Integrating Services for Recovery: Lessons from the American Experience

Michael F. Hogan, Ph.D.

Commissioner, NYS Office of Mental Health

Mental Health Care Has Been Transformed; Integrating Care Remains a Challenge

• From hospital to community care has meant– More freedom and opportunities for recovery– More fragmentation

• “Falling through the cracks”• Is there no place on earth for me? (Sheehan, 1983)

• Can care really be coordinated?• How does a “recovery paradigm” change the

challenges and opportunities?

Care WAS Transformed:Care WAS Transformed:State $ for Inpatient, Community Services--FY'81 to FY'06State $ for Inpatient, Community Services--FY'81 to FY'06

27%

63%

33%

70%

Community

0%

10%

20%

30%

40%

50%

60%

70%

80%

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Coordination In Hospital and Community Care

Coordinating care in the hospital:--Health care--Psychiatric treatment--Housing--RehabilitationAll under one roof…

Substance Abuse Services

Parole/Probation

Employment &Job Readiness Services

Money Management

Recreation

Transportation

Grocery, landromat, bank, etc.

Home-BasedServices

Stress Management

Community Service Opportunities

Family Preservation/Reunification

HealthCare

Psychiatric Services

MentalHealthServices

Counseling Services

Child Care & Children’s Services

CrisisIntervention

Coordinating care in communities presents daunting challenges

Consumer

CMHC

DMH

M.H. Care

M.D.

Meds

Housing

Income Support

Job Support

Case Mgt.

SAMHSA

U.S.--Coordinated Mental Health Services in Theory

Federal level

State level

Local level

Coordinated Care

Consumer

CMHC

DMH

M.H. Care

M.D.

Meds

Housing

Income Support

Job Support

Case Mgt.

PHA

V.R.

Medicare Medicaid

State Medicaid Agency

HUDCMHS Education SSA

Fragmentation of Mental Health Services, in Reality

HRSA

Clinic ?

Fragmented Care: Easy to Criticize… Impossible to “Fix”?

• “Falling through the cracks”…”a system in shambles” would seem to demand ACTION

• But action to integrate care was resisted

• Meeting mental health needs well is unlikely in the American political system…our system resists consolidation of power (Marmor & Gill, 1989)

Veto Message (May 3, 1854) Pres. Franklin Pierce:An act making a grant of public lands to the several States for the benefit of indigent insane personsThe question presented…is upon the constitutionality and propriety of the Federal Government…to enter into a novel and vast field of legislation…providing for the care and support of all those…who by any form of calamity become fit objects of public philanthropy.

If Government Can’t Be Fixed…Is There Another Way? How Has the Well-Being of

People With Mental Illness Changed in the Past 50 Years?

Health Insurance Financing for MH Care Increased: In the Mainstream

0%

20%

40%

60%

80%

100%

1971 2001

OOP

Private Insurance

Medicaid

Medicare

Other Federal

State

Misc

Frank and Glied, 2006

With Reduced Financial Burden for Those Getting Care(Out-of-Pocket Share of Expenses)

0

10

20

30

40

50

60

70

% OOP

MD Visits Non-MDVisits

Rx Hospital

1977

1987

1996

Frank and Glied, 2006

Today, More People Report MH Treatment(Even If It’s Often Not Enough and Not Good Enough)

0

5

10

15

20

25

30

35

40

45

Any Treatment Any Treatment -Disorder

Any Treatment - SMI

1990-1992

2001-2003

Source: NCS and NCS-R

While Improvements are not due to Increased Medical Sector MH Spending

0

50

100

150

200

250

300

1971 1991 2001

Per C

apita

200

1 D

olla

rs

0.70%

0.75%

0.80%

0.85%

0.90%

Shar

e of

GD

P

Per Capita Real MH Share of GDP Frank and Glied, 2006

Mental Health Spending -- Real per Capita and as a Share of GDP

More People with SMI are living Independently or with Family

0

10

20

30

40

50

60

70

80

90

100

1970 2000

Per

cen

tag

e Community n.o.c.

Family

Institutionalized

Hotels,Boardand Care

Frank and Glied, 2006

Though Many Are Also Homeless or Incarcerated

On Balance, Frank and Glied Conclude…

• People with a mental illness are better off, but not well off• Improvements are largely attributable to “mainstreaming”…

– Inclusion in health reform and insurance expansion– Access to social benefits (SSI, SSDI, housing

• Rather than advances via “exceptionalism”– Special benefits and services (as in the case of people with

developmental disabilities)– Improvements in mental health treatment

• Implications for Israel:– There is potential to improve services in HMO’s– The challenge of integrating services for people with disabling conditions

remains. Are there any emerging U.S. trends and tools?

