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State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder

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October 31, 2018

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The current opioid epidemic is driving a heightened focus on substance use disorder (SUD) prevention and treatment for pregnant and parenting women, who have unique needs and face unique challenges. However, gaps in care often remain, particularly during the postpartum period. This NASHP webinar, supported by the Health Resources and Services Administration, will highlight a state that is coordinating across agencies and systems to meet the needs of pregnant and parenting women affected by SUD. Speakers from Colorado will describe the coverage, financing, and care delivery strategies that their state agencies and safety net providers leverage to facilitate recovery among pregnant and parenting women with SUD, including opportunities for cross-system collaboration.

Webinar: State Strategies for Using Shared Plans of Care to Improve Care Coordination for Children and Youth with Special Health Care Needs

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Wednesday, October 31, 2018
3:00pm to 4:00pm EDT

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Children and youth with special health care needs (CYSHCN) currently comprise nearly 20 percent or 14.6 million of the US pediatric population between ages birth to 18 years. Many CYSHCN require significant care coordination across a continuum of physical health, behavioral health, and educational supports, as well as coordination with social, financial, and community-based services and supports. To improve care coordination for CYSCHN, health care delivery systems are increasingly using of integrated health care teams, health information technology, and actionable, comprehensive plans of care, individually referred to here as a shared plan of care (SPoC). Guided by the patient and family and the child’s care team, a SPoC describes shared goals, negotiated actions, and assigns responsibility for various actions and activities to address the diverse needs of the child or youth with special health care needs, both medical and non-medical. Adopting SPoCs as an expected aspect of chronic care can enhance patient- and family-centered health care delivery and overcome some of the barriers to controlling costs and ensuring quality.
This national webinar featured a national overview by Jeanne McAllister, an expert from the Indiana University School of Medicine, and presentations from representatives from Oregon and Iowa, two states that have implemented SPoC for CYSHCN.

State Strategies for Shared Plans of Care to Improve Care Coordination for Children and Youth with Special Health Care Needs

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Care coordination is an essential component of care for children and youth with special health care needs (CYSHCN). When successfully implemented, it can improve care, reduce costs, avoid fragmented and duplicative care, and improve family functioning and satisfaction. As states work to provide quality care coordination, many are adopting shared plans of care (SPoC) to enhance patient- and family-centered care delivery, and support improved outcomes and care quality. This issue brief, developed by the National Academy for State Health Policy with support from the Health Resources and Services Administration’s Maternal and Child Health Bureau, identifies approaches and strategies states can use to promote the use of SPoCs as part of care coordination. It also features case studies showcasing how Iowa, Oregon, Utah, and West Virginia are implementing SPoCs for CYSHCN.
Read or download: State Strategies for Shared Plans of Care to Improve Care Coordination for Children and Youth with Special Health Care Needs
Blog: Why Shared Plans of Care Are Critical to Coordinated Care and How States Are Implementing Them

Why Shared Plans of Care Are Critical to Coordinated Care and How States Are Implementing Them

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Children and youth with special health care needs (CYSHCN) can require significant care coordination across a continuum of health and social services. Improved care coordination for CYSHCN can lead to better outcomes for CYSHCN, as well as cost savings for states. To achieve those goals, state Medicaid agencies and Title V CYSHCN programs are increasingly using individual, comprehensive plans of care, called shared plans of care (SPoCs), to strengthen care coordination for CYSHCN.
States play a significant role in coordinating care for CYSHCN and in implementing SPoCs. Nationally, state Medicaid agencies and Children’s Health Insurance Program (CHIP) provide health insurance to 48 percent of all CYSHCN, and their Title V programs are an essential resource for care coordination for CYSHCN and can play a central role in supporting and implementing SPoCs.
Health care delivery transformation and other federal and state reforms present key opportunities for states to promote the use of SPoCs. For example, states are now integrating SPoCs into patient-centered medical home (PCMH) initiatives, health home models, Medicaid managed care arrangements, and state accountable care organizations. To implement SPoCs, states are:

  • Creating a standardized SPoC document for use or adaptation by Title V CYSHCN program staff, health care providers, health plans, and others that serve CYSHCN;
  • Contractually requiring Medicaid managed care organizations to use SPoCs as part of their care coordination services; and
  • Working within programs or with outside entities to modify existing care planning processes to accommodate SPoCs and ensure they meet shared care planning standards.

