Beyond Beds Crisis Now Business Case National Dialogues NOLA 2017

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Beyond Inpatient The Business Case for Crisis Now 1 David W. Covington, LPC, MBA CEO & President, RI International

Transcript of Beyond Beds Crisis Now Business Case National Dialogues NOLA 2017

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Beyond InpatientThe Business Case for

Crisis Now

1

David W. Covington, LPC, MBA

CEO & President, RI International

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Phoenix, Arizona

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Dr. Michael Hogan, NYS MH

Commissioner (2007-2012)

Officer Nick Margiotta, Retired

Phoenix PD, CIT International BOD

Joy Brunson Nsubuga, RI Crisis

Administrator, NC Crisis Center

Wendy Martinez Farmer, LPC

CEO Behavioral Health Link

Dr. Michael Allen, Professor

Psychiatry & Emergency Medicine

Sarah Blanka, RI Crisis

Administrator, Arizona Crisis Center

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The NeedFor Better Crisis Care

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Psychiatric

BoardingSeattle Times (2013): Lack of

space forced those

involuntarily detained to wait

for treatment, on average

three days, in chaotic hospital

EDs and ill-equipped medical

rooms. Frequently parked in

hallways or bound to beds,

usually given medication but

no psychiatric care.

Carolinas Healthcare

benchmarked boarding times

in their EDs in 2015 but has

since reduced wait times 50%

from the figure cited.

Law EnforcementChappell, D (2013) Policing

and the Mentally Ill:

International Perspectives.

Boca Rotan, FL: CRC Press)

Madison, Wisconsin data

cited by Ruby Qazilbash,

Associate Deputy Director,

Bureau of Justice Assistance,

August 31, 2017 ISMICC

Federal Committee

One study found that 1 in 10 calls for service

involved a person with a serious mental illness

Law Enforcement:Impact on Public Safety

In Madison, Wisconsin, law enforcement found

that behavioral health calls for service take

twice as long to resolve (3 hours versus 1.5 hours on average)

Disastrous Access to Care Wastes Resources

72 hrs

40 hrs

2-3 hrs

Washington State North Carolina Person without SMI

In 2014, Washington

State Supreme Court

ruled the waits

unconstitutional.

Psychiatric Boarding: Long

Hospital ED Waits

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74%

40%

20%

None Visual, Hearingor Ambulatory

Disability

SMI

Half as likely to be

employed as other

individuals with

disabilities

Finance: Employment

No Disability SMIVisual, Hearing or

Ambulatory Disability

What are the Current Real Outcomes?HealthLife expectancy data WHO

and NASMHPD, and Disease

Prevalence from World

Psychiatry

FinanceEmployment data from

American Community Survey

and NAMI SMI

CommunityNation data from World

Happiness Report (“Someone

to rely on in times of trouble”).

SMI data from AZ Health Risk

Assessments (“Someone to

talk to about problems” and

“Someone invites me out for

dinner/activity.”)

Autonomy“Prevalence of SMI Among

Jail Inmates” and “Poverty

and Severe Psychiatric

Disorder”

Life for the nearly 10

million people with SMI

in the US has

comparable outcomes

to the average person

in Afghanistan.

98%

90%

57%

Iceland USA SMI in USA Afghanistan

55-65%

Community: Friends &

Social Supports

Loneliness Increases

Likelihood of Early

Death by 30%

4%

20%

% of Population w/ SMI % with SMI in Jail

3-5x increase Poverty,

Homelessness &

Incarceration

Autonomy: Making Own Life

Decisions15-20%

% of Jail Population w/ SMI

8479

61

Japan USA Afghanistan SMI in USA

2-3x increase Obesity,

Diabetes &

Cardiovascular

Disease

Health: Avg Life Span

54-69

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People with SMI

Suicide RiskAccording to the American

Association of Suicidology, the 2014

suicide rate for males 65+ was 32

per 100,000, but 51 per 100k for

those over 85.

