Positive Approaches Journal, Volume 11, Issue 2

Volume 11 ► Issue 2 ► August 2022

Pennsylvania Office of Developmental Programs, Office of Mental Health and Substance Abuse Services, and Allegheny Department of Human Services START Pilot Partnership

Brenda Bulkoski

Pennsylvania’s human services have long struggled with the challenges associated with the needs of individuals with intellectual disability and/or autism (ID/A) and acute behavioral health (BH) issues. In response to that need, the Systemic, Therapeutic, Assessment, Resources, and Treatment Model (START) is being explored as a viable option to address the complexities of this population.  Pennsylvania’s Department of Human Services on Dual Diagnosis received expert feedback that identified there needed to be network development for diversionary services and crisis response to optimize the coordinated planned crisis response and diversion strategies from state facilities.   It was suggested that implementation of model programs such as START would optimize proactive crisis prevention strategies and coordinated crisis response through the expansion of these services and activities.  

START is:

START is not a habilitative service, rather, it is a treatment service and a behavioral health response to better serve individuals with ID/A and behavioral health challenges. The START model is designed for anyone ages six and up with ID/A and Behavioral Health issues. The model is flexible and can be stylized for many different sub-populations within these parameters.

At an operational level, START uses a Tiered or Tertiary Approach.²

What we hope to accomplish

In the spring of 2021, Pennsylvania’s Office of Developmental Programs (ODP) along with the Office of Mental Health and Substance Abuse (OMHSAS) approached Allegheny County Office of Developmental Supports (ODS) and Office of Behavioral Health (OBH), asking if Allegheny County Department of Human Services would be interested in partnering on piloting the implementation of the START model. This pilot will last three years. This approach is very appealing to Allegheny. The opportunity to invest the time in building capacity through education and partnerships is very exciting. The results associated with responding to the need versus reacting to a situation will be a true cultural shift, yet one that is vital. Allegheny County DHS has made a commitment to provide services that are accessible, culturally competent, integrated, and comprehensive. To assure that all perspectives are considered, Allegheny County wants to have a diverse group of individuals. Through exploration of the START model, Allegheny County aims to learn better ways to address service and support needs for those individuals with the most complex ID/A and behavioral health conditions. One way to accomplish this is by providing the opportunity – as well as have the expectation – that those systems work together to identify gaps and needs and then collaborate and plan to address the needs of those more effectively. One of the goals of this pilot is to strengthen our current provider network by building competency and confidence and capability in serving persons with ID/A and BH needs. By assisting providers in meeting the needs of these complex individuals, results should indicate an increase in the stability of the persons current life and reduce the frequency of discharges and placement in restrictive settings. Furthermore, there should be evidence of less unnecessary contact with hospital emergency rooms or encounters with law enforcement. By contrast, when such encounters cannot or should not be avoided, the outcome to better support the person’s needs and reduce the likelihood of additional encounters. It’s important to acknowledge the current struggle providers have in recruiting and retaining staff. Allegheny County hopes to see a connection between staff who are trained, supported, and encouraged, and a more stable workforce. One final goal to have the ability to offer enhanced support to families who live with and support individuals with complex issues. Part of the START model aims to equip our families with resources so their experiences with their loved ones are more enjoyable and they are more confident in knowing where to go, what to do, and who to call for help when needs arise. According to the University of New Hampshire Center for START Services Annual Report 2021, the START approach has seen some positive outcomes. Of the crisis calls received in 2021, 85% of those calls resulted in the person remaining in their community setting and an additional 9% returning home following a brief emergency department visit.  Seventy-one percent of individuals had a reduction in mental health symptoms as measured by the ABC.

Currently in Allegheny County

As of May 2022, in Allegheny County, there are 6,238 individuals active with the Office of Developmental Supports (ODS). 244 of them (or 4%) are also active in our Office of Behavioral Health (OBH). 

