Minnesota

State Levers to Advance Accountable Communities for Health

May 24, 2016/in Policy California, Minnesota, Vermont, Washington Reports Accountable Health, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Essential Health Benefits, Health Coverage and Access, Health Equity, Health System Costs, Housing and Health, Medicaid Expansion, Medicaid Managed Care, Population Health, Quality and Measurement, Social Determinants of Health /by Lesa Rair, Taylor Kniffin and Felicia Heider

States are testing a myriad of models that strive to achieve the Triple Aim objectives of improved care, reduced health care costs, and better health. Though several statewide health care delivery and payment system reforms have been shown to help slow the growth of health care expenditures and improve methods for delivering health care, taken alone they are not enough to fully attain the Triple Aim goals. In an effort to improve the overall health of populations while further reducing healthcare costs, many state and federal health policymakers are partnering with communities to implement population health initiatives that engage new community partners to address the social factors influencing health such as housing, food, work, and community life. Among the models for implementing community-based interventions, Accountable Communities for Health (ACHs) are surfacing as a promising state strategy to integrate and align state health care delivery system transformation with community-based social services to create communities that promote health and well-being.
This brief and the accompanying state profiles identify state levers that advance ACHs by examining the ACH programs in California, Minnesota, Vermont, and Washington State. Specifically, this brief weighs the roles states and communities have played in establishing core ACH components including governance structures, geographic boundaries, financing mechanisms, priority conditions and target populations. It also considers state-level resources that can be leveraged to support and sustain ACH models going forward.
Full Brief
California State Profile
Minnesota State Profile
Vermont State Profile
Washington State Profile

Talking Coverage: SBMs Keep Lines of Communication Open with Consumers

November 24, 2015/in Policy California, Colorado, Connecticut, District Of Columbia, Massachusetts, Minnesota, Rhode Island, Vermont Blogs Health Coverage and Access, State Insurance Marketplaces /by NASHP

Heading into the third week of open enrollment, early outlook has been positive for state-based marketplace (SBM) states. California recently wrapped up a 2,000-mile bus tour to “spotlight” the launch of open enrollment; Massachusetts and Vermont, which in prior years struggled with technical systems, report smooth enrollment via their enhanced systems; Minnesota is touting a new report that showcases the potential for savings for its marketplace consumers; and Maryland has more than doubled its enrollment traffic from this point last year. Where issues are arising, states are flexing their nimbleness to address concerns, such as Rhode Island’s recent steps to ramp up customer service supports and New York’s extension of enrollment deadlines for consumers impacted by the closure of the state’s Co-op.
Many of the improvements states have implemented in recent months, including updated marketing, enhanced purchasing tools, and increased access to assistance, have been in response to time spent over the past year speaking to and learning from consumers. SBMs have been reaching out to the uninsured in their states through the use of surveys, phone calls, and focus groups to learn more about barriers to enrollment. Open dialog between customers and the marketplaces, targeted data collection, and the agility of states to adjust and adapt based on this feedback, represents a unique and important opportunity for those states that have chosen to run their own SBMs.
Assessing Customer Satisfaction
In fielding consumer surveys, many SBMs found customers have high levels of satisfaction with both the enrollment systems available in their states and the coverage purchased. Surveys conducted in California, Colorado, Connecticut, and New York found that between 85 and 92 percent of their consumers reported they would recommend use of the SBM to friends and family. In Vermont, 82 percent of customers reported that their 2014 selected plan either met their needs “somewhat well” or “very well”.
Altering Outreach to Reach the Uninsured
Even with high levels of engagement and satisfaction from existing customers, there are still a significant number of uninsured in many states and an increased need to provide support to identify and enroll these individuals. In mid-2015, Maryland’s SBM conducted a series of focus groups with the uninsured to identify perceived barriers to obtaining coverage. Participants in these groups reported that the complexity of health insurance choices can be “immobilizing” and increased support is necessary to help make decisions. In response, Maryland is expanding its in-person assistance offerings – with larger numbers of “ConnectNow!” enrollment events and the addition of 23 partnership organizations with application counselors (adding to the 35 existing partnerships in the state).
Messaging to Improve Consumer Awareness
Reports from California, Maryland, and Vermont have found that a significant number of consumers remain unaware of the availability of federal subsidies to improve affordability of coverage purchased through the marketplaces. This knowledge gap is coupled with the results of multiple surveys that found affordability to be the biggest driver of consumer enrollment and plan selection.
Based on these survey findings, messaging becomes an important strategy for the marketplaces to not only ensure that consumers are aware of the opportunity to purchase coverage but that they also know about the tax credits to support affordability. Wanting to improve their efficiency, states have been thoughtful in strategizing where to best allocate resources to maximize reach to desired consumers. A Connecticut survey found that an increased number of consumers engaged with the SBM after receiving brochures and pamphlets in the mail. In response, the state is planning on modifying marketing materials this open enrollment to ensure they are engaging and informative.
Supporting Consumer Education and Insurance Literacy
Surveys from several SBM states found that consumers are seeking more support in selecting the right plan for their families and, despite considerable gains over the past three years, require refreshers on important health insurance literacy topics. For example, an independent survey conducted in Colorado recommended that the state develop materials to support increased consumer health insurance literacy, including a simple and accessible glossary of important health insurance terms. The state responded by creating a comprehensive list of terms and definitions, which includes a search function and is available directly on the Connect for Health Colorado website.
Boosting Call Center Performance
Call centers continue to be an important tool for consumer engagement and satisfaction, often representing the SBM’s most public face. In many states, call center utilization grew during last year’s open enrollment period. Despite these increased numbers, most consumers still reported receiving useful information and support from call center representatives. In Vermont, 66 percent of respondents indicated that they were satisfied with the amount of information received. In Connecticut, 65 percent of those who enrolled in a self-purchased, qualified health plan indicated that they were either “very satisfied” or “extremely satisfied” with the call center service.
Some customers, however, have reported long wait times and unanswered questions. In response, states are implementing new strategies to relieve call center back log. In response to feedback from customers, Vermont has placed an increased focus on call center training in 2015. This has already significantly reduced the number of cases that need to be escalated, resulting in customers having answers during their first call to the contact center.
Looking Forward
Following this open enrollment period, several SBMs have plans to roll out additional consumer surveying, which will allow them to engage with their customers and implement changes to improve the enrollment experience. The District of Columbia is planning to issue a comprehensive survey, including questions that focus on moving consumers from coverage to care, to be completed by July 2016. In releasing its updated proposed strategic plan, Washington State identified consumer surveying as a key tool in 2016 for measuring transparency, engagement and affordability.
NASHP will be tracking the work being done by the SBMs and the federally-facilitated marketplace, as well as the experience of enrollees around the country, and will report on the best practices and lessons learned as we move through this latest enrollment period.

