Partners in Wellness: Evaluation of a Pay for Performance Program for High-Utilizers of Mental Health Services

Evaluation of the Santa Clara County Mental Health Service Pay for Performance Quality Improvement Initiative

Healthcare systems in the United States (U.S.) have long faced the considerable challenge of managing budgetary pressures while at the same time helping people with serious mental illness and/or addiction. One potential way to address this challenge is to offer community-based services for individuals who are high-utilizers of expensive emergency and inpatient psychiatric services. Due to the decentralized nature of California governance, responsibility for mental health services falls primarily to the individual counties. The County of Santa Clara, CA invests significantly in community-based services as well as 24-hour care settings. This County adopted an innovative Pay for Performance (PFP) model and contracted with a new care provider to better meet the needs of this patient population and, in turn, reduce demand on the County's 24-hour psychiatric services. Whether this innovative contracting framework will help individuals who thus far have not responded well to mental health services is unknown. The purpose of this study was to determine whether the quality of care for these high-need patients was improved and at a sustainable cost. To this end, a randomized clinical trial (RCT) was conducted to determine whether this innovative quality improvement initiative, referred to as "Partners in Wellness", was successful at reducing the total cost of 24-hour psychiatric care used by enrollees compared to individuals who concurrently received services from the county. Individuals were randomly assigned to the Usual Care (UC) or Pay-For-Performance (PFP) conditions. The primary outcome of this evaluation was reduction in the total cost of 24-hour psychiatric services in the target population.

the primary outcome of this evaluation was reduction in the total cost of 24-hour psychiatric services in the target population.

Inclusion Criteria:

• Individuals with a history of extensive utilization of 24-hour psychiatric services in Santa Clara County, CA and a likelihood of continuing to use them in the future.

Exclusion Criteria:

• Age 17 or younger

• Born before 1952

• Not current resident of the County

• Currently residing in a state hospital

• Registered sex offender with legally imposed residency restrictions

• Have a DSM-V diagnosis of (or meet diagnostic criteria for):

  • Dementia
  • Autism Spectrum Disorder
  • Catatonia
  • Brief Psychotic Disorder
  • Traumatic head injury resulting in severe cognitive impairment
  • IQ of 69 or lower
  • Eating disorders, including Pica, Anorexia Nervosa and Bulimia Nervosa, or
  • Pyromania, or Psychogenic Polydipsia paired with life threatening behaviors in the past 12 months.

• Serious risk to self (i.e., suicidal intent with specific plan OR command hallucinations for self-harm that were acted on in the last 30 days and resulted in significant physical injury, or without staff intervention would have resulted in significant physical injury.

• Risk to others (e.g., sexual aggression or other violent, assaultive behavior toward clinical staff in the past 12 months).

• Serious medical diagnoses that either require intensive and regular home health care (e.g., Cystic Fibrosis, Parkinson's, Cancer), imminent risk of placement in a Skilled Nursing Facility or nursing home (e.g., non-ambulatory; needing would care), or are terminal or are life-threatening.

• Significant functional impairments (e.g., unable to toilet, incontinent and refuse to wear diaper, refuse to eat or drink, refuse to dress self or wear clothes, unable to transfer in/out of bed)