Beyond the Black BoxThe Transformation to a Population Health Approach

Arthur C. Evans, Jr. PhDCommissionerPhiladelphia Department ofBehavioral Health and Intellectual Disability Services

University of Pennsylvania@ArthurCEvans

Acknowledgements• Colleagues and friends in Connecticut and Philadelphia who have helped

my understanding and shaped my thinking.

• Special thanks to DBHIDS Staff, People in Recovery, Providers and Community Stakeholders

New Zealand

Alexis LintonEvents Manager

Vivienne MillerThe MHS Director

Rob Gill Manager, Strategic Direction

Rob WarrinerChief Executive

Fran SilvestriIIMHL

Australia

John FenelyCommissioner

Jenny CrockerManager, Communications and Stakeholder Relations

Elizabeth BurfordActing Executive Officer

Samantha KnaggsExecutive Assistant

Philadelphia

• Birthplace of America• 5th Largest U.S. City• 1.5million Population • Culturally Diverse, Large Immigrant Population• Institutions of Higher Learning• Highest Poverty Rate for Major U.S. city

Philadelphia

“We want an effective and efficient government and a city where every citizen is healthy and well.”

-Phila. Mayor James Kenney

Department of Behavioral Health and Intellectual disAbility Services

• Administrator/Payor for public mental health and addiction service system• Provide Safety Net for 1.5 Million people• $1.2billion Annual Budget• ~140,000 People served in Behavioral Health Treatment• Full Financial Risk for Medicaid Population (~600k)• Children, adult and family services• 200+ providers, full continuum of services

Traditional Treatment Model

CommunityLife

In this model, clinical care is viewed as one of many resources needed for successful integration into the community.

Recovery Oriented System of Care

• 1st WAVE: Building the Foundation

– De-institutionalization & Community Capacity Building

(Getting people into the community)

• 2nd WAVE: Transformation Decade

– Improving quality of life(Helping people to be a part of the community)

• 3rd WAVE: Population Health

– Promoting Health & Wellness for the population

(Promoting healthy Communities)

Evolution of The Philadelphia System

Severe Mental Illness

Diagnosable Mental Disorder

Everyone Else

5%

20%

75%

Current Treatment Approach

Factors that Influence Health Status

HEALTHCARE

LIFESTYLE• Smoking• Obesity• Stress• Nutrition• Blood Pressure• Alcohol• Drug Use

ENVIRONMENT

HUMAN BIOLOGY

10%

19%

20%

51%

Population Health: Kindig, 2003 (IHI)

The health outcomes of a group of individuals,

including the distribution of such outcomes within the group.

These groups are often geographic populations such

as nations or communities, but can also be other

groups such as employees, ethnic groups, disabled

persons, prisoners, or any other defined group.

Diagnosed

At Risk

Healthy

Population Health Approach

Effective & Efficient Clinical Care

Mitigate Risk & Early Intervention

Keeping People Healthy

PeopleGoal

GOAL: long-term recovery for adults and resilience for children and adolescents

• Recovery & Resilience-Oriented Services

• Person-Driven

• Evidence-Based Practices

• Outcomes focused

• Individualize Treatment

• Recovery Support Services

Improving Treatment Services

Evidence Based Practice and Innovation Center (EPIC)

• Trauma Initiative – Prolonged Exposure (PE)

• Philadelphia Alliance for Child Trauma Services (PACTS) – Trauma Focused CBT (TF-CBT) and Child Family Traumatic Stress Intervention (CFTSI)

• Dialectical Behavior Therapy (DBT)

• Ecosystemic structural family therapy (ESFT)

• Partners for change outcomes management system (PCOMS)

• Beating the Blues

EBP Initiatives

500+ THERAPISTS at 60+ PROGRAMS

DATA DRIVEN DECISION MAKING:Pay for Performance

Mental Health Outpatient CHILDEarly Engagement: Percent of Episodes Having 2 or Fewer Services Within 7 Days of Referral

Individualizing Treatment

Morris Home

Trend or Fad?

Trend or Fad?

