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Enhancing Value in Medicaid for Children in Foster Care Sheila A. Pires Human Service Collaborative Three Branch Institute on Child Social and Emotional.

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Presentation on theme: "Enhancing Value in Medicaid for Children in Foster Care Sheila A. Pires Human Service Collaborative Three Branch Institute on Child Social and Emotional."— Presentation transcript:

1 Enhancing Value in Medicaid for Children in Foster Care Sheila A. Pires Human Service Collaborative Three Branch Institute on Child Social and Emotional Well-Being: Meeting for State Teams July 25, 2013 Philadelphia, PA

2 Lessons from States Design elements and contractual specs need to reflect state child welfare, Medicaid and behavioral health system policy and goals – Collaborative planning, design, implementation needed; also, state agencies need to approach implementation in partnership with managed care entities

3 Eligibility and Enrollment (State policies that affect access)  Presumptive eligibility (MA, MI) or fast track enrollment  Continued eligibility for youth transitioning out of foster care (2014 ACA requirement – to age 26) Implications for coverage of home and community services Addiction and mental health treatment accounted for 42% of hospital claims for 19-25 year olds enrolled in their parents’ health plans in 2011 through ACA (Employee Benefit Research Institute, April 2013) Greater prevalence in transition-age foster care population  Transition coverage upon leaving foster care (any age) AZ: 60 days of coverage post foster care exit  Youth involved in both foster care and juvenile justice – Suspend rather than terminate Medicaid eligibility if youth is in juvenile justice facility

4 Trauma-Informed Screening and Early Intervention ( 3/27/13 CMCS and SAMHSA Informational Bulletin and 7/11/13 SMD Letter)  Incorporate state child welfare requirements for physical, behavioral and dental health screens within specified timeframes AZ: Urgent response requiring behavioral health screen within 72 hrs of entering care and “fast track” linkage to services MA: Medical screening required within 7 days and comprehensive exam within 30 days, including behavioral health  Mandate use of standardized screening tools and inclusion of behavioral and developmental (not only physical health) screens  Quality payments for providers meeting trauma-informed standards  May require enhanced rate (MA)

5 Service Coverage  Cover a broad array of behavioral health home and community-based services ( May 7, 2013 CMCS and SAMHSA Informational Bulletin ) AZ: In-home services; respite; life skills training; family and youth peer support; therapeutic foster care; case management; supported housing; supported employment; mobile crisis intervention; crisis stabilization; transportation; Wraparound process MA: In-home services; family peer support; mobile response; therapeutic mentoring; behavior management therapy and behavior therapy monitoring; intensive care coordination using a Wraparound approach NJ: Mobile response and stabilization; therapeutic group home care; treatment homes/therapeutic foster care; intensive care management; Wraparound process; behavioral assistance; intensive in-home/community services; transportation; youth support and development

6 Service Coverage  Cover evidence-based practices, e.g. Trauma-Focused Cognitive Behavioral Therapy, Multisystemic Therapy, Functional Family Therapy, Multidimensional Treatment Foster Care (growing number of states) A word about a “special benefit” for foster care population through a foster care carve out –  TANF (and SSI children) need the same service array as foster care pop (while prevalence rate for behavioral health is higher for children in foster care than TANF population, there are many more TANF children)  Children don’t stay in foster care forever (median LOS in 2011 was 13.2 mos) but may remain Medicaid-eligible and in need of services  Can lead to unintended consequence of parents having to relinquish custody to access care (especially an issue for children with serious behavioral health challenges)

7 Provider Network  Mandate inclusion of providers knowledgeable about the child welfare population AZ: sexual abuse, trauma MA: state required same network of providers across all MCOs for behavioral health home and community-based services (Rosie D); requirements for expertise in trauma-informed care TN: Best Practices Network  Allow out-of-network specialists if needed (MA, MI)  Develop protocols and practice guidelines related to children in foster care and interface with child welfare system AZ: how to work with the child welfare agency and the courts; clinical needs of the child welfare population

8 Orientation and Training  Incorporate orientation/training for MCOs on foster care population, child welfare system, role of court  Incorporate training for Medicaid providers on effective practices Wraparound approach (MA, MI, NJ, LA, MD) Trauma-Focused CBT and Parent Management Training-Oregon Model (MI) Trauma-informed care (AZ, MA) Screening tools (MA)

