Скачать презентацию MHA Issues Forum March 6 2013 Harvey Rosenthal Скачать презентацию MHA Issues Forum March 6 2013 Harvey Rosenthal

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MHA Issues Forum March 6, 2013 Harvey Rosenthal www. nyaprs. org THE OPPORTUNITIES FOR MHA Issues Forum March 6, 2013 Harvey Rosenthal www. nyaprs. org THE OPPORTUNITIES FOR RECOVERY AND PEER SERVICES IN NYS HEALTHCARE REFORM 1

BACKDROP TO HEALTHCARE REFORM EXPECTATIONS PREDICT OUTCOMES People with ‘serious’ mental health conditions will BACKDROP TO HEALTHCARE REFORM EXPECTATIONS PREDICT OUTCOMES 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 2

THE COST TO PEOPLE AND TAXPAYERS People are poor, idle, isolated, segregated…lack hope, purpose THE COST TO PEOPLE AND TAXPAYERS 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 3

THE PERFECT STORM Financial: governments can’t afford to continue to fund uncoordinated, inefficient, costly THE PERFECT STORM 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 4

THE NEED FOR HEALTHCARE REFORM NYS EXAMPLE New York’s Medicaid program serves almost 5 THE NEED FOR HEALTHCARE REFORM NYS EXAMPLE 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 ($800 m); 70% have BH diagnoses, 3/5 of these admissions are for medical reasons 15% unemployment, high homelessness rates Lots of $ Spent, Very Poor Outcomes 5

NYS MEDICAID REDESIGN PLAN Integrating services to work in a more coordinated, collaborative and NYS MEDICAID REDESIGN PLAN 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 6

WHAT ARE HEALTH HOMES? A health home is a ‘hub’ not a house Health 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 7

HEALTH HOME NETWORK LEADER Health home lead agencies provide: q Dedicated care managers who HEALTH HOME NETWORK LEADER Health home lead agencies provide: q 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 q in accordance with a single care management plan q that is shared with all providers via an electronic healthcare record 8

HEATH HOMES GOAL Health homes are accountable for reducing avoidable health care costs, specifically 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 9

HEALTH HOME FUNDING Health home leaders get a monthly rate for each person served 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 we move to managed care. 10

HUDSON RIVER HEALTHCARE Hospitals: Good Samaritan Hospital; Hudson Valley Hospital Center; St. Francis Hospital 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 11

HUDSON RIVER HEALTHCARE BH Providers: Dutchess County Department of Mental Hygiene; Hudson Valley Mental 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; 12

WHY JOIN A HEALTH HOME? CONSUMERS Integrated Care Help with Navigating the Health Care WHY JOIN A HEALTH HOME? CONSUMERS Integrated Care Help with Navigating the Health Care System Better Access Better Coordination Wellness and Person Centered Focus on Skills to Stay Healthy 13

WHY JOIN A HEALTH HOME NETWORK? PROVIDERS Part of an Integrated Care Team Access WHY JOIN A HEALTH HOME NETWORK? PROVIDERS Part of an Integrated Care Team Access to Referrals Electronic Data Sharing To Get Connected to the Future Outcome Focused and Accountable 14

WHY JOIN A HEALTH HOME NETWORK? PROVIDERS Positioned for Managed Care Health Homes are WHY JOIN A HEALTH HOME NETWORK? PROVIDERS 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 15

PEER SERVICES IN HEALTH HOMES Health homes can re-program care management dollars to buy PEER SERVICES IN HEALTH HOMES 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 16

PEER SERVICES IN HEALTH HOMES Sample arrangement…working in subcontract with a health home to 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, coaching, diversion, advocacy 17

FROM FEE FOR SERVICE TO MANAGED CARE Some states are preparing to ‘carve in’ 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’ 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. 18

OUR OPPORTUNITY IN MANAGED CARE Managed care companies and BHOs have great flexibility beyond 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. States can expect and even require managed care to buy peer services…especially if it’s in the request for proposals and contracts 19

MANAGED CARE HAS THE FLEXIBILITY TO BUY …IF IT’S IN THE RFP AND CONTRACT MANAGED CARE HAS THE FLEXIBILITY TO BUY …IF IT’S IN THE RFP AND CONTRACT 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 20

PLANS USING PEER SERVICES Optum. Health: peer bridgers in Wisconsin, Tennessee, New York, New PLANS USING PEER SERVICES Optum. Health: 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 21

PLANS USING PEER SERVICES Community Care: recovery institute, learning collaborative, supported housing reinvestment; consumer/family PLANS USING PEER SERVICES Community Care: recovery institute, learning collaborative, supported housing reinvestment; consumer/family satisfaction teams Value. Options: self directed care program in Texas, peer services and consumer research and evaluation in Massachusetts Health plans are becoming interested too. 22

OTHER NEW PAYERS Accountable Care Organizations Medicaid/Medicare Demonstration Programs Hospitals Medical providers Mental health OTHER NEW PAYERS Accountable Care Organizations Medicaid/Medicare Demonstration Programs Hospitals Medical providers Mental health and addiction service providers Subcontracts are key to preserving integrity 23

NEW ROLES, GROUPS FOR PEER SERVICES From a rights protection, advocacy and empowerment focus NEW ROLES, GROUPS FOR PEER SERVICES 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 24

BEYOND PEER SPECIALISTS EXAMPLES OF SPECIALTY SERVICES Peer Bridging Peer Crisis Diversion: warm lines, BEYOND PEER SPECIALISTS EXAMPLES OF SPECIALTY SERVICES 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 25

DATA IS KEY SOME NYS EXAMPLES 2010 study: Rose House crisis respite guests did DATA IS KEY SOME NYS EXAMPLES 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 26

DATA IS KEY SOME NYS EXAMPLES 2010: Mental Health Peer Connection’s Life Coaches helped DATA IS KEY SOME NYS EXAMPLES 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 27

DATA IS KEY PEER WELLNESS COACHING: ONE PERSON’S OUTCOMES • • Required persistent engagement, DATA IS KEY PEER WELLNESS COACHING: ONE PERSON’S OUTCOMES • • 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 28

PEER SERVICES CAN PLAY A CRUCIAL ROLE… If we’re prepared to play an effective PEER SERVICES CAN PLAY A CRUCIAL ROLE… 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, 29

PEER SERVICES CAN PLAY A CRUCIAL ROLE… If we can describe in clear terms PEER SERVICES CAN PLAY A CRUCIAL ROLE… 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 30

STATE LEVEL ADVOCACY NEEDED Services must promote recovery and wellness, health literacy and ‘self STATE LEVEL ADVOCACY NEEDED 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. 31

STATE LEVEL ADVOCACY NEEDED Peer run services should play prominent roles in BHO, health STATE LEVEL ADVOCACY NEEDED 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 32

STATE LEVEL ADVOCACY NEEDED Outcomes: Beyond Days To Outpatient and Medication Use Cultural and STATE LEVEL ADVOCACY NEEDED Outcomes: Beyond Days To Outpatient and Medication Use 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 33

NEXUS BETWEEN PEER SUPPORT, HEALTHCARE AND BUDGET REFORM AND OLMSTEAD We’ve come from being NEXUS BETWEEN PEER SUPPORT, HEALTHCARE AND BUDGET REFORM AND OLMSTEAD We’ve come from being ahead of our time to being right on time…if we raise the bar on our service design/delivery/marketing and our advocacy! 34