A Perspective on Behavioral Healthcare

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A Perspective on Behavioral Healthcare

• CCPA
• December 11, 2008
• Linda Rosenberg, M.S.W.
• President and CEO, National Council for Community
  Behavioral Healthcare

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• It was the best of times, it was the worst of
  times it was the spring of hope, it was the
  winter of despair we had everything before us,
  we had nothing before us.
• Charles Dickens

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7 Measures of a highly effective association

• Commitment to purpose
• Customer Service Culture - broad, strong, engaged
  membership
• Alignment of products and services with mission
• Commitment to analysis and feedback
• Data driven strategies
• CEO as Broker of Ideas
• Dialogue and Engagement
• Commitment to Action
• Organizational Adaptability
• Alliance building - industry leadership.

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Thank you
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Member Issues

• Funding, Medicaid, Medicare
• Reform privatization, competition, managed
  care
• Health Integration
• Workforce
• Technology

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Today

• Mental illnesses and addictions - come so far, so
  far to go
• Taking the future into our own hands public
  policy
• Taking the future into our own hands - quality

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• Come so far, so far to go

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Come a long way

• generation long effort to move hundreds of
  thousands of people warehoused in institutions to
  community care
• creation of outpatient and rehabilitation
  programs, case management, assertive community
  treatment, peer support, club houses, housing,
  jail diversion initiatives

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Come a long way

• Passage of Medicaid and Medicare, expanding
  Social Security Disability Insurance and
  Supplemental Security Income
• from centralized state hospitals to decentralized
  pluralistic, market oriented system

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Come a long way

• PORT Recommendations, Surgeon Generals Report,
  Presidents New Freedom Commission, and Institute
  of Medicine reports all agree that
• mental health and freedom from addictions are
  vital to overall health
• effective treatments exist and recovery is
  possible

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Come a long way

• Up to 90 of people with a mental illness that
  are treated with a combination of medication and
  therapy experience substantially reduced
  symptoms, enhanced quality of life increased
  productivity
• Science has revolutionized our understanding of
  addictions treatment has been shown to cut drug
  use in half, reduce crime by 80 reduce arrests
  up to 64.

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Come a long way, but

• People with mental illnesses and addictions
  remain poor, stigmatized and dependent upon
  publicly financed Medicaid - services.

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So far to go

• Mental illness and addictions are more common
  than cancer, diabetes, or heart disease. Almost
  60 million Americans one in four adults and one
  in five children have a mental illness that can
  be diagnosed and treated in a given year.

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So far to go

• Mental illness drains our economy of more than
  80 billion every year
• Alcohol and drug abuse causes death of more than
  100,000 Americans each year
• 25 of all hospital admissions have an
  accompanying mental illness or addictions
  disorder
• More than half of all jail and prison inmates
  have mental health problem up to 75 meet the
  criteria for substance abuse

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So far to go

• Up to two-thirds of homeless adults suffer from
  chronic alcoholism, drug addiction, mental
  illness or some combination of the three
• 27 of all SSI payments and 35 of SSD payments
  are for mental illnesses
• Late detection/intervention
• Complexity of illnesses and effects of poverty
  early mortality and increased morbidity

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So far to go

• Only one third of people diagnosed with
  schizophrenia receive appropriate dose for the
  appropriate duration
• Fewer than one half who also have symptoms of
  depression receive antidepressant medication
• Only one half typically receive appropriate
  treatment to counteract disturbing side effects

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So far to go

• Fewer than 10 of families of outpatients with
  schizophrenia receive education and support
• Less than 25 of people diagnosed with
  schizophrenia are involved in vocational services
• Only 2-10 of individuals with schizophrenia
  receive ACT services

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• Taking the future into our own
  handspolicy

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Policy Issues

• Decentralized policy and decision making
• Dependence on Medicaid and limited to no access
  for non Medicaid
• From open access to tailored benefit packages for
  specific populations
• Multiple hospital and community providers with
  fierce competition for Medicaid
• Integration with general healthcare

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2008 - Assertive, focused policy agenda

• Medicaid
• Parity/ Medicare
• Veterans
• Criminal Justice Mentally Ill Offender Treatment
  and Crime Reduction Act Second Chance
• Community Mental Health Services Improvement Act
  - Primary care in behavioral sites

