Meeting the Challenges of the Changing HealthCare Environment:Transformation of the Mental Health System in New York State

ANN MARIE SULLIVAN, M.D.

COMMISSIONER, NEW YORK STATE OFFICE OF MENTAL HEALTH

2Strategy: The Triple Aim

BETTER HEATLH OF THE POPULATION: Prevention and Maximizing Wellness

BETTER CARE FOR EACH PATIENT:

Quality Care focused on patient choice, engagement, and satisfaction; clinical best practices; integrated care between medical and psychiatric services; coordinated care with Primary care Medical Home; Increase in insured patients requires increased access to care

LOWER COST: Performance based payment; More efficient and effective care focused on less admissions and readmissions and more comprehensive ambulatory care (PCMH) and Behavioral Care; risk based models such as the Accountable Care Organization (ACO)

3Triple Aim: Population Health

Collaborative Care

Collaborative/Integrated Care with Adult Primary Care Providers that screen for Depression and Substance Use and provide rapid access to treatment; School Based and Pediatrics collaborative care for children and adolescents

Collaborative/ Integrated care in Behavioral Health with management and monitoring of chronic disease

Integration Substance Use and Mental Health treatment in Behavioral Health settings

Wellness Care for Individuals with Serious Mental Illness: Health and Recovery Plan (HARPs)

Crisis respite services; employment and education supports; family supports; peer supports; physical health wellness; rehab; self directed care; skills training; financial management.

4Triple Aim: Better Care for Each Patient

1-Patient Centered Care focused on patient choice, self directed care; engagement, and satisfaction;

2-Clinical best practices; integrated care between medical and psychiatric services; coordinated care that focuses on community based treatment; decreased inpatient use and decreased inpatient readmissions;

3-Easy access to services when and where they are needed in the community

5Triple Aim: Lower Cost

Performance based payment based on measured outcomes; More efficient and effective care focused on less admissions and readmissions and more comprehensive ambulatory care (PCMH; Behavioral Health Homes); risk based models such as the Accountable Care Organization (ACO)

Managed Medicaid focused on reduction of unnecessary inpatient use and reinvestment of dollars in community based care; Integrated physical and behavioral health care.

6PATIENT CENTERED CARE

INTEGRATED CARE MIND AND BODY

PATIENT CENTERED SYSTEMS OF CARE

7TRANSFORMATION:

INTEGEGRATED PATIENT CENTERED CARE

Disproportionate burden of health conditions and risks among those with poor mental health

Source: NYC DOHMH Community Health Survey, 2009, http://nyc.gov/health/epiquery

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Co-occurring disorders among Medicaid beneficiaries with mental illnesses

Source: United Hospital Fund, New York Beneficiaries with Mental Health and Substance Use Conditions, 2011

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Co-occurring disorders among Medicaid beneficiaries with substance use disorders

Source: United Hospital Fund, New York Beneficiaries with Mental Health and Substance Use Conditions, 2011

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11The Need for Integrated Care: Potentially Preventable Readmissions (PPR’s)NYS Costs $814M (2007)

Patients without MH/SA diagnosis, medical readmission $149M

Patients with MH/SA diagnosis, MH/SA readmission $270M

Patients with MH/SA diagnosis, MH/SA readmission $270M

12Collaborative Care:Population Health and Wellness

Collaborative/Integrated Care with Adult Primary Care Providers that screen for Depression and Substance Use and provide rapid access to treatment; School Based and Pediatrics collaborative care for children and adolescents

Collaborative/ Integrated care in Behavioral Health with management and monitoring of chronic disease

Integration Substance Use and Mental Health in Behavioral Health settings

13Population Health:Unipolar Depression

Lifetime prevalence of significant depression in NCS (2001-2) 16%; 12 month prevalence 6.6%

42% of significant depression in US is still untreated

Still only 22% of patients treated receive evidence based care

Lack of treatment increases inpatient days; results in poor compliance for chronic illnesses and poor outcomes

PopulationHealth:Neuropsychiatric diseases areamong the top 10 causes ofdisability worldwide (ages 15-44)

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15Need for Better Care in Primary Care

Under recognized and undertreated patients with depression, anxiety and substance in primary care

6 to 9 % of primary care patients have a significant treatable depression

Co-morbid depression increases morbidity and mortality in heart disease, diabetes, stroke

High cost of depression functional disability in all societies

16IMPACT PROGRAM

Collaborative Care for late life depression

Primary Care patients 60 and older with major depression or dysthymia

Randomized trial 8 health centers and 18 clinics

Treatment: Pharmacologic and Care Management

Outcomes:

>50% drop in SCL-20 depression scores at 6months and 12 months

The Need for Integrating Primary Care in SMI Treatment

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Coronary Disease Risk Factors-Framingham Study These Risks Are Typical for people with SMI

VA Co-located primary care in VA behavioral health services with significant improvement in physical health indicators: screening and preventive services ( mammograms, colonoscopies) and in treatment adherence for diabetes, hypertension, heart disease

CIDP Project in NY , provided care coordination for mental health and physical health, significant improvement in treatment engagement and decrease in hospitalizations both medical and psychiatric

Health Homes Care Coordination in NY State a work in progress: care coordination physical and mental health and shared care planning

Need for Better Care in Behavioral Health: Models of Care

19Delivery System Redesign Implementation Plan : DSRIP

MRT WAIVER AMENDMENT: $8.0 BILLION ALLOCATION

o$500 Million for the Interim Access Assurance Fund (IAAF) – Time limited funding to ensure current trusted and viable Medicaid safety net providers can fully participate in the DSRIP transformation without unproductive disruption.

o$6.42 Billion for Delivery System Reform Incentive Payments (DSRIP) – Including DSRIP Planning Grants, DSRIP Provider Incentive Payments, and DSRIP Administrative costs and DSRIP related Workforce Transformation.

o$1.08 Billion for other Medicaid Redesign purposes – This funding will support Health Home development, and investments in long term care workforce and enhanced behavioral health services, (1915i services).

