Care Coordination – The National Academy for State Health Policy

States Use Appendix K and Emergency Waivers to Support Home- and Community-Based Services in Response to COVID-19

October 13, 2022/in COVID-19 State Action Center Charts, Featured News Home, Maps Care Coordination, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Equity, Long-Term Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Salom Teshale

State Community Health Worker Models

December 10, 2021/in Community Health Workers Featured News Home, Maps 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, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home Community Health Workers /by NASHP Staff

Tennessee’s Care Coordination Tool: Marshaling Data to Help Providers Coordinate Care

September 1, 2021/in Care Coordination Tennessee Blogs, Featured News Home Care Coordination, Primary Care/Patient-Centered/Health Home /by Neva Kaye

For many years, states have worked to ensure that Medicaid participants have access to patient-centered medical homes (PCMH). In 2010, the Affordable Care Act (ACA) authorized state Medicaid programs to create health homes to improve and better coordinate the full range of services needed by Medicaid beneficiaries with chronic health needs. Capitalizing on these opportunities, Tennessee almost simultaneously implemented both a PCMH program to meet the primary care needs of all Medicaid beneficiaries and a health home program to coordinate behavioral and physical health services for beneficiaries with high behavioral health needs (Tennessee Health Link or THL). The PCMH program began in January 2017 and THL began in December 2016.

TennCare (Tennessee’s Medicaid agency) recognized both PCMH and THL providers needed comprehensive information about the service needs and services received by their Medicaid patients to be most effective. However, in the absence of a state health information exchange (Tennessee’s statewide HIE disbanded in 2012), there was no ready source of that data nor was there any existing organization seeking to turn data into the information providers could use to enhance performance. To meet this need, TennCare developed a care coordination tool (CCT) that marshalled data from diverse sources to help both PCMH and THL providers meet the primary and behavioral health care needs of their Medicaid patients. This brief is based on research and an interview with TennCare representatives.

What is the CCT?

The CCT is a cloud-based application that draws from Medicaid claims data, encounter data from TennCare’s contracted managed care organizations (MCOs), immunization data from the Tennessee Department of Health’s (TDH) statewide immunization information system (TennIIS), and information about admissions, discharges and transfers (ADTs) provided by hospitals via data exchange partners, Tennessee Hospital Association (THA), East Tennessee Health Information Network (etHIN) and Community Hospital Systems (CHS). This information, as presented by the CCT, helps providers identify and fill gaps in patient care. It also speeds notification of hospitalizations and emergency department visits enabling providers to more quickly provide transitional and follow-up care when these events occur. Specifically, the types of information in the CCT include:

Name and available demographic information for Medicaid beneficiaries who are members of a provider’s panel
Claims based clinical data drawn from both claims and encounter data, including medication and diagnosis history, as well as records of visits to providers.
ADT information from emergency departments and hospitals.
Immunization data for children under 2 years and those 9-13 years of age.
Each provider’s performance on the quality measures to which PCMH and THL value-based payments are tied.
Care alerts that identify ‘past due’ services needed by an individual patient such as, mammogram, follow-up to a hospital discharge, or an update to the patient’s comprehensive person-centered care plan.

PCMH and THL providers are eligible for bonus or outcome payments based on each organization’s performance on total cost of care, and a set of efficiency and quality measures. The method of calculating efficiency and the specific quality metrics included in the set varies between THL and PCMH providers—and among PCMH providers by the mix of children and adult Medicaid beneficiaries attributed to the practice. Although the CCT is an optional tool for providers participating in the THL and PCMH programs, it provides a platform for providers to act on near real-time data and shows the impact of their work on the quality and efficiency measures by which provider performance is measured. (More information on payment can be found in TennCare’s PCMH and Health Link operational manuals.)

Multiple data sources produce more useful data

“Reach out to providers early…find out their wishlist. What is it that would help them take care of their patients better?”

—TennCare representative

Designed for PCMH and THL providers, the CCT ultimately offers a single consolidated source of information about providers’ panel members, even when members are enrolled in different MCOs. The CCT includes information to help providers identify their members’ primary care needs, any services that have been delivered by other providers, hospital and emergency department ADTs, and more. TennCare obtains much of this information from the claims and eligibility data contained in the agency’s Medicaid Management Information System (MMIS). However, TennCare recognized there are still challenges which exist with incorporating multiple data sources for the CCT. One challenge is the sometimes significant lag between when a service was delivered and when data about that service appears in claims data. Another common barrier for providers and other users of the tool is the lack of connectivity between the CCT and their electronic health records (EHRs), which may mean users need to enter the same information in both the CCT and EHR. Both challenge providers’ ability to use the CCT to obtain the information they need to care for their patients.

TennCare’s partnerships with other organizations that maintain other data sources is a large factor in the agency’s success. The THA became the agency’s first partner when, in 2017, TennCare began contracting with the association to obtain near real-time ADT data to populate the CCT. Because TennCare needed complete ADT information it then worked with the THA to draw in those hospitals that were not already submitting data to the THA. For example, TennCare issued guidance to hospitals requiring them to submit ADT data to qualify for the directed payment of funds that were formerly distributed as unreimbursed hospital cost pool payments. 100% of hospitals in Tennessee now submit ADT data to the THA. Thus, the THA was able to create a more complete data set by partnering with TennCare.

In 2019, TennCare also began contracting with the Tennessee Department of Health (TDH) to incorporate specific immunization data from the statewide immunization information system (TennIIS) into the CCT. This data is used to supplement claims data which populates performance on specific Healthcare Effectiveness Data and Information Set (HEDIS) immunization measures and to identify patients in need of immunizations. Like the THA, the TDH benefits from the contract, as it commits TennCare to working with the TDH to improve the quantity and quality of data submitted to the registry by providers and furthers the shared work of both TennCare and the TDH of improving immunization rates for children in Tennessee.

“One of the biggest draws was that live ADT feed. It helped care coordinators keep up to date with admissions, emergency department use, and discharges so that they could follow-up in real time.”

—TennCare representative

Although these specific data sources may not be available in other states, it is likely that others are. TennCare representatives advise thorough planning is necessary to identify the information needed in the tool—both at launch and in the future. Identifying the partners and resources needed to access data outside of the Medicaid agency’s control also requires thorough planning. Further, developing mutually rewarding partnerships (and contracts) takes time. It is important to have a long-term plan in place early in development.

The CCT is a large investment, but state costs are offset by federal matching funds

The CCT is a large investment. Its development required leadership and dedication of a wide range of staff. Multiple TennCare departments were involved, including the chief medical office, behavioral health operations, information systems, legal, and others. The CCT’s development required the input and feedback of providers and MCOs that would ultimately benefit from the tool. In addition to the contracts with the CCT vendor (HealthEC), THA and TDH, TennCare information system (IS) contractors were also utilized for design and implementation. TennCare representatives estimate that a group of 15-20 were heavily involved in development, but many others were called in as needed.

Of course, the largest part of the investment is the cost to develop and maintain the CCT. TennCare conducted a procurement to select the first vendor to develop and operate the CCT—this contract was awarded in 2016. The second CCT, launched in November 2020, was procured through a current TennCare IS contractor. TennCare representatives feel the new CCT better meets their vision for the tool and the needs of THL and PCMH organizations.

Based on their experience, TennCare representatives advise states seeking to develop a tool to ensure that the selected vendor has qualifications to accurately provide and process the data as inaccuracies will quickly lead to distrust of information flowing through a tool. TennCare representatives advised that it is important for states to:

Set basic qualifications for vendors and involve knowledgeable information technology staff in determining whether potential vendors meet those qualifications.Select a vendor already working with large, multi-site locations and processing many different types of data from multiple data sources.
If state plans include generating HEDIS measures it is important the vendor have a National Committee for Quality Assurance (NCQA) Measure Certification.

“After you choose a vendor, set strategy immediately. The strategy should be as detailed and inclusive as possible, but general enough to grow to what you need in the future.”

—TennCare representative

Seek input from the providers who will be using the tool, for example by convening technical assistance groups of providers to help with design or conducting end user testing with providers.
Conduct detailed reference checks on potential vendors to find out their strengths and weaknesses.
Have a strategic training and engagement plan for the 12 months post go-live

Although the investment was large, the original CCT implementation qualified for 90/10 federal matching funds under the Health Information Technology for Economic and Clinical Health (HITECH) Act. As part of the Medicaid agency’s MMIS, TennCare receives 75/25 federal matching funds for the new HealthEC CCT. This funding greatly reduced the cost to the state. (Note: HITECH funding is only available through 2021, but other opportunities will remain to secure 90 percent funding for design and development of HIE and HIT.)

There is evidence of success

One measure of success is whether providers use the tool. As of June 2021, all PCMHs, THLs, and MCOs have registered at least one staff person to use the tool and a total of 662 MCO, PCMH, and THL users have registered. TennCare representatives report the enhanced ADT data was a big draw for these providers. TennCare offers monthly trainings to some users and individualized assistance to others. TennCare and its contractor have also developed a learning library that includes recorded trainings and quick reference guides to help providers use the CCT to accomplish tasks such as identifying frequent emergency department users.

The most important measure of success, however, is whether using the CCT produces improved cost and quality outcomes. This question is difficult to answer due to the multiple influences in reducing cost and improving quality. However, TennCare did evaluate both the PCMH and THL programs, and agency representatives believe there are indications in these evaluations that using the CCT did produce improved outcomes. Key findings from these evaluations include the following.

The state’s evaluation of the PCMH found evidence of improved quality, increased access to primary care, and increased follow-up visits following emergency department and inpatient visits.
The state’s evaluation of the THL program found indications of improved access to primary care among THL members. It also found the THL members had lower inpatient and emergency department visit rates then a comparison group of similar Medicaid program participants who were not enrolled in the program.

