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Supercharge Crisis Services - Gabriella Guerra (Natcon15)
Mercy Maricopa Integrated Care was awarded a contract to manage the regional behavioral health authority in Maricopa County, Arizona, focusing on integrated care for a large population of Medicaid and non-Medicaid eligible individuals with mental health and substance abuse needs. The organization aims to redesign the crisis system by improving accessibility of services, enhancing community partnerships, and implementing evidence-based practices to better serve community members facing crises. Recommendations from a recent evaluation emphasize performance-based measures, service development, and increased support for those not previously connected to services.
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Supercharge Crisis Services - Gabriella Guerra (Natcon15)
- 1. Crisis: From thePerspective of the Funder Mercy Maricopa Integrated Care Gabriella Guerra, MSW Head of Crisis & Cultural Services
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- 3. Mercy Maricopa Sponsorship 2 SouthwestCatholic Health Network Corporation (SCHN) dba Mercy Care Plan Maricopa Integrated Health System (MIHS) Mercy Maricopa Integrated Care Managed by Aetna Medicaid through a Plan Management Services Agreement St. Joseph’s Hospital and Medical Center, A Dignity Health Member Carondelet Health Network, a Member of Ascension Health
- 4. Regional Behavioral HealthAuthority in GSA 6 • Mercy Maricopa was awarded contract to manage the integrated Regional Behavioral Health Authority (RBHA) program in Maricopa County, Arizona • One of the largest public behavioral health system in the United States • Contract began April 2014 • Redesigning and enhancing the behavioral health system to support integrated care delivery 3
- 5. Populations Served 4 Population ProgramsEligibles Medicaid eligible individuals with a Serious Mental Illness Integrated physical, behavioral health, and substance abuse services 15,456 Medicare-Medicaid eligible individuals with a Serious Mental Illness Integrated physical, behavioral health, and substance abuse services 1,532 Medicaid eligible adults with general mental health/substance abuse needs Behavioral health and substance abuse services 365,594 Medicaid eligible children Behavioral health and substance abuse services, case management for high needs children 396,475 Total Medicaid Eligible Members 779,057 Non-Medicaid eligible individuals with a Serious Mental Illness Behavioral health and substance abuse services, housing, and supported employment 4,339 Non-Medicaid eligible children and adults Crisis services *4,000,000 * All residents of Maricopa CountyNumbers as of October 2014
- 6. Regulators and SystemInfluencers 5 State Government • Comprehensive Medical and Dental Plan • Department of Child Safety • Division of Developmental Disabilities • Rehabilitation Services Administration Court System • Administrative Office of the Courts • Az Department of Juvenile Justice • Probation/Parole • Maricopa County Jails Center for Medicaid and Medicare Services Arizona Health Care Cost Containment System (State Medicaid Authority) ADHS Mercy Maricopa System Partners • Hospital Association • Police Department • Fire Department • Schools • Veteran’s Administration • Indian Health Services • Maricopa County • NAMI Regulators System Influencers
- 7. Maricopa County CrisisSystem 6 Our Community: • GSA 6 covers approximately 9,224 square miles • Including five tribal lands • Population approximately 4,000,000 • Houses over half Arizona’s residents • 4,000+ Primary Care Physicians • 1,500+ Congregations of Faith • 1,100+ Elementary, Middle and High Schools • 100+ Mercy Maricopa Contracted Providersce and Fire Mu • 25 Hospitals • 20 Colleges
- 8. Vision for theCommunity Crisis System Goals: 1. Address the needs of the entire community as a community of service providers 2. Leverage available state, county, federal, and local resources to meet the community’s needs 3. Maximize funding streams 4. Reduce duplicative services 5. Work together to address local issues 7
- 9. Vision for theCommunity Crisis System 6. Increase availability of funding for direct services 7. Take a systematic, data-driven approach to continuously improve the responsiveness and effectiveness of the crisis system 8. Provide all community members access to a full continuum of crisis services 9. Facilitate access to appropriate, community-based services and reduce inappropriate facility-based admissions 8
- 10. Vision for theCommunity Crisis System 9 Moving away from unconnected care
