Behavioral Health Integrated Healthcare Home Arizona Department of Health Services (ADHS)

Department of Behavioral Health Services (DBHS)

January 10, 2011 Dr. Laura Nelson

Chief Medical Officer ADHS Deputy Director DBHS

Partnering for Improved Health Outcomes: Chronic Conditions Medical Home for Medicaid Eligible Seriously

Mentally Ill (SMI) Individuals

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Profile of a Member of the Target Population

Jeannie, 55 year old female

Bi-polar disorder with substance use and various medical complications, including diabetes and obesity.

Marginally housed – periodic bouts of homelessness

Few social or family supports to help her navigate the health care system or adhere to a treatment plan

Has poor linkage to primary care, due to discomfort with providers other than her usual mental health provider team and difficulty using public transportation

Has difficulty following through on treatment recommendations due to symptoms associate with her mental illness

Makes frequent calls to EMS

In the last year Jeannie has had multiple ED visits and inpatient stays and has used EMS for reasons that are frequently non-emergent.

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Why a Health Home?

Meet consumers where they already are: At the behavioral health care site, which will be the entry point for care.

Recognize and address the challenges consumers with SMI face in accessing

and coordinating their healthcare needs: Strong and robust use of case management.

Use a whole person approach: Offer support services to resolve problems that

compromise health (e.g., reluctance to use public transportation, inability to clearly articulate needs or symptoms to health care providers).

Ensure coordination of provider team: Co-location of providers (primary care

providers at behavioral health site) and use of HIT supports communication and allows real time consultation and access to medical records.

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Individuals with serious mental illness face multiple barriers to conventional primary care.

Individuals with serious mental illness have significantly higher overall Medicaid health care costs than other Medicaid populations.

Die more than 30 years younger than their peers

At least 75% smoke tobacco

40-60% of those with Schizophrenia are overweight

15% have diabetes

12 million visits annually to ERs by people with MH/SUD

ER visits driven by psychological and medical conditions

High cost due both to higher illness burden and lack of preventive care.

Behavioral health clinics already see these clients face-to-face several times per month on average.

The Problem: Lack of Integration Between Physical and Behavioral Health

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Integrated Health Home (IHH) Structure

Individuals with SMI and medical co-morbidities should have a behavioral health centered medical home.

In order to improve access to care, primary care services and basic management of chronic conditions will be provided within the behavioral healthcare site as an integrated health home.

The RBHA is incentivized to manage and improve the overall health of the client.

HIT and care management staff enable tight coordination with the broader physical health delivery system.

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14 Essential Elements

Fully integrated service model

Shared continuity of care record

Specialized chronic care improvement program

access to BH and primary care

Routine screening and prevention

Whole health peer supports

Strengths-based services and language

Shared governance

Shared resources allocated by level of risk

Outcome and System Efficiency tracking

Recipient voice and participation

Family support and engagement

Self-mgmt tools and education

Self-advocacy

Voice and Participation

Shared Governance & Accountability

Early and Enhanced Collaboration

Living Healthy Working

Well

Prevention and Early Intervention

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Health Home Structure Components

There are 20 PNO SMI clinics across Maricopa County all on the same EMR (ClaimTrak). SMI clinics will serve as the integrated health home.

MIHS CHCs, inpatient and specialty services create full physical healthcare network all on the same EMR (Epic)

PCPs will be located in each SMI clinic; anticipate increased utilization of primary care providers/services but decreased use of inpatient and ED services

Capacity of PNOs to manage chronic physical illness will be augmented both through staffing and through training of existing staff.

BH services will be available as needed in each MIHS CHC and will be provided by Magellan/PNO; will not increase MIHS-employed BH providers

Higher functioning members may choose to go to the MIHS clinic for primary care services rather than see the PCP at the SMI clinic. Four Quadrant Model and consumer choice will be other driving factors.

