Peer Services: Challenges and Opportunities In Healthcare Reform

1. Peer Services: Challenges and Opportunities In Healthcare Reform MHA America May 8, 2013 Harvey Rosenthal www.nyaprs.org

2. New York Association of Psychiatric Rehabilitation Services (NYAPRS) A peer-led statewide coalition of people who use and/or provide community mental health recovery services and peer supports that is dedicated to improving services, social conditions and policies for people with psychiatric disabilitiesby promoting their recovery, rehabilitation, rights and community integration and inclusion. harveyr@nyaprs.orgwww.nyaprs.org

3. Unprecedented Pace of Change Which Services? From Which Providers? In What Networks? With What Goals and Expectations? For How Long? How Reimbursed? With How Much Information and Choice? With What Level of State Oversight?

4. Backdrop to Healthcare ReformCritical Challenges at Medicaid Systems Level Poor engagement: system not patient failure? Office/program based service delivery Fragmentation and lack of coordination : within medical and BH systems Lack of accountability Reactive vs. preventive Crisis response = ER, Detox and Inpatient

5. Backdrop to Healthcare ReformCritical Challenges at BH Systems Level Low Outcomes/Expectations: Maintenance, Symptom Management…‘it’s the illness’ Chronic Condition = Lifelong Services Relapses and Readmissions Expected Deficit and illness based not skills or recovery based Power not partnership Poverty not economic self sufficiency

6. Barriers to Engagement for People with ‘Serious’ BH Conditions • Shame, Stigma and discrimination • Loss of hope • Dehumanizing care • Loss of rights and choices around where you live, with whom and around major life decisions • Isolation; expectations of single, childless life • Idleness: Lack of social meaningful roles work, school.

7. Barriers to Engagement for People with ‘Serious’ BH Conditions • Poverty (reliance on entitlements) • Loss of personal and family relationships • Loss of sexuality (medication side effects) • Criminalization of emergency care: handcuffs, police, coercion, • Lack of health literacy • Complex eligibility, coverage and admission criteria • Absence of gender or culturally appropriate services

8. New Groups, New Challenges • ‘At risk, high cost, high needs’ unengaged Medicaid beneficiaries • Lack hope, stable housing, accurate addresses, health literacy, transportation, organization • Often have multiple ongoing conditions including psychiatric conditions, addictions, AIDS, hepatitis, diabetes, cardiovascular illnesses • Medicaid expansion • Commercial insurance

9. Backdrop to Healthcare ReformFinancial Impact of Current Systems Lifelong services = unlimited, increasing costs Incentives are for more visits and services not outcomes, especially in a Medicaid Fee for Service environment Mental health funds are ‘trapped’ in costly institutional settings: inpatient, emergency, nursing and adult homes Substance use treatment limited to time-limited, intense, acute symptom-focused services rather than ongoing recovery supports

10. The Cost to People and Taxpayers • People are poor, idle, isolated, segregated and sick…lack health, hope, purpose and community. • People have ‘chronic conditions’, dying 15-25 years earlier due to higher rates of obesity, diabetes, lung and cardiovascular diseases • Federal, state and local governments spend huge amounts of public funds on healthcare, homeless, criminal justice services to people w ‘chronic conditions’ • The total costs of drug abuse and addiction due to use of tobacco, alcohol and illegal drugs are estimated at $559 billion a year. (Surgeon General’s report 2004; ONDCP; 2004; Harwood, 2000)

11. The Need for Healthcare Reform NYS Example • $54 billion Medicaid Program • 20% (1 million beneficiaries) use 80% of these $ • Hospital, emergency room, medications, services • 40% have behavioral health conditions • NY last in nation in avoidable readmissions, costing $800m to $1 billion • 70% have BH diagnoses, 3/5 of these admissions are for medical reasons • Add 85% unemployment, high rates of homelessness and incarceration Lots of $ Spent, Very Poor Outcomes

12. ACA HEALTHCARE REFORMSMajor Federal Drivers Triple Aim: improving outcomes, improving quality, reducing cost Medicaid/managed care expansion, BH parity Focus on better coordinated, accountable and integrated physical and behavioral health care Major emphasis on home and community based services and less reliance on institutional care Promoting wellness, preventing relapses upstream Person centered individualized care

13. The Perfect Storm for Recovery Financial Pressures: federal, state and local governments can’t continue to fund uncoordinated, inefficient, costly services that don’t produce good healthcare outcomes Mental Health Parity and Addiction Equity Act Affordable Care Act: coordinated, active, engaging, accountable, integrated outcome oriented, person centered Managed Care Expansion: brings flexibility and interest in funding peer services and addressing social determinants Olmstead Enforcements: pressures states to serve people with disabilities in most integrated not institutional settings Consumer, Rehab & Recovery Movements: have ready made models to promote choice, rights, wellness, community integration, life beyond services, alternatives

14. Recovery Movement Recovery is not only possible, it is expected Providing tools to promote and protect choice: Wellness Recovery Action Plans, Advance Directives, Recovery Capital Scales and Recovery Management Plans Outreach: going to the person, not expecting the person to come to us Engagement based on hope, empathy and starting where the person is

