COUNCIL OF THE CITY OF PHILADELPHIA2 COMMITTEE OF THE WHOLE - - - Room 400, City Hall4 Philadelphia, Pennsylvania Wednesday, April 20, 2011, 10:27 a.m.5 - - - RES. 110161 - Five-Year Plan7 BILL 110135 - Capital Program 2012 through 20178 BILL 110136 - FY 2012 Capital Budget9 BILL 110137 - FY 2012 Operating Budget10 BILL 110138 - Wage Tax Bill11 12 COMMITTEE MEMBERS PRESENT: 13 Anna C. Verna, Chair Marian B. Tasco, Co-Chair14 Jannie C. Blackwell Blondell Reynolds-Brown15 W. Wilson Goode, Jr. Bill Green16 James F. Kenney Frank Rizzo17 Maria Quiñones-Sanchez 18 - - - 19 20 21 22 23 24 25 2 4.20.11 COMM. OF THE WHOLE - BILL 1101371
Good2 morning. This is a continued public3 hearing of the Committee of the Whole.4 I would ask Mr. McPherson to5 please read the titles of the resolution6 and the bills.7 MR. McPHERSON: This is a8 continuation of the hearing for:9 Resolution 110161, the City's10 Five-Year Plan;11 Bill No. 110135, the Capital12 Program for 2012 through 2017;13 Bill No. 110136, the Capital14 Budget for 2012;15 Bill No. 110137, the Operating16 Budget for Fiscal 2012;17 And Bill No. 110138, the wage18 tax.19 Today we're continuing20 testimony on Bill No. 110137, the21 Operating Budget for Fiscal 2012.22 And the first department is23 Behavioral Health.24 (Witness comes forward.)25 3 4.20.11 COMM. OF THE WHOLE - BILL 1101371
Good2 morning. Please identify yourself for3 the record and proceed with your4 testimony.5
Okay. Good6 morning. I'm Dr. Arthur C. Evans, Jr.,7 Commissioner for the Philadelphia8 Department of Behavioral and Intellectual9 Disability Services.10 COUNCIL PRESIDENT VERNA:11 Please proceed.12
Sure. Good13 morning, Council President Verna and14 members of Council. My name is15 Dr. Arthur C. 11 COMM. 11 COMM. S. Senator Barbara6 Mikulski introduced legislation that7 would bar the use of the word in8 government offices. 17 We work with consumers,18 families, and providers to ensure that19 services are accessible, effective,20 appropriate, and of high quality. 11 COMM. OF THE WHOLE - BILL 1101371 disparities. 18 In FY '11, DBH/IDS has19 continued its efforts to address20 behavioral health and intellectual21 disability needs of Philadelphia22 citizens. Key activities supporting23 these efforts include:24 1. 11 COMM. 6 2. 12 3. In the fall of 2010, IDS13 convened a strategic planning process to14 enhance its commitment to the employment15 of individuals with intellectual16 disabilities. 20 4. 11 COMM. OF THE WHOLE - BILL 1101371 communities. 4 And 5. The continuation of5 crisis intervention training to assist6 police officers in interacting with7 people impacted by serious behavioral8 health challenges. 18 Examples of our efforts include the19 following:20 1. The reduction of21 out-of-state placements. The residential22 reduction initiative involves bringing23 youth back to their communities from24 out-of-state placements. 11 COMM. OF THE WHOLE - BILL 1101371 DBH/IDS has worked to reduce the number2 of out-of-state placements from 1513 children to 28 children; that is a 814 percent decrease. 17 Secondly, securing federal18 grants. Over the course of the last19 year, DBH/IDS has secured a number of20 state and federal grants that will become21 fully operational during FY '12. 11 COMM. 13 The Veterans Jail Diversion14 Project is a four-year, $576,000 grant15 from the Commonwealth, which will16 integrate veterans' issues into the17 crisis intervention training I mentioned18 earlier. 11 COMM. 7 3. Early intervention. 11 COMM. 4. 11 COMM. 3 And 5. Evidence-based4 practice. The use of evidence-based and5 promising practices is being expanded to6 maximize the effectiveness of the7 behavioral health and intellectual8 disabilities services. Examples include9 the following:10 Cognitive therapy. Cognitive11 therapy has voluminous empirical support12 as a highly effective treatment. 17 Philadelphia's employment of18 cognitive therapy is expected to19 constitute one of the first large-scale20 implementations of an evidence-based21 psychotherapy in a public mental health22 system. 11 COMM. OF THE WHOLE - BILL 1101371 Wellness recovery action plans2 is another evidence-based tool developed3 by Mary Ellen Copeland, which has proven4 to be highly effective in promoting5 personal recovery. These are self-6 directed and self-implemented tools that7 enable people to proactively manage their8 mental illness. 12 Trauma training is being13 initiated in response to research that14 shows that over 90 percent of people with15 mental health and/or addiction challenges16 have experienced at least one traumatic17 event in their lifetime. 11 COMM. 5 And 6. Enhancing minority-,6 women-, and disabled-owned business7 participation. DBH/IDS continues to be8 committed to serving the Administration's9 goal of minority-, woman-, and10 disabled-owned businesses. It should be11 noted that the majority of the DBH/IDS12 are with not-for-profit providers and,13 therefore, cannot be officially14 classified as minority-, women-, or15 disabled-owned. DBH's efforts to date16 include the following:17 First, continuing support of18 the Office of Economic Opportunity's19 efforts to build supplier diversity20 programs within the not-for-profit21 sector. 11 COMM. OF THE WHOLE - BILL 1101371 policies. 4 Secondly, the department has5 surveyed the board composition of all of6 our nonprofit providers. Based on the7 most current information, 25 percent of8 all DBH/IDS nonprofit providers had more9 than 50 percent of their board consisting10 of minorities and/or females.