“There are some members THL providers cannot find. With ADT, they can locate and maybe enroll the member if they show up at the hospital.”

—TennCare representative

While these changes cannot be directly attributed to use of the CCT, TennCare representatives believe it did play a role by, as designed, helping providers identify gaps in care and providing the information needed to improve follow-up and coordination. This belief is bolstered by findings from focus groups and interviews with PCMH and THL providers. These providers frequently mentioned the importance of the tool for care coordination, especially the ADT data. Also, many of the providers wanted even more information, suggesting they see great value in the information provided by the CCT. There is anecdotal evidence the information in the CCT helped providers identify the specific primary care and behavioral health needs of their patients and facilitate access to care.

Summary

TennCare’s experience illustrates how state Medicaid agencies can develop IT tools that successfully help providers improve the care delivered to Medicaid beneficiaries, even in the absence of a statewide HIE. TennCare’s success was rooted in meeting provider needs. The agency considered end user needs and preferences during the CCT’s development, provides accurate and near real-time data to improve care coordination efforts, and focuses on giving providers the information they need to improve performance linked to payment. To accomplish this, TennCare looked to data sources outside those operated by the Medicaid agency to create a more timely and complete set of data and developed a strong partnership with the state’s IS agency. Finally, access to enhanced federal matching funds offset the cost of the investment.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank the state officials from Tennessee who contributed to the brief as well as Health Resources and Services Administration Project Officer Diba Rab and her colleagues for their feedback and guidance. We also thank the state officials from Montana and the staff of the Montana Healthcare Foundation whose interest in improving the care delivered to Montana Medicaid participants led to the creation of this brief. Finally, the author wishes to thank Hemi Tewarson, Kitty Purington, Jodi Manz, and Luke Pluta-Ehlers of NASHP for their contributions to the paper. This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials. The information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

Confronted with Overdoses, Rhode Island’s Emergency Departments Employ Peer Services to Promote Treatment

April 12, 2021/in Policy Featured News Home, Reports Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration /by Jodi Manz and Kitty Purington

Drug overdose deaths nationwide have continued to rise during the COVID-19 pandemic, exceeding 88,000 between August 2019 and August 2020, signaling a critical need for substance use disorder (SUD) treatment services and the workforce to provide them. Non-fatal overdoses, which are a predictor of future fatal overdoses, also rose, leading to an increase in opioid-related emergency department (ED) visits even as overall ED visits declined during the pandemic.

While overdose-related ED incidents are traumatizing to individuals and costly to payers – especially state Medicaid programs – Rhode Island has found that hospital emergency rooms can be low-barrier and successful access points to SUD treatment with the right crisis response – including peer services – in place.

Background

Peer recovery services for substance use disorder (SUD) have been demonstrated to help individuals stay in treatment, increase satisfaction with treatment experiences, and reduce rates of return to use.

Responding to existing and projected behavioral health workforce shortages, states are building capacity for SUD treatment by developing certification pathways and reimbursement structures for peers as a non-licensed, supportive workforce.

Rhode Island, and 38 other states, have integrated the use of peers as care team members who can provide Medicaid-reimbursable, non-clinical treatment and recovery support services. In 2014, the state developed an innovative model, AnchorED, that introduced peers into hospital EDs to link patients who experienced overdoses with treatment and recovery. This program is the result of cross-agency collaboration among Rhode Island’s Department of Health (RIDOH), Department of Behavioral Health, Developmental Disabilities and Hospitals (BHDDH), the Providence Center (a community behavioral health provider), and Anchor Recovery Community Centers.

Currently, post-overdose peer services are accessible at all hospitals in the state – with the exception of a Veterans’ Affairs hospital – and peers who provide services are available 24 hours a day, seven days a week. Early evaluation of AnchorED showed that in the program’s first year, peers had contact with 1,329 patients. Among those patients, 88.7 percent were trained to use naloxone and 86.8 percent agreed to engage with a peer after hospital discharge. Further evaluation showed that ED providers consulted with peers in over 85 percent of overdose cases, and referral to treatment upon discharge increased from 9 to nearly 21 percent.

Building Blocks for Rhode Island’s AnchorED Program

State Leadership

State leadership ensures that peer services are recognized as a valuable component of opioid/substance use disorder (OUD/SUD) systems in Rhode Island. The Rhode Island Governor’s Overdose Prevention and Intervention Task Force, established through an Executive Order in 2015, provides a forum for consistent communication related to all SUD-related initiatives and has been important in promoting the peer workforce. This group, composed of stakeholders as well as state policy leaders, is co-chaired by the directors of the RIDOH and BHDDH, the two agencies that were instrumental in implementing policy for peer services in hospital EDs. In 2017, the governor signed another Executive Order making additional policy actions in response to the needs of the state emerging from the task force, including several initiatives supporting peer services that align to the task force’s Action Plan. Outcomes, including data on the number of peer recovery specialists (PRS) in the state and the number of services they provide, are reported on regularly updated public dashboards.

Data for 2020 showed an increase in the number of newly trained PRS, which reached 958 by September, and new client enrollments in services, which has increased steadily from a low point in April, 2020, likely related to the COVID-19 pandemic. The task force, which continues to hold open monthly meetings, recently issued an updated strategic plan that includes goals to further expand and enhance the peer recovery workforce. Task force meeting notes and presentation archives are also publicly posted.

Rhode Island state leaders were also engaged in concurrent efforts on workforce development as a component of their State Innovation Model (SIM) project. The state’s Health System Transformation Program published a Healthcare Workforce Transformation report that advocated expanding the role of peers as members of integrated behavioral health teams. The report recommended providing a pathway for state certification for peers as a strategy to build behavioral health workforce capacity with non-clinical team members in supportive roles.

Infrastructure

Rhode Island, through a number of policy actions, has created a regulatory framework that supports delivery of peer services in hospital EDs. In 2016, the state passed legislation that requires hospitals to submit comprehensive discharge plans to its health department director and outlines specific requirements for post-overdose patient care. Aligning with this statute, RIDOH and BHDDH developed standards for hospital EDs, requiring integration of peer services into ED overdose response across all state hospitals, as well as Freestanding Emergency Care Facilities (FECF) that provide emergency services outside of a hospital’s structure. The agencies delineated these standards in the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder, creating three levels of certification for EDs across the state. In order to gain certification at any of these levels, hospitals and EDs are required to complete and submit a self-assessment that reviews where each facility falls on the continuum of services identified in the standards.

Rhode Island Hospital Levels of Care Standards

Level 3: Minimum standards – indicating readiness and capacity to:

Level 2: These certified facilities must meet Level 3 criteria, and also show capacity to:

Level 1 In addition to meeting levels 1 and 2 criteria, these certified facilities must:

1. Offer peer recovery support services in their emergency departments.

2. Follow the discharge planning standards as stated in current law.

3. Administer standardized substance use disorder screening to all patients.

4. Educate all patients who are prescribed opioids on safe storage and disposal.

5. Dispense naloxone for patients who are at risk, according to a clear protocol.

6. Provide active referral to appropriate community provider(s).

7. Comply with requirements to report overdoses within 48 hours to RIDOH.

8. Perform laboratory drug screening that includes fentanyl on patients who overdose.

1. Conduct comprehensive standardized substance use assessments.

2. Maintain capacity for evaluation and treatment of opioid use disorder using support from addiction specialty services.

1. Maintain a Center of Excellence or comparable arrangement for initiating, stabilizing, and re-stabilizing patients on medication-assisted treatment:

· Evaluate and manage medication assisted treatment, and

· Ensure transitioning to/from community care to facilitate recovery.

These standards for EDs also inform licensing regulations for both hospitals and Freestanding Emergency Care Facilities (FECF) in Rhode Island. Those regulations require that overdose patients and/or patients who are evaluated and found to have SUD are informed of available treatment services and that those patients are offered an opportunity to speak with a PRS. RIDOH also encourages hospitals in Rhode Island to use the BHDDS model consent form language for peer services, facilitating patient consent to both peer and medical services simultaneously. This approach to incorporating peer services into hospital consent forms was mandated by the legislature in 2018.

At this time, the standards are currently under revision by a workgroup of state leaders and stakeholders to identify and address gaps in alignment between the standards and the provider experience. These revisions, however, are not expected to lead to changes in the regulations.

Workforce Development

As officials developed certification requirements for peers, members of the peer community and people in recovery from SUD explained that being paid to help others conflicted with an important tenet of their personal journeys, which is to give freely of their time helping others with SUD and “pay it forward.”

The state began laying the groundwork for peer certification in 2012 when BHDDH began trainings for mental health peer recovery specialists through certification planning developed as part of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Transformation Transfer Initiative (TTI). In 2014, the Rhode Island Certification Board (RICB) – not a state entity – began certifying SUD peer recovery specialists as well, this led to BHDDH ultimately integrating mental health and SUD peer recovery trainings after the state brought together stakeholders through SAMHSA’s Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS) program.

Peer certification in Rhode Island begins with the state’s integrated peer recovery and mental health training provided through Anchor Recovery. Requirements include:

46 hours of didactic learning across four domains (advocacy, mentoring/education, recovery/wellness support, and ethical responsibility)
500 internship hours, including or in addition to 25 supervised hours.
Evidence of passing the International Certification and Reciprocity Consortium (IC&RC) peer recovery certification exam. To prepare for the exam, IC&RC provides a Candidate Guide, and BHDDH contracted with JSI International to develop the Rhode Island Peer Recovery Specialist Certification Study Guide.

