Closing the Gaps and Disparities in Continuity of Care
Actions and discussions this year indicate a serious effort on the part of state leaders and interest groups to address one of the remaining major disparities affecting behavioral healthcare which is the lack of a commitment to continuity of care that is much more prevalent in attending to purely physical health conditions.
In this subject area the most obvious deficits are follow up after a crisis and lack of attention to behavioral health needs and follow up after a visit to primary care or an emergency room.
New models of care and new evidence of need and cost effectiveness are driving change in both of these situations and related ones.
For decades the most common model for crisis care was police transport to an overcrowded emergency room, a long wait for a bed a person may not really need, and whether they do or don’t get a bed they are discharged quickly without a solid treatment plan.
The new emerging model fueled by SB 82 (Steinberg 2013) funding, is instead of the ER people are taken to a crisis stabilization center by a mobile crisis outreach team that is connected to a crisis residential center all of which are part of a system of care staffed substantially by peers with a “no force first” approach to de-escalate the crisis and to develop and implement a treatment plan that can guide care for several months. Under this model some (estimated to be about 1/3) will still go to a hospital but when they do so it will be directly to a bed and with a treatment plan for follow up and connection to the system of care already established. The treatment plan would include getting “full service” “whatever it takes” recovery oriented client centered care. That level of care would be the presumed need of someone emerging from a behavioral health crisis.
More funding is needed to fully develop this model for both youth and adults and more discussions are required to ensure that it is utilized for everyone – including people in commercial health plans. But I believe we have turned a major corner with an emerging consensus that this new model will be much more successful in saving lives and dollars.
At the opposite end of the continuum of care there are very similar transformations taking place in primary care and emergency rooms for people who do not enter with a diagnosis of a behavioral health condition. In the old model these conditions were largely ignored with a focus on physical symptoms or someone was given a prescription for an anti depressant without seeing a mental health professional.
We now know that a behavioral health disorder is present for at least one third of the population seen in these facilities. We also know that ignoring these conditions leads to significantly greater physical health problem and costs and that making sure that all behavioral health disorders are identified and treated will generate savings that outweigh the costs of that care.
The Department of Health Care Services recognized this and has included comprehensive bi-directional integration of physical health and behavioral health in its pending Section 1115 Medicaid Waiver together with the Medicaid Health Home Option with up front funding for plans and counties and expected shared savings for plans counties and providers.
The new model envisions that everyone who enters these facilities will receive a comprehensive screen for all behavioral health conditions and that those who screen positive will then have a “warm hand off” to a behavioral health provider who can complete the evaluation and begin behavioral health care then and there either through co-located behavioral health professionals (ideally a provider who is funded to address all types and levels of severity of a behavioral health disorder) or one who is reachable through telemedicine.
Since 70% of primary care physicians see people with MediCal this model will start the transformation across much of the state.
Expanding it to everyone in commercial plans is also essential since these plans cover most of the people who develop psychiatric disabilities (usually due to neglecting their behavioral health disorder for many years until it becomes a crisis).
Ensuring that screens cover all disorders and that the behavioral health clinician has the skills and the funding to address any type of condition and has appropriate cultural competence is also important.
In that regard the recently approved Waiver to create County Alcohol and Drug managed care systems will help to align that system with mental health care and should eventually allow for integrated contracts for providers. More work is still needed in most counties to make this provider network also the network to address so called mild or moderate mental health conditions for which most counties are not currently responsible.
There is a long way to go to make these transformations the norm instead of isolated islands of excellence as they are now. But we have turned a big corner on both fronts with a recognition that the new model not only makes the most clinical sense but also makes the most financial sense for the state, counties and health plans.
August 25, 2015