9 Customized Care Coordination  Incorporate intensive care coordination using Wraparound approach for children with serious behavioral health challenges (growing number of states – MA, LA, NJ; PRTF Waiver Demo states; CHIPRA Care Management Entity Quality Collaborative states – better outcomes, lower per capita costs. May 7, 2013 CMCS Informational Bulletin Intensive care coordination rates for this population range from $780 pmpm to $1300 pmpm (CHCS Matrix) In high fidelity intensive care coordination/Wraparound approaches, all-inclusive cost of care (e.g., admin, care coord, placements, clinical treatment, informal supports) averages $4200 pmpm – compare to $8,000 pmpm in PRTFs, higher in psych hospital  Require that every child has a designated primary care provider and coordination between physical and behavioral health care providers  Require coordination with child welfare system  Require coordination with Part C, CSHCN

10 Psychotropic Medications ( 8/24/12 and 11/23/2011 CMCS Informational Bulletin and SMD )  Require tracking and monitoring of outlier use, e.g. too young, too many, too much, (growing number of states) – interface with Drug Utilization Review Board  Require consultation to prescribers, including primary care providers (MA, VT)  Orient MCOs to state’s informed consent and assent policies in child welfare  Provide coverage and training for treatment alternatives (aggression, sleep disorders)

11 Financing Incentives  Risk-adjusted rates for the foster care population AZ BH carve out: capitation rate is 29% higher than for children in general  Incentive payments to providers (MI BH carve out)  Adequate intensive care coordination rates using fidelity Wraparound (e.g. specified care coordination rate or “pass-through” case rate for high utilizers)  Enhanced rate for comprehensive physical, behavioral and development screens (MA)  Explore potential for Medicaid match from child welfare – most children are Medicaid eligible; many services paid for by child welfare are Medicaid-allowable (NJ, AZ, MI)

12 Values-Based, Goal-Oriented Utilization Management Criteria  Access: require no prior authorization for basic behavioral health outpatient services (MA)  Coordinated Care: require that plans of care developed through Wraparound process determine medical necessity (with outlier management) (AZ, MA, NJ, LA)  Require no “fail first” criteria to access services or medications  Prior auth for certain psychotropic meds, e.g. antipsychotics for young children (MD)

13 Data and Performance Requirements  Require specific tracking and reporting of: Foster care population penetration rate and utilization (services and medications) Performance expectations (not only HEDIS) AZ: PH-access to primary care, adolescent well care visits, annual dental visits, immunization measures; BH-emotional regulation, avoiding delinquency, stability of living situation, substance abstinence, children in psych hospitals awaiting placements MI: BH-reduced use of residential treatment, maintenance in the community, improved functioning using CAFAS NJ: PH-timeliness of assessments and comprehensive exams; exams in compliance with EPSDT guidelines; semi-annual dental checks; immunization measures; BH-access to BH services following EPSDT assessment; clinical and functional outcomes using CANS Require periodic focus groups/surveys with child welfare workers, youth and families/caregivers Require electronic health record/health passport and interface with child welfare IT system (SACWIS)

14 Administrative Requirements  Designated liaison within MCO to child welfare system  Periodic meetings between MCOs, Medicaid and child welfare system for trouble-shooting, quality improvement  Inclusion of families and youth with lived experience in quality review process, as system navigators, as advisory body members  “Warm line” for child welfare workers and caregivers It is also very helpful to have child health units or designated staff in child welfare to interface with MCOs; Medicaid administrative case management and Title IV-E can both be used to help finance this capacity (NJ, UT)

15 Section 2703, Patient Protection and Affordable Care Act Authorizes health home services for Medicaid enrollees with chronic conditions Authorizes 90% Federal match for 1 st eight quarters Designed to facilitate access to and coordination of physical and behavioral health care and long term community-based services and supports Goal of improving the quality and cost of care and enrollee’s experience with care Provisions

16 Health Home Eligibility At least two chronic conditions, or One chronic condition and at risk for another, or One serious and persistent mental health condition  Can target health home services to those with particular chronic conditions or with higher severity of chronic condition, but cannot target by age  Medicaid comparability is waived – can offer health home services in a different amount, duration and scope than offered to individuals not in health home and can target by geographic area

17 Health Homes vs Medical Homes Medical Homes All children Coordination of medical care Physician-led primary care practices Health Homes Children with chronic health conditions, children with serious behavioral health conditions Coordination of physical, behavioral, and social supports Specialty provider organizations, including behavioral health specialty organizations (e.g., not only medical)

18 Analysis of Medical Home Services for Children with Behavioral Health Conditions* “All behavioral health conditions except ADHD associated with difficulties accessing specialty care through medical home” “The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the medical home model has more to do with difficulty in accessing specialty care than with accessing quality primary care”. Sheldrick, RC & Perrin, EC. “Medical home services for children with behavioral health conditions”. Journal of Developmental Pediatrics, 2010 Feb-Mar 31 (2) 92-9

