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ACCESS QUALITY AND APPROACH
FOR BEHAVIORAL HEALTH IN
NORTH EAST TENNESSEE
5th Annual Health Care Symposium
October 17, 2014
Presenter
Randall E. Jessee, Ph.D.
Senior Vice President
Frontier Health
BEHAVIORAL HEALTH CARE IN NE TN
A HISTORICAL PERSPECTIVE
• 1956 - Federal Community Mental Health Act
• 1957 – Mental Health Centers Open in Kingsport,
Johnson City, and Bristol
• 1967 – Kingsport Council on Alcohol and Drug
Dependency opens
• 1972 - Nolachuckey Mental Health Center Opens in
Greeneville
• 1972 - First Mental Health Center Alcohol and Drug
Treatment Program Begins in Johnson City
MENTAL HEALTH CENTERS
AND CATCHMENT AREAS
1972
Nolachuckey Mental Health Center
Holston Mental Health Center
Bristol Mental Health Center
.
U.S
23
.
U.S
23
Watauga Mental Health Center
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FREE STANDING SUBSTANCE ABUSE
PREVENTION AND TREATMENT SERVICES
1972
Kingsport - KingsportAlcohol & Drug Council
Johnson City - Comprehensive Communtity Service
.
U.S
23
.
U.S
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Elizabethton Crossroads
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ALONG THE WAY
• Assess the needs, fill the gaps in care.
• Developmental and Intellectual Disability
Programs joined with existing MHCs in
Kingsport, Bristol and Johnson City.
• Kingsport Alcohol and Drug Council opens
school based intervention/education program
and the first student assistance program.
• All MHCs add various adult and C&Y
residential group homes, foster care, court
services, special population services (geriatric,
women, school based, job placement training
and coaching.
ALONG THE WAY
• First merger between CMHC and Freestanding
Alcohol and Drug Treatment in Tennessee – 1989
• Hospital and Hospital Systems – Emergency
Rooms become a gateway to behavioral health
care
• 1981 PD1 Contracts with Holston Services
(Kingsport Mental Health) for MH/SA Services in
Scott, Lee and Wise counties
• First State funded 24/7 Regional Crisis Programs
are opened in 1994
• In 1985 Woodridge Psychiatric Hospital is opened
by Watauga Mental Health Center
CONTINUUM OF CARE
By 1990:
Developing a Continuum of Care became
the leading goal and activity of all the
Region One CMHCs:
• Attracting resources
• Creating opportunities
• Developing partnerships in the
community
CONTINUUM OF CARE
COMPONENTS
Added:
• Prevention and early intervention - (HIV education,
screening, case management and support) HOPE, SI
TSPN
• Ongoing assessment, diagnosis, treatment and referral
• Use of Evidence Based Practices in all services (as
available)
• Service provision to children, youth, adults, geriatric
and other special populations (intellectual disabilities)
• Medical/Psychiatric Services
CONTINUUM OF CARE
COMPONENTS
• Levels of care:















Outpatient
Intensive Outpatient
Case Management
Medication evaluation and management
Detoxification and residential treatment
Crisis Assessment
Emergency Commitment
Crisis Stabilization Unit
Intensive Case Management
Intensive group living (SPMI)
Group Homes
Independent living
Transitional recovery living
Psychiatric Hospital
Day Treatment
.
U.S
23
.
U.S
23
FRONTIER HEALTH
CONTINUUM OF CARE
SERVICE AREA
2014
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CONTINUUM OF CARE
CO-OCCURING DISORDERS AND
INTEGRATED CARE
Integrated care requires “one stop” services
for Co-Occurring Disorders (COD) which
include physical, mental, substance
abuse/addiction, intellectual, and behavioral
disorders/diseases. One individual with
multiple conditions. Treatment occurs
within an inter disciplinary-assessment,
treatment planning and treatment
application team at one single site. This
model is replicated at multiple regional
sites.
PRINCIPLE-DRIVEN ADULT AND
CHILDREN SYSTEMS OF CARE
All services are:
• Hopeful
• Person or family centered
• Empowering and strength based
• Designed to help people achieve their
most important and meaningful goals
PRINCIPLE DRIVEN ADULT AND
CHILD SYSTEMS OF CARE
All services are:
• Hopeful
• Person or family centered
• Empowering and strength-based
• Designed to help people achieve
their most important and
meaningful goals
Minkoff Zia Partners
INTEGRATED SYSTEMS OF CARE
• Complexity is an expectation, not an
exception
• All services are designed to welcome,
engage, and provide integrated
services to individuals and families
with multiple complex issues (MH,
SUD, DD, BI, health, trauma, housing,
legal, parenting, etc.)
