medicaid rate setting and psyr practices

1

Medicaid Rate Setting and PsyR PracticesThoughts for NJPRA advocacy:Changing bottom up granularity to top down strategy

2

Thinking Like A Systems Coach

3

What’s The Goal?

5

4 Parameters

How To Get There?

Phases of Care Elements of Care Evidence Based Practices Aspects of Need

6Parameters: 6 Phases

Crisis

Critical

Containment

Remediation

Rehabilitation

Recovery

7Parameters: 6 Phases3 Elements

Time

Setting

Service Type

8Parameters: 6 Phases3 ElementsSeveral EBPs

EBPs

IMR

Family PsyEd

ACT

IDDT

Supp Empl

Supp Hous

Parameters: 6 Phases3 ElementsSeveral EBPs15 Aspects

9

EBPs

IMRFamily PsyEd

ACT

IDDT

Supp Empl

Supp Hous

10Immediate1. Psychiatric2. Medical3. Functional4. Financial

Important5. Legal6. Educational7. Residential8. Occupational

Convenient9. Transportational10.Social 11.Emotional12.Recreational

Discretionary13. Cultural14. Political15. Spiritual

11

EBPs

IMRFamily PsyEd

ACT

IDDT

Supp Empl

Supp Hous

12

Phase of Care

Elements of Care Crisis Care Critical Care Containment Care Remediation Care Rehabilitation Care

Recovery Care

Timeframe 1-4 days

5-14 days 2-8 weeks 4-16 weeks 6-18 months 1-5 years

Timeline—Compressed (< 2 years)

Day 1 to Day 4 Day 5 to Day 10 Day 11 to Day 25 Day 26 to Day 50 Day 51 to Day 231

Day 232 to Day 597

Timeline—Extended (~7 years)


Day 731 to Day 2556

Typical Settings Inpatient

Hospital ER

Intensive detox unit

Inpatient

Hospital Level IV

Inpatient

Hospital Level III

Institutional

Partial Hospitalization

Group focus

Intensive Residential

Intensive Outpatient

Communal housing

Outpatient

Individual housing

Group housing

Alternative Settings

Soteria Homes Soteria Homes

Therapeutic Communities



Oxford Houses


Oxford Houses

Clubhouses

Service Types Private hospitals

Public hospitals

Intermediate residential clinics

Family support groups

State hospitals

Private hospitals

Private residential programs

Wilderness programs

Self-help groups (i.e. 12 step programs)