State Marketplaces’ Proof Is in their Performance at Congressional Oversight Hearing

October 6, 2015/in Policy California, Connecticut, Hawaii, Massachusetts, Minnesota, Oregon Blogs Eligibility and Enrollment, Health Coverage and Access, Medicaid Expansion, State Insurance Marketplaces /by NASHP and Alice Weiss

Last week, six state-based marketplace directors (CA, CT, HI, MA, MN, and OR) testified before the U.S. House of Representatives Energy and Commerce Committee’s Oversight and Investigations Subcommittee, where they faced tough questions on their marketplace performance, impact and future prospects. The hearing was notable for its intensive focus on operations, signaling a new emphasis on marketplace performance and outcomes. For those who missed it, here’s our recap on the highlights.
Marketplace Enrollment and Coverage: Marketplace and Congressional leaders shared evidence of a number of positive impacts that state-based marketplaces have had on the health care system including lower rates of uninsured, increased plan choice and competition, and steady or reduced growth of health insurance plan pricing. Five states, including Massachusetts, have lowered their uninsurance rates to below five percent. Connecticut testified that marketplace enrollment has exceeded federal goals by 200 percent while competition and oversight have kept marketplace premium rates flat. California noted that its active purchaser strategy, which requires issuers to offer the same benefits package so consumers can easily compare plans, has resulted in improved access to preventive care for most enrollees. California also testified that each resident will have at least three plans to choose from during the 2016 open enrollment period.
Improving Governance and Project Management: Subcommittee members and marketplace leaders freely admitted that marketplaces had seen their share of implementation challenges, including tight timeframes and mistakes in managing state and vendor work. States testified about changes they are implementing to improve operations, including reorganized governance structures, stricter project management, and new, more robust workplans. Massachusetts has replaced managers and hired for skills in IT systems oversight, and reestablished a formal governance structure with clearer reporting authority to the Secretary for Health and Human Services to strengthen the integration of marketplace and Medicaid systems. Oregon has moved its marketplace from an independent entity to a state agency charged with insurance market oversight, which allows for improved coordination, accountability, and economies of scale in staffing. Minnesota and are establishing new oversight and advisory authorities. Also suggested was stricter adherence by states and CMS to performance measurement gateways already developed for the marketplaces such as adherence to marketplace Blueprints.
Financing and Sustainability: Subcommittee members peppered state marketplace leads with detailed questions about budgets and sustainability. All states, reported they are on track to achieve financial sustainability, except Hawaii, which will transition its marketplace to the supported state-based marketplace model. Members raised concerns and signaled further investigation into state marketplaces’ operational and establishment spending, especially the use of federal establishment grants. While these grants were intended to only fund activities related to establishment, not operations, of the marketplaces, a lack of clarity on the definition of these types of activities has led to some confusion over appropriate use of funds. All states testified that they had not spent federal grants outside of the authority given to them under CMS, with the exception of Hawaii, which noted one item that it is in the process of reconciling with auditors before funding would be released. Where they had figures available, states shared details about operational and establishment budgets, with others expressing ability to review and report back further details to the Subcommittee. States also clarified that any funds granted to a state, but not ultimately approved for use by CMS would remain with the federal government.
Addressing Consumer Needs and Services: Each state has taken concrete steps to improve system functionality and implement new tools to better serve consumers. Many states reported positive utilization and consumer satisfaction survey findings during last year’s open enrollment period. Minnesota reported that more than 500,000 individuals had used their site, MNSure, to compare, shop and purchase coverage. Connecticut reported that 96 percent of consumers found the AccessHealth CT site easy to use. For the next open enrollment period, Minnesota is adding functionality to its enrollment system, improving website performance and Medicaid system functionality. Massachusetts is planning to improve customer service by adding four additional walk-in centers and evening and weekend hours to reduce call center demand.
Focus on Performance: Subcommittee members repeatedly asked for evidence of state performance, seeking a detailed accounting on state spending, state governance and oversight, federal audits, and renewal data. While state exchanges are already complying with substantial federal and state oversight and reporting requirements, as detailed in a NASHP brief released this week, the hearing indicates an increased focus on state outcomes and performance that state exchanges will want to heed for future years. Also underscored was that the marketplaces, by their nature as IT projects, are not static, and will continue to evolve and improve over time, something that should be accounted for as part of future oversight.
Looking ahead, most state marketplace leads said covering the remaining uninsured and for the marketplace were among their top priorities. . States and members also discussed the role of the marketplaces in the context of health care reform including improving access to higher value care. Importantly, states highlighted the value of flexibility as state-based marketplaces to tailor marketplace policies and structures to adapt to unique state needs and priorities (e.g., providing subsidies to a greater range of low-income individuals in Massachusetts or pursuing an active purchaser model to set benefit standards in California). How these and other state marketplaces demonstrate their value in innovating and improving coverage, in their own states and for the nation, will certainly be a topic for continued conversations in the years ahead.

