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3/12/2015 12:00 AM

Top 10 Recommendations for Significant Impact in the Mental Health and Substance Use Disorder Arena Within the Next Two Years

Submitted by the Mental Health and Substance Use Disorder Stakeholder Group

Ensure Safety Net Funding — Immediately

  • Maintain and increase funding for the Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant, in order to address the needs of people who remain uninsured and provide for critical health services, activities, primary substance abuse prevention and social wraparound services not covered by the Affordable Care Act (ACA). Ensure that Medicaid and commercial insurance rates for mental health/substance use disorders (MH/SUD) services, whether in federally qualified health centers (FQHCs) or free-standing specialty facilities, are at parity with other comparable medical/surgical services to support the quality that patients deserve. Increase funding for continuity of care to ensure that appropriate services are in place for patients with behavioral health conditions recently discharged from emergency departments, acute care units and inpatient psychiatric units. Patients discharged from these settings have been shown to have the highest risk of suicide of any population. Reduce Institution for Mental Disease (IMD) barriers to the use of Medicaid funds for community residential and community inpatient services, and eliminate the Medicare 190-day lifetime limit on inpatient care.

Top 10 Recommendations for Significant Impact in the Mental Health and Substance Use Disorder Arena Within the Next Two Years

Submitted by the Mental Health and Substance Use Disorder Stakeholder Group

Ensure Safety Net Funding — Immediately

  • Maintain and increase funding for the Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant, in order to address the needs of people who remain uninsured and provide for critical health services, activities, primary substance abuse prevention and social wraparound services not covered by the Affordable Care Act (ACA). Ensure that Medicaid and commercial insurance rates for mental health/substance use disorders (MH/SUD) services, whether in federally qualified health centers (FQHCs) or free-standing specialty facilities, are at parity with other comparable medical/surgical services to support the quality that patients deserve. Increase funding for continuity of care to ensure that appropriate services are in place for patients with behavioral health conditions recently discharged from emergency departments, acute care units and inpatient psychiatric units. Patients discharged from these settings have been shown to have the highest risk of suicide of any population. Reduce Institution for Mental Disease (IMD) barriers to the use of Medicaid funds for community residential and community inpatient services, and eliminate the Medicare 190-day lifetime limit on inpatient care.

Affordable Care Act/Parity — next 22 months

  1. The Center for Consumer Information and Insurance Oversight (CCIIO) should (1) issue guidance regarding lawful compliance with the requirements of the ACA and Mental Health Parity and Addiction Equity Act, regarding both quantitative and nonquantitative treatment limitations, including (a) issuing final parity regulations for Medicaid as quickly as possible; (b) conducting a review of all essential health benefits packages, including intermediate services (e.g., residential, intensive outpatient, partial hospitalization), medications and recovery supports; and (c) providing a mechanism for consumers and service providers around the country to report problems they experience without fear or risk of retribution; and (2) take corrective action to rectify identified problems with ACA and parity compliance and provide guidance to insurers, consumers, providers and others on compliance by (a) making available outcomes of compliance investigations — including the number of investigations opened and closed, the benefit classification(s) examined by each investigation, the subject matter(s) of each investigation and a summary analysis of the final decision rendered for each investigation — on the Department of Health and Human Services (HHS) and Department of Labor websites, with names redacted where appropriate, and (b) issuing FAQs based on reviews and compliance activities. Provide more resources to the CCIIO for these functions.
  2. Facilitate enrollment of people with untreated MH/SUD and minimize interruptions of coverage and care by (1) working with the Department of Justice (DOJ) in providing guidance to states and localities in order to facilitate enrollment and linkage to mental health, substance use disorder and physical care of everyone in the criminal justice system, including ceasing the termination of Medicaid of those who are incarcerated; (2) continuing Medicaid payments for pre-adjudicated detainees; and (3) targeting outreach to enroll and link uninsured persons to MH/SUD care by enlisting insurance navigators and peers and working with homeless service providers, recovery community organizations and mental health drop-in centers.

