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2009-1534-Minutes for Meeting November 04,2009 Recorded 11/25/2009COUNTY OFFICIAL NANCYUBLANKENSHIP, COUNTY CLERKDS CJ 7049•i53~ 11illCOMMI!SSIONERS1'1J111OURNAL 11/25/2009 08:26:02 AM Do not remove this page from original document. Deschutes County Clerk Certificate Page If this instrument is being re-recorded, please complete the following statement, in accordance with ORS 205.244: Re-recorded to correct [give reason] previously recorded in Book or as Fee Number and Page Deschutes County Board of Commissioners 1300 NW Wall St., Suite 200, Bend, OR 97701-1960 (541) 388-6570 - Fax (541) 385-3202 - www.deschutes.orc MINUTES OF WORK SESSION DESCHUTES COUNTY BOARD OF COMMISSIONERS WEDNESDAY, NOVEMBER 4, 2009 Present were Commissioners Tammy Baney, Dennis R. Luke and Alan Unger. Also present were Dave Kanner, County Administrator; Erik Kropp, Deputy County Administrator; David Givans, Internal Auditor; Tom Anderson, Nick Lelack, Cynthia Smidt, Peter Russell and Kristen Maze, Community Development; Marty Wynne, Finance; Laurie Craghead, Legal Counsel; Chris Brown,, Susan Quatre and Richard Klyce, Planning Commission; Hillary Borrud of The Bulletin, and approximately a dozen other citizens. Chair Baney opened the meeting at 1:32 p.m. 1. Update on Secure Residential Treatment Facility: Next Steps. Scott Johnson distributed a document showing affordable housing and residential services available to citizens, including inventory for 2010. Discussion took place regarding the telecare project. Telecare is considering purchasing or leasing property to fill the demand for housing. Out of ten beds, the County will get six beds in Bend, plus another six apartment units in Redmond. Mr. Johnson gave a PowerPoint presentation on these efforts geared towards health care reform in Central Oregon for people with mental illnesses and addictions. Commissioner Baney asked for clarification of the financial support aspect. Susan Ross stated that any years not honored would be pro-rated at that point. She added that the lease amounts should cover debt service. Dave Kanner said that the building could be used for other purposes if necessary, such as an Alzheimer care facility or a nursing home. Commissioner Luke said that under federal law, the State has to provide these services. It is best to have the services handled at a local level rather than at the State hospital. Minutes of Board of Commissioners' Work Session Wednesday, November 4, 2009 Page 1 of 8 Pages Mr. Kanner said that as part of the Economic Recovery Act, the bond is tax- exempt. The payment will be made from revenue generated by leasing the property to the State. Marty Wynne said that he has been waiting for the go-ahead on this. He will contact bond counsel to develop the proper documentation. 2. Integration Project - D.C. Demonstration Site. Mr. Scott said that on average, a person with serious medical illness dies 25 years earlier than one without this problem. He also talked about the partner groups in the region. C & D are complimentary when needed. Professionals who do this kind of care are available in the area. Some of these do work for the County on a regular weekly basis. They may even be seeing some of these patients already, Tracking and record keeping is kept simpler this way. Mr. Johnson then went over the concepts. Many of the clients also need other kinds of care. Commissioner Luke asked if physical health care dollars could be used for these clients. Mr. Johnson said that school-based health centers and a few other locations could provide for some of this. There is some interaction, but the services are not integrated. There are a number of health indicators that need to be tracked in conjunction with mental health issues. Mr. Johnson showed a map of the tri-county area and how residents are assisted. The La Pine clinic also helps people living in Klamath County and Lake County. The State wants to implement several demonstration sites, and this has been offered to Deschutes County. They are seeking accountability through one point, financial integration, service integration, and outcome measures. The group discussed funding options at this point. Minutes of Board of Commissioners' Work Session Wednesday, November 4, 2009 Page 2 of 8 Pages Commissioner Luke asked how this project benefits the community. Mr. Johnson said people with mental illness would have some options. Chair Baney stated that they start with the high highs - the frequent flyers - those with the most severe problems. Instead of sending a person to another place, they can receive care all at once. This keeps them from bouncing around to the emergency room and health providers. Commissioner Luke added that this coordinated effort eliminates multiple visits and expenses. The dollars are still there and will be used for health reasons, but in a more logical fashion. Chair Baney stated that the County needs to be certain that it retains its authority and does not end up with no authority and all the liability. This is in short a Central Oregon Regional Health Authority, through the State's Oregon Health Authority. Chair Baney feels this is on the right track but there are potential problems, such as declining funds; long-term support by the State; federal reform that may help or hinder; how a new Governor and legislature will look at this; whether other regions will become involved; and if there might be inequity in funding the uninsured as the program grows. Commissioner Unger noted that it appears that Deschutes County is carrying much of the workload on this project. Mr. Johnson said that if the dollars promised come to pass, this funding will help. Chair Baney added that St. Charles Medical Center has offered a staff person to assist. The local Addictions and Mental Health Advisory Board unanimously supports this effort towards service integration and improved health outcomes. Collaboration with local partners would take place. A single point of accountability through a regional health authority could be considered. A letter, white paper and other documents will be presented to the Commissioners for consideration. 3. Follow-up Discussion on Comprehensive Plan Update. Chair Baney said that there seems to be a rumor that the Commissioners plan to scrap the comprehensive plan. This has never been considered, although an update is being worked on at this time. Minutes of Board of Commissioners' Work Session Wednesday, November 4, 2009 Page 3 of 8 Pages Commissioner Luke stated that the Planning Commission wanted more time to review this work and to get more public input. The Board of Commissioners wants the PC to be comfortable with a potential final product. Commissioner Unger said that citizen involvement is the beginning. Richard Klyce and Christen Brown of the Planning Commissioner asked to comment. Mr. Klyce said he is representing his view, not that of the Planning Commission. Mr. Brown stated that they were instructed not to speak for the others and they have not yet had an opportunity to meet with the Planning Commission as a group to talk about this issue. They do not meet until November 5. Nick Lelack explained that the question about whether the Plan should be scrapped has arisen, and he has been told that five of the seven Planning Commissioners feel that it should be. However, this was voiced by one Planning Commissioner and not the group as a whole. This would mean staff would work with the Planning Commission and start with a blank sheet, instead of staff creating documents for the Planning Commission to review. Commissioner Luke suggested that perhaps individual sections can be analyzed and common ground found first. Then the areas of dispute can be discussed. Mr. Brown said there are a lot of pieces in the draft plan, which is 422 pages, that have merit. Other portions are problematic. Reconsidering the entire Plan might be a better way to look at it. A matrix is being prepared showing the actions, goals and policies in the document, many of which the Planning Commission is going to support. It would be foolish to ignore what is there, as some will be of value. Chair Baney asked if they are talking about content or format. The actions and goals may or may not be included. The information is based on feedback from the community. Commissioner Unger said that he hopes the Planning Commission bases its decisions on a public process. Chair Baney stated that the budget process is an example; recommendations are made as to what to keep and what should be left out. She would like to see what is being requested to be eliminated. The Board has to know what it has to stand on when policy decisions are made. Minutes of Board of Commissioners' Work Session Wednesday, November 4, 2009 Page 4 of 8 Pages Commissioner Luke feels that this type of discussion is premature, as the Planning Commission is the first step. What staff recommends, the Planning Commission recommends and public input are all considered by the Board. Mr. Lelack said that the other issue is public outreach, which is part of the process and has been ongoing. Chair Baney would like to see all of this included. Commissioner Luke would like to see the process continued for as long as necessary, since the final result will affect the area for many years. It was noted that this would cost additional general funds, but that should not be a barrier to getting to the right document. Chris stated that the continued public comment is a concern of his. The Planning Commission is considering deleting or changing a great deal, and will have to go back to the public then with a draft plan that might then contain a lot of changes. This could cause confusion. Chair Baney would like to see public input on the entire document, not just what the Planning Commission wants to include. Mr. Brown said that the document is already out, and the public is aware and will have things they want to bring to the table. Chair Baney indicated that a consensus of the Planning Commission is needed to change gears like this. Commissioner Unger noted that he prefers not to change gears so radically; they should let the public provide input and make adjustments based on that. Mr. Lelack said what needs to be considered is the Plan and the process. He asked if the public process should be suspended to allow time for editing, or continued into January, at which time a rewrite could happen and the public process begun again. He added that it does not seem fair to have a moving target. Chair Baney said she does not want to confuse the public. Ms. Maze noted that staff and the Planning Commission might have differing opinions. She will see if they can reconcile this before the formal process. Commissioner Luke stated that an e-mail quoted a statewide group comment, with personal attacks on Planning Commission members. It is legitimate to make opinions known, but this is hard work and personal attacks are neither appropriate nor helpful. Minutes of Board of Commissioners' Work Session Wednesday, November 4, 2009 Page 5 of 8 Pages Chair Baney said she appreciates all the public outreach thus far. Not everyone will be happy when the process is over, but at least they would have been heard. 