TaskForce TimelinessAccessBehavioralHealthServices

Andrew Sarkin, Ph.D. University of California, San Diego How are access and timeliness being measured  or proposed to be measured by other counties or programs, or in other areas? What do we want to know about access to and  timeliness of services? What would this data be used for? How can we make it actionable? Pros and cons of alternate definitions?  Consideration of additional information needed  to draw conclusions about whether to add a new indicator(s) and how to calculate it (that would be presented to Task Force at the next meeting). Structural Access Indicators (locations, hours)  Wait Times  Engagement, Retention, and Discharge  Disparities in Access and Penetration Rates  Cultural Accommodations (translators, etc.)  Stigma and other Barriers  Client Perceptions of Access and Effectiveness  Community Perceptions of Access  National Beh. Healthcare Quality Framework  Comments and Discussion  Access to health services means the timely  use of personal health services to achieve the best health outcomes, which is defined in terms of 3 measures: Gaining entry into the health care system  Accessing a health care location where  needed services are provided Finding a health care provider with whom the  patient can communicate and trust Timeliness is the health care system's ability  to provide health care quickly after a need is recognized. Measures of timeliness include: Time spent waiting in doctors' offices and  emergency departments Time between identifying a need for specific  assessments and treatments and actually receiving those services Barriers to accessing health  services lead to: ◦ Unmet health needs ◦ Delays in receiving appropriate care ◦ Inability to get preventive services ◦ Preventable hospitalizations Timeliness  Availability  Convenience (geographically and otherwise)  Affordability (including expenses like travel)  Cultural “competence”  Community knowledge of resources  Stigma and other barriers reduced  Integration with other services  Capacity  Locations (transportation provided?)  Hours  Languages accommodated (translator?)  Populations served (specific needs?)  Staffing  Peer availability  Training of staff and peers  “No Wrong Door” policies and connections  Access and Crisis Line functioning  From first contact, track number of days to:  ◦ First appointment offered ◦ First appointment scheduled ◦ First appointment attended ◦ First assessment (usually same as first appointment) This is tracked for first appointment with:  ◦ Any mental health professional ◦ A psychiatrist (if appropriate, or other prescriber) Less has been done with wait times in waiting  rooms, e.g., minutes waiting (hard to define) Emergency Department/Crisis wait times  Time to follow-up after hospitalization/crisis  Staff use standard spreadsheet to track wait times  ◦ Clinics are allowed flexibility in tracking procedure ◦ Submit standard sheet to county evaluators ◦ Standard sheet has built in formulae for evaluation Should be made available for actionable use  ◦ Currently, many people focus on FY13-14 data to make critical decisions about county resources ◦ Solid data from almost two years ago for decisions today ◦ More current data can be made available for “live” action ◦ Dashboards to inform managers and contract reps ◦ Can inform immediate temporary personnel allocation ◦ Head off organizational problems while there is still time Should be within 7 days as per guidelines  Measured simply by days until first service  Some suggest rehospitalization rate is a fair  measure of access post-hospitalization Complications and definition challenges  ◦ Type of service accessed, appropriateness ◦ Not all services tracked in our electronic system ◦ Some are involuntary hospitalization ◦ Disengagement can prevent needed hospitalization Retention is considered a measure of access  ◦ Length of unbroken service (definition problem?) ◦ Number of services received (definitions again?) No-shows indicate failure to engage initially  MORS is a validated measure of engagement  Reasons for discharge can also be examined  Specific to program expectations and current  trends, so often examined comparatively Look for group differences to indicate cultural  competence and need for special services Avoidable hospitalization days, if inpatient  Less time in appropriate level of care  Blocked resources if space is needed  Perception of stalled progress by client  Can be computed as:  ◦ Time to discharge in days (definition challenges)  If no housing, then are they “ready for discharge”? ◦ Point-in-time counts of people awaiting DC Mapping of Services (Structural Access)  Using Zip Code Matching  ◦ Must have actual client and service zip codes ◦ Identifies disparities, in addition to overall gaps Client Surveys  ◦ How far do you have to travel for appointments? ◦ What are your out-of-pocket transportation costs? ◦ MHSIP – The location of services was convenient (parking, public transportation, distance, etc.). Community Surveys  ◦ How easy is it to get services in YOUR community? ◦ Look at differences by zip code, culture, income. Done as part of MHSIP once in San Diego  Please complete these questions if you sought  help for mental health issues in the past year: ◦ How long did it take to get an appointment with a mental health professional? (Less than a week…More than a year) ◦ How difficult or easy was it to find help? (Very Difficult, Difficult, Easy, Very Easy) ◦ How long after your appointment time did you have to wait to see a health professional? Minutes______ I was able to get all the services I thought I  needed. Staff were willing to see me as often as I  felt it was necessary. Services were available at times that were  good for me. I was able to see a psychiatrist when I  wanted to. Staff were sensitive to my cultural  background (race, religion, language, etc.). Example questions currently used in LA:  ◦ I am able to provide or arrange the kinds of services I want for my clients at this program ◦ My program is able to provide or arrange the kinds of services I want for my clients Could also ask about wait times, etc.  Disadvantages include subjectivity and bias  As with client surveys, burden is an issue  Done as part of PEI survey in San Diego every  18 months through random digit dialing. Could be part of the statewide CHIS  Please complete the questions if you sought  help for mental health issues in the past year: ◦ Where did you seek help? ◦ How long did it take to get an appointment with a mental health professional? ◦ How difficult or easy was it to find help? (Very Difficult, Difficult, Easy, Very Easy) Are you getting treatment for mental health?  Do you know anyone getting treatment?  Unless the incidence of mental health  problems decreases, these percentages of people getting treatment should rise with increasing access. (until full penetration is reached, i.e., everyone who needs services is getting appropriate services) How much do you agree with the following  statements? ◦ “It is easy to get mental health assistance in my community.” ◦ “I know where to go for mental health assistance if I need it.” ◦ “I feel comfortable getting mental health help.” ◦ “My community has appropriate mental health services for people with severe mental illness.” (Demographics also, to look at disparities)  • Consumers reported experiencing significantly less overall mental illness stigma in 2014 than consumers did in 2009. This survey was distributed along with the MHSIP. • There was also a significant difference in both the Discrimination and Disclosure subscales between 2009 and 2014. Adults with SMI receiving appropriate treatment  without having to be involuntarily hospitalized or committed Adults with SMI served in treatment settings  rather than jails/prisons Percentage of juvenile offenders served in  treatment rather than incarceration settings Wait times in emergency departments for  psychiatric and/or substance abuse related issues Wait times to see a behavioral health practitioner  upon other practitioner or self-referral • Methodologies in place to ensure eligible individuals are enrolled in health insurance. • Follow-up after Hospitalization for Mental Illness at Payer/System/Plan Level (e.g., SAMHSA, HRSA, Medicaid/Medicare, State Govt). Existence of mechanisms (number, percentage) to • monitor, receive, and adjudicate reports of noncompliance with parity regulations. Follow-up after hospitalization for a substance • use disorder at Payer/System/Plan Level (e.g., SAMHSA, HRSA, Medicaid/Medicare, State Govt). Percentage of patients with behavioral health • diagnoses that are able to afford co-payments and/or deductibles. Ability to bill equally for equivalent treatment for • behavioral health and other health conditions. Rehospitalization rates for persons with behavioral • health conditions. Economic impacts, social costs, and costs to • employers of behavioral health conditions. Economic impacts on health care costs of untreated • behavioral health conditions. Annual proportion of total health expenditures • related to behavioral health. Rates of behavioral health conditions among those • without insurance. Ability to afford and access appropriate levels of • behavioral health care for the condition. Out-of-Pocket costs to consumers  Percentage of people who get emergency or  hospitalization services who were not connected to regular services Percentage of eligible individuals who get  enrolled in health insurance Percentage who have access to a primary care  physician Referral pathways  Definitions!  New treatment modalities like telemedicine  Integrated services difficult to track  Referrals can be difficult to track  Anything you want to share that is  relevant to access and timeliness! Send additional comments:  asarkin@ucsd.edu