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BEHAVIORAL HEALTH ADMINISTRATION Annual Conference Presentation

Barbara J. Bazron, Ph.D., Deputy Secretary Behavioral HealthDate: May 3, 2017

VISION

Improved health, wellness, and quality of life for individuals across the life

span through a seamless and integrated behavioral health system of care.

MISSION

The BHA will, through publicly-funded services and support, promote recovery,

resiliency, health and wellness for individuals who have or are at risk of

emotional, substance related, addictive and/or psychiatric disorders to improve

their ability to function effectively in their communities.

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Note: Based on claims data through 01/31/2017. Total Individuals is an unduplicated count of individuals receiving mental health or substance use disorder services in the PBHS.Dually Diagnosed are those individuals receiving services in the PBHS with MH and SUD diagnoses during the year.Claims can be submitted up to 12 months from the service date and therefore data regarding FY 2016 and FY 2017 are incomplete now.

Total Number of Individuals Served in Public Behavioral Health System FY 16 and FY 17

198,196

67,832

52,656

0

50,000

100,000

150,000

200,000

250,000

300,000

FY 2016 FY 2017

241,602TOTAL INDIVIDUALS

TOTAL INDIVIDUALSTOTAL

DUALLY DIAGNOSED INDIVIDUALS

DUALLY DIAGNOSED INDIVIDUALS

4

Individuals Receiving Mental Health Services in Maryland’s Public Behavioral Health System

0

50,000

100,000

150,000

200,000

250,000

FY 2015 FY 2016

188,315203,546

Note: Based on claims data through 01/31/2017. Claims can be submitted up to 12 months from the service date and therefore data regarding FY 2016 and FY 2017 are incomplete now.

• 8.09% increase from FY 2015 to FY 2016

5

Individuals Receiving Substance Use Disorder Services in Maryland’s Public Behavioral Health System

Note: Based on claims data through 01/31/2017. FY 2015 data for substance use disorder services is for only six months January through June 2015. Claims can be submitted up to 12 months from the service date and therefore data regarding FY 2016 is incomplete now.

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

FY 2015 FY 2016

51,832

75,766

6

1. Moving towards an integrated system of care.

2. Improving access and quality of care throughout the

continuum of care.

3. Build the infrastructure to support capacity to collect,

analyze and track data to improve service outcomes.

4. Develop and implement population-based efforts to

promote wellness, improve overall health and ensure safety

of people in care, their families and communities.

5. Review the array of services provided to individuals

requiring in-patient care to develop specific strategies to

address hospital capacity.

FY 2016 -2017 Goals

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Goal 1:Moving towards an integrated system of care

Service Integration is a significant systems change

process….

“With every act of creationthere is an act of destruction to make room for the new order of things.”

Pablo Picasso

1. Seamless system oversight.

2. Policy that supports best practices through the provision of resources, including funding.

3. Service delivery system provides:

• Co-occurring competent and enhanced services

• Assertive outreach and engagement

• Person-centered goals for active treatment

• Skill development and support to manage one’s illness

• Recovery services and supports.

4. Data-driven decision-making to determine what works, what does not work and why to identify/fill gaps in service.

Key Elements to Service Integration

10

Service Integration Accomplishments to Date…

1. Restructured BHA

2. Expanded the role of the Forensic Services Department

3. Reduced Wait List for State Hospitals

4. Began restructuring jurisdiction-level systems management

5. Provided funding and geo-maps to support local capacity building

6. Moved ambulatory SUD services to FFS

7. Developed residential SUD rates and established phased transfer of services

8. Provided technical assistance, support and funding for accreditation

9. 2% rate increase obtained for all providers

10.SUD Roll-over funds made available for the first time

11.Allocated $369,422,508 in funds (Federal and State) to address SUD

12.Maryland received 1115 Waiver to support reimbursement for SUD services and presumptive eligibility. Implementation process developed

13.Developed credentialing requirement for Recovery Residences

Goal 2:Increasing Access and Quality of Care

• Person-centered approach

• Expanding the Provider Network

• Expanding Services:

8-507 placements;

increasing bed capacity in hospitals;

1115 waiver to support residential care;

presumptive eligibility; tele-health applications Tele-health consultation for pediatricians serving children,

youth and OB/GYNs serving women at-risk or with SUD issues

Enhancing quality within the system of care

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• Bringing Evidence-based practices to scale

Assertive Community Reinforcement Approach (ACRA)

SBIRT (screening brief intervention and referral to treatment) is being adopted as a routine part of primary care and used in emergency rooms

SBIRT is an Integrated Early Intervention Strategy used for the purpose of identifying, reducing and preventing the misuse, abuse, and dependency on alcohol and illegal drugs.

