Behavioral/Mental Health and SUD – Page 22 – The National Academy for State Health Policy

Improving Behavioral Health Access & Integration Using Telehealth & Teleconsultation: A Health Care System for the 21st Century

November 10, 2015/in Policy Reports Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health IT/Data, Health System Costs, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Quality and Measurement, Safety Net Providers and Rural Health, Workforce Capacity /by Lesa Rair

Individuals with medical and behavioral health comorbidities often receive fragmented care, resulting in higher costs and poorer outcomes. States, the federal government, and providers have all made significant investments to build and expand evidence-based integration models, such as the collaborative care model, to reduce fragmentation and improve care. However, workforce shortages and limited resources may hinder the feasibility of these models, particularly in rural areas. Emerging evidence demonstrates that telehealth services and provider teleconsultation may be viable alternatives for individuals that are willing to participate and can deliver equal or better care when compared to traditional in-person care for individuals with behavioral health needs. While telehealth is often framed as a way to improve access in rural settings, patients in urban settings may also benefit.
While some individuals may prefer to continue to receive traditional in-person care, telehealth and teleconsultation offer opportunities for states to increase patient choice and expand the scope of services individuals can receive at their usual care site—including primary care clinics, mental health centers, and correctional facilities. These programs may also build the primary care systems’ capacity to treat mild-to-moderate behavioral health conditions. More research is necessary to understand the full effect on service utilization and healthcare costs, but early findings demonstrate that telehealth and teleconsultation programs for behavioral health services may reduce state spending or produce overall cost savings.
Read the full brief.

Top 5 Themes We Saw Emerge From #NASHPCONF15

November 2, 2015/in Policy Blogs Behavioral/Mental Health and SUD, Care Coordination, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health IT/Data, Health System Costs, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, State Insurance Marketplaces /by NASHP

State health policy leaders from all 50 states and the District of Columbia converged in Dallas for our largest-ever annual conference. Packed sessions and hallway conversations had the place abuzz with ideas and challenges as states move ahead with system-changing reforms. Without the brainpower of our members and attendees identifying key issues and best practices at events like this, we could not do our work. We are back in the swing of things here at NASHP, but I wanted to take some time to reflect on some of the leading issues and themes to emerge from the conference.
The Uninsured – Good News; Bad News
The ACA has reduced the rate of uninsured in every state – down to 11.4 percent nationally – but many states noted there’s still work to be done in reaching the remaining uninsured and shared key strategies and priorities. Although the rules are incomplete and the challenges many, some states are exploring 1332 waivers as a way to reorganize coverage programs and financing to create a more seamless system of coverage.
Whole Person Care (and Community Care) – Bridging the Silos
Health, specifically poor health, is often determined by social, economic, and physical environments. But what happens when we take on health needs holistically and cover the whole person? Coverage and delivery systems need to cover the whole person throughout the life span, while also linking to factors outside of traditional health care that extend to community life. Integrating care across silos of payment and delivery; across health and health care; as well as behavioral and physical health is no easy task but emerging models hold promise. Additionally, community development resources can be tapped to improve the built environment and address adverse social determinants.
Consolidation – A Bridge Too Far?
The emergence of ACOs and other integrated systems of care can reduce fragmentation, strengthen care coordination, and improve quality. Coupled with payment reforms, improving coordination by these entities can address overutilization – a key cost driver. But the flipside of coordinated care is the consolidation of health care delivery systems. As hospitals merge and more own physician practices, their market power increases and prices go up. States have important responsibilities to provide a check and balance on reform, increasing data availability and transparency, certifying health care consolidation, and developing approaches to rate oversight.
Total Cost of Care – Addressing Affordability
Health care costs have been stabilized with record low growth, but challenges with affordability of coverage remain; drug prices continue to rise and predictions show an expected increase in health care spending on the horizon. Importantly, health care premium and out of pocket costs far exceed wage growth and inflation. States are full of demonstrations to affect costs, largely financed by CMMI. Three- quarters of Medicaid programs are operating four or more. We have much to learn from these demonstrations, yet some payers and providers reel from “demo fatigue”. Three states, Maryland, Massachusetts, and Vermont, are experimenting with global hospital budgets and annual limits on expenditure growth through all payer models that will yield important lessons for the field.
Data, Data, Data- More States are Collecting and Using Data
Without comprehensive, accessible, and trustworthy data the health reforms noted above are stymied. Who is covered, at what cost, and with what outcomes? States are faced with the balance between consumer privacy needs and public policy interests, as well as how to use state and national claims data sets to track and monitor the impact of new policies. Some states shared how they are using a variety of methods to link and use data to target initiatives and improve population health efforts.
As we continue to reflect on all of the tremendous information that was presented and shared over the course of the conference, NASHP will provide more in-depth coverage of topics and ideas in the coming weeks. We look forward to working with state health policy leaders across agencies and branches of government to support their work and advance reforms.

