Behavioral Health in a Reformed Health Care System: Challenges and Solutions

1. Behavioral Health in a Reformed Health Care System: Challenges and Solutions January 2011 Mike Hogan, Ph.D. Commissioner, NYS Office of Mental Health

2. Health and Mental Health Care—New Challenges • Basic physical and mental health care must BOTH be available in virtually all clinical settings: • Many adult health and mental health problems result from untreated child behavioral problems and trauma. Untreated children’s mental health problems cost money and lives • Most people with mental illness are seen in general medical settings not specialty mental health clinics. But mental health problems are usually poorly detected and undertreated • Many people with serious mental illness have co-morbid medical conditions. These are generally undetected and undertreated in mental health settings; Coordination of care via referral is inadequate • Episodic, point of service treatment is ineffective and inefficient for chronic and mental illnesses: • Co-morbidity of mental health problems for people with other medical problems is high. The failure to use specialty care management leads to increased costs and bad outcomes • Specialty care management of behavioral health needs is effective

3. Challenges--1 • Many adult health and mental health problems result from untreated child behavioral problems and trauma • Effective treatments for child behavioral problems are available • The Adverse Childhood Experiences (ACE) Study: • Adverse Childhood Experiences* are common • ACE’s are strong predictors of adult health risks and disease • This combination makes ACE’s “the leading determinant of the health and social well-being of our nation” (Felitti and Anda) * Psychological or physical abuse by parents; Sexual abuse; Household Dysfunction: Substance Abuse, Mental Illness, Mother Treated Violently, Imprisoned Household Member

4. Behavioral Health Consequences: ACE’s and Suicide Attempts 4+ 3 2 1 0

5. Childhood MH Issues Also Drive Chronic Adult Illness

6. Challenges and Opportunities • Many adult health and mental health problems result from untreated child behavioral problems and trauma • Science now supports early intervention for these conditions • Early intervention programs do not focus on mental health • Pediatrics is overwhelmed by child behavioral problems, with little support • Pediatrics (with support) is a logical place to intervene and to stage care • Project TEACH: training, consultation and referral assistance to pediatrics/family practice…is a significant initial step for NYS

7. Project TEACH Four Winds C.A.P.E.S. coverage area CAP PC academic center coverage areas Columbia University coverage area LIJ/Zucker Hillside coverage area SUNY Upstate Medical University University of Rochester University of Buffalo

8. Challenges and Opportunities • Many adult health and mental health problems result from untreated child behavioral problems and trauma • Science now supports early intervention for these conditions • Early intervention programs do not focus on mental health • Pediatrics is overwhelmed by child behavioral problems, with little support • Pediatrics (with support) is a logical place to intervene and to stage care • Project TEACH • Behavioral development/self regulation should be the primary focus of early intervention • Provide evidence based parent training/ support e.g. • Positive Parenting Program • Incredible Years • Parent Corps • Nurse/Family Partnership

9. Challenges--2 • Many people with serious mental illness have co-morbid medical conditions • Managing these via referral works poorly • Basic medical care should be but is usually not provided in specialty MH settings

10. Prevalence of Conditions Among OMH Clients with Medical Co-morbidity SOURCE: NYS Office of Mental Health Patient Characteristics Survey (PCS) Portal: http://bi.omh.state.ny.us/pcs/index NOTES: Percentages sum to more than 100% because a client can have more than one condition. The number of clients with at least one chronic medical condition is 76,963.

11. Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts Overall 1998-2000 2.2RR 1.5RR 4.9RR 3.5 RR

12. Challenges and Opportunities • Many people with serious mental illness have co-morbid medical conditions • Managing these via referral works poorly • Basic medical care should be but is usually not provided in specialty MH settings • Basic primary care must be provided or co-located in high volume behavioral health clinical settings • All adult and child OMH clinics monitoring health indicators quarterly (e.g. BP, BMI and smoking status in adults) • OMH Wellness Self-Management now operating in 12 Art 31’s and starting in OASAS clinics • Develop “mental health health homes” featuring: • Mental health and medical care • Peer wellness coaches

