Changing Communities Changing Lives Money Follows the Person Behavioral Health Pilot Evaluation 2014...

Changing CommunitiesChanging Lives

Money Follows the PersonBehavioral Health Pilot Evaluation 2014

UT Austin – Center for Social Work Research

Background

• MFP began in Texas in 2001.• Since then, more than 36,000 returned to community.• BHP began in spring 2008 (Bexar) & fall 2010 (Travis).• Develop skills to live successfully in community.• Improve quality of life.• Minimize recidivism to NF.• Save money.

• Targets adults in NF 3+ months, meet NF care criteria, SMI or other BH with serious functional impairment.• CAT, enhanced substance disorder TX, ongoing HCBS.

Quality Improvement Evaluation

• How does the BH Pilot help participants in nursing facilities successfully transition to the community?• How can the Pilot be improved and sustained?

Evaluation Activities• Literature Reviews of Best Practices in community transitions.• Qualitative interviews with current and completed Pilot participants to learn

about their experiences and satisfaction with Pilot services and long-term outcomes after completing the program.• Interviews with project partner key informants to gain perspective on the

project from the staff point of view.• Interviews with family members, CTT members, and CAT therapists.• Analysis of quantitative data to document participants’ measurable

outcomes during and after discharge from the Pilot.• Video about participants’ return to community.

Participants Returned to Community• Jim: Poker player, comic fan, volunteer, and fiancé. After

3 years in the nursing home, he has lived for 5 years in an apartment or house.

• Stone: Artist, student, and nature lover. After 7 months in the nursing home, she has lived for 3 years in an apartment.

• Barb: Life-long artist and teacher. After 30 months in the nursing home, she has lived in an apartment for 3 years.

• Jerry: Chess player, reader, friend, and grandfather. After 3 years in the nursing home, he has lived for 4 years in apartments.

• Diane: Avid reader, cook, sister, and girlfriend. After 2 years in the nursing home, she has lived for 2 years in an apartment.

• Don: Student, group leader, and pastor in training. After 14 months in the nursing home, he has lived for 4 years in an apartment.

Literature Review

• Prevalence of MI in nursing homes: 14% - 33%.• Burden of BH.• Greater medical comorbidity.• Higher overall healthcare costs.• Poorer quality of care.• Poorer adherence to prescribed treatment.

• Person-centered planning and services.• Integrated physical and behavioral healthcare. • Reasonable staffing ratios.

Literature Review (con’t.)

• 24-hour access & single point of contact to professionals.• Services within 5-10 miles of clients.• Criteria for likelihood of successful transition: desire to live in community, minimal

cognitive impairment, low physical care requirements, well-managed BH, good safety net in community.• Family engagement, peer support, detailed transition planning, ample

communication between providers.• Housing First.• Social Action Group.• Telephone care management.• Peer support.

Participant Characteristics

BHP Participants’ Program Status367 referrals (May 2008 to Spring 2014)

San Antonio - 216 , Austin - 151

• Completed: 41%• Current: 17%• Disenrolled: 11%• Pre-trans: 10%• Died: 6%• Out of area: 5%• Returned to NF: 9%

Current or Completed Participants (N=214)• ~ Equal gender balance

• Age range: 27 - 89 (mean=58)• 18 to 30: 2%• 31 to 40: 5%• 41 to 50: 19%• 51 to 60: 32%• 61 to 64: 14%• 65 to 70: 11%• 71 and older: 10%

Current or Completed Participants: Race/Ethnicity

• African-American:• San Antonio: 12%• Austin: 22%

• Hispanic:• San Antonio: 40%• Austin: 12%

• White Non-Hispanic:• San Antonio: 44%• Austin: 66%

• Other/unknown:• San Antonio: 4%• Austin: 0%

Current or Completed Participants: Primary MH Diagnoses

• Depression: 46%• Bipolar: 14%• Anxiety: 13%

• Schizophrenia: 12%• Dementia: 4%

• Substance Use: 3%

• Substance use disorder treatment: 41% in Austin and 25% in San Antonio

Pre-Transition Only (N=37)

• Similar demographically and diagnostically to those who moved out.

