was referenced many times in the forum.

Another area of concern is the availability and response of crisis services. This was specifically cited as a problem in New Haven County. People are going to the emergency room because they cannot get mental health crisis help. In the Community forums, some people were not aware of the specific crisis hotlines for mental health while others were familiar with the crisis line and staff.

Mental Health Service Availability Least Available Services

2010-12 Comparison

In the category of least available services, the providers cited that acute inpatient beds are hard to access. The trend from 2010 to 2012 has shown an increase in the difficulty obtaining an acute inpatient bed. The Sub Acute status, the step down unit from acute inpatient, is basically non-existent. The forum participants echoed this sentiment and talked about the challenges of inpatient access and length of stay at hospitals. The access issue causes safety concerns for the patient who needs care and others who are attending to the patient. There was a lot of discussion regarding long wait times in the emergency rooms and patients backing up because there arent appropriate levels of service ready for patients to access. Emergency rooms are not equipped to keep patients for an extended period of time, yet they will if there are severe enough symptoms. Also, when patients get released from the emergency room because they are not in acute crisis, there are not enough appropriate levels of care to discharge a patient to such as a respite bed or other less acute setting. Police officers gave examples of bringing someone to the emergency room only to have them released shortly after the admission. There was frustration with the process. Emergency room clinicians said that they cannot keep someone if they do not need to be an inpatient. They would like more options. There was a man in the emergency room waiting for a bed at Connecticut Valley Hospital. This patient, in the ER too long, became agitated and broke a caregivers arm proving unsafe situations can be a result of lack of availability of appropriate inpatient beds. Another challenge is if someone is admitted to the city hospital inpatient unit they are usually discharged in only 72 hours. One police officer stated I

know I am not a mental health person but I dont think 72 hours is enough time to evaluate a person. He said it becomes discouraging to paper someone if you know they will not be treated for enough time.

Barriers to care from our key informant community forums: Priority Area: Coordination of Service System Barriers /Gaps- Highlights Town Social Service, lack of knowledge of available services and contact persons After hour coverage limited Eligibility requirements Navigation of the service system Knowledge of service system Coordination of Services once referred Timely Client Engagement Medication complications and follow up In the forums it was revealing to hear the diversity of knowledge of the service system. Most people felt that it is a challenge to access the mental health system. There are different requirements for various providers and eligibility can be confusing to figure out. Some providers discussed the frustration they have when a private practitioner or provider will not take someone who has Medicaid insurance. Also, if a patient cannot afford the insurance copay they are not able to obtain services and end up with the providers in our region who then bear the financial responsibility. One town social service person felt she used to know the system, then people or processes changed at an agency and she lost her connection. Even if she attempted to make additional connections, she did not have the same response because the case manager or clinician was more challenging to contact, etc. Another emergency room physician said I dont know how to get people into the system, if one exists, in some coordinated fashion. The lack of coordination of services was a major theme in many of the forums. There was a helpless feeling among participants at times because they are willing to go the extra mile to help someone get into treatment or care but they are not sure of the mechanism. In Wallingford specifically it was

mentioned that there arent a lot of people that sit around the table together and discuss services or issues. There are problems with timely client engagement which stems from lack of quick appointment access or lack of follow through after someone is in treatment. Case managers, housing authority personnel, and town employees discussed working with a client and not having access to the persons clinician or case manager at an agency for follow up information. HIPPA was discussed as a legitimate barrier in some of these cases due to the nature of the relationship of the client to the outside referral person. If a person is assisting a consumer/client and there isnt a release signed, no information can be shared with the outside helper. In some cases, however, even if a release was signed, people described the challenges to get the information because of lack of follow through with a case manager or clinician. There was a consistent theme of frustration or disappointment with the collaborative efforts with agencies. However, it was felt that HIPPA is sometimes used to keep information from being shared when it is in the best interest of the client, such as traumatic relationships, etc. Another barrier discussed were difficulties with client medications and its impact on treatment and symptomatic behavior. While participants shared stories about times when residents in a housing complex can be intimidating to a person with a psychiatric disability they also described situations related to psychiatric medications. At times, clients do not take their medication(s), it can be challenging for the other residents and employees of the building. One person said that when the person was on their medication they were fine, and when they werent they terrorized the other tenants. Another discussion point was in reference to the skill set that is required to work with someone with medication issues or non-compliance. More skilled clinicians and case managers are needed for clients to increase compliance. Some felt that physicians or APRNs should prepare patients better for the side effects of medications and thoroughly explain the implications and contraindications of the psychotropic medications. Forum participants noted that medication stabilization can take weeks and it is a challenging time. Clients/consumers need to feel that they have an experienced person guiding them through the process of side effects, etc.