Per MRT WEBSITE DOH

20DSRIP and Behavioral Health

PPSs( Performing Provider Systems) must have appropriate linkages to community and hospital based behavioral health services in their networks

All applicants had to include one behavioral health project and 30 of the 36 applications included Collaborative Care in Primary Care as one of their projects; or primary care in behavioral health

Major request for regulatory relief was in collaborative care projects for Primary and Behavioral Health: relief of space requirements; dual licensure; visit thresholds; and billing restrictions.

Systems will need to improve rates of readmission and decrease avoidable admissions for psychiatric patients with medical problems

21Collaborative Care in NY State

FQHC’s: 25 across the state have implemented collaborative care for depression in primary care; supported by grants CHCANYC and MHANYC

NY State OMH/DOH 2 year funding to establish collaborative care in 20 Academic Medical Centers and 31 primary care clinics

Geriatric demonstration Project: over 20 sites collaborative care in primary care and behavioral health

Challenges: OMH/DOH working on a rate/payment/ structure to sustain these and other programs eg. rate increase for implementing collaborative care for depression; regulatory relief

22INTEGRATED CARE: What does it mean to be Patient Centered

The Person to Person interaction

Engagement: What does the individual see as his or her problem, simply ask?

Meet the patient where he or she is: motivational interviewing

Partnership with patients: sharing goals and choices

Asking what the patient wants? What does the patient expect?

If the patient “non- compliant” seek to understand why? What are the obstacles the patient faces? What are the patients choices??

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TRANSFORMATION:

PATIENT CENTERED SYSTEMS OF CARE

24What does it mean to be a Patient Centered System of Care

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Easy access to care when and where needed

The right level of care

Care coordination among multiple providers

The basic needs: housing, good food, people supports

Knowledge about illness and wellness , patient partnership, patient choice

Access to wellness activities

25An opportunity to transform mental health services

RE-INVESTMENT IN Community ServicesRe-investment funding and the state hospital system

HousingAdult Home, re-investment, MRT and other housing funds

Medicaid Managed Care

Integrated Managed Care

Health and Recovery Plans (HARPs)

DSRIP

26A Few Numbers….Community Services

$25 Million pre investment to expand State and voluntary operated community services focused on reducing admissions and readmissions including crisis beds, respite, Home and community waiver slots, first episode psychosis teams, peer operated services .

If successful at reducing 400 beds at a reinvestment of 110,000 per bed then annual reinvestment will be 44 million

Planning for services with the Local Mental Hygiene Directors , OMH Regional Office and local stakeholders.

Housing

Currently 35,000 housing units in NY State

$30 million to support residential units for individuals transitioning out of adult homes

625 New housing units from state reinvestment

Downstate supported housing stipend increase of $550 annually to cover higher cost rents.( 6.5 million)

Additional Housing from MRT Initiative and NY/NY III Housing

Medicaid Managed CareInclude all individuals with serious mental illness in managed care January 2015.

$20 Million for system readiness to develop infrastructure for managed care/ HARPs

$15 Million to enhance clinic reimbursement for integrated behavioral and health care and implementation of the collaborative care model

30 million to establish 1915i services for HARPs: peer supports; educational and employment supports; crisis respite; family supports and self directed care.

$30 Million in Vital Access Provider (VAP to preserve critical access to behavioral health inpatient services in some areas.

Medicaid reinvestment for inpatient closures

27State Hospital Transformation

Increased community based services and decrease of unnecessary inpatient admissions and readmissions

Safe and appropriate housing in least restrictive setting

Recovery and personal choice focused Integrated medical and psychiatric care

28MEDICAID MANAGED CARE: Patient Centered

Health and Recovery Plans: HARPS Ensuring true integration of physical and

behavioral health Integration of Health Homes: care coordination Waiver Services/ Wellness services:

employment support, peer services, skills training, respite and crisis services; family support services

Self Directed care/ Patient directed care plans

29DSRIP

PPS: Provider systems focused on a network comprehensive coordinated care

Provider systems ensure access to behavioral health services

Coordination is seamless to the patient

Providers work together to ensure appropriate care for patients

Care is increasingly wellness, prevention and community focused with decreased unnecessary inpatient admissions and readmissions

30SummaryA Major Opportunity to Transform the System

Major investment over the next 3-5 years in system redesign that will transform how we provide care

There must be coordination in planning and implementation of all the moving parts:

Integration of Medical and Behavioral Health: Integrated Care

Patient Centered Care at the individual and system level

State Hospital redesign , DSRIP redesign and Medicaid managed care that supports these goals