Putting integrated care into practice within Certified Community

Behavioral Health Clinics

Putting integrated care into practice within CCBHCs

Jane King, PsyD, LP | CCBHC | Behavioral Health Division

2018 MARRCH ANNUAL CONFERENCE

11/6/2018 | Minnesota Department of Human Services | mn.gov/dhs

Putting Integrated Care into practice within CCBHCs

Agenda

• CCBHC demonstration timeline

• Minnesota CCBHC demonstration information

• Elements of Integrated Care

• Integrated services in CCBHC

• Demonstrating 245G SUD reform services

• Experiences with Integrated care from the 6 current CCBHCs

Minn. Legislature supported seeking federal planning

grant May 2015

Minn. selected for federal planning

grantOct 2015

Minn. selected as a Section 223 state

Jan 2017

Minn. Legislature authorizes payment system & state share

of MedicaidMay 2016

Section 223 Demo begins

July 1, 2017

Six clinics certified Oct 2016

Evaluation data collected on 8 states

2017 -- 2019Section 223 Demo ends

June 30, 2019CCBHC included in

1115 Waiver* July 1, 2019 - 2023

11/6/2018 4*pending CMS

approval

CCBHC States

Minnesota

Missouri

New York

New Jersey

Nevada

Oklahoma

Oregon

Pennsylvania

CCBHCs in Minnesota

• 6 CCBHCs

• 29 locations

• 18 counties & adjacent to 4 Tribal

Nations

• CCBHC Medicaid recipients in DY1:

14,840

11/6/2018 6Minnesota Department of Human Services | mn.gov/dhs

Minnesota CCBHC Profile

• Population Density - 3 Urban, 1 urban/rural, 2 rural/frontier

• Organizational structure – 1 government run, 5 non-profit orgs

• Health Homes – 4 certified Behavioral Health Homes

• Designated Collaborating Organizations – 4 providing crisis services

CCBHC Service Delivery Model

CCBHC service delivery model

• Only outpatient services

• Comprehensive, trauma-informed, evidence based, person- and family-centered

• “One-stop-shop” offering full array of integrated outpatient MH and SUD services while retaining client choice of providers

• Includes Care Coordination

• Serve all ages and cannot deny services based on inability to pay or geographic location

• Provide outreach to and increase access for underserved populations

• Non 4-walls

• Governance Structure includes consumers and family members of consumers

CCBHC Services

• Outpatient mental health and substance use services

• Primary care screening and monitoring

• Screening, assessment and diagnosis, including risk management

• Crisis mental health services, including 24-mobile crisis teams, emergency crisis Intervention services and crisis stabilization

• Person-centered treatment planning

• Targeted case management

• Peer and family support

• Services for members of the armed forces and veterans

• Psychiatric rehabilitation services

CCBHC payment model (Prospective Payment Rate – PPS)

• Reimbursement based on allowable costs of furnishing all CCBHC services, not on fee schedule

• PPS is a per diem rate and is unique to each CCBHC

• Integrated payment for mental health and substance abuse disorder services

• PPS methodology bears rational relationship to provider’s costs of providing CCBHC bundle of services

• Likely will not result in reimbursement that precisely equals costs for a given year

• Is not subject to cost settlement

• Creates incentive to contain costs so that costs of care do not outpace inflation

CCBHC Reporting/Quality Measures

• As a condition of the federal demonstration Minnesota is part of a national evaluation, including reporting on:

• 22 federally required Quality Measures

• 8 state-chosen Impact Measures based on 2 goals: Provide full scope of services and Increase access and availability of services

• Added service coverage for adults (Family Psychoeducation and Clinical Care Consultation)

• Expanded Peer services and Functional Assessment to anyone served in the CCBHC

• Adding new service for Ambulatory Withdrawal Management

• Measure increased access to services for communities of color and non-native English speakers

• obtained from encounter claims and clinic-reports

Sustainability of CCBHC

• Federal demonstration ends on June 30, 2019

• All 8 states will submit evaluation reports to SAMHSA in 2019 & 2020

• SAMHSA final report to congress in 2021 – potential to make CCBHC the national standard for integrated behavioral health care clinics

