1. Clark County Department of Juvenile Justice Services: Detention Review and Release
The proposed represents a program expansion that involves the use of Multisystemic Intervention and Intensive Case Management Services (extramural funding is being sought). The proposed Detention Release program expansion represents an attempt to provide ongoing services to youth upon their release from detention. Multisystemic Intervention and Intensive Case Management Services are innovative approaches whereby an arrested youth diverts prolong detention stays and along with his/her families/caregivers, receive home- and community-based services. The youth and his/her family are engaged weekly by teams of detention officers and interns. Concrete services, clinical services, and education/skill building services are provided to the youth and his/her family. Initially, services are provided in the youth’s home. Detention officers provide general oversight and review the youth’s progress toward intervention goals. Intensive Aftercare Case Management services are provided to the youth at the end of the Multi-systemic intervention. Services include information and referral, community resources education groups, and community-based mentoring. Top

2. Factors of Re-Abuse and Re-Neglect Among Reunified Children in Southern Nevada
The objective of this new study is to determine the incidence of re-abuse in children who have been re-unified with biological parents or other kin and to find the factors that increase the risk of re-abuse. The project will involve a retrospective analysis of 1,000 case records of children who were reunified with their primary caregivers between the years of 1990-2000. A non-experimental, ex-post facto design, the “after-only study of participants and non-random controls” will be used. Two cohort groups will be formed: Cohort One will consist of at least 500 children who were initially reunified with their parents but later experienced at least one incident of re-abuse or re-neglect and Cohort Two will comprise at least 500 children who were successfully reunified with their parents and did not experience re-abuse and re-neglect. The relationship between characteristics predicting re-abuse versus those that predict the absence of re-abuse will be explored. Top

3. Foster Grandparent Program
This partnership focuses on the more that 400 retired seniors in Las Vegas who provide tutoring, mentoring, and classroom assistance for pre-school to elementary age children. These services are done under the auspices of EOB Adult and Senior Services Program. The Foster Grandparent Program is interested in establishing a program evaluation infrastructure whereby the impact of their services can be measured.  Top

4. Economic Opportunity Board
The Center for Urban Partnerships (CUP) is currently contracted to provide quarterly training sessions for Child and Family Service workers employed by the Economic Opportunity Board. Training topics center on child and family issues and vary depending upon the agency’s needs. The training contract can be renewed annually.  Top

5. Minority Retention Study
This study examines psychosocial correlates of retention in higher (post-secondary) education among ethnic minority students. Specifically, researchers at CUP investigated learning about individual, familial, and educational factors that help some students make a smooth transition to campus life. As part of an exploratory study several focus groups were conducted with different age groups: 1) UNLV students; 2) Clark County high school students; 3) UNLV faculty. Guided by focus groups, CUP researchers developed a self-report questionnaire, which was mailed to underrepresented minority students who attended UNLV in the fall semester, 2001. Funding agencies for this project included UNLV (Planning Initiative Award), Clark County Commissioners, and a donation from Stations Casino, Inc.  Top

6. Safe Nest: A Religious Response to Domestic Violence
This study evaluates the impact of domestic violence awareness training. A local group of faith leaders underwent extensive training in domestic violence awareness and were given information about methods for increasing sensitivity to domestic violence among congregants. Additionally, an extensive amount of domestic violence educational material was provided to the group of inter-denominational faith leaders so that they might disseminate the information to their respective congregations. A process and outcome evaluation is being conducted. Top

7. Vanderpool
CUP staff and faculty assisted the organization in revising the workplace-training proposal for submission to Clark County by: (1) strengthening the experimental design, (2) improving the intervention-related assessment, and (3) developing a more methodologically rigorous evaluation component. A second component of the contract included data entry, statistical analysis, and report construction for a prior workplace-training program D’Arcy Vanderpool and Associates completed previously for Clark County. The final product consisted of an ASCII data file that included the summary evaluation materials provided by the organization in hard copy as well as the written report detailing statistical analysis of the workplace performance data. Top

