PeaceHealth Medical Group is a non-profit treatment facility within Eugene, OR. Eugene is the third largest metro area in the state and the largest community served by PeaceHealth. They have operated the only psychiatric inpatient facility in the county for over a decade. Due to financial issues, they started a partnership with Lane County Behavioral Health Services and formed a transition team. Lane County Behavioral Health Services is a public mental health provider receiving funding mainly from state mental health grants, Medicaid, and Medicare reimbursements. In this partnership, PeaceHealth provided staff for the RAISE project and the county provided other financial funds and supports.
The idea of treating first-episode psychosis had been considered for several years by the partnership. There were prior first-episode psychosis study grants under the Early Assessment and Support Alliance supported by the Oregon Health Authority, but the site was not prepared to put in proposals at that time. However, they continued communication with the state and later learned about the potential involvement in the RAISE study. This study was seen as a good fit because of the site's success with clients with psychotic illnesses and having many required elements already in place. In addition, lack of funding for mental health services in the public system has encouraged collaboration among all parties. Having direct access to emergency rooms, hospitals, and other providers allows the site to identify and recruit participants for the study. There are 21 participants enrolled in the study, and while there were a few referrals from the University of Oregon, the majority of the referrals were from emergency rooms and hospitals.
Financing of Services
The main sources of funding for the services are state Medicaid and state General Funds. Currently, out of the 21 enrollees, 11 are on Medicaid, three have private insurance, and seven are uninsured. The RAISE study funds the project director's time and pays for four hours a week of a supported employment specialist time.
The Center has a Federally Qualified Health Center (FQHC)1 designation which provides a higher reimbursement for Medicaid-eligible services compared to other providers. FQHCs are safety net providers, such as community health centers and other outpatient health programs with the main purpose of enhancing the provision of primary care services in underserved urban and rural communities. The staff interviewed during the site visit stated that the difference between enhanced rate due to FQHC status and normal Medicaid reimbursement covers the cost of other services in NAVIGATE that are generally not reimbursable (Table 3.4).
The site also acknowledges that enrolling participants in SSI to get health care benefits also creates some disincentives to obtain and maintain employment. Thus, the supported employment is considered to be an important addition to the site's services through RAISE. However, they were not able to hire a qualified staff person to provide these services. Some aspects of the supported employment were provided by the case managers (mostly reimbursable services that they can bill under Medicaid) and for some others they use referrals to other partner agencies with supported employment staff.
While the Medicaid reimbursement under FQHC status seems to be working for now, the staff was not sure how the Medicaid prospective payment system will be restructured under the ACA. There are some discussions to move from a fee-for-service system to capitated and outcome-based payment in the next years. The implications of such an arrangement on funding first-episode psychosis services are also not clear. The Governor has signed a new law that will change the funding for people covered by the Oregon Health Plan (the state's plan for individuals covered by Medicaid). This transformation will result in a greater emphasis on prevention and the integration of medical, mental health, and substance abuse care. The law calls for local communities to come together to form Coordinated Care Organizations (CCOs) to design and manage the new local health care systems for local Oregon Health Plan members. A Steering Committee has formed to lead this work in Lane County and there is some discussion to provide coverage for supported employment services under the CCO system.
Recently, the Center has obtained innovation funding from state Medicaid to develop a health home model of treatment. In the future, first-episode psychosis services will be offered through the health home. They hope to hire a SE specialist and provide services directly aligned with return to work (and/or education) philosophy.