In a new issue brief, State Strategies for Using Shared Plans of Care to Improve Care Coordination for Children and Youth with Special Health Care Needs, the National Academy for State Health Policy (NASHP) outlines state strategies to effectively launch and implement SPoC. The report also features four state case studies that explore how Iowa, Oregon, Utah, and West Virginia are implementing and advancing their SPoC initiatives. Highlights include:

  • Iowa’s Title V CYSHCN program developed an electronic SPoC using ACT.md, a web-based platform that serves as the central hub for SPoCs. Iowa uses the SPoCs to support care coordination for a subset CYSHCN who receive services through the state’s Pediatric Integrated Health Home Program or Child Health Specialty Clinics (the state’s community-based public health agencies).
  • Oregon is implementing SPoCs for a select group of CYSHCN through its local public health agencies (LPHAs), which it contracts with to provide care coordination services. SPoCs are developed during meetings with all of the child’s providers, which helps ensure that everyone involved in the child’s care receives the same information. To enable LPHAs to better provide cross-sector care coordination and support integration of care in the community, Oregon maintains a resource-rich SPoC website that includes its SPoC Implementation Guide.
  • Utah’s SPoC initiative targets CYSHCN living in rural areas who receive direct clinical services from the state’s Title V CYSHCN program, with the Title V care coordinators leading the development and oversight of SPoCs. SPoCs are housed in the state’s electronic medical record system (Cadurx). Families can access their children’s SPoCs through a patient portal and they also receive a printed copy. Training, tools, and information on care coordination and SPoCs are available to providers and care coordinators through the Utah Children’s Care Coordination Network.
  • West Virginia’s Title V program developed its SPoC initiative when it redesigned its care coordination program for CYSHCN. The care coordinators within the state’s Title V CYSHCN program lead the development of SPoCs and collaborate with the Medicaid managed care organizations’ (MCOs) medical case managers, foster care services agencies, and primary care physicians to provide care coordination. The strong partnership between the state Medicaid agency and state Title V program helped the Title V program established memos of understanding (MOUs) with the four state Medicaid MCOs. Through the MOU, MCOs and the Title V program are required to coordinate the care planning process for CYSHCN, including the use of SPoCs.

State Strategies to Advance Medical Homes for Children and Youth with Special Health Care Needs

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mother hugging childMedical homes are critical components of comprehensive care systems for children and youth with special health needs (CYSHCN). They can reduce costs and improve outcomes and care experiences for CYSHCN and their families. This new report, State Strategies to Advance Medical Homes for Children and Youth with Special Health Care Needs, examines effective strategies used by 16 states to advance a medical home model of care for CYSHCN and their families, as part of the Maternal and Child Health Bureau, Health Resources and Services Administration’s State Implementation Grants to Enhance Systems of Services for CYSHCN through Systems Integration. Read the report.

Additional children and youth with special health care needs resources:

How States Can Improve Access to Care for Children Under the Medicaid Managed Care Rule

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Next month, states face new federal requirements for establishing and maintaining Medicaid managed care provider networks. As they work to comply with these new rules, states have an opportunity to strengthen access to care for children and youth with special health care needs (CYSHCN).
Medicaid and beautiful childrequirements, which address how enrollees access care and the scope of provider networks, are scheduled to go into effect July 1, 2018. The network adequacy provisions of the rule, in particular, may have implications for how CYSHCN can access care.
As outlined in a recently published NASHP analysis, the rule requires states to develop and implement network adequacy standards in their Medicaid managed care programs, including time and distance standards, for certain types of providers:

  • Pediatric dental
  • Pediatric primary care
  • Pediatric behavioral health, including mental health and substance use disorder services
  • Pediatric specialist
  • OB/GYN
  • Adult primary care
  • Adult specialist
  • Adult behavioral health, including mental health and substance use disorder services
  • Hospital
  • Pharmacy
  • Long-term services and supports that require the enrollee to travel to the provider

In requiring network adequacy standards – yet avoiding dictating the specific time and distance standards themselves — the rule recognizes that states differ in their geographic conditions and provider capacity. It thereby gives states flexibility to establish standards in a way that fits their unique needs.
Many CYSHCN, especially those with complex needs, typically use multiple specialty providers and home- and community-based providers. By including these provider types in network adequacy standards, states can help ensure access to pediatric and specialty services for CYSHCN.
NASHP recently analyzed how states provide managed care services to CYSHCN enrolled in Medicaid. Several states have implemented network adequacy policies in their Medicaid managed care programs. Of the six states NASHP studied, all of the states include time and distance standards for generalist, specialist, and behavioral health care providers. These standards varied for urban, rural, and frontier areas in geographically diverse states. For example:

  • Colorado’s Accountable Care Collaborative Phase II program specifies that enrollees must have access to primary care providers (PCPs) within 30 miles or 30 minutes in urban areas, 45 miles or 45 minutes in rural areas, and 60 miles or 60 minutes in frontier areas.
  • Texas requires MCOs to establish networks in its STAR Kids program so that enrollees have access to two age-appropriate PCPs within 30 miles (or 20 miles in more densely-populated areas). Texas also requires that managed care organizations (MCOs) contract with telehealth providers to ensure access to specialty care in rural areas.
  • In Virginia’s CCC Plus program, MCOs must offer enrollees a choice of at least two providers of each provider service type located within 60 minutes of their residences, and a choice of at least two specialists within a 30-mile radius in urban areas and no more than a 60-mile radius in rural areas.

In addition to network adequacy requirements, state Medicaid agencies and MCOs use other strategies to ensure that CYSHCN have access to specialty providers. One approach is an analysis of fee-for-service claims data to identify the providers that enrollees have used in the past. The state then makes efforts to enroll those providers who have a history with these children in MCO networks. This strategy is employed by MCOs in Ohio and by the Texas Medicaid agency, which has used the method to help ensure that “significant traditional providers” are included in its MCO networks. Virginia’s Medicaid agency works with the state’s 13 hospital health systems to ensure that they contract with at least three of the participating Medicaid MCOs in the hospital system’s geographic area.
As states work to comply with the network adequacy requirements spelled out in the managed care final rule, they have an opportunity to strengthen access to care among all of their CYSHCN.
For more information about how states are organizing their Medicaid managed care programs to ensure access to care for CYSHCN, visit NASHP’s recent analysis of six state programs.

How Six States Use Medicaid Managed Care to Serve Children with Special Health Care Needs

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Medicaid managed care provides a unique opportunity for states to strengthen the structure and delivery of care for children and youth with special health care needs (CYSHCN). The National Academy for State Health Policy (NASHP), studied how six states (Arizona, Colorado, Minnesota, Ohio, Texas, and Virginia) designed their managed care systems to serve CYSHCN and examined some of their best practices and strategies to meet the unique needs of these children in three reports:

These studies reveal that while there is variation among states in the design, scope of services, and targeted populations, there are strategies that states can employ in Medicaid managed care to ensure delivery of quality care for CYSHCN, including:

  • Assessing the needs of CYSHCN to better coordinate care;
  • Establishing network requirements for specialty providers;
  • Promoting continuity of care during transitions; and
  • Creating quality measures around processes and outcomes.

