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.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
652
Wraparound mental health, psychosocial, and addiction treatment services provided by contractor under an schedule of rewards or penalties that was agreed to with Santa Clara County.
Outpatient and inpatient mental health and psychosocial services delivered by Santa Clara County services and systems.
Total cost of 24-hour psychiatric services (12 months)
Total cost of the following care types beginning from enrollment until 12 months post-enrollment: Emergency Psychiatric Services (EPS), Barbara Arons Pavilion (BAP) Acute Psychiatric Inpatient, Contract Hospital, Institutes of Mental Disease (IMD), State Hospital, Crisis Residential, Transitional Residential, Super Board and Care, and Residential Care Facility. Days of utilization for each service were multiplied by estimates of the average costs per client, per day provided by the County. To create the primary outcome measure, costs from all of these sources were summed.
Time frame: 12 months post-enrollment
Total cost of 24-hour psychiatric services (24 months)
Total cost of the following care types beginning from enrollment until 24 months post-enrollment: Emergency Psychiatric Services (EPS), Barbara Arons Pavilion (BAP) Acute Psychiatric Inpatient, Contract Hospital, Institutes of Mental Disease (IMD), State Hospital, Crisis Residential, Transitional Residential, Super Board and Care, and Residential Care Facility. Days of utilization for each service were multiplied by estimates of the average costs per client, per day provided by the County. To create the primary outcome measure, costs from all of these sources were summed.
Time frame: 24 months post-enrollment
Total cost of 24-hour psychiatric services (36 months)
Total cost of the following care types beginning from enrollment until 36 months post-enrollment: Emergency Psychiatric Services (EPS), Barbara Arons Pavilion (BAP) Acute Psychiatric Inpatient, Contract Hospital, Institutes of Mental Disease (IMD), State Hospital, Crisis Residential, Transitional Residential, Super Board and Care, and Residential Care Facility. Days of utilization for each service were multiplied by estimates of the average costs per client, per day provided by the County. To create the primary outcome measure, costs from all of these sources were summed.
Time frame: 36 months post-enrollment
Total cost of Barbara Arons Pavilion (BAP) Acute Inpatient Psychiatric Care (12 months)
Total cost of Barbara Arons Pavilion (BAP) Acute Psychiatric Inpatient Care in the 12 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 12 months post-enrollment
Total cost of Barbara Arons Pavilion (BAP) Acute Inpatient Psychiatric Care (24 months)
Total cost of Barbara Arons Pavilion (BAP) Acute Psychiatric Inpatient Care in the 24 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 24 months post-enrollment
Total cost of Barbara Arons Pavilion (BAP) Acute Inpatient Psychiatric Care (36 months)
Total cost of Barbara Arons Pavilion (BAP) Acute Psychiatric Inpatient Care in the 36 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 36 months post-enrollment
Total cost of Emergency Psychiatric Services (EPS) - 12 months
Total cost of Emergency Psychiatric Services (EPS) in the 12 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 12 months post-enrollment
Total cost of Emergency Psychiatric Services (EPS) - 24 months
Total cost of Emergency Psychiatric Services (EPS) in the 24 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 24 months post-enrollment
Total cost of Emergency Psychiatric Services (EPS) - 36 months
Total cost of Emergency Psychiatric Services (EPS) in the 36 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 36 months post-enrollment
Total cost of Contract Hospital (12 months)
Total cost of Contract Hospitals in the 12 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 12 months post-enrollment
Total cost of Contract Hospital (24 months)
Total cost of Contract Hospitals in the 24 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 24 months post-enrollment
Total cost of Contract Hospital (36 months)
Total cost of Contract Hospitals in the 36 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 36 months post-enrollment
Total cost of Crisis Residential Facility (12 months)
Total cost of Crisis Residential Facility care in the 12 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 12 months post-enrollment
Total cost of Crisis Residential Facility (24 months)
Total cost of Crisis Residential Facility care in the 24 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 24 months post-enrollment
Total cost of Crisis Residential Facility (36 months)
Total cost of Crisis Residential Facility care in the 36 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 36 months post-enrollment
Total cost of Transitional Residential (12 months)
Total cost of Transitional Residential care in the 12 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 12 months post-enrollment
Total cost of Transitional Residential (24 months)
Total cost of Transitional Residential care in the 24 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 24 months post-enrollment
Total cost of Transitional Residential (36 months)
Total cost of Transitional Residential care in the 36 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 36 months post-enrollment
Total cost of Residential Care Facility (12 months)
Total cost of Residential Care Facilities in the 12 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 12 months post-enrollment
Total cost of Residential Care Facility (24 months)
Total cost of Residential Care Facilities in the 24 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 24 months post-enrollment
Total cost of Residential Care Facility (36 months)
Total cost of Residential Care Facilities in the 36 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 36 months post-enrollment
Total cost of Institutes of Mental Disease (12 months)
Total cost of Institutes of Mental Disease in the 12 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 12 months post-enrollment
Total cost of Institutes of Mental Disease (24 months)
Total cost of Institutes of Mental Disease in the 24 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 24 months post-enrollment
Total cost of Institutes of Mental Disease (36 months)
Total cost of Institutes of Mental Disease in the 36 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 36 months post-enrollment
Total cost of Custody Health (12 months)
Total cost of Jail-based mental health care in the 12 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 12 months post-enrollment
Total cost of Custody Health (24 months)
Total cost of Jail-based mental health care in the 24 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 24 months post-enrollment
Total cost of Custody Health (36 months)
Total cost of Jail-based mental health care in the 36 months post-enrollment. Days of utilization for this service was multiplied by estimates of the average costs per client, per day provided by the County.
Time frame: 36 months post-enrollment
Incarceration (12 months)
Proportion of patients who had any days of incarceration during the 12 months post-enrollment.
Time frame: 12 months post-enrollment
Incarceration (24 months)
Proportion of patients who had any days of incarceration during the 24 months post-enrollment.
Time frame: 24 months post-enrollment
Incarceration (36 months)
Proportion of patients who had any days of incarceration during the 36 months post-enrollment.
Time frame: 36 months post-enrollment
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