13 And then, thirdly, continued14 support of our minority, women, and15 disabled providers through community16 behavioral health. CBH contract17 providers with minority and female18 executive leadership account for 73 of19 our 208 contract providers. 11 COMM. 3 And, finally, the current4 economic conditions at the state and5 federal levels continue to challenge6 efforts to provide essential services to7 individuals who are uninsured or8 underinsured. 19 We appreciate Council's20 historical efforts to advocate for21 sustaining funding and are willing to22 partner with you in these ongoing23 efforts. 11 COMM. 4
Thank5 you very much.6 Dr. Evans, you are requesting7 $919 million in FY 2012 for Health8 Choices Behavioral Health Program. Will9 you explain for the record, please, the10 funding source for these funds and the11 various per-month type of service fees12 that you receive.13
I got the first14 part of the question; I didn't get quite15 the last part. You said something about16 fees? I'm not quite -- could you repeat17 that part? I'm sorry.18 COUNCIL PRESIDENT VERNA:19 Certainly. Will you explain for the20 record the funding source for these funds21 and the various per-month, per-member --22
Per-member,23 per-month.24 COUNCIL PRESIDENT VERNA:25 19 4.20.11 COMM. OF THE WHOLE - BILL 1101371 Per-member, per month --2
Sure. The Health7 Choices Program is a contract that the8 City has with the State of Pennsylvania9 to provide all of the behavioral10 health-care services for individuals who11 have medical assistance who live in the12 City.13 That -- the latest numbers are14 about 440,000 people in Philadelphia have15 medical assistance. The City is16 capitated for that entire population.17 And so, we get paid a per-member,18 per-month fee for each person who is19 Medicaid-eligible.20 That -- the actual rates vary21 from a low of anywhere of $31 per member22 per month to as high as over $500,23 depending on the category of aid that the24 person is in. And so, people who are25 20 4.20.11 COMM. OF THE WHOLE - BILL 1101371 more disabled, we get paid a higher rate2 for.3 So the revenue that we generate4 and we're projecting to generate is based5 on the number of people that we have in6 each category of aid and the rate for7 that category.8 And so, when we look at the9 projections of where we think Medicaid10 enrollment will be, what our per-member,11 per-month fee is, we're able to then12 determine what our revenue will be for13 the year.14
For FY -- the20 Health Choices Program is on a calendar21 year, not a fiscal year.22 And in the current fiscal year,23 which began January 1, the fees have been24 set through the end of December of this25 21 4.20.11 COMM. OF THE WHOLE - BILL 1101371 year.2
Do3 you estimate that your reserves will4 increase in 2012?5
In 2012, they will6 most likely increase.7 We have two types of8 contractual reserves. One is an equity9 reserve, which is 5 percent of our10 capitated revenue. And so, this year,11 that will be around $850 million we12 anticipate in terms of capitated revenue.13 And so, we will be required to have in14 reserve about 5 percent of that amount.15 The other reserve account that16 we have to have, per the contract, is a17 risk and contingency reserve, and that's18 based on medical expenses for the year.19 And it's a range of between 45 and 6020 days of medical expenses; a day is about21 $1.8 million. And so, our revenue would22 be between 45 to 60 days of 1.8.23
In24 the event that the federal and state25 22 4.20.11 COMM. OF THE WHOLE - BILL 1101371 governments reduce its funding support to2 the level that you are no longer covering3 your costs, what happens?4
Well, at that5 point, the City can always get out of the6 Health Choices contract. We have a7 120-day clause, and if we ever felt that8 we were in a position where we didn't9 have the -- have adequate funding, the10 City could always choose to get out of11 the contract.12 However, the reason that the13 contract requires us to have reserves is14 in the event that in any given year, if15 we were to go over the revenue that we16 had, we would have reserves to cover17 that.18 And so, our revenues again19 right now are $140 million? Or $16020 million? So it would have to be a pretty21 catastrophic problem for us not to be22 able to cover any given year's medical23 expenses.24
Thank25 23 4.20.11 COMM. OF THE WHOLE - BILL 1101371 you, Doctor.2 The Chair recognizes Councilman3 Goode.4
Oh,7 I'm sorry. We have a number of8 Councilmembers that want to be9 recognized. So for the first go-around10 today, each Councilmember will be given11 five minutes.12
Thank you,13 Madam President.14 Good morning, Dr. Evans.15
What's the18 largest contract that you will award in19 Fiscal '12?20
Since the beginning7 of the contract with the Commonwealth.8 If you are interested in the9 provider, you know, CBH is a City-created10 entity. If we are looking at for-profit11 providers, the largest contract would be12 with an organization --13
Or nonprofit. It19 would be -- if it's a City contract, it20 would be Resources for Human Development.21
A little over24 $6 million.25 25 4.20.11 COMM. OF THE WHOLE - BILL 1101371
It's a contract4 that includes a variety of different5 services. And over the years, they've6 done a variety of different service,7 residential service, other kinds of8 behavioral health services. So it's not9 one -- sort of one contract, per se.10