These three studies build on NASHP’s 50-state scan of Medicaid managed care systems serving CYSHCN and states’ use of Medicaid quality metrics for CYSHCN.
These resources were developed with support from the Lucile Packard Foundation for Children’s Health and the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number UC4MC28037 Alliance for Innovation on Maternal and Child Health.

States Drive Innovations in Quality Measurement and Improvement for Children with Special Health Care Needs

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Children and youth with special health care needs (CYSHCN) are a diverse population whose health care needs and costs often exceed those of most children. Improving care for this population is critical, yet challenging, due to the complexity of conditions of some children, and the multitude of systems (e.g., health, education, social services) and supports that children typically use.
With Medicaid and CHIP programs financing health care services for 44 percent of all CYSHCN in the United States, state Medicaid agencies are increasingly targeting CYSHCN as part of their health system transformation efforts to improve health care quality and outcomes. A recent NASHP 50-state scan of state Medicaid managed care programs found that 37 states and Washington, DC, now enroll some or all populations of CYSHCN in risk-based Medicaid managed care. As state payment and delivery system reform efforts advance, tailoring quality measurement and improvement strategies to CYSHCN is a growing priority for many states to improve care for this vulnerable population.

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Despite this growing interest, states face numerous barriers in implementing quality improvement strategies for CYSHCN. For example, many Medicaid agencies lack the resources and capacity to develop robust quality improvement initiatives for this population of children. Many existing quality measures have limitations in their applicability across all CYSHCN populations, and may not fully assess the overall quality of care. Surveys that can be used to measure family experience with care are often challenging and burdensome to administer. Quality improvement is a lengthy and iterative process and requires substantial time and resources for non-complex patient populations. These challenges are more pronounced when developing quality improvement initiatives that meet the unique needs of CYSHCN.
Some state Medicaid agencies, however, are leading the way by designing innovative programs and exploring new ways to align and embed quality measurement for CYSHCN in within broader state initiatives.

  • Michigan: Michigan’s Children’s Special Health Care Services (CSHCS) program serves children with special needs. Michigan Medicaid utilizes the Consumer Assessment of Healthcare Providers and Systems 5.0 Child Medicaid Health Plan Survey with the Children with Chronic Conditions measurement set to assess the experience of care and quality of care for children enrolled in the CSHCS program. The survey results are used to guide improvements in the CSHCS program, and they are factored into incentive payments for the state’s managed care organizations (MCOs).
  • New York: As part of New York’s overall Medicaid Redesign Team initiatives, the state is changing how children, including CYSHCN, are served in the state’s Medicaid program. One new program that is specifically driving quality measurement and improvement for CYSHCN is Health Homes Serving Children (HHSC). Through this program, participating Health Homes use a care management model to support to Medicaid-enrolled children with complex physical and/or behavioral health conditions. Health Homes report on the “Health Homes Measures Subset,” which is a list of performance measures designed to assess members’ well-being and the impact of care management activities. Some of these measures include adolescent well-care visits, time from health home referral to outreach, and follow-up after hospitalization for mental illness. The HHSC program also develops and maintains a Quality Management Program that monitors, evaluates, and ultimately improves the quality of care for members. The current quality measurement activities are laying the groundwork for New York to eventually integrate Health Homes into its statewide transition to value-based payments, with the goal of holding Health Homes accountable for the quality of care rendered and the outcomes of their members.
  • Texas: Texas Medicaid serves children and youth with disabilities and complex conditions in a specialized managed care program called STAR Kids, which uses several strategies to measure and improve the quality of care for enrollees. Prior to the launch of STAR Kids, a study established baseline data for utilization, access, and consumer satisfaction. Now that the program is in its first year, Texas Medicaid will conduct a post-implementation survey of the children enrolled in STAR Kids to assess its performance, compare the performance of MCOs, and determine which measures to integrate into future quality improvement activities. Texas Medicaid also plans to implement additional quality improvement activities for STAR Kids over the next several years, including releasing MCO report cards that can help STAR Kids enrollees and their families select a health plan, and linking financial incentives and disincentives to MCO performance.