15. Recovery Movement We are not responsible for the ‘illness’ or trauma but we are responsible for our recovery and our choices We are not our illness or label Recovery = risk and responsibility Can’t be ‘person-centered’ and ‘self directed’ if we don’t explore what we want and make a commitment to try Fully informed choice

16. A Focus On Wellness From Illness to Wellness Self Management: evidence based practices Wellness Recovery Action Plans Whole Health Recovery Management 8 Dimensions of Wellness: Emotional, Environmental , Intellectual , Physical, Sexual, Occupational, Social and Spiritual

17. State Medicaid Redesign Plans Integrating services to work in a more coordinated, collaborative, activist and accountable fashion through federally incentivized health home networks Integrating health, pharmacy, mental health and addiction services under managed care Rewarding outcomes vs paying for visits

18. What are Health Homes? A health home is a ‘hub’ not a house Health homes are multidisciplinary teams comprised of medical, mental health, and addiction treatment providers and social services organizations who work together to improve care and reduce costs for those with more serious ongoing conditions

19. Health Home Network Leader • Health home lead agencies provide: • Dedicated care managers who assure that enrollees receive all needed medical, behavioral, and social services from their assembled networks of treatment, housing and social services • in accordance with a single care management plan • that is shared with all providers via an electronic healthcare record

20. Heath Homes Goal • Health homes are accountable for reducing avoidable health care costs, specifically preventable hospital admissions/readmissions, skilled nursing facility admissions and emergency room visits and meeting quality measures. • Active engagement • 24-7 response • Focus on well coordinated discharge and treatment planning

21. Health Home Funding Health home leaders get a monthly rate for each person served that pays for care management, electronic health care record system and administrative costs. Health home network members continue to bill existing funding streams….until the move to managed care.

22. Hudson River Healthcare Hospitals: Good Samaritan Hospital; Hudson Valley Hospital Center; St. Francis Hospital and Health Centers; St. John's Riverside Hospital; Vassar Brothers Medical Center Health Plans: Hudson Health Plan Medical Providers: Health Quest Medical Practice; Healthcare Opportunities Provided with Excellence (HOPE) Center; Institute for Family Health Misc: Arms Acres; AIDS Related Community Services (ARCS); Hudson River Housing; St. Christopher's Inn; Sullivan County Department of Community Services; Taconic Health Information Network and Community (THINC RHIO); Together Our Unity Can Heal, housing, social , disability services

23. Hudson River Healthcare BH Providers: Dutchess County Department of Mental Hygiene; Hudson Valley Mental Health; Human Development Services of Westchester; Lexington Center for Recovery; Mental Health America of Dutchess County; Mental Health Association of Westchester; Mental Health Association of Rockland; Occupations; Putnam Family and Children's Services; Rehabilitation Support Services; Rockland County Department of Mental Health; The Recovery Center; Gateway Community Industries; Westchester Jewish Community Services (WJCS); Westchester County Department of Community Mental Health;

24. Health Home Advantages for Consumers Integrated Care Help with Navigating the Health Care System Better Access Better Coordination Wellness and Person Centered Focus on Skills to Stay Healthy Availability of Peer Based Recovery Supports

25. Health Home Advantages for Providers • Part of an Integrated Care Team • Access to Referrals • Electronic Data Sharing • Outcome Focused and Accountable • Positioning for Managed Care • Health Homes are organizing networks which will contract with managed care payers

26. Critical Value of BH Services Behavioral health providers bring vital services to networks, e.g., care management, rehabilitation and recovery services, skills in engagement and motivation, housing, employment, peer outreach, engagement, diversion and support services, clinical treatment for ‘co-occurring’ conditions

27. Peer Services in Health Homes • Health homes can re-program care management dollars to buy peer services that can promote: • Outreach and engagement • Recovery coaching and supports before, during and after treatment • Hospital/Prison/Adult Home to community transitional support/bridging • Wellness self management support • Crisis diversion and relapse prevention

28. Peer Services in Health Homes • Sample arrangement…working in subcontract with a health home to be part of a ‘service triangle’: • Care manager • Nurse • Peer wellness coach/navigator: outreach, engagement, service planning, recoverycoaching, diversion, advocacy

29. NYAPRS/OPTUM Wellness coaching: One Person’s Outcomes • Abstinent for 1 year • Relapsed 1 year post rehab-went back to rehab-returned to abstinent lifestyle • 2009-prior to enrollment: 7 detox stays (4 different facilities) $52,282 • 2010-1 detox, 1 rehab (referred by the CIDP team) $20,650. • 2011-1 relapse with detox/rehab no claim yet.

30. From Fee for Service to Managed Care Some states are preparing to ‘carve in’ Medicaid behavioral health services, turning them over to the coordination of managed health insurance plans . Plans will be paid on a ‘capitated’ per person per month basis for outcomes not visits. Plans will authorize payments to contracted providers and networks based on their success in engaging and serving beneficiaries….and reducing avoidable costs.