That contract -- or17 those services have -- most of the18 services, I should say, that they have19 provided are not services that we bid out20 because they've been for-profit, not-for21 profit residential services --22
So they will23 be required to submit a supplier24 diversity plan?25 26 4.20.11 COMM. OF THE WHOLE - BILL 1101371
Okay. Are3 they currently compliant with the City's4 living-wage-and-benefits standard?5
Okay.13 That's all I have.14 Thank you, Madam President.15
Thank16 you.17 The Chair recognizes Councilman18 Green.19
First of24 all, I want to say really I want to25 27 4.20.11 COMM. OF THE WHOLE - BILL 1101371 commend you and your department and your2 staff on tremendous testimony on the way3 you run your department.4 The detail that is available5 with respect to specific outcomes in all6 of what you do, or almost all of what you7 do, it is, I think, a model that every8 single department should follow. There9 are metrics by which people can judge how10 successful they've been compared to11 goals. And you've been doing that for12 years.13 And, you know, I think you are14 the model for outcome and program-based15 budgeting that we need to spread to the16 rest of city government.17 So I just want to commend you18 on, you know, the work that you19 continue -- the good work that you and20 your staff continue to do in that regard.21
You24 testified about the department's25 28 4.20.11 COMM. OF THE WHOLE - BILL 1101371 data-driven approach, the commitment of2 you and your team to using data to access3 performance and strive for continuous4 improvement. It's impressive.5 I understand that DBH has a6 series of system metrics, both7 programmatic and financial, that it uses8 to assess the department's performance.9 What process did you use to develop these10 metrics?11
Okay, thank you.12 The process has evolved over13 several years. It's led by Dr. Kathy14 Bolton, who is in the audience, but we15 have a team of whom who work with her.16 The primary purpose -- the17 primary way that we figure out what we18 want to look at is based on our system19 goals. You know, I talked a lot about20 recovery in my testimony. Our goal is to21 help as many people as possible get into22 long-term recovery, and that includes23 individuals who have serious mental24 illness or people who have addictions.25 29 4.20.11 COMM. OF THE WHOLE - BILL 1101371 And so, the measures that we2 look at are derived from what we believe3 are good indicators of people making4 those kinds of gains.5 We look at at least three6 levels, what we call three levels of7 analysis. We try to look at systems8 indicators that show our people at -- if9 we look at the system as a whole, our10 people moving towards recovery, are they11 sustaining the gains that they make in12 acute treatment, are they doing better.13 The second level that we look14 at is at the program or provider level,15 and we do a variety of things at that16 level, including provider profiling so17 that we can determine who are the18 providers who are doing a good job and19 who are the providers who are not doing a20 good job in those areas.21 And then we try to look at the22 individual level, at specific cohorts,23 and how they're doing. And so, we look24 at, for example, how are individuals who25 30 4.20.11 COMM. OF THE WHOLE - BILL 1101371 are homeless in our system doing; or how2 are kids in residential treatment doing.3 And so we try to look at all4 three of those levels to determine both5 how we're doing as a system in managing6 the system, but how are providers doing7 in terms of meeting those goals.8
And within9 that, how do you choose the performance10 metric to determine whether or not a11 child is being successful or a provider12 is being successful -- or is it -- you've13 looked at data and outcomes over years in14 terms of what has worked, and then you're15 driving providers towards using that16 practice, and then, you know, measuring17 the outcome of, you know --18
That's10 both empirically determined and11 theoretically determined.12 So we -- for example, to get13 concrete, one of the things that we think14 is really important -- when we look at15 the literature and when we look at our16 own data, one of the things that we know17 that happens in the system is that people18 tend to use the most acute parts of the19 system, and there are a cohort of people20 that use those systems over and over.21 So if you look at our22 recidivism rate, our recidivism rate and23 inpatient psychiatric hospitalizations is24 about 15 percent. We think that that25 32 4.20.11 COMM. OF THE WHOLE - BILL 1101371 number should be at around 10 percent.2 And despite a lot of things that we've3 done, we've not been able to drive that4 number down appreciably.5 So one of the things we start6 to look at are things that we think are7 correlates of performance that would get8 that number down.9 So one of the things that we10 know is that providers who make sure that11 individuals are connected to the next12 level of care tend to have lower13 recidivism rates. And so, that's one of14 the things we now track.15 (Timer bell rings.)16
