1. The DSAMH High-End User Program Steven Dettwyler, Ph.D. Director of Community Mental Health Services Steven.Dettwyler@state.de.us

2. The Genesis of the Project Cost of in-patient services Cost of in-patient services Volume of involuntary commitments Volume of involuntary commitments Belief that costs were associated with a small percentage of clients hospitalized Belief that costs were associated with a small percentage of clients hospitalized

3. The Delaware Acute Care System Emergency Rooms Emergency Rooms Current Commitment Law Current Commitment Law –Limited initial oversight –Conflict over disposition at ER –No voluntary benefit High involuntary commitment rates High involuntary commitment rates

4. Acute Care System cont. Psychiatric in-patient Psychiatric in-patient Community mental health providers Community mental health providers Community drug and alcohol addiction service providers Community drug and alcohol addiction service providers Discharge planning, Continuity of Care – Discharge planning, Continuity of Care – the good, the bad, and the ugly

5. The Analysis Identify the clients: Identify the clients: –Using database to identify “excessive” in- patient stays Assess associated “collateral” costs in both DSAMH and Medicaid claims data Assess associated “collateral” costs in both DSAMH and Medicaid claims data –Detoxification services –DOC correctional stays –Cost of community-based outpatient services

6. The Envelope Says…. 20 individuals (out of ~1500) dominated admissions to all in-patient psychiatric facilities 20 individuals (out of ~1500) dominated admissions to all in-patient psychiatric facilities These individuals are the “High-End Users” These individuals are the “High-End Users” Of these 20 individuals, all had significant associated collateral costs including detox stays, DOC involvement, and community MH services Of these 20 individuals, all had significant associated collateral costs including detox stays, DOC involvement, and community MH services

7. Costs for High-End Users $880,735 for one year of service for these 20 individuals $880,735 for one year of service for these 20 individuals Of the $880,735, fully 70% represents in- patient hospital costs Of the $880,735, fully 70% represents in- patient hospital costs

8. High End User (HEU) Program April 2004 – Roll Out April 2004 – Roll Out Initial enrollment of 56 individuals Initial enrollment of 56 individuals –20 originally identified HEUs –36 additional individuals with frequent hospital stays

9. HEU Assumptions Acute length of stay is generally too short Acute length of stay is generally too short Discharge planning and coordination is poor Discharge planning and coordination is poor Existing system is neither client- nor recovery-oriented Existing system is neither client- nor recovery-oriented Mutually exclusive “silo” systems of services undermine comprehensive care (Ex: if MH, then not AOD) Mutually exclusive “silo” systems of services undermine comprehensive care (Ex: if MH, then not AOD)

10. High End User Program Admission and Graduation Criteria Admission and Graduation Criteria At-Risk Monitoring At-Risk Monitoring Coordination/Continuity of Care Coordination/Continuity of Care On-going routine communication On-going routine communication Appropriate Community Provider(s) Appropriate Community Provider(s) Rapid follow-up around IP stay Rapid follow-up around IP stay Remove time constraints of IP stay Remove time constraints of IP stay –Concept of “extended acute” IP stays

11. Two and a half years later… 127 individuals admitted to the program 127 individuals admitted to the program 59 individuals currently active in the HEU program 59 individuals currently active in the HEU program 68 individuals have been removed from the program 68 individuals have been removed from the program

12. Of these 68... 28 either moved out of the area (majority), are currently incarcerated, or have died 28 either moved out of the area (majority), are currently incarcerated, or have died 40 individuals have graduated from the program, i.e., no in-patient psychiatric admissions for one year 40 individuals have graduated from the program, i.e., no in-patient psychiatric admissions for one year

13. Monetary Cost Savings for these 40... These 40 individuals spent 725 days IP in the year preceding admission to HEU program These 40 individuals spent 725 days IP in the year preceding admission to HEU program At about $700/bed-day, the cost of this care was $507,500 At about $700/bed-day, the cost of this care was $507,500 These 40 individuals spent 454 days IP after admission to the program (until graduation), or $317,000 in bed-day costs These 40 individuals spent 454 days IP after admission to the program (until graduation), or $317,000 in bed-day costs

14. Summary The cost of IP care in the year preceding HEU and while enrolled in HEU: The cost of IP care in the year preceding HEU and while enrolled in HEU: $825,300 $825,300 The cost of IP during the year preceding graduation: The cost of IP during the year preceding graduation: $0 $0

15. Criminal Justice Involvement (DOC) One year prior to enrollment in HEU: One year prior to enrollment in HEU: 339 days incarcerated In the period after HEU enrollment: In the period after HEU enrollment: 101 days of incarceration Cost difference: $27,120 vs. $8,080 Cost difference: $27,120 vs. $8,080($80/day)

16. Criminal Justice Involvement One year prior to enrollment in HEU: One year prior to enrollment in HEU: total of 13 years 3 months on probation In the period after HEU enrollment: In the period after HEU enrollment: total of 5 years on probation

17. Data Bases, Monitoring, & Evaluation Corrections (DELJIS) Corrections (DELJIS) MMIS MMIS Paper-DSAMH Paper-DSAMH –Clinical Records E-DSAMH E-DSAMH –Excel/Access - various –Data Warehouse

18. Conclusions High-End User Program works High-End User Program works –It is more effective for the clients –It saves money –It relieves stress on the system

19. Key points: Key points: –Identification of participants –“Extended Acute” IP services –Collaboration/coordination between IP and OP service providers Steven.Dettwyler@state.de.us