DMHAS Transformations

1. DMHAS Transformations Lynn Kovich - Assistant Commissioner Raquel Mazon Jeffers – Deputy Director April 28, 2012

2. How Our System is Advancing The goal is to build a continuum of services that will meet the holistic needs of our consumers We are striving to create a system where consumers can find the services they need from a single point of entry There have been many positive improvements in our system of care resulting from planning activities undertaken with consumers and other stakeholders This continues to be a time of important and profound changes to the behavioral health service system Consumers and Advocates must continue to inform and participate in our system development

3. Building on a Strong Foundation • Our Vision builds on planning and work done by many over the last few years • Governor’s Task Force on Mental Health • Wellness and Recovery Transformation Action Plan (2008) • “Home to Recovery” Plan (2008) • Dual Diagnosis Task Force (2008) • Co-Occurring Mental Illness and Substance Abuse Disorders Task Force (2010) • Acute Care Task Force (2010) • Hagedorn Closure Plan (2010) • Consumer Merger Forums (2011) • Healthcare Reform • Medicaid Information Forums for Consumers (2011-2012) with MHANJ

4. Crisis Management to Recovery Consumers have told us that they can’t get services in our system until they are in crisis We want to move our system from one that response to crisis to one that is focused on prevention, wellness and recovery

5. Psychiatric Advanced Directives • Psychiatric Advanced Directives allow consumers to make decisions in advance about his/her mental health treatment, including medications and voluntary admission to inpatient treatment and electroconvulsive therapy • As of March 30, 2012, the Division had 857 PAD’s in the Division’s Directory • Submitted PAD’s are treated as confidential protected health information • On May 11, 2011, the Division issued a brochure, “Understanding Mental Health Advance Directives”. The brochure is available in English and Spanish and is on our website. • To register a PAD, mail your original PAD and Registration form to the Division at 50 E. State Street, PO Box 727, Trenton, NJ 08625 • To access your PAD info, call Centralized Admissions at 609-777-0317 • DMHAS Website for Advance Directives: http://www.state.nj.us/humanservices/dmhs/home/advdirective.html

6. Recommendations • These planning activities resulted in many recommendations for system improvement, among them: • PH and BH integration • MI and SA integration • DD/MI integration and service improvement • Moving toward a Wellness and Recovery Oriented system of care • All of the recommendations have informed the development and mission/vision/values of DMHAS

7. Our Mission • Our Mission - Wellness Recovery Prevention • DMHAS, in partnership with consumers, family members, providers and other stakeholders, promotes wellness and recovery for individuals managing a mental illness, substance use disorder or co-occurring disorder through a continuum of prevention, early intervention, treatment and recovery services delivered by a culturally competent and well trained workforce.

8. Our Vision • Our Vision – Laying the Foundation for Healthy Communities, Together • DMHAS envisions an integrated mental health and substance abuse service system that provides a continuum of prevention, treatment and recovery supports to residents of New Jersey who have, or are at risk of, mental health, addictions or co-occurring disorders. At any point of entry the service system will provide prompt and easy access to appropriate and effective person-centered, culturally-competent services delivered by a welcoming and well trained work force. Consumers will be given the tools to achieve wellness and recovery, a sense of personal responsibility and a meaningful role in the community.

9. Our Values • Our Values – We are driven by our values • We value consumer’s dignity and believe that services should be person-centered and person-directed • We value the strength of consumers, their families and friends because we believe it serves as a foundation for recovery • We value our partner agencies and believe in their commitment to professionalism, diversity, hope and positive outcomes • We value evidence-based practices and believe that consumer-informed and peer-led services improve and enhance the prevention and treatment continuum • We value the public trust and believe that it is essential to provide effective and efficient services

10. Our Mission in Action • Closure of Hagedorn Psychiatric Hospital • State reorganization • DD/MI services being administered by DMHAS • Senior Services moving from DHSS to DHS • Addiction services for adolescents being moved to DCF • Merger of mental health and addictions • Medicaid Wavier implementation/management through an ASO

11. 1. Hagedorn Closure • Will close by June 30, 2012 • Updates are available at http://www.state.nj.us/humanservices/dmhs/home/hph_closure_pg.html • The census as of 4/11/12 is 73 patients with approximately 36 of whom to be transferred to GPPH and 13 to Ancora. The remaining 24 patients will be discharged to various community settings • As of 4/11/12 there are three units open with one of those units scheduled to close in early May