We also know that17 providers who make sure that they do a18 good job of discharge planning are also19 going to have lower recidivism rates.20 And so, once we've identified21 sort of the problem area in our22 department or in the system, we then try23 to go back and look at what are the24 things we think or correlates of that and25 33 4.20.11 COMM. OF THE WHOLE - BILL 1101371 begin to measure those and then to tie2 performance to those indicators that we3 think are related to the outcome that4 we're trying to get.5
Thank you,6 Doctor. I have more questions but my7 time is up.8
The11 Chair recognizes Councilwoman Blackwell.12
Thank13 you, Madam President.14 We have so many issues. I15 won't ask any now. I will say thank you16 to Mr. Evans. If I have any questions17 about anything in the City, I call him;18 he always comes up with a answer.19 But we thank you for your20 commitment to our city and for all you21 do, and thank you for personally for22 answering all of my questions about23 government.24 (Laughter.)25 34 4.20.11 COMM. OF THE WHOLE - BILL 1101371
You're certainly2 welcome, although I don't know how good a3 job I do, but I appreciate the sentiment.4
Thank5 you.6 Thank you, Madam President7 Madam President.8 COUNCIL PRESIDENT VERNA:9 You're welcome.10 The Chair recognizes11 Councilwoman Sanchez.12
Good13 morning. Thank you.14 Thank you, Dr. Evans.15
This is17 going to sound like a parade of18 everybody's congratulating Dr. Evans.19 But in my case, I do want to echo -- I20 inherited some challenging situations in21 my district, and I want to thank you and22 your department for always being there to23 work through the challenges of how --24 what do we do with folks in recovery and25 35 4.20.11 COMM. OF THE WHOLE - BILL 1101371 how do we make sure they get integrated2 back into their own neighborhoods and3 that they get service. So I greatly want4 to say that I appreciate your willingness5 to work with me through all of those,6 from prevention point to our recovery7 house situation.8 Last year, when we talked, we9 talked about figuring out ways in how we10 get our stakeholders, our providers to11 work better with us and their clients in12 the neighborhoods, and one of the things13 that I had requested from the department14 was, could we get our providers to be15 more engaged in providing house visits or16 home visits, particularly in places that17 we understand recovery houses and18 recovery support is provided in19 neighborhoods.20 Can you update me on that?21
Sure. The issue22 that you brought up was that there are a23 number of recovery houses around the City24 that don't necessarily do a good job, and25 36 4.20.11 COMM. OF THE WHOLE - BILL 1101371 the thing that we pointed out last year2 was that of the 200 -- we estimate there3 are over 200 recovery houses in the4 City -- about 20 of those are funded by5 the department and we have direct control6 over and oversight.7 For those 20 that we do provide8 direct oversight over, you know, we don't9 get complaints; they are viewed as good10 neighbors and so forth.11 The issue you raise are the12 others that we don't have under our13 control and how do we get those providers14 to really adhere to the standards that we15 have for the other providers. And one of16 the things you suggested was whether our17 providers who provide service and have18 clients who live in those recovery houses19 could do more to try to encourage those20 not-so-good recovery houses to do better21 the.22 I got the issue, right?23
So there've been a25 37 4.20.11 COMM. OF THE WHOLE - BILL 1101371 number of things that we have tried to do2 to increase our footprint within the3 recovery house world. So one of the4 things -- and I think we mentioned this5 last year -- is that even though there6 are providers who we have really no7 control over, we've asked them to8 voluntarily adhere to our standards.9 And so, we've had -- initially10 we got 35 providers to do that. And so,11 those providers are adhering to the same12 standards as the providers that we13 directly fund.14 In terms of providers doing15 site visits, we didn't go to the point of16 requiring them to do that, but we have17 encouraged providers to do that. And I18 think that that has helped because I19 think more providers have voluntarily20 stepped up to adopt our standards because21 of that.22 The thing that has happened in23 the last year that I think has been --24 that will really make a big impact is25 38 4.20.11 COMM. OF THE WHOLE - BILL 1101371 that we received a federal grant that2 allows us to fund additional recovery3 houses. We won't be able to give them a4 grant, but if a person needs a recovery5 house, we can give them a voucher and6 they can attend the recovery house.7 Obviously, all of those providers now8 have to, if they want to have that source9 of income, will have to adhere to our10 standards.11 So I think that it is, you12 know, realistic that we will easily, in13 the next year, again, increase our14 footprint in terms of the number of15 providers who are adhering to those16 standards. Already we have at least five17 or six that have taken on our standards18 because of that. And we're just19 starting; we're only a couple of months20 into the grant.21
What's22 value of the voucher? What is -- how is23 that going to work?24
It's $31 a day.25 39 4.20.11 COMM. OF THE WHOLE - BILL 1101371
