visit with........................... scotch plains, nj, january 24, 2014

Visit with ...........................

Scotch Plains, NJ, January 24, 2014

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Outline

PsyR: What? Where? Who?

NJPRA World: Sector Analysis

NJPRA Stand: Issues and Positions

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Psychiatric Rehabilitation: What? Where? Who?

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What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

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What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

Psychosocial

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What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

SchizophreniaBipolarSchizoaffectiveBorderlineDepression

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What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

CopingRelaxation

LivingFinancial

SocialEmploymentEducationHousing

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What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

Social lifeClubs

Church

FriendsLover

SpouseCollege

Grad SchoolTech School

WorkerManagerVolunteer

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What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

ChoiceCommunity

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What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

ProgramsDoctors

Hospitals“Interventions”

“Disability” supportsSSI / SSD

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What is PsyR?

...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

“Stabilization”Remission“Normal”

AdjustmentActualizationAutonomy

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Recovery Principles...

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What Is PsyR?

A goal

A role

A specialty

A discipline

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Who Provides PsyR?

Psychiatrists

Psychologists

Nurses

Social Workers

Direct Care

Peer Providers

Consumer

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Where is PsyR? Day services Residential abodes Case management PACT (Programs of Assertive Community

Treatment) Vocational programs Educational programs Hospitals Families Peer initiatives

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Why PsyR? Severe and persistent mental illness is...

Long term Recurrent Difficult Disruptive (of life) Interruptive (of development) Debilitating (of capacity)

PsyR thus advances... Long-term recovery Community integration Quality of life

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PsyR Values Self determination Individual dignity and worth Individual potential Cultural sensitivity Hope

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PsyR Principles Individual services Maximum individual choice Normalized community basis Strengths-based Situational assessments Holistic, integrated supports and skills training Accessible, coordinated services Environmental modifications Partner with families Practical outcomes

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Challenges to PsyR Institutional pessimism Organizational barriers Training demands Funding shortages Quick-fix thinking “Courtesy” stigma

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Since 1975 Formerly IASPRSFormerly USPRA8000 members

The National Organization

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What Is A CPRP?

“Certified Psychiatric Rehabilitation Practitioner”

Supervised by the Commission

Partly “founded” in NJ

Transdisciplinary

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Who Are CPRPs

Professors Melissa Roberts, PhD, CPRP Doctors Psychologists Social Workers Nora Barrett, MSW, CPRP Occ. Therapists Managers Tom Pyle, MBA, CPRP Peer Specialists Harry Coe, CPRP Nurses Direct Care

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The State Organization

1000 individual members

A leading state chapter (along with NY, CA,

MA, IL, GA...) 501c4 501c3

A 2 day annual conference > 250 people

Various trainings Advocacy work

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Organizational Members

• Advance Housing• Atlanticare• Bridgeway• CareLink • Collaborative Support

Programs of NJ• Consumer Provider

Association of NJ• Greater Trenton

Behavioral Healthcare

• Northwest Essex • Project Live, Inc.• Prospect House (MHA

of Essex County)• SERV Behavioral

Health Triple C Housing• Rutgers PsyR Dept.• Volunteers of America

(Greater New York)

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Sector Analysis

Government, Industry, Market, Customer, Product...

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Government of New Jersey

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Government of New Jersey

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Government of New Jersey

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Government

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Government

Increasing regulations

Electronic Medical Records

“RAC” Audits

Capricious and arbitrary administration

Industry: An Optimal Tx Plan?Intensity Level 5

Hospital Setting (Highly Staffed)

Level 4 Professional Care Setting (Moderately Staffed)

Level 3 Residential (Treatment) Setting

Level 2 Partial Hospitalization (Day Program)

Level 1 Community (Outpatient)

Very High

High

Moderate

Low

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Industry: An Optimal Tx Plan?Intensity Level 5

Hospital Setting (Highly Staffed)

Level 4 Professional Care Setting (Moderately Staffed)

Level 3 Residential (Treatment) Setting

Level 2 Partial Hospitalization (Day Program)

Level 1 Community (Outpatient)

Very High

High

Moderate

Low

1.Hospital

Need(IDDT)

2.TreatmentResidential

3.SupportedResidential

4. IOP

4.IndependentResidential

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Industry: Treatment vs. NeedIntensity Level 5

Hospital Setting (Highly Staffed)

Level 4 Professional Care Setting (Moderately Staffed)

Level 3 Residential (Treatment) Setting

Level 2 Partial Hospitalization (Day Program)

Level 1 Community (Outpatient)

Very High

High

Moderate

Low

Hospital

CurrentTx

Gap

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Industry: Tx vs. Need: ChoicesIntensity Level 5

Hospital Setting (Highly Staffed)

Level 4 Professional Care Setting (Moderately Staffed)

Level 3 Residential (Treatment) Setting

Level 2 Partial Hospitalization (Day Program)

Level 1 Community (Outpatient)

Very High

High

Moderate

Low

Hospital

Need(IDDT)

