The District of Columbia Department of Mental Health (DMH) has made a considerable investment in service expansion, including adding many housing units and other services for its clients who are homeless. Earlier parts of this chapter described the agency's investments in housing and expansion of Assertive Community Treatment services. Here we describe the larger scope of the District of Columbia's mental health services, looking at how the service categories created in 2008 were able to include Assertive Community Treatment and other evidence-based practices to promote community-based care.
Of the nine service categories included in the District of Columbia's Mental Health Rehabilitative Services, three are specifically designed to be delivered in the community (community support, community-based intervention, and Assertive Community Treatment). Two of these, Community Support Services and Assertive Community Treatment, are the services most commonly used with people who are or have been homeless. Specific aspects of the District of Columbia's Assertive Community Treatment services were described earlier, so here we focus on the aspects of its Community Support Services that are relevant to PSH tenants. Community Support Services are intended to help consumers manage the symptoms of their illness sufficiently to adapt to a home environment, manage their finances appropriately (which helps keep the rent paid), maintain independent living, and regain coping skills and strategies to avoid institutionalization and possibly losing their housing.
Four service categories (diagnosis/assessment, medications/somatic treatment, counseling, and crisis/emergency) do not specify a treatment location and thus could occur in the context of the three community-based services as well as in other contexts. Only two categories (day services and intensive day treatment) specify that they must be delivered in a DMH-certified Community Mental Health Rehabilitation Services Agency.
The District of Columbia's Department of Mental Health also recognized that transforming the service delivery system required other actions. In addition to enhancing the Assertive Community Treatment reimbursement rate, specifying Assertive Community Treatment reimbursable services, articulating the certification criteria for agencies offering Assertive Community Treatment services, and expanding the program from three to 12 Assertive Community Treatment teams, the Department of Mental Health contributes to the development of Assertive Community Treatment and other mental health services for high-need populations in several ways.
The department's director describes his agency's strategy for eliciting quality care for clients of Assertive Community Treatment services as follows:
Pick an evidence-based practice that does what you need and that you have confidence can be replicated in your own setting--in this case Assertive Community Treatment.
Write the criteria you will use to certify that an agency is qualified to deliver that practice in a way that supports the fidelity of the practice.
If using contracts, require in contract language that the provider meet the fidelity criteria (but even if you do not do contracts, use the leverage you have through the certification criteria and monitoring practices).
Set rates that will attract providers who can meet and maintain fidelity.
Provide training, initial and ongoing, that moves agencies toward doing the job in a way that meets fidelity criteria.
Provide oversight and accountability; pick a fidelity scale and use it to monitor, in person, against the scale's criteria and also monitor for positive outcomes for clients (the District of Columbia's Department of Mental Health has been doing the former since 2009 and began to do the latter in 2011).
Have a mechanism for enforcing contract provisions; the District of Columbia's Department of Mental Health has two: (1) withholding referrals of new clients for a time until an agency comes into compliance; and (2) decertifying the agency if it continues to resist or remains unable to comply with fidelity criteria.
Having had a lot of experience with Assertive Community Treatment in previous jobs, the director appreciated that an agency new to Assertive Community Treatment would take a while to get up to fidelity standards and that even an experienced agency would need some time for a new team to receive enough client referrals to reach full capacity and be able to sustain itself largely from Medicaid reimbursements. The department estimated that the start-up time for an agency that had never previously done Assertive Community Treatment was 3-6 months. The Pathways-DC director says that, in her experience, it takes a new team in an experienced agency a couple of months to reach self-sustainability, depending on the rate of client referrals to reach 100 clients. That agency also gives a new member of an existing Assertive Community Treatment team a start-up/orientation period of 3-5 weeks that involves shadowing other staff, discussing approaches, and getting explicit training before being expected to pull his or her own weight. During these start-up periods, staff need to be paid, but Medicaid reimbursement does not cover costs for staff orientation.
To cover the start-up period, the Department of Mental Health offered no-interest loans of $175,000-$200,000 to agencies willing to become Assertive Community Treatment providers. These loans were to be paid back as the new agencies could (all have done so). The department also offered, and still provides, training to new and existing providers, via a training contractor.