Transcript Harvey Rosenthal - Mental Health America

MHA America
May 8, 2013
Harvey Rosenthal
www.nyaprs.org
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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
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 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?
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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
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 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
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• 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.
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• 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
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 ‘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
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 Lifelong
services = unlimited, increasing costs
 Incentives are for more visits and services not
outcomes, especially in a Medicaid Fee for
Service environment
 Mental health funds are ‘trapped’ in costly
institutional settings: inpatient, emergency,
nursing and adult homes
 Substance use treatment limited to time-limited,
intense, acute symptom-focused services rather
than ongoing recovery supports
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 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)
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 $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
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 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
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Financial Pressures: federal, state and local governments
can’t continue to fund uncoordinated, inefficient, costly
services that don’t produce good healthcare outcomes
 Mental Health Parity and Addiction Equity Act
 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
 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

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 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
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 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
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From
Illness to Wellness Self
Management: evidence based practices
Wellness Recovery Action Plans
Whole Health Recovery Management
8 Dimensions of Wellness: Emotional,
Environmental , Intellectual , Physical,
Sexual, Occupational, Social and Spiritual
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 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
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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
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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
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 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
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 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.
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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

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
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;
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 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
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 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
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 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
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 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
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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
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• 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.
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 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.
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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.
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 Social
determinants of health
• Employment supports and benefits advisement
• Housing relocation start up costs
• Culturally competent outreach and engagement
 Peer
services
 Clubhouse services
 Crisis services
 Self directed budgets: emergency housing
supports, health club memberships,
computer/internet, alternatives
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 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
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 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
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 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
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 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
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 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
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• 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
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 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
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 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:
• 72% drop in NY state psychiatric hospital and a
• 50% drop in numbers of people hospitalized in local
Medicaid psychiatric inpatient units and total hospital days
when admitted
 2010
Optum Health Peer Link reduced hospital
days by 71% in Wisconsin, by 41% in Tennessee
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 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
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 Differences
between government and corporate
contracts
 Fiscal: budget projections must be right, know your
costs, risks
 Legal: understanding and negotiating the contract
 HR: hiring and supervision to clearer performance
standards, having back up plans for turnover
 Liability: increase our coverage
 Documentation: more forms and reports
 Navigating through protocols with hospital and
clinics
 Tremendous
opportunities to address
underemployment and to open up new career
paths that help people turn their experience
into service and a job
 Increased wages and compensation
 Development of more full time positions
Marketing
and promotional materials
• What service, for whom, with what
outcomes
Effective, cost effective: offer evidence
Negotiating terms and reimbursement
Propose..don’t ask.
Hiring, specialized training, supervision
Program Accreditation, Peer
Credentialing
Cash Flow, Fee for Service vs Grants
Liability, Documentation, Protect Privacy
Maintaining the Integrity of Peer
Support
 Services
must promote recovery and wellness,
health literacy and ‘self management’
 Beneficiaries must be guaranteed Informed
choice, privacy and other basic rights protections
 Peer run services should play prominent roles in
BHO, health homes and managed care re-designs.
 There must be significant reinvestment of
Medicaid savings into peer services, housing,
rehabilitation/ employment services expansion.
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 Services
must promote recovery and wellness,
health literacy and ‘self management’
 Beneficiaries must be guaranteed Informed
choice, privacy and other basic rights
protections, supported by peer advocates and/or
enrollment brokers, with consumer access to
personal electronic records that prominently
features advance directives.
 There must be significant reinvestment of
Medicaid savings into peer services, housing,
rehabilitation/ employment services expansion.
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