Divert, At What Cost? Diversion, Team Support and Innovative Payment Strategies

Learning Objectives Identify diversion strategies and maintain the clinical relevance and responsibility of a diversion intervention. Define Social Impact Bonds/Social Stock Exchange and strategies to implement in your community.

Integral Care About Us

Our History 1967: Established as local authority for mental health and intellectual and developmental disabilities in Travis County as designated by state law 1 of 39 Community Mental Health Centers in Texas Authority and Provider Roles Many people aren’t aware of this but Integral Care has been serving our community for over 50 years. Back in 1967, we started with one location on Red River Street with a Quonset hut next door, which housed our methadone clinic. Now, we have over 40 locations across Travis County as well as mobile teams providing care out in the community. We serve our community in both provider and authority roles.

What We Do - Provider Care Coordination 24/7 Crisis Response Integrated Behavioral Health Residential Services Homelessness and Housing Services Jail Diversion Substance Use Treatment Prevention and Wellness We provide a wide range of services, including 24/7 crisis response through our Helpline, mobile teams and urgent care walk-in clinic. We provide integrated behavioral health where individuals can receive both primary and mental health care as well as substance use disorder treatment - all in one location. This is important because people who live with mental illness die 25 years earlier on average. This is not from a mental illness. It’s from an unmanaged chronic diseases like diabetes or heart disease. We provide residential crisis services to prevent inpatient hospitalization and support people coming out of in-patient hospitalization. We have a team of almost 100 staff engaging individuals who are experiencing homelessness in our community. We work to get them on a path to housing. We currently house over 450 people in permanent supportive housing, which includes providing the rehabilitation supports to help them gain stability and get on a path to recovery from homelessness, mental illness and/or substance use disorder. As we know, too many individuals with mental health and substance use issues end up in jail. We have a strong working relationship with law enforcement and the justice system to help divert individuals from jail into treatment rather than incarceration. Our Mobile Crisis Outreach Team can co-respond with law enforcement and divert an individual from arrest. We provide a range of substance use treatment services including outpatient detox and medication assisted treatment. The individuals we serve in this area also have a co-occurring mental illness. Lastly, we know that individuals we serve often lack the resources or knowledge to pursue living a healthier life, which can benefit their mental health. We offer wellness services, such as tobacco cessation programs, nutrition counseling and support, exercise training and support for people who want to learn ways to lead a healthy life.

Programs and services offered Overview Total Number of People Served, By Area 45+ 30+ Locations with direct services and mobile teams Programs and services offered

What is diversion?   We hear the word in our sleep… Divert, divert, divert. But what are we saying? Are we acting like bouncers at a popular nightclub?

What is diversion? Are we getting distracted from the real goal and mission of our work?

Diversion Use of legal leverage with behavioral health services are not wanted. Use of behavioral health services when legal leverage is not needed.

What does diversion look like? Criminal Justice Inpatient Settings Outpatient Settings Diversion Courts Strategic Use of Legal Leverage Community Crisis Plans Collaborative Assessment Transitional Housing/Crisis Respite On call systems

Strengthening Jail Diversion Expanded Mobile Crisis Outreach Team co-responds with Law Enforcement and EMS 3,244 Dispatches by 911 last year Respond to booking to divert post arrest prior to booking Expanded training opportunities Austin Travis County EMS, Travis County Sheriff’s Office (TSCO), Court Staff, Jail Staff, Probation Staff, Inmates, etc. Forensic Assertive Community Treatment (FACT) 90 individuals to be served with housing for 60 Austin State Hospital Redesign Judge Guy Herman Center for Mental Health Crisis Care Receives emergency detentions from TCSO and other law enforcement

Do we really want to divert?

Or do we want to engage?

Tailoring Services What we are really trying to do in our “diversion” work is to be prudent with our resources. Ensure clients are receiving care at the right place, time and in the right amount of care to meet their needs. We want to guide our clients to the least restrictive, most helpful resource or provider to meet their needs, so we can better engage them. Diversion interventions will not be one size fits all. Diversion should still be person centered and voluntary.