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Partnership MAG-0048 000008

Partnership T19 SMI recipients and their families: Profound benefits exist for individuals and families in both

quality of life and life-span by creating the Integrated Health Home that centers on the comprehensive needs of the whole person.

ADHS/DBHS: There is a significant opportunity for ADHS/DBHS to lead the development and implementation of innovative integration programs, such as the Integrated Healthcare Home, and put in place the right framework and oversight that will help meet the unique challenges of the SMI population.

Magellan Health Services: As one of the nation’s leading diversified specialty healthcare management companies, with significant Medicaid and behavioral healthcare expertise, Magellan is the right organization to partner with and deliver an innovative approach, such as the Integrated Health Home for those challenged with SMI.

Maricopa Integrated Health Systems (MIHS): Magellan already contracts with MIHS as the exclusive provider for psychiatric inpatient court-ordered evaluation services at Desert Vista. MIHS also has a tertiary-level acute-care hospital, specialty medical care, 11 FQHC look-alike family health centers, a strong behavioral health annex program and a walk-in center with more than 90,000 individuals served last year.

Network of providers: Healthcare reform, Medicaid expansion and an increased focus on measurable outcomes will provide significant opportunities, and threats, for agencies, depending upon their ability to respond to overall health and wellness. The Integrated Health Home will give these entities much needed direction and support.

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Analyzed proportion of services in each type projected to fall under Section 2703-eligible services Crisis Services (Stabilization) – 10% Crisis Intervention via Telephone – 100% Medical Management – 48% Health Promotion – 100% Living Skills Training – 20% Case Management – 100% Family Support – 50% Peer Support – 80% Consultation, Assessment and Testing – 30%

24% (66% vs. 90%) FMAP increase for eligible services

80% of Health Home Services are Case Management

Potential Total Short-Term Savings, Maricopa County SMI Title XIX: $18 million annually. May be adjusted upon additional guidance from CMS. (Note: This estimate is based on encounter data and not total expenses.)

Estimate of Impact from Enhanced 2703 FMAP MAG-0048 000010

Opportunities for Budget Savings Near-term:

Enhanced FMAP can apply to elements of existing behavioral health care management and care coordination ($18M annual savings)

Reduced Rx, lab costs

Long-Term:

Reduced illness burden associated with impactable or preventable chronic conditions.

Reduced utilization of Level 1 acute hospitalization (behavioral and medical admissions & readmissions)

– Individuals with SMI have high or very high use of ED as Site of Care.

Reduced use of mental health crisis services

Favorable Financial Implications MAG-0048 000011

No other population has the level of ED overutilization and avoidable chronic illness burden.

Other states have seen large savings from programs focused mostly or entirely on preventive care for Medicaid SMI population.

California – Frequent Users of Health Services Initiative Missouri – Focused Disease Management Strategy Washington – Screening, Brief Intervention and Referral to

Treatment Project Pennsylvania – County-based HealthChoices mandatory

Medicaid managed care carve-out program

Opportunities from Downstream Budget Savings MAG-0048 000012

California: Frequent Users of Health Services Initiative

Program Description

Six-year $10 million joint project of the California Endowment and the California HealthCare Foundation. Evaluation findings of 6 pilot sites funded under the initiative show reductions in hospital emergency department (ED) and inpatient utilization resulting from care management and care coordination.

Population Individuals with barriers accessing medical care, housing, mental health care and substance abuse treatment, contributing to their frequent hospital ED visits.

Intervention Pilot programs assisted frequent users with navigating multiple systems of care (primary, mental health, substance abuse and social services). Through a multidisciplinary team approach consisting of physicians, social workers, case managers and benefit advocates, the pilot programs connected frequent users with housing and other non-clinical services such as transportation and legal advocacy which enabled clients to attend appointments, manage prescriptions and ultimately stabilize their health.

