At the beginning of the second day of the workshop, the participants broke into two sessions that discussed major topics emerging from the first day’s discussions. Participants in one session discussed issues with a focus on what providers need, which also encompassed political leadership. Participants in the other session discussed the financing and other policy issues associated with integrating suicide prevention into care for people with serious mental illness.
CREATING MOMENTUM AT THE STATE LEVEL
Oscar Morgan, project director for the Central East Mental Health Technology Transfer Center, who reported for the first breakout session, noted that many important observations made by individuals participating in the breakout session have been operationalized by the National Action Alliance for Suicide Prevention in its report Crisis Now: Transforming Services Is Within Our Reach.1 Extending these observations, participants in the breakout session discussed the possibility that the Substance Abuse and Mental Health Services Administration (SAMHSA) might send a letter to the governor of each state quantifying the crisis for the nation and for that state. The letter then would suggest implementing the recommendations contained in Crisis Now and offer free technical assistance from SAMHSA to do so. SAMHSA’s technical assistance centers could develop a uniform
1 The report is available at https://theactionalliance.org/sites/default/files/crisisnow.pdf (accessed November 27, 2018).
implementation strategy that may differ from state to state but that would lead to implementation of a zero suicide approach for people with serious mental illness.
In response to the report from the breakout session, Richard McKeon, chief of the Suicide Prevention Branch in SAMHSA’s Center for Mental Health Services, noted that an important issue is the nexus of responsibility between the Centers for Medicare & Medicaid Services (CMS) and the states. “When I talk to colleagues at CMS, one of the things that they emphasize, at least in terms of Medicaid funding, is how much it’s a state issue.” Clear guidance would be helpful to states, for example, in Medicaid plans. One way to provide this guidance is through strong relationships between mental health commissioners and Medicaid commissioners, he noted. However, he questioned how feasible it would be for SAMHSA to send a letter to all of the governors of the states, though he noted that letters to Medicaid directors have come jointly from SAMHSA and CMS. Perhaps the state secretaries of health and human services would be the most appropriate recipients of such letters, though engaging the nation’s governors would also be “critically important.”
In this regard, Christine Moutier, chief medical officer of the American Foundation for Suicide Prevention, noted that it has been building a mechanism to encourage all of the states to have a state suicide prevention day in which all the evidence and needed steps could be presented at the state level.
TRANSITIONS IN CARE AND BUNDLED PAYMENTS
The participants in the second breakout session spent much of their time discussing transitions in care—and in particular the transition from an emergency department contact or a psychiatric hospital into the community. Health systems need incentives to focus resources on people with serious mental illness who are at risk for suicides during these transitions, observed Andrey Ostrovsky, chief executive officer of Concerted Care Group, who provided a report from the session. Measuring the factors associated with a good transition raises challenges, he noted. Such a transition involves not just a medical model but consideration of the community, family, and other resources that are involved, along with the provision of adequate support for a good transition.
Participants focused in particular on the use of bundled payments to ensure care continuity across transitions. Precedents exist for such bundled payments, both with public funding mechanisms and with commercial insurance. One challenge noted by several participants is to bring an evidence-based approach to the population of people with severe mental illness who are at risk for suicide. Important factors identified by various
participants in the breakout session include appropriate assessment for people at risk of suicide, establishing a safety plan, and making sure that a person has an adequate number of contact points, including family members and community providers.
Participants in the breakout session also discussed ways of providing financial incentives upstream of transitions, such as during contacts with the primary care system or an emergency hotline. As a specific example, could organizations be incentivized to adopt electronic health records in the behavioral health care space, which would facilitate transitions?
Ostrovsky pointed out that bundled payments would be “perfect grounds for an 1115 demonstration” under the Medicaid program. It would have to be done on a state-by-state basis, though the Center for Medicare & Medicaid Innovation (CMMI) could also promote a model that is more comprehensive than Medicaid. He also thought commercial group insurance was a possibility, so long as the financial case can be made either by care savings or by increased market share. If “you get a progressive group or employer-based insurer to take this up, you don’t have to wait for a model to be designed by CMMI or through the long process of getting an 1115 demonstration approved.”