Priority Area: Coordination of Service System Strengths Existence of DMHAS provider collaborations is a positive trend that occurs usually because the providers have a natural collaborative nature based on the fact that they have DMHAS contracts and there is one Lead Mental Health Agency (LMHA) that is the lead provider in the area. These efforts tend to lead to a cooperative spirit among the agency leaders to discuss system issues, trends, and coordination of services. In New Haven there is the Community Services Network (CSN), in Middletown there is the RVS Provider Meeting, also statewide there is the 10 Year Plan to End Homelessness and Communicare is the collaborative of two agencies, BHCare (Ansonia, Branford) and Bridges of Milford. There is a newer grant funded collaborative which will be highlighted later in the report that is the Middlesex Hospital Grant which pulls together a multifaceted group from Middletown to address the high utilization of the emergency room and other hospital services. There are many great success stories from the Middlesex coordinated endeavor.

Priority Area: Coordination of Service System Recommendations Provide training/courses to outside referral sources regarding the service system (EMS, town hall staff, senior center staff, walk in medical providers, police departments, dispatchers, schools, etc.). This was asked for by the people who attended the forums. They are craving information regarding services and availability. Include Community Referral Sources in Provider meetings - While it would not be possible to do this at every provider meeting, it would be beneficial to open up a provider meeting once a quarter to discuss relevant

changes to the service system and field general questions from the community members or stakeholders. This would be an effective tool for both groups of people. The providers could work with the Regional Mental Health Boards to develop an invitee list to create these meetings. Crisis Intervention Training (CIT) for first responders Throughout the community forums, it was evident that the police departments did not have the appropriate contacts or understanding of the resources available to them for someone with mental health issues. It is important to keep recruiting new officers and departments to participate in this important training which teaches them what to do in crisis situations. Increase Web Access During the age of internet access, it is vital to develop strategies and coordinated networks on the web. Creating a website for young adults is an important outreach to the population that accesses the web the most. It is recommended that increased website visibility of services is provided in a use-friendly format. A further recommendation would be to have the accessibility of services, such as DMHAS inpatient beds and appointment information from outpatient facilities on the web for the community to access. Commissioner Rehmer said that the DMHAS inpatient beds are listed on the website and the challenge is keeping the data up to date. She is encouraged by the Malloy administration and his desire to keep the community informed about the department and the service system. 211 - Marketing services for DMHAS- We recommend centralizing information and provide easy access to the community for such things as a crisis line and coordinated information dissemination for the DMHAS service system. Navigation Expert Positions This is a key recommendation that developed from the consistent theme of people being dropped left and right when they were trying to access services. A Navigation Expert position would be filled by someone who has the expertise and develops the contacts across a region or the state and would be an assistant to a person in need. The image of holding someones hand is the concept and not dropping the persons hand until they are secured with services that are appropriate for them. A Navigation Expert could be a peer or a trained staff member for this new area within the DMHAS service system. We envision 10 positions would be necessary to fill this community liaison role and would help bridge the gap between someone in need and the proper providers.

