Thinking Creatively: Examples of Successful Delivery Models for High-Need Behavioral Health Patients

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1 Thinking Creatively: Examples of Successful Delivery Models for High-Need Behavioral Health Patients Linda Elam, PhD, MPH DHHS/ASPE National Governors Association April 21, 2015 Baltimore, MD

2 Overview Who are high-need behavioral health patients? What are current challenges in delivering care to them? What financing and system innovations can allow states to serve them better? Lessons from states 2

3 Populations of Concern (Spoiler we are talking Medicaid) People with serious mental illness/serious emotional disturbance chronically homeless People with multiple chronic conditions, including mental health and substance use disorders (and dually diagnosed MH/SUD) TANF population Dual eligibles Expansion populations Formerly incarcerated populations 3

4 Non-Clinical Factors Complicate Care Social determinants of health Physical, social and housing challenges Arrangement and financing of services through different systems Gaps in provider-level and agency/organizational coordination 4

5 Room for Improvement Most people with SMI do not receive care that qualifies as evidence-based Too much care in high-intensity settings (ED vs ambulatory) Too much time between onset of a BH condition and treatment initiation Physical comorbidities often go unaddressed Fragmentation in the delivery system 5

6 Opportunities Provided by the ACA to Improve Care Higher rates of insurance coverage Medicaid expansion Better coverage and access Greater reach for Mental Health Parity And Addiction Equity (MHPAEA) 1915(i) refinements Data system enhancements/health IT Incentives to improve care coordination Integrated care demos ACOs Health homes 6

7 Medicaid Health Homes, Sec Enhanced FMAP 90% for 8 quarters Patients must have two chronic conditions, SMI, or one chronic condition and risk for another Health home services: Comprehensive care management Care coordination Health promotion Comprehensive transitional care Individual and family support services Linkages to community and social support services Use of health IT 7

8 Certified Community Behavioral Health Clinic Demonstration Two years, 8 states, starting in 2017 New certification program New prospective payment system (PPS) Federal guidance to states Up to 16 planning grants will be awarded in Fall 2015 Annual reports to Congress Recommendation to continue, expand, or modify the demonstration by January 1,

9 State Strategies for Improving Care Coordination ASPE study of how states are improving coordination of behavioral health services Key ingredients for care coordination: Enabling provider-to-provider coordination, and collaboration between the health care system and other systems Reimbursement for case management Data sharing Leveraging local understanding 9

10 Incentivizing Value and High Quality Care Focus on performance monitoring and value based purchasing Potential to improve care and use resources more wisely Must guard against unintended consequences Critical role of quality measurement Behavioral health has lagged in the development of meaningful quality measures 10

11 Takeaway Messages Case management or care coordination is key Linkages to care are essential, especially for certain populations People must be connected to services to address the social determinants of health New financing mechanisms and organizational arrangements alone will not accomplish this Importance of strong collaborations between Medicaid and other critical players, e.g., housing and criminal justice 11

12 Takeaway Messages Variation in state structures and population needs calls for creativity at all levels Unprecedented focus on people with behavioral health needs and their impact on health systems provides important opportunities to best serve this vulnerable group 12