A Day in the Life of Nurse Planner Joan Kindt in the Minnesota Health Care Home Program

January 7, 2015/in Policy Minnesota Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Coverage and Access, Long-Term Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Workforce Capacity /by NASHP Staff

Health care reform goals established by the Minnesota Legislature call for all Minnesotans to have access to patient-centered care, accessible, comprehensive, and coordinated primary care. The HCH program is the path to these goals.
Becoming a health care home (HCH) in Minnesota means adopting “an approach to primary care in which primary care providers, families, and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.”9
Certifying that clinics are meeting standards that align with this definition is a priority for the state of Minnesota and it is the job of nurse planner, Joan Kindt, RN. Of the 171 clinics in Joan Kindt’s 38-county region, 139 have yet to become a HCH.

Preparing Practices for Certification

At her home in Rock County, Joan Kindt is preparing for a HCH certification visit. During today’s visit, she will lead a team to certify whether or not a health system that provides primary care services onsite at assisted living and long-term care facilities meets HCH standards. She is concerned about the readiness of the health system, and therefore has asked Marie Maes-Voreis, Director of the Health Care Homes for the Minnesota Department of Health to accompany the team.
The role of the nurse planner starts with reaching out to clinics in his or her region of the state. Making the case to prospective HCH clinics is something that Joan does both on- and off-site. From home, she checks her list of clinics, provided by the Minnesota Department of Health, that have not gone through the HCH certification process and those that have expressed interest to become certified through a letter of intent.
For the former group of clinics, she often “cold calls” them aiming to arrange a time to go on-site to meet with the clinic staff, including the lead primary care provider, to answer questions and discuss the benefits of becoming a HCH. Joan and the other nurse planners provide free on- and off-site coaching about how to become more patientcentered and how becoming more efficient will save the clinic money and improve quality. In addition, certified HCHs are eligible to receive monthly payments from both commercial and public payers for their patients receiving care coordination. Joan often organizes webinars and invites local certified HCH clinics to speak so that prospective clinics have an opportunity to learn first hand from their peers.
When a clinic decides that it wants to pursue HCH certification, Joan walks its staff through the certification process. The clinic sends a letter of intent to apply for certification, which prompts the Minnesota Department of Health to send an application and a self-assessment tool. The clinic uses the self-assessment tool to determine its readiness to apply. Joan then functions as a “coach” and guides each clinic through the certification process. Coaching requires both remote and face-toface time to talk about the certification process, what the clinic needs to do to meet the standards, and what kind of documentation is necessary to demonstrate that it is meeting the standards.
Before the certification site visit today, Joan spent a fair amount of time providing technical assistance to the health system, especially on the care planning process— one of the core tenets of a HCH—because its model of integrating primary care services into assisted living facilities is quite different than the typical primary care clinic. Joan has found that many clinics have faced challenges in becoming more patient-centered, especially in developing processes that increase consumer and family engagement in the care planning process.
All HCH clinics need to design quality improvement projects in order to gain certification. The health system undergoing certification today chose to focus on advanced care planning and care coordination. Joan encouraged the health system to apply for a grant to help with those projects. Like other clinics, the health system also needed to develop a registry to help report data to the state and use the registry to better track care. Joan ensured that the facility attended a two-day learning collaborative that she also helps to organize and teach.

Leading the On-Site Certification

Joan briefed the certification team three weeks ago, sharing the data, and her concern about the health system’s readiness. The certification team consists of Joan, a consumer representative, and a clinician “peer” consultant—typically a nurse or a physician—and for today’s visit, Marie Maes-Voreis. Joan has developed the agenda, dividing the interviews among the certification team. These interviews typically include providers, nursing staff, care coordinators, and front-office staff. The interviews always include patients and often, family members. Today, family members both in-person and via conference line accompany the patients.
Joan arrives at the clinic and huddles with her site visit team before they fan out to begin the interviews. Joan first meets with the quality improvement coordinator. She sits down with the coordinator in front of the computer to review the health system’s use of a registry for reporting quality and utilization measures. Site visits ensure that what the facility reports on paper is actually occurring at the clinic. She asks the coordinator, “tell me how you are tracking preventive care, and assigning risk scores to identify patients for care planning,” and the coordinator walks her through how the registry is used.
Next Joan meets with the reception staff and asks about their HCH vision and goals. The receptionist responds by describing facility policy for answering calls— an important aspect for meeting HCH access standards.
She also talks with the medical director of the facility and discusses how care delivery has changed since starting the HCH process. He describes transformational changes about embedding a nurse practitioner on-site and how the facility is better meeting the patients’ primary care needs. He explains that the facility is just beginning to put in place population-based panel management and Joan offers advice about how to help the facility advance to the next stage.
Meanwhile another member of the certification team meets with a nurse practitioner at the health system to discuss after-hours access to primary care. She requests that the nurse practitioner describe the processes in place to ensure that care coordination and referrals are being effectively made.
Joan also meets with the nurse supervisor at the facility who talks about newly formed care processes that include daily huddles with the primary care team. The nurse supervisor remarked, “we worked really hard with our care teams… we’ve had live lunch meetings to prepare. Every week was focused on one of the standards, such as access.”

Measuring Performance

At the end of the afternoon, the certification team reserves an hour to huddle to discuss what it observed. The consumer representative discusses how she interviewed two patients and their family members. Both families knew the names of their primary care provider, described strong communication between the primary care provider and the family, and were generally satisfied with their care. At the end of the day the certification team met with the health system seeking certification and reviewed examples of their positive work and areas for improvement.
Following the huddle, the certification team meets with the health system staff. Together, they review the positives from the site visit—strong team culture, commitment to patient-centered care, use of shared decision-making tools, and other innovative work. They discuss areas to improve, including the care planning process, after-hours care, communication, and focus on goals. The health system staff expresses appreciation for the feedback and its commitment to transforming care delivery.

