1. In Crisis: Clinical Solutions for the Revolving Door Mary Ruiz MBA, CEO Melissa Larkin Skinner LMHC, CCO Florida's Premier Behavioral Health Annual Conference August 5 - 7, 2015

2. Door #1: Emergency Rooms 9.3% of all emergency room visits (2013 NC) 31.1% of behavioral health emergency room visits admitted (2013 NC) 70% of emergency room docs report increase in “boarding” mental health patients (2004)

3. Door #2: Jails Florida: Odds of jail vs hospital 4.9 to 1 Broward County FL: $80/day vs $130/day for mentally ill inmates Orange County FL: 26 day vs 51 day stay for mentally ill inmates

4. Door #3: Crisis Units Suncoast : Readmits 29.5 % of all crisis unit admits 12 months (2010) Manatee : Readmits 27.8% of all crisis unit admits 12 months (2010) Canada: 37% 12 mo. hospital readmit rate for BH admits and 27.3% for non BH (2003)

5. How Did We Get Here? 1955 one psych bed per 300 Americans 2005 one psych bed per 3000 Americans Shortened stays Federal Medicaid Institution for Mental Disease Exclusion Return to 1840’s of large number of mentally ill in jails

6. Which Way Out? Are we missing levels of care? Is crisis chronic or undertreated? Is treating behavioral health enough? Can assisted treatment decriminalize mental illness?

7. Circuit 12 Acute Care Study 2011 Identify causative factors for readmissions Study all admissions between July-Dec 2010 Recommend models for improvement

8. Circuit 12 Acute Care Study 2011 Compare consumers with one vs two or more admissions Diagnosis, age, gender, homeless Involuntary, follow up services, length of stay 10+ Days

9. Circuit 12 Acute Care Study 2011 One vs Multiple Admissions No differences in diagnosis, age, gender, homeless Teens and involuntary adults significantly less likely to follow up with outpatient 10+ days stay related to med acceptance in adults and placement for youth

10. Circuit 12 Acute Care Study 2011 Recommendations Increased engagement most promising practice Relapse prevention strongly indicated New service models needed

11. Crisis Behavioral Medical Home Pilot Manatee 2011-14

12. Crisis Medical Home Staff Psych/ARNP.25 RN/LPN 1.0 MA Clinicians 2.0 Case Managers2.0 Project Assistant1.0

13. Crisis Medical Home Budget Serving 80 enrollees at average cost of $7,812.50/year Salaries$305,728 Benefits$ 73,932 Operating$195,349 Client Needs $ 50,000 TOTAL $625,000

14. Crisis Medical Home Features Just in time transition Daily services 24/7 integrated team Holistic care coordination Co-occurring, comorbid, trauma informed Medical, legal and social needs Coaching for recovery/relapse prevention Assisted outpatient and supervised release

15. Crisis Medical Home Enrollees 70% co-occurring substance abuse/use 57% medically complex 50% actively psychotic 50% risk of suicidality 32% teens and twenties

16. Length of Enrollment in Crisis Medical Home (N=214) 20% 0-8 weeks 25% 9-16 weeks 24% 17-24 weeks 31% 25 + weeks

17. Key Clinical Services Integrated care Management Medication delivery and observation 24 hour crisis intervention Individual and family therapy, support, education Wellness and recovery coaching Family education, support and participation Emergency funds for food, shelter, medication Healthcare coordination and linkage

18. Number of Crisis Center Admissions 6 Months After Discharge (N=203) 0 Admissions 75% 1 Admission 14% 2+ Admissions 10%

19. Six Months Before and After Crisis Medical Home (N=203) 73% reduced crisis center admissions (322 to 88) 99% diversion BA-8’s from state hospital (174 of 176) 100% jail diversion with assisted outpatient (15 of 15) 91% reduction homelessness (55 to 5)

20. Discharge Disposition After Crisis Medical Home (N=203) 82.8% traditional outpatient services (meds, case management) 9.3% against medical advice 5.9% assertive community treatment 1% state hospital 1% jail or prison

21. Crisis Medical Home Manatee 12 mo readmits reduced from 27.8% (2010) to 26.1% (2014) of total admits Manatee admits reduced from 5.17/1,000 in 2010 to 4.73/1,000 in 2014 (8.5%) Manatee length of stay increased from 3.87 days in 2010 to 4.34 days in 2014

22. Return on Investment 100% return on investment diverting 4 crisis admissions per year

23. Return on Investment 100% return on investment diverting one state hospital stay for every 8 enrollees

24. Which Way Now? Are we missing levels of care? Inpatient: community BA-8 beds for three week medical stabilization Outpatient: time-limited intensive community services Needed levels of care not supported by insurance models—need state funded models

25. Which Way Now? Is crisis chronic or undertreated? Move from danger to self/others to need for treatment Frequent flyer staff attitudes Flexible payment models Short lengths of stay not a good thing and readmission not a bad thing.

26. Which Way Now? Is treating behavioral health enough? Medical care coordination Medications and housing Wellness coaching Benefits Legal assistance Whatever it takes!

27. Which Way Now? Can assisted treatment decriminalize mental illness? Not often required but essential when needed Assisted treatment/supervised release equally effective Powerful tool for forensic diversion if behavioral health services available

28. One of the nation’s largest behavioral health nonprofits $225 million organization with 160 locations in Florida, Illinois, Indiana and Tennessee Employing more than 3,200 people Serving an estimated 142,000 individuals.