Elevate Behavioral Health Pinellas County A strategic review of & roadmap for the Pinellas County Behavioral Health System of Care

May 2020

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Executive summary

Pinellas County (County) engaged KPMG in December 2019 to undergo a roughly three-month project to scan the behavioral health system, interview stakeholders, review leading practices, and bring back to the County a new vision to improve the system of care around behavioral health in Pinellas. This has led to this strategic report to “Elevate Behavioral Health,” with this being the foundational step in moving the County in a new direction in patient-centric services, enhanced governance, funding, and performance management aimed at improved outcomes for the County’s residents.

Introduction

The Pinellas Project Planning Team provided KPMG with the following Top 5 questions to guide the analysis. High-level responses to each of these questions are provided in the following pages of the executive summary, with additional details contained throughout the report.

Question 1: Do we have the data to know how well our system of care is performing in terms of access, capacity, productivity, and quality outcomes?

Question 2: Should we build a new Marchman facility or expand current capacity?

Question 3: Should we increase case management compliment to better accommodate the Baker Act population to ensure no one falls through the cracks?

Question 4: Should we consolidate all our contracts and funding into fewer providers?

Question 5: Should we be doing more as a system of care to combat the opioid crisis?

Based on answers to the Top 5 Questions above, KPMG recommends that the County take immediate action and consider investment in the following foundational issues:

1) Establish a systemic performance management approach in terms of access, quality, capacity, productivity, and outcomes—grounded on a Minimum Data Set (MDS) across all providers, allowing for benchmarking comparison and trend analysis. This requires establishing a contractual MDS requirement for all providers arising from collective development of an MDS with behavioral health funders within the County.

2) Establish a robust Coordinated Access Model that allows for increased transparency in how clients, families, caregivers, and professionals can access the right services within the system. This requires various enabling elements including a 1-800 number; standardized screening, triage and scheduling practices; and an evaluation of the current systems in place by providers to ensure interoperability and exchange of information to allow for a consolidated view of consumer demand, level of need, available capacity, and access to care.

Impacts of COVID-19 on our report and recommendations

While the fieldwork and analysis of this engagement concluded in early March 2020, KPMG believes the current circumstances surrounding COVID-19 make the strategy and recommendations put forth in this report even more relevant and urgent. For instance, increasing access in primary care and other community-based settings to improve prevention and early intervention will rely even more heavily on scaling up telehealth channels and infrastructure.

Additionally, economic and emotional stressors may drive an increase in community need for mental health and substance abuse services both during and long after social distancing guidelines abate. Finally, the impact of distancing guidelines in the clinical setting for both consumers and providers may cause significant challenges in access, capacity, and timeliness of care – all under-scoring the need for an enhanced model of coordinated access across all settings of care in the County’s behavioral health system.

Overview

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Executive summary

KPMG has identified a need for better coordination, management, and alignment of strategy across the services being provided. It is important to note that KPMG did not conduct a review or analysis of the third-party providers and their delivery of services. Our findings reflect the perspectives of a broad range of stakeholders interviewed and system-level information reviewed. The foundational questions asked of the 50 organizations interviewed were:

— What is going well in the Pinellas County Behavioral Health system?

— What can be improved for residents needing services?

— What are the pain points in the current system?

— What can the County do to improve the governance and funding structure?

— What services and/or capabilities (if any) are missing?

— How does the County measure performance?

This report is the collated result of these questions. There are no findings, solutions, or options presented herein that were not discussed or supported by input from and discussions with County stakeholders. KPMG filtered those perspectives and assessed them against the available performance and budgetary data that was provided. A further narrowing of issues, options, and recommendations was accomplished by reviewing the existing literature and leading practices to assess the viability and validity of our recommendations.

Approach

KPMG’s scope centered on scanning the existing continuum of programs and services across the County’s Adult Behavioral Health System of Care to identify high-level gaps, and inform a future-state vision and roadmap for action, considering both County and State-funded providers and programs.

The County asked KPMG to provide a new vision for the County in how it could meet the requirements of its residents. The County is in a unique position as it is not the direct provider of services nor the primary funder of the services described in this report. The County instead funds services that fill three buckets:

— Matched funding: The State of Florida (State) funds some behavioral health services and requires a 25% match by County governments within those programs.

— Gap funding: The County identifies gaps in services throughout the system and proactively contributes to enhancing funding for existing programs and services. Grants are also used for this purpose.