Mental Health Priority Area: Young Adult Services Access In the DMHAS funded and operated Young Adult Services (YAS) a specialized team provides age appropriate services for the age group of 18-25 years old. Some of the key elements are mental health treatment, employment support, life skill
development and housing assistance. It is designed to build a stable foundation for young adults by including the clients, family, significant persons, and provider community. The key elements are listed below:

Natural Supports Network Case Management Supported Education Vocational Services

Housing Smooth Transition for Front Door Referrals from DCF system to YAS Priority Area: Barriers /Gaps During our community forums barriers were highlighted regarding young adults receiving the mental health services provided by YAS. Many young adults need services and not all are in the DCF system of care so the limited amount of slots is a challenge. While it is understandable that there are specific requirements it leaves many individuals who may need services left out. Community members spoke of the challenge of getting appropriate care for young people in crisis, lack of inpatient care, respite care and housing for this particular group. Also, more dollars are needed to have the YAS program available for every area of Region II. There are also a slew of young people who need to have homeless outreach teams to assist them in obtaining services. There are many young adults that are couch surfing, staying with various friends, etc., because they do not have a home. It is a

challenging population to engage and there were many discussions in our forums about the fact that building trust with young adults takes time and dedicated clinical care. Competing for limited slots, prioritization Housing Supports Homeless outreach for Young Adults Crisis services lacking Eligibility Requirements

Priority Area Strengths It has been reported that when young persons receive services from YAS, they have found a gem. They receive dedicated case management, housing supports, and a well laid out plan. Parents we have spoken with said once they found the services their child progressed wonderfully with the right supports. Also, clients we spoke to felt supported well and were going back to school or were using the vocational services as well. It is such a critical age to be engaged in higher education or working in some capacity. Usually, the onset of mental illness can strike during this critical developmental age group and it is vital to get into services in a timely manner. YAS incorporates a recovery model that has proven effective in many cases. With the right supports these young people thrive and flourish at their own pace. In addition to the types of services, the coordination effort and level of collaboration with DCF and DMHAS has increased dramatically over the last few years which increases stability in the lives of the young people who have a road map for recovery and treatment. This program is meeting unmet needs of an age group that has been underserved for a long time.

Priority Area Recommendations Our recommendations include the following: Access to supports for non-DMHAS eligible clients - YAS informed training for providers would help establish formally the principles that make the young adult program successful. The providers and community referral persons are searching for ways to help this extremely important and fragile population. Criminal Justice Collaboration Many young people end up as offenders and get involved in the criminal justice system. There needs to be better coordinated efforts with the criminal justice system key players to make sure the young people end up getting mental health or addiction services instead of getting criminal offenses on their record and ending up in the wrong system for them. Many officers described wanting to help the youth find a better avenue for their treatment especially after being in crisis. Increase funding for residential staff to be more experienced and credentialed, and have more skills training There is a need for more experienced staff to teach basic life skills to the young adults. For any young adult this is a critical time to learn skills, and especially for someone with Severe and Persistent Mental Illness (SPMI), it is vital to learn life skills such as maintaining a living space, money management, vocational techniques, managing a transportation system and social skill development. The residential staff is not a highly paid or credentialed position. It is not the primary focus of the staff necessarily to provide such training, however, it is a good setting to incorporate the skills training. We recommend upgrading the staff positions to include more skills training and clinical supports.

 Increase partnerships with colleges (Supported Education) It is necessary for clients to be engaged in higher education, if possible, and desired to increase their chances of competitive employment. More partnerships with colleges need to be established and fostered to provide this opportunity for the young adults served by YAS. Increase Bureau of Rehab Services (BRS) connections for vocational services Foster a stronger bond with the BRS service system to enable the young adults to build their vocations skills and obtain competitive employment. Extend YAS services in our region to Meriden and along the Shoreline Mental Health Priority Area: Elderly Services access The categories for elderly services system needs were discussed in our community forums as well as our CAC meetings. The following is a list of the top four priorities that emerged: Access to appropriate services Physical Health and Mental Health complexities in the elder years Lack of Education of the Community regarding elder services Nursing Home Accessibility

