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Behavioral health payment improvement overviewOctober 18, 2012 – Commission Meeting

DRAFT

PRELIMINARY WORKING DRAFT, SUBJECT TO CHANGE

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Behavioral health levels of service PRELIMINARY

SOURCE: Division of Behavioral Health Services

Screening and Assessment (e.g., level of care or service array determination for functional needs)

Rec

ove

ry /

Re

sili

ence In

ten

sive Care

Co

ord

inatio

n

Care C

oo

rdin

ation

Crisis S

ervices

Pre

ven

tio

n

Acute Inpatient

Residential or Intensive Home & Community Based

Intensive Outpatient

Early Intervention

Outpatient

Com

mun

ity-b

ased

opt

ions

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Key questions for identifying and prioritizing payment improvement initiatives

What are the key issues in the

behavioral health system?

Which of these issues can be

addressed through

payment? What is the prioritization of

the payment initiatives?

PRELIMINARY

A B C

For today's discussion

Which can be addressed

through practice or policy changes?

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Issues within the behavioral health system fall in 5 categories

Prevention Treatment

Recovery/ Resilience

Early intervention

PRELIMINARYA

Screening and

assessment

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Issues in prevention

Prevention

Awareness of available services can be improved

▪ Discrimination and stigma associated with behavioral health creates challenges for clients

▪ Need to improve public communications around the services that are available

Gaps in services for behavioral health needs (mental health and substance abuse)

▪ Lack of funding for comprehensive array of prevention programs and support services

▪ Need to provide options for behavioral health prevention in different settings (e.g., shelters, hospitals, long term care settings, schools, job centers, justice system, DHS)

– Includes RSPMI, PBIS, PBSS, Coordinated School Health Services, anti-bullying

▪ Limited utilization of peer, family / significant others, and community involvement services and supports for prevention

▪ Need to improve identification of high risk populations, including those with BH needs among clients with physical or developmental disabilities

Need for additional training programs

▪ Prevention services need to be client centered

▪ Lack of prevention training across key stakeholders, e.g., BH and DD providers, general practitioners, hospitals, job centers, shelters, teachers and other direct care staff

PRELIMINARY

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Issues in early intervention

Gaps in early intervention services, including crisis intervention

▪ Access to crisis intervention and stabilization services is limited, especially after-hours and on weekends

▪ Lack of mobile crises services across the state

▪ Additional early intervention tools can potentially be incorporated (e.g., SBIRT, Ages and Stages, Conscious Discipline, ACT teams)

Existing early intervention can be enhanced

▪ Limited consistency in early intervention across the state, e.g., EPSDT, juvenile drug and mental health courts, diversion, infant mental health, ACT teams

▪ Lack of coordination with primary care providers and other direct care providers

Areas for improvement in current referral and awareness programs

▪ Education about referral options could be better coordinated by early intervention providers

▪ Limited utilization of peer and family / guardian supports, including family / significant other education

▪ There are gaps in significant others / family / guardian-oriented early intervention services

Early intervention

PRELIMINARY

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Issues in treatment

Gaps in current treatment delivery system

▪ Need to develop the recommendation to create the Center of Excellence program to ensure centralized access to training resources for serving special populations

▪ Individuals do not always have access to appropriate types of care (e.g., telemedicine, intensive outpatient, transportation) due to limitations in current set of offerings and workforce challenges, resulting in increased utilization of high intensity services

▪ Lack of integrated mental health and substance abuse treatment

Treatment is not always delivered in an evidence-informed manner

▪ Treatment for some conditions across the state does not always accord with clinical practice guidelines (includes polypharmacy use)

▪ The use of paraprofessionals is not always aligned with the level of care need

▪ Unspecified diagnoses are used too frequently and for too long

▪ Evidence-based standards (e.g., patient- and family-centered, trauma informed, gender sensitive, culturally informed, age appropriate) are not widely practiced

▪ Client engagement in plan development and treatment is difficult and inconsistent

▪ Standards for single point of entry providers need development and monitoring

Care integration and coordination is limited

▪ Some clients have multiple, separate behavioral health treatment plans, and treatment plans in multiple areas (e.g, BH with DD and LTSS)

▪ BH care is not well coordinated with other care types and systems (e.g., primary, DD, LTSS)

– Includes poor coordination of treatment throughout the continuum of care

– Extends to gaps in pharmacy (e.g., medication management, polypharmacy)

– Covers data and information sharing between providers

▪ Substance abuse treatment is not integrated with mental healthcare

Outcomes are not tracked effectively

▪ Data and findings are currently not tracked and used effectively to inform program design and practice

▪ Lack of integrated system for data transfer between providers / state agencies

▪ Low participation rates in the YOQ

Treatment

PRELIMINARY

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Issues in recovery and resilience

There are gaps in the ways providers address recovery and resilience today

▪ Clients do not always have clinical support after they leave high intensity levels of service (including community-based supports such as a 1915i, and case management/care coordination)

▪ Limited support for clients in finding/maintaining housing and supportive employment

▪ There is lack of funding for evidence-based recovery services

Opportunity to improve consistency in existing recovery / resilience efforts

▪ Providers and individuals may not always have a recovery-based orientation

▪ Medical care for patients in recovery is often high cost and is not always well managed

Consumer, peer, family, and community supports are not always leveraged most effectively

▪ There is a lack of peer support in recovery

▪ Limited structure for engaging and communicating with consumers in recovery

Recovery / Resilience

PRELIMINARY

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Issues in screenings and assessments

