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Allegheny County Acute Community Support Plan (ACSP) Process

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Allegheny County Acute Community Support Plan (ACSP) Process. MRSAP Steering Committee August 21, 2009. Acute Community Support Plan (ACSP).

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acute community support plan acsp
Acute Community Support Plan (ACSP)
  • Comprehensive support and resource planning process that is driven by a blending of the consumer’s, family’s, and treatment/service coordination team’s preferences, recommendations, and competencies.
  • Promotes higher levels of accountability
  • Uses external facilitator to encourage new thinking and provide objective review
  • Supported by web-based application to ensures all parties working with the same information
  • Modeled after the Mayview CSP discharge process
key characteristics of a csp
Key Characteristics of a CSP
  • Shared responsibility between County, MCO, IP team, community providers, consumer, and other supports
  • A disciplined and highly facilitated process using a non-affiliated facilitator and recorder
  • Consumers get to where they need to be rather than following a continuum of care
  • Avoid ‘one size fits all’ approach to discharge planning
  • An incremental approach to discharge planning
  • Recovery focused and person-centered
why do an acsp outcomes
Why do an ACSP: Outcomes
  • Positive consumer outcomes
      • Understanding and respecting the client’s choices is critical for long-term success
      • Greater satisfaction
      • Improved quality of life
      • Greater ownership in discharge process
  • Positive system outcomes
      • Improved collaboration among key stakeholders
      • Higher level of accountability
      • Services/supports match consumer needs
      • Reduced inpatient recidivism
      • Initiated to improve consumer outcomes and not just to increase access to resources
acute inpatient discharge process overview
Acute Inpatient Discharge Process: Overview





Acute Inpatient


Treatment Team

Discharge Planning Facilitated

by ACSP Coordinator

Level 3

Discharge Planning

Facilitated by

County Disposition Coordinator

Level 2


Treatment Team

on Inpatient Unit

Level 1

acsp eligibility criteria draft
ACSP Eligibility Criteria (Draft)

To be eligible, consumer must meet one of the following criterion:

  • 4 inpatient admissions in last 12 months
  • 2 prior state hospitalizations or any continued state hospital stay greater than 2 years in duration
  • An acute inpatient hospitalization greater than 90 days in duration in past 12 months
  • EAC, RTFA, LTSR treatment in the last 12 months
  • Has had disposition meeting within the last 12 months
  • Consensus that the ACSP process is necessary to assure the development of a plan that promotes recovery, safety and community stability.
acute csp discharge process
Acute CSP Discharge Process
  • The County Disposition Coordinator and inpatient treatment team can refer to the ACSP process when ACSP criteria is met.
  • ACSP Facilitator introduces process to consumer
  • If consumer is not ready to participate in the ACSP process, the Facilitator works to the engage consumer
  • Assessments are completed
    • CART completes Peer and Family assessments
    • SW completes Clinical Assessment
  • Facilitated ACSP meetings are conducted according to phases
    • Information Gathering and Options
    • Resource Coordination and Transition
    • Final Plan
acsp participants
ACSP Participants
  • Consumer and anyone the consumer invites
  • Family members of the consumer or representatives of the family
  • Members of the hospital treatment team and community provider (Service Coordinator or CTT is critical)
  • MHA Advocate
  • County ACSP Coordinator
  • MCO representative
  • Peer support
  • The facilitator and recorder
current status
Current Status
  • Piloted at the TRU in Fall 2008
  • A phased roll-out started in January 2009 that included seven training sessions which occurred from January through July 2009
  • All hospitals (11) and service coordination units (9) in Allegheny County have received training
  • Currently 14 consumers are in some part of ACSP process, 3 of which are transition age.
  • There have been 2 discharges from the ACSP process with an average of 4 meetings each.
  • Barriers
what we re working on
What we’re working on…
  • Psychiatrist attendance in meetings
  • Providing community supports including service coordination and housing to insure desired match
  • Continuous education to providers about supports in the community
  • A conflict resolution process is in development
acsp other supports and activities
ACSP: Other Supports and Activities
  • The ACSP Advisory Committee meets every other month. Participants include Allegheny County OBH, DRN, MHA, PSAN, St. Clair Hospital, Mercy Behavioral Health, WPIC, OMSHAS, CCBHO and AHCI.
  • Weekly meetings occur between Allegheny County OBH and AHCI to discuss referrals to the process.
  • Pamphlets have been developed to guide families and consumers through the process