Health Centers’ Role in Affordable Care Act Outreach and Enrollment: Experience from Kentucky and Montana

October 30, 2015/in Policy Kentucky, Montana Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health System Costs, Medicaid Expansion, Medicaid Managed Care, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home, Safety Net Providers and Rural Health, State Insurance Marketplaces /by NASHP, Najeia Mention and Alice Weiss

The Affordable Care Act created new opportunities for health centers and primary care associations (PCA) to play a leading role in supporting outreach and enrollment into new and expanded health coverage programs. Health centers and PCAs received new funding, sometimes from multiple state and federal entities, new training and tools, and a new mandate to find and enroll eligible individuals, both within their patient caseload and in the broader community. In undertaking this charge, many health centers and PCAs found themselves engaging new partners, building stronger relationships with state Medicaid and insurance or exchange agencies, and often playing a central role in coordinating outreach and enrollment activities in their state or community.

To better understand the new roles of these entities and identify promising strategies in their coordination with state Medicaid and insurance/exchange agencies, NASHP undertook a case study review of Kentucky and Montana, two states with strong enrollment performance where the state PCA and health centers played an important role. With support from the Health Resources and Services Administration’s National Organizations of State and Local Officials Cooperative Agreement, NASHP interviewed representatives from the PCA, a health center, and a Medicaid agency in each state about their respective roles in and coordination of outreach and enrollment assistance during the first two years of Affordable Care Act implementation.

Findings from these interviews are summarized here, with case studies highlighting each state’s circumstances and experiences, followed by a discussion of common themes relating to collaboration with state and federal agencies, lessons learned, and future priorities for outreach and enrollment work with states.

Download the full brief here

Conference Presentations 2015

October 21, 2015/in Policy Annual Conference Behavioral/Mental Health and SUD, Care Coordination, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health System Costs, Medicaid Managed Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Value-Based Purchasing /by NASHP

Preconference	First Name	Last Name	Presentation
Finding Shared Solutions Across Mental Health, Substance Use Disorders, and Medicaid to Promote Recovery	Tamara	Sale	Sale.precon.prevention.pdf
Finding Shared Solutions Across Mental Health, Substance Use Disorders, and Medicaid to Promote Recovery	Tom	Betlach	Betlach.precon.health reform.pdf
Finding Shared Solutions Across Mental Health, Substance Use Disorders, and Medicaid to Promote Recovery	Carol	Kress	Kress.precon.recovery.pdf
Finding Shared Solutions Across Mental Health, Substance Use Disorders, and Medicaid to Promote Recovery	Brian	Hepburn	Hepburn.precon.prevention.pdf
Finding Shared Solutions Across Mental Health, Substance Use, and Medicaid to Promote Recovery	Terri	Timberlake	timberlake.precon.prevention.pdf
Finding Shared Solutions Across Mental Health, Substance Use Disorders, and Medicaid to Promote Recovery	Tamara	Sale	Sale.precon.prevention.pdf
Finding Shared Solutions Across Mental Health, Substance Use Disorders, and Medicaid to Promote Recovery	David	Shillcutt	shillcutt.precon.IAP.pdf
Improving Health, Lowering Costs: Translating Population Health into Effective State Policy	Eduardo	Sanchez	e.sanchez.pop.health.precon.pdf
Improving Health, Lowering Costs: Translating Population Health into Effective State Policy	Barry	Kling	b.kling.pop.health.precon.pdf
Improving Health, Lowering Costs: Translating Population Health into Effective State Policy	patty	hayes	p.hayes.pop.health.precon.pdf
Improving Health, Lowering Costs: Translating Population Health Into Effective State Policy	Terry	Cline	t.cline.pop.health.precon.pdf
Improving Health, Lowering Costs: Translating Population Health into Effective State Policy	Bechara	Choucair	b.choucair.pop.health.precon.pdf
Improving Health, Lowering Costs: Translating Population Health into Effective State Policy	Chris	DeMars	c.demars.pop.health.precon.pdf
Improving Health, Lowering Costs: Translating Population Health into Effective State Policy	Catherine	Anderson	c.anderson.pop.health.precon.pdf
Improving Health, Lowering Costs: Translating Population Health into Effective State Policy	Judy Mohr	Peterson	Peterson.precon.health reform.pdf
Improving Health, Lowering Costs: Translating Population Health into Effective State Policy	Edward	Ehlinger	e.ehlinger.pop.health.precon.pdf

