visit with........................... scotch plains, nj, january 24, 2014
TRANSCRIPT
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Visit with ...........................
Scotch Plains, NJ, January 24, 2014
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Outline
PsyR: What? Where? Who?
NJPRA World: Sector Analysis
NJPRA Stand: Issues and Positions
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Psychiatric Rehabilitation: What? Where? Who?
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What is PsyR?
Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.
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What is PsyR?
Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.
Psychosocial
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What is PsyR?
Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.
SchizophreniaBipolarSchizoaffectiveBorderlineDepression
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What is PsyR?
Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.
CopingRelaxation
LivingFinancial
SocialEmploymentEducationHousing
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What is PsyR?
Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.
Social lifeClubs
Church
FriendsLover
SpouseCollege
Grad SchoolTech School
WorkerManagerVolunteer
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What is PsyR?
Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.
ChoiceCommunity
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What is PsyR?
Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.
ProgramsDoctors
Hospitals“Interventions”
“Disability” supportsSSI / SSD
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What is PsyR?
...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.
“Stabilization”Remission“Normal”
AdjustmentActualizationAutonomy
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Recovery Principles...
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What Is PsyR?
A goal
A role
A specialty
A discipline
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Who Provides PsyR?
Psychiatrists
Psychologists
Nurses
Social Workers
Direct Care
Peer Providers
Consumer
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Where is PsyR? Day services Residential abodes Case management PACT (Programs of Assertive Community
Treatment) Vocational programs Educational programs Hospitals Families Peer initiatives
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Why PsyR? Severe and persistent mental illness is...
Long term Recurrent Difficult Disruptive (of life) Interruptive (of development) Debilitating (of capacity)
PsyR thus advances... Long-term recovery Community integration Quality of life
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PsyR Values Self determination Individual dignity and worth Individual potential Cultural sensitivity Hope
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PsyR Principles Individual services Maximum individual choice Normalized community basis Strengths-based Situational assessments Holistic, integrated supports and skills training Accessible, coordinated services Environmental modifications Partner with families Practical outcomes
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Challenges to PsyR Institutional pessimism Organizational barriers Training demands Funding shortages Quick-fix thinking “Courtesy” stigma
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Since 1975 Formerly IASPRSFormerly USPRA8000 members
The National Organization
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What Is A CPRP?
“Certified Psychiatric Rehabilitation Practitioner”
Supervised by the Commission
Partly “founded” in NJ
Transdisciplinary
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Who Are CPRPs
Professors Melissa Roberts, PhD, CPRP Doctors Psychologists Social Workers Nora Barrett, MSW, CPRP Occ. Therapists Managers Tom Pyle, MBA, CPRP Peer Specialists Harry Coe, CPRP Nurses Direct Care
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The State Organization
1000 individual members
A leading state chapter (along with NY, CA,
MA, IL, GA...) 501c4 501c3
A 2 day annual conference > 250 people
Various trainings Advocacy work
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Organizational Members
• Advance Housing• Atlanticare• Bridgeway• CareLink • Collaborative Support
Programs of NJ• Consumer Provider
Association of NJ• Greater Trenton
Behavioral Healthcare
• Northwest Essex • Project Live, Inc.• Prospect House (MHA
of Essex County)• SERV Behavioral
Health Triple C Housing• Rutgers PsyR Dept.• Volunteers of America
(Greater New York)
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Sector Analysis
Government, Industry, Market, Customer, Product...
