Narrowing the Gap in Recovery-Oriented Community Services...Peer-run programs uControlled and...

Narrowing the Gap in Recovery-Oriented

Community Services

A presentation by Alyssum, Another Way Community Center, Pathways Vermont, and Vermont Psychiatric Survivors

October 22, 2019

Vermont Department of Mental Health Conference

Killington, VT

About the presenters

Promise of 2012 Act 79

“It is the intent of the general assembly to strengthen Vermont’s existing mental health care system by offering a continuum of community and peer services, as well as a range of acute inpatient beds throughout the state. This system of care shall be designed to provide flexible and recovery-oriented treatment opportunities and to ensure that the mental health needs of Vermonters are served.”

Source: Act 79. An act relating to reforming Vermont’s mental health system. (H.630), sec. 1.

Peer-run programs

u Controlled and operated by people with lived experience of mental health challenges and/or mental health system

u Non-judgmental

u Values-driven approach that promotes multiple perspectives

u Advocates for human rights and dignity

u Focuses on genuine, mutual relationships

u Result in significantly fewer hospitalizations

Source: Mead, S., & Hilton, D. (2003). Crisis and Connection, Psychiatric Rehabilitation Journal, 27, 87-94; Dumont, J. & Jones, K. (2002, Spring). Findings from a consumer/survivor defined alternative to psychiatric hospitalization. Outlook, 4-6; Burns-Lynch, B., & Salzer, M.S. (2001). Adopting innovations – lessons learned from a peer based hospital diversion program. Community Mental Health Journal, 37, 511-21.

Vermont Psychiatric Beds, By Type

184149 151 151

188 188 199 199 201 213

1836 37 37

49 49 49 49 49 4927

33 33 36

36 36 36 36 36 36

0 2 2 2

2 2 2 2 2 2

0 0 0 0

5 55 5

5

5

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020*

Psychiatric Beds, By TypeInpatient Intensive Residential Recovery Crisis Bed Peer Respite Peer Intensive Residential Recovery

Source: 2019 VT DMH

*Projected

DMH Peer Services Funding

FY2018Level

14% DMH Admin

4%

AOP, Addult

Community etc.5%

CRT26%

Emergency Grants

5%

Peer Supports

1%

Childrens Services

45%

MTCR1%

VPCH9%

Expenses

FY2020Level

14% DMH Admin

3%

AOP, Adult Community

Partners etc.7%

CRT27%

Emergency Grants

3%Peer

Supports1%

Childrens Services

22%

Success Beyond

Six/CUPS30%

Children's PNMI

Residential3%

Expenses

Source: FY2018 and FY2020 Proposed Expenses (VT DMH)

Emergency department visits resulting in psychiatric diagnosis, 2002 - 2017

7,9568,345

8,8219,410

10,088 10,08910,666

10,329

11,54512,042 12,138

12,483 12,48513,257

13,85214,462

0

2000

4000

6000

8000

10000

12000

14000

16000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Source: Vermont Uniform Hospital Discharge data set that is publicly available online at http://www.healthvermont.gov/health-statistics-vital-records/health-care-systems-reporting/hospital-discharge-data.

ED Average Length of Stay

0.53 0.55

1.35 1.37 1.37 1.4 1.43 1.471.28 1.24

1.972.15 2.13

2.26 2.3

2.57

0

0.5

1

1.5

2

2.5

3

2010 2011 2012 2013 2014 2015 2016 2017

Day

s

All ED Psychiatric ED

Source: Vermont Uniform Hospital Discharge data set that is publicly available online at http://www.healthvermont.gov/health-statistics-vital-records/health-care-systems-reporting/hospital-discharge-data

Typical Psychiatric ED Visitor

2010u More than half under 40 years old,

with 18 -24 most prevalent (18.6%)

u Slightly more males (50.4%)

u 11.7% uninsured

u UVM Medical Center (28.9%)

u Discharged to home (78.3%)

u Average LOS 1.28 days

u Primary Dx, mood disorder (25.6%)

2017u More than half under 40 years old,

with 18-24 most prevalent (16.3%)

u Slightly more males (51%)

u 7% uninsured

u UVM Medical Center (28.4%)

u Discharged to home (77.7%)

u Average LOS 2.57 days

u Primary DX, alcohol-related (27.6%)


ED Visits CCS Diagnoses, By Prevalence

2010u Mood disorders (25.6%)

u Alcohol-related disorders (21.9%)

u Anxiety disorders (18.9%)

u Substance related disorders (9.7%)

u Schizophrenia and other psychotic disorders (5.6%)

2017u Alcohol-related disorders (27.6%)

u Mood disorders (18.7%)


u Suicide and intentional self-inflicted injury (10.5%)

u Substance-related disorders (9.0%)