The primary goals are to improve the health status of Marylanders through the integration of behavioral health and somatic health care services, reduce overdose deaths and promote health equality through the provision of universal behavioral health prevention and early intervention approaches, and to demonstrate increased capacity to treat SUD in underserved regions of Maryland.

SBIRT services are using a Peer Coach model in hospitals

Fatality Review Committees

Prescription Drug Monitoring Program (PDMP)

Goal: reduce Rx drug misuse & diversion

Integrated with CRISP, the state-designated health information exchange

Secure, electronic database with information on the prescribing and dispensing of Rx controlled substances

Data is reported by drug dispensers, including pharmacies and dispensing practitioners

Access granted to healthcare practitioners, licensing boards, law enforcement & specific DHMH agencies

In January 2017, clinical users generated over 189,000 queries in portal and integrationsType of User # of Registered

Users (Feb 2017)

# of Active Users

(% of Registered)

% of Licensees who

are PDMP Registered

Prescriber 22,670 17,569 (77.50%) 67.06%*

Pharmacist 4,149 3,114 (75.05%) 36.73%**

Delegates 3,607 2,117 (58.69%) N/A

Total 30,426 22,800 (74.94%) 67.46%


Enhancing Access to Care: Expansion of Residential Placements Under 8-507

$4

$5

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FY

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FY

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FY

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FY

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FY

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FY

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Budget Expenditures

in m

illio

ns

In FY 16, Governor Hogan provided an additional $3M to the Justice Reinvestment Act to support residential placements. FY 17 a total of $10.5M was available to support this service.

• Existing Capacity: BHA Contracts with 3 programs for 245 available residential treatment slots

❑ Gaudenzia - 135

❑ Jude House - 45

❑ New Horizons -65

Residential Treatment Program Capacity

Funded Treatment Slots

FY 2015 FY 2016 FY 2017

120

($6M from base budget)

180

($3M from JRA –

July 2016)

240

($1.5M from

Governor’s Budget

– January 2017)

Expanding Recovery Support through Recovery Residences

HB 1411 Requirements:

Department of Health and Mental Hygiene (DHMH) shall approve credentialing entity to develop and administer a certification process for Recovery Residences.

– Establishing processes to administer the application, certification, and recertification process

– Establishing processes to monitor and inspect recovery residences

– Issue certificate of compliance valid for one year

– Submit a list of credentialed entities by October 1, 2017

– Post list of residences on BHA website by November 1, 2017

HB 1411 - Limitations

Not all residences where individuals in recovery for a substance use disorder reside are required to become

certified. A residence must be certified if it:

– Receive funding from the Department; or

– Advertises, represents, or implies to the public that it is a recovery residence.

Implementation Plan for HB 1411 Requirements

• The Behavioral Health Administration (BHA) will be the Credentialing Entity

• Grandfathering process will be available for currently credentialed providers in good standing

• Field Assessors (BHA Consultants) will conduct housing inspections

• Consultation from Florida Association of Recovery Residences (John Lehman) used to develop the credentialing process

• Maryland Association of Recovery Residences will provide - Training & Education and Outreach

Expanding Recovery Supports - Provision of Recovery Residences in Compliance with HB1411

Credentialing

Process

Established

February 2017

Technical Assistance and

Training for Providers

• Service and environmental standards

established based upon the National

Association of Recovery Residence

(NARR) Standards

Technical Assistance

and Training to Providers

March 2017July 1, 2017 November 1, 2017

Establishing credentialing, monitoring and inspection process for

Recovery Residences (N=136 houses with a capacity of 1,271 beds)

Application

Posted on

Website and

Distributed

Applications

Due

Certification

Due for all

Recovery

Residence

Providers

List of

Credentialed

Recovery

Residences

Published

October 1, 2017

• Providers Currently

Holding

Certificates/MSARR

Membership will be

“grandfathered”

Residential Substance Use Reimbursement Process

Medicaid will pay for two 30-day stays in

a rolling calendar year.

An individual can move to another level of

care within a stay as long as there is not

more than a 48 hour break in service.

Only clinical services will be Medicaid

reimbursable.

• ASAM Level 3.3 - $189.44

• ASAM Level 3.5 - $189.44

• ASAM Level 3.7 - $291.65

• ASAM Level 3.7WM - $354.67

BHA will pay for all days over 30 days

within a stay and room and board

($45.84/day).