Transforming the Workforce to Provide Better Care: The Role of Nurses in Certifying Minnesota Health Care Homes

January 7, 2015/in Policy Minnesota Reports Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Workforce Capacity /by Mary Takach

^{Part 4 in the Transforming the Workforce to Provide Better Chronic Care:

The Role of Registered Nurses series.}^{Click to see the rest of the series.}
Minnesota Health Care Homes (HCH), a patient-centered medical home initiative, utilizes regionally-based nurse planners to ensure that HCH practices are meeting specific standards of care that aim to foster improved health outcomes and consumer satisfaction, while also controlling costs. Nurse planners are charged with certifying primary care practices as HCHs and providing practices with resources and technical assistance to help them improve their capacity to function as a HCH.
In addition to highlighting state policy implications, this brief also showcases how Joan Kindt, nurse planner, assists practices in functioning as HCHs that provide patients with quality, comprehensive and coordinated care. Nurse planners, like Joan, have helped to certify over 40 percent of primary care practices in the state.
This brief is the fourth in a six-part series, supported by the AARP Public Policy Institute, which explores the evolving role of nurses in new delivery system models.

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A Day in the Life of Behavioral Health Nurse Care Coordinator Amber Morgan of Hennepin Health

January 5, 2015/in Policy Minnesota Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Long-Term Care, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home, Workforce Capacity /by NASHP Staff

Caring for the health care needs of vulnerable populations has inherent challenges. Doing this in an accountable care organization (ACO), where providers bear financial risk for meeting cost, quality, and patient satisfaction metrics, intensifies the challenges.
When Hennepin Health launched in 2012 to serve as a safety-net ACO for Minnesota’s early Medicaid expansion population, it sought to reinvent the way it identified, engaged, and cared for its vulnerable and homeless populations. This included hiring Amber Morgan to bring primary care to Hennepin County Mental Health Center—where these patients seek most of their services.

Playing Quarterback

Amber Morgan begins each day sorting through numerous telephone and email messages left by the mental health center’s providers asking for help directing, providing, or connecting patients to needed health care services—a role that one psychiatrist described as “quarterbacking.”
Today, this includes a call to a pharmacist about prescription refills and to a county shelter to secure housing for a homeless patient being discharged from a hospital after hip surgery.
As the “quarterback,” Amber consults face-to-face with clinical social workers and psychiatrists to discuss medication management and housing issues. She coordinates referrals for her caseload of patients by making appointments with specialists and briefing the specialists’ offices about the patients’ medical, behavioral health, and social history. In the past 6 months, she has had a “rolling caseload” of about 70 patients.
Her job didn’t start out this way. When Amber began in February 2013, her main responsibility was to find patients with unmet primary care needs. At Hennepin Health, there are community health workers on staff who perform Medicaid outreach and enrollment; Amber’s role is to connect enrolled patients to primary care services. Without this connection, patients will often seek primary care in places like the emergency department or go without any health care services.
When first hired, Amber began with cold calling potential patients to come into the mental health center so that she could assess their medical, dental, social, and behavioral health needs. But this effort turned out to be mostly unsuccessful. She changed strategies and more strongly promoted her role and service options to the clinical staff. She also began co-facilitating a group for homeless men, called “Connections,” two times per week with a clinical social worker. This group allowed her to meet and link with potential patients. Amber added “drop-in” hours directly following each meeting, and these now allow her to meet with patients while they are already at the mental health center.
Amber’s first patient of the day is having total hip surgery in 2 days. She reviews his pre-op directions and gives him a bus pass to get to the hospital. Her second patient is an uncontrolled diabetic, who is now seeing dramatic improvement in his blood sugar levels after making dietary changes. Amber provides dietary counseling routinely to patients, but she also offers counseling to the mental health center staff to promote “a culture of wellness” for the patients.
Afterward a social worker asks Amber to evaluate a patient scheduled for later in the day who has been complaining of vision changes. Integrating a care coordinator into the team at the mental health center took a little time, but now, according to the social worker, the team sees the value of having a behavioral health nurse care coordinator in the office. “Amber is here for the warm handoff. With our population, you will lose them if you don’t make the connection right away,” the social worker explains.
Now that the mental health center has Amber on staff, referrals from psychologists, psychiatrists, and others on staff have also increased; emergency department services are down; and primary care visits are up. No-show rates at both the mental health center and primary care practices have fallen since Amber joined the team.
Next, Amber quickly makes a connection with a new patient who has been waiting to see her. This patient has been referred by his therapist and has been complaining of chest pain. She takes his vital signs and completes an assessment, during which the patient denies current symptoms, but acknowledges discomfort several days before. She determines that he can wait to be seen by a primary care provider until later in the week. She makes the appointment for him, sets up transportation services through Medicaid, and reviews with him an emergency plan should his symptoms recur or worsen.

Running the Drop-In Clinic

The drop-in clinic that follows the homeless men’s “Connections” group has been an important source for identifying patients in need of brief primary care interventions. After these brief drop-in visits, Amber will often set up a subsequent 1-hour appointment to perform a comprehensive health and lifestyle assessment or to provide educational counseling about medication adherence.
This afternoon, Amber has a 1-hour scheduled appointment to review blood sugar glucometer readers with a patient that she has been seeing for a few months. The patient has been making steady progress with checking his blood sugar several times a day. She provides him with positive feedback about his blood sugar monitoring and listens to him as he talks about how he thinks he is ready to find a job. She makes a note about getting a referral for an “Employment” group and schedules the next visit before the patient leaves. She tells the patient he will receive a gift card as an incentive to return. “Offering bus tokens and gift cards,” explains Amber, “can be an enormous incentive to connect patients to needed services.”
The steady stream of patients continues, and Amber makes time to see the patient whom the social worker described as having vision changes. Amber performs an exam that includes checking the patient’s blood glucose and taking her blood pressure. The patient’s blood glucose and blood pressure are both above normal. Amber picks up the phone and makes a prompt referral to a primary care practice and sends the patient on her way with a cab voucher.
“Working in this position has been eye-opening for me,” says Amber. “It has been rewarding and intense. It requires me to problem solve and think creatively to keep patients engaged and keep them coming back.”
“As a behavioral health care coordinator, I try to resolve urgent needs as necessary. For ongoing concerns, I make the connections to get them on the road to health. Whether or not I can solve the problem, patients are reassured simply by knowing someone is there to help.”