— County programs: The County develops and contracts for its own programs or is required to fund services such as those medical and behavioral health services provided in the County jails.

The County allocates two types of funds across the behavioral health system: general funds from the County’s budget and grant funding acquired through a variety of sources. The County is active in pursuing grants to deliver enhanced services to residents; however, these grants often come with significant restrictions that do not allow for sufficient flexibility in allocation or distribution to services to fit the specific needs of the County. These funds and the County’s current strategy described above have allowed the County, along with community and State partners, to deliver a wide breadth of services to its residents.

The scope of behavioral health services observed by KPMG is consistent with those found in other jurisdictions with a more mature continuum of care. KPMG’s recommendations focus on improved analysis, optimization, and coordination of existing programs before further investments are considered.

Background

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Executive summary (continued)

KPMG was consistently impressed by the input, passion, and dedication of the County and its stakeholders who were engaged in this process. The County operates a broad and mature set of programs and services, resulting in KPMG’s desire to highlight the following selection of commendable practices observed.

Commendations

Investment in high utilizers

The County has further invested in programs to address the needs of highest-need clients, such as the Pinellas Community Empowerment Team and Health Care for the Homeless Co-occurring Assistance Recovery & Empowerment Team.

Focus on supportive services

The County has continued to invest in programs providing supportive services for homeless individuals and aimed at ending the Opioid Crisis, such as the Co-operative Agreement to Benefit Homeless Individuals and Opioid Site Based Grant for Strategic Information Partnerships.

Cross-system data sharing

The County has made progress in enabling interagency data sharing within and outside of behavioral health by investing in the Data Collaborative and Care Connect.

Investment in receiving and diversion

The County has shown a strong commitment to expanding and enhancing receiving and diversion options away from hospitals and jails through programs such as Personal Enrichment Through Mental Health Services (PEMHS) and Westcare Turning Point Homeless Inebriate Shelter.

Cross-systems leadership and collaboration

The County has continued to embrace system-wide collaboration through the Pinellas Integrated Care Alliance (PICA) and focus on alignment across agencies and providers to improve long-term outcomes.

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Executive summary (continued)

The KPMG team presented our independent findings to County leadership periodically and validated the information and recommendations contained within this report. This validation serves not as an endorsement of KPMG findings but helps to ensure that the information contained herein is County-focused and is consistent with the Statement of Work for this project. KPMG identified five core findings, which guided the solution development for the County’s consideration. Those findings are as follows:

Key findings

Finding 1: Primary entry into behavioral health services is through crisis care settings (e.g., emergency department, jail, receiving facilities).

Finding 2: Silos persist such that the behavioral health system functions more as a set of programs than a coordinated system of care.

Finding 3: There is a lack of data-driven transparency and accountability on how well behavioral health providers and services are performing collectively, and in some cases individually.

Finding 4: Funding structures and reporting requirements are siloed, causing a lack of the flexibility and transparency needed to follow patients through the system of care.

Finding 5: The unique geographic dimensions and population density of the County limit the practicality of one central receiving facility to effectively serve an ever-growing population.

While not all-encompassing of the varying perspectives of County stakeholders, the challenges illuminated from these five findings have resulted in a robust set of strategic options to improve the behavioral health system. The options presented on the following page have been validated against leading practices and available performance and quality data, with a key focus on outcomes for County residents. While provider service and treatment-level data was not accessible or available for this strategy and visioning process, we do understand that the County’s system of care faces three critical and growing community problems.

Challenges include:

— Increased suicide deaths of 10% from 199 in 2015 to 219 in 2018 1

— Increased opioid-related overdose deaths increased by 78% from 2015 to 2018 2

— Decreased count of homeless individuals from 3,387 in 2015 to 2,415 in 2019, but an increase in certain sub-groups such as those with disability status, homeless veterans, chronically homeless and homeless individuals residing in Pinellas County Jail 3

These key system-level challenges guided the “why” and “why now” for developing possible options and strategies, leveraging leading practices and strategies in place and under consideration by other jurisdictions. The options presented on the following page are presented in two categories: System Management and Service Delivery.