4. Other Items. Chair Baney said that she attended a luncheon hosted by Cornell University, where they discussed a certificate program the hospitality field and Oregon State University - Bend. The meeting was well attended. There is no program like this in the northwest. With the passage of the COCC bond, it is promising. In regard to card locks for fuel purchases, Commissioner Luke asked if there are issues with the current system. Mr. Kanner said that the State and others are getting a much more favorable rate than the County. This service has not been bid out for a long time. There could be more than one provider, or the County could tie into the State's contract, which would cost about $5,000 a year. A lot of money could be saved by bidding it out. The current agreement is not limited to just one provider. He would like to find a provider that would mirror the cost to the State. Another consideration is where the points of sale are. Mr. Kanner said that the County is not unhappy with Bend Oil Company. Hoover, the County cannot simply renegotiate with them but has to go through a bid process. Nick Lelack said the destination resort work group at the State is meeting almost weekly. There are a lot of creative thoughts coming together, and he feels it is very important that the County remain involved in this process. They are hoping to come up with a legislative concept by February. Commissioner Unger stated that he hears a lot of negative comments about destination resorts, and much of it is based on misinformation. Commissioner Luke noted that the comprehensive plan and land use laws are not meant to stop growth, which will happen anyway; instead, these are meant to help plan for orderly growth. Mr. Lelack said that there are some creative ideas being considered that he hopes to share with the Board at some point. Minutes of Board of Commissioners' Work Session Wednesday, November 4, 2009 Page 6 of 8 Pages Commissioner Unger said he attended a meeting of the South Redmond Collaboration Group, consisting of members of the BLM, the Department of State Lands, the military, the City and the County. They brought up the proposed BLM transfer of La Pine and Redmond properties. Some land is being requested by the City for runway protection zones and runways and the Rod and Gun Club. Everyone has commented. They are working with Theresa Rozic of the County as a point of contact, as the County is the facilitator. The three properties in La Pine are now being considered in Congress. Mara Stein, Tumalo resident, said she is interested in land use, water, and destination resort issues, as well as the connectivity plan and safety issues in Tumalo. She is surprised how the community perceives things, as misinformation that spread like wildfire. She noted that strategic planning is very important. Too many procedures confuse people. Perhaps there could be a single source contact so people can get the real story and not be overwhelmed with messages that were forwarded multiple times. People need to be clear on the process, whether it is through the Planning Commission or the Board. Commissioner Luke said that it helps to have input from citizens so major issues or concerns can be addressed. Ms. Stein said that all needs to be considered, regardless of the personal opinions of the Planning Commission members. Commissioner Luke noted that if people keep getting e-mails as a call to action and there is no real "emergency", they might begin to ignore them. ODOT has said that the project at Lower Bridge Road is finalized and according to the agreement, Wimp Way will be open for ninety days. Erik Kropp said that the A-frame cabins are being placated for people to view them and for decisions to be made regarding how they might be placed to use as homeless shelters. Chair Baney said that she was told that placing them on church grounds could be a problem because they should be non-secular. Some people are worried about additional crime, and zoning and other issues may be problematic. Minutes of Board of Commissioners' Work Session Wednesday, November 4, 2009 Page 7 of 8 Pages Being no further items addressed, the meeting adjourned at 3:10 p. m. of Commissioners. ATTEST: 6-0" Recording Secretary ao~yv Tammy Baney, Chair Dennis R. Luke, Vice Chair C- e~~ Alan Unger, Commissioner DATED this 4th Day of November 2009 for the Deschutes County Board Minutes of Board of Commissioners' Work Session Wednesday, November 4, 2009 Page 8 of 8 Pages Deschutes County Board of Commissioners 1300 NW Wall St., Suite 200, Bend, OR 97701-1960 (541) 388-6570 - Fax (541) 385-3202 - www.deschutes.orm WORK SESSION AGENDA DESCHUTES COUNTY BOARD OF COMMISSIONERS 1:30 P.M., WEDNESDAY, NOVEMBER 4, 2009 1. Update on Secure Residential Treatment Facility: Next Steps - Scott Johnson 2. Integration Project -D.C. Demonstration Site -Scott Johnson 3. Follow-up Discussion on Comp Plan Update 4. Other Items PLEASE NOTE: At any time during this meeting, an executive session could be called to address issues relating to ORS 192.660(2) (e), real property negotiations; ORS 192.660(2) (h), pending or threatened litigation; or ORS 192.660(2) (b), personnel issues Meeting dates, times and discussion items are subject to change. All meetings are conducted in the Board of Commissioners' meeting rooms at 1300 NW Wall St., Bend, unless otherwise indicated. If you have questions regarding a meeting, please call 388-6572. Deschutes County meeting locations are wheelchair accessible. Deschutes County provides reasonable accommodations for persons with disabilities. For deaf, hearing impaired or speech disabled, dial 7-1-1 to access the state transfer relay service for TTY. Please call (541) 388-6571 regarding alternative formats or for further information. C O N L Q ~ nI V s O Z Cl-i N C O s ~ p a N°f ~ rl- r ~ c b lJ~ N N J - N 3 Ln N tit W z o J~ S W 2~ Department of Administrative Services Dave Kanner, County Administrator M rA A %A 1300 NW Wall St, Suite 200, Bend, OR 97701-1960 (541) 388-6570 - Fax (541) 385-3202 www. co. deschutes. or. us October 29, 2009 TO: Board of Commissioners FROM: Dave Kanner, county administrator RE: Secure residential treatment facility Staff first began discussing the SRTF project with the Board nearly a year ago. This arose after the state decided, as part of the State Hospital Master Plan, to decentralize certain services now provided at the state psychiatric hospital, and to provide for new, smaller facilities in other parts of the state. The County offered to construct for the state a secure residential treatment facility with the agreement that the County would be entitled to use a certain number of beds for local patients. This evolved into a somewhat different understanding wherein the state will use all of the beds in the SRTF, but will also contract with Telecare to operate two five-bed residential treatment homes (RTH) in which the County will be entitled to use six of the ten beds. All costs for this project and for the operation of these facilities are borne by the state. The following table illustrates the planned beds and their usage. State Hospital PSRB State Hospital Civil Commit. County Beds 16-bed SRTF 7 9 0 5-bed RTH 0 4 6 5-bed RTH 0 Total 7 13 6 As a measure of their commitment to the project, the state last April provided the County with $750,000. About $126,000 of this has already been spent on design and some site preparation work. In addition, Telecare is in the process of leasing or purchasing two facilities that it will use for the smaller RTHs. The County needs to issue full faith and credit bonds in order to raise the money required to actually build the SRTF. We have been waiting for some kind of intergovernmental agreement with the state before taking a resolution to the Board that would authorize us to issue the debt. Mark Pilliod's October 27 memo to you explains the various Enhancing the Lives of Citizens by Delivering Quality Services in a Cost-Effective Manner machinations we have gone through trying to get an agreement in place. I must emphasize that such an agreement is not necessary in order to issue FF&C bonds. The state's position at this point is that they already have an agreement with the County to provide this service element and that the additional money to cover the operation and debt service can be appropriated to us via an amendment to that existing agreement. Although it can be argued that the state could disappropriate these funds in the next round or some other future round of budget cuts, it should be noted that the state did not cut funding for this particular service element in the '09 legislative session and never has done so in the past. The state must house PSRB and civil commitment patients. It effectively, therefore, has no choice except to provide funding for this purpose and cut other services instead. Attached is a letter from Madeline Olson, deputy director of the Addictions and Mental Health Division, in which she notes this fact. Given the state's obvious commitment to this project and the fact that we have already accepted a substantial down payment from the state for it, I recommend that we move forward and prepare for a bond issue using our allocation of Recovery Zone Economic Development Bonds. Again, a separate IGA is not required for the issuance of these bonds (which are FF&C bonds) and we have already agreed to have this facility built and operational by August 31, 2010, a deadline that I believe we'll need to renegotiate with the state. Staff looks forward to answering your questions about this at the November 4 work session. DESCHUTES COUNTY LEGAL COUNSEL MARK E PILLIOD ^m Ext. 6625 Legal Counsel TO: Board of Commissioners DATE: October 26, 2009 RE: Secure Residential Treatment Facility FILE NO.: The purpose of this memo is to outline the options available to the County in its effort to achieve the most favorable financing for design and construction of a secure residential treatment facility (SRTF) in Deschutes County. The Board is well aware that Central Oregon needs additional residential spaces and treatment options, including a facility for mental health clients, who represent a security risk. The County has made a commitment to design and construct