Session Name	First Name	Last Name	Presentation
Beefing up the Value in Healthcare and Improving the Patient Encounter	Suz	Schrandt	s.schrandt.8.beefing.up.value.pptx
Beefing up the Value in Healthcare and Improving the Patient Encounter	Daniel	Lessler	d.lessler.8.beefing.up.value.ppt (Read-Only).pdf
Beefing up the Value in Healthcare and Improving the Patient Encounter	Kevin	Lembo	k.lembo.8.beefing.up.value.pptx (Read-Only).pdf
Behavioral Health Precon -Aligning mental health and substance use disorder services with broader state reform initiatives	Judy Mohr	Peterson	Peterson.precon.health reform.pdf
Blazing the Trail of Reform for Children and Youth with Special Health Care Needs	Rylin	Rodgers	rodgers.7.blazing.the.trail.cyshcn.pdf
Blazing the Trail of Reform for Children and Youth with Special Health Care Needs	Jeanne	McAllister	McAllister.ChildrenYouthSpecialHealthCareNeed.pdf
Blazing the Trail of Reform for Children and Youth with Special Health Care Needs	Sharon	Fleischfresser	fleischfresser.7.blazing.the.trail.cyshcn.pdf
Blazing the Trail of Reform for Children and Youth with Special Health Care Needs	Jimael	Johnson	johnson.7.blazing.the.trail.cyshcn.pdf
Care Beyond Cure: Palliative and End-of-Life Care	Harriet	Warshaw	h.warshaw.15.care.beyond.cure.pdf
Care Beyond Cure: Palliative and End-of-Life Care	Daniel	Lessler	d.lessler.15.care.beyond.cure.pdf
Care Beyond Cure: Palliative and End-of-Life Care	Rosemary	Gibson	r.gibson.15.care.beyond.cure.pdf
Catching the Next Waiver: State Flexibility, Section 1332 and “Super Waivers”	Bachrach	Deborah	d.bachrach.18.1332 waiver.pdf
Drilling Claims Data to Fuel State health Policy Decisions	Christopher	Whaley	c.whaley.24.drilling.claims.data.pdf
Drilling Claims Data to Fuel State Health Policy Decisions	Fernando	Wilson	f.wilson.24.drilling.claims.data.pdf
Giving Silos the Boot, State Demonstrations Integrate Medicare and Medicaid	Kathy	Stiffler	stiffler.10.giving.silos.pdf
Harnessing Data Analytics for Population Health	Mary	McIntyre	mcintyre.3.harnessing.data.analytics.introduc.pdf
Harnessing Data Analytics for Population Health	Greg	Moody	moody.3.harnessing.data.analytics.pdf
Harnessing Data Analytics for Population Health	Laura	Nasuti	nasuti.3.harnessing.data.analytics.pdf
Managed Care for Special Populations	Makalah	Wagner	wagner.9.managed.care.pdf
Managed Care for Special Populations	Kay	Ghahremani	ghahremani.9.managed.care.pdf
Managed Care for Special Populations	Lindsay	Cogan	cogan.9.managed.care.pdf
Measuring What Matters: Marrying Individual Outcomes to Aggregate Date in HCBS and Beyond	Alice	Lind	lind.10.giving.silos.pdf
Medicaid Expansion: Staking New Ground and Corralling Cost Savings	Seema	Verma	s.verma.21.medicaid.expansion.pdf
Medicaid Expansion: Staking New Ground and Corralling Costs	Susan	Birch	s.birch.21.medicaid.expansion.pdf
Medicaid Expansion: Staking New Ground and Corralling Costs	Donna	Spencer	d.spencer.21.medicaid.expansion.pdf
Medicaid Expansion: Staking New Ground and Corralling Costs	Lisa	Lee	l.lee.21.medicaid.expansion.pdf
Mind Meld: Integrating Behavioral Health Services for Individuals with Complex Needs	Lisa	Kirsch	kirsch.session14.mindmeld.speaker3.pdf
Mind Meld: Integrating Behavioral Health Services for Individuals with Complex Needs	Beth	Tanzman	tanzman.session14.mindmeld.speaker4.pdf
Mind Meld: Integrating Behavioral Health Services for Individuals with Complex Needs	Dena	Stoner	stoner.14.mind.meld.pdf
Myth Busters! Examining Privacy Rules that Inhibit Data Sharing	Linette	Scott	scott.5.mythbusters.pdf
New in the Community, Managed LTSS Plans Meet Community Providers	Patti	Killingsworth	killingsworth.12.new.community.pdf
New in the Community, Managed LTSS Plans Meet Community Providers	Beth	Jackson	jackson.11.Truven.home.community.508.pdf
New in the Community, Managed LTSS Plans Meet Community Providers	Lowell	Arye	arye.12.new.community.pdf
New in the Community, Managed LTSS Plans Meet Community Providers	Brian	Burwell	burwell.12.new.community.final.pdf