Transforming the Workforce to Provide Better Chronic Care: The Role of a Behavioral Health Nurse Care Coordinator in Minnesota

December 31, 2014/in Policy Minnesota Reports Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Community Health Workers, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Workforce Capacity /by Mary Takach

^{Part 3 in the Transforming the Workforce to Provide Better Chronic Care:

The Role of Registered Nurses series.}^{Click to see the rest of the series.}
Hennepin Health, a safety-net accountable care organization in Minnesota, has begun to integrate primary care into Hennepin County Mental Health Center through a behavioral health nurse care coordinator. The behavioral health nurse care coordinator ensures her patients’ care is comprehensive and coordinated by doing complete assessments of patients’ medical health, behavioral health, and social needs, as well as providing basic on-site medical triaging and patient education.
In addition to highlighting state policy implications, this brief also showcases how Amber Morgan, the behavioral health nurse care coordinator, is able to drive improvements in care for her patients. Since hiring Amber, early data has shown that inpatient hospitalizations and the use of the emergency department among behavioral health patients have decreased.
This brief is the third in a six-part series, supported by the AARP Public Policy Institute, which explores the evolving role of nurses in new delivery system models.

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Minnesota – Medical Homes

April 1, 2014/in Policy Minnesota /by Medical Homes

The Minnesota Department of Health and the Minnesota Department of Human Services are jointly leading Minnesota’s Health Care Homes Project. In 2008, the state enacted legislation requiring that all state-regulated Minnesota payers begin paying for health care homes. The state then worked with a wide range of stakeholders to develop specific criteria for certifying practices as health care homes.
Medicaid received state plan amendment approval from the Centers for Medicare & Medicaid Services (CMS) in July 2010 to begin making health care homes payments. The Health Care Homes program includes 11 participating insurers in addition to Medicaid:

Medicare, through the Multi-payer Advanced Primary Care Practice Demonstration
State employee group insurance
Blue Plus (Blue Cross Blue Shield of Minnesota)
HealthPartners
Itasca Medical Care
Medica
Metropolitan Health Plan
Preferred One
Primewest Health
South County Health Alliance
UCare Minnesota

According to a January 2014 report to the Minnesota Legislature, as of December 31, 2013, the state’s 322 certified Health Care Homes (HCHs) include 43% of all primary care clinics in the state and serve over 3 million Minnesotans. These practices are geographically dispersed and serve a wide range of patients. Practices receive support through a learning collaborative, practice coaching, and data feedback.
Minnesota’s multi-payer program is unique in several respects:

Practices are required to have quality improvement teams that include patients/families.
Enhanced payment is only made on behalf of patients with at least one chronic condition.
In order to receive enhanced reimbursement for a given patient, the practice must actively identify him or her as qualifying member of their panel. In most other multi-payer initiatives, plans determine patient attribution.

Going forward, the state hopes to develop accountable care organization (ACO) models built on the health care home model.

Federal support: Minnesota is receiving several types of federal support:

Minnesota is one of six states selected in February 2013 by the Centers for Medicare and Medicaid Innovation (CMMI) to receive a State Innovation Model (SIM) Model Testing Award. Minnesota received $45 million to implement and test its State Health Care Innovation Plan, which builds on the state’s Health Care Homes program and Medicaid Accountable Care Organizations, profiled on the Minnesota page of NASHP’s State Accountable Care Activity Map.
Minnesota is one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program, though several Minnesota counties are being excluded from MAPCP due to participation in a Medicare 646 Quality Demonstration.
Minnesota has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
The state has received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate primary, acute, behavioral and long-term supports and services for dual eligibles.”
HealthPartners Research Foundation has a grant from the Agency for Healthcare Research & Quality (AHRQ) to study how primary care clinics in Minnesota become health care homes.
The federal government provides federal financial participation (FFP) for the enhanced reimbursements that Medicaid managed care organizations and Medicaid fee-for-service pay to participating practices.