|TABLE 3.4. PeaceHealth, Eugene, OR: RAISE NAVIGATE Early Treatment Components and Funding Sources|
(e.g., VA, Tricare)
|Outreach and engagement||X||X||X|
|Alcohol and substance use treatment||X||X||X||X||X||X|
|Other outpatient visits||X||X||X||X||X|
|Inpatient care as needed||X||X||X||X|
|Planning (e.g., treatment and/or recovery plans)||X||X||X||X||X||X||X|
|Job coaching and other vocational supports||X||X||X||X||X|
|Individual resilience training||X||X||X||X||X||X|
|Benefits counseling (e.g., WIPA)||X||X||X||X|
|Treatment and primary care coordination||X||X||X||X||X|
|Other (e.g., occupational or psychosocial therapy, groups, etc.)||X||X||X||X||X|
|NOTE: In-house means RAISE grant funding and PeaceHealth contribution and Other means federal WRAP payments. State MH Resources means indigent care funds. Local MH Resources means county indigent care funds.|
Saint Clare's Behavioral Health, Denville, NJ
St. Clare's Health Systems, an affiliate of Catholic Health Initiatives, operates a community mental health program that sponsors the NAVIGATE site in Denville, NJ. It also operates a hospital and other behavioral health services in the area. St. Clare's is the dominant behavioral health provider in Morris County. It has a staff of approximately 150 professionals of all specialist types, serving 2400 clients in 2009, the most recent year of complete data. They serve adults and children with the full range of behavioral problems and diagnoses. Although they did not have a first-episode psychosis service prior to RAISE and NAVIGATE, the state and St. Clare's have an emphasis on early intervention services, which includes emergency response services and medications. This emphasis on early intervention services set the groundwork for participating in RAISE.
NAVIGATE is located within the same program that supports the ACT teams at St. Clare's. The NAVIGATE program is embedded within this program area and is entirely funded by categorical mental health resources provided by the state mental health authority. Those state funds have made it possible for St. Clare's to finance NAVIGATE and participate in the RAISE study.
The catchment area for St. Clare's is suburban and not very densely populated. Recruitment was limited, and only four individuals of the 24 screened are participating in the study. Only ten people consented, and of them, three were found ineligible for the study, and three withdrew consent, deciding not to participate. The participants are considered uninsured for the purpose of the study, as St. Clare's pays for all of their services from public mental health services resources. The site did not consider it worth the effort to bill for any insured services for this small number of participants, when they were able to use public resources to cover all of the NAVIGATE services.
The NAVIGATE program, and the community program in which it is embedded, is surrounded by a service system operated by St. Clare's, delivering a wide range of non-NAVIGATE services. The non-NAVIGATE,other behavioral health programs, include hospital and partial hospital services, outpatient services, and supported housing services. These services are financed entirely with state funds, while any other behavioral health services are financed through a $650,000 grant from the local Morris County Mental Health Administration.
St. Clare's provides all of the services listed in the NAVIGATE service matrix in one form or another, as needed, to NAVIGATE participants, funded by state mental health authority resources. The larger program of enhanced outpatient and support services is also funded in this manner with an $8.5 million grant from the State of New Jersey and serves 100-120 clients. Supported education and supported employment (SEE) services are included in this package of services, which includes some support from the state Division of Vocational Rehabilitation services.
Unlike any of the other sites, New Jersey discussed some training activities that they had initiated in response to questions concerning training in evidence-based practices, such as those included in the NAVIGATE intervention. The only training resources mentioned by the other sites were those provided by the central RAISE project itself. The state behavioral health agency also provides financial support for training practitioners and programs in evidence-based practices, including ACT and SEE. In addition, the state funds training in Illness Management and Recovery, which has some similarity to IRT. Prior to site involvement in RAISE, training was provided both by the University of Medicine and Dentistry of New Jersey and by out-of-state trainers from Dartmouth and Boston University. With respect to SEE, staff members have been trained in both Individual Placement and Support and Choose-Get-Keep approaches. During RAISE, of course, the training in the various NAVIGATE service elements has been provided by the RAISE study team.
The NAVIGATE team is currently comprised of four FTE staff members. Their salaries are covered by the state behavioral health agency grant, and they serve many more clients in addition to the four NAVIGATE participants. The NIMH grant supplement for SEE covers the cost of SEE services not covered by the state grant.
|TABLE 3.5. St. Clare's Behavioral Health, Denville, NJ: RAISE NAVIGATE Early Treatment Components and Funding Sources|
(e.g., VA, Tricare)
|Outreach and engagement||X||X|
|Alcohol and substance use treatment||X||X|
|Other outpatient visits||X||X||X|
|Inpatient care as needed||X||X|
|Planning (e.g., treatment and/or recovery plans)||X|
|Job coaching and other vocational supports||X|
|Individual resilience training|
|Benefits counseling (e.g., WIPA)||X||X|
|Treatment and primary care coordination||X||X|
|Other (e.g., occupational or psychosocial therapy, groups, etc.)||X||X|