8. Project S.O.A.R.: Seeking Opportunities and Accepting Responsibility
This research study assesses the long-term effectiveness of a broad-spectrum competence-based enhancement intervention for increasing academic retention among middle school students. The proposed research also explores the extent to which this intervention influences parent-child relations, improves communication in the home, and reduces social deviance among participants. Four cohorts of students (N=96) with school records indicating relatively high rates of truancy and academic problems as well as students with court records indicating misdemeanor behavior have been selected for a multi-component intervention based on developmental models of deviance including problem-behavior and social strain theory. Intervention components include: (1) an intensive weekend retreat focusing on enhancing social, communication, and peer mediation (conflict resolution) skills, (2) a parent component that includes parent effectiveness training (Parent Teen Solutions) coupled with an instructional home visit; (3) extensive aftercare follow-up based on dynamic group process models to improve social interaction and peer mediation; (4) academic mentoring to improve school-based performance; and (5) a 20-session generic life skills competence enhancement program that targets increased personal and social self-efficacy. The intervention strategies are hypothesized to improve personal self-management and decision-making skills, increase social competence (i.e., assertiveness and communication skills), increase personal control and self-reinforcement strategies, and enhance parent-child communication. In turn modifications to these risk factors will reduce social deviance and truancy as well as increase conventional behavior and academic retention. Extensive follow-up is conducted at 6, 9, and 12 months post-intervention with scheduled incentives to students and their parents to reduce subject attrition.
This intervention represents a unique collaboration between the Clark County Department of Family and Youth Services, Clark County Department of Juvenile Justice Services (Psychological Services Unit), Department of Parks and Recreation, Nevada Army National Guard (Counter-Drug Task Force), and the UNLV Center for Urban Partnerships, Greenspun College of Urban Affairs, and Department of Counseling. The program of research draws on a strong acumen of skills and the collective resources of the participating agencies that will help ensure the success of this intervention.  Top

9. Blue Ribbon Committee Report
In December 2003, the Center for Urban Partnerships of the Greenspun College of Urban Affairs joined with the Blue Ribbon Psychiatric Committee in regard to issues of concern in mental health in Southern Nevada. The goals that developed for this project included the following: (1) a project investigating resources for those with serious mental illness in Southern Nevada, (2) a research project reviewing the fifty states for use of registries in mental health, and (3) a review of best practice models nationally. All of these projects are continuing to some extent at the present time, with the plan to investigate grant opportunities for research in the future.

As background to this project, a review of a number of Nevada’s state documents regarding mental health and disabilities was undertaken. There are a few findings from that review that should be noted. Significantly, the members of the Nevada Task Force on Disability (currently responsible for the Olmstead plan for the state) are primarily representatives of disabilities issues and primarily from Northern Nevada. In contrast, mental health issues appear to be represented by a sole member, and that one from Northern Nevada. This disparity can be seen when placed against the numbers. The Strategic Plan states that 88% of those served by the Division of Mental Health and Developmental Services receive mental health services, with the remaining 12% developmentally disabled. However, 52% of the budget is expended on those with mental illness, while 46% on those with developmental disabilities (p. 176). Given the stated need for increased mental health and emergency room services in Clark County, the equity in the budget areas between mental health and disabilities--as well as between southern and northern Nevada--needs to be reviewed.

Of particular note has been the evolving crisis in emergency room beds in Clark County. This crisis was brought to the attention of the federal review site team by the Mental Health Planning Council, and is stated in the state of Nevada Community Mental Health Services Block Grant Core Monitoring Report, May 21-23, 2002:

This year, Nevada received national attention due to a statewide hospital emergency room crisis. Individuals with mental illness were forced to wait in the emergency rooms 24-96 hours for treatment, including inpatient psychiatric care. In Nevada, all admissions to inpatient psychiatric units must be cleared of any other medical conditions prior to admission. The demand for inpatient services is beyond current staffing capacities and has reached the stage where people with mental illness are waiting 1-4 days in hospital emergency rooms before they are moved to inpatient psychiatric care…The State is encouraged to identify solutions and seek technical assistance to address this crisis.

Since that time, what action has been taken? Although the SNAMHS and the Nevada Division of Mental Health and Developmental Services received praise from the site review team in several areas, this is the one most relevant to the concerns of this committee, and does not appear to be addressed in these reports. The only reference found to the recommendation by the oversight committee is a general planning goal in the next report to “Address emergency room crisis in southern Nevada hospitals.” Hospital social workers report that the wait in emergency rooms is now often 7 days to 2 weeks. The difficulty most critical to service delivery appears not so much the quality or array of services provided by the SNAMHS, but the difficulties in the interface between that public system and the other systems providing emergency services to those in psychiatric crisis.

Although there is still work continuing for the Southern Nevada Mental Health Coalition, the following is a report on the findings of the work that has already been undertaken. In particular, a summary of the results of the three projects follows: (1) the resources project, (2) the registry project, and (3) the best practices project.