Oral Health Access: Putting Teeth in Public Policy	Paul	Glassman	p.glassman.22.oral.health.pdf
Oral Health Access: Putting Teeth in Public Policy	Sabrina	Johnson	s.johnson.22.oral.health.pdf
Oral Health Access: Putting Teeth in Public Policy	Marty	Milkovic	m.milkovic.22.oral.health.ppt
Pioneering Behavioral Health Treatment and Therapy – State Approaches to Providing Coverage for Applied Behavior Analysis (ABA)	James	Hussey	j.hussey.pioneering.aba.pdf
Pioneering Behavioral Health Treatment and Therapy: State Approaches to Providing Coverage for ABA	Ann	Garfinkle	a.garfinkle.pioneering.aba.pdf
Pioneering Behavioral Health Treatment and Therapy: State Approaches to Providing Coverage for ABA	Alan	Rosenblatt	a.rosenblatt.19.pioneering.aba.pdf
Privacy and Security: Dispelling Myths That Inhibit Data Sharing	Lucia	Savage	savage.5.mythbusters.pdf
Public Health in the Changing Healthcare Landscape	Eileen	Barsi	e.barsi.1.public.health.pdf
Public Health in the Changing Healthcare Landscape	David	Lakey	d.lakey.1.public.health.pdf
Public Health in the Changing Healthcare Landscape	Kris	Kummerfeld	k.kummerfeld.1.public.health.pdf
Spurring Population Health Improvements Through Delivery System Innovations	Laura	Seeff	l.seeff.2.spurring.population.health.pdf
Spurring Population Health Improvements Through Delivery System Innovations	Karen	Gaffney	k.gaffney.2.spurring.population.health.pdf
State Care Coordination Requirements for Managed LTSS	Susan	Reinhard	reinhard.16.state.care.coordination.pdf
State Care Coordination Requirements for Managed LTSS	Gary	Jessee	jessee.16.state.care.coordination.pdf
States and the Physician Workforce: Bringing GME into the 21st Century	Richard	Gottfried	r.gottfried.25.pdf
States and the Physician Workforce: Bringing GME into the 21st Century	John	O’Shea	j.o’shea.25.gme.pdf
States and the Physician Workforce: Bringing GME into the 21st Century	Rebekah	Gee	r.gee.25.gme.pdf
Tackling the Prescription Drug and Opioid Abuse Epidemic	Jim	Graham	j.graham.06.opioid.abuse.pdf
Tackling the Prescription Drug and Opioid Abuse Epidemic	Mark	Biagioni	m.biagioni.06.opioid.abuse.v2.pdf
Tackling the Prescription Drug and Opioid Abuse Epidemic	Jerome	Adams	j.adams.06.opioid.abuse.pdf
The Enrollment Rodeo: Who’s Galloped In and Who Will Be Lassoed Next?	Buffy	Heater	heater.pdf
The New Frontier of Children’s Health Coverage	Christina	Goe	goe.23.children.coverage.pdf
The New Frontier of Children’s Health Coverage	Sharon	Carte	carte.23.children.coverage.pdf
The New Frontier of Children’s Health Coverage	Kevin	Patterson	patterson.23.children.coverage.pdf
The Stampede of the State Innovation Models	Beth	Waldman	b.waldman.20.stampede.of.sim.pdf
The Stampede of the State Innovation Models	Mike	Motley	m.motley.20.stampede.of.sim.pdf
The Stampede of the State Innovation Models	Heather	Petermann	h.petermann.20.stampede.of.sim.pdf
Updates from Health Homes on the Range	Melinda	Thomason	thomason.m.13.health.homes.pdf
Updates from Health Homes on the Range	Gregory	Allen	g.allen.13.health.homes.pdf
Updates from Health Homes on the Range	Samantha	Ferencik	s.ferencik.13.health.homes.pdf
What Works: State Strategies for Funding Effective Recovery-Oriented Services and Supports	Susan	Bergeson	Bergeson.precon.recovery.pdf
What Works: State Strategies for funding Effective Recovery-Oriented Services and Supports	Tom	Lane	Lane.precon.recovery.pdf
What Works: State Strategies for Funding Effective Recovery-Oriented Services and Supports	Erin	Leavitt-Smith	LeavittSmith.precon.recovery.pdf
What Works: State Strategies for Funding Recovery-Oriented Services and Supports	Shawn	Thiele	Thiele.precon.recovery.pdf
Wrangling Medicaid Managed Care: Tested Strategies and New Challenges	Darin	Gordon	d.gordon.4.WranglingMedicaidManagedCare.pdf
Wrangling Medicaid Managed Care: Tested Strategies and New Challenges	John	McCarthy	J.McCarthy.4.WranglingMedicaidManagedCare.pdf
Wrangling Medicaid Managed Care: Tested Strategies and New Challenges	Cindy	Mann	C.Mann.4.WranglingMedicaidManagedCare.pdf

