Health Plan In Innovations: Im Improving the Behavioral Health of - - PowerPoint PPT Presentation

Health Plan In Innovations: Im Improving the Behavioral Health of Children, Youth & Young Adults

July 26, 2018

Suzanne Fields, University of Maryland Earlie Rockette, Amerigroup, Georgia Tad Gary, Mercy Maricopa, Arizona Katherine Hobbs-Knutson, Alliance Behavioral Health, North Carolina

AGENDA 10:30-10:40 Welcome, Introductions, Setting the Stage 10:40-11:00 Amerigroup, Georgia 11:00-11:20 Mercy Maricopa, Arizona 11:20-11:40 Alliance Behavioral Health 11:40-12:00 Q & A

Who Do We Have In In the Sessio ion?

Children in Medicaid Who Use Behavioral Health Care Are An Expensive Population

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• 11% of children in Medicaid use behavioral health care and

account for 36% of all Medicaid child expenditures

• Mean expense is 4x higher than for children who don’t use

behavioral health services

• Expense for top 10% most expensive children = $47,000 –

expense driven by use of behavioral health care, not physical health

Pires, SA, Grimes, KE, Allen, KD, Gilmer, T, Mahadevan, RM. 2013. Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditures: Center for Health Care Strategies: Hamilton, NJ

Chronic Physical Health Conditions Among Children in Medicaid Using Behavioral Health Services*

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• 38% of children with BH claims also had claims for at least
• ne chronic medical condition
• Pulmonary diseases were the most common physical health

condition (overall mean expense of $1,091)

• High-cost medical conditions (e.g. cancer at $19,065) had

low frequency

*Using Chronic Disability Payment System (CDPS) Methodology

Pires, SA, Grimes, KE, Allen, KD, Gilmer, T, Mahadevan, RM. 2013. Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditures: Center for Health Care Strategies: Hamilton, NJ

Dis istributio ion of f Psychiatric ic Dia iagnoses among Chil ildren in in Medic icaid id Usi sing Behavioral l Healt lth Services

Pires, SA, Gilmer, T, Allen, K., McClean, J. 2017. Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditures Over Time, 2005-2011. (In process). Center for Health Care Strategies: Hamilton, NJ

ADHD 36.4% 32.5% 31.9% 21.4% 5.9% 5.3% 2.7% 6.1% Conduct Disorder Mood Disorder Anxiety PTSD DD Psychosis SUD

Changes in in Top Three Chil ild Behavioral Healt lth Expense Drivers

2005 Res/GH $1.5 OP $1.3B Psyc Meds $1B 67%  in residential treatment/group homes expense 90%  in psychotropic medication expense 39%  in psychosocial rehab expense 2011 Res/GH $2.5B Psyc rehab $2.1B Psyc Meds $1.9B

Pires, SA, Gilmer, T, Allen, K., McClean, J. 2017. Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditures Over Time, 2005-2011. (In process). Center for Health Care Strategies: Hamilton, NJ

Changes in in Mean Expense of Top Three Chil ild Behavioral Health Expense

2005

• Res. treat./group

homes: $21,671

• Outpatient: $1,275
• Psych meds: $1,267
• Psychosocial rehab:

$3,416 29%  in psychotropic medication 5%  in residential treatment/group homes Psychosocial rehab unchanged 35%  in outpatient mean expense 2011

• Res. treat./group

homes : $22,711

• Outpatient: $827
• Psych meds: $1,640
• Psychosocial rehab:

$3,412

Pires, SA, Gilmer, T, Allen, K., McClean, J. 2017. Faces of Medicaid: Examining Children’s Behavioral Health Service Utilization and Expenditures Over Time, 2005-2011. (In process). Center for Health Care Strategies: Hamilton, NJ.

One Size Does Not Fit All: Designing a Care Integration Continuum

• 75% of children with diagnosed mental health disorders are seen in the primary care setting.
• Racially and ethnically diverse families especially feel less stigma in pediatric settings than with specialty

behavioral health providers.

• Pediatricians play a key role in early detection for children enrolled in Medicaid through the Early and Periodic

Screening, Diagnostic and Treatment (EPSDT) benefit, which provides comprehensive and preventive screening and health care services for children under age 21.

• The persistent shortage of behavioral health specialty providers further contributes to the increased role of

primary care.

• Yet, numerous studies have found that primary care practices often struggle with managing child behavioral

health conditions and access to a medical home is uneven.