Minkoff Zia Partners
WHAT IS A SYSTEM?
Sets of nesting dolls that are not quite so
nesting:
 Systems
 within systems
 sitting next to other systems
 within systems
Minkoff Zia Partners
TRANSFORMATION
• Involves EVERY system, subsystem, and
sub-sub-system in a common process to
achieve a common vision, with EVERY
dollar spent and EVERY policy,
procedure, and practice
• In a provider agency, that means the
agency as a whole, every program in the
agency, and every person delivering care
is working toward a common vision.
Minkoff Zia Partners
COMPREHENSIVE, CONTINUOUS INTEGRATED SYSTEM
OF CARE
CCISC
• All programs in the system become
welcoming, hopeful, strength-based
(recovery- or resiliency-oriented), traumainformed, and complexity-capable
• All persons delivering care become
welcoming, hopeful, strength-based,
trauma-informed, and complexity-capable
• 12- Step Program of Recovery for Systems
Minkoff Zia Partners
PERSON-CENTERED, RESILIENCY/RECOVERY-ORIENTED
COMPLEXITY CAPABILITY
Each program organizes itself, within its
mission and resources, to deliver
integrated, matched, hopeful, strengthbased, best-practice interventions for
multiple issues to individuals and
families with complex needs who are
coming to the door.
Minkoff Zia Partners
PERSON-CENTERED, RESILIENCY/RECOVERY-ORIENTED
COMPLEXITY COMPETENCY
Each person providing clinical care is
helped to develop core competency,
within their job and level of training,
licensure or certification, to become an
inspiring and helpful partner with the
people and families with complex needs
that are likely to already be in their
caseloads.
Minkoff Zia Partners
PERSON-CENTERED, RESILIENCY/RECOVERY-ORIENTED
COMPLEXITY CAPABILITY
• CCISC Program Self-Assessment Tools




COMPASS-EZTM
COMPASS-IDTM
COMPASS-PH/BHTM
COMPASS-PreventionTM
 12 Steps for programs developing
Complexity Capability
% SUCCESS RATE
100.0%
PERCENTAGE OF C&Y RESIDENTIAL CONTINUUM YOUTH
SUCCESSFULLY DISCHARGED TO A PERMANENT EXIT*
20.0%
0.0%
GOAL**
70%
2009
2010
2011
2012
2013
91.3%
79.2%
76.3%
40.0%
84.9%
84.0%
60.0%
87.6%
80.0%
2014
* Goal of 70% based on State Contract expectation. **Includes Traces, Level I, II, & III placements.
SUCCESSFUL COMPLETIONS OF A&D RESIDENTIAL SERVICES
NATIONAL
0.0%
BENCHMARK
57%
2008
2009
2010
2011
2012
2013
84.2%
81.5%
66.7%
20.0%
56.3%
40.0%
63.2%
60.0%
75.6%
80.0%
63.5%
SUCCESS RATE
100.0%
2014
* Treatment Episode data set (TEDS) published by the Office Of Applied Studies, Substance Abuse
and Mental Health Services (SAMHSA)
TOTAL OPENED CASES SERVED IN OUTPATIENT SERVICES
40,000
30,000
29,968
27,450 29,198
33,467 32,262 31,456
30,825
33,321 34,111 33,719 33,281 33,744 32,595
30,130
20,000
10,000
0
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
2000- 2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010- 2011- 2012- 201301
02
03
04
05
06
07
08
09
10
11
12
13
14
TOTAL SESSIONS COMPLETED BY FRONTIER HEALTH CASE
MANAGERS, THERAPISTS, AND MEDICAL STAFF
400,000
300,000
200,000
100,000
0
313,825 311,906 319,773 318,392 303,017
284,965 269,409
279,631 283,050 292,523 301,094 285,997
259,543
250,183
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
2000- 2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010- 2011- 2012- 201301
02
03
04
05
06
07
08
09
10
11
12
13
14
10,000
NUMBER OF FACE-TO-FACE CRISIS CONTACTS IN TN AND PD1
SERVICES
8,932 8,910 9,031
8,630
6,955 7,040
8,000
6,000
4,000
2,000
8,325
1,742 1,780 1,774 1,368
7,661 7,591
5,980 5,817
6,958 7,101
3,783 3,486 3,182
3,074 2,822 3,392
*
2,630
2,201
2,139
0
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
2001- 2002- 2003- 2004- 2005- 2006- 2007- 2008- 2009- 2010- 2011- 2012- 201302
03
04
05
06
07
08
09
10
11
12
13
14
PD1
TN
DAYS OF SERVICE - ADULT SUBSTANCE ABUSE RESIDENTIAL
15,000
10,275
10,121
9,406
9,334
9,881
8,718
8,892
6,267
3,000
6,094
6,000
6,559
9,000
6,256
# OF DAYS
12,000
0
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
FY
2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14
99.1%
99.1%
99.2%
99.3%
99.4%
99.2%
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
99.0%
PERCENTAGE OF CASE MANAGEMENT CONSUMERS* REMAINING STABLE
FUNCTIONING IN A HOME SETTING, WITHOUT PSYCHIATRIC HOSPITILIZATION
2008
2009
2010
2011
2012
2013
2014
*Includes adults and children in standard case management services.
