2006 APA Achievement Awards: Silver and Bronze Achievement Awards
Silver Award: Community Support Services, Wyandot Center for Community Behavioral Healthcare, Kansas City, Kansas—Providing Recovery-Based Treatment to Enhance Quality of Life
The Wyandot Center for Community Behavioral Healthcare was founded in 1953 and is dedicated to serving the residents of Wyandotte County (Kansas City, Kansas) with its innovative behavioral health services. The center is currently recognized locally, regionally, and nationally for its consumer-driven, recovery-based program and has developed extensive partnerships with several community agencies and national programs to provide quality services that enrich and strengthen the lives of persons with behavioral health concerns.
Community Support Services, a department within Wyandot Center, focuses on providing this comprehensive support to adults with serious and persistent mental illness. In the early 1990s the focus shifted from a traditional psychiatrist rehabilitation program to one that concentrates on consumer-driven, recovery-based treatment. To better facilitate recovery-based services, staff partnered with consumers to provide peer support services, community education and awareness, and consumer involvement in program development activities.
With the belief that people with severe and persistent mental illness can reclaim their lives, Community Support Services integrates the clinical dimension of psychiatric and case management services with strong consumer peer support. This philosophy and the "recovery paradigm" permeate all aspects of the program, which include case management, psychiatric services, vocational training, psychosocial services, and general services focused on giving consumers tools for successful community living. As a result, this program benefits the 1,407 consumers who were served in the past year. These consumers support one another as they transition from being concerned about basic necessities to being concerned with advocacy and emphasizing holistic health—that is, their health as persons with mental illness.
In recognition of a program that embraces the recovery model, demonstrates its effectiveness in practice, and continues to provide responsible innovation to enhance the quality of life of its consumers, Community Support Services, Wyandot Center for Community Behavioral Healthcare, has been awarded APA's Silver Achievement Award for 2006.
Community Support Services' approach exemplifies what the Substance Abuse and Mental Health Services Administration outlined in February 2006 as the ten fundamental components of recovery: self-direction, individualized and personalized care, empowerment, a holistic approach, a nonlinear model of services, strengths-based support, peer support, respect, responsibility, and hope.
Community Support Services values consumers as providers and as peer supports. For example, in 1992 the department hired its first consumer-providers and in subsequent years hired a full-time consumer affairs and development specialist. Currently, the department employs 15 consumers as providers, many of whom have worked at the center for several years. Also, two of Community Support Services' consumer-providers serve by gubernatorial appointment on the Kansas Mental Health Planning Council.
The department has made significant contributions to the field of mental health. Community Support Services is one of the original three Kansas sites that implemented a supported employment program. This program has led Kansas in employment outcomes in supported employment for the past three years. Community Support Services and S.I.D.E. (Socialization, Interdependence, Development, and Empowerment), a consumer-run organization, are participating in a pilot program titled "Using Medications as Part of the Recovery Process." This interactive, video-based program emphasizes choice and self-determination as cornerstones to a recovery-based approach. The department is also helping to develop a consumer-oriented toolkit for peer support and consumer-operated programs in collaboration with the U.S. Surgeon General's Office. This toolkit will be used to develop best practices and guide other programs that want to develop consumer-driven services.
In addition, since 2002 Community Support Services has participated in two evidence-based practice projects with Dartmouth University: one on supported employment and the other on integrated dual diagnosis treatment. Also, because of the quality of Community Support Services' work and its use of evidence-based practices, the department was selected as one of only 21 programs nationwide to participate in the $47 million Mental Health Treatment Study being sponsored and funded by the Social Security Administration. The study will examine the value of eliminating programmatic work disincentives, establishing an accurate diagnosis, and delivering appropriate mental health and employment supports for Social Security Disability Insurance beneficiaries with a primary impairment of schizophrenia or affective disorder.
Funding for Community Support Services totals more than $7 million a year and comes from client fees (largely Medicaid) and state and county funds. Community Support Services has worked to overcome funding barriers. For example, the department did not receive special funding or resources to implement its recovery-based program. However, the department was able to implement the program by educating staff and consumers, partnering with other experts and agencies interested in recovery (for example, the University of Kansas and Dartmouth), and accessing resources that were available without great costs (for example, Wellness Recovery Action Plans, which assist consumers in identifying triggers, defining health, and developing strategies for recovery and wellness).
