Measuring Outcomes of a Psychiatric Rehabilitation Intervention for Medicaid Beneficiaries using Pro

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Measuring Outcomes of a Psychiatric
Rehabilitation Intervention for Medicaid
Beneficiaries using Propensity Sores

• Presented by Marsha Langer Ellison, Ph.D.
• Center for Health Policy and Research
• Univ. of Mass. Medical School
• Shrewsbury MA.
• Marsha.Ellison_at_umassmed.edu
• and
• Asya Lyass, Ph.D. (Cand).
• Center for Psychiatric Rehabilitation
• Boston University
• Boston, MA 02215
• 617-353-3549
• Presented at American Public Health Association
  Annual Meeting.
• Boston, MA, November 2006

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Background

• The Intensive Psychiatric Rehabilitation (IPR)
  initiative evolved as a response to consumers of
  mental health services who wanted additional
  psychiatric rehabilitation services that would
  assist them in overcoming disabilities resulting
  from SPMI. Other stakeholders that promoted
  implementation of IPR included rehabilitation
  providers, the Iowa Department of Human Services,
  and families.
• The occasion of writing a renewed contract for a
  behavioral health care carve-out allowed DHS to
  include IPR as a performance indicator. At the
  same time Iowa mental health services regulatory
  code was amended to support implementation of the
  new service.
• The IPR initiative was developed and implemented
  in 1997 by Magellan Behavioral Care of Iowa (MBC
  of Iowa), a subsidiary of Magellan Behavioral
  Health. MBC of Iowa is the contracted
  administrator of state behavioral health services
  described in the Iowa Plan for Behavioral Health.
  

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The Guiding Vision of IPRRecovery is Possible
for Mental Health Consumers

• Core elements of the IPR initiative
• The belief that people with SPMI can recover.
• A mission of enhanced role functioning through
  personal goal development that aims to improve
  success and satisfaction in key areas of life.
• The empowering value of self-determination.
• The availability of readiness, skill, and support
  development intervention strategies.
• IPR is an aid to recovery and is one of the
  essential components of a comprehensive community
  system.

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IPR Service Description and Components
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IPR Implementation

• MBC of Iowa was the first managed behavioral
  healthcare company to design and implement a
  formal IPR initiative that incorporates
  recovery-oriented principles as part of a public
  sector carve-out.
• The IPR initiative has worked directly with more
  than 30 agencies in Iowa. Over 700 people have
  been referred to the IPR program from 1998 to
  2002.
• Demographics of baseline data (738) show a group
  that is predominantly white, of divided gender,
  mean age 38, who have either schizophrenia or
  major affective disorders. Most are not married,
  live in supervised facilities, have earned a high
  school diploma, and are either not working or
  earn very little money.

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Service Delivery Requirements and Supports

• IPR services are provided by bachelors or
  masters-level clinicians who meet State of Iowa
  accreditation standards for Psychiatric
  Rehabilitation Practitioners.
• MBC of Iowa/DHS Sponsored Training including an
  initial 120 hours of rigorous IPR training for
  practitioners as well as ongoing training focused
  on the needs of the IPR provider sites.
• Joint Site Visits and case consultation to
  providers by representatives from DHS and MBC of
  Iowa for technical assistance and specific
  implementation planning.
• Formal Outcomes Evaluation of the IPR Initiative
  co-sponsored by DHS and MBC of Iowa and conducted
  by the Boston University Center for Psychiatric
  Rehabilitation.

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IPR Outcomes Study Design

• Baseline to end-point comparisons were made for
  IPR participants and sub-groups, in 3
  rehabilitation outcomes (IAPSRS Toolkit, 1995).
• Cross group comparisons were made with the
  drop-out group. The drop-out group did not
  differ from IPRs for most demographics, except
  that they were 4 years younger, and had lower
  monthly earnings than IPRs at baseline.
• A quasi-experimental comparison was made of
  changes in mental health service utilization and
  related costs for IPR recipients and a control
  group of matched treatment as usual mental
  health service recipients. Control group members
  were matched to experimentals on age, gender,
  diagnosis and number and cost of in-patient
  mental health services using propensity scoring
  techniques.
• Analysis used Medicaid claims for mental health
  services made available to BU from MBC of Iowa.

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Pre and Post Changes in Employment Status Among
IPR Participants

• Significant increases in average employment
  status from baseline to endpoint were found for
  graduates and 18 month completers. There was a
  significant decrease for drop-outs and no change
  for the Intent to Treat group.

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Pre and Post Changes in Earnings Among IPR
Participants

• Significant increases in gross monthly earnings
  were found for graduates and 18 month
  completers. Intent to Treat group had a
  significant but smaller increase. Drop-outs had
  a non significant change in earnings. (All tests
  were adjusted for baseline differences)

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Pre and Post Changes in Residential Status

• Significant increases in average residential
  status from baseline to endpoint were found for
  graduates, 18 month completers, the ITT groups
  and for drop-outs, although the increase is
  larger for IPRs.