31. Our Opportunity in Managed Care Managed care companies and BHOs have great flexibility beyond traditional Medicaid rules and more narrow medical necessity restrictions to buy approved non traditional services that are proven to work, if the state’s design expects, rewards and enforces those values.

32. Examples of What MCOs Could Fund/Support • Social determinants of health • Employment supports and benefits advisement • Housing relocation start up costs • Culturally competent outreach and engagement • Peer services • Clubhouse services • Crisis services • Self directed budgets: emergency housing supports, health club memberships, computer/internet, alternatives

33. New Roles, Groups for Peer Services From a rights protection, advocacy and empowerment focus for people within the mental health and substance use treatment system to… Bringing hope, wellness, resilience and rights protections to a broader array of people (pre-SSI and private insurance beneficiaries) as a part of the greater healthcare system

34. Preserving the Integrity of Peer SupportSome Key Principles We try to see the world through the eyes of the people we support, rather than viewing them through an illness, diagnosis and deficit based lens. We learn to ask “what happened’…..not what’s wrong?” We form mutually accountable relationships: both parties are invited to share experience and learn and grow together

35. Preserving the Integrity of Peer SupportSome Key Features We start where people are….and offer encouragement for people to define and move towards the goals and the life they seek We foster hope through example and trust through empathy and mutuality. We look beyond individual responsibility  for change and examine the impact of relationships and communities We support and connect people to multiple pathways to recovery

36. Preserving the Integrity of Peer SupportSome Key Distinctions We are not assistant case managers or transportation aides; nor are we ‘cheap staff who get people to take their medicine’. On the other hand, we can help a person with appointments and medications IF they define those needs as part of their self defined wellness and recovery plan

37. Peer Service Innovations Can Play Crucial Roles in Improving Care, Health, Cost • Helping to address the challenges of: • Effective person-centered outreach and engagement; bringing services to the beneficiary • Successful transitions from hospital and other institutions to the community • Reduced ER visits and readmissions to inpatient and detox

38. Peer Service Innovations Play Crucial Roles in Improving Care, Health, Cost • Effective crisis management and diversion supports and services • Critical health literacy training and coaching that promotes improved self management and improved health outcomes • Advancing active participation in outpatient services

39. Beyond Peer SpecialistsExamples of Peer Run Specialty Services Peer Crisis Diversion: warm lines, respite house Peer Bridging Recovery Coaching Peer Wellness Coaching/Navigator Rights Protection & Advocacy: Ombuds Life Coaching: work, economic self sufficiency Peer Supported Housing Services not Programs

40. DATA IS KEYPeer Service Outcomes • 2010 study: 90% of PEOPLeInc’s Rose House crisis respite guests did not return to hospital in the following two years • NYAPRS Peer Bridger programs helped support a: • 72% drop in NY state psychiatric hospital and a • 50% drop in numbers of people hospitalized in local Medicaid psychiatric inpatient units and total hospital days when admitted • 2010 Optum Health Peer Link reduced hospital days by 71% in Wisconsin, by 41% in Tennessee

41. DATA IS KEYPeer Service Outcomes 2010: Mental Health Peer Connection’s Life Coaches helped 53% of individuals with employment goals to successfully return to work 2011: Housing Options Made Easy helped 70% of residents to successfully stay out of hospital in the following year

42. Our Challenges Differences between government and corporate contracts Fiscal: budget projections must be right, know your costs, risks Legal: understanding and negotiating the contract HR: hiring and supervision to clearer performance standards, having back up plans for turnover Liability: increase our coverage Documentation: more forms and reports Navigating through protocols with hospital and clinics

43. Opening Up New Careers Tremendous opportunities to address underemployment and to open up new career paths that help people turn their experience into service and a job Increased wages and compensation Development of more full time positions

44. Going to the Next Level • Marketing and promotional materials • What service, for whom, with what outcomes • Effective, cost effective: offer evidence • Negotiating terms and reimbursement • Propose..don’t ask. • Hiring, specialized training, supervision

45. Going to the Next Level • Program Accreditation, Peer Credentialing • Cash Flow, Fee for Service vs Grants • Liability, Documentation, Protect Privacy • Maintaining the Integrity of Peer Support

46. State Level Advocacy is Crucial! Services must promote recovery and wellness, health literacy and ‘self management’ Beneficiaries must be guaranteed Informed choice, privacy and other basic rights protections Peer run services should play prominent roles in BHO, health homes and managed care re-designs. There must be significant reinvestment of Medicaid savings into peer services, housing, rehabilitation/ employment services expansion.

47. State Level Advocacy is Crucial! Services must promote recovery and wellness, health literacy and ‘self management’ Beneficiaries must be guaranteed Informed choice, privacy and other basic rights protections, supported by peer advocates and/or enrollment brokers, with consumer access to personal electronic records that prominently features advance directives. There must be significant reinvestment of Medicaid savings into peer services, housing, rehabilitation/ employment services expansion.