Continuum of Care Workgroup
October 31, 2011,
Bebe Smith, Don Herring, Amelia Mahan, Laurie Crocker, Heather Brewer, Susan Osborne
Call from Oct 21- Jim described the all inclusive program- maybe a one stop shop. Summary from the last
Broad array of things that is available in the community- primary care to mental health care but difficult to put all the pieces together. A care coordination that is also meaningful. –
Integrated care coordination, whole health care needs along with social supports- where so things like that would be located- person centeredness.
Every dual eligible will be assessed and will get the full array of services they need – a front end assessment , to identify the needs as well as who we should be targeting.
People who show up in EDs with a medical condition but also need mental health services- they need an assessment and get connected with the mental health system
- No wrong door referral
- Outreach services
- Integrated care coordination ( coordinators)
- Continuum of services
Easily accessible assessment center- mental health issues get assessed. Lot of people who show up at the down town health plaza- some place out in the community and be evaluated for both mental and physical health issues. People who did not need immediate assessment – but keep them connected to healthcare based on the assessment.
Federal policy level – medical care home – mental health illnesses included as a chronic care illness. Well controlled or not well controlled.
Stokes County- how would you do this? It can be done on a smaller scale.
PACE program is an interesting concept- think about it as a model.
Heather Brewer: (Easter seals) Integrated program , started seeing individuals from Oct 10th, based on a KBR grant- treating both mental and physical care- there is trust with their mental health provider, more willing to take care of their
Reverse care location- Mount Airey and Rocky Mount with a family nurse practitioner, designed a model, where primary care is also provided. A large learning curve, medication management, case management, ACTT teams, MST and IIH for children- but now seeing just adults- needed to just start with SPMI adult population , disease management , referred internally from their behavioral health physician or doctor.
Internal referrals are challenging – but we will see long term what the outcomes look like.
Medicaid eligibles do not have Medicaid- if things can be collocated. Some people do not like having physical health care because of stigma. Co- locate is such a good idea. Lot of people doesn’t have transportation.
25% earlier average shorter life span is also because of medications and of poor lifestyle. Medications are not being monitored properly. All medications have side effects. Focus on long term effects of medications should be monitored.
Medical monitoring of psychotropic medications.
UNC- early intervention program with a early episode of psychotic behavior- monitor weight, lower dose medication. Different kinds of health outcomes.Healthy lifestyle education.
Australia,- ahead of the curve in integrating mental and physical health care and also in integration nutrition and physical activity.
Coordination of care becomes critical.- lot of people don’t know how to get to the different pieces
A robust and useful statewide resource center and maintained by an entity- a care line
Community Resource connections- Forsythe and Surry- a model that was funded – a plan to expand it. – what do they do. A wrong door approach- a connection center for disabled and elderly- where they can get their needs met in the system.
There is no clinical component but do coordinate crisis intervention, discharge planning etc but no direct services.
In orange county, a human services center, with DSS, housing etc but no mental health- it’s nice to have those entities in one place- not a very pleasant place but still it’s there.
Integrated care coordinators, should be well trained and cross trained- People getting training in motivational interviewing- you have to understand psychiatric issues before you can even start MI.
People do have specialties- even our Thomas S – Easter seals program- IDD, severe emotional problems, it’s been very difficult to find people who are trained – so instead (training would be very expensive) – a team of care coordinators who have their own specialty- but this could get crazy for the individual.
Specialist should be available but there has to be one point person. – Resources for consultation- strengthening those things, care coordinators have access to consultation.
Everyone is not an expert- the system of care model is very successful.
Services are already in the system, so we become a model focused- the idea is to focus on a best practice model that would be more successful. The conveyor belt of services
The system of care, the recovery model, the PACE model- There needs to be engagement between providers, systems, services.
CCNC becomes the body to facilitate coordination- ?
Everything is very clinically driven- health home as a concept and health services as a piece of the concept- get the foundations to support the health services- communicate with the clinical side.
Another role for the MCO world- the ombudsman- has the authority to make things happen for a person.
The authority comes with the funding- Case management should stay with psychiatrist- but if we are going to have integrated care then there needs to be some power along with Care coordination- people with complex health needs- authority to make things happen for a small group- so many different skill sets needed.
Have to reduce the number a care coordinator serves. 10-15 people and not 1000
How do you provide comprehensive services long enough , - so they get engaged, at the end a period hand them off to a different entity. Flexible, responsive system.
The recent recovery conference, one of the providers who was promoting recovery oriented services- engagement takes time and dedication, kind of engagement that gets a person to stay with aservice . It is not paid. – how much money we spend on the long run, but to pay for the services
Here are the people with some complex needs,
Prevention, outreach, referral, assessment, coordination of care, recovery based approaches, maintenance, robust care coordination with authority, collaborative , reentry, education - walk in resource coordination , consultation- a Flexible, responsive system.
Concepts from public health need to be pulled into this care world.
Large group. 10/31/11
Elise, Amelia, Laurie, Don, heather, Peggy Balak, Nena, Laurie, Erica Arrington, Pam shipman,
Nidu will work with Bebe to put something down on a template and get it out to the group to review and comment; we will meet the first hour of the 14th.
Call time for the provider participation work group- 10th at 8.00 am.
Bebe: needing to have a robust integrated care system which looks at a persons whole needs- where should it be located. People are going to show up in many places-
CCNC – integrated coordinator to be locate- flexibility, authority, funding is needed, recovery oriented.
There be a lot of focus on engagement, people who are not connected to the services they needed. The potential of using some resource centers.
People getting a integrated assessment, if you use the community resource centers,
CRC- Surry and Forsythe has a physical center- a statewide very frequently updated resource center.
The integrated care coordinators have a very strong training along with the facility to get on the spot consultation.
A search system, the MCO and CCNC does care management- not create a third system but may be use the CCNC infrastructure and the CCNC informatics- a lot of people in the mental health system are dual eligibles- they can be triaged from the assessment.
A lot of people who are not being reached by the mental health or physical health system- there needs to eb a one point person or authority who ahs the arial view to get people engaged and make things happen for an individual. It should be part of the roll out of the MCOs –
How do we ensure that they get the services they need.
The federal govt is working with CRCs which will act as a point of information and will be able to move the people towards mental/behavioral health services. It is an expectation on part of the CMS that this will be a component of what we are doing here in NC. This is in existing development –
Has the state plan amendment been approved- there are components in the draft that is necessary. It has not been approved, the health homes amendment.
The top 100 Medicaid paid claims data, we threw out ones that were because of placement; we went after the top 25 and did care coordination. We engaged and got them involved till they got engaged with the medical health providers.
The preference is to move towards models and not services- a model approach for every age group. – a system of care in the adult sector. The services become so disconnected.
Focus on needs, rather than a model adherence- the Pace elements, ie, identify pieces of various models that we would have to have in place.
A broadly used model; where the services are now to move them to where you want this to be.
The finance people will default to services.
Provider participation:
3 primary categories ( take from grid)
Recommendation 1- aligning credentials
2. Billing and payment systems- we need those systems to be most efficient- providers should be paid the full rate
3. Waiting time- the delay is another hurdle- make the payment system more efficient, make a presumptive denial- certain codes and services that Medicare will not pay for, so why don’t you just assume this is a denial and make the payment process faster and easier.
3. BC waiver- Reprocity; maybe the possibility of having a database- a repository where all MCOs can go and look. The technology we have available and make that an option.
Psychotic disorders- general mental health problems- most severely ill people are dual eligibles-
Elise: one topic, 60% of the high hospitalization is behavioral health for people under 65- the 40% over 65- recognizing in the needs determination group the people who have been on medications for a long term medication encephalopathy. Grown older and MI onset- a behavioral health consideration.
A dementia, is it a physical health, or a behavioral health or psychosis. – a behavioral health system needs to support the long term care community.
There may be a workforce issue on the LCSW end that there is a deficit with people trained on the specific needs of this population – there may be training needs.
Geriatric Specialty Teams are groups that go in and provide the training and support to these staff in the care of this population. CAS programs –
Medical geriatric as well as a gerontology representation.
What are the needs of this population? People who were being taken care of by their families
Other gaps- how difficult to find people who work with IDD and MI- ? find someone who can give comments on the work of this group.
TABA- targeted case management and ACTT team.