Getting Ready for Managed Care: What Will It Mean to Consumers, Provider and Peer Professionals?

NYAPRS North Country Regional MeetingMay 16, 2013

Harvey Rosenthal www.nyaprs.org

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New York Association of Psychiatric Rehabilitation Services (NYAPRS)

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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Unprecedented Pace of Change 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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Backdrop to Healthcare ReformCritical Challenges at Medicaid Systems Level

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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Backdrop to Healthcare ReformCritical Challenges at BH Systems Level

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

Barriers to Engagement for People with ‘Serious’ BH Conditions

• 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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Barriers to Engagement for People with ‘Serious’ BH Conditions

• 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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New Groups, New Challenges ‘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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The Cost to People and Taxpayers 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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The Need for Healthcare Reform NYS Example

$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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ACA HEALTHCARE REFORMSMajor Federal Drivers

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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The Perfect Storm for Recovery Financial Pressures: federal, state and local governments can’t

continue to fund uncoordinated, inefficient, costly services that don’t produce good healthcare outcomes

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

Mental Health Parity and Addiction Equity Act 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 Movement 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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Recovery Movement 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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State Medicaid Redesign Plans 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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From Fee for Service to Managed Care

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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Our Opportunity in Managed Care

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.

Moving Behavioral Health Services Into Managed Care

By October 2014, currently ‘carved out’ Fee for Service OMH and OASAS services will be integrated into upstate managed care plans, either on their own or in partnership with a “qualified” Behavioral Health Organization.

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Moving Behavioral Health Services Into Managed Care

Those services include OMH/OASAS mental health and substance abuse inpatient and clinic services• OMH Medicaid services like PROS, ACT, IPRT, ACT,

CDT, Partial Hospital, CPEP, Targeted Case Management and rehab supports within community residences and

• OASAS Medicaid services like Opioid treatment and outpatient chemical dependence rehabilitation.

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Health and Recovery Plans (HARPS)

Will provide a range of more intensive services for individuals with ‘significant behavioral health needs’.

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Health and Recovery Plans (HARPS)Enhanced Mental Health Services

Services in Support of Participant Direction: Information and Assistance in Support of Participant Direction and Financial Management Services

Crisis: Crisis Respite Support Services: Community Transition,

Family Support, Advocacy/ Support and Training and Counseling for Unpaid Caregivers

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Health and Recovery Plans (HARPS)Enhanced Mental Health Services

Empowerment Services: PEER SUPPORTS Service Coordination Rehabilitation: Pre-vocational, Transitional

Employment, Assisted Competitive, Employment, Supported Employment, Supported Education, Onsite Rehabilitation, Respite and Habilitation

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Sample HARP Outcome Measures Increased access Service engagement Physical health improvements Participation in employment; Enrollment in vocational rehab services and

education/training; Housing status; Community tenure; Criminal justice involvement; Peer service use and Improving functional status

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Managed Care Designs Mainstream plans can be approved to operate

HARPs by themselves if they meet ‘rigorous’ state standards.

Such plans may also choose to partner with a BHO to meet those standards.

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CY 2011 Top 20 Health Plans – HARP/non-HARPPlan Name HARP non-HARPFIDELIS 19,904 54,279HEALTH FIRST PHSP INC 14,409 33,138METROPLUS HEALTH PLAN INC 11,262 27,756AFFINITY HEALTH PLAN INC 7,330 20,476HEALTH PLUS PHSP INC 6,605 18,754BLUE CHOICE/BLUE CHOICE OPTIO 6,777 18,338UNITED HEALTHCARE OF NY INC 6,238 16,127HLTH INSURANCE PLAN OF GTR NY 7,174 14,433NEIGHBHD HLTH PROVIDER PHSP 5,482 12,678HUDSON HEALTH PLAN INC 3,165 9,701CAPITAL DISTRICT PHYS HLTH PL 3,077 7,832HEALTHNOW NY INC 1,926 5,812SYRACUSE PHSP 2,011 5,506INDEPENDENT HLTH ASSOCIATION 1,886 5,521MVP HEALTH PLAN, INC 1,754 4,918AMERIGROUP NEW YORK LLC 1,688 4,866BUFFALO COMMUNITY HEALTH INC 1,279 4,439WELLCARE OF NEW YORK INC 1,323 3,478UB FAMILY MEDICINE 1,764 1,770NY PRESBY SYS SELECT HLTH SN 1,472 1,466

BHOs USING PEER SERVICES Magellan: self directed care program in Pennsylvania; crisis

alternatives in Arizona; psychiatric rehabilitation in Iowa Optum: peer bridgers in Wisconsin, Tennessee, New York,

New Mexico; peer warm line, crisis respite and bridgers in Washington

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

Timelines

Spring 2013: Program design finalized Winter 2013: Contract Requirements for

MCOs, HARPs finalized: RFQ posted on website for upstate groups

Summer 2014: Qualified MCOs and HARPs are selected for upstate

Fall 2014: HARPS, MCOs are operational upstate

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= Physical and/or

behavioral health care provider

MCO/BHO (A) MCO/BHO (B) HARP

HH Team

DOH/OMH/OASAS

HH Team

HH Team

HH Team

HH Team

Managed Behavioral/Physical Careand Health Homes

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What are Health Homes?