Last Updated: April 2014

Forming Partnerships	The Minnesota Departments of Health and Human Services hosted many meetings to develop the Health Care Homes Program. Stakeholders in attendance included representatives of: providers and their professional associations health plans patients and families patient advocates
Defining & Recognizing a Medical Home	Definition: According to the Minnesota Health Care Homes website, a health care home is: “an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.” Recognition: The state-developed certification standards include expectations related to: Access and communication Participant registry and tracking participant care activity Care coordination Care plan Performance reporting and quality improvement Patient- and family- centered care Team-based care delivery Submission of quality data to Minnesota Community Measurement The certification rule is available here. Additional information for practices is also available.
Aligning Reimbursement & Purchasing	As per Minnesota law, state-regulated payers (including Medicaid managed care plans) are required to pay for health care home services in manners that are consistent with the Medicaid fee-for-service methodology. The following payers and purchasers are making enhanced payments: State employee group insurance Blue Plus (Blue Cross Blue Shield of Minnesota) HealthPartners Itasca Medical Care Medica Metropolitan Health Plan Preferred One Primewest Health South County Health Alliance UCare Minnesota In order to receive enhanced reimbursement, practices must actively identify patients as qualifying members of their panel. According to the state plan amendment authorizing the Medicaid payment methodology, payments are tiered based on the number of “major condition groups” (i.e., cardiovascular, respiratory, neurologic, renal, etc.) within which a patient has a severe, chronic condition requiring a care team. Tier 1 (1-3 major condition groups): $10.14 per-member per month (PMPM) payment Tier 2 (4-6 major condition groups): $20.27 PMPM Tier 3 (7-9 major condition groups): $40.54 PMPM Tier 4 (10+ major condition groups): $60.81 PMPM The monthly PMPM payment is increased by 15% if a patient’s (or patient caregiver’s) primary language is not English or if the patient (or patient caregiver) has a severe and persistent mental illness. If both of these complexity factors are present, the PMPM is increased by 30%.
Supporting Practices	Health care homes in Minnesota are receiving a variety of supports: In select areas of the state, community care teams (CCTs) have been funded to support health care homes in, “coordinating seamlessly with a broad range of health and community service providers,” to better serve patients and families. Further information is available in the CCT request for proposals. Practice coaching is available through several state-funded health care homes regional nurse consultants. The Institute for Clinical Systems Improvement (ICSI) has been selected to lead a statewide health care home learning collaborative. Minnesota maintains a resource guide of materials that may help practices in undertaking transformation. Payers are providing data feedback to support health care homes in measuring progress and identifying areas for improvement.
Measuring Results	Minnesota’s Evaluation of Health Care Homes: 2010-2012, released by the Minnesota Department of Health in January 2014, produced a number of positive findings on the program’s impact on quality of care, utilization, and cost: Clinical Quality: The report found that health care home practices performed better than non-health care home practices on a variety of clinical quality measures, including (* indicates statistically significant difference): Colorectal cancer screening, Asthma care, Diabetes care, Vascular care (percentage of patients with Ischemic Vascular Disease who have optimally managed modifiable risk factors), and Depression follow-up. The report notes that all statistically significant results indicated that clinical quality at health care home practices was higher than clinical quality at non-health care home practices. Asthma care showed the largest difference in quality of care (over 20%) between health care homes and non-health care homes. Utilization: Medicaid enrollees attributed to health care home practices had significantly fewer emergency department visits than those attributed to non-health care home practices in 2010, 2011, and 2012. Cost: Over the three-year evaluation period, the average per-member cost for Medicaid enrollees attributed to health care homes was $2,588, compared to $2,850 for enrollees attributed to non-health care home practices. This represents 9.2% net cost savings. Minnesota’s Outcomes Measurement Work Group previously developed recommendations for the state’s evaluation, proposing to focus evaluation efforts on clinical quality (especially care for patients with asthma and vascular conditions), patient access to care and experience of care, and cost (especially rates of hospitalizations, readmissions, emergency department use, and total cost of care).

November 4, 2013/in Policy Minnesota /by NASHP

In Minnesota:

As of July 1, 2011, there were 847,638 beneficiaries enrolled in Medical Assistance, Minnesota’s Medicaid program. Of these, 556,665 were enrolled in managed care. Children enrolled in Medical Assistance and who are certified disabled are not enrolled in managed care plans; instead, they receive services on a fee-for-service basis.
Home and Community-Based Services are provided through a number of waivers, including:
- Community Alternative Care (CAC) Waiver, which provides HCBS services to Medical Assistance-eligible children and adults who are chronically ill and who would otherwise require the level of care provided in a hospital;
- Community Alternatives for Disabled Individuals Waiver, which provides HCBS services for Medical Assistance-eligible children and adults who would otherwise require the level of care provided in a nursing facility; and
- Developmental Disability Waiver, which provides HCBS services for Medical Assistance-eligible children and adults with developmental disabilities or related conditions.

As of 2013, 493,381 individuals were eligible for Minnesota’s Child and Teen Checkups (C&TC) program (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2013, Minnesota achieved an EPSDT screening ratio of 89% and a participation ratio of 71%. 186,943 children received dental services of any kind, with 167,499 receiving preventive dental services.

Last updated June 2014.