12. 1. Hagedorn Closure • Closure of Hagedorn will provide additional resources to help us move the system • If budget is approved the division will realize $5.6 million to $12.8 million in 2014 annualizedfrom the closure • These dollars will be used to • Develop Behavioral Health Home • Increase outpatient services • Rental subsidies • Additional beds

13. 2. State Reorganization to Support Integrated Services • GOAL: Better coordination and delivery of services and better use of resources • STEPS TAKEN: • DD/MI included in ASO • Adolescents with substance use disorders moving to the Children's System of Care • Senior Services coming to DHS as new Division

14. 3. Medicaid Wavier Implementation/Management Through an ASO • GOAL: • Sustain the Medicaid Program • Prepare for Health Reform • Through better management of resources, will move from hospital based services to increased services in the community and decreased reliance on institutional care • Improved Care Coordination to help consumers navigate the system • Improved integration of services

15. 3. Medicaid Wavier Implementation/Management Through an ASO • What does it mean for consumers? • Integrated care SA/MH and BH/PH • Service expansion for SA services • Allows for consumer and family participation in the design of access and quality standards and ongoing monitoring of performance and outcome • Reimbursement for community-based services instead of acute care • Better access, enhanced quality, improved outcomes

16. 3. Medicaid Wavier Implementation/Management Through an ASO • The ASO will help us increase services and access • Some programs that we have are planning with the ASO or have implemented to help move the system: • EISS • Expanded Outpatient services • Expanded Access • Expansion of Evidenced Based Practices • System of Tiered Case Management

17. Integration of Behavioral Health and Primary Care Services • GOAL: Coordination of BH and PH to provide screening, access and treatment for co-occurring behavioral health and physical health needs • STEPS TAKEN: • Working with Medicaid to develop Behavioral Health Homes • Including in MCO and ASO contracts the requirement for sharing information and assisting in the coordination of care

18. Integration of Behavioral Health and Primary Care Services • The waiver includes provisions for behavioral health homes for people with severe mental illness, addictions and one other chronic condition, or co-occurring MH/SA disorders.  • Health Home services include bidirectional behavioral health and primary care screening, identification, referral to, and linkage for consumers • New Jersey has been fortunate to have several Health Homes initiatives that have developed at the grass roots level • Two providers are implementing SAMSHA-funded Behavioral Health Home Pilots • In addition, the Nicholson Foundation, through a public-private partnership, has provided funding to two FQHCs to implement health homes providing integrated behavioral health care

19. 4. Merger of Mental Health and Addiction Services • The mergerwill lead to a more integrated services system so that there is better access to appropriate care for consumers with co-occurring mental illness and substance use disorders

20. Why Merge? • To build capacity to address the co-occurring substance use and mental health needs of consumers • To bring together and build upon strengths in each system

21. Recommendations from the Consumer Forums • Increase and Simplify Access to Services • Improve Services from a Client Centered Perspective • Increase and Improve the Workforce • Increase the availability and quality of information regarding services

22. What is Underway Today to Integrate Care? • Co-Occurring Learning Collaborative • Regional Strategic Planning Sessions • Staff Cross trainings • Internal work to unify regulations, contract, policies and procedures

23. What is the Role for Consumers in the New System? • Participation in Steering and Advisory groups • Work in the field providing peer supports and case management activities • Ongoing quality improvement activities

24. Discussion Based on Case Examples • These case studies highlight important features that we envision will be key to the system of care • Streamlined eligibility and assessment • Integrated MH/SA services • PC/BH care coordination • Access to evidence-based practices • Focus on housing

25. James • James is a 52 year old Caucasian male who has a history of alcohol dependency and major depression. James reports that he started drinking alcohol at age 18. He acknowledges increased consumption at age 42, subsequent to his father’s death, which also marked the onset of his depression. His mother has been deceased for several years prior to the death of his father. James has been homeless for the past 10 years since his father passed away. He lost his parent’s home shortly thereafter, due to his lack of financial resources and not being able to hold a job due to unmanaged depression and use of alcohol. James never held steady employment longer than 3 months; however, he did complete high school. James has never received any formal substance abuse treatment. James has a history of multiple psychiatric and medical admissions to area hospitals. His psychiatric admissions have been both voluntary and involuntary.