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Comparison of Change Values Between Participants
and Drop-Outs

• There are significant differences between change
  values in employment status and in monthly gross
  earnings comparing Graduates and 18 Month
  Completers with Drop-Outs (with adjustments made
  for significant differences in baseline
  earnings).

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Changes in Mental Health Services Units Used
Costs

• On the whole IPRs used more services at baseline
  than controls (despite matching techniques).
  Mean change values were adjusted for these
  differences when comparing groups for change.
• Combining all mental health services units used
  (excluding IPR), control group subjects showed
  significantly larger decreases in mental health
  service units used costs compared with IPR
  participants (Graduates, 18 month completers and
  ITT).

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Change in All Mental Health Service Units Used
Baseline to Endpoint (over 2 months)
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Changes in Units Used Costs Selected Mental
Health Services

• For day treatment this pattern continues when use
  and costs of selected services are compared
  between IPR participants and controls.
• The decreases found for in-patient use among IPR
  and control sub-groups are not significantly
  different.
• There are increases in use of out-patient
  services by IPR participants that are
  significantly different from the decreases found
  for controls.
• For community services the decreases for controls
  are not always significantly larger than
  decreases for experimentals.

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Changes in Selected MH Services IPR Graduates
and Controls
Statistically significant difference in values
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Discussion

• Data demonstrate appreciable evidence for the
  success of ICM on improved rehabilitation
  outcomes especially for employment status and
  gross monthly earnings.
• Given that findings show an improvement in
  residential status for all groups including
  drop-outs, this suggests that there may be
  changes in state housing policy affecting all
  groups. However, findings for the larger
  improvement for IPR participants support
  continuation of the program.
• A sizeable number of people were lost to the
  study for a variety of reasons (e.g., missing
  data, changing service providers). This
  indicates some bumps in the road with
  implementation of IPR as well as difficulties
  with study data collection. The result is that
  the outcomes for a large number of people are
  unknown.
• Further, there is a large group of formal
  drop-outs (their dropout status was communicated
  to the study). This result (common to many
  mental health interventions) indicates that
  further study is needed to learn when, for whom,
  and under what circumstances IPR works.

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Discussion (continued)

• Findings for service utilization pose several
  questions
• Decreases in mental health service use and cost
  that are seen for both IPR and controls suggest
  that an underlying goal of managed care i.e., to
  reduce unnecessary services or costs, is being
  realized.
• While psychiatric rehabilitation is often assumed
  or hoped to promote integration and thereby
  reduce use of acute mental health services, this
  relationship has received little formal testing.
  A theory of the impact of improved role
  functioning on symptoms and service use is still
  to be developed.
• The relative shallower decrease or increase of
  service use among IPRs suggests that IPR actually
  improves service access or the acquisition of
  services needed. Anecdotally providers suggest
  that IPRs become service savvy through the
  program.

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Implications for future policy and study

• Continued piloting of IPR in other states is
  warranted in concert with testing using a more
  rigorous design.
• A recovery mission and rehabilitation focus is a
  successful strategy to promote employment.
  Services such as these can be integrated into
  behavioral healthcare contracts.
• A full-blown costeffectiveness study of IPR is
  still outstanding.
• While reduction of acute services use can be
  interpreted as a good thing for individuals, a
  mission of improved access or increased
  penetration to an underserved population appears
  unsuccessful.
• Different strokes for different folks -- findings
  suggest that a wide array of community-based
  rehabilitation services with multiple entry
  points is needed to promote outcomes.

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Citations

• Ellison, M.L. Anthony, W.A., Sheets, J.L., Dodds
  W., Barker, W.J., Massaro, J.M. Wewiorski, N.J.
  (2002) The integration of psychiatric
  rehabilitation services in behavioral health care
  structures A state example. Journal of
  Behavioral Health Services and Research, 29(4),
  381-393.
• Ellison, M.L. Lyass, A., Anthiny, W.A. Massaro,
  J. (November 2005) Outcomes Study of the
  Intensive Psychiatric Rehabilitation Program in
  Iowa 4th Interim Report. Center for Psychiatric
  Rehabilitation, Boston University
• Sheets, J. Yamin, Z. (1998) Intensive
  psychiatric rehabilitation services A best
  practice design for managed care. In 1999
  Medicaid managed behavioral care sourcebook. New
  York Faulkner Gray.
• International Association of Psychosocial
  Rehabilitation Services Research Committee
  (1995). Toolkit for Measuring Psychosocial
  Outcomes, Columbia, MD Author.