Slide 1 Health Planning Council Meeting 5 Madeleine Biondolillo, MD Director, Bureau of Health Care...

Slide 1

Health Planning Council

Meeting 5

Madeleine Biondolillo, MDDirector, Bureau of Health Care Safety and Quality

Interim Associate CommissionerDepartment of Public Health

October 24, 2013

Slide 2

Agenda

• Approve minutes from August meeting

• Discuss proposal for first health planning analysis– Priority Area– Timeline– Deliverables– Key questions

• Presentation from the DPH Bureau of Substance Abuse Services (BSAS)

• Discuss methodological issues in projecting need

• Next steps

Slide 3

Agenda





• Next steps

Slide 4

Agenda





• Next steps

Slide 5

2013 – 2014 Proposal: Priority Area

Propose focusing existing resources on a Level III analysis of a single service line:

• Allows staff to identify methodological and process challenges and correct them in future iterations

• Pursues a rigorous, comprehensive approach to one issue area, rather than a superficial analysis of many issue areas (depth rather than breadth)

• May be able to add additional service lines, time and resources permitting Propose Behavioral Health as Year 1 focus:

• Directly relevant to all agencies represented on the council

• Significant policy interest in understanding and addressing weaknesses of the current system; active area of focus through initiatives to integrate care, address parity, improve access

• Need for immediate, purposeful study of existing resources and need

Slide 6

2013 – 2014 Proposal: Timeline

Slide 7

2013 – 2014 Proposal: Deliverables

Deliverable 1A: Analytic Outline• Description of proposed methodology for Level III analysis

• Terms requiring definitions

• Proposed data sources and analyses

• Geographic regions for subservices


• Deliverable 1B: Service Maps

• Maps of existing facilities by geographic location• Based on current definitions, databases• Broken down by services offered, number of beds (if possible)• Subject to change based on new definitions, methodologies, etc.

• Propose to include the following services:• Acute inpatient psychiatric beds (child/adult/geriatric)• Continuing care beds operated by DMH• Community mental health centers• Community Based Flexible Supports providers• Emergency Service Programs • Acute inpatient substance abuse beds (child/adult/transitional age youth)• Residential substance abuse beds (child/adult/transitional age youth)• Outpatient substance abuse counseling• Substance abuse day treatment

Slide 8


• Deliverable 2: Key Definitions• Final definitions of all terms required for Level III analysis

• Emphasis on using existing definitions as much as possible• Any new definitions developed to be vetted with expert stakeholders

Example: Day Treatment: an outpatient service providing direct client services through group, individual, and family substance abuse counseling a minimum of 3.5 hours per day five days per week (105 CMR 164).

– How does daily minimum hour requirement affect calculations of capacity?– How does single licensure category for group, individual and family substance abuse

counseling affect classification within inventory?– Are “direct client services” defined on BSAS-issued license? How variable are services?

Psychiatric nurse: a nurse licensed pursuant to section seventy-four of chapter one hundred and twelve who specializes in mental health or psychiatric nursing (MGL c. 123)

– Does “specialize” refer to BORN licensure as Psychiatric Clinical Nurse Specialist? – How can definition be expanded to capture work location, weekly hours worked, specialized

services performed, etc.? Slide 9


• Deliverable 3: Level III Analysis • As proposed by Freedman Health Care, including:

Slide 10

Deliverable Description Date (2014)

Identification of key questions

• Prioritize areas for further analysis• Ascertain whether there are areas where additional targeted data

collection is desirable/feasible

January

Estimation of Need • By service/provider/bed type• Including projections of future need

January – March

Definitions • Drafted and vetted with stakeholder participation• To include ideal occupancy rates and other standards

February – March *Deliverable 2

Inventory • Start with services included in Deliverable 1 Maps, with potential for additional refinement

January - May

Analysis of Capacity

• Based on accepted industry standards, where possible• Standards vetted with experts and stakeholders, if needed

April - June

Issues Brief • Identification of laws, policies, etc. known to affect system• Narrative description of expected effect

May - July

Public Hearings • Goal to hold hearings in geographic areas of state identified as being over- or under-capacity in analysis

August – October

Final Report • Completed and submitted to legislature December*Deliverable 3

Slide 11

2013 – 2014 Proposal:Methodology

Key Questions for Analysis:

•Are there particular aspects of the behavioral health system that should be prioritized for analysis?

•What are the major challenges in the current system?

•Where are there major data gaps that the Council should consider addressing?

