Continuum of Care
October 21, 2011
On the call: Jim Graham, Bebe Smith, Don Herring, Amelia Mahan, and Mike Lancaster(joined last 30 minutes)
Trying to pick up from where we left off from the call on Monday the 17th. We were talking about splitting into sub groups- describing a continuum of care and the other on provider participation.
We were also given a spread sheet to track topics discussed- the continuum of care list done by Mike for the statewide partners.
Items were listed by Mike – range of services, recovery focused and the implications of waivers.
Who are we talking about- this includes people who are disabled- elderly and not just the severely mentally ill. [Physical, psychiatric, intellectual disabilities]
Bebe: PACE could be a model that we should be looking at.
Jim – running a program called PACE, 39 states, national model- 55 and older, alternative to nursing homes. Stay at home and given an intensive care management. Provider is at risk for the services and has to provide all the services from dental care to hip replacement. Everyone well and keep them in the community. Services should be unobstructed by bureaucracy. [NPAonline.org]
This may be a model to be kept in mind- is there a mental health component? The interdisciplinary team MUST contain a behavioral health expert. For dual eligibles there is no one overseeing the entire care- think beyond mental health or developmentally disabled.
Is there a budget for PACE? How do you handle the ‘provider at risk’ – we are doing it on the backs of other people’s data- a elderly woman with multiple issues-[82 year old woman with three concurrent diagnoses] each year the rate of PMPM is reviewed and revised. The model is population based – a person, this age, this gender with a these issues will cost this much but could be less or more.
PACE develops and approves the plan [It’s like insurance managed care, except PACE is also the provider. Potential ethical issue, but…] there is external oversight of the plan.
How population is identified: - dual, and have to be in need of a level of care that requires nursing home admission.
How do you get referrals: [Each group has a Marketing/Intake person, but the majority of referrals come through…] community education, friends of people in PACE. Some exit PACE and go home but less likely to do that the more they stay in the nursing home? [Some people exit nursing homes to move home with PACE, but often their homes have been sold while they are in the nursing home, which complicates it.]
Model: [All providers under one roof], A MD, nurse, masters level SWs, [OT, PT], drivers, Home health care workers. Going into home doing assessments, the doctor may go to the home to provide care, taken to day center for activities, [socialization].
[The PACE model operates like a solar systemin which the patient is the sun. All providers orbit the sun, some closer as needs are high, then farther out. ]
Don: The model [Is similar to]- System of Care for children- children with needs beyond typical MH/SA – a complex system. The bottom line is we do whatever it takes- wrap around care- It is a best practice model. Children who have dual eligibility.The Recovery movement may be a good way to organize this for people in the middle (between System of Care and PACE.)
Jim: There are often times a lot of similarity to end of life and beginning of life. The focus is mostly on stabilizing illness, slowing the progress of illness.
Bebe: With folks I work with – a) SMI, ill for many years, with functional impairment. Some need a little service, others a lot of services. [Many are in their 40’s and 50’s with significant health issues.] They have difficult time connecting to primary care, either because they don’t want to go, or doctors don’t want to deal with them. The whole person doesn’t get accounted for]. B) Young adults at start of a psychotic disorder- need something different, idea of prevention is key. [Health promotion will help insure]they avoid some of the chronic conditions that the middle aged people have.
You are able to slow the process or stop the progression as early as possible- if prevented.
ED (Emergency Department) visits are not for only mental health care, but also for physical health visits.
Don: We are talking about it in a different way- if we have a system of care for youth, Recovery-based for adults, and PACE for elderly and PCP for all of these ages. -Everyone has research and evidence behind all these programs already in existence and in NC. [You don’t have to define it per service or support, but define it around the person, surrounded by enough smart people. The task is huge though.]
You can help these people be more successful in their homes. If we looked at approaches that are already in existence in NC that may be the best way to go
Don – a recovery approach- recovery education centers- [modeled after schools, where]people are called students [not patients]. They can walk in, call in- they have medical and peer support- a place where people can say – no matter where I am in my recovery process I can always go back there- skill development classes- Vocational training.
Expanded PSR to a much more active- get you back into community; get your life back model.
Bebe: How do you coordinate the care of a person with complex needs?
That is the responsibility of the center, which includes transportation [by Peer support specialists]. On the Substance Abuse side of things there is a 24 hr call.
Bebe: What about Case management?