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Government of New Jersey
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Government of New Jersey
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Government of New Jersey
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Government
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Government
Increasing regulations
Electronic Medical Records
“RAC” Audits
Capricious and arbitrary administration
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Industry: An Optimal Tx Plan?Intensity Level 5
Hospital Setting (Highly Staffed)
Level 4 Professional Care Setting (Moderately Staffed)
Level 3 Residential (Treatment) Setting
Level 2 Partial Hospitalization (Day Program)
Level 1 Community (Outpatient)
Very High
High
Moderate
Low
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Industry: An Optimal Tx Plan?Intensity Level 5
Hospital Setting (Highly Staffed)
Level 4 Professional Care Setting (Moderately Staffed)
Level 3 Residential (Treatment) Setting
Level 2 Partial Hospitalization (Day Program)
Level 1 Community (Outpatient)
Very High
High
Moderate
Low
1.Hospital
Need(IDDT)
2.TreatmentResidential
3.SupportedResidential
4. IOP
4.IndependentResidential
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Industry: Treatment vs. NeedIntensity Level 5
Hospital Setting (Highly Staffed)
Level 4 Professional Care Setting (Moderately Staffed)
Level 3 Residential (Treatment) Setting
Level 2 Partial Hospitalization (Day Program)
Level 1 Community (Outpatient)
Very High
High
Moderate
Low
Hospital
CurrentTx
Gap
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Industry: Tx vs. Need: ChoicesIntensity Level 5
Hospital Setting (Highly Staffed)
Level 4 Professional Care Setting (Moderately Staffed)
Level 3 Residential (Treatment) Setting
Level 2 Partial Hospitalization (Day Program)
Level 1 Community (Outpatient)
Very High
High
Moderate
Low
Hospital
Need(IDDT)
Therapeutic Communitie
s
Clinical Residential
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HospitalHospital
PACT
4. IOP
4.IndependentResidential
Group Homes Local
PHPSupported Housing
Local IOP
State Hospital
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Industry: Tx vs. Need: ChoicesIntensity Level 5
Hospital Setting (Highly Staffed)
Level 4 Professional Care Setting (Moderately Staffed)
Level 3 Residential (Treatment) Setting
Level 2 Partial Hospitalization (Day Program)
Level 1 Community (Outpatient)
Very High
High
Moderate
Low
Hospital
Need(IDDT)
Therapeutic Communitie
s
Clinical Residential
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HospitalHospital
PACT
4. IOP
4.IndependentResidential
Group Homes Local
PHPSupported Housing
Local IOP
State Hospital
Illness Management & RecoverySupp HousingSupp Education
Supp Employ
Assertive Community Treatment
Family Psychoeducation
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Industry: 120 AgenciesOf which... Bridgeway Catholic Charities Drenk Easter Seals Family Services Greater Trenton Mental Health Assn Essex Twin Oaks ...others...
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Industry: Specialty Providers Supported Housing: 46 agencies
Supported Employment: 22 agencies
Consumer-operated: 33 centers
State Hospital patients: ~1500 per year
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Market: Medicaid Enrollments(Centers for Medicare and Medicaid, 2012)
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Market: NJ Medicaid Enrollment
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Customer: Consumers
DMHAS BG appl. says...
Governor’s budget says..
285,000 “unduplicated consumers in community settings”, of which...
123,000 with SMI
Community Care Services 329,664Screening Services 98,217Outpatient Services 136,704Partial Care 12,127Residential 3,499Supported Housing 5,858Supported Employment 2,371Self-help Centers 6,240Integrated Case Mgt 10,725PACT 2,443
State Psychiatric Hospitals 1,500
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Product: PsyR Evidence-Based Practices
Illness Management and Recovery Integrated Dual Disorder Treatment Assertive Community Treatment Family Psychoeducation Supported Employment Supported Education* Supported Housing* Other “promising” practices
PsyR Recovery
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Recovery: As Outcome
RECOVERY
time
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Recovery: As Process
RECOVERYtime
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Recovery: 3 Models of Care
RECOVERY Psychiatric Rehabilitation
Individual Empowerment
Med
ical
time
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Models of Care
RECOVERY Psychiatric Rehabilitation
Individual Empowerment
Med
ical
Psychotherapy
time
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Models of Care
RECOVERY Psychiatric Rehabilitation
Individual Empowerment
Med
ical
Psychotherapy
Illness Management & Recovery
time
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Models of Care
RECOVERY Psychiatric Rehabilitation
Individual Empowerment
Med
ical
Psychotherapy
Supported Housing
Illness Management & Recovery
time
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Models of Care
RECOVERY Psychiatric Rehabilitation
Individual Empowerment
Med
ical
Psychotherapy
Supported Education
Supported Housing
Supported Employment
Illness Management & Recovery
time
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Models of Care
RECOVERY Psychiatric Rehabilitation
Individual Empowerment
Med
ical
Psychotherapy
Supported Education
Supported Housing
Supported Employment
Illness Management & Recovery
Family Psychoeducation
Assertive Community Treatment
time
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US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.37
Finance: Rate Ratio (Zuckerman et al., 2009)
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US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.37
Finance: Rate Ratio (Zuckerman et al., 2009)
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US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.37
Finance: Rate Ratio (Zuckerman et al., 2009)
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US 0.72
WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43
NJ 0.37
50th
!
