Foster Care Electronic Health Record Large-Scale Applicability Kay Ghahremani Medicaid/CHIP Director for Policy Development October 2011

2 Overview  Texas Medicaid serves about 30,000 children in foster care through a managed care model called Star Health  Children in foster care are perhaps the most vulnerable population, with expenditures for behavioral health totaling about 40 times more than healthy Medicaid children and overall expenditures totaling about five times more.  The Texas Legislature adopted S.B.6 in 2005 to provide comprehensive reform in the state’s child protective services, including the requirement for a managed healthcare system with a “health passport” to help coordinate care.

3 STAR Health  STAR Health became operational April 1,  Texas has administered services using managed care since the early 1990s, and already had experience with managing HMOs providing services to the aged and disabled populations.  Texas decided to contract with only one managed care organization (MCO) statewide in order to facilitate continuous healthcare for children in foster care as they moved placements.  Texas was able to avoid CMS requirements for at least two choices of health plans by making the model “voluntary”.  Superior Health Plan is the MCO that administers STAR Health.

4 Features of STAR Health Medical home model (PCP) Immediate enrollment upon entering state custody Focus on preventive care Broad network of providers 24/7 nursing and behavioral help-line Integrated services including physical, behavioral, dental and vision Service Management Teams across the state Medical advisory committees to monitor the provision of the healthcare Health Passport for continuity of care

5 Service Management Health risk screening: All clients are screened within 30 days upon entry to the STAR Health program. A general screening is completed on each child to evaluate their individual health care needs. The score identified on completion of this screen falls into one of three categories:  No case management healthcare needs identified at this time  Client has no significant needs and requires no assistance at this time  Service Coordination  Some physical and/or behavioral problems  Client appears stable  Monitored by LVN’s, social workers, degreed professionals  Service Management  Medically Fragile, transplants, pregnant, major behavioral health needs  Highest priority  Monitored by RN’s and licensed clinicians  Health care service plans are completed within 30 days of entry to program

6 Service Management Specialty Teams: Transplant Team – for clients in need of transplant services and/or are post transplant OB/GYN Team – for pregnant and postpartum clients Discharge Planning Teams –to ensure clients have all services in place upon discharge from the hospital Complex Case Management Teams – to monitor clients with complex medical needs Psychotropic Medication Utilization Review Team – to monitor adherence to Texas’ psychotropic medication guidelines

7 Health Passport Secure, web-based electronic health record (EHR) system Accessed at (follow the link to “sign- up”) Provides access by authorized users according to their role Populated with two years of Medicaid and CHIP claims history and pharmacy data for children in those programs before entering conservatorship When the child leaves foster care, the Passport is available in electronic or printed formats to: child’s legal guardian, managing conservator, or parent child if at least 18 years of age or an emancipated minor

8 Health Passport System Features: Demographics: Displays personal contact information of the child’s physicians and other individuals involved in the child’s care Visit History: Displays claim-based record of each visit to a health care provider with date of service, diagnosis, and procedure(s) performed Medications: Displays claims-based record on all prescriptions filled Immunizations: Displays a comprehensive list of a child’s immunizations Lab Results: Displays results of lab tests performed, if available Electronic Documentation: Providers can document Texas Health Steps, dental, and behavioral health assessments within the Passport Vital Signs: Providers can record vital signs at the point of care Allergies: Providers can record allergies at the point of care; Passport checks the allergy for medication interactions

9 Health Passport

10 Health Passport

11 Health Passport Examples of Uses:  Case worker avoided duplication of dental services for a large family because the claim records of previous services were in the Passport  In a pre-adoption review, case worker intervened when a pattern of non-compliance with behavioral health treatments was noticed  Child began exhibiting behavioral issues. With the historical data contained in the Passport, Child Protective Services was able to contact the previous provider to obtain detailed medical history and prevent a placement breakdown  In a kinship placement, relative of a diabetic child did not know about the medication needs of the child. The care coordinator used the Passport to identify the child’s previous physician to obtain medication dosage information

12 Electronic Health Record Incentive Program ARRA made billions available to states to award federal dollars for electronic health records to providers of Medicaid services. Providers can qualify for both Medicare and Medicaid payments. Providers can be reimbursed for up to 85% of costs Medicare providers that do not demonstrate meaningful use of an electronic health record (EHR) by FY 2016 will be penalized 1% reimbursement. Providers must show over time an increasing sophistication with the “meaningful use” of EHRs to include clinical decision support and advancing better health outcomes.

13 Medicaid ID Card and Health Information System New System  Digital technology to streamline Medicaid eligibility verification.  Enables providers to access Medicaid recipients’ health history. New Card  Replaces paper Medicaid ID.  Most recipients received both the paper ID and new card for month of September.  Beginning October 1, 2011 all recipients will have received their new card. Eligibility Verification  Personal Computer –  Standard Card Reader  Point of Service Card Reader Recipients’ Health History – Winter 2011  Basic claims-based health information system  Diagnosis history  Lab data  E-prescribing  Prescription history  E-prescribing tool for Medicaid providers  Immunization details

14 Medicaid ID Card and Health Information System Single phone number for help. Statement that the card itself does not guarantee eligibility.. Website address for more information. Instructions to call the health plan for the primary care provider’s information. Back of card:

15 Conclusions  The health passport is used more by MCO staff and state staff than by providers, who have been slow to adopt usage.  The new EHR ARRA money will make it more likely providers will adopt electronic medical records (EMRs).  Providers will increasingly use the web portals to access the health passport and the Medicaid health information system.  Ultimately, providers will be interested in the health passport and the Medicaid health information system if they can use them to pull data into their EMRs.  EMRs/EHRs will be important tools for providers and service coordinators/case managers in advancing strategies to better health outcomes.