19 Children and Youth with Serious Behavioral Health Conditions Are a Distinct Population from Adults with Serious and Persistent Mental Illness Children with SED do not have the same high rates of co-morbid physical health conditions as adults with SPMI Children, for the most part, have different mental health diagnoses from adults with SPMI (ADHD, Conduct Disorders, Anxiety; not so much Schizophrenia, Psychosis, Bipolar as in adults) Among children with serious behavioral health challenges, two- thirds are also involved with child welfare and/or juvenile justice systems and 60% may be in special education – governed by legal mandates Coordination among children’s systems – child welfare, juvenile justice, schools – and among behavioral health providers consumes most of care manager’s time, not coordination with primary care To improve cost and quality of care, focus must be on child and family Pires, S. 2012. Human Service Collaborative

20 * Customizing Health Home Approaches for Children with Serious Behavioral Health Challenges Using High Quality Wraparound and Intensive Care Coordination * State may submit one HH State Plan Amendment that incorporates distinct approaches for adults with SMI and for children with SED, or *State may submit two separate HH SPAs – one for adults with SMI and one for children with SED – but clock starts on 90% Federal match with first one approved

21 CMS-Funded CHIPRA Quality Collaborative on Care Management Entities (Maryland, Georgia, Wyoming) What is a Care Management Entity? An organizational entity – such as a non profit organization* - that serves as the “locus of accountability” for defined populations of youth with complex challenges and their families who are involved in multiple systems Is accountable for improving the quality, outcomes and cost of care for populations historically experiencing high-costs and/or poor outcomes *Could also be a high quality wraparound team embedded in a supportive organization (e.g. Oklahoma) Pires, S. 2010. Human Service Collaborative

22 Care Management Entity Functions At the Service Level:  Child and family team care planning and oversight using high quality Wraparound practice model  Screening, assessment, clinical oversight  Intensive care coordination at low ratios (1:8-10)  Care monitoring and review  Peer support partners  Access to mobile crisis supports At the Administrative Level (directly or in partnership):  Information management – real time data; web-based IT  Provider network recruitment and management (including natural supports)  Utilization management  Continuous quality improvement; outcomes monitoring  Training Pires, S. 2010. Human Service Collaborative

23 Core Health Home Services Comprehensive care management  Identifying, screening and assessing children appropriate for HH  Youth and family engagement  Mobilizing child and family team  Development and updating of coordinated plan of care  Monitoring of clinical and functional status Care coordination and health/mental health promotion  Ensure coordinated implementation of plan of care  Support youth and family to make and keep appointments and to achieve goals  Facilitate linkages for youth and family and among providers and systems  Ensure communication across providers, systems and with youth and families Comprehensive transitional care from inpatient to other settings, including appropriate follow-up  For children, other out-of-home treatment settings, e.g. residential treatment Individual and family support services  Family and youth peer support (families/youth with lived experience) Linkage to social supports and community resources

24 24 Wraparound Milwaukee (1915 a) Wraparound Milwaukee. (2010). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch. CHILD WELFARE Funds thru Case Rate (Budget for Institutional Care for Children-CHIPS) JUVENILE JUSTICE (Funds budgeted for Residential Treatment for Youth w/delinquency) MEDICAID CAPITATION (1557 per month per enrollee) MENTAL HEALTH Crisis Billing Block Grant HMO Commercial Insurance Wraparound Milwaukee *Care Management Organization $47M Per Participant Case Rates from CW,JJ and ED range from about $2000 pcpm to $4300 pcpm Intensive Care Coordination Child and Family Team Provider Network 210 Providers 70 Services Plan of Care 11.0M 11.5M16.0M8.5M Families United $440,000 SCHOOLS youth at risk for alternative placements Mobile Response & Stabilization co-funded by schools, child welfare, Medicaid & mental health *All inclusive rate (services, supports, placements, care coordination, family support) of $3700 pcpm; care coordination portion is about $780 pcpm

25 UMDNJ Training & TA Institute Department of Children and Families Division of Child Behavioral Health Services (now Division of Children’s System of Care) Dept. of Human Services Medicaid Division BH, CW, MA $$ - Single Payor Provider Network Contracted Systems Administrator- PerformCare – ASO for child BH carve out 1-800 number Screening Utilization management Outcomes tracking Any licensed DCF provider Family peer support, education and advocacy Youth movement Lead non profit agencies managing children with serious challenges, multisystem involvement New Jersey *Care Management Entities- CMOs Family Support Organizations *Care coordination rate of $1034 pcpm

