ACTION Campaign Webinar Surviving in a Health Reformed World Victor Capoccia, PhD March 17,2011 Creating the Behavioral Health Future: What To Do?

“Get ready for health reform…”

The ‘get ready’ message – Coverage 32 million 18 Million Medicaid Parity – Integration Primary Care and Mental Health – Evidence Comparative effectiveness – Accountability

A Modern Day Story Once upon a recent time…. There were 6 community basedtreatment organizations…. InMassachusetts…. …… That together provided 27+ % of all the treatment in the state….

Massachusetts Context – Chpt 58 Universal coverage, 2006 – Full SUD Medicaid and SSA-BG benefit – 570,000 require tx, 82,000 receive tx 117,000seek tx, leaving 370,000 who qualify but, are notseeking treatment 1 1. Brolin M, Horgan C, Doonan M. Substance Abuse Treatment in the Commonwealth of Massachusetts: Gaps, Consequences and Solutions. Boston (MA): Massachusetts Health Policy Forum; 2006.

What happened? –Shift in revenue source –Flat admissions –Growth via service change –One exception

…And the ‘moral of the story‘ is… "Every system is perfectly designed to get the results it gets.“ Paul Batalden, MD

So what should I do???

Positive Deviance –The PD approach is a strength-based, problem-solving approach that enables the community to discover existing solutions to complex problems. –The PD approach differs from "needs based” approaches in that it does not focus primarily on identification of the external inputs necessary to meet those needs or solve problems. It invites the community to identify and optimize existing, sustainable solutions, which speeds up innovation.

Four D’s of Positive Deviance Approach –Define the Problem –Determine the Presence of PD –Discover the Uncommon Qualities –Design Activities and Systems

Uncommon Qualities: –can schedule and assess all patients that are referred, or that call within ‘opportunity window’ –can offer appropriate level of specialty or medical service and live referral to any patient and family –can bill any insurance… but especially Medicaid –can maintain patient engagement, and follow up patient status over time –can coordinate support or wrap around services with care plan –can report patient outcomes and process measures to patients and payers –can engage in community level health system development and population based health promotion activity

Achieving Uncommon Qualities As Advocate: –Exchange that includes strong SUD and MH benefit –Coordination of benefit between BG and public insurance including exchange –Purchasing standards that use evidence, and promote continuous care –Eligibility process that is simple, timely, presumptive –Resources for infrastructure development, especially IT and workforce –Payments that are fair, and that promote integration and results

Achieving Uncommon Qualities As Manager: –Scheduling and assessments are timely –Connections to MH and PC are seamless, and transparent for patient and family –Care is continuous, and includes active follow up –Care is based on patient needs and best available evidence –Workforce appropriately selected, supervised, supported, provided with tools –Technology engaged, including tele-medicine, PDA, computer assisted engagement

Achieving Uncommon Qualities As leader: –Establish vision for future, that is understood and held by board and staff –Continuous communication with staff, patients, community –Expand service, and location per need and resource –Establish cooperative, explicit connections with MH and PC providers –Actively pursue participation in ‘system of health care’, including Accountable Care Organizations –Determine need for collaborative or aligned ventures with other health providers that include ASO, Medical Home, Affiliation, and ‘M’ word…( merger) –Establish and reinforce presence in community health system

CONDITIONS FOR REFORMWHAT EXISTSWHAT'S NEEDED Patient IdentificationPrimarily through criminal justice referralReferrals from all health care systems & non- traditional health systems & populations centers Accountability for patient care &Specialty care focusIntegrated health services, seamless handoffs outcomes & follow up Treatment practicesMix of personal experience, evidence-National Quality Forum based practices & self helpEvidence Based Practices Data driven treatment planning Patient & Family RoleDependent on clinician for treatment &Goal of self-care that is technology enabled care managementFamily & peer support or knowledge exchange Family has no formal roleFamily supports self-care WorkforceSparse MD, sparse RN; up to 50% licensedMore MDs, more RNs; 70% licensed & trained peers TechnologyLimited to billing systemsNeed for follow up & track across the continuum; EMR, patient self management Infrastructure (Business system)Separate registration, appointment &Integrated patient and business management follow up systemssystems Difficult to accept new payersEasy to accept new payment sources A data repository for evaluation or ongoing assessment of business operations Assessing Your Qualities

The future looks like…..