Integrating Services for Recovery: Lessons from the American Experience

1. Integrating Services for Recovery: Lessons from the American Experience Michael F. Hogan, Ph.D. Commissioner, NYS Office of Mental Health

2. 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?

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

4. Coordination In Hospital and Community Care Coordinating care in the hospital: --Health care --Psychiatric treatment --Housing --Rehabilitation All under one roof… Stress Management Counseling Services Psychiatric Services Transportation Health Care Employment & Job Readiness Services Mental Health Services Family Preservation/Reunification Coordinating care in communities presents daunting challenges Recreation Child Care & Children’s Services Money Management Community Service Opportunities Crisis Intervention Parole/ Probation Substance Abuse Services Grocery, landromat, bank, etc. Home-Based Services

5. U.S.--Coordinated Mental Health Services in Theory SAMHSA Federal level DMH State level Local level CMHC Case Mgt. M.H. Care Housing Coordinated Care Job Support Consumer M.D. Meds Income Support

6. Fragmentation of Mental Health Services, in Reality HRSA Medicare Medicaid CMHS HUD Education SSA DMH State Medicaid Agency V.R. CMHC PHA Case Mgt. M.H. Care Housing Job Support Consumer M.D. Meds ? Income Support Clinic

7. 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 persons The 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.

8. 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?

9. Health Insurance Financing for MH Care Increased: In the Mainstream Frank and Glied, 2006

10. With Reduced Financial Burden for Those Getting Care(Out-of-Pocket Share of Expenses) Frank and Glied, 2006

11. Today, More People Report MH Treatment(Even If It’s Often Not Enough and Not Good Enough) Source: NCS and NCS-R

12. While Improvements are not due to Increased Medical Sector MH Spending Mental Health Spending -- Real per Capita and as a Share of GDP Frank and Glied, 2006

13. More People with SMI are living Independently or with Family Though Many Are Also Homeless or Incarcerated Frank and Glied, 2006

14. 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?

15. Improvements and Opportunities • A recovery model changes and improves possibilities: • Earlier, Better treatment with a real-world orientation can change people’s lives • Person-centered care coordination and better use of technology can fill the biggest cracks… especially for those most in need

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

17. 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

18. 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

19. 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

20. Recovery • After • 1nitial • Schizophrenia • Episode 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

21. Early Intervention With a Real World, Developmental View

22. The RAISE Intervention(Columbia/Univ. Md. Approach) Peer Support Outreach/Engagement Shared Decision Making Evidence-based Sequential Pharmacological Treatment Supported Employment/ Education Recovery Specialist Recovery Behavioral Skills Training (SUD, Social Skills, FPE) Family Support/ Education Suicide Prevention Care Coordination is Person Centered, Reality Focused, and “Embedded”

23. 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

24. The Need for Care Coordination:Potentially Preventable Readmissions (PPRs) NYS Medicaid Data • A potentially preventable readmission (PPR) is involves poor care related to the initial hospital admission…. Examples: • Discharged too quick / too sick • Lack of follow-up appointment • Not all hospital readmissions are preventable • Total cost of PPRs $813M for 70,294 readmissions

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

26. 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. New York Care Coordination Program • 4 urban and 3 rural counties, 3.3 million people

28. ACT • ICM • SCM Focus Care Coordination on People Who Need It 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 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. 28

29. Practice of Care CoordinationNYCCP Initiatives

30. Outcomes for NYCCP Full report available at www.carecoordination.org * 2009 Periodic Reporting Form Analysis

31. 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

32. Thank You