2017 ED Length of Stay, by disposition

1

45

1 1

9

1 1

2.83

8.69

14.84

2.73 2.27

9.5

1.982.57

0

2

4

6

8

10

12

14

16

Another acutehospital

Skillednursingfacility

Intermediatecare

Anotherfacility

Home Hospice AgainstMedicalAdvice

Overall,psychiatric

Day

s

Median LOS Average LOS


Psychiatric inpatient discharges originating in ED, 2007 - 2017

55.7

0%

54.6

0%

55.8

0%

59%

57.8

0%

56.3

0%

57.8

0%

57.4

0% 68% 72

.60%

77.6

0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

PSYCHIATRIC


Inpatient psychiatric diagnoses, by prevalence

2010u Mood disorders (37.6%)



u Substance related disorders (9.4%)


2017u Mood disorders (27%)


u Suicide and intentional self-inflicted injury (18.6%)


u Substance related disorders (5%)


Drivers of ED Visits – VPS Study

uHomelessnessuPain of isolationuInterpersonal conflict in the homeuMania

Source: Vermont Psychiatric Survivors. Report-Addendum to the Legislature on the Implementation of Act 82 Sec. 5, InvoluntaryTreatment & Medication Review, January 15, 2018, at p. 4. Accessed on March 8, 2019,https://legislature.vermont.gov/Documents/2018/WorkGroups/House%20Health%20Care/Reports%20and%20Resources/W~Vermont%20Psychiatric%20Survivors~Report%20Addendum%20to%20the%20Legislature%20on%20the%20Implementation%20of%20Act%2082%20Sec.%205,%20Involuntary%20Treatment%20and%20Medication%20Review.%201-15-2018~5-4-2018.pdf.

Drivers of ED visits – case study

Chief Complaint:“I overdosed on Prozac because I had no where to go.”

Needs to obviate ED visits

u Housing (75 percent)

u Friends

u Supportive family

u Physical affection

u Someone with whom to talk

u A known, alternative to the emergency department

Source: Vermont Psychiatric Survivors. Report-Addendum to the Legislature on the Implementation of Act 82 Sec. 5, Involuntary Treatment & Medication Review, January 15, 2018, at p. 4. Accessed on March 8, 2019,https://legislature.vermont.gov/Documents/2018/WorkGroups/House%20Health%20Care/Reports%20and%20Resources/W~Vermont%20Psychiatric%20Survivors~Report%20Addendum%20to%20the%20Legislature%20on%20the%20Implementation%20of%20Act%2082%20Sec.%205,%20Involuntary%20Treatment%20and%20Medication%20Review.%201-15-2018~5-4-2018.pdf

Risks and Challenges of Increased Inpatient Beds

u Increased barrier daysuStaffing shortages

uLoss of Medicaid Funding through IMD Exclusion

u Increased risk of suicide following discharge from psychiatric hospital

Investment in additional community resources required

“… there is a continuing need and opportunity to provide increased community capacity to offset unnecessary ER wait times or inpatient admissions.”

2019 Report to Legislature, Agency of Human Services

Characteristics of future investments

u Align with the goal of recovery-oriented mental health system

u Significantly increase community capacity to keep pace with planned inpatient psychiatric beds

u Mitigate risks and address challenges created by planned increase in inpatient psychiatric beds

The Proposal: Network of Community Centers with attached 2-bed Peer Respite

u Six, new peer-run community centers

u Affiliated two-bed peer respites

u Located across Vermont to provide access as close to an individual’s home as possible

u Operated as a statewide association

Benefits of network of community centers and attached 2-bed peer respites

u Divert individuals away from inpatient hospitalization

u Provide a step-down from inpatient hospitalization

u Provide community services the lack of which currently prolong inpatient hospitalization

u Do not increase risk of suicideu Achieve economies of scale

Community Centers Description

u Currently two peer-run community centers in Vermont: Another Way in Montpelier and Pathways Community Center in Burlington

u Address social isolation and lack of social connectedness that some ED visitors say they feel

u Offer a range of services, including peer support, support groups, housing and employment assistance, transportation, art, music, meals, Internet access, body work, recreation, exercise, showers

u Also offer opportunities to develop new social and interpersonal networks

Source: Barker, Stephanie L.; Maguire, Nick. “Experts by Experience: Peer Support and its Use with the Homeless,” Community Ment Health J (2017) 53: 598-612. DOI 10.1007/s/0597-017-0102-2.

