Bulkoski | 23-36
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:
- Treatment-focused and specifically designed to serve those with
intellectual disability and/or autism and behavioral health needs.
- Person-centered, trauma-informed, and evidence-informed,
recognizing that this particular population has suffered various levels of
trauma in the form of multiple hospitalizations, medication changes, and
residential placements.
- Emphasizes the central importance of building linkages. START begins with the focus on the persons existing supports/resources. Then in partnership with those supports/resources, the person begins identifying strategies all team members will utilize in an integrated approach. 1
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
- The Primary Intervention level focuses on outreach and
relationship building, training/education, partnerships and linkages, building
capacity of skill and competency. This is the least restrictive level of
intervention and can meet the needs of the most individuals.
- The Secondary Intervention level is prevention focused.
This involves more resources and increased focus on planning strategies for
individuals when supporting and serving them.
- The Tertiary level is that of direct crisis response,
intervention, and stabilization. There is always a debrief with the serving
team following any significant crisis event.
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:
- The authorization amounts reflect duplicative individual counts
considering individuals cross different services and can receive multiple
service combinations simultaneously as needed.
- The utilization amounts and authorization averages may appear lower than expected due to individuals not being placed for a full year, interrupted placements, discharges, and/or COVID.
Figure 5: Top 5 most frequently authorized services from Office of Developmental Supports
ODS Service Subgroup |
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 |
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:
- Look to broaden the ability to collaborate across stakeholders and within the same framework.
- Agree in our joint need to enhance our planning potential, by providing technical assistance to both service providers and supports coordinators.
- Uphold the commitment to equal participation in the Interagency
Team meeting process.
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:
- Pre and post services and costs – this may determine if individuals are getting an enhanced or a different combination of services with better result.
- Direct
feedback and input from individuals, their families, and providers involved in
serving our target groups. Are their experiences and quality of life
improving?
- Incident reports, by person, and by reason. There will be a special
focus on the number of times law enforcement may have been called to assist
with a crisis. Is this number decreasing with the support of the START
team?
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
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