From challenges to strategic options

[1] Florida Health for Suicide Deaths http://www.flhealthcharts.com/charts/DataViewer/DeathViewer/DeathViewer.aspx?indNumber=0116

[2] The Opioid Epidemic in Pinellas County https://www.arcgis.com/apps/Cascade/index.html?appid=8c02b926f02c4498b1dda55f00e4a1aa

[3] Analysis of Pinellas County Point in Time (PIT) Data from 2015 through 2019 https://www.pinellashomeless.org/performance http://www.flhealthcharts.com/charts/DataViewer/DeathViewer/DeathViewer.aspx?indNumber=0116 https://www.arcgis.com/apps/Cascade/index.html?appid=8c02b926f02c4498b1dda55f00e4a1aa https://www.pinellashomeless.org/performance

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Executive summary (continued)

The figure below visualizes the future-state vision for the County’s behavioral health system in two parts. The top of the triangle representing acute and subacute services, and the base focuses on prevention, early intervention, and community treatment models.

A vision for the system of care

Top of the triangle: Acute and subacute interventions

— Crisis Receiving and Stabilization: Includes services that are open 24/ 7 days a week, 365 days a year for clients whose needs are not met through traditional outpatient methods of care. These clients may have gone into a crisis that requires immediate attention by a psychiatrist, nurse, social worker, or other staff. Crisis programs make every effort to stabilize the client, and if deemed safe, discharge patients back to lower acute care for treatment and follow-

up. It is only for clients that the crisis program is unable to stabilize that are transferred to subacute or acute care.

— Residential/Detox Services: Includes services for clients who require a stabilization period from substance abuse.

These programs differ from a short-stay admission to a long-stay admission based on client presentation and willingness to engage in treatment. Clients typically reside in the facility and engage in these services through voluntary admission.

— Inpatient Psychiatric Care: It is important to note that clients who are admitted directly from the crisis stabilization unit to inpatient psychiatric care are often those with a serious mental illness (including those with a co-occurring disorder). Clients are admitted either voluntarily or under the mental health act (i.e., Bakers Act) for a 72-hour for assessment and observation. An interdisciplinary team works with the client to stabilize them and transition them back to lower acute care, that is often a step-down program within the base of the triangle.

Base of the triangle: Prevention and early intervention

— The center of the triangle is where the resident sits with a strong social network and community surrounding them.

This is a crucial part of the patient journey, where social support is what keeps them engaged with community-based services and supports.

— The left and right corners represents prevention and/or early intervention programs that the majority of the population can be served through. Once clients enter these programs, the majority of their needs are met if programs are able to offer timely access and evidence based care.

— Primary care is sought for early symptom detection, diagnosis, referrals to name just a few. They stand before the crisis receiving and stabilization components, because if the client is attached to a primary care team and can stabilize without seeking a more intrusive measure of care, then that is the preferred treatment approach.

— The goal is for client to be self-reliant for as long as possible and for services to be available in order to effectively transition care and treatment close to home once they have completed their subacute/acute treatment.

Based on research from the KPMG Global Center of Excellence for Healthcare, it is estimated that 96% of a typical community (not accounting for high-risk populations) needs are met by an effective “base” in a healthcare system.

Residential/detox care

Crisis receiving and stabilization

Screening/assess/ referral, community care, CBT, and education-based care

Inpatient psychiatric care

Primary care

Resident

Support self-reliance for as long as possible

AA, NAMI, Clergy Behavioral Health

Support, and Promotion of Healthy

Living

Effective transition of care and treatment close to home

5 5

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Executive summary (continued)

KPMG developed a set of strategic options across six categories for change, at both the System Management and Service Delivery levels. We recommend the County and its stakeholders consider these options from left-to-right, enhancing Performance and Coordination before considering Funding or Receiving and Diversion.

Options considered

G-1 Enable Performance-Based Contracting at County Level

G-2 Engage a Managed Entity at County Level and/or State

F-1 Consolidate Funding Across County & State Sources

F-2 Hybridize Funding Across County & State Sources

PM-1 Develop County Minimum Data Set

PM-2 Develop System wide Minimum Data Set

PM-3 Integrate County Minimum Data Set with Funding

D-1 Enhance Existing Public Receiving Service Capability

D-2 Standardize Across Public & Private Receiving Model

D-3 Enhance Existing Public Receiving Capacity

C-1

Establish a County & Provider- Managed Model of Coordinated Access for Consumers

C-2 Establish a Managed Entity & Provider-Managed Model of Coordinated Access

PE-1 Enhance Existing Prevention & Early Intervention Services

Governance FundingPerformance management

Receiving & diversionCoordination Prevention & early intervention

S ys te m m an ag em en t

S er vi ce d el iv er y

KPMG validated the above options with the County and organized options into five pathways to implementation. Even in isolation, each recommendation would be impactful if adopted; however, KPMG recommends a more comprehensive program of transformation to enhance overall potential impact on systemic efficiency and resident outcomes. The recommendations also cannot be viewed as an a la carte menu of options. These options ask the County to consider these fundamental changes:

System management

— Performance Management: Develop a more robust strategic performance management framework.