•What are key factors that are impacting the system that need to be taken into account (on both supply and demand side)?

– E.g. Supply side: training pipeline, role of non-physician providers, organizational changes in health care delivery system, changes to payment structure

– E.g. Demand side: population growth and demographic changes, geographic patterns, coverage changes, underlying disease prevalence, changes in treatment methods (pharmacological vs. behavioral interventions), patient experience with care

Behavioral Health

Slide 12

• Developing a taxonomy of the care system

Taxonomy for Adult Mental Health Services

(For Discussion)

Slide 13

Slide 14

Agenda





• Next steps

Department of Public HealthBureau of Substance Abuse Services

Overview of ServicesHilary Jacobs, LICSW, LADC I

Director

[email protected]

AGENDA

• Introduction to BSAS

• Descriptive data on persons served

• Inventory of current programs and services

• Discuss priority areas for further analysis

BSAS HistoryKey Dates

• 1950 Division of Alcoholism established within DPH

• 1970 Division of Drug Rehabilitation established within DMH

• 1986 two divisions merged within DPH as the Bureau of Substance Abuse Services

BSAS Major Responsibilities

• Single State Authority

• Overall responsibility for system development

• Overall responsibility for quality of care

• Fund prevention, intervention, treatment and recovery support services

• License treatment facilities

• License addiction counselors

BSAS Guiding Principles

• Addiction is a chronic, progressive, relapsing disorder

• Cannot be cured, but managed effectively with long term, ongoing support

• Adherence to prescribed treatment regimens are on par with other chronic conditions such as asthma, diabetes and hypertension

• Effective treatment attends to the multiple needs of the individual, not just substance use

• Paradigm shift away from acute and episodic care to a more holistic approach over the life cycle

BSAS EnrollmentsFY 2013

• 104,143 new enrollments – Represents 54,198 discrete individuals

• 153,289 total enrollments served– Represents 88,437 unique individuals

Notes: Enrollment totals on all slides are primary enrollments only Data is as of 10/22/13

MA Treatment Admissions Compared to Admissions in States

with Similar Populations

(2011 TEDS Data)

State

State Population

(Census 2010)# Admission of

12+

# Admissions per 100,000 of

12+State Rank

MA 6,547,629 90,986 1,608 4

Indiana 6,483,802 18,004 336

Arizona 6,392,017 19,217 355

Characteristics ofFY 13 enrollments served

N=153,289

• Client Gender– 69% male– 31% female– < 1% transgender

• Primary Drug of Choice– 46% heroin– 9% other opiate drugs– 32% alcohol

• Other Characteristics– 59% report opiates as their primary or secondary drug of choice– 40% between the ages of 16 and 29– 48% unemployed– 14% homeless

Prevention Services

SAPT = Substance Abuse Prevention and Treatment SAMHSA = Substance Abuse Mental Health Services AdministrationSBRIT = Screening, Brief Intervention & Referral to Treatment

Underage Drinking Prevention Grants

SPF-PFS II

SBIRT Sites

MOAPC

Prevention

Licensed Acute Treatment Programs

(detoxification)ACUTE TREATMENT SERVICES

Medical

Detoxification

All Drugs Methadone

Outpatient

Acupuncture

Detoxification

Inpatient

Medically Managed

Clinically

MonitoredMedically

Monitored

Adult Youth Adult Youth

Transitional Age Youth Services

SBRIT = Screening, Brief Intervention & Referral to Treatment

OTP Funded OBOT map

Licensed Residential Treatment Programs

RESIDENTIAL REHABILITATION SERVICES

Adults

with familiesOUI

Second

Offenders

YouthAdults Only

Short - Term

Transitional

Support

Services

Long - Term

Recovery

Home

Social

Model

Therapeutic

Community

Residential Tx Map

Licensed Outpatient Programs and Services

Adult

OUTPATIENT TREATMENT SERVICES

Day

Treatment

OUI

First

Offender

Opioid Treatment

(Methadone Maintenance)

Counseling

Youth

Criminal Justice and Court Services

Non-licensed Services to Support Community Tenure

Housing & Homeless

Non-licensed Services to Support Community Tenure

ACC = Assertive Continuing CareCSP = Community Support Program

Services that Support Community Tenure

35

ATR

Housing and Homeless ServicesPeer Recovery Support CentersLearn to Cope

Youth and Family Intervention (ACRA/ACC & ARISE)