Tailoring Services

Social Determinants of Health

Forensic ACT Specialized Mental Health and Case Management Registered Nurse & Nurse Practitioner 24/7/365 On call Transitional and Permanent Supported Housing Integrated Primary Care Peer Support & Substance Use Counseling

Case Example

Tips to Support Staff Build strong partnerships at leadership levels. Additional resources for “non billable services” Advocate for macro level/systemic change. Celebrate the small successes

What do we get for all of that work?

IMPACT DATA

$127,896

Outcomes!!

Outcomes!!

Cost savings to the community for 12 months of service 12 Months Impact Reduction in emergency medical services decreased by 44%, totaling $419,696 Reduction in psychiatric hospitalization resulted in a 71% decrease, totaling $78,785 Cost savings to the community for 12 months of service $598,841

Forensic ACT

FACT Baseline 0-1 year prior to enrollment   0-1 year prior to enrollment 1-2 year prior to enrollment 2-3 year prior to enrollment # of Arrests (N = 48) 4 3 Total # of Days in Jail (N = 48) 153 133 90 Average state hospital days (N = 58) 85 57 32 Average % of year spent in jail 65% 52% 33%

What makes a successful diversion? Cost effective interventions. Positive treatment outcomes. Marked reduction in emergency service utilization Collaboration

I understand diversion I understand the need I understand the positive impacts Now…How to I get paid?!

Types of Payment Models Social Impact Investments Value Based Payments Capitated Payments, Bundled Payments, Case Rates

Social Impact Investments Pay for Success – NEW stakeholders coming to the table to try their luck in the Social Stock Exchange. It is time to prove up our worth and social service providers. She How many of you have had someone gawk over you at a party? “I can’t believe you do that work.” “It takes a special kind of person”. “Our community is so lucky to have you”. Well…times have changed and opportunities have arisen to allow everyone the opportunity to be

Social Impact Investments

Value Based Sustainability January 4, 2018 Martin Cook Director of Reimbursement Management

Value Based Payments Provide services that help a client to their best possible outcome for that individual. Social determinants of health

Value Based Sustainability Model Operational Excellence Patient Value Community Value Community Leadership Funding and Investment

Operational Excellence Patient Value Community Value Community Leadership Community Investment Definition - A philosophy of organizational leadership that stresses continuous improvement, teamwork, and problem solving throughout the organization by focusing on the needs of the customer, empowering employees, and focusing management attention towards sustainable improvement of organizational performance.

Operational Excellence Patient Value Community Value Community Leadership Community Investment Patient value = Patient Outcomes / Cost of Care Focus : Person- Centered Trauma informed Care Evidence based practices Culturally Competent Care Cost Effectiveness

Operational Excellence Patient Value Community Value Community Leadership Community Investment Patient Value x Target Population Access Provider Capacity Service Locations Continuum of services Strong community relationships Payers Partners Stakeholders Health information network Reputation Excellence Innovation

Operational Excellence Patient Value Community Value Community Leadership Community Investment Key member of Health Safety Net Active participation in Local and State health initiatives Effective communication and brand awareness efforts Advocate for target populations Openness to strategic partnerships

Operational Excellence Patient Value Community Value Community Leadership Community Investment Community Leadership leveraged for Competitive Advantage Talent acquisition and retention Expand funding opportunities Contract negotiations based on Value vs Volume New populations

Operational Excellence Patient Value Community Value Community Leadership Community Investment Where do we start?

Where to start? Recommendation: Organize cross functional Task Force with the following objectives: Develop sustainable solutions for targeted improvement opportunities Facilitate the transition and adoption of solutions into ongoing operations Track KPI’s to monitor solution effectiveness Incorporate Task Force learnings into recommendation for enterprise change management strategy focused on achieving operational excellence

Value Based Payment Partnerships Determine Desired Outcomes Know what your payer needs (i.e. reduction in childhood diabetes, reduction in inpatient admissions) Managed Care Companies seeking to adhere to CCBHC measures

Data – importance and challenges Interventions should be data driven Data should capture to goals of the payor Data agreements may need to be developed

Questions? David Weden, Chief Administrative and Financial Officer David.weden@integralcare.org Elizabeth Baker, Practice Manager of ACT Elizabeth.baker@integralcare.org