Barriers /Gaps

These priority areas generated discussion from some providers because they are seeing an increase of people over 60 with physical and mental health complications. This causes challenges to the agencies to ensure that the physical health is taken care of for the clients that are served there. It is also a challenge for the psychosocial clubs who have some members that have attended for 30 years and the needs of their older population are becoming more complex. An additional component is that as people age, there can be lack of family supports for daily living and service coordination for the elder person. Another issue is that there are an insufficient number of clinicians trained in geriatric needs and with baby boomers aging, it will become increasingly important to fill the gap in services. Also, outreach to the elderly population is lacking and many are isolated and reaching them can be difficult. There are also many elders who need nursing home level care and the vacancies are limited to access. Priority Area Strengths

Currently, the DMHAS Working for Integration Support and Empowerment (WISE) Program works with nursing homes to transfer residents to live in the community with SPMI and require the nursing home level of care. The waiver program allows the State to furnish an array of home and community-based services that assist Medicaid beneficiaries to live in the community and avoid institutional care. Waiver services complement and/or supplement services available to participants through the Medicaid State plan and other federal, state and local public programs as well as natural supports that families and communities provide. Currently, some senior centers provide assistance in accessing care for their clients and have a natural connection to assist seniors. Also, many church groups provide outreach to seniors and would be willing participants to help with mental health referrals. There is a group of Catholic nurses who would be willing to do mental health assessments if trained properly. Another group that the community forums presented as a liaison would be the police officers who connect with seniors, as first responders to help in a variety of situations. They often encounter domestic issues that could result in a referral for services for an elder person.
Priority Area Recommendations Increase use of existing social structures (senior centers, churches, police, libraries, etc., to provide MH information and collaboration These established groups were excited to get mental health courses or information regarding referrals. They encounter many seniors and would like to be better equipped in providing assistance and support for the elderly.

 Move forward with plan to run DMHAS owned nursing home We encourage DMHAS to pursue the ownership of their proposed nursing home to fill the need for elders with mental health issues to be in a safe and appropriate level of care. Consider expanding capacity of Woodward Hall This recommendation is to expand the existing services at Woodward Hall on the CVH campus to increase capacity. Coordinate with local areas on aging This is a natural collaboration to increase communicating available services and provide mental health courses. Provide trainings/courses and consultation (like MH first aid) for nursing homes Many of the nursing home staff and leadership said they would like to receive training on the signs and symptoms to look for in patients mental health issues. They would also like agencies to come out and present the types of services available to elders. Provide or arrange psychiatric treatment onsite, in home or nursing home Arrange for more mobile care units, clinical staff to provide care in the elderly persons place of residence. Collaborative efforts with hospitals to connect to care Increase collaboration with hospitals to find appropriate levels of care for a person being discharged from their services. Additional Recommendations 1:1 Counseling Option (77% failure rate for youth who were referred to agencies and placed in groups - Shelton) this statistic is alarming in the young adult population. One town representative said that many of the young people have a difficult time trusting people in a group and sometimes their personal story is scary to share with others because it is related to trauma. Outpatient counseling is available from multiple sources, at our LMHAs and private settings. However, in most of our meetings with families and consumers there was discussion about needing to provide individual counseling for patients. While some groups are great and provide the support that people need, it is not a fit for everyone. Some people found that when they asked for individual counseling, it was more difficult to get treatment in a timely manner. Consumers and family members share the feeling that the attention one receives in a one on one

session is valuable and sometimes necessary. People would like the option to choose what type of treatment works best for their recovery.

Police Chaplain Training Chaplains who work in Police Departments would like courses on handling someone with mental health issues or addictions. They are often the persons who talk to someone who is having difficulty and are engaged with the police department. General training on medications, psychiatric illness and signs and symptoms would be helpful to this specialized group. Sober housing, halfway house, safe housing, permanent housing is critical Keep the necessary funding and collaborations with housing agencies to provide the safe and appropriate level of housing for people with SPMI. It is a cornerstone to recovery! Case Management hire more, coordinate services Increase Trauma Informed Services The majority of clients have a history of trauma and it is essential to provide trauma informed care in all of the clients/consumers in our region from the clinical and non clinical staff in the agencies.