such a secure facility on land donated by the County for this purpose. The County has also informally agreed with the State (Addictions and Mental Health or AMH) to allocate space to persons transferred to such a facility by the State, with the concurrence of Deschutes County Health Services and the facility operator. Residents in the secure facility would be people on conditional release by the Oregon Psychiatric Security Review Board or patients at the Oregon State Hospital on a civil commitment. The State has already contributed $750,000 to apply toward this project and the County has already spent some of that money on design/engineering and encasing the irrigation canal. The concern is that the County intends to issue full faith and credit obligations, and while it is unnecessary that the County identify a specific, reliable funding stream, some assurance is desirable for budgeting purposes. The Board has asked that the State provide some form of assurance that it will continue to fund mental health services and thus provide a source of funds for debt service. The conflict here is that the State is constitutionally prohibited from encumbering funds from one biennium to the next. The County is aware of this restriction, as demonstrated in the Intergovernmental Agreement for the Financing of Community Mental Health, Developmental Disability and Addiction Services. Initially, the arrangement between the State, the County and the facility operator, Telecare, had Telecare entering into a lease agreement with the County and getting payment directly from the State (AMH) to cover both operational costs and lease payments. Lease payments would enable the County to make debt service. However, payments to the operator would depend upon occupancy of the facility, i.e., if only a portion of beds were filled, the operator would receive proportionally less. The County Administrator asked that I prepare a form of agreement which might be used to assure a steady payment stream from the State without violating the Constitutional prohibition on extending credit. With the assistance of outside counsel I prepared such agreement, amending the anticipated agreement between the State and Telecare and enabling the County to take over operations, if Telecare defaulted. Since the structure of this transaction later changed to what I describe next, the County's proposed amendment to the State-Telecare agreement was abandoned. The best the State could offer in this regard has been a letter from the Deputy Assistant Director of AMH reciting the history of funding support for this program from the State Legislature since the 1989-91 biennium, when community mental health budget was first adopted. This initial arrangement was later changed. To strengthen the County's hand in facility and program oversight Telecare would still lease the facility from the County, but the County would receive payments directly from the State in an amount designed to cover both the cost of Telecare's operating the facility, as well as lease payments. There are several concerns with this arrangement. First, while the County would be able to directly oversee Telecare's performance, the County was not directly involved in selecting Telecare as the area provider. The State conducted its selection process in accordance with state law, OAR 125-247-0288(2)(c)(B) and ORS 279A.050(6)(a)(A). I have requested background material from the State to document the selection process it followed and to determine whether the County can legally enter into direct contract negotiations with the Telecare without further competitive procurement. In order to avoid possible dispute in the future the Board may wish to proceed with a contract-specific special procurement under ORS 279B.085(1)(b), which would enable the County ultimately to contract directly with Telecare for the operation of the SRTF and the related facilities. Another concern is the basis on which the County would disburse funds to Telecare. The State's suggested approach is to use funds received by the County under the bi-annual State agreement (Intergovernmental Agreement for the Financing of Community Mental Health, Developmental Disability and Addiction Services) as the method of paying for Telecare's operation of the facility while enabling the County to meet debt service. This two-year agreement currently serves as a conduit for funding a variety of services connected with mental health. The State identified Service Element 28 as the specific provision enabling State funds to be used to pay Telecare for SRTF operating costs. The State also suggested that the County could withhold some funds from Telecare under Service Element 20, designed for non- residential treatment, on the theory that Telecare would be responsible for lease payments and Service Element 20 provides that funds can be used in part to assist clients in obtaining and maintaining housing. A third option might be to have the State become tenant of the SRTF under a lease agreement with the County. This lease would be similar to the lease of the Deschutes Services Bldg and the future lease of the OSP/911 building. Like those leases, it would contain a "subject to appropriation" provision allowing the State to cancel if the Legislature cancels funding. The State would also enter into an agreement with Telecare to operate the facility. While the PSRB clients are not wards of the State, the State can order persons subject to PSRB jurisdiction to stay in SRTF's. This arrangement avoids potential problems the County might encounter, not having undertaken a competitive procurement, but still directly negotiating with Telecare over the terms of the operating agreement. The State could also negotiate the terms of Telecare's compensation based on its selection process and on terms it is already familiar with. The problem for the State under this scenario is that the payments it makes to Telecare can be reimbursed from Medicare. On the other hand if the State is the tenant, its lease payments would not be subject to Medicare reimbursement, but would be payable entirely from State funds. Staff Recommendation The County would enter into a lease/operating agreement with Telecare. Funding for such operation would be provided by the State through its community mental health assistance agreement. Such funds would be allocated to operating expenses payable to Telecare and lease payments withheld by the County to meet debt service obligations. The County would need to negotiate a lease/operating agreement with Telecare outlining specific services and fees payable therefor, as well as lease provisions. There may be examples from other jurisdictions of both components. This agreement would encompass both the SRTF, to be utilized principally by persons under PSRB jurisdiction, as well as the two other non-secure facilities to be utilized principally by persons under County jurisdiction. In the event funding were for some reason discontinued or reduced to unacceptable levels, the County would have the option to terminate the agreement and operate its own facility as residential housing for persons with mental health problems. The County (acting through the Contract Review Board) would need to follow a process leading to adoption of a special procurement and thus enable a direct contract with Telecare. This would be justified largely upon the competitive process followed by the State. Copy: Dave Kanner, County Administrator Scott Johnson, Director, Deschutes County Health Services Department iregon Theodore R. Kulongoski, Governor October 9, 2009 Scott Johnson, Director Deschutes County Mental Health Department 2577 NE Courtney Drive Bend, OR 97701 Dear Scott: 500 Summer Street NE E86 Salem, OR 97301-1118 Voice 503-945-5763 Fax 503-378-8467 As we discussed during our telephone conversation October 7, I agreed to provide a brief statement of fact regarding the funding for the operation of residential treatment services. Darcy Strahan has provided the statutory and rule citation for the department's procurement process for client services to the county attorney. Since the implementation of the 1989-91 community mental health budget, the department has not cut funding for the operation of residential treatment services created as part of the process for decreasing the size of state hospitals. Over that period of time, the department has worked with local programs to create specialty residential services that allowed the department to downsize Oregon State Hospital and close Dammasch State Hospital. More than 1,000 community placements and residential beds have been created. The funding for the provision of these services was not cut by the department or the Legislature during the financial crises following Ballot Measure 5 in the mid 1990s. The funding for these services was not cut by the department or the Legislature during the major reductions in the 2001-03 biennium and in the 2003-05 biennium. I have been a member of the mental health management staff since September 1989 when Barry Kast, Assistant Administrator for Mental Health hired me as his Budget and Operations Manager. I was Assistant Administrator for Mental Health from 1994 until 2001 when the department was reorganized and I became the Deputy Assistant Director for Addictions and Mental Health. Department of Human Services Addictions and Mental Health Division If you need this letter in alternate format, please call 503-945-5763 (Voice) or 800-375-2863 (TTY) "Assisting People to Become Independent, Healthy and Safe" An Equal Opportunity Employer HSS1601 (11106) Scott Johnson October 9, 2009 Page 2 I hope this information will be helpful to you in your briefing with the Board of County Commissioners. Please let me know if I may be of further assistance. Sincerely, Madeline M. Olson Deputy Assistant Director MMO:je cc: Richard Harris Len Ray Darcy Strahan ~)regon Theodore R. Kulongoski, Govemor May 6, 2009 Scott Johnson, Director Deschutes County Health Services 2577 NE Courtney Drive Bend, OR 97701 Dear Mr. Johnson: Department of Human Services Addictions and Mental Health Division 500 Summer Street NE E86 Salem, OR 97301-1118 Vbi.ce 503-945-5763 Fax 503-378-8467 As part. of the ECLO request for proposals, Deschutes County'proposed the development of a secure residential treatment facility (SRTF), serving a combined population of Psychiatric Security Review Board (PSRB) residents, Extended Care Management Unit (ECMU) residents, and Deschutes County referred residents. During a videoconference on January 16, 2009, all parties agreed to include only PSRB and ECMU residents in the proposed SRTF. The beds for Deschutes County referred residents would be moved to the proposed development of