The last 4 years practicing social work in the public sector in New York State has been quite a roller coaster. Due to Medicaid reform it has been a challenging time…and we are not done yet.
A post in The Guardian making five big suggestions to reform mental health care in the United States certainly got my wheels spinning. First it got me to think about how reforms have affected my job(s) and the people I have treated. Also children’s case intensive case management (my current job) will face sweeping changes in the future. In some ways I think we are headed in the right direction but others leave me concerned.
First let’s rewind to about four years ago when I was working in adolescent day treatment program run by New York State in partnership with local schools. It was for 18 youth with significant mental health issues in a structured setting. In addition to educational programming we had a social worker (yours truly), a psychologist, psychiatrist, recreational therapist, therapy aide, and a community mental health nurse providing services for these youth. The program was working well and was perhaps one of the most clinically rich settings I have worked in. But in the interest of making more money, the program closed. The thinking was “imagine if this clinical team were an outpatient clinic, think about how many clients we can serve.” What about these 18 youth at a time that could benefit from this level of service.
Partially out of anger and partially out of not wanting to work in a clinic setting, I went to work in a short term adult inpatient unit. I liked this but a promotional opportunity to work with kids came up. To work with youth in the community and in their homes with a case load of 12 where I see them weekly to monitor and coordinate services (called intensive case management). In New York State this is called targeted case management (TCM). To meet criteria children have been admitted to inpatient psychiatric setting at least once. There also exists supportive case managers with a caseload of 20 and see the clients bi-weekly. The adult system was doing this as well but closed down to open a care management model. Where they are seen face to face only one time per month and the caseload can be around 40+.
The children’s system in New York State, myself included is bracing itself for a similar change. Here we go again, seeing more persons with less face to face engagement. I think more people need to be “reached” however more people also need a relationship with someone. To answer the Guardian article, reform is happening but it is not well thought out.
Social clubs are no longer paid for, day treatment for adults has moved to a “quicker” model called PROS (Personal Recovery Oriented Services). Clinics have to be more “productive” and “see more people.” For the most vulnerable populations in New York, what I see slowly getting lost is the engagement, the relationship with your providers. It has become about “staying afloat” and not caring for others. The attached article highlights the need to care for both. Engage with but see more people; get more “contacts” but prevent crisis at the same time. As Medicaid moves to a more managed care model, the fifth goal of more fiscal accountability will happen. There is not a sophisticated system in Medicaid as there is with private insurance for utilization. This alone will probably assist with the “bottom line.”
Change is hard and I understand it needs to happen, my concern is that patient care will be lost. Let’s not lose sight that these are people we are caring for, not dollar signs. The question moving forward is: how can we provide good patient care in an efficient way? We are looking at ways to manage crisis care, integrate care, and provide more vocational services. Despite this, the “business” of mental health has me worried. Thank you to Paul S. Appelbaum and The Guardian for starting the conversation. What are other systems of care doing to engage with others but also meet the ever increasing “bottom line?”