Powerpoint Slides/Speaking Points

Powerpoint Slides/Speaking Points

POWERPOINT SLIDES/SPEAKING POINTS

TO THE CALIFORNIA HOSPITAL ASSOCIATION ON DECEMBER 8, 2009 IN RIVERSIDE

SLIDE 1:

Title of Presentation: Models for Community and Hospital Collaboration

Riverside, CA,

December 8, 2009

SLIDE 2:

Presenter: Alfredo Aguirre, LCSW

President, California Mental Health Directors Association

Mental Health Director, San Diego County

SLIDE 3:

KEY ISSUES FACING COUNTY MENTAL HEALTH

  • Our County Mental Health charge: The future of Specialty Mental Health

 Social Justice is driving principle behind County Mental Health Services

 Economic realities impacting severe decline in core revenues: State General Purpose e.g. Managed Care allocation, sales tax and Vehicle License Fees generated realignment funding, and local General Purpose Revenue (GPR) dollars driven by property tax

 Mental Health Services Act (MHSA-Prop 63) taking over as prominent non federal revenue source to fund the County mental health system; but this will also begin to decline in FY 10-11 with even greater drops in FY 11-12 and FY 12-13

 We are the safety net for those with serious and persistent mental illness and children/youth with serious emotional disorders; this includes not only psychiatric emergency and inpatient services but alternatives to respond to emergencies such as crisis residential and mobile crisis teams

 Ensuring that population with mental disorders who are most vulnerable, most disabled continue to receive recovery oriented, client and family centered, culturally competent quality mental health care and related resources to advance optimal functioning in all domains of life

 Importance of recognizing how counties have reduced costs in institutional costs (emergency, inpatient and jail/juvenile facilities), reduction of homelessness, achievement of educational/vocational goals and for children, helping them stay with their family or in homelike settings

 Continue to support integration at policy, program and practice levels to address individuals with co-occurring disorders

 Realization that our charge of specialty mental health care will narrow due to financial realities but support other systems in addressing the behavioral health for relatively higher functioning Medi-Cal and indigent residents e.g. Federal Qualified Health Center’s (FQHC’s), faith based communities, and other low fee or categorical funded Community Based Organizations (CBO’s)

  • The Medi-Cal Waiver (Section 1115): Opportunities for Integration

 Importance of partnering with California Hospital Association (CHA) on ensuring that the waiver serves our mutual interests

 California Mental Health Directors Association (CMHDA) has developed a position paper (see handout) that emphasizes the following:

 Counties must be viewed by the State as full partners

 Mental Health’s current 1915 (b) waiver (i.e. freedom of choice) and key State plan amendments (rehabilitation option and targeted case management) is cost-effective and should be extended

 The new 1115 demonstration waiver should address barriers to access among all high-need Medi-Cal beneficiaries, and aim to improve monitoring of results and positive outcomes; encourage the use of the Four Quadrant Clinical Integration model in promoting innovative approaches for establishing “health care homes” cognizant of the varying degrees of medical and behavioral health conditions

 1115 waiver should encourage innovative approaches for improving integration of primary care, Mental Health and Alcohol and Drug services while building on Mental Health system transformation fueled by MHSA

  • Expanding the long term care continuum

 Institutions for Mental Diseases (IMD’s) are not sustainable financially and are out of step with overall goals of least restrictive care that advances recovery

 Looking at alternatives that support these goals above

 Full service partnership and Assertive Community Treatment (ACT) teams can provide whatever it takes services while developing permanent and supportive housing capacity

 Working with Skilled Nursing Facilities (SNF’s) that enhanced mental treatment option that meets the needs of difficult to place conserved patients languishing in hospitals; better place to provide integrated treatment addressing both medical and psychiatric needs

  • Provides for better financing through the ability to bill Medi-Cal

SLIDE 4

KEY ISSUES FACING COUNTY MENTAL HEALTH (continued)

  • “Coming Home”: Dealing with the challenges of

Returning servicemen and women:

 Post Traumatic Stress Disorder and Traumatic Brain Injury related behavioral health challenges that lead to visits to emergency room’s, psychiatric emergency/inpatient care and jail psychiatric units

 Stigma, and real fear, of loss of stature for seeking mental health care on the base or through their family’s health plan

 Importance of both County Mental Health and local hospitals building relationship with local Veteran’s Administration office, local VA and armed forces personnel to build better community support system to prevent use of emergency/inpatient care

  • Returning parolees (diametric appeal value compared to our soldiers)

 Developing relationships with California Department of Corrections and Rehabilitations (CDCR) (local parole) to avoid dumps on the emergency room doorsteps (progress is being made)

 Misinterpretation that state inmates with elderly and infirmed are LPS (Conservatorship) candidates (their real need is a nursing home; importance of educating CDCR institutional, State parole and community parole staff of this distinction