Figure 1: Age breakdown of those active in Allegheny DHS, ODS and OBH  

Age	Number of Individuals	% of total (N=244)
21 and younger	102	42%
22 and older	142	58%

 Figure 2: Gender breakdown of those active in Allegheny DHS, ODS and OBH 

Gender	Number of Individuals
Male	147
Female	97

Data from the Allegheny County ODS for FY 21/22 

These individuals are well known to both the intellectual disability/autism and behavioral health systems. Many of them experience a pattern of rotating hospital stays and multiple residential placements. In addition, these individuals experience trauma related to inconsistent staff who are not familiar with their personal history.  For years, the systems responsible for meeting the needs of those with intellectual disability (ID), developmental disabilities, autism, and behavioral health needs have recognized support gaps and uncoordinated care.  Some of the challenges for the service delivery system have rested in regulatory and statutory rulings and uncoordinated funding. In addition, professionals serving from each of these systems have often reported feeling ill-equipped to serve the more comprehensive needs of persons they were supporting, which resulted in a reliance toward the ‘other system’ to serve the more ‘primary’ need.  Though many dedicated professionals have tried to bridge this gap through collaboration, something was still missing.

Allegheny DHS Target Groups

Allegheny County has identified a target group who could best benefit from this model. This cohort includes individuals between the ages of 12 – 35 with either ID or autism and significant behavioral health needs. This age range has experienced some of the longest hospital stays, highest cost of services, and highest turnover in residential placements.   

For the initial phase of the pilot, 70 individuals have been targeted as “first referrals” to START.  

For the most recent FY (21/22), key elements related to this grouping included whether or not individuals are receiving services and funding (Figure 4). 

Figure 3: Race and Gender breakdown for 70 “First Referrals” 

Race	Gender
42 Black	24 Male	18 Female
22 White	17 Males	5 Females
2 other		2 Females
1 Asian		1 Female
1 Hispanic	1 Male

 Data from the Allegheny County ODS for FY 21/22

Figure 4: Funding of 70: “First Referrals” 

Total Unique Individuals Identified	70	% of total
Individuals with ODS Funding	34	48.6%
Individuals without ODS Funding	36	51.4%
Individuals with OBH Funding	59	84.3%
Individuals without OBH Funding	11	15.7%
Individuals with either ODS/OBH Funding	62	88.6%
Individuals with No Funding	8	11.4%

 Data from the Allegheny County ODS for FY 21/22 

Figures 5 and 6 highlight the top 5 services received through each office. The following considerations should be noted when looking at this data:

Figure 5: Top 5 most frequently authorized services from Office of Developmental Supports 

ODS Service Subgroup  FY 2021/2022	Auths	Amt Utilized	Amt Auth	Auth Amt Avg
Res Hab - Licensed	62	$3,262,305	$4,857,653	$78,349
In-Home & Community Supports	36	$374,876	$627,065	$17,418
INELIGIBLE Costs	41	$260,136	$372,104	$9,076
Supplemental Habilitation	10	$144,448	$229,924	$22,992
SUPPORTS COORDINATION Services	64	$133,187	$227,644	$3,557

Figure 6: Top 5 most frequently authorized services from Office of Behavioral Health 

OBH Cost Center  Calendar Year 2021	Total Cost
Psychiatric Inpatient Hospital	$1,443,872
Community Residential Services	$802,555
Outpatient	$345,978
Not yet define in DW	$87,775
Targeted Case Management	$86,670

Data from the Allegheny County Analytics for FY 21/22 

When considering all available services associated and expensed across these 70 individuals, the total annualized cost was $7,471,687 (Figure 7).

Figure 7: Annualized estimates for the 70 “First Referrals” 

Estimated Annual ODS Funding for the group		$4,391,355
Estimated Annual OBH Funding for the group		$3,080,332
		$7,471,687

 Data from the Allegheny County ODS for FY 21/22 

Partnerships

Allegheny County is pleased to be working with so many of our system partners both within and outside of DHS. The Executive Committee and various subcommittees include representation of Allegheny County DHS program offices, Community Care Behavioral Health Organization (our Behavioral Health Managed Care Organization), Pennsylvania’s DHS Office of Developmental Programs (including the Bureau of Autism Supports and Special Populations) and the Office of Mental Health and Substance Abuse Services.

