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The remarkably transparent document concedes resource deficiencies at the AZ State Hospital & highlights AHCCCS behavioral health network & oversight shortcomings that occurred during the prior administration

As I mentioned last week, the state legislature passed a bill that places additional scrutiny on the performance of the Arizona State Hospital, including a requirement that the ADHS and ASH (ADHS both runs & regulates ASH) publish a Clinical Improvement and Human Resource Plan by September 1^st that’s supposed to:

• Identify necessary enhancements to ASH services, facilities, and staff to provide statutorily required treatment and services to patients;
• Provide options and recommendations to reduce the number of patients statewide who are seeking admission to ASH and to reduce the wait time for admission;
• Identify optimal levels of acuity-based staffing with full-time employees and minimal use of contract staff as well as ways to increase the number of forensically trained clinical staff;
• Identify levels of service that assist in transitioning patients from ASH into clinically appropriate settings; and
• Identify an independent third party, residing outside of Arizona, to investigate incident reports and to receive complaints from patients, families, and advocates.

Upcoming Arizona State Hospital Events, Reports, & Deadlines

The report was published late last Friday. It’s over 100 pages long in all…  so, I can’t summarize the whole thing here, but I can point you toward some key areas.

Read the Plan

Extra Resources Needed to Meet Minimal Clinical Standards w/ Current Census

One of the most meaningful parts of the report are from pages 15—25 where they disclose how much money and how many people they’d need in order to “meet their current obligations”. In other words- it shows how much more they need just to meet the minimal clinically required treatment services!

Editorial Note: It’s refreshing to see the Department admit that they do not have adequate resources to meet the basic needs of their patients. The first step to self-improvement is being honest with yourself!

Here’s an excerpt from that portion of the Report:

An additional 117 FTE would need to be added to the Hospital’s maximum allowable headcount to accommodate the need for 846 employees, and an increase of $10.7 million in annual funding would be required to fully staff the Hospital under current conditions. In addition, annual salary adjustments would help maintain competitiveness with the healthcare labor market and increase recruitment and retention efforts.

Insufficient Network Sufficiency to Discharge Patients

Civil Reintegration Unit

Another interesting part of the report covers shortcomings in the overall behavioral health network that ASH believes are impacting their effectiveness (called network sufficiency).   Pages 37 and 38 propose developing a ‘civil reintegration unit’ (CRU) on the hospital campus that would be available for patients at the civil hospital to be discharged to a less restrictive (lower) level of care.

“The Civil reintegration program would allow for the application of evidence-based pharmacotherapies combined with individualized psychosocial interventions and development of treatment plans that can be tested and adjusted in the approximate community setting. It would also allow for a more creative treatment environment which would extend into community residential placement after completion of the reintegration program.”

The projected costs to design and construct the necessary CRU facility would be an estimated $8 million. It would require an additional annual appropriation of $4.15 million, and 30 additional staff to operate the transitional facility.

Editorial Note: This is a good idea that will definitely help the system. My sense is that stakeholders would support this initiative, but I believe there would be resistance to having ADHS/ASH operate the facility. That’s just a hunch.

Network Insufficiency

Part of the report is quite candid that the behavioral health system as a whole has insufficient capacity. In particular, the report cites that there aren’t enough secure behavioral health facilities available to accept ASH civil patients that are ready for a less restrictive level of care but not ready for pure community treatment.

I found it remarkable (and good) that the authors were willing to admit that resources for more intensive psychiatric care are insufficient. It’s also unusual to read a report in which one part of an executive branch is critical of another (in this case ADHS being critical of AHCCCS’ capacity and oversight over the behavioral health system). From the report:

Neither (ADHS) the Hospital, are responsible for providing oversight of the statewide behavioral health system of care and ensuring the network adequacy or sufficiency thereof. This responsibility was transferred from the Arizona Department of Health Services to the Arizona Health Care Cost Containment System (AHCCCS) in 2016.