State Strategies for Integrating Health Care and Housing for Homeless Individuals and Families

September 14, 2015/in Policy Webinars Accountable Health, Behavioral/Mental Health and SUD, Blending and Braiding Funding, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Equity, Housing and Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by NASHP

Date: September 14, 2015
Time: 12:30pm-2pm ET

Download Webinar

States interested in improving population health and containing costs are increasingly examining the intersection of housing and health care. As numerous studies show, housing chronically homeless people can improve their health and save money for state and local governments. [1] This webinar offered participants an opportunity to learn about cross-agency levers states can use to meet the housing and health needs of homeless populations. The webinar also addressed the financing mechanisms, data infrastructure and strategic partnerships that facilitate the blending of health care and housing funding streams.

12:30	Welcome and Introductions Trish Riley, NASHP Executive Director
12:35	Overview The overview will provide a primer on housing programs and identify intersections between state housing, behavioral health, and Medicaid programs.Peggy Bailey, Senior Policy Advisor, Corporation for Supportive Housing
12:45	Panel discussion During the panel portion of the webinar, the moderator will ask the panelists a number of questions related to housing and health care.Facilitator: Trish Riley, NASHP Executive DirectorPanelists: Peggy Bailey, Senior Policy Advisor, Corporation for Supportive Housing Chris DeMars, Director of Systems Innovation, Transformation Center, Oregon Health Authority Elewechi Ndukwe, Program Policy Manager, Medicaid and CHIP Office of Policy, Texas Health & Human Services Commission
1:30	Questions and Discussion Trish Riley, NASHP Executive Director
1:55	Conclusion Trish Riley, NASHP Executive Director

[1] https://www.commonwealthfund.org/publications/newsletters/quality-matters/2014/october-november; https://shnny.org/research/integrating-housing-health/; https://jama.jamanetwork.com/article.aspx?articleid=183666https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046466/

Is Housing Good Medicine for States?

August 24, 2015/in Policy Blogs Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Housing and Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by NASHP Writers

Recent media reports have featured chronically homeless individuals who have improved their health and reduced their emergency department use thanks to one intervention:supportive housing. According to one federal agency, supportive housing is “an approach to subsidized housing that provides voluntary services for people with disabilities and chronic conditions to promote long-term stability, recovery and improved health.”
Some state policymakers are exploring the potential of supportive housing to reduce costs and improve the health of their homeless populations. Assisted by recent federal guidance, states are leveraging a variety of funding streams to pay for housing services and supports, including federal health care reform initiatives, Medicaid waivers, and private investment.
As states take increasingly innovative approaches to housing and health care, a number of questions arise: What do states need in order to explore housing services as a means to improving health and lowering costs for certain populations? Which funding streams are states leveraging, and what do they pay for? What will Medicaid pay for? How can states tailor their health and housing efforts to their state-specific circumstances?
To help states navigate these questions, NASHP’s State Refor(u)m offers the following resources:

A national webinar, September 14, 2015, at 12:30pm EDT, featuring state officials from Texas and Oregon discussing their efforts to meet the housing and health needs of their homeless populations. Peggy Bailey, a national expert on supportive housing, will offer an overview of efforts to house and support vulnerable populations across the country. The panelists will explore the financing mechanisms, data infrastructure, and strategic partnerships needed to facilitate the blending of health care and housing funding streams. Click here to register for the webinar.
A new NASHP State Refor(u)m chart of state strategies to support health through housing services looks at initiatives in 10 states. The chart identifies the initiatives’ funding mechanisms, covered services, target populations, and strategic partnerships. Links to state and federal documents, program descriptions, and other sources provide additional information. Special thanks to the Corporation for Supportive Housing, whose resources on Medicaid and housing were invaluable.

As more states view housing as integral to a culture of health, it will become even more important to share best practices and evidence of what works in other states. To that end, watch for additional NASHP projects on health and housing, as we bring our cross-agency Medicaid, public health, and behavioral health policy experience to bear on the pressing issues of health care and homelessness.
On October 19, 2015, NASHP convened a pre-conference meeting, “Improving Health, Lowering Costs: Translating Population Health into Effective State Policy,” supported by the Robert Wood Johnson Foundation. Materials from the pre-conference, which took an in-depth look at housing and other population health issues, are available here.
The preconference preceded the 28th Annual NASHP State Health Policy Conference,which featured a breakfast plenary with Douglas Jutte, MD, MPH, from the Build Healthy Places Network. The plenary explored efforts to integrate state health policy with housing and social supports to more fully address the social determinants of health. Click here for the conference agenda and materials.

Certified Community Behavioral Health Clinics: What’s in It for States?

June 29, 2015/in Policy Blogs Behavioral/Mental Health and SUD, Chronic and Complex Populations, Physical and Behavioral Health Integration /by NASHP