7 Conceptual Shifts We needed for a Population Health Approach

1. Working Upstream (Intervening Earlier)

Public Health Approach to Trauma

Early Intervention

Trauma Response Teams

Philadelphia Alliance for Child Trauma Services

Provider Map

2. Broad Set of Strategies(Beyond Psychotherapy and Medications)

Youth in Residential Treatment

3. Working With Non-Diagnosed Populations

Southeast by Southeast Collaborative Partnership with Mural Arts

• Improve community connections

• Engage stakeholders

• Embed partnerships of mental health staff and artists in the community

• Empower the community

Community Coalitions

4. Deliver Health Promotion Interventions

Free, Supportive, Comprehensive and Not diagnostic

In-person Community Screening Events

Online Screenings data

5. Working in Non-Treatment Settings

Addressing the Social Determinants of Health

• Income and Income Distribution,

• Education, Unemployment and Job Security,

• Employment and Working Conditions,

• Early Childhood Development,

• Food Insecurity,

• Housing,

• Social Exclusion,

• Social Safety Network,

• Health Services,

• Aboriginal Status,

• Gender Race and Disability.

• Housing First– Targeted outreach to individuals with longest histories of homelessness,

collaboration with the Veteran’s Administration

• Journey of Hope– Specialized residential substance abuse treatment programs for people

experiencing long-term homelessness

• Safe Havens / Shelters– Referrals exclusively for persons experiencing chronic street homelessness

– In 2015, 554 persons served, 239 discharged to a positive next step, primarily supportive housing

Multiple Pathways to End Homelessness

$85

$32

$154

$86 $97

$176

$145 $139

$112

$182

$157 $149

$18 $18

$53

$28

$-

$40

$80

$120

$160

$200

Safe Haven (n=94) Journey of Hope (n=93) Residential Pilot (n=68) Total (n=255)

Co

st p

er

Day

Year 2 Before Voucher Issuance (n=244) Year 1 Before Voucher Issuance (n=255) During (n=252) Year 1 After Lease-Up (n=231)

Average Cost per Day over Time (n=255)

Note: Annualized average cost calculated by total (sum) cost/365 days year 2 before voucher issuance, year 1 before voucher issuance and year 1 after lease-up; during period equates to total (sum) cost/days between voucher issuance and lease-up.

Successful PSH Client —

6. Health Activation & Empowerment

• Story Telling--BEyondExpectation Series

• Building Brotherhood Mural• Workshops• Town halls

Integrating Community & System Collaboration

Tarik Trotter(Black Thought)

7. Working at the Community Level

Fables of Fortune

Addresses problem

gambling, particularly

within the Asian

communities

Bridging the Gap

Addresses the

importance of

overcoming conflict &

building relationships

Resilience

Acknowledges the pain

of trauma and violence

while illuminating the

resilience that exists

within us.

It Has To Be From Here

Depicts strength

and resilience of the

Latino community

Building Brotherhood

Addresses the

importance of

dialogue and

relationship-building

amongst males of color

Finding the Light Within

Sheds light on suicide

through relationship

building among

survivors, attempters,

families and friends

© 2010 James BurnsJEVS ACT II – 1745 N. 4th Street

Personal Renaissance

“It gave addiction and recovery a real voice.”

–Michael

Coming Together…

© 2010 James BurnsJEVS ACT II – 1745 N. 4th Street Photo by Mustafah Abdulaziz

Personal Renaissance

The Porch Light ProgramCommunity Healing Through Public Art

VISIT:

porchlightvirtualtour.org

WATCH:

bit.ly/porchlightprogram

1. Working upstream (Earlier Intervention)

2. Broad set of strategies

3. Working with at risk & healthy populations

4. Deliver health promotion interventions

5. Working in non-treatment settings

6. Health activation approaches

and empowering others

7. Working at the community level of analysis

7 Conceptual Shifts We needed for a Population Health Approach

2002 1st PRO-ACT Recovery Walk

150 People

Can we activate communities around behavioral health issues?

Yes!

2015 PRO-ACTRecovery Walk

Over 25,000 People

Change is Possible!

Arthur C. Evans, Ph.D.@ArthurCEvansArthur.C.Evans@phila.govDBHIDS.org ●Healthymindsphilly.org

• Mental Health and Addiction Issues are ubiquitous, complex and have a significant impact on communities & society at large

• The predominant paradigm for addressing mental health and addictions is inadequate for the complexity of mental health and addictions issues

• A Population Health approach offers an opportunity to address mental health and addiction issues in a comprehensive manner that addresses

unmet needs and promotes overall health and wellness

Take Home Messages