Assessing MHICM: Program Effects on Mental Health Care Utilization and Costs*,***Funding from HSR&D grant IIR 06-115  and the VISN5 MIRECC**Data provided by the following VA research centers: SMITREC, NEPEC, and HERC

Investigators: 	Eric Slade1,2

	Lisa Dixon1,2

	Marcia Valenstein3,4

	John McCarthy3,4

Analysts:	Stephanie Visnic3, Rose Ignacio3, Deborah Welsh3, Lan Li1,2

1VISN 5 Mental Illness Research and Education Clinical Center, Baltimore

2University of Maryland School of Medicine

3VA Serious Mental Illness Treatment Research and Evaluation Center, Ann Arbor

4University of Michigan School of Medicine

*

Please let me know if you have any questions, and feel free to contact me for further information.

Thank you!

The MHICM Program
        - A psychiatric “hospital without walls” 

Uses the Assertive Community Treatment (ACT) model. 

Similar in staffing intensity to inpatient psychiatric care

Team-based mobile care

Small caseloads per team member

Team available 24/7

Care is comprehensive 
        - Improves patients’ quality of life and satisfaction with care, and reduces their inpatient utilization

1980’s VA randomized trials of Intensive Psychiatric Community Care (IPCC) (Rosenheck et al., 1995 & 1998)

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

MHICM

*

The MHICM Program
        - Formally implemented as MHICM in FY2000

Implemented “high hospital use” entry criterion
        - Rapid growth

			FY00		FY07

Teams	46		100

Clients	2,655		7,609

Cost		$14.5 mil.	$46 mil.
        - <10% of eligible veterans have enrolled

MHICM programs require a max. client-staff ratio of 12 to 1 

*

Total mental health budget is around $2.4 billion. 

MHICM is around 2% of total mental health budget.

MHICM clients represent 0.9% of all mental health patients

MHICM costs around $7,500 per patient per year. 

For comparison, ave. VA MH tx cost is around $5,000 per patient with SMI.

Objectives
        - Estimate the effects of MHICM on mental health services utilization during the first 12 months following clients’ first enrollment in MHICM

psychiatric inpatient days of stay

partial hospital program days 

other outpatient mental health days  
        - Assess the VA cost consequences of the MHICM program

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

Net Impact ($)

Inpatient Psychiatric Utilization in the Prior Year

0

Lower

Higher	r

> 0

< 0

MHICM’s Net Impact on Psych Costs

Hypothesized 

A

B

C

Declining VA psychiatric inpatient use may reduce savings achieved with MHICM

		FY00	FY07	%Δ

LOS (Days)	15.0 	11.4	-24

Bed Census 	4,106 	2,958	-28

Bed Days/Veteran 	22.0	16.8	-24

Trend in VA Psychiatric Inpatient Use

*

MHICM costs around $7,000 per patient per year. 

For comparison, ave. VA MH tx cost is around $5,000 per patient with SMI.

$

0

Time

VA Trend in  Inpatient Psych Days Per Patient

Net Savings from MHICM ($)

Net Savings

Net Costs

Expected Cost Consequences of MHICM 

*

Study Design

Retrospective observational design

Sample: MHICM-eligible VA patients in FY01 to FY04

“Intervention”: Enrollment in MHICM 

“Comparison”: Usual care 

Follow-up period: The 12-month period following either MHICM initiation or becoming MHICM-eligible

*

All VA patients who began MHICM between FY01 and FY04.

All VA patients who met eligibility criteria but did not enroll in MHICM between FY01 and FY04

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

Study Timeline

MHICM Enrollees

MHICM Eligible Non-Enrollees

-12

-12

0

+12

+12

0

Months

Months

Enrolled

Eligible

“High Hospital Use”

“High Hospital Use”

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

Sample

Data sources

VA National Psychosis Registry (SMITREC)

VA MHICM enrollment data archive (NEPEC)

VA HERC Average Costs data archive

Inclusion criteria

Schizophrenia or bipolar disorder diagnosis

Residence within 60 miles of a VA hospital

Recent history of “high hospital use” 

Inpatient psychiatric utilization of >30 days or ≥3 stays in the past 12 months

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

Sample

2,102 new MHICM clients 

25,630 MHICM-eligible non-enrollees

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

Estimation

Potential selection bias

	Enrollment into MHICM could be related to severity of illness or need for MHICM

*

Standard regression estimates of MHICM’s impacts may be biased. 

Estimation
        - Want to estimate E(y|x,M), where: 

yi = α0 + α1’xi + δMi + ui.

δ is the average effect of MHICM on study outcome y.  

E(u)=0, Cov(M,u)=0 are key assumptions of model.
        - Initiation into MHICM services: 

			Pr(Mi =1) = F(β0 + β1’zi + vi)
        - If Cov(v,u) ≠ 0: Cov(M,u) ≠ 0, and regression estimates of δ will be biased and inconsistent. 

*

Estimation

	Propensity score one-to-one matching was used to “balance” the sample on observable characteristics z

	If selection into MHICM is correlated with unmeasured confounders, 

		i.e., E(y|z,M,v) ≠ E(y|z,M)

	propensity score matching will not alleviate bias

→	Method of “instrumental variables” was used to further minimize selection bias

		But, there is another complication...