• One study found that “all behavioral health conditions except attention deficit hyperactivity disorder (ADHD) were

associated with difficulties accessing specialty care through the medical home.”

• A 2013 study in Pediatrics found that youth of color, lower-income youth, youth from households with limited

English proficiency, and those with mental (as opposed to physical) health conditions were less likely to have a medical home where they could obtain routine, family-centered care. There have been similar findings with respect to Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) youth. 10

One Size Does Not Fit All: Designing a Care Integration Continuum

• Much of the literature examining integrated care approaches has been devoted to adults

with SMI or co-morbid conditions with less known about which methods or models of yield optimal clinical and functional outcomes for children, youth, and young adults.

• For example, the Collaborative Care Management model has shown promise with adolescents

with depression receiving treatment in office-based settings and Intensive care coordination using fidelity Wraparound has proven effective for children and youth with serious behavioral health challenges who often have multi-system involvement.

• Much knowledge is still needed to understand which children could benefit from which

integrative approach, including those with brief, moderate, and intensive treatment needs, those with mild, moderate and/or complex behavioral health conditions, very young children to transition-age youth, children and youth involved with multiple child- serving sy/stems such as child welfare, and diverse racial and ethnic groups.

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Children and Youth -Distinct Population from Adults

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• Do not have the same high rates of co-morbid physical health conditions
• Have different mental health diagnoses from adults with SPMI (ADHD, Conduct

Disorders, Anxiety; not so much Schizophrenia, Psychosis, Bipolar)and diagnoses change often

• Two-thirds are also involved with child welfare and/or juvenile justice systems and

60% may be in special education – systems governed by legal mandates

• Coordination with other children’s systems – child welfare, juvenile justice, schools –

and among behavioral health providers consumes most of care coordinator’s time, not coordination with primary care

• To improve cost and quality of care, focus must be on child and family/caregiver(s)–

takes time

Pires, S.A. 2014 Customizing Health Homes for Children with Serious Behavioral Health Challenges. Center for Health Care Strategies: Hamilton, NJ

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Care Management Organization’s Innovations to Improve BH Services to Youth in the Child Welfare System

COMPANY CONFIDENTIAL | FOR INTERNAL USE 14

Earlie Rockette, RNP, MN Regional Vice President, Special Populations Amerigroup Community Care - Georgia

Technology Supported Pediatric ER BH Crisis Re-Direction Program

• Focus on behavioral health crisis
• Assist members with connecting to providers

from the comfort of their homes

• Deliver services via telehealth
• Redirect from PH to BH facilities and providers
• Engage primary care BH provider in crisis care
• Increased sharing of information between

facilities, members and providers

• Enhance EMS Transport system engagement

COMPANY CONFIDENTIAL | FOR INTERNAL USE 16

ER Redirection

Health Plan CMO Care Coordination Community Training (caregivers,

parents stakeholders etc.)

BH Providers BH Facilities DFCS/DJJ/ /DPH/DBHDD /DCH EMS Law Enforcement Hospitals

Integrated One-Stop-Shop Mobile Clinics

COMPANY CONFIDENTIAL | FOR INTERNAL USE 18

Single location benefits foster parents and child welfare workers in accessing healthcare, transportation, referrals and services to children Range of health care services (Behavioral, physical, and dental healthcare services Increased continuity of care – all records posted to centralized state operated health information exchange network Enhanced exchanged of clinical information Care coordination of clinical services

Member and provider incentive program

COMPANY CONFIDENTIAL | FOR INTERNAL USE 19

Concierge Services

20 COMPANY CONFIDENTIAL | FOR INTERNAL USE

Concierge Services Exception to the rule of where traditional medical services are delivered Personalized and not bulk- service driven Integration of Behavioral and Physical healthcare Positive impact on health care expenditure and member experience

“House Calls”

Behavioral health services delivered in least restrictive environment Appointment set based on availability and convenience of the member Assessment and therapeutic services Improved care and decreased member cost (transportation, child care etc.) Completed within 10 days of request, as indicated

COMPANY CONFIDENTIAL | FOR INTERNAL USE 21

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Addressing the Behavioral Health Needs of Children in the Child Welfare System

Tad D. Gary, MEd, MA, CRC, LPC Administrator/Chief Operating Officer

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Who is Mercy Care?

