Fall 2018 NAMD Conference The Future of behavioral health integration in Medicaid November 14, 2018 Washington Hilton, Washington, D.C. Brian M. Hepburn, M.D. Executive Director National Association of State Mental Health Program Directors (NASMHPD)

Trends in Behavioral Health SAMHSA and ISMICC report Beyond Beds Will Discuss NASMHPD Trends in Behavioral Health SAMHSA and ISMICC report Beyond Beds Goals for Future Behavioral Health System

Represents the $41 Billion Public Mental Health System serving 7 Represents the $41 Billion Public Mental Health System serving 7.5 million people annually in all 50 states, 4 territories, and the District of Columbia. Affiliated with the approximately 195 State Psychiatric Hospitals: Serving 147,000 people per year and 41,800 people at any one point in time.

MISSION NASMHPD will work with states, federal partners, and stakeholders to promote wellness, recovery, and resiliency for individuals with mental health conditions or co-occurring mental health and substance related disorders across all ages and cultural groups, including: youth, older persons, veterans and their families, and people under the jurisdiction of the court across the full continuum of services including inpatient.

Trends in behavioral health

State Mental Health Agency Controlled Expenditures for State Psychiatric Hospital Inpatient and Community-Based Services as a Percent of Total Expenditures: FY'81 to FY'15 © 2017 National Association of State Mental Health Program Directors Research Institute www.nri-inc.org

Individuals Served by State Mental Health Authority SMHAs provided mental health services to over 7.5 million individuals during FY 2015 2.3% of the US Population 68% of Adults served had a Serious Mental Illness (SMI) 70% of Children served had a Serious Emotional Disturbance © 2017 National Association of State Mental Health Program Directors Research Institute www.nri-inc.org

98% of clients received community-based mental health services Percent of Clients Served, by Service Setting: 2014 Uniform Reporting System 98% of clients received community-based mental health services 22.3 per 1,000 population (range from 0.8 to 51.2 per 1,000) 2% of clients received services in state psychiatric hospitals Range from less than 1% of clients (in 11 states) to 12% in (2 states) of total clients served 4.6% of clients received services in other psychiatric inpatient settings (37 states reporting on OPI) In looking at where consumers received their Mental Health services, we find that almost all consumers (98%) were served in Community Mental Health Systems. Only 2% of clients were served in State hospitals, and over twice that many (4.6%) of clients received services in Other Psychiatric Inpatient Settings (probably mostly in General Hospital psychiatric units that are not IMDs and thus can bill Medicaid. Note, consumers can receive services in more than one setting during the year, and thus percentages total to more than 100%. That is by design, as hopefully with good continuity of care, individuals who are released from inpatient care in either state psychiatric hospitals or Other Psychiatric Inpatient settings will receive follow-up care in the community. Range is from 0.8 per 1,000 in the Marshall Islands to 51.2 per 1,000 in Maine. The lowest figure for a state is 4.7 per 1,000 in Massachusetts. © 2017 National Association of State Mental Health Program Directors Research Institute www.nri-inc.org

SMHA-Controlled Revenues for Mental Health Services: FY 1981 to FY 2014

Medicaid Status of State Mental Health Agency System Clients: 2017 In 2017, states provided mental health services to 7,524,119 clients Medicaid status was not reported for 432,985 or 5.8% of clients 5.1 million clients had Medicaid pay for some or all of their MH services 2.1 million clients had no Medicaid payments for MH services (state, local, and other federal funds paid for their care) Source: SAMHSA 2017 Uniform Reporting System

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA)

SAMHSA Elinore McCance-Katz New national and regional TA/T programs for opioids, mental illness, and substance abuse prevention Provide resources to individuals and organizations serving those with mental and substance use issues as well as those who are working on prevention activities.

Interdepartmental serious mental illness coordinating committee (ISMICC)

ISMICC Report The Way Forward: Federal Action for a System That Works for All People Living With SMI and SED and Their Families and Caregivers The ISMICC is chaired by Dr. Elinore F. McCance-Katz, Assistant Secretary for Mental Health and Substance Abuse. The committee includes federal and non-federal members. The non-federal members submitted a report with recommendations

Focus 1: Strengthen Federal Coordination to Improve Care for persons with SMI/SED

Focus 2: Access and Engagement 2.2. Develop a continuum of care that includes adequate psychiatric bed capacity and community-based alternatives to hospitalization. 2.6. Prioritize early identification and intervention for children, youth, and young adults. 2.7. Use telehealth and other technologies to increase access to care. 2.8. Maximize the capacity of the behavioral health workforce. 2.10. SMI and SED screening to occur in primary care settings.

Focus 3: Treatment and Recovery 3.1. Provide a comprehensive continuum of care. 3.2. Make screening and early intervention a national expectation. 3.3. Make coordinated specialty care for first-episode psychosis available nationwide. 3.4. Make trauma-informed, whole-person health care the expectation in all our systems of care. 3.5. Implement an effective systems of care for children, youth, and transition-age youth throughout the nation.

Focus 3: Treatment and Recovery 3.6. Make housing more readily available 3.7. National adoption of effective suicide prevention strategies. 3.9. Make integrated services readily available to people with co-occurring mental illnesses and substance use disorders, including medication-assisted treatment (MAT) for opioid use disorders. 3.10. Develop national and state capacity to disseminate and support implementation of the national standards for a comprehensive continuum of effective care for people with SMI and SED.

Focus 4: Increase Opportunities for Diversion and Improve Care for People Involved in the Criminal and Juvenile Justice Systems 4.1 Consider diversion at all points in the sequential intercept model. 4.2. Develop an integrated crisis response system to divert from the justice system. 4.3. Prepare and train first responders on how to work with people with SMI and SED.

5.2. fund the services needed. Focus 5: Develop Finance Strategies to Increase Availability and Affordability of Care 5.2. fund the services needed. 5.4. Eliminate practices and policies that discriminate against behavioral health care. 5.5. Pay behavioral health services at rates equivalent to other healthcare services. 5.6. Provide reimbursement for outreach and engagement services.

Goals for future behavioral health system

Goals for future Behavioral Health System Access to quality services at each point in the continuum including “beds” (with emphasis on crisis services). Health, wellness, and resiliency Integrated care, parity, IMD exclusion, EMTALA Prevention, Early Intervention but focus on persons with SMI Suicide Prevention and Crisis Services Trauma-informed approaches Interventions that minimize individuals’ contact with police, jails, prisons, juvenile correctional facilities, and courts. Sequential intercept. Workforce Development and expansion of peer services Employment, housing and reducing homelessness (Needed for Recovery) Technology , Technology, Technology

Brian Hepburn Brian.Hepburn@nasmhpd.org Thank you!