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Policy success

• Mentally Ill Offender Treatment and Crime
  Reduction Act (MIOTCRA) program advocating for
  full funding of 50 billion in FY 2008 - 10
  billion proposed
• Re-entry Legislation part of bipartisan
  coalition supporting the Second Chance Act (H.R.
  1593/S.1060)
• Increased funding for Center for Substance Abuse
  Prevention (CSAP), Substance Abuse Prevention and
  Treatment (SAPT) Block Grant, and Safe and
  Drug-Free Schools and Communities State Grants
  Program

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Medicaid

• Make Medicaid look like commercial health
  insurance.
• Medicaid should not be a financing option for
  other public systems for non-Medicaid purposes.
• Rein in federal health spending.

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Medicaid

• In DRA, Congress rejected Bush efforts -
  President uses administrative measures attack
  on case management and rehab options
• Council member political heat, member testimony,
  rallying partners
• Moratorium in place until April 1, 2009
• Senator Debbie Stabenow (D-MI) introduced S.
  3611, Medicaid Services Restoration Act of 2008
  in Sept.
• Improve the provision of Medicaid's
  rehabilitation services and case management and
  targeted case management services.

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Medicaid

• Create a new service category to finance
  therapeutic foster care
• Authorize "habilitation" services under the
  rehabilitation option.
• Allow states to use bundled rates
• Authorize Medicaid to pay for physical health
  care for children who are placed in a 24-hour
  psychiatric hospital or psychiatric residential
  treatment center

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Medicaid

• Codify the Olmstead case management standard that
  permits 180 days of intensive case management
  services for Medicaid beneficiaries with a
  disability who are transitioning from
  institutions to the community.
• Authorize states to assign case managers to
  individual Medicaid beneficiaries, including
  multiple case managers.

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Parity

• Senator Paul Wellstone Mental Health Parity Act
  of 2007 parity for mental health and addictions
  
• Medicare HR 6331 - ends mental health
  discrimination (2010 to 2014)
• Re-authorization of SCHIP - 2 Medicare
  provisions marriage family therapists/
  licensed professional counselors as providers
  additional covered services including case
  management, ACT, rehab
• Vetoed by President but passage by Congress is
  important legislative record

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Parity

• 1-2 increase in total health plan costs
• 30 increase in MH/SA spending
• More competition
• Increase community hospital
• More integration within primary care
• Parity universal coverage end of safety net
  funding?

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The Veterans Mental Health Outreach and Access
Act

• President Bush signed S 2162 into law on October
  10 Section 107 creates 3-year pilot will be
  carried out in at least three Veterans Integrated
  Service Networks (VISNs).
• VA to contract with community mental health
  centers to provide treatment, support services,
  readjustment counseling.
• All contract-providers required to hire a
  qualified peer specialist and have clinicians
  participate in a training program

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Community Mental Health Services Improvement Act

• Create legislation to help implement, from the
  bottom up, recommendations of the Presidents New
  Freedom Commission Report and the IOM report
• Capacity Building
• Financing Reform

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Community Mental Health Services Improvement Act

• Primary care in behavioral sites
• Co-occurring disorders funding demo
• Workforce improvements, salary study
• Paperwork reduction - elimination of regulatory
  redundancy
• Advancing tech. electronic health record
• Rural behavioral health treatment incentives

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Coming soon - 2009

• Federal funding stream to cover the mental health
  treatment costs of the uninsured
• Restore eligibility for social security
  disability for people with addictive disorders
• Cost based re-imbursement that supports salaries
  that can attract and retain skilled staff
• Chronic disease management project medical home
  

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Policy strategic relationships

• Chronic Disease, Healthcare, Medicaid Coalitions,
  Medicaid Directors
• Addiction Treatment Advocacy and Criminal Justice
  Leadership
• Mental Health Groups Campaign, NAMI, MHA,
  Consumers, NASMHPD, Guilds
• Feds SAMHSA, HRSA, CMS
• Presidential Election Whole Health
• International IIMHL, Netherlands and European
  Union

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• Taking the future into our own handsquality

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Emerging Market Models
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Creation of the New Roll-up Company

• Previously independent (often non-profit)
  provider organizations
• Business drivers include unit cost/economy of
  scale, access to capital, and human
  finance/capital to succeed in competitive markets
• Clinical influence of corporate office varies
  by organization

• Almost Family
• Ardent Health Services
• Childrens Comprehensive Services
• Cornell Company
• CRC Health Corporation
• Geo Group (GeoCare Atltantic Shores)
• National Mentor
• NHS Human Services
• Providence Service Corporation
• Psychiatric Solutions
• ResCare

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What Happens When Needed Services Are Not
Available/Accessible?