Substance Abuse Recommendations

SUBSTANCE ABUSE & CO-OCCURRING

I. Service Area: Immediate/Same Day Response

Recommendation 1: Implement MH/SA Crisis Phone Line

Rationale: People with mental health or addiction issues who use the telephone to find help are at a disadvantage; two-way communication is difficult for many MH/SA clients. Friends and relatives calling on a clients behalf are often too distraught to concentrate on complex information. Strategy and service system changes needed: Implement and advertise a special phone line for MH/SA emergencies that first responders (e.g., 211 operators, service agency receptionists) and the general public can use. This line could be housed within a community health, substance treatment, or prevention agency.

Recommendation 2: Improve coordination of same-day community services

Rationale: While life-or-death situations (detox, suicide) are adequately handled in our region, crises that could lead to substantial harm are not. People on the scene or people to whom those in distress first turn (pastor, town clerk, librarian, police, busy ED doctors) can find themselves performing triage and trying to handle situations they may not be prepared for. Focus group members had innumerable stories of these stressful situations. A chronic lack of residential care, cited by 90% of survey respondents, contributes to this situation.

Strategy and service system changes suggested include: (a) Develop a website that holds current information on treatment beds, shelter beds, appointment availability, etc. The challenge is maintaining current status on an hourly basis, 24/7. One strategy might be to combine the MH/SA crisis phone line with website services, manned by the same staff. (b) Offer Mental Health First Aid training to people who are often, by default, first responders. (c) Support and replicate the Middlesex Hospital Community Collaborative model, which lowers the incidence of crisis situations through community-based management of high-risk individuals (described below). Recommendation 3: Research best locations to expand intensive residential service

Rationale: Year after year, intensive residential services tops the survey respondents least available list at 90%. It is a direct outcome of the 1970s de-institutionalization movement, which saved dollars in the shortterm but led to a paucity of intensive-support housing; the only workable substitute for hospital-type institutions. While Connecticut outperforms most other states, we still find undertrained staff given the task of helping MH/SA clients take prescribed medications and/or avoid illicit substances, among other life skills. Patients become non-compliant. Their situations deteriorate and they return to (costly) crisis mode. Strategy and service system changes needed: Connecticut lacks the funds and political mandate to provide free residential care for citizens suffering from alcoholism and other addictions. To make the most of scarce dollars, therefore, a comprehensive review of existing hospital-type recovery centers (CVH, Rushford, private facilities), in light of projected demand for services (e.g., alcohol and opiate trends) is needed.

Recommendation 4: Market DMHAS Ambulatory Detox services Rationale: Seventy-five percent of surveyed informants noted that ambulatory detox services were not often available. At the same time, DMHAS reports that such services are ready and waiting; people do not take advantage of these services as they seem to prefer residential detox. Strategy: Market ambulatory detox services at several levels, from key management (surveyed informants) and to the recovery community. Peer support may replace the family support systems often lacking among adult MH/SA clients.

Recommendation 5: Make better use of existing peer navigator / peer supports for clients entering treatment

Rationale: More adults are first-time users of DMHAS services, entering MH/SA treatment with no family history of DMHAS involvement. Loss of job and health insurance, adult-onset substance abuse, domestic violence and other environmental factors all play a part. Peer support from members of

the recovery community is a low-cost means of providing experienced guidance to new clients.

Strategy and service system changes needed: Continue to support such peer organizations as Focus on Recovery-United (FOR-U), presently in Middletown and New Haven, AA and NA groups, faith-based outreach and recovery support, and Dry Dock type organizations. (More on the latter below.)

II. Service Area: Intermediate Care

Recommendation 1: Provide the critical bridge between detox or crisis services, and low-cost, low-intensity, long-term support Rationale: Survey respondents and focus group members are particularly concerned with the lack of intermediate care for the MH/SA population, especially those with dual-diagnosis. Clients who are stabilized and discharged after 72 hours have nowhere to go, and even willing family members cannot always cope with the severe stress the clients are in. Again, the survey put intermediate residential services at 89% unavailable or seldom available. And in barriers to adequate SA treatment, housing at 67% was most often cited.

