Improving Behavioral Health Outcomes Through Collaborative Efforts and Strategies

The Staten Island Performing Provider System (SI PPS), formed as a partnership between Richmond University Medical Center and Staten Island University Hospital (SIUH), is leading the New York State Delivery System Reform Incentive Payment (DSRIP) program on Staten Island (SI). The goal of DSRIP is to restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over 5 years, by 2020 for Medicaid beneficiaries and the uninsured. SI has one of the highest incidences of opioid related deaths within the 5 boroughs of New York City. SI PPS has been working with a cross-sector group to facilitate sharing of best practices, improved workflows, solutions, and to test new innovative ideas that are becoming sustainable within organizations and across the system. Participation is representative from all sectors including substance use disorder (SUD), mental health, government agencies, medical providers, community-based organizations, and managed care organizations.

In order to measure Staten Island’s performance to improve quality of care and population health outcomes, numerous quality measures are being monitored that pertain to people with behavioral health (BH) needs. A cross-sector group met regularly to identify and implement strategies that will enhance measure outcomes, which included decreasing potentially preventable emergency department (ED) visits for people with BH conditions, and the initiation and engagement of alcohol and drug treatment. Individuals with alcohol and substance use disorders are deemed the highest utilizers of ED services and emergency medical services (911) based on recent PPS data. A high proportion of these ED visits are avoidable. Initiating individuals with SUD needs in to treatment and keeping them engaged in treatment is another measure and has been a challenge not only on SI but across the State and country. Several studies have shown that a high percentage of individuals who have a SUD do not seek or choose to stay in treatment (SAMHSA, 2017). Making improvements in these measures and quality of care for the BH population required the cross-sector group to focus on practical changes within the four walls of treatment provider organizations, beyond their four walls to bring care to individuals, and the increase of new specialized staffing.

Changes within the Four Walls of Treatment Providers

The first effort treatment providers initiated was the expansion of ancillary withdrawal services for opioid and other SUDs. Ancillary withdrawal services comprise of the medical management of mild or moderate symptoms of withdrawal from opioid or other substances within an OASAS certified setting. Medical staff monitor withdrawal symptoms and establish a treatment plan that will include the medication protocol to achieve safe withdrawal management, clinical interventions to provide engagement, management of urges and cravings, addresses cognitive and behavioral issues and recovery supports. Multiple sites have expanded ancillary withdrawal capacity and are designated by OASAS. Since 2015, the providers have engaged approximately 1,300 unique clients in ancillary withdrawal services on SI. With the increase in opioid overdose deaths and substance misuse on SI, treatment providers recognized a need to increase the hours of operation for outpatient programs to allow community members access to treatment and support services beyond regular business hours and to help avoid unnecessary trips to the emergency room. SI PPS conducted an analysis to identify the hours in which there was a gap. Most providers extended their business hours and now outpatient treatment sites are available from 7am- 9pm. In addition, Stabilization, Crisis respite, and Resource & Recovery centers are also available 24/7 to support individuals with their BH needs. Inpatient and residential facilities are continuously available 24/7 to individuals who need that level of care.

In order to help more individuals, initiate and engage in treatment, providers also looked to expand services they offered to not only individuals with SUD, but to the client’s family, spouse, or significant other. This approach of leveraging the individual’s support system has proved to be a worthy and growing best practice among providers, with positive outcomes. In addition, providers have been trained in care coordination and have connected patients to dedicated care coordination resources. Providers have also improved patient engagement strategies through intensive motivational interviewing training and robust patient education resources.

These implemented changes have contributed to positive trends in multiple measure performances particularly decrease in ED visits for individuals with SUD (33%) and increase in number of individuals initiated and engaged in treatment (Salient).

Beyond the Four Walls

Meeting people where they are and bringing the appropriate care to them is a critical component to ensuring a patient centered care delivery approach. Changes in New York State regulations under OASAS and OMH agency regulations ultimately enabled expansion of off-site services to individuals in the community. Treatment providers like Silver Lake Behavioral Health have implemented off-site services to fill the gap in initiating treatment for patients that were deemed ‘high risk’, as well as, to reduce the stigma of addiction treatment. The option of meeting someone in the community creates a much more benign introduction to treatment and the resources that may be available for that individual. The role of Silver Lake Behavioral Health’s ‘Diversion Specialist’ is to provide off-site services to current and potential patients. The Diversion Specialist is an OASAS approved Qualified Health Professional (QHP) with a background in crisis intervention. The DS can provide billable services that include; individual counseling, collateral visits, and complex care coordination.

Many other providers on the Island are providing services outside their “four walls” or working to expand their capacity to meet patients where they are. These changes have fueled many providers to explore innovative ideas to better engage patients and has offered a sustainable model for future years.

Increase of Specialized Staffing to Support Individuals with SUD

The providers identified a need to have people with different expertise to support the engagement of individuals with substance use disorders and their linkage to appropriate services. The inclusion of professionally trained peers in clinical and non-clinical settings is a growing trend, supported by state and local regulatory agencies. Peers are individuals who have been certified and utilize their lived experience to provide coaching, advocacy, information, guidance, and motivation to those seeking or sustaining recovery from a substance use diagnosis. The Richmond University Medical Center have placed certified peers in the ED to engage patients and expedite their linkages to services in the community. Similarly, the inclusion of professional trained SBIRT health coaches in non-SUD treatment settings such as the ED and primary care practices is a growing trend and evidenced-based practice supported by state and local government health agencies. SBIRT is an evidence-based approach to identifying patients who use alcohol and other drugs at risky levels with the goal of reducing and preventing related health consequences, disease, accidents and injuries. SIUH has placed SBIRT health coaches in the ED to ensure individuals are screened and linked to appropriate SUD treatment and/or support services. The changes in OASAS regulations has aided in retention of specialized staff within BH and non-behavioral health organizations. Similarly, the provision of funding reimbursement from regulatory agencies for peer support and SBIRT services has enabled for a sustainable model.

Due to the collaborative effort of the providers on SI, they identified areas of improvement within their own four walls, outside the four walls, and the need of specialized support staff to deliver the best care for individuals with BH conditions. Solutions implemented have impacted multiple indicators including initiation and engagement of SUD treatment, and the reduction of ED utilization for BH and has accelerated plans for sustainability of improved outcomes.

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