MHA Issues ForumMarch 6, 2013Harvey Rosenthal www.nyaprs.org

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People with ‘serious’ mental health conditions will have life long struggles: Will be in clinic, day and housing programs

for all of their lives Will regularly relapse and require

emergency and hospital readmissions Will be on a range of powerful medications Will never work = poverty, entitlements Will not engage easily/be non-compliant

and require mandated treatment

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People are poor, idle, isolated, segregated…lack 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 funding lifelong services to people w ‘chronic conditions’

NYS: $54 billion Medicaid program; $8.7 billion behavioral health system; homeless, CJ costs

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Financial: governments can’t afford to continue to fund uncoordinated, inefficient, costly services that don’t encourage wellness rather than ‘chronicity’

Affordable Care Act/NYS Medicaid Redesign: coordinated, active, engaging, accountable, integrated outcome oriented person centered

Managed Care: flexibility and interest in funding peer services, social determinants

Olmstead: emphasis on most integrated supports vs. institutional services (hospitals, nursing/adult homes, sheltered workshops, day programs (?)

Consumer & Recovery Movements: choice, rights, wellness, community integration, life beyond services, alternatives

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New York’s Medicaid program serves almost 5 million beneficiaries at a cost of about $54 billion annually.

20% of Medicaid beneficiaries use almost 80% of the money, 40% have BH diagnoses. Hospital, emergency room, medications, services

NY spent the most in avoidable readmissions ($800m); 70% have BH diagnoses, 3/5 of these admissions are for medical reasons

15% unemployment, high homelessness rates

Lots of $ Spent, Very Poor Outcomes

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Integrating services to work in a more coordinated, collaborative 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

Consolidating Medicaid under the Department of Health

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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 we 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

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Part of an Integrated Care Team Access to Referrals Electronic Data Sharing To Get Connected to the Future Outcome Focused and Accountable

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Positioned for Managed Care Health Homes are Organizing Networks

Which Will Contract with MC Behavioral health providers bring vital

services to networks, e.g., care management, rehabilitation and recovery services, skills in engagement and motivation, housing, employment, peer staff, treatment

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Health homes can re-program care management dollars to buy peer services that can promote: Outreach and engagement Hospital/Prison/AH 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, coaching, diversion, advocacy

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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.

States can expect and even require managed care to buy peer services…especially if it’s in the request for proposals and contracts

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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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OptumHealth: peer bridgers in Wisconsin, Tennessee, New York, New Mexico; peer warm line, crisis respite and bridgers in Washington

Magellan: self directed care program in Pennsylvania; crisis alternatives in Arizona; psychiatric rehabilitation in Iowa

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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

Health plans are becoming interested too.

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Accountable Care Organizations Medicaid/Medicare Demonstration Programs Hospitals Medical providers Mental health and addiction service

providers

Subcontracts are key to preserving integrity

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From a rights protection, advocacy and empowerment focus for people within the mental health 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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Peer Bridging Peer Crisis Diversion: warm lines, respite

house 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: Rose House crisis respite guests did not return to hospital in the following two years

NYAPRS Peer Bridger program helped support a 72% drop in OMH hospital & a 50% drop in Optum Medicaid hospital readmissions/days

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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• Required persistent engagement, recovery and relapse prevention support, health coaching and re-connection to benefits

• 2009-prior to enrollment: 7 inpt stays (4 different facilities) $52,282

• 2010-1 detox, 1 rehab (referred by the CIDP team) $20,650.

• 2011 relapse with detox/rehab

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If we’re prepared to play an effective and transformative role in the healthcare system

If we’re successful in getting state government, managed care and health homes to value us and include us as desirable if not mandatory benefits people are offered

If we can manage new requirements re liability, cash flow, documentation, privacy protections,

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If we can describe in clear terms our services, methods, outcomes and costs..and make the business care for our services

If we’re prepared to define and meet training and professional standards

If we can promote and protect the integrity of true peer support and peer run agencies

If we can promote self directed budgets and alternatives, based on our success in HCR

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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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Peer run services should play prominent roles in BHO, health homes and managed care re-designs.

Open access to medications of choice

Crucial importance of cultural competence and other strategies to address health disparities

Inclusion of 1915.i self direction and flexible recovery services in HARPs

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Cultural and linguistic competence, engagement and diversion

Use of peer services Reduced mortality and health

disparities Reduced criminal and juvenile justice

involvement (diversion, re-entry?) Reduction in use of court-ordered

outpatient treatment Improved care transitions

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We’ve come from being ahead of our time to

being right on time…if we raise the bar on our

service design/delivery/marketingand our advocacy!

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