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Human and Cost Benefits of Community Behavioral Support in Minnesota

by Joan Oslund, Wayne Larson, and Charlie Lakin

Minnesota entered the 1990s with a goal of rapidly moving people from state institutions to community settings and of eventually closing the institution doors behind them. Between June, 1990, and June, 1995, Minnesota’s state institution population decreased from 1,337 to 524 people. During the same period an average of 122 people were admitted to state institutions each year. The vast majority (77% in 1994) were admitted for short-term stays of less than 90 days in response to behavioral crises and other emergencies. Minnesota’s legislature recognized the need to end this pattern of admissions, and authorized funding for a community behavioral support and crisis response demonstration program, specifying that it be evaluated for its ability to reduce institutionalization in a cost-beneficial manner.

Special Services Program Design

The Special Services Program (SSP), was established as the authorized demonstration. It targets five counties in the Minneapolis area, and its primary goal is to prevent institutional and other out-of-home placements due to behavioral episodes or emergency circumstances at equal or lower costs than more restrictive residential treatment. Achieving these goals requires two types of services: outreach in the individual’s home, workplace, school, or other community setting; and short-term (90 days or less) inpatient treatment in a specialized unit. Both involve an interdisciplinary team focusing on non-aversive behavioral interventions guided by a functional assessment of challenging behavior. The program staff include a director with extensive experience in mental health, two behavior analysts, a psychiatric nurse, an intake worker, and experienced direct care staff in the crisis unit. Ongoing consultation is provided by a board-certified psychiatrist and licensed psychologist. This team is able to assess a range of environmental, medical, psychiatric, psychological, and communicative factors.

Outreach services include functional assessment of the behavior for which the individual is referred, technical assistance in devising appropriate interventions, and care provider training. The residential unit provides intensive support and intervention for individuals whose behavioral challenges have seriously jeopardized (or resulted in loss of) current residential or other service situations. Consultation is provided by the SSP staff on long-term planning of more appropriate accommodations or enhancing supports to permit the individual to return home. The short-term crisis unit is staffed 24 hours per day and can accommodate four people at a time. To the extent feasible these persons maintain their school, work or other activity while living on the unit.

Outreach and crisis unit services are provided in three phases: 1) assessment; 2) intervention/training (including the development of a crisis prevention/intervention plan); and 3) follow-up. The foundation of the assessment and intervention process is the instruments and procedures designed by the Institute for Applied Behavior Analysis:

• Assessment. Originally, the assessment was designed to be brief, but intense, so that preliminary recommendations could be developed and presented to interdisciplinary teams within one week of service commencement. With the development of the Metro Crisis Coordination Program for the more urgent situations, the assessment has become more comprehensive and therefore the timeframe has expanded to 30 days or less. Assessments are conducted by a behavior analyst and a psychiatric nurse, and include individual and group interviews with family members and service providers, a records review, and direct observation of referred persons in their home and day setting.
• Intervention/Training. Recommendations for intervention and training include a) proactive strategies; b) environmental modifications; c) reactive/emergency strategies; d) staff/care provider training; e) data collection; and f) follow-up. Intervention strategies concentrate on the developing alternative social and communication skills, and environmental conditions that may affect behavioral patterns. Often additional recommendations are received from the consulting psychiatrist and psychologist. Referrals may be made to other medical specialists or to communication specialists. Reactive strategies are also devised to intervene in challenging behavior. These include crisis prevention plans to assist families and service providers. Ongoing consultation regarding the implementation of specific interventions is provided. As possible, the SSP directly or via other specialists in the community provides educational materials and training on specialized issues.
• Follow-up. The SSP team follows referred individuals for a year from service commencement. Follow-up enables SSP to keep informed of the individual’s adjustment following services, offer assistance, and maintain evaluation of service effects.