*

Standard regression estimates of MHICM’s impacts may be biased. 

*

Estimation
        - IV methods with non-linear outcomes required modification of the model
        - Terza, Basu, Rathouz, J. Health Econ, 2008

Estimate: 

Obtain: 

Estimate: 

*

Estimation

IV model requires that z include at least one variable that is not in x

These “instruments” must be correlated with M but not with y conditional on M

For tests of these assumptions, see Baum et. al., Stata Journal, 7(4), 2007.  

Instruments:

distance to the nearest MHICM team and 

whether a MHICM team was onsite at the VA hospital where client had last psych inpatient stay 

*

Estimation
        - Used two-part generalized linear model (GLM)

P(y) > 0 (vs. 0) modeled as a normally distributed binary random variable 

E(y | y > 0) modeled as a gamma distributed random variable with a “log link”

	ln{ E(y) } = α0 + α1’xi + δMi 

where y is gamma distributed. 
        - To calculate averages, used: 

		E(y) = P(y>0)×E(y|y>0)

*

One-to-One Matching

Pre-matching

2,102 new MHICM clients 

25,630 MHICM-eligible non-enrollees

Post-matching

2,102 new MHICM clients 

2,102 MHICM-eligible non-enrollees

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

| Descriptive characteristics pre-/post- matching        |
|--------------------------------------------------------|
| Unmatched Sample (N=28,032)                            | Matched Sample (N=4,204) |
|                                                        | No MHICM | MHICM | No MHICM | MHICM |
| Male %                                                 | 92.7 | 90.6 | * | 90.2 | 90.6 |
| Age in years                                           | 51.9 | 51.3 | * | 51.2 | 51.3 |
| Any inpatient psych care  past 30 days %               | 45.3 | 67.3 | * | 66.0 | 67.3 |
| Inpatient psych days   past 12 months                  | 51.5 | 68.5 | * | 68.1 | 68.5 |
| Inpatient psych stays   past 12 months                 | 2.7 | 2.7 | 2.7 | 2.7 |
| Partial hospital days   past 12 months                 | 3.3 | 9.8 | * | 10.6 | 9.8 |
| Schizophrenia dx %                                     | 62.2 | 80.3 | * | 81.4 | 80.3 |
| Homeless past 12 months                                | 36.2 | 26.5 | * | 27.6 | 26.5 |
| % with a service connected   disability rating >50% | 48.3 | 54.3 | * | 54.8 | 54.3 |
| Substance use dx %                                     | 57.5 | 47.3 | * | 48.2 | 47.3 |
| Charlson comorbidity index                             | 0.75 | 0.70 | * | 0.70 | 0.70 |
| Died during 12 month follow-up   period %              | 10.7 | 4.4 | * | 4.4 | 4.4 |
| * Differs from “No MHICM” at P<.05                  |

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

| Mean use of mental health services during the first 12-months post-enrollment [matched sample, N=4,204]                                     |
|---------------------------------------------------------------------------------------------------------------------------------------------|
| No MHICM(N=2,102)                                                                                                                           | MHICM(N=2,102) |
| Any Service Use (%)                                                                                                                         |
| Inpatient Psychiatric                                                                                                                       | 57.9 | 61.2a |
| Partial Hospital                                                                                                                            | 18.4 | 29.9a |
| Other Mental Health Outpatientb                                                                                                             | 85.3 | 80.5a |
| Nursing Home                                                                                                                                | 10.4 | 4.3a |
||
| Days of Service Usec                                                                                                                        |
| Inpatient Psychiatric                                                                                                                       |
| Per year                                                                                                                                    | 50.1 | 36.3a |
| Per stay                                                                                                                                    | 26.3 | 15.1a |
| Partial Hospital                                                                                                                            | 59.9 | 52.3a |
| Other Mental Health Outpatientb                                                                                                             | 19.2 | 17.5a |
| Nursing Home                                                                                                                                | 184.4 | 98.8a |
| a Different from No MHICM at P<.05b All non-MHICM outpatient mental health servicesc Among persons with some use of services in category |