— Governance: Enact performance-based contracting and consider the assistance of a third party.

— Funding: Consider consolidation of funding into high-performing programs and service providers.

Service delivery

— Coordination: Reduce silos and improve resident navigation of the behavioral health system.

— Prevention: Expand and enhance prevention services building on existing County and State services.

— Receiving and Diversion: Enhance services for individuals in crisis leading to increased clarity on capacity needs.

The pathways described on the following page all imply a shift in existing capacity and/or additional effort/ funding not currently present in the system. As noted previously, the County does not directly provide services to consumers nor is it the lead funder of services—that role falls to Central Florida Behavioral Health Network (CFBHN) on behalf of the State. The successful adoption of these recommendations necessarily falls on the entire system of care, which includes the providers, the State through its departments and its Managing Entity, and multiple County agencies as well. A coordinated approach to change across stakeholders is necessary if the County and its partners are to be successful in improving resident outcomes.

From strategic options to pathways for action

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The five pathways below integrate the strategic options into logical groups based on the interdependencies and represent significant multiyear efforts. For instance, consolidated funding being predicated on performance-based contract governance and a system-wide Minimum Data Set. Similarly, investment in expanded public receiving capacity should be predicated on residual needs once Coordinated Access Models and enhanced prevention services are in place. Implementation pathways include:

Executive summary (continued)

Implementation pathways

Pathway 1 System-wide

Pathway 2 County-focused comprehensive

Pathway 3 Focus on prevention

Pathway 4 Enhanced

Pathway 5 Enhanced plus new capacity

This implementation pathway emphasizes system-wide collaboration between County and State funders and providers for performance management and the coordinated access model of care. A hybrid approach is taken to contracting, funding, and receiving and diversion.

This implementation pathway focuses on what the County can independently influence, including a consolidated approach to contracting, funding and performance management, and further investment in receiving and diversion, coordination, and prevention and early intervention.

This implementation pathway focuses on investing further in prevention and early intervention services, while enhancing performance-based contracting and the existing public receiving facility.

This implementation pathway focuses on enhancing existing contractual frameworks and their public receiving facility, and developing a County Minimum Data Set requirement for all providers.

This implementation pathway focuses on creating net new capacity across diversion programs and receiving facilities, while enhancing critical components in contracting and funding.

C-2 Coordinated Access Model – Managed Entity &

Provider Managed

D-1 Enhance Existing Public Receiving Service Capability

C-1 Coordinated Access Model – County & Provider

Managed

F-2 Hybridize Funding Across County & State Sources

PE-1 Enhance Existing Prevention & Early

Intervention Services

D-3 Enhance Existing Public Receiving Capacity

D-1 Enhance Existing Public Receiving Service Capability

F-1 Consolidate Funding Across County & State

Sources

PM-2 Develop System-Wide Minimum Data Set

G-1 Enable Performance- Based Contracting at County

Level

PM-1 Develop County Minimum Data Set

PM-1 Develop County Minimum Data Set

PM-3 Integrate County Minimum Data Set with Funding

G-2 Engage a Managed Entity at County Level and/or

State

F-2 Hybridize Funding Across County & State Sources

G-1 Enable Performance- Based Contracting at County

Level

G-1 Enable Performance- Based Contracting at County

Level

G-2 Engage a Managed Entity at County Level and/or

State

D-2 Standardize Across Public & Private Receiving

Model

PE-1 Enhance Existing Prevention & Early

Intervention Services

D-2 Standardize Across Public & Private Receiving Model

⚫ Performance Management

⚫ Governance ⚫ Funding ⚫ Coordination

⚫ Prevention & Early Intervention

⚫ Receiving & Diversion

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Executive summary (continued)

The pathways in the previous page are presented left-to-right in terms of level of impact and required stakeholder collaboration. High-level duration, complexity, and costs indicated above are summarized in the figure below and further detailed in the body of this document. Finally, in our view, the adoption of one pathway by the County would not preclude shifting direction to another in the future as circumstances and drivers may change.