Don: [Under the waiver,] B3 services, IDD side there is a------; children – fill in some of the gaps
Don: When Jim describes PACE- there is a care plan which may or may not be intense. My perspective is a there is a need of a plan- who holds the pieces together? For special needs population- there is care coordinators. – People who check in and make sure they don’t fall out of services- they will be employed by the MCOs. Piedmont does it themselves- law was passed [House Bill 916] that they have to be employed by the MCOs.
[Bebe: Can we put that on the table? Clinical CM is a key part of what we provide.
Amelia: We can put anything on the table.]
Don: Here is how CMS looks at it- we should have control of front end- they should be in control of care coordination since we are at risk- but we feel that we have providers with high trust level so there is no difference.
If you have a team like with PACE- it makes a whole lot of sense-
[Don: It makes more sense than care coordination not part of the team. Would have to have ownership of the team.]
Bebe: When talking about people with SMI- there has to be outreach and focus on coordination.
All the different settings people are going to for their care- primary care, private setting, CCNC network, FQHC, health department or just an ED.
Don: One page model that western put together for CCMC- DON will send it – Basically looking at a four quadrant model- [Chris Collins and] Mike at DMH and CCNC worked together to do integrated mental health care.
Bebe: Wheredo people choose to go? People with significant needs are not always in the mental health system. We don’t have control over this. Where might they show up? Rural health clinic may need to be beefed up.
[Amelia: Co-location or reverse co-location models. How do you bring medical services into an ACT team?
Bebe: Whatever we do needs to account for that kind of flexibility.
Some MHSA providers say that some of the people they serve stay with them and not go elsewhere. Lot of people in WG go for mobile service, access or EDs.What’s going for you rather than where can we fit you in?
I have a colleague, a comnplex discharge manager at Duke. Last year she worked with a man who was homeless, and mentally ill, significant health issues- need a single person to work with that individual across systems to open doors and put a coordinated plan together.
Don?: Open doors of the system. Peer Support Specialist to make sure the person has transportation and gets in, shows up in the right place. Not handholding but – a partnership in care access.
The intensity has to be significant and slow down and back off as their needs progress down. Constant monitoring is also needed.
You have to make everything look like ‘not health care’ but a normal part of the daily life in Indian health services. [Professionals in the Indian Health Service still wear a uniform, which makes many uncomfortable.]
Health outreach experts, peer support specialists with training- who can do some health coaching- [getting connected.] We went after Opinion leaders- if you can get them. They will do their work for you. – There is no way to get paid employees everywhere.
Jim: WE DON’T NEED to design a new system but we need to identify the systems currently in place [that work. Services are like a big buffet, people don’t know how to get what they need, the right order, strength and proportion.] In the service array out there, how do you make sure care happens in some continuity? There is a model in system of care- recovery model- peer support- there is PACE. How do we communicate back to the larger group- there is not a system of arranging those pieces of care/?
Bebe: For person in need that whole array is complicated to get to. Is it sort of a guide through system, somebody to help navigate the system and where should the person be located?
Don: As close to the person as possible. You want them to be a shadow- it changes as a person’s illness wanes and waivers- a health coach is always orbiting, seen as a personal advocate. – do not use the term advocate. Medicare/Medicaid won’t pay for an advocate.
There is 80 hour training for peer support- overwhelming enthusiasm that can burn [them] out [easily—you want to avoid relapse.]
Bebe: What is the proper level for a person to do that? [I do lot of CM and it’s pretty complex: conversations with a mother whose daughter is in jail, a woman who is acutely ill kicked out of shelter. I don’t want to put too much responsibility on Peer support specialists. It’s complex navigating care systems. Ex: taking someone in for cancer treatment who wouldn’t have done it without support.]
Don: Must be Cautious about the numbers of people – 1 :1000 at CCNC- we need 1:10 or 1:15. [CCNC staff came to work with them, with W.highlands paying the salary to get what they needed.] This population needs a lot of hand holding, [needs intensive case management]
Bebe: But we can’t call it case management any more- call it coordinated care. Integrated care coordination. [Looking at a person’s whole needs.]Most complex – person with schizophrenia who develops cancer: people don’t want to deal with someone who is psychotic in a medical waiting room or in a ward. Special massaging that needs to happen.
Should we describe the various components that a person should have access to? - We are going to focus on an array of services. We have them in all ages- But the young numbers are small. There are services available for children and a system of care.
Amelia: Many get SSDI if their parents do.