Care Integration/Value Purchasing/Delivery System Reform — next 22 months

  1. Provide practical models and examples of delivery system reform initiatives, including those that incorporate social wraparound services, so that state, county and city mental health and substance use disorder provider entities can undertake key steps to foster reforms that will lead to good integrated care. This can include piloting and evaluating model system reforms — including requiring public health programs overseen by HHS to provide evidence-based services, such as prescribing naloxone and treatment medications by contracting with specialty MH/SUD programs or expanding in-house staff — to identify best practices and replicable models for the rest of the health care system. Use focus groups and expert input to identify the challenges and barriers to instituting value purchasing and payment reform for MH/SUD programs (e.g., how to implement core performance measures, how to incorporate funding in case rates for preventive care to avert suicides, how to deal with payment structures that create barriers to integration of care, such as policies that prevent same-day billing for different needed health care services), and provide technical assistance to the field in resolving those problems.
  2. Facilitate operational planning and reforms so that more effective working relationships can be developed between MH/SUD providers and primary and physical health care providers, specifically FQHCs. Since these programs operate under very different federal rules, effective collaboration is frequently difficult. Specifically address the Section 223 Demonstration in these reforms.
  3. HHS has a critical window in the next two years to catalyze national implementation of first-episode psychosis programs. The National Institute of Mental Health (NIMH) has invested significant resources, and data will be published this summer on clinical trials for these programs. International and recent U.S. studies (including preliminary results from the NIMH-funded studies) indicate improved outcomes from reducing the duration of untreated psychosis and providing an evidence-based package of services. Other countries have been working on implementation, with the United Kingdom putting into effect a national strategy since 2000. We very much appreciate the work that NIMH and the Substance Abuse and Mental Health Services Administration (SAMHSA) have been doing in this area. HHS can further drive national implementation by: setting forth a national strategy, publicizing the results of the studies using the highest levels of leadership, clarifying the evidence-based practices, issuing guidance from the Centers for Medicare & Medicaid Services on how to finance these services, allowing all of the component pieces to be billed as one service under Medicaid, providing training for the workforce and technical assistance to stakeholders and states, collaborating with the Social Security Administration (SSA) on their demonstration project and encouraging private insurers to cover such services.

Opioid/Heroin Problem — next 22 months

  1. Increase funding for SAMHSA to help states, counties and localities purchase naloxone. Target funding to the substance use disorder care system (state/county/local agencies, providers, families and recovery community). Ensure that HHS divisions are coordinating on this issue and ensure agency-level coordination with the Department of Justice and Office of National Drug Control Policy. Incentivize co-prescription of naloxone with extended-release long-acting opioids by prescribers in the public health system.
  2. Maintain and increase support for treatment and prevention services addressing opioids and other drugs — including medication-assisted treatment. Provide additional funds for all effective treatments and prevention interventions. Ensure that all approved medications for treating addiction are included in all insurance and Medicaid plans, that use of medical necessity criteria and other medical management for MH/SUD is no more restrictive than for medical/surgical conditions, and that inappropriate limitations on dosage or duration and even outright exclusions of particular medications (such as recently announced by Maine) are eliminated. Incentivize all HHS-funded programs to have the capacity to prescribe medications to treat addiction. Increase funding for SAMHSA programs that target primary substance abuse prevention programs and recovery supports in order to help address access and availability, and to change community norms as they relate to opioids. This commitment should include increased support for community coalitions in order to ensure the response is localized and coordinated across a number of sectors.

Workforce — next 22 months

  1. Continue and expand Medicaid reimbursement for certified peer support specialists, including family and youth peers, addiction recovery coaches and health navigators; incentivize states to establish this access; and streamline the ability of physical health entities, including FQHCs and emergency departments, to directly bill for these services.
  2. Expand the participation of mental health and substance use trainees in the National Health Service Corps, and develop an outreach and technical assistance program to educate behavioral health organizations about how to participate in the Corps. Expand loan forgiveness, scholarship, fellowship and other workforce initiatives for MH/SUD practitioners, such as psychiatrists, psychologists, social workers, mental health nurse practitioners, marriage and family therapists, licensed counselors, certified alcohol and drug abuse counselors, addiction medicine specialists, certified prevention specialists and peer specialists, to increase the availability of licensed clinicians and improve recruitment and retention.
  3. Encourage the Health Resources and Services Administration (HRSA) and SAMHSA to take measures to promote systematic implementation of Suicide Prevention and the Clinical Workforce: Guidelines for Training, established by the Clinical Workforce Preparedness Task Force of the National Action Alliance for Suicide Prevention. (See http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Guidelines.pdf.)

Community Culture and Strengths Initiative — Beyond the next 22 months

  • Develop a national public health campaign to assess and change community culture, demonstrate strength-based approaches to inform attitudes and perceptions commonly associated with mental health and substance use conditions, and educate the public about heroin/opioid addiction and the availability of effective mental health and substance use treatments. This national campaign will focus on core principles that promote positive coping, hope and recovery for persons living with mental health and substance use conditions.
2/12/2015 12:00 AM

The founders of the first free national crisis counseling service delivered through text messaging knew that young people needed a better medium for reaching out for help when they had a mental health–related problem. Yet even they were surprised at the demand that surfaced almost immediately after the Crisis Text Line was initially launched with teens in Chicago and El Paso, Texas, in 2013.

The founders of the first free national crisis counseling service delivered through text messaging knew that young people needed a better medium for reaching out for help when they had a mental health–related problem. Yet even they were surprised at the demand that surfaced almost immediately after the Crisis Text Line was initially launched with teens in Chicago and El Paso, Texas, in 2013.

