customizing care coordination in medicaid for children with
TRANSCRIPT
7/22/2014
1
Georgetown University 2014 Training Institutes
Customizing Care Coordination in Medicaid Delivery Systems for Children with Serious Behavioral Health Challenges:
The Use of Care Management Entities and Wraparound Teams
PRESENTERS
Sheila A. PiresSenior Partner, Human Service Collaborative; Core Partner, Technical Assistance Network
Jody Levison‐JohnsonJody Levison‐JohnsonDeputy Assistant Secretary, Louisiana Office of Behavioral Health
Elizabeth ManleyDirector, System of Care Division, New Jersey Dept. of Children and Families
Jackie ShippDirector, Community Based Services, Oklahoma Dept. of Mental Health and Substance Abuse Services
Dayana SimonsSenior Program Officer, Center for Health Care Strategies, Inc.; Core Partner, Technical Assistance Network
Michelle ZabelUniversity of Maryland Baltimore, Institute for Innovation and Implementation; Lead Core Partner, Technical Assistance Network
Setting the Context
Why Children with Significant Behavioral HealthChallenges Need Customized Care Coordination
2
Mental Health = Costliest Health Condition of Childhood
$8.90
$20.00
$25.00
$30.00
S of Dollars Mental Health
Disorders
3
$2.90
$3.10
$6.10
$8.00
$0.00
$5.00
$10.00
$15.00
BILLIONS
Asthma
Trauma Related ConditionsAcute BronchitisInfectious Diseases
Source: Soni, 2009 (AHRQ Research Brief #242)
Children in Medicaid: Behavioral Health Penetration and Total Expense
• Children in Medicaid using behavioral health (BH) care:• Under 10% of children enrolled in Medicaid, but • An estimated 38% of total Medicaid child expenditures ($19.3b)
• 9.6% of children in Medicaid used BH care• 6.7% used BH services (with or without psychotropic meds)• 5.8% used psychotropic medications (with or without BH services)
• 0.8% of Medicaid children used substance use disorder services
4
Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid:Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies
Children in Medicaid Using BH Care:A High‐Cost Population
• Mean Medicaid expenditures (PH and BH) = $8,520 per year • Nearly 5x higher than for Medicaid children in general ($1,729 per
year*)• TANF‐enrolled children – nearly 3x higher• Foster care – 7x higher• SSI/disabled – nearly 9x higher• SSI/disabled – nearly 9x higher
• Expenditures driven more by behavioral – rather, than physical – health service use, except for children on SSI/disability who have slightly higher physical health expense
• Children with top 10% of BH expense are 28x more expensive than Medicaid children in general
*As estimated in Center for Medicaid and State Operations: Statistical Report on Medical Care: Eligibles, Recipients, Payments, and Services (HCFA 2082), MSIS. 2008 Statistical Supplement.
5
Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies
Children in Foster Care Use More Restrictive, More Expensive Services in Medicaid
•More likely to use: •Inpatient psychiatric services•Residential treatment •Therapeutic group care •Emergency room services •Psychotropic medications
•One‐fifth the size of the TANF population, but use: •Nearly the same amount of dollars for residential, group care andER visits
•3.5 times more for therapeutic foster care
Pires, S., Grimes, K., Allen, K., Gilmer, T, and Mahadevan, R. 2012, Faces of Medicaid: Examining Children’s Behavioral Health Service Use and Expenditures. Hamilton, NJ; Center for Health Care Strategies
6
7/22/2014
2
2 - 5%
More complex needs Intensive
Services –60% of $$ Home &
community services Prevention
Prevalence/Utilization Triangle
15%
80%Less
complex needs
and supports;
early intervent’n–35% of $$
and Universal Health Promotion –5% of $$
Pires, S. 2006. Human Service Collaborative. Washington, D.C.
7
Children and Youth with Serious Behavioral Health Conditions:Distinct Population from Adults with Serious and Persistent Mental Illness
• Do not have the same high rates of co‐morbid physical health conditions as adults with SPMI
• Have different mental health diagnoses from adults with SPMI (i.e. ADHD, Conduct Disorders, Anxiety); not as much Schizophrenia, Psychosis, Bipolar; and diagnoses change often
• Two‐thirds are typically involved with child welfare and/or juvenile justice systems, and b l d d b l l d60% may be in special education – systems governed by legal mandates
• Care coordinator’s time is primarily spent on coordination with other children’s systems (i.e. child welfare, juvenile justice, schools), behavioral health providers, family needs/concerns, not coordination with primary care
• To improve cost and quality of care, focus must be on child and family/caregiver(s) which takes time
Pires, S. March 2013 Customizing Health Homes for Children with Serious Behavioral Health Challenges .Human Service Collaborative
8
Customized, Intensive Care CoordinationApproaches Are Needed
•Traditional case management and care coordination approaches for adults are not sufficient
•Need for:i•Lower case ratios
•Higher payment rates•Approach based on evidence of effectiveness
9
Customized Care Coordination Approaches for Children with Serious Behavioral Health Challenges
• Care Management EntitiesOrganizations providing intensive care coordination at low
ratios (1:10) using high quality Wraparound* care planning approach
• High Quality Wraparound Teamsb dd d i ti i ti h CMHC FQHCembedded in supportive organization, such as CMHC, FQHC
or school‐based mental health center, providing intensive care coordination at low ratios
Pires, S. 2013. Washington DC: Human Service Collaborative
Growing number of states experiencing better outcomes, lower per capita costs. (MA, LA, NJ, WI, IL; PRTF Waiver Demo states; CHIPRA Care Management Entity Quality Collaborative states(MD, GA, WY); OK)
(*May 7, 2013 CMCS SAMHSA Joint Informational Bulletin)
10
Important Points About Wraparound• Wraparound is:
– A defined, team‐based service planning and coordination process
– A structured approach to service planning and care coordination
• It is NOT a service per se• The Wraparound care planning process ensures that there is
one coordinated plan of care and one care coordinator• The ultimate goal is to improve:
– Outcomes – Family and youth experience with care– Per capita costs of care – health care’s triple aim
11
What’s Different in Wraparound?• High quality teamwork
– Collaborative activity– Brainstorming options– Goal setting and progress monitoring
• The plan and the team process is driven by and “owned” by the family and youth
• Taking a strengths based approach• Taking a strengths based approach• The plan focuses on the priority needs as identified by the
youth and family• Focus on:
– Whole youth and family– Developing optimism and self‐efficacy– Developing enduring social supports
12
7/22/2014
3
In wraparound, a care coordinator coordinates the work of system partners and other natural helpers so there is one coordinated plan
BehavioralJuvenile J ti
Education Child
Care Coordinator(+ Peer Partner)
Health
13
Behavioral Health
Justice welfare
YOUTH
FAMILY“Natural Supports”
•Extended family
•Neighbors
•Friends
“Community Supports”
•Neighborhood
•Civic
•Faith‐based
ONE PLAN Adapted from Laura Burger Lucas, ohana coaching, 2009
care
Wraparound is Increasingly Considered “Evidence‐Based”
• State of Oregon Inventory of Evidence‐Based Practices (EBPs)
• California Clearinghouse for Effective Child Welfare Practices
• Washington Institute for Public Policy: “Full fidelity wraparound” is a research‐based practice
14
Costs and Residential Outcomes are Robust
CMS Psychiatric Residential Treatment Facility (PRTF) Waiver Demonstration (Urdapilleta et al., 2011)
• Average per capita saving by state ranged from $20,000 to $40,000
Los Angeles County Department of Social Services• Found 12‐month placement costs were $10,800 for Wraparound‐discharged youths compared to $27,400
for matched group of RTC youths
Wraparound Milwaukee• Reduction in placement disruption rate in child welfare from 65% to 30%• School attendance for child welfare‐involved children improved from 71% days attended to 86% days p y y
attended• 60% reduction in recidivism rates for delinquent youth from one year prior to enrollment to one year post
enrollment• Decrease in average daily pop. in residential treatment centers from 375 to 50• Reduction in psychiatric inpatient days from 5,000 days per year to <200 • Average monthly cost of $4,200 (compared to $7,200 for RTC, $6,000 for juvenile detention, $18,000 for
psychiatric hospitalization)
Maine• Experienced 30% net reductions in Medicaid spending, comprised of decreases in PRTF and inpatient
psychiatric with increases in targeted case management and home‐ and community‐based services
15
Child and Youth Populations Typically Served by CMEs/High Quality Wraparound Teams
• Children and adolescents:• With serious emotional/behavioral challenges at risk of out‐
of‐home placement in residential treatment, group homes, and other institutional settings
• Returning from institutional placements in residential treatment, correctional facilities, or other out‐of‐home settingg
• At risk of or returning from psychiatric inpatient settings• in child welfare
• Youth at risk of incarceration or placement in juvenile correctional facilities
• Detention diversion and alternatives to formal court processing for juveniles
