The%20DSAMH%20High-End%20User%20Program

1
The DSAMH High-End User Program

• Steven Dettwyler, Ph.D.
• Director of Community Mental Health Services
• Steven.Dettwyler_at_state.de.us

2
The Genesis of the Project

• Cost of in-patient services
• Volume of involuntary commitments
• Belief that costs were associated with a small
  percentage of clients hospitalized

3
The Delaware Acute Care System

• Emergency Rooms
• Current Commitment Law
• Limited initial oversight
• Conflict over disposition at ER
• No voluntary benefit
• High involuntary commitment rates

4
Acute Care System cont.

• Psychiatric in-patient
• Community mental health providers
• Community drug and alcohol addiction service
  providers
• Discharge planning, Continuity of Care
• the good, the bad, and the ugly

5
The Analysis

• Identify the clients
• Using database to identify excessive in-patient
  stays
• Assess associated collateral costs in both
  DSAMH and Medicaid claims data
• Detoxification services
• DOC correctional stays
• Cost of community-based outpatient services

6
The Envelope Says.

• 20 individuals (out of 1500) dominated
  admissions to all in-patient psychiatric
  facilities
• These individuals are the High-End Users
• Of these 20 individuals, all had significant
  associated collateral costs including detox
  stays, DOC involvement, and community MH services

7
Costs for High-End Users

• 880,735 for one year of service for these 20
  individuals
• Of the 880,735, fully 70 represents in-patient
  hospital costs

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High End User (HEU) Program

• April 2004 Roll Out
• Initial enrollment of 56 individuals
• 20 originally identified HEUs
• 36 additional individuals with frequent hospital
  stays

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HEU Assumptions

• Acute length of stay is generally too short
• Discharge planning and coordination is poor
• Existing system is neither client- nor
  recovery-oriented
• Mutually exclusive silo systems of services
  undermine comprehensive care (Ex if MH, then not
  AOD)

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High End User Program

• Admission and Graduation Criteria
• At-Risk Monitoring
• Coordination/Continuity of Care
• On-going routine communication
• Appropriate Community Provider(s)
• Rapid follow-up around IP stay
• Remove time constraints of IP stay
• Concept of extended acute IP stays

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Two and a half years later

• 127 individuals admitted to the program
• 59 individuals currently active in the HEU
  program
• 68 individuals have been removed from the program

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Of these 68 . . .

• 28 either moved out of the area (majority), are
  currently incarcerated, or have died
• 40 individuals have graduated from the program,
  i.e., no in-patient psychiatric admissions for
  one year

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Monetary Cost Savings for these 40 . . .

• These 40 individuals spent 725 days IP in the
  year preceding admission to HEU program
• At about 700/bed-day, the cost of this care was
  507,500
• These 40 individuals spent 454 days IP after
  admission to the program (until graduation), or
  317,000 in bed-day costs

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Summary

• The cost of IP care in the year preceding HEU and
  while enrolled in HEU
• 825,300
• The cost of IP during the year preceding
  graduation
• 0

15
Criminal Justice Involvement (DOC)

• One year prior to enrollment in HEU
• 339 days incarcerated
• In the period after HEU enrollment
• 101 days of incarceration
• Cost difference 27,120 vs. 8,080
• (80/day)

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Criminal Justice Involvement

• One year prior to enrollment in HEU
• total of 13 years 3 months on probation
• In the period after HEU enrollment
• total of 5 years on probation

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Data Bases, Monitoring, Evaluation

• Corrections (DELJIS)
• MMIS
• Paper-DSAMH
• Clinical Records
• E-DSAMH
• Excel/Access - various
• Data Warehouse

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Conclusions

• High-End User Program works
• It is more effective for the clients
• It saves money
• It relieves stress on the system

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• Key points
• Identification of participants
• Extended Acute IP services
• Collaboration/coordination between IP and OP
  service providers
• Steven.Dettwyler_at_state.de.us