SAMHSA Expert Panel on Best Practices in Statewide Real-time Crisis Bed Databases

NASMHPD Commissioners Meeting

July 29, 2018 [Draft – 072518]

David Morrissette, PhD, LCSW

Captain, US Public Health Service

Office of the Chief Medical Officer

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

Debra A. Pinals, MD

Medical Director, Behavioral Health and Forensic Programs

Michigan Department of Health and Human Services

Clinical Professor of Psychiatry

Director, Program in Psychiatry, Law and Ethics

University of Michigan

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The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).

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Disclaimer

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Section 9007 of the 21st Century CURES Act 

21st Century CURES Act

Realtime database of beds at 

inpatient psychiatric facilities, crisis stabilization units, and residential community mental health and residential substance use disorder treatment facilities.... for adults and children

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Interdepartmental Serious Mental Illness Coordinating Committee Recommendations

2.2 Develop a continuum of care that includes adequate psychiatric  bed  capacity 

and community based  alternatives 

to hospitalization.

3.1.g. Psychiatric crisis response using 

least-restrictive appropriate settings... 

eliminating “psychiatric boarding” 

in hospital emergency departments;

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Crisis Services Continuum

Slide 5

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To examine the experiences of states and MCOs that have implemented bed registries.

To identify the practical aspects of an effective registry.

To examine the policy challenges which must be resolved for a registry to be effective.

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Expert Panel Objectives

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Panelists represented a variety of stakeholders:

State mental health authorities

State health authorities

Managed care organizations

Hospital systems

Crisis service providers

Family members

Individuals with lived experience

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Expert Panelists

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SAMHSA Expert Panel on Best Practices in Statewide Real-time Crisis Bed Databases

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Seemingly Simple, but with Challenges to Overcome

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Challenge 1: Stakeholders are invested in the existing process and distrustful of changes.

Use the SMHA’s role as a convener to conduct an analysis of the current system operation.

Question to stakeholders: How can a database improve the system operations for all users?

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Challenge 1: Stakeholders are invested in the existing process and distrustful of changes. (2)

Stakeholders

SMHA

State Medicaid Office

State Health Authority

Attorney General

Families

People with lived experience

Police and EMS

Emergency departments

General hospital inpatient units

Receiving hospitals

Crisis services providers

Managed care organizations

NAMI/MHA

State hospital association

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Challenge 2: Databases do not have a value in and of themselves.

Value proposition for databases.

Increased accountability across the system and hierarchically

Better utilization of existing services.

Identification of mismatches between service needs and service capacities.

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Challenge 3: Relying on the database alone to make placements.

Even though registries are automated, placements are always hands-on.

Complex cases will remain complex.

Receiving facilities may assert right to refuse individual cases

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Challenge 4: Inadequate resolution of policy issues affects overall buy-in into the database.

Navigating policy issues around EMTALA and the IMD exclusion

Requires partnerships among state agencies

State Medicaid Office and Attorney General are essential partners on addressing policy issues.

Transparency with stakeholders and organizations feeding data into the database

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SAMHSA Expert Panel on Best Practices in Statewide Real-time Crisis Bed Databases

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How Should a State Proceed...

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State mental health commissioner can serve as a convener to the process.

Inventory of state and local crisis systems

Call centers

Mobile and static crisis responses

Crisis stabilization

Community respite or residential

Inpatient

Specialized inpatient

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1. Inventory Existing Services and Systems

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2. Develop a Description of the Existing System

Georgia System Description

* Private Hospital beds are purchased by DBHDD for uninsured individuals when a crisis bed is not available.

Source: J. Quesenberry/W. Farmer (2018)

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The database should be designed with two goals in mind:

To reflect the system that exists and 

With an eye towards the system you want

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3. Design a Database

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What are the benefits of a realtime electronic system for all stakeholders?

Improving access to and use of most appropriate care

Reducing wait times

Reducing reliance on most expensive care

Providing reliable data on utilization 

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4. Engage Stakeholders 

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Market to providers and hospitals that will feed data into the database.

Supply providers/hospitals with data which is meaningful to them.

Use the database as a tool to improve the system as opposed to an enforcement mechanism.

MCOs can more easily build incentives and disincentives in a database.

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5. Incentivize Participation in the Registry

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Few databases are real-time in that availability data are refreshed as beds become available or beds are filled.

However, limited daily refreshes are a threat to long-term utility of the database.

“Real time” must be operationalized for each registry.

Virginia: Revised statute requires the database be updated as the bed becomes available.

Georgia: Providers must update the database when a discharge date is set.

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6. “Real Time” Must be Useful to Users

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Transparency increases accountability across the system.

Transparent to whom?

Hospitals

Service providers

Managed care organizations

Families and people in need of services?

Public-facing vs. Provider-facing levels of access

Data-sharing of protected health information.

Improves value of the system for providers and hospitals who can make a determination as to whether the person in need of treatment matches the level of care they can provide.

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7. Transparency and Quality Data-Sharing

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Role

Oversight/accountability

Ensure long-term utility of the database

Monitor for patterns of cherry-picking

Examine utilization and bed capacity data to determine where need exists within the system for particular levels of care

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8. High-Level Decision-Maker Oversees Registry

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The four key stakeholders at the state-level are the

SMHA

State Health Authority

State Medicaid Office

Attorney General

The State Medicaid Office needs to have a seat at the table.

Many of the policy-level issues required SMO leadership.

EMTALA

IMD exclusion

Medicaid billing on more than one procedure per day

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9. Engage the State Medicaid Office in the Process

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SAMHSA Expert Panel on Best Practices in Statewide Real-time Crisis Bed Databases

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Discussion

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Is there interest in your state to establish an electronic database of real time (no lag time in identified openings) crisis response bed registry? 

Does your state have a vision for a crisis system that minimizes the use of inpatient beds and maximizes the use of community resources?

Does your state have a inventory of local and state crisis response systems?

What are the incentives for hospitals and state systems to maintain the status quo?

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Discussion 

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Are there existing stakeholder organizations that can be convened? 

Are there contract mechanisms to build alternative incentives for real time systems such as MCOs?

What incentives exist in your state to implement a registry save money or use resources more efficiently? 

What opportunities do you see in your state to create a system?

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Discussion (2)

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Thank You

David Morrissette: david.morrissette@samhsa.hhs.org

Debra Pinals:

Pinalsd@michigan.gov

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SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s communities.

www.samhsa.gov

1-877-SAMHSA-7 (1-877-726-4727) ● 1-800-487-4889 (TDD)

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