• Other populations (e.g., youth at risk for alternative school placements)
Pires, S. 2010. Human Service Collaborative16
Customization Strategies – Regardless of Medicaid System Design
Customized Care Coordination(May 7, 2013 CMCS and SAMHSA Informational Bulletin)
•Incorporate intensive care coordination using Wraparound approach for children with serious behavioral health challenges (growing number of states –MA, LA, NJ; PRTF Waiver Demo; CHIPRA Care Management Entity Quality Collaborative states)Collaborative states)
•Intensive care coordination rates for this population range from $780 pmpm to $1300 pmpm (CHCS Matrix)•In fidelity intensive care coordination/Wraparound approaches, all‐inclusive cost of care (e.g., admin, care coord, placements, clinical treatment, informal supports) averages $3700‐$4200 pmpm (about $2100 is Medicaid ) –compare to $9,000 pmpm in PRTFs, higher in psych inpatient
Pires, S. & Stroul, B. 2013. Making Medicaid Work for Children in Child Welfare. Hamilton, NJ: Center for Health Care Strategies17
Care Management Entity Functions
Service Level
• Child and family team facilitation using fidelity wraparound practice model
• Screening assessment
Administrative Level
• Information management –real time data; web‐based IT
• Provider network recruitment and management (including
Pires, S. 2010. Human Service Collaborative18
• Screening, assessment, clinical oversight
• Intensive care coordination• Care monitoring and review• Peer support partners• Access to mobile crisis supports
and management (including natural supports)
• Utilization management• Continuous quality improvement; outcomes monitoring
• Training
7/22/2014
4
Variation in Types of CME Entities
•Public agency as CME – Wraparound Milwaukee
•New non profit organization with no other role – New Jersey Care Management Organizations
•Existing non profit organization with other direct service capability –Massachusetts Community Service AgenciesMassachusetts Community Service Agencies
•Hybrid – Non profit organization with other direct service capability in formal partnership with neighborhood organization – Cuyahoga County, OH Coordinated Care Partnerships
•Non profit HMO – Massachusetts Mental Health Services Program for Youth
Pires, S. 2010. Human Service Collaborative19
Integration at the Systems/Medicaid Purchaser Level: Caveats
Research has shown that…
• When adult and child behavioral health dollars are integrated, there is a risk of child behavioral health dollars being absorbed by adult services
• When physical and behavioral health dollars are integrated there is• When physical and behavioral health dollars are integrated, there is a risk of behavioral health dollars being absorbed by physical health services
Especially in the absence of customization within the design for children with serious BH challenges, risk‐adjustment strategies, strong contractual performance measures and monitoring mechanisms
See publications and issue briefs published by the Health Care Reform Tracking Project at: http://www.fmhi.usf.edu/cfs/stateandlocal/hctrking/hctrkprod.htm20
Medical Homes vs. Health Homes
Medical Homes
All children
Health Homes
Children with chronichealth conditions, childrenwith serious behavioral health conditions
Coordination of medical care
Physician‐led primary carepractices
Coordination of physical,behavioral, and social supports
Specialty provider organizations,including behavioral health specialtyorganizations (e.g., not only medical)
21
Analysis of Medical Home Services for Children with Behavioral Health Conditions
“All behavioral health conditions except ADHD are associated with difficulties accessing specialty care through a medical home”
“The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with theand youth with behavioral health conditions are not consistent with the medical home model has more to do with difficulty in accessing specialty care than with accessing quality primary care”.
There is a need for more customized, intensive care coordination approaches for children with significant behavioral health challenges.
Pires, S. 2013. Washington DC: Human Service Collaborative
Sheldrick, RC & Perrin, EC. “Medical home services for children with behavioral health conditions”. Journal of Developmental Pediatrics, 2010 Feb‐Mar 31 (2) 92‐9
22
“Integration” with Primary Care in a Wraparound Approach
• Ensuring child has an identified primary care provider (PCP)
• Tracking of whether child receives EPSDT screens on schedule
• Ensuring child has at least an annual well‐child visitEnsuring child has at least an annual well child visit• Communicating with PCP opportunity to participate in child and family team and ensuring PCP has child’s plan of care and is informed of changes
• Ensuring PCP has information about child’s psychotropic medication and that PCP monitors for metabolic issues such as obesity and diabetes
Pires, S. 2013. Customizing Health Homes for Children with Serious Behavioral Health Challenges. Hamilton, NJ; Center for Health Care Strategies23
Accountable Care Organizations• “I believe, with some exceptions, ACOs will not succeed…it will be difficult for anything
but an organization that has been at it a long time to develop the team culture needed to be an ACO”
• “The reason that patient‐centered medical homes will not succeed is that health care follows the 80/20 rule ‐ 20% of patients generate 80% of the costs. Those 20% are the chronically ill, and I don’t see how primary care physicians serving those patients add value to their care.”
• “Focused factories of care – that is a term I use for provider organizations that deliver highly specialized care for a certain group of patients, such as those with diabetes…you need specialists for that. They are the opposite of ACOs that do everything for everyone.”
‐‐Regina Herzlinger, Harvard Business School, as quoted in Managed Care Magazine Online (http://www.managedcaremag.com)
REALITY: Care coordination ratios within Medicaid ACOs‐ for the highest need‐ run 1:50‐75.
Pires, S. 2013. Washington DC: Human Service Collaborative24
7/22/2014
5
Medicaid Vehicles to Support Customized IntensiveCare Coordination Using Fidelity Wraparound
• With population pmpm case rate or with care coordination pmpm rate
• 1915(a) – Wraparound Milwaukee, Children Come First (Dane Co WI)
• Targeted Case Management – NJ, MA• 2703 Health Home SPA OK (for SED) NJ (for subset of children• 2703 Health Home SPA – OK (for SED), NJ (for subset of children
with SED and co‐occurring medical or developmental conditions• 1915(b) or (c) – LA• 1915(i) – MD• Money Follows the Person (GA)• Balancing Incentive Program (GA)• CMMI Health Innovations Grant (CHCS and 4‐state application)
Pires, S. 2014. Human Service Collaborative: Washington DC25
State Examples
•Intensive Care Coordination/Wraparound•Structures•How Embedded within Medicaid Delivery System•Medicaid Vehicles Used•Populations Served
26
27
Customizing Care CoordinationCustomizing Care CoordinationThe Louisiana ExperienceThe Louisiana ExperienceJuly 17 & 19, 2014July 17 & 19, 2014
29
OVERVIEWOVERVIEW
Louisiana Coordinated System of CareThe Coordinated System of Care (CSoC) is an initiative to serve Louisiana’s youth with significant behavioral health challenges who are in highest need and at greatest risk. CSoC is a component of the Louisiana Behavioral Health Partnership.
CSoC is a philosophy and approach to service delivery that results in i d i i d di i h d i ff iimproved integration and coordination, enhanced service offerings and improved outcomes.
At full implementation the CSoC will serve 2400 youth.
Specific goals for the CSoC include decreasing the number of youth in residential/detention settings, reduction in the state's cost for providing services by leveraging Medicaid and other funding sources, and improving the overall outcomes for these children/youth and their caregivers.
Louisiana Department of Health and Hospitals – Office of Behavioral Health 30
7/22/2014
6
Winn
Grant
LaSalle Catahoula
Concordia
Caldwell
Natchitoches
Caddo
Bossier
RedRiverDeSoto
Sabine
Webster
Bienville
Claiborne
Lincoln
Jackson
Union Morehouse
Ouachita Richland
FranklinTensas
Madison
CarrollWest East
CSoC Implementing Regions Region 8 – Shreveport; WAA = ChoicesDavid Sikes, 318‐221‐1807, [email protected](Bienville, Bossier, Caddo, Claiborne, DeSoto, Jackson, Natchitoches, Red River, Sabine, Webster)
Region 9 – Monroe; WAA = Wraparound of Northeast LouisianaCurtis Eberts, 318‐654‐4245, [email protected](Caldwell, East Carroll, Franklin, Lincoln, Madison, Morehouse, Richland, Ouachita, Tensas, West Carroll)
Region 7 – Alexandria; WAA = EckerdJodie Roberts; 318‐443‐7900, [email protected] (Avoyelles, Catahoula, Concordia, Grant, LaSalle, Rapides, Vernon, Winn)
Region 2 – Baton Rouge; WAA = National Child and Family Services (NHS)Carolina Jones, LCSW, 225‐456‐2006, cjones02@nhsonline(Ascension, East Baton Rouge, East Feliciana, Iberville, Livingston, Pt. Coupee. West Baton Rouge, West Feliciana)
Region 1 – Greater New Orleans; WAA = National Child and Family Services (NHS)Karen Davis, Ph.D., LPC, LMFT, 504‐266‐2576, [email protected](Jefferson Orleans Plaquemines St Bernard)
WestFeliciana
Washington
St. Tammany
Tangipahoa
St.Helena
Livingston
CoupeePt.
East
Avoyelles
Baton RougeW.
Iberville Orleans
JohnSt.
