The DSAMH High-End User Program

1. The DSAMH High-End User Program Steven Dettwyler, Ph.D. Director of Community Mental Health Services Steven.Dettwyler@state.de.us

2. The Genesis of the Project • Cost of in-patient services • Volume of involuntary commitments • Belief that costs were associated with a small percentage of clients hospitalized

3. The Delaware Acute Care System • Emergency Rooms • Current Commitment Law • Limited initial oversight • Conflict over disposition at ER • No voluntary benefit • High involuntary commitment rates

4. Acute Care System cont. • Psychiatric in-patient • Community mental health providers • Community drug and alcohol addiction service providers • Discharge planning, Continuity of Care – the good, the bad, and the ugly

5. The Analysis • Identify the clients: • Using database to identify “excessive” in-patient stays • Assess associated “collateral” costs in both DSAMH and Medicaid claims data • Detoxification services • DOC correctional stays • Cost of community-based outpatient services

6. The Envelope Says…. • 20 individuals (out of ~1500) dominated admissions to all in-patient psychiatric facilities • These individuals are the “High-End Users” • Of these 20 individuals, all had significant associated collateral costs including detox stays, DOC involvement, and community MH services

7. Costs for High-End Users • $880,735 for one year of service for these 20 individuals • Of the $880,735, fully 70% represents in-patient hospital costs

8. High End User (HEU) Program • April 2004 – Roll Out • Initial enrollment of 56 individuals • 20 originally identified HEUs • 36 additional individuals with frequent hospital stays

9. HEU Assumptions • Acute length of stay is generally too short • Discharge planning and coordination is poor • Existing system is neither client- nor recovery-oriented • Mutually exclusive “silo” systems of services undermine comprehensive care (Ex: if MH, then not AOD)

10. High End User Program • Admission and Graduation Criteria • At-Risk Monitoring • Coordination/Continuity of Care • On-going routine communication • Appropriate Community Provider(s) • Rapid follow-up around IP stay • Remove time constraints of IP stay • Concept of “extended acute” IP stays

11. Two and a half years later… • 127 individuals admitted to the program • 59 individuals currently active in the HEU program • 68 individuals have been removed from the program

12. Of these 68 . . . • 28 either moved out of the area (majority), are currently incarcerated, or have died • 40 individuals have graduated from the program, i.e., no in-patient psychiatric admissions for one year

13. Monetary Cost Savings for these 40 . . . • These 40 individuals spent 725 days IP in the year preceding admission to HEU program • At about $700/bed-day, the cost of this care was $507,500 • These 40 individuals spent 454 days IP after admission to the program (until graduation), or $317,000 in bed-day costs

14. Summary • The cost of IP care in the year preceding HEU and while enrolled in HEU: • $825,300 • The cost of IP during the year preceding graduation: • $0

15. Criminal Justice Involvement (DOC) • One year prior to enrollment in HEU: 339 days incarcerated • In the period after HEU enrollment: 101 days of incarceration • Cost difference: $27,120 vs. $8,080 ($80/day)

16. Criminal Justice Involvement • One year prior to enrollment in HEU: total of 13 years 3 months on probation • In the period after HEU enrollment: total of 5 years on probation

17. Data Bases, Monitoring, & Evaluation • Corrections (DELJIS) • MMIS • Paper-DSAMH • Clinical Records • E-DSAMH • Excel/Access - various • Data Warehouse

18. Conclusions • High-End User Program works • It is more effective for the clients • It saves money • It relieves stress on the system

19. Key points: • Identification of participants • “Extended Acute” IP services • Collaboration/coordination between IP and OP service providers Steven.Dettwyler@state.de.us