Peer-Run Respites Effectiveness

u Peer respite guests 70 percent less likely to use inpatient or emergency services

u Respite days associated with fewer inpatient and emergency service hours

u Respite guests showed statistically significant improvements in healing, empowerment, and satisfaction

u Average psychiatric costs for respite users and non-users were $1,057 and $3,187, respectively

u Respite guests experience greater improvements in self-esteem, self-rated mental health symptoms, and social activity functions compared to inpatients at psychiatric facilities

Source: Croft, B, & Isvan, N. (2015). Impact of the 2nd Story Peer Respite Program on Use of Inpatient and Emergency Services, Psychiatric Services, 66(6), 632-637; Greenfield, T.K., Stoneking, B, Humphreys, J, Sundby, E, & Bond, J. (2008). A Randomized Trial of a Mental Health Consumer-Managed Alternative to Civil Commitment for Acute Psychiatric Crisis. American Journal of Community Psychology, 42(1), 135-144; Dumont, J, & Jones, K. (2002). Findings from a consumer/survivor defined alternative to psychiatric hospitalization. Outlook (Vol. Spring 2002, pp. 4-6). Cambridge, MA: Evaluation Center @ HSRI and National Association of State Mental Health Program Directors (NASMHPD) Research Institute.

Vermont’s current peer/crisis respites

Peer-Run Respiteu Alyssum, a 2-bed peer respite

located in Rochester (Windsor County)

u Drew guests from every Vermont county except Essex, Grand Isle, and Lamoille

u FY2018 operated at 92% capacity

u Five-day wait time for a bed

System-Run Respitesu 36 crisis beds in designated agency

system

u FY2018 operated at 75% capacity, below DMH’s targeted 80 percent occupancy rate

u No wait time for a bed

Source: van den Berg, Gloria. “Alyssum Fiscal Year 2018 Fourth Quarter and Year End Program Report,” at pp. 1-3. (June 30, 2018). Availablethrough the Vermont Department of Mental Health and Alyssum.

Startup Costs – Independent versus Network Structure

uProposed roll-out calls for staggered opening of centers over six years

u Independent structure startup costs total approximately $987,299

uNetwork structure startup costs total approximately $590,966

Operating expenses – independent structure

Year Year Year Year Year Year1 2 3 4 5 6

Number of Centers Added 1 0 1 1 2 1Number of Centers at Year End 1 1 2 3 5 6

Personnel ExpensesSalaries and Wages $550,994 $550,994 $1,101,988 $1,652,982 $2,754,970 $3,305,964 Fringe Benefits $131,560 $135,016 $277,358 $427,686 $733,392 $906,249

Total Personnel Expenses $682,554 $686,010 $1,379,346 $2,080,668 $3,488,362 $4,212,213

Building Expenses $52,200 $52,200 $104,400 $156,600 $261,000 $313,200

General and Administrative $45,450 $45,450 $90,900 $136,350 $227,250 $272,700

Respite Program Expenses $32,025 $32,025 $64,050 $96,075 $160,125 $192,150

Community Center Program Expenses $19,820 $19,820 $39,640 $59,460 $99,100 $118,920

TOTAL EXPENSES $832,049 $835,505 $1,678,336 $2,529,153 $4,235,837 $5,109,183

Operational Statistics – Year Six

u Six Community Centers serving approximately 4,100 unique visitors annually

u Six, 2-bed Peer Respites serving approximately 540 guests per year, assuming 87 percent occupancy and average length of stay of one week

u 98 new jobs with weighted average wage per new job of $21.64/hour

Comparison of Annual Cost/Unique Individual

$568

$634

$693

$790

$1,101

$1,425

$2,537

Vermont Recovery Network Recovery Center/Unique Visitor

Peer-Run Respite bed

Designated Agency Crisis bed

Intensive Residential bed

Peer Respite + Community Center/Unique Visitor

Designated Hospital bed

Vermont Psychiatric Care Hospital bed

Cost/Individual

Source: Vermont Care Partners. “FY2018 Outcomes and Data Report,” p.14 (2018); Vermont Department of Health, Division of Alcohol andDrug Abuse Programs. “Annual Overview 2017,” p. 3 (2017). Accessed on March 8, 2019http://www.healthvermont.gov/sites/default/files/documents/pdf/ADAP_Annual_Overview.pdf

Return on Investment

u 45% ROI ($7.1MM) from hospital diversion

u 91% ROI ($14.2 MM) from hospital diversion plusdecreased barrier days

Potential Funding Sources

u Tobacco Master Settlement Agreement ($59 million in 2018)

u Volkswagen Settlement

u Northern Border Regional Commission grant ($7.9 million in 2019)

u Other grants

For more information

Wilda L. [email protected]

and

Creating a Network of Peer-Run Community Centers and Two-Bed Peer Respites: Narrowing the Gap in Recovery Oriented Community Services (A White Paper)

mailto:[email protected]

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