Cost Savings Among Medi-Cal enrollees after two years in the program: • 60% reduction in hospital ED visits • 55% decrease in hospital ED charges • 67% reduction in average inpatient admissions • 69% reduction in average inpatient days • 80% reduction in average inpatient charges

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Missouri: Focused Disease Management Strategy

Program Description

Analysis conducted by the Missouri Department of Mental Health (DMH) to determine total Medicaid cost savings associated with individuals pre-and post-enrollment in Medicaid community mental health center-case management (CMHC-CM) programs.

Population Medicaid enrollees with multiple chronic conditions (including depression, diabetes, asthma , ESRD), high social service needs, high use of hospital ED and inpatient care, low use of primary care and low adherence to medication and scheduled appointments.

Intervention The state’s preliminary analysis showed that for persons with severe mental illness, total Medicaid healthcare costs decreased by 15-20% after entering CMHC case management and community support service programs. DMH and Medicaid are now working in partnership to expand CMCH-CM services for individuals with SMI who do not receive services from the specialty mental health system.

Cost Savings DMH estimates potential savings with an investment in expanded Medicaid case management/community support services: Year 1 – Break even Year 2 – 10% off-trend Medicaid savings ($4.5 million) Year 3 – 15% off-trend Medicaid savings ($11.6 million)

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Washington: Screening, Brief Intervention and Referral to Treatment Project

Program Description

Evaluation of the State of Washington’s screening, brief intervention, referral and treatment (SBIRT) project and cost outcomes for Medicaid patients screened in hospital EDs.

Population Medicaid eligible disabled adults who sere screened and received a brief intervention from April 2004 though September 2006 from participating hospitals.

Intervention To address substance use and abuse, SBIRT was offered to patients in 6 hospital emergency departments. SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders. A key aspect of SBIRT is the integration of screening with a system of treatment services through coordinated referral activities.

Cost Savings The SBIRT program was associated with an estimated reduction in Medicaid PMPM costs of $366 for all patients.

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Pennsylvania: County-based HealthChoices mandatory Medicaid managed care carve-out program

Program Description

PA first implemented its HealthChoices mandatory Medicaid managed care program under a Federal 1915(b) waiver in 1997 in the five counties comprising the Philadelphia metro region, subsequently expanded the program in 1999 to the 10 counties in the Pittsburgh metropolitan region, and in late 2001 to the 10-county Lehigh/Capital region, including Harrisburg, Reading, and Allentown.

Population Behavioral health is administered by a single management entity for the full Medicaid population of the county

Intervention Programs were managed by the county behavioral health authorities, in partnership with Pennsylvania-based managed care entities in a de-centralized relationship with the Commonwealth.

Cost Savings The Pennsylvania Medicaid Behavioral HealthChoices program saved an estimated $4 Billion between 1997 and 2008 in the Southeast, Southwest, and Lehigh/Capital regions at the same time it increased access to behavioral services overall and for key vulnerable sub-populations, and also demonstrated improvement on key quality performance measures.

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Savings Opportunities

Substantial savings are suggested from other state experiences with negligible required investments in administrative/infrastructure and additional primary care services.

Potential Savings

Total

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Timeline/Next Steps Submit a Planning Grant request to CMS (January 2011) Work with AHCCCS data to identify target population (January 2011) Formulate a model framework for health home services delivery, which will

include a description of client-flow processes as well as referral and transitional care points (Spring 2011)

Document needs and propose solutions for health information exchange between SMI clinics & and primary care providers (Spring 2011)

Identify options/considerations for piloting health home services (Spring 2011) Develop cost and service models across various scenarios (e.g., county vs.

statewide implementation) (TBD) Identify key implementation dates (TBD)

Planning grant period Conduct Planning Grant Activities/Submit State Planning Grant Stakeholder Input Coordination with SAMHSA Refinement of Proposed Model

SPA Development SPA Submittal Respond to CMS Questions

Effective date of Medicaid SPA Pilot phase (8 quarters)

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