Okay.5 So someone will be able to pay...6 In addition to this oversight,7 because now you have a voucher and people8 get involved, or hopefully will get more9 involved, is there anything else that you10 think we need to be doing in terms of how11 we communicate with our community, that12 we should be doing?13
Well, I think if --14 and I do appreciate your work and15 willingness to work with us around some16 of these issues. I would say two things.17 One is if there are providers18 who are problematic, for whatever reason,19 to call our office. And, again, even20 though we don't have the authority to21 make providers do things, we do have some22 influence.23 (Timer bell rings.)24
And so, we have no25 40 4.20.11 COMM. OF THE WHOLE - BILL 1101371 problem in stepping into those2 situations.3 The other thing is that on a4 national level, there is a move to create5 national standards for recovery houses6 and create actually a network of recovery7 houses so that there will be some peer8 review of what people are doing. We are9 encouraging, and, in fact, there's some10 organizing in Philadelphia to do that.11 We think that that will help12 because it will create essentially a peer13 group of people who are really trying to14 do the right thing and to be neighbors.15 And so, if there are recovery houses in16 your community that you think could17 benefit from that, we could certainly18 connect them to that group.19
Yeah. I20 mean, one of the results of all the21 attention that has been paid is that the22 good guys have stepped up, and at least,23 in Frankford and West Kensington, they24 have started a coalition that's being25 41 4.20.11 COMM. OF THE WHOLE - BILL 1101371 more aggressive on the ground in terms of2 cleanups and showing and demonstrating to3 the community that they're better4 members. So we've seen that immediately.5
And7 that's good and that's a result of our8 town halls, our annual town halls, and I9 look forward to next year having even10 more progress.11
You16 know, and when we call them, they're17 there, and they're really helping us with18 our parks --19
-- and21 just showing neighbors in the22 neighborhood that they want to be there.23
So I25 42 4.20.11 COMM. OF THE WHOLE - BILL 1101371 want to thank you for that. Thank you.2
Thank6 you.7 The Chair recognizes8 Councilwoman Tasco.9
And thank13 you for the good job that you all are14 doing there.15 Under -- and this question may16 have been asked; I've been distracted.17
Under19 Governor Corbett's budget, significant20 cuts have been proposed, the State21 education funding. If cuts are shifted22 from State education funding and State23 behavioral health funding, what areas are24 mostly likely to be impacted by25 43 4.20.11 COMM. OF THE WHOLE - BILL 1101371 reductions?2
I do a lot of3 thinking about that every night,4 Councilwoman.5 I think that it is most likely6 that the State will cut where they have7 cut before, and that is the State-only8 dollars. The Medicaid dollars and the9 Medicaid program is a cost-sharing10 program. So for every dollar that the --11 roughly every dollar the State puts in,12 they get a dollar back from the federal13 government.14
So it doesn't make16 a lot of sense to make deep cuts into the17 funding of Medicaid because of the18 leverage that the State uses to bring in19 additional federal dollars.20 So that means that the most21 likely place are the grants that we give22 to providers to cover the uninsured and23 in what we call the BHSI, Behavioral24 Health Special Initiative, program, which25 44 4.20.11 COMM. OF THE WHOLE - BILL 1101371 has received consistent cuts over the2 last several years. That is a program3 that is a hundred percent State-funded.4 It is for the uninsured.5 It is the -- the irony is that6 as the economy gets worse, that's where7 we have the greatest need, because more8 people lose their jobs, they don't have9 health insurance. And we depend on that10 funding to serve those individuals.11 So it's most likely to be in12 the area of BHSI or community grants that13 we pay our providers to cover the14 uninsured in our community mental health15 centers.16
You talked17 about the providers, not all of them18 being a part of the organization. If19 someone decides to become a provider of20 services, where do they get their funding21 from; is it through Medicaid?22
It is through23 Medicaid. So the primary way that new24 providers come into our system is through25 45 4.20.11 COMM. OF THE WHOLE - BILL 1101371 the CBH network.2
And so, if a4 provider meets the criteria, we5 credential the provider; they would be6 then be paid on a fee-for-services basis7 for the services that they provide.8
But9 otherwise, they're dealing directly with10 what department with the State?11
They would be12 dealing with either other private13 providers if they are seeking public14 funds. And if they are in Philadelphia,15 they would receive those through my16 department, through one of the funding17 streams that we manage and control.18
We talked19 about the reserves, and when we started20 CBH years ago and we knew that we had to21 set up the reserve account, has there22 ever been any effort to remove those23 reserves from you to --24
No. One of the4 things that the State has done is to5 change the reserve requirements.6 So when I took this job, the7 reserve requirements were between 60 and8 90 days of paid claims, and I mentioned9 earlier that our paid claims were about10 $1.8 million a day.11