Inconsistent screening and assessment process

▪ Medical providers may not routinely screen for behavioral health issues (e.g., children during Well Child checkups and post-partum depression screenings)

▪ There are inconsistent evaluations of need for determining the most appropriate level of care

▪ Need to ensure that people get the right screenings irrespective of where they enter the system

▪ Screening and assessment process is not coordinated, meaning some clients receive redundant assessments

▪ Training on administering assessments can be improved to ensure results accurately reflect client circumstances

Need to improve the use of data

▪ Can improve collection of information from multiple sources (including other departments)

▪ Can increase availability of data to providers and stakeholders

▪ Support providers in accessing information through electronic systems

Arkansas has a high prevalence of SED/SMI designations

▪ There may be premature diagnoses of severe mental health conditions, resulting in some over-identification

▪ Definitions need to be enhanced to include functional needs

Screeningand

Assessments

PRELIMINARY

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Episode-based

care delivery

The Arkansas approach is designed to reward coordinated, team-based care across the whole person and for specific conditions or procedures

Our overall approach

▪ Providers proactively work as a team to manage a client’s overall health

The goal▪ Client journey: all

healthcare and support services needed by a client over time

▪ Client journey: all services related to a specific condition, procedure, or physical / developmental disability

How it works

▪ Typically one provider is designated as ‘quarterback’ for all client needs for a period of time

▪ Quarterback: the provider in best position to influence prevention and management of chronic disease

▪ Quarterback: ‘Principal Accountable Provider’ in best position to influence cost and quality of services for the episode

How we are implementing it…

Medical homes andHealth homes

Incentive▪ Providers are

rewarded for providing high-quality care at an appropriate cost

▪ Outcome measured includes overall health of the provider’s client population (across all conditions and episodes)

▪ Outcome measured is average cost and quality of care for all clients that experience a given ‘episode’ (e.g., a surgery)

B

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Recovery

Outpatient

Care coordination by PCMH

Recovery

Recovery

Prevention

Behavioral Health: innovative care delivery system

Outpatient

Early Intervention

Example providers

▪ CMHC

▪ LMHP

▪ Primary care providers

▪ AHEC

▪ Substance abuse providers

▪ School-based mental health

Example providers

▪ Rehabilitative service provider

▪ CMHC

▪ LMHP

▪ Primary care providers

▪ AHEC

▪ Substance abuse providers

▪ School-based mental health

▪ Other community supports

Acute inpatient

Residential or Intensive Home and Community Based

(includes CFCO)

Intensive Outpatient (May include 1915i)

Example providers

▪ Rehabilitative service provider

▪ CMHC

▪ LMHP

▪ Primary care providers

▪ Psychiatric hospital

▪ Acute care facility

▪ Private residential treatment facility

▪ Substance abuse providers

Screening and Initial

Assessment

DRAFT: SUBJECT TO CHANGE

Intensive care coordination by Health Home

Care coordination by PCMH

PRELIMINARY

Comprehensive AssessmentReferral

Referral

Referral

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Behavioral health reform options

Regular FMAP 6% FMAP increase

Eligibility criteria does not require institutional level of care determination

Eligibility criteria requires institutional level of care determination

Benefits can be targeted to a specific population ("Targeted benefits"), services can differ in amount, duration, and scope

Services must be provided without regard to the individual’s age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports the individual requires to lead an independent life

Both options provide community and home based services and supports

1915(i) CFCO

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Potential payment initiatives to address issues within the BH systemPRELIMINARY

B

Health homes (& link to medical homes)

1▪ Deliver integrated care coordination to facilitate quality care and

positive outcomes through:– Ensuring effective treatment of BH conditions– Integrating care coordination across BH, medical, and long-term

supports

Episode-based care delivery2▪ Increase adoption of evidence-informed practices by creating

accountability for all services related to a specific BH condition (e.g., ADHD, and potentially ODD, depression and bipolar disorder)

Reimbursement adjustments3▪ Modify reimbursement rules to encourage appropriate diagnosis and

utilization of services (e.g., placing appropriate time limits on unspecified diagnoses)

Reimbursement for new services4▪ Add reimbursement for selected new services that are known to be

cost-effective and evidence-informed (e.g., crisis intervention, substance abuse treatment services, medication management, rural access and community-based services)

Reimbursement for pharmacy (including polypharmacy)

5▪ Build on recent work in pharmacy management utilization rules to

ensure appropriate use of medications (includes polypharmacy, therapy interactions, step therapy, and dosage)

Policy changes/enabling initiatives

6▪ Develop policy changes or initiatives that enable or compliment the

payment initiatives (e.g., changes to certifications for all BH providers, specialty certifications, new screenings)

Initiative Description

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Appendix – Acronym dictionary

AHEC Area Health Education CenterBH Behavioral healthCFCO Community First Choice OptionCMHC Community Mental Health CenterDD Developmental disabilitiesEPSDT Early Periodic Screening, Diagnosis, and TreatmentLMHP Licensed Mental Health ProviderLTSS Long term services and supportsNCQA National Committee for Quality AssurancePBIS Positive Behavioral Interventions and SupportsPBSS Positive Behavioral Support SystemPCMH Patient Centered Medical HomesRSPMI Rehabilitative Services for Persons with Mental Illness SBIRT Screening, Brief Intervention, and Referral to TreatmentYOQ Youth Outcomes Questionnaire