TN MENTAL HEALTH RESIDENTIAL SERVICES IMPROVEMENT
IN HOSPITALIZATION RATE
100%
80%
60%
40%
20%
0%
1/10/10 6/30/10
FY 20102011
FY 20112012
FY 20122013
FY 20132014
HOSPITALIZATION % BEFORE
ADM
6.4%
5.9%
9.1%
10.3%
10.4%
HOSPITALIZATION % AFTER ADM
0.2%
1.1%
1.0%
0.8%
1.1%
MEDIAN DAYS
MEDIAN ACCESS TIME TO OUTPATIENT SERVICES
20
15
10
5
4.5
0
BENCHMARK*
10.5 Days
2008
4.5
3.9
4.5
4.3
2009
2010
2012
2013
4.5
2014
5.0
CONSUMER REPORT OF “DEGREE TO WHICH TREATMENT HELPED
YOU DEAL WITH YOUR PROBLEM/COMPLAINT**
4.0
4.0
3.9
3.9
4.0
4.0
2.0
4.0
4.0
3.0
3.9
3.9
4.0
3.9
3.9
1-5 LIKERT SCALE
*Mental Health Corporations of America Benchmark
1.0
2009
2010
2011
NATIONAL BENCHMARK*
2012
2013
FRONTIER HEALTH
*Mental Health Corporations of America. ** Rated on 1-5 Likert Scale
2014
THE NOW CHALLENGE
• Innovation in health care is now
• The focus is on vulnerable populations
with little or no access to healthcare
• Strategies promote public and private
collaborations
• Integration of Behavioral Health Care
and Primary Health Care
THE BASIS FOR CHANGE
• Virginia cites data indicating that 50% of
intensive users of health care have a
behavioral health diagnosis
• Medical providers are often ill equipped
to effectively respond to individuals with
behavioral health conditions
• More than 45% of SMI individual also
have a substance use disorder which
further complicates the treatment
response
Healthy VA (Virginia)
THE BASIS FOR CHANGE
• The cost of treatment for individuals with
a chronic physical health disease and a
co-occurring behavioral health diagnosis
is 75% higher than those without the
behavioral health diagnosis
Healthy VA (Virginia)
PREVALENCE OF PSYCHIATRIC
DISORDERS IN PRIMARY CARE
No Mental Disorder
61.4%
Somatoform
14.6%
Major Depression
Dysthymia
11.5%
7.8%
Minor Depression
6.4%
Major Depression (partial remission)
7.0%
Generalize Anxiety
6.3%
Panic Disorder
Other Anxiety Disorder
Alcohol Disorder
Binge Eating
3.6%
9.0%
5.1%
3.0%
National Council
PREVALENCE OF PSYCHIATRIC
DISORDERS IN LOW INCOME PRIMARY
CARE PATIENTS
• 35% of low income patents with a psychiatric
diagnosis saw their PCP in the past 3 months.
• 90% of patients preferred integrated care.
