A cohort of persons with serious and persistent mental illness (SPMI) will continue to require extended inpatient psychiatric treatment beyond 2015, the year during which NYS will enroll virtually all of its Medicaid insured into managed care. Where their care will be provided remains to be determined. I advocate that community based extended care in specialized inpatient psychiatric units with programs developed to meet the particular needs of the SPMI population should be included among the options along with the appropriate use of state psychiatric centers.
Community based extended care deserves inclusion for four reasons: (1) It is best when persons receive care in or close to their own communities thus allowing for easy inclusion of families as part of treatment planning. (2) The clinical strength of the programs on such dedicated units. It is reasonable to believe that those requiring extended stays receive improved services when cared for on dedicated units than when stays are extended on units meant to provide acute care. (3) The federal government, even under Medicaid managed care continues to pay a significant share of the cost which is not the case when persons receive care in state psychiatric centers. (4) By locating such dedicated units within NY’s Article 28 hospitals it allows for those often-stressed institutions to generate needed revenue by returning units to clinical use which may have been shuttered due to decreasing admissions to inpatient medical and surgical services.
Currently, two such units exist in NYS, both located in Westchester County. For the reasons enumerated above, I have advocated for the creation of such units at strategically placed locations throughout our state since I chaired the NYS Mental Health Services Council. Some questioned about the added value of such units. The key questions then are does treatment on such units permit more of those with SPMI to be discharged to the community rather than requiring transfer to state psychiatric centers and do they improve the community tenure of those discharged from them?
In an effort to answer those questions I reached out to the NYS Office of Mental Health (OMH). OMH staff was generous in their willingness to collaborate. Provided with the names of 12 persons discharged during an agreed-on time period from the extended stay unit at Saint Joseph’s Medical Center (SJMC), OMH captured the cost of care utilized by those persons during the year prior and subsequent to their stay on the unit using OMH’s powerful PSYCKES claims based data base.
These data, based on the experience at Saint Joseph’s Medical Center, offer strong support to the value added by care on the extended stay unit. Dramatically, the total number of inpatient days for the cohort in the year prior to admission was 1508 whereas it dropped to 623 in the year after discharge. The total expended by the Medicaid system for inpatient care during the year prior to admission to the extended stay unit was $892,734; it dropped to $315,473 during the year subsequent to discharge, a meaningful decrease. During the year prior to admission the amount expended on all outpatient services was $185,895, the amount paid for prescriptions was $13,622 and the number of prescriptions filled was 358. During the year subsequent to discharge the amount expended on all outpatient services rose to $ 311,977 and the amount spent on the 569 prescriptions filled was $23,643. (Outpatient service use captured included: licensed mental health clinic, continuing day treatment, partial hospital, care management (TCM), community residence, and assertive community treatment (ACT).) Clearly the trends are those which recipients, their families, advocates and policy makers would wish, that are less spent on inpatient care and more on outpatient services, including what appears to be improved adherence to prescribed medications as evidenced by prescriptions filled. (The SJMC unit opened in 2006 at a time when transfers from community hospitals to state psychiatric centers were marked by long delays. The program was meant to avert such transfers and return the vast majority of those admitted to the community without need for state psychiatric center admissions. With regard to this goal, the unit also has met with success.)
I suggest that these data provide a compelling reason for maintaining those extended stay units licensed by OMH to provide these specialized services and considering establishment of such units more widely across NYS.
OMH, I believe, has data which would allow reasonably accurate prediction of the number of extended stay beds which would be likely to be needed in a managed care environment. As for the financing of such units, two approaches seem workable and there are likely others. One would be to include in the per member per month (PMPM) payments to the Medicaid managed care plans either regular or HARP, an actuarial allowance for such stays in a cohort of covered SPMI lives. The other would be to carve out the cost of stays on such units. Under either scenario, but particularly appropriate under the former, managed care plans might reasonably be expected to manage stays on such units as long as those plans were expected to play a collaborative, risk bearing role in implementing appropriate discharge plans for the individuals served and actively working to pave the way for access to the next level of care. (It is worth noting that under the current plan, extended stays in state psychiatric centers will not be managed.)
In conclusion, I assert, for the reasons laid out in this article, that the maintenance of and creation of additional units the mission of which would be to care for those persons with SPMI requiring extended inpatient psychiatric care would represent a win for the persons served, for the state, for the hospitals and even for the plans. They should therefore be considered by those currently working on the redesign of the mental health delivery system as part of the NYS Medicaid Redesign effort and the federal Delivery System Reform Incentive Payment (DSRIP) Program implementation.
Dr. Perlman is the Legislative Chair of NYSPA, and the Director of the Department of Psychiatry at Saint Joseph’s Medical Center in Yonkers, New York.