Missouri tests new federal community mental health model
Cruising bleak downtown St. Louis streets looking for clients, community mental health outreach worker Britney Barbour stops her vehicle and hails a thin bearded man in a poncho who’s standing in the median strip in the cold rain, clutching a plastic cup he’s using for panhandling.
“Hi, Steve, how’s it going?” she asks. “Wanna meet me at the McDonald’s in 15 minutes?”
“I can’t now, I need to make some money,” he replies, scanning the deserted street.
After pulling away, Barbour explains that Steve is a former high school soccer star now in his mid-40s who has a severe substance abuse problem. She’s struck out so far in trying to get him into treatment at her community behavioral health center, Places for People. She’s not giving up.
“The door’s open, but he’s not quite ready yet,” said Barbour, who has a master’s in social work and loves doing this gritty street work. “It’s hard for him to think of a life where he doesn’t have to stand in the street and ask for money.”
Barbour is one of six outreach workers who try to lure St. Louisans with mental health and substance abuse problems into Places for People, using a meal, a shower, laundry service and a bus pass as bait. Once there, clients— many of whom are homeless— receive a wide range of coordinated behavioral and physical health services, along with housing assistance and other social services.
Starting in July, Places for People will reinvent itself as a certified community behavioral health center, or CCBHC, adding new services for children and for substance abuseonly patients. It’s one of dozens of sites in eight states funded by a $1 billion federal demonstration program to test a new, multidisciplinary model for delivering community-based mental health and addiction treatment. All programs offered must be evidence-based, meaning they’ve been proven effective in randomized trials.
Under the Excellence in Mental Health Act of 2014, CCBHCs will receive enhanced, cost-based reimbursement from Medicaid through a global payment per patient model, similar to the way federally qualified health centers get paid. They’ll have to report 22 quality measures, such as follow-up after hospitalization and reconciliation of medications.
For participating centers in Missouri, the demonstration will increase federal matching payments by about 11 percentage points, boosting funding by $25 million to $35 million a year, said Brent McGinty, CEO of the Missouri Coalition for Community Behavioral Health, who worked with Sen. Roy Blunt (R-Mo.) in developing the legislation.
The new model, to be tested over two years, will enable the centers to cover the costs of many support services they already provide, such as outreach, case management, housing, legal and employment services. “The things we do no one pays for,” said Joe Yancey, CEO of Places for People. “Hopefully, the CCBHC model will change that.”
Experts say it’s critical to expand and strengthen community-based behavioral and addiction services as a proactive alternative to the current, woefully inadequate patchwork of treating patients with advanced serious mental illness in hospital emergency departments or warehousing them in jails and prisons. Research has shown that people whose mental illness is detected and treated early can live healthy and productive lives.
“We’re trying to get further upstream to treat people earlier in their illness,” Yancey said. “It’s not OK to wait for Stage 4.”
The CCBHC demonstration is the biggest federal investment in many years in improving community-based mental healthcare. Behavioral health advocates ardently hope the program will deliver improved outcomes and cost savings and that Congress will expand it across the country.
“If we can keep people from the crisis stage by incenting community health centers and behavioral health centers to take care of people better on the front end, that would be amazing,” said Robert Fruend, CEO of the St. Louis Regional Health Commission, an umbrella group for hospitals and other healthcare providers.
Fruend and others say it would help a lot if Republican-led
Missouri joined 31 other states in expanding Medicaid coverage to low-income adults, because that would make it easier for behavioral health centers to get their patients into medical, mental health and substance abuse treatment. “The CCBHC is an incredible step forward in serving more people, but some sort of additional coverage is a critical component,” McGinty said.
The 315-employee Places for People, which started in the 1970s to provide housing and other services for patients left stranded by the closing of state mental hospitals, uses multidisciplinary teams to address clients’ behavioral and physical health needs.
The agency’s 29 teams provide most of their behavioral and physical health services out in the community- in clients’ homes, city shelters, criminal justice settings and the street. They frequently target people identified as high utilizers of hospital ERs and those referred by law enforcement officials.
The agency collaborates with the Family Care Health Center, a federally qualified health center, in delivering medical services on-site, including having an internist hold clinic hours. It also offers an on-premises pharmacy. All these services are coordinated through Missouri’s acclaimed Medicaid health home program, which was launched in 2012 with Affordable Care Act funding.
Recent state statistics show the Medicaid health home program, which served 80,000 Missourians, reduced total Medicaid spending by $35.9 million in 2016, including a $73.3 million reduction in hospital costs, McGinty said. Most of the savings were associated with behavioral healthcare patients.
Dr. Amanda Hilmer, the on-site internist, said before she started doing clinic hours at Places for People, it was hard in a 20-minute visit to understand the whole range of her behavioral patients’ issues, which could include insecure food and housing, and substance abuse. Now she’s able to talk to members of the behavioral health team before seeing the patients.
“I understand what’s going on with patients better, and there’s a lot more trust and honesty,” she said. “It saves a lot of time, and I’m so much more useful to patients.” Under a federal primary behavioral healthcare grant, Places for People has a new focus on working with clients to improve their health through diet and exercise. That includes swimming workouts at a nearby YMCA and sessions with an occupational therapist in the gym. Clients report that eating better, quitting smoking, exercising and losing weight helps a lot with their psychiatric conditions.
“I’m eating better and exercising,” said David Clement, 57, who has suffered from paranoid schizophrenia since he was a teenager and has had long bouts of hospitalization and homelessness. He dropped from 229 pounds to 180 in three months.
Diane McGuire, who directs the agency’s Medicaid health home program, said Clement initially wasn’t cooperative in finding a solution to his homelessness but now is doing very well. Most agencies, she added, stop working with uncooperative clients who miss appointments or engage in substance use. “We don’t have those rules, because recovery works differently for each person,” she said.
Facing a shortage of psychiatrists, psychologists and other highly trained mental health professionals, Places for People deploys so-called peer specialists on its treatment teams. These are people who personally have experienced mental health and/or substance abuse problems in the past, done well in treatment and recovery, and received training and certification in providing services. They use their own experiences to gain clients’ trust and engage them in treatment.
“My story is my greatest tool,” said Steven Spratt, a community support specialist whose mother died of drug addiction and who previously struggled with mental illness, addiction to crack and homelessness. He got clean in 2011 and went back to school. “I tell people they don’t have to feel ashamed. I offer a beacon of hope to them.”
But many clients aren’t ready to fully engage in treatment because, in Spratt’s view, the pain in their life hasn’t gotten bad enough yet. He has one client who winds up in the hospital emergency department every other week or so. Even though the client has refused so far to do what’s necessary to stay healthy, Spratt keeps working with him.
“I can’t lose patience, because his life is at stake,” Spratt said. “People didn’t give up on me.”