Peers delivering services in Rhode Island must receive ongoing supervision from either licensed health care practitioners or certified peers who provided peer services for at least two years. Supervisors must also complete BHDDH-approved core competency training provided through a contract with Anchor Recovery. Agencies providing peer services must maintain a ratio of 1 supervisor for every 10 peer full-time-equivalents, and document provision of supervision totaling at least two hours per month or 30 minutes per week. Agencies must also provide at least a monthly opportunity for group meetings for working peers. In order to deliver services, these agencies must also be certified by BHDDH as Peer Based Recovery Support Services (PBRSS) providers and can use the PBRSS Provider Billing Manual to bill for services.

State Investment and Resources

Initial grant funding. Peers initially began meeting with overdose patients in hospital EDs as a volunteer engagement opportunity supported by Providence Center’s Anchor Recovery, a community recovery organization established in 2010 and funded through the state’s Substance Abuse Prevention and Treatment (SAPT) block grant.

Direct patient crisis response in partnership with a community organization was a familiar approach for the first Rhode Island hospital site to provide SUD peer services. The hospital already had an agreement with a local intimate partner violence organization that allowed volunteers to connect with patients in the ED. The hospital also maintained an agreement with the Providence Center to provide a clinician to triage and assess patients who came into the ED indicating mental health and SUD-related needs. Initial grant funding and existing relationships helped to facilitate development of peer integration.

Medicaid reimbursement. In the long term, paying for peers meant developing a source of sustainable funding for the program, and Rhode Island’s health policy leaders saw an opportunity to reimburse for peer services in Medicaid. While states have a variety of authority options to cover recovery support services in Medicaid, including health home models and 1915(b) and 1915(c) waivers, Rhode Island is one of nine states to provide these services under an 1115 demonstration waiver, submitted to the Centers for Medicare & Medicaid Services (CMS) in 2016 and approved in 2018. The waiver specifies that reimbursable services under the authorized Recovery Navigation Program (RNP) and Peer Recovery Specialist (PRS) Program include “an array of interventions that promote socialization, long-term recovery, wellness, self-advocacy, and connections in the community,” delivered as part of a care team.

Rhode Island’s waiver requires the state to credential peers using the International Certification & Reciprocity Consortium (IC&RC) exam and to develop standards for peer supervisors, as outlined in the previous section. The Rhode Island waiver created a bundled payment, which incorporates services provided by peer recovery specialists as part of the Recovery Navigation Programs. Services outside of such programs, which include those provided in EDs, are billed by the Medicaid-enrolled provider organization employing the PRS and are paid as a flat fee – peer services are reimbursed by Medicaid at rates of $13.50/15 minute unit for one-on-one services and $4/15 minute unit for up to 10 participants for group services.

Reporting and Outcomes

State regulations require that hospitals must report all opioid overdoses to RIDOH within 48 hours through a case report form that captures information about the patient and the overdose event. Additionally, AnchorED captures and reports on each unique patient contact, including data describing whether peer or other counseling services were accepted by the patient. Patients may also be referred to outpatient MOUD treatment, admitted to detox, or refuse engagement altoghter. This data is reported to the state by each hospital as de-identified, aggregate demographic and incident data. This is used to inform state leaders about who is seeking services and what factors may be leading to overdose, and how services are being initiated by PRS.

Anchor Recovery peer specialist services include:

Linking individuals to treatment and recovery resources;
Educating about overdose, prevention, and how to obtain naloxone, a drug that reverses the effects of an opioid overdose when administered quickly;
Providing additional resources to individuals and family members; and
Contacting the individual after release from the ED with a follow-up phone call.

Source: Anchor Recovery

AnchorED reports:

Average minutes between contact and team connection to a patient;
Whether naloxone training was done;
Whether an individual agreed to see a PRS;
Whether an individual agrees to a treatment referral; and
Whether an individual agrees to initiating MOUD that day.

State agencies use these data sets to track outcomes and understand how hospitals are engaging individuals after an overdose to ensure connections to treatment are made. Rhode Island’s overall SUD response strategy includes collection and analysis of treatment and recovery data, and the state uses its Prevent Overdose RI website as a platform to publicly report on measures. ED overdose visits are reported publicly on a monthly basis, along with location and naloxone provision data, and the AnchorED outcomes of patient engagement. Reports include quarterly numbers showing total ED visits, as well as post-overdose counseling, which was accepted by 26 percent of overdose patients in the most recent data reported for the fourth quarter of 2020. Data for that time period also shows that of a total 267 overdose patients, with 45 percent receiving naloxone before being discharged from the hospital.

Challenges and Considerations in Maximizing Peer Workforce

Engage stakeholders. Peer stakeholders have been engaged with policymakers since the inception of the AnchorED program. These relationships helped to develop the policies that support the program, particularly for peer certification requirements. Stakeholder and cross-agency communication continues to drive policy in Rhode Island; regular informal communication through weekly calls among PRS contractors/peer recovery organizations, ED providers, law enforcement, detox centers, and state agencies has been key to identifying emerging trends and resulting needs.

Build workforce diversity. Several state leaders and stakeholders noted that diversity is lacking in the existing peer workforce and suggested that targeted recruitment of peers who are people of color, are bilingual, and/or identify as LGBTQ may help better meet the state population’s needs. A February 2021 update to the Governor’s Task Force – which has recently created a Racial Equity Workgroup – prioritizes this as a goal for the state’s recovery work, listing recruitment and training of people of color and those who speak languages other than English as a short-term recommendation.

Delineate peer roles. While the goals of peer engagement include patient retention and continuity of care, ED providers and stakeholders repeatedly stressed that connecting overdose patients to medications to treat opioid use disorder (MOUD) was the most important intervention to reduce overdose death. Providers noted concern regarding peers advocating for patients to choose either MOUD or abstinence-based recovery, a clinical decision that may test role definition and boundaries. While they emphasized that most peer-to-patient interactions are not clinical in nature and do not include discussions of medical interventions, there have been occasions when providers felt that peers may be overstepping in their roles by dissuading overdose patients from initiating MOUD. Providers and peers alike are mindful of existing tension in the recovery community regarding the use of medications. Abstinence-based recovery programming sometimes discourages medications, though this perspective is far from universal. In the most recent Governor’s Task Force strategic plan update, Rhode Island included a goal to develop PRS who focus on supporting patients in MOUD treatment, and to integrate these specialty PRS into services across the SUD continuum of care.

Identify hiring barriers. When Rhode Island first shifted toward employing peers to work within the hospital, leaders within the recovery organization and the hospital system had to decide whether peers would need to go through hospital system human resources checks and procedures, which may have posed barriers to peers being able to work in the hospital environment due to felony backgrounds or other prior issues. Rhode Island determined that the best course of action was to have peer candidates evaluated as part of the the recovery organization’s human resources to avoid this. Within some health systems, internal hospital policies can prevent the hiring of individuals with felony records, a challenge for some people in recovery who had past convictions. To mitigate this, states can consider approaches in which peers are hired by the organizations that bill for peer services rather than directly by hospitals.

Conclusion

The importance of relationships across systems and among team members in developing and integrating peer services in EDs was a dominant theme in interviews with state leaders and stakeholders. Relationships between the recovery community and hospital clinicians were already in place before AnchorED became a Medicaid-reimbursable model, and leaning on those relationships was key to licensure and Medicaid policy creation. Further, the relationships that develop between team members when providing peer services in the ED help to reduce stigma. As one peer leader said, integrating “education along the way” by talking with providers about the realities of active use and the fears that emerge from it helped humanize recovery for ED providers. Rhode Island’s leaders routinely pointed to the small size of the state and the opportunity that affords them to develop such relationships across systems. While the state’s small size is a unique factor that cannot be replicated, it suggests that states can support regional relationships among community behavioral health, community recovery organizations, and hospital systems through formal regional networks and activities.

Acknowledgements: This brief was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials cooperative agreement. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA/HHS, or the US government. The authors would like to thank HRSA project officer Diba Rab for her support and guidance. Further, the authors would like to acknowledge the dedication, leadership, and input of Rhode Island state agency leaders and staff, as well as providers, stakeholders, and peers who contributed to this brief.

State Approaches to Improve Comprehensive School Mental Health Systems

March 29, 2021/in COVID-19 State Action Center Blogs, Featured News Home Back to School, Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, COVID-19, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Population Health, Relief and Recovery, Social Determinants of Health /by Olivia Randi

The COVID-19 pandemic has negatively impacted the mental health of many children and adolescents and reduced students’ access to comprehensive school mental health systems (CSMHS) as schools shifted to remote learning.

In recent years, states have implemented policies that have successfully expanded access to CSMHS. Lessons learned from these initiatives can help address students’ growing mental health needs and may help reduce states’ health care costs by decreasing mental health-related emergency department visits, which have escalated during the pandemic.

Background

The availability of a comprehensive behavioral health system is critical to a child’s health and well-being. Nearly 17 percent of children and adolescents have a mental health condition, yet almost half of these children do not receive needed treatment. This is more pronounced among children and youth who are Black, Latinx, and come from other racial and ethnic minority groups, which disproportionately face barriers to accessing quality mental health care. These disparities have been amplified by the COVID-19 pandemic. A lack of regular, accessible mental health programs, services, and supports may lead to greater use of emergency departments, which are costlier and often lack appropriate policies to serve children with mental health needs, such as how to transition children and adolescents to other services and provide appropriate care coordination.

Schools are a primary source of mental health services for children and have been shown to improve students’ access to mental health programs, services, and supports. This is true for an increasing number of students, as the percentage of adolescents receiving mental health services and supports in educational settings has grown from 12 percent in 2011 to 15 percent in 2019.

A CSMHS approach is a best practice identified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare & Medicaid Services (CMS). Schools can use this approach to support:

Prevention of mental health needs among all students;
Early identification of students and intervention for those who are at risk; and
Services and treatment for those who have mental health needs.

