In Crisis: Clinical Solutions for the Revolving Door

Mary Ruiz MBA, CEO

Melissa Larkin Skinner LMHC, CCO

Florida's Premier Behavioral Health Annual Conference

August 5 - 7, 2015

Door #1: Emergency Rooms

• 9.3% of all emergency room visits (2013 NC)

• 31.1% of behavioral health emergency room visits admitted (2013 NC)

• 70% of emergency room docs report increase in “boarding” mental health patients (2004)

Door #2: Jails• Florida: Odds of jail vs

hospital 4.9 to 1

• Broward County FL: $80/day vs $130/day for mentally ill inmates

• Orange County FL:

26 day vs 51 day stay for mentally ill inmates

Door #3: Crisis Units• Suncoast : Readmits

29.5 % of all crisis unit admits 12 months (2010)

• Manatee : Readmits 27.8% of all crisis unit admits 12 months (2010)

• Canada: 37% 12 mo. hospital readmit rate for BH admits and 27.3% for non BH (2003)

How Did We Get Here?

• 1955 one psych bed per 300 Americans

• 2005 one psych bed per 3000 Americans

• Shortened stays

• Federal Medicaid Institution for Mental Disease Exclusion

• Return to 1840’s of large number of mentally ill in jails

Which Way Out?

• Are we missing levels of care?

• Is crisis chronic or undertreated?

• Is treating behavioral health enough?

• Can assisted treatment decriminalize mental illness?

Circuit 12 Acute Care Study 2011

• Identify causative factors for readmissions

• Study all admissions between July-Dec 2010

• Recommend models for improvement

Circuit 12 Acute Care Study 2011

• Compare consumers with one vs two or more admissions

• Diagnosis, age, gender, homeless

• Involuntary, follow up services, length of stay 10+ Days

Circuit 12 Acute Care Study 2011

One vs Multiple Admissions

• No differences in diagnosis, age, gender, homeless

• Teens and involuntary adults significantly less likely to follow up with outpatient

• 10+ days stay related to med acceptance in adults and placement for youth

Circuit 12 Acute Care Study 2011

Recommendations

• Increased engagement most promising practice

• Relapse prevention strongly indicated

• New service models needed

Crisis Behavioral Medical Home Pilot Manatee 2011-14

Crisis Medical Home Staff

Psych/ARNP .25

RN/LPN 1.0

MA Clinicians 2.0

Case Managers 2.0

Project Assistant 1.0

Crisis Medical Home Budget

Serving 80 enrollees at average cost of $7,812.50/year

Salaries $305,728

Benefits $ 73,932

Operating $195,349

Client Needs $ 50,000

TOTAL $625,000

Crisis Medical Home Features

• Just in time transition• Daily services• 24/7 integrated team• Holistic care coordination• Co-occurring, comorbid,

trauma informed• Medical, legal and social needs • Coaching for recovery/relapse

prevention • Assisted outpatient and

supervised release

Crisis Medical Home Enrollees

• 70% co-occurring substance abuse/use

• 57% medically complex

• 50% actively psychotic

• 50% risk of suicidality

• 32% teens and twenties

Length of Enrollment in Crisis Medical Home (N=214)

20% 0-8 weeks

25% 9-16 weeks

24% 17-24 weeks

31% 25 + weeks

Key Clinical Services

• Integrated care Management

• Medication delivery and observation

• 24 hour crisis intervention

• Individual and family therapy, support, education

• Wellness and recovery coaching

• Family education, support and participation

• Emergency funds for food, shelter, medication

• Healthcare coordination and linkage

Number of Crisis Center Admissions 6 Months After Discharge (N=203)

0 Admissions

75%

1 Admission

14%

2+ Admissions

10%

Six Months Before and After Crisis Medical Home (N=203)

• 73% reduced crisis center admissions (322 to 88)

• 99% diversion BA-8’s from state hospital (174 of 176)

• 100% jail diversion with assisted outpatient (15 of 15)

• 91% reduction homelessness (55 to 5)

Discharge Disposition AfterCrisis Medical Home (N=203)

• 82.8% traditional outpatient services (meds, case management)

• 9.3% against medical advice

• 5.9% assertive community treatment

• 1% state hospital

• 1% jail or prison

Crisis Medical Home

• Manatee 12 mo readmits reduced from 27.8% (2010) to 26.1% (2014) of total admits

• Manatee admits reduced from 5.17/1,000 in 2010 to 4.73/1,000 in 2014 (8.5%)

• Manatee length of stay increased from 3.87 days in 2010 to 4.34 days in 2014

Return on Investment

100% return on investment

diverting 4 crisis admissions per year

Return on Investment

100% return on investment

diverting one state hospital stay for every 8 enrollees

Which Way Now?

Are we missing levels

of care?

• Inpatient: community BA-8 beds for three week medical stabilization

• Outpatient: time-limited intensive community services

• Needed levels of care not supported by insurance models—need state funded models

Which Way Now?

Is crisis chronic or undertreated?

• Move from danger to self/others to need for treatment

• Frequent flyer staff attitudes

• Flexible payment models

• Short lengths of stay not a good thing and readmission not a bad thing.

Which Way Now?

Is treating behavioral health enough?

• Medical care coordination• Medications and housing• Wellness coaching• Benefits• Legal assistance• Whatever it takes!

Which Way Now?

Can assisted treatment decriminalize mental

illness?• Not often required but

essential when needed• Assisted

treatment/supervised release equally effective

• Powerful tool for forensic diversion if behavioral health services available

• One of the nation’s largest behavioral health nonprofits

• $225 million organization with • 160 locations in Florida, Illinois, Indiana and

Tennessee • Employing more than 3,200 people • Serving an estimated 142,000 individuals.