— How much change does the County need? If the County believes significant change is needed to achieve its expected outcomes, the County must consider pathways 1 and 2. Pathways 3 and 4 would be the best fit if the County is seeking more incremental change.

— What level of impact does the County expect? Pathways 1, 2, and 3 would provide the highest impact to the County. The changes would drive fundamental changes to treatment delivery and strategic performance management.

— What level of investment is available? Pathways 3 and 4 come at the lowest cost, with pathways 1 and 2 representing about an equal level of additional investment in new and enhanced services.

Pathway 5 has the possibility to be the highest cost.

— What will the level of effort be? Pathway 1 represents a high level of effort due to its implied systematic changes. Pathway 2 falls in the middle, and 3 and 4 are low effort options that still can provide great benefits to the County. Pathway 5 could represent significant effort if the County goes down the path to build a new facility.

Implementation pathways (continued)

Pathway 1 System wide

Pathway 2 County-focused Comprehensive

Pathway 3 Focus on prevention

Pathway 4 Enhanced

Pathway 5 Enhanced plus new capacity

Level of Impact

High High Medium Low Low

Level of Effort

High Medium Low Low High

Level of Investment

$2–3M (>20% current budget)

$2–3M (>20% of current budget)

$500–1M (>10% current budget)

$500K to $1M (<10% current budget)

$3–10 M (>30% current budget)

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Executive summary (continued)

The KPMG team believes that the County needs to engage in a systematic implementation program that is sequenced in decision-making, is considerate and inclusive of stakeholders, and designed for long term sustainable change. Regardless of the County’s selected Pathway, KPMG recommends the following sequence of change to provide for a period of evaluation, optimization of existing resources, and incremental identification of investment thereafter in enhanced services and/or expanded capacity.

Implementation phases

Decide

The first phase is about determining and deciding on the most optimal implementation pathway for Pinellas County between:

1) System wide

2) County- Focused Comprehensive

3) Focus on Prevention

4) Enhanced

5) Enhanced Plus New Capacity

Evaluate

The second phase is about ensuring effective evaluation and performance management structures are implemented across all programs within the County.

Without this foundational element, program leaders will be unable to make informed decisions on where to invest and address gaps in the behavioral health system.

Optimize

The third phase is about using the existing assets available within the system and ensuring Pinellas County is optimizing care coordination between them.

This process begins to shift the incentives towards a performance-based environment.

Innovate

The fourth phase is predicated on the idea that you have built a foundational performance management system and have optimized existing resources.

Once that is complete, the innovation phase is about identifying new programs or expanding existing initiatives that address identified gaps in the system.

Sustain

The fifth phase is focused on monitoring the newly implemented recommendations to confirm they function according to intended outcomes in a consistent, repeatable manner.

This involves monitoring post-implementation performance monitoring and continuous improvement

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Executive summary (continued)

The Pinellas Project Planning Team provided KPMG with 5 top questions to guide the analysis. The following provides high-level responses to each of these questions, with additional details contained throughout the report.

Question 1: Do we have the data to know how well our system of care is performing in terms of access, capacity, productivity, and quality outcomes?

No, the system does not, based on the data reviewed. There is a lack of data-driven accountability regarding the performance of behavioral health providers at both an individual and system level. As a result, provider performance remains largely opaque to the County and system stakeholders due to lack of transparency around efficiency and effectiveness of processes and outcomes—making it difficult to consistently and continuously evaluate quality of care, access to care and value of care for the level of investment. Various stakeholders have commented on the need for performance-based and data-informed funding, so that return on investment can be more accurately assessed based on a “true” understanding of the cost and outcomes of care.

Question 2: Should we build a new Marchman facility or expand current capacity?

No, not until we have better system-level data on capacity, utilization, and productivity. Stakeholders in Pinellas County have asked the question of whether they need a new facility to address the behavioral health needs of their residents. At first glance, it appears the increase in suicides and substance-abuse-related deaths may indicate that the current system is not managing the problem well and a new public receiving facility might be needed. However, it is unclear if Pinellas County citizens are not accessing the right level of care at the right time by the most appropriate clinicians, with treatment that is aligned with standards of care, or if the high volume that accesses care through crisis services is not well transitioned into appropriate follow-up services due to the current fragmented care system. Until these questions are answered, it is difficult to state whether the solution is a new Marchman facility or an expansion of current capacity. It is noteworthy than the practice of forced detention of substance abuses has mixed results and there is disagreement regarding the efficacy of this practice.