So,13 you know, do the math. Roughly 1.8 times14 90 would have been the maximum amount15 that we could have had in reserve.16 Over the years, the State has17 sort of played with that as a way of18 getting dollars back into the State19 coffers. And so, they've pushed that20 number down. And so, today our reserve21 requirements are between 45 and 60 days22 of paid claims.23
And so, but they25 47 4.20.11 COMM. OF THE WHOLE - BILL 1101371 wouldn't -- the reason that they wouldn't2 the reserve requirements is that if for3 whatever reason the City decided to get4 out of the business, we would need5 reserves to pay for claims and to pay for6 services that may have been provided as7 we were trying to bring the program down.8
Let me18 underscore the accolades expressed by my19 colleagues. I agree 2,000 percent.20
You've22 mentioned a number of constituencies.23 I'm particularly interested in the24 infant, toddler early-intervention25 48 4.20.11 COMM. OF THE WHOLE - BILL 1101371 program. What type of intervention2 strategies or services are delivered to3 children with developmental delays?4
Sure. So the5 early-intervention program is a program6 that tries to identify developmental7 delays in kids early on and tries to8 intervene.9 And so, depending on what the10 delay is, there are therapies, there are11 interventions that are made. So12 sometimes kids may have speech problems13 or are not developing their speech or14 maybe have hearing difficulties or maybe15 it's a visual difficulty.16 So what happens is, after the17 kids are assessed, screened and assessed,18 a plan is put together. And then, based19 on the kinds of developmental problems20 that they have, there will be either21 speech pathologists or some other22 professional that will work with the23 child to try to ameliorate those24 problems.25 49 4.20.11 COMM. OF THE WHOLE - BILL 1101371
Any2 special focus or emphasis on children3 with developmental delays as a result of4 lead poisoning?5
Not lead poisoning6 per se, but I would imagine that if a7 child has a delay as a result of lead8 performing, they would be picked up in9 that screening process; and, again, they10 would get the same kinds of interventions11 as other kids would whose delays may be12 caused for some other reason.13
Mm-hmm.14 Is there any categorizing of the reasons15 why young people may have a developmental16 delay? Like do you put in a box all of17 those children who have a developmental18 delay because of lead poisoning, and they19 get a certain type of treatment problem?20
I don't think so,21 but the person who would know that agrees22 with me, no. No, no, there's not.23 I think at that age, what24 we're -- you know, whether it's a25 50 4.20.11 COMM. OF THE WHOLE - BILL 1101371 congenital problem or genetic or2 whatever, the issue is, you know, what is3 the delay, and then how do we then4 intervene and treat that.5
But we don't then7 go back and try to find out the etiology8 of the delay and that kind of thing9 necessarily.10
Okay, all11 right. I'll have a separate sidebar12 around this whole lead opining issue.13
'Cause15 we're going to look at that very, very16 closely soon.17 Are diagnosis of developmental18 delays among African-American children19 equal to their proportion of the20 population?21
That, I don't know22 that number. I do know the number and I23 don't know if --24 (Addressing colleague.) Kathy,25 51 4.20.11 COMM. OF THE WHOLE - BILL 1101371 do you know the number? Do you know if2 the proportion diagnostically is equal3 across racial groups?4 (Kathy's response is off-mic5 and, therefore, inaudible to6 stenographer.)7
Okay. So she said8 that she believes there are more male9 children.10 I think that socioeconomic11 status does affect delays. And so, to12 the extent that you have disproportionate13 numbers of people with color in the lower14 socioeconomic status, you would expect15 them to find greater delays in some of16 those populations.17
A lot of24 concern was raised last year around25 52 4.20.11 COMM. OF THE WHOLE - BILL 1101371 out-of-state placements.2
And we see4 here that that's dropped significantly5 from 151 to 28 children last year.6 So under what circumstances now7 are children placed in facilities outside8 the state?9
Yeah. Well, we're10 very proud of the fact that we are11 serving children in Philadelphia in the12 community, and it is only the rare13 instance now that we will have to use a14 facility out-of-state.15 The only time that that happens16 is -- right now is if there is a service17 that is not provided within Pennsylvania18 or the five-county area, that -- where we19 can send a child.20 So it tends to be, for example,21 residential programs for children who22 might be -- who might have a core23 occurring intellectual disability and24 mental health problem.25 53 4.20.11 COMM. OF THE WHOLE - BILL 1101371
So it's those kind3 of really specialized programs that we4 may not have a program for in the City --5
So what8 systemic changes did you make to make it9 clear that in-state placements are the10 priority?11
Okay. So a couple12 of things. One is, as you know, the Blue13 Ribbon Commission that you were a14 co-chair of, one of the things that was15 identified was that we serve too many16 children in residential settings outside17 of the State, which makes it very18 difficult to do family work, it makes the19 transition back to the community very20 difficult.21 We had kids who were doing22 quite well in Texas for two or three23 years and would come back to the City and24 not do so well.25 54 4.20.11 COMM. OF THE WHOLE - BILL 1101371 (Timer bell rings.)2