two (2) residential treatment homes (RTH) and the two (2) current adult foster homes The proposed. developments are as follows: • Deschutes Recovery. Center -A sixteen (16) bed (SRTF), serving eight (8) individuals who are deemed (ECMU) eligible and eight (8) individuals who are under the jurisdiction of the (PSRB). • Two (2) RTHs Each home will provide housing for a five (5) individuals, for a combined total. of ten (10) ,placements. These placements will serve either individuals who are deemed ECMU eligible or individuals referred by Deschutes County- The County is providing the land for the SRTF development in exchange for. Six (6) County referred beds. The six beds will float between the two (2) RTH's and the two (2) existing AFH's. The Deschutes County Mental Health Department will have sole`di's'cr`etion in deterrririiig who's eligible for placement in the County TFferred beds, using criteria approved by the Addictions and Mental Health t0fbAbn. ,n+F•tn ~l ,1 ,aI 'i ric^n }.r r,77(" i':n r I..: ` If you need this letter in alternate format, please call 503-945-5763 (Voice) or 800-375-2863 (TTY) "Assisting People to Become Independent, Healthy and Safe" An Equal Opportunity Employer HSS1601 (11/06) 10 Scott Johnson,'Director Deschutes County Health Services May 6, 2009 Page 2 Addictions and Mental Health will provide funding for development of the three facilities based on requirements outlined in the Award Letter and facility operations based on requirements outlined in the County Contract. Addictions and Mental Health is not in a position to guarantee Deschutes County bond payments for the next 30 years and encourages the County to work with Telecare, their development partner for the three facilities, to develop a similar long term relationship. We thank you for your commitment to the development of community placements in Deschutes County. Sincerely,. Len Ray, L. .S.W., B.C.D. Administrator, Adult Mental Health Services DS/cec Cc: Lori Hill, Deschutes County Mental Health Darcy Strahan, AMH Cissie Bollinger, AMH Tony Guillen, AMH File - re on Theodore R. Kulongoski, Govemor April 3, 2009 Dennis R. Luke, Board Chair Deschutes County Board of Commissioners 1300 NW Wall Street Bend, OR 97701 Department of Human Services Addictions and Mental Health Division 500 Summer Street NE E86 Salem, OR 97301-1118 Voice 503-945-5763 Fax 503-378-8467 Re: Approval of AMH Housing Development Award for Deschutes County Recovery Center SRTF Building Additions Dear Mr. Luke: I am pleased to inform you that. the Addictions and Mental Health Division (AMH) has conditionally approved a grant award in the amount of $75,000 for the Deschutes County Recovery Center project located in Deschutes County. The funds are for the development of a 16-bed SRTF for persons with serious mental illness. This final award is in addition to the $675,000 previously awarded through grant #126155. It is important to note that the funds cannot be used to refund or reimburse any expenses or costs that occurred prior to the date of this award letter. All conditions listed below must be met before your award is committed. All requirements as specified in the award letter dated August 1-8, 2008 are applicable to this additional award. Including specifications listed below. Please respond in writing to the following conditions to obtain final approval of the award. 1. Occupancy. The Grant is conditioned on occupancy of the community housing occurring no later than August 31, 2010. This deadline may require modification prior to project completion. If required, modifications will be made in the form of an amendment to the Grant Agreement extending this requirement as needed. 2. Insurance Requirement. AMH requires that insurance be maintained for the life of the grant. Insurance required is: oC -.2009-19 If you need this letter in alternate format, please call 503-945-5763 (Voice) or 800-375-2863 (TTY) "Assisting People to Become Independent, Healthy and Safe" An Equal Opportunity Employer HSS1601 (11/06) Housing Development Award Letter Grantee: Deschutes County Project: Deschutes County Recovery Center April 3, 2009 Page 2 of 9 • Real Estate Hazard Insurance: coverage on all real estate that is collateral for the grant in the amount of the full replacement cost (equal to current appraisal). • Liability Insurance: is required for all grants in an amount not less than $1,000,000 with an insurance company satisfactory to AMH. Flood Insurance: zany portion of the collateral is located in a flood hazard zone, flood insurance, or other appropriate special hazard insurance, is required in the amounts equal to the lesser of the insurable value of the property or the maximum limit of coverage available. Please complete and return the enclosed Designation of Insurance form. This allows AMH to work directly with your insurance agent to obtain the insurance requirements prior to funding (or project completion). 3. Monthly Progress Reports. Provide AMH with a brief monthly progress report on the development of your project. Please use the attached report format. If you are already sending monthly progress reports to other funding sources, you may be able to substitute an alternative format. 4. Annual Confirmation Reports. After completion and occupancy of your project, AMH will conduct monitoring on an annual basis. As recipient of a grant award you will be asked to complete a confirmation report to document the continued use of the property for the agreed purpose. 5. Securing State's Interest. AMH requires that investments in real property acquisition or improvement be secured. Execution of a Housing Development Grant Agreement, Promissory Note and Trust Deed will be required. The Trust Deed must be recorded and will remain a lien against the property for a term of 30 years. These documents will be available for your agency to review before closing. Housing Development Award Letter Grantee: Deschutes County Project: Deschutes County Recovery Center April 3, 2009 Page 3 of 9 The equity value on the subject property must support all secured lien positions. Any project that reflects a negative equity margin must.be secured by additional collateral approved by AMH. 6. Disbursement of Award. The grant award funds will be disbursed through an escrow account. Please complete the'enclosed Title Company Information form regarding the title company that will be handling this transaction for you. You will be responsible for any fees associated with this transaction. Unless the parties agree otherwise in writing, the Closing shall occur no later than June 30, 2009. 7. Use of Rinds. Grant awards must be used to support community housing living quarters for people with chronic mental illness. Approval of your award is based on the application that was received in response to the solicitation dated August 7, 2008. Please inform us immediately, if the housing project changes. This includes changes to your budget documents that exceed 10% for any budget category and any changes in funding commitment amounts. Oregon statutes mandate that these funds be used by June 30, 2009. If you will not use your award by this date, please inform us immediately. Your award will be withdrawn for this biennium. 8. Project Development Budget. Include a budget that identifies cost for all proposed housing development activities (acquisitions and construction). Identify sources and uses of resources that will finance the housing development. Provide a brief status of each funding source (i.e. committed, application pending, etc.). Sample forms are available upon request. 9. Award Acceptance. You must complete one of the following within 15 days from the date of this award letter: a. Initial each page, sign the letter and return the on W al indicating your acceptance of the grant award and all the terms and conditions (a copy is Housing Development Award Letter Grantee: Deschutes County Project: Deschutes County Recovery Center April 3, 2009 Page 4 of 9 enclosed for your records); or b. If you have concerns about any of the conditions or timelines contained in this letter, contact me. I will discuss your concerns with the Community Housing, Employments and Supports Manager and if necessary we may schedule a conference with you to discuss your specific concerns. Please send the requested information to: Tony Guillen, PSRB Coordinator Addictions and Mental Health Division (AMH) 500 Summer Street NE, E-86 Salem, OR 97301-1118 I look forward to the successful completion of your housing project and appreciate your efforts to increase housing opportunities for persons with psychiatric disabilities. If you have questions or need further assistance, please call the PSRB Coordinator, Tony Guillen, at 503-947-5534 or e-mail him at anthonY. uillen@state.or.us; or the Housing Investments Coordinator, Karen Knight, at 503-945-5911 or e-mail her at karen.knightastate.or.us. Sincerely, /"G Bv- Len Ray, L.C.S.W., B.C.D. Administrator, Adult Mental Health Services TG/cc Enclosures cc: Tony Guillen, PSRB Coordinator Jay Yedziniak, CHES Program Manager H(,usint; DevelopmC."t Award Lcttei Grtuttcc: lleschtrtL:s Oulty Prrjcct: I)escl•iutcs ('(Rutty Recovery Center 4/3/09 P~Igc 5 of 9 Karon Knight. I lousing Investments Coordinator AMII Vile ACIItl,ED TO AND ACCEPTED ON THE TERMS AND CONDITIONS SET FO W114 ABOVI,: Deschutes C:oaiity Recovery Center Bell(l, Deschutes 0)"nly ilcnrsittg I)cvclopnj(-iit Award Cfl ,(i07 Fond - $37,A0 I'Sit13 C;I,G07I- Fund - $37,500 Agency: De,c•Ittr~ ,ounty By _ C~." • Date DcnuisLuke Title: _ Deschutes Cotrnt Board of Commissioners Housing Development Award Letter Grantee: Deschutes County Project: Deschutes County Recovery Center April.3, 2009 Page 6 of 9 PROPOSED PROJECT SCHEDULE Project Name: Date Schedule Developed: PROPOSED REVISED COMPLETED ACTIVITY DATE DATE DATE month/ ear * month/ ear * month / ear fill -au. ;~3 4trtiv ata Y'.'i .3,.y ~ 's'~~,Wr q_,y"'i v • Y?j ^.y3 _ f W yr~ •nr't ' Y"" gl,-. '1 6" : i4. s7r 7 c . r . . : ? ,3 O tion/Contract executed Site Acquisition Zoning Approval Site Analysis Building Permits & Fees Off-site rovements .y '.:4ic- N, a . .;i. rcw 'rte-+. p4if a i58 fir ...4:;x3 hrF Plans Completed Final Bids Contractor Selected s ~kh Rp. v "T u.. rE•~h 1 ; m ` y - cxrq, ¢ s 4 ,t.5.+ 'j~a. ~i w a '5i ~ LE 35 r°~'. coNSTlucrlarr>:OAN; Proposal Firm Commitment Ar rrr L"O, PER 7777 Proposal Written Commitment SYNDICATION AGREEMENT CONSTRUCTION BEGINS CONSTRUCTION COMPLETED CERTIFICATE OF OCCUPANCY LEASE UP COMPLETED * Indicates completion by end of month. Housing Development Award Letter Grantee: Deschutes County Project: Deschutes County Recovery Center April 3, 2009 Page 7 of 9 AMH HOUSING DEVELOPMENT MONTHLY PROGRESS REPORT Report # Project Name: Project Contact: Contact Phone Reporting Dates From To: REPORTS ARE DUE BY THE 10TH OF EACH MONTH 1. 