26. James con’t • Also, James frequently presents at multiple area emergency rooms with difficulty ambulating, significant swelling of both ankles and discoloration of his feet and toes. James has been diagnosed with diabetes, hypertension, and edema in both of his lower extremities. These medical conditions have essentially gone untreated except for the care he receives during his ER visits and hospitalizations. Upon previous discharge from any of his prior hospital admissions, he has failed to follow-up with any aftercare but seeks re-admission to the hospital with the chief complaint of suicidal ideation, both with and without a plan. James lacks the ability to follow through with discharge recommendations to go to the welfare office to apply for benefits. Additionally, he does not have forms of identification needed to apply for benefits or access stable housing. James reports that he has lost his identification during his transient lifestyle and activities.

27. James con’t • During an inpatient psychiatric hospitalization, James was connected with an ICMS Case Manager. The Case Manager participated with James and his treatment team to plan for his discharge and aftercare needs. His ICMS worker was able to arrange for James to get new identification through the local County Clerk’s Office, which was accepted by welfare to reapply for benefits. Additionally, the treatment team determined that James would benefit from housing/residential supports, co-occurring treatment, and primary health care. The ICMS Case Manager contacted the ASO and James was assigned a Care Coordinator. The ASO Care Coordinator provided authorization to refer James for co-occurring treatment and residential services.

28. James con’t • James was also given authorization for primary care services through a Behavioral Health Home to coordinate his medical conditions, medications, nutrition and treatment for depression and alcohol dependency. Upon graduating from the residential program, James wishes to live in supported housing where he can develop further independence and increase healthy living skills and receive home visits by his Care Manager/Nurse. He will continue to have care coordination through the Health Home who will report back to the ASO about James’ health outcomes and any future needs.

29. Katie • Katie is a 22-year old single white female. She reports being sexually abused by her stepfather between the ages of 9 and 14. When her mother discovered the abuse she separated from her husband who had been the sole financial support in the household. The abuse was never reported to DYFS or the county prosecutor. Katie and her mother became homeless and turned to the county welfare agency, where they applied for and received TANF benefits and food stamps. Katie and her mother then moved in with her maternal grandmother. Katie began smoking marijuana and drinking alcohol soon after her mother and stepfather separated. By age 17, she was also smoking cocaine and started snorting heroin, and eventually started injecting heroin. Katie had been stealing from her mother and her grandmother and when she turned 18, her grandmother refused to allow her to continue to live in her home. Katie began to live with friends, “couch surfing” moving from one place to another, and turned to prostitution to support her heroin dependence.

30. Katie con’t • Between the ages of 19 and 22, Katie intermittently sought help for her heroin dependence, and had three admissions to community-based detoxification programs, relapsing shortly after discharge each time. An outreach worker at the local syringe access program encouraged Katie to seek help through a toll-free hotline. Katie called the hotline and was screened for substance abuse dependence and eligibility for public behavioral health benefits. The screener facilitated a “warm hand-off” to a DMHAS ASO care coordinator, who reviewed screening information electronically and talked to Katie about various treatment options for heroin dependence. Prior to talking to the Care Coordinator, Katie had heard of medication-assisted treatment, but knew very little about Suboxone. The care coordinator offered to connect Katie with a community-based behavioral health provider able to provide Suboxone induction and stabilization as well as counseling services. Katie accepted the referral and her Care Coordinator arranged and authorized an intake assessment for Katie.

31. Katie con’t • Katie was assessed and admitted for Suboxone induction and stabilization and also received a comprehensive psychosocial assessment, during which she disclosed some limited details of her history of child sexual abuse and the assessing clinician formulated a diagnostic impression of heroin dependence and depression. The clinician requested and received authorization from the MBHO to provide Katie with a specialist in trauma-informed therapy as well as a subsequent link to counseling to address her opioid dependence, as well as case management services to support housing and educational/vocational needs. The clinician also requested and received MBHO authorization for Katie to receive primary care services for her physical health needs including screening for sexually transmitted infections, hepatitis and HIV. Katie was able to engage in these counseling services with the support of medication-assisted treatment to manage her opioid cravings. Katie’s Case Manager facilitated her referral to and acceptance into recovery housing, as well as providing linkage to employment services through the Division of Vocational Rehabilitation (DVR).