Investments in Behavioral Health Service Systems: Top Three Emerging Themes from State Home and Community-Based Services Spending Plans
States, taking advantage of federal flexibilities and new federal funding, are implementing policy changes that seek to increase availability of and equitable access to behavioral health services. In anticipation of the one-year, 10% increase in the federal medical assistance percentages (FMAP), provided by the American Rescue Plan Act (ARPA), states have submitted spending plans to the Center for Medicare and Medicaid Services (CMS) outlining how they intend to use these one-time funds to invest in home and community-based services (HCBS) that aim to keep individuals out of high cost institutional settings. These proposals reveal priorities across states for investing in home in community based behavioral health services.
State behavioral health systems have been experiencing multiple challenges since before the onset of the COVID-19 pandemic: the opioid crisis is ravaging communities, mental health crisis services are not sufficiently available, and behavioral health systems face serious staffing shortages. The pandemic has brought these crises into focus. Since 2019, more than half of states saw a more than 30% increase in overdose fatalities, emergency department visits for suspected suicide attempts by teenagers and young adults increased by 31%, and according to the Centers for Disease Control and Prevention (CDC), 40% of adults surveyed this spring reported struggling with their mental health or substance use. This accelerated demand for behavioral health services and the heightened risks of working in healthcare settings during the pandemic have left states facing staffing shortages, in some cases so severe that institutional settings are experiencing full on crises. Five of Virginia’s state mental health hospitals temporarily suspended admissions in July, Oregon’s state hospital saw a 45% increase in direct-care staff on COVID-related leave between February and March of this year, and New York Governor Hochul declared a statewide disaster emergency due to healthcare staffing shortages in September. As such, states and the federal government are preparing to make considerable financial investments in home and community-based services, to both relieve stressors on institutional settings as well as to provide comprehensive behavioral healthcare at an accessible delivery point to Medicaid members.
Developing and Enhancing Mobile Behavioral Health Crises Response
Through ARPA, states see an important opportunity to improve behavioral health systems, with a particular interest in enhancing crisis response systems. Several state HCBS spending plans propose to use funds to develop and expand the capacity of mobile crisis response, and some states plan to use these funds to bolster supports to specific, underserved populations. West Virginia and New York’s propose expanding existing mobile crisis capacity to better serve individuals with intellectual disabilities, while Michigan and Washington plan to build out crisis response for children. Other states propose using funds to add crisis stabilization units and to use ARPA funds to implement 988, a nationally-accessible hotline for people in suicide and other mental health crisis situations, established by the National Suicide Hotline Designation Act of 2020.
Updating Technology and Data Infrastructure
State HCBS spending plans underscore the need to improve technological capacity in HCBS systems. Several states propose extending facility-based data such as admissions, discharge, and transfer notifications to HCBS providers; others, including Alabama, Maine, New Jersey, and Texas plan to provide grants to providers and/or families for assistive technology and broadband access. Several states, including Colorado, plan to connect and share data across state agencies and/or among providers to better track and coordinate services for the HCBS population. Similarly, Georgia plans to develop a comprehensive case management platform for all HCBS populations that would include a dashboard for outcomes and reporting, streamlining data collection and usage. Georgia also builds in funding to train staff on new technology. New Jersey proposes using funds to develop a public facing registry, to allow members and families to access information on their waitlist status, available services, wait times.
Investing in the Behavioral Health Workforce
State HCBS spending plans reflect widespread and increasing shortages in the behavioral health workforce. States propose multi-faceted approaches: a handful of states seek to implement permanent rate increases for some sectors of the HCBS workforce, and North Carolina, Minnesota, Vermont, New York, and others plan to raise rates for mental health and substance use disorder (SUD) providers specifically. As a shorter-term strategy, other states are taking a specialty pay approach, building in one-time hiring and sign-on bonuses for behavioral health and other direct care workers. States are also planning to allocate funds for training staff to encourage specialization in behavioral health, or to develop specific skills particularly in-demand in the field. For example, Iowa plans to provide training and scholarships for Crisis Response and Behavioral Health Technician certification. Michigan plans to provide loan forgiveness and internships for students in behavioral health who commit to working in behavioral health shortage areas.
COVID-19 and its related risks in institutional settings have heightened the need for care in the community for people with significant behavioral health needs. State ARPA spending plans reflect the tremendous demand for behavioral health services across states, as well as the growing need to address workforce and build more technological capacity for a sector that has long lagged behind physical health systems. Nearly all state HCBS spending plans have been conditionally approved by CMS, final versions are likely to change in response to CMS comment and guidance.
