Transcript 'The Growing Power of Grassroots Disability Advocacy

NYAPRS North Country Regional Meeting
May 16, 2013
Harvey Rosenthal
www.nyaprs.org
1
A peer-led statewide coalition of people who
use and/or provide community mental health
recovery services and peer supports that is
dedicated to improving services, social
conditions and policies for people with
psychiatric disabilities by promoting their
recovery, rehabilitation, rights and community
integration and inclusion.
[email protected] www.nyaprs.org
2
 Which
Services?
 From Which Providers?
 In What Networks?
 With What Goals and Expectations?
 For How Long?
 How Reimbursed?
 With How Much Information and Choice?
 With What Level of State Oversight?
3
Poor
engagement: system not patient
failure?
Office/program based service delivery
Fragmentation and lack of coordination :
within medical and BH systems
Lack of accountability
Reactive vs. preventive
Crisis response = ER, Detox and Inpatient
4
 Low
Outcomes/Expectations: Maintenance,
Symptom Management… ‘it’s the illness’
 Chronic Condition = Lifelong Services
 Relapses and Readmissions Expected
 Deficit and illness based not skills or
recovery based
 Power not partnership
 Poverty not economic self sufficiency
5
• Shame, Stigma and discrimination
• Loss of hope
• Dehumanizing care
• Loss of rights and choices around where you
live, with whom and around major life
decisions
• Isolation; expectations of single, childless life
• Idleness: Lack of social meaningful roles
work, school.
6
• Poverty (reliance on entitlements)
• Loss of personal and family relationships
• Loss of sexuality (medication side effects)
• Criminalization of emergency care: handcuffs,
police, coercion,
• Lack of health literacy
• Complex eligibility, coverage and admission criteria
• Absence of gender or culturally appropriate
services
7
 ‘At
risk, high cost, high needs’ unengaged
Medicaid beneficiaries
• Lack hope, stable housing, accurate addresses, health
literacy, transportation, organization
• Often have multiple ongoing conditions including
psychiatric conditions, addictions, AIDS, hepatitis,
diabetes, cardiovascular illnesses
 Medicaid
expansion
 Commercial insurance
8
 People are poor, idle, isolated, segregated and
sick…lack health, hope, purpose and community.
 People have ‘chronic conditions’, dying 15-25 years
earlier due to higher rates of obesity, diabetes, lung
and cardiovascular diseases
 Federal, state and local governments spend huge
amounts of public funds on healthcare, homeless,
criminal justice services to people w ‘chronic
conditions’
 The total costs of drug abuse and addiction due to use
of tobacco, alcohol and illegal drugs are estimated at
$559 billion a year. (Surgeon General’s report 2004;
ONDCP; 2004; Harwood, 2000)
9
 $54
billion Medicaid Program
 20% (1 million beneficiaries) use 80% of these $
• Hospital, emergency room, medications, services
 40%
have behavioral health conditions
 NY last in nation in avoidable readmissions,
costing $800m to $1 billion
• 70% have BH diagnoses, 3/5 of these admissions are for
medical reasons
 Add
85% unemployment, high rates of
homelessness and incarceration
Lots of $ Spent, Very Poor Outcomes
10
 Triple
Aim: improving outcomes, improving
quality, reducing cost
 Medicaid/managed care expansion, BH parity
 Focus on better coordinated, accountable and
integrated physical and behavioral health care
 Major emphasis on home and community based
services and less reliance on institutional care
 Promoting wellness, preventing relapses
upstream
 Person centered individualized care
11
Financial Pressures: federal, state and local governments
can’t continue to fund uncoordinated, inefficient, costly
services that don’t produce good healthcare outcomes
 Affordable Care Act: coordinated, active, engaging,
accountable, integrated outcome oriented, person centered
 Managed Care Expansion: brings flexibility and interest in
funding peer services and addressing social determinants
 Mental Health Parity and Addiction Equity Act
 Olmstead Enforcements: pressures states to serve people
with disabilities in most integrated not institutional settings
 Consumer, Rehab & Recovery Movements: have ready
made models to promote choice, rights, wellness,
community integration, life beyond services, alternatives