• But more likely to be African-American.• 30% of those who received pre-

transition only.• 16% of those who moved out to

community.

NF Returnees (N=33)

As compared to those who remained in the community:• About 6 years older.• Twice as likely to have a diagnosis of dementia or physical

illness.

BHP Participant Outcomes

Key Questions

• Do the Pilot services improve functioning and quality of life? Are improvements sustained over time?

•What percentage of BHP participants eventually return to a nursing facility?

•What participant characteristics predict the probability of return to a nursing facility?

Data Sources

• Participant characteristics, from project databases maintained by UTHSCSA and CHCS.• Participant measures of functioning and quality of life

collected by UTHSCSA.• Participant institutional status, obtained from Medicaid

data from HHSC.

Percentage of BHP Participants Who Remained in the Community, by BHP Program Status

• Returned to NF (n=29): 10%• Out of service area (n=7): 43%• Not appropriate for services

(n=8): 50%• Dis-enrolled prematurely

(n=18): 72%• Died (n=16): 88%• Current (n=31): 100%• Completed (n=147): 72%

Functional and Quality of Life Measures• The Quality of Life Scale (QLS) (21 items) was developed to

evaluate deficit symptoms and impaired functioning in people with schizophrenia.• The Multnomah Community Ability Scale (MCAS) (17 items)

measures the functioning of chronically mentally ill persons living in the community.• The Social and Occupational Functioning Assessment Scale

(SOFAS) is a single item that measures an individual’s level of social and occupational functioning resulting from mental and physical health problems.

QLS Mean Scores over TimeQuality of Life: n= 270• 0 days

• Mean score: 2.55• Confidence index (CI) range: 2.45 to 2.64

• 90 days• Mean score: 2.65• Confidence index (CI) range: 2.57 to 2.78

• 180 days: • Mean score: 2.79• Confidence index (CI) range: 2.68 to 2.90

• 270 days• Mean score: 2.81• Confidence index (CI) range: 2.71 to 2.94

• 365 days• Mean score: 2.88• Confidence index (CI) range: 2.75 to 3.03

• 545 days• Mean score: 2.90• Confidence index (CI) range: 2.77 to 3.08

• 730 days• Mean score: 2.95• Confidence index (CI) range: 2.83 to 3.17

MCAS Mean Scores over TimeMultnomah Community Ability Scale (MCAS): n= 270• 0 days

• Mean score: 3.7• Confidence index (CI) range: 3.33 to 3.43

• 90 days• Mean score: 3.6• Confidence index (CI) range: 3.54 to 3.66

• 180 days: • Mean score: 3.58• Confidence index (CI) range: 3.53 to 3.65

• 270 days• Mean score: 3.61• Confidence index (CI) range: 3.55 to 3.67

• 365 days• Mean score: 3.58• Confidence index (CI) range: 3.53 to 3.66

• 545 days• Mean score: 3.55• Confidence index (CI) range: 3.46 to 3.64

• 730 days• Mean score: 3.57• Confidence index (CI) range: 3.49 to 3.68

SOFAS Mean Scores over TimeSocial and Occupational Functioning Assessment Scale (SOFAS): n= 270• 0 days

• Mean score: 35.2• Confidence index (CI) range: 34.6 to 36.2

• 90 days• Mean score: 38.5• Confidence index (CI) range: 37.6 to 39.1

• 180 days: • Mean score: 39.0• Confidence index (CI) range: 2.68 to 2.90

• 270 days• Mean score: 39.4• Confidence index (CI) range: 38.2 to 40.8

• 365 days• Mean score: 40.1• Confidence index (CI) range: 38.7 to 41.5

• 545 days• Mean score: 40.2• Confidence index (CI) range: 38.6 to 42.0

• 730 days• Mean score: 39.7• Confidence index (CI) range: 37.7 to 41.5

Institutional Status

• Medicaid data showing nursing facility stays were obtained for 256 participants to determine whether they were still in the community.