Step-down group living

Community behavioral health programs

Adult foster care

PACT teams

Public clinics

Private providers

Self-help centers

Clubhouses

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13

Phase of Care


Recovery Care

Timeframe 1-4 days




Day 232 to Day 597



Day 731 to Day 2556


Hospital ER


Inpatient

Hospital Level IV

Inpatient

Hospital Level III

Institutional


Group focus



Communal housing

Outpatient

Individual housing

Group housing






Oxford Houses


Oxford Houses

Clubhouses


Public hospitals



State hospitals

Private hospitals


Wilderness programs




Adult foster care

PACT teams

Public clinics

Private providers

Self-help centers

Clubhouses

13

14

Phase of Care


Recovery Care

Timeframe 1-4 days




Day 232 to Day 597



Day 731 to Day 2556


Hospital ER


Inpatient

Hospital Level IV

Inpatient

Hospital Level III

Institutional


Group focus



Communal housing

Outpatient

Individual housing

Group housing






Oxford Houses


Oxford Houses

Clubhouses


Public hospitals



State hospitals

Private hospitals


Wilderness programs




Adult foster care

PACT teams

Public clinics

Private providers

Self-help centers

Clubhouses

14

15

Phase of Care


Recovery Care

Timeframe 1-4 days




Day 232 to Day 597



Day 731 to Day 2556


Hospital ER


Inpatient

Hospital Level IV

Inpatient

Hospital Level III

Institutional


Group focus



Communal housing

Outpatient

Individual housing

Group housing






Oxford Houses


Oxford Houses

Clubhouses


Public hospitals



State hospitals

Private hospitals


Wilderness programs




Adult foster care

PACT teams

Public clinics

Private providers

Self-help centers

Clubhouses

15

16

Phase of Care


Recovery Care

Timeframe 1-4 days




Day 232 to Day 597



Day 731 to Day 2556


Hospital ER


Inpatient

Hospital Level IV

Inpatient

Hospital Level III

Institutional


Group focus



Communal housing

Outpatient

Individual housing

Group housing






Oxford Houses


Oxford Houses

Clubhouses


Public hospitals



State hospitals

Private hospitals


Wilderness programs




Adult foster care

PACT teams

Public clinics

Private providers

Self-help centers

Clubhouses

16

17

Phase of Care


Recovery Care

Timeframe 1-4 days




Day 232 to Day 597



Day 731 to Day 2556


Hospital ER


Inpatient

Hospital Level IV

Inpatient

Hospital Level III

Institutional


Group focus



Communal housing

Outpatient

Individual housing

Group housing






Oxford Houses


Oxford Houses

Clubhouses


Public hospitals



State hospitals

Private hospitals


Wilderness programs




Adult foster care

PACT teams

Public clinics

Private providers

Self-help centers

Clubhouses

17

18

Phase of Care


Recovery Care

Timeframe 1-4 days




Day 232 to Day 597



Day 731 to Day 2556


Hospital ER


Inpatient

Hospital Level IV

Inpatient

Hospital Level III

Institutional


Group focus



Communal housing

Outpatient

Individual housing

Group housing






Oxford Houses


Oxford Houses

Clubhouses


Public hospitals



State hospitals

Private hospitals


Wilderness programs




Adult foster care

PACT teams

Public clinics

Private providers

Self-help centers

Clubhouses

18

19

Phase of Care

Aspect of Need Crisis Care Critical Care Containment Care

Remediation Care Rehabilitation Care

Recovery Care

Immediate Psychiatric Stabilization Meds:

establishment

IDDT Treatment Approach commenced (for dual diagnosis)

1..Diagnosis proferred

Meds: adjustment

Trauma therapy

Meds: refinement

Cognitive therapy

Family therapy

2. Diagnosis confirmed

Meds: management

Cognitive therapy

Family therapy

Meds: maintenance

Therapy (ongoing)

Medical Intensive Detoxification

Essentials replenishment

Basic health restoration

Smoking cessation Basic health improvement

Good health maintenance

Functional Bewilderment reduction

Basic coping skills Basic social skills Intermediate coping skills

Intermediate social skills

Financial Individual and family health insurance terms reviewed and confirmed

3. Disability application submittedDisability financial supports researched

4. Disability application approvedSSI/SSDI begun

Medicaid begun

Food stamps begun

Representative payee appointed

Individual bank accounts opened

Rent supports researched

Medicare commenced (two years after Medicaid)

Financial wellness measures undertaken

Financial independence goals established

Disability support transition programs studied

5. Disability supports transcended.

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20

Phase of Care



Recovery Care

Immediate Psychiatric Stabilization Meds:

establishment

IDDT Treatment Approach commenced (for dual diagnosis)1..Diagnosis proferred

Meds: adjustment

Trauma therapy

Family education

Meds: refinement

Cognitive therapy

Family therapy

Family Psychoeducationnfirmed

Meds: management (IMR)Cognitive therapy

Family therapy

Meds: maintenance

Therapy (ongoing)

Medical Intensive Detoxification

Essentials replenishment

Basic health restoration

Smoking cessation Basic health improvement

Good health maintenance

Functional Bewilderment reduction

Basic coping skills Basic social skills Intermediate coping skills

Intermediate social skills

Financial Individual and family health insurance terms reviewed and confirmed

3. Disability application submittedDisability financial supports researched

4. Disability application approvedSSI/SSDI begun

Medicaid begun

Food stamps begun

Representative payee appointed

Individual bank accounts opened

Rent supports researched

Medicare commenced (two years after Medicaid)

Financial wellness measures undertaken

Financial independence goals established

Disability support transition programs studied

5. Disability supports transcended.

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21Important

Legal Resolution of pending cases

Special Needs Trust considered.

Independent legal status established.