A CSMHS also supports adherence to treatment, decreased stigma, and improved educational attainment. Implementing and expanding a CSMHS may also help to reduce racial and ethnic disparities in school responses to students’ behavior by encouraging mental health services over punishment. Children and youth with mental health needs who are Black and Latinx are more likely to receive punishment instead of mental health care services in comparison to White children.

A CSMHS is one component of a system of care for children and youth with special health care needs (CYSHCN) and behavioral health needs, and can be considered within a broader framework of policies to support mental health of children and adults.

Federal Policy

There are a variety of federal initiatives that support state efforts to develop and expand these critical school programs, including:

The Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health (DASH) provides funding at state and local levels to promote health and well-being through schools, including programs and services to support students’ mental health;
SAMHSA’s Project Advancing Wellness and Resilience in Education (AWARE) provides funding to state education agencies to partner with state mental health agencies to increase awareness of mental health in schools, provide training to school staff, and connect students with behavioral health needs to services; and
The School-Based Mental Health Services Grant Program, authorized by the 2020 Department of Education budget, provides $10 million to six states to increase the number of mental health service providers in schools.

The Biden Administration has underscored the importance of behavioral health services for students by setting a goal to double the number of mental health professionals in schools. The day after his inauguration, President Biden issued an executive order stating that the federal government will support states in promoting mental health and social-well-being in schools, and the American Rescue Plan Act of 2021 that was signed into law in March 2021 allocates more than $120 billion in grants to states through the Elementary and Secondary School Emergency Relief Fund. The majority of this funding will be distributed to local education agencies, which could use these subgrants to provide mental health services and supports and to implement interventions that address learning loss while responding to students’ emotional needs, among other purposes.

State Policy Considerations

Schools have adapted to shifting priorities over the past year and continue to implement innovative strategies to meet students’ growing mental health needs. During the pandemic, several states have introduced legislation to support schools in various ways to enhance their mental health programs during and after the pandemic.

Implementing statewide task forces. Schools face a variety of barriers to developing CSMHSs for students, including allocating adequate funding, adhering to data privacy regulations, and identifying and implementing best practices. To support school districts’ diverse needs, states are forming committees to review existing approaches and make recommendations to improve mental health programs. This process may be particularly helpful to identify and address emerging challenges and strategies during and after COVID-19.

In 2017, North Carolina created the Superintendent’s Working Group on Student Health and Well-Being to produce recommendations to support students’ mental health, which were released in a report in May 2018. In October 2020, Illinois introduced legislation that would create a similar mental health task force consisting of mental health providers, school nurses, state General Assembly members, school board members, principals, parents, and students to produce recommendations in 2021.

Developing mental health policies in schools. Clear policies at the state and local level can support comprehensive, consistent, and appropriate approaches to addressing students’ mental health needs in schools. State policies can provide guidance for local school districts regarding expectations and best practices, while allowing flexibility for schools to meet their students’ specific needs while considering the local context.

On June 8, 2020, North Carolina enacted SL 2020-7 S476, which implemented recommendations from the state task force. This law requires the Department of Public Instruction to adopt a statewide, school-based mental health policy, and requires each school to adopt its own policy following task force recommendations.

Supporting universal screening practices. Widespread screening for children’s behavioral health needs is a recommended best practice. While schools have a unique opportunity to screen a high proportion of their students for behavioral health needs, less than 15 percent of schools have implemented a universal screening process. States are supporting schools by issuing recommendations for schools to increase mental health screening among students and guidance for funding for these services.

New Mexico requires in its administrative code that schools screen all students for health and well-being, including behavioral health needs. The state has developed guidance on funding sources for screening services, which may include operational funds, Title I and Title III funds, and Coordinated Early Intervening Services funding through the Individuals with Disabilities Education Act. In January 2020, New Jersey introduced legislation that would require schools to provide annual depression screening for students in grades seven through twelve.

Expanding the availability of mental health services in schools. Few schools meet the recommended student-to-staff ratios for counselors, psychologists, nurses, and social workers due to a lack of funding and workforce shortages. States are enhancing CSMHSs through policies that provide funding to increase the availability of mental health professionals in schools and support partnerships with community-based behavioral health agencies.

Washington, D.C. has made significant efforts to support the expansion of behavioral health services to all students by earmarking local and federal funding and increasing funding over time for schools to develop partnerships with community-based mental health services. In October 2020, New Jersey introduced legislation that would require all public school districts to have at least one school counselor and to meet a maximum student-to-school counselor ratio of 250 to 1 – the national recommended ratio.

Improving mental health training and education. School staff who are frequently in contact with students are an important resource to support students’ mental health. States are providing guidance and support to train these staff to identify indicators of mental health needs among students and facilitate appropriate referrals. States also advise on school curricula and education that support mental health awareness among students.

North Carolina’s SL 2020-7 S476 requires the state’s mental health policy to include a model mental health training program for school staff that local school districts must adopt. All school staff who work with students in grades K-12 must be trained in youth mental health, suicide prevention, and other mental health-related topics. Pennsylvania introduced similar legislation in September 2020 that requires schools to train school staff in identifying signs of depression and referring students and their families to mental health services.

Conclusion

Comprehensive school mental health systems are an important component of systems of care for CYSHCN and behavioral health needs. The National Standards for Systems of Care for CYSHCN, which were developed by a national work group of state and national health policy leaders, is a valuable resource that states can use to guide improvements to systems of care for CYSHCN, including considerations for mental health systems. States can implement systems based on the following standards to improve care for CYSHCN during and after COVID-19, including:

Improve mental health care access, especially for marginalized communities;
Increase the use of medical homes serving individuals with chronic and complex conditions;
Improve coordination of care across behavioral health, social and health systems; and
Improve access to CSMHS.

Schools have played an important role in supporting students’ mental health, but often face challenges in implementing CSMHS. Mental health needs among children and adolescents have been rising for several years, and this trend has been exacerbated by the pandemic. One way that states can address this is through policies that strengthen CSMHS to support students during and after the pandemic. The National Academy for State Health Policy will continue to track state policies that support CSMHSs during and after the COVID-19 pandemic.

Maryland’s Family Recovery Courts: Successfully Reuniting Families with the Help of Customized Substance Use Disorder Treatment

March 22, 2021/in Policy Maryland Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health /by Mia Antezzo

To reduce substance use as a key cause of children removed from their homes, Maryland implemented a Family Recovery Court program in 2004 that connects parents to intensive treatment for substance use disorder (SUD) and provides case management and incentives. Over a one-year period, program evaluations show the program produced a 25 percent higher reunification rate, reduced days that children spend in non-kinship foster care (252 vs. 346), and produced more than $1 million in savings for the state’s child protective system due to reduced foster care utilization.

Background

Substance use is a major contributing factor in child removals. The rate of removals associated with substance use rose nearly 20 percent between 2000 and 2016 and peaked at 36 percent in 2018 before falling slightly to 34 percent in 2019. To address substance use as a driver of children entering foster care, Maryland uses a Family Recovery Court (FRC) model that connects parents to intensive services, case management, and incentives – all emphasizing SUD treatment as an opportunity to support family reunification.

FRC is a civil court proceeding that works closely with the state’s child welfare/child protection system. Individuals are referred to the FRC when they interact with the judicial system because their abilities to parent have been impaired as a result of SUD. Parents participating in FRCs have an underlying child welfare case in civil family court, where they often face the threat of losing custody following allegations of neglect. Maryland’s FRCs recognize the chronic nature of SUD and that without support and treatment, parents with SUD may continue to struggle. Maryland’s successful model is centered around services and engagement that incentivize the safety, health, and stability of families.

Outcomes of Maryland’s Family Recovery Court Model:

Improved family reunification rates;
Fewer days in non-kinship care;
Increased treatment completion rates; and
Net savings for Maryland child welfare system

Establishing Family Recovery Courts

Maryland’s Code and Court Rules established a formal process for creating “problem-solving courts” that include FRCs. An administrative order from the Chief Judge of the Court of Appeals details the court’s process.

A county circuit court or district court judge is required to lead its development, which includes consulting with and receiving commitments from other government agencies that are willing to participate as partners in the problem-solving court.
Planning must establish community need indicated by SUD rates, child abuse/neglect cases related to parental SUD, rates of SUD treatment retention. The leaders outline program goals, protocols, and an estimated budget.

“The range of services available are so rich and so focused on getting at the source of the medical issue that is driving their use disorder. Not to simply achieve a period of negative urine analysis screenings, but to get to the core causes that will bring them to that ‘I’m done’ day.” – Maryland state official

Maryland established its first FRC in Harford County in 2004, followed by Baltimore City in 2005. Today, the state operates five such courts across the state. To standardize best practices and requirements across jurisdictions, the Maryland Office of Problem Solving Courts released Guidelines for Planning and Implementing Family/Dependency Drug Treatment Court Programs in 2017. These guidelines spell out the process of establishing a FRC, including programming details, target populations, the role of the judiciary, policy issues, and funding strategies.

Eligibility:Parents who participate in Maryland’s FRC programs do so voluntarily, understanding that family reunification is the goal of the program. Eligible participants include:

Parents of infants with positive screens for substances;
Parents with reported neglect;
Parents who maintain custody, but neglect is indicated through a petition; and
Parents who maintain custody following a court’s disposition.

Parents may be referred into the program by child protective services, public defenders, magistrates, and social workers.

Services: Parents participating in a Maryland FRC are provided with an immediate assessment followed by comprehensive SUD treatment services and intensive supports to stabilize the family unit. “The range of services available are so rich and so focused on getting at the source of the medical issue that is driving their use disorder,” noted one Maryland state official. “[The goal is] not to simply achieve a period of negative urine analysis screenings, but to get to the core causes that will bring them to that ‘I’m done’ day.” All parents undergo extensive intake by internal court case managers who develop personalized treatment plans. Plans are closely monitored by the court, which convenes weekly to review open cases and participant progress.