• Based on Findings, authors argue for system change
7.0%
10.0%
Eating Disorder
7.0%
Alcohol Abuse
17.0%
11.0%
Anxiety Disorder
36.0%
16.0%
Mood Disorder
33.0%
28.0%
At Least One Psychiatric Dx
0.0%
10.0%
General PC Population
20.0%
30.0%
51.0%
40.0%
50.0%
Low Income Patients
National Council
60.0%
PRIMARY CARE AND
BEHAVIORAL HEALTH
• Most PCPs do a good job of diagnosing and beginning
treatment for depression(Annals of Internal Medicine,
9/07)
 1,131 patients in primary care practices across 13
states
• PCPs did less well following up with treatment over time
– less than half of patients completed a minimal course
of medications or psychotherapy
• Lowest quality of care occurred among those with the
most serious symptoms, including those with evidence
of suicide or substance use
• “right now PCPs don’t have the tools necessary to
decide which patients to treat and which to refer on to
specialized MH care”
CO-MORBIDITY AND SUBSTANCE
ABUSE
• Almost 25% of general healthcare
patients report they have a co-morbid
substance use conditions likely related to
the physical sequelae that result from
untreated substance misuse and
dependency (NSDUH, 2005)
• Substance use conditions often
complicate management and treatment
of other chronic diseases in primary care
such as diabetes, hypertension, asthma
and others (PRISM, 2008)
National Council
TREATMENT IMPACT
CONSUMER OUTCOMES - MISSOURI
•
Independent living increased by 33%
•
Vocational activity increased by 44%
•
Legal involvement decreased by 68%
•
Psychiatric hospitalization decreased by 52%
•
Illegal substance use decreased by 52%
•
IN ADDITION – study shows CMHCs services substantially decrease
overall medical costs
National Council
HEALTH HOMES
The Virginia Behavioral Health Home: Pilot
Project
• Behavioral Health Care and Primary Health Care
coordinated/integrated to meet individual where they
are
• Features of this pilot program will include:
 A focus on prevention and early intervention
 Facilitation of joint treatment planning sessions among
providers
 Strategies to close gaps in care and address societal factors
that discourage individuals from seeking medical services
 Robust use of care management, outreach and community
services
 Carefully managed transitions in care and medications
 Peer support specialists for assistance with social and lifestyle
changes
 Coordination of care through use of technology to share
critical health information
 Use of data to better understand health care needs
Healthy VA (Virginia)
CONTINUUM OF INTEGRATION
Key Element: Communication
CO-LOCATED
INTEGRATED
Key Element: Physical
Proximity
Key Element: Practice Change
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Minimal Collaboration
Basic Collaboration at a
distance
Basic Collaboration OnSite
Close Collaboration OnSite with Some System
Integration
Close Collaboration
Approaching an
Integrated Practice
Full Collaboration in a
Transformed/Merged
Integrated Practice
Behavioral Health, Primary Care and Other Healthcare Providers Work:
In separate facilities,
where they:
In separate facilities
where they:
In same facility not
necessarily same offices,
where they:
In same space within
the same facility, where
they:
In same space within
the same facility (some
shared space) where
they:
In same space within
the same facility sharing
all practice space where
they:
•
Have separate
systems
•
Have separate
systems
•
Have separate
systems
•
Share some systems
like scheduling or
medical records
•
Actively seek system
solutions together
or develop work-arounds
•
Have resolved most
or all system issues,
functioning as one
integrated system
•
Communicate about
cases only rarely
and under
compelling
circumstances
•
Communicate
periodically about
shared patients
•
Communicate
regularly about
shared patients, by
phone or mail
•
Communicate in
person as needed
•
Communicate
frequently in person
•
Communicate
consistently at the
system, team, and
individual levels
•
May never meet in
person
•
Communicate
driven by specific
patient issues
•
Collaborate driven
by need for each
others services and
more reliable
referral
•
Collaborate driven
by need for
consultation and
coordinated plans
for difficult patients
•
Collaborate driven
by desire to be a
member of the care
team
•
Collaborate driven
by shared concept
of team care
•
Have limited
understanding of
each other’s notes
•
May meet as part of
larger community
•
Meet occasionally
to discuss cases due
to close proximity
•
Have regular faceto-face interactions
about some
patients
•
Have regular team
meetings to discuss
overall patient care
and specific patient
issues
•
Have formal and
informal meetings
to support
integrated model of
care
•
Appreciates each
other’s roles as
resources
•
Feel part of a larger
yet ill-defined team
•
Have a basic
understanding of
roles and culture
•
Have an in-depth
understanding of
roles and culture
•
Have roles and
cultures that blur or
blend
National Council
THE FUTURE: HEALTH HOMES
Patient care access and quality improves
at the expense of professional and
organizational agendas.
• Who are your partners?
• Building new relationships, trust and
success
REFERENCES
1.
2.
Frontier Health, Access and Quality Data. 2000-2014.
National Alliance for Mentally Ill (NAMI), Achieving the Promise:
Transforming Mental Health Care in America 2012.
3. Managed Care Mental Health Substance Use and Wellness,
Association of Behavioral Health and Wellness, 2011
(www.abhw.org).
4. Programs and Tools to Improve the Quality of Mental Health
Services, Research in Action.16.2013.
5. Health Care Reform, Monitor on Psychology, American
Psychological Association, 2009.
6. Priority Goals – Health Care Reform, American Psychological
Association, 2014 (www.apa.org).
7. Access to Care: Tools for Hospital Emergency Departments (MBHP
Network Providers), Massachusetts Behavioral Health Partnership,
2014 (www.mbhp.org).
8. A Healthy Virginia, Inovation Report, 2014
(www.vahealthinnovation.org)
9. The National and State Context for Integrated Care: Developing
New Opportunities, 2013 (www.the national council.org).
10. Changing the World: Inspiring Hope, Health and Recovery,
Christine Cline, M.D., MBA; Kenneth Minkoff, M.D., Zia Partners
2014 (www.ziapartners.com)