Transition to Fee-for-Service

Rate

Established

March 2017

Technical Assistance to

grant-funded providers

• Regulations developed and approved

• Reconfiguration of Beacon System

• Build required workflows in Beacon

System

Technical Assistance to

remaining providers

July 2017

• Transition of grant-

funded residential SUD

services.

• Levels 3.3, 3.5,

3.7/3.7D

January 2018

• Transition of grant-

funded residential SUD

services for:

• Pregnant women &

children

• Child welfare

• Drug exposed

newborns

• 8-507

Transition of Residential Substance Use Disorder Services

to Fee-for-Services

January 2019

• Transition of

grant-funded

residential SUD

services.

• Level 3.1

Moving Toward an Integrated System of CareAccreditation and Licensure

Programs will be required to be accredited by January 1, 2018 in order to be licensed.Therefore, License applications must be submitted before January 1, 2018 in order to receive a License before April 1, 2018.

Accreditation

Licensure

• Joint Commission

• CARF

• ACHC

• COA (in process)

• Fire/building codes

• Policy requirements

• Environment of care

• Quality of Care

• DHMH

Goal 3:Building the infrastructure to support system capacity to

collect, analyze and track data to improve service outcomes

Framework for Data-Driven Decision-making

R Reporting

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Data Analysis

Moving towards a Date-Driven Decision-making

Framework

1. Expansion of Outcomes Management System to include SUD

2. Data Briefs developed and distributed

3. Template for county-specific data reports on opioid drug use

and consequences developed

4. Created MD-specific overdose predictive risk model

5. Collected and analyzed non-fatal overdose data

6. Established the Applied Research and Evaluation Unit

CRISP – DATA DASHBOARD

• BHA is working with CRISP to develop data dashboards for overdose-related hospital encounters (HSCRC data) and controlled substance prescribing, dispensing and use.

• The dashboards will include dynamic maps and charts. Users will be able to filter results based on drug classes, geographic levels (state, jurisdiction, zip code) and patient demographics.

• Estimated completion of first versions in June with roll out to DHMH and LHD users soon afterward.

Goal 4:Develop and implement population based efforts to

promote wellness, improve overall health and ensure the safety of people in care, their families and communities

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Opioid Operational Command Center (OOCC)Goal: Reduce the number of deaths related to opioid use

Position Lead Agency NameOOCC Director Governor’s Office Clay Stamp

Admin Support MEMA Lydia Simonaire

Legislative Affairs Governor’s Legislative Office Chris Shank

Lead Public Information Officer Governor’s Communications Team Erin Montgomery

Joint Information Center (JIC) Manager MEMA Charissa Cooper

Legal DHMH Linda Bethman

Position Lead Agency Name

Planning Section Chief DHMH Jessica Goodell

Current Planning Unit DHMH Genevieve Polk

Situational Awareness Group - Data Unit GOCCP Angelina Guarino

Situational Awareness Group – Data Unit DHMH Michael Baier

Situational Awareness Group – Progress Reporting Unit DHMH Smita Sarkar

Future Planning Unit MEMA Kyle Overly

GIS Unit MEMA MEMA GIS Unit


Finance/Admin Section Chief DBM Nick Napolitano

Center Costs & Logistics Unit MEMA DonaldLumpkins

Crisis Costs Unit DBM Nick Napolitano

Position Role Agency Name

Operations Section Chief MEMA Elizabeth Jones

Social Services Branch Lead DHR Bethany Brown

Health and Medical BranchLead DHMH Sara Barra

Support MIEMSS Randy Linthicum

Support MIA Joy Hatchette

Public Safety BranchLead MSP Michael Parker

Support DPSCS Zola Rowlette and/or Latawyna Stallworth

Support DJS Terrence Proctor

Education BranchLead MSDE Reginald Burke

Support MHEC Emily Dow

Local Liaison BranchLead MEMA Brian Bauer

Support Baltimore Regional IMT John Scholz


Resources Section Chief GOCCP

Opioid Operations Command Center Updates

• The OOCC continues the mobilization phase (0 - 120 days) to engage partners at the state and local level working on heroin and opioid-related initiatives

• OOCC Director continues to have direct dialogue with local efforts and persons-impacted across the state to identify best practices for sharing of lessons learned and coordination of efforts for future support.

• All 24 local jurisdictions have established Opioid Intervention Teams as defined by their local partnerships and need

• Evaluate streamlining the hiring process for Peer Recovery Support Specialists by local health departments, including assessment of the DBM classification and job descriptions

• BHA helped design and contributed to the content on the OOCC website, due to launch in mid May.