“Within four months, we were getting texts from all over the country,” Baylee Greenberg, the Crisis Text Line’s director of operations, told MHW. “We’re doing no marketing, and we’re exchanging about 15,000 messages a day.”

For its innovative use of technology in mental health, the New York City–based Crisis Text Line was named a 2014 Community Innovation Award winner by Connect 4 Mental Health, an initiative to encourage innovative approaches to improve the lives of people with serious mental illness.

Origins

The idea for the Crisis Text Line originated out of DoSomething.org, a youth platform for social change. Administrators were finding an increasing volume of texts of a serious nature, Greenberg explained. Someone might text, “I can’t hold a jeans drive; I’m struggling with my homework.” But then another person would text, “I can’t get involved; my boyfriend’s pressuring me.” At the most serious end of the spectrum, one girl texted to DoSomething that she was being sexually assaulted, Greenberg said.

These types of messages demonstrated that youths in trouble will likely turn to texting over other forms of communication. Greenberg cited several reasons for this:

  • Texting is “just what young people do,” she said. “So this is meeting them where they are.”
  • Texting offers privacy. “You don’t have to be seen talking to someone at your locker, or observed going into a therapist’s office,” Greenberg said.
  • Texting is more factual than phone conversation, where pauses and superfluous language can muddle the message. “By the third text message, we know the exact issue at hand,” Greenberg said.

Founders of the Crisis Text Line launched the initiative by telling 4,000 DoSomething.org participants in Chicago and El Paso that the service was available, and it didn’t take long for the effort to go national.

Crisis counselors

A group of paid and volunteer crisis counselors form the backbone of the effort; the Crisis Text Line is designed to have a texter engage with a crisis counselor within five minutes of sending an initial text. Greenberg explained that the effort started with organizers contracting with crisis response organizations, but it sees volunteer counselors as its emphasis for the future.

The initiative uses a 34-hour training course that can be completed online. Around 250 crisis counselors have been trained so far, but the Crisis Text Line hopes to have 2,000 counselors in place by the end of this year (more information about the volunteer effort can be found at www.crisistextline.org/volunteer).

Greenberg said the opportunity to serve as a crisis counselor attracts a variety of individuals, from students pursuing an M.S.W. to military veterans looking for another way in which they can save lives. She believes the characteristics that make for a good crisis counselor are empathy, good decision-making, and the ability to learn a new skill and execute it.

“We don’t accept everybody who applies,” Greenberg said. “You’re talking to young people about heavy subjects.”

Topics of texts

The Crisis Text Line is designed for use by teens, but no one is asked for any identifying information, so it is possible that younger children use the free service as well. Greenberg said that around 20 percent of the texts that come in address depression. Another 10 percent each focus on self-harm and suicide.

For most texters, the task for the counselor becomes one of “moving them from a hot moment of crisis to a cool calm,” Greenberg said. “The texter usually just wants someone to speak to in the moment.” In more serious cases, the crisis counselor’s active listening and guided questions may uncover cases of imminent risk (the system also prioritizes response to any texts that use specific words such as “cut,” “hurt” or “kill”).

For the most serious cases in which it is believed that the teen has the plan and the means to cause grave harm, the Crisis Text Line will initiate an active rescue, in which a check of the texter’s cellphone area code (this predicts the location of teens in about 94 percent of cases) will then lead to a call to local police. The service averages about 1.25 active rescues a day, Greenberg said.

Program data

Crisis Text Line leaders do not at this point have data on the extent to which texters pursue specialty mental health services subsequent to receiving the crisis counseling. Greenberg said they do know that if a person is texting the line frequently, that probably means the service is inadequate to meet that person’s specific needs.

A school or a bathroom tends to be the most common location from which a text is sent to the crisis line. Greenberg said the initiative has a great deal more data, in areas such as the most active days of the week for texts and the busiest locations for certain topics. It has decided to make this data public via the website www.crisistrends.org.

“This data could be powerful for local governments,” she said. “A school administrator could say, ‘Texts about bullying in my district are most common on Tuesday mornings. I’m going to put an extra teacher in the halls on Tuesdays.’”

The Crisis Text Line’s program costs are covered by funding from a handful of large foundations. Greenberg says organizers are hoping to make the effort self-sustainable within a few years, partly by offering corporations an opportunity to pay to have their employees engage in the volunteer effort.

10/23/2014 12:00 AM

The world continues to move faster for mental health treatment organizations as reimbursement mechanisms change and providers are pushed to integrate services with general health, and the CEO of Harbor Corporation in northwest Ohio likens the situation to “changing the engines of a 747 in flight.” This means mental health treatment organization employees need more diverse clinical and business training than ever, but face greater time pressures for achieving this, Harbor CEO John Sheehan explains.