St.Charles
St. Bernard
Plaquemines
Jefferson
AscensionSt.James
sAssumption
LafourcheSt.Mary
Terrebonne
Beauregard Allen
Calcasieu
Cameron
JeffersonDavis
Evangeline
St. Landry
Acadia
Vermilion
Lafayette
St.Martin
Iberia
Vernon Rapides
East
(Jefferson, Orleans, Plaquemines, St. Bernard)
Statewide FSO: Ekhaya Youth ProjectDarrin Harris, [email protected], 504‐821‐2601 x577
3132
STRUCTURESSTRUCTURES
Intensive Care Coordination / Wraparound Structure in Louisiana
Department of Health & Hospitals
Office of Behavioral HealthMedicaid
Statewide Management Organization
(SMO)
Wraparound Agencies Family Support Organization Provider Network
Louisiana Department of Health and Hospitals – Office of Behavioral Health 33
Medicaid Vehicles in Louisiana
• CMS Authority:• 1915(b) Waiver allows for the use of Managed Care in the Medicaid Program
• 1915(c) Waiver allows for the provision of long1915(c) Waiver allows for the provision of long term care services in home and community based settings under the Medicaid Program
• Wraparound Agencies: administrative payment• Peer Support Services (Youth & Parent): Fee for service payment
34Louisiana Department of Health and Hospitals – Office of Behavioral Health
Population Served in Louisiana
• Age 21 or under• DSM diagnosis or exhibiting behaviors indicating a behavioral health diagnosis may exist
li i l li ibili h CA S• Meets clinical eligibility on the CANS Comprehensive
• Generally involved with multiple child‐serving systems
• In or at‐risk of out of home placement
35Louisiana Department of Health and Hospitals – Office of Behavioral Health36
7/22/2014
7
Keeping Families Strong Keeping Children Safe and Well Children’s System of Care
Presented byPresented by
Elizabeth Manley
Division Director
At HomeSuccessfully living with their families and reducing the need for out-of-home treatment settings.
Children’s System of Care ObjectivesTo help youth succeed…To help youth succeed…
39
In School
In the Community
Successfully attending the least restrictive and most appropriate school setting close to home.
Successfully participating In the community and becoming independent, productive and law-abiding citizens.
Children’s System of Care Values and Principles
Child Centered & Family DrivenCommunity Based
Culturally Competent
Strength Based Family Involvement Individualized
Unconditional Care
Promoting
Independence
Collaborative
Cost Effective
Comprehensive
Home, School & Community Based
Team Based
40
FinancingRehab OptionChild Welfare and Juvenile JusticeTargeted Case Management1915 like (i) or (c)1115 WaiverCHIP/SCHIPState Funds
EnvironmentPolitical
Perspectives of LeadersLaw Suits/Settlements
Crisis/TragedyMandates
Community WillEconomic
Priorities Structure
CSOC Values &
Final System of Care
iPrioritiesServe MoreEBPsCare ManagementSystem CoordinationReduce Institutional CareParticular Populations
StructureGovernment
State vs. CountyExisting Reality
Envisioned IdealMedicaid AgencyLocus of Control
Leadership Structure
Factors That impact Design
Principles
Design
41
Key System Components
Contracted System Administrator • CSA is the single portal for access to care available 27/7/365
Care Management Organization
• Care Management Organization utilizing a wraparound model of care serving youth with complex and moderate and their families
Mobile Response & Stabilization Services • Crisis response and planning available 24/7/365
Family Support Organization • Family‐led support and advocacy for parents and caregivers and youth
Fle ible m lti p rpose in home/comm nit clinical s pport for parents/caregi ersIntensive In‐Community
• Flexible, multi‐purpose, in‐home/community clinical support for parents/caregivers and youth with behavioral and emotional disturbances who are receiving care management, MRSS, or out‐f‐home services
Out of Home • Full continuum of residential treatment / out of home care
DD‐Family Support Services• Supports, services, resources, and other assistance designed to maintain and enhance the quality of life of a young person with developmental disability and his or her family, including respite services and assistive technology
Substance Abuse Treatment Services • Out of home and outpatient substance abuse treatment services (limited)
Traditional Services • Partial Care, Partial Hospitalization, Inpatient and Outpatient services
42
7/22/2014
8
Role of Contracted Systems Administrator (CSA)
CSA creates pathways for youth and young adults by providing access to the right care at the right
time.
CSA authorizes services, based on the most recent clinical information that is submitted to them.
CSA does not provide direct services.
Anyone helping children and families may contact CSA on behalf of a youth in need of a referral. However, the parent/legal guardian of the youth must
give consent for services.
CSA has a dedicated child welfare unit
43
The vision of CSOC is to create positive outcomes for children with emotional and behavioral needs and those with intellectual and developmental disabilities by:
The Role of Assessment within CSOC
Appropriate Services
AppropriateLength of Stay
PositiveOutcomes
• Identifying the child and family’s needs
• Determining the most appropriate Intensity of Service
Assessment Tools
Child and Family Needs
Appropriate Intensity of Service
ServicesIntensity of Service
• Delivering the most appropriate servicesfor the most appropriate length of time
• Using standard assessment tools --the foundation of the Children’s
System of Care.
44
Intensities of Service (IOS)
Inpatient Treatment
Out of Home Treatment
Care Management Organization (CMO)
Mobile Response & Stabilization Services
Intensive In‐Community (IIC) & Behavioral Assistance (BA) Services
Outpatient Treatment
Assessment Services
Access / Triage and Information and Referral (PerformCare)
45
Care ManagementCare Management Organizations (CMO’S)Utilize Child Family Teams (CFT’s) within Wraparound Model to facilitate a planning process to address the individualized needs of each youth.
46
New Jersey Department of Children and Families
Commissioner
NJ Department of Children and Families
Division of Children’s System of
Care(formerly DCBHS)
Division of Child Protection &
Permanency (formerly DYFS)
Division of Family
& Community Partnerships
(formerly DPCP)
Office of Adolescent ServicesDivision on Women
47 48
7/22/2014
9
Oklahoma Systems of Care
49 50
Children and Youth Served
• Children and youth*– Up to age 22– With SED or co‐occurring disorderAt risk of out of home or out of school placements– At risk of out of home or out of school placements
– With complex needs served by multiple agencies
*Up to age 26 at Healthy Transitions Sites
51
Care Coordination
• Care coordination in the wraparound process is designed to facilitate a collaborative relationship among the child with SED, the family and all systems involved The Carefamily and all systems involved. The Care Coordinator ensures that the wraparound process is organized and integrated across all child‐serving systems to enable the child to remain in his/her own home community.
52
Wraparound In Oklahoma
Wraparound teams (Care Coordinator and FSPs) are trained, coachedand credentialed through the well‐established process managed by theODMSHAS. Mandatory ODMHSAS sponsored/conducted trainingsinclude:• SOCWraparound 101 Training:
h d d f h l• This is an introductory two‐day training focusing on the principlesand values of Wraparound. It is an in depth look at the phases ofWraparound and teaches participants how to complete thenecessary components including Strengths, Needs, Culture,Discovery (SNCD) assessments, functional assessments, crisis/safetyplans, Wraparound plans, and other items.
• SOC Family Support Provider Training is required for FSPs.
53
.
Rehab Option of State Plan Amendment
Role in Wraparound HCPC Code Rate Timeframe
Behavioral Health Aide H2019 $ 7.52 15 minutes
F il S t P id H2015 9 75 15 i tFamily Support Provider H2015 9.75 15 minutes
Care Coordinator (TCM) – bachelor’s T1017 16.21 15 minutes
Care Coordinator (TCM) – LBHP T1016 21.61 15 minutes
54
7/22/2014
10
55
Customizing Care Coordination in the Medicaid Delivery System for Children with Serious Behavioral
H l h Ch ll I h
www.chcs.org
Health Challenges In MassachusettsTargeted Institute #3
Georgetown Training Institutes
Dayana Simons, M.Ed. LMHC
July 2014
State Context: Massachusetts
• Services are delivered through statewide system (not county‐based)
• Direct services are delivered primarily by contracted agenciesg
• There is the greatest concentration of teaching hospitals in the U.S.
• Medicaid managed care state
57
Adapted from Massachusetts Executive Office of Health and Human Services
System of Care/Wraparound Timeline
1980’s: Federal CASSP Grants
1998: RWJ Mental Health Services Program for Youth (MHSPY)
2003: WCC incorporated into to Coordinated Family-Focused Care (CFFC), which together with MHSPY, served ten cities and towns through Medicaid Waiver
1991: Parent/Professional Advocacy League (PPAL - state organization of the Federation of Families for Children’s Mental Health)
1999:SAMHSA SOC Grants to Worcester Communities of Care (WCC)
58
Adapted from Massachusetts Executive Office of Health and Human Services
The Massachusetts Catalyst: “Rosie D.”
