Meeting the Challenges of the Changing HealthCare Environment: Transformation of the Mental Health System in New York State ANN MARIE SULLIVAN, M.D. COMMISSIONER, NEW YORK STATE OFFICE OF MENTAL HEALTH

Strategy: The Triple Aim  BETTER HEATLH OF THE POPULATION : Prevention and Maximizing Wellness  BETTER CARE FOR EACH PATIENT : Quality Care focused on patient choice, engagement, and satisfaction; clinical best practices; integrated care between medical and psychiatric services; coordinated care with Primary care Medical Home; Increase in insured patients requires increased access to care  LOWER COST : Performance based payment; More efficient and effective care focused on less admissions and readmissions and more comprehensive ambulatory care (PCMH) and Behavioral Care; risk based models such as the Accountable Care Organization (ACO) 2

Triple Aim: Population Health  Collaborative Care Collaborative/Integrated Care with Adult Primary Care Providers that screen for Depression and Substance Use and provide rapid access to treatment; School Based and Pediatrics collaborative care for children and adolescents Collaborative/ Integrated care in Behavioral Health with management and monitoring of chronic disease Integration Substance Use and Mental Health treatment in Behavioral Health settings  Wellness Care for Individuals with Serious Mental Illness: Health and Recovery Plan (HARPs) Crisis respite services; employment and education supports; family supports; peer supports; physical health wellness; rehab; self directed care; skills training; financial management. 3

Triple Aim: Better Care for Each Patient 1-Patient Centered Care focused on patient choice, self directed care; engagement, and satisfaction; 2-Clinical best practices; integrated care between medical and psychiatric services; coordinated care that focuses on community based treatment; decreased inpatient use and decreased inpatient readmissions; 3-Easy access to services when and where they are needed in the community 4

Triple Aim: Lower Cost  Performance based payment based on measured outcomes; More efficient and effective care focused on less admissions and readmissions and more comprehensive ambulatory care (PCMH; Behavioral Health Homes); risk based models such as the Accountable Care Organization (ACO)  Managed Medicaid focused on reduction of unnecessary inpatient use and reinvestment of dollars in community based care; Integrated physical and behavioral health care. 5

PATIENT CENTERED CARE INTEGRATED CARE MIND AND BODY PATIENT CENTERED SYSTEMS OF CARE 6

TRANSFORMATION: INTEGEGRATED PATIENT CENTERED CARE 7

Disproportionate burden of health conditions and risks among those with poor mental health Source: NYC DOHMH Community Health Survey, 2009, 8

Co-occurring disorders among Medicaid beneficiaries with mental illnesses Source: United Hospital Fund, New York Beneficiaries with Mental Health and Substance Use Conditions,

Co-occurring disorders among Medicaid beneficiaries with substance use disorders Source: United Hospital Fund, New York Beneficiaries with Mental Health and Substance Use Conditions,

The Need for Integrated Care: Potentially Preventable Readmissions (PPR’s) NYS Costs $814M (2007) 11 Patients without MH/SA diagnosis, medical readmission $149M Patients with MH/SA diagnosis, MH/SA readmission $270M

Collaborative Care: Population Health and Wellness  Collaborative/Integrated Care with Adult Primary Care Providers that screen for Depression and Substance Use and provide rapid access to treatment; School Based and Pediatrics collaborative care for children and adolescents  Collaborative/ Integrated care in Behavioral Health with management and monitoring of chronic disease  Integration Substance Use and Mental Health in Behavioral Health settings 12

Population Health: Unipolar Depression  Lifetime prevalence of significant depression in NCS (2001-2) 16%; 12 month prevalence 6.6%  42% of significant depression in US is still untreated  Still only 22% of patients treated receive evidence based care  Lack of treatment increases inpatient days; results in poor compliance for chronic illnesses and poor outcomes 13

PopulationHealth: Neuropsychiatric diseases are among the top 10 causes of disability worldwide (ages 15-44)

Need for Better Care in Primary Care  Under recognized and undertreated patients with depression, anxiety and substance in primary care  6 to 9 % of primary care patients have a significant treatable depression  Co-morbid depression increases morbidity and mortality in heart disease, diabetes, stroke  High cost of depression functional disability in all societies 15

IMPACT PROGRAM  Collaborative Care for late life depression  Primary Care patients 60 and older with major depression or dysthymia  Randomized trial 8 health centers and 18 clinics  Treatment: Pharmacologic and Care Management  Outcomes:  >50% drop in SCL-20 depression scores at 6months and 12 months 16

The Need for Integrating Primary Care in SMI Treatment HTNDM Smoking BMI >27 TC >220 Single Risk Factors Multiple Risk Factors Odds ratios Smoking + BMI 2 + TC >220 3 Smoking + BMI + TC >220 + DM 4 Smoking + BMI + TC >220 + DM + HTN 5 Coronary Disease Risk Factors-Framingham Study These Risks Are Typical for people with SMI

 VA Co-located primary care in VA behavioral health services with significant improvement in physical health indicators: screening and preventive services ( mammograms, colonoscopies) and in treatment adherence for diabetes, hypertension, heart disease  CIDP Project in NY, provided care coordination for mental health and physical health, significant improvement in treatment engagement and decrease in hospitalizations both medical and psychiatric  Health Homes Care Coordination in NY State a work in progress: care coordination physical and mental health and shared care planning Need for Better Care in Behavioral Health: Models of Care