Through the FRC, parents can access:

Psycho-social supports, including counseling, as well as medication for opioid use disorder (MOUD) when clinically indicated;
Peer support;
Assistance in applying for Medicaid;
Linkages to housing and transportation;
Life skills training; and
Continued access to the staff and resources of the FRC to gain continued parenting and SUD support.

FRCs take an incentives-based approach that embraces the reality that SUD is a chronic relapsing disorder – it does not terminate parents from the program solely on the grounds of their return to substance use.

Funding/State Support: Maryland utilizes several funding sources to operate its FRCs. State grant funds from the Office of Problem-Solving Courts, within Maryland’s Administrative Office of the Court, are the primary source of financial support. These grants cover administrative, staffing, training, and drug testing costs, and some ancillary services. In recent years, the state legislature has reduced the judiciary’s budget, but exempted problem-solving courts from any reductions. In 2017, the state’s Heroin and Opioid Prevention Effort (HOPE) and Treatment Act included an ongoing, mandated an appropriation to fund drug courts, including FRCs. FRCs and the Office of Problem-Solving Courts also partner with the Department of Behavioral Health, Department of Social Services, and other agencies to fund and navigate services such as transportation and housing supports. Finally, health care services, such as in- and outpatient treatment, psycho-social therapy, and MOUD are covered by Maryland Medicaid for eligible participants.

Outcomes:While the core goal of this court model is to achieve residential permanency for children, Maryland’s FRCs seek to achieve the often more difficult goal of family reunification by emphasizing holistic rehabilitation. In addition to treatment adherence, parental skill development and engaged participation are critical to the program’s success, and meeting the requirements for graduation from the program can be challenging. As part of annual reporting, the Administrative Office of the Courts routinely reviews all problem-solving courts, including FRCs. The 2020 Annual Report to the legislature indicated that, after adjusting for participants who left for administrative reasons, an average of 19 percent of participants graduated across FRCs in the state; Baltimore County had the highest graduation rate at 34.5 percent.

An external evaluation covering one year in 2008 also showed:

A reunification rate of 70 percent for families participating in FRCs, as opposed to a 45 percent reunification rate among families who did not participate;
Fewer days spent in non-kinship foster care placement (252 days vs. 346 days)
A net savings of over $1 million for the state’s child protection system due to decreased utilization of the foster care; and
A treatment completion rate by participating parents of 64 percent, compared to 36 percent of non-FRP parents.

Further, one FRC in a small jurisdiction was closed as the result of positive outcomes that led to a lack of subsequent need in the community.

Key Takeaways

To establish an FRC in a state, Maryland officials recommend policymakers:

- Seek judicial leadership. Maryland’s Problem-Solving Courts are championed, developed, and supported by leadership within the judiciary, included judges across the state and from various levels of the state’s court system. Critical administrative funding, guidance, and enabling regulation flows from and is overseen by the judicial system, contributing to the program’s overall sustainability and success.
- Frontload a diverse and intensive array of services, and then maintain connections. State officials credit the program’s wraparound approach as an integral part of its success. Maryland’s FRCs provide case management services, short- and long-term family housing and transportation assistance, and employment preparation and life skills development. State leaders view the FRC as a lifelong program. FRCs employ parent locators who seek out FRC alumni and either re-engage them in treatment or encourage their participation in the program as peer support specialists. Parents may continue to receive services in the community after program completion.
Encourage cross-agency collaboration. Maryland’s FRCs and adult drug courts are administered by the Office of Problem-Solving Courts and share an oversight committee, which provides an opportunity for collaboration across criminal and civil dockets. This approach also requires coordination among systems and agencies – the courts work with social services, health and behavioral health/SUD providers, and housing and transportation services to align resources and policies to ensure that the necessary supports are in place to help parents and families remain unified, healthy, and safe.

The National Academy for State Health Policy is providing this fact sheet with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. The authors would also like to thank Richard Abbott, Director, Juvenile and Family Services, Gray Barton, Director, Problem Solving Courts, Lou Gieszl, Assistant State Court Administrator for Programs, and the Hon. Robert Kershaw, Associate Judge, Baltimore Circuit Court, for contributing their expertise and state experiences to this report.

How States Improve Housing Stability through Medicaid Managed Care Contracts

February 19, 2021/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Social Determinants of Health /by Ariella Levisohn

In 2019, more than 500,000 individuals experienced homelessness and nearly 20 million renters spent 30 percent or more of their income on housing. These numbers are increasing as the COVID-19 pandemic exacerbates housing insecurity for people of color and low-wage workers. To improve housing stability – a critical social determinant of health (SDOH) – states are using Medicaid managed care contracts to encourage health plans to support members’ housing-related needs and promote coordination between housing providers and health plans.

Background

Housing status is a key social determinant of health. Many individuals experiencing homelessness suffer from diabetes, heart disease, and HIV/AIDS at rates that are up to six times higher than the general population, and are at increased risk for contracting COVID-19. Rates of mental illness and substance use disorders are also significantly higher among individuals experiencing homelessness.

Many individuals experiencing or at risk of homelessness qualify for Medicaid. Medicaid can be a valuable resource for helping individuals facing housing insecurity, and research shows that investing in housing can save states money and improve health. One study found that hospitalization, emergency room use, and total expenditures for individuals experiencing homelessness in Massachusetts were 3.8-times higher than for the average Medicaid recipient.

Increasingly, state Medicaid agencies are focusing on addressing housing-related needs of their enrollees through their managed care contracts.

The National Academy for State Health Policy (NASHP) recently completed its three-year Health and Housing institute. Read its final report, Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives, to learn how Illinois, Louisiana, New York, Oregon, and Texas improved their respective health through housing initiatives.

How States Use Medicaid Managed Care Contracts to Address Housing Needs

While Medicaid managed care contract language varies significantly between states, there are some similarities in states’ approaches to addressing Medicaid enrollees’ housing needs, including these managed care organization (MCO) contractual requirements:

Screen enrollees for housing-related needs;
Hire designated housing coordinators; and
Ensure the coordination of care between housing providers or agencies and Medicaid programs.

States working to address housing insecurity and homelessness among Medicaid enrollees, or states that already require plans to focus on SDOH more broadly but wish to tailor initiatives specifically towards improving housing status, can adopt some of the contractual language and initiatives described below.

Screening for Housing Insecurity

According to NASHP’s scan of states’ Medicaid managed care contracts, 16 states (of 38 with publicly available contracts or requests for proposals) require contractors to conduct routine screenings for certain SDOH. Of the 16 states, 14 require their managed care plans to screen members about their housing needs during these assessments. These screenings can occur at any interval from annually to quarterly, with some states specifying that individuals who qualify as high-needs members should be screened more frequently. In New Hampshire, community mental health programs that contract with the state’s Medicaid program are required to conduct quarterly assessments and document all members’ housing status. In Pennsylvania, providers must complete an SDOH assessment that focuses on housing security, among other things, at least annually and more often depending on the individual’s risk level.

While some states require health plans to screen all enrollees, others only require screenings for certain populations. For example, Minnesota’s Medicaid MCO requires outreach and screening for members who have been to the emergency department for services three or more times within four consecutive months. In Alabama, the maternity psychosocial assessment includes questions related to homelessness.

Screening for housing status in order to identify members experiencing housing insecurity or homelessness is an important first step in addressing housing needs. However, in the absence of mechanisms to connect individuals to community resources that can help them find appropriate housing assistance, the impact of SDOH screenings is limited.

Hiring Housing Coordinators

According to NASHP’s analysis, seven state Medicaid MCOs identify a designated, full-time employee exclusively responsible for addressing enrollees’ housing needs – Arizona, Kansas, Louisiana, New Hampshire, New Jersey, New Mexico, and North Carolina. Other states, including Delaware and Pennsylvania, require their plans to hire more broadly defined care coordinators or SDOH specialists. They work on housing as part of their jobs, but are also responsible for addressing other member needs, such as employment, transportation, and education.

Through its contract with Kansas Medicaid, United Healthcare employs a housing navigator, a position added in 2016. The housing navigator develops partnerships statewide to identify resources for providing housing supports – including vouchers, prevention services, public housing, and homeless service agencies – and to help members locate housing. United Healthcare’s housing navigator has assisted more than 200 Medicaid members with housing needs.

The Louisiana MCO contract requires the plan to hire a permanent supportive housing program liaison who works with the Louisiana Department of Health to help implement the PSH program deliverables, which include providing affordable housing and tenancy supports. While hiring housing navigators or specialists requires MCOs to invest financial resources, onboarding navigators to help connect members directly to housing services and supports has been shown to be one effective way to address Medicaid enrollees housing-related needs, especially those identified during SDOH screenings.

Partnering with Housing Providers and Agencies

State housing agencies and local housing providers are also valuable resources for improving both the health and housing needs of individuals. Rather than building new systems, managed care plans can address housing insecurity among members by partnering with existing housing services and working to eliminate siloes between health and housing agencies.

For example, in New Mexico, health plans are required to contract with a federally qualified health center that specializes in providing health care for populations experiencing homelessness. Similarly, in New York, health plans are required to coordinate care with Health Care for the Homeless providers. In Oregon, Coordinated Care Organizations – the state’s Medicaid accountable care organizations – have contracted with community-based organizations to provide housing supports and helped develop a medical respite program to house individuals experiencing homelessness following an inpatient hospital stay.

Initial data from New York’s pilot partnership project between Medicaid MCOs and housing providers to reach individuals experiencing homelessness who are high utilizers of Medicaid services showed a 46 percent reduction in emergency room (ER) visits, a 47 percent decrease in Medicaid costs, and a 99 percent reduction in ER costs for participants.

