Measuring Outcomes of a Psychiatric Rehabilitation Intervention for Medicaid Beneficiaries using Propensity Sores

1. Measuring Outcomes of a Psychiatric Rehabilitation Intervention for Medicaid Beneficiaries using Propensity Sores Presented by: Marsha Langer Ellison, Ph.D. Center for Health Policy and Research Univ. of Mass. Medical School Shrewsbury MA. Marsha.Ellison@umassmed.edu and Asya Lyass, Ph.D. (Cand). Center for Psychiatric Rehabilitation Boston University Boston, MA 02215 617-353-3549 Presented at: American Public Health Association Annual Meeting. Boston, MA, November 2006

2. Background • The Intensive Psychiatric Rehabilitation (IPR) initiative evolved as a response to consumers of mental health services who wanted additional psychiatric rehabilitation services that would assist them in overcoming disabilities resulting from SPMI. Other stakeholders that promoted implementation of IPR included rehabilitation providers, the Iowa Department of Human Services, and families. • The occasion of writing a renewed contract for a behavioral health care carve-out allowed DHS to include IPR as a performance indicator. At the same time Iowa mental health services regulatory code was amended to support implementation of the new service. • The IPR initiative was developed and implemented in 1997 by Magellan Behavioral Care of Iowa (MBC of Iowa), a subsidiary of Magellan Behavioral Health. MBC of Iowa is the contracted administrator of state behavioral health services described in the Iowa Plan for Behavioral Health.

3. The Guiding Vision of IPR:Recovery is Possible for Mental Health Consumers Core elements of the IPR initiative: • The belief that people with SPMI can recover. • A mission of enhanced role functioning through personal goal development that aims to improve success and satisfaction in key areas of life. • The empowering value of self-determination. • The availability of readiness, skill, and support development intervention strategies. • IPR is an aid to recovery and is one of the essential components of a comprehensive community system.

4. IPR Service Description and Components

5. IPR Implementation • MBC of Iowa was the first managed behavioral healthcare company to design and implement a formal IPR initiative that incorporates recovery-oriented principles as part of a public sector carve-out. • The IPR initiative has worked directly with more than 30 agencies in Iowa. Over 700 people have been referred to the IPR program from 1998 to 2002. • Demographics of baseline data (738) show a group that is predominantly white, of divided gender, mean age 38, who have either schizophrenia or major affective disorders. Most are not married, live in supervised facilities, have earned a high school diploma, and are either not working or earn very little money.

6. Service Delivery Requirements and Supports • IPR services are provided by bachelors or masters-level clinicians who meet State of Iowa accreditation standards for Psychiatric Rehabilitation Practitioners. • MBC of Iowa/DHS Sponsored Training including an initial 120 hours of rigorous IPR training for practitioners as well as ongoing training focused on the needs of the IPR provider sites. • Joint Site Visits and case consultation to providers by representatives from DHS and MBC of Iowa for technical assistance and specific implementation planning. • Formal Outcomes Evaluation of the IPR Initiative co-sponsored by DHS and MBC of Iowa and conducted by the Boston University Center for Psychiatric Rehabilitation.

7. IPR Outcomes Study – Design • Baseline to end-point comparisons were made for IPR participants and sub-groups, in 3 rehabilitation outcomes (IAPSRS Toolkit, 1995). • Cross group comparisons were made with the drop-out group. The drop-out group did not differ from IPRs for most demographics, except that they were 4 years younger, and had lower monthly earnings than IPRs at baseline. • A quasi-experimental comparison was made of changes in mental health service utilization and related costs for IPR recipients and a control group of matched “treatment as usual” mental health service recipients. Control group members were matched to experimentals on age, gender, diagnosis and number and cost of in-patient mental health services using propensity scoring techniques. • Analysis used Medicaid claims for mental health services made available to BU from MBC of Iowa.

8. Pre and Post Changes in Employment Status Among IPR Participants • Significant increases in average employment status from baseline to endpoint were found for graduates and 18 month completers. There was a significant decrease for drop-outs and no change for the Intent to Treat group.