12
 Recovery
is not only possible, it is expected
 Providing tools to promote and protect
choice: Wellness Recovery Action Plans,
Advance Directives, Recovery Capital Scales
and Recovery Management Plans
 Outreach: going to the person, not expecting
the person to come to us
 Engagement based on hope, empathy and
starting where the person is
13
 We
are not responsible for the ‘illness’ or
trauma but we are responsible for our
recovery and our choices
 We are not our illness or label
 Recovery = risk and responsibility
 Can’t be ‘person-centered’ and ‘self directed’ if
we don’t explore what we want and make a
commitment to try
 Fully informed choice
14
 Integrating
services to work in a more
coordinated, collaborative, activist and
accountable fashion through federally
incentivized health home networks
 Integrating health, pharmacy, mental health
and addiction services under managed care
 Rewarding outcomes vs paying for visits
15
 Some
states are preparing to ‘carve in’ Medicaid
behavioral health services, turning them over to
the coordination of managed health insurance
plans .
 Plans will be paid on a ‘capitated’ per person per
month basis for outcomes not visits.
 Plans will authorize payments to contracted
providers and networks based on their success in
engaging and serving beneficiaries….and reducing
avoidable costs.
16
Managed
care companies and BHOs have
great flexibility beyond traditional
Medicaid rules and more narrow medical
necessity restrictions to buy approved
non traditional services that are proven
to work, if the state’s design expects,
rewards and enforces those values.
17
By
October 2014, currently ‘carved out’
Fee for Service OMH and OASAS services
will be integrated into upstate managed
care plans, either on their own or in
partnership with a “qualified” Behavioral
Health Organization.
18
 Those
services include OMH/OASAS mental
health and substance abuse inpatient and clinic
services
• OMH Medicaid services like PROS, ACT, IPRT, ACT,
CDT, Partial Hospital, CPEP, Targeted Case
Management and rehab supports within
community residences and
• OASAS Medicaid services like Opioid treatment and
outpatient chemical dependence rehabilitation.
19
Will
provide a range of more
intensive services for individuals
with ‘significant behavioral health
needs’.
20
 Services
in Support of Participant Direction:
Information and Assistance in Support of
Participant Direction and Financial
Management Services
 Crisis: Crisis Respite
 Support Services: Community Transition,
Family Support, Advocacy/ Support and
Training and Counseling for Unpaid Caregivers
21
 Empowerment
Services: PEER SUPPORTS
 Service Coordination
 Rehabilitation: Pre-vocational, Transitional
Employment, Assisted Competitive,
Employment, Supported Employment,
Supported Education, Onsite Rehabilitation,
Respite and Habilitation
22
 Increased
access
 Service engagement
 Physical health improvements
 Participation in employment;
 Enrollment in vocational rehab services and
education/training;
 Housing status;
 Community tenure;
 Criminal justice involvement;
 Peer service use and
 Improving functional status
23
 Mainstream
plans can be approved to operate
HARPs by themselves if they meet ‘rigorous’
state standards.
 Such plans may also choose to partner with a
BHO to meet those standards.
24
Plan Name
FIDELIS
HEALTH FIRST PHSP INC
METROPLUS HEALTH PLAN INC
AFFINITY HEALTH PLAN INC
HEALTH PLUS PHSP INC
BLUE CHOICE/BLUE CHOICE OPTIO
UNITED HEALTHCARE OF NY INC
HLTH INSURANCE PLAN OF GTR NY
NEIGHBHD HLTH PROVIDER PHSP
HUDSON HEALTH PLAN INC
CAPITAL DISTRICT PHYS HLTH PL