And so, there were3 several things, starting with the Blue4 Ribbon Commission.5 Secondly, when Commissioner6 Ambrose came on, one of things we agreed7 to, because most of those kids are8 involved in the DHS system, we agreed9 that we would begin shutting off10 residential programs that were out-of-11 state and forcing people to do -- to find12 alternatives.13 And then, thirdly, and I think,14 very importantly, I think Nancy Lucas,15 Kenny Selonka (sp?) at CBH, I think, did16 a really fantastic job of looking at17 alternatives, 'cause this doesn't work18 unless you have community-based19 alternatives.20
And so, there are a22 couple of things that happened. One is23 that we expanded the use of things like24 family functional therapy, evidence-based25 55 4.20.11 COMM. OF THE WHOLE - BILL 1101371 practices that kids could access within2 the City.3 And then the other thing that I4 think has made a huge difference is that5 we created an assertive outreach team, an6 assertive after-care team so that as kids7 were coming out of residential or being8 diverted out of residential, we had9 basically case managers that made sure10 that those kids got connected to local11 services and that those services were12 working.13 So we didn't just refer kids to14 local community services; we made sure15 that those services were working for kids16 and that they were having access.17
Okay.21 Thank you. I'll circle back my next22 chance.23 Thank you, Madam President.24
Thank25 56 4.20.11 COMM. OF THE WHOLE - BILL 1101371 you.2 The Chair recognizes Councilman3 Green.4
Thank you,5 Madam Chair.6 The Five-Year Plan highlighted,7 and you had testified about, DHS's new8 pay-for-performance, approach which is9 designed to enhance service delivery and10 client outcomes. And you and your team11 were kind enough to brief my office on12 this initiative.13 And I wondered if you could,14 for the record, describe how DBH's15 provider profile and pay-for-performance16 model works. The current model uses17 incentive payments to reward high-18 performing providers.19 How does the department plan to20 address low-performing providers either21 in terms of helping them to improve22 services or end their contracts?23
And before25 57 4.20.11 COMM. OF THE WHOLE - BILL 1101371 you answer that question, if you could2 just describe to us how you came up with3 this plan and, you know, how it's worked4 for you so far.5
Sure. So as we9 were discussing a little while earlier,10 one of our major concerns is the -- what11 we think is the excessive recidivism rate12 for people leaving acute in-patient13 hospitalization.14 And so, we identified that as15 one of our primary goals is to reduce16 that because we think it's better care17 for people, and it's certainly more18 efficient and effective care to make sure19 that people are sustaining the gains that20 they make in in-inpatient post-discharge.21 So for our -- for the paid-22 for-performance, I think it was a23 combination of two things that happened.24 One, at the State level, the State was25 58 4.20.11 COMM. OF THE WHOLE - BILL 1101371 encouraging counties to move to pay-for-2 performance. And then, secondly, we had3 these issues where we wanted to make an4 impact, and for as much as we have spent5 a tremendous amount of time and energy6 and training and all those kinds of7 things, we know that the most powerful8 incentive that we can use is money.9 And so, we really wanted to tie10 resources to increased performance to11 shape provider behavior.12 So that's sort of the13 background as to how we got there.14
Did you do15 any kind of return-on-investment analysis16 in determining what the appropriate17 amount of pay-per-performance is, because18 if they achieve that, it was going to19 save even more than you were giving as20 the incentive?21
Sure, yes. It's a22 great question. And the answer to that23 is -- I'll give you an example of the24 benefit.25 59 4.20.11 COMM. OF THE WHOLE - BILL 1101371 So we spent for the entire2 pay-for-performance project last year3 about $3 million. And if you look at the4 levels of care that we use that on,5 that's about 3 percent of what we spent6 on those levels of care. So $3 million7 pay-for-performance.8 We did another analysis that9 looked at recidivism over a three-and-a-10 half year period, and we stratified the11 population in different groups. And so,12 there was one group that had four to nine13 readmissions over a three-and-a-half year14 period.15 We calculated that if we were16 to reduce the number of episodes in the17 people that had four to nine by just one18 episode, it would save the system about19 $18 million.20 So if you look at the impact,21 the potential impact, that this can have,22 it's more than -- do the math -- six23 times potentially just for that one24 cohort. So the cost benefit is pretty25 60 4.20.11 COMM. OF THE WHOLE - BILL 1101371 large.2
Are there3 additional service areas where you think4 you might be able to expand this model,5 and are you looking at that?6