9. Pre and Post Changes in Earnings Among IPR Participants • Significant increases in gross monthly earnings were found for graduates and 18 month completers. Intent to Treat group had a significant but smaller increase. Drop-outs had a non significant change in earnings. (All tests were adjusted for baseline differences)

10. Pre and Post Changes in Residential Status • Significant increases in average residential status from baseline to endpoint were found for graduates, 18 month completers, the ITT groups and for drop-outs, although the increase is larger for IPRs.

11. Comparison of Change Values Between Participants and Drop-Outs • There are significant differences between change values in employment status and in monthly gross earnings comparing Graduates and 18 Month Completers with Drop-Outs (with adjustments made for significant differences in baseline earnings).

12. Changes in Mental Health Services Units Used & Costs • On the whole IPRs used more services at baseline than controls (despite matching techniques). Mean change values were adjusted for these differences when comparing groups for change. • Combining all mental health services units used (excluding IPR), control group subjects showed significantly larger decreases in mental health service units used & costs compared with IPR participants (Graduates, 18 month completers and ITT).

13. Change in All Mental Health Service Units Used – Baseline to Endpoint (over 2 months)

14. Changes in Units Used & Costs – Selected Mental Health Services • For day treatment this pattern continues when use and costs of selected services are compared between IPR participants and controls. • The decreases found for in-patient use among IPR and control sub-groups are not significantly different. • There are increases in use of out-patient services by IPR participants that are significantly different from the decreases found for controls. • For community services the decreases for controls are not always significantly larger than decreases for experimentals.

15. Changes in Selected MH Services IPR Graduates and Controls * = Statistically significant difference in values

16. Discussion • Data demonstrate appreciable evidence for the success of ICM on improved rehabilitation outcomes especially for employment status and gross monthly earnings. • Given that findings show an improvement in residential status for all groups including drop-outs, this suggests that there may be changes in state housing policy affecting all groups. However, findings for the larger improvement for IPR participants support continuation of the program. • A sizeable number of people were lost to the study for a variety of reasons (e.g., missing data, changing service providers). This indicates some bumps in the road with implementation of IPR as well as difficulties with study data collection. The result is that the outcomes for a large number of people are unknown. • Further, there is a large group of “formal” drop-outs (their drop–out status was communicated to the study). This result (common to many mental health interventions) indicates that further study is needed to learn when, for whom, and under what circumstances IPR works.

17. Discussion (continued) Findings for service utilization pose several questions: • Decreases in mental health service use and cost that are seen for both IPR and controls suggest that an underlying goal of managed care i.e., to reduce unnecessary services or costs, is being realized. • While psychiatric rehabilitation is often assumed or hoped to promote integration and thereby reduce use of acute mental health services, this relationship has received little formal testing. A theory of the impact of improved role functioning on symptoms and service use is still to be developed. • The relative shallower decrease or increase of service use among IPRs suggests that IPR actually improves service access or the acquisition of services needed. Anecdotally providers suggest that IPRs become “service savvy” through the program.

18. Implications for future policy and study • Continued piloting of IPR in other states is warranted in concert with testing using a more rigorous design. • A recovery mission and rehabilitation focus is a successful strategy to promote employment. Services such as these can be integrated into behavioral healthcare contracts. • A full-blown cost–effectiveness study of IPR is still outstanding. • While reduction of acute services use can be interpreted as a good thing for individuals, a mission of improved access or increased penetration to an underserved population appears unsuccessful. • Different strokes for different folks -- findings suggest that a wide array of community-based rehabilitation services with multiple entry points is needed to promote outcomes.

19. Citations Ellison, M.L. Anthony, W.A., Sheets, J.L., Dodds W., Barker, W.J., Massaro, J.M. & Wewiorski, N.J. (2002) The integration of psychiatric rehabilitation services in behavioral health care structures: A state example. Journal of Behavioral Health Services and Research, 29(4), 381-393. Ellison, M.L. Lyass, A., Anthiny, W.A. Massaro, J. (November 2005) Outcomes Study of the Intensive Psychiatric Rehabilitation Program in Iowa: 4th Interim Report. Center for Psychiatric Rehabilitation, Boston University Sheets, J. & Yamin, Z. (1998) Intensive psychiatric rehabilitation services: A best practice design for managed care. In 1999 Medicaid managed behavioral care sourcebook. New York: Faulkner & Gray. International Association of Psychosocial Rehabilitation Services Research Committee (1995). Toolkit for Measuring Psychosocial Outcomes, Columbia, MD: Author.