Don: We are mostly talking about the adult population- Medicaid is much more robust for young people than Medicare.
** Start with 18 year olds- **
Primary care- preventive care – family planning – disease management (diabetes, asthma, SPMI, Substance) – Outpatient treatment
Specialty care- psychiatry, Ob Gyn any other things they may need, hospitalization, mental health treatment that may be therapy, ACTT. Health education, recovery education, healthy living DEAR (Diet Exercise, Attitude, Relaxation)
We do need to go to community support type needs – housing, supported housing (90 day),- one of the most successful programs – what we do is we put out a provider who does housing, we have a mental health provider do a supported housing piece- a CABHA in there constantly making sure the outcomes are met. – This happens before they come out of the hospital. They have to live by the rules- this is motivation to move by themselves to community living.
Jim: Just focus as a resource- but not a place as a place of recovery- we are talking about housing integrated with care service- although they need both. [ If someone wants just housing, are they on the continuum?]
Amelia: List both- just housing, and housing with care; that’s where you have choice- they may choose to just go to section 8 and not have any care – we have to support people both ways.
Bebe: There is a big difference between the two. – It would be nice to have the flexibility- what’s going to help you is to live on your own and give them the flexibility.What are the services that support people in their homes?
Don/Jim: Personal care to assistedtechnology-Accessibility? Universal design, build the space to adapt to persons needs.
Bebe: Home health services, institutions – upper end of the continuum.
Jim: Or it could be a short term intervention. – Rehab center.
Don: AFL- alternative family living. Take in people for short periods- interim foster home for adults. People who can function as family with knowledge of your needs so they can take care of your needs- [until you get back on your feet. Needing individual care, group environment too overwhelming.]
Jim: We have a great world, but can’t get everybody to it. I would consider continuing education, training opportunities - it all exists- we have meaningful engagement in the community, - school, volunteering, the problem is that we have a problem reorganizing all the components in a meaningful way.Organizing the silos.
[Bebe: One person may need just a few things from the list.
Jim: Once you get in a silo, it limits access.
Don: Difficult to get access to the care at the levels you need- difference between routine care and individualizing –
Bebe: Bringing the focus back to Dual Eligibles and the numbers here in NC, what do we need to individualize care for the person with barriers?]
Broad menu of things that all exist but how do we help the one person get all the services they need.
We need a Google for this- where one is able to choose the service- in order for the continuum of care to be titrated to the system.
[Bebe: If there were a centralized person across multiple divisions across HHS…
Don: Single door and knock, asking what I need and wanted. Something like STR (LMEs’ Screening, Triage and Referral), but people don’t know what an LME is.]
They will know where to find the service they need-
Bebe: In Orange County there is a human services center, not quite a one-stop shop, but there are a series of services available- still difficult to access, behind a glass window- might have to draw a number – it’s not like you’re treated like a human being. Nearby a gorgeous senior center is welcoming, can talk about resources, needs, participate in activities.
-Someone would want to go there. – a recovery education center. – Information, participates in activities.
-That’s what senior centers do for people- classes, presentation, get fed, social network.
Jim: 2.5 day conference in Charlotte, NC Conference on Aging. No wrong door- the people answering are not sold on prescribing their services but to lead to the right services.
Partners in care rather than competitors: - STAR function is available- a buffet of service.
Compare to Chicago behavioral health, cradle to grave care, but being deconstructed. Recovery was seen as a model for saving money.
Mike: walking in the door and get what you need – PSR on steroids. A lot of people in the Dual Eligible program can’t travel. Need services to people who can travel and others who can’t.
Don: PSS role.
Bebe: We need a health outreach model. Issues of poverty: – not talking poverty but health care reform. One way or the other things are changing- Making the Health Care Systemresponsive to the whole person. Is it at the Primary care practice- is it FQHC, public health dept- one place where all services are available?
Don: STR function at the HHS level.
Mike: Identify what the continuum needs to look like. A single door or all places to locate a ‘greeter’- put it in many different systems- NO WRONG DOOR – Integrated care coordinators.
Jim: In agreement we need a greeter who knows the system. Given the Dual Eligible population, where do we locate the greeter?
Bebe: In many different settings, operationalize No Wrong Door. Integrated care coordinator, maybe at the Emergency Department to catch people who don’t need the ED.
***WHERE to WHAT- Bundled service – a function needs to be paid for irrespective of where they go. Need to pay for it in a lot of places.