- 11. Vision for theCommunity Crisis System 10 Turning connected care into coordinated care Community Based Observation Level I Involuntary
- 12. Vision for theCommunity Crisis System A Patient-Centered Recovery Model 11 Natural & Community Supports Outpatient Services Crisis Services
- 13. Vision for theCommunity Crisis System The Patient-Centered Recovery Model includes: 1. Prevention & Early Intervention 2. Community Based Care 3. Recovery Focused Interventions 4. Coordination Among a Continuum of Accountable Care Providers 5. Stabilization in the Least Restrictive Environment 6. After Care 12
- 14. Components of aCrisis System 13
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- 16. Crisis 360 EvaluationOverview • Activities conducted from April 2014 – August 2014 • Utilized a member- centered approach • Engaged community stakeholders • Final report completed and published online • (http://mercymaricopa.or g/assets/pdf/get- involved/Crisis-360- Evaluation-Final- Report.pdf) 15
- 17. Crisis 360 EvaluationProcess Engaged stakeholders (over 40 persons participated) • Members • Families • Providers • Crisis service providers • First responders • Hospitals Collected and reviewed quantitative and qualitative data • Literature review of best practices and empirical evidence • Focus groups • Online surveys • Reviews of existing data • Workgroups 16
- 18. Workgroup Focus Areas 17 Outcomesof Ideal Crisis System Defining Crisis Needs & Services COT Process Outcomes & Pay-for- Performance Measures Community Stabilization Services Convened workgroups of subject matter experts in key areas:
- 19. Overview of Findingsfrom Crisis 360 Evaluation • For all populations • Prevent members from going into crisis • Intervene as quickly as possible • For adults • Support self-determination • Improve functioning • Provide effective coordination of care • For children, youth, and families • Increase stability • Promote security • Enhance capacity of the system to better meet this population’s needs 18
- 20. Member and FamilyOutcome Domains 19 Adults Children and Youth Reduce reliance on crisis system Provide the right service, right time, right dosage Increase engagement in services Support and therapeutic intervention Accessibility (on-demand responsiveness) Reduce out-of-home placements Keep members safe and alive Culturally competent and responsive to the needs of the family Create positive member experiences/heightened satisfaction Educate foster care providers (early identification and intervention of crisis symptoms) Increase in voluntary access Reduce number of days in EDs Crisis prevention Create awareness and accessibility Cultural competency in care Reduce disruptions Improve health (physical, mental) Intervene in the least restrictive environment Awareness of mental health crisis and how to access services
- 21. System Outcome Domains 20 SystemOutcome Domains Keep crisis utilization under defined benchmarks Connect individuals who are using the crisis system for the first time to services Decrease hospital admission and readmission Reduce/no hospital holds Decrease ED utilization for individuals with psych axis 1 diagnosis Decrease bed days and length of stay Decrease court-ordered evaluation (COE) and court-ordered treatment (COT) Reduce suicide rates Increase capacity to serve individuals with co-morbid physical conditions Reduce incarceration
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- 23. Recommendations Based on analysisof data gathered through the Crisis 360 evaluation process, six key recommendations were identified: 1. Incentivized performance measures 2. Contract adjustments 3. Service development 4. Supporting individuals not previously connected to services 5. System partnerships 6. Additional recommendations Plans developed to implement recommendations over the next three years 22
- 24. Incentivized Performance Measures 23 Recommendation •Align payment and incentives to achieve identified system outcomes Outcomes to Target • Improve the experience of care for members and families • Decrease in hospital holds percentage (<10%) • Decrease in ED utilization for BH needs for connected members • Contact with outpatient provider within 24 hours of crisis episode • Decrease in avoidable inpatient admissions; decrease in readmission rate for connected members
- 25. Contract Adjustments 24 Recommendation • Modifyexisting service provider contracts to support members and families in achieving recovery and to promote resiliency Outcomes to Target • Engage the following service providers in this process: • SMI clinics • Outpatient providers • Hospital rapid response • Connect to Care (to provide warm hand off) • Transition support • Parent assistance center • Court-ordered evaluation/court-ordered treatment • Mobile teams