Washington Demonstrates Cost Savings and Improved Outcomes from Supporting Family Caregivers
Washington has been at the forefront of providing supports to family caregivers, in large part, because state policymakers have been able to demonstrate cost savings and improved quality of life. Washington’s Medicaid Transformation Project proactively supports caregivers of individuals likely to spend down to Medicaid long term services and supports (LTSS). It was designed after Washington’s Family Caregiver Support Program, (FCSP) which assesses caregivers and provides training, respite, and other resources. Robust data collected from these programs demonstrate that Washington’s investments in family caregivers have ultimately contained costs while improving the wellbeing of caregivers and individuals receiving care.
Proven Return on Investment
Washington’s comprehensive Medicaid 1115 waiver program, the Medicaid Transformation Project, has shown a return on investment since its inception in 2017. This waiver has two caregiver support programs: Medicaid Alternative Care (MAC), which serves caregivers of Medicaid-eligible individuals not using Medicaid LTSS, and Tailored Services for Older Adults (TSOA), which supports individuals and caregivers of individuals who are not yet eligible for Medicaid or are choosing to not participate in Medicaid, but likely to eventually need Medicaid LTSS. TSOA and MAC both offer similar benefits for caregivers, including:
- Caregiver assistance with household tasks, respite, home-delivered meals, and minor home repairs
- Training and education
- Specialized medical equipment and supplies
- Health maintenance and therapy supports, such as adult day centers and counseling
The dollar value of the benefits depends on the caregiver’s assessment. Caregivers are eligible for benefits if they receive a screening with TCARE, an evidence-based tool for assessing a caregiver’s own needs. Caregivers can receive up to $4,362 over a six-month period depending on their assessed level of need and care plan. Eligibility is determined primarily by age, income, and assessment, with more flexibility with income and asset limits than traditional Medicaid. Perhaps due to these flexibilities, more individuals and caregiver/recipient pairs have enrolled in TSOA than MAC. Enrollment in the program has been lower than anticipated, in part due to challenges reaching people who do not self-identify as caregivers.
| Eligibility for Medicaid Transformation Project LTSS Initiatives | |
| Medicaid Alternative Care (MAC) | Tailored Supports for Older Adults (TSOA) |
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Washington analysts determine cost effectiveness with a synthetic estimate projection, a method of statistical analysis that compares actual expenditures with projected expenditures if no program had been implemented. Though the waiver is still in progress, data from the first few years show that the program is succeeding in delaying Medicaid LTSS and preventing hospitalizations. Furthermore, survey results find high levels of satisfaction among caregivers and recipients. Washington’s evaluation is largely based on data from TCARE family caregiver assessments combined with data on emergency department visits, inpatient admissions, 30-day readmission rate, nursing home admission rate, and mortality rate.
Prior to the initiation of the Medicaid Transformation Project, Washington used data to demonstrate the cost-effectiveness of expanding its Family Caregiver Support Program (FCSP) in 2012. Under Washington’s FCSP, interested caregivers receive a TCARE screening. Subsequently, eligible caregivers receive support in finding local resources, training on caregiving topics, help with securing respite, and advice and support on specific challenges. This assessment strategy produces a range of data on caregivers and recipients of care and allows the state to establish a baseline from which to study the impact of the program. In an analysis of the FCSP expansion, Washington found that care recipients whose caregivers were screened following FCSP expansion were 20 percent less likely to enroll in Medicaid LTSS in the year post-screening, controlling for other factors. These results identified a return on investment using baseline and implementation data, demonstrating the value of the state’s investment in caregivers and serving as a precursor to the Medicaid Transformation Project waiver.
Multi-Faceted Approach to Support Caregivers and Reduce Medicaid Costs
Washington’s efforts on caregiver supports are multi-faceted to delay the need for Medicaid services. Both Washington’s FCSP expansion and its Medicaid waiver place an emphasis on identifying caregivers in need of support before more formal LTSS are needed and connecting them with resources. These initiatives align with other efforts Washington has taken to support caregivers and older residents, including the state’s Paid Family Leave program and its first-in-the-nation public long-term care insurance program. The combination of these supports, emboldened by robust data demonstrating their effectiveness, forms a cohesive caregiver support strategy that allows Washington to provide LTSS care while spending less per resident on Medicaid LTSS than the national average.
Acknowledgement: Thank you to Susan Engels, Office Chief, Home and Community Services, Washington State Department of Social and Health Services, for presenting much of this information to NASHP’s State Medicaid Policy Institute on Family Caregiving on June 16, 2021. This blog is part of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center and is supported by The John A. Hartford Foundation.