I. Resources Project

A research assistant has been reviewing resources available to the Las Vegas Valley by interviewing both the hospital social workers and other providers in the community. The HELP Community Services Directory was also reviewed. In general, the hospital social workers seem very aware of what is available as services. While there is some need for information about programs (below) which the state lists as the most important for people with mental illness, these programs are either not very available, as Shelter Plus Care is not--with its 1-2 year waiting list--or are accessed through SNAMHS. Information regarding these services is currently being compiled for distribution to the hospital social workers. In general there simply aren’t enough of any given services, and not enough services in the most needed areas, rather than a lack of information concerning them. The most sought after services are these: housing, medications, financial assistance, and social supports.

The biggest problem mentioned in service delivery seems to be the difficulty in the interface between that public system and the other systems providing emergency services to those in psychiatric crisis. According to the federal review of the Community Mental Health Services Block Grant Core Monitoring Report of May 21-23, 2002, “Because all services are provided by the State, there appears to be little room for innovation or flexibility.” Interviews with stakeholders and work with this committee would suggest that there is widespread agreement with this statement by the federal review team. Although the Strategic Plan generally lists low numbers on the waiting lists for services (e.g., 10 average per month on the waiting list for residential community-based services), placement on the waiting list apparently ends when an individual is seen by an intake worker, whether or not that individual receives other services beyond intake; this is seen as a contributing factor to a quick return to a hospital emergency room. The disparity between the stated needs of the community and the SNAMHS’ waiting lists should be further explored. There is also disparity between the 3 days wait that SNAMHS asserts, and the 7 day to 2 week delay that the hospital social workers assert.

The services that the state of Nevada asserts in its formal documents as available and particularly helpful to those with serious mental illness are these:

• PATH, the Project for Assistance in the Transition from Homelessness, available through the Salvation Army. This federally funded program is designed to assist consumers who have been or are at risk of becoming homeless. The Salvation Army says that there is no waiting list for the assistance of its PATH workers as case managers or even generally for extended stays in their shelter, but there are waiting lists of 4-6 months for the group home and transitional living apartments.
• Shelter Plus Care, a program through HUD, is a federally funded program to help disabled homeless people with mental illness and their families find shelter. Unfortunately the waiting list for services is reported to be at 1-2 years.
• Healthcare for the Homeless, through SNAMHS.
• Senior Mental Health Outreach Program, through SNAMHS.
• PACT programs through SNAMHS.

Although there is the potential for these state-highlighted programs to be helpful in referrals from the hospital social workers, they are not necessarily readily accessible, with lengthy waiting lists for both PATH and Shelter Plus Care, and admission to the other programs through the SNAMHS process.

II. Registry Project

The important issue seems to be how the state figures out who needs state assistance. In other words, how does it build its service array or continuum and its biennial budget? How does Nevada’s process compare with other states, and might there be something we can learn from other states? In order to find out, a state-by-state survey was undertaken to determine what factors states consider when they build service systems and budgets. Of the states, we have information from all but five as of the time of this report. Although there is a great deal of information to digest, the most relevant question for this report is the following: Does/how does the state track people through the emergency room and/or emergency detention processes?

The majority of states do not undertake any individual tracking either of those who are in emergency rooms or under emergency detentions on any statewide basis, until the point at which they may enter publicly funded services in some way. Tracking of general trends or client movement occurs in most states, although again generally at the point of public funding. Some use claims processes to track spending in hospitals when state monies are involved. Many states use some form of a community mental health system to screen those in emergency rooms for services, with these numbers being kept by the mental health center, but not necessarily in any integrated or comprehensive way for state planning purposes. In some other cases, data is maintained by a county or catchment area system, and is used as a part of the planning process.

Some states are using—or beginning to use—some real data from community mental health, or regional planning centers, or state facilities, or more rarely, from emergency detentions. A few states like Vermont have taken an initiative in this area, although they remain in the minority. Most of these few states are addressing the collection of real data in selected facilities rather than crisis psychiatric care in private hospitals. There does appear to be something in a trend developing toward obtaining real data on statewide needs, and there was interest in the results of this survey project in some states. Delaware, for instance, not only provides some tracking of individuals, but is beginning to set up a High End Users Project, to look specifically at those individuals who enter the system multiple times. This analysis of high end users builds on a recent history of subcapitation and capitation strategies in funding the quasi-public sector. States seeking creative and sometimes cost-saving solutions have freed up at least some of their funding so that agencies can develop supportive housing, medication management, case management, mobile crisis intervention services, psychiatric evaluation and other services, as strategies to stabilize individuals from inpatient crisis care through managed care/capitation funding strategies.

