1. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 0 Behavioral health payment improvement overview October 18, 2012 – Commission Meeting DRAFT PRELIMINARY WORKING DRAFT, SUBJECT TO CHANGE

2. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 1 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) Recovery / Resilience Intensive Care Coordination Care CoordinationCrisis Services Prevention Acute Inpatient Residential or Intensive Home & Community Based Intensive Outpatient Early Intervention Outpatient Community-based options

3. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 2 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 ABC For today's discussion Which can be addressed through practice or policy changes?

4. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 3 Issues within the behavioral health system fall in 5 categories PreventionTreatment Recovery/ Resilience Early intervention PRELIMINARY A Screening and assessment

5. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 4 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

6. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 5 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

7. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 6 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

8. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 7 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

9. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 8 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 Screening and Assessments PRELIMINARY

10. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 9 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 and Health 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

11. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 10 Recovery Outpatient Care coordination by PCMH 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 Assessment Referral

12. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 11 Behavioral health reform options Regular FMAP6% 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

13. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 12 Potential payment initiatives to address issues within the BH system PRELIMINARY 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) InitiativeDescription

14. Working Draft - Last Modified 10/4/2012 6:01:59 PM Printed 10/3/2012 10:18:30 AM 13 Appendix – Acronym dictionary AHECArea Health Education Center BH Behavioral health CFCOCommunity First Choice Option CMHCCommunity Mental Health Center DDDevelopmental disabilities EPSDTEarly Periodic Screening, Diagnosis, and Treatment LMHPLicensed Mental Health Provider LTSSLong term services and supports NCQANational Committee for Quality Assurance PBISPositive Behavioral Interventions and Supports PBSSPositive Behavioral Support System PCMHPatient Centered Medical Homes RSPMIRehabilitative Services for Persons with Mental Illness SBIRT Screening, Brief Intervention, and Referral to Treatment YOQYouth Outcomes Questionnaire