Medical Necessity	Minnesota’s Administrative Rules define medical necessity or medically necessary as “a health service that is consistent with the recipient’s diagnosis or condition” and: Is recognized as the prevailing standard or current practice by the provider’s peer group; and Is rendered in response to a life threatening condition or pain; or to treat an injury, illness, or infection; or to treat a condition that could result in physical or mental disability; or to care for the mother and child through the maternity period; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition; or Is a preventive health service “provided to a recipient to avoid or minimize the occurrence of illness, infection, disability, or other health condition.” The Administrative Rules describe EPSDT services using the federal definition.
Initiatives to Improve Access	Minnesota has included multiple financial incentive programs in managed care contracts designed to increase and improve service delivery to children. Managed Care Organizations (MCOs) can receive: $90 for each well child examination beyond the previous year’s rate. The rate is measured by the number of participants screened per 1,000 enrollee months; $50 for each lead screening conducted beyond the previous year’s rate. There is no monetary cap on the incentive payment, but the number of lead screenings is limited to 2 screenings per child (a 5% withhold on each MCO contract is tied to lead screening performance, as well); and $25 for each child mental health or developmental screening conducted beyond the previous year’s rate.
Reporting & Data Collection	Child and Teen Checkups (C&TC) Reporting The state uses specialized software to track C&TC-enrolled children and to assist C&TC Coordinators and outreach staff in conducting and documenting outreach and follow-up activities. The software generates and tracks standard mailings to the children and families about the program as well as information on how to access services. Once a month, updated information on enrolled children and families is collected from the state’s Medicaid Management Information System (MMIS) and MAXIS, a computer system used in Minnesota to determine eligibility for public programs. Encounter data is also collected on a monthly basis from health plans. This information is then compiled and distributed to users of the software, who can update beneficiary information such as name, address, and language.
Behavioral Health	Children’s Therapeutic Services and Supports (CTSS) CTSS is a flexible package of mental health rehabilitative services available to youth enrolled in Medical Assistance or MinnesotaCare who have been diagnosed with an emotional disturbance of any severity. Services include: psychotherapy, skills training, Mental Health Behavioral Aide (MHBA) and direction of MHBA, crisis assistance, children’s day treatment, and therapeutic preschool programs. CTSS services can be provided both by traditional mental health providers and a variety of approved social service agencies, including Head Start. Integrated Behavioral Health Homes Minnesota received a CMS planning grant to develop Section 2703 Health Homes for Medicaid enrollees with chronic conditions. Children experiencing a severe emotional disturbance (SED) are one of four target populations in this initiative. The goals of the integrated behavioral health homes are to: improve health outcomes; improve experience of care for the individual; improve the quality of health & wellness of the individuals; and reduce health care costs. For more information about behavioral health services for children enrolled in Medicaid, see: “Behavioral Health in the Medicaid Benefit for Children and Adolescents: Minnesota.”
Support to Providers and Families	Support to Providers The Minnesota Department of Human Services operates a Child and Teen Checkups (C&TC) program website, which contains the C&TC provider manual and coordinator handbook; age-specific C&TC documentation forms for providers and clinics; quality indicators for child health and developmental screening documents; screening schedules; and multiple factsheets, among other resources. The state also provides ongoing provider training on the C&TC program. E-Learning training on topics such as hearing, vision, oral health, and developmental screenings.
Care Coordination	Child and Teen Checkups (C&TC) Coordinators Administrative, outreach, and education services are provided to children and their families who are eligible for C&TC services by C&TC Coordinators. Each C&TC contracting Community Health Board/tribe has a C&TC Coordinator, who is often a county or tribal public health nurses (PHN). Among their responsibilities, C&TC Coordinators must: Provide timely information to eligible families/children about the C&TC program and its services; Identify and assist families needing or requesting assistance with access to C&TC services; Maintain provider lists and make these lists available to families/children; Provide follow-up referrals; and Coordinate with other related child/health programs (coordination with WIC is a required C&TC activity). Medical Homes Since July 2010, the Minnesota Department of Health and the Department of Human Services have led the Health Care Homes Project, which serves more than 2 million Minnesotans (including children) through 190 certified health care homes (“health care home” is Minnesota’s name for a Patient Centered Medical Home). The state defines a health care home as “an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic health conditions and disabilities.” For more information on Minnesota’s Health Care Homes project, see NASHP’s medical homes map. Accountable Communities for Health In 2011, Minnesota launched a Health Care Delivery Systems Demonstration within Medicaid. Building upon this work, Minnesota received a State Innovation Model grant from CMS in 2013, which will be used in part to support the development of Accountable Communities for Health. These communities will integrate medical care, mental health and chemical dependency, community health, public health, social services, schools and long-term services and supports. During phase one of this project (January-June 2013), nine accountable care organizations (ACO) were launched within the state. Phases two and three will allow for expanded ACOs and continued testing and infrastructure building. For more information on Minnesota’s ACO work, visit NASHP’s Accountable Care Map.
Oral Health	The Minnesota Department of Health website hosts an Oral Health Screening Online Module that offers primary care providers information on their role in providing oral health screenings for Medicaid-enrolled children.

Behavioral Health in the Medicaid Benefit for Children and Adolescents: Minnesota

November 1, 2013/in Policy Minnesota /by NASHP

(As of April 2013)

At a glance:

The Children’s Mental Health Division of the state mental health authority supports community-based service for children, including through local children’s mental health collaborative
Separate billing is allowed for standardized developmental and mental health screening instruments in primary care settings, and the state has compiled a list of screening instruments
The state implemented a Medicaid benefit, children’s therapeutic services and supports, for children with a range of therapeutic and rehabilitative behavioral health needs
The state has supported the expansion of evidence based early childhood mental health services for children birth to five throughout the state.

Introduction

Minnesota, through a robust partnership between Medicaid and the state children’s mental health authority, has worked to increase developmental and mental health screenings for Medicaid-enrolled children and to develop a package of mental health treatment services and supports for children. (The Medicaid children’s benefit is also known as the Early and Periodic, Screening Diagnostic, and Treatment benefit or EPSDT.) Children in Medicaid enroll in the Minnesota Prepaid Medical Assistance Program, a comprehensive Medicaid managed care program that includes mental health and substance abuse services. The mental health screening and treatment services covered by Medicaid are specified by the Department of Human Services (DHS)—which houses the Medicaid program—and included in managed care contracts.

Coordination and Collaboration

The state Medicaid agency and the state mental health authority, both located within the DHS, work together in close collaboration. The state mental health authority is responsible for Medicaid behavioral health policy within the department; accordingly, the authority’s Children’s Mental Health Division (CMHD) assumes responsibility for children’s behavioral health policy in Medicaid. The CMHD is responsible for supporting an array of community-based mental health services for children.

The CMHD works with other county and state-level partners to implement developmental and mental health screenings for children across agencies and child-serving systems in Minnesota. State law requires that children in the juvenile justice and child welfare systems receive mental health screenings; in addition to working with those partners, CMHD has worked with Head Start agencies, early childhood and education programs, and the Medicaid children’s benefit (also known as the Early and Periodic, Screening Diagnostic, and Treatment benefit or EPSDT) to promote screening.

Since 1993 the state has had a Children’s Mental Health Integrated Fund that supports a number of children’s mental health collaborative and family services collaborative. These collaborative connect key partners—including counties, school districts, local mental health entities, juvenile corrections, public health, parents, and other community-based organizations—to provide wraparound services for children with serious emotional disturbance (SED). The collaborative pool funding, including Medicaid dollars, to design a set of integrated and coordinated services for children. The collaborative help to create links across governmental agencies and other organizations to provide individualized care to meet each child’s needs.

Screening, Assessment and Referrals

Beginning in 2004, under the Assuring Better Child Development (ABCD) II program, Minnesota committed to expanding early childhood mental health screenings and establishing a separate billing mechanism for the screens. The state followed up on this with an ABCD III project, Communities Coordinating for Health Development, beginning in 2009 that sought to create more effective linkages between primary care practices and other child and family service providers in the community for young children identified as at-risk for developmental delays through standardized screening.