RAISE Family Caregiving Advisory Council Releases Report to Congress: September 2021 Meeting Summary
On Tuesday, September 21, the RAISE Family Caregiving Advisory Council met to discuss the release of the RAISE Initial Report to Congress and recognize the outstanding work of all those who helped make the report a reality.
Call to Order
Acting Administrator and Assistant Secretary for Aging of the Administration for Community Living (ACL) Alison Barkoff began the meeting by commending the council for their work in completing the report to Congress, especially under the challenging circumstances of the COVID-19 pandemic. This report is the first major step of the RAISE Act, and the recommendations serve as the foundation for the next step, the National Caregiver Strategy. Barkoff expressed her eagerness to move expeditiously on the National Caregiver Strategy and seize this opportunity to support America’s 53 million caregivers.
Overview of Report
Council co-chairs Nancy Murray, MS, Casey Shillam, Ph.D., and Alan Stevens, Ph.D. shared their appreciation for the report as the culmination of years of advocacy and two years of intense work with a wide range of stakeholders. While caregiver stories are intensely personal and unique, the report captures common themes across all caregivers. They also expressed their gratitude for the help that NASHP, ACL, and The John A. Hartford Foundation provided.
Following the co-chairs’ presentations, Barkoff shared a video featuring numerous caregivers speaking about their experiences with caregiving. Following the video, Barkoff spoke with two family caregivers featured in the video, Sarah and Debbi. Sarah discussed how important it is for caregivers to be engaged as partners in an individual’s care. Debbi shared the challenges and sacrifices she has made to serve as a caregiver to her son, but also the powerful bonds for her entire family that have formed through caregiving. She described caregiving as giving quality of life to others and said that it has enhanced her life in ways she could not have imagined.
Looking Ahead to the National Strategy Development
Jessica Schubel, Director of Affordable Care Act and Health Care for the Domestic Policy Council at the Executive Office of the President, shared the Biden administration’s priorities on family caregiving. She described how states can use the American Rescue Plan to expand home and community-based services (HCBS) by using funding to support telehealth, reduce waitlists, and pay for transition costs. Other possibilities to support family caregivers include paying for supplies and equipment, PPE, and in-home vaccination.
Two speakers from the National Alliance for Caregiving (NAC) followed Schubel. First, Mike Wittke shared how caregiving is a dynamic experience. As a result, it is important that the strategy receives ongoing attention to ensure it remains effective. Then, C. Grace Whiting of NAC shared the five pillars of the national effort to implement the RAISE Act:
- Awareness and outreach- not all caregivers identify as such and some resist the label. It is the responsibility of systems to reach out to individuals, not vice versa.
- Recognizing caregivers as partners- the CARE Act is a good start, but there are other opportunities to engage caregivers, such as those in the 21st Century Cures Act 2.0.
- Income security- caregivers would benefit from paid family and medical leave and wage replacement programs. Additionally, the Credit for Caring Act and universal family care would assist caregivers and recognize the value of their work.
- Family centered support- Important work is being conducted to engage the caregivers who are often forgotten, especially young caregivers. State actions like Maryland’s Caregiver Services Corps have helped during COVID.
- Research and data gathering- Actions like expanding the caregiver module of the Behavioral Risk Factor Surveillance System (BRFSS) and implementing the strategic plan created by the National Institute of Nursing Research would help with gathering robust, consistent data.
Closing Remarks
Alison Barkoff concluded the meeting by once again expressing her excitement for the release of the report and for this opportunity to change the landscape for caregivers. She ended the meeting by expressing that the strategy will recognize the hard work of caregivers to let others live with dignity and independence, with the hope that the report will make caregiving sustainable.
End of Life Planning: Best Practices in Using POLST
The POLST form is a portable medical order that communicates treatment goals and preferences for people with serious illness or advanced frailty. POLST is implemented at the state level, and some states use other terms such as MOLST for its Medical Orders for Life-Sustaining Treatment. Listen to this webinar to learn the latest about national and state POLST practices.
Speakers:
- Rani Snyder, Vice President, Program, The John A. Hartford Foundation
- Amy Vandenbroucke, JD, Executive Director, National POLST
- Delegate Danielle Walker, West Virginia House of Delegates
- Danielle Funk, Program Manager, West Virginia Center for End-of-Life Care
- Cindy Munn, Chief Executive Officer, Louisiana Health Care Quality Forum
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