As a way of effectively garnering new resources and support, the Community Support Services program participates in pilot projects. Although these projects may bring some financial support, they more frequently provide helpful technical assistance.
Community Support Services employs an advanced registered nurse practitioner and five nurses, as well as 130 other employees in various roles—a consumer affairs and development specialist, wellness associates, case managers, vocational staff, homeless team members, attendant care staff, community integration team members, liaisons, therapists, an integrated dual diagnosis treatment specialist, and representative payees.
The department is also staffed by one psychiatrist who provides initial consumer evaluation, sees consumers along with nurses to prescribe medications and monitor symptoms, participates as a member of the evidence-based practice leadership team, and meets weekly with service coordinators to facilitate communication and treatment. The psychiatrist also pilots a medication education course for consumers and staff to help facilitate active participation in treatment and has developed a model of shared decision making related to psychiatric care that includes software to allow consumers to describe how they are taking and using their medications. The psychiatrist also signs off on every consumer treatment plan (plans are updated quarterly) and offers training for Community Support Services staff on psychiatric diagnoses.
Community Support Services treated 1,407 persons last year and serves 900 consumers currently. A total of 670 of those individuals receive intensive services including case management, psychosocial services, and attendant care; 195 are currently receiving supported employment services. The program values providing assistance to consumers to help them live, work, learn, and play in the community of their choice. Currently 96 percent of all enrolled consumers live independently, and 92 of the 195 clients currently enrolled in the supported employment services are working. Thirty-one clients in the supported employment group are involved in a credit-bearing educational program.
On an annual basis, Community Support Services' homeless team does outreach and identifies and serves 150 persons. Fifty percent of these persons transition from homelessness to being housed and to being active participants in the Community Support Services program.
Annually the state contracts with local consumer-run organizations to conduct consumer satisfaction surveys. These surveys provide feedback upon which Community Support Services can act—for example, addressing transportation issues of consumers. In 2005 and 2006, 85 percent of the department's consumers rated their access to care, service quality, service outcomes, treatment planning, and general satisfaction as "highly satisfactory" and scored above the state average in every category.
Wyandot Center and Community Support Services have received numerous accolades for their programs. In 2005 Community Support Services' outstanding efforts in the area of supported employment received an award of recognition from the Johnson & Johnson Dartmouth Community Mental Health Program. Also, the commitment of Wyandot Center staff, innovative programming, and community engagement were acclaimed by members of the team making an evaluative site visit for the Federal Block Grant program in September 2005. Wyandot Center was selected by the state to be the site visited by the evaluating team.
Community Support Services works to treat adults with serious and persistent mental illness with dignity and respect by implementing a consumer-driven, recovery-based program. In this way, the department focuses on integrating consumers into the community.
Bronze Award: Missouri Mental Health Medicaid Pharmacy Partnership Project—A Successful Partnership to Improve Prescribing Practices
The Missouri Mental Health Medicaid Pharmacy Partnership Project was created to align psychiatric prescribing practices with national standards for evidence-based best practices. Of the 500,000 enrollees in the Missouri Medicaid program, about 40 percent receive psychiatric medication, for a cost of $300 million annually. Psychiatric medication uses about 30 percent of the Medicaid pharmacy budget because of the chronic nature of psychiatric illness and the development of new, expensive medications. The goals of the program are to improve patient adherence and outcomes, contain pharmacy costs, and maintain access to psychiatric medications without resorting to preferred drug lists, fail-first approaches, or other restrictive practices.
In 2003 a partnership was struck between the Missouri Department of Mental Health (DMH), the Missouri Division of Medical Services (DMS), and Comprehensive NeuroScience, Inc. (CNS). Pharmacy claims are examined to find prescribing patterns of psychiatrists and primary care physicians that run counter to best-practice guidelines. Once anomalies are identified, DMH mails the prescriber information about the areas of concern and the current best practice. This information is intended to encourage physicians to modify their prescribing patterns and avoid external restrictions.
Several outcome studies have shown that the educational program has helped to reduce inpatient admissions and days hospitalized. On the basis of three independent analyses of spending trends in Missouri Medicaid behavioral health conducted in late 2004 and in 2005, the DMS pharmacy director reported that the partnership program had contributed to at least $7.7 million in Medicaid savings by 2004. In recognition of its success in improving the quality of prescribing practices for psychiatric medications and patient outcomes, the Missouri Mental Health Medicaid Pharmacy Partnership Project was selected to receive APA's Bronze Achievement Award for 2006.