• Federal Class Action Lawsuit (2001) on behalf of children and youth with serious emotional disturbance
• Final judgment issued July, 2007
• MassHealth, found to be out of compliance with “reasonable promptness” and “Early Periodic Screening Diagnosis and Treatment” (EPSDT)provisions of federal Medicaid law
59
Adapted from Massachusetts Executive Office of Health and Human Services
The Remedy
• Statewide Implementation of:
► Standardized BH screening in primary care
► Standardized scope of BH assessment using the Child and► Standardized scope of BH assessment, using the Child and Adolescent Needs and Strengths (CANS) tool
► New home‐ and community‐based BH services, including intensive care coordination with high quality wraparound
60
Adapted from Massachusetts Executive Office of Health and Human Services
7/22/2014
11
MassHealth(Office of Medicaid)
MassHealth Managed Care Entities
Access to Services & Supports: Medicaid Managed Care in MA
61
Primary Care Clinician (PCC) Plan (medical)/Massachusetts Behavioral
Health Partnership (MBHP)(behavioral health carve out)
Managed Care Program
Health New England Be Healthy
Massachusetts Behavioral Health Partnership (MBHP)
(behavioral health)
Neighborhood Health Plan
Boston Medical Center
HealthNet Plan
Beacon Health Strategies
(behavioral health)
Fallon Community Health Plan
Network Health (medical and
behavioral health)
Massachusetts1115 Waiver, State Plan (TCM)
MCO MCO MCO MCO
Standardized tools for screening and assessment by PCPs
State Medicaid Agency (MassHealth) – Purchaser
BHO
PCCM MCO
Community Services Agencies (CSA)Non Profit BH and Specialty Providers
(Locally‐Based Care Management Entities)
Standardized tools for screening and assessment by PCPsCANS
62
Massachusetts Definition of Intensive Care Coordination (Targeted Case Management)
Includes:• Assessment• Development of an Individual Care Plan• Referral and related activities• Monitoring and follow‐up activities
All of which is done using a high quality wraparound care planning process
63
Massachusetts Populations Served in Intensive Care Coordination
All children under the age of 21, and enrolled in MassHealth Standard or CommonHealth with:
• A diagnosis of SED as defined by SAMHSA OR The Individuals with Disabilities Education Act (IDEA)
And: • Needs or receives multiple services other than ICC from the same or multiple
provider(s) Or:• Needs or receives services from, state agencies, special education, or a
combination thereof; And:• Needs a care planning team to coordinate services the youth needs from
multiple providers or state agencies, special education, or a combination thereof
64
65
Maryland’s ApproachMichelle Zabel, MSSDirector & Clinical Instructor,
The Institute for Innovation & ImplementationThe Institute for Innovation & Implementation
Director, The Technical Assistance Network for Children’s Behavioral Health (TA Network)
[email protected]://theinstitute.umaryland.edu
7/22/2014
12
The Institute for Innovation & Implementation 67
Maryland: 1115 Waiver & Behavioral Health Carve‐Out; 1915(i) SPA in submission process
Children’s Cabinet
Interagency
Children’s Cabinet
Interagency Administrative Administrative Individual
Agency Funds & F d l
Individual Agency Funds & F d l
Department of Human
Resources (child welfare)
Department of Human
Resources (child welfare)
Department of Juvenile Services
Department of Juvenile Services
Maryland State
Department of Education
Maryland State
Department of Education
Department of Health & Mental
Hygiene (including Medicaid)
Department of Health & Mental
Hygiene (including Medicaid)
1115 Waiver1115 Waiver
+ Governor’s Office for Children, Maryland
Department of Disabilities, Department of Budget &
Management
+ Governor’s Office for Children, Maryland
Department of Disabilities, Department of Budget &
Management
Children’s Cabinet
FundFund Service Organization
Service Organization
Managed Care OrganizationsManaged Care Organizations
& Federal Grant Funds& Federal
Grant Funds
Public Mental Health System (specialty)
Public Mental Health System (specialty)
Intensive Care Coordination using Wraparound Practice Model
Intensive Care Coordination using Wraparound Practice Model
***All children with Medicaid (Medicaid, CHIP, CHIP Premium, State Custody, Family of One) have an MCO and access to the full Public Mental Health System (access to those services for which they meet medical necessity criteria)
Standardized Assessment Tools: CANS is used throughout the system for care planning; CASII is used for eligibility for the 1915(i) & will be used for PRTF level of intensity determinations
Primary Mental Health Services (non‐
specialty)
Somatic Health Care,
incl. Oral Health
Pending 1915(i) SPA & TCM SPA
The Institute for Innovation & Implementation
68
Current/Proposed Funding MechanismsCME CCO (proposed)
Funder Governor’s Office for Children on behalf of the Children’s Cabinet
Medicaid through State Plan Amendments for Targeted CaseManagement (and 1915(i) re: population eligibility)
# youth Up to 370 at any time 200 first year; ultimately 500‐750
Populations Served
MD CARES & Rural CARES (SOC Grants)Stability Initiative
1915(i) State Plan AmendmentTargeted Case Management, Tier 3
The Institute for Innovation & Implementation
Served Stability InitiativeSAFETY Initiative
Targeted Case Management, Tier 3
Functions and Responsibilities
• Intensive Care Coordination using a Wraparound service delivery model • Child and Family Team Facilitation• Utilize assessment tools (e.g., Child and Adolescent Needs and Strengths)• Connections and referrals to natural and professional supports, including peer
support• Management of the Plan of Care• Utilization of management information system• Continuous Quality Improvement, including participating in fidelity monitoring,
satisfaction, and evaluation activities• Provider network recruitment and management (CME only)
69
BREAK
State Examples
•Care Coordinator Requirements, Certification,Training, Rates, Case Ratios, Supervisory Structure
•Peer Partner RequirementsPeer Partner Requirements•Certification•Training•Rates•Case Ratios•Supervisory Structure
•Interface between Care Coordinators and Peer Partners72
7/22/2014
13
CARE COORDINATORSCARE COORDINATORSPEER PARTNERSPEER PARTNERS
Wraparound Agencies in Louisiana
• Wraparound Facilitators (Care Coordinators)– Engage family and team members– Facilitate Child and Family Team (CFT)– Monitor plan implementation– Prepare for transition– Document outcome data– Collaborate with Peer Partners
• Paid PMPM ($1035)• Case ratio: 1 to 10• Supervisory structure: 1 supervisor to 8 facilitators
74Louisiana Department of Health and Hospitals – Office of Behavioral Health
Wraparound Agencies in Louisiana
• Training– Current contract with University of Maryland– Development of core competencies through prescribed training program for Facilitators andprescribed training program for Facilitators and Supervisors
– Creation of in‐state trainers/coaches for sustainability
75Louisiana Department of Health and Hospitals – Office of Behavioral Health
Peer Partners in Louisiana• Parent/Youth Support Specialists
– Engage parent and youth– Provide education/support in wraparound process– Provide education on behavioral health issues and servicesOff kill b ildi i f d id tifi d b CFT– Offer skill building in areas of need identified by CFT
– Collaborate with Wraparound Facilitators• Paid Fee‐for‐Service ($40/hour, rate change pending)• Case ratio: 1 to 20• Supervisory structure: 1 supervisor to 4 PSS/YSS
76Louisiana Department of Health and Hospitals – Office of Behavioral Health
Peer Partners in Louisiana• Training
– University of Maryland WAA training– University of Maryland Parent Partner training– Functional Behavioral Approach trainingpp g– Content specific training
• Use of self in relationship (boundaries)• Ethics• Confidentiality• Other
77Louisiana Department of Health and Hospitals – Office of Behavioral Health78
7/22/2014
14
Care Management• Care Managers are have a BA/BS or masters degree in social service.
• The CMO’s have established a certification process and different levels of certification.
• Care Managers’ are required to attend a series ofCare Managers are required to attend a series of trainings provided by CSOC.
• Family Support Partners are certified through Rutgers – UBHC. CSOC training partner.
• Care Managers are trained by Family Support Organizations
79
Care Management• Care management is provided for youth with both high and moderate needs
• NJ is moving toward a caseload size of 14 with a mixed caseload of high and moderate (currently in t iti )transition)
• Care Managers are supervised by a master’s prepared supervisor
• Supervisors have 6 Care Managers on their team
80
Behavioral Health HomeNJ is currently working on a pilot BHH. The goal of the BHH is to expand the Child Family Team. We are looking to add a nurse and wellness coach to all teams for youth identified with a chronic condition.
81 82
Contract Requirements
• Caseloads of 10• Child and Family Teams• Strengths Needs and Culture Discovery• Wraparound Care Plan• Ohio Scales• Staff attends all training and coaching required
83
Billing Wraparound
• Wraparound teams bill fee for service through the integrated MMIS system.
• Request prior authorization:– For Medicaid as payor source; andFor Medicaid as payor source; and– For ODMHSAS state funding as payor source.– CC is the highest level of targeted case management.
– Must submit letters of collaboration with all other providers billing MMIS system.