Therapeutic Communitie

s

Clinical Residential

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HospitalHospital

PACT

4. IOP

4.IndependentResidential

Group Homes Local

PHPSupported Housing

Local IOP

State Hospital

Industry: Tx vs. Need: ChoicesIntensity Level 5

Hospital Setting (Highly Staffed)

Level 4 Professional Care Setting (Moderately Staffed)

Level 3 Residential (Treatment) Setting

Level 2 Partial Hospitalization (Day Program)

Level 1 Community (Outpatient)

Very High

High

Moderate

Low

Hospital

Need(IDDT)

Therapeutic Communitie

s

Clinical Residential

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HospitalHospital

PACT

4. IOP

4.IndependentResidential

Group Homes Local

PHPSupported Housing

Local IOP

State Hospital

Illness Management & RecoverySupp HousingSupp Education

Supp Employ

Assertive Community Treatment

Family Psychoeducation

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Industry: 120 AgenciesOf which... Bridgeway Catholic Charities Drenk Easter Seals Family Services Greater Trenton Mental Health Assn Essex Twin Oaks ...others...

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Industry: Specialty Providers Supported Housing: 46 agencies

Supported Employment: 22 agencies

Consumer-operated: 33 centers

State Hospital patients: ~1500 per year

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Market: Medicaid Enrollments(Centers for Medicare and Medicaid, 2012)

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Market: NJ Medicaid Enrollment

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Customer: Consumers

DMHAS BG appl. says...

Governor’s budget says..

285,000 “unduplicated consumers in community settings”, of which...

123,000 with SMI

Community Care Services 329,664Screening Services 98,217Outpatient Services 136,704Partial Care 12,127Residential 3,499Supported Housing 5,858Supported Employment 2,371Self-help Centers 6,240Integrated Case Mgt 10,725PACT 2,443

State Psychiatric Hospitals 1,500

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Product: PsyR Evidence-Based Practices

Illness Management and Recovery Integrated Dual Disorder Treatment Assertive Community Treatment Family Psychoeducation Supported Employment Supported Education* Supported Housing* Other “promising” practices

PsyR Recovery

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Recovery: As Outcome

RECOVERY

time

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Recovery: As Process

RECOVERYtime

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Recovery: 3 Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

time

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Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

time

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Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

Illness Management & Recovery

time

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Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

Supported Housing

Illness Management & Recovery

time

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Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

Supported Education

Supported Housing

Supported Employment

Illness Management & Recovery

time

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Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

Supported Education

Supported Housing

Supported Employment

Illness Management & Recovery

Family Psychoeducation

Assertive Community Treatment

time

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US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

Finance: Rate Ratio (Zuckerman et al., 2009)

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US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

Finance: Rate Ratio (Zuckerman et al., 2009)

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US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

Finance: Rate Ratio (Zuckerman et al., 2009)

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US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

50th

!

Finance: Rate Ratio (Zuckerman et al., 2009)

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Industry: Providers = f(Rate Ratio) (Decker, 2013)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

% doctors accepting

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Competition (“Stakeholders”)

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Competition (“Stakeholders”)

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Competition (“Stakeholders”)

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Competition (“Stakeholders”)

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Competition (“Stakeholders”)

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Competition (“Stakeholders”)

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Issues and Positions

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3 Mega Issues affecting PsyR

1. “Biological Reductionism”

2. Managed Care

3. Medicaid Expansion

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1. Reductionism

Paternalism

“Brain” over “mind

ST over LT

“Evidence”: only RCTs...

Problems:Stigma. Pharmacology.

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2. Behavioral Health Managed Care

Administrative Services Organization (ASO)

Fee-for-service

Problems: Cost reduction, NOT value optimization...

Incremental care, NOT continuum of care...Stressed operations: compliance

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3. Medicaid Expansion

Medicaid funds 65% of public mental health

Enrollment: 25% 234,000 new beneficiaries in NJ

Providers: no increase, likely decrease

Problems:Access, Availability,

Quality, Cost, Innovation

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Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

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Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

COLA

CPRP (dissemination)

Pay parity (with hospitals)

Training (R-SHRP)

Licensing (hurdles)

Peer Providers

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Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Transition support ($)

“RAC” auditing

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Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Medicaid Rate Setting

“Medical Necessity”

Community Support Services (CSS)

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Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Supported Housing (a “medical necessity”)

Supported Employment (“balkanized” process)

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Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Support Olmstead funding (for housing)

Oppose National Registry

Improve crisis screening

Support CIT for police

Benefits parity for “old” Medicaid eligibles

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Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Mental health courts

More and better outcome measurements

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Advocacy: NJPRA Strategy

More diversification of outreach

More individualized positioning

Higher public profile

More impact

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Advocacy: What NJPRA Needs...

More non-legislative representation A meeting with Governor’s office More focus on Medicaid office and rate setting process More “assertion” with DMHAS More help with interdepartmental contact, e.g. DCA

More press contacts and networks News articles Radio and TV appearances

More contacts with philanthropies, corporations