I. 2001 Best Practices Symposium

The next Medical Directors Best Practices Symposium will occur in conjunction with APA's Institute for Psychiatric Services in Orlando in October 2001. As agreed at the previous Medical Directors meeting, Dr. Radke and Dr. Goetz will submit applications to conduct workshops at the APA Institute on sexual offenders and seclusion and restraint respectively.

The Council discussed disassociating its Best Practices Symposium from the APA Institute in future years, given the uneven quality of that APA meeting. Several scheduling alternatives were mentioned, including affiliating with another relevant public mental health meeting (such as the Psychiatric World Congress or the Superintendents' Meeting) or holding the Symposium as a stand-alone meeting. Given that there was no strong support for these alternatives and that attendance at the Symposium meeting has been high, the group agreed to continue scheduling the Symposium in conjunction with the APA Institute.

The Medical Directors Council also planned the format and content of the 2001 Symposium. Participants favored the current structure (a day and a half length incorporating four 2-hour sessions and a business meeting).

The group suggested several topics for the upcoming Symposium: polypharmacy issues for children; special populations (adolescents and children services, geropsychiatry, forensic); models to ensure continuity of care between hospitals and the community; strategies for controlling costs and still maintaining guidelines; review of practice guidelines; NRI ORYX update on performance measures and how to use this data in clinical-based decision-making; community-based outcome research; advanced directives/therapeutic contracts and avoiding commitment; alternatives to state hospitals (community-based support programs) given the Olmstead decision; and adult psychopharmacy.

Dr. Glover pointed out that the Summer 2001 Commissioners meeting will focus on children and adolescents, a high priority with the Commissioners. He also urged the Medical Directors to consider areas where they can make a unique contribution to the Commissioners, given their expertise and credibility (e.g. polypharmacy issues).

While discussing the upcoming Symposium, some Medical Directors expressed their discomfort with pharmacy representatives attending the meeting, particularly given some state's strong conflict of interest rules. Some believed that the pharmacy representatives' presence could change the tone and agenda of the meeting, particularly around access to and cost of medications. The group also discussed the impact of having pharmaceutical companies subsidize the Symposium's costs and the possible cost if the meeting received no outside pharmaceutical support. If the meeting were to become self-supporting, the estimated participant cost would be $500-$700 per person.

Participants discussed several alternatives to resolve this concern, including designating a certain day as closed to all non-Medical Directors, opening up the meeting and inviting additional pharmaceutical representatives to avoid perceived conflicts of interest, and limiting pharmaceutical representatives' participation to social functions during the meeting.

Action: After some discussion and a vote, the Medical Directors Council selected the sessions for its 2001 Symposium with several members volunteering to chair the sections:

• NRI's Performance Measurement System Update: Examine the data through expert eyes and then provide a pragmatic example of how a state uses the data to make quality improvement and funding decisions Section Chair: Dan Luchins, M.D.

• Children Psychopharmacy Issues Section Chairs: Brian Hepburn, M.D. and Penny Knapp, M.D.

• Update on practice guidelines including changes by APA and modifications by the tri-universities Chair: Joe Parks, M.D. will contact Steve Shon, M.D. to see if he's willing to chair the session or work together with Dr. Parks

• Continuity of Care from the Hospital to the Community (Successes and Failures) Section Chair: Alan Radke, M.D.

Action: Dr. Glover and/or Dr. Hester will discuss with the pharmaceutical companies whether they'd be willing to confine their participation in the Symposium to the social functions (breakfast, lunch, reception). At the December Medical Directors meeting, they will report back on their discussions and the Council will revisit this issue.

II. Technical Reports

The Council brainstormed proposed topics for the upcoming Technical Reports. Suggested topics included: outpatient commitment (including alternatives and the use of existing laws); evidenced-based practices for children and adolescents; continuity between the hospital and community; medical leadership in community mental health centers; public sector managed care models; culturally competent practices; and polypharmacy.

Action: Participants selected two topics for future Technical Reports:

• Outpatient Commitment and Alternatives Brian Hepburn, M.D. will serve as Chief Editor

• Polypharmacy Joe Parks, M.D. will serve as Chief Editor.

III. Input for Upcoming Meeting with Medicaid Directors

Dr. Hester invited Medical Directors to suggest hot issues to be addressed at the November 2000 joint meeting between NASMHPD Medical Directors and Medicaid Directors Pharmacists and Medical Directors. The group raised the following concerns:

• Discriminatory practice of patients losing their medical assistance when they go into a state hospital or an IMD and the delay in their becoming Medicaid eligible upon discharge

• Individuals on SSDI inability to qualify for Medicaid and the lack of Medicare coverage for medications

• Interruption in medication compliance due to Medicaid's periodic spend-down requirements and the need for patients to save receipts and demonstrate eligibility several times per year

• Promotion of generic medication

• Polypharmacy

• Deviations from standard clinical practices

• Need to pressure drug companies to look at costs (e.g., prioritizing the use of the four new generation antipsychotics to put pressure on companies to lower the cost)

• Discontinued Medicaid coverage when patients enter detention centers (jails)

• Lack of consultation between some SMHA's and Medicaid Departments

• Physicians who are not trained in psychiatry prescribing the majority of psychotropics funded by Medicaid

• Lack of parity in payment for medication visits

• Rules and limits on the number of prescriptions funded per month

• Medicaid's policy of paying for one service at a time that creates difficulty for patients to obtain psychotropic medication and psychotherapy during one visit

The Medical Directors also anticipated some issues that Medicaid Directors would raise, including concern that psychotropics are budget busters; questions about whether polypharmacy is good practice; the need for provider management and education, particularly in nursing homes; shortage of child psychiatrists overall and general psychiatrists in rural areas; the possibilities of telepsychiatry.

The group concluded that Medicaid Directors and SMHA Medical Directors should work to identify best practices, figure how to achieve those by working together and develop a relationship where the SMHA is seen as mental health expert and a resource to Medicaid.

IV. Discussion with AACP about LOCUS

Rick Seiger, President of Deerfield Behavioral Health, and Robert Jimmerson, Deerfield Behavioral Health's Director of Development, discussed their company's partnership with the American Association of Community Psychiatrists (AACP) to develop and promote the Level of Care Utilization System Overview (LOCUS).

Most Medical Directors were familiar with LOCUS, a holistic tool based on functioning (not diagnosis) used for defining the necessary intensity of services to be deemed any particular level of care. Mr. Jimmerson reviewed the evaluation parameters of LOCUS, including risk of harm; functional status; medical, addictive and psychiatric comorbidity; recovery environment; treatment and recovery history; and engagement. The instrument, which requires limited training, has been used for preadmission screening, continued stay reviews and discharge criteria. In addition to front-line clinicians, LOCUS can be used by administrators for provider monitoring, resource management and planning in response to the Olmstead ruling.

Medical Directors interested in more information about LOCUS can contact Robert Jimmerson at (814) 456-2457.