Question 3: Should we increase case management compliment to better accommodate the Baker Act population to ensure no one falls through the cracks?

No, not until further evaluation of how existing case management capacity is utilized. We caution against funding additional case management without properly evaluating current capacity, effectiveness and models in place. The recent study conducted by University of Southern Florida on the Pinellas County Empowerment Team (PCET) program of the top 33 high utilizers of CSU and jails, demonstrated good outcomes with a reduction in jail costs (decreased by 52%), crisis stabilization unit services (decreased by 82%), Medicaid costs (decreased by 58%), and shelter costs (decreased by 94%). Of interest, is that through the collaboration with partners and leveraging existing resources, “only 69% of the funding allocated by the Board of Commissioners for PCET was expended during year one.” Prior to funding additional case management, we would encourage a full evaluation of current case management services.

Question 4: Should we consolidate all our contracts and funding into fewer providers?

Potentially yes, once a better view of system performance is achieved. Behavioral health entities across the country are consolidating to drive efficiencies, increase effectiveness and save money. The private industry and providers are leading these changes nationwide. Governments are following to ensure that funding is tied to a unified strategy. The core to those strategies involves holistic wraparound care of patients. The leading practitioners have realized that funding silos result in operational and programmatic silos—a situation in which Pinellas County is a case study. In order to deliver world class service aligned with leading practices providers and government entities are using consolidated funding tied to strategic holistic care, which includes coordination and case management. To achieve this, the County should consider consolidating its services into fewer contracts to align its vision for patients with the practical tools for programmatic and performance management.

Top 5 questions

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Executive summary (continued)

Question 5: Should we be doing more as a system of care to combat the opioid crisis?

Potentially yes, building on the County’s existing efforts and with improved models of coordinated access and management of system performance. While KPMG did not conduct a detailed operational scan of interventions currently in place by providers, the County and its stakeholders should consider the use of physician training, peer support, and data and analytics in line with localized initiatives and national trends in Opioid Crisis prevention and early intervention. Additionally, the County should consider more closely integrating behavioral health efforts (i.e., mental health and substance use) to achieve greater outcomes. Leading practices show that treatment of co-occurring disorders demonstrate better outcomes than treatment conducted in silos of care.

Top 5 questions (continued)

Based on answers to the Top 5 Questions above, KPMG recommends that the County take immediate action and consider investment in the following foundational issues:

1) Establish a systemic performance management approach in terms of access, quality, capacity, productivity, and outcomes—grounded on a Minimum Data Set (MDS) across all providers, allowing for benchmarking comparison and trend analysis. This requires establishing a contractual MDS requirement for all providers arising from collective development of an MDS with behavioral health funders within the County.

2) Establish a robust Coordinated Access Model that allows for increased transparency in how clients, families, caregivers, and professionals can access the right services within the system. This requires various enabling elements including a 1-800 number; standardized screening, triage and scheduling practices; and an evaluation of the current systems in place by providers to ensure interoperability and exchange of information to allow for a consolidated view of consumer demand, level of need, available capacity, and access to care.

Once the above foundational issues are addressed, KPMG recommends that the County reevaluate its needs and appropriate levels of investment in the following service delivery and system management elements.

— Explore the County’s receiving and diversion needs in terms of capacity by optimizing utilization of current bed capacity or contracting for additional flex beds within its existing provider network, as appropriately evidenced by data-driven performance management and coordinated access across the system of care.

— Evaluate, enhance and/or expand existing case management services—specifically through focusing on the individual’s strengths, promoting the use of informal supportive networks, and utilizing either transitional case management (up to 3 months) or long-term case management to effectively bridge clients and assist in navigating a complex behavioral health system of care.

— Consolidate the County’s services into fewer performance-based contracts and collaborate with funding partners to identify ways to reduce silos of care based upon established performance management and coordinated access capabilities.

Top recommendations

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Executive summary (continued)

We believe the County and its stakeholders are in a great position for change. KPMG was consistently impressed by the people and teams who contributed to this effort and were dedicated to improving the system of care in the County. Our view is that the recommendations presented will take the County from a capable funder of services to a much more involved actor driving change that would push the County to be a leading innovator in the nation. The State’s unique system of care underscores for KPMG that the County’s continued focus on performance, governance, coordination and prevention remain critical paths to improve the system. The County should consider the following questions as it moves forward with its path to implementation:

Stakeholders and funders

— How does the County continue to build consensus with County and State-level stakeholders on the path forward?