Finance: Rate Ratio (Zuckerman et al., 2009)
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Industry: Providers = f(Rate Ratio) (Decker, 2013)
𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒
% doctors accepting
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Competition (“Stakeholders”)
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Competition (“Stakeholders”)
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Competition (“Stakeholders”)
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Competition (“Stakeholders”)
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Competition (“Stakeholders”)
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Competition (“Stakeholders”)
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Issues and Positions
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3 Mega Issues affecting PsyR
1. “Biological Reductionism”
2. Managed Care
3. Medicaid Expansion
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1. Reductionism
Paternalism
“Brain” over “mind
ST over LT
“Evidence”: only RCTs...
Problems:Stigma. Pharmacology.
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2. Behavioral Health Managed Care
Administrative Services Organization (ASO)
Fee-for-service
Problems: Cost reduction, NOT value optimization...
Incremental care, NOT continuum of care...Stressed operations: compliance
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3. Medicaid Expansion
Medicaid funds 65% of public mental health
Enrollment: 25% 234,000 new beneficiaries in NJ
Providers: no increase, likely decrease
Problems:Access, Availability,
Quality, Cost, Innovation
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Advocacy: 6 Development Domains1. Workforce
2. Agency
3. Sector
4. Practice
5. Client/Consumer/Family
6. Government
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Advocacy: 6 Development Domains1. Workforce
2. Agency
3. Sector
4. Practice
5. Client/Consumer/Family
6. Government
COLA
CPRP (dissemination)
Pay parity (with hospitals)
Training (R-SHRP)
Licensing (hurdles)
Peer Providers
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Advocacy: 6 Development Domains1. Workforce
2. Agency
3. Sector
4. Practice
5. Client/Consumer/Family
6. Government
Transition support ($)
“RAC” auditing
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Advocacy: 6 Development Domains1. Workforce
2. Agency
3. Sector
4. Practice
5. Client/Consumer/Family
6. Government
Medicaid Rate Setting
“Medical Necessity”
Community Support Services (CSS)
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Advocacy: 6 Development Domains1. Workforce
2. Agency
3. Sector
4. Practice
5. Client/Consumer/Family
6. Government
Supported Housing (a “medical necessity”)
Supported Employment (“balkanized” process)
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Advocacy: 6 Development Domains1. Workforce
2. Agency
3. Sector
4. Practice
5. Client/Consumer/Family
6. Government
Support Olmstead funding (for housing)
Oppose National Registry
Improve crisis screening
Support CIT for police
Benefits parity for “old” Medicaid eligibles
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Advocacy: 6 Development Domains1. Workforce
2. Agency
3. Sector
4. Practice
5. Client/Consumer/Family
6. Government
Mental health courts
More and better outcome measurements
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Advocacy: NJPRA Strategy
More diversification of outreach
More individualized positioning
Higher public profile
More impact
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Advocacy: What NJPRA Needs...
More non-legislative representation A meeting with Governor’s office More focus on Medicaid office and rate setting process More “assertion” with DMHAS More help with interdepartmental contact, e.g. DCA
More press contacts and networks News articles Radio and TV appearances
More contacts with philanthropies, corporations