• 174 or 68% of participants remained in the community.• Median tenure was 28.5 months.• Longest tenure was 71.8 months.• Total community time in years for group was 446 person-years.

• Over 50% of those who returned to nursing facility (n=82) were in community for 13.5 months or longer. Total time in community was 106 person-years.

What Predicts Return to NF?• Used logistic regression to predict return to nursing facility (n=213).• Potential predictors of return:

oAgeoGenderoRace/ethnicity:

African-American compared to Anglo Hispanic compared to Anglo

o Substance misuse treatment receivedo Serious mental illness presentoDementia presentoNumber of inpatient stays during prior 12 months to return to communityoRate of inpatient stays for 6-month period after return to communityo Site: Austin versus San Antonio

• Reporting adjusted relative risk for statistically reliable predictors of return to community.

What Predicts Return to NF? (con’t.)

• Rate of in-patient stays was only reliable predictor of return to nursing facility. • On average, participants experiencing 1 episode of inpatient care every six

months (39%) were 1.93 times more likely to return, compared with participants who experienced 0 inpatient stays during six-month periods (21%).

• This is a potentially important way to identify participants who need additional assistance.

• A trend showed African-Americans (15%) were less likely than Anglos (33%) to return to nursing facility.

Potential Cost Savings• Cost of living in the community under MFP is 61% of the cost of living

in a nursing facility. • $3,937 in nursing facility based on Medicaid reimbursement rates.• $2,407 in MFP, accounting for initial expenses.*• Additional first month costs were $2,470 per person.

• Total potential savings to date were $11,051,348 (calculated as Person-months in community times Monthly savings minus Initial investment costs).

• It takes only 1.4 additional months of community residence to recover initial costs.

BHP Interviewees

• 10 participants living in the community (2 to 5.5 years) (average 3.2 years).

• 4 participants who returned to a nursing facility (9 to 24 months) (average 16.5 months).

• All had significant physical impairments:

• Eight were in wheelchairs, one paralyzed from the shoulder down, one paralyzed on the left side, one on kidney dialysis.

• Several had been affected by heart attack, stroke, spinal cord injury, osteoporosis of the spine, amputation, broken hip, hip replacement, degenerative arthritis, double pneumonia, or diabetes.

• Behavioral Health: Bi-polar, Schizophrenia, Borderline, Depression, PTSD, SUD

Resilience! Determination! Attitude!

• Remarkable resilience and determination to make it despite sometimes overwhelming physical and/or psychological challenges.• Positive attitude and absolutely determined to remain in the

community.• Will do anything it takes not to return to a nursing facility –

medical, emotional, psychological, physical, social.• All emphasized that they would not have been successful without

having received help from various sources, and particularly from their CAT therapists.

Client Testimonials• If you maintain a positive attitude and a feeling you

can make it, then you will.• During my three hospitalizations, I was ready to give

up, but she [CAT therapist] encouraged me to just give it one more day – that kept me motivated to stay out of the nursing home.• When I feel like I need to go back to the nursing

facility, I just talk to my doctor, and he says, “You’re ok, you can do it.” So I stay and keep going.• My family and friends helped me through that

transition and wouldn’t let me give up. Also, I figured God had a plan for me that wasn’t fulfilled yet, so I had to persevere.

Coping Skills: Be Active

• Artist: Imagines art, paints in her apartment.• Attends Comic Con, plays poker, cooks, works with a non-profit that

sponsors social events for the disabled, uses a computer.• Goes on occasional trips to the beach with friends, spends time with

her children and grandchildren, neighbors.• Facebook with 56 friends, Lone Star Circle of Care.• Goes to the park with the dog, cooks for friends, reads.• Plays chess with buddies downtown, reads.• Conducts a support group, goes to VA and ministers, attends church.

Community ServiceDon: Yeah, I get to go to the hospital and help people out, and talk to them. I get to go to group and talk to people. I talk to people around my neighborhood about different things, but that’s part of ministering, comforting people, encouraging them to have a positive attitude.

Wanda: I talk to the young kids around my neighborhood about drugs. I share my problems with addiction and encourage them to quit using.