(ASH) has noticed a consistent and pervasive trend of limited early engagement for those needing care, as well as outpatient providers often losing contact with patients resulting in either a failure to initiate treatment, or subsequently poor treatment retention. Additionally, too often providers opt to elevate patients to the State Hospital out of a sense of desperation because they believe they do not have the resources to meet the individual’s needs, to mitigate their own risk, and/or a fear that the individual’s needs are so extensive that caring for them is cost-prohibitive.

Furthermore, there seems to be a recurring phenomenon of providers not beginning the AHCCCS enrollment process or fully assessing the individual’s potential medical benefits, especially pursuing an SMI determination – which would quickly expand the array of services available to the individual.

Although this may be due to the patient disengaging during the process, it may be worthwhile for the system to invest in or expand the use of care navigators at outpatient facilities, jails, crisis psychiatric centers, walk-in health clinics, schools, or other community-based locations to expedite enrollment and promptly establish care connections.

This portion of the report concludes that:

(ADHS) recommends the State solicits an independent third-party consultant to conduct an end-to-end sufficiency analysis of the continuum of care and quantify the unmet treatment needs of the population. In order to develop tangible recommendations that include potential expansions to community-based care settings, and due to cross-contracting, this analysis must be based at the provider level to assess the State’s true capacity for treatment services.

Editorial Note: It’s refreshing to see one part of the executive branch call out poor performance of another portion. Too often in my experience, state agencies protect each other from criticism or scrutiny for fear of breaching a ‘brotherhood’ pact of having each other’s back. In this case, we see ADHS calling out what they believe are shortcomings in AHCCCS’ behavioral health system.

Care Transition to Less Restrictive Facilities

The report also candidly discusses financial incentives to escalate care to places like ASH in the behavioral health system. One excerpt candidly states:

It is more cost-effective for outpatient providers to refer the patient for involuntary treatment at an inpatient facility, including ASH, than engage them at a lower level of care, as doing so removes high service utilizers from their rosters while simultaneously mitigating risks associated with caring for treatment-adverse patients.

… under the oversight of a health plan, is financially disincentivized from establishing an adequate service array for patients needing discharge from the State Hospital or another inpatient facility – as these patients are viewed as “too complex” and “difficult to manage” (i.e., high-cost and high-need). From a purely cost-containment perspective, the provider assumes significant financial risk by accepting these individuals into their program for ongoing care post-discharge.

Throughout State Fiscal Year 2023, there was a fluid population of seven (7) patients, on average, who were approved for discharge from the Civil campus, yet they remained at ASH for several months before discharging because no outpatient provider was ready, willing, and able to accept responsibility for their aftercare, they lacked financial eligibility for services.

If the individual were treated in another setting, including a smaller (≤16 bed) inpatient or residential facility (e.g., secure residential behavioral health facility), Medicare and/or Medicaid would cover the costs for their stay, providing the care is medically necessary.

The report points out that the lack of network capacity of small (<16 bed) secure residential facilities is impairing patient care and greatly limiting ASH’ ability to discharge patients.

The FY 22-23 Budget passed at the end of the Ducey Administration included $25M for “Secure Behavioral Health Facility Capital Funding”. It also included $10M in state match to pay capitation fees for an AHCCCS contractor to run the facilities (about $25M including federal match). The budget signed by the Governor swept the $25M in capital costs for secure residential facilities (See line 86 in the AHCCCS budget) and eliminated the capitation costs to run those facilities (See line 23 in the AHCCCS budget).

Editorial Note: I found this to be remarkable and refreshing comment from ADHS. In this case, ADHS admits that additional step-down secure capacity (secure residential behavioral health facilities) is needed – even though the budget bill their Governor signed this year eliminated funding for just such facilities.

Final Note: Remember that the resource deficiencies at the AZ State Hospital & the shortcomings in oversight and network capacity in AHCCCS’ behavioral health network didn’t develop overnight. They are a result of 8 years of underinvestment and leadership decisions made during the Ducey administration. These major problems developed over an 8-year period and won’t be solved quickly – but with consistent pressure and attention from stakeholders and a commitment to quality improvement from the executive branch, change is possible.