84
7/22/2014
15
85
Intensive Care Coordination:Massachusetts
• 1:10 average care coordinator to youth/family ratio• Average length of enrollment for youth who graduate from ICC is 11‐12 monthsg
• CANS is used as part of a comprehensive psychosocial assessment for ICC
• 1:8 average ICC supervisor to care coordinator ratio
86
Intensive Care Coordination:Massachusetts
• Care Coordinators: ► CANS certified► Skill‐ and competency‐based training in the delivery of ICC consistent with Systems of
Care philosophy and the wraparound planning process and have experience working with youth with SED and their families
► Weekly individual supervision with a behavioral health clinician licensed at the independent practice levelindependent practice level,
► Weekly individual, group, or dyad supervision with the senior care coordinator.► Master’s degree in a mental health field; or bachelor’s degree in a human services field
and one year of relevant experience working with families or youth. If the bachelor’s degree is not in a human services field, additional life or work experience may be considered in place of the human services degree. Individuals with an associate’s degree or high school diploma must have a minimum of five years of experience working with the target population; experience in navigating any of the child/family‐serving systems; and experience advocating for family members who are involved with behavioral health systems.
87
Intensive Care Coordination:Massachusetts
• T1017‐HN Targeted Case Management, per 15 minutes (service provided by a Bachelor‐level care manager) :► $18.88 August 1, 2013 ‐ July 31, 2014 ► $19.07 August 1, 2014, and after
• T1017‐HO Targeted Case Management, per 15 minutes (service provided by a Master‐level care manager): ► $23.74 August 1, 2013 ‐ July 31, 2014 ► $23.98 August 1, 2014, and after
88
Family Support & Training (Family Partners):Massachusetts
•A Family Partner must have ► Experience as a caregiver of youth with special needs, preferably youth with mental health needs► Experience in navigating any of the youth‐and family‐serving systems► Either a bachelor's degree in a human services field from an accredited academic institution, or an associate’s degree in a human services field from an accredited academic institution and one year of experiencefrom an accredited academic institution and one year of experience working with children, adolescents, or transition‐age youth and families, or a high school diploma or equivalent and a minimum of two years of experience working with children, adolescents, or transition‐age youth and families. If the bachelor's or associate‘s degree is not in a human services field, additional life or work experience may be considered in place of the human services degree.
•H0038 $15.60 per 15 minutes
89
Payment & Financing for All Remedy Services
• No data to build case rate
• Rate setting agency developed 15‐minute unit costs for each service
M d titi (MCE ) id th h dditi
Massachusetts Executive Office of Health and Human Services
90
• Managed care entities (MCEs) paid through addition to capitation rate, based on unit rates and assumed utilization
• MCEs not at risk for Remedy services initially –performed an annual reconciliation
7/22/2014
16
91
Training & Technical Assistance• The Institute for Innovation & Implementation at the University of Maryland
School of Social Work provides training, coaching, policy and finance support, fidelity and outcomes monitoring, and evaluation to support the CME and CCOs in Maryland.
• The Institute is a founding member of the National Wraparound Implementation Center (NWIC).
• Wraparound Practitioner Certification:– Online trainings– In‐person training– On‐Site Coaching– Team Observations– Document Review– Ongoing Certification
(For more information on the Wraparound Practitioner Certificate Program at the UM SSW, please contact Marlene Matarese at [email protected])
The Institute for Innovation & Implementation 92
Staffing Requirements• CMEs in MD must employ:
– Executive Director– Chief of Finance– Provider Network Director– Clinical DirectorClinical Director– Care Coordinator Supervisors– Care Coordinators– Community Resource Specialists– Quality Assurance and Data Director
• CCOs have few required personnel (care coordinators, care coordinator supervisors, clinical director) in the proposed SPA; more delineation will occur in the individual RFPs.
The Institute for Innovation & Implementation 93
Care Coordinator Requirements• Care Coordinators in MD must:
– Have a minimum of a bachelor’s Degree and be enrolled in or have completed the Wraparound Practitioner Certificate Program
OROR– Have a minimum of a high school diploma or equivalency,– Be at least 21 years old– Have been a participant of or are/were the direct caregiver of
an individual who received services from the public mental health system
– Have completed the Family Support Partner Certificate Program and are enrolled in or have completed the Wraparound Practitioner Certificate Program
The Institute for Innovation & Implementation 94
Case and Supervisor Ratios• Staff‐family Ratio
– CME: 1:9 to 1:11– CCO: 1:8CCO: 1:8
• Supervisor‐care coordinator ratio (supervisors do not maintain a caseload)– CME: 1:6 to 1:8– CCO: 1:7
The Institute for Innovation & Implementation 95
Care Coordinator Supervisor Requirements
• Care Coordinator Supervisors in MD must:– Have a Master’s Degree in a human services field and two years
of experience in a human services position– Have at least one year experience working in community‐based
service provisionservice provision– Have at least one year experience working with children, youth
and families– Possess an understanding of child and adolescent development– Have completed trainings on Wraparound, crisis planning,
system of care, and comprehensive screening and assessment tools
– Be enrolled in or have completed the Wraparound Practitioner certificate program or other equivalent training and certification
The Institute for Innovation & Implementation 96
7/22/2014
17
Billing Rates• CME:
– The state funded rate as of July 1, 2014 will be a full year equivalent of $14,048.62 annual per child (approximately $1170.71 per child per month).
– This rate is inclusive of CC costs and CME operating expenses for the first year of the CME contract
• CCO: – Under the pending TCM SPA, billing units will be in 15‐minute
increments. – Proposed rate in 1915(i) SPA (version released for public comment, fall
2013): $24.06/15 minutes or $294.24/week (up to $15,003/year)– Proposed reduced rate while child is in a residential placement up to a
certain length of stay (40% of regular rate)
The Institute for Innovation & Implementation 97
Provision of Family Peer Support• Family peer support is available to families enrolled in care coordination.
Family peer support specialists are employed through family support organizations.
• Family Support Specialists must meet the following requirements:– Be at least 21 years old– Receive supervision form an individual who is at least 21 years old and has at p y
least 3 years of experiencing providing peer support– Have current or prior experience as a caregiver of a child with a SED or young
adult with SMI– Be enrolled in the Wraparound Practitioner Certificate Program for Family
Support Partners• Under the 1915(i), family peer support will be reimbursed at $15.97 per 15
minute unit for face‐to‐face services or $7.98 per 15 minute unit for telephonic or non‐ face‐to‐face activities
• Youth enrolled in the CME can access peer support through discretionary funds
The Institute for Innovation & Implementation 98
State Examples
•Access to Services and Supports•Provider network•Interface with MCOs/BHOs/ASOfor Service Authorizationfor Service Authorization
•Coordination with Primary Care, Courts,Schools
99 100
101
SERVICES & SUPPORTSSERVICES & SUPPORTS
Services & Supports in Louisiana• State Plan service array
– Inclusive of evidence‐based practices– Community‐based alternatives– Out of home placement optionsS i li d S i f th i CS C• Specialized Services for youth in CSoC– Parent Support & Training– Youth Support & Training– Crisis Stabilization– Independent Living/Skills Building– Short‐term Respite
• Natural supportsLouisiana Department of Health and Hospitals – Office of Behavioral Health 102
7/22/2014
18
Authorization Process in Louisiana
• Statewide Management Organization (SMO) receives and reviews plan of care created and authorized by the Child & Family Team (CFT).
• SMO approves authorization based on indications from CANS, Independent Behavioral Health Assessment and , pCFT recommendations.
• SMO builds and monitors authorization to ensure youth receive appropriate level, frequency and duration of care.
103Louisiana Department of Health and Hospitals – Office of Behavioral Health
Coordination in Louisiana• State level
– Entire managed behavioral healthcare system is partnership of:
• Office of Behavioral Health• Medicaid• Department of Children and Family Services• Department of Education• Office of Juvenile Justice
– Established Governance Board through Executive Order
– Meetings: Judges, provider associations, etc.
104Louisiana Department of Health and Hospitals – Office of Behavioral Health
Coordination in Louisiana
• Regional level– Community Teams– Child and Family TeamsRelationships– Relationships
• Judges• Schools• Informal/Natural supports
105Louisiana Department of Health and Hospitals – Office of Behavioral Health
106
• Referral to Perform Care is not required for outpatient services, such outpatient counseling, psychiatric evaluations / medication monitoring, anger management, etc.
• NJ MentalHealthCares maintains a thorough
Outpatient Services
NJ MentalHealthCares maintains a thorough directory of services and can be accessed by visiting njmentalhealthcares.orgor calling 866‐202‐HELP
107
Intensive In-Community Services
Our in-community services are flexible therapy services that are provided at the home or other in-
community sites.
Intensive In Community ServicesIntensive In-Community Services –Psychotherapy services provided in the youth’s home.
Behavioral Assistance – Under a plan developed by an IIC therapist, the BA will work to modify specific behaviors of the youth.