2. 3. 4. 5. 6. Description of project development activities accomplished in this period: Activities anticipated to be accomplished by next reporting period: What percentage of construction activities have you completed to date? Estimated date of completion of construction: Estimated date of occupancy: Any change in the Proposed Project Schedule since last report? Yes No If "yes", submit an updated "Proposed Project Schedule. " 7. Any change in the development of the project (i.e., number of units, target population, development team, sources/uses, proposed rents, etc)? Yes No If "yes", provide details about the change(s). An updated "Sources and Uses "form is required when the budget is adjusted by 10% or more for any sub-total or total. i , Housing Development Award Letter Grantee: Deschutes County Project: Deschutes County Recovery Center April 3, 2009 Page 8 of 9 CERTIFICATION: A signature for regularly mailed reports or a typed name for e-mailed reports in the signature space below certifies that the information contained in this report is true, correct and accurately reflects the progress and status of the project. Signature: Printed Name: Date: Telephone Mail, fax or a-mail this form to AMR: Housing and Homeless Services Unit, AMH A 500 Summer Street NE, E86 Salem, Oregon 97301-1118 Fax (503) 947-5043 Housing Development Award Letter Grantee: Deschutes County Project: Deschutes County Recovery Center April 3, 2009 Page 9 of 9 •'J' Deschutes County Health Services Housing Development (for people with mental illness needing affordable housing / residential services) 2009-2010 County Goals & Objectives Goal: Ensure Deschutes County can meet its long term public safety needs. Objective: Increase local bends for mental health treatment, preventing more costly care or homelessness Actions: Action Measure 1. # of new beds July 2010 32 new beds / units 2. # of total beds / housing units July `10 72 total beds / units 3. % of community need met by 2011 (based on AMH need estimate of 580 12 percent 2010 Projected Inventory Projects New ro eds noted in .yellow Location Psychiatric Security Review Board * State Hospital Civil Commit Mainly Community Telecare 16-bed Secure RTH Bend 8 8 - Telecare 5-bed RTH #1 Bend - 4 6 Telecare 5-bed RTH #2 Bend - Hosmer House RTH Bend 5 - - Golden Eagle Foster Home Bend - 5 - Brietenbush Foster Home C) Bend - 5 - Horizon House Transitional Bend - - 14 Emma's Place Apartment Bend - - 11 Barbara's Place Apartment Redmond - - 6 Total 13 * 22 * 37 *includes some Deschutes and Central Oregon as well as used as a State resource availability of locally managed beds is critical to our system going forward We also have a few PSRB conditional release living in the community. r Deschutes County's Strategic Plan HOUSING CONTINUUM: For adults with mental illness Updated June 2009 (includes both facilities and services) Adopted by Deschutes County Board of Commissioners Key: New projects or needs in italics Highlighted signifies in process regional (Central Oregon) project DCMH=Deschutes County Mental Health PSRB=Psychiatric Security Review Board HW=Housing Works INDEPENDENT LIVING Offer / expand supported housing, case management GROUP HOUSING & SUPPORT Emma's Place 11 units w. voucher 1 Facility 8-12 units @ N County center Z Barbara's Place 6-unit Redmond HW South County project tbd HousingFirst projects annually RESIDENTIAL PROGRAMS Two 5-bed foster homes (10-beds total) in Bend Hosmer House 5-bed PSRB home, Bend 2009: 2-5-bed Telecare RTHomes s, Bend? 2009: Telecare secure 16-bed facili - 4 Bend (Deschutes County development) South county project(s) Urgent need: short-term respite 3-5 beds TRANSITIONAL HOUSING Horizon House 14 units Bend s Parole / Probation transitional facility Bend 6 Additional transitional facility Bend Transitional beds Redmond -Housing Works? House of Hope - limited; $400 / month Bend EMERGENCY SHELTER & ASSISTANCE DCMH homeless outreach worker(s). Need: more homeless outreach staff capacity 7 Bridge Corrections Program 2 FTE; need 3rd position Bethlehem Inn (est. 15-20 people mentally ill) Shepherds House * Sage View 15-beds Cascade Healthcare Community Psychiatric Emergency Services 5-bed (St. Charles CHC) Psychiatric Emergency Service 1-bed St. Charles Redmond LESSNESS / INSTABILITY / HIGH RISK homeless outreach worker(s) corrections Program 2 FTE; need 3rd position es County jail est. 8% mentally ill (20-30 of 220) alcohol, other drug treatment in jail and after INFRASTRUCTURE & SUPPORT - DCMHHousinSpecialists new to 1 Emma's Place: 9 of 11 residents have housing vouchers 11.07 z New apartment building on site of the proposed Redmond Deschutes County Service Center ' Residential treatment homes with 6 County placement beds and 4 Extended Care from State Hospital beds Secure residential treatment facility with 8 beds Extended Care; 8-beds PSR13 s Horizon House: 10 of 14 residents have vouchers 11.07 6 Parole & Probation transitional facility: estimated 4 to 8 of the 18 beds are people with a mental illness 11.07 ' Grant application submitted to State of Oregon Addictions & Mental Health; PENDING 11~ HEALTH SERVICE; 2577 NE Courtney Drive, Bend, Oregon 9770 Public Health (541) 322-7400, FAX (541) 322-746 Behavioral Health (541) 322-7500, FAX (541) 322-756. www.deschutes.orc To: Deschutes County Board of Commissioners (Board) Dave Kanner, County Administrator From: Scott Johnson, Deschutes County Health Services Date: November 4, 2009 Work Session (update of October 9, 2009 memo to BOC) Subj: Central Oregon Integration Project Potential State Demonstration and Regional Health Authority Concept This memo will provide the most current information about our work with Commissioner Baney and other jurisdictions about improving the health care system for the people we serve. Early mortality for clients There is an emerging body of evidence that suggests changes should be made in the way community health care is provided to people struggling with mental health and addictions. For example, people with a serious mental illness die 25 years earlier than the general population'. Eighty-seven percent of these lost years are directly due to medical illnesses. In addition, the disconnect between primary care and behavioral health compromises health outcomes and contributes to this problem. Central Oregon (CO) discussions Stakeholders in CO have been meeting to explore this topic and consider whether we should be changing our system. Commissioner Baney has been following this work on behalf of the Board. If it is possible, local groups are likely to support changes in the system to improve care. These groups include all three counties, the hospital system, our Oregon Health Plan insurance groups (ABHA, CDO, COIHS Z), Health Matters (a local health collaborative), Mosaic Medical, LaPine Community Clinic, Volunteers in Medicine, NAMI and the Cascade Peer and Self-Help Center. Richard Harris, State Addictions and Mental Health Director, has met with the group here to receive a briefing and express interest in our work. 1 Measurement of Health Status of People with Serious Mental Illnesses, Parks, Radke, Mazade, National Association of State Mental Health Program Directors, October 16, 2008. 2 ABHA (Accountable Behavioral Health Alliance), the CDO (Deschutes County Chemical Dependency Organization) and COIHS (Central Oregon Independent Health Systems / Clear One). To promote and protect the health and safety of our community a The concept of integration As outlined in the literature, integration would mean developing multi-disciplinary teams of health care providers, including mental health and addictions workers, who would work together to improve health outcomes for people enrolled in services at a community clinic. For example, County mental health workers could work in a primary care clinic like Mosaic Medical, with a care coordinator, a physician, a nurse and psychiatric consultation. Also, a specialty clinic like the DCHS annex program for people with serious mental illnesses could include a primary care component, to address primary care needs of people receiving intensive behavioral health services. National and State reform Numerous national reports are calling for system reform and this integration of behavioral health and primary care in clinic settings or "medical homes". With better coordination and integration, there is evidence client health will improve and costs could be contained. In Oregon, the 2009 Legislature passed a budget note calling for two to three demonstration projects. We are currently evaluating whether it would be beneficial to become a demonstration site. We may be the State's most likely candidate. Central Oregon counties meet September 30 The CO County Commissioners on the ABHA Board (Commissioners Fahlgren, Ahern and Baney) agreed that we should seriously consider a joint project. It may mean changes in the nature and scope of ABHA; it could also mean forming some sort of new regional health authority, with significant County leadership in this organization. The scope of work for a regional authority might include policy development, resource oversight and a regular review of system outcomes. No decisions were made but we were encouraged to keep working, October 20 State offer of demonstration site We received a letter (enclosed) from the State Addictions and Mental Health Division and the Division of Medical Assistance Programs offering the opportunity for our collaborative to be a "Demonstration Project site". The letter focuses on four things: 1. creation of a single point of accountability, 2. financial integration, 3. service integration and 4. agreed upon outcomes. The letter asks that our local group consider becoming a State sponsored demonstration site and to work together to develop a Memorandum of Agreement. Questions emerging for the Deschutes County Board of Commissioners 1. As a matter of policy, do you as the local mental health and public health authority endorse health care service integration (behavioral health, primary care and preventative care) as a concept and do we want to see service models that can move our system in that direction? 