Visit with ...........................

Scotch Plains, NJ, January 24, 2014

2

What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

3

What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

Psychosocial

4

What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

SchizophreniaBipolarSchizoaffectiveBorderlineDepression

5

What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

CopingRelaxation

LivingFinancial

SocialEmploymentEducationHousing

6

What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

Social lifeClubs

Church

FriendsLover

SpouseCollege

Grad SchoolTech School

WorkerManagerVolunteer

7

What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

ChoiceCommunity

8

What is PsyR?

Psychiatric Rehabilitation...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

ProgramsDoctors

Hospitals“Interventions”

“Disability” supportsSSI / SSD

9

What is PsyR?

...helps those with psychiatric disabilities...get emotional, social and intellectual skills and supports... to live, love, learn and work... as and where and how they wish... as independently of professional supports as possible...thus to engage, pursue and achieve recovery...as they determine it for themselves.

“Stabilization”Remission“Normal”

AdjustmentActualizationAutonomy

10

Recovery Principles...

Substance Abuse and Mental Health Services Administration, 2003

11

What Is PsyR?

A goal

A role

A specialty

A discipline

Evidence-based

12

Who Provides PsyR?

Psychiatrists

Psychologists

Nurses

Social Workers

Direct Care

Peer Providers

Consumer

13

Where is PsyR? Programs Residences Service support PACT (Programs of Assertive Community

Treatment)

Workplaces Schools Hospitals Families Self-help Centers

14

Why PsyR? Psychiatric disabilities can be...

Lengthy Recurrent Difficult Disruptive (of life) Interruptive (of development) Debilitating (of capacity)

PsyR thus advances... Long-term recovery Community integration Quality of life HOPE

15

PsyR Principles1. Person-centered 2. Partnership 3. Peer support4. Natural supports5. Strengths based6. Work7. Goal-related8. Integration of treatment and rehabilitation 9. Sustained, coordinated services10. Empirical orientation 

16

Challenges to PsyR Institutional pessimism Organizational barriers Training demands Funding shortages Quick-fix thinking “Courtesy” stigma

17

Since 1975 Formerly IASPRSFormerly USPRA8000 members

The National Organization

18

What Is A CPRP?

“Certified Psychiatric Rehabilitation Practitioner”

Supervised by the Commission

Partly “founded” in NJ

Transdisciplinary

19

The State Organization

1000 members 30 org members Leading state

chapter

Annual conference Various trainings Advocacy work

20

Sector Analysis

Government, Industry, Market, Customer, Product...

21

Government of New Jersey

22

Government of New Jersey

23

Government

24

Government

Increasing regulations

Electronic Medical Records

“RAC” Audits

Capricious and arbitrary administration

25

Industry: 120 AgenciesOf which... Bridgeway Catholic Charities Drenk Easter Seals Family Services Greater Trenton Mental Health Assn Essex Twin Oaks ...others...

26

Industry: Specialty Providers Supported Housing: 46 agencies

Supported Employment: 22 agencies

Consumer-operated: 33 centers

State Hospital patients: ~1500 per year

27

Market: NJ Medicaid Enrollment

28

Market: Medicaid Enrollments(Centers for Medicare and Medicaid, 2012)

29

Customer: Consumers

DMHAS BG appl. says...

Governor’s budget says..

285,000 “unduplicated consumers in community settings”, of which...