- 26. Service Development 25 Recommendation • Needto develop additional services and/or expand existing services to meet the needs of members and families Outcomes to Target • Possible services to consider include: • Community stabilization • Crisis respite • Home care training to home care client ((HCTC) • Secure transportation • Mental health first aid and crisis system awareness • Crisis management services • Short-term stabilization housing • Short-term stabilization for specialty populations (DD, dementia, autism) • Psychiatry consult line • Medication access clinic
- 27. Support Individuals NotPreviously Connected to Services 26 Recommendation • Provide information and support to individuals and families regarding availability of BH services prior to crisis Outcomes to Target • Develop clinical pathways specific for members experiencing first episode of psychosis • Provide Mental Health First Aid training throughout the community (e.g., neighbor-to-neighbor programs, community centers, schools) • Require and incentivize follow-up care • Consider new members that have accessed crisis services as priority for intake appointments – emergent timeframes • Warm transfer individuals to ongoing supports (e.g., Crisis Navigator, community stabilization) • Continue Crisis Intervention Training • Partner with community information and referral organizations
- 28. System Partnerships 27 Recommendation • Developand maintain system partnerships to coordinate services within all systems in which individuals and families participate to effectively and efficiently meet their needs Outcomes to Target • Possible opportunities to expand system partnerships to coordinate service delivery include: • Health plans • Arizona Long Term Care System (ALTCS) • Department of Child Safety • Schools • Workforce connection • Hospital association • Department of Developmental Disabilities • Indian Health Services • Housing providers • COE courts • Veterans Administration • Universities • Public health • Community prevention coalitions • Police and Fire department(s) • Dept. of Juvenile Corrections
- 29. Additional Recommendations 28 Recommendation • Identifyopportunities to maximize funding and resources to increase the accessibility of services, and improve the member and family experience Outcomes to Target • Increase monitoring and auditing of engagement efforts for members on COT • Create process to expedite admission to residential care for members in crisis/inpatient care • Assess system capacity to determine the need for additional sub-acute/crisis facilities • Teach providers how to pursue TPL and other funding streams • Enhance clinical practice • Use national standards of care • Incorporate crisis services into At-Risk Crisis Plans – should build upon each other • Improve the use of psychiatric evaluations prior to inpatient admission • Mercy Maricopa will continue to engage stakeholders (e.g., members, families, community members, system partners) throughout implementation process
- 30. Next Steps andNew Opportunities for the Crisis System
- 31. Next Steps andNew Opportunities 30 Redesigning and enhancinh To address this need and lead this change process, Mercy Maricopa will: • Continue to engage stakeholders (e.g., members, families, community members, system partners) throughout the implementation process • Incorporate evidence-based practices to increase the quality and range of services for members and their families • Identify innovative and proactive methods to reduce crisis service needs of members and families
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Editor's Notes
- #9 Taken from the bid.
- #11 In this model, providers work independently, only focusing on members as they are presenting in the moment. Once the member is out of site, they are out of mind.
- #12 Providers consistently do warm handoffs to the next level of care. There is no engagement in their care once the members has left their facility.
- #13 Engages multiple ‘systems’ of care and support in the perpetual stabilization of members.
- #15 The crisis system is comprised of dozens of services and levels of care, all geared towards stabilizing members in the least restrictive environment. As rapid transitions of care occur there is greater opportunity for enhanced communication and coordination across multi-disciplinary teams, guided by member-driven decision making, medical necessity and public safety.