IIC
BA
108
7/22/2014
19
Focuses on (re)engaging the family into community based services
(must have CMO or MRSS involvement)
Securing appointmentsPreparing for appointments
Processing through transition
What are IIC and BA Services?
Provided based on an evaluation of need
Address symptom reduction
Part of a comprehensive plan of care
Time limited
Provided in the community
Focused on skill strengthening
109
IIC is Not:
“In Home Therapy” delivered in the home only for the convenience of the family A long‐term service
BA is Not:
Mentoring
A way to get supervision for the youth / young adult to get him/her out of the
houseA long‐term service
A substitute for individual and/or family therapy
110
Out of Home Intensity of Service*
• Psych Community Homes (PCH)
• Specialty Beds (SPEC)
• Residential Treatment Centers (RTC)
• Group Homes (GH)
• Treatment Homes (TH)
111
* Intensity of Service (IOS): Levels of OOH treatment based on intensity, frequency, and duration of treatment.
CSOC SUBSTANCE ABUSE TREATMENT SERVICES
Available Services:• Assessment (SA Evaluation, Needs Bio Psychosocial‐BPS)• *Outpatient (OP)• *Intensive Outpatient (IOP)• *Partial Care (PC)• *Long‐Term Residential (LT‐RTC)Long‐Term Residential (LT‐RTC)• *Short‐Term Residential (ST‐RTC)• Detoxification
All service authorizations are based on clinical justification.
*Qualifies for enhancement services for co‐occurring youth
112
Access to Community Services
• In 2000, NJ Served Approximately 7000 Children In Community‐based Care Management, In‐Home and day treatment programs
• In 2013, NJ Served over 44,000 In Care Management, In‐Community and day treatment programs(∆+500%)
• In 2003, 40% of newly enrolled children were under 14 years old, in 2013 that percentage had grown to 65%
‐Tends to indicate system of care has become more preventative, families are seeking services sooner
113 114
7/22/2014
20
CHILDREN’S HEALTH HOME
Child & Family SOC Team
INTEGR
PCMH
Access to physicianConsultation with HHEPSDT screeningImmunization
LinkageAssessment
Specialty BH Services
Community Support
HousingTransportationFood
LinkageEngagementAdvocacySupports
Schools
WraparoundPsychiatrist
IDEATransitionsEducation
Specialty Healthcare
ATION
ImmunizationReferral to specialty care
Transition to/from hospital care
pp
Community Safetyplacement
OJATeam ApproachOne Care Plan
Team ApproachOne Care Plan
Support
OKDHSSafety
Placement(s) Permanency
PsychiatristMedication Management
TherapyFamily Support
Wellness Services & Services
115 116
Massachusetts CBHI/Remedy Services
• Intensive Care Coordination (Wraparound)
• Family Support & Training (Family Partners)
• In‐Home Therapy
• In Home Behavioral Services• In‐Home Behavioral Services
• Therapeutic Mentoring
• Mobile Crisis Intervention
• Crisis Stabilization *
117
Massachusetts Executive Office of Health and Human Services
Intensive Care Coordination(Wraparound)
•Clinical Assessment inc. CANS•SED determination for eligibility•Medical Necessity determination
•Care coordination
In-Home Therapy
•Clinical Assessment inc. CANS•Medical necessity determination
Families decide on
most appropriateinitial service
AdditionalServices
(accessedthrough
core clinicalservices)
I H
Access to Care Coordination
Massachusetts Executive Office of Health and Human Services
118
•Medical necessity determination•Care coordination available
Outpatient Therapy
•Clinical Assessment inc. CANS•Medical necessity determination
•Care coordination available
initial service
EmergencyServices
Mobile CrisisIntervention
•In-Home Behavioral
Services
•Family Partners
•TherapeuticMentoring
Massachusetts1115 Waiver, State Plan (TCM)
MCO MCO MCO MCO
Standardized tools for screening and assessment by PCPs
State Medicaid Agency (MassHealth) – Purchaser
BHO
PCCM MCO
*Locally‐Based Care Management Entities Non Profit BH and Specialty Providers(called Community Services Agencies)
Ensure Child & Family Team Plan of CareProvide Intensive Care Coordination
Provide peer supports and link to natural helpersManage utilization, quality and outcomes at service level
Standardized tools for screening and assessment by PCPsCANS
119
Managed Care Entity Authorization Parameters for Services
• INITIAL AUTHORIZATION PERIOD FOR ICC AND FS&T :
► Intensive Care Coordination (ICC) 1 unit = 15 minutes ► Family Support and Training (FS&T) 1 unit = 15 minutes ► 192 total units for ICC and FS&T combined, with no maximum units for either
• EVERY 90 DAYS FOLLOWING INITIAL AUTHORIZATION:
► Intensive Care Coordination (ICC) 208 units/90 days (13 weeks) 1 unit = 15 minutes
► Family Support and Training (FS&T) 208 units/90 days (13 weeks) 1 unit = 15 minutes*
120
Note: All authorization parameters are floors not ceilings. If a provider uses up the units authorized in a given time parameter prior to the end of the end date of the authorization, the provider can contact the MCE to request additional
units. Dayana Simons, Center for Health Care Strategies, 2014
7/22/2014
21
CBHI Coordination and Governance EOHHS
Secretary(17 Agencies)
CBHI Staff (4.5 FTE)
121
CBHI Executive Committee
Interagency Implementation
Team
Children’s BH Advisory Council
Office of Medicaid
Office of Behavioral Health (9 FTE)
MassHealthImplementation
TeamMCE Workgroup
Massachusetts Executive Office of Health and Human Services122
Maryland’s Public Behavioral Health System• Maryland has an 1115 Waiver, which creates the following
structures for Medicaid service delivery:– HealthChoice—MCOs for somatic health and dental– Behavioral Health Carve‐Out—Fee‐For‐Service
• Administrative Service Organization (ASO)—ValueOptions (new contract to be awarded in early 2015)
• Medicaid eligible youth can access the fee for service PBHS and 1915(i) eligible use will be able to access specialty services through the SPAthe SPA
• Discretionary Funds (CME Only) ‐ General funds allocated per youth per day to support components of the Plan of Care not otherwise funded. (All State‐only or grant funds)
• Residential Services– Medicaid funds inpatient or RTC stays (Medical Necessity)– Custodial agency funds group home or foster care placement, with some
Medicaid reimbursement through the Rehab Option• Behavioral Health Homes—Designed around the population of
adults with SPMI, although youth with SED can be served
The Institute for Innovation & Implementation 123
Role of the ASO• Manage the Behavioral Health Carve‐Out, which will include CCOs
and providers of 1915(i) services• Deliverables related to the 1915(i) (per RFP) include:
– Designate a staff member to be the liaison with responsibility for oversight and problem resolution and to interface with CCOs
– Register providers of specialized servicesg p p– Review and authorize requests for specialized services– Jointly determine with local mental health authorities medical
eligibility for admission using needs‐based eligibility criteria– Assure that POCs for each participant reflect all behavioral health
services authorized and develop a mechanism to assure that participants are actively engaged in behavioral health treatment
– Conduct on‐site audits of providers
The Institute for Innovation & Implementation 124
Simplified Version of Maryland’s Public Behavioral Health System Service Array for Youth
Family Peer
Intensive Care Coordination & 1915(i)
Inpatient Psychiatric
Hospitalization
Health Home PRP
General Care
Coordination
Mobile Treatment
Partial Hospitalization
Program
Moderate Care
Coordination
Mobile Crisis &
Residential Treatment
Outpatient Therapy
Respite Care
Support Services Stabilization
Treatment Center
Therapy Care
Least intensive Most intensive
The Institute for Innovation & Implementation
Maryland has a traditional but robust PBHS for children and youth with Medicaid and MCHP
Other services and supports outside the Public Behavioral Health System include Multi‐Systemic Therapy, Functional Family Therapy, Parent‐Child Interaction Therapy, Treatment Foster Care, Peer Support, and Community‐Based and Natural Supports. Eligibility will depend on the funder and associated parameters for each individual service.
125
Proposed Services under the 1915(i)Maryland has a robust public mental health system; these services will fill gaps in the current home‐ and community‐based provider array:• Care Coordination (provided by CCO who is a TCM Provider)• Community‐Based Respite Care• Out‐of‐Home Respite• Family Peer SupportFamily Peer Support• Mobile Crisis Response and Stabilization• Intensive In‐Home Services (differentiated from Therapeutic Behavioral
Services and from Psychiatric Rehabilitation Programs)• Expressive & Experiential Behavioral Services (art, dance, drama, music,
equine, horticultural)• Mental Health Consultation to Health Care Professionals (only paid to the
consulting professional)• Customized Goods and Services
The Institute for Innovation & Implementation 126
7/22/2014
22
Eligibility and Authorization Process for Care Coordination Services
• For populations served by the CME, eligibility screenings are performed by referral sources (DJS, DHR, CSA, LCT, LMB, public local school systems)– After the referral source gatekeeper has determined that a youth is
eligible and has referred the youth to the CME, the CME's Clinical Di t i th f l d th i ll tDirector reviews the referral and authorizes enrollment.
