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States Use Policy Levers and Emerging Research to Address Antipsychotic Use in Children in Foster Care
State policymakers must often take action during an emerging crisis even when evidence identifying the best policy approach is not be available. This report, Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System, explores successful state responses to dramatic increases in antipsychotic prescription rates in Medicaid-enrolled children in foster care. It highlights several strategies, including payment reforms, delivery system innovations, and quality supports for clinical care.
The report results from a convening by the National Academy for State Health Policy of researchers and state officials with expertise in financing and operating Children’s Health Insurance Program and Medicaid programs, children’s health, and health policy and pharmacy research. The meeting preceded the release of a Patient-Centered Outcomes Research Institute-funded study, which examines the comparative effectiveness of state oversight systems in Ohio, Texas, Washington, and Wisconsin.
Read or download: Evidence-Based Policymaking Is an Iterative Process: A Case Study of Antipsychotic Use among Children in the Foster Care System
States Drive Innovations in Quality Measurement and Improvement for Children with Special Health Care Needs
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.
Creating the Perfect Storm for Community-Based Prevention
by Jill Rosenthal and Manel Kappagoda of ChangeLab Solutions
April 2014
The United States ranked 15th among affluent countries in life expectancy in 1980. By 2009, it had dropped to 27th place. Our fragmented health care delivery and public health systems, and the lack of coordination between the two, has resulted in an imbalance of high health spending and poor health outcomes.
A recent report by the Robert Wood Johnson Foundation’s Commission to Build a Healthier America, confirms what we already know: dramatically changing these statistics requires a combined approach that comprises investment in health care delivery and expanding “our focus to address how to stay healthy in the first place.”
Read more
Financing Prevention: How States are Balancing Delivery System & Public Health Roles
This report, developed by the National Academy for State Health Policy and produced by ChangeLab Solutions, highlights leading states’ approaches to support community-based prevention initiatives by bridging the health care delivery and public health systems. It examines various mechanisms – both previously existing and created through health reform – that states can leverage to implement sustainable community-based prevention programs. They include Medicaid waivers, federal grants, accountable care and medical home models, pooled funding, and new federal requirements for nonprofit hospitals. The report includes opportunities and lessons from featured states (California, Maryland, Massachusetts, Minnesota, North Carolina, Oregon, Texas, and Vermont).
| Download the ChangeLab Solutions for the Publication. | 5.6 MB |
Texas
In Texas:
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As of July 1, 2011, there were 3,943,189 beneficiaries enrolled in Texas’s Medicaid program. Of these, 2,786,985 were enrolled in managed care. Texas has multiple comprehensive Medicaid managed care programs. Its STAR program is mandatory for Medicaid-enrolled children in managed care service areas and covers physical, behavioral, and oral health services. A primary care case management program provides these services to children in areas not covered by the STAR program. A managed care program for foster children, STAR Health, provides comprehensive and coordinated services.
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In a small number of counties, a Behavioral Health Organization operates the Texas NorthSTAR program to provide comprehensive mental and substance abuse benefits to enrollees, including children in those counties.
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Home and Community-Based Services are provided through waivers, including:
- Medically Dependent Children Program, provides services to support families caring for children and young adults who are medically dependent and to encourage de-institutionalization of children in nursing facilities;
- Youth Empowerment Services, which provides HCBS services for Medicaid-eligible children with serious emotional disturbance and their family; and
As of 2012, 3,589,690 individuals were eligible for Texas’s Health Steps (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2012, Texas achieved an EPSDT screening ratio of 74% and a participation ratio of 62%. 2,120,116 children received dental services of any kind, with 1,686,946 receiving preventive dental services.
Last updated February 2014.
| Medical Necessity |
Under the Texas Administrative Code, medically necessary means:
“For Medicaid members birth through age 20, the following Texas Health Steps services:
The definition also specifies that medical necessity for children may take into account other factors relevant in the state’s adult medical necessity definition, including the following.
For non-behavioral health services, that services are:
For behavioral health services, that services:
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| Initiatives to Improve Access |
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| Reporting & Data Collection |
The Texas Health and Human Services Commission requires managed care organizations to report on the number of check-ups provided to children under Texas Health Steps.