HEALTHNOW NY INC
SYRACUSE PHSP
INDEPENDENT HLTH ASSOCIATION
MVP HEALTH PLAN, INC
AMERIGROUP NEW YORK LLC
BUFFALO COMMUNITY HEALTH INC
WELLCARE OF NEW YORK INC
UB FAMILY MEDICINE
NY PRESBY SYS SELECT HLTH SN
HARP
19,904
14,409
11,262
7,330
6,605
6,777
6,238
7,174
5,482
3,165
3,077
1,926
2,011
1,886
1,754
1,688
1,279
1,323
1,764
1,472
non-HARP
54,279
33,138
27,756
20,476
18,754
18,338
16,127
14,433
12,678
9,701
7,832
5,812
5,506
5,521
4,918
4,866
4,439
3,478
1,770
1,466
 Magellan:
self directed care program in
Pennsylvania; crisis alternatives in Arizona;
psychiatric rehabilitation in Iowa
 Optum: peer bridgers in Wisconsin, Tennessee,
New York, New Mexico; peer warm line, crisis
respite and bridgers in Washington
 Community Care: recovery institute, learning
collaborative, supported housing reinvestment;
consumer/family satisfaction teams
 ValueOptions: self directed care program in Texas,
peer services and consumer research and
evaluation in Massachusetts
 Spring
2013: Program design finalized
 Winter 2013: Contract Requirements for
MCOs, HARPs finalized: RFQ posted on website
for upstate groups
 Summer 2014: Qualified MCOs and HARPs are
selected for upstate
 Fall 2014: HARPS, MCOs are operational
upstate
27
DOH/OMH/OASAS
MCO/BHO (A)
HH
Team
MCO/BHO (B)
HH
Team
HH
Team
HARP
HH
Team
HH
Team
= Physical and/or
behavioral health
care provider
28
A
health home is a ‘hub’ not a house
 Health homes are multidisciplinary teams
comprised of medical, mental health, and
addiction treatment providers and social
services organizations who work together to
improve care and reduce costs for those with
more serious ongoing conditions
29
Health home lead agencies provide:
Dedicated care managers who assure that enrollees
receive all needed medical, behavioral, and social
services from their assembled networks of treatment,
housing and social services
in accordance with a single care management plan
that is shared with all providers via an electronic
healthcare record
30
 Health
homes are accountable for reducing
avoidable health care costs, specifically
preventable hospital admissions/readmissions,
skilled nursing facility admissions and
emergency room visits and meeting quality
measures.
• Active engagement
• 24-7 response
• Focus on well coordinated discharge and treatment
planning
31
 Health
home leaders get a monthly rate for
each person served that pays for care
management, electronic health care record
system and administrative costs.
 Health home network members continue to
bill existing funding streams….until the move
to managed care.
32
 Current
plans are to ‘lock in’ and track all
carved in behavioral health dollars to guard
against migration of funds and to reinvest all
savings into enhancing needed services
 At the outset, the average per person per year
cost for HAPR services is $30,000.
 The recently enhanced monthly rate for ‘high
touch’ health home enrollees with behavioral
health needs is about $950.
33
Hospitals: Good Samaritan Hospital; Hudson Valley Hospital
Center; St. Francis Hospital and Health Centers; St. John's
Riverside Hospital; Vassar Brothers Medical Center
 Health Plans: Hudson Health Plan
 Medical Providers: Health Quest Medical Practice;
Healthcare Opportunities Provided with Excellence (HOPE)
Center; Institute for Family Health
 Misc: Arms Acres; AIDS Related Community Services
(ARCS); Hudson River Housing; St. Christopher's Inn; Sullivan
County Department of Community Services; Taconic Health
Information Network and Community (THINC RHIO);
Together Our Unity Can Heal, housing, social , disability
services