• For the 1915(i) SPA, eligibility screenings are performed by the CCO based on Certificate of Need (CON) documents (psychiatric/psychosocial assessments). The clinical information will be compared to the MD Medicaid medical necessity criteria (MNC) for this level of care. – the ASO, in a team decision process with the CSA, will review the CON
documents and complete a CASII assessment. When the CON is determined to meet the MNC, the ASO authorizes all of the medically appropriate behavioral health services.
The Institute for Innovation & Implementation 127
Interagency Coordination• At the state level, the Children’s Cabinet (which funds the CME) is chaired
by the Executive Director of GOC and comprised of the Secretaries of the Departments of Budget and Management, Disabilities, Health and Mental Hygiene, Human Resource (child welfare), Juvenile Services, and the Superintendent of the Maryland State Department of Education
• At the practice level, the CME’s program plan must:D ib h it ill d l i iti l ti hi th l d– Describe how it will develop or improve upon positive relationships the lead agencies (e.g., DSS, DJS)
– Describe how it will enhance their current relationships with the direct services provider community to facilitate appropriate linkages and services to families
• CCOs and CMEs are required to commit to coordination with all agencies involved in the participant’s POC and work with the State and local child‐and family serving agencies to develop a network of clinical and natural supports in the community to address strengths and needs identified in each POC
The Institute for Innovation & Implementation 128
State Examples
•Evaluation, Quality Monitoring anda uat o , Qua ty o to g a dOutcomes
129 130
131
EVALUATIONEVALUATIONQUALITY MONITORINGQUALITY MONITORING
OUTCOMESOUTCOMES
Quality Monitoring/Evaluationin Louisiana
• National Wraparound Initiative Tools • Wraparound Fidelity Index (WFI EZ):
• Office of Behavioral Health is currently conducting the WFI EZ with all five Wraparound Agencies
• Document Review Measure (DRM): • SMO will use the DRM to compliment the WFI EZ with all five Wraparound Agencies
• Planned evaluation activities with University of Washington Wraparound Evaluation & Research Team
132Louisiana Department of Health and Hospitals – Office of Behavioral Health
7/22/2014
23
Tracking Outcomes in Louisiana
• Child and Adolescent Needs and Strengths Assessment (CANS) scores
• Out of Home placements• Psychiatric Emergency Department utilizationPsychiatric Emergency Department utilization• Inpatient Psychiatric utilization• Home and Community Based Service utilization• School suspensions and expulsions• Costs
133Louisiana Department of Health and Hospitals – Office of Behavioral Health
CANS Scores
52
94
4850
60
70
80
90
100
2c ‐ CSoC
2d ‐ TGH
3 Nursing Facility
134
25
18
1113
39
11
00 0 0 0
24
13
86
48
18
20
10
20
30
40
Initial 180 Days 360 Days 540 Days
3 ‐ Nursing Facility
4 ‐ PRTF
5 ‐ Inpatient Psyc
Out of Home Placements(3/1/12 to 3/31/14)
Percent of CSoC children and youth who had restrictive placements prior to enrollment in WAA: 31.4%
Percent of CSoC children and youth place in restrictive placement after enrolling in WAA = 18.3%
135135
CSoC Children Inpatient Psychiatric Utilization
0100200300400500
Admits / 1000
0100020003000400050006000
Days / 1000
136
Total Admissions for all CSoC Inpatient Stays in Month /Number of CSoC Participants in Month * 1000
(Total Days for all CSoC Inpatient Stays Discharged in Month) / (Number of CSoC Participants in Month) * 1000
05
1015
Average Length of Stay
Total Days for all CSoC Inpatient Stays in Month /Total Admissions for all CSoC Inpatient Stays in Month
Home and Community‐Based Service Utilization
4000
5000
6000
7000
2012‐03
2012‐04
2012‐05
2012‐06
2012‐07
2012‐08
2012‐09
2012‐10
2012‐11
2012‐12
2013‐01
2013‐02
2013‐03
2013‐04
2013‐05
2013‐06
2013‐07
2013‐08
2013‐09
2013‐10
2013‐11
2013‐12
2014‐01
2014‐02
2014‐03
Services Utilized 401 952 16861978194622462218270323552245253120262215265328472491304639224103509851295759611457885882
0
1000
2000
3000
137
School Performance/Conduct(Suspensions and Expulsions)
20%
25%
30%
School Performance Measures
0%
5%
10%
15%
Period 1 Period 2 Period 3 Period 4
% Members with Missed Days
% Members with Suspensions
% Members with Expulsions
*based on quarterly data reported by CSoC Wraparound agencies
138
7/22/2014
24
CSoC Expenditures
$10,933,421
$8,000,000
$10,000,000
$12,000,000 Waiver Services and WAA Payments
$378,451
$5,940,505
$1,143,567
$0
$2,000,000
$4,000,000
$6,000,000
Waiver Services WAA Payments
Contract Yr 1Contract Yr 2
Louisiana Department of Health and Hospitals – Office of Behavioral Health 139
CSoC Expenditures
$5,522,977
$4 000 000
$5,000,000
$6,000,000
State Plan Services for CSoC Enrollees
$930,454
$1,784,486$2,173,438
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
Inpatient Outpatient
Contract Yr 1Contract Yr 2
Louisiana Department of Health and Hospitals – Office of Behavioral Health 140
141
What Have We Learned?
• The system of care model works– Less children in institutional care– Less children accessing inpatient treatment– Closure of state child psychiatric hospital and RTCs– Very few children in out‐of‐state facilitiesy– Children in out of home care have more intense needs than prior to
the system of care development– Wraparound works – Less youth in detention centers – many reasons, not necessarily
because of the system of care • Federal funding support under Title XIX
142
Evaluation Quality Monitoring• All providers certified on CANS Tool• Certification for BA and FSO• Credentialing for IIC/IIHUtili ti M t b CSA• Utilization Management by CSA
• Contracting monitoring by CSOC• Child Family Teams • WFI is used by CMO’s• Management by data
143
NJ Department of Children and FamiliesFiscal Year 2014 $1.65 BillionOverall Department Budget
144
Funds by State/Federal/Dedicated Funds by Division
7/22/2014
25
NJ Department of Children and FamiliesFiscal Year 2014 $498 Million
Children’s System of Care
145
Funds by State/Federal Funds by Service
A Continuum of Care: Mobile ResponseWorking hard to keep children & youth successfully at home & avoid hospitalization or
placement.
Did not stay in current living situation
4%
NJ DCF CHILDREN'S SYSTEM OF CARE (CSOC)Mobile Response Children Stabilized in Current Living Situation
4/1/2014 ‐ 4/30/2014( n = 1,532 )
Stayed in Current Living Situation96%
146
A Continuum of Care: Mobile Response
1,4981,585
1,278
1,443
1,760
1,610
1400
1600
1800
2000
MRSS Service Dispatch Data2011 ‐ April 2014
147
1,055
693 657
1,095 1,1211,296
0
200
400
600
800
1000
1200
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
2011 2012 2013 2014
Out of Home TreatmentAuthorizations (which provide access to out of home care) is reduced due to more access and availability of
community resources
148
In April 200753% (157) of youth in Out of State programs were involved with child welfare system further complicating opportunities for family engagement
Today
327
299
229
200
250
300
350
NJ DCF CHILDREN'S SYSTEM OF CARE (CSOC)Authorized Out-of-State Placements
Number of youth in Out-of-State placements at the first of the month
There are 3 youth in Out of State behavioral health treatment programs, 1 youth is involved with child welfare
149
98
3620
6 4 30
50
100
150
Mar.2006
Apr.2007
Jan.2008
Jan.2009
Jan.2010
Jan.2011
Jan.2012
Jan.2013
Jan.2014
A Continuum of Care: Care Management Organization (CMO)Serving over 10,000 children, with a focus on the high need youth and their families
150
7/22/2014
26
A Continuum of Care: Out of Home TreatmentCurrently, most youth receiving out of home treatment are adolescents
151
Gender # PctFemale 616 36%Male 1077 64%Total 1693 100%
152
E Team ‐ OU
• Measurement (E‐TEAM) Department of the University of Oklahoma. The E‐TEAM is a full service social research department with senior researchers, data analysts, technical writers, data base developers and managers, and a pool of p g , presearch assistants representing decades of experience in all phases of research data processing and analysis. Belinda Biscoe Boni, Ph.D., Associate Vice President, Public and Community Services, at the University of Oklahoma, College of Continuing Education, is the Director of E‐TEAM.
153
Youth Information System (YIS)
YIS provides a wide range of reports for use by managers, site personnel and community stakeholders also provides a wide range of reports for use by managers, site personnel and community stakeholders . YIS tracks the following:g
• Process monitoring: Referrals, enrollments, discharges• Flex fund expenditures• Wraparound implementation• Outcomes measures: periodic (6‐month) assessments.