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 Network Leader 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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Heath Homes Goal 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 Funding 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.

Following the Money… Current plans are to ‘lock in’ and track all

carved in behavioral health dollars to guard against migration of funds and to reinvest all savings into enhancing needed services

At the outset, the average per person per year cost for HAPR services is $30,000.

The recently enhanced monthly rate for ‘high touch’ health home enrollees with behavioral health needs is about $950.

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Hudson River Healthcare 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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Hudson River Healthcare 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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Health Home Advantages for Consumers

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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Health Home Advantages for Providers

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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Critical Value of BH Services

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

Housing First 2000 “Pathways to Housing: Supported Housing for

Street-Dwelling Homeless Individuals With Psychiatric Disabilities” Psychiatric Services Tsemberis and Eisenberg An innovative ‘harm reduction’ housing and support program model was able to achieve an 88% service retention rate and general stability among a group of primarily young men of color with psychotic disorders and previous histories of homelessness and non-participation with services http://ps.psychiatryonline.org/cgi/content/abstract/51/4/487 39

Housing, Employment and Medicaid Savings

A 2002 University of Pennsylvania study found supported housing produced an average of $16,282 in savings from reduced use of hospitals, ERs, shelters et al.

A May 2006 Mathematica study found that “on average, Buy-In participants cost Medicaid $984 per-member per-month (PMPM) in 2000, almost 40 percent lower than the cost of other Medicaid enrollees with disabilities.”

Criminal Justice Diversion, Re-Entry services too

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Westchester County Care Coordination Project 2007-10

Intensive program consisting of care manager, peer mentor and self directed budget

Total local funds: $176,000 for 48 people Reductions

• Medicaid services: 35%• Incarceration: 53%• State hospital: 78%• Total: 53% $2.3 million down to $1.2 million

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Peer Services in Health Homes 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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Peer Services in Health Homes 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

NYAPRS/OPTUM Wellness coaching: One Person’s Outcomes

• 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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New Roles, Groups for Peer Services 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

Peer Service Innovations Can Play Crucial Roles in Improving Care, Health, Cost

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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Peer Service Innovations Play Crucial Roles in Improving Care, Health, Cost

• 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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Beyond Peer SpecialistsExamples of Peer Run Specialty Services

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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DATA IS KEYPeer Service Outcomes

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:• 71% drop in NY state psychiatric center readmissions• 50% drop in numbers of people hospitalized in local

Medicaid psychiatric inpatient units and in total hospital days when admitted

2010 Optum Health Peer Link reduced hospital days by 90% in Wisconsin, by 72% in Tennessee

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DATA IS KEYPeer Service Outcomes

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

Preserving the Integrity of Peer SupportSome Key Principles

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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Preserving the Integrity of Peer SupportSome Key Features

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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Preserving the Integrity of Peer SupportSome Key Distinctions

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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OMH Academy of Peer ServicesSample Curriculum Topics

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History of Peer SupportIntentional Peer SupportAvoiding Co-optationPeer Support PracticesPeer Service ModelsPeer Crisis ServicesPeer BridgingPeer Wellness CoachingPeer Health NavigatorsPeer HousingPeers in Clinic SettingsPeer Recovery Centers

OMH Academy of Peer ServicesSample Curriculum Topics

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Outreach & Engagement First Contact Motivational Interviewing Self Assessment Navigating Choice Cultural Sensitivity Mutuality/Reciprocation Power Dynamics Ethics & Boundaries Active Listening Communication Skills Appreciative Inquiry

OMH Academy of Peer ServicesSample Curriculum Topics

Crisis De-escalation Harm Reduction Conflict Resolution Relapse Prevention/Crisis Planning Self-Injury

Advocacy for Others Mental Health Rights Mental Health Laws Informed Choice

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OMH Academy of Peer ServicesSample Curriculum Topics

Self-Disclosure Documentation & Reporting Work Ethic Navigating Systems Workspace Organization Negotiation Skills Community Assets

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OMH Academy of Peer ServicesSample Curriculum Topics

8 Dimensions of Wellness Suicide Prevention Psychiatric Rehabilitation Employment Services Benefits and Entitlements Supported Education Person-Centered/Recovery Principles Trauma-informed Care Health and Alternative Healing

http://www.academyofpeerservices.org/

http://www.academyofpeerservices.org/

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