R.I. leaders collaborate to fix behavioral health system

Nearly 10 percent of Rhode Island’s $8.7 billion state budget goes toward services addressing behavioral health conditions, from incarceration costs to child welfare services and social services.

Yet more Rhode Islanders report unmet need for behavioral health care services than residents of other New England states, according to the “Rhode Island Behavioral Health Project: Final Report” commissioned by the Executive Office of Health and Human Services and released last fall.

Truven Health Analytics conducted this assessment of the supply, demand and costs associated with the full continuum of behavioral health services and developed recommendations for reforms.

What’s primarily driving total spending, the Truven report stated, are relatively greater expenditures on inpatient care and prescription medications.

Rhode Islanders aged 18-44 had the highest rate of psychiatric general hospital admissions than similarly aged adults in other New England states and nationally.

Among Medicaid beneficiaries hospitalized for a mental illness, one in five had no follow-up treatment 30 days following discharge.

“We’ve had constrained budgets across Rhode Island in health and human services and we arguably spend a good deal of money in the Medicaid budget on services to people who live with mental illness, and we don’t seem to be getting our money’s worth,” said Maria Montanaro, director of the Department of Behavioral Health, Developmental Disabilities and Hospitals (BHDDH).

The Truven report was commissioned at a cost of $296,649 for the period Sept. 1, 2014, through Aug. 31, 2015, with half the cost covered by state dollars and half by Medicaid.

While no legislative directive was attached to the Truven report, Rhode Island’s health care leaders are pursuing its recommendations for increased investments in early intervention and prevention, wider use of community programs and interagency collaboration within the Executive Office of Health and Human Services.

Headed by Secretary Elizabeth Roberts, the office includes BHDDH, the Department of Health (RIHEALTH) and the Department of Children Youth and Families (DCYF).

Roberts, Montanaro and RIHEALTH Director Nicole Alexander-Scott, M.D. discussed some of the findings of the Truven report during testimony at a Jan. 19 hearing conducted by the Rhode Island Senate Committee on Health & Human Services.

“To say that we meet regularly is an understatement,” Montanaro said in an interview. “We really are quite coordinated in all of our approaches. We’re focused on population. We are bringing to the table the capacity of each department’s resources to deal with problems on a population basis.”

Montanaro and Alexander-Scott are co-chairs of the Governor’s Overdose Prevention and Intervention Task Force.

In 2015, there were 221 unintentional drug overdose deaths in Rhode Island, a number expected to rise because it often takes several months to confirm drug overdose deaths.

In 2014, 241 people died of unintentional drug overdose deaths, giving Rhode Island the sixth highest rate of drug poisoning deaths in the nation, according to the Centers for Disease Control and Prevention.

The task force created a strategic plan to reduce opioid overdose deaths by one-third in three years. The state was making progress on this goal as the year started.

In January, Gov. Gina Raimondo (D) signed into law the Good Samaritan Act of 2016, which provides immunity against arrest to any individual who calls for medical assistance when someone is experiencing an overdose. The law reinstates a previous version that had expired on July 1, 2015.

Also in January, BHDDH and RIHEALTH co-sponsored a training session for more than 215 physicians, physician assistants, nurse practitioners, dentists and nurses to qualify them to deliver medication-assisted treatment for opioid-use disorders.

Increasing the number of qualified providers is a goal of the task force. Last year, the state had about 150 qualified prescribers but Alexander-Scott said the number needs to be closer to 750.

Raimondo’s proposed fiscal 2017 budget seeks to allocate $2.5 million to the Department of Corrections for medication-assisted treatment programs plus $1.5 million for expanded access to naloxone, a prescription monitoring program and peer recovery coaches.

“We have a lot of work to do as a state, but the communication and collaboration within the Executive Office of Health and Human Services is extremely strong,” Alexander-Scott said.

Alexander-Scott also highlighted the Rhode Island Children’s Cabinet led by Roberts, which created a five-year plan to improve children and families’ health outcomes, including behavioral health.

The Children’s Cabinet includes staff from RIHEALTH, BHDDH, DCYF and the Department of Human Services.

RIHEALTH and BHDDH are also developing a statewide Population and Behavioral Health Plan through a State Innovation Model grant.

Alexander-Scott said she considered the most opportunity for improvement lies in the integration of primary care and behavioral health.

“Our aim is not to just have primary care providers conduct behavioral health assessments and make diagnoses, but instead for them to be well connected enough to the behavioral health resources in Rhode Island that patients get the follow-up care they need,” she said.

“This kind of approach will allow us to cut costs and achieve better health outcomes – a substantial portion of physician visits involve a behavioral health issue, and similarly, many adults with behavioral health conditions have one or more physical health issues.”

Montanaro sees the greatest opportunity in housing, starting off the year with a redesign of the Integrated Health Home Program launched two years ago through a state plan amendment to Medicaid.

The Affordable Care Act created health homes to allow individuals with chronic health conditions, including mental health and substance use disorders, to live in their community while receiving services to help them manage the symptoms of their illness on a daily basis.

“It builds off what we’ve learned in the first two years and refines the program to be more population focused, to have health outcome measures on a quarterly basis to help these community mental health centers transform their systems of care so that they really are more effective in care coordination,” Montanaro said.

“It is based on evidence-based models of Integrated Health Homes that have been enacted in other states like Missouri, Iowa, Minnesota and Michigan. So there are a number of other states that have pioneered these efforts and we’ve learned from their model.”

Sen. Josh Miller (D – Cranston, Warwick), chairman of the Senate Committee on Health & Human Services, said several bills are forthcoming aimed at addressing the issues raised in the Truven report, including a plan to revise legislation to help open up approval and coverage process for medication-assisted treatment for opioid use disorder.

Miller said he planned to re-introduce a bill to create an Office of Health Policy charged with reducing the cost of health care while increasing access to quality health care.

He also anticipated there would be legislation proposed to increase accountability in DCYF, where an audit last year documented a failure to follow basic accounting and purchasing practices.

“I think that Rhode Island is presented with many challenges but also has a lot of strengths and opportunity,” Montanaro said. “There are gaps in every mental health system there is no question, but there is also a lot of good work that has and will continue to press forward in Rhode Island.”