154
OutcomesAfter Six months, SFY2013 (n=836)
• Reduced Days of Out‐of‐Home Placement 49%• Reduced School Detentions 51%• Reduced Number of Youths Self Harming 42%• Reduced Number of Youths Self‐Harming 42%• Reduced Arrests 66%• Reduced Contacts with Law Enforcement 51%• Reduced Days Absent from School 46%• Reduced Days Suspended from School
155 156
7/22/2014
27
Massachusetts Quality/Fidelity Monitoring
• Wraparound Fidelity Assessment System ‐MA WFAS (NWI)
• Wraparound Fidelity Index (WFI 4) – initially
• Wraparound Fidelity Index Parent/Caregiver
• Treatment Observation Measure (TOM)
• Document Review Measure (DRM) ‐ initially
• MCE Medical Record Review (standardized tool)• System of Care Practice Review ‐ SOCPR (USF)
157Louisiana Department of Health and Hospitals – Office of Behavioral
Dayana Simons, Center for Health Care Strategies, 2014
Massachusetts Outcomes Tracked
Multiple process variables including:• Utilization of:
• Mobile Crisis Intervention• Inpatient PsychiatricInpatient Psychiatric• Home and Community Based Services
• Out of Home placements• Costs
158
Dayana Simons, Center for Health Care Strategies, 2014
Massachusetts Outcomes: Reduced Use of Inpatient Care
Penetration Rate and Bed Days per 1000 Members Under 19 of Psychiatric Inpatient Services(Based on MBHP Claims thru 1/13/12)
0.25%
0.30%
0.35%
0.40%
ion
200
240
280
320
Massachusetts Executive Office of Health and Human Services159
0.00%
0.05%
0.10%
0.15%
0.20%
Quarter
Penetrati
0
40
80
120
160
Penetration 0.30% 0.32% 0.32% 0.27% 0.21% 0.25% 0.27% 0.27% 0.21% 0.27% 0.25% 0.28% 0.21%
Units/1000 216 215 209 243 153 168 178 186 144 175 176 200 147
2009 Q 1 2009 Q 2 2009 Q 3 2009 Q 4 2010 Q 1 2010 Q 2 2010 Q 3 2010 Q 4 2011 Q 1 2011 Q 2 2011 Q 3 2011 Q 4 2012 Q 1
160
Outcomes & Evaluation• Fidelity and quality of the CME is monitored by The Institute at UM
SSW under contract with GOC• The Institute utilizes the WFI‐EZ, COMET, TOMS, IOTTA, California
Health Kids Survey ‐ Resilience & Youth Development Module, and Family Empowerment Scale data from the families being served to y p gmonitor and measure ICC/Wraparound quality and fidelity.
• Use of TMS WrapLogic will support the fidelity monitoring and the additional data collection
• Resiliency measures are incorporated into the WFI process as part of CHIRPA
• Outcomes related to clinical and functional status and cost are being assessed, both independently and through the use of an administrative comparison group
The Institute for Innovation & Implementation 161
Reasons for Discharge from the CME: July to December, 2013
Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD.
The Institute for Innovation & Implementation 162
7/22/2014
28
Semi‐Annual Trend in Successful Completions: July, 2012 to December,
2013
The Institute for Innovation & Implementation
Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD.
163
Wraparound Fidelity Index – Short Term (WFI‐EZ)
The Institute for Innovation & Implementation
Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD.
164
Additional CME Outcomes• 75% of youth discharged to a stable, non‐restrictive living situation
(parent or relative’s home, regular foster home, adoptive home, or living independently) during the first and second quarters of FY14. This is an increase from the previous reporting period (68%) and the first and second quarters of FY13 (63%).
• The number of CANS Needs items on which youth demonstrated d f i i ( f 2 3) di h h i dneed for intervention (score of 2 or 3) at discharge has remained
consistently low, with an average of 5.5 (sd=5.70) out of 41 items during the first and second quarters of FY14
• These continued improvements in youth outcomes may reflect Maryland Choices, LLC adapting to the demands of serving as Maryland’s single Statewide CME provider and working on ways to improve its implementation of the Wraparound model over the past 18 months.
The Institute for Innovation & Implementation
Source: The Institute for Innovation and Implementation (2014). Care Management Entities: Maryland Implementation Report: FY14 QTR 1 & 2. Baltimore, MD.
165
Costs of Care: Results from MD’s PRTF Demonstration
• Youth enrolled in the PRTF Demonstration Grant and served by the CME had an average per member, per year cost of care of $32,987 (Medicaid costs only; n=174)
• Youth enrolled in a PRTF during the same time (not served by the CME) had an average per member, per year cost of care of
166
) g p , p y$153,417 (Medicaid costs only; n=1,119)
• These costs include the capitated MCO rate, medications, inpatient hospitalizations, oral health care, home health services and all services covered by Medicaid.
Time Period: September 30, 2009‐June 30, 2011 (claims paid through 10/31/11)
Source: Medicaid claims data provided by The Hilltop Institute to the University of Maryland under the CHIPRA Quality Demonstration Grant (November 2011)
The Institute for Innovation & Implementation
Federal Medicaid Guidance
7/11/13 State Medicaid Director’s Tri‐Agency Letter onTrauma‐Informed Treatment http://www.medicaid.gov/Federal‐Policy‐Guidance/Downloads/SMD‐13‐07‐11.pdf
5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children,Youth and Young Adults with Significant Mental Health Conditionshttp://www.medicaid.gov/federal‐policy‐guidance/downloads/CIB‐05‐07‐2013.pdf
3/27/13 Informational Bulletin on Prevention and Early Identification of MentalHealth and Substance use Conditionshttp://www.medicaid.gov/federal‐policy‐guidance/downloads/CIB‐03‐27‐2013.pdf
8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populationshttp://www.medicaid.gov/Federal‐Policy‐Guidance/Downloads/CIB‐08‐24‐12.pdf
11/21/11 State Medicaid Directors Tri‐Agency Letter on Appropriate Use ofPsychotropic Medications Among Children in Foster Carehttp://www.medicaid.gov/federal‐policy‐guidance/downloads/SMD‐11‐23‐11.pdf
167
Resources
Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditureshttp://www.chcs.org/publications3960/publications_show.htm?doc_id=1261588#.U1gmMvldUud
Making Medicaid Work for Children in Child Welfare: Examples from the Fieldhttp://www.chcs.org/usr_doc/Making_Medicaid_Work.pdf
Customizing Health Homes for Children with Serious Behavioral Health Challengeshttp://www.chcs.org/usr_doc/Customizing_Health_Homes_for_Children_with_Serious_BH_Challenges_‐p // g/ _ / g_ _ _f _ _ _ _ _ g __SPires.pdf
Psychotropic Medications Quality Improvement Collaborative:Improving the Use of Psychotropic Medications Among Children in Foster Carehttp://www.chcs.org/info‐url_nocat3961/info‐url_nocat_show.htm?doc_id=1261326
CHIPRA Care Management Entity Quality Collaborativehttp://www.chcs.org/info‐url_nocat3961/info‐url_nocat_show.htm?doc_id=1250388
Return on Investment in Systems of Care for Children with Behavioral Health Challengeshttp://gucchdtacenter.georgetown.edu/publications/Return_onInvestment_inSOCsReport6‐15‐14.pdf
168
7/22/2014
29
Massachusetts Resources
• CBHI website: www.mass.gov/masshealth/childbehavioralhealth
• Rosie D. v. Patrick (United States District Court, District of Massachusetts), Civil Action Number 01‐30199‐MAP
• National Wraparound Initiative website:• National Wraparound Initiative website: www.rtc.pdx.edu/nwi
• Building Systems of Care: A Primer, Sheila A. Pires, MPA, Human Service Collaborative Download at: http://gucchd.georgetown.edu/72377.html
169
For further information, contact:
Sheila A. [email protected]
Contact Information
Jody Levison‐JohnsonDeputy Assistant SecretaryOffice of Behavioral [email protected]
Louisiana Department of Health and Hospitals – Office of Behavioral Health 171
For more information…1
Elizabeth Manley, Division Director CSOC [email protected]
Children’s System of Care
172172
http://www.state.nj.us/dcf/families/csc/
PerformCare Member Services: www.performcarenj.org
Presented byJackie Shipppp
Director of Community Based ServicesODMHSAS
405‐522‐[email protected]
173
Contact Information
Dayana SimonsSenior Program OfficerCenter for Health Care Strategies IncCenter for Health Care Strategies, [email protected]
174
7/22/2014
30
Contact Information
Michelle Zabel, MSSDirector & Clinical Instructor,
The Institute for Innovation & Implementation
175
Director, The Technical Assistance Network for Children’s Behavioral Health (TA
Network)[email protected]
http://theinstitute.umaryland.edu
The Institute for Innovation & Implementation