*

| Estimated marginal effects of MHICM services on use of other mental health services in the first 12 months post enrollment, by service category [matched sample, N=4,204] |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                                                                                                                                                           | Standard | Instrumental Variables |
| Service Category                                                                                                                                                          | μ0a | ME | t | P | ME | z | P |
| Any Service Use                                                                                                                                                           |
| Inpatient Psychiatric                                                                                                                                                     | 0.648 | 0.033 | * | 2.11 | 0.035 | -0.084 | -1.57 | 0.117 |
| Partial Hospital                                                                                                                                                          | 0.169 | 0.128 | *** | 10.16 | <0.001 | 0.486 | *** | 24.08 | <0.001 |
| Other Mental Health Outpatientb                                                                                                                                           | 0.927 | -0.050 | *** | -4.41 | <0.001 | -0.256 | *** | -6.89 | <0.001 |
| Nursing Home                                                                                                                                                              | 0.061 | -0.047 | *** | -6.72 | <0.001 | -0.011 | -0.51 | 0.607 |
||
| Days of Service Usec                                                                                                                                                      |
| Inpatient Psychiatric                                                                                                                                                     |
| Per Year                                                                                                                                                                  | 56.0 | -7.5 | ** | -3.22 | 0.001 | -29.5 | ** | -2.73 | 0.006 |
| Per Stay                                                                                                                                                                  | 30.4 | -9.1 | *** | -7.18 | <0.001 | -21.7 | *** | -3.76 | <0.001 |
| Partial Hospital                                                                                                                                                          | 38.5 | -5.8 | -1.67 | 0.095 | -1.1 | -0.10 | 0.924 |
| Other Mental Health Outpatientb                                                                                                                                           | 14.7 | -0.1 | -0.14 | 0.890 | 7.9 | *** | 3.54 | <0.001 |
| Nursing Home                                                                                                                                                              | 159.1 | -28.1 | 1.61 | 0.107 | -94.3 | -1.37 | 0.171 |
| * P<.05; ** P<.01; *** P<.001                                                                                                                                    |
| a Estimated average among MHICM-eligible non-enrollees                                                                                                                    |
| b All non-MHICM mental health outpatient services                                                                                                                         |
| c Estimates for persons with any service use in each category                                                                                                             |

*

| Adjusted effects of MHICM on average service days, first 12 months post-enrollment (matched sample)* |
|------------------------------------------------------------------------------------------------------|
| Without MHICM                                                                                        | With MHICM | Δ | %Δ |
| Standard                                                                                             |
| Inpatient psychiatric                                                                                | 28.0 | 24.2 | -3.8 | -14% |
| Partial hospital                                                                                     | 7.0 | 10.6 | +3.6 | +52% |
| Other mental health outpatient                                                                       | 16.1 | 14.7 | -1.4 | -9% |
||
| Instrumental Variables                                                                               |
| Inpatient psychiatric                                                                                | 28.0 | 14.8 | -13.2 | -47% |
| Partial hospital                                                                                     | 7.0 | 28.0 | +21.0 | +300% |
| Other mental health outpatient                                                                       | 16.1 | 10.3 | -5.8 | -36% |
| * N=4,204                                                                                            |

*

| Adjusted effects of MHICM on VA costs, first 12 months post-enrollment (matched sample)* |
|------------------------------------------------------------------------------------------|
| Without MHICM                                                                            | With MHICM | Δ | %Δ |
| Standard                                                                                 |
| Total cost                                                                               | $31300 | $32541 | +$1241 | +4% |
| Inpatient psychiatric                                                                    | $25913 | $19976 | -$5937 | -23% |
| Partial hospital                                                                         | $1007 | $1585 | +$577 | +57% |
| Other mental health outpatient                                                           | $1365 | $1254 | -$111 | -8% |
| Instrumental variables                                                                   |
| Total cost                                                                               | $31300 | $33666 | +$2366 | +7% |
| Inpatient psychiatric                                                                    | $25913 | $16985 | -$8927 | -34% |
| Partial hospital                                                                         | $1007 | $5468 | +$4460 | +443% |
| Other mental health outpatient                                                           | $1365 | $1447 | +$83 | +6% |
| N=4,204Average MHICM cost is $7669                                                       |

*

Net savings from MHICM during the 1st year of enrollment

Average effect

Clients' Inpatient Psych Days of Stay 1 Yr Prior to MHICM 

Inpatient Use in the Year Prior to MHICM

HIGHER

LOWER

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

Implications
        - MHICM is a cost-effective program

However, financial savings from MHICM have decreased

Future expansions should continue to focus on the disabled
        - Enrollment in MHICM increases subsequent use of partial hospitalization program services 

Unclear whether this effect is desirable   
        - Thousands of MHICM-eligible VA patients are not enrolled in MHICM

Persons who are homeless, have concurrent substance use conditions, and reside further away from MHICM teams may have less access than others

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

Future Work
        - What happens to utilization/costs in the second year of MHICM?
        - What predicts disengagement from MHICM? 
        - Does fidelity to the ACT model matter? 

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.

Thank you!

Contact Information: 

Eric Slade

VISN5 Capitol Network MIRECC

Baltimore, Maryland

Eric.Slade@va.gov

410-706-2490

*

Interdisciplinary teams.  

Responsible for patients’ care 24/7.

community visits, with low caseloads (seven to fifteen veterans per clinician),

allowing rapid attention to crisis and development of community living skills

to prevent crisis in this exceptionally vulnerable population.

􀂾 Flexibility and Community Orientation. Flexibility and community orientation

with most services provided in community settings and involving integration

with natural support systems whenever possible (e.g., family members,

landlords, employer).

􀂾 Rehabilitation Focus. Focus on rehabilitation through practical problem

solving, crisis resolution, adaptive skill building, and transition to self-care and

independent living where possible.

􀂾 Continuity and Responsibility. Identification of the team as a “fixed point of

clinical responsibility” providing continuity of care for each veteran, wherever

the veteran happens to be, for at least one year, with subsequent care subject to

review of continuing need for intensive services.