McKeon agreed that the evidence is solid regarding things that need to be done during the transition period. However, whether this evidence translates to populations other than the ones studied to date remains unknown. For example, does it apply to people with schizophrenia, bipolar disorder, or other serious mental illness? “That’s a piece that we don’t know as much about.”
McKeon added that bundled payments would be “useful and important.” In addition, they would provide an opportunity to learn from innovations and move forward. For example, different people have different needs, and some of these needs could be met at little cost, such as text message interventions, while other needs may require face-to-face contact or home visits, “presuming that you have a home.”
COMMENTS ON IDEAS FROM THE BREAKOUT SESSIONS
As part of the plenary session following the breakout session, workshop participants commented on several issues raised during the breakout discussions and earlier in the workshop.
Nadine Kaslow, professor of psychiatry and behavioral sciences at the Emory University School of Medicine, pointed to the need to collect data to see how effective different approaches are with people who have serious mental illness and to modify those approaches accordingly. Greater knowledge could bring other funders into the room besides people who fund health care policies, she said.
Amy Loudermilk, state initiatives manager for the Suicide Prevention Resource Center, asked where the responsibility for suicide prevention among those with serious mental illnesses resides organizationally. Is there a need for an organization or formalized collaboration to focus on suicidality and people with serious mental illness, she asked. This population is the responsibility of several different professions but not of a single one.
Jim Allen noted that implementation science has shown the difficulty of getting professionals to buy in, which is crucial to implementing or changing a system of care. He also pointed out that a thoughtful rollout requires local decision making. “There are many models of how you respond to an actively suicidal individual. They all have an evidence base. The important issue is that the provider community in the state pick one so everyone shares the same pathway and shares the same vocabulary. They’ll do that if they feel they were part of the decision process in arriving at that.” He suggested involving consumers in that decision as well.
Jennifer Shaw, a senior researcher at Southcentral Foundation, reminded the group that people are very diverse and one size does not fit all. While the evidence may be strong in one population, “we need to be very thoughtful about who was included and how it was evaluated for the diverse populations that make up our United States.” Research needs to be validated in minority communities (even though they are often majorities) and also be culturally grounded and culturally driven.
Shari Ling, Deputy Chief Medical Officer, CMS, advocated identifying bright spots that are working “no matter where they are.” Integrated care offers tremendous opportunities, she said, but people working today have worked out important parts of the answer, and “we can learn from what is working.”
Julie Goldstein Grumet, director of health and behavioral health initiatives at the Suicide Prevention Resource Center and director of the Zero Suicide Institute at the Education Development Center, described seeing many best practices and good outcomes occurring on the local level, “but people have a hard time publishing those results and sharing those practices.” As a result, these practices and outcomes remain siloed and hidden. One solution would be for journals to reach out and solicit articles about the intersections of people with serious mental illness and suicide. They also could cultivate authors who do not typically submit articles. “We have many state suicide prevention coordinators, tribal elders and leaders, and people in rural areas who have been heroic in finding ways to combat suicides in their communities and have outcomes but have a hard time getting it onto a national stage.”
Mike Hogan of Hogan Health Solutions called attention to SAMHSA’s new program to provide technical assistance through the National Dissemination Center and the Department of Health and Human Services’ region-
specific centers. This new technical assistance structure could be extremely helpful because the field is still at an early adoption stage where targeted information is very useful. The evidence base for people with high suicidality is “pretty clear, but it’s also new and . . . hasn’t been synthesized,” Hogan observed. Because suicide is a low base rate event, a randomized controlled trial with suicide as one outcome would be prohibitively large. The existing evidence rests largely on the concept that effective interventions “have achieved bigger reductions in suicide than anything else in the world.” Also, suicide prevention programs are made up of components that all have an evidence base.
In addition, Hogan observed that the Interagency Serious Mental Illness Coordinating Committee was considering some of these issues at the same time as the workshop, and it may be a valuable partner in considering these issues. The National Mental Health and Substance Use Policy Laboratory is another innovation-oriented organization that could help drive policy changes.
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