In one focus group, the theme of treat em and street em reverberated throughout the discussion. A focus group member recalled her successful detox followed by a frightening ten days: the time it took to get enrolled in an intensive outpatient program. Fortunately she had residential services in the form of caring family members and twenty years later she is substance free. However, without care during those ten most vulnerable days, this woman doubts she would have made it.

It may be worth noting that the problematic transportation issue, which comes in just after housing as most often lacking (85%), could be alleviated by more intermediate residential care: if one is already in care, one need not drive there.

Strategy and service system changes needed: While it is very expensive to provide beds, meals, and staff time for longer than 72 hours, it is costsavings in the long run to steer clients, at this critical juncture, toward longterm sobriety managed on an outpatient basis.

III. Service Area: Long-term Treatment

Recommendation 1: Support Middlesex Hospital Community Collaborative model

Rationale: By definition, long-term treatment is outpatient and community based. Survey informants identified three factors of long-term treatment as strengths in our region: coordination of services, accessibility of services, and public awareness (79% availability). Standard outpatient services also scored highly (74%) among the key informants. These optimistic assessments were at odds with our focus groups. One reason may be that key informants are involved in newer collaborations which are very promising, successful for the initial small group of clients, but have yet to spread to a wider MH/SA population. Strategy and service system changes needed: The Middlesex Hospital Community Collaborative includes River Valley Services, CVH, Gilead Community Services, Rushford, Middletown CHC, Advanced Behavioral Health, and Value Options. It is case managing 39 clients with one grant funded position. This efficient model should be supported and duplicated in the New Haven region.

Recommendation 2: Replicate the Dry Dock model Rationale: In the continuum of recovery services and relapse prevention there is a lack of supportive programming in Region 2 beyond the traditional 12-step programs. Just as Friendship Clubs provide useful support and opportunities for supportive social interaction for many mental health clients, substance abuse clients need opportunities for safe and sober interactions with others. Dry Dock is a non-profit organization in Wallingford started by persons in recovery that hosts 12-step meetings, music festivals, and drop in nights, caf meals and coffee in a supportive

informal atmosphere. Because of the reputation of Dry Dock, persons in crisis and family members also come to the center and are linked to emergency services and residential treatment or are referred for clinical services to the local DMHAS funded treatment provider. Rushford Center is continuing to develop a working relationship with Dry Dock to support local clients who may be in need of treatment services. Strategy and service system changes needed: The Dry Dock model provides a new access point for services for substance abuse clients that is community centered and user friendly. The non-threatening and accepting atmosphere allows persons in recovery and their family members and friends to normalize activities. The visibility of Dry Dock and the family friendly activities have gone a long way to breaking down the stigma associated with addiction and addicts. This model provides a communitysupported service that is essential to the continued sobriety of clients and creates an awareness that everyone contributes to the health of a community.

IV. Service Area: Opiate Abuse Prevention & Treatment

Drug overdoses in CT are the leading cause of adult injury death, more than deaths due to motor vehicle accidents and firearms combined. Heroin is the most commonly cited drug among primary drug treatment admissions in CT. (ONDCP, April 2012). In addition, admissions for primary abuse of other opiates such as prescription pills have increases since 1997 according to July 2012 Substance Abuse and Mental Health Service Administration data. The Centers for Disease Control and Prevention report that for every 1 overdose death from prescription painkillers there are

10 treatment admissions for abuse 32 emergency department visits for misuse or abuse 130 people who abuse or are dependent 825 people who take prescription painkillers for nonmedical use

Recently, CT participated in a study funded by the Centers for Disease Control (CDC) with principal investigator Traci Green, PhD, MSc, Assistant Professor of Medicine and Epidemiology, the Warren Alpert School of Medicine at Brown University. The study was based on the premise that drug overdoses in CT are the leading cause of adult injury and death (out-

numbering the combined deaths resulting from motor vehicle accidents, fire and firearms) the study sought to identify issues that surround these overdose injuries and deaths. Three communities in CT were selected to be part of the study that aimed to determine and understand why high rates of prescription opioid abuse and overdose are occurring in these communities. These communities include: Ansonia, Seymour, and Wallingford.