To learn more about these and other innovative Medicaid quality measurement strategies targeted to CYSHCN, read NASHP’s new issue brief, State Strategies for Medicaid Quality Improvement for Children and Youth with Special Health Care Needs. The brief includes a table highlighting selected Medicaid quality measurement sets and tools for children, and three case studies featuring ongoing work Michigan, New York, and Texas.
For more information about NASHP’s work on Medicaid Quality Measurement and CYSHCN, contact Becky Normile at bnormile@oldsite.nashp.org.

States Work to Improve Care for Children with Special Health Needs with Quality Measurement

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Improving the quality of care that children and youth with special health care needs (CYSHCN) receive is a growing priority for state Medicaid programs. However, many quality improvement efforts are in their infancy as states work to overcome the challenges of measuring and assessing care quality for this vulnerable population. NASHP, with support from the Lucile Packard Foundation for Children’s Health, convened a national work group recently to identify gaps and opportunities in measuring care and designing quality improvement initiatives. This issue brief and case studies from Michigan, New York, and Texas, examine strategies that states can use to advance quality measurement and improvement for CYSHCN.

Success Spurs Growth of Medicaid Managed Care for Children with Special Health Care Needs

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Two decades ago, the majority of state Medicaid programs that served children and youth with special health care needs (CYSHCN) relied on a traditional, fee-for-service model to pay for the complex mix of health care services that this group of children often need. But as states became more adept at designing new health care delivery programs, they have begun enrolling Medicaid beneficiaries with chronic and complex medical needs into Medicaid managed care (MMC) programs.
Some states are discovering that MMC can provide greater opportunities for coordinating care, controlling costs, and improving health care quality and outcomes for CYSHCN.
To implement these programs, state Medicaid agencies are contracting with managed care organizations (MCOs) to provide care and support services for a set price (per member, per month) with the goal of providing high-quality care at lower costs. These state programs are unique, with each state creatively designing plans to serve specific CYSHCN populations. Knowing what plans and policies states have adopted, outlined in a 50-state scan, provides important insights into national trends and new approaches that states can use to transform their MMC models to serve CYSHCN.
A recent NASHP nationwide analysis found 47 states and Washington, DC, now use some form of managed care to serve all or some children and adults enrolled in Medicaid today. Of the states with managed care delivery systems, all enroll at least some or all of their CYSHCN into some type of Medicaid managed care. Most enrollment is in risk-based managed care, where the MCO assumes financial risk.
NASHP’s issue brief, and 50-state map and chart provide an easy-to-use reference guide to learn what individual states are doing as they redesign health care for their CYSHCN. NASHP’s analysis found that enrollment in MMC varies by state and subpopulation of CYSHCN:

  • 42 states enroll children in the Medicaid Aid to the Aged, Blind and Disabled (ABD) category of assistance in MMC;
  • 42 states enroll foster care youth in MMC;
  • 22 states enroll children who receive Supplemental Security Income (SSI) in MMC; and
  • 14 states enroll children in 1915(c) Medicaid waiver programs in MMC.

Most states with MMC enroll CYSHCN on a mandatory basis and serve CYSHCN in standard health plans that serve all Medicaid beneficiaries. A small number of states have developed specialized managed care plans for CYSHCN.
In addition to rapidly expanding MMC, states are also evaluating if this health care delivery model is truly improving the quality of care for Medicaid beneficiaries. Two-thirds of states (33) have incorporated quality measurement requirements specifically for CYSHCN into their managed care contracts to assess how well these systems are serving children’s needs. These and other findings about enrollment of CYSHCN in MMC are summarized in a new issue brief and a 50-State Chart and Map. NASHP has also taken an in-depth look at Medicaid managed care delivery systems for CYSHCN in six states, and state use of Medicaid quality metrics for CYSHCN. These and other resources will be released in the next two

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