System Analysis

One advantage to a project such as this is the opportunity to collaborate across offices within Allegheny County DHS. There is a chance to discuss how this project is to be implemented.  Through these conversations, the planning team came to consensus on some key concepts: 

It is imperative to make connections across leadership that result in enhanced system knowledge and improved facilitation of complex case reviews. Ultimately, these connections will equip us as a county to provide enhanced responsiveness to crisis situations. Conversely, there are gaps in our interdisciplinary process around shared accountability, shared outcomes, and universal expectations around behavior supports. Related to workforce development, there is an acknowledgment that currently providers do not have an abundance of skilled and confident staff to support complex needs. There is also agreement in that being in a constant state of crisis response only allows for reaction not planning. Individuals who are active in the START model are the same as those who get stuck in highly restrictive settings, in part due to the lack of flexibility of the community setting or state regulations. Currently, there is no early involvement of clinical supports when there is NOT a crisis. Additionally, there tends to be no early learning about the individual, their history, or triggers. This learning could contribute to the development of a better response when a crisis is occurring. This is not only an educational need of providers, but for families as well. Finally, it is apparent that there are still silos across and between ID/A and BH services. This makes communicating individual needs and coordinating supports difficult. It also makes it difficult to recognize success when systems gauge success differently. The team will need to be able to address these gaps over the course of the pilot. If not to solve them, to address and include them in our future planning.

Outcomes and Business Questions

Pennsylvania’s ODP, OMHSAS, and Allegheny County will be exchanging data and reports as part of the pilot with the University of New Hampshire Center for Start Services.  Allegheny County is working to ensure that the data being collected is representing an accurate depiction as to whether or not an impact is being made on the lives of those being served.   

Through analyzing and monitoring of outcomes, Allegheny County hopes to demonstrate an overall improved quality of life has been achieved - whatever that life may include for each person.  Everyone deserves the opportunity to be employed or experience some other form of meaningful day activity. All of us deserve and seek out friendships and other social connections.  Meaningful activity, social connectedness, and support – however defined for and by an individual – is important to happiness, fulfillment, and well-being. 

Currently, Allegheny County has an enormous amount of data, much of which is aimed at measuring service effectiveness. However, as part of this pilot, there will be measurements of other elements, including the following: 

Finally, there will be activities related to tracking satisfaction of both individuals and families  involved and getting support of the START team.

Early Challenges

There are some challenges that have already been encountered through the initial phases of this pilot. The first involves the multitudes of plans each system has. In ID/A it’s the ISP (or Individual Support Plan). In Behavioral Health, every provider and in some cases, every level of service or type of care, has its own service and/or treatment plan. The START model has both a treatment and crisis plan. How do the various service systems combine and reflect the START plans in the ISP and BH Treatment plans? What are the best practices that assure information is represented and used to guide services and supports needs? Secondly, following a hospitalization, individuals and teams often need time to re-group. Maybe the community home needs to add modifications or staff need a different training than what was originally planned for.  What service options need planned for in order to support individuals between hospitalization and return to the community/private home? Allegheny County is currently looking at gaps in our housing continuum. There are limited “transition” or “step down” options for individuals leaving highly restrictive settings prior to a full-time return to the community setting. The feasibility of offering these types of settings will be part of our work throughout the pilot. Finally, there will be focus on determining the sustainability of the START model as part of the continuum of treatment. Analysis of our data and outcome measures will be important in making this determination. 

Allegheny County is excited and humbled at the opportunity to contribute to system development and enhancement. With the support of everyone in the system – families, advocates, government officials, and service providers – individuals with disabilities can and should decide how to live their best life.³

References

1.     Dr. Jill Hinton, The START Model: Mental Health and Crisis Intervention for People with IDD. Center for START Services – University of New Hampshire Institute on Disability/UCED, 2018 

2.     Dr. Jill Hinton, The START Model: Mental Health and Crisis Intervention for People with IDD. Center for START Services – University of New Hampshire Institute on Disability/UCED, 2018

3.     Pennsylvania Department of Human Services, Everyday Lives, 2016.

Biography

Brenda L. Bulkoski, M. Ed. has been the deputy director of the DHS Office of Developmental Supports since September 2019. As deputy director, Brenda L. Bulkoski oversees the daily operations of the Office of Developmental Supports. This includes assuring compliance with the Pennsylvania AE Operating Agreement, development of best practices, and maintenance of a strong and varied network of programs. Ms. Bulkoski has been active as an advocate for individuals living with intellectual disability and/or developmental delays since she started working as a DHS program specialist in May 1994. Ms. Bulkoski received her bachelor’s degree in Child Development from the University of Pittsburgh and her master’s in Special Education from Duquesne University.

Contact Information

Brenda L. Bulkoski

Deputy Director, Office of Developmental Supports

Allegheny County Department of Human Services

phone - 412-436-2804

fax - 412-271-1392 2020