— What discussions and flexibilities does the County wish to explore with the State in choosing its path?

Sustainment and investment

— How will the County sustain a multiyear change effort?

— How well is the County’s budget process aligned year over year for such a change program?

— Where will further investment in the behavioral health system come from?

— What is the investment threshold for the recommendations noted in this document?

Skills and resources

— Does the County currently have the organizational capacity to drive comprehensive systems change?

— How will the County align the organizational skills and people needed to drive implementation?

Including:

- Performance management: resources to design and implement performance-driven management approaches described in strategic options and implementation pathways

- System of care management: resources to design and implement elements of coordination, prevention, receiving and diversion, governance, and funding as described in implementation pathways

- Data/analytics management: resources to identify, merge, and analyze system performance and capacity to support ongoing decisions in system design implementation of selected pathways

- Program/change management: resources to detail and manage action plans, escalate risks, communicate changes, and generate stakeholder involvement and buy-in

This report is designed to be a forward-looking decision-making tool as the County seeks to improve outcomes for its residents, and is crafted to be a framework of recommendations to be considered in a future system of behavioral care. KPMG makes no conclusions as to the performance of individual providers, as that was not intended by the County nor included within the Statement of Work. This document should not be considered a criticism of any particular organization or individual, and should be viewed constructively to aid in discussions of the future model and the selected pathways to achieve a vision to Elevate Behavioral Health Pinellas.

Taking action

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Contents

Section 1: Project overview

— County overview 16

— Project overview 17

— Project scope and limitations 18

— Project approach and methodology 19

Section 2: System overview

— Governance overview 21

— Financial overview 22

— Programs overview 23

— Services overview 24

Section 3: Key findings

— Finding 1 26

— Finding 2 27

— Finding 3 & 4 28

— Finding 5 29

Section 4: Future-state vision

— Guiding principles 31

— Future state of behavioural health 32

— Overview of options 33

— 4.1 Performance management 35

— 4.2 Governance 41

— 4.3 Funding 43

— 4.4 Coordinated access model of care 47

— 4.5 Prevention and early intervention 60

— 4.6 Receiving and diversion 75

Section 5: Implementation pathways

— Overview of implementation pathways 80

— Implementation steps for pathways 81

— Comparison of implementation pathways 86

Appendix

— Section A: Stakeholder engagement 89

— Section B: Data requests 90

— Section C: Literature review citations 96

Section 1:

Project overview

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County overview

Pinellas County Government aims to be the standard for public service in America, and is committed to progressive public policy, superior public service, courteous public contact, judicious exercise of authority, and responsible management of public resources to meet the needs and concerns of residents today and tomorrow.

The Pinellas County Strategic Plan in the figure below was developed to enable the most efficient and effective use of public resources, provide the highest quality customer service, and create a supportive, rewarding work environment. The plan incorporates five strategic goals that reflect the elements of sustainability and contribute to the County’s ability to fulfill its mission.

County’s mission and vision

The Pinellas County Human Services (PCHS) Department is responsible for programs and activities focused on supporting disadvantaged County residents in meeting essential needs and achieving maximum potential for self-sufficiency.

The County manages various programs, related financial obligations (including Medicaid Match and other State mandates), and contracts to ensure health, safety, and welfare for County residents. Target areas include physical and behavioral health, homelessness prevention and assistance, rapid rehousing, and financial assistance.

Human Services programs and activities are closely aligned with the Board of County Commissioners Strategic Plan as seen in the figure below.

County’s role

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Project overview

Pinellas County (County) engaged KPMG in December 2019 to undergo a roughly three-month project to scan the behavioral health system, interview stakeholders, review leading practices, and bring back to the County a new vision to improve the system of care around behavioral health in Pinellas.

The project was formally initiated after the project charter was presented and endorsed by the Pinellas Integrated Care Alliance (PICA) Team, including Lourdes Benedict (Pinellas County Assistant County Administrator), Dr.

Ulyee Choe (Director of Florida Department of Health Pinellas), Linda McKinnon (CEO of Central Florida Behavioral Health Network), and Sheriff Gualtieri (Pinellas County Sheriff). Individuals interviews were also conducted with all members of the PICA Team, as well as Barry Burton, the County Administrator.

