NYAPRS North Country Regional Meeting May 16, 2013 Harvey Rosenthal 1

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 disabilities by promoting their recovery, rehabilitation, rights and community integration and inclusion. 2

 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? 3

 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 4

 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 5

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. 6

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 7

 ‘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 8

 People are poor, idle, isolated, segregated and sick…lack health, hope, purpose and community.  People have ‘chronic conditions’, dying 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) 9

 $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 10

 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 11

 Financial Pressures: federal, state and local governments can’t continue to fund uncoordinated, inefficient, costly services that don’t produce good healthcare outcomes  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  Mental Health Parity and Addiction Equity Act  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 12

 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 13

 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 14

 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 15

 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. 16

 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. 17

 By October 2014, currently ‘carved out’ Fee for Service OMH and OASAS services will be integrated into upstate managed care plans, either on their own or in partnership with a “qualified” Behavioral Health Organization. 18

 Those services include OMH/OASAS mental health and substance abuse inpatient and clinic services OMH Medicaid services like PROS, ACT, IPRT, ACT, CDT, Partial Hospital, CPEP, Targeted Case Management and rehab supports within community residences and OASAS Medicaid services like Opioid treatment and outpatient chemical dependence rehabilitation. 19

 Will provide a range of more intensive services for individuals with ‘significant behavioral health needs’. 20

 Services in Support of Participant Direction: Information and Assistance in Support of Participant Direction and Financial Management Services  Crisis: Crisis Respite  Support Services: Community Transition, Family Support, Advocacy/ Support and Training and Counseling for Unpaid Caregivers 21

 Empowerment Services: PEER SUPPORTS  Service Coordination  Rehabilitation: Pre-vocational, Transitional Employment, Assisted Competitive, Employment, Supported Employment, Supported Education, Onsite Rehabilitation, Respite and Habilitation 22

 Increased access  Service engagement  Physical health improvements  Participation in employment;  Enrollment in vocational rehab services and education/training;  Housing status;  Community tenure;  Criminal justice involvement;  Peer service use and  Improving functional status 23

 Mainstream plans can be approved to operate HARPs by themselves if they meet ‘rigorous’ state standards.  Such plans may also choose to partner with a BHO to meet those standards. 24

 Magellan: self directed care program in Pennsylvania; crisis alternatives in Arizona; psychiatric rehabilitation in Iowa  Optum: peer bridgers in Wisconsin, Tennessee, New York, New Mexico; peer warm line, crisis respite and bridgers in Washington  Community Care: recovery institute, learning collaborative, supported housing reinvestment; consumer/family satisfaction teams  ValueOptions: self directed care program in Texas, peer services and consumer research and evaluation in Massachusetts

 Spring 2013: Program design finalized  Winter 2013: Contract Requirements for MCOs, HARPs finalized: RFQ posted on website for upstate groups  Summer 2014: Qualified MCOs and HARPs are selected for upstate  Fall 2014: HARPS, MCOs are operational upstate 27

= Physical and/or behavioral health care provider MCO/BHO (A) MCO/BHO (B)HARP HH Team DOH/OMH/OASAS HH Team 28

 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 29

 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 30

 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 31

 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. 32

 Current plans are to ‘lock in’ and track all carved in behavioral health dollars to guard against migration of funds and to reinvest all savings into enhancing needed services  At the outset, the average per person per year cost for HAPR services is $30,000.  The recently enhanced monthly rate for ‘high touch’ health home enrollees with behavioral health needs is about $

 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 34

 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; 35

 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 36

 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 37

 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 38

 2000 “Pathways to Housing: Supported Housing for Street-Dwelling Homeless Individuals With Psychiatric Disabilities” Psychiatric Services Tsemberis and Eisenberg An innovative ‘harm reduction’ housing and support program model was able to achieve an 88% service retention rate and general stability among a group of primarily young men of color with psychotic disorders and previous histories of homelessness and non- participation with services /487 /487 39

 A 2002 University of Pennsylvania study found supported housing produced an average of $16,282 in savings from reduced use of hospitals, ERs, shelters et al.  A May 2006 Mathematica study found that “on average, Buy-In participants cost Medicaid $984 per-member per-month (PMPM) in 2000, almost 40 percent lower than the cost of other Medicaid enrollees with disabilities.”  Criminal Justice Diversion, Re-Entry services too 40

 Intensive program consisting of care manager, peer mentor and self directed budget  Total local funds: $176,000 for 48 people  Reductions Medicaid services: 35% Incarceration: 53% State hospital: 78% Total: 53% $2.3 million down to $1.2 million 41

 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 42

 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, recovery coaching, diversion, advocacy 43

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, detox, 1 rehab (referred by the CIDP team) $20, relapse with detox/rehab no claim yet. 44

 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 45

 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 46

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 47

 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 48

 2010 study: 90% of PEOPLe Inc’s Rose House crisis respite guests did not return to hospital in the following two years  NYAPRS Peer Bridger programs helped support a: 71% drop in NY state psychiatric center readmissions 50% drop in numbers of people hospitalized in local Medicaid psychiatric inpatient units and in total hospital days when admitted  2010 Optum Health Peer Link reduced hospital days by 90% in Wisconsin, by 72% in Tennessee 49

 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 50

 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  51

 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 52

 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 53

54  History of Peer Support  Intentional Peer Support  Avoiding Co-optation  Peer Support Practices  Peer Service Models  Peer Crisis Services  Peer Bridging  Peer Wellness Coaching  Peer Health Navigators  Peer Housing  Peers in Clinic Settings  Peer Recovery Centers

55  Outreach & Engagement  First Contact  Motivational Interviewing  Self Assessment  Navigating Choice  Cultural Sensitivity  Mutuality/Reciprocation  Power Dynamics  Ethics & Boundaries  Active Listening  Communication Skills  Appreciative Inquiry

 Crisis De-escalation  Harm Reduction  Conflict Resolution  Relapse Prevention/Crisis Planning  Self-Injury  Advocacy for Others  Mental Health Rights  Mental Health Laws  Informed Choice 56

 Self-Disclosure  Documentation & Reporting  Work Ethic  Navigating Systems  Workspace Organization  Negotiation Skills  Community Assets 57

 8 Dimensions of Wellness  Suicide Prevention  Psychiatric Rehabilitation  Employment Services  Benefits and Entitlements  Supported Education  Person-Centered/Recovery Principles  Trauma-informed Care  Health and Alternative Healing 58