When it comes to behavioral health systems, many states struggle with the lack of “system.” Services provided are often a compilation of available Medicaid state plan options, with little in the way of unifying structures to ensure coordination of care or linkages to other systems. The Substance Abuse and Mental Health Services Administration (SAMHSA) recently announced Certified Community Behavioral Health Clinic (CCBHC) program seeks to address these challenges through the development of community behavioral health organizations that offer a comprehensive array of services, with standards designed to foster continuity and coordination.
On May 20, SAMHSA released the Request for Applications (RFA) for its CCBHC program. The two-phase program includes a RFA for one-year planning grants (of up to two million dollars) to support states in developing CCBHCs. States will use the planning grants to certify community behavioral health clinics based on SAMHSA criteria, develop a prospective payment system for reimbursement of CCBHCs, and prepare an application for the demonstration phase of the program. Phase two, slated to begin in 2017, will engage eight states in a two-year demonstration to implement CCBHCs and evaluate the impact of these new providers on access, cost, and quality of community behavioral health care. States that participate in the two-year demonstration will receive matching federal funding at their state’s Children’s Health Insurance Program (CHIP) Federal Medicaid Assistance Percentage (FMAP) for services delivered by the CCBHCs during the two-year demonstration. Note, this CHIP FMAP rate for CCBHC services does not include the 23 percentage point bump that applies to CHIP between October 1, 2015 and September 30, 2019. Higher FMAP rates do apply to CCBHC services provided to CHIP expansion enrollees and certain newly eligible Medicaid enrollees, however.
Advocates welcomed the announcement of the CCBHC program as one of the most significant investments in behavioral health system transformation in decades, citing the opportunity to create a more standardized and high-performing community mental health system nationwide.
Does the CCBHC program provide solutions to critical state mental health systems issues, and if so, at what cost? The answer for each state may depend on both the existing community mental health infrastructure and the state’s broader healthcare context:
Is your state’s community behavioral health system able to deliver?
State community behavioral health systems are increasingly viewed as a key piece of the health reform puzzle. Whether we are talking about integrating with physical health care, addressing the needs of Medicaid’s most expensive and complex populations, or being the go-to system for high-visibility public health issues (suicide prevention, opioid addition) more is expected of community behavioral health systems than ever before. However, these systems often lag behind in critical areas such as workforce, HIT, common quality measurement tools, and other infrastructure. The CCBHC program, with its focus on establishing standards, beefing up services and systems, and the potential for enhanced Medicaid funding during the demonstration phase, could provide a very timely vehicle for states to do some comprehensive system planning and reform.
Are CCBHCs a good fit with your state’s regulatory framework?
CCBHCs are required to provide – either directly or through formal arrangements with other providers – a comprehensive set of behavioral health services, including crisis services (unless the state has an existing system), screening, assessment, and diagnosis, treatment planning, outpatient mental health and substance use services, targeted case management, psychiatric rehabilitation services, peer and family supports, and community-based mental health care for members of the armed forces and veterans.   Although states are ultimately responsible for certifying CCBHCs based on state criteria, SAMHSA has also laid out some fairly detailed baseline requirements, covering topics such as staffing, cultural competence, access and care coordination. All of this creates a fairly robust regulatory structure, which may or may not align with a state’s existing behavioral health services and systems. States will want to think about how this overlay could help them leverage and strengthen what is already on the ground.
Who (and what) is currently covered?
States that are selected for the CCBHC demonstration must ensure that their CCBHCs are ready to provide a mandated minimum set of services to all in need, regardless of ability to pay or residency requirements. The CCBHC prospective payment, however, may only include costs related to serving eligible Medicaid recipients. States, especially those that have not expanded Medicaid coverage, will need to understand how CCBHCs will support delivery of services to this uninsured/self-pay population. Similarly, states whose benefit package does not currently include all mandated CCBHC services will want to think about how this set of services can be sustained post-demonstration.
Does the CCBHC framework align with other reform efforts and initiatives?
States are engaged in a multitude of delivery system and payment reform initiatives, from improving care coordination to the development of system-wide, value-based purchasing strategies. Behavioral health, while often included in these efforts, can sometimes feel like a sideshow to the main event: carved out, lacking data, and limited by state plan option restrictions. States that have struggled with how to bring behavioral health into the big tent of payment reform may find an opportunity in the CCBHC program. The Centers for Medicaid and Medicare Services lays out two different prospective payment strategies for the CCBHCs, both of which permit states to use quality bonus payments to incentivize good care. States may certify as few as two CCBHC sites as a way to explore these changes while minimizing disruption or conflict with existing reform efforts.  CCBHCs may also provide health home services, so these initiatives need not be mutually exclusive.
High-performing behavioral health systems are critical to broader state health reform efforts, and opportunities for major investment in these systems have been few and far between. The CCBHC program may be an important tool for state policymakers to consider as they think about improving these important systems of care; states will want to review this opportunity to see if it’s a good fit.
Applications from states for CCBHC planning grants are due to SAMHSA on August 5^th, 2015. For more information on the program, visit the SAMHSA CCBHC webpage.

Transition Team Bridge Inpatient to Outpatient Mental Health Services for Complex Mentally Ill

May 28, 2015/in Policy Oregon Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health System Costs, Long-Term Care, Physical and Behavioral Health Integration, Primary Care/Patient-Centered/Health Home /by Mary Takach

In my previous “Walkabout Medical Home” blog posts I have highlighted the work Primary Health Care Organizations (PHCOs) in Australia (Medicare Locals) have done to connect people with mild to moderate mental health diagnoses to primary care or community-based services. This blog highlights the innovative work being done stateside by Oregon’s Health Share.
Health Share is one of the state’s 16 Coordinated Care Organizations (CCO) targeting patients with complex mental illnesses. The CCO utilizes the Intensive Transition Team (ITT), which is designed to address a gap in the care system and provide services to those hospitalized with mental illnesses that are faced with a discharge but have had no prior or inadequate connection with a community mental health provider. For example, patients undergoing their first psychotic break who have not established relationships with the mental health system or patients with long-term disabilities that have ‘given up’ on the mental health system due to multiple environmental and psychosocial reasons.
With funding from the federal Centers for Medicare and Medicaid Innovation, the ITT were launched in three parts of Health Share’s catchment representing diverse geographic areas ranging from urban Portland to rural Clackamas County. This required that the model be adapted in each region to develop appropriate care pathways from hospital to outpatient mental health services reflecting available community resources such as peer, housing, and social services.
Getting referrals for the ITT from the hospitals took some ramping up. After using a media campaign to disseminate information, as well as visiting many of the inpatient psychiatric units to explain the program, referrals have grown to a point where it is often challenging to take on more.
Referrals are typically made either by hospital social workers or the CCO’s care coordinators. Eligible patients must be willing to be involved in intensive, short-term therapy and have no current involvement in outpatient mental health services. The ITT begins by visiting the patient while in the hospital—a key strategy for establishing the relationship. Post-discharge, the team follows the patients for 30-45 days connecting them to a community-based mental health provider, sometimes accompanying the patient on the first couple of visits, as well as a range of transitional support services.
HealthShare’s ITT clinicians are:

Patient-centered and skilled case managers
Based at county crisis centers placing them in a vantage point to intervene if the patient begins to destabilize post discharge
Masters prepared and trained in motivational interviewing
Experts at understanding available community resources
Team members working with peer support staff and medical providers

The ITT has not only increased access to critical services for some of the most vulnerable members of the community, but has established new care pathways improving coordination between providers and leveraging existing services.
Australia Outback: Roadside Art
I’ve heard about the Australian outback, but on a recent trip to the Northern Territory I got a snapshot of how rugged and remote most of Australia is. One thing I didn’t expect was the unique ‘roadside art’ that occupies the hundreds of miles between Alice Springs known as the country’s “Red Center” and Darwin also know as the “Top End”. Aussies have added their creative flair to many of the countless termite mounds that line the Stuart Highway offering motorists an outdoor gallery that is quite entertaining and uniquely Australian!
This represents my last “Walkabout Medical Home” blog from Australia. I’m back at our NASHP Portland, Maine office on July 1 where you can reach me at mtakach@oldsite.nashp.org. G’day mates!

The Mental Health Parity and Equity Addictions Act Proposed Rules – a Checklist for States

May 20, 2015/in Policy Blogs Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Essential Health Benefits, Health Coverage and Access, Medicaid Managed Care, Physical and Behavioral Health Integration /by NASHP

State policymakers have a critical role to play in how the Mental Health Parity and Addictions Equity Act (MHPAEA) is operationalized in state programs, including Medicaid managed care organizations, alternative benefit plans, and the Children’s Health Insurance Program (CHIP). Now that CMS has released long-awaited proposed rules on implementation of the MHPAEA in these programs, policymakers have an opportunity to comment on the rule and start thinking about how to implement its provisions going forward. The proposed rule is open for comment until June 9^th, 2015 and can be accessed here.
The MHPAEA does not require that health insurers or health plans cover mental health or substance use disorder services (MH/SUD). Very generally, the act does require the following:

Health insurers and health plans that provide these services must provide the benefits at the same level as medical/surgical benefits.
If included as a benefit, health insurers and health plans may not impose more restrictive financial requirements, additional cost-sharing, different treatment limitations, or different out-of-network requirements for these services than for medical/surgical benefits.
Medical necessity criteria used to deny these services must be available upon request.

The Affordable Care Act further requires that state alternative benefit plans include MH/SUD services as part of their essential health benefits, and mandates that those benefits be offered at parity with medical/surgical services.
Prepare for the parity analysis. Are your Medicaid MH/SUD services carved in or carved out? The rule proposes that if a state provides any Medicaid state plan benefits to enrollees under an MCO contract, those enrollees receive the protections of the MHPAEA. States that cover their medical/surgical benefits through a managed care organization, and carve out MH/SUD services through other arrangements (such as through a Behavioral Health Organization, or fee-for-service) will need to provide evidence of compliance with parity. States that have multiple MCO and BHO contracts will want to review their various vendor combinations to make sure that Medicaid enrollees have access, regardless of how their MH/SUD services are arranged.
Define your terms. Whether states have their MH/SUD services carved in or carved out, the analysis of parity may still be tricky. While quantitative limitations (Number of visits, for example) may be a more straightforward comparison, “nonquantitative treatment limitations” – such as prior authorizations, continuing review, and stepped therapy – can be harder to compare, and has some states thinking about standardizing terms in order to simplify the analysis. State policy makers will also want to pay close attention to so-called “intermediate services” – more specialized MH/SUD services for which there are no easy comparisons in the medical/surgical world (think substance use residential treatment, for instance).
Plan ahead for any additional costs. Section 438.6(e) of the proposed rule would allow state Medicaid agencies to include benefits beyond the state plan in the MCO capitation rate, to the extent that those benefits are necessary to comply with the parity rules. Policymakers will want to plan ahead to ensure that any increases required in capitation rates are part of state Medicaid budgeting. Note that CMS is interested in receiving comments on this provision, and how to mitigate the risk that could come with overbroad state interpretations.
Be aware of unique challenges. Federal rules prohibit Medicaid federal financial participation for treatment at so-called Institutes of Medical Disease (IMDs) for Medicaid enrollees between the ages of 18 and 65. Other services, like Methadone or Buprenorphine assisted treatment, can be heavily regulated at both the state and federal level regarding how, where, and by whom these treatments are delivered – which can result in limited access. Policymakers will want to track how these limitations impact their Medicaid parity analysis.
Coordinate benefits. Low-income adults and children with serious MH/SUD issues may move through various health coverage options (Medicaid, CHIP, ABPs) as income and health status change. Differences across these benefit packages will persist due to varied medical necessity criteria, service definitions, and service limitations. As implementation of parity regulation moves forward, state policymakers will want to pay particular attention to how individuals with serious mental health needs move between benefit plans in order to ensure coordinated care and continuity with treatment providers, medication, and community supports.
Keep working on workforce. A 2013 report to Congress from the Substance Abuse and Mental Health Services Administration highlighted the significant challenges facing the aging and under-funded MH/SUD work force. Expansion of health care coverage through the Affordable Care Act is expected to increase the demand for these services. Parity is therefore only a piece of the puzzle for state policy makers looking to ensure network adequacy and access to services. States are already tackling the work force shortage through varied approaches such as telehealth, psychiatrist extenders, education loan forgiveness programs, and the use of grant funding to encourage the growth of MH/SUD services in underserved areas. States are also looking to integrated physical/mental health care initiatives and safety net providers, such as Federally Qualified Health Centers, to help with the expected increase in demand.
According to the proposed rule, states will have up to 18 months after the final regulation is posted to comply with parity requirements. Additional information about the MHPAEA proposed rule and its impact on state Medicaid programs can be found at the CMS MHPAEA webpage.