The data collected addressed three main areas: 1. Problem definition. Is there a prescription opioid problem occurring; what drugs are involved; how do people first initiate use of these medications; perceptions of safety of prescription opioids; relative local street prices; who is using b. who is dying; and, how are overdoses being discovered and responded to. 2. Sources of prescription opioids and other drugs diversion. 3. Specific overdose intervention needs: Information needed about local assets and resources for coordinating response.

CT Study Findings: Growing involvement of prescription opioids These deaths occur among 35-54 age range, primarily non-Hispanic Whites, increasingly female die at home (more than half female) (Ages 24-58 (primarily >35) Nearly all involved opioid medication prescribed to decedent Toxicology suggest involvement of other pharmaceuticals: antidepressants, sedatives/hypnotics Limited alcohol involvement; heroin, alcohol, and/or cocaine more common combinations Died at home, often with others in house Deaths clustered in space Themes: drug &/or alcohol abuse/ dependence, SA/MH treatment, domestic violence, past suicide attempts, previous overdose, other chronic disease or conditions (diabetes, obesity, back problems, chronic pain), incarceration, recent acute events-surgery, work injury

Recommendation 1: Focus treatment resources on opiate addiction

CT is a treatment desert for opiate addiction. While we have providers, they are not convenient to many residents because of location and transportation challenges with the treatment centers being located in large cities. One of the largest obstacles is the not in my back yard (NIMBY) discrimination directed at substance abuse providers who choose to provide opiate treatment. A recommendation to expand opiate treatment availability includes encouraging additional private and public providers to prescribe Suboxone, as well as offering residency programs in addiction medicine.

Recommendation 2: Support CT Prescription Monitoring Program According to the National Alliance for Model State Drug Laws (NAMSDL), a PDMP is a statewide electronic database that collects designated data on substances dispensed in the state. The PDMP is housed by a specified statewide regulatory, administrative or law enforcement agency. The agency distributes data from the database to individuals who are authorized under state law to receive the information for purposes of their profession. The benefit of CTs PMP includes: Enables law enforcement to detect suspicious activity quicker. Exposes potential doctor/pharmacy shopping and other fraudulent behaviours. Provides automated patient controlled-substance history reports online 24/7. Offers ability to request a prescribers controlled substance prescribing history report online 24/7. Saves investigative hours, transportation and other departmental resource costs. Allows law enforcement to post alerts on possible suspects.

Identifies patients for early intervention, assessment and treatment. For more information on CTs system visit: http://www.ct.gov/dcp According to findings from a study published in Pain Medicine Journal; 2012 by Dr. Tracie Greene: PMP use was associated with greater awareness of

potential abuse of prescription opioids and with taking clinical rather than legal or no action when faced with suspicious medication use behavior. Wider use of electronic PMPs by prescribers may have a more direct influence on opioid abuse and ultimately overdose risk than non-use, paperbased PMPs, and predominant law enforcement use.

Our findings have found that CT does not have consistent or high use by prescribers of the PMP system. Therefore we recommend that we work towards a policy on implementing stronger use of the system and advocate for consistent funding for the system. It can be a crucial key in early identification of potential substance abuse disorders among individuals in which early intervention can improve health outcomes.

Recommendation 3: Provide prescriber toolkits / mandates This recommendation is one of the most challenging to address. Many medical doctors have voiced concern that there is already a lot of continuing medication education (CME) mandates and adding one more can become burdensome. A lot of work is being done to address this issue through voluntary CME workshops and symposiums as well as on-line education and toolkits for use, residency curriculums, etc. It is issues we feel DMHAS should be involved with and advocating for consistent practices within the state.

Recommendation 4: Provide Overdose prevention education Overdose prevention education is limited to a few providers and almost nonexistent in within primary care settings. It is exciting to note that with newly passed legislation doctors can now prescribe family members an overdose prevention kit. With this being said, DMHAS has been in the forefront with already scheduled provider educational workshops on this issue. However, we need to expand our educational efforts into the medical community and encourage primary care providers to conduct brief screening assessments, utilize the prescription monitoring program, and provide overdose information to the client and their family.