Some state Medicaid contracts also identify opportunities for MCOs to support housing initiatives run by state or federal housing agencies. In Texas, the Medicaid MCO service coordinator must work with staff from their Section 811 Project Rental Assistance program, a federal program that helps provide supportive housing for individuals with disabilities, to coordinate care for Texans receiving Section 811 services and those leaving nursing facilities. This helps integrate health and housing services for individuals previously identified as having housing needs. In Louisiana, the state housing authority and the Department of Health co-manage the permanent supportive housing (PSH) program. The Louisiana MCO contract outlines a number of ways that MCOs are required to support the PSH program, including:

Provide outreach to members who qualify for PSH;
Help members apply for PSH;
Ensure timely prior authorization for PSH tenancy and pre-tenancy supports;
Refer members approved for PSH to relevant providers; and
Work with PSH program management to ensure an adequate and qualified network of PSH program staff and service providers.

The MCO is also required to contract directly with housing providers approved by the state to provide tenancy and pre-tenancy supports to members participating in the PSH program. One analysis of Louisiana Medicaid recipients pre- and post-PSH showed a 26 percent reduction in emergency room visits, a 12 percent reduction in hospitalizations, and an increased use of behavioral health services among participants. Through partnerships with PSH programs, MCOs can improve integration of health and housing services for members and expand the reach of housing programs by helping to identify Medicaid enrollees in need of housing and connect them directly to resources.

Creative Financing

State Medicaid managed care contracts employ creative ways to use Medicaid funding to support efforts to address housing insecurity among enrollees. Although Medicaid cannot directly fund housing, there are many other strategies to effectively invest in housing services. Oregon’s Coordinated Care Organizations (CCOs) are required to spend a portion of their profits or reserves on health-related services, and specifically on housing supports. Starting January 2021, CCOs are also required to submit annual spending plans to the state, which include the CCO’s spending priorities related to addressing SDOH and health equity, and how they align with the state’s housing-related priorities. In Kansas, the state’s MCO request for proposal calls for alternative payment strategies to incentivize warm handoff transitions for individuals moving from institutions into community-based programs and services.

In Massachusetts, the managed care contract mentions the Social Innovation Financing for Chronic Homelessness Population Program (SIF), a Pay For Success (PFS) initiative that finances PSH. Through the Community Support Program for People Experiencing Chronic Homelessness (CSPECH), Medicaid managed care entities fund support services for PSH tenants in the PFS program. As of October 2020, 860 members have enrolled in CSPECH. Together with the PFS program, CSPECH has improved housing retention, decreased emergency room stays, and saved millions in costs. While the current budget climate arising from the COVID-19 pandemic makes adopting new funding strategies difficult, investing health plan dollars in housing services can not only improve members’ housing status, but also decrease Medicaid spending down the line.

Pilot Programs

In addition to established methods, such as screening for housing needs and partnering with housing service providers, some states are using their managed care plans to launch new initiatives to address their Medicaid enrollees’ housing needs. In Florida, MCOs are participating in a voluntary pilot program to provide behavioral health services and supportive housing assistance directly to Medicaid enrollees who are homeless or at risk of homelessness and who also experiencing either serious mental illness or substance use disorder. The North Carolina managed care contract provides for an Enhanced Case Management Pilot program in up to four areas of the state. MCOs in each area work to determine the most effective, evidence-based interventions to address four priority domains, which include housing. The program also requires each program to evaluate the effect of the interventions on health care costs and outcomes. There is no “one-size-fits-all” approach to addressing housing, but piloting programs like these, or creative financing solutions like those mentioned above, can help MCOs determine which methods are best for reaching housing-insecure members in their state, while also improving health outcomes and decreasing costs.

Conclusion

As efforts to address SDOH become increasingly common among Medicaid managed care plans, many states are narrowing their focus to address housing insecurity and homelessness specifically. By working to identify enrollees’ housing needs and directly connect them to housing and supportive services, health plans can improve housing stability, which in turn improves health outcomes and decreases costs.

During the COVID-19 pandemic, states face budget challenges while their Medicaid managed care plans may experience financial gains from a decline in demand for physical health services. This leaves health plans in a unique position to invest new resources upfront in housing-related services. In 2020, many insurers reported large profits, in part due to the decline in non-COVID-19-related hospital admissions. Medical Loss Ratio rules, however, limit the amount insurers can keep for profit or overhead costs – health plans must either issue rebates or spend more on health-related services, which presents an opportunity to use these additional funds to address housing insecurity and homelessness among enrollees. And, by requiring health plans to indirectly invest in housing by hiring housing coordinators, partnering with existing housing agencies who are already immersed in the work, financing housing-related services, or by piloting new, creative solutions, states can take the lead in guiding Medicaid managed care plans’ work.

This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.

States Use Appendix Ks to Provide Innovative Flexibilities for Medicaid Enrollees and Caregivers during COVID-19

December 11, 2020/in The RAISE Act Family Caregiver Resource and Dissemination Center Connecticut, Georgia, Washington Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, COVID-19, Long-Term Care, Medicaid Managed Care, Population Health, State Resources, The RAISE Family Caregiver Resource and Dissemination Center /by Salom Teshale, Paige Spradlin, Wendy Fox-Grage and Kitty Purington

During the COVID-19 pandemic, states have used the Appendix K Emergency Preparedness and Response authority to amend Medicaid 1915(c) home- and community-based services (HCBS) waivers and quickly provide more flexible services and supports to Medicaid enrollees and, indirectly, their caregivers.

The Appendix K amendment was developed to reduce states’ administrative burdens during a crisis by enabling states to rapidly modify or add services provided through Medicaid waivers. States can specify proposed effective dates and anticipated end dates for Appendix Ks, which are generally tied to the period of the public health emergency.

During the emergency period, states can temporarily modify waiver features, such as the types of services and providers included under the waiver, reporting requirements, payment rates and retainer payments, and modes of service delivery such as telehealth. States can also temporarily increase the unduplicated number of participants (Factor C) and make a host of other temporary changes. Appendix K provides flexibility without providing new funding to states, and states cannot use Appendix K to make changes not allowed under statute.

This report highlights examples of innovative modifications incorporated through Appendix K amendments by Connecticut, Georgia, Utah, and Washington to support older people, adults with physical disabilities, and their caregivers during the pandemic. Additional information about states’ use of Appendix K, including more information on other approaches taken by the four states highlighted below, can be found on NASHP’s interactive map of state Appendix K amendments. This map is part of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, funded by The John A. Hartford Foundation and in collaboration with the US Administration for Community Living.

Connecticut: Maintaining Key Services while Limiting COVID-19 Exposure

Connecticut submitted multiple Appendix K amendments for multiple home- and community-based services waivers, including the Personal Care Assistance (PCA) and Home Care Program for Elders waivers, in order to leverage federal flexibility to sustain services while maintaining social distancing for especially vulnerable older adults and people with disabilities.

Through its Appendix K amendments, Connecticut is supporting remote delivery for a range of services such as adult day programs, counseling, evaluation and assessment. The state has permitted family members to receive payment for providing certain personal care-related services in the home, added home-delivered meals to the PCA waiver, and allowed additional or non-traditional home-delivered meal providers for both waivers. These changes have allowed participants to maintain connections and receive support while reducing the risk of exposure to the virus.

To help Medicaid enrollees get the long-term services and supports they need during the COVID-19 crisis, states use waivers and amendments granted by the Centers for Medicare & Medicaid Services to add flexibility in their program delivery.

Many states have used these tools to modify their home- and community-based services for older adults and their family caregivers during this crisis.

Connecticut’s Department of Social Services reports positive feedback on the changes, noting that modifications have effectively supported continuity of care for waiver enrollees. For the Home Care Program for Elders and PCA waivers, other important changes in Connecticut included temporarily allowing emergency increases in individual cost limits for current enrollees, and, within the Home Care Program for Elders waiver, allowing substitution of lower- level staff in the service plan when necessary.

Georgia: Paying for Services in Temporary Living Situations

Georgia drafted multiple combined Appendix K amendments for two of its waivers, the Elderly and Disabled waiver and the Independent Care waiver. During the emergency, among other changes, Georgia now allows family caregivers in neighboring states to receive reimbursement for providing care when the Georgia Medicaid waiver beneficiary is temporarily living with and relying on care from them during the pandemic. The state also permits family caregivers or legally responsible individuals to receive payment for providing certain personal support services and out-of-home respite. Georgia allows certain specified waiver services, including respite, to be delivered in temporary living situations, including hotels and other accommodations both in and out of state.

Utah: Allowing Payment to Nontraditional Meal and Transportation Providers

Utah used a combined Appendix K amendment to make emergency changes across seven of its waivers. Among these waivers, the Aging, Physical Disabilities, and New Choices waivers cover older adults and people with physical disabilities. Among a range of changes and flexibilities, Utah’s combined Appendix K amendments expand provider types to permit service delivery by nontraditional providers and in alternate settings. For home-delivered meal services, Utah added the ability to use delivery services such as DoorDash and UberEats in a community meal option. For non-medical transportation, the state currently allows reimbursement for non-enrolled providers, such as Lyft or Uber drivers.

Utah also expanded provider types for environmental adaptations, specialized medical equipment, and assistive technology to include the use of a purchase card to buy items from nontraditional vendors on a case-by-case basis. The state now permits direct care services, respite, day supports, and supported employment to be provided in nontraditional settings, such as churches, hotels, shelters, or the home of a direct care worker for participants who are displaced from their home due to COVID-19, or when providers are unavailable due to COVID-19. Day supports may also be allowed in an enrollee’s home. Utah also temporarily increased the unduplicated number of participants by 250 for its New Choices waiver.