Delivery System Redesign Implementation Plan : DSRIP  MRT WAIVER AMENDMENT: $8.0 BILLION ALLOCATION  o $500 Million for the Interim Access Assurance Fund (IAAF) – Time limited funding to ensure current trusted and viable Medicaid safety net providers can fully participate in the DSRIP transformation without unproductive disruption.  o $6.42 Billion for Delivery System Reform Incentive Payments (DSRIP) – Including DSRIP Planning Grants, DSRIP Provider Incentive Payments, and DSRIP Administrative costs and DSRIP related Workforce Transformation.  o $1.08 Billion for other Medicaid Redesign purposes – This funding will support Health Home development, and investments in long term care workforce and enhanced behavioral health services, (1915i services). Per MRT WEBSITE DOH 19

DSRIP and Behavioral Health  PPSs( Performing Provider Systems) must have appropriate linkages to community and hospital based behavioral health services in their networks  All applicants had to include one behavioral health project and 30 of the 36 applications included Collaborative Care in Primary Care as one of their projects; or primary care in behavioral health  Major request for regulatory relief was in collaborative care projects for Primary and Behavioral Health: relief of space requirements; dual licensure; visit thresholds; and billing restrictions.  Systems will need to improve rates of readmission and decrease avoidable admissions for psychiatric patients with medical problems 20

Collaborative Care in NY State  FQHC’s: 25 across the state have implemented collaborative care for depression in primary care; supported by grants CHCANYC and MHANYC  NY State OMH/DOH 2 year funding to establish collaborative care in 20 Academic Medical Centers and 31 primary care clinics  Geriatric demonstration Project: over 20 sites collaborative care in primary care and behavioral health  Challenges: OMH/DOH working on a rate/payment/ structure to sustain these and other programs eg. rate increase for implementing collaborative care for depression; regulatory relief 21

INTEGRATED CARE: What does it mean to be Patient Centered The Person to Person interaction  Engagement: What does the individual see as his or her problem, simply ask?  Meet the patient where he or she is: motivational interviewing  Partnership with patients: sharing goals and choices  Asking what the patient wants? What does the patient expect?  If the patient “non- compliant” seek to understand why? What are the obstacles the patient faces? What are the patients choices?? 22

TRANSFORMATION: PATIENT CENTERED SYSTEMS OF CARE 23

What does it mean to be a Patient Centered System of Care :  Easy access to care when and where needed  The right level of care  Care coordination among multiple providers  The basic needs: housing, good food, people supports  Knowledge about illness and wellness, patient partnership, patient choice  Access to wellness activities 24

An opportunity to transform mental health services RE-INVESTMENT IN Community Services Re-investment funding and the state hospital system Housing Adult Home, re-investment, MRT and other housing funds Medicaid Managed Care Integrated Managed Care Health and Recovery Plans (HARPs) DSRIP 25

A Few Numbers…. Community Services $25 Million pre investment to expand State and voluntary operated community services focused on reducing admissions and readmissions including crisis beds, respite, Home and community waiver slots, first episode psychosis teams, peer operated services. If successful at reducing 400 beds at a reinvestment of 110,000 per bed then annual reinvestment will be 44 million Planning for services with the Local Mental Hygiene Directors, OMH Regional Office and local stakeholders. Housing Currently 35,000 housing units in NY State $30 million to support residential units for individuals transitioning out of adult homes 625 New housing units from state reinvestment Downstate supported housing stipend increase of $550 annually to cover higher cost rents.( 6.5 million) Additional Housing from MRT Initiative and NY/NY III Housing Medicaid Managed Care Include all individuals with serious mental illness in managed care January $20 Million for system readiness to develop infrastructure for managed care/ HARPs $15 Million to enhance clinic reimbursement for integrated behavioral and health care and implementation of the collaborative care model 30 million to establish 1915i services for HARPs: peer supports; educational and employment supports; crisis respite; family supports and self directed care. $30 Million in Vital Access Provider (VAP to preserve critical access to behavioral health inpatient services in some areas. Medicaid reinvestment for inpatient closures 26

State Hospital Transformation  Increased community based services and decrease of unnecessary inpatient admissions and readmissions  Safe and appropriate housing in least restrictive setting  Recovery and personal choice focused  Integrated medical and psychiatric care 27

MEDICAID MANAGED CARE: Patient Centered Health and Recovery Plans: HARPS  Ensuring true integration of physical and behavioral health  Integration of Health Homes: care coordination  Waiver Services/ Wellness services: employment support, peer services, skills training, respite and crisis services; family support services  Self Directed care/ Patient directed care plans 28

DSRIP  PPS: Provider systems focused on a network comprehensive coordinated care  Provider systems ensure access to behavioral health services  Coordination is seamless to the patient  Providers work together to ensure appropriate care for patients  Care is increasingly wellness, prevention and community focused with decreased unnecessary inpatient admissions and readmissions 29

Summary A Major Opportunity to Transform the System Major investment over the next 3-5 years in system redesign that will transform how we provide care There must be coordination in planning and implementation of all the moving parts:  Integration of Medical and Behavioral Health: Integrated Care  Patient Centered Care at the individual and system level  State Hospital redesign, DSRIP redesign and Medicaid managed care that supports these goals 30