Unintentional Prescription Opioid Poisoning Deaths in CT and RI: Prescription Monitoring and Community Responses Goal: We are conducting a rapid assessment and response (RAR) to better understand why high rates of prescription opioid abuse and overdose is occurring in four communities, two in RI and two in CT, and to determine ways that prescription monitoring programs (PMPs) and other responses can be used to prevent fatal prescription overdose there. Data will be collected addressing three main areas: 1)Problem definition (is there a prescription opioid problem occurring, what drugs are involved, how do people first initiate use of these medications, perceptions of safety of prescription opioids, relative local street prices for the drugs, who is using vs. dying from prescription opioids, how are overdoses being discovered and responded to), 2)Sources of prescription opioids and other drugs and diversion, and 3)Specific overdose intervention needs at the local level, including local assets/resources to coordinate response. Growing involvement of prescription opioids These deaths occur among 35-54 age range, primarily non-Hispanic Whites, increasingly female, die at home Toxicology suggests involvement of other pharmaceuticals: antidepressants, sedatives/hypnotics Limited alcohol involvement; heroin, alcohol, &/or cocaine more common combinations Unintentional poisoning deaths involving prescription opioids in RI & CT 2-year CDC funded project: started 09/10 Collaborations with CT & RI state medical examiners, departments of health, consumer safety, mental health & addiction services, corrections

 4-part study: Forensic case review & data linkage, provider & pharmacists survey, geospatial analysis, & community based rapid assessment field study

Decedents: CT All white, more than half female Ages 24-58 (primarily >35) Nearly all involved opioid medication prescribed to decedent Died at home, often with others in house Deaths clustered in space Themes: drug &/or alcohol abuse/ dependence, SA/MH treatment, domestic violence, past suicide attempts, previous overdose, other chronic disease or conditions (diabetes, obesity, back problems, chronic pain), incarceration, recent acute events-surgery, work injury Rapid Assessment A method for rapidly ascertaining, understanding, and characterizing the nature and extent of health and social problems in a particular locale, and for suggesting ways in which those situations can be improved Standard approach used by WHO/CDC One published RAR on prescription opioid abuse & diversion in Delaware (Inciardiet al., 2009) Rapid Assessment & Response Investigate who, what, when, where, & why abuse/ deaths occurring 12-week period Data Collection Review publicly available, media, online resources Existing local data sources (ambulance run data) Key informant interviews Brief surveys

 Intervention mapping

The CAB and field team will be assembled and trained in RAR methods to answer the following questions and to make actionable recommendations to help prevent unintentional overdose mortality

Is there a prescription opioid overdose problem in this community? If so,

which opioids are involved and in which populations? How are overdoses arising (through which routes of administration, what are the dominant sources of the prescriptions, are other drugs also being abused)? How best can we prevent overdoses in this community?

Study conducted by: Traci C. Green, PhD, MSc Assistant Professor of Medicine & Community Health The Warren Alpert School of Medicine at Brown University Center for Prisoner Health & Human Rights Rhode Island Hospital, General Internal Medicine

In conclusion, Community members were a key resource for this 2012 Priority Setting Process and expressed their appreciation of being included and many are vested in helping people with behavioral/mental health disorders. Each year there is an array of concerns and our community based system of care and hospitals manages the challenges the best they can in the current funding structure. As we presented, it is important to not just maintain the level of funding but look at areas to increase the services necessary to help people recover from challenging circumstances whether they be mental health, substance use or both (co-occurring). We strive to improve our contribution into the DMHAS planning process so the department can strategically design the most effective levels of care for each individual in need of services. We recognize that many people are not in treatment and could use the excellent resources that the state provides funding for such as our non-profit provider and the state operated providers. We truly appreciate the dedication and effort put forth by the many dedicated clinical and non clinical professionals who serve in the critical field of care.