2. In reviewing the letter from the State of Oregon, do we support working with Jefferson and Crook counties and others to become a State demonstration site? 3. As we learn more about the option of forming a Regional Health Authority, do we want to seriously consider a more formal regional entity to lead this effort and support our work? I look forward to the opportunity to meet with you on November 4 to discuss the project and the State invitation. No decision will be needed but general guidance would be appreciated. Thank you. Lo cal Wh 1te. Fav er 11 Central Oregon Health Integration Project (COHIP) Operational Model for Medical / Behavioral Health Integration DRAFT 1. Context Sparked by a pilot project initiative started by Senator Bates and Representative Kotek and promoted by the State Division of Addiction and Mental Health, a number of key providers and insurers in Central Oregon have worked cooperatively to design an integrated service system bringing together behavioral health and primary care. The organizations involved in this redesign effort include: • Cascade Healthcare Community • Community Mental Health Programs from Crook, Deschutes, & Jefferson • Central Oregon Independent Health Services (COINS) • Accountable Behavioral Health Alliance (ABHA) • Mosaic (the regional Federally Qualified Health Center) • Health Matters The issues with which we struggle to develop an integrated system are complex, especially as the state and federal environments we work within are in a period of rapid change. Despite the challenges, the discussions and work we have done have been marked by a high degree of collaboration, collegiality, and honesty. We have found it easy to agree on what needs to be done, but we have struggled to understand how to get it done within the regulatory and financing spaghetti that is today's system. The current primary care and behavioral health model is not sustainable. The episodic and fragmented nature of the current health care system leads to poor outcomes and higher costs for people living with chronic conditions. People living with serious mental illnesses are dying 25 years earlier than the rest of the population, in large part due to unmanaged physical health conditions. In the existing primary care environment, psycho-social needs generally are not addressed, resulting in many poor outcomes in people with chronic health and behavioral health conditions. Many people with chronic conditions are not engaged in a primary care setting and receive care through emergency room settings. This leads to significantly worse health outcomes at significantly higher costs. Central Oregon has recently seen a number of ambitious reform initiatives spring up in an attempt to address serious local needs in the face of little meaningful change at the federal or state level. In one of the more ambitious local initiatives, HealthMatters of Central Oregon, was formed as a 501(c)(3) non-profit to facilitate cooperation among partners and members of the community in an effort to provide better health for more people at less cost. In this context, the Central Oregon Health Integration Project is one of a number of initiatives under the HealthMatters umbrella that creates a coordinated network of providers to deliver critical services to underserved populations in a sustainable manner. CO Health Integration White Paper Page 1 11/3/2009 The initial focus of the Central Oregon Health Integration Project is to develop an effective care network for people who frequently utilize hospital emergency departments in order to help them obtain higher quality and lower cost care in person-centered health care homes. The person-centered health care homes will be either primary care clinics or specialty behavioral health clinics offering integrated medical/behavioral health services. II. Emergency Room Diversion Initiative For many people with behavioral health issues, the Emergency Room (ER) becomes the first place they go for all healthcare needs. We are proposing a voluntary program that would identify high utilizers of ER services who have high medical needs and high behavioral health needs, and offer them services within our community that would better meet their medical/behavioral health needs and reduce the visits to the ER. The project would initially identify those people who meet these criteria and are on the Oregon Health Plan. They would be asked to voluntarily participate in "Health Link"-the Central Oregon Pathways program. Care Coordination Pathways is a tool used to shift the focus of health and human service providers from activities to outcomes and support the client's treatment team. Pathways are unique in that the outcomes are tracked at the level of the individual. The Pathways (developed by the treatment team) provide a step by step guide for the care manager (nurse, social worker, community health worker) to work through a specific client problem focusing on achieving a positive result. Each step of the Pathway addresses a clearly defined action towards problem resolution. The Pathways utilized can span any health or social service issue. In each Pathway the "at risk" individual is identified, confirmed to connect to care and the result measured. The steps of the Pathway define patient education, social and access issues such as transportation, in addition to the medical care. The Pathway is not considered complete until an identified problem is successfully resolved. Completion of a Pathway may involve more than one agency and/or health care provider and is part of a Community Hub (a neutral multi-agency community network). One client may have many different Pathways depending on the problems identified. The Community Hub employs, trains and supports Community Health Workers (CHWs) to improve outreach to communities most at-risk for poor health outcomes. The model of Pathways serves as the outcome focused care management tool for Community Health Workers. There are developed contracts which help change the financial focus of this work to outcomes. The Community Hub does not receive payment for services unless specific individually tabulated outcomes are achieved. COHIP's goal is to hire a Pathways Coordinator to oversee the project development and treatment teams for the patients who are involved in the project. There will be a Nurse Care Manager who will assist in overseeing coordination of medical care, and two-three Community Health Workers to carry out the treatment plan recommendations by the end of 1St quarter 2010. CO Health Integration White Paper Page 2 11/3/2009 r III. Person-centered Healthcare Homes Person-centered healthcare homes are medical homes that have integrated medical and behavioral health care. A person-centered healthcare home can exist in a primary care setting or in a behavioral health setting, with the care following wherever the patient chooses to obtain his or her services. A person-centered healthcare home will require the integration of both the mental health and the chemical dependency benefits into a coordinated care system. COHIP plans to have Behavioral Health in the Primary Care Medical Homes by the end of 1St quarter 2010, and Primary Care in the Behavioral Health setting as soon as the funding mechanisms can be worked out. A. Behavioral Health in Primary Care Medical Homes Effectively integrating behavioral health into primary care medical homes can (a) help improve both behavioral and medical outcomes, (b) help avert medical crises resulting in expensive care, and (c) increase the utilization of behavioral health services for people who would not otherwise go to specialty mental health and addiction community clinics. The key elements of behavioral health integration in Central Oregon primary care settings that we plan to implement are: Embedded behavioral health consultants - Each participating primary care medical home would have a behavioral health consultant (LCSW, QMHP, or RN) integrated into its clinical team. The behavioral health consultant would provide a range of services including: screenings, patient consultation sessions, counseling sessions, therapeutic groups, and helping patients access and engage in services at specialty behavioral health clinics, when appropriate. The medical home would use the specialty behavioral health clinics as a resource for the services of the behavioral health consultant. 2. Designated consulting psychiatrists or psychiatric nurse practitioners -Each participating primary care medical home would have a designated consulting psychiatric prescriber (psychiatrist or prescribing mental health nurse practitioner) whom the behavioral health consultant and primary care physicians can readily access for support and information. 3. Routine screening and brief interventions for behavioral health issues -The primary care medical homes will implement standardized, evidence-based screening and brief interventions for mental health and substance abuse disorders. 4. Access to a broad continuum of care in behavioral health - Working with the behavioral health consultant, the clinical team will implement a wide array of interventions, from brief consultations and recommendations to individual counseling to intensive outpatient and residential services. CO Health Integration White Paper Page 3 11/3/2009 5. Engagement with community social services - Using community health care workers and other peer support services, patients will be given support for engagement in the appropriate social services. A strong focus on social services already exists in most medical homes in Central Oregon. Behavioral health integration would add to the focus on wraparound services. B. Primary Care in a Community Behavioral Health Setting The National Council for Community Behavioral Healthcare published a paper in April 2009 called "Behavioral Health /Primary Care Integration and the Person- Centered Healthcare Home." This serves as the core model for primary care services in a community behavioral health setting that we seek to implement. The key elements of our model include: Regular screening and tracking of health indicators - The community behavioral health care homes shall adopt the National Association of State Mental Health Program Directors Health Indicators Project. This commits each community behavioral health clinic to track ten key health indicators with the observation that we cannot manage what we cannot measure. 2. Medical nurse practitioner- Each behavioral healthcare home shall have a medical nurse practitioner who provides easy access to primary care services in the clinic, preferably contracted from the primary care person-centered health care home within this project. 3. Embedded nurse care manager - Duties would include maintaining the health indicator registry, communicating the need for treatment adjustments to the primary care team, coordinating care across multiple settings, and support ongoing peer-led groups that support smoking cessation, weight management, and physical exercise. 