Ascension Care Management

• St. Joseph’s Hospital and Medical

Center, a Dignity Health member

dba Mercy Care & Mercy Care Advantage Managed by Aetna Medicaid Administrators, LLC through a Plan Management Services Agreement

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Current research: foster care

• As of 2016, in the United States there were 437,465

children in foster care. (Children’s Bureau, 2017)

• Studies suggest that up to 80% of children in foster care

have significant mental health issues. (Dore, 2005 and Pecora et

al., 2009)

• Approximately 18% to 22% of children in the general

population have significant mental health issues. (Dore,

2005)

• 2013 SAMHSA report: Adjustment disorders, mood

disorders, anxiety disorders, and attention-deficit, conduct, and disruptive behavior disorders were commonly comorbid with each other across all ages.

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Brief overview of Arizona system: Child Welfare and Behavioral Health

• Department of Child Safety (DCS)
• Regional Behavioral Health Authorities (RBHAs)
• Jacob’s Law
• Child welfare data

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Arizona DCS data

• Total children in DCS care

(9/30/17): 15,840

• Decrease of 16% Since March

2016

• Ages 0-5: 43% of total children in

care

• Total children entering DCS

care April 2017 to September 2017: 4,331

• 23.6% decrease from previous

year

• Removals in Maricopa County:

2,498 (58% of statewide removals)

42.00% 58.00%

Child Removals April 2017 - September 2017

Other AZ Counties N=1,833 Removals in Maricopa County N=2,498

58% of all DCS Removals

• ccurred in

Maricopa County

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Trended quarterly Mercy/CMDP penetration rate (October2015 to December 2017)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Oct-Dec '15 Jan-Mar '16 Apr-Jun '16 July-Sep '16 Oct-Dec '16 Jan-Mar '17 Apr -Jun '17 Jul-Sep '17 Oct - Dec '17 61% 62% 62% 66% 69% 73% 77% 79% 81% 12803 12732 12775 12669 11929 11892 11421 10824 10264

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Four-pronged approach

Network Development Provider & Community Training Stakeholder Engagement Collaboration

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Network development

• Developed comprehensive clinical model, inclusive of parent

support services and case management for all youth and addressing both physical and behavioral health needs

• Focus on evidence-based practices
• Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
• Dialectic Behavioral Therapy (DBT)
• Multi-Systemic Therapy
• Transition to Independence Program
• Specialized programs specific to the child welfare system needs:
• Healthy Connections, Substance Exposed Newborn Services Program
• Foster Care stabilization program inclusive of respite, coaching and

therapeutic services

• Family Center of Excellence

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Provider and community needs

• On-site community trainings for DCS
• ffices, group home and foster care

providers

• Monthly Foster/Adoptive/Kinship

“Navigating Behavioral Health” Forums

• Training
• Foster/Adoptive/Kinship Caregiver

Training Series Infant-Toddler Mental Health Training Series

• Evidence Based Practice Training (TF-

CBT, TIP, CBT-SUD)

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References

1. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2017). The AFCARS report: Preliminary FY 2016 estimates as of October 2017. Retrieved April 30, 2018 from: https://www.acf.hhs.gov/sites/default/files/cb/afcarsreport24.pdf 2. Dore, M. (2005). Child and adolescent mental health. In G. Mallon and P. Hess (eds.), Child Welfare for the Twenty-first Century: A Handbook of Practices, Policies and Programs. (148-172) New York: Columbia University Press. 3. Allen, K. Medicaid Managed Care for Children in Child Welfare. Center for Health Care Strategies. (2008). Available at: http://www.chcs.org/resource/medicaid- managed-care-for-children-in-child-welfare/ 4. Center for Mental Health Services and Substance Abuse Treatment (SAMHSA). Diagnoses and Health Care Utilization of Children Who Are in Foster Care and Covered by Medicaid. HHS Publication No. (SMA) 13-4804. Rockville, MD: Center for Mental Health Services and Center for Substance Abuse Treatment, 2013. Retrieved April 2018 from: https://store.samhsa.gov/shin/content//SMA13- 4804/SMA13-4804.pdf 5. Arizona Health Care Cost Containment System (AHCCCS). SB 1375 Report. October,

• 2015. Available at:

https://www.azahcccs.gov/Members/Downloads/Resources/SB1375Report10-1- 15.pdf

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Thank You

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Suzanne Fields sfields@ssw.umaryland.edu Earlie Rockette earlie.rockette@amerigroup.com Tad Gary garyt@mercymaricopa.org Katherine Hobbs-Knutson khobbs-knutson@alliancebhc.org