In 2010, USA Today reported the

US Army suicide rate at 22 per

100,000 but the Fort Hood rate was

47 per 100,000.

The Suicide Prevention Resource

Center (SPRC) reported Alaskan

Native/American Indian males ages

15 to 24 had the highest rate at 28

per 100k. In 2010, USA Today

reported those AN living in Alaska

had a suicide rate of 42 per

100,000.

The SPRC says little can said with

certainty about death rates for

LGBT youth due to limited data

collection. Other research suggests

two three times the national rate.

In 2008, a UK study by Osborn

found the hazard ratio for

individuals with SMI, including

Schizophrenia, to be nearly 13

times the general population. In

2010, King’s Health Partners found

the risk to be 12 times greater

during the first year following

diagnosis of a serious mental

illness.

ViolenceWhile rare, incidents of individuals

with SMI who were untreated being

involved in the tragic deaths of

others have garnered the attention

of our national dialogue.

Thousands Die Alone and In Despair

Suicide Rate: Hazard Ratio vs. General Population

White Males 65+

Veterans/Military

Alaskan Natives/

American Indians

LGBT Youth

In 2013, Virginia State Senator Creigh Deeds told

CNN he was alive to work for change in mental

health. A week earlier, he was stabbed multiple

times by his son, who then died of suicide. This

happened hours after a mental health evaluation

suggested “Gus” needed more intensive services.

Tragically, he was released before the appropriate

care could be found.

Unspeakable Family Pain: Tragic Outcomes

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The SkillsFor Optimizing a Crisis

System

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New Year’s Day, you are taking inventory on a key product and you have the following number remaining

on the shelf from December. Which is best?

1mScenario A

1Scenario B

0Scenario C

1

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Average Wave:9 Waves Were “Average”

Lowest Wave: 21% of Average

Highest Wave: Nearly 200% of Average

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%

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3 ModelsLet’s Build

TraditionalState Hospital

Beds

Model #1

Crisis Now

Model #2

Crisis Now

Model #3

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Action Alliance

NSPL Lifeline

NASMHPD

National Council

Arizona AHCCCS

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TraditionalPublic Inpatient

In the First Model, implement the 50 public sector psychiatric inpatient beds per

100,000 population necessary to meet community crisis needs.

Model #1

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/100,000

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/100,000The consensus opinion of an expert panel on psychiatric care estimated the

need as around 50 public psychiatric beds per 100,000 population (Treatment

Advocacy Center).

/100,000

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AnyBigCity, USAPop. 4mAnyBigCity, USAPop. 4m

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AnyBigCity, USAPop. 4m

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AnyBigCity, USAPop. 4m

Core Community

Crisis Demand/Flow

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AnyBigCity, USAPop. 4m

AnyBigCity, USAPop. 4m Choke Point

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AnyBigCity, USAPop. 4m

AnyBigCity, USAPop. 4m Choke Point

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AnyBigCity, USAPop. 4m

Dimensions

Risk of Harm

Functioning

Co-Morbidity

Environment

Treatment

History

Engagement

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AnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

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InpatientAnyBigCity, USAAnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

Inpatient

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AnyBigCity, USAAnyBigCity, USAPop. 4m

Inpatient

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AnyBigCity, USAAnyBigCity, USAPop. 4m

Inpatient

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AnyBigCity, USAAnyBigCity, USAPop. 4m

Inpatient

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AnyBigCity, USAPop. 4m

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AnyBigCity, USAAnyBigCity, USAPop. 4m

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Readmission

Rate%Bed

Capacity

ALOS

Occupancy %

Persons Served Per Month

Crisis Now Calculator

%

Bed Days Per Month

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AnyBigCity, USAPop. 4m

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Level of Care Beds ALOS Occupy % Readmit

Rate

State Hospital 55 400 95% 0%

COE 215 12 95% 15%

Med-Psych 46 30 95% 10%

Hospital-Based 200 6 95% 15%

New Capacity 1484 20 95% 10%

AGGREGATE 2000 16 95% 11%

AnyBigCity, USAPop. 4m

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What does it cost per year?