• MN is pursuing an 1115 waiver, which includes a request to continue the CCBHC demonstration for 4 more years (July 2019-2023)

2019 CCBHC Expansion Planning

• SAMHSA grant recipients will be certified and provide CCBHC model with time-limited federal grant funding (2018-2020) :

• Human Development Center (Duluth)

• Western Mental Health Center (Marshall)

• Inclusion of CCBHCs into Prospective Payment System (PPS)

• Two clinics certified/operating in 2020 (post SAMHSA grant)

• Three additional clinics certified/operating in 2021

11/6/2018 13Minnesota Department of Human Services | mn.gov/dhs

Elements of Integrated Care

The ASAM 6 dimensions as an architecture for integrated assessment and treatment planning

• Needed to find a shared understanding, language and structure for both MH and SUD

• Across the country, people are using the 6 dimensions structure beyond just SUD to assess co-occurring disorders

• Hired MNCAMH to train the MH Professionals on how to understand the 6 dimensions as well as provide risk ratings

• Heard feedback from clinics that 6 Dimensions are too SUD focused, especially when assessing a person without SUD or a child

• Expanded the 6 Dimensions into 6 Areas that focus on both MH and SUD called MI MAP

Elements of Integrated Care

The Minnesota Integrated Model for Assessment and Planning MI MAP

• Two Sections

• 6 Areas instead of 6 Dimensions

• Risk rating structure change

Elements of Integrated Care

The Minnesota Integrated Model for Assessment and Planning MI MAP

Section A: Assessment

Section B: Recovery and Care Planning

Area 1: Acute Risk

Area 2: Physical Health History

Area 3: Behavioral Health History

Area 4: The Self and Personal Goals

Area 5: Barriers and Symptoms

Area 6: Interpersonal Engagement

Elements of Integrated Care

The Minnesota Integrated Model for Assessment and Planning MI MAP

Section A

Risk Scores

0 No risk

1 Mild risk

2 Moderate risk

3 Serious risk

4 Severe risk

Section B

Recovery Status / Engagement Scores

0 Maintenance ready for discharge

1 Action, active in care and implementing strategies

2 Preparation, engaged in care not yet implementing strategies

3 Contemplation, ambivalent about care but somewhat engaged

4 Precontemplation, not engaged in care process

Elements of Integrated Care

The Minnesota Integrated Model for Assessment and Planning MI MAP

Area 1: Acute Crisis and Safety

• Assessment of recipient risk to self or to others, including suicide risk factors

• Intoxication or Withdrawal Potential

• Medical Emergency

• Physical Safety

Elements of Integrated Care

Integrated Care Coordination

• According to CCBHC federal criteria:

• Care coordination is the linchpin of the CCBHC program

• CCBHCs should provide integrated and coordinated care to address all aspects of a person’s health.

• Person-centered and family-centered care considers the consumer’s choice in care services provided, as well as the physical, behavioral health, and social service needs of each individual as these factors influence the well-being of the whole person.

Elements of Integrated Care

Integrated Care Coordination

• Care coordination is available to all people served by the clinic

• DHS is clarifying the similarities and differences between CCBHC care coordination, SUD Treatment Coordination, Targeted Case Management, Behavioral Health Homes, Special Needs Basic Care and other waiver case management services within the Case Management Redesign project

Integrated Services

ASAM Withdrawal Management Levels of Care

Integrated Services

Outpatient (Ambulatory) Withdrawal Management

• ASAM Levels of Withdrawal Management

• Level 1-WM: Ambulatory WM without extended on-site monitoring

• Minimal risk of severe withdrawal syndrome

• Office visit with Physician

• Level 2-WM: Ambulatory WM with extended on-site monitoring

• Moderate risk of severe withdrawal syndrome

• Monitoring of symptoms throughout the day, sufficient support at home at night

Integrated Services

Outpatient (Ambulatory) Withdrawal Management

• SUD Reform includes converting Detox units to Residential Withdrawal Management services billable to Medicaid

• Outpatient WM Level 2 (2-WM) is only billable at CCBHCs

• Provided within behavioral health clinics to supplement the MH and SUD services CCBHC clients are already receiving at the clinic when withdrawal symptoms are acting as a barrier to engaging in those services

Integrated Services

2-WM Outpatient (Ambulatory) Withdrawal Management

• Who is appropriate for the service?