The world continues to move faster for mental health treatment organizations as reimbursement mechanisms change and providers are pushed to integrate services with general health, and the CEO of Harbor Corporation in northwest Ohio likens the situation to “changing the engines of a 747 in flight.” This means mental health treatment organization employees need more diverse clinical and business training than ever, but face greater time pressures for achieving this, Harbor CEO John Sheehan explains.

“The work happens faster now — patients are not in treatment as long as they once were,” Sheehan told MHW. As a result, productivity concerns predominate for clinicians, and the idea of sending a treatment team to an out-of-town training conference for several days quickly takes on the appearance of an unaffordable luxury.

This has made the concept of blended learning, combining online training with live sessions as needed, more attractive to mental health organizations in recent years. Harbor Corporation in July formally entered into an agreement with Cary, N.C.–based Relias Learning under which it now uses the online training company’s learning management system to assign training and to develop curricula on important subjects.

“One of the great things about e-learning is that if a staff member’s client cancels [an appointment], they can go in at that time,” Tracy Sokoloski, Harbor’s director of human resources, told MHW. “Also, we can use the system to track [employees’ training progress] and to run reports.”

Multiple needs

Sheehan says the historically disparate funding mechanisms for behavioral health and the rest of medicine have kept the mental health community “on an island” isolated from health care. But now the emphasis has turned to chronic disease management, seeking to improve outcomes while reducing costs. Harbor responded to the change this year in part by forming a joint operating company with ProMedica, which has the same level of experience on the inpatient mental health side in the Toledo area that Harbor has achieved in outpatient services.

This development and others could eventually fuel a doubling of Harbor’s staff (it currently has around 650 employees), and it already is creating more complex training needs in the organization. For one, the merging organizations are accredited by separate national entities, making accreditation-related topics even more of a focus. Confidentiality provisions also have become a prominent training topic, as Harbor’s client base exhibits a greater prevalence of comorbid substance use problems.

In today’s fast-changing clinical and business environment, “We’re constantly in an innovation state,” Sheehan said. To understand how best to manage reimbursement and establish a financial model that is sustainable, staff training becomes a critical component, he said.

Having an arrangement with a training organization that serves as an exclusive partner with the National Council for Behavioral Health allows Harbor to respond to the diverse training needs and learning styles of its staff, Sheehan indicates.

“Physicians are scientists, clinicians are a little more on the feeling side and nurses are somewhere in the middle,” he said. “For us to develop a curriculum on our own would be challenging. The experts understand these needs.”

Sokoloski believes the Relias learning management system’s ability to track employees’ training progress and to conduct pre- and post-testing exercises greatly benefits her organization. “We need to determine ‘Are we delivering what we need?’” she said.

Sheehan says an organization could lose a bit of the human interaction element as it moves to more online training, but there are ways to compensate for that with online forums and other features.

Sheehan considers the investment in training to be a critical marker of his organization’s long-term viability. “Some reports estimate that up to 40 percent of mental health centers could eventually be out of business,” he said. “A lot of disruptive things are happening. The ones that will make it are those that are progressively looking at what they need to survive.”

Broader training needs

Kristi McClure, L.C.S.W., senior product manager for health and human services at Relias, told MHW that clinical and management staff in mental health organizations now need a broader scope of knowledge. “It’s not as much ‘I work with just this population’ anymore. Now it’s ‘I need to treat the whole person,’” McClure said.

Relias’ learning management system and content libraries offer mental health organization employees regular access to self-paced courses on key clinical and management topics. McClure says the technology has come a long way since the days when the Health Insurance Portability and Accountability Act (HIPAA) training she received as a social worker a decade ago took the form of a giant text file. “Now it is interactive and involved,” she said of online learning.

Users of the Relias system also can manage any live trainings they conduct themselves or through another outside source via the Relias learning management system.

McClure said some of the clinical topics that are proving very timely in training right now include primary care integration and trauma-informed care. On the management side, she is hearing a great deal about leadership issues as longtime executives leave organizations, forcing these companies to take a close look at promoting from within and easing employees’ transition from a clinical peer role to that of a supervisor.

Relias made news of its own on the business front last week, as the European media group Bertelsmann SE & Co. (which includes book publisher Penguin Random House among its holdings) announced that it had reached a deal to acquire Relias from private equity firm Vista Equity Partners.

From the Field
9/26/2013 12:00 AM
FromtheField
8/7/2013 12:00 AM
In Case
7/11/2013 12:00 AM
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    Valerie Canady, managing editor of Mental Health Weekly, knows the mental health field inside and out. She uncovers the essential stories and gets the scoop directly from leaders and advocates in the field.
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