4. Evidence-based Wellness programs - Each community behavioral health clinic shall create and support wellness programs for their clients. The wellness program should include such things as peer mentors, support groups, nutrition and healthy cooking classes and walking groups and access to local fitness centers. We plan to use local partners wherever possible, such as Living Well Central Oregon for classes on how to live with chronic conditions. C. The Outpatient Chemical Dependency Benefit Unidentified and untreated substance abuse issues are a significant cost driver in health care, with additional serious social costs in criminal justice, child welfare, mental health, and employment. The effective integration of the chemical dependence benefit can provide for better medical outcomes and gains in these other social areas. The types of services would include: CO Health Integration White Paper Page 4 11/3/2009 • Wide use of evidence-based services • SBIRT: Screening, Brief Intervention, and Referral to Treatment in medical settings • Range of intensity for outpatient services depending on clinical need • Case management • Recovery coaches (specialized community health workers) • Higher payments for dual disorder enhanced services and pain management services We will use clear clinical priorities and improved analysis of medical, mental health, and chemical dependency utilization to create medical cost off-sets for the plan. Special attention will be paid to setting up services for the highest need people (dual disorders of pain management / addiction and mental health / addiction), with active outreach, immediate access to services, and community-based supports. We will consider integrating residential addiction treatment into the project. A number of issues make such integration challenging at this time. We will also explore ways to achieve key operational goals, such as improved access for pain management clients, through agreements with the residential providers in the area. IV. Integrated Electronic Medical Record and Data Analysis The most effective integrated care approach will require electronic medical records (EMR's) that can help the hospital, the key primary care clinics, the behavioral health clinics, and the Oregon Health Plan managed care organization to "talk" to each other. This would allow for the efficient sharing of real time information across providers, thus increasing quality of care and decreasing medical errors. This is an expensive and complex initiative, but one that can tremendously facilitate high quality integrated care. Shared data analysis will be critical to create continuous performance improvement systems. So far we have seen that it has taken months to successfully share basic data. For the integrated system to more quickly see meaningful improvements in care and increased efficiencies in the use of resources, we will need to set up data driven performance improvement initiatives throughout the system. The data will need to be timely and easily accessible for analysis. An integrated EMR will provide the kind of data base necessary. V. Outcomes We will track three levels of outcomes: efficiency metrics, quality metrics, and process metrics. a. Per member per month cost of care Efficiency b. Acute admissions and ER visits per 1000 covered people metrics c. Acute care readmission rates d. Primary acute care admission rates for avoidable conditions CO Health Integration White Paper Page 5 11/3/2009 a. Increase in care contacts through the healthcare homes Quality b. Acute care readmission rates metrics c. Improvements in individual health status d. Patient satisfaction a. Full implementation of the ER Diversion Initiative across the region Process b. Full implementation of behavioral health integration into all the metrics Federally Qualified Health Centers in Central Oregon c. Full implementation of primary care in behavioral health clinics VI. Financing Our initial focus is on implementing medical/behavioral health integration around the Oregon Health Plan benefit. We hope to move quickly to add indigent care into the integration effort, , as Cascade Healthcare Community has offered to hire one Community Health Worker for this population as soon as the project gets underway. Other populations we will consider for inclusion are people who are covered by Medicare and people who are working but uninsured. The Department of Human Services, Addiction and Mental Health Division has committed $150,000 to this project for the 2009-11 biennium, with future funding as approved by the Legislature. All of the major partners in this effort have promised resources as well, which should fully fund the initial project start up and operations. Current resource commitment is as follows: Draft - Source of Funds Use Amount AMHD Staff $150,000 Cascade Healthcare Community Community Health Worker $35,000 COINS RN Care Manager $80,000 ABHA Community Health Worker $25,000 Chemical Dependency Organization Community Health Worker $10,000 HealthMatters Staff $50,000 Mosaic Medical Space TOTAL $350,000 VI. Summary COHIP appreciates the opportunity to be a demonstration pilot for DHS in reforming how our healthcare delivery system operates. It is our hope that the partnership with HealthMatters, and the unique opportunities this region presents in terms of existing delivery systems, grants, and other characteristics will provide us the opportunity to truly make a difference in the long term health of the people we serve. CO Health Integration White Paper Page 6 11/3/2009 n In tyregon '$9 Theodore R. Kulongoski, Governor October 20, 2009 Scott Johnson Robin Henderson Central Oregon Integration Project 2577 NE Courtney Drive Bend, OR 97701 Dear Mr. Johnson and Ms. Henderson; Department of Human Services Addictions and Mental Health Division 500 Summer Street NE E86 Salem, Op 97301-1118 Voice 503-945-5763 Fax 503-378-8467 SWe. offer of a demonStfaIton slfieJI The Legislature directed Department of Human Services (DHS) to establish demonstration projects with willing local partners to develop an integrated management and service delivery system that includes physical health, addictions and mental health services. We know that the task in front of us and our local partners can seem daunting. The legislative intent includes using all existing funding to improve services, developing a single point of accountability for the delivery of services, reducing the use of emergency department, residential and hospital services and managing and evaluating contracts on outcomes. We appreciate what the Central Oregon Integration Project (COIP)'members have already accomplished in developing a possible demonstration project. The discussions between local partners and key members of the Addictions and Mental Health Division (AMI-I) have been very productive. We especially appreciate the time COIP members took to brief Richard Harris and Len Ray from AMH. We are offering COIF the opportunity to be a Demonstration Project site. Upon acceptance by all COT members additional details will be negotiated in a Memorandum of Understanding (MOIL) and contract language and as needed. DHS understands that local communities may not be able to accomplish the full mandate at the beginning of the project. Local projects may propose demonstrations that incrementally approach the different components of the demonstration that meet the legislative intent- This includes the four basic components of the demonstration projects: 1. Creation of a single point of accountability; 2. Financial integration; If you need this letter in alternate format, please call 503-945-5763 (Voice) or 800-375-2863 (TTY) "Assisting People to Become Independent, Healthy and Safe" An Equal Opportunity Employer HSS1601 (11/06) Scott Johnson and Robin Henderson October 20, 2009 Page 2 3. Service integration; and 4. Agreed upon outcome measurements. DHS supports the essential role of the three counties, as Local Mental Health and Public Health Authorities in this effort. We understand that local accountability and ownership, including leadership from the counties, greatly increases the opportunity for success of this project. The single point of accountability should be designed by the local demonstration project in close consultation with the Local Mental Health Authority (LMHA). Ultimately, we see a single point of accountability as one entity managing the financing, governance, provision of services and local planning. It would include physical health, mental health, and addiction services. We have no preconceived entity in mind but firmly believe that the entity must have the necessary expertise in all areas of service delivery and management. This could be an administrative services organization serving as an umbrella organization, a limited partnership, a Medicaid managed care entity that will take on broader responsibilities, or some new concept that we have not developed. Please let us be clear, that we are interested in seeing your proposal on the concept. Your proposal will help guide discussions. We seethe demonstrations as collaborative projects with local communities and look forward to working with local projects to finalize details. This includes negotiations regarding financial support, use of different financial resources, timing, outcomes and governance structures. You will have the opportunity to take on the responsibility for managing long-term care and services for residents of the demonstration region, even if you are not ready to do so initially. Proposed demonstration projects should submit business plans including proposed populations, timelines, and governance structures. The plans should discuss movement toward consolidation of administration and financing. DHS will provide additional clarity around the four components and additional guidance to help proposed demonstration sites complete the business plan. DHS also knows that developing new systems across funding streams, providers and populations can appear to be risky. DHS will work closely with local projects to minimize potential risks, especially related to Medicaid funding and will work Scott Johnson and Robin Henderson October 20, 2009 Page 3 internally and with the federal government to remove barriers and reduce potential negative outcomes. We will actively engage other divisions within the department and other state agencies to help support access to other social services and supports. DHS is not asking local communities to shoulder the entire responsibility for the demonstration. DHS will work closely with the demonstration sites to: • Provide $150,000 this biennium to support Demonstration efforts. Future funding for the project will be negotiated during the budget and contract development process and of course will be contingent on legislative approval. • Provide access to a new data.system that will allow local systems and providers access