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| Behavioral Health |
Behavioral health screenings are required at each Texas Health Steps checkup. Texas Health Steps offers primary care providers several developmental and behavioral health screening forms:
Texas Health Steps requires one of those standardized instruments to be used for a checkup to be considered complete.
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| Support to Providers and Families |
Support to Families
The state has a Texas Health Steps webpage to help families understand how a child can get a checkup, as well as additional available services like transportation. A dedicated webpage for teens is aimed at informing adolescents about the benefit and helping to connect them to services. Support to Providers
Texas Health Steps offers free online provider education on a number of topics, including:
In addition, the website provides introductions to Texas Medicaid Programs for Children and Texas Health Steps in particular.
Texas Health Steps also offers providers Child Health Clinical Record Forms to assist providers in documenting all the required components of a well-child visit. The use of these forms is not mandatory.
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| Care Coordination |
Texas Health Steps offers an online training module for primary care providers on creating and maintaining medical homes for children and adolescents.
Primary care provider that provide a medical home for Medicaid enrollees under age 20 who have special health care needs can receive payment for Clinician-Directed Care Coordination Services. Primary care providers offering these services to children and adolescents must provide:
These may be both face-to-face and non face-to-face.
Standardized referral forms for children provided by the state help primary care providers to link children with needed services.
A managed care plan for foster children, STAR Health, provides a coordinated, comprehensive health system for enrolled children. Children receive a medical home and coordination of physical and behavioral health services, as well as other clinical service management benefits.
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| Oral Health |
Pediatric and general dentists participating in Texas Health Steps are being trained to provide children aged 6-35 months with a First Dental Home. Dentists can bill an all inclusive bundled code for a First Dental Home visit, which has the following components:
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Texas – Medical Homes
The Texas Medical Home Work Group has been meeting regularly for more than three years. This group, convened by the Texas Department of State Health Services, exists to, “to enhance the development of Medical Homes within the primary care setting.” Several state agencies are represented in the group, as are a wide range of stakeholders. The group serves as a forum to coordinate and share information on public and private medical home activities in the state. These activities have included:
- A now-suspended plan for a $12 million Medicaid Health Home Pilot for children. Further information on the previously planned pilot is available in this National Academy for State Health Policy (NASHP) report.
- The development of an online course to help primary care providers serve as medical homes for pediatric populations. The course is offered in conjunction with Texas Health Steps, Texas Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit.
Last updated: December 2013
| Forming Partnerships |
The following state agencies are represented on the Texas Medical Home Work Group:
Additional participating stakeholders include health plans, providers, provider professional associations, and the primary care association.
It also bears noting that primary care providers in Texas have a history of enthusiastically supporting medical homes. The Primary Care Coalition, a group of almost 15,000 doctors from the Texas Academy of Family Physicians, the Texas Chapter of the American College of Physicians, and the Texas Pediatric Society released a 2008 report, The Primary Solution, calling for the Texas legislature to, “support a patient-centered primary care medical home for all Texans.”
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Lessons from the Field: State- and Practice-Level Policies to Foster High Performance in Cervical Cancer Screening in Federally Qualified Health Centers
States can make important strides in eradicating cervical cancer deaths. This report features promising state and federally qualified health center policies that support high performance in cervical cancer screening within the context of the medical home. Drawing from Colorado, Maine, Maryland, New York, Texas, Vermont, and Virginia, this report summarizes innovative programs, practices, and partnerships that facilitate improvement in cervical cancer screening. Experiences in these states offer examples for adoption by others to ensure high-quality preventive care for women. This publication was made possible through the support of the Health Resources and Services Administration.
| Download the Publication | 497.1 KB |
Federal and State Policy to Promote the Integration of Primary Care and Community Resources
Around the country, models are emerging to link primary care providers not only to other medical service providers but also to resources and services in the community. This report—the first in a series supported by The Commonwealth Fund to explore opportunities for improvement in federal and state policy–highlights relevant policy levers and federal and state initiatives to integrate these resources. It also discusses opportunities for policy improvement identified during a Commonwealth Fund-supported discourse among high-level state and federal officials hosted by NASHP.
August 2013
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For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