Improvements and Opportunities

• A recovery model changes and improves possibilities:

1) Earlier, Better treatment with a real-world orientation can change people’s lives

2) Person-centered care coordination and better use of technology can fill the biggest cracks… especially for those most in need

A First Meaning of Recovery: “Realistic Optimism” Long Term Outcomes are Better Than Expected

Study Sample Size

Follow-Up (in years)

% Significantly

Recovered

Bleuler (1972) 208 23 53%-68%

Huber et al. (1979) 502 22 57%

Ciompi & Muller (1976) 289 37 53%

Tsuang et al. (1979) 186 35 46%

Harding et al. (1987) 269 32 62-68%

1. Bleuler (1978). The Schizophrenic Disorders. New Haven, Yale Press 2. Huber et al (1975). Long-term follow-up…Acta Psychiatrica Scand. 53:49-57. 3. Ciompi & Muller (1976). Lebensweg und alter…Berlin. Verlag Springer. 4. Harding et al. (1987). Vermont longitudinal study…Am. J. of Psychiatry 144: 718-735. 5. Tsuang,M. et al (1979). Long-term outcome…Arch. Gen. Psych. 36:1295-1301

25 Years Since the Carter Commission:New Opportunities in

Mental Health

“The biggest change in mental health from 1978 to today is that…

…we now know that recovery is possible for any individual with a mental illness”

Rosalyn Carter

However…The Important Meaning of Recovery Is Not Better Outcomes…But Better Focus

• Being in recovery can occur without cure/remission• Mental health professionals and researchers focused on

treatment and relief of symptoms…• However, recovery defined by those who have lived it is

creating a meaningful life despite symptoms and disability• “Mental health recovery is a journey of healing and

transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her potential.” SAMHSA

• This understanding of recovery requires a new approach to care

President George W. Bush On the New Freedom Commission

Albuquerque, New Mexico: April 29 2002

• “The Commission’s goal shall be to recommend improvements to enable adults with serious mental illness and children with severe emotional disturbance to live, work, learn, and participate fully in their communities.”

President’s Executive Order

Treatment in a Recovery Model

The current model for treating schizophrenia focuses on managing established illness and disability

RAISE will test whether early treatment/rehabilitation can slow or halt disability in people with schizophrenia

RecoveryAfter1nitialSchizophreniaEpisode

Early Intervention With a Real World, Developmental View

Recovery

Supported Employment/

Education

Family Support/Education

Evidence-basedSequential

Pharmacological Treatment

Suicide Prevention

Behavioral SkillsTraining

(SUD, Social Skills, FPE)

Recovery Specialist

Shared Decision Making

Peer Support

The RAISE Intervention(Columbia/Univ. Md. Approach)

Outreach/Engagement

Care Coordination is Person Centered, Reality Focused, and “Embedded”

Person-Centered Care Coordination Helps Integrate Care For People Falling Through the Cracks?

• Technology helps to identify people needing better care– Missed prescriptions– Repeated ER visits– Costly, repeat acute care

• Team based, person centered care coordination fills the gaps

The Need for Care Coordination:The Need for Care Coordination:Potentially Preventable Readmissions (PPRs)Potentially Preventable Readmissions (PPRs)

NYS Medicaid Data NYS Medicaid Data

A potentially preventable readmission (PPR) is A potentially preventable readmission (PPR) is involves poor care related to the initial hospital involves poor care related to the initial hospital admission…. Examples:admission…. Examples:– Discharged too quick / too sickDischarged too quick / too sick

– Lack of follow-up appointmentLack of follow-up appointment

Not all hospital readmissions are preventableNot all hospital readmissions are preventable

Total cost of PPRs $813M for 70,294 readmissionsTotal cost of PPRs $813M for 70,294 readmissions

2424

Most Readmissions to Patients with MH/SA Most Readmissions to Patients with MH/SA Diagnoses for Medical ConditionsDiagnoses for Medical Conditions

Patients with MH/SA diagnosis,

medical readmission

$395M

Patients with MH/SA diagnosis,

MH/SA readmission

$270M

Patients without MH/SA diagnosis,

medical readmission $149M

2525

Can Person-Centered Care Coordination Help With People Falling Through the Cracks?

• Technology helps to identify people needing better care– Missed prescriptions– Repeated ER visits– Costly, repeat acute care

• A personal plan leads to a better approach• Team care monitoring and follow-through

make a difference• A Western NY example

27

4 urban and 3 rural counties, 3.3 million people

New York Care Coordination Program

28

Of Erie and Monroe mental health users, the “top 10% in total cost” represent 63%

of Medicaid hospital and residential spending…

…yet only a quarter of the “top 10%” were enrolled in available Care Coordination

programs

• ACT• ICM• SCM

0%

20%

40%

60%

80%

100%

Not Enrolled

Enrolled

100%

0%

20%

40%

60%

80%

100%

Other Erieand MonroeCounty MHConsumers

Top 10%

22,836 $69.1M

Focus Care Coordination on People Who Need It

Note: Analysis of all 2007 claims for Medicaid recipients 18 or over, with any mental health claim, excluding individuals with any OMRDD or nursing home claim.

Practice of Care CoordinationNYCCP Initiatives

29

Outcomes for NYCCP Full report available at www.carecoordination.org

30 * 2009 Periodic Reporting Form Analysis

Integrating Services for Recovery: Lessons from the American Experience

• Moving from hospital to community was right, but care coordination was never sufficient– Policies and programs led reform, not integration– A government with divided powers makes

integration harder

• The recovery model offers opportunities:– Focus on the consumer’s goals: alignment– People in recovery learn to manage their affairs

• Technology and care coordination can plug the cracks

Thank You