Family Financial Planning begun

Special Needs Trust established

Reconciliation of family estate planning documents with Special Needs Trust

Advance Directive prepared

Educational Basic Individual PsychoeducationNAMI Family-to-Family Education

PsychoeducationFamily-to-System education (to be developed)

Multifamily Group (MFG) joined

Wellness and Recovery Action Plan (WRAP)Education about financial wellness considered.

Multifamily Groups

Supported Education considered

Supported Education commenced

Residential Housing options researched

Supported Housing considered

Housing applications started

Housing found

Housing arranged

Occupational Job and work strategy considered

Supported Employment considered

Ticket to Work options explored

Job counselor sought

Job search prepared

Job sought

Job found

Work engaged

Phase of Care



Recovery Care

21

22Convenient

Transportational Transportation supplements (medical transport) engaged

If Medicaid eligible and owning a care, explore special auto insurance programs (e.g., NJ’s “Dollar a day” program)

Social Connect with support groups (e.g., NAMI Just Friends, CSP Self-Help Centers)

Join a Clubhouse

Emotional Recreational

Discretionary Cultural Political Participate in

advocacySpiritual Deny Curse Question Accept Reconcile Embrace 22

23Evidence Based Practice

Crisis Care Critical Care Containment Care Remediation Care Rehabilitation Care

Recovery Care

IMR

Fam PsychEd

ACT

IDDT

SuppEmpl

SuppHous

SuppEd

Phase of Care

EBPs

IMRFamily PsyEd

ACT

IDDT

Supp Empl

Supp Hous

23



Recovery Care

IMR

Fam PsychEd

ACT

IDDT

SuppEmpl

SuppHous

SuppEd

Phase of Care

EBPs

IMRFamily PsyEd

ACT

IDDT

Supp Empl

Supp Hous

24



Recovery Care

IMR

Fam PsychEd

ACT

IDDT

SuppEmpl

SuppHous

SuppEd

Phase of Care

EBPs

IMRFamily PsyEd

ACT

IDDT

Supp Empl

Supp Hous

25



Recovery Care

IMR

Fam PsychEd

ACT

IDDT

SuppEmpl

SuppHous

SuppEd

Phase of Care

EBPs

IMRFamily PsyEd

ACT

IDDT

Supp Empl

Supp Hous

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27

What EXACT Service Steps For Each EBP?

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For example…ACT(SAMHSA, 2008)

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Supported Housing Services…(SAMHSA, 2008)

Mental Health Services Psychological assessment Counseling Group therapy Support groups Recovery classes Peer mentoring Psychoeducation Psychiatry appointments Therapy

Substance Abuse Stages-of-change assessment Motivational interviewing Relapse prevention Counseling Methadone services AA/NA groups Sober recreation

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Vocational and Employment Job readiness training Job retention classes Job development services Job skills training Education Onsite employment

Health and Medical Services Routine medical care Medication management Health/wellness education Nurse care Home health aide HIV/AIDS services Physical therapy Pain management


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To Support Retention Tenant orientation Tenant councils Case management Psychosocial assessment Service planning Counseling Referrals Crisis intervention Peer mentoring Support groups

Independent Living Skills Communication skills Conflict resolution Budgeting Representative payee Cooking Personal hygiene Self care Housekeeping

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Medicaid: How To Pay?

Now… “Medical Necessity”

Should be… “Recovery Necessity”

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What Is Paid Now?...

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34

What Is Paid Now?...

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What Necessary Services Not Paid By Medicaid?

36

Can NJPRA…? Establish all the steps necessary in our EBPs? Determine which steps are and are not paid by NJ Medicaid? Present this “gap analysis” to NJ Medicaid? Propose and advocate for a such a “top down” strategy for

Medicaid rate setting?

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References

Substance Abuse and Mental Health Services Administration. (2008). Assertive community treatment: Evidence-based practices (EBP) kit. (DHHS Pub. No. SMA-08-4344). Rockville, MD: Center for Mental Health Services Retrieved from http://store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA08-4345.

Substance Abuse and Mental Health Services Administration. (2010). Permanent supportive housing: Evidence-based practices (EBP) kit. (HHS Pub. No. SMA-10-4509). Rockville, MD: Center for Mental Health Services.

http://store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA08-4345

http://store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA08-4345

medicaid rate setting and psyr practices

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