Minnesota’s provider manual for Child and Teen Checkups (Minnesota’s name for the Medicaid children’s benefit) states that providers can receive additional reimbursement for developmental and mental health screenings during well-child visits if they use a standardized screening instrument; providers must document this by providing the name of the instrument used, the score, and the anticipatory guidance provided based on the screening results. If the screenings are done without the use of a standardized instrument, then the reimbursement for the screening is included in the payment of the evaluation and management code used for the visit and cannot be billed separately.

Providers are instructed to use the CPT code 96110 to bill for developmental screenings conducted with a standardized instrument; the same code, when used with a modifier (UC), is used to indicate a mental health screening conducted with a standardized instrument. The state allows providers to bill both a developmental and a mental health screening on the same date of service on the same claim, though the manual is clear that no single recommended standardized instrument can cover both developmental and mental health screening.

The Department of Human Services and Department of Health jointly produced a fact sheet on socio-emotional/mental health for primary care providers offering well-child visits to Medicaid-enrolled children. In addition to recommendations for mental health history items to include and tips for how to conduct mental health and chemical use screenings, the fact sheet lists three recommended social-emotional/mental health screening instruments: the Ages & States Questionnaire: Social—Emotional (ASQ:SE), the Brief Infant Toddler Social Emotional Assessment (BITSEA), and the Pediatric Symptom Checklist (PSC). The departments have also produced an “All Instruments at a Glance” chart that compares features of these three instruments, as well as a range of standardized developmental screening instruments.

The Department of Human Services has also moved to place greater emphasis on screening for co-occurring substance abuse and mental health disorders. In June 2011, substance use disorders screenings became a required component of Medicaid-reimbursable mental health diagnostic assessments. The department has approved two standardized screening tools for the detection of co-occurring disorders: the CAGE-Adapted to Include Drugs (CAGE-AID) and the Global Appraisal of Individual Needs – Short Screener (GAIN-SS). The department noted in its provider bulletin that the CAGE-AID is validated for use with adolescents aged 12-17, while the GAIN-SS is validated for adolescents aged 10 or older.

Following a screening, a face-to-face diagnostic assessment must be completed by a mental health professional to determine if a Medicaid beneficiary is eligible for mental health services. In 2011 the State of Minnesota revised its Mental Health Outpatient Rules to include extended diagnostic assessments for children under the age of five using the DC:0-3R- a diagnostic process for young children grounded in developmental and attachment theory. Since 2004, over 1000 mental health professionals have been trained in using the DC:0-3R. In addition, the Department of Human Services requires mental health providers to utilize at intake the Child & Adolescent Service Intensity Instrument (CASII) or the Early Childhood Service Intensity Instrument (ECSII) and the Strength & Difficulties Questionnaire (SDQ) on all children under 6 years of age receiving mental health services.

Treatment

A number of mental health treatment services are available to children under Medicaid, ranging from inpatient and outpatient mental health treatment and medication management to more specialized services for children. Managed care organizations (MCOs) in Minnesota are responsible for securing access to behavioral health treatment services for Medicaid-enrolled children who need them, including chemical dependency services such as Screening Brief Intervention and/or Referral to Treatment in primary care clinics.

Medicaid covers psychiatric consultations to primary care providers (including pediatricians) via phone, email, and other means of communication. Children under the age of 18 meeting the criteria for serious emotional disturbance (SED) are eligible for children’s mental health residential treatment. Residential treatment is designed to help the child to improve family living and social interaction skills to facilitate a return to the community. Children’s Mental Health Targeted Case Management (or a substitute model offered by the MCO) provides children with SED access to a case manager who works with the family to develop an individual family community support plan.

For children experiencing a mental health crisis, Minnesota Medicaid supports Children’s Mental Health Crisis Response Services. The statute authorizing them specifies that these supports include mental health crisis assessments, mental health mobile crisis intervention services, and mental health crisis stabilization services. Before they can receive crisis services, children must be screened for a potential crisis, followed by a crisis assessment that evaluates the child’s immediate needs. Mental health mobile crisis intervention services are short-term intensive mental health services that are provided on site and face-to-face during a mental health crisis emergency. They are intended to help children cope with immediate stressors, identify and utilize available resources and strengths, and begin to return to a baseline level of functioning. Crisis stabilization services include further assessment, help with referrals, updates to the crisis stabilization treatment plan, supportive counseling, skills training, and collaboration with other service providers in the community.

Minnesota has also designed a set of rehabilitative mental health services for children. Medicaid covers children’s therapeutic services and supports, defined by the state as a flexible package of mental health services for children who require varying therapeutic and rehabilitative levels of intervention. These supports are available under the Medicaid benefit and include: individual, family, and group psychotherapy; individual, family, or group skills training provided by a mental health professional or mental health practitioner; crisis assistance; mental health behavioral aide services; and direction of a mental health behavioral aide. These services can be combined to form therapeutic programs, including children’s day treatment programs and therapeutic preschool programs.

In December 2012, the CMHD notified providers that Youth Assertive Community Treatment (ACT) would become a covered service under Medicaid once it is added to the State Medicaid Plan and approved by the Centers for Medicare and Medicaid Services. Youth ACT is an intensive rehabilitative service provided by an interdisciplinary team to a youth with a serious mental illness.

In providing access to mental health treatment services, MCOs agree to certain stipulations for care delivery. MCO contract language requires MCO care management systems to include procedures for coordinating with care coordination and services provided by the children’s mental health collaborative and the family services collaboratives. MCOs must also reimburse the travel time of mental health providers who provide community-based mental health services at a place other than their usual place of work. They must also allow telemedicine to be utilized for covered mental health services.

Acknowledgements

The authors wish to thank the many state officials and stakeholders who contributed to and reviewed the information in this document.

This document was prepared by NASHP for the Centers for Medicare & Medicaid Services (CMS) under a contract to NORC at the University of Chicago. It does not reflect the views of CMS.