• The Need For Services Does Not Change
• Those In Need Gravitate To Easiest and/or Next
  Most Appropriate Available Service
• Sometimes, This Is No Care
• Sometimes, This Is An Emergency Department
• Sometimes, This Is Criminal Justice
• Sometimes, This Is Homelessness
• Sometimes, This Is A Clinically Inappropriate
  Level Of Care
• This May Cost More Money In Total, But Costs May
  Be In Different Systems and Not Be Readily Visible

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Quality issues

• Staffing crisis - low prestige and pay
• Early mortality
• No uniform standards of care/limited use of
  outcome data to refine treatment
• Continuity - criminal and juvenile justice
  involvement/re-hospitalization
• Low rates of continuity access, retention
  adherence

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Quality

• Healthcare Collaborative
• Access and Retention
• National Benchmarking Project
• Six Sigma Initiative
• Veterans Project
• Psychiatric Leadership Project
• Awards of Excellence
• International Passport program
• Transition Aged Youth Project
• Mental Health First Aid
• National Council conference

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Quality alignment and data driven

• Promoting Wellness - Saving Lives
• Survey on medical services
• Health Wellness Roundtables
• Primary Care and Behavioral Health Learning
  Community - 23 organizations/phase 2 stay tuned
• Collaborative Project 3rd phase/phase 4 stay
  tuned
• Medical/healthcare homes

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Collaborative Care Project
Massachusetts Iowa Montana Washington Florida I
ndiana Illinois Texas South Dakota Colorado
(2) Washington Maryland Indiana Colorado Florida

• Systems improvement activity uses collaborative
  learning model pioneered by IHI and HRSA
• Started with 4 sites (1/07)each site is a
  partnership between a CMHC and CHCexpanded
  additional 8 sites (9/07) and 4 sites (8/08)

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Access and Retention
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Access and Retention- If you dont measure it you
cant improve it! 

• Florida, Oregon, Maine and New Mexico
• Executive Staff Walk through Intake, Assessment
  First Appointment from consumers perspective
  complete all paperwork/ processes identify
  barriers strategies for improvement
• Number of data elements collected in the process
  1,854
• Number of redundant elements 564
• Number required 957
• Staff time required to administer
• original flow process 4 hours 10 minutes
• revised flow process 1 hour 20 minutes

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Mental Health First Aid

• The help provided to a person developing a mental
  health problem or experiencing a crisis until
  professional treatment is received or the crisis
  resolves.

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Vision for MHFA in U.S.

• Mental Health First Aid will be as commonplace in
  10 years as CPR and First-Aid are today
• 100 instructors certified during 2008 pilot

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Mental Health First Aid

• Two components
• Instructor Certification Program
• 12 Hour Community Training
• Builds understanding of mental health
• Introduces risk factors and warning signs
• Overviews top-line evidence-based treatments
• 5-step action plan teaches participants to assess
  a situation, select and implement interventions
  and secure appropriate care for the individual

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Audiences?

• Hospitals and Health Practices
• State/local policymakers
• Employers
• Faith communities
• Schools
• Law Enforcement
• Nursing homes staff
• Families and caring citizens

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Paid Conference Attendance
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• National Council Conference
• The Hyatt RiverWalk
• San Antonio, Texas
• April 5 - 8, 2009

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• These are times in which a genius would wish to
  live. It is not in the still calm of life that
  great characters are formed. The habits of a
  vigorous mind are formed in contending with
  difficulties... when a mind is raised, and
  animated by scenes that engage the heart, then
  those qualities which would otherwise lay
  dormant, wake into life and form the character of
  the hero and the statesman. Abigail Adams to her
  son John Quincy