AnyBigCity, USAPop. 4m

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Model #2

Crisis Now

In the Second Model, add the principle services of the Crisis Now Continuum: a

Crisis Call Center, Mobile Crisis and Crisis Facility Services

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Crisis Call

Center

Mobile

CrisisCrisis

Facilities

The Crisis Now Continuum

Outpatient Inpatient

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Detox

Crisis

Respite

Hub

Mobile

AnyBigCity, USAPop. 4m

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Mobile

Detox

Crisis

Respite

Hub

AnyBigCity, USAPop. 4m

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MobileMobile

Detox

Crisis

Hub

Respite

AnyBigCity, USAPop. 4m

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Mobile

RespiteDetox

Crisis

Hub

AnyBigCity, USAPop. 4m

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Mobile

RespiteDetox

Crisis

Hub

AnyBigCity, USAPop. 4m

AnyBigCity, USAPop. 4m Choke Point

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Inefficient Processes

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In the Third Model, fully deploy the principle practices of the Crisis Now System

and add Crisis Navigator and a 24/7 Outpatient Clinic

Model #3

Crisis Now

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Outpatient Inpatient

Real Time

Data

Exchange

Meet at

Their

Location

Immediate

Police Drop

Off

The Crisis Now System

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Detox

MobileCrisis

Respite

Hub

AnyBigCity, USAPop. 4m

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24/7

Navigator

Detox

MobileCrisis

Respite

Hub

AnyBigCity, USAPop. 4m

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Detox

Crisis Mobile

Respite

24/7

Detox

Crisis

Hub

AnyBigCity, USAPop. 4m

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Detox

Mobile

Respite

24/7

Hub

Crisis

AnyBigCity, USAPop. 4m

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Detox

Crisis Mobile

Respite

24/7

Hub

AnyBigCity, USAPop. 4m

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Detox

Crisis Mobile

Respite

24/7

Hub

AnyBigCity, USAPop. 4m

AnyBigCity, USAPop. 4m Throughput

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MobileMobile

Detox

Crisis

Hub

Respite

AnyBigCity, USAPop. 4m Core Community

Crisis Demand/Flow

*8,232 ED visits, representing 7,409 unique

persons

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❶❷

❹❺

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❻❺

❻ ❻❺

❶❷

❻❺

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❶❷

❹❺

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❶❷

❹❺

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❶❷

❹❺

❶❷

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24/7

Navigator

Detox

MobileCrisis

Respite

Hub

AnyBigCity, USAPop. 4m

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OutcomesOf Better Crisis Care

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AnyBigCity, USAPop. 4m

TraditionalPublic Sector

Inpatient Beds

Model #1

Crisis Now

Model #2

Crisis Now

Model #3

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Calculated from BJA presentation at ISMICC (2017), Madison, Wisconsin data

Saved hospital EDs $37m in

avoided costs/losses

Reduced total psychiatric

boarding by 45 yearsCalculated from “Impact of psychiatric patient

boarding in EDs” (2012) (Nicks and Manthey)

Reduced potential state

inpatient spend by $260m

Calculated from Arizona data, 2017

The Crisis Now Difference

Saved equivalent of 37

FTE police officers

In 2016, according to Aetna/Mercy Maricopa, metropolitan area Phoenix law enforcement engaged 22,000 individuals that they transferred directly to crisis

facilities and mobile crisis without visiting a hospital emergency department. What difference did it make?

Improved Crisis Clinical Fit to

Need (CCFN) by 6x

Fire savings just starting.

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States Self-Assessment

Crisis Now Continuum System

Framework

14%

29%

38%

12%

0%

Level 1 Level 2 Level 3 Level 4 Level 5

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Q&ACrisis Now: Transforming

Services

David W. Covington, LPC, MBA

CEO & President, RI International