• People with Mild to Moderate or Persistent withdrawal symptoms

• This might include people recently discharged from a more intensive withdrawal management or treatment service, in an outpatient or residential treatment program or people withdrawing at home

• People who are engaged in other services to support their recovery; however, engagement in services is not required

• Person with adequate formal and informal support systems to support medication assisted withdrawal in an outpatient setting

Integrated Services

Outpatient (Ambulatory) Withdrawal Management

• What is the service?

• Prescription of a medication specific to the substance (e.g. Buprenorphine for Opioids, Benzodiazepines for alcohol, Chantix for tobacco)

• A withdrawal management assessment

• A withdrawal management plan

• Support services including counseling, education, and coordination of care

• Monitoring of ongoing symptoms of withdrawal

Integrated Services

Outpatient (Ambulatory) Withdrawal Management

• Who is on the WM care team?

• Physicians, psychiatrists, NPs, CNS’, PAs for prescribing medication

• Pharmacists, RNs, LPNs for monitoring of symptoms

• LADCs and MH Professionals for assessment and planning

• Alcohol and Drug Counselors, MH Practitioners, Rehab Workers, and Peers for providing support services

• Care coordinators and SUD treatment coordinators for providing care coordination

Integrated Services

Medication Assisted Treatment

• CCBHC criteria: Staffing, “must include a medically trained behavioral health care provider who can prescribe and manage medications independently under state law, including buprenorphine and other medications used to treat opioid and alcohol use disorders.”

• Example from Missouri (a CCBHC demo state):

• Medication Assisted Recovery

• “Medication First” model

Integrated Services

Medication Assisted Treatment

• Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders

• Research shows that a combination of medication and therapy can successfully treat SUDs

• Medication Assisted Treatment allows individuals to physically tolerate their withdrawal and ongoing symptoms while engaging in treatment and care coordination services as they build long term support to increase their chances of success.

Demonstrating 245G SUD reform services

Certified Peer Recovery Specialists

• A focus of the CCBHC demonstration is the use of peers

• In MN, MH peer services were expanded beyond just rehab and crisis services to be offered throughout clinic services

• CCBHCs could bill for Certified Peer Recovery Specialists at the beginning of the demonstration

• This will soon be a statewide service

Demonstrating 245G SUD reform services

Direct Access to SUD treatment services

• CCBHCs can bill Medicaid for the Comprehensive SUD Assessment

• CCBHCs can authorize outpatient SUD treatment at their own CCBHC

• Only for MA Fee For Service (straight MA)

• Use the risk ratings from the comprehensive assessment (rather than a Rule 25 assessment)

• Do not need County Service Agreement

• CCBHCs use the CHATS system

Experiences with Integrated care

CCBHCs

• Northern Pines Mental Health Center – Brainerd area (6 counties)

• Northwestern Mental Health Center – Crookston area (6 counties)

• People Incorporated – Twin Cities (4 counties)

• Ramsey County Mental Health Center – Ramsey County

• Wilder – Ramsey County

• Zumbro – Rochester area (2 counties)

Questions?

DHS Team

• Julie Pearson, CCBHC Project Manager

• Jane King, Certification Specialist

• DiAnn Robinson, Payment Specialist

• Ma Xiong, Evaluation Specialist

• John Zakelj, Payment Specialist

• Jeffrey Hunsberger, SUD policy

• Lucas Peterson, MCO Liaison

Jane King, PsyD, LP

Jane.king@state.mn.us

651-431-4860

Tanya Freedland, MPS, LADC

University of Minnesota

free0165@umn.edu