David LeCount Report

Hospital Reduction & Cost Strategies

1. Payment per episode.
   
2. Payment on the basis of diagnosis - referred to as Diagnostic Related Groups (DRGs) and based on severity.
   
3. Closing out the bed after discharge and funding follows the person into the community.
   
4. Specify authorization time frames.
   
5. Payment reduced for custodial care.
   
6. Staff realigned into the community.
   
7. Wards and beds closed following discharge.
   
8. Develop community option programs, whereby community-based treatment is funded in lieu of hospitalization.
   
9. People, if determined long-term, could be placed in nursing home settings with psychiatric staffing patterns provided, as needed.

Hospital Diversion/Reductions - Front-End (Decision Making Pertaining to Hospitalization)

1. Least restrictive environment principle adhered to at the point of referral.
   
2. In-patient must be an effective treatment for the presenting disorder.
   
3. In-patient should be used primarily for acute stabilization.
   
4. Rule out all community alternatives prior to admission.
   
5. Community agent/agency replace the hospital in assessing the appropriateness of all new referrals for inpatient. Social control is not an acceptable reason for in-patient.
   
6. Community agent should specify in writing the length of time to be authorized and the cost of the episode.
   
7. Aftercare planning should be formulated at the point of admission.
   
8. Community representatives should be involved in the admission process, along with family members or significant others. If it is an involuntary admission, the person should have representation, preferably due process.
   Following an approved inpatient treatment episode, the community agency acting as the review and authorization entity, should continue to have daily contact with the person/staff in the hospital, to review progress towards discharge.
   
9. Progress reports should be written on a regular basis, with notations indicating progress towards discharge.
   
10. If there is disagreement about the discharge process per the treating hospital MD and the community entity, the treating MD sign over the primary ongoing treatment responsibility to the primary MD who will be doing the treatment in the community.

Hospital Diversion: Back End (For those already in-patient)

1. Community designated entity should be informed of all of the people within their jurisdictions and the reasons for in-patient, treatment progress, profile, and projected length of stay.
   
2. Hospital and community staff should assess who is ready for discharge and determine what resources in the community are needed to make the discharge possible. This plan should be put into writing.
   
3. Assessment should be made regarding whether the people in-patient are treatment responders. In other words, is in-patient an effective treatment for their presenting disorder? If in-patient is not deemed to be appropriate, an immediate plan should be developed eventuated for aftercare specifying again what community resources are needed, significant others to be involved, and time frames designated along with how to accomplish every step of the process.

Reasons for Hospital Discharge

1. In-patient is not appropriate (e.g. social control).
   
2. In-patient is not effective-the person is not a treatment responder, or has no desire to engage in treatment beyond symptom reduction (e.g. attempting to change character deficits, etc.).
   
3. Anytime symptom stabilization has occurred, community placement should occur as quickly as possible. Staying in-patient for psychosocial rehabilitation is a practice that should be discouraged.
4. Custodial care is another reason for discharge. If the person is abandoned, a significant other should be designated to act on their behalf as an advocate. A community resource entity could act in this capacity.

Hospital General Discharge Strategy

1. Start with the easiest in-patient people and work back towards the more difficult (e.g. social control first, most ready, symptoms controlled, family and community readiness and acceptance, etc.).
   
2. The people who have been hospitalized for years should be assessed, but, for some, the community may prove to be elusive. In other words, the community placement process may not be a reality because of the degree of institutionalization, however, there was a person at the Yadokarinosato that had been discharged after 35 years of in-patient and appeared to be doing well. Sadly, however, many of these long-term people may be a part of the "lost generation," never being able to make the transition back to the community.

Hospital Related Use - Dementia Related

The use of hospitals or nursing homes for people with Alzheimers and related forms of dementia is appropriate, particularly in latter stages when in-home and day services can no longer respond to the level of care needed. This is particularly true if nursing homes are not able to perform this function and hospitals are capable of meeting the basic needs and providing the daily orientation programming in a cost effective manner. Hospitals are already providing this service, and the need will increase as the population continues to age. These are people who are suffering from brain failure for which there is little recourse for accomplishing therapeutic treatment results. Daily orientation and meeting their basic needs in a benign environment is critical at this stage. Psychosocial rehabilitation and acute treatments have limited therapeutic value.

Obihiro Pilot Project - A Model Community Centered System of Care

Given the considerable amount of interest that was expressed throughout Japan about community-based treatment, I am recommending that a pilot project be established in Obihiro to demonstrate best practices pertaining to community-based treatment. This pilot would represent a comprehensive and coordinated system of care similar to the Madison Model, and be implemented in keeping with community practice principles represented in this report. Obihiro is a city that is somewhat similar in size to Madison. It has a base of living arrangements, work opportunities, and life supports already existing in the community. It has a core group of receptive professionals and likely consumers who are very interested in keeping the focus of treatment in the community. Most importantly, I think there is a skillful and innovative professional and community organizer in the person of Mr. Kadoya, along with a couple of community oriented psychiatrists, that present great potential for making this pilot successful. The Health Care agency that Mr. Kadoya directs could become the central coordinating lead agency in this project. The project could demonstrate best community practices that, in turn, could be used as a national model throughout Japan. Following the successful development of this comprehensive community mental health system of care, it could become a nationally endorsed training site to generalize best practices throughout Japan. I would be willing to help with this project to see that those community principles and practices are adhered to, and that fidelity to this model throughout the implementation phased is accomplished. The goal would be to create a comprehensive system of care that offered a continuum of well-coordinated services for persons with the most serious and persistent mental illnesses. In addition to all of the above principles and strategies, some of the following administrative services would also be included:

• A central coordinating agency that would have the fixed responsibility for the planning, development, implementation, and evaluation of the project.
  
• The central entry point into the service delivery system would be through the lead agency, and services would be authorized based on the level of need and consumer choice, to the extent this would be possible.
  
• The lead agency would be responsible for both in-patient and community services.
  
• Least restrictive environment and treatment approaches would be emphasized, and consumer-centered recovery oriented approaches would be practiced.
  
• In-patient would be used primarily for short periods of time, primarily for acute stabilization purposes, with only a small number of people with the most recalcitrant symptoms requiring longer-term hospitalization.
  
• It would represent a comprehensive, integrated, coordinated, community-based service delivery system, with continuums of care being available for a wide spectrum of needs. Services provided would be those suggested throughout this report.