Washington State: Providing a Lifeline to Adult Day Centers

To support Medicaid enrollees who rely on long-term services and supports, their family caregivers, and long-term care workers, Washington State instituted multiple Appendix K amendments to multiple waivers, including three of its home- and community-based services waivers: the Residential Support, Community Options Program Entry System (COPES), and New Freedom waivers.

Noting that key HCBS providers – such as adult day centers – that rely on face-to-face contact were at risk of shutting down, the state used Appendix K amendments to implement retainer payments during the pandemic. One official noted that the state’s ability to offer these retainer payments, and to permit day support services to be delivered both remotely and outside the adult day care setting, have been critical to maintaining care and keeping adult day centers open during the pandemic. Washington also used Appendix K amendments to, among other changes, allow up to two daily home delivered meals (in COPES and New Freedom waivers), and support the cost of Personal Protective Equipment (PPE) as part of specialized medical equipment and supplies for beneficiaries (in COPES and Residential Support waivers).

What’s Next?

While these policies are temporary, understanding the impact of these changes on the cost and quality of care for Medicaid enrollees and their family caregivers will be important in determining whether some or all of these innovations should continue after the pandemic.

States may want to consider which flexibilities provide long-term value by reviewing how reimbursement to alternative providers (such as family caregivers) and in alternate settings impacts their costs, quality, utilization, and/or waiver capacity. States may also consider how or whether newly developed infrastructure, such as telehealth, alternative providers, and service delivery mechanisms, can improve care options post-pandemic. States can also apply for a Section 1115 Demonstration opportunity to evaluate how flexibilities undertaken during the COVID-19 emergency affected the provision of care for Medicaid enrollees. States can engage Medicaid enrollees and their family caregivers to better understand impact, identify other potential innovations, and to prepare for future emergencies.

The National Academy for State Health Policy will continue to update its interactive map of state Appendix K amendments to cover policy changes that emerge as a result of the ongoing pandemic.

Massachusetts Increases Adolescent Substance Use Treatment by Building Primary Care Provider Capacity

November 30, 2020/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Integrated Care for Children, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration /by Veronnica Thompson

To increase much-needed early identification and treatment of adolescent substance use – and prevent the onset of substance use disorder – the Massachusetts Child Psychiatry Access Program and the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital partnered to offer readily available consultation services to the state’s primary care providers and their adolescent patients with substance use needs.

Early intervention in adolescent substance use has the potential to promote healthy development, facilitate more integrated care to address related behavioral health concerns, and reduce development of a substance use disorder (SUD), resulting in significant cost savings to states. But many primary care providers (PCPs) report they are not comfortable managing the substance use needs of their adolescent patients and only 10 percent of adolescent patients who need SUD treatment receive it. The Massachusetts model provides an easily accessible expert resource to bolster access, early intervention, and primary care provider capacity to respond to this health care need.

Background

Substance use among adolescents is common. In 2019, 29 percent of US adolescents reported current use of alcohol with 13.7 percent reporting binge drinking within the past 30 days. During this same timeframe, approximately 22 percent of adolescents reported using marijuana. Among adolescents who have used substances at any point in their lifetime, 37 percent reported using marijuana and 14.3 percent reported misusing prescription opioids.[1]

View NASHP’s interactive map, State Strategies to Promote Children’s Preventive Services, to learn which states have Medicaid measures or incentives for children’s behavioral health screening.

While most adolescents who try substances, such as alcohol or marijuana, do not develop an SUD, substance use at an early age can be an important predictor of later life SUDs.[2] The majority of those with SUDs started using substances before age 18 and developed a disorder by age 20.[3] This risk is greatest for those who begin use in their early teens. In total, SUDs cost state Medicaid programs approximately $7 billion annually.[4] Even brief substance use that does not meet criteria for an SUD can affect normal adolescent brain development and key social transitions, resulting in potential long-term consequences.[5]^,[6] Despite the prevalence and well-documented effects of adolescent substance use, only 10 percent of 12- to 17-year-olds in need of substance use treatment actually receive services.[7]

As states explore opportunities to increase access to substance use services for adolescents, there is growing interest in the integration of behavioral health into primary care settings. This case study focuses on the Massachusetts Child Psychiatry Access Program’s partnership with the Adolescent Substance Use and Addiction Program to strengthen the identification and treatment of adolescent substance use within primary care settings.

Massachusetts Child Psychiatry Access Program

In 2003, Massachusetts launched a pilot program, the Massachusetts Child Psychiatry Access Program (MCPAP), to assist primary care providers managing the mental health needs of their patients. Originally developed by the University of Massachusetts Medical School under a grant from the Centers for Medicare & Medicaid Services and MassHealth (the state Medicaid program), MCPAP expanded statewide in 2004 under the Massachusetts Behavioral Health Partnership.[8]^,[9] MCPAP is a public health model that emphasizes universal screening, supports access to services in the appropriate setting based on need, and mitigates gaps in child psychiatry resources by building provider capacity.[10] Similar child psychiatry access programs (CPAPs) exist in at least 30 states and Washington, DC.[11]

MCPAP has seven regional children’s behavioral health consultation sites staffed by pediatric psychiatrists, licensed behavioral health providers, and care coordinators. These teams provide free, ongoing consultation and education to primary care providers serving children with mental health conditions. While PCPs must enroll in MCPAP, they can request a telephone consultation with MCPAP for any child, regardless of the child’s insurance status.[12] Requests to MCPAP can include:

Questions about diagnosis and treatment options;
Use of medications and screening tools;
Available community resources;[13] and
Requests that MCPAP staff provide diagnostic face-to-face or telehealth consultations with the youth/family.

MCPAP is financed by state general revenue funds (totaling $3.87 million in fiscal year 2019) under the Massachusetts Department of Mental Health, which covers operational costs under MCPAP, including staff salaries and administrative expenses. [14] While MassHealth does not currently claim Medicaid reimbursement for MCPAP consultation services provided to eligible enrollees, in-person visits provided under the program are eligible for Medicaid reimbursement. For children with commercial insurance served by MCPAP (representing 60 percent of consultations), insurers reimburse the state for their members’ portion of MCPAP costs under a formula used by the state’s Pediatric Immunization Program Assessment.[15]^,[16]

Available outcome data on MCPAP suggests promising results, particularly relating to the perceived competency of participating providers. Among the PCPs enrolled in MCPAP, 77 percent reported feeling comfortable treating attention-deficit hyperactivity disorder (ADHD) and 68 percent and 67 percent reported feeling comfortable treating depression and anxiety, respectively. However, fewer than 15 percent of these providers reported feeling comfort treating adolescent SUDs, suggesting a need for enhanced support.[17]

Partnership Approach

In 2019, MCPAP entered into a partnership with the Adolescent and Substance Use and Addiction Program (ASAP). Based at the Boston Children’s Hospital, ASAP is a specialty clinic that provides adolescent substance use services, including in-person comprehensive evaluation, diagnostic assessments, and treatment services (e.g., therapy and medication-assisted treatment). Using a team-based approach, ASAP staff include developmental-behavioral trained pediatricians, addiction medicine specialists, licensed social workers, and child and adolescent psychiatrists who are uniquely equipped to serve adolescents with a full range of substance use problems and disorders.[18]

The ASAP-MCPAP partnership operates using the existing MCPAP structure, in which PCPs enrolled in MCPAP submit consultation requests to their regional MCPAP team via telephone. Substance use-specific requests are then routed to an ASAP clinician for additional information and education. Similar to MCPAP, consultation services under ASAP are available to all adolescents regardless of their insurance status.

Depending on the nature of the request, ASAP clinicians consult on a variety of care management activities, such as brief intervention tools and behavioral contracting, medications to curb withdrawal and drug testing programs, and referrals to behavioral health services, including the ASAP clinic.[19] The partnership with ASAP costs $70,000 annually and is funded using available state funds appropriated to support MCPAP.[20] These appropriated funds cover a portion of ASAP clinicians’ time, allowing them to provide consultation services under MCPAP.

Massachusetts Child Psychiatry Access Program and Adolescent and Substance Use and Addiction Program Partnership Model

Since the ASAP-MCPAP partnership launched in October 2019, requests for substance use-specific consultation have steadily increased. While some incoming calls to ASAP are critical (e.g., a recent overdose), most questions relate to more routine adolescent substance use problems (e.g. excessive marijuana use) and requests for referrals. These initial utilization trends mirror those seen when MCPAP first launched. Drawing from the lessons learned from MCPAP’s early years, ASAP and MCPAP are using these initial consultation requests as an opportunity to promote stronger primary care management.[21] For example, ASAP clinicians often begin by assisting a provider with a referral or obtaining a buprenorphine waiver for medication-assisted treatment for an opioid use disorder. As PCPs continue to submit requests, ASAP clinicians will gradually empower them to manage their adolescent patients’ substance use needs independently. While building primary care providers’ clinical competency and capacity takes time, this approach has the effect of sustainably improving access to adolescent substance use treatment services over the long-term.

As the ASAP-MCPAP partnership continues to evolve and telehealth becomes more widely accepted due, in part, to COVID-19, ASAP-MCPAP is piloting a program in which PCPs connect adolescents to SUD counselling by calling the ASAP-MCPAP. Under this pilot, an ASAP clinician submits third-party reimbursement claims for any counselling rendered, with MCPAP providing supplemental funds to offset the ASAP clinician’s downtime.[22] By offering telephonic substance use treatment under the ASAP-MCPAP, there may be additional consultation requests, and thus, more opportunities to strengthen providers’ capacity to manage adolescent substance use needs in primary care.