Yes, we are.7 Our goal is to have a8 pay-for-performance strategy for each9 type of service in our system. Last10 year, we did three: We did inpatient11 hospitalization, we did residential drug12 treatment, and we did residential13 children's services.14 This year, we're doing BHRS,15 we're doing targeted case-management.16 We're also going to be doing some17 incentives for outpatient providers.18 Our goal is that by 2013, our19 entire system will have some kind of20 pay-for-performance. Next year I think21 if you added -- did it by revenue, we22 would probably be up to about 75 percent23 of our service system.24
Thank you.25 61 4.20.11 COMM. OF THE WHOLE - BILL 1101371 You testified about some of2 your diversionary -- working with the3 courts on -- mental health courts and4 providing the resources for treatment5 instead of prison, and I know that6 program has just begun.7 But are you or anybody else in8 the system going to measure outcomes in9 terms of recidivism for, you know, on the10 criminal side in addition to outcomes11 sort of on your treatment area of mental12 health?13
Mm-hmm. Yeah,14 we're early on right now, so it's kind of15 hard to do that now.16 (Timer bell rings.)17
For any of these18 kinds of programs that we do, we will do19 some kind of analysis.20 And so we do one of two things:21 Either we do it by ongoing data22 collection and looking at the numbers, as23 I mentioned earlier; or we'll do a small24 study to look at that. So we've done25 62 4.20.11 COMM. OF THE WHOLE - BILL 1101371 that with a variety of services, and2 we'll be doing that with this one.3
Thank you.4 My time's up. I just have a few more5 questions, so I'll come back one more6 time.7
Thank8 you.9 The Chair recognizes10 Councilwoman Brown.11
Persons12 with disabilities, how has the business13 community responded to the work you're14 doing in that area?15
Well, I think -- I16 think two things. One is that when we17 talk about people with severe mental18 illness, for example, we've put a lot of19 emphasis on recovery, on normalizing,20 helping people to have a more normal kind21 of life. A lot of emphasis on what in22 the field is called "community23 inclusion," and I'll just give you an24 example.25 63 4.20.11 COMM. OF THE WHOLE - BILL 1101371 When the State hospitals were2 closed -- and I think this happened3 really around the country -- people were4 deinstitutionalized, they were taken out5 of large state hospitals and brought back6 to communities, but the reality is that7 people were what we call8 "institutionalized within the community."9 They're not really a part of the10 community; they live in segregated living11 situations, they're not really12 interacting.13 And, frankly, the way we had14 structured our treatment system, we15 really contributed to that to some16 extent.17 Over the last several years,18 we've made a concerted effort to look at19 how do we help people become a part of20 the community and not just live in the21 community.22
And so, we've --24 with one program in particular, where25 64 4.20.11 COMM. OF THE WHOLE - BILL 1101371 people were going to those programs2 literally for years, day after day,3 brought to the program by a -- by medical4 transportation, taken home at the end of5 the day, sort of in that pattern for6 literally ten, fifteen years, we7 radically changed those programs so that8 those programs were focused on recovery,9 they were focused on people obtaining10 jobs, getting an education, we taught11 people how to use public transportation.12 And the -- sort of the short13 story here is that not only did we14 improve outcomes, for example, we -- for15 people who went through those programs,16 we saw a 33 percent decrease in crisis17 visits, and we saw -- half of those18 visits would have converted to inpatient19 hospitalization.20 So we know from a system21 standpoint that it's been very effective22 in both saving resources but also in23 improving people's clinical care.24
But the real, I2 think, important part is that it really3 has improved people's quality of life. A4 number of people have gotten jobs,5 they've gone back to school. I think6 we've tried to model the importance of7 hiring people who are in recovery who8 have disabilities.9 And so, we have a number of10 people within our department who are11 people who have had psychiatric12 disabilities or who are in recovery from13 drug addiction.14
And so, I think16 we're getting there, but we have a long17 way to go to really get the larger18 business community to really embrace19 that.20
Mm-hmm.21 So have you had a chance, then, to22 explore strategically how you penetrate23 that community in a real strategic way?24
I heard a really25 66 4.20.11 COMM. OF THE WHOLE - BILL 1101371 interesting presentation a few weeks ago2 in Washington of a group that has done3 just that, and it was led by people who4 are in recovery themselves, who were5 business people themselves, and they had6 done some really interesting things in7 terms of engaging the business community.8 So I think there's some lessons9 learned out there that we want to tap10 into.11
But, you know,14 getting -- you know, breaking through the15 stigma around having behavioral health16 problems is a big challenge. So if you17 can help us with that, we'd appreciate18 it.19
Will23 Philadelphia have a face with the24 national effort to standardize best25 67 4.20.11 COMM. OF THE WHOLE - BILL 1101371 practices for recovery agencies?2