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.

harveyr@nyaprs.org 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 incarcerationLots 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 planthat 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 (pre-SSI 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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