34

BH Providers: Dutchess County Department of Mental
Hygiene; Hudson Valley Mental Health; Human
Development Services of Westchester; Lexington
Center for Recovery; Mental Health America of
Dutchess County; Mental Health Association of
Westchester; Mental Health Association of Rockland;
Occupations; Putnam Family and Children's Services;
Rehabilitation Support Services; Rockland County
Department of Mental Health; The Recovery Center;
Gateway Community Industries; Westchester Jewish
Community Services (WJCS); Westchester County
Department of Community Mental Health;
35
 Integrated
Care
 Help with Navigating the Health Care System
 Better Access
 Better Coordination
 Wellness and Person Centered
 Focus on Skills to Stay Healthy
 Availability of Peer Based Recovery Supports
36
 Part
of an Integrated Care Team
 Access to Referrals
 Electronic Data Sharing
 Outcome Focused and Accountable
 Positioning for Managed Care
• Health Homes are organizing networks which will
contract with managed care payers
37
 Behavioral
health providers bring vital services
to networks, e.g., care management,
rehabilitation and recovery services, skills in
engagement and motivation, housing,
employment, peer outreach, engagement,
diversion and support services, clinical
treatment for ‘co-occurring’ conditions
38

2000 “Pathways to Housing: Supported Housing for
Street-Dwelling Homeless Individuals With Psychiatric
Disabilities” Psychiatric Services Tsemberis and
Eisenberg
An innovative ‘harm reduction’ housing and support
program model was able to achieve an 88% service
retention rate and general stability among a group of
primarily young men of color with psychotic disorders
and previous histories of homelessness and nonparticipation with services
http://ps.psychiatryonline.org/cgi/content/abstract/51/4
/487
39
A
2002 University of Pennsylvania study found
supported housing produced an average of
$16,282 in savings from reduced use of hospitals,
ERs, shelters et al.
 A May 2006 Mathematica study found that “on
average, Buy-In participants cost Medicaid $984
per-member per-month (PMPM) in 2000, almost
40 percent lower than the cost of other Medicaid
enrollees with disabilities.”
 Criminal Justice Diversion, Re-Entry services too
40
 Intensive
program consisting of care manager,
peer mentor and self directed budget
 Total local funds: $176,000 for 48 people
 Reductions
• Medicaid services: 35%
• Incarceration: 53%
• State hospital: 78%
• Total: 53% $2.3 million down to $1.2 million
41
 Health
homes can re-program care
management dollars to buy peer services
that can promote:
• Outreach and engagement
• Recovery coaching and supports before,
during and after treatment
• Hospital/Prison/Adult Home to community
transitional support/bridging
• Wellness self management support
• Crisis diversion and relapse prevention
42
Sample
arrangement…working in
subcontract with a health home to be part
of a ‘service triangle’:
• Care manager
• Nurse
• Peer wellness coach/navigator: outreach,
engagement, service planning, recovery
coaching, diversion, advocacy
43
• Abstinent for 1 year
• Relapsed 1 year post rehab-went back to
rehab-returned to abstinent lifestyle
• 2009-prior to enrollment: 7 detox stays (4
different facilities) $52,282
• 2010-1 detox, 1 rehab (referred by the
CIDP team) $20,650.
• 2011-1 relapse with detox/rehab no claim
yet.
44
 From
a rights protection, advocacy and
empowerment focus for people within the
mental health and substance use treatment
system to…
 Bringing hope, wellness, resilience and rights
protections to a broader array of people (preSSI and private insurance beneficiaries) as a
part of the greater healthcare system
45
 Helping
to address the challenges of:
• Effective person-centered outreach
and engagement; bringing services to
the beneficiary
• Successful transitions from hospital
and other institutions to the community
• Reduced ER visits and readmissions
to inpatient and detox
46
• Effective crisis management and
diversion supports and services
• Critical health literacy training and
coaching that promotes improved self
management and improved health
outcomes
• Advancing active participation in
outpatient services
47
 Peer
Crisis Diversion: warm lines, respite
house
 Peer Bridging
 Recovery Coaching
 Peer Wellness Coaching/Navigator
 Rights Protection & Advocacy: Ombuds
 Life Coaching: work, economic self sufficiency
 Peer Supported Housing
Services not Programs
48
 2010
study: 90% of PEOPLe Inc’s Rose House crisis
respite guests did not return to hospital in the
following two years
 NYAPRS Peer Bridger programs helped support a:
• 71% drop in NY state psychiatric center readmissions
• 50% drop in numbers of people hospitalized in local
Medicaid psychiatric inpatient units and in total hospital
days when admitted
 2010
Optum Health Peer Link reduced hospital
days by 90% in Wisconsin, by 72% in Tennessee
49
 2010:
Mental Health Peer Connection’s Life
Coaches helped 53% of individuals with
employment goals to successfully return to
work
 2011: Housing Options Made Easy helped 70%
of residents to successfully stay out of hospital
in the following year
50
 We
try to see the world through the eyes of
the people we support, rather than viewing
them through an illness, diagnosis and deficit
based lens.
 We learn to ask “what happened’…..not what’s
wrong?”
 We form mutually accountable relationships:
both parties are invited to share experience
and learn and grow together
51
 We
start where people are….and offer
encouragement for people to define and move
towards the goals and the life they seek
 We foster hope through example and trust through
empathy and mutuality.
 We look beyond individual responsibility for
change and examine the impact of relationships
and communities
 We support and connect people to multiple
pathways to recovery
52
 We
are not assistant case managers or
transportation aides; nor are we ‘cheap staff
who get people to take their medicine’.
 On the other hand, we can help a person with
appointments and medications IF they define
those needs as part of their self defined
wellness and recovery plan
53
History of Peer Support
 Intentional Peer Support
 Avoiding Co-optation
 Peer Support Practices
 Peer Service Models
 Peer Crisis Services
 Peer Bridging
 Peer Wellness Coaching
 Peer Health Navigators
 Peer Housing
 Peers in Clinic Settings
 Peer Recovery Centers

54












Outreach & Engagement
First Contact
Motivational Interviewing
Self Assessment
Navigating Choice
Cultural Sensitivity
Mutuality/Reciprocation
Power Dynamics
Ethics & Boundaries
Active Listening
Communication Skills
Appreciative Inquiry
55
 Crisis
De-escalation
 Harm Reduction
 Conflict Resolution
 Relapse Prevention/Crisis Planning
 Self-Injury
 Advocacy
for Others
 Mental Health Rights
 Mental Health Laws
 Informed Choice
56
Self-Disclosure
Documentation
& Reporting
Work
Ethic
Navigating Systems
Workspace Organization
Negotiation Skills
Community Assets
57









8 Dimensions of Wellness
Suicide Prevention
Psychiatric Rehabilitation
Employment Services
Benefits and Entitlements
Supported Education
Person-Centered/Recovery Principles
Trauma-informed Care
Health and Alternative Healing
http://www.academyofpeerservices.org/
58