Youth Services

SBRIT = Screening, Brief Intervention & Referral to Treatment DYS = Department of Youth ServicesACC = Assertive Continuing Care

Youth Services

37

Prevention

Intervention

Recovery Support

Treatment

Transitional Age Youth Services

SBRIT = Screening, Brief Intervention & Referral to Treatment

Transitional Age Youth (16-24 years old)

39

Intervention

Recovery Support

Treatment

CharacteristicsTransitional Age Youth (TAY)

FY13 Enrollments Served (16-24 years old)

• 30,387 enrollments served, 20% of total enrollments served• 18,370 unique clients• Client Gender

– 66% male– 34% female– < 1% transgender

• Primary Drug of Choice– 49% heroin– 12% other opiate drugs– 21% alcohol

• Other Characteristics– 65% report opiates as their primary or secondary drug of choice– 65% unemployed– 11% homeless – 20% had children under 6 years old

Health Concerns in Transitional Age Youth (TAY)

(16-24 years old)

National Data:•Less likely to be insured or have a PCP and more likely to use ED•Highest rate of drug use, including prescription misuse (NIDA)•Accounted for 40% of 2010 ED visits related to club drugs (SAMHSA)•Highest HIV incidence rates in 20-24 year olds (CDC)•Emerging mental illness

MA Data TAY represent:•24% of all ED visits for opioid poisoning (2011)•11% of all in-patient hospitalizations for opioid poisonings (2011)•10% of all opioid poisoning deaths (2011 preliminary data)•CDC estimates for every opioid death in 2011 there were:

– 9 abuse treatment admissions– 35 emergency rom visits– 161 who are abuse/are dependent– 761 non-medical users

Health Concerns in Transitional Age Youth (TAY)(16-24 years old)

MA Data TAY represent:

•8.7% of newly diagnosed HIV cases in 2002

•11.7% of newly diagnosed HIV cases in 2011

•45% of enrollments served received prior mental health treatment (BSAS FY 2013)

Age distribution of newly reported confirmed cases of hepatitis C virus

infection --- Massachusetts, 2002 and 2009

* N = 6,281; excludes 35 cases with missing age or sex information.† N = 3,904; excludes 346 cases with missing age or sex information.

Source: Onofrey et al MMWR: May 6, 2011 / 60(17);537-541

Discussion and Next Steps

• Feedback on data presented

• Priority questions/areas of focus for further analysis

REMEMBER

TREAT ADDICTION

SAVE LIVES

Slide 46

Agenda





• Next steps

Slide 47

Approaches to Estimating Need

• Present examples of approaches used by other states

• Obtain Council input on methodological approach

Slide 48

Approaches to Estimating Need

Method Description Pros ConsCurrent Use Model Determines need based on

current utilization rates and adjusts for expected population change

• Does not require complex analytics

• In use in several other states; accepted method

• Assumes current utilization reflects need

• Does not adjust for trends in utilization

Trend Analysis Model Determines need based on current utilization rates, and adjusts for expected population change and recent trends in service utilization

• More likely to reflect current changes in treatment approaches

• Unable to respond to rapid changes

• Assumes historical changes will continue in future

• Requires more complex analytics

Disease prevalence Estimate need for services based on prevalence of specific disorders and/or behaviors in the population

• Accounts for known underutilization of services

• Accounts for possibility that current treatment patterns are not ideal

• Must build specific models for different service areas

Incorporation of specific factors known to influence need

Uses factors known to influence service utilization (e.g. referral policies, payment, relapse rates) to enhance prediction model

• Incorporates nuanced factors that influence current and future utilization

• Complex analytics required

• Must build specific models for different services

Comparison of Acute Psych Bed Projection Methodologies Used in Select States

Slide 49

Source: Meeting the Needs for Inpatient Mental Health Services: A Framework for Planning. Prepared for the Task Force on the Plan to Guide the Future Mental Health Service Continuum. Maryland Health Care Commission. Presented 2008.

Footnotes 1 Source: http://www.vdh.state.va.us/OLC/Laws/documents/COPN/SMFP%20composite.pdf

2 Sources: http://www.hcawv.org/CertOfNeed/Support/Behavioral_Health.pdf and http://www.hcawv.org/CertOfNeed/Support/AcuteBedsapp.pdf

3 Source: http://facility-services.state.nc.us/plan2007/plan2007.pdf

4 Source: COMAR 10.24.07

North Carolina: Trend Analysis Model

• Each step explained below is applied to the 16 geographic areas used by NC to arrive at bed surpluses/deficits in each area.