Most Important Services: Housing(includes furniture, kitchen supplies, food, clothes, etc.)• Represents freedom.• I can do what I want when I want.• Can come and go as I please.• I can live life again.• Having a lock on the door.• Privacy.• Having family and friends over.

Most Important Services: Home Health Care

• Clean and cook.• Nursing services.•Medication assistance.• Organize my daily life/medicine.• Bathing assistance.• Grocery shopping.• Someone to talk to.

Most Important Services: CAT Therapy• Support.• Someone to help me acquire and navigate services.• Keep appointments. • Transportation. • Organize my daily life/medicine. • Someone to talk to. • Help/teach me to cook. • Shopping. • Create “To Do” lists.• Take care of my appearance.

Nursing Facility Returnees• Homeless, kidney dialysis, amputee, heart problems, wheelchair. • Heart attack before and I was suffering from pneumonia,

bronchitis and a bladder infection, so they put me in the hospital for fear I would have another heart attack.• I got blood clots in my legs so I was sent here, degenerative

arthritis, five hip replacements, wheelchair.• Two heart attack, diabetes, back and knee problems, very limited

mobility.

All want to move back to the community if they are able.

Extending CAT Beyond a Year• Follow-up for a year after the initial first year – least every 6

months •Wish I could have had 1.5 years instead of 1 year.• Stay in contact past 1 year. Follow-up every 4 months for 2-3

years.• Extend CAT for 2 years, more contact with organizations to

help you out, need an advocate to help with options after first year.• Extend CAT for 2 years.

Factors Associated with Success

•Motivation to live successfully outside an institution. • Realistic expectations of the obstacles they may face,

limitations in housing options, etc.• Prior (relatively recent) experience living independently.• Physical health problems under control.• Behavioral health condition that can benefit from Pilot

services – e.g. not too severe.• Adequate cognitive capacity – i.e. no dementia.

Factors Associated with Success (con’t.)

• Younger age.• Ability to perform activities of daily living with minimal

assistance.•Willingness to engage with needed services and adhere to

medical regimens – e.g. CAT, medical appointments, adherence to medications, diabetic diet, etc.• Availability of informal social support (ideally, active support,

but at the least, no strong family opposition to independent living).

The Pilot Today • Over 367 people have been served since 2008.• Approximately 70% of BHP participants remain in the community up to 5 years. • Participants show increased functional status and quality of life across time, and

gains achieved during the intervention persist for at least a year after the end of services. • Examples of increased independence include getting a paid job at competitive

wages, driving to work, volunteering, getting a GED, teaching art classes, leading substance use peer support groups and working toward a college degree.• The most important factor associated with community tenure appears to be

stability of physical health and timely receipt of health services, including home health care and outpatient visits. • After initial relocation expenses, the Pilot annually saves Medicaid money, since

community care costs about 40 percent less than nursing facility care.

Recommendations from Year 3 Evaluation

Continue participant contact with CAT therapists on an occasional or per need basis for at least a year after participants have completed the intervention.

Potentially incorporate tele-health interventions (care management, information and support) into the Pilot, as an adjunct to in-person services and particularly after services end.

Continue assessing completed participants’ functioning and quality of life to see how long gains achieved during the intervention persist.

Recommendations from Year 3 Evaluation (con’t.)

Further investigate why a higher proportion of African American participants, as compared to whites and Hispanics, never leave the NF after receiving pre-transition services from BHP.

Continue conducting analyses of Medicaid and other data (e.g. MDS) to better understand factors associated with successful community tenure or need to return to a NF.

Conduct a study of the readiness and information needs of MCOs and community agencies to provide best practices in BH services (especially under new mandate).

Contact InformationQuality Improvement Evaluation Team

UT Austin – Center for Social Work Research

Lynn Wallisch, Ph.D., Research Scientist and PIlynn.wallisch@austin.utexas.edu(512) 232-0611

Tom Bohman, Ph.D., Research Scientistbohman@austin.utexas.edu(512) 232-0605

James Bradley, MSW Project Coordinatorjabradley@austin.utexas.edu(512) 232-0603

Questions?