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

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

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

Behavioral Health Consequences: ACE’s and Suicide Attempts

Childhood MH Issues Also Drive Chronic Adult Illness

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

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

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

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

Prevalence of Conditions Among OMH Clients with Medical Co-morbidity SOURCE: NYS Office of Mental Health Patient Characteristics Survey (PCS) Portal: 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,

Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts Overall RR 4.9RR 2.2RR 1.5RR

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

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

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

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

© 2010 APS Healthcare, Inc. 16 The Need for Care Coordination: Another State Example  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 Avoidable Costs--Most Expensive 5% 69% of ACS Costs Excludes pregnancy/neonates; dually eligible; and LTC populations 93% of Re- admit costs 37% of ER Costs

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

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 Improves Utilization

( NYS Care Coordination Program—Erie, Monroe) 46% decrease in emergency room visits per enrollee* 53% reduction in days spent in a hospital* 78% of enrollees report “dealing more effectively with problems” (2009 Enrollee Survey) Better quality 31% increase in gainful activity* 54% decrease in self harm among enrollees* 53% reduction in harm to others* Better outcomes Lower costs 20 * 2009 Periodic Reporting Form Analysis 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

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

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

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