Community Health Worker Models in Evolving State Health Care Systems

May 6, 2015/in Policy 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 System Costs, Long-Term Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home /by Jackie LeGrand

Community health workers (CHWs) are often employed to improve health equity, cultural competency, health literacy and access to care, among other issues. Because they have such varied roles, there are many definitions of CHWs; however, they are commonly identified by their in-depth understanding of the population they serve.
On a recent State Refor(u)m webinar, speakers from Massachusetts, New Mexico, South Carolina and the Center for Medicare and Medicaid Innovation spoke about the role of community health worker models in changing state health care systems. We asked our audience of over 900 listeners to identify the biggest challenge to integrating CHWs into state health care systems. Financing was voted the biggest challenge, followed by defining roles and scope of practice for CHWs, ensuring appropriate training and certification of CHWs, and forming effective partnerships across state government, health plan and provider roles. There are many ways to approach these challenges; every state has unique circumstances and has a unique way to seek solutions, but there are commonalities that enable other states to learn from leaders.
Several states’ models for financing CHWs were discussed. Medicaid has traditionally only paid for care provided by Medicaid licensed providers, which has precluded payment for CHWs. New Mexico uses near-universal managed care for Medicaid recipients and these managed care providers are required to offer the services of community health workers to their members, as part of the capitation contract. Each Medicaid Managed Care Organization then finances CHW-provided care through direct-hire, contracting with groups that hire CHWs, covering the costs, via a flat-fee or per member per month payment, as part of a care team or fee-for-service. This model ensures that Medicaid recipients have access to CHWs.
Massachusetts and South Carolina rely mostly on grants to finance their CHWs. Massachusetts is currently exploring the new SPA to allow for billing of preventive care by non-clinicians based on recommendations from Medicaid providers, allowable under a recent Medicaid rule change. South Carolina warned that defining an encounter as being face-to-face, either with an individual or a group, under their fee-for-service model, has been a barrier to wider use of CHWs. Non-face to face activities such as contacting patients who miss a recommended cancer screening test may not be reimbursed with this definition.
Defining the roles of CHWs, along with certification and training, are also big challenges to integrating CHWs into state health care systems, since their roles can vary widely. In Massachusetts, many stakeholder groups, including relevant state agencies, came together to identify ten core competencies that CHWs are expected to have, no matter their specific role within the health care system. The state is expecting to promulgate regulations during 2015, allowing certification to move forward.
South Carolina has already moved forward with a certification program. The program, offered at a number of public technical colleges, is six weeks long and involves 120 classroom hours, 120 hours in practice and then passing an exam. Grandfathering is allowed for CHWs with at least three years of experience.
Tensions around formalizing the CHW role, and the fear that the demands of certification and training will drive away community members who act as CHWs has developed as states move forward with a formal definition of roles and a training and certification process. Ensuring process participation by a wide variety of stakeholders can ease some of these tensions.
Additional issues that states are facing while working toward formalizing the CHW profession are the financing of the education and certification process, as well as the need to develop a plan for continuing education for certified CHWs.
There is no right way to incorporate CHWs into the health care system and each state that is considering integrating CHWs into its delivery model must take an approach that fits their unique health care system. While each approach will be different, most states find financing, defining formal roles and certification, and stakeholder partnerships to be key issues that require attention.
How is your state using CHWs or working through financing or certification issues? Let us know in a comment below or in the CHW discussion.