This deliverable builds upon the options and recommendations identified and validated with the Pinellas Project Planning Team and County Administration through a number of working sessions.

Project overview

The objective of the project is to develop recommendations for system enhancement, integration, and improved outcomes within the Pinellas County Adult Behavioral Health System of Care.

These recommendations take the form of this deliverable, which consists of two primary components:

Project objective

System design of behavioral health innovation in Pinellas County and roadmap to integrated continuum of care

Prioritization framework for implementation of the system design

© 2020 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved. NDP062450-1A 18

Project scope and limitations

KPMG’s scope centered on scanning the existing continuum of programs and services across the County’s Adult Behavioral Health System of Care to identify high-level gaps and inform a future-state vision and roadmap for action that considers both County and State-funded providers and programs.

Project scope

KPMG understood that certain limitations were placed on this effort considering the breadth, depth and scope of the system being reviewed. Behavioral health systems of care are complex, from their funding to the breadth of their treatment services—with a wide variance seen across jurisdictions. A behavioral health system has to have a grip on a wide range of factors when considering any change program. While the below considerations will remain important to the future vision and strategy of the County’s system of behavioral care, the functions as limitations to this engagement are as follows:

The County will not become a provider of direct services to patients.

The County made clear at the onset of the engagement that it does not intend to change its system of contracted provider-based care and begin to deliver direct services to consumers. Unlike other jurisdictions, the County remains only a funder of services and not the provider itself. This limits the control the County has over quality, consistency, and efficiency of care. The impact on this report and our process is that the KPMG team did not consider options for County-provided services.

This was not a community behavioral health needs assessment.

A leading practice for adoption of change in a behavioral health system starts with a community needs assessment. This has been conducted by the State and we assume the information to be reliable and robust. The County should rely on this and other sources of information in conjunction with this report when making decisions about its behavioral health system. The impact on this report is that KPMG considered reported outcomes instead of underlying needs. A study that examines more thoroughly the needs of County residents may result in further recommendations for change.

This was not an assessment of County, State, or provider performance.

As any system of care is a sum of its component parts, the efficiency and effectiveness of the County, State, or their respective contracted providers is critical to delivering the appropriate access, quality, and cost of care. We observed certain provider self-reporting that had been performed in recent years, and reviewed aggregate performance information on a provider basis to understand and identify gaps as well as improvements in the system of care. The impact on this report is that recommendations for discrete improvement of provider performance are not contained herein, and instead is intended to be a forward-looking guide to improve outcomes regardless of where performance currently stands.

This was not an organizational needs assessment of the County or providers.

An organizational needs assessment considers aspects of financial, operational, and governance-related performance of an organization. Typically, the front- and back-office operation is reviewed to understand efficiency and effectiveness, and technology utilization and enablement is assessed at a detailed level. The engagement team was not asked to review PCHS or their providers in this way; however, this level of information may further assist in improving services to residents at appropriate points in the future to better optimize the use of existing resources by the County and its providers.

Limitations

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Project approach and methodology

This deliverable summarizes findings from stakeholder engagement, data and documentation request, review and analysis, literature review, and options and recommendations identified and validated with the PCHS leadership team and County Administration.

Over a 12-week period, the KPMG team conducted the following activities:

— Individual interviews, focus groups, and tours were conducted with 50 organizations and their stakeholders identified by the County and scheduled based on participant availability and representation of a cross-systems view of behavioral health, including:

Board of County Commissioners, DCF-contracted Managing Entity (CFBHN), providers, justice agencies, homeless services, community leadership and advocates, and other government agencies.

— A survey was distributed to all participants of the System of Care meeting on January 13, 2020 to gather stakeholder input on the following topics:

1) If Elevate Behavioral Health Pinellas is successful in improving behavioral health for the community, what does that success look like?

2) What do you see as the largest gap in Pinellas County's behavioral health system?

3) What do you see as the greatest successes or strengths in Pinellas County’s behavioral health system?

4) What opportunities do you see for improving Pinellas County's behavioral health system?

5) Do you have any additional comments, questions, or concerns you would like to share?

— A leading-practice review was conducted on the six categories for change based on counties recognized for innovative models of care within behavioral health.

— Six volumes of documentation and data (e.g., intercept mapping, studies, reports), all PCHS program budgets and contracts, and provider reporting (based a limited number of responses) were reviewed.