123,000 with SMI

Community Care Services 329,664Screening Services 98,217Outpatient Services 136,704Partial Care 12,127Residential 3,499Supported Housing 5,858Supported Employment 2,371Self-help Centers 6,240Integrated Case Mgt 10,725PACT 2,443

State Psychiatric Hospitals 1,500

30

Product: PsyR Evidence-Based Practices

Illness Management and Recovery Integrated Dual Disorder Treatment Assertive Community Treatment Family Psychoeducation Supported Employment

Supported Education Supported Housing Other “promising” practices

PsyR Recovery

31

Product: PsyR Evidence-Based Practices

Illness Management and Recovery Integrated Dual Disorder Treatment Assertive Community Treatment Family Psychoeducation Supported Employment

Supported Education Supported Housing Other “promising” practices

PsyR Recovery

32

Recovery: As Outcome

RECOVERY

time

33

Recovery: As Process

RECOVERYtime

34

Recovery: 3 Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

time

35

Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

time

36

Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

Illness Management & Recovery

time

37

Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

Supported Housing

Illness Management & Recovery

time

38

Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

Supported Education

Supported Housing

Supported Employment

Illness Management & Recovery

time

39

Models of Care

RECOVERY Psychiatric Rehabilitation

Individual Empowerment

Med

ical

Psychotherapy

Supported Education

Supported Housing

Supported Employment

Illness Management & Recovery

Family Psychoeducation

Assertive Community Treatment

time

40

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

Finance: Rate Ratio (Zuckerman et al., 2009)

41

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

Finance: Rate Ratio (Zuckerman et al., 2009)

42

US 0.72

WY 1.43AK 1.40DE 1.00PA 0.73CA 0.56NY 0.43

NJ 0.37

50th

!

Finance: Rate Ratio (Zuckerman et al., 2009)

43

Industry: Providers = f(Rate Ratio) (Decker, 2013)

𝑥=𝑴𝒆𝒅𝒊𝒄𝒂𝒊𝒅 𝑟𝑎𝑡𝑒𝑀𝑒𝑑𝑖𝑐𝑎𝑟𝑒𝑟𝑎𝑡𝑒

% doctors accepting

44

Competition (“Stakeholders”)

45

Competition (“Stakeholders”)

46

Issues and Positions

47

3 Mega Issues affecting PsyR

1. “Reductionism”

2. Managed Care

3. Medicaid Expansion

Paternalism

“Brain” over “mind

ST over LT

“Evidence”: only RCTs...

Problems:Stigma. Pharmacology.

48

3 Mega Issues affecting PsyR

1. “Reductionism”

2. Managed Care

3. Medicaid Expansion

Paternalism

“Brain” over “mind

ST over LT

“Evidence”: only RCTs...

Problems:Stigma. Pharmacology.

49

3 Mega Issues affecting PsyR

1. “Reductionism”

2. Managed Care

3. Medicaid Expansion

Administrative Services Organization (ASO)

Fee-for-service

Problems: Cost “containment”Incremental careStressed operations.

50

3 Mega Issues affecting PsyR

1. “Reductionism”

2. Managed Care

3. Medicaid Expansion

Medicaid: 65% of public mental health

Enrollment: 25% 234,000 in NJ

No provider increase...

Problems:Access, Availability,Quality, Cost, Innovation

51

Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

52

Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

COLA

CPRP (dissemination)

Pay parity (with hospitals)

Training (R-SHRP)

Licensing (hurdles)

Peer Providers

53

Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Transition support ($)

“RAC” auditing

54

Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Medicaid Rate Setting

“Medical Necessity”

Community Support Services (CSS)

55

Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Supported Housing (a “medical necessity”)

Supported Employment (“balkanized” process)

56

Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Support Olmstead funding (for housing)

Oppose National Registry

Improve crisis screening

Support CIT for police

Benefits parity for “old” Medicaid eligibles

57

Advocacy: 6 Development Domains1. Workforce

2. Agency

3. Sector

4. Practice

5. Client/Consumer/Family

6. Government

Mental health courts

More and better outcome measurements

58

Advocacy: NJPRA Strategy

Outreach diversification

More individualized positioning

Higher public profile

More impact

59

Advocacy: What NJPRA Needs...

More non-legislative representation A meeting with Governor’s office More focus on Medicaid office and rate setting process More “assertion” with DMHAS More help with interdepartmental contact, e.g. DCA

More press contacts and networks News articles Radio and TV appearances

More contacts with philanthropies, corporations