Conclusion

In an effort to increase access to substance use services for adolescents, Massachusetts successfully expanded MCPAP through a partnership ASAP to strengthen the identification and treatment of adolescent substance use by building the capacity of PCPs. With child psychiatry access programs (CPAPs) in at least 30 states and Washington, DC, Massachusetts’s partnership model can inform other states’ efforts to augment their CPAP to better support adolescent substance use needs.[23]

Notes

[1] “Prescription Opioid Misuse and use of Alcohol and Other Substance Among High School Students-Youth Risk Behavior Survey,” Department of Health and Human Services, Centers for Disease Control and Prevention, 2019. https://www.cdc.gov/mmwr/volumes/69/su/pdfs/su6901a5-H.pdf

[2] “Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide,” National Institute on Drug Abuse, 2014. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/podata_1_17_14.pdf

[3] Dennis, M.; Babor, T.F.; Roebuck, C.; and Donaldson, J. Changing the focus: The case for recognizing and treating cannabis use disorders. Addiction 97:(s1):4–15, 2002.

[4] Mark, T., et al., Insurance financing increased for mental health conditions, but not for substance use disorders, 1986-2014. Health Affairs, June 2016. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.0002

[5] National Institute for Drug Abuse, “Principles of Adolescent Substance Use Disorder Treatment: A Research -Based Guide”

[6] “Teen Substance Use and Risks,” Department of Health and Human Services, Centers for Disease Control and Prevention. Accessed October 1, 2020. https://www.cdc.gov/ncbddd/fasd/features/teen-substance-use.html

[7] “Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings,” Substance Abuse and Mental Health Services Administration, 2013.

[8] Dube, N., “Massachusetts Child Psychiatry Access Project,” Objective Research for Connecticut’s Legislature Research Report, 2013. https://www.cga.ct.gov/2013/rpt/2013-R-0011.htm

[9] Massachusetts Behavioral Health Partnership is the state’s contracted Medicaid mental health and substance abuse provider.

[10] “Overview, Vision, and History,” Massachusetts Child Psychiatry Access Program. Accessed October 1, 2020. https://www.mcpap.com/About/OverviewVisionHistory.aspx

[11] “The Network,” The National Network of Child Psychiatry Access Programs. Accessed November 9, 2020. https://nncpap.org/thenetwork.html

[12] “Overview, Vision, and History,” Massachusetts Child Psychiatry Access Program

[13] Dube, Massachusetts Child Psychiatry Access Project

[14] “Budget Summary FY2019, Child and Adolescent Mental Health Services,” Office of the Governor. Accessed October 2, 2020. https://budget.digital.mass.gov/bb/gaa/fy2019/app_19/act_19/h50425000.htm

[15] John Straus. (Massachusetts Child Psychiatry Access Program Founding Director) Email. September 22, 2020.

[16] Code of Massachusetts Regulations: 104 CMR 30.08, “Massachusetts Child Psychiatry Access Program Assessment,” February 8, 2019. https://www.mass.gov/files/documents/2019/02/11/jud-lib-104cmr30.pdf

[17] John Straus, Sharon Levy, “Stopping Behavioral Health and Substance Use Disorders Before They Start: Prevention and Treatment in Adolescence,” Aspen Institute, May 2020. https://ascend.aspeninstitute.org/webinar-stopping-behavioral-health-and-substance-use-disorders-where-they-start-prevention-and-treatment-in-adolescence/

[18] “Overview: Adolescent and Substance Use Program,” Boston Children’s Hospital. Accessed October 2, 2020. http://www.acaam.org/wp-content/uploads/2017/04/Pharmacologic-Treatment-in-Pediatric-PC_FINAL-LEVY-AMFDA_LiveLink_2017_04_03-003CBS-first.pdf

[19] Straus and Levy, Stopping Behavioral Health and Substance Use Disorders Before They Start: Prevention and Treatment in Adolescence

[20] John Straus. (Massachusetts Child Psychiatry Access Program Founding Director) Email. September 22, 2020.

[21] Ibid.

[22] Ibid.

[23] “The Network,” The National Network of Child Psychiatry Access Programs. Accessed November 9, 2020. https://nncpap.org/thenetwork.html

Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. The information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.

States Work to Improve Long-Term Care in the Age of COVID-19

November 23, 2020/in The RAISE Act Family Caregiver Resource and Dissemination Center Ohio, Washington, Wisconsin Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, COVID-19, Health Equity, Long-Term Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, State Resources, The RAISE Family Caregiver Resource and Dissemination Center /by Paige Spradlin

Nursing home residents account for at least one-third of COVID-19 deaths, and this disparity reveals numerous problems with infection control in institutional settings. As a result, many states are rethinking and restructuring their long-term services and supports (LTSS) programs.

A recent National Academy for State Health Policy (NASHP) annual conference session explored what states have learned during the current health crisis that could improve LTSS during and beyond the pandemic. State officials from Washington State, Wisconsin, and Ohio highlighted their states’ responses to the current crisis, emerging innovations, and prospects for restructuring LTSS in a post-COVID-19 era.

Maximizing the Flexibility of Home- and Community-Based Waiver Services

Washington State, home to the first nursing home to be ravaged by COVID-19 in the United States, immediately worked with federal partners to maximize the flexibility of home- and community-based waiver services following its first reported case. The state was among the first to receive approval from the Centers for Medicare & Medicaid Services (CMS) for its 1135 and 1115 Medicaid waivers, which provided enrollees with increased access to services during the COVID-19 pandemic and additional supports to LTSS workers. State officials noted that the presumptive eligibility measures incorporated into these new waivers ensured that individuals were able to access the LTSS they need without having to wait for their applications to be fully processed. This flexibility has helped minimize administrative burdens on eligibility workers as states face increased demands on their Medicaid programs.

Like Washington State, Wisconsin utilized waivers to implement much-needed flexibility within its home- and community-based services (HCBS) provided through the state’s 1915(c) Medicaid waiver. Importantly, the state expanded the ability of its HCBS agencies to provide waiver services remotely, including care coordination and day services. The state also modified service delivery for Medicaid acute primary services, allowing these to be delivered through telehealth and other technologies to comply with social distancing.

Leveraging State Resources to Prevent and Contain Outbreaks for High-Risk Individuals

To contain and prevent outbreaks, Ohio relied on the following guiding principles to support its nursing facilities throughout the pandemic:

Leverage regional and local leadership to coordinate a unified response; and
Provide resources to support nursing facilities, including additional health services and technical assistance. These efforts were supported by $314 million from the US Department of Health and Human Services (HHS), some of which was provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, that was specifically dedicated to Ohio skilled nursing facilities (SNFs). Each SNF in Ohio with six or more certified beds was eligible to receive a fixed distribution of $50,000 plus an additional $2,500 per bed.

To coordinate a unified state COVID-19 response, Gov. Mike DeWine and leaders from a major hospital chain created three health care zones divided among the state’s large metro areas to manage hospital capacity and maintain patient level of care during an anticipated surge in hospitalization services. State officials in the three health care zones paired nursing facilities with local hospitals to manage distribution of personal protective equipment (PPE) and to ensure that staff were well-equipped to treat patients.

Additionally, the state developed the following resources to support nursing facilities, staff, and patients throughout the pandemic:

A toolkit developed by the Ohio Department of Aging, Department of Health, Department of Developmental Disabilities, and Department of Medicaid to assist nursing facilities with assessing residents and determining their care needs during a COVID-related surge in service utilization;
Increased testing services for nursing facility staff as mandated by a Public Health Order signed by the director of the Ohio Department of Health and conducted by the Ohio National Guard over a period of two months; and
Congregate Care Unified Response Team (CCURT) Bridge Team, composed of staff from the Ohio Department of Health and Ohio Department of Medicaid, to assist nursing home staff with decision making in emergency situations and coordinating facility communication with relevant state agencies, the Emergency Operations Center, health care zones, and hospitals in the area.

Many of the steps taken by Ohio state officials track with the principal recommendations issued by the CMS-appointed Coronavirus Commission Report for Safety and Quality in Nursing Homes, including establishing a statewide strategy for testing in nursing homes, coordinating with state and local leadership, leveraging resources to support the nursing home workforce, and assembling a long-term care emergency response team to evaluate and guide emergency care coordination. With these strategies and systems in place, Ohio and other states now have the infrastructure to better manage infection control in institutional settings for future public health emergencies.

Post-COVID-19 Planning

While many of the policy changes highlighted here are temporary and in effect only during the pandemic, it is important to understand the impact of these changes on cost and quality of life to determine which, if any, should be retained after the pandemic. State officials from Washington State, Ohio, and Wisconsin reported they found the following flexibilities especially helpful:

Presumptive eligibility for LTSS, so the state can initiate home- and community-based services as quickly as possible;
Waiving plan signatures and self-attestation in favor of post-enrollment verification to ensure that enrollees receive timely supports; and
Flexibilities for respite care for family caregivers, particularly those supporting individuals with intellectual and developmental disabilities, to reduce stress and burnout.

State officials noted it would be helpful to receive support from CMS in retaining these flexibilities. State officials also suggested that broader legislative changes to Medicaid, such as streamlining Medicaid authorities that support HCBS and making HCBS mandatory state plan services on par with nursing home care, would help reduce administrative complexity and facilitate rebalancing efforts.

State Community Health Worker Models

Tennessee’s Care Coordination Tool: Marshaling Data to Help Providers Coordinate Care

Confronted with Overdoses, Rhode Island’s Emergency Departments Employ Peer Services to Promote Treatment

Maryland’s Family Recovery Courts: Successfully Reuniting Families with the Help of Customized Substance Use Disorder Treatment

States Use Appendix Ks to Provide Innovative Flexibilities for Medicaid Enrollees and Caregivers during COVID-19

Massachusetts Increases Adolescent Substance Use Treatment by Building Primary Care Provider Capacity

States Work to Improve Long-Term Care in the Age of COVID-19

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