to real time data. • Contract for an external evaluator similar to the Children's System Change Initiative evaluation process. The intent is to limit any additional burden on the demonstration partners but to clearly show key leaders, including the Legislature, the progress being made. • Actively partner on federal and foundation grant applications that support the demonstration's goals and objectives including researching available opportunities, applying for state-only funding opportunities, and supporting local grant applications. • Support local efforts with a DHS team to resolve problems and negotiate barriers. • Provide flexibility, where possible, regarding financing and administrative requirements. • Provide COIF partners current biennial details regarding state and federal funding to show a baseline of the resources that are provided to the region for physical health care, mental health services and addiction services. • Work with the LNMs to consolidate all state funding in the state/county behavioral health Financial Assistance Agreement to each county to increase flexibility and reduce silo thinking, as long as state and federal mandated and core services are available to all prioritized citizens. Scott Johnson and Robin Henderson October 20, 2009 Page 4 You have requested that DHS provide the COIP team the "Kessler formula using prospective population estimates for 2009-2011, to determine the relative state mental health and addiction investment in each county." The Kessler formula is a methodology to distribute funds with a much broader context then the demonstration projects. AMI-I will work with AOCMHP to work on the formula issue in a stand alone process. We do not see the demonstration projects tied.to the issue of formula allocations and are not making any changes at this time. However, we will provide COIP both the current contracted amounts and the impact of the Kessler formula on the region and the state as an example at your request. We also understand that state's financial situation may change causing program and service cuts. Additionally, local budgetary situations may also change. If these situations do occur, the entire demonstration project agreement would be open for discussion at that time. DHS developed specific examples of measurable outcomes for individuals receiving services in the demonstration projects. However, final measurable outcomes will be developed between the site and DHS. We will provide information to the Legislature explaining the agreed upon outcomes. We believe increasing access is a vital component. One way we believe this will happen is through savings resulting from reduced utilization of high cost services back to the local community. However, we also understand that increased access is contingent on stable funding and may not be realized if funding scenarios change. We also want to assure local communities that we are committed to the success of these projects and have no preconceived end-date. We believe that moving in this direction provides better accountability, higher quality of care and better access to those in need. DHS will support the Demonstration through 2013-2015 biennium providing it doesn't conflict with legislative direction and measurable progress is being made on agreed upon outcomes. We believe that the demonstration projects will continue to change and adapt to new information and to the experience in the demonstration as we progress. Also, DHS and local partners should have the option to terminate the demonstration if the project is not meeting expectations or if there is irreconcilable differences. Scott Johnson and Robin Henderson October 20, 2009 Page 5 We look forward to working with the COIP to finalize a formal agreement including negotiated outcomes by December 1, 2009. This agreement will describe the partnership between DHS and local partners and expectations on both sides. If you have questions, please feel free to call Jane-ellen Weidanz, DHS Integration Demonstration Project Manager at 503-945-9725 or e-mail her at Jane- ellen.weidanz@state.or.us. Sincerely, --e-,-`:~~' Richard L. Harris Assistant Director Addictions and Mental Health Division Judy Mohr Peterson Assistant Director Division of Medical Assistance Programs June 29, 2009 The Department of Human Services, Addictions and Mental Health Division (AMH), worked with stakeholders to develop a Policy Note that captured the full intent of the integrated management and service delivery system demonstration project. Though the policy note has been shortened, AMH has assured our stakeholders that we intend to follow the principles and processes described in the negotiated text provided below. Negotiated Policy Note Language In order to increase the availability, access and quality of addictions and mental health prevention, treatment and recovery services and to improve health outcomes and access to primary care so that individuals with mental health and/or substance use disorders are served in the most natural environment possible and so that the use of institutional care is minimized, the Department of Human Services (DHS) is directed to take the following actions by June 30, 2011. • Institute two or three demonstration projects, with willing Local Mental Health Authorities, Mental Health Organizations, Fully Capitated Health Plans, Federally Qualified Health Clinics and mental health, addiction and health care providers in the communities, to develop an integrated management and service delivery system including physical health and addictions and mental health treatment and recovery services. In the demonstration projects: • Existing State, Federal, Other and Medicaid funds currently administered by DHS will be administered through an integrated management entity or other local collaborative structure with a single point of accountability for the delivery of integrated health, mental health and addictions services. • Services should include preventative, routine, acute and specialty medical care, a full continuum of mental health and addictions services including (but not limited to): peer delivered services, detoxification, acute and sub-acute mental health care, residential addictions and mental health treatment, outpatient, and supportive housing and employment. iLittegratea wtanagement and Service Delivery System Demonstration Project a~ A~ O O ~ O o `V .U.~z", a~ ~ o v ~~v V z 0 .TEO O a~ .o e O V 0 0 N a~ 0 z 0 U m s~ c~ a~ c~ U v FEE4 ~ Cn 4~ . r+ V N ~ .V ~ O ~ V V .O O ~ V • O ~ O O c 00, ■ ■ O U U cd O .O c~ .V O GU c~ U ■ +J • 0 5 O V ~ , U cc U co) + O U CD d C CD . . a cd co) ~ n O ~ ~ • O ~ ~ V U ■ 'V V ~ V U 0 ~ o ~Q O d ~ ~ U U , ~J ■ ■ ~ x 0 0 ~ o O ~o o 0 O V O 0 V ■ ~I V O c~ 0 0 .O V A ^ O V V O V O -ij ~ V cd w ■ Cl) V c~ CO) 0 c~ O A O c~ V Cd u O V ~ V V ~ w O 0 c 9 4 a~ 0 O 0 w 0 Cf) V ~ 77 77 fi c .-1F1 ~ Q U A Q 4 .m a r~ X S y.S i t/)' W W a Z 4 WI--i~ LLJ a~ o J; U © { Z >Zl~ r ur)o f- L ~J Y V ~ w- ~I 0 O C~ U H P1 O 3i P1 O O P1 O ~ V v~ • b,A O V H .O b,A O 0 • U V ^ •O O V V O V O ~ V c~ x 4-1 O 4~ O 0 ~ ~ V ~ • bJ0 V ~ N c~ W6 ^ z 'O i-1 •--1 C O U ~ X10 V 4~ ^ V W o cd V ~ V O ~ V~ M . ^ M U 4 O c~ c~ V c~ ^ c~ V O V .V O V 'I:~ X10 4-j .z O O O b,A V c~ c~ d' ~ c~ c~ bA a~ U O V H ~w Wo H~ ■ cc W WJ 'TEO O 1 ~ V .o ~ V ~ V W ■ O i-I O O V c~ U ■ O ■ W V V 4~ Z V ■ O TME4 a~ V ~ o O ~ U W x 00 O .O ■ O ■ ~1D 0 7~ .o O V O u a~ c~ .O U O c~ U "d u O sa N 3 ■ bA V a~ V ■ c~ O a~ j o ~ O ~ 0 V ~A O O E O ■ a~ s~ c~ U «i O U U 71 CO) O U U c~ O F --q ■ c~ 4~ E 1 n. s~ v CO) v O c~ U s.~ d) E J r I I I - 17 '4~I Y !CI ...X ,J 27 CL c~ J c~ M N ~ y ~ A G~ O 1-~ b U O ~ N A U _+J +J +J 7V 7~ ,•O V c~ .r' m x A 0 N 0 M V i:,~ O U 4.4 U~ V ~ ,r..~ . 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O ~ O O ~ O ~ V ~ ca ~ +J ~ O ■ r O O X10 V a~ ■ (1 • O O ~ ~ O • 'ti a~ 0 U a~ u O V V O •O O U 0 z ■ i:--a O •o U ^ ^ a O a~ a~ r~ O c~ •o 0 0 pp •O •V O O ~ o •V ~ ~ V O ~ ■ • i-1 cad V O O V O a~ O 0 c~ 0 U ■ c 0 4~ A •O O cM 0 c~ 0 c~ U - 514 ■ O^ V ~ O ~ V O •V .o (I)l O Q ■ •O 0 V • O •O ~ V V V U ~ ;MMI •o V O (u c~ x ■ Community Development Department Planning Division Building Safety Division Environmental Health Division 117 NW Lafayette Avenue Bend Oregon 97701-1925 (541)388-6575 FAX(541)385-1764 http://www.co.deschutes.or.us/cdd/ DATE: November 4, 2009 MEMORANDUM TO: Board of Commissioners FROM Nick Lelack, Planning Director SUBJECT: Comprehensive Plan Update Direction On October 28, the Board conducted a work session to discuss the Comprehensive Plan update. The Board, members of the Planning Commission, and staff discussed several key issues. Both at the work session and since, the Board has: (a) clarified Planning Commission and staff roles and responsibilities; (b) provided flexibility in the timeline to complete the Plan update; and (c) directed staff to work with the Planning Commission to revise the "action items" into policies or to remove them from the draft Plan (and maintain them separately). The purpose of this agenda item is to further clarify Board direction on the Comprehensive Plan update. One issue the Planning Commission and staff seek direction on is how the Comprehensive Plan update should move forward. The Planning Commission may discuss and vote on whether the draft Plan should be scrapped (deemed "dead on arrival") and re-written at its next regularly scheduled meeting on Thursday, November 5. Three Commissioners do not believe any element of the current draft Plan can be salvaged. If the Planning Commission votes to initiate a re-write of the draft Plan, and the Board supports the Commission, then the publicly noticed work sessions and open houses on the current draft Plan should be suspended and/or completely revised. A new schedule would be established for the Planning Commission and staff to re-write the Plan update. Key issues with this revised approach include: (a) significant public notification has been provided on the work sessions and open houses; (b) the Planning Commission has just begun to express its views on the substance of the current draft Plan; and (c) public comments have indicated support for elements of the draft Plan and/or provided specific input on how it should be revised and improved. Alternatively, the current approach - Planning Commission work sessions and open houses to gain input on the current draft Plan - may be continued as scheduled through January 7, 2010. Then, the Planning Commission and staff would conduct public work sessions to edit the draft Plan as necessary to prepare a revised Plan for consideration at public hearings. However, the key issue with this approach is whether the Planning Commission supports it. Quality Services Perfonned with Pride