• BHA also was the lead on the April 27, 2017 a twitter event sponsored by the OOCC promoting national Drug Take Back Day. The Twitter event produced more than 1.1 million impressions.

Overdose Prevention Initiatives

• Improve epidemiology & strategic planning at state & local levels– Overdose surveillance & data dissemination

– Local Overdose Fatality Review Teams

– Opioid Misuse Prevention Program

• Naloxone training & distribution (Overdose Response Program)

• Reduce Rx opioid misuse & inappropriate prescribing– Prescription Drug Monitoring Program

– Medicaid “lock-in” standardization across MCOs

– Prescriber education

• Targeted outreach to high-risk individuals for treatment & recovery support services– Overdose Survivors Outreach Program

– Medication-assisted treatment and recovery support grant

– Overdose Awareness Campaign

Outreach and Engagement

Public Education – Awareness Campaign

Collaboration with MPT on documentary on recovery from opioid addiction. (Aired February 11, 2017)

Public Service Announcements for TV and movie theaters on:

– Naloxone

– Good Samaritan

– Anti-stigma

Billboards and bus ads on naloxone

Fentanyl alert cards for high risk population

PDMP awareness outreach

Digital Stories covering treatment and recovery, fentanyl, use of naloxone, peers, medication assisted treatment

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• Estimated statewide treatment gap for opioid use disorders is for 29,909 citizens

• Key strategies:

–Support Federal expansion of the pool of prescribers to include Nurse Practitioners and Physician Assistants in addition to physicians

–Expand use of buprenorphine in Opioid Treatment Programs and Outpatient Mental Health Clinics

–Emergency Department(ED) initiative: prescribe buprenorphine in ED and use peers to link to community based providers (N=4 hospitals; Bon Secours, Harbor, Mercy and Franklin Square)

–Buprenorphine induction in SUD crisis beds to be funded by CURE Grant

–Creating statewide consultation service to support prescribers to be funded by Cure Grant

Treat Opioid Dependence - Buprenorphine Expansion

• Created to develop recommendations for managing potential impacts of programs in a community setting and quality of care standards for OTPs. Workgroup membership includes representation from BHA, the Local Addictions Authorities (LAA), Medical Care Programs (MA), Opioid Treatment Programs (OTPs), Community Representatives, and Consumer Advocates.

• Outcomes:

• Needs Assessment Report (2016), which is an analysis of treatment needs and capacity required to meet the need in each jurisdiction of the state .

• LAAs provided data to identify areas in which additional OTPs are needed. This information is shared with potential providers who are required to notify LAAs prior to submission of licensure applications.

• Compiled best practices in managing potential the impact of programs on a community.

• Obtained agreement from the Board of Professional Counselors to require specific CEUs to increase counselor competence in Medication Assisted Treatment.

• LAAs required to participate in audits, complaint investigations, and monitoring quality of care as a Condition of Grant Awards.

• Created quality of care standards in areas of staffing, training, use of the PDMP, medical coverage and treatment of individuals with co-occurring disorders.

Treat Opioid Dependence – Established the OTP Quality of Care Workgroup

Expanding Recovery Support Services

Maryland Recovery Net

State Care Coordination

Continuing Care

Recovery Community Centers

Care Coordination for Pregnant/Postpartum Women with SUD

Detoxification

Supportive Recovery Housing for Women with Children

Expand Recovery Supports

Continuum of Care Program:

Projects for Assistance in Transition from Homelessness (PATH)

Assertive Community Treatment (ACT):

Supported Employment

SOAR

Wellness and Recovery Action Plan

Peer Recovery Support Services

✓accompanying individuals to appointments/12-step meetings and leisure activities

✓providing assistance with completing paperwork for social services and other support services

✓providing assistance/preparation for employment such as shopping for work related clothing coaching to prepare for an interview

Certified Peers (N=108) perform activities aligned with four domains:

✓Advocacy

✓Recovery & Wellness

✓Mentoring & Education

✓Ethical Responsibility

Conducted Peer Listening Sessions

Expand Peer Recovery Supports

• Use of Peers throughout

system: Homeless shelters

Hospitals (N=10)

Peer Hotlines/Warm lines

First Responder/Overdose Calls

Office of Problem Solving Courts

Treatment Centers

Individual Recovery

Medicated Assisted Therapy

Physiological Therapy

Telephone Based Support

Jails/Reentry Programs

Community Outreach

Wellness Programs

Outreach and Engagement

• Assertive engagement by providers

• Community-based case management

Goal 5:Review of the array of services provided to individuals

requiring in-patient care to develop specific strategies to address hospital capacity