Special Services Program Outcomes

Evaluation results have shown diversity in persons served, general effectiveness in services offered, and cost-benefits for Special Services Program as a whole:

• Individual Characteristics. The most common behavioral concerns at the time of initial referral have included: physical aggression toward other persons (71%); verbal aggression (50%); property destruction (26%); and self-injurious behavior (21%). More than three-fourths (82%) of all persons referred have had a psychiatric diagnosis, most frequently schizophrenia or other psychotic disorders, personality disorders, affective disorders, and impulse control disorders. The ethnic composition of referrals is similar to that of the Twin Cities metropolitan area. Referred individuals have ranged in age from 8 to 67 years, with an average of 29.6 years. A quarter of persons referred were less than 17 years old. Two-thirds (67%) were male.
• Placement Effects. Fifty-eight percent of the individuals served via outreach services, but only 25% of the crisis unit users, have remained in the same residential setting throughout the whole year following initial referral. By the end of 1994, one of the 24 individuals who had been admitted to and discharged from the SSP unit had entered an institution; this was early in the program when a local agency did not develop a home for a crisis unit resident within 90 days as required, and SSP decided not to deviate from the established requirement. In comparison, in 1994 3 of 14 individuals unable to access SSP services because of limitations on capacity or from being outside the catchment area were placed in a state institution for long-term placement.
• Satisfaction. Post-service telephone interviews have been conducted with 32 primary care providers of persons receiving SSP services. Fifty-six percent rated their overall satisfaction as “very high” and 44% rated it “high.” Four-fifths of care providers gave staff “very high” satisfaction ratings. Of 46 service coordinators interviewed in the evaluation, 63% rated their satisfaction with services as “very high” and 37% rated it “high.” The specific dissatisfactions most often revolved around the time lapse between referral and initiation of service. The 90-day placement limit for crisis unit services was also considered by some to be too short to develop new residential programs for people who were unable to return to their previous home, a criticism which led to development of transitional housing options.
• Cost Effectiveness. Estimates of the cost effectiveness of SSP are based on projections of the most likely service disposition for each SSP referral in the absence of the program. These projected outcomes were obtained through interviews with each individuals service coordinator. Dispositions are stated in terms of residential and other support services and their probable length that would have occurred. Expenditures are estimated based on average costs for those services in the area. Alternative dispositions are limited to a 90-day period from referral because of lower reliability of longer projections. It is projected that 27 of 54 individuals completing SSP services would have been placed on a short-term basis (90 days or less) in an institutional setting. The estimated costs projected for persons who were served in the crisis unit had the unit not been available are $414,619 or $20,731 per person. Expenditures of $307,703 or $9,050 per person are projected for persons served off campus had the services not been available. Thus, the average projected alternative expenditures for SSP participants are $13,376 per person. Actual expenditures for SSP operations were $435,148, including $26,553 for 1,308 resident days on the crisis unit (89.6% of full capacity). The net projected expenditures for SSP participants in the absence of the program are $722,320. It is estimated that annual costs for SSP participants are $287,172 less than likely costs in the absence of SSP (i.e., $722,320-$435,148).
• Validation. While there are no better sources of likely outcomes in the absence of SSP than those of individuals’ service coordinators, it is important to validate their projections. This has been done though follow-up on 14 individuals who were unable to access SSP services because of limited capacity and catchment area restrictions. Because these individuals were similar to those persons served in the SSP, their actual experiences were used to test the accuracy of the service coordinators’ projections. Seven of the 14 individuals were admitted on short-term basis to a state institution and one was placed in a psychiatric hospital. This yielded a per person average estimated expenditure of $13,273 in the absence of SSP, nearly identical to average projected expenditures of $13,376 for SSP participants in the absence of the SSP. This provided strong support for the service coordinators’ projections of outcomes and expenditures in the absence of the SSP.

All the evaluations of the SSP model have shown it demonstrated success in preventing institutionalization, satisfying care providers and service coordinators, and saving service dollars. The extensive needs of individuals and the gaps in the present service system have become obvious, and SSP has demonstrated an effective response.

Joan Oslund is Program Director and Wayne Larson is Executive Director of Crisis Services at Mount Olivet Rolling Acres, Victoria, Minnesota. She may be reached at 952/401-4844 or by e-mail at JoanO@mtolivetrollingacres.org. He may be reached at 952/474-5974 or WayneL@mtolivetrollingacres.org.
Charlie Lakin is Director of the Research and Training Center on Community Living, University of Minnesota, Minneapolis. He may be reached at 612/624-5005 or lakin001@tc.umn.edu.

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Citation: Hanson, R., Wieseler, N., & Lakin, K. (2000). Impact: Feature Issue on Behavior Support for Crisis Prevention and Response, 14(1) [online]. Minneapolis: University of Minnesota, Institute on Community Integration. Available from http://ici.umn.edu/products/impact/141/.

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