Part 1: Determining Projected Patient Days of Care and Bed Need for Children andAdolescents

• Step 1: The estimated Year 2015 days of care for children/adolescents is determined by taking the actual 2011 days of care for the age group birth through 17, multiplying that number by the projected Year 2015 child/adolescent population and then dividing by the Year 2011 child/adolescent population.

• Step 2: The projected Year 2015 days of care is then adjusted downward by 20 percent to take into account the projected continued decrease in utilization by this age group.

• Step 3: The adjusted Year 2015 days of care is divided by 365 and then by 75 percent to arrive at the child/adolescent bed need in Year 2015, assuming 75 percent occupancy.

• Step 4: The number of existing child/adolescent beds in the planning inventory is then subtracted from the bed need (from Step 3) in order to arrive at the Year 2015 unmet bed need for children and adolescents.

Slide 50

North Carolina Example

Slide 51

Geo Area Hospital County

Licensed Adult Beds

Licensed Child Beds

Total Licensed

Beds

License PendingTotal Adult

Total Child

Total BedsCON

AdultCON

Child

1

A X 10 0 10 0 0 10 0 10

B X 45 0 45 0 0 45 0 45

C Y 40 0 40 0 0 40 0 40

D Z 12 0 12 0 0 12 0 12

Geo Area 1 Totals: 107 0 107 0 0 107 0 107

A B C D E F G H I J

Geo Area

2011 Days of Care*

2011 Population Projected

2015 Population Projected

2015 Projected Days of Care

(B x D) / C

2015 Adjusted Days of Care(E – 20%E)

Number of Beds Needed

(F/365)

Total Beds Needed (G/75%)

Child / Adol

Inventory

Child / Adol Need

(I – H)

1 3,629 196,611 194,129 3,583 2,867 8 10 0 10

*All figures in second table, above, are for < 18 population

Source: North Carolina Department of Health and Human Services. State Medical Facilities Plan. 2013. http://www.ncdhhs.gov/dhsr/ncsmfp/2013/2013smfp.pdf

Considerations in Predicting Need for BH Services: Maryland Health Care Commission

• “Since not all who meet the diagnostic criteria for a mental health disorder experience significant impairment, at issue is how many residents of a state will actually need treatment services, and of what type and intensity.”

• “Many people with mental illness actually receive mental health care from providers outside the traditional publicly financed mental health system, such as primary care providers, health centers, schools, child welfare, juvenile services, courts, local jails, homeless systems or nursing homes. Planning for mental health services must therefore balance these issues of frequency of occurrence, variability in severity, and the role that other systems may have in providing care. ”

• “Typically, predictions of the need for public sector capacity to deliver behavioral health services rely heavily on poverty rates, using this as an indicator of the population reliant on publicly funded treatment.”

• “Special factors that are often considered include the rate of homelessness, since this population has been shown to have a greater need for behavioral health services than the general population.”

• “In addition to need, the supply of health care services significantly influences demand for services. In fact, some researchers discourage the use of ‘rates under treatment’‖ (the percent of those with a mental disorder who receive treatment), saying that it represents ‘effective demand’ more than ‘need.’ Commercial insurance practices can drive the need for public sector services when benefit packages are limited and use of inpatient treatment is restricted. Inadequate coverage for community-based alternatives can increase demand for inpatient treatment, either in increased admissions or increased length of stay.”

Slide 52Source: Meeting the Needs for Inpatient Mental Health Services: A Framework for Planning. Prepared for the Task Force on the Plan to Guide the Future Mental Health Service Continuum . Maryland Health Care Commission. Presented 2008.

Slide 53

Agenda





• Next steps

Slide 54

Next Steps

• Service Maps:

• Meeting with DMH and BSAS to identify existing inventory data• Confirm facility categorization

• Meeting with other DPH bureaus to identify GIS mapping capabilities

• Analytic Outline:

• Reviewing other states’ methodologies for calculating need

• Working with Health Policy Commission on geographic area definitions for behavioral health services

• Identifying data sources and analyses to be used

• January 2014: Estimation of Need

• Identifying methodology for calculating need• Current use model vs. trend analysis model vs. other

• Proposed November & December Meeting Dates to be e-mailed out this week

• Joint meetings of the Council and Advisory Committee moving forward?

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Slide 1 Health Planning Council Meeting 5 Madeleine Biondolillo, MD Director, Bureau of Health Care...

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