13. Challenges and Opportunities--3 • Most people with mental illness are seen in general medical settings (primary care, general acute care, etc) not specialty mental health clinics • More than 50% of mental health visits occur in general medical settings • Most psychiatric drugs are prescribed by other-than- psychiatrist MD’s • Depression is strongly linked with other chronic illnesses – diabetes, CAD, CA, asthma; Individuals with MDD make 2x PCP visits • Adequate treatment for depression is provided for about 25% of cases • Provide basic mental health care in all ambulatory health settings. • Make collaborative care standard: • MH professional available on the floor • Screening, treatment protocols • Model well known but insufficiently used The de facto policy: Don’t ask, don’t tell

14. Challenges--4: Care Coordination • Co-morbidity of mental health and substance use and other medical problems is high… especially among people with chronic medical illness • Co-morbid mental health problems lead to poor health outcomes: • Depression (especially) strongly linked with other chronic illnesses – diabetes, CAD, CA, asthma • Individuals with major depression make 2x as many visits to PCP’s • Depressed patients: • 2x risk of developing CAD & stroke • 4x more likely to die within 6 months of MI • 3x more likely to be non-compliant with treatment • Who have diabetes have 4x health expenditures • Specialty Care Management improves care and reduces costs

15. The Need for Care Coordination: Potentially Preventable Readmissions (PPR’s) Patients without MH/SA diagnosis, medical readmission $149M Patients with MH/SA diagnosis, medical readmission $395M Patients with MH/SA diagnosis, MH/SA readmission $270M NYS Medicaid 2007

16. The Need for Care Coordination: Another State Example Avoidable Costs--Most Expensive 5% • High Cost High Risk (HCHR) members account for: • 37% of all avoidable ER visits • HCHR rate/1000 – 3 times higher than others • 69% of all costs for Admissions for Ambulatory Sensitive Conditions (ACS) • HCHR rate/1000 – 6 times higher than others • 93% of all Readmission costs • HCHR rate/1000 – 36 times higher than others 93% of Re-admit costs 69% of ACS Costs 37% of ER Costs Excludes pregnancy/neonates; dually eligible; and LTC populations

17. The Need for Care Coordination:Data From NYC Care Monitoring Initiative-- High Need Individuals With Gaps in Care

18. The Need for Specialty Care Coordination:NYC Care Monitoring Initiative--Impact of Health Plan Membership • 40% of CMI high-need individuals with an alert were enrolled in Medicaid managed care organizations (MCO) (over a dozen plans operated by 10 MCO’s). • Nearly 50% of these enrolled individuals (20% of all individuals triggering an alert) were in “full-benefit” plans. • Individuals with full-benefit managed care are at least as likely to trigger alerts as other cohort members. • “The CMI has found no case in which a MCO care manager was aware of or attempting to coordinate mental health services for a disengaged individual.” (CMI Report, Sederer and Smith, 2011)

19. Average number of visits/year for service users shows significant decline between pre- and post-enrollment into specialty care mgt. Example: Specialty Care Management ImprovesUtilization

20. Example: Specialty Care Management ImprovesUtilization (NYS Care Coordination Program—Erie, Monroe) • 2008 Medicaid mental health costs for Care Coordination populations in NYCCP vs. comparison counties: • 92% lower for inpatient services • 42% lower for outpatient services • 13% lower for community support * 2009 Periodic Reporting Form Analysis

21. Specialty Care Management Yields Improved Outcomes (Youth Example: Erie County System of Care)

22. Erie County Youth Example: Coordinated Community Care With Quality Improvement Impact on High Cost Services Use

23. Summary: State of the Art in Behavioral Health Care Coordination • Specialty management dominant in large employer, state employee plans (e.g. NYS) • Few (no?) examples of successful management of deep MH benefits in integrated plans • MBHO successes in Medicaid: (PA, MI, MA, AZ). • Critical success factors: • Successful approaches are tailored to state/regional variance • One specialty plan per region for successful coordination • With Health Plans • With County/local systems • Typical performance metrics: • Increase access to short term psychotherapy • Manage but maintain access to inpatient, expand alternatives: ACT, IOP, Partial Hospitalization • Data informed team/nurse care management of high cost/risk care in partnership with peer outreach/peer wellness coaches (High Tech and High Touch) • Focus on integration via joint programs, training, cross-privileging

24. Health and Mental Health Care—Solutions • Basic physical and mental health care must BOTH be available in all clinical settings: • Episodic, point of service treatment is ineffective for chronic and mental illnesses • Specialty care management of behavioral health benefit Thank you