When the partnership was formed in January 2003, the medical director of DMH and the pharmacy director of DMS established that they would use an educational approach to improve the quality of behavioral health prescribing practices. Founding principles were to respect physician autonomy; to minimize unintended consequences, such as requiring preauthorization or step therapy; and to support the prescribers. The project assumes that pres!cribing consistent with nationally recognized best-practice standards will lower overall health care costs and that prescribers will voluntarily adhere to national standards once informed.
On a monthly basis, CNS analyzes Missouri Medicaid prescription drug claims, comparing them with a set of quality indicators that signal questionable prescribing patterns. Indicators include prescribing three or more antipsychotics to one patient, prescribing unusually high or low dosages of antipsychotics, a lapse in refilling a prescription, prescribing two or more sedative-hypnotics or anxiolytics to one patient, polypharmacy in several therapeutic classes, and prescribing three or more psychotropics to children. Of the Missouri Medicaid patients who receive psychiatric medication, 28 percent are prescribed dosages and combinations of drugs by nearly 7,500 prescribers (44 percent) that are potentially inconsistent with best practices.
Physicians whose practices coincide with the indicators receive a an information packet that includes a quality consideration letter from DMH that outlines the possible deviation from best practices, a 90-day pharmacy history for the patient, and best-practice guidelines, including monographs on the clinical issue. The first educational alerts were mailed to prescribing psychiatrists and primary care physicians in June 2003. Between 1,500 and 3,000 alerts are mailed per month. In addition, prescribers are offered telephone consultation by psychiatrists with specific psychopharmacology expertise.
The partnership operates with a project management team of staff from DMH, DMS, and CNS. Twice yearly the team receives feedback from an advisory board of prominent Missouri physicians (half are psychiatrists) and mental health stakeholders. In addition, an editorial board of nationally recognized psychiatrists advises CNS on evidence-based practices. With that input, the directors develop and choose quality prescribing indicators and clinical messages. CNS is responsible for indicator design, testing, and educational contacts.
The project is funded through a contract between Eli Lilly and Company and CNS, which provides data analysis, mailing services, and some project management. Because of the success of the program, additional grants have been made by Janssen Pharmaceutica Products, AstraZeneca Pharmaceuticals, and Abbott Laboratories.
The Missouri partnership has improved the quality of psychiatric prescribing, improved clinical outcomes, and saved money. In 2005 the partnership jointly published results of a study that tracked the patients of prescribers who were identified as having outlier prescribing patterns. Inpatient admissions were compared for the six months before and after their prescribers' first receipt of educational mailings. The study found that inpatient admissions and days hospitalized dropped by nearly 50 percent after the intervention messages were received.
Using continuous feedback from prescribers and from the advisory board, the partnership continues to refine the program and develop pilot projects. Examples include reformatting the alerting packets to highlight key points, expanding the sets of quality indicators, creating new indicators relating to children, and testing new indicators for patients with bipolar disorder and complex needs. In a pilot program Missouri's community mental health centers received a specially tailored reporting system that allows them to benchmark information on comparable patients, thus better serving patients who have the most serious mental health disorders and most complex needs. Another pilot program provides medical profiles and clinical care consideration alerts to physicians of the approximately 895 children diagnosed as having attention deficit hyperactivity disorder and complex needs.
Also, when Part D of the Medicare Modernization Act took effect January 1, 2006, many state Medicaid agencies stopped receiving pharmacy claims information for dual-eligible patients. DMS collaborated with pharmacies and prescription drug plan providers serving Missouri to ensure timely access to behavioral health pharmacy claims for these patients, who account for at least half of the Medicaid patients with disabilities. This access provides continuity to the state's prescription quality management efforts, which in turn has ensured continued funding from Eli Lilly and Abbott Laboratories.
The success of the Missouri Mental Health Medicaid Pharmacy Partnership is also indicated through its replication. Twenty-four states have implemented the same or a similar approach. The federal Center for Medicaid and Medicare Services has identified the program as a national model.
Prescription of psychiatric medications for the treatment of mental illness is the most common and effective treatment modality available. The partnership is a model for reducing hospitalizations, containing pharmacy costs and reducing polypharmacy, and maintaining open access to psychiatric medications through collaboration and education.