A common enough practice is not to keep any individual tracking information at all, but to build budgets based on a growth factor using the priorities established by commissions and task forces. This last approach is the one used by the state of Nevada, but interestingly, the differential growth in the state is apparently not taken into priority consideration in the planning processes. Thus the importance of asserting the presence of representatives of Southern Nevada on the many commissions and task forces in the state, currently notable because most of their members come from Northern Nevada. While understanding the desire to save money by bringing local representatives to the table in Carson City, the crisis needs of the state are so slanted toward southern Nevada that representatives from this area are an absolutely necessary ingredient to the planning processes.

III. Best Practice Models.

In the Community Mental Health Services Block Grant Core Monitoring Report of May 21-23, both the Neighborhood Care Centers of Las Vegas with children and family services and the Program of Assertive Community Treatment (PACT) for those with serious mental illness were highlighted as recognized best practice programs. Of particular interest to this report, the PACT team of Northern Nevada was recommended for its fidelity to this well-respected model of best practice in mental health.

Although we have been asking states for their advice on best system models, this has been a difficult part of the research, largely due to the differences in state political environments. No state has clearly offered itself as a model, although a few seemed relatively satisfied with their efforts. A couple of things are clear, however, in discussions with the states. First there should be an expansion in the Program for Assertive Community Treatment (PACT) model of intensive case management, which has remained the operative model of treatment for about 20% of the most disabled of those with mental illness. There are now 2 PACT teams through SNAMHS, and this model should be expanded. This model includes the use of mobile crisis team services. Obviously, retaining people for extended periods of time on Legal 2000s presents a potential legal crisis for the state. The CIT program in Memphis, which is already known to this committee, has also been cited for its success.

Secondly, the other main support service that states consistently recommend as vital for the stabilization of client populations is the expansion of housing availability with residential supports. These and other recommended services seem to be available to a limited extent within the SNAMHS/Mojave Mental Health service system, once a client is able to access the services. Again, other programs outside this network, such as Sheltered Plus Care that provides housing for those who are mentally ill and homeless, has 1-2 year waiting lists. The Salvation Army, which considers itself something of a last stop for people, has waiting lists for its residential services of 4-6 months. According to the states surveyed, a strengthening of the housing/residential supports component of available services cannot be outdone as a systemic strategy for positive outcomes in client stabilization. Utah’s Valley Mental Health has shown a track record of innovative housing development, and increased emphasis in this area should be pursued.

Along with a strategy for speedy evaluations on Legal 2000s, resolving the inflexibility in provision of services needs to be on the front burner. It appears that Mojave or other private agencies could expand and develop more responsive services following such a review of the funding strategies and goals by the state of Nevada.

Recommendations:

1. The Blue Ribbon Psychiatric Committee and all the individuals and hospitals that have worked to coordinate the emergency room data should be congratulated for their efforts. From the review of other states, the use of real data is increasingly being pursued by states as a result of litigation, legislative demands, or executive responsiveness. In the survey of other states, there does not seem to be another group of private sector representatives developing their own database to further services for individuals with psychiatric crises. This data may well prove to be the key to the solution of the emergency room crisis in Southern Nevada.
2. Hospital social workers should make referrals to all appropriate programs, if only to document outcomes of the referrals as much as possible. The seeming disparity between stated needs by the hospitals and the waiting lists for services noted in the Strategic Plan needs to be developed and addressed, and one strategy is to have strong data revealing the outcomes of referrals. Information requested regarding the state-highlighted programs will be made available to them.
3. The Blue Ribbon Psychiatric Committee and the Mental Health Coalition, as well as any other appropriate channels, should consider a formal request to the Governor that the State of Nevada more appropriately include representatives of mental health issues from Southern Nevada on all task forces and commissions. Particularly due to Nevada’s current reliance on the advice and advocacy provided by commissions and task forces, the importance of this recommendation cannot be overstated.
4. The formula and strategies for funding services should be reviewed by the state of Nevada to increase the flexibility of services, as recommended in the federal review of May 2002.  Top

CENTER FOR URBAN PARTNERSHIPS (CUP)
Greenspun College of Urban Affairs
4505 Maryland Pkwy. Box 453061
Las Vegas, NV 89119-3061
1-866-UNLV-CUP (1-866-8658-287)
Phone: 702-895-2926 – Fax: 702-895-0415
E-mail: cup@ccmail.nevada.edu
Website:www.unlv.edu/centers/cup