26 Louisiana (1915 b and 1915 c waivers) State Purchaser – Medicaid and BH Contracting Claims processing Payment of providers Training and Capacity building Statewide Management Organization (ASO) - Magellan Registration Determination of appropriateness Ongoing services auth Population level tracking/UM/UR/Quality assurance/ Outcomes management/monitoring *Regional Care Management Entities – non profit specialty providers Screening, intake, initial service auth child and family teams intensive care management, connection to natural supports Indiv level tracking/UM/UR/Quality assurance/ Outcomes management/monitoring Shared MIS with SMO Local Providers and Natural Supports Family Support Orgs. – family-run Provide/build capacity for Participation in policy making and Quality improvement at all levels, Participation in child/family teams, Family liaisons, Family educators, Youth peer mentors manage provider network support as needed from ASO work w ASO to fill provider gaps Interagency Governance *Care coordination rate of $1035 pcpm

27 Massachusetts (1115 Waiver) MCO PCCM BHO State Medicaid Agency - Purchaser *Locally-Based Care Management Agencies ( called Community Services Agencies) – Non Profit Specialty Organizations Ensure Child & Family Team Plan of Care Ensure Intensive Care Coordination Link to peer supports and natural helpers Manage utilization, quality and outcomes at service level Standardized tools for screening and assessment *Care Coordination Rate: Massachusetts does not use a PMPM rate. However, for comparative purposes, (if assuming a productivity standard of approximately 26 hours a week, and an average caseload of 10), the 15-minute rate for Care Coordination and Family Support &Training may appear to suggest a PMPM of $1,100 - $1,200.

28 28 High Quality Wraparound Team as Health Team Oklahoma Community Mental Health CenterHealth Team for Adults with SMI:Children with SED: Nurse Care ManagerWraparound Facilitator ACT TeamIntensive Care Coord. Adult Peer ConsumerFamily and youth peer support Improve quality and cost of care

29 Coordination with Primary Care in a Wraparound Approach For children with complex behavioral health challenges enrolled in Health Home, Care Management Entity or Wraparound Health Team is responsible for: Ensuring child has an identified primary care provider (PCP) Tracking of whether child receives EPSDT screens on schedule Ensuring child has at least an annual well-child visit Communicating with PCP opportunity to participate in child and family team and ensuring PCP has child’s plan of care and is informed of changes Ensures PCP has information about child’s psychotropic medication and that PCP monitors for metabolic issues such as obesity and diabetes

30 Important to Ensure -- Health home services do not duplicate those of other management entities – for example, patient-centered medical homes, managed care organizations, targeted case management providers  Develop matrices that show distinct functions of each and interface between health home and these other entities Options to Avoid Duplication with Targeted Case Management Replace TCM with HH SPA Distinguish TCM and HH populations: keep TCM for children at high risk and designate HH for children with most serious, complex behavioral health challenges Distinguish TCM and HH functions for same population/ HH as augmentation of TCM - HH rate does not include aspects of care coordination provided through TCM function

31 Important to Ensure -- Sufficiency of rate  In Care Management Entity approaches nationally, care coordination rate ranges from about $780 pmpm to about $1300 pmpm Other Lessons *New York’s Chronic Illness Demonstration Project: Lessons for Medicaid Health Homes. December 2012. Center for Health Care Strategies  Establish much closer connections from the outset between the organizations responsible for case management and provider organizations  Address data sharing issues and needs  Ensure reimbursement for location and enrollment of high risk, high cost enrollees  Extensive education required to build good relationships with other organizations, be clear on roles, build consistent communication mechanisms  “Given the intensity of the job, it was difficult to hire the right people to do community-based case management with clients, and there was considerable turnover…Need workforce training that prepares case managers to provide coordinated patient-centered care… and a particular emphasis on training peer support specialists”

32 Federal Medicaid Guidance 7/11/13 State Medicaid Director’s Tri-Agency Letter on Trauma-Informed Treatment 5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children, Youth and Young Adults with Significant Mental Health Conditions 3/27/13 Informational Bulletin on Prevention and Early Identification of Mental Health and Substance use Conditions 8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populations 11/21/11 State Medicaid Directors Tri-Agency Letter on Appropriate Use of Psychotropic Medications Among Children in Foster Care

33 Resources Making Medicaid Work for Children in Child Welfare: Examples from the Field Customizing Health Homes for Children with Serious Behavioral Health Challenges Psychotropic Medications Quality Improvement Collaborative: Improving the Use of Psychotropic Medications Among Children in Foster Care CHIPRA Care Management Entity Quality Collaborative

34 For further information, contact: Sheila A. Pires

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