1. Improvements in bed capacity realized

2. Developing an implementation strategy to address the recommendations of the Forensic Services Work Group:

– Increase bed capacity

– Increase availability of community crisis services

– Expand capacity of the Office of Forensic Services

– Increase outpatient provider capacity to meet the needs of forensic patients

– Centralize DHMH forensic processes

– Increase education to reduce stigma in both the general public and the mental health treatment community

3. Forensic Services Advisory Council (FAC) established

4. Opened Segue, step-down unit, on Springfield Hospital campus

5. SETT transferred from Perkins Hospital to Springfield Hospital

6. Perkins new unit opened, which established another step-down unit

7. Enhancing service array for individuals who are forensically involved

Addressing capacity Issues in BHA hospitals

44

Actions Taken by DHMH to Address the Hospital Capacity Issue

Activity January February March April May June July August

1. DHMH hires new Behavioral Health Executive Director; CEO at Perkins and

Spring Grove Hospital Center X X X

2. BHA began tracking data weekly to monitor admissions and dischargesX

3. BHA begins an intensive discharge planning process for 98 patients “ready

to discharge.” To date, 69 have been discharged. X

4. Letter sent from Secretary Mitchell informing the judiciary of the issue

related to State hospital bed capacity X

5. DHMH staff in court to defend against finding of contempt X X X X

6. BHA implements a standardized Admissions Policy in all State facilities and

identified “intensive discharge process” for those ready to be discharged

(ongoing monitoring)X

7. Forensic Services Workgroup was convened to develop strategies to

address the capacity issue X

8. The Segue Program, operated by Way Station, opened on Springfield

Hospital campus creating 16 step-down beds X

9. Renovations began to relocate the SETT Unit from Perkins to create 16 in-

patient beds X

10. Forensic Services Work Group report submitted to the SecretaryX

45

Activity Sept Oct Nov Dec Jan Feb Mar Apr May June July

1. Recommendations by

Forensic Workgroup Report

reviewed & implementation

strategies identified

X

2. Continued to communicate

with Court Officials and

respond to Court Orders

X X X X X X X X X

3. A Forensic Advisory Board

Convened to monitor

progress and advise

Executive Director

X X

4. Moved SETT unit from

Perkins to Springfield

Hospital campus

X

5. Perkins renovation started)X

6. Closely monitoring

admissions-discharge

process

X X X X X

7. Opened Perkins UnitX

8. Draft central admissions

policy developedX

Actions Taken by DHMH to Address the Hospital Capacity Issue (continued)

46

Addressing Hospital Safety

In response to a FY 17 Joint Chairman’s Report, findings of a Security Needs Assessment were addressed.

• Needs Assessment completed in 2016

• Chief of Police was hired February 2016

• Assures that all security personnel are trained and credentialed to ensure compliance with policy and with Public Safety Article.

• Works with each hospital CEO to assess security needs, assists with recruitment and provides ongoing trainings.

• Salaries of security personnel continues to be a barrier in recruitment and retention.

Moving Forward…Developing FY17-18

Strategic Goals

Mission

Customers

Major goals for this perspective:

• Goal 1

• Goal 2

• Goal 3

Finance


• Goal 1

• Goal 2

• Goal 3

Internal Business Processes


• Goal 1

• Goal 2

• Goal 3

Learning and Innovation


• Goal 1

• Goal 2

• Goal 3

Areas of Focus

Moving Forward……

1. Integrated System of Care Development

Work with jurisdictions to integrate systems management

functions

Continue Transfer of Funds process for residential services

Implement accreditation and licensure

2. Improving Access and Quality of Services

Develop state-wide crisis service system

Establish a recovery-oriented system of care (ROSC)

Develop co-occurring capable and competent service delivery

capacity

Build provider capacity

Expand peer services

Continue efforts to address the opioid crisis

49

Moving forward….

3. Data-collection, Analysis and Tracking• Track impact of Transfer of Funds and accreditation on provide

capacity• Establish dashboards to track progress and identify gaps in services• Determine what is working, what’s not and redirect funding to support

successful efforts• Move towards value-based contracting• Acquire/develop EHR and data-tracking systems

4. Promoting Wellness, Health and Safety• Develop/implement mental health and SUD prevention activities• Continue public education and awareness activities• Continue opioid prevention, intervention efforts

5. Hospital Access• Implement recommendations from the FAC• Centralize Forensic Services

Thank you, and Enjoy your day!

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