 Awareness of new programs that are starting up across the state to work with returning parolees with serious and persistent mental illness who require comprehensive full service partnership like services via a CDCR procurement awarding community providers (e.g. Telecare)

SLIDE 5:

COUNTY MENTAL HEALTH’S RELEVANCE TO HOSPITALS

  • Front end

 Recognize CHA’s white paper on: “Behavioral Health Delivery System” in California:

 Most important point elaborated on in your paper is the closure and downsizing of hospitals providing behavioral health services, thus aggravating the crowding of Emergency Departments (ED’s) having to address the myriad of behavioral health conditions presenting at their doorsteps

 Dearth of mental health crisis stabilization

 Your survey of 2006 re ED and availability of psychiatric services in hospitals points out the significant time it takes to have patients appropriately evaluated and treated

 The Center of Behavioral Health and Emergency Medical Services/Trauma committees met your meeting in 2009 to discuss common interest and came up with several options

  • Emphasizing more surveys to develop better data on patients presenting with mental health issues
  • Importance of doing this locally with your mental health department so that we can be responsive partners in looking at solutions
  • Use of telepsychiatry for ED evaluation and crisis intervention
  • Counties have used Prop 63 to develop these strategies to address front end demand particularly for handling crisis that surface in remote/rural regions
  • MHSA funding strategies: Community Services and Supports (CSS), Innovations, Technology components
  • Mechanism to distribute best practices to all ED’s
  • MHSA funding strategies: County and regional Workforce, Education and Training resources
  • Other strategies that Counties have done both pre and post Prop 63:
  • Mobile Crisis Teams
  • Mobile Crisis in collaboration with law enforcement e.g. San Diego’s Psychiatric Emergency Response Team (PERT)
  • Walk in centers strategically located (i.e. Mental Health’s “urgent care” centers)
  • Crisis residential treatment (note funding sustainability challenge here)
  • Back end:

 Again, recognize CHA’s white paper on: “Behavioral Health Delivery System” in California

 Within the confines of laws governing involuntary holds and detentions (i.e. LPS), the paper elaborates on the limitations throughout the State pertaining to the community system to support appropriate treatment and rehabilitation and to lessen pressures on scarce inpatient resources

  • County Mental Health, along with their patient rights office, needs to build constructive relationships with their hospital partners to clarify these parameters, address hospital shortcomings with technical assistance/continuous improvement approach

 Paper also speaks to the “significant unavailability of step-down community based mental health treatment options for patients ready for discharge”

  • Many counties have, first through the AB 2034 and the Children’s SOC 377 initiatives, then through Prop 63, have developed 24-7 whatever it takes comprehensive, community based full service programs to work with those with serious mental illness or Serious Emotionally Disturbance (SED) who also are homeless, at-risk of homelessness or at risk for out of home placement
  • Counties are already showing excellent results from their Prop 63 efforts in regards to reduction of inpatient utilization and jail detentions while successfully finding and sustaining housing for those enrolled

 An additional point made is the “limited access to maintenance programs designed to prevent relapse and provide rehabilitation support”

  • To be honest, Counties have been moving away from the concept of “maintenance” , instead, advancing options that support rehabilitation and recovery; even the more restrictive IMD’s have become shorter term with the goal of helping patients improve and prepare for more independent living in the community
  • As mentioned earlier, Counties are beginning to look at alternatives to IMD’s such as providing behavioral health patches to SNF’s
  • This requires improved communication between Counties and inpatient providers to help see SNF’s as potentially viable sources for referrals, and frankly, offering a better alternative for those languishing in your beds due to psychiatric and medical complexities

SLIDE 6:

HOSPITAL’S RELEVANCE TO COUNTY MENTAL HEALTH

  • An essential part of our systems of care

 As counties develop Systems of Care for all age groups, it is imperative that hospitals be included as key partners and not be segregated as a separate treatment system

 Importance of hospitals seeing patients as individuals through a recovery, strength based perspective; as individuals who are expected to set their own goals and learn to understand and better manage their illness

 Shared accountability to outcomes: including recidivism, housing stability

 Our piece: to include hospitals in our planning and evaluation efforts

  • Treatment partners

 Seeing psychiatric emergencies and hospitalizations as part of the course of recovery as opposed to failure in treatment

 Sharing of information: partners in emerging new County Mental Health Management Information System (MIS)

 Medication regimens

 Welcoming new partners into the hospital treatment team: the patient, the family, peer recovery specialists, family support partners, care and wrap coordinators

 Active discharge planning: coordinating efforts with community team (if present)

 Encourage hospital administrators; Behavioral Health administrators; Medical Directors to get to know your local Behavioral Health/Mental Health Director

 Both on individual basis, and

 Through existing stakeholder/committee structure (e.g. San Diego’s Hospital Partners monthly group)

SLIDE: 7

Questions and answers

  • My contact information:

Phone: 619 563 2765

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