Mis­souri tests new fed­eral com­mu­nity men­tal health model

Modern Healthcare - - NEWS - By Harris Meyer

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.”

BILL HEALY Steven Spratt, a com­mu­nity sup­port spe­cial­ist, pre­vi­ously strug­gled with men­tal ill­ness, ad­dic­tion and home­less­ness.

BILL HEALY

Daren Jones, left, a sub­stance abuse spe­cial­ist with Places for Peo­ple, helps or­ga­nize med­i­ca­tions for client Randy Mil­ton at his home.

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