The Wyoming Department of Health is in the progress of reorienting its priority populations in the mental health sector. The department director Stefan Johansson said this reform was needed as the financial support for behavioral health continues to grow. Wyoming Public Radio’s Kamila Kudelska asked Johansson how the state decided reforming mental health was needed.
Stefan Johansson: One thing over the years that the state has really identified as a need or a problem is to reduce reliance on institutional care for the populations that we serve. So think of institutions like the State Hospital, Department of Corrections facilities, different kinds of facilities on a residential basis for kids and adolescents, where we really see a relative handful of folks that kind of slipped through the cracks, slipped through the cracks of society, even with the programs and the systems we have set up. We really had a need to kind of redefine what the role of the state is, what the purpose of those state systems are, given that you have more insurance coverage, a higher volume of private providers, folks that can access a counselor or a therapist on their phone, especially if they have insurance coverage or something to that effect. And so what we've seen is some unsustainable economics on the community program side, where I had a real concern going back several years ago that we could really see community mental health centers struggling financially, consolidating, even some serious financial issues like bankruptcies, etc. And we really need to focus on setting those centers and those partners of the state up for sustainable success. So to that end, how do we do that? Or, the most important question, what's the role of the state government in providing these types of behavioral health supports, funding and coverages? Basically, what's the mission here? And the legislature in that and the executive branch task force, in my opinion, did really good work to determine the problems, set the mission and the state policy, and then design, build and implement what those facilities would look like. And the result of that, as you probably know, we have a brand new state hospital that's been built in Evanston. We have a brand new Life Resource Center in Lander, which will cut a ribbon later this month. We're very excited about that. And both of those facilities have been repositioned, and what North Stars are we shooting at? And what populations are we really trying to serve?
Kamila Kudelska: You were just mentioning the North Star, like, what is the community, what are the people that you're trying to reach with these resources?
SJ: Those North Stars, those missions, really to put it simply, the state hospital should be an acute stabilization facility. Short term, psychiatric acute stabilization. The Life Resource Center, will act, and is currently acting, as kind of an intermediate facility. So in many cases, they serve folks with developmental disabilities or intellectual disabilities, which has kind of been their historic or legacy population. But with the new mission, they will also partner with the state hospital for folks that have, you know, exceptionally difficult behaviors, but might not need hospital level of care in Evanston anymore. And also, folks like your geriatric psychiatric that no facility in the private sector is able or willing to treat, we will be able to take a long term care population from Evanston, which is not appropriate for the hospital and serve them in Lander. So there's kind of a joint and shared mission there.
But I want to make a strong connection here in how the state kind of set up the new missions and policies for our two safety net facilities, and how that connects to this community mental health and behavioral health conversation. The legislature, through Enrolled Act 56 in ‘21, really kind of took that model of the Facilities Task Force and asked the question, ‘What's the role of the state? With these state funds, that $100 million that I mentioned in my budget for Community Mental Health, what's the policy? With all this changing landscape and how everything has evolved, what are we trying to accomplish? What problems are we trying to solve with those dollars?’ And House Enrolled Act 56 in 2021 set us on that path where with those state funds, the legislature gave us a set of priority populations that first and foremost should be served. And that those are acute psychiatric populations. So think of Title 25 civil commitments. Second, criminal justice involved populations. So think Title Seven, think folks who may be cycling in and out of jails, detention centers, prison, etc, that have mental health or substance use needs. Very importantly, a third category, high needs adolescents and their families. So folks that we see between the Department of Health and Department of Family Services, very challenging cases with kids, where we're trying to reduce the need to place a kid in facilities either in Wyoming or around the state and better serve them in the communities. And finally, extremely low income, indigent folks with higher needs. So with that law that was put into place, it directs us to kind of reform this system. And we have a target implementation date of July 1 of 2024. And I want to say, and this is very serious and meaningful for me, we have done great work in the first year or two of that implementation because of the partnership we have with our community mental health providers and the legislative members who have worked with us.
KK: And could you go into a little more detail of how the reforms to the community mental health centers are going to change the way that those resources are provided to the communities?
SJ: What we're really hoping to see is kind of a three fold approach. Very similar to what we do now. We want to make sure that we are adequately financing our partners and the communities and in this case, our community mental health and substance abuse centers. One is through kind of fixed payments or base payments, something we do now. But we think it's probably necessary to increase that. We're kind of paying for infrastructure, right? We want these centers to be available, to be open to these priority populations that I’m mentioning. And so part of how we'll change on the payment side is to implement as perhaps a larger base payment. The second will be kind of traditional. We want to make sure that folks that receive services, that we're compensating the center or the providers for delivering those. So kind of a fee for service type structure that will pay for those units of service. An hour of therapy, for example, a unit of medication management. And we want to compensate at appropriate rates for that. The third, and I think most important element that we're working to implement, that gives me the most hope for something exciting we could do in the state of Wyoming, is what we're calling outcomes based payments. And everybody that you'll talk to in Health and Human Services or mental health, talk about achieving outcomes and paying for outcomes. Especially, as you'll know, this buzzword is “the social determinant of health.” That's a buzzword that people use often. But very few systems around the country actually pay for achieving those types of outcomes. And let me connect that to mental health and behavioral health, because it is so important. We know from years and years of experience and research and literature that folks that I'm talking about might encounter or cycle through higher levels of care and state institutions. What correlates most strongly to that type of recidivism or reliance on higher levels of care are social type determinants like housing, like employment, or volunteering, that community connection, education, and attending school, depending on your age and where you are in your life. These types of things we know need to be worked on and are kind of outside of the traditional realm of service delivery in health care or mental health. We've really worked and will continue to work over the next year with our stakeholder group and our providers, on what it could look like in Wyoming.
KK: How do you think people on the ground, like just normal Wyomingites, will see these changes as they come along and how it will potentially help them?
SJ: These are not folks that exist in a vacuum. These are our neighbors, these are our community members. And I think this is one of those issues where with behavioral health, it's almost like an issue that touches every sector of state and local government. I'll give you a few examples. We see folks in behavioral health crises that might be encountering law enforcement or in an emergency room, really in crisis and in need of help. And so what happens in a small community is the hospital's involved, law enforcement is involved, potentially, you know, county government through a county attorney through Title 25, judges, you know, other entities, community entities, like mental health providers. You really do see these folks and talking to all of these different stakeholders, we know who these folks are, and we feel for them. Part of what we're hoping this change, in